Old Fashioned Medicine – How I Remember It

A Tribute to Saul Solomon, M. D.

I wish there was more time—time to be a husband, a father, a friend and to be a doctor. I grew up in a different era. When I was 4 years and too sick to go to school our family doctor, Dr. Solomon, made house calls! He charged us 3 to 5 dollars but often accepted payment in the form of chicken noodle soup. And though he was often quite busy he managed to become an integral part of my family’s life.

When I turned 5 he drove me and my family to Beth El Hospital in Brooklyn (now Brookdale) and later took out my tonsils while my parents paced in the lobby. I stayed in the hospital overnight and he gave my parents—who never owned a car- -a lift back to their apartment on Sackman Street. The next day he discharged me and drove me home to my parents—I still remember the “ice cream reward” he gave me for being a good patient. Sounds unbelievable; doesn’t it? It really happened. I don’t know how he had the time to do all this but I remember feeling that our family was very special to him.

He saw us through my brother’s mental illness, my father’s prostate surgery, my mother’s hypertension and depression. And in 1971, during my junior year at Brooklyn College, he helped me pick a medical school—and that’ how I ended up at the University of Rochester. The story’s a bit more complex but let’s save it for another time.

Times were different, of course, in the 1950s and 1960s. Even in Brooklyn, with its 2 million people we were much closer to our neighbors and family doctors were considered, along with priests and rabbis, as the most trusted members of the community. We treated them with greater respect and there’s little question that we received greater respect and care from them. In short, there was a “relationship” between us and our doctors.

You and I can’t change health care in this country—it won’t ever be 1950 again and God only knows where it’s headed. But we don’t have to change the entire system we just have to change our little corner of the world.

Below, I wrote an article called “Balancing Your Life.” In truth, I struggle each day to balance my own and to bring a proper balance to yours. You are more than a chart and collection of numbers summarized in a lab or a pathology report. Your needs do matter and while I can’t provide all the answers I can generally find the right direction to point you in. Our practice doesn’t pretend to be all things to all people but we are committed to being more than a modern-day doctor’s office. I can’t make house calls—at least not very often–and there’s only so much chicken-noodle soup we can eat here on South Clinton Avenue but with your help this can feel more like family and less like professionals entering data into an electronic medical record.

All relationships take time and trust. A doctor-patient relationship is a very special one. You expect certain things from your doctor that you’re entitled to— privacy, dignity, respect for your time and your feelings, and confidentiality. There are no silly questions and nothing so embarrassing that you can’t talk about it. Ours is a different kind of practice; most of you already know that. For those of you who don’t please give it a try. We’re often told that our office looks more like a home—that’s no accident. It reflects how we want you to feel when you’re visiting a neighbor or a friend.

As for Dr. Solomon he lived to be 89 years old and worked well into his seventies. He cared for my parents and my brother long after I left Brooklyn in 1972 and left a legacy of compassion and trust. And like most of those who have an enormous impact on our lives he would never imagine I’d be writing about him almost 55 years after he took out my tonsils and he’d certainly never imagine how often I’ve thought of him as I strive to be your trusted physician.

Balancing Your Life

One of the most common reasons that women seek health care is related directly or indirectly to depression or its cousin, anxiety. The causes are too numerous to mention but most of us are familiar with the more common ones. None of us passes through life without experiencing disarray involving our jobs, our health, our families, friends or “significant other.” To make matters worse our wounds are often compounded. A woman loses a parent and is under pressure from her boss not to take time off from work. After two weeks her husband and children have decided that she’s had enough time to grieve and expect her to be her old “happy self.” It’s no wonder that we often hear the statement “when it rains it pours.”

It’s no wonder we get depressed. At times it seems that when we’re depleted those around us expect more not less. To make matters worse we live in a society where depression is medicalized—we’re often taught that it’s a disease when it’s simply “life.” And all too often doctors and health care providers are quick to prescribe a pill rather than give you what you need most—their time, their advice and occasionally their wisdom.

It’s not that real depression doesn’t exist—it does. But this article isn’t about longstanding depression that needs medical intervention. This is about the kind of depression and anxiety that most of experience in our everyday lives—the unavoidable kind. Unfortunately, it too, is medicalized and often doctors, therapists and psychologists seem more interested in classifying us than helping us.

A good friend of mine just found out that his chest pain wasn’t indigestion but was an early warning sign of heart disease. There were plenty of technicians to do EKGs, place stents in his arteries and prescribe medications and tests. But when the dust settled he realized that he was sad—and with good reason. His depression isn’t something that will get fixed with a pill but it, like his heart, will heal.

In fact, what many of us need to do is consider that depression is a way in which our body tells us that we need to re-balance our lives.

There is little that can be said in one article that can change your life but consider what the ancient sage, Hillel, (100 BCE 10 CE) once said “if I am not for me who will be for me, if I am only for myself what am I, and if not now when.” The beauty of Hillel’s words lie in their wisdom and eternal relevance. Hillel teaches us about balance.

If I am not for me who will be for me?

From the start Hillel sends a clear message. The inspiration to face life and its challenges cannot come from without—it needs to come from within. Only we are entrusted with the zeal to accomplish our goals and give meaning to our life. Hillel’s sage advice is a wake up call to all of us who believe that a parent, a spouse or government is supposed to “fix” our problems. Unfortunately, we live in an era when we are told that everyone is responsible for our misfortune but us. Falling while working on a construction site is no longer an accident that we might be responsible for–it’s a potential lottery ticket! Lawyers specialize in motorcycle accidents, illnesses related to diet pills and the potential ill-effects of silicone breast implants.

In fact we—each of us—are our own lottery ticket. No one will advocate better for us, fight harder for us or be more concerned for our welfare than we. No matter the circumstances that brought us into the world, an alcoholic father, a heroin- addicted mother, our parent’s divorce or the tragic death of a spouse or child there comes a time to stop looking outside yourself for help and begin reaching inside yourself for the desire to change your life. Despite inadequate schools, poor role models and abusive parents men and women have overcome the longest of odds and succeeded in changing their lives. A more contemporary example of “being for me” is found in the movie series Rocky. No amount of training and coaching can substitute for the desire to triumph and realize his or her dreams. It starts with knowing your dream, your role in achieving it and “being for yourself.”

If I am only for me what am I?

Remember Oliver Stone’s 1987 movie, Wall Street? Michael Douglas played corporate raider Gordon Gekko, who will always be remembered for the phrase “Greed is good.” Two decades later we are now paying the wages of unbridled greed. We’ve lived in a culture of unchecked excess forgetting the balance between “me” and “them.”

In January 2000 I visited Kenya along with a group of physicians trying to bring health care to an underserved area west of Nairobi. Despite unimaginable poverty I realized a fascinating truth—as long as people were reasonably healthy and well-fed they appeared far happier than the average Rochesterian in her wealthiest suburbs. Why? Because they were connected! They understood the importance of forming close bonds, helping one another and the joy of giving and helping not for any expectation of reward—but for its own sake.

This isn’t about writing checks to your favorite charity or donating a new wing or auditorium to a college campus—it’s about the direct involvement in someone else’s life.

Balancing one’s life requires the harmony of “being for me” while willfully avoiding greed and taking the time to “be for someone else.” To give to another person is how we rejuvenate and enrich ourselves. The gifts don’t necessarily require large sacrifices. Offer to help someone carry their grocery bags, stop and allow someone to enter traffic instead of driving right past them, say “thank you,” tell someone you appreciate them or give someone an unnecessary smile—pay it forward! However you do it remember that that an act of loving kindness is its own reward.

And if not now when?

Don’t try and change your life all at once but start somewhere and start now. If you need to set aside time for yourself to exercise talk to your family and schedule it the way you would any other appointment. This is time I reserve for myself! Let your family know that they’ll have to figure out how to manage without you for an hour. Let them do some chores and let them know that when you’re replenished there’ll be more of you “to go around.”

If your goal is to quit smoking start somewhere! Go on-line and see what resources are available to you – many are free. Make an appointment with your primary care provider but do something different. Remember that if you always do what you’ve always done you’ll always get what you’ve always got!

Summary

Depression and anxiety are a common and unavoidable part of life. We all experience it and there are phases of our lives when anxiety seems the “norm.” It’s fine to ask for help but remember that no one is as interested in your mental and spiritual well-being as you are. Know how to involve friends, family, professionals and other resources and most of all remember that for your life to work you need to find a balance and you need to do it soon.

BOTOX…Is It For You?

Most of you don’t know that we offer a variety of cosmetic services at our office. Some of these services include the use of Botox, and facial fillers such as Restalyne, Juvaderm and Radiesse. We will cover the last 3 of these in future newsletters and they will also appear on our website. For today let’s talk about a cosmetic treatment almost everyone has heard of—BOTOX.

Botox

As you all know Botox is the most commonly used cosmetic procedure in the United States. When properly administered you can still smile and have other facial expressions—but without those lines between your brows. Botox diminishes those lines between your brows that result from muscle movement and the passage of time. It works by temporarily weakening those muscles so that they don’t draw the skin together causing those deep furrows. Botox is also used to treat other areas of the face— though it’s not FDA approved for those purposes. This includes forehead creases , skin bands on the neck and even the lines known as “crow’s feet .” Properly injected Botox can also create a “brow lift”.

There are other situations in which Botox is not a good option and these include wrinkles caused by sun-damaged skin or wrinkles around the mouth. Weakening the muscles around the mouth would be undesirable as you need them for talking and eating! The result you can expect from Botox depends on several factors including your skin type, its thickness and how well developed your facial muscles are.

What is Botox?

Botox is derived from a bacteria that is found in the soil—Clostridium Botulinum. There are seven different types named A through G. Botox is a therapeutic agent derived from Clostridium Botulinum type A, also known as Botulinum Toxin Type A.

What is Botox used for?

The FDA has approved Botox for cosmetic use—specifically to improve the look of fine lines and superficial wrinkles between the brows caused from every day facial expressions (See areas ‘a’ and ‘b’ above)—specifically furrowing. However, though not approved by the FDA, Botox is also very effective for wrinkles—and their prevention– that result from smiling, frowning or squinting.

So, one could argue, Botox can be used to save your marriage—as long as you don’t cuss your spouse—or help you win a hand at poker!

And there are other uses of Botox too. It’s commonly used to control excessive sweating (hyperhydrosis) in such areas as the palms of the hands, soles of the feet and underarms. This too might save your marriage, or at least reduce your laundry bills.

How does Botox work?

Whenever a facial muscle (or any muscle) is activated a message is sent from your brain to your spinal cord and through a nerve that activates the muscle. The transmission of the electrical impulse from the nerve to your muscle is facilitated by the chemical acetylcholine. Botox works by blocking the nerve endings from releasing acetylcholine.

You can see from the drawing above that just beneath the facial skin is an intense array of muscles that produce and endless number of facial expressions—no doubt you’re making some now! Botox is approved for the Procerus and Corrugator muscles but can be used for the ones in the forehead, in the outer corners near your eyes (crow’s feet) as well as others.

What to expect at your first appointment

If you’ve never had a Botox treatment this will be an opportunity to learn some of the “BOTOX BASICS.”

  • Expectations

    It’s important to review your expectations and determine if they’re realistic. For instance, Botox will do little for nasolabial folds—the lines that develop between the corners of the mouth and your nose.

  • Risks

    In general the use of BOTOX poses few risks. BOTOX may cause temporary headaches, bruising or temporary drooping of the eyelid. Rarely, it can cause temporary double vision. Obviously you will need to tell us about any medical condition you have. Certain antibiotics— Levaquin, Cipro or Clindamycin—shorten the therapeutic effect of BOTOX so you may wish to complete your antibiotic treatment before receiving BOTOX injections.

  • Contraindications

    BOTOX should not be used if you are pregnant, breastfeeding or are taking certain medications (aminoglycosides antibiotics).

  • How is it given? Is it painful?

    Botox is given by fine needle injection. The number of injections will depend on the number of areas you wish to have treated. Most women say that the pain is minimal. We often apply a topical local anesthetic cream and wait 10-15 minutes to allow it to work. A typical treatment takes 10-15 minutes—again, depending on the number of areas you wish to have treated.

  • What can I expect afterwards?

    There may be some temporary swelling and occasional bruising. The swelling typically lasts a few hours so you don’t want to have this done just before an evening out on the town. After treatment you will see the effects of BOTOX within 1-3 days although the full effect may take 10-14 days. Some doctors ask their clients to frown or squint a lot so that the medication settles in. I generally instruct women to gently massage some of the areas—but how you do this is important. Don’t massage the injection sites without specific instructions from me. It’s important that you don’t lie down or bend over for 4 hours after injection. I generally ask women to not exercise for 4 hours afterwards as well.

  • Things to avoid

    Do not lie down or bend over for 4 hours after your treatment. Minimize your exposure to the sun and wear sunblock!

  • The two-week visit

    If you’re a first time patient you may wish to make a 2 week appointment so that we can evaluate how it worked for you. Obviously, if you’re having any problems—bruising or eyelid drooping—you’ll call us immediately. The 2-week visit is an opportunity to see how it worked and if you’re satisfied. Occasionally, some “touching up” is necessary at the 2 week visit for optimum results.

  • How long does it last?

    For most women BOTOX seems to last 3-4 months. The effects wear off gradually and you’ll be the best judge of when to come in for your next appointment.

  • How much does it cost?

    The cost varies with the number of areas that are treated. A complete price-list is available to you on request.

  • Is there anything else I should know?

    Avoid aspirin and non-steroidal anti-inflammatory drugs (Ibuprofen, Advil, and Aleve) for at least one week prior to your planned treatment. This will reduce the possibility of bruising afterwards. Also, avoid Ginkgo and ginseng, Vitamin E, Fish Oil supplements and red wine for at least a few days prior to treatment—again to avoid bruising.

“OH MY GOD I HAVE AN OVARIAN CYST!”

Introduction

If you are a woman within the age range of 13 – 50 and you’re told that you have an ovarian cyst you need to take a deep breath and stop thinking that you’re going to die of ovarian cancer.

Ovarian cysts are common and are one of the leading reasons that women seek help from their gynecologists. Often they produce symptoms of lower abdominal pain. Other symptoms associated with them include distention, abnormal menstrual bleeding or pain during intercourse. However, with the large number of ultrasound examinations, CT scans and MRIs that are performed—often for reasons other than pelvic pain– we see an increasing number of patients that are referred from their primary care doctors or radiologists that have been told that they have an ovarian cyst or cysts. These women often have no symptoms other than the tremendous anxiety that may have cancer or infertility.

In my last newsletter I talked about the difference between perception and reality—in that particular newsletter (Volume 1, No.2), if you recall, the topics were coffee (it really is good for most women!) and female cancers (no, that’s not what most women are going to die of!). The reality of ovarian cysts is that every woman who ovulates gets them—because a cyst is critical to the development of an egg as well as the hormones estrogen and progesterone. Unfortunately, there are some abnormal ovarian cysts but the overwhelming majority of them are benign. Rarely, there are ovarian cancers that occur in this age group—very rarely. The reality is that most ovarian cysts are physiologic and a few are pathologic.

A physiologic cyst is one that serves a purpose in reproductive function—it’s where your eggs are made and where the hormones estrogen and progesterone are made. For that reason physiologic ovarian cysts are also called functional ovarian cysts. These cysts appear and disappear as you progress from one menstrual cycle to the next.

Pain sometimes accompanies physiologic ovarian cysts. Cysts occur as part of every menstrual cycle—but most women do not experience pain during every menstrual cycle. The reasons why some cysts cause pain and others don’t are complex but here are some of them:

Larger ovarian cysts are more likely to cause pain even though larger ones aren’t any more “dangerous” than smaller ones.

Larger cysts may be more likely to “leak” fluid—and that can cause pain

In most cases, however, it simply isn’t clear why some women experience pain some of the time but not at others.

Pathologic cysts serve no reproductive or hormonal function; all they do is to scare you. In most cases they need to be removed. Usually an ultrasound examination can tell the difference between a physiologic (functional) ovarian cyst and a pathologic cyst (one that should be removed).

How do physiologic (functional) ovarian cysts occur?

As I already said these are also called functional ovarian cysts—because they serve a function! Here’s how they occur. In the early part of your menstrual cycle—beginning with the onset of your period—your eggs are already maturing and being selected for you next ovulation. The next ovulation often occurs 14 days after the onset of your period. During that 14 day stretch from the first day of your period until ovulation several small cysts start to grow on your ovary. These look like tiny little balloon structures and vary from 1⁄4 inch to an inch in diameter. During a typical cycle your ovaries may grow several of these cysts—as many as a dozen— but only 1 or 2 will actually mature enough to ovulate and produce a mature egg ready for ovulation. The fluid within this little “balloon” contains estrogen. So you see that the cyst in the early part of your menstrual cycle serves at least two functions—first, it’s where your eggs grow and second it’s where estrogen production occurs.

After these cysts get to a certain size—around an inch in diameter—they rupture. This is called ovulation!

Notice the hole to the right portion of the ovary. This is where ovulation occurred and the egg passed into the fallopian tube. That’s why we often refer to physiologic (functional) ovarian cysts that occur prior to ovulation as “ovulation cysts”. These cysts can be painful as many women experience some pain as these cysts are enlarging and getting ready to “pop” (ovulate).

After ovulation, something miraculous happens. The very cyst where the egg grew—which is now collapsed and empty for a short while—starts to fill in with blood vessels and that “ovulation” cyst starts producing cholesterol–you see, a certain amount of cholesterol isn’t a bad thing! The cholesterol undergoes a chemical change and becomes the hormone progesterone. Progesterone is made in another type of physiologic cyst called a corpus luteum cyst. Corpus is the Greek work for “body” and “lutea” means “yellow”. These cysts are often yellow in color because of the cholesterol (which is a fat) in them. The purpose of progesterone is to nurture an early pregnancy. If a pregnancy doesn’t occur during that cycle the cyst dissolves and your next menstrual period starts about 2 weeks after ovulation and about 4 weeks since the onset of your previous menstrual period. Occasionally, these corpus luteum cysts can grow quite large—3 to 4 inches in diameter. At that size they’re bigger than your uterus. They can be quite painful and scary—especially if at the same time you’re worrying about something like cancer! The good news is that these cysts go away by their selves. It may take a week or two but they disappear as your body is getting ready for the next cycle.

Cysts are easily seen on ultrasound examination—and that’s how we diagnose them. It’s quite simple to see them. On ultrasound exam solid structures (like your uterus which is mostly muscle) show up in different shades of grey. Cysts are filled with fluid and all fluids show up on ultrasound as black.

Notice how this ovary is made up of several small “black balloons” with one dominant one—the largest one. These are all individual cysts— however, only the largest of these is likely to “ovulate” and produce an egg, while the others shrivel (a process called atresia). In this case one can easily count at least 5 cystic cavities (follicles) on this single ovary. From experience I can tell you with great certainty that this most likely represents an ovulation cyst—one that occurs just prior to ovulation. Remember that ovulation cysts (also called follicular cysts) produce two things: eggs and estrogen.

Now here’s an example of the second type of functional ovarian cyst—the corpus luteum cyst. We see that the “balloon” is still black but it has a fine mottled appearance as if there are small cobwebs within it.

The point is that both of these kinds of cysts happen in every woman virtually every cycle during her reproductive years—even if she is taking oral contraceptives. Corpus luteum cysts last about 14 days before they dissolve and allow the next cycle to begin. Should pregnancy occur, the corpus luteum cyst, which produces progesterone, will sustain the early pregnancy throughout the first trimester (12 weeks) and becomes known as the corpus luteum of pregnancy.

So let’s review:

Cysts can be either:

  • Physiologic (also called functional)
    • one kind occurs prior to ovulation and is called an ovulation or follicular cyst
    • another kind occurs after ovulation and is called a corpus luteum cyst

    WITH FEW EXCEPTIONS PHYSIOLOGIC CYSTS GO AWAY ON THEIR OWN AND DON’T REQUIRE SURGERY.

  • Pathologic—these are abnormal and generally do not go away by their selves.

What is a pathologic ovarian cyst?

These cysts don’t serve a function–the majority of them occur in women under 50 and are benign.

There are many different kinds of pathologic ovarian cysts – most are benign.

You may have heard of some of these.

  • Endometriomas. These cysts form in women who have endometriosis—a whole other subject for a future newsletter. Endometriosis occurs when tissue that normally lines the inside of the uterus grows outside the uterus—often on the surface of the uterus, bowel, bladder or ovaries. When the tissue becomes attached to the ovary it tends to grow rapidly and can produce large ovarian cysts. These cysts can produce pain, infertility and even make it difficult to have sex.
  • Cystadenomas. These cysts form from cells on the outer surface of the ovary. They are often filled with a watery fluid or thick, sticky gel. They can become large and cause pain. Most often, however, these cysts do not cause pain unless they twist or rupture.
  • Dermoid cysts. These cysts contain many types of cells. They may be filled with hair, teeth, and other tissues that become part of the cyst. They too are generally painless but can become large and often show up on either a pelvic examination or a routine ultrasound.
  • Polycystic ovaries. These cysts are caused when eggs mature within the “little balloons” but are not released. The cycle then repeats. The sacs continue to grow and many cysts form. Women with polycystic ovaries often have other issues which may include irregular periods and infertility.
    What are the symptoms of an ovarian cyst?

Symptoms of ovarian cysts (physiologic or pathologic) include:

  • pressure, swelling in the abdomen
  • pelvic pain
  • dull ache in the lower back and thighs
  • problems passing urine completely
  • pain during sex
  • pain during your period
  • abnormal bleeding
  • breast tenderness
  • nausea and vomiting

What do I do if I’m told I have an ovarian cyst?

The best thing to do is try and talk to your health care provider as soon as possible. Generally, she or he will assure you that your cyst is most likely benign and often you’ll be given a “best guess” that the cyst is functional (physiologic) and will likely disappear on its own. It’s easy to say don’t panic—but try not to. Remember that the vast majority of cysts between the ages of 13 and 50 are normal structures that you make in the process of ovulation and hormone production. Most ovarian cysts will not cause future problems though they may certainly cause inconvenience. Only a very small number of them will require intervention—surgery.

Did you know?

  • Getting adequate sleep has many health benefits—one of them is that it’ll help you lose weight. Don’t burn the candle at both ends! Adequate sleep will decrease certain food cravings (the bad ones) and allow you enough energy to exercise! There are several theories why this occurs.
    • Adequate sleep increases your body’s level of the hormone leptin. Leptin is the hormone that tells your brain when you’re full. When leptin levels are high your cravings are easily satisfied and you feel “full” with less food. Additionally, adequate sleep lowers the level of the hormone ghrelin, the hormone that causes food cravings.
    • The result of poor sleep is a double whammy—you’re increasingly hungry (because ghrelin levels go up and it takes more food to fill you up as your leptin levels go down.
    • Moreover, sleep deprived people tend to crave high calorie sweets and salty and starchy foods.
  • Many studies have shown that poor dental hygiene, and in particular periodontal disease (gum recession, inflammation or bleeding) is a significant risk factor for heart disease. One study found that 85% of heart attack patients also had periodontal disease. This compares to 29% of controls who had no gum disease.
  • That Americans over the age of 85 are the fastest growing group of older adults?
  • Whether you’re a woman or a man the best things you can do to live a long and productive life are avoid smoking, inactivity, obesity, diabetes and hypertension. If you have hypertension or diabetes–keeping it under control makes a huge difference.
  • Twice as many women die of lung cancer than breast cancer each year in the U.S? Colorectal cancer kills about 40% more women than breast cancer. The message is simple. If you’re going to be diligent about your health get your colonoscopy and quit smoking!
  • We all need fats—it’s essential for producing cell membranes, nerve conduction and a host of other important bodily functions. Good fats are monounsaturated fats (MUFA). You can find monounsaturated fats in peanuts, walnuts, almonds, pistachios, avocados, canola and olive oil. MUFAs can increase good cholesterol and lower bad cholesterol.