How Should Doctors Get Paid

How Should Doctors Get Paid?

Categories: Medical Economics | Leave a comment

Chestnut Top Trail

I took another solo hike recently. I had planned to go with my usual hiking partner but that didn’t work out. We still got our usual pre-hike omelets though.

I was hopeful that Chestnut Top Trail was going to be full of wild flowers. The Little Brown Book records it as the best wildflower hike in April in the park. They must have meant late April. There were only about 200 yards of greenery on the whole hike. The rest was still the winter browns.

On a solo hike you always get to see more wildlife than in a group. I came face to face with a young buck. He studied me for about five minutes then wandered off.









Categories: Great Smoky Mountains National Park | Tags: , , | Leave a comment

Why am I still sick?

“Why am I still sick?”
That’s a common question I hear after someone has been infected with influenza and started on therapy.  Most of us associate our times of illness with some common bacterial infections: sinusitis, pneumonia, ear or skin infections.  When we get infected with these bacterial pathogens they tend to stay localized to the area affected and not to invade different parts of the body all at once.  These infections can cause massive inflammation but are focused at a single site.  Additional bacteria only accumulate if the original organism has the resources to make more.  This is why bacterial infections tend to start slowly and build.  It takes time to grow more organisms.
Appropriate antibiotic therapy usually causes the bacterial invaders to be actively destroyed.  That is, most antibiotics kill bacteria thereby reducing the number of invaders left in the body.  Although some antibiotics only slow the replication of bacteria.  People often feel dramatically better after about 24-48 hrs of antibiotic therapy because the number of invading organisms declines rapidly.
Viral invaders, of which influenza is a beast, follow a different set of rules.  These invaders are known for their ability to cause havoc in several different parts of the body at once.  Remember the last cold you had?  You had a runny nose, a sore throat, and an annoying cough.  Three parts of your respiratory track were infected and therefore you had three types of symptoms.  Compare this to strep throat where only the throat hurts but there is no runny nose or cough.
Additionally, viral invaders are masters at sabotage.   They invade your own cells and overtake them.  They will insert their own genetic structure into the manufacturing systems of the cells. Instead of making normal healthy proteins useful for your body you are now making more virions (virus particles).  You are now making more of the invading army.  To kill off these viral invaders the body must sacrifice the cells infected by programming their early death.
When you get started on an antiviral medication, like Tamiflu for influenza, it hinders production of new virions.  The virion particle number peaks and doesn’t increase at the exponential rate it had been doing.  Antiviral therapy does not, however, kill off any virions already made.  Your body has to do that and that takes time.  The body must develop antibodies that recognize the specific threat and attack it.  This process often takes the better part of two weeks to occur under the best of circumstances.  Unfortunately, there are many different types of viral infections but only a few of them have good antiviral therapy available.  Thankfully, most viral infections are annoyances and are no real threat to our health.  For some of the more severe infections, like influenza and herpes (especially when it infects the brain), we have some relatively good therapies if they are initiated at the right time.
So it is easy to see why viral infections tend to linger causing symptoms even after antiviral therapy has begun and why early therapy for influenza makes such a difference in symptom intensity and duration.
Categories: Health Information | Tags: , , , , | Leave a comment

Book Review “The China Study” by T Colin Campbell, PhD.

T Colin Campbell’s book The China Study summarizes his journey starting with basic science research in the effects of nutritional changes in laboratory animals and ends with what is likely the largest observational study on nutrition and health ever conducted.

The book is based upon a published research article concerning the same information. In this article an enormous number of factors where studied in relationship to a populace’s nutritional intake. The conclusion made by Dr Campbell is that a plant based diet devoid of animal protein of any kind, milk, and oils provides the best possible diet to reduce one’s risk of developing cardiovascular disease or cancer. This is essentially the same hypothesis presented by Dr Dean Ornish and Dr Caldwell Esselstyn in their books.

Dr Campbell provides some compelling theories in his book but ultimately I find several short comings. First, he bases his study findings on blood that has been pooled for easier study. In this approach he is able to simplify the bench work required to process so many blood samples but it may falsely alter his results and correlation. As many other authors have pointed out when the original data is examined it often tends to point in a different direction than Dr. Campbell’s hypothesis.

Second, correlation does not provide causation. Acknowledging that a particular people group eats a particular diet and has a low or high risk for a disease does not indicate that the two factors are necessarily related. That is the critical element that observational studies like this one simply cannot prove. They provide wonderful information with which to develop causal theories but cannot provide causation. There are just too many variables unaccounted.

Lastly, Dr. Campbell glosses over the critical missing element of an all plant diet. That is, what to do about nutrients that only come from animals. Of the four he discusses (cholesterol, vitamin A, vitamin D, vitamin B12) only two are challenges in my mind for the modern day plant eater.

Vitamin D is a substance easily made in the skin of most people when exposed to sufficient levels of UVB irradiation. It is often found in the oils of many saltwater fish including salmon and tuna. Dr. Campbell contends that people can make enough vitamin D if they receive regular sun exposure. He argues that humans do not require additional intake in their diet from animals. However, in my professional experience I find almost no patients who have a naturally normal level of vitamin D. Even those that receive above average levels of sun exposure such as roofers and outdoor landscapers tend to have subpar vitamin D levels. Many studies confirm that it is difficult for most people to achieve adequate sun exposure with a typical American lifestyle of indoor work and outdoor play.

Vitamin B12 is an even trickier problem. This vitamin is easy to come by from animal protein, can be difficult to absorb under many different medical conditions, and is almost entirely in the plant kingdom. Dr. Campbell contends that plants grown in vitamin B 12 rich soil can increased levels of vitamin B 12. He cites a research article in which vitamin B12 in enriched cow manure was used to fertilize spinach plants. The spinach plants indeed had a higher level of vitamin B12 but still was so much lower than naturally occurring B12 in animals. By my calculations I would be required to eat almost 15 cups of spinach grown in this special soil per day to achieve adequate levels of vitamin B 12. Ultimately I do not believe any diet that requires supplementation from the very beginning is teleologically appropriate for humans for a healthy life.

I believe one very important aspect of Dr. Campbell’s work should be highlighted. He deserves great credit for pointing out the correlation that the lower amounts of processed foods and refined sugars and carbohydrates is correlated with a healthier lifestyle. I believe that most of the beneficial effects seen in a plant based nutrition diet are achieved directly from this dietary finding. Dr. Ornish’s and Dr. Esselstyn’s work follow the same guidelines and I believe their successes are from this aspect also.

Categories: Book Reviews | Tags: , , | Leave a comment

Hierarchy of Christian work: My job is better than your job.

Here is a great sermon by Tim Keller of Redeemer Church New York City. It’s a good discourse on rightly understanding our position of working in God’s kingdom.

Our Work and Our Character

Categories: Podcasts | Tags: , , , , | Leave a comment

Jake’s Creek to Jake’s Gap

I got an unexpected chance to go solo hiking the other day. I decided to head up Jake’s Creek starting in the Elkmont camping area. I traveled about four miles up the trail to Jake’s Gap. This is where the trail intersects the Panther Creek trail headed west and the Miry Ridge Trail headed east up to the AT.

It was a beautiful crisp morning and I needed to get moving just to warm up. The sunlight and bright blue sky was brilliant. I traveled alone about the whole time with only a few overnighters and day travelers toward the end. At Jake’s Gap I sat in utter silence listening to a few scavenging small birds looking for food and the distant woodpecker doing the same. It was a wonderful day.

My solo hikes always provoke a good spiritual conversation environment for me to spend time with God. This is about the only time in my life where I feel it easy to live out Paul’s instruction to “pray without ceasing.”


Morning sun starts to crest the ridge.


Walking towards the light on purpose.


I took the high road.


At Jake’s Gap


Two paths before me and I took the one more traveled.


My favorite picture of the day. Wonderful tree-scape against the bright blue sky. I took this for my buddy Brent.


Campsite 27 with the bear hanging wires


Central rock of Campsite 27.

Categories: Great Smoky Mountains National Park, Hiking | Tags: , , , | Leave a comment

Book Review “What’s Eating Your Kids?”

Kelly Dorfman’s recent book What’s Eating Your Child? is an exploration of how food affects the physical and emotion health of children.  She uses anecdotal pseudo-case studies to demonstrate how particular children had improvement focusing on particular nutritional changes.

Throughout her book she helps parents and practitioners alike understand better ways to involve their children in meal time decisions and allow them to buy-in on health food choices.  Her E.A.T program to make health food changes I think will be particularly helpful in my practice.

I have three main problems with her book.  First, each chapter is focused around a particular problem in a child in which the answer is an addition or subtraction of a nutrient.  I think the best quote that sums up what is lacking in these chapters is from one of my former residency attendings who said “The eye cannot see what the mind doesn’t know.”  Mrs Dorfman’s training lacks the depth and breadth necessary to take into account a more full understanding of the health of these children.  Don’t get me wrong some of the points she makes are very insightful from having investigated many different children but her differential diagnosis only includes food treatable illnesses.

The second point of contention is the use of physician ad hominem arguments throughout.  Too many of her chapters base her success on the fact that so many physicians have ‘failed’ before her.  If a therapy or treatment is true and right and valid for children it is true and right and valid all the time not just when it helps show the perceived failures of other medical professionals.  True medical therapy doesn’t require this type of argument.

The last and most problematic issue of her book is the lack of evidence on which to base her claims.  She uses reasoning such as milk produces mucus in the respiratory track.  This child doesn’t have a runny nose any more, therefore the mucus must be someone were else like the lungs.  There is no commentary on evidence supporting the milk does or does not produce mucus nor that it can change where it produces mucus over time.  Likewise there is not evidence to support her therapy options.  No trials, no studies, not even a peer reviewed journal to point to.  She uses a long bibliography in the back of the book but never correlates these references to particular points of evidence within the book.  For the medical professional this is just unacceptable.  I can in no way go to my patients and tell them to pursue a course of therapy where there is no evidence that it is beneficial let alone safe.  We need science to lead us to the next step in medical therapies not false logic and trial and error.  Lets take the next step with nutrition therapy and perform blinded trials of nutrient intervention on particular well defined disease states.  With that we can then guide our patients into better health with clear evidence.


Categories: Book Reviews | Tags: , , , | Leave a comment

Book Review: “Why We Get Fat And What To Do About It” by Gary Taubes

Science writer Gary Taubes most recent book is a follow-up to his tome “Good Calories, Bad Calories”. Many have claimed it as the reader’s digest version of his first work. I think it is that and more. It certainly is a shorter and quicker read but also has some updated information and more practice application of what a lower carbohydrate diet and lifestyle should look like.

I believe Taubes has presented in this and his first work on the subject the best description of how our diet affects our waistline. He explains this in clear terms and logical sequences. As all works of this sort must do he oversimplifies several topics but only occasionally loses his way with grounded science.

I would recommend this work as a foundation for any patient wanting to better understand the relationship between what they eat and their health. I use these principles daily in practice to help patients achieve substantial weight loss and better health. In my practice, my partners and I have developed a program of “Nutritional Counseling” whereby we spend a significant amount of time just in counseling our patients on better nutrition. When this is done and patients begin to make the proper changes at home we routinely see reducing in weight, reduction in blood pressure, and reduction in serum blood sugar levels. It is not uncommon for patients who really understand these principles to begin to resolve their diseases. With this we have the very fun privilege of recommending less medication rather than more. It can be very rewarding to work ourselves out of a job.


Categories: Book Reviews | Leave a comment

Oops – Radiolab

Oops – Radiolab.

This unexpectedly grace and mercy fill podcast demonstrates the unimaginable glory of a God who isn’t surprised.  Ever.

Categories: Podcasts | Tags: , , | Leave a comment

Schoolhouse Gap to Campsite #6

Here are two pics from a recent 12 mile hike I took with my dad up Schoolhouse Gap to Chestnut Ridge Trail west to campsite #6.

It rained about 70% of the time. I’m glad I packed my hammock’s rainfly which allowed us to get out of the rain for lunch.



Categories: Great Smoky Mountains National Park | Tags: , , | Leave a comment