Tag Archives: physician

Madhumeha: Ancient Origins, Recent Epidemic

Diabetes has existed for millennia. It has been recognized by several ancient cultures including Indian, Egyptian, Chinese, and Persian. Sushruta, a surgeon and physician who lived around 600BC in the Varanasi area in northern India, documented it in his works. They recognized that ants were attracted to the urine of affected individuals and it was named Madhumeha (Sanskrit; madhu- honey).

Ancient physicians also recognized that there were two types of conditions that involved excessive urination and loss of weight. This recognition of excessive sugar in individuals affected by diabetes was refined over the next 2000 years, and in the 18th century, England Johann Peter Frank is credited with the identification of two forms of diabetes- diabetes mellitus and diabetes insipidus. Mellitus (Greek; honey) was associated with high levels of sugar in the urine, while insipidus was not. In fact, diabetes insipidus is an unrelated condition related to hormonal control of the kidneys, leading to excessive urination. 

By the 5th century physicians in India and China had noticed that there are two kinds of diabetes mellitus- one of which was prevalent in older and heavier individuals. Methods to recognize, understand and treat diabetes mellitus have evolved with technological developments. Relatively rapid progress since the 18th century has identified insulin as the hormone secreted by the pancreas that plays a central role in this indication, and also defined type 1 and type 2 diabetes.

Type 1 (also termed ‘early onset’ and ‘insulin dependent’) is a condition that generally develops in children and younger individuals where insulin production by the pancreas is compromised or completely shut down due to several reasons. Type 2 diabetes (also termed ‘adult onset’ and ‘non-insulin-dependent’) is the focus of this article and has become a global health problem. 

In its current trend of prevalence Type 2 diabetes, or T2D, has blurred two boundaries. It was previously confined to low- and middle-income countries but is now on the rise even in the higher-income countries. Secondly, the age of onset is not confined to older patients. Among the Indian population worldwide, T2D is gaining numbers within India and also within expatriate Indian and southeast Asian communities. Some studies put the number of Indians in the US as the group with the highest incidence of diabetes than any other racial group at an age group above 20. Similar reports have been made with respect to Europe and UAE. Within India itself the numbers of T2D in adults 20 years and above has tripled over the past 3 decades.

This appreciable increase in T2D in southeast Asian expatriate communities, and also within their countries especially India and China, is thought to be due to the relatively recent cultural changes in diet and lifestyle over the past 50 years, such as an increase in consumption of fried foods, fast food, refined grains and sugars, lack of dietary fiber, and sedentary lifestyles.

In addition to these behavioral changes T2D is caused by an interplay of genetic and environmental factors, and familial history serves as an indicator for individuals to be forewarned about their own health. That said, considering the speed with which changes in the age of onset and frequency of T2D are being documented, it appears that environmental, diet, and lifestyle changes are the major contributors to the current epidemic. Also, in general, Indians have a higher degree of insulin resistance than Caucasians, which occurs when the cells of the body lose the capacity to respond to insulin even when it is being produced by the pancreas. 

The burden of the long-term health effects of T2D are significant to the individual and from a public health perspective. The more stark chronic manifestations include neuropathies, foot ulcers, blindness, kidney dysfunctions, accelerated aging, and a general decline in health and productivity. In addition to insulin, newer medicines exist to control blood sugar and insulin response, and other therapies are being developed including stem cell therapeutics. 

If there is a good aspect to T2D it is that it can be prevented or the onset delayed. The fact that onset can be delayed is a point of practical importance, as most of the clinical manifestations arise due to cumulative effects of high circulating sugar. Prevention is the best cure, as the adage goes. A regular health check-up will flag a ‘pre-diabetes; condition. Glucose intolerance tests, HbA1c levels in the blood, body mass index, and overweight are common tests to gauge pre-diabetes. This indication should be taken as a warning, and acted upon seriously and with a positive attitude. 

The trinity of diet, exercise, and stress management are often called upon. Eat less. Eat on time. Walk more. In general, the lifestyle changes that are recommended are geared towards helping maintain an even level of blood sugar and reduction to, or maintenance of, an optimal body weight.

Processed grains, and refined carbohydrates like maida (all-purpose flour), have a high glycemic index. As against whole grains, they are quickly metabolized to sugar and result in a sudden spike of increase in glucose in the blood. Our standard fare includes white rice or chappatis/other breads as a base, and this can be substituted with brown rice and atta (whole wheat).

Instead of serving up a plate with a large portion of rice and sides of vegetables and protein, switch around the amounts and serve up rice as a side dish instead. Control portion sizes, and maintain steady time intervals between meals and snacks. Include soupy low-calorie items which will serve to fill up the stomach. Fasting is not recommended. Eat a diet of high fiber which includes green leafy vegetables and excludes starchy vegetables, skim milk-based yogurt, and whole grains. High fiber dals (moong, masur, urad, etc., along with sprouted whole dals) and beans (such as chole and rajma) should be a mainstay. Including methi (fenugreek) regularly in cooking, and in salads and dals after sprouting (sprouting methi completely reduces its bitter taste) adds flavor and a health benefit. Fruits that are delicious and low in sugar include papaya, guavas, blueberries, and jamoon

Items to be conscious of and exclude, or eat in disciplined quantities, include fried foods and fatty foods in general (including our delicious tea-time snacks!), foods that include sugar and artificial sweeteners (yes, some sweeteners and bulk additives added to sweeteners can produce a sugar spike!), and processed grains. While regulating these will help with the maintenance of body weight, avoiding sugar, sweeteners and the inclusion of whole grains will maintain even levels of blood sugar. Depending on the stage of diabetes fruits may be eaten in moderation, but high sugar fruits such as mangoes, grapes, and sapotas should be avoided. 

As with diet, steady exercise is highly recommended for diabetes. Even our hoary sage Sushruta recommended this, and in some studies, the inclusion of exercise had the most obvious ameliorative effect. The type of exercise will need to vary based on the individual’s age and capacities, but even a basic activity like a daily brisk walk for about thirty minutes would make a difference. Obviously, more will be required if weight loss is an objective. Although yoga is excellent for weight maintenance, it will not suffice for weight loss regimes. Walking, yoga, and exercise, in general, will also help in stress management, and others may be included, such as reading, meditation, etc., depending on individual preferences. 

Tackling the diabetes epidemic at the global level would need to start with the individual. 


L Iyengar has lived and worked in India and the USA. A scientist by training, she enjoys experiencing diverse cultures and ideas. She can be found on Twitter at @l_iyengar .


 

Using Patient Stories To Mentally Survive As A COVID-19 Clinician

Dr. Christopher Travis, an intern in obstetrics-gynecology, has cared for patients with COVID-19 and performed surgery on women suspected of having the coronavirus. But the patient who arrived for a routine prenatal visit in two masks and gloves had a problem that wasn’t physiological.

“She told me, ‘I’m terrified I’m going to get this virus that’s spreading all over the world,’” and worried it would hurt her baby, he said of the March encounter.

Travis, who practices at the Los Angeles County + University of Southern California Medical Center, told the woman he knew she was scared and tried to assure her she was safe and could trust him.

Asking many questions and carefully listening to the answers, Travis was exercising the craft of narrative medicine, a discipline in which clinicians use the principles of art and literature to better understand and incorporate patients’ stories into their practices.

“How do we do that really difficult work during the pandemic without it consuming us so we can come out ‘whole’ on the other end?” Travis said. Narrative medicine, which he studied at Columbia University, has helped him be aware of his own feelings, reflect more before reacting, and view challenging situations calmly, he said.

The first graduate program in narrative medicine was created at Columbia University in 2009 by Dr. Rita Charon, and the practice has gained wide influence since, as evidenced by the dozens of narrative medicine essays published in the Journal of the American Medical Association and its sister journals.

Learning to be storytellers also helps clinicians communicate better with non-professionals, said writer and geriatrician Dr. Louise Aronson, who directs the medical humanities program at the University of California-San Francisco. It may be useful to reassure patients — or to motivate them to follow public health recommendations. “Tell them a story about having to intubate a previously healthy 22-year-old who’s going to die and leave behind his first child and new wife, and then you have their attention.”

“At the same time, telling that story can help the health professional process their own trauma and get the support they need to keep going,” she said.

Teaching Storytelling To Doctors

This fall, Keck School of Medicine of USC will offer the country’s second master’s program in narrative medicine, and the subject also will be part of the curriculum in the new Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, which opens its doors July 27 with its first class of 48 students. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Narrative medicine trains physicians to care about patients’ singular, lived experiences — how illness is really affecting them, said Dr. Deepthiman Gowda, assistant dean for medical education at the new Kaiser Permanente school. The training may entail a close group reading of creative works such as poetry or literature, or watching dance or a film, or listening to music.

He said there’s also “real, intrinsic value” for patients because a doctor isn’t only being trained to care about the body and medications.

“Literature in its nature is a dive into the experience of living — the triumphs, the joys, the suffering, the anxieties, the tragedies, the confusions, the guilt, the ecstasies of being human, of being alive,” Gowda said. “This is the training our students need if they wish to care for persons and not diseases.”

Dr. Andre Lijoi, a geriatrician at WellSpan York Hospital in Pennsylvania, recently led a virtual session for 20 front-line nurse practitioners who work in nursing homes. Two volunteers recited Mary Oliver’s 1986 poem “Wild Geese,” which reads, “Tell me about despair, yours, and I will tell you mine. Meanwhile the world goes on.”

Sharing the poet’s words helped the nurses relieve their pent-up tensions, enabling them to express their feelings about life and work under COVID-19, Lijoi said.

One participant wrote, “As the world goes on around me I mourn seeing my aging parents, planning my daughter’s wedding, and missing my great niece’s baptism. I wonder, when will life be ‘normal’ again?”

Processing Fear To Provide Better Care

Dr. Naomi Rosenberg, an emergency room physician at Temple University Hospital in Philadelphia, studied narrative medicine at Columbia and teaches it at Temple’s Lewis Katz School of Medicine. The discipline helps her “metabolize” what she takes in while caring for COVID-19 patients, including the fear that comes with having to enter patients’ rooms alone in protective gear, she said.

The training helped her counsel a worried woman who couldn’t visit her sister because the hospital, like others around the country, wasn’t allowing relatives to visit COVID-19-infected patients.

“I’d read stories of Baldwin, Hemingway and Steinbeck about what it feels like to be afraid for someone you love, and recalling those helped me communicate with her with more clarity and compassion,” Rosenberg said. (After a four-day crisis, the sister recovered.)

Dr. Pamela Schaff (right) discusses narrative medicine in the Hoyt Gallery at the Keck School of Medicine of the University of Southern California, as Chioma Moneme, a student in the class of 2020, looks on. (Credit: Chris Shinn)

Close readings can also help students understand the various ways metaphor is used in the medical profession, for good or ill, said Dr. Pamela Schaff, who directs the Keck School’s new master’s program in narrative medicine.

Recently, Schaff led third-year medical students through a critical examination of a journal article that described medicine as a battlefield. The analysis helped student Andrew Tran understand that describing physicians as “warriors” could “promote unrealistic expectations and even depersonalization of us as human beings,” he said.

Something similar happens in the militarized language used to describe cancer, he added: “We say, ‘You’ve got to fight,’ which implies that if you die, you’re somehow a failure.”

In the real world, doctors are often focused narrowly, devoting most of their attention to a patient’s chief complaint. They listen to patients on average for only 11 seconds before interrupting them, according to a 2018 study in the Journal of General Internal Medicine. Narrative medicine seeks to change that.

While listening more carefully may add one more item to a physician’s lengthy “to-do” list, it could also save time in the end, Schaff said.

“If we train physicians to listen well, for metaphor, subtext and more, they can absorb and act on their patients’ stories even if they have limited time,” she said. “Also, we physicians must harness our narrative competence to demand changes in the health care system. Health systems should not mandate 10-minute encounters.”

Telling The Patient’s Whole Story

In practice, narrative medicine has diverse applications. Modern electronic health records, with their templates and prefilled sections, can hamper a doctor’s ability to create meaningful notes, Gowda said. But doctors can counter that by writing notes in language that makes the patient’s struggles come alive, he said.

The school’s curriculum will incorporate a different patient story each week to frame students’ learning. “Instead of, ‘This week, you will learn about stomach cancer,’ we say, ‘This week, we want you to meet Mr. Cardenas,’” Gowda said. “We learn about who he is, his family, his situation, his symptoms, his concerns. We want students to connect medical knowledge with the complexity and sometimes messiness of people’s stories and contexts.”

In preparation for the school’s opening, Gowda and a colleague have been running Friday lunchtime mindfulness and narrative medicine sessions for faculty and staff.

The meetings might include a collective, silent examination of a piece of art, followed by a discussion and shared feelings, said Dr. Marla Law Abrolat, a Permanente Medicine pediatrician in San Bernardino, California, and a faculty director at the new school.

“Young people come to medicine with bright eyes and want to help, then a traditional medical education beats that out of them,” Abrolat said. “We want them to remember patients’ stories that will always be a part of who they are when they leave here.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.