Looking After American Indian Patients at an outpatient Clinic

One of the great pleasures of working with Indians is the pleasant encounter one can expect from the patients.

Two things was taught me from the beginning:

Always make sure that your patients leave happier than when they entered.

Show respect to each and every patient who sits in front of you.

For a medical student, a patient presenting with Vitiligo is an intellectual challenge since it makes him think of the various autoimmune dysfunctions one associates with that sign. I have looked after this patient for a very long time, and when he started complaining of atypical symptoms, I thought it was time to investigate other autoimmune failures associated with Vitiligo. Sure enough he had vitamin B12 deficiency which is easily corrected with monthly injections and the symptoms were relieved. He had a very responsible position within the tribe and many times, he would come with the stress of the finance management of the tribe which was his responsibility.

Today he comes to see me, not out of any medical necessity, but to check on the status. The first thing I noticed about him was that his face was radiant, there was a nice colour to his face and that there were fewer wrinkles on his face and his smooth face made him look much younger than his 69 years.

I am the greatest supporter of this clinic, he said. Years ago when I went to see a Specialist in the nearby town, he asked, how come you are so well aware of your health and know all the laboratory measurements. He proudly said, we have dedicated people running a clinic at the tribe and they come to your office and tell you what is happening, they call you up and make sure that you keep your appointment, and they don’t just focus on your medical problem but talk about other aspects of life of interest to me.

I was looking in the Electronic Health Records, under what category shall I record this visit?

His fasting Blood sugar and 2 hour post prandial sugars are below 100, thus ruling out Diabetes from biochemical point of view. His Blood Pressure today is 128/66 affirming the efficacy and frequency of intake of the medication prescribed. Hemoglobin A1C is 6.0.

I thought this would be the time to launch into my explanatory model for his wellness.

You look well, keyn eyn hora, I evoked a Yiddish prayer. Yes I feel well. I think you are well because of two things that come to my mind: the lack of stress in your life and the spiritual life you lead.

It is not up to me to talk about the Spiritual life, but it is up for others to say. A truly spiritual person knows that inside of him. I am not a man given to many words, and I don’t feel a need to speak at occasions when the community gets together. But I have noticed one thing.. normally at the end of a speech by a member of the community, it is followed by Aho.. the Indian equivalent of an applause.. but when I finish talking, it is followed by silence. I take it to mean that what I said, those words have had an effect and that the praise for them are inside of the listeners rather than in the open. If someone comes to speak to me about spirituality I would speak to them about it

To me, I said, when I saw you this morning, I felt a power, a connection to the universe and all the energies around us, and I told myself, here walks a man who is well connected with all that exists in this universe.

When you come to see me, this relationship we have, is not a doctor patient relationship but a relationship based on mutual respect and the exchange we have is based on that respect. There is medical and spiritual exchange between us without us naming it as such.

He then told me, two incidents. He had gone to see the Cardiologist in the nearby town and was subjected to a battery of tests at enormous expense and he was sitting there, not knowing what to ask since the doctor had not entered into any sort of discourse with him. He wanted to note down what to say, and what all the doctor was said that , here is a prescription for you, which will take care of the problem and that you can fill it at a Pharmacy.

He has had no conversations with the doctor, the doctor has not informed him of anything more than saying every thing is fine, and had not given him the opportunity to enter into a discourse about his health. He felt very disgusted and walked out, thanking all the time the fine service oriented health care he receives at the Indian Health Services.

We had a fine chat. This is what a medical consultation should be like, the patient is very satisfied, his questions answered plus he feels that he was able to enter and touch the human world that we all inhabit. The doctor feels good that the long trip has been worth while and that the Indians continue to teach him that connection to the Universe.. which many of us consider an essential part of Spirituality…

Diabetes Care among American Indians

Diabetes Care in America and among American Indians

May 27, 2009

I was intrigued by an article just published in the American Journal of Medicine (2009)122, 443-453

Diabetes prevalence and Therapeutic target achievement in the United States, 1999-2006

What drew my immediate attention was that the authors were doctors and scientists all based in Hong Kong or UK, thus giving me a sense of security that there would less manipulation of data based on the social lived in experience of being in the USA.

Prevalence of Diabetes has increased, there are no surprises there; the control of diabetes as measured by A1C is better now than ten years ago, that is good news indeed; the Cholesterol is coming down so is the blood pressure.. all good news indeed.

For a person, not well versed with medical statistics, I was at a loss to interpret much of the data especially what they had said in the conclusions:

The prevalence of diagnosed diabetes increased significantly from 1999 to 2006. The proportion fo people with diagnosed diabetes achieving glycaemic and LDL targets also increased. However, there is a need to achieve glycaemic, blood pressure and LDL targets simultaneously.

I work as a Consultant Endocrinologist to rather small clinics within the Indian Health Care system in the USA. I am very proud fo my association with the system and the patients, and has been a fruitful association for me as well as patients. Realizing that Endocrine Fellowship (postgraduate studies) alone does not prepare to take care of patients, this lesson was taught me by the Indians, I went back back to university and had a very enjoyable study period gaining knowledge in Medical Anthropology, whereby my vision changed from the body oriented, mechanistic vision of the western medicine to one which is one more holistic, taking into consideration the effects upon the body of society, politics and economics. It augured well for me, since my professional life is linked to people who are marginalized, exiled, oppressed or denied their basic freedoms.

The article sited: Only one in eight patients with diagnosed diabetes reached therapeutic targets for blood glucose, blood pressure and LDL.

It reinforced my experience, even taking a cholesterol lowering medication occasionally will show the LDL to be below 100, but taking anti hypertensive medications or anti diabetic medications only occasionally will not reflect in lower values, thus reflected in the audit or surveys. ( I just saw an Indian patient, whose A1c is 12.4, Blood Pressure is 142/86 and LDL of 95.. she takes her three medications only occasionally).

So, I decided to ask Deb Parker, coordinator of the Diabetes Programme with whom I work. Can we look at our data and find out what percentage of patients have all three indices of “good care” meeting the national standards. Since our individual results are below the national results, should our combined results (all three parameters meeting the standards), be the same, lower or higher than the national levels of only one in eight patients?

Here is where the lived in experience of being an endocrinologist to the Indians comes in handy. From my personal experience of taking care of hundreds of Indian patients with Diabetes, I felt intrinsically that the results must be more than one in eight, but I was not totally prepared for the results the computer and deb parker presented to me.

Putting the following criteria into the computer,

BP less than 131/81

HgbA1c less than 7.0

LDL less than 100 mg/dl

In patients who had come to our clinic in the past one year, 2008 and received care for their diabetes,

How many of them have ALL THREE numbers in the excellent range?

The total number of patients seen during 2008 who carried the diagnosis of Diabetes was 369.

And OUT OF THOSE 369, 194 HAD ALL THREE LEVELS SATISFYING NATIONAL STANDARDS! 52.5%

I was truly elated, now I will leave to the Statistics mavens to pour through these excellent results to come up with their answers or criticism. But now I can proclaim as I have over the period of time:

The Best care for Type 2 DM in these United States of America is in the clinics of the Indian Health Services. ( I would expect VA Hospital system also to produce excellent results since their care model resembles closely to the Indian model of caring for patients with diabetes)

Your Boss and Your Blood Sugar

An overbearing or inquisitive boss and especially one that is perceived as unhelpful to your personal goals is bad for your health has been proven in many clinical studies both from England and the United States. The end results studied have been death from Cardiac diseases. So choose your boss carefully!

This becomes even more important if you already suffer from a chronic disease such as Diabetes. As we all know, Diabetes requires constant attention, to the nutrition and the exercise, which have to be done on a daily basis..Having a meddlesome boss can be dangerous to your diabetes control is illustrated by the following patient.

22 April 2009

As I walked into the room, I see this slight woman, engrossed in her bead work, with a young granddaughter observing her. She looks at up me and I am so reminded of a brave patient many years ago, who battled her diabetes and carried all the burdens of a busy and responsible life but unable to meet all demands succumbed to her disease while still young.

Yes, I am her sister. The same slight build. Looking younger than her 50 years, and for an Indian patient with type 2 Diabetes, she is thin. People who call themselves Indian in this continent, with less racial admixture are most likely to be overweight or obese, whether they have diabetes or not. In fact only 5 per cent of American Indians are of normal weight.

Two visual clues immediately, she is the sister of Ms C who had a brave and grave battle with type 2 DM to which she succumbed. Secondly, she is thin, working.

 She is worried that her work situation has deteriorated to some degree that she is unable to go to the wellness centre for the required exercise. She is wiling to exercise on a daily basis, some thing we would like to hear from all our patients but seldom do so. Recent studies show that exercise advice is only seldom listened to and acted upon, unless the effects of exercise are fully explained to the patient, which requires time in a consulting room.

Her new boss began her duties in march of last year and because of the increased scrutiny, our patient had given up running one and half miles per day at the wellness centre around September. Her Hemoglobin a1c was 5.8 at that time, reflecting an average blood sugar of 101 and now it is 12.4, which means an average blood sugar of 316… three times the average sugar when she was exercising. Once again using the little table of what causes A1C to rise, we can see that in this lady, it is a clear cut case of Lack of Exercise, and the physiology in her metabolism is different, a type 2 DM with thin body habitus, who is already on Insulin therapy, but needs exercise for that insulin to work. So the resistance is at the level of peripheral muscles.

I wrote a prescription for 45 minutes of exercise per day and we will assess her in one month and see the improvement, of which I am certain.

Health of the Indigenous Peoples

American Indians at one time were the healthiest of the Nations, now among the Unhealthiest. To reverse this process, to treat the afflictions that have resulted, a Medical AND a Social understanding is necessary.

 

It is only by your sacrifice that you can bring your goodness and expertise to take effect on your patients. ..Pierre, a patient

If you make a medical error we will forgive you, if you make a social error we will not forgive you… Jim, a patient

 

American Indians are burdened with a myriad of Physical, Emotional, Social and Traumatic issues. Please make sure you do not add to them, instead provide relief to each of their concerns… Michele, a coworker

 

INDIANS as the Native populations of the American Continent are called, refer to themselves by their individual tribal identities. They are the most studied group of people on Earth, having been subjected to all sorts of scrutiny over the years: Medical, Psychological and Anthropological.

UmonHon Tribe with whom all the major early Anthropologists had worked, have even given the nomenclature for Kinship system now used all over the world: The Omaha Kinship. Franz Boas, considered Father of American Physical Anthropology had noted in his book published in 1907 that “ Pathologic Obesity does not exist among the Indians, and their health is superior to that of their European neighbours “.

What has happened in the intervening 100 years and how can we go back to the previous state of excellent health enjoyed by the Indians? A successful approach would be a role model for other indigenous peoples of the world, such as Australian Aboriginals, San Bushmen, Aotearoa NZ Maoris as well as the population in emergent economies such as Bresil, India, China with an already heavy burden of the suffering from Diabetes.

Charcot Marie Tooth

I was waiting for the train to take me into the centre of Paris. An elderly lady was walking past. What was distinct about her gait was that it was the classic Foot Drop!

A professor at London once advised us all medical students, “the greatest pathological museum is the London Underground”, and requested that we keep our eyes open, while being discreet. Sure enough, we learned to spot Parkinson’s Disease, an odd graves Diseases, various forms tics and palsies and several types of growths…

What is a Foot Drop? It is a (high)steppage gait, “Foot Drop” presenting with two unique features.

High Steppage: this consists of knees raised unusually high to allow the drooping foot to clear the ground. And yet, since the toes of the lifted foot remain pointed downward, they still scrape the floor.

Second part is the Foot Slap, creating a double loud sound of contact (first the heel and then the forefront)..

No, perhaps this is not the classic foot drop I said to myself while feeling very sad at the plight of this unkempt lady, trying to avoid the gaze of others..

Could this be Charcot-Marie-Tooth gait? Charcot’s name came to my mind because here I was in his town, Paris…

Before I tell you about Charcot and then Marie, let me say the causes of Foot Drop are LMN disease, Peripheral Neuropathy, peroneal injury and muscular dystrophies

Jean M Charcot 1825-1893 was a legend in French Medicine and if any one deserves the name Father of Neurology,it should go to Charcot. He has 15 medical eponyms to his credit, he was also the first one to describe ALS (amyotrophic Lateral sclerosis). He was an animal lover and a talented artist. He was a Beethoven fanatic. He was well remembered as a Charismatic Teacher, who influenced the likes of Pierre marie, Joseph Babinski, Vladimir Bekhterev, Desiree Bourneville, Gilles de la Tourette, and a 29 year old Sigmund Freud. For aspiring clinical diagnosticians, it is well worth remembering his words: We tend to see only what we are ready to see, what we have been taught to see. We eliminate and ignore everything that is not part of our prejudices. Hence, if the clinician wishes to see things as they areally are, he must make a tabula rasa of his mind and proceed without any preconceived notion..

(a fine medical anthropological study of encounters between patients and their family doctors, has alluded to the fact that the Family Physician tend to make the diagnosis even before he has seen the patient,so strong is his prejudice against certain patients).

Pierre Marie was a student of Charcot, started as a Law student, saw the futility of that discipline and switched to Medicine, much to our benefit.

Henry Tooth was British Surgeon during the Boer War and World War I. He was also an excellent carpenter and musician..

A gentleman and a Poet .. enocunters in Mexique

A Patient and A Poet

I had met him on my previous visit to Northern Mexico. My dear friend and colleague, Dra Estela Rosales Garza from Muzquiz had become interested in helping patients with Diabetes using complementary Medicine, especially using them to prevent complications.

This is Antero Alvarado Trevino. He is in his sixties and lives in a small town, Allende, forty five minutes drive south from Piedras Negras, the border town of Northern Mexico.

An engineer by trade, he is a man of all trades and a virulent seeker of knowledge. As Hippocrates had stated, he reminded me once: Eat naturally and give the body help to heal itself. I visited him at his home with Dra Estela. The house is built in the typical northern Mexican tradition,  had a very nice welcoming feel to it.

Ozone is after all an isotope of Oxygen, this self educated man said, and it is not inflammable. Every time there is a spark of light or when the lightning travels through the air, it creates ozone. I had known about it for a long time but did not know that one day it will prolong my life.

Like all northern Mexicans, where grazing cattle in big ranches is a common sight, he was a dedicated carnivore: red meat, sausages, chorizos, menudos, and he ate it with gusto when he could lay his hands upon it. Diabetes crept in slowly and before he knew it, he was sitting in front of a Nephrologist in San Antonio and listened carefully as the doctor pronounced, your kidneys have stopped functioning, almost, and I can do nothing more for you, Dialysis is the only recourse.

This was in September of 2006, almost two years ago. His Serum Creatinine at that time was a very high 5.9, with blood analysis all revealing evidence of chronic end stage kidney disease: high potassium, high phosphorus, high blood urea, low calcium.

He was not willing to accept the advice. It is that or death, the concerned doctor said to him. But what the doctor did not realize was that Antero is a voracious reader and very inquisitive one at that. He began a research on his own, and he realized that there are other therapies available which can delay Dialysis.

He contacted Dra Estela and requested that he receive Ozone Therapy. Dra Estela had just come back from Cuba after learning about Ozone Therapy and applications and had brought back with her all the equipments necessary.

He began receiving once a month ozone therapy at the offices of Dra Estela.

His investigative reading did not stop there. This lover of poems, who recited poems of Mexican and Colombian poets, found out what is the best diet for him. First of all, eat no Meat. He was determined in his quest, to prove that Nephrologist wrong, that only death was an alternative. He found the vegetables and fruits which did the most benefit and least harm to the kidney. I don’t eat Banana or Tomato, he said, because of their potassium content, and however much I love our ancient Avocado, I had to give it up, when I realized that it might not be good for my kidneys.

So this man has learned to listen to his body and adjust to his new life. The serum creatinine has been coming down, he knows not to get dehydrated or do anything that would make his kidneys work harder than necessary.

Being an ingenious engineer, he has found a way to produce ozone in his workshop and then he pipes it to  his house through the air conditioning system. No wonder why I felt a nice sensation of well being when I entered his house..

All throughout the weekend, I was thinking, why is that the richest country is the world is unable to provide a wholistic care for its people, why don’t the Indians deserve good wholistic care, instead of just their symptoms being attended to? Somethings are beyond us, but if each one of us did our bit, we will make more Indians comfortable.

The Diabetes Clinic in Siem Reap in Cambodia will be influenced by the philosophy of Wholistic Healing, not just numbers but the physical and emotional weffare of the patients. Then we can show the people form rich countries that being poor is not an obstacle to obtaining wholistic care… we just need more committed people, who believe that there is more to practicing Medicine than a western view point alone..

Dancing for your supper

Dancing for your Supper

Is an age old expression, that you must spend some energy to collect the food that you are eating. A century ago, when this was the norm, there was no obesity anywhere in the world. When the indigenous peoples, used to hunting and gathering, were caged into reservation, their free walking activities were curtailed, soon metabolic alterations were to continue.

I walk all the time, at work, at home I am always doing something or other, this is true. Free living human beings in the West walk on the average about 7 miles per day, about and as food becomes available the walking distance decreases by about 3.5 miles per day and in these people, obesity and fat accumulation occurs. This is accelerated by overfeeding.

Thus metabolic alterations are in the continuum of

 

Walking to get water

Walking to get your food

And the availability of food was adequate

Agricultural people had no feast or famine, in general

Hunters and gatherers did

Overfeeding, on a constant basis, led to a deficit in walking

And increased sitting

 

So on the average about 2 hours of walking was lost

In some parts of Africa, 5 hours of walking is necessary to get water

Cuna Indian women have to row about five hours per day to get water and food

So SEDENTARY lifestyle means a CHANGE in your lifestyle

Overfeeding forces you to slow down a little bit

Overweight forces you to slow down a bit

Both the above, decreases the velocity of walking, since lean people do walk faster and longer.

 

What was the 2 hours replaced with?

Work? Tension?

Fast Pace of Life, no time

All increasing stress hormones

 

Walking

Eating

Stressful life

 

Are possibly the fundamental blocks in the making of a healthy body

 

More walking

Less Eating

Less Stressful Life

 

Less walking

More eating

More stress in life

 

The choice is yours..