#the attending dr. kristophine

[scientia-rex]

Hey, exercise question I'm asking because nobody will give me a straight answer (obligatory "everybody is different, you are not my doctor"): How long should it take for regular exercise to have a visible effect on resting heart rate? I get really discouraged because nothing seems to improve mine, but I also have no idea whether I'm expecting too much too soon, and all the advice is like "it helps! :)" without giving a timeframe. (I mostly walk (can't run) but am also getting back into martial arts classes, if that clarifies anything). Thanks for your time!

Oh, I have no idea. Sorry! I think it’s variable—many people never do see an impact on resting heart rate—but it’s not something I’ve ever been taught or had reason to learn about. You’ll see cardiovascular and other health benefits even if your heart rate doesn’t go up during or down after—walking alone is light-years better than nothing.

(And to get on a soap box, I think the exercise industry’s obsessive focus on metrics is damaging.)

#the attending dr. kristophine

[scientia-rex]

For the most part, my approach to prescribing hormones is “sure,” but I will note that the one thing I lean HARD on patients about is smoking. If you’re transgender, and you’re on hormones, the number one thing we want to protect is your cardiovascular health. That’s frankly the number one thing I want to protect in all my patients, but anyone taking exogenous hormones is at higher baseline risk. And the best thing you can do for your heart is DON’T SMOKE. It’s a bitch to quit, and I didn’t even smoke much or long before I quit in my late teens, and I STILL didn’t enjoy quitting and had smoking dreams for years. It’s harder to quit than just about anything else up to and including crack and heroin, and that’s coming from a patient of mine who recently passed in her early 60s who’d done all of those things—for years and years—but eventually was able to quit everything except smoking. And that killed her. She developed severe COPD and eventually called to say her blood oxygen saturation was dipping into the 70s, which is incompatible with life. She was lucid enough to decline medical care, including refusing to call 911 or go to the ER. A week later, after both I and one of our outreach nurses had contacted her to ask her to please go to the ER, I got a notification that she’d been found dead. She had been so frustrated that she wasn’t a candidate for a lung transplant.

One of my oldest trans patients is in her late 50s. She’s had blood clots that went to the lungs. Repeatedly. Smoking raises that risk. Estrogen raises that risk. She’s a veteran with PTSD; of course she smoked.

These aren’t theoretical. These are humans I’ve cared for over years of their lives. I have been rooting for them—my beloved former addict, who spoke without shame about her years of homelessness and drug use in the city; my queer elders, who are slowly trading in their motorcycles for power scooters. I want everyone to live their fullest, best life.

Smoking doesn’t fit into that. Please don’t smoke. I don’t want you to die like that—not now and not later. I want you to have the future that you may not be able to see yet, but exists.

Since I moved home as an out queer, word got out, and there’s a whole apartment complex of lesbians in their 60s to their 80s who come see me—sitting next to their wives in the office, nagging about blood pressure meds, tattling about not having gotten the shingles shot they said they would. To be clear, when I was growing up in town, I knew no lesbians. Not one. I knew one gay kid in my class, which eventually turned into two. We were it. To see these women living decades with their wives and being able to squabble like any couple in my office over who was supposed to bring their home blood pressure cuff in for us to check it… it means the world to me.

#the attending dr. kristophine

[scientia-rex]

As a doctor, do you have any hygiene tips you think most people could use hearing? Like things people seem to neglect or do wrong that pop up and cause problems? Thanks!

EARS. Earwax is genetically determined. Some people get dry, scant earwax and others get wet, copious earwax. The biggest mistake I see is relying on Q-tips. Every time you stimulate the inside of your ear canal it makes your ears go “oh shit, there’s a threat! I better make more protective wax!” and next thing you know you’ve managed to jam a bunch of wax you told you ears to make back up against your ear drums and you can’t hear as well. Don’t rely on Q-tips. When you’re in the shower, let warm water run in, mush it around by pushing on your tragus (the cartilage flap in front of the canal), and let it drain. Repeat. Blot dry your ears with the edge of a towel or a Kleenex or something afterwards. If you tend to get really stubborn wax, use Debrox drops once or twice a week.

And vaginas. They’re mucus membranes once you get past the labia majora! You wouldn’t soap the inside of your mouth, don’t soap your vagina! It’s a self cleaning oven and if it smells weird GO SEE A MEDICAL PROVIDER because over the counter shit probably isn’t the right answer.

Dandruff isn’t because your scalp is dry. It’s because of a microorganism called malassezia furfur. It eats scalp oils. Dandruff shampoos mostly work pretty well.

Those are the three I can think of off the top of my head. Never use Irish Spring soap! It’s so heavily fragranced it’s a contact dermatitis waiting to happen! I once had a guy develop full body itching and I was JOKING when I said “what, did you just switch to Irish Spring?” and from then until he died he was convinced I was a witch because I was RIGHT.

#the attending dr. kristophine

[scientia-rex]

A lot of younger people have no idea what aging actually looks and feels like, and the reasons behind it. That ignorance is so dangerous. If you don’t want to “be old,” you aren’t talking about a number of years. I have patients in their late 80s who could still handily beat me in a race—one couple still runs marathons together, in their late 80s—and I lost someone who was in her early 60s to COPD last year. What you want is not youth, it is health.

If you want to still be able to enjoy doing things in your 60s and 70s and 80s and even 90s, what you want to do, right now, is quit smoking, get some activity on a regular basis (a couple of walks a week is WAY better for you than nothing; increasing from 1 hour a day of cardio to 1.5 will buy you very little), and eat some plants. That’s it. No magic to it. No secret weird tricks. Don’t poison yourself, move around so your body doesn’t forget how, and eat plants.

If you have trouble moving around now because of mobility limitations, bad news: you still need to move around, not because it’s immoral not to, but because that’s still the best advice we have. I highly recommend looking up the Sit and Be Fit series; it is freely available and has exercises that can be done in a chair, which are suitable for people with limited mobility or poor balance. POTS sufferers, I’m looking at you.

If you have trouble eating plants because of dietary issues (they cause gas, etc.) or just because they’re bitter (super taster with texture issues here!), bad news. You still want to find a way to get some plants into your body on a regular basis. I know. It sucks. The only way I can do it is restaurants—they can make salads taste like food. I can also tolerate some bagged salads. On bad weeks, the OCD with contamination focus gets so bad I just can’t. However, canned beans always seem “safe,” and they taste a bit like candy, so they’re a good fallback.

If you smoke and you have tried quitting a million times and you’re just not ready to, bad news. You still need to quit. Your body needs you to try and keep trying. Your brain needs it, too. Damaging small blood vessels racks up cumulative damage over time that your body can start trying to reverse as soon as you quit. I know it’s insanely, absurdly addictive. You still need to.

You cannot rules lawyer your way past your body’s basic needs. It needs food, sleep, activity, and the absence of poison. Those are both small things and big asks. You cannot sustain a routine based on punishment, so don’t punish your body. Find ways to include these things that are enjoyable and rewarding instead. Experiment. There is no reason not to experiment—you don’t have to know instantly what’s going to work for you and what won’t, you just need to be willing to try things and make changes when things aren’t working for you.

You will still age. Your body will stop making collagen and elastin. Tissues you can see and tissues you can’t see will both sag. Cushioning tissues under your skin will get thinner. You’ll bruise more easily. Skin will tear more easily. Accumulated sun damage will start to show more and more. Joints will begin to show arthritis. Tendons and ligaments will get weaker and get injured more easily, as will muscles. Bones will lose mass and get easier to break. You’ll get tired more easily.

But you know what makes the difference between being dead, or as good as, in your 60s vs your 90s? Activity, plants, and quitting smoking. And don’t do meth. Saw a 58-year-old guy this week who is going to have a heart attack if he doesn’t quit whatever stimulant he’s on. I pretended to believe it was just the cigarettes, and maybe it is, but meth and cocaine will kill you quicker. Stop poisoning yourself.

Baby steps; take it one step at a time; you don’t need to have everything figured out right now. But you do need to be working on figuring things out.

#the attending dr. kristophine

[scientia-rex]

genuine question- how do you feel about vaccination?

Very pro. I’ve gotten every vaccine I’ve ever been offered. I’m behind on my flu shot this year but that’s just because they keep doing the work clinics on days when I’m either not there or working through lunch. Our immune systems are ticking time bombs that are always looking for an excuse to kill us and so far all available evidence suggests that exposing them to things via vaccine reduces the rate of autoimmune issues due to that specific virus or bacteria later, in addition to decreasing frequency and severity of infection. The shingles vaccine may even decrease risk of dementia, which is HUGE.

#the attending dr. kristophine

[scientia-rex]

Listen, I know we dunk all the time on people who think they can flawlessly tell who’s trans, but as a doctor looking at bodies is my job. I can tell who has heart failure or liver failure from looking at them. I can identify Parkinson’s from a shuffling walk or hip arthritis from an antalgic gait. I cannot, for the life of me, clock every trans person visually.

You know how I know this? When I started at this job, my new boss told me that a member of the staff transitioned a few years back and everyone did some learning and was supportive (or else). He told me this bc he knows gender care is one of my special clinical interests, right up there with psych and migraines. And when I met my new team I said to myself, ah! There is the trans person. I felt SO bad for her being seated next to the vaguely fascist Republican Ortho guy. I told her repeatedly about how excited I was to have the opportunity to care for trans patients.

Turns out not only is she cis, SHE’S a Republican. I made her uncomfortable! I was like cisgender? With THAT hair???? GIRL YOU ARE SIGNALING THINGS! There are SIGNIFIERS!!!!

So yeah no. People can’t “just tell.” I ought to have gaydar and I ruined an entire work dinner for that woman.

#the attending dr. kristophine

[scientia-rex]

"Why does a 15-minute visit with a doctor cost 150 bucks in America???" you're gonna want to read Money-Driven Medicine, by Maggie Mahar, and probably also The Social Transformation of American Medicine, to answer that question. It is not because your doctor is a greedy bastard; your doctor does not see most of that money. It is because the system is broken to a level that is truly impressive in its dedication to making a shit ton of money for insurance company executives and shareholders.

#the attending dr. kristophine

[scientia-rex]

as someone in clinical psych, it drives me up the wall that everyone accepts as a goddamn fact that stress is directly linked to weight gain, and yet every single study on diet and exercise just… ignores this as a confounding factor? it’s gotten to the point where if i open a study on weight and don’t see a stress measure anywhere i just close it again because EVERY TIME the behavior they’re saying causes weight gain is… surprise… a behavior people do when they’re stressed. so either the behavior itself is a spurious correlation to the already established causal relationship between stress and weight gain, OR the behavior does contribute some unique amount to variability in health outcomes, but we’re ignoring why people are doing that behavior. like ok maybe eating nothing but spaghetti-o’s causes you to gain weight. why is no one ringing alarm bells going WHY IS THIS PERSON SO STRESSED THEY CAN EAT NOTHING BUT SPAGHETTI-O’S? the intervention is always “eat less spaghetti-o’s” not “holy fuck what can we address in your life so you aren’t forced into the miserable existence of eating nothing but spaghetti-o’s.” setting aside “why is weight loss even your outcome variable,” if weight loss IS your target why the FUCK are you ignoring this piece! i am grabbing my fellow scientists by the shoulders and shaking them vigorously!!

HELL! FUCKING! YES!!!!!!!! You, YOU keep talking!

#the attending dr. kristophine

[scientia-rex]

Yesterday had an infuriating situation where someone who should have known better messaged a patient about their new surprise serious diagnosis when I specifically told them to call. Today found a new breast cancer diagnosis dumped in my inbox as if it were nothing with note “patient unaware.” NOT FOR LONG THEY AREN’T, the results automatically release, what the fuck is wrong with you? If you’re the provider who ordered the test and it’s positive, call the patient and set up the urgent referral, don’t wait THROUGH THE WEEKEND. Jesus Christ.

#the attending dr. kristophine

[scientia-rex]

I gave my soapbox speech about how weight loss is mostly bullshit to two different patients in a row yesterday and so help me I’m pretty sure one of these days someone is going to say “but SURELY you agree I’d be HEALTHIER if I lost weight!” bc you can see the disbelief in their eyes. And like. Sure, maybe! You might see some improvement in biomarkers like LDL and A1c, and your knees would probably feel better. But you would be amazed at how much more good you can do for yourself by focusing on things you can actually meaningfully change without resorting to making yourself miserable. Eat more fresh fruits and vegetables—it’s hard bc they’re more difficult to prepare and more expensive per calorie and go bad faster than other foods, but they’re what we evolved eating the most of so they’re what our bodies need the most of. And walk around more; sure, cardio is great for you, but if it sucks so bad you don’t do it, it isn’t doing shit for you. And we evolved to walk very very long distances, a little bit at a time, so our bodies respond actually very well to adding walks into our schedules, which is vastly easier than adding workouts that are frankly designed to be punishing when the definition of punishing is “makes you less likely to do it again in the future.”

You get one life. It is shorter than you can begin to imagine. Don’t waste it hating yourself because somebody is going to make money off that self-hatred. You deserve better than to be a cash cow for billionaires who pay aestheticians and dermatologists to make them (or at least their trophy wives) look thin and beautiful no matter what they actually do.

#the attending dr. kristophine

[scientia-rex]

Was thinking today about how money is like a rewind button for life. I didn't have it until a year ago, when I finally graduated from medical residency and my salary tripled overnight; I just never had the kind of money that makes these things possible. But now I do, and I can tell you that I don't fear making a lot of the mistakes that used to terrify me. If I spent 5 bucks on a mascara and hated it, well, tough luck, I either don't wear mascara or I wear that one. I couldn't buy shoes online. What if I have to return them? What if I can't get away from work long enough to return them? So I'd buy them in person, walking around and around the store, hoping I'd figure it out if they were going to pinch or hurt me because I wasn't getting a second shot at that money.

I dyed my hair. I'm bored with it now and trying to get the dye out, and I'm not stressed about it, because worst case scenario, I have the money to buy more bleach and more dye and if I need to I can pay for a stylist to fix it.

I bought shoes online. One pair didn't fit. I just gave them away. Easier than returning and the money means something totally different to me now.

I'm doing things I simply would never have done, could never have done, because I have the money to fix them if I make mistakes at these things that are new to me.

It is beyond inhumane that this is what gets people the ability to make mistakes and come back from them, erase them, fix them, rewind. We need to make life easier for everyone, not minuscule increments better for the already very rich.

#the attending dr. kristophine

[scientia-rex]

Hi, your blog is a LIFESAVER.

I recently heard someone say their GP told them the best way to prevent cancer in their case was to lose weight - because if your body has less mass and therefore fewer cells, there are less of them there that can develop/turn into cancer.

It sounds like nonsense to me and to be clear I am NOT asking for your ruling on their case in particular, but you are infinitely smarter than I am and I wondered if perhaps this DOES make sense and I am just not able to see it. The advice is flawed for all the usual reasons that "lose weight" is garbage medical advice anyway to be clear, but does it actually logically track?

Thank you again for your blog, I have shared it with so many people and you have changed so many lives here and irl ❤️

Fat causes cancer is bullshit, you gotta read "Food Is Not Medicine," great book by a doctor-former fitness junky-former fat guy who started getting into the actual data and was like "wait. what the fuck. Everything I've been taught about this is contradicted by the actual data." and like a BOSS actually changed his opinions. He has a section on that.

Also I would just like to note that that explanation is particularly insane bullshit.

#the attending dr. kristophine

[scientia-rex]

So many people commenting on my “exercise doesn’t lead to weight loss” post who have not read my pinned post. Buddy. I’m not sitting here going “exercise doesn’t lead to weight loss but I HAVE THE MAGICAL SECRET KEY TO WHAT DOES and I’m just hiding it from you because I want the whole world to be fat!”

If there was a real answer, we’d know it. But we don’t. That’s the point. The POINT is that exercise doesn’t lead to more than a couple of pounds of weight loss, but it’s good for you anyway. The point is that dietary restriction can lead to weight loss, but it’s not sustainable, so you should eat lots of fruits and veggies and whole grains because they’re good for you anyway. The point is that health isn’t the same thing as thinness and the lie that it is, is both recent and so profitable to the rich and powerful that we have been drowning in it since before we were born. The point is that if you want to massively modify your body you must understand that there are concomitantly massive risks.

“I just want to—“

“My reasons are better than other people’s—“

Your body doesn’t care. It wants to live. It wants to survive this famine and the next. It wants your children and their children to survive the famine. Your body is made from much older pieces than your neocortex; your ability to think yourself into a hole is younger and less powerful than your body’s ability to survive you.

#the attending dr. kristophine

[scientia-rex]

Hey. HEY. We aren’t good at understanding how bodies work. I spent five years in undergrad (I was indecisive; graduated with six years’ worth of credits), two in my terminal master’s program, four in med school, and three more in residency. I know a whole lot about how bodies work. I am qualified to tell you that we don’t know a lot more than we do know.

This means that, when you encounter a claim, you need to weigh it against what you have experienced.

I have met doctors who were sure fibromyalgia, or “muscle hurty disease,” from the roots of the word, was just women being crazy. Turns out it’s probably at least partly due to autoimmune dysfunction. Or maybe not! Sure would be nice if we knew! But I sure as shit know it’s real, because I have it and so do the women in my family. Our bodies don’t work right, somehow. They don’t work like other people’s bodies work. I experience more pain than I “should” based on what stimuli other people find painful. I have less ability to build and maintain muscle strength. This has not kept me from doing what I love most in the world, which is have opinions, to the point where I went through the horrifically awful process that is medical training in the US just so I could have opinions all day long and get paid for it. I gain nothing from saying I have it, and in fact risk the opinions of my professional peers if I do admit to it, since it is still seen as a disease of mental or moral weakness. I’m perfectly qualified to self-diagnose, as a board-certified family physician.

And yet I believed people in positions of authority for a long, long time who said it was a mental illness and not a bodily one. As if those even can be distinct, when our brains are part of our bodies and our experience of reality is filtered through their circuitry. But I believed that I was somehow to blame for being in pain.

Life has been better since I accepted that I just need to do some things differently. If I lift weights, I need to use machines, I need to start on the lowest possible setting, and I need to increase very gradually. If I do cardio, I need a low-impact model like an elliptical trainer; running outside, every time I have tried it in my life, results in incapacitating shin splints, even if I try to work up slowly. I no longer buy laundry bins that don’t roll. My home is all on one level. I go to physical therapy. I stash freezer dinners that contain (shudder) vegetables, my least favorite thing, so that when I do feel like shit, I have an alternative to starving (or eating a block of cheese that upsets my stomach).

Accommodate yourself. This society isn’t going to help much, if at all. In your good times and days, be the person whose help you’ll need in your worst days.

#the attending dr. kristophine #once again I am not asking for anyone’s advice #don’t tell me how you think I can start running #that’s not the point and it’s a real dick move

[scientia-rex]

Why does your body have different systems for liquid and solid waste?

Trick question. It doesn’t. Urine isn’t filtered off feces—it’s filtered from your bloodstream. Your kidneys rely on seeing a lot of blood flow, and they have intricate mechanisms for tightly regulating the chemistry of your blood. Kidneys are built to keep our blood within the very narrow range of acidity where we can stay alive. (Which is why “alkalinizing” diets are generally going to be bullshit.) They keep us from having so much salt that our brains stop working, or so little that our medullas explode. They regulate our potassium so that our heart doesn’t go into a fatal arrhythmia due to membrane instability. Kidneys do break down many chemicals, including NSAIDs (aspirin, ibuprofen, naproxen), but they have one fundamental job—keep our blood from making our bodies an unlivable environment. And they do that by using water from our blood to carry away whatever we don’t want at a given moment.

Bowels, meanwhile, handle food. After food gets churned to chyme in the stomach, it gets squeezed into the small intestine. The small intestine is very long but smaller in diameter than the large intestine. It has one job: retrieve nutrients. The digested-digesting-food slurry makes it way through the small intestine thanks to rhythmic, longitudinal muscle contractions called peristalsis. After about 30 feet of this, it reaches a hard turn into the large intestine in your lower right abdominal quadrant, where the appendix hangs off the main channel. The large intestine goes up to the diaphragm, turns about 90 degrees, runs across your belly at the top just under your ribs, and at your left side makes another hard turn down, hanging a right at the spleen to dive down the left front side of your belly and then back and down to your rectum and then your anus. The large intestine, also known as the colon, has one job: get water back out of the food slurry, now that the water has helped the body absorb nutrients by creating a lot of surface area for contact with membranes lining the small intestine. So the longer stool spends in your colon, the more water gets sucked out of it, the harder and drier your stool gets, and the more difficult it is for the combination of peristalsis and your conscious effort to get it to move down and out of your body.

Anyway, eat lots of fiber. Drinking water won’t make you poop; your kidneys are way too good at regulating your fluid balance. Only fiber and indigestible sugars can save you now.

#the attending dr. kristophine

[scientia-rex]

It is WILD to me that people continue to think they can "gotcha" me into saying the science on weight loss doesn't say what it says. Like, it's not what the authors say; it's what the data reflect. And the data don't give one single hot shit about your reason for wanting weight loss. You can have a terrible reason or a great reason and it doesn't matter. The reason behind your desire for an outcome doesn't change whether the data support the likelihood of it happening or not. There isn't a secret Option C here. The options are A) try to make peace with your weight or B) fight it forever. And if you fight it, the data are pretty clear that you're worse off than if you make peace and take the best care of yourself that you can. You can hate vegetables, you can want it to be easier to find clothes that fit, you can be disabled and find physical exertion challenging, but it doesn't matter. There is no secret option where, because you hate vegetables, your body works differently than every other body that's been studied.

There IS a database of people who have managed to sustain long-term large-scale weight loss. They're so rare we study them extensively. In general, they eat severely restricted diets and exercise for at least an hour a day. I have no desire to recommend eating disorders to my patients. If staying thin is occupying time and brain-space you could be putting into other things that are more meaningful to you, do those other things.

#the attending dr. kristophine #eating disorder tw