One of the most frequent complaints people have when they go to their physician is fatigue. We all have suffered through days or weeks of this and are delighted when it finally passes. But many people suffer through weeks, months and years of this disabling symptom and are often frustrated by the lack of answers.

Early diabetes and hypothyroidism are both disorders of your endocrine system that are very frequently associated with fatigue. Usually these conditions are screened for at most general physicals (if you get them) but can be missed if not specifically looked for.

But I would like to review some of the more common but not always obvious causes of fatigue.

The easiest problem to screen for is a sleep disturbance.

Now just because someone falls asleep when their head hits the pillow does not mean they do not have a sleep disturbance. The most common sleep disturbance is snoring/sleep apnea. “But I don't snore!” Really? Who says. Your spouse snores too so their no help. A good look in your mouth might give you a clue if you snore. If your uvula (that thing that hangs down the back of your throat) ends below your tongue when you go “aaah” (do this in the mirror when no ones looking) and/or you have a soft palate that extends downward—you probably are a snorer (at least some of the time.) If this is the case then you might want to ask for a sleep study. Former sleep apnea patients often report that before treatment they felt like they had cotton in their brains and after treatment they feel much more alert and energetic. But any sleep pattern that does not give you at least 7 hours of uninterrupted sleep will cause chronic fatigue.

Several nutritional deficiencies are related to fatigue. The most common are deficiencies in iron, Vitamin B12, and Vitamin D.

Women can obviously become iron deficient due to their menses, but both men and women can develop iron deficiency due to some type of chronic slow blood loss from he intestine. The most serious would be a colonic bleeding polyp or colon cancer. Other causes of blood loss are severe esophageal reflux, gastric ulcers/gastritis, and AVMs (tangle of blood vessels that are too close to the surface of the intestines.)

Vitamin B12 is a classic cause for fatigue and can present as pernicious anemia—an anemia caused by an autoimmune condition which prevents the absorption of Vitamin B12 in the lower intestine. But people without pernicious anemia can also develop significant, symptomatic B12 deficiency. The absorption of B12 is odd. First the stomach produces a protein that binds to the B12 molecule then this complex travels to the lower intestine where it is absorbed. Recently it was discovered that an acid stomach is required to bind the B12 in the stomach. So chronic antacid users (ie prilosec, zantac, prevacid) can slowly develop B12 deficiency. Often, by taking mega-doses of Vitamin B12 (1000mcg daily) you can force the vitamin into the tissue. Vitamin B12 is needed for your nervous system and your bone marrow. Patients with low B12 are often extremely pale, frequently more so than you would expect from the degree of their anemia.

Vitamin D is a recently popular vitamin that everyone is being tested for. Normal levels are 35-50 and patients with levels below 10 are not uncommon. Some people are lactose intolerant so avoid all dairy. Or they avoid dairy to reduce the fat calories. Sun light is needed to active the Vitamin D we ingest from our diet so us fools in the Northeast can get very low. You really cannot get toxic from B12 but too much Vitamin D can cause kidney stones so best be careful before taking to much Vitamin D.

Lack of exercise is another counter intuitive cause for fatigue. Tell a person who is always tired they need to exercise more and your liable to get quick smack across the head. But this type of fatigue just can't be rested away. The more you rest, the worse it gets. Even modest exercise can help lift this fatigue. Walking, swimming or biking for 20 minutes 3-5 times a week can often be enough to slowly lift the energy level to let you know you are on the right track.

Hopefully this will be helpful for you and look for more blogs in the near future addressing other problems in primary care.

Caring for my elderly patients is both a challenge and a delight. For one, most of them are so complicated that a medical intern would run screaming from the room. I, however, enjoy the layers of problems and solutions...this problems has led to that problem...and that problem's treatment will make that problem worse. Through years of experience we can usually find a happy balance between treatment and just letting nature take it course.

But these wonderful people are also (most times) lovely to care for. They are so thankful to be listed to and to have people caring for them. I have learned over the years that most 85+ year olds really just want quality of life and are not so hung up on length of life. I let them know that I get it and I often can see them visibly relax.

One important service that more families should take advantage of are Geriatric Care Managers (GCM). These are typically nurses or social workers who work with patients, families and physicians to navigate the complexities of caring for elderly patients. Whether it is moving an elderly parent close to an adult child's home, transitioning from home to assisted living or just optimizing the home situation so the patient can remain in their home longer.

There are so many questions that the GCM can answer that does not require my input. They can also help interpret symptoms, medical tests and results and often can be a shoulder to cry on for for both patient and child.

I have worked with several managers in the last decade. I have recently been working closely with Tracey Driscoll, RN of Transition with Care, out of the Concord area. We exchange emails and text messages several days a week about our mutual patient. Her advocacy for her patient is something to marvel at. The patient is doing very well, mostly because of the extra time that Tracey gives her and her family.

So if you are struggling to care for an elderly parent or sposue and find that you wish you had someone to do some of the leg work, coordinate with the physician or interpret medical jargon, then consider a Geriatric Care Manager. They can often make a very challenging situation much more manageable.

Obesity can simply be defined as maintaining an unhealthful level of excess body fat. The World Health Organization has devised a chart that will help you to determine whether or not you suffer from obesity. When a person does suffer from obesity, their body is unable to function properly; therefore, they may suffer from serious health risks.

The manner in which a person becomes obese can also be simply defined; obesity results when a person consumes more calories than they burn. And yes, our bodies do burn calories just by breathing and blinking our eyes, however, if we do not blink as many times a day as it requires us to burn all of the calories that we consume, eventually we will begin to gain weight; women more quickly than men.

There are many different things that factor into weight gain; our age, our gender, our genetics, environmental aspects, our physical activity, or lack thereof, illness, medications and possibly one of the most difficult to control are psychological factors.

 If you find the needle on the scale slowly creeping upwards, and begin to have difficulty, fitting into your own clothing, then stop buying new clothes with elastic waist bands and start paying attention to what you are eating and how much you are moving. Obesity does not happen overnight, yet it is often “overnight” that you wake up and wonder, just how it is, that you are now obese. It seems as though you may gain a pound or three, and then the next time you are brave enough to step onto a scale, those three pounds have mutated into fifteen pounds. At this point, we often tumble out of control until we reach a new level of obesity.

Finding a (concierge!) physician that can guide you along the path back to a healthy weight is not always an easy task. Remember that you are hiring a medical professional that will help you, not one that will degrade and scold you. You will want to find someone that is interested in your overall health care. You need them to be a kind and compassionate, yet a firm mentor, which is able to evaluate your current level of obesity and to determine just how and why it is, that you have become obese.

Once you have found your physician, you and he (or she)  will begin to establish a long-term, working relationship with the goal of helping you to lose whatever amount of weight is needed, to return you to your proper and healthier weight. This will not be easy, and this will not happen overnight, that is why you will need a physician that you, not only like and respect, but one that will take stake in you and your health.

So how do I work with my patients? By education and follow-through! Read on…

My first task is to determine the cause of a person’s obesity. I rule out reversible medical causes such as hypothyroidism, cushings disorder, and sleep apnea. I then look for and usually find the common culprits—poor food choices and lack of exercise.

I calculate a daily caloric intake based on sex and BMI and then devise a caloric distribution throughout the day that will obtain weight loss but will not cause uncomfortable hunger pangs. I push a diet plan with a high intake of lean protein and low in carbs. The three main meals should be 300-500 calories and  two-three are limited to snack 200-250 calories (high protein/low-fat bars or Greek yogurt).

I next pick a goal weight loss the first year of 15% of your current weight. This is usually obtained at an average weight loss of 1lb/week. Usually more comes off at first and then less and less as you approach your goal. So to lose 30 lbs. would take 30 weeks.

I also repeat several important teaching points:

Carbohydrates are ADDICTIVE! You will never feel satisfied with a high carbohydrate diet—your body will always want more and more. It’s like trying to keep a fire lit with only paper.

Cheese is NOT YOUR FRIEND! Although cheese has some protein content, it usually has a high fat content which is not going to help you lose weight.

Walk at least 30 minutes daily (or some other similar exercise) and add light weight lifting/muscle toning after the first ten pounds of weight loss.

Stay lightly hungry most of the day—when you are hungry…you are burning fat (but you need to have a high lean protein intake so you do not also burn your muscle protein).

Then watch the weight fall off. And if it doesn’t I find out why!

Being obese will put you at risk for many different health related conditions and illnesses such as; diabetes type 2, high blood pressure, high cholesterol, high triglycerides, cancer, cardiovascular disease, non-alcoholic fatty liver disease, osteoarthritis and even sleep apnea. All of these can be life threatening.

You are born with just one heart; obesity taxes that heart tremendously. It is easy to envision how obesity appears on the outside; we begin to see our bodies enlarge. What is not easy to see, is how our obesity affects the internal part of our bodies. You must know that fat cells are not just isolated on the outside of our bodies, just under our skin; they are also wrapped around and throughout our internal bodies, surrounding all of our organs. Imagining our heart and lungs totally encompassed in fat cells is not a pretty sight.

So, there is no better time than the present to take our own obesity, into our own hands and find a physician (maybe me) that is willing to consider treating all of you, not just your fat cells. And teach you why you are still “not at your goal weight” and guide you, day by day, minute by minute, to a healthier you. 

It is a common knowledge that most diseases detected early are easier to treat and (in the majority of cases) easier to cure. The optimal way to approach any disease however is to prevent it from occurring in the first place.

One of those preventable conditions is high cholesterol, a precursor to cardiovascular disease that causes narrowing and hardening of arteries which may lead to heart disease, heart attack and stroke.

Cholesterol itself is not dangerous; it’s just another type of lipid (fat made by the body). Lipids are an important part of cells’ structure and play a role in hormone and energy production. There are two important types of cholesterol: HDL and LDL. HDL reduces the amount of harmful cholesterol in you arteries and guards against atherosclerosis. LDL is the bad kind that - in higher amounts - can lead to the development of cholesterol build-up in your arteries and thus cardiovascular disease.

Preventing high cholesterol is in essence a two-prong approach which aims at lowering the levels of LDL while raising the levels of HDL.

As much as no amount of determination can stop a heart attack or a stroke, just a little self-discipline can help prevent high cholesterol. Whether you want to ward off high cholesterol altogether or have high cholesterol levels already and even if you’re taking cholesterol-controlling medication, there are a few simple steps you can take to control - and effectively, lower - your cholesterol levels. (Those of you who are on prescriptions to lower your cholesterol: continue taking your meds while following the steps outlined below. Once your blood test shows that your cholesterol levels have significantly decreased, we may either adjust the dosage of your medication or discontinue it. Don’t make this decision yourself!)

Lifestyle changes to lower your cholesterol:

1/ Control - and if necessary, lose - weight. (Excess weight consists of cholesterol-laden fat tissue.)

2/ If you smoke, quit: cigarettes are a contributing factor to many diseases, including heart disease and atherosclerosis.

3/ If you drink alcohol, limit your drinking to special occasions, only. (High alcohol consumption increases levels of bad cholesterol, while small amounts of alcohol (5-7 drinks per week) actually raise the level of HDL “good-cholesterol”.)

4/ Eat smart: the foods you choose can not only lower your bad cholesterol but also raise the levels of the good one. (See below for dietary tips.)

5/ Believe it or not, physical activity (exercise, a daily brisk walk or dancing) can actually raise your good cholesterol levels.

The bottom line: cholesterol is made from fat and the better you understand the types of fat, the better you’ll be able to take charge of your cholesterol.

First and foremost, our body's requirement for fat is low. The average American diet is much too high in fat. The fats in our diet are not equal; it’s not only how much fat you eat but what kind of fat. The dangerous fats are saturated fats (think animal fats: bacon, meat, butter, cream, etc.). The most dangerous fats are called trans fats (think margarine, baked goods, French fries and other fried foods). The best types of fat are monounsaturated and polyunsaturated fats, these are many (not all) plant oils. Oils such as olive or canola, increase good cholesterol (HDL) and lower the bad (LDL).

Food that keep cholesterol in check:

1/ Reduce your fat consumption and try to eliminate all foods that contain animal fat. (By the way, even if you use exclusively olive oil, you shouldn’t have more than 2 tablespoons of it a day.) A good measure is based on 20% of your daily calorie intake should be from fat. Most people should be consuming close to 2000 calories a day.

2/ Eat fatty fish once or twice weekly (Mackerel, Halibut, Salmon, Sardines, Herring, etc.). Not any, but the fatty fish are rich in Omega 3 Fatty Acids that lower bad cholesterol. Eating more than this can lead to excess mercury levels. Better to take Omega II fatty acid tablets, 2000-3000mg daily, with at least 800mg of DHA/EPA type of Omega III fatty acids.

3/ Eat unsalted and unsweetened nuts (including almonds) as a source of protein instead of animal meat. Most nuts are rich in polyunsaturated fatty acids, the “good for you” type of fat. Walnuts in particular, promote cardiovascular health. (One handful a day is the recommended serving size.)

4/ Load up on fiber of the soluble variety! (As with fat, there are different types of fiber: insoluble which is found mainly in grains, and soluble which is abundant in beans, barley, vegetables, dried and fresh fruit.) Soluble fiber helps reduce the amount of cholesterol in your blood.

5/ Eat a large amount and variety of fruits and vegetables, as these have valuable antioxidants which tend to make your cholesterol less “sticky” and thus less likely to corrode your arteries.

Incidentally, if you stop eating foods that make you sluggish (fatty food and foods high in refined carbohydrates), you’ll feel a lot younger and more energetic.

Here you have it: don’t smoke; don’t drink in excess; eat smart and move a lot. And see your physician at least yearly to have your lipids checked. That's the recipe for low cholesterol, good overall health and a renewed zest for life!

To my dear patients,

It has been an honor and a pleasure being your primary care physician. I want to thank you for allowing each of us at Weston Primary Care to assist you in curing your ills and guiding your overall healthcare. Since starting my practice in October 2007, I have strived to give exceptional, educational and personalized care. Many of you have commented on how much you have enjoyed the relaxed, efficient and friendly way we run our office.

Weston Primary Care is now at an important crossroads. As you are probably aware, the practice and financing of health care will be undergoing significant changes in the very near future.

Boston Globe February 17, 2011

“Gov. Deval Patrick unveiled legislation [February 17] designed to control spiraling costs by rewarding doctors and hospitals for improving patient care while limiting expensive but often unnecessary tests....

...The overall goal would be to significantly reduce fee-for-service payments and replace them with alternative payment method by 2015.”

My goal is to stay a viable business in this new healthcare market, without sacrificing my style of personalize and attentive medical care. As you may know, since January 2009, I have offered the Executive Health Service, a concierge practice model that has received high praise from those who have joined it. I am now expanding on this model to include additional tiers of concierge care (and with added technology) to allow me to continue to care for you in a thorough, efficient and personalized manner which is consistent with my belief on how healthcare should be delivered.

Specifically, I have recently added an online service that will allow me to remotely track your blood pressure measurements, weight, percent body fat and blood sugar using digital monitors connected to your home or work computers. This will allow unprecedented monitoring of your health and rapid intervention if certain health goals are not being met. In addition, we now have the availability to perform remote consultations with me using Skype video conferencing.

The following concierge plans are now being offered:

The Virtual Medical Evaluation (VME) package at $300 per year will allow for 3 Skype remote-evaluations per year for appropriate routine follow-ups and simple problem visits. This feature is ideal for traditional practice patients who desire extra conveniences without the extra features and fees of the higher level concierge models.

The Enhanced Practice Model ( EPM), ($1700/ year) will give patients 24/7 access to me by email, cell phone or text. Appointments will be made for same-day or next-day office visits. Appointments will be 30 minutes for each routine visit (sick or follow-up), and 90 minutes for annual physicals.

The Executive Health Service (EHS), ($2800/year) will offer the same conveniences as above but with several added benefits, including the availability of physicals and routine visits on the weekends, and video conferencing with Skype up to five times per year.

The Mobile Health Service (MHS), ($3600/year) which includes all the conveniences of the EHS, plus one monthly home or work visit. This is a great service for very busy individuals and especially for the elderly for whom getting to the physician's office can be a major event for themselves or their caretakers.

I recognize that you may prefer to continue to have your care given in a traditional care practice model, without paying a monthly fee. Rest assured, this will still be available to you at Weston Primary Care, but with some necessary changes. I will continue to perform your yearly physical, and will remain closely involved in your care. However, traditional practice patients needing follow-up or sick visits will be seen most often by my excellent physician-assistant, Ms. Kate Tye, and possibly a nurse-practitioner, with very close oversight by me.

Please visit the home page of this web site  for more details and to review the various practice model contracts which are available for download. If you sign up for a concierge service (not including the VME) before May 1^st you will receive a 15% discount. Also additional family members will receive a 10% discount. Please be aware that space is limited in each model, so if you are interested in joining please contact us soon.

I am planning to add additional services and conveniences to these plans over the coming years as health care related technology becomes available. I believe the future success of Weston Primary Care will be through continuing to offer exceptional medical care designed to keep my patients healthier by improving their access to high caliber yet personalized health care.

Sincerely,

Timothy P. Murphy, MD

One of the frequent questions from patients I get in the office is why they can't lose weight. I ask the usual questions like what is their diet ("I don't eat that much...really".), how much exercise do they get ("I get exercise...I walk for 10 minutes a day") and perhaps what other medical problems they may have (Diabetes, hypothyroidism etc). But it may be surprising to some of you that I also ask if the snore.

Severe Snoring sometimes indicates possible sleep apnea. Sleep apnea in effect gives the patient a lousy sleep--the brain will prevents REM sleep because with deeper sleep they obstruct their airway even more. Some sleep apnea patients will refuse to believe they snore but they often report chronic fatigue, needs forlate afternoon naps and even sudden nighttime awakenings-- which is their brain in effect screaming at them "Breath ya' idiot!!".

So how does all this effect the ability to lose weight. Recent research has shown that chronic sleep deprivation lowers a person's metabolism. Not only that but sleep apnea patients are so chronically tired they don't have the energy or desire to exercise.

Now trying to convince someone that they may have sleep apnea and that if we improve their sleep this will help them lose weight is usually a hard sell. I tell them they just have to trust me. I've had patients have a sleep study, get treated with the CPAP mask at night and suddenly within a few weeks they start feeling better, exercising more and losing weight at a regular clip. And frequently they can come off the CPAP device if they lose a significant amount of weight.

So if you struggle with weight, you may want to ask your significant other is you snore. Or maybe you already get "The elbow" on a nightly basis. Another simple self-check to see if you are risk for snoring: look in the mirror and go Aaaah. If you can't see your entire uvula ( the little fleshy thing that hangs in the back of your throat) then you could be a snorer. If you cant see your uvula at all...you are most certainly a snorer and I am sure you struggle with your weight.

So to lose weight, follow a well balanced diet, exercise 30 minutes daily, and fix that snoring.

Let's face it. The current medical model isn't working for either the patients or the physicians. Patients complain of not being able to see their physycian in a timely fashion and when they do, they feel rushed. Us Primary Care Physicians, which is actually an insurance company created term--I am an Internist--it says so on my diploma, are over-worked, under paid and under appreciated for what we do. And it's going to get worse.

The Obama health plan, although created in the best of intentions (work with me), is going to put even more stress on this system and push it to the breaking point. A savy patient recently pointed out that the high emergency room volume is often not due to patients without physicians seeking care, but rather filled with patients who cannot be seen in a timely fashion by their physician's office. Our physician's offices are booked to the last available second. Now we are adding more patients to the system, all well and good, but we have no capacity for them to be seen. And medical residents are not choosing primary care as a career because they rightly see the specialty as over-worked and underpaid.

It's because of this unpleasant health care climate that I started Weston Primary Care in 2007 and why I now offer my Executive Health Service in 2008 (a direct pay concierge service). Strictly speaking, my practice is a hybrid-concierge practice, ie I offer both traditional and concierge medical services. My timing wasn't great.

With the economy tanking in 2008-2009, patients were reluctant to spend discretionary funds on health care when they were not sure if they would have a job in 6 months. But since late 2009, the concierge practice has steadily grown by several patients a month. People are now ready to address their health care again.

Now some of you may claim that this is a service only for the wealthy. But at $2500.00 a year, this is close to what people spend on combined cableTV/phone/internet service per year, or what they spend going out to eat on a yearly basis. My concierge patients often choose this service, not because it is a nice perk, but because they truly need access to me more frequently, often at odd hours or on weekends, or they need longer visits (recently I spent 2 1/2 hours with a new patient during a weekend physical) to address complex or confusing problems. I also do home visits for the elderly or disabled. Patients and families rapidly learn to love the convenience and attention they receive. I also love the ability to practice "old fashioned medicine", you know when doctors had time to listen to their patients and ask insightful questions and maybe even read (!!!) about their patients symptoms and problems.

A surprising benefit has been that I have also found that I can now spend more time with my traditional patients as well. By having a more solid business, I don't need to overload my schedule and I can spend a little more time with patients or take some extra time to call a patient at home to discuss lab or test results. And some of my traditional patients like the idea that I offer this enhanced concierge service in the event that they develop medical problems in the future that will require extra time and access. My patients now have a choice, and they like it.

I may not be able to solve the nations health care system woes, but in my little corner of health care delivery, I believe I have created a system which allows me, as a well trained and compassionate physician, to be compensated for my time and effort, but also gives my patients better care and more choices in how they receive their medical care. And its going to get better.

From time to time, I will be blogging about my experiences in my practice and hope you will enjoy my postings.

More later,

Timothy Murphy, MD

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