The Pain Conundrum: Options & Alternatives

I’m a woman with chronic pain. It waxes and wanes, but I have been on flourbiprofen, a prescription-strength NSAID for about 20 years. I take it about a week before and the week of my menses. That is two weeks a month of strong NSAID use. Plus, ibuprofen for occasional headaches or other pains.

After spending a week observing a nephrology office in January, I started thinking about my own NSAID use and  kidney health. After getting some lab evaluation (creatinine, BUN and GFR) it turns out I have stage 2 kidney disease. WHAT!! I consider myself an extremely healthy woman, and no doctor has ever mentioned kidney issues, much less had a conversation with me about the well known, scientifically proven ways that NSAIDS like ibuprofen, alleve, midol, and aspirin damage kidneys.

Here is the science: The kidneys receive about 25% of the blood flow from the heart, and filter blood through their delicate & intricate filter and tube mechanisms.

 It is prostaglandins that increase pain and inflammation. All NSAID medications work by inhibiting the cyclooxygenase (COX) enzyme, thus decreasing prostaglandin synthesis.However, ibuprofen and all NSAIDs also interfere with the body’s natural blood vessel constriction and dilation hormones through this system, ultimately affecting the kidneys. In the long term, this damages the delicate kidney structures from irregular blood flow. It can also lead to chronic high blood pressure.

To make matters worse, there is a second way that ibuprofen, aspirin and other NSAIDs damage the kidneys. The immune system can react against these drugs and cause an inflammatory reaction right in the matrix of the kidneys. This is called Acute Interstitial Nephritis and can happen after only one week of use. It can also become a chronic, simmering problem that is definitely underdiagnosed.

So, what to do? We cant use opioid pain medication like we used to because it is extremely addicting, and now ibuprofen, aspirin and products like Motrin or Alleve are also harmful. Sadly, acetaminophen, or Tylenol is a centrally acting medication with little anti-inflammatory action and it doesn’t work well for most pain although it is great for fever.

First of all, I would argue we as a culture need to become a little more tolerant to living with some discomfort. Pain is often a sign that something else needs to be addressed: like, hydration, nutrition, posture, or drug/alcohol overuse.

Second, the practice of prevention goes a long way to decreasing the duration and quantity of pain medications needed. WE ARE LAZY!! Simple stretching and at-home exercises can do wonders for back and body pain as can weekly yoga. People who don’t know basic stretches can be referred to physical therapy for individual assessment; this is covered by most private and federal insurances. The newest guidelines from the American Academy of Family Physicians recommend:

“Nonpharmacologic treatment, including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, low-level laser therapy, cognitive behavioral therapy, or spinal manipulation, should be used initially for most patients who have chronic low back pain.”

Finally, botanical medicine has an evidenced role in combating pain. Most herbs are better used proactively for prevention of pain and inflammation than acutely when symptoms are already present. Turmeric, ginger, black pepper and boswellia all have a long history of use for muscle and joint issues. New Chapter has a herbal Zyflammend product line that specifically addresses pain and/or age-related joint disease that is worth trying. Take as directed on the label, 2 tabs daily for at least 6 weeks to assess your response.

DLPA is a less used supplement for chronic pain and depression. This is DL-phenylalanine, an amino acid that gets converted into tyrosine. Rather than directly addressing pain, DLPA slows endorphin breakdown by decreasing enzymatic function. This results in higher endorphin levels for pain control as well as increased adrenal hormones such as norepinephrine. The dosage varies from 1500mg on an empty stomach each morning to 200mg twice daily. For gynecological pain like mine, cramp bark is another option. This needs to be taken in moderately high doses (3 caps 2-3 times per day)  just before menstrual pains begin, and continued throughout the pain window.

These are all good options for all kinds of pain, not just back pain. If we as a consumers were willing to put the same effort into treating & preventing our various pains proactively instead of just popping 3 Advil every 4 hours, we may live longer and healthier. The effect on the kidney is also real, and needs to be talked about more. I see patients dying of kidney failure in the hospital every day, and it is not pretty. I know that I am forcing myself to be more tolerant of the low grade pains I live with, and I just started using herbs (Vitanica’s cramp bark) and (walking and stretching) exercises in an attempt to minimize the pain medications I may really need in a few days. I am hoping it makes a difference, because my kidneys aren’t really up for another 10 years of this.

Share

Embedding Resilience in Medicine

      Half an inch from the first four thoracic vertebrae lie the central nervous system transistors (stellate ganglion) for your fight and flight nervous system. Needless to say, my upper back is constantly aching. I am metabolizing the unique stress of being a brand new doctor/medical student in hospital life. It’s a different kind of stress than the first two academic years: those were crushing content & exams, but they were ivory tower academia. This is the very real medicine that is literally birth, life and death stuff. More visceral than literal, I find myself often crying,  sometimes gagging, and occasionally elated.

The purpose of third year clerkship aka #MS3 is to get a sampling of each major specialty to help us decide on a residency. Its a generic med school formula consisting of: Pediatrics, Surgery, OB/GYN, Internal Medicine Inpatient & Outpatient, Family Medicine, Psychiatry, Community Health. Inpatient, we legally cannot write patient notes. While we can actively participate in patient care,  everything we do needs to be seconded by a licensed doc; therefore, we are mostly shadows, errand runners, and absorbent sponges.

Unfortunately, some throwbacks to fraternal physician hazing rituals are still in place even for third year medical students. For example, my Internal Medicine inpatient rotation, which is already a 6am – 6pm shift 5 days a week (with a 1 hr drive on each side) also requires 6 -24 hour shifts in the 6 weeks. I asked a friend who is a year ahead of me and attended a different hospital clerkship if her rotation was scheduled as such, and she said she had to follow hospitalist hours for that same rotation – roughly 730am – 330pm. If the point is to learn each of the specialty’s roles, it makes sense to follow the professional hours. If the goal is to teach us that Internal Medicine requires an exhausting slog of hospital life, and how to forsake all other aspects of our personal and academic life for our career, then this approach in third year makes sense. Slate Magazine said it best: Third Year Kills Humanity of Medicine.

I haven’t done the above inpatient IM rotation yet and yes, I’m actively worried about my health, my marriage, and my coping skills during that onslaught. I did one 86 hour “sneak peek” week with our Family Medicine inpatient service last Fall.  I did enjoy the steep learning curve and patient contact; however,  I often felt lost and useless as my resident dictated her many notes and ran around the hospital following up on pages and other details. I did get some good studying done and learned some basic inpatient skills but there were hours, especially after the first 8,  that I wished I had something more productive I could be doing in.

In reality, the residents are much more forgiving than the administration and often let us leave early (6am – 10/11pm) saying “there is nothing we could learn at 2am that cant be learned at 2pm.” I am eternally grateful for this ray of grace. And I do understand that night shifts and on-call hours are foundational for many physician careers and practicing them could be relevant.  But why, when 55% of Internal Medicine and Family Doctors report burnout, are we being subjected to these mind numbing hours as third years? How will medicine ever change if the hazing continues to be perpetrated generation after generation?

I accept that being a doctor requires selflessness & sacrifice. I accept that long hours are often required and I like to work – for an income, for a team, and for a good reason. I’m a second career medical student, I study and practice clinical skills because this is what I love! I accept that as a resident I will bear the brunt of hours spent watchdogging and admitting in part because we are the cheap labor force of institutionalized medicine. But, I have 1.5 years of med school left, and 3-6 years of residency/fellowship ahead. What is the purpose of having me work 86 hour weeks now,  and how is it going to benefit my relationship towards medicine?

To embed resilience in doctors, we as a profession and as an academic incubator need to provide time & space for rest, relaxation, and quietude. Only in parasympathetics can we metabolize the soul-rattling experience that comes from facing death and sickness and the burden of chronic disease in North America. Not only are we facing grief/loss/mortality, we are taking on the enormous responsibility of decision maker. A backlog of unprocessed emotion leads to substance abuse, chronic pain, sleep disorders, lack of compassion, and who knows what other organic & chemical dysregulation. We need regular daily time to cook good food, sleep with our loves, be intimate and vulnerable, Netflick and chill, get to the gym or get outside. Only in that space can we emotionally integrate this transformation.

Our clerkship Dean Dr. Taylor sent out this  reaffirming blogpost last month in which an experienced physician Dr. Youngson writes to his younger self. He says:

     “As a medical student or junior doctor, it’s easy to feel powerless especially in a hierarchical medical system that too often teaches by humiliation, punishes those who question the status quo, and grinds people down through overwork and inhuman working conditions…”

Change medical education so that we as medical students (and residents and attendings and all doctors actually) are seen as people who are more than life-saving, problem fixing, chart dictating, disease curing machines. A more gentle, humane practice of time & space for medicine while living life alongside the role of physician has to start at the beginning of the clerkship year when we integrate it’s practice with our academic foundations, or it wont be ingrained as part of the way we approach medicine.

Once I started thinking about time, resilience and integration as the cure of medical burnout, I began seeing evidence everywhere. I heard a NEJM Interview from 01/03/18 with Dr. Armstrong from Massachusettes General Hospital’s new Pathways program where residents are given time and a scientific team to investigate complex patient-based cases. The 12/26/17 issue of JAMA has an article by Jack Coulehan, MD MPH from the Center for Medical Humanities, Compassionate Care and Bioethics on Negative Capability and the Art of Medicine that speaks to “sustaining the physician through the ‘humdrum routine’ of professional life… [Using]… the power to recognize the ‘true poetry of life'” and of medicine. This is a reflective practice. He says:

In pursuing the steadiness and detachment required to master clinical practice, it is tempting to neglect the more difficult project of nourishing engagement and tenderness in our relationships with patients – and with ourselves.”

The future of medical education is not only about competencies met and clinical acumen. The true scholars of the next generations of physicians will be those who can achieve their best in patient care and scientific fulfillment, while also living a satisfying, integrated and joyful life.

Share

Evolutionary Success vs Child Free Living

As you know, I have been struggling with my biological clock: my age and stress level tick louder than ever. Weighing the cost of motherhood against my career in medicine has never been an equal balance with scales always tipped in the favor of my seemingly insatiable appetite for knowledge. And yet – I’ve been studying fertility since 2004, seeing fertility docs since 2008, and  froze my eggs in 2013. I am always scheming to figure out “when is a good enough time”. Yes, I know there “is never a good time: but as a lesbian with a choice, isnt there a “better time”? And here I am, child free, finally happily coupled, and in my third year of medical school in 2017.

I just completed 6 weeks working with newborns and doing well-baby checks to mostly women under 30 in my first pediatric rotation. I I couldn’t help thinking about the definition of evolutionary success as progeny. Many moms I worked with had 4-8 other babies. Some were on opioids, many smoked pot and tobacco or even took buspirone and SSRIs throughout their pregnancy and had sick/addicted babies. Some were very very young. But evolutionarily, each of them had already surpassed me even with my 2.5 degrees, $500k of education,  and diverse, privileged, happy life. I realized I am currently an evolutionary failure.

I am an archetype of my Generation X.  I don’t have many excuses for child-free living left, having had a bacchanalian and free-spirited 20’s and 30’s. Is it time for me to “settledown”? Who am I if I choose NOT to have a child of my own?

My primary reasoning for not spawning includes RESPONSIBILITY – towards my career/education and more importantly, to the kid. Who brings a child into the world who is guaranteed a mom who is away from home 12-18 hours a day (unavoidable in medical school -residency)? Where is the evolutionary success in that? Generationally, I do not have the same programming my parents had to marry/reproduce, and as a lesbian it didn’t happen by accident. Also, as a kid myself who had a high ACE score, I don’t want to perpetrate even a privileged neglect into another generation. So, here I am: struggling with my generational expectation to break the glass ceiling, achieve my highest ambitions, follow my dreams … and shouldering the unspoken price of doing that.

Maybe I could redefine evolutionary success. Not “survival of the species” but survival of the…planet? Conscious eco-systeming? Or maybe even the more complicated redefining of family/familial success – what if evolutionary success was a life well-lived and well-loved, and a small carbon footprint; a kinship network of peers, lovers, and lifelong friends instead? Children no longer live to serve their elder parents, and even if I had a child, I would not be promised a safe and well-cared for death. Still, at the end of the day, even though I have many cousins with beautiful babies carrying on the family line in all directions, my personal lineage of Wright-Larson will not be carried on unless I have a kid. That feels sad. That does feel like failure.

I stand with my aching feet and my scrubs and pager, knowing raising my own babies is not likely going to be the life I get to live this time around.

I have always been an outlier. I chose Naturopathic medical school in the 90s, chose the urban underbelly in the 2000s, and chose osteopathic medical school in the 20-teens.  I’m 92% reconciled that I will enjoy my child-free life and travel to Tokyo, Vatican City, Barcelona, and live in expensive, romantic urban centers. Because I consistently choose career, love and adventure over a baby and domesticity I will be able to live a certain kind of lifestyle. But that doesn’t make it easier when I come home smelling like babies from a day at work, or when I see my cousins achingly beautiful creative charming kids. There is no consolation prize for evolutionary failure. Only the small faith that I am making the right choice for the kid I would create and maybe a for this planet, and hopefully for, myself and my love.

Share

(Least)* Complicated

Walking the tightrope between being a current MSII medical student and a Naturopathic Doctor is a delicate balance sometimes. I never know whether my career as an expert in alternative medicine is going to be a blackball or a gold star because of the very mixed opinions people have about my former profession in the medical world. My plan, heading into the first day of medical school was not to tell anyone my (second) degree when I started (my third degree) at UNECOM, but it was announced in orientation so my cover was blown.

Being a ND in general is pretty complicated – working outside of insurance in most states is a financial challenge for patients as well as doctors, and public knowledge about the profession is highest on the west coast of the US and Canada, and in more affluent areas of the NorthEast. Many people get excited when I say I am a doctor, then look back blankly when I tell them what kind of medicine I practice(d). People who know the field have reactions that are pretty love: hate. Lots of lovers, quite a few haters, and an ever-growing population of quiet converts who realize that, as one anonymous Twitter medical student said in my recent Twitter Flaming on the topic: people who are interested in alternative medicine are usually trying to take care of their health and make themselves feel better.

IMG_6031I have recently been made aware of a woman who attended a west coast Naturopathic Medicine College who has turned against the profession “with an inside view” and who is engaging in aggressive muckraking. She is getting recognition and validation as an “insider” to Naturopathic Medicine as she did complete our 4-year postgraduate degree before she quit and moved to Germany. She has started a petition to defame the profession worldwide. The unfortunate thing is she lives outside the US and is not accountable for US or CDN slander laws. What she is doing is poignantly effective because she has inflamed the haters. One doctor in particular is a physician and educator with the influential Doctors in Training Boards Exam Review Series. He has a large Twitter following and has enthusiastically joined in the slander of the Naturopathic Profession. I worry about how his “expert” personal opinion will effect future generations of physicians who have not considered their professional opinions of Naturopathic Medicine due to lack of exposure.

Big media like Forbes has jumped on the “tin foil hat” bandwagon by supporting her claims that botanical medicine, nutrition, physical medicine, homeopathy, mind/body practices and stress management are invalid sciences without evidence. The American and Canadian federal Naturopathic associations have both started a counter-petition against these muckracking efforts.

All of this is personally upsetting for me. It stirs a complicated turmoil of emotions, injustice, pride, and frustration that mixes my own choices with a very clear working knowledge of the weight that “the big lie” technique can carry in the world of propaganda. All of this comes at a time when “Functional Medicine” and “Integrative Medicine” are the new darlings of allopathic medicine alongside epigenetics and the microbiome.

Newsflash: Functional Medicine and Integrative Medicine ARE evidence based Naturopathic Medicines, researched by and for NDs originally.

Naturopathic Doctors are systematically being defamed and slandered while our actual practice techniques are being picked up and renamed and celebrated for their effectiveness.

I feel helpless in the face of this complicated adversity. I made my personal choice to add an Osteopathic Degree to my knowledge base because there was more to medicine I wanted to know – pharmacology, emergency medicine, psychiatry, and other facets of transgender medicine I need additional training on. I know the great value of Naturopathic Medicine and so do a great number of North American consumers. I suppose I need to trust that the greater good will prevail in the end…. but that may not help me or my career path when I am placed in a hospital as an MSIII or resident with an attending like the Internist above who hates everything alternative and Naturopathic medicine stands for.

Share