I'm currently having a chance to do one of my least favorite things: be a patient. And the whole time, I'm missing no opportunity to declare what a bad patient I am. "I'm sorry I'm such a bad patient," I said to the phlebotomist when I winced as she drew my blood. "I know I'm a bad patient," I said to the x-ray technician who re-positioned my fractured arm. "We doctors are the worst patients," I said to the physician whose advice I questioned.

But am I really such a bad patient? Is a good patient simply one who never complains or disagrees?

The woman sitting before me is in her 60s, obese, and exasperated. "I'm telling you, doctor, I eat almost nothing."

I ask her to describe her daily food intake and she launches into her recitation: a small bowl of cereal...a little cottage cheese...a chicken leg with salad. She can't possibly be gaining weight on these grim rations.

Or can she?

Like many of my medical school classmates I'd decided against a career in pediatrics even before setting foot on the children's ward. "Who could bear to see a child sick...or die?" we asked ourselves--most of us knowing that we couldn't.

Over 20 years later I have seen many patients die. Most of them have been old, their deaths not tragedies, not crimes against nature--but still losses.

Sometimes, when I can't sleep at night, I think of them, one by one:

It's estimated that the average American adult stares at screens at least eight hours a day. Though I barely watch any television, I'm still sure I'm doing my part to keep the numbers up.

All day long at work I check patients' lab results, enter data into their electronic charts, and send and receive e-mails. That would be troubling enough, in terms of concerns I've explored previously about what's been called "distracted doctoring."

What's been worrying me more lately, is the possibility that I may be addicted to the Internet and--if the numbers of patients I find sitting on exam tables, half-naked, surfing the web is any indication--I'm not alone.

"Shingles" is one of those marvelously quaint old medical terms that could have gone the way of "dropsy" and "rheumatism" but still happens to be in use.

Cool word. Bad disease.

A study published yesterday in The American Journal of Preventive Medicine by researchers at Harvard Medical School and Beth Israel Deaconess Medical Center offers what may be, for many, some unsurprising news: a large number of obese people try to lose weight. Furthermore and equally unsurprising, the most popular methods used by obese people trying to lose weight are exercising more, cutting calories, and eating less fat. Here's the surprising part: they actually lose weight.

This happens almost every day in a primary care practice, and it's uncomfortable for patient and practitioner alike: A patient drags himself or herself out of bed, feeling miserable with cough, runny nose, sinus pain, fever, chills...fights traffic...pays for parking...sits in the waiting room...and is then told by a doctor or nurse practitioner to go back home, get back into bed, drink fluids and take over the counter fever reducers and decongestants. "You mean," says the disappointed patient, "you're not going to give me anything for this?" If "anything" means a prescription for antibiotics, more and more frequently, the answer is no.

Many years ago I had a job as an assistant in the busy laboratory of a cancer researcher at Johns Hopkins Hospital in Baltimore. It was dull work--transferring cells suspended in red culture broth from one plastic flask to the next with a pipette--but the researcher was a nice man who tried to enliven it by telling me interesting things about the larger significance of my tedious task. For example, he asked one day, did I know that the cells I was handling were called HeLa (pronounced Hee-Lah) because they originally came from a woman named Helen Lane?

It wasn't until thirty years later that I learned that what he'd told me was wrong.

According to an old joke, a patient drinks too much when he drinks more than his doctor does. Turns out that when it comes to weight, this standard is no joke.
A recent study in the journal Obesity found that overweight physicians are less likely to diagnose obesity or counsel overweight patients about their weight than their normal weight colleagues.

A patient of mine had a really scary experience the other night. An obese woman in her 50s who takes medication for high blood pressure, she'd had a few episodes of chest pain over the previous two days. Then, she woke with a terrible sense of chest pressure and burning at 4 am and, when it lasted until daylight, she came to the emergency room. After many hours in the emergency room during which she had several blood tests and EKGs, she was sent home on antacids.

In 2012, isn't there any less expensive and less traumatic way to diagnose heartburn?

The green tips of spring bulbs are popping up all over Boston and I've yet to see a case of influenza. No high fevers, no head-to-toe body aches, no urgent trips from office to emergency room with a previously healthy person suddenly gasping for breath. This is good, right?

They say a doctor should be a patient now and then, get a taste of her own medicine. I did not expect that mine would be administered by the guy from the gas company.

Remember when you were a kid and every trip to the doctor was dominated by one question: "Will I have to get a shot?" As an adult, the need for vaccines may not even cross your mind--and it may even slip your doctor's mind, too--but incidents like the recent outbreak of measles at Super Bowl Village in Indianapolis remind us that adults are vulnerable to serious, preventable infections and should be inoculated.

Medical practice--like life, come to think of it--sometimes feels like a series of difficult conversations. One of the most difficult, for me anyway, is discussing with an older person the possibility that he or she may no longer be fit to drive safely.

The morning I had my colonoscopy I went to my lawyer’s office to finalize my will. No, it’s not how it sounds. This procedure, recommended for everyone over 50 (over 40 if you have a family history of colon cancer or pre-cancerous polyps) is very safe, performed thousands of times every day across America in hospitals and freestanding endoscopy units with an incidence of serious complications well less than 1%.

The woman, a stay-at-home mom in her 30s, had bronchitis and I was about to write a prescription for antibiotics. I'd never met the woman before--she was one of my colleague's patients. "When was your last period?" I asked. She told me. "Are you using contraception?" She said she wasn't. "Are you sure you aren't pregnant?" She was sure. "How can you be sure?" I asked. "Because," she said, "I'm married to a woman."
Arg! I thought. How could I, with over 20 years experience in practice, be so bumbling! A rookie mistake, to assume what ought not be assumed. Someone who comes to the doctor feeling rotten from bronchitis shouldn't have to deal with feeling misunderstood, too. Next time, I thought, I'll be more sensitive.

Recommendations just released from Fenway Health, though, remind health care providers that asking patients about their sexual orientation isn't just about sensitivity. Healthy People 2010 and 2020, statements of public health goals established by the U.S. Department of Health and Human Services, outline the health disparities faced by individuals who identify themselves as lesbian, gay, bisexual, and transgender (LGBT). A few of these include: discrimination in housing and health insurance for LGBT people; increased incidence of suicide, alcoholism, and tobacco use; increased risk of STDs for gay men; increased incidence of obesity in lesbian and bisexual women; decreased cancer screening and preventive services for lesbians; increased cardiovascular disease for transgender people; and increased violence against LGBT people.

The Fenway recommendations include suggestions for how health care workers can elicit information about a patient's sexual orientation. There are many reasons doctors fail to inquire about patients' sexual orientation: We may lack of awareness of the large numbers of LGBT people in the population; we may lack awareness of the particular health risks LGBT people face; we may feel embarrassed; we may be concerned about "insulting" the patient by asking about sexual orientation.

All of these reasons have more to do with the ignorance and biases of even the most well-meaning doctor than with the needs of the patient.

Thanks, Fenway Health, for reminding us of that.

Let's begin with a quick quiz. What was your reaction on learning yesterday that Paula Deen has diabetes?

a) Duh! That's what happens when you gorge on deep fried mac and cheese, Krispy Kreme bread pudding, bacon cheeseburgers served on doughnuts (no, I did not make that up) and the other sugary, fatty treats Deen cooks up on her popular Food Network show.

b) Aww! That just seems unfair. A woman who's led such a hard life, an impoverished single mom who put her last few bucks into a home catering business and built a one-woman empire on her own talent, warmth, and love of feeding people (and, okay, butter) deserves better than this.

c) Who's Paula Deen?

"Put your pen on the table," the patient said, sharply. Startled, I did as I was told, wondering for a second if I should put my hands in the air, too. The woman was talking about her past treatment for bulimia--for years she had struggled with binge eating followed by self-induced vomiting--and she did not want this information in her chart. Yet, she felt it was an important part of her medical history and wanted me to know about it.

So it's just a few days into the new year and there's a good chance you've already broken your diet and also a good chance that you've concluded you will always break diets and that, despite all you know about the health risks of excess weight, despite the fact that you don't like the way you look and feel, you will never lose weight. And if you read the New York Times Magazine last Sunday, the cover article may have dashed the last shred of hope you had about this subject: it details research about how our brains and bodies conspire to hold on to every ounce we try to lose. Especially discouraging, Tara Parker-Pope, the author of the article and the Times' health columnist, a woman who knows more about nutrition and exercise than just about anybody, acknowledges that she is 60 lbs overweight and unable to lose it.

I have gotten a few actual letters in the mail (and some delightful books of poetry and other literature as well) since I started writing the monthly In Practice column for the Boston Globe last March, and the In Practice blog in August, but I've gotten many, many e-mails via inpracticemd@gmail.com in response to these writings--and I'd like to share some of them with you: the angry, the moving, and the enlightening.

Sometimes, as I walk around the hospital, I find myself wondering what a time traveler, one of those 18th and 19th century physicians whose names grace the plaques along the corridor walls, would think about the electronic gadgets attached to all the humans. Would we look like pod (?ipod) people? A futuristic nightmare? I notice that the medical staff, particularly, are rarely unplugged. It's not unusual for me to be standing in an elevator with 5 or 6 doctors and nurses, eyes all glued to our smart phones. Now, some worry that our addiction may affect patient care.

Medicine has never been immune from politics (as this interesting editorial argues). Indeed, it would be naive to think that health care, which involves matters of life and death (not to mention sex) and costs trillions of dollars annually wouldn't be politicized. But many medical professionals were still surprised by the Obama administration's recent decision to reject the FDA's unanimous recommendation to make emergency contraception (also known as "the morning after pill" and sold as Plan B) more readily available.

This is a medical story--bear with me. On December 8th, 1941, the day after the Japanese attacked Pearl Harbor, my dad, then a third year medical student, went to a recruiting station in New York City (along with thousands of other young men) to enlist in the U.S. army. He was turned away, told that he'd be of better service to his country if he finished his M.D. plus a year of internship. In 1944, he tried again. A minor medical condition threatened to disqualify him from the military, but he recognized one of the recruiters--an acquaintance--and begged his way in. For the remainder of the war, Dad served as a regimental surgeon (a title, he would admit, that was a bit grandiose for a guy with only an internship under his belt) with the 102nd infantry division, nicknamed "The Fighting Ozarks" because so many of the soldiers were from Arkansas. It must have been quite a culture shock for Dad, a Jewish kid who'd barely left Brooklyn at that point, to serve alongside men from all over the country, first at a base in El Paso and then on the battlefields of the European theater. He rarely spoke of those years--I sensed he did not want to gloss over the horrors of war with nostalgia--and yet he did say that his bonds with his army comrades were the strongest he'd ever experienced. He recalled with particular affection his jeep driver, a fellow named Dave from North Carolina, who enjoyed the kosher salami my grandmother used to send my Dad ("Send a salami to your boy in the ah-my," the ad went, I believe).
Okay, here's the medical part: Fast forward 60+ years. In 2004, my dad lay dying in an ICU in Florida. He was in his 80s, his lungs shot from years of smoking (like so many in the Greatest Generation). He'd been in a coma for a month when, out of the blue, my mom got a call from Dave, the jeep driver. He hadn't been in touch for decades, but he was in Florida and he'd love to visit. Mom said Dad was very ill...it wasn't such a good idea...maybe some other time. But Dave wouldn't be deterred. He went to the hospital, insisted on going to Dad's bedside, grasped his hand and said "It's me! Dave! The jeep driver!"
And, to the surprise of his doctors and nurses, Dad opened his eyes and smiled.
Dad died not long afterwards, dreaming, I hope, of what he and his comrades did for all of us.

A migraine without a headache? Isn't that kind of like fat-free half and half? Isn't a headache what a migraine is?
That's what my patient Lisa thought until just a few weeks ago. A busy mom in her 40s, Lisa has had migraines occasionally for many years. These have been very predictable. If she drinks too much coffee, or becomes dehydrated, she sees sparkly lights in her right field of vision and then gets horrific, throbbing pain in one side of her head, often with nausea and vomiting.
Not long ago, Lisa had symptoms that were, ultimately, also attributed to migraine, but which felt nothing like what she'd experienced before. First of all, she hadn't drunk too much coffee and she wasn't dehydrated. It started with some subtle and disturbing word-finding difficulties. She would say something to her husband, but the right words didn't come out. This happened a few times over a couple of days. Then, at work, she had the sensation of a shade being drawn over her right eye. In fact, she asked a co-worker if she'd turned the lights down. Then, her right shoulder began to tingle. At this point she came to the hospital and was admitted for a neurological evaluation. She was diagnosed with migraine--and she had no headache at all during the entire episode.

Migraine is a very common disorder, frequently running in families and affecting women more often than men (probably because of women's cycling hormone levels). It has long been thought due to dilation and constriction of blood vessels in the brain, though newer theories implicate dysfunction in serotonin and other neurotransmitters, irritability of nerve cells, and other factors. About a third of people have what's called an aura, a visual disturbance (like Lisa's sparkly lights), smell, or other sensation that signals a headache is coming. Then, in its most typical form, a migraine starts on one side of the head (the word "migraine" is a shortened version of "hemi-cranium" or "half-skull"), often behind one eye. The pain may spread, and nausea and vomiting can occur. Lying down in a dark room, sleeping, and taking medications such as caffeine, aspirin, ibuprofen, or triptans (Imitrex, Zomig) finally bring relief.

But some people don't have typical migraines. They may have prolonged or clustered headaches, or they may not have a headache at all. Sometimes called "silent migraine" (or "acephalic migraine"), these attacks may involve partial loss of vision or hearing, focal weakness or numbness, or difficulty speaking, such as Lisa had. These symptoms are terrifying and, if the patient has never had them before, a stroke, brain tumor, multiple sclerosis and other serious conditions need to be ruled out.

Writer Joan Didion is a long-time migraine sufferer (in fact, she weighed in on whether Michele Bachmann's migraines would affect her candidacy for the presidency--remember that controversy last summer?) I have always loved Didion's essay "In Bed"about her migraines, especially the last line, about how she feels when a migraine is finally over:

I open the windows and feel the air, eat gratefully, sleep well. I notice the particular nature of a flower in a glass on the stair landing. I count my blessings.

I am sure any migraine sufferer can relate to this. I imagine that for someone like Lisa, who experiences a frightening "silent migraine," the feeling of relief when it's over must be even greater.

Though I'm an internist, not a psychiatrist, sometimes patients make appointments "just to talk." These are among my favorite kinds of visits, because patients bring to them such varied concerns: physical, psychological, and social. They may wish to discuss job or marital stresses, to review advice they've received from specialists about proceeding with surgery or other treatment, or even to get help with a family member's medical problem. Often, in one of these "just talking" appointments, a woman (with or without her partner) will come in seeking guidance as she decides whether or not to try to become pregnant. It's always a more complex question than it first seems.