Another Young Man

The medical record of another young man in our practice went into the office basement Friday after being stamped “DECEASED” across the front of the manila folder.

In all my years of practice in this community I cannot remember a single young male patient of mine who died from a disease like cancer or AIDS, but I have known over a dozen who shot themselves, jumped off the bridge, took a deliberate or accidental overdose, or died as a result of a motor vehicle accident.

This time it was a self-inflicted gunshot wound in the context of a failed marriage and a troubled new relationship that ended a young life. Several staff members knew Thursday morning what had happened to the young man I only met once about a year ago.  Someone had even heard it from an eyewitness, but the “DECEASED” stamp didn’t go on the record until the obituary appeared in Friday’s newspaper.

When adolescent or preadolescent males come in for physicals, we don’t often find new diseases. We’re certainly on the lookout for boys who might be developing hypertrophic cardiomyopathy and are at risk for collapsing during vigorous exercise. We also preach the importance of testicular self-examination. This is extremely important, since the majority of testicular cancers are discovered this way. I still remember the last case I saw, probably four years ago now. The young man felt a lump I wasn’t sure I could feel. I ordered an ultrasound, which identified the cancer and confirmed his self-diagnosis.

The most important part of the adolescent male physical is talking about the things that most often threaten or end the lives of young men. I have no illusions that we as physicians can stop suicides or deaths from risk-taking behaviors or accidents in even a fraction of cases, but what if some of us can do that even once? We don’t know when we might indirectly save a life by nudging someone toward better conflict resolution skills or away from situations like getting in a car with an impaired driver behind the wheel.

The young man who ended his own life Wednesday seemed like a decent fellow. I’ll probably never know what made him do what he did, but it does sensitize me to my role as a fiftysomething physician who has the privilege and responsibility of sometimes, however briefly, being in the position of elder or mentor for young men making their way into a complicated adult existence. Am I open and aware enough to offer my ear or my hand when it is wanted?

Orthorexia Nervosa – Too Much of a Good Thing

In Swedish, there is a word that just can’t be translated succinctly into English. “Lagom” means “just enough” or “adequate”, but it is saturated with overtones of moderation, contentedness and political, even social, correctness. “Lagom” is a way of life – moderation in everything.

It is no surprise that Swedish newspapers seem to be on the lookout for stories about people who stray from that middle-of-the-road way of life.

One story in Dagens Nyheter caught my eye (for interested/concerned readers, my right eye is almost back to normal) during the flight back to the States this morning. It sent me out on the Internet once I landed and got connected to the airport wireless network: “Exaggerated Healthfulness Can Lead to Serious Disease” is a feature about a 30-year old woman, who after eating a lot of junk food while living in the US started on a journey filled with strict diets and rigorous exercise. She never thought she was too fat, which is the defining feature of Anorexia Nervosa, but she somehow felt she had to eat extremely healthfully to compensate for her prior indiscretions. Her condition, Orthorexia Nervosa (obsession with healthy eating), described by Steven Bratman in 1997, although not officially recognized, is getting increasing attention. Its complications are not dissimilar from those of Anorexia Nervosa, as it can lead to malnutrition with all its consequences.

I had not run into the term before – figures I would run into it in Sweden, the Mecca of Moderation. I can see that this is a culture-dependent variety of Anorexia Nervosa, which was first described in the late 1800’s as Fasting Girls. The culture was not focused on healthfulness the same way then as it is today. In Victorian times, fasting was of body image and spiritual interest, and Fasting Girls were said to have mystical powers.

Our current DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) classification of Anorexia Nervosa doesn’t mention restricting foods based on their healthfulness, and Orthorexia Nervosa isn’t recognized in it at all.

I looked around for blogs on the topic, and found some, including “There’s no such thing as orthorexia nervosa, it’s only a fancy term for a health food junkie“.

I like that title, because I think that whenever there is a “new” disease or when an “old” disease gets more attention, patients tend to over-report the symptoms of it and doctors have a tendency to over-diagnose it. While the DSM-IV has weight criteria that help keep the diagnosis of Anorexia Nervosa more objective, most psychiatric diagnoses hinge on value-laden words like often, intense or undue, which are all subjective to some degree.

I have said before that there is a tendency (at least in the US) to medicalize the human experience. The last thing we want to do is start calling “health food junkies” sick; let’s not forget that “junk food junkies” have been well proven to get very bad complications from their food choices, too!

I have made the observation a few times that the spectrum of what we call the human experience can be defined by what lies at the extremes or by the nuances within the range where most people find themselves. People say “I’m depressed” even if they know they are only experiencing a temporary sadness. They say “I have OCD”, even if they don’t meet the DSM-IV criteria. Going too far with our words isn’t always the most effective way to communicate.

Now that there is a new medical term with no DSM-IV definition behind it yet, we all need to be careful how we use it. Let “health food junkies” be just that as long as they don’t suffer medical or social consequences. Let’s restrict use of the new medical term for people who, as Steven Bratman originally suggested, suffer negative consequences of their behavior.

It is ironic that we now have a new disease for people who do everything they can think of to be healthy. This is where the concept of “lagom” comes in: Instead of holding perfect eating and maximum exercise as an ideal, we should all do as the Swedes, and aim for pretty good eating and pretty adequate exercise. I guess it’s always hard to see for yourself when you cross the line to extremism.

As the old Swedish saying goes: “Lagom är bäst!”

Altered Vision

Sweden, Saturday night: 

Sitting in my aunt’s living room on the eleventh floor as the late summer sun set and the sky turned dark, the conversation over after-dinner-coffee and cognac turned to her recent stroke and emergency carotid artery surgery. My mother had a small stroke a couple of years ago, which fortunately only affected her peripheral vision to her right. My aunt’s sequelae are less specific, affecting a few fingers, her balance and some parts of her memory. I let my gaze wander to my right from the coffee table to her windowsill with several blooming orchids and the city lights below.

“How funny”, I thought to myself, “there’s a spider web between those two orchids”.

A perfect, round spider web sat between the two orchids with a distant light source illuminating it from behind. I tilted my head to make sure; my aunt was always a good housekeeper and it seemed unlikely she would have cobwebs on her orchids. “Maybe the stroke did even more things to her”, I thought to myself.

With my head tilted I saw another spider web of the exact same size and appearance, between the next two orchids on the windowsill, also illuminated by a bright light in the distance. “No way she would have two cobwebs”, I decided. “It must be my eyes”.

As the conversation continued I drifted off with my own project. Closing one eye at a time and discretely tilting and turning my head, I determined the spider webs were only visible with my right eye. Sudden cataract of one eye seemed an unlikely diagnosis, so I figured it must be something else, probably a vitreous detachment. I saw no flashing lights, which can be a symptom of either a vitreous or a retinal detachment, and there certainly was no curtain over any part of my visual field or any loss of peripheral vision.

With no ominous diagnosis immediately apparent to me, and not wanting to ruin the evening, I beamed myself back to the conversation and finished out the evening without saying a word about my vision.

Driving back to the hotel, I knew for the first time what people mean when they describe the difficulties of night driving with cataracts. The spider webs seemed more like small haloes around streetlights and headlights of oncoming cars. This is a classic symptom of cataracts, but this was too sudden. Squinting with my right eye allowed me to drive comfortably.

After parking the car outside the hotel I continued my exploration. What looked like a halo with a spider web configuration was also a circle filled with a swirl of movement, like water circling a drain. Inside this swirl of water were squiggly, small worm-like shapes, similar to the small, unobtrusive floaters I have had for years.

I went up to my room and pondered my fate. I wanted to be a doctor from about the age of four, ever since as a sickly child I had our general practitioner come for house calls. When I became severely and progressively nearsighted starting at age seven, I became fascinated with ophthalmology. My first eye doctor was a thin, old man with an office in an ancient apartment building with marble stairs, oak doors and a musty smell. As he leaned into me with his bright lights, he spoke with great concern about my worsening eyes. Every year I would get new, thicker lenses, and every year he would seem more concerned. After puberty, things seemed to slow down, and the old doctor seemed to be more content with my situation. He was so wise and kind. I wanted to be just like him.

In medical school I flirted with the idea of becoming an ophthalmologist; I learned everything I could about refraction, and as an avid photographer and dark room enthusiast, it seemed like a natural fit. I took electives in ophthalmology and thought this would be my life’s work.

Then one thought, one factoid, stopped me in my tracks: As a severe myopic, I might be at increased risk for suffering a retinal detachment – then where would I be as an eye doctor who couldn’t see well? The rest, as they say, is history. I decided to become the kind of general practitioner I first identified with as a young child. 

Fast forward to 2008, a middle aged Family Practitioner, sitting in a hotel room with a self-diagnosis of a vitreous detachment in a country where I no longer have any medical connections – do I have a harmless condition with no need for intervention? Do I trust what I think I know about ophthalmology beyond my own specialty training? Do I trust whoever is on duty at the small hospital nearby? Or do I call my wife back home in the States and ask her to pull some strings and get me an appointment Wednesday with the best ophthalmologist I know back home?