Monday, May 26, 2014

Life Lessons

Admiral William H. McRaven, ninth commander of US Special Operations Command, delivered the commencement address at the University of Texas at Austin. Adm. McRaven distills his six months of basic SEAL training into ten life lessons that apply to everyone.

The first task of every day was to make the bed. “It was a simple task, mundane at best. It seemed a little ridiculous at the time, particularly in light of the fact that we were aspiring to be real warriors, tough battle-hardened SEALs, but the wisdom of this simple act has been proven to me many times over.

“If you make your bed every morning you will have accomplished the first task of the day. It will give you a small sense of pride and it will encourage you to do another task and another and another. By the end of the day, that one task completed will have turned into many tasks completed. Making your bed will also reinforce the fact that little things in life matter.

“If you can’t do the little things right, you will never do the big things right. Any if by chance you have a miserable day, you will come home to a bed that is made – that you made – and a made bed gives you encouragement that tomorrow will be better.”

Watch the rest of the address here.

Monday, May 19, 2014


Match Day was in March and May brings caps and gowns. The medical school graduates of the Class of 2014 will soon be starting the next stage of training; with luck and hard work they will get ‘real’ jobs in three to eight (or more) years (after completing residency training).

At graduation, the median educational debt last year was $168,000. The median cost to attend a private medical school was more than $286,000 and 11% of private medical school graduates owed more than $300,000. More than a third of students from public medical schools owed more than $200,000.

In 1984 the median private medical school debt was $22,000 ($46,000 in today’s dollars). The monthly loan payment was an annoyance, not a burden.

In order to pay back $300,000 in twenty years, the monthly payment is more than $2000. Many loans allow forbearance during residency and there are options (such as National Health Service) to reduce debt.  Nonetheless, young doctors face a daunting economic challenge: finishing paying their own educational debt before their children start college. 

Monday, May 12, 2014

Knee Pain

Knee pain that is gradual in onset and not related to an injury is usually osteoarthritis (wear and tear arthritis). Other causes of knee pain include tendinitis, bursitis, infection or tumor. Mechanical symptoms such as locking or catching, and instability due to buckling, catching, or weakness help the physician determine possible causes of the pain. Infection is characterized by warmth, redness, exquisite point tenderness and pain with even a small amount of movement. A joint infection may be a medical emergency and requires prompt evaluation and treatment.

The first imaging technique for non-traumatic knee pain should be regular x-rays. These will show the knee alignment as well as any joint space narrowing.  X-rays will also reveal hidden fractures or tumors. If the initial X-rays are negative, the patient should be given a three to six week trial of conservative therapy: (rest, NSAIDS, ice, compression, elevation, activity modification, physical therapy, crutches).

A MRI can be considered if there is no improvement with conservative therapy. However, MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films.  Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms. 

Many experts recommend an orthopedic consultation before obtaining a MRI if conservative therapy does not relieve pain. A knee MRI will cost at least $1500, a big consideration in these days of high-deductible health insurance plans. It’s a high ticket item that might not add much to the clinical plan.

The Mayo Clinic has an excellent guide for patients.

Saturday, May 3, 2014

Nothing New

It’s common wisdom that the saturated fats found in butter, cheese and red meat lead to heart disease – the smart patient will choose chicken, canola oil and fat-free yogurt. But is this true? Nina Teicholz persuasively argues that our current nutrition policy is based on bad science.

Ms. Teicholz discusses her hypothesis at TedxEast: as we cut back on fat we are loading up on carbohydrates. The carbohydrates break down into glucose, which causes the body to increase insulin, raising the risk for diabetes and heart disease. Substituting vegetable fats for animal fats leads to increased inflammatory and oxidative effects.

I found her well-argued précis entertaining but one needs to view it with a critical eye. Each decade brings new dietary recommendation but we still need to use some common sense. Did anyone really think that fat-free cookies were a good idea? Does anyone today think that unlimited bacon is healthy?

There is nothing new under the sun: eat small portions of different foods. Don’t ingest chemicals. Fresh is preferred but flash frozen can be better. Plan the meal and then sit down to eat it. Sweets should be a rare treat.