Today I saw a patient with epilepsy. She came to me from another neurologist. Her and her husband were very upset with his care. He has a good reputation. I've met him twice. I've seen a handful of his patients. This is the third time that we've met. Today they complained about the care they had again. They've spent a fair amount of time on that issue at each of the visits. I think they felt betrayed. Today, she said the key words: "He didn't listen." When we don't listen to our patients they feel betrayed. They feel that we don't care. Care is what they really come for. They come for that even more than anything else. We are, after all, "Health CARE providers." We provide care. Not listening is probably one of the biggest mistakes that we make as doctors. It causes failures in diagnosis. It causes loss of faith. It causes anger. I try to listen.
Yesterday I sent a letter of dismissal to a patient, telling her that I can no longer be her physician. It is a woman with severe, disabling chronic pain. I never could figure out what was wrong with her. Nothing really helped her very much. I sent her for a second opinion at a fancy tertiary care institution, but they didn't really figure out what was wrong with her, either. Finally, we ended up with her on narcotics. Even that didn't seem to help that much. It's been a very difficult case. I just haven't been able to figure things out. Last week, she could hardly walk around the office or get up on the exam table. I watched her out the window. When she got in her car, she was able to bend over easily and turn the steering wheel while holding the phone between her shoulder and ear. The pharmacist called me to ask about her prescription. She told me that my patient was walking around perfectly normally and standing there very comfortably. So I had been listening to the patient when I shouldn't have been. I should have been listening to something else. Something that would have told me that things didn't add up.
Tonight, when I got home, the plants out back wanted water. The hibiscus bonsai were drooping. That's how you know they want water. So I listened to them and went out there with the hose. I found a baby eggplant growing. It's about two inches now. It's quite a miracle when an eggplant grows. I try to listen to the plants, but they're hard to understand sometimes. It's kind of like people. All in all, though, I think it's easier to listen to the plants than the people.
Wednesday, August 29, 2007
Tuesday, August 28, 2007
Where did the baby go?
Everyone gets very excited with a baby. The baby creates happiness. We look at it. It is "precious". It doesn't do anything. It just sleeps and poops and eats. It just does the basics necessary to live. That's all. We expect nothing from the baby. We love the baby. We love it just because it is. It's like that as it grows. Babies turn into todlers. Todlers turn into children. Children turn into teenagers. Teenagers turn into adults. Somewhere in that sequence, we change. We no longer look at that "baby" the same way. We may love the person they've become but that love is different. That love comes with expectations and restrictions. We rarely just look at an adult and get happy and see that he or she is precious. So the "baby" inside a person has disappeared. At least our ability to see it has disappeared. So what was that?
What is it that makes a baby so precious. Is it only the potential to do something? Most of us wouldn't want to admit that. We would say that it is the beauty of life. But adults aren't dead. They are alive. If babies are precious because they are a human life, then we shouldn't change our feelings for them as they grow. I'm not sure I understand why babies are so precious. I think we like helplessness and dependency. I think we like something that is completely incapable of producing a "threat". It can't hurt us. But people can only hurt us when we won't accept how they are (excluding the rare cases of true violence). It's a failure of love, of compassion. We refuse to accept the imperfections that people develop over time. That's because their imperfections affect us in ways that we don't want to be affected. We want to have control over life. So when someone else is involved, we lose something we want. That hurts us. Teenagers want to control the world because they know that they know everything that there is to know. That is their nature. This attitude robs us of our ability to maintain control over our own lives. So we are upset with them. That is because we lack compassion for their total lack of humility. But humility comes with the realization that we lack control over our own lives. Hopefully, as we grow we gain some compassion for others. But it isn't enough to see everyone as a baby. The truth, is that everyone is a baby.
What is it that makes a baby so precious. Is it only the potential to do something? Most of us wouldn't want to admit that. We would say that it is the beauty of life. But adults aren't dead. They are alive. If babies are precious because they are a human life, then we shouldn't change our feelings for them as they grow. I'm not sure I understand why babies are so precious. I think we like helplessness and dependency. I think we like something that is completely incapable of producing a "threat". It can't hurt us. But people can only hurt us when we won't accept how they are (excluding the rare cases of true violence). It's a failure of love, of compassion. We refuse to accept the imperfections that people develop over time. That's because their imperfections affect us in ways that we don't want to be affected. We want to have control over life. So when someone else is involved, we lose something we want. That hurts us. Teenagers want to control the world because they know that they know everything that there is to know. That is their nature. This attitude robs us of our ability to maintain control over our own lives. So we are upset with them. That is because we lack compassion for their total lack of humility. But humility comes with the realization that we lack control over our own lives. Hopefully, as we grow we gain some compassion for others. But it isn't enough to see everyone as a baby. The truth, is that everyone is a baby.
Monday, August 27, 2007
x-box games
G, the wife of W came today. They are both patients of mine. G has migraines, and W has Parkinson's. I had meant to write about W the last time he was here. It's on the list of things to write about, but it didn't get to the Blog yet. Some ideas seem to do better if they ferment in the mind cellar for a while. Parkinson's is such an amazing disease that it's hard to even explain in a book, let alone in a Blog. It's a slowly degenerative state in which we lose motor function as well as emotional function (it causes depression). There is shaking and slowness, especially slow reflexes. If you're a truck driver it renders you unable to work. The way we think is mostly geared towards accomplishment, prestige, success and productivity. It's how we define ourselves. We greet each other and ask, "What do you do?" We want to know what people DO. This doesn't really tell us anything. There are doctors who are wonderful people, and there are others who are terrible people. So how does it help me to know anything about the person? Still, it's our focus. When we lose our ability to produce, we lose our identity. It's a shame, really. It's a shame that our identity is now our occupation, our productivity, our economic contribution. I'm not sure exactly how that's happened. Parkinson's takes away your identity if your identity is your occupation. We value our "contribution". The problem is that our definition of "contribution" is largely an economic one. It's not our kindness, love, compassion, humor, personality -- those "don't count". Since he stopped work, he's been playing X-box games. He's "addicted to them", according to his wife. Video games suck people into an unusual interaction. They have "achievement". You can produce a higher level, a higher score, a "win" or some other sense of accomplishment. The "winning" isn't real in a certain sense. That's because it doesn't really create any benefit. So there isn't a contribution. The interaction is with a computer which doesn't change. So even though we play, we aren't really playing "with" anyone. "Playing" should involve interaction with others, I think. The video games cause us to suspend our perceptions of time and lose ourselves. They are an escape from the world. People want to escape when they've had their identity stolen. It's a shame, because what they do have left is given up. The illness takes part of you and you escape to survive, giving up the part of you that's left. I don't see us moving towards defining people more by their personality or their goodness. In fact, I think we're moving more towards seeing each other as "commodities" with "productivity" potential. We assess 0ne another according to our "worth". If you die through an accident, we have formulas used by the lawyers to decide what your life was "worth". Different people are "worth" different amounts. That's why they play video games. They're no longer "worth" anything. It's crazy, but there's a certain reality to it in our culture. If everyone all around thinks that way, it's hard not to let it affect you. So if it affects him, he has no choice but to go somewhere else - somewhere with different rules. X-Box world has different rules. In that world your value depends on how well you score in a game. If you can be completely objective about it, there isn't really any difference. Both criteria are arbitrary. If you are born with certain physical attributes, you may generate a huge income and be "worth" a great deal. It's a purely genetic lottery. At least with X-Box there is a certain amount of skill and practice involved. An altogether different approach would be to value humans because they're humans. Perhaps we could consider intrinsic human value. Or at least we could consider virtues such as kindness, love, caring, compassion as a factor in a person's "worth". It would help with Parkinson's disease, anyway.
Wednesday, August 22, 2007
Celebration
It's a birthday day. My wife's birthday is today. Some years ago, I came upon a song by Paul Westerburg: "A good day". He has a line that says "A good day is any day that you're alive". Perhaps it should have sunk in earlier since I see so much death in my profession. We should keep awareness of death. Death is always close. I began a practice of imagining the death of my loved ones each night before bed. Then, I can wake up and find out that they're still alive. Each day they live is a great blessing. Since that time I can say with honesty that there hasn't been a single day that I haven't been thankful that she's alive. It helps me love her better. I know that she may die today. I know that she is the most precious "thing" in my life. So when I worry about nonsense like money, prestige, success, aggravation, unpleasant toxic people, medicare, the broken health care system, the crazy country, the unbearable global poverty, the environmental destruction and the future I know that I am not focused on the important reality of life. I forget, of course. I forget often. But I am able to come back sometimes to Truth. According to Ghandi, "Truth is highest God." My wife is the most powerful seeker of truth I know. She cannot permit even microscopic dishonesty. She searches with an electron microscope of emotion for the seeds of dishonesty before ordinary humans can perceive it. And she heals it before it becomes disease. Many centuries ago in China, the emporer asked his physician who was the greatest physician in the land. He said this. "I am well known. I see illness in the body. I use potions and herbs to cure illness and my name is spread far and wide through the land. My brother can see illness in the heart, before it reaches the body. His name is not known outside our village. My father can see illness in one's soul, before it reaches the heart. So his name is not known outside our family." But my wife, she sees illness before it reaches a soul. So her name is unknown. She takes no credit. So there's no hope that she will look back at her accomplishments. She sees none. She has dedicated herself entirely to the protection of the souls of the family. Her success is invisible. The damage that would have occured without her was unseen, since it never came to be. Today is a special day for me to keep in my mind and my heart that I have the privilege to be with her.
Monday, August 20, 2007
Resting
Life is very toxic. There are events and there are interactions with others. They are inevitably imperfect. Events occur as a result of natural forces and actions of others and ourselves. Since all people are imperfect the consequences of their actions are imperfect; this accounts for many events. Interactions with others are necessarily imperfect since the people involved are all imperfect. So we suffer the consequences of the imperfection. To some extent this is "toxic".
That is why we must ensure that resting is an integral part of our daily lives. We have to create a habit of rest. Perhaps in hobbies or perhaps in exercise time. It can be in meditation. Or it can be in having tea. Some cultures have "siesta". But many people don't understand resting. Even resting can be toxic. We use television a lot (average american watches 20 hours per week). Television is very toxic. It is an unnatural interaction, because we don't get to respond. We're just presented to. What we're presented is a lot of violence and advertising. Advertising tells us that we have to have more than we have since what we have is not enough, or inadequate. It has to do that because its intention is to sell us something that we don't already have. The advertiser has to create a desire or a need which is also a lack of satisfaction. The programming has to create something spectacular. That is rarely restorative.
We live a very busy life. We live in constant doing something. Even when we don't do anything, we don't tend to have quiet minds. We don't rest. We go and do something and become toxic. Then we don't stop and "detoxify". We just keep going all of the time. I see so many people who can't get to sleep. They just can't turn their mind off and rest. People actually lose the ability to rest. There is constant stress just in our daily lives.
Often, the patients come with stress induced or stress exacerbated illness. Often, they ask me if this illness could be from stress. That is because they realize, somewhere deep down, that they are under an unhealthy amount of stress. They don't know any way to stop that stress. It seems to be an integral component of life. It is, I think, an integral component of our culture: of our focus on productivity and business.
I wish there was a way to measure the disease burden of stress. All that I can say is that in my own practice the stress of our culture is creating a great deal of illness. There's no science to prove it, but I think a lot of our epidemic of obesity is due to stress. People eat too much because they have stress. Eating (very temporarily) comforts us. It is one of the only ways that people have left to detoxify. Sadly, they eat in a way that is actually toxic. We are left with nothing that can detoxify us.
I often say to people "Don't have stress." They laugh because it seems like I must be joking. The notion is unimaginable for most of the patients. They know that there is no way one can live without stress. I can see that we have some input into our stress level. We can detoxify. It's just that there is no generally known method for it to be found.
That is why we must ensure that resting is an integral part of our daily lives. We have to create a habit of rest. Perhaps in hobbies or perhaps in exercise time. It can be in meditation. Or it can be in having tea. Some cultures have "siesta". But many people don't understand resting. Even resting can be toxic. We use television a lot (average american watches 20 hours per week). Television is very toxic. It is an unnatural interaction, because we don't get to respond. We're just presented to. What we're presented is a lot of violence and advertising. Advertising tells us that we have to have more than we have since what we have is not enough, or inadequate. It has to do that because its intention is to sell us something that we don't already have. The advertiser has to create a desire or a need which is also a lack of satisfaction. The programming has to create something spectacular. That is rarely restorative.
We live a very busy life. We live in constant doing something. Even when we don't do anything, we don't tend to have quiet minds. We don't rest. We go and do something and become toxic. Then we don't stop and "detoxify". We just keep going all of the time. I see so many people who can't get to sleep. They just can't turn their mind off and rest. People actually lose the ability to rest. There is constant stress just in our daily lives.
Often, the patients come with stress induced or stress exacerbated illness. Often, they ask me if this illness could be from stress. That is because they realize, somewhere deep down, that they are under an unhealthy amount of stress. They don't know any way to stop that stress. It seems to be an integral component of life. It is, I think, an integral component of our culture: of our focus on productivity and business.
I wish there was a way to measure the disease burden of stress. All that I can say is that in my own practice the stress of our culture is creating a great deal of illness. There's no science to prove it, but I think a lot of our epidemic of obesity is due to stress. People eat too much because they have stress. Eating (very temporarily) comforts us. It is one of the only ways that people have left to detoxify. Sadly, they eat in a way that is actually toxic. We are left with nothing that can detoxify us.
I often say to people "Don't have stress." They laugh because it seems like I must be joking. The notion is unimaginable for most of the patients. They know that there is no way one can live without stress. I can see that we have some input into our stress level. We can detoxify. It's just that there is no generally known method for it to be found.
Sunday, August 19, 2007
Litigation
I really should address litigation. It isn't "illness" what I think the blog is about. But it is definitely about trying to practice medicine. It is about the "illness of the health care system". Something is very wrong with our health care system. We spend over $7,000 per capita on our health care to be ranked 54th in the world in quality. That's not right. We have far too many people without insurance. And one of the economic factors is definitely the litigation. So here is my story:
A neurosurgeon sent a patient to me with a weakness in his leg which he said was "definitely not coming from his spine." I though that he had a small stroke. It didn't show up on his MRI, but that doesn't 100% exclude a stroke. He didn't get better with physical therapy, which he should have. He came in and got upset with me. My biggest mistake at that time was horrible notes. They were about two or three lines. I told them at that time that he might not have a stroke. That was probably something I should have figured out before. But he developed a new complaint. His illness had progressed from weakness to weakness + pain. I said I thought he needed a spine MRI. But he refused it. He then went home. He had always been very conscientous about contacting doctors with all of his symptoms. He went to his cardiologist. The cardiologist's note said "patient didn't like Dr.___. Wants new neurologist. ? MRI spine." He then developed weakness in the other leg and incontinence. He never called me. After two more days, he couldn't walk. He got an MRI of the Spine (the one I had recommended) and had surgery on the problem. He got worse after surgery. He ended up in a wheelchair. I was sued for failure to diagnose. The lawsuit alleged that if the diagnosis had been earlier, he would have never had any problems. He would have been fine. There is no literature to support that. After his surgery, the tumor wasn't completely removed. Those tumors usually can't ever be totally removed. But my notes were terrible. My deposition was awful. My insurance company offered a settlement. It was $1,000,000. That was for an 87 year old man. The plaintiffs demanded 5.2 Million. The trial was a nightmare of torture. The family was all there. They were laughing and partying in the hallways while my wife and I would walk by quielty. The number one cause of "monoparesis" (weakness in one leg) is a stroke. That accounts for most of those. Spinal cord processes are a very rare cause of monoparesis. The expert for them said that strokes never cause monoparesis. He is known lawyer who spends most of his time testifyinig for plaintiffs. My lawyer called him a "plaintiff's whore". So did my brother (a lawyer). The trial ended with me being "not guilty". According to the jury, I did nothing wrong. About two and half years after that, all of the appeals were dropped. That family was very angry. I appologized to them at the mandatory mediation. I don't think it helped.
Now, I have very good notes. I refer many patients for a second opinion. I write down that they don't want to go. I recommend many tests. I write down that they refuse them.
After the lawsuit (seven years ago), I order about $1,000,000 or more in tests that I wouldn't have before the lawsuit. I don't live a day without it. I don't see a patient without it. It is in every single one of my notes. Their anger will cost our system at least $20,000,000. My insurance rates nearly doubled. We all pay that. Their anger has forever change me.
It's not that I don't forgive them their anger. It's just that I gained wisdom. I have an obligation to treat my patients, to protect myself, to my family. I want to continue in practice. Here in this state, if you have three judgements against you that prevail, you lose your license. We really have to be cautious. I am cautious. I understand that these are the "rules of the game". I have to either follow them or pay the price. I accept that. I accept it with no anger. But I do have some sadness that our culture doesn't have the insight to see that the consequences of our system are unacceptable. I think the 20million could be better spent.
A neurosurgeon sent a patient to me with a weakness in his leg which he said was "definitely not coming from his spine." I though that he had a small stroke. It didn't show up on his MRI, but that doesn't 100% exclude a stroke. He didn't get better with physical therapy, which he should have. He came in and got upset with me. My biggest mistake at that time was horrible notes. They were about two or three lines. I told them at that time that he might not have a stroke. That was probably something I should have figured out before. But he developed a new complaint. His illness had progressed from weakness to weakness + pain. I said I thought he needed a spine MRI. But he refused it. He then went home. He had always been very conscientous about contacting doctors with all of his symptoms. He went to his cardiologist. The cardiologist's note said "patient didn't like Dr.___. Wants new neurologist. ? MRI spine." He then developed weakness in the other leg and incontinence. He never called me. After two more days, he couldn't walk. He got an MRI of the Spine (the one I had recommended) and had surgery on the problem. He got worse after surgery. He ended up in a wheelchair. I was sued for failure to diagnose. The lawsuit alleged that if the diagnosis had been earlier, he would have never had any problems. He would have been fine. There is no literature to support that. After his surgery, the tumor wasn't completely removed. Those tumors usually can't ever be totally removed. But my notes were terrible. My deposition was awful. My insurance company offered a settlement. It was $1,000,000. That was for an 87 year old man. The plaintiffs demanded 5.2 Million. The trial was a nightmare of torture. The family was all there. They were laughing and partying in the hallways while my wife and I would walk by quielty. The number one cause of "monoparesis" (weakness in one leg) is a stroke. That accounts for most of those. Spinal cord processes are a very rare cause of monoparesis. The expert for them said that strokes never cause monoparesis. He is known lawyer who spends most of his time testifyinig for plaintiffs. My lawyer called him a "plaintiff's whore". So did my brother (a lawyer). The trial ended with me being "not guilty". According to the jury, I did nothing wrong. About two and half years after that, all of the appeals were dropped. That family was very angry. I appologized to them at the mandatory mediation. I don't think it helped.
Now, I have very good notes. I refer many patients for a second opinion. I write down that they don't want to go. I recommend many tests. I write down that they refuse them.
After the lawsuit (seven years ago), I order about $1,000,000 or more in tests that I wouldn't have before the lawsuit. I don't live a day without it. I don't see a patient without it. It is in every single one of my notes. Their anger will cost our system at least $20,000,000. My insurance rates nearly doubled. We all pay that. Their anger has forever change me.
It's not that I don't forgive them their anger. It's just that I gained wisdom. I have an obligation to treat my patients, to protect myself, to my family. I want to continue in practice. Here in this state, if you have three judgements against you that prevail, you lose your license. We really have to be cautious. I am cautious. I understand that these are the "rules of the game". I have to either follow them or pay the price. I accept that. I accept it with no anger. But I do have some sadness that our culture doesn't have the insight to see that the consequences of our system are unacceptable. I think the 20million could be better spent.
Friday, August 17, 2007
Clear Thinking
What we need is more clear thinking. B asked: "What do I do -- just live with it?" He has pain. It got so bad that he had to go to the emergency room. The pain is in the chest, on the left side. It is very intense. He's had it for several years. It comes and goes for no clear reason. The pain typically lasts about twenty minutes, although it can be more. It is a very sharp intense pain, "like stabbing". There is a sensation that is also similar to a "cramp", like a "charley horse." He has had ECG tests, GI tests and finally me, the neurologist. He had nerve tests, MRI of the spine, and GI endoscopy. There is no very clear, specific diagnosis. It's just "chest pain".
He doesn't like the lack of a specific disease name. It makes him feel nervous. We don't know what he has, according to his way of thinking.
This is not clear thinking. At some level, we know nothing. We certainly know nothing when you get down to the real details. I tell my patients, sometimes, "You have peripheral neuropathy." That makes them somewhat happy. There is a real diagnosis! They ask "What is peripheral neuropathy?" But even so, they are happy because now we "know" what they have. In reality, we don't know very much. We know that the nerves are damaged, and that's about it. Then, there are many kinds of neuropathy. There are many causes. Much of the time, we don't find the cause. We end up saying "Chronic Idiopathic Axonal Polyneuropathy." That's what they have. That, in short, is nerve damage that we don't understand. This isn't very different than what B has. It just has a fancy name. I don't know what causes either one. And that is clear thinking.
So we know what we know. We know he has this type of pain with this type of intensity in this location occurring intermittently with this frequency. We know that. It's his experience. It could be given a name, but that really doesn't change anything. It doesn't change the reality or the experience or the nature of the problem. Yet we allow the existence of the diagnosis to alter our perceptions of the reality. The reality is improved somehow with the name.
This sort of thinking is allowing us to fool ourselves; it's allowing others to fool us. Since the presence of just a name changes our perception of reality it's very easy to change our perception of reality. We need to be careful about these things. I suppose I could take advantage of that. I could give people fancy names and then tell them what I know about what they have with an authoratative presentation. It would make them feel better, maybe. But I wonder if we're "dummying down" by refusing to accept the very high level of uncertainty that truly exists. We need to become comfortable with the reality of uncertainty. Everything is uncertain.
He doesn't like the lack of a specific disease name. It makes him feel nervous. We don't know what he has, according to his way of thinking.
This is not clear thinking. At some level, we know nothing. We certainly know nothing when you get down to the real details. I tell my patients, sometimes, "You have peripheral neuropathy." That makes them somewhat happy. There is a real diagnosis! They ask "What is peripheral neuropathy?" But even so, they are happy because now we "know" what they have. In reality, we don't know very much. We know that the nerves are damaged, and that's about it. Then, there are many kinds of neuropathy. There are many causes. Much of the time, we don't find the cause. We end up saying "Chronic Idiopathic Axonal Polyneuropathy." That's what they have. That, in short, is nerve damage that we don't understand. This isn't very different than what B has. It just has a fancy name. I don't know what causes either one. And that is clear thinking.
So we know what we know. We know he has this type of pain with this type of intensity in this location occurring intermittently with this frequency. We know that. It's his experience. It could be given a name, but that really doesn't change anything. It doesn't change the reality or the experience or the nature of the problem. Yet we allow the existence of the diagnosis to alter our perceptions of the reality. The reality is improved somehow with the name.
This sort of thinking is allowing us to fool ourselves; it's allowing others to fool us. Since the presence of just a name changes our perception of reality it's very easy to change our perception of reality. We need to be careful about these things. I suppose I could take advantage of that. I could give people fancy names and then tell them what I know about what they have with an authoratative presentation. It would make them feel better, maybe. But I wonder if we're "dummying down" by refusing to accept the very high level of uncertainty that truly exists. We need to become comfortable with the reality of uncertainty. Everything is uncertain.
Thursday, August 16, 2007
Finding a New Path
Yesterday, M came in. M is very difficult. He is a professor with migraines that are impossible. They come every time he reads. He has a vision problem, and he can't see very much. He can see, but poorly. The more serious issue is the severe pain of migraine that occurs with reading. He did well as a professor. Now, with his reading problem, he can't do it anymore. He's going through a bitter divorce at the same time, because "when it rains it pours". Of course, there isn't much that can be done for him. I give him some pills which cause a decrease in his suffering.
But he is interesting. He creates almost all of his suffering himself. Not the medical illness -- he doesn't create that. What he creates is his response to it. He is very busy feeling his loss. His marriage is a big loss. But his bigger loss is the work. It's the prestige, the sense of value, intelligence, contribution, importance and, believe it or not, being busy. We say we don't like being busy. But we really do like it. It takes us away from sitting around and having to think about life, about how we're really doing, what we're really doing. Most of us don't really spend much time doing what's really most important. I know of very few people who spend more time with those they love than they do with their job. But they think that they value their loved ones more than they value their job, or money. So we like being busy to avoid looking at reality too long.
In order to decrease suffering, M wants to replace his career. He wants a similar career. That's because he wants the same sort of reward. He wants the same sort of "success": prestige and importance. But everything he thinks of requires his eyes. Everything he thinks of is academic. He wants to use his intellectual talent like he's always done. It's very scary to think about life without that particular tool. So he doesn't want to jump off that cliff. He doesn't want to confront the world without his academic credentials and background to support him. He doesn't want to start life all over; and he hates the thought of developing a new way to create importance and meaning.
Illness takes things from us. It takes physical things from us. But we choose whether or not we'll give it more. We can give it our happiness. We can give it our mind. We can give it our spirit. Or we can give it nothing more than what it has taken. We can give it only the physical piece of our body that it has rightfully claimed. Respect for illness means that you accept what it takes, and you give that up. You give up your leg or your eye. It doesn't mean that you don't fight illness. That's part of respecting it. Illness comes and it plays a game with us. We didn't ask to play. It's like when someone comes and teases you on the playground. You have to tease back. Some of the things they say are true. And so we have to accept that. But we have to tease back or we'll become sad and hurt. The things that were said that were true that hurt are important. Those are the things we have to look at about ourselves. Those are the things we have to consider improving. The "teaser" shows us what we need to do in order to grow more as a person. It's not that we want to be teased when we're on the playground. It's just that we have to be careful how we respond. People don't want illness. But it comes to play with us. So we have to respond until the play time is over.
We must give up what is rightfully taken and no more. But if we plan to take the least suffering, the illness has to teach us growth. What would you do if you had to give up your academic prestige, your brilliant thinking power? I think it's about people value. We know that babies are so precious, don't we? So where does that precious go that we have to prove our value in some other way? I don't know. We just lose respect for that. My orchids have value, but they don't do anything. They just live. Just being alive creates a value for the babies. But the elderly, demented people who just live aren't of the same value to most of us. It's a terrible thinking pattern, but I think it's true. It's not universal, but it's very prevalent in America. If we can't know that we're precious like an orchid or a baby just for living, then we're in for some great suffering.
People are so precious. They aren't precious when they're newborn babies. People are precious all of the time. They're precious because they're alive. They're precious because they exist. They're even, according to me, precious after they die. They don't have to be a movie star, or famous, or successful, or this or that or anything. They just have to be. If someone is, then they are precious. If we could all only see that, things would be better. We probably wouldn't kill each other so often. We couldn't have genocide. If we believe that our value disappears without some activity, then we can just throw away or even kill all of the people who aren't doing something. They aren't worth anything. We can throw out whatever isn't worth anything. This is what growing we need when we lose a piece of body from an illness that makes us unable to do something that we think is the thing that makes us valuable. We need to grow to see that we are all wonderful.
But he is interesting. He creates almost all of his suffering himself. Not the medical illness -- he doesn't create that. What he creates is his response to it. He is very busy feeling his loss. His marriage is a big loss. But his bigger loss is the work. It's the prestige, the sense of value, intelligence, contribution, importance and, believe it or not, being busy. We say we don't like being busy. But we really do like it. It takes us away from sitting around and having to think about life, about how we're really doing, what we're really doing. Most of us don't really spend much time doing what's really most important. I know of very few people who spend more time with those they love than they do with their job. But they think that they value their loved ones more than they value their job, or money. So we like being busy to avoid looking at reality too long.
In order to decrease suffering, M wants to replace his career. He wants a similar career. That's because he wants the same sort of reward. He wants the same sort of "success": prestige and importance. But everything he thinks of requires his eyes. Everything he thinks of is academic. He wants to use his intellectual talent like he's always done. It's very scary to think about life without that particular tool. So he doesn't want to jump off that cliff. He doesn't want to confront the world without his academic credentials and background to support him. He doesn't want to start life all over; and he hates the thought of developing a new way to create importance and meaning.
Illness takes things from us. It takes physical things from us. But we choose whether or not we'll give it more. We can give it our happiness. We can give it our mind. We can give it our spirit. Or we can give it nothing more than what it has taken. We can give it only the physical piece of our body that it has rightfully claimed. Respect for illness means that you accept what it takes, and you give that up. You give up your leg or your eye. It doesn't mean that you don't fight illness. That's part of respecting it. Illness comes and it plays a game with us. We didn't ask to play. It's like when someone comes and teases you on the playground. You have to tease back. Some of the things they say are true. And so we have to accept that. But we have to tease back or we'll become sad and hurt. The things that were said that were true that hurt are important. Those are the things we have to look at about ourselves. Those are the things we have to consider improving. The "teaser" shows us what we need to do in order to grow more as a person. It's not that we want to be teased when we're on the playground. It's just that we have to be careful how we respond. People don't want illness. But it comes to play with us. So we have to respond until the play time is over.
We must give up what is rightfully taken and no more. But if we plan to take the least suffering, the illness has to teach us growth. What would you do if you had to give up your academic prestige, your brilliant thinking power? I think it's about people value. We know that babies are so precious, don't we? So where does that precious go that we have to prove our value in some other way? I don't know. We just lose respect for that. My orchids have value, but they don't do anything. They just live. Just being alive creates a value for the babies. But the elderly, demented people who just live aren't of the same value to most of us. It's a terrible thinking pattern, but I think it's true. It's not universal, but it's very prevalent in America. If we can't know that we're precious like an orchid or a baby just for living, then we're in for some great suffering.
People are so precious. They aren't precious when they're newborn babies. People are precious all of the time. They're precious because they're alive. They're precious because they exist. They're even, according to me, precious after they die. They don't have to be a movie star, or famous, or successful, or this or that or anything. They just have to be. If someone is, then they are precious. If we could all only see that, things would be better. We probably wouldn't kill each other so often. We couldn't have genocide. If we believe that our value disappears without some activity, then we can just throw away or even kill all of the people who aren't doing something. They aren't worth anything. We can throw out whatever isn't worth anything. This is what growing we need when we lose a piece of body from an illness that makes us unable to do something that we think is the thing that makes us valuable. We need to grow to see that we are all wonderful.
A Good Day
Tuesday, S, W and A came in. They are migraine patients. Everyone had a success story. They have had horrible, intractable, disabling headaches. But with treatment they are doing very well right now. One of them had forty-three years of headache which "was lifted". She is very happy, because I am apparantly "a miracle worker". I had praise from W and from A also. They are thankful, happy patients. O was here. He is eighty five, crusty, tough and very successful. He lived his own way. He is my complete patient. I have to do his primary care. "You are my doctor". He won't go to an internist. I have explained to him that he would get better care with someone who is an expert in general care, but he won't go anywhere else. He has had a stroke. He still gets himself out in the garden every day. He strongly believes that there is no better doctor for him to see, even for primary care. L called on the phone. She feels great. I have been slowly removing her Parkinson's drugs which she has taken the last five years. She was diagnosed by another physician in another place with Parkinson's which she doesn't have. People love to feel better. They love to have health improved through the wonders of modern medicine. They want the suffering to decrease, or to stop. A doctor has the power to do that sometimes.
Work is good. Work is always good. It gives us meaning and productivity. It makes us feel that we have personal importance. It allows us to give our own personal contribution to the world. Work is what gives us meaning. When I say this, I also mean "work" involved in the care of others: children, spouses, family, friends, countrymen, and people in the world. Giving money to the victims of living in Africa where someone comes and burns the village and rapes the girls who are ten and cuts the achilles tendons of the men. That is "work" also. That is the work of taking care of our fellow man.
Some people think they can't work. That's because they don't have a paying "job". It is very hard. They think they lack value and meaning. They lack money, which is another thing that is good. But they have a wrong perception. They can't see what work really is. Work is not about money (which is nice). It is about the feeling that comes from success. Success can seem to be in a creation. I might be a builder. Then, I think that when I have finished building a building I have succeeded. I might be a banker who thinks when I have created wealth I have succeeded. But these thoughts are incomplete. Why does this mean there is success? Because a building helps people to live and work, things which are hard to do outside there is success. Because when we create wealth someone has more money and possibly more happiness (or more money to send to Africa or wherever). The "success" in reality is the possibilty of helping someone. Work is a form of socialization. The ants of the colony, who are just like us, work so that the other ants in the colony can survive.
It's amazing to be able to do what we do with our skills. It's amazing to see what we've created. We have jet planes and sky scrapers and cell phones. We have computers. And for me, we have medicine. The ants don't get all of that. Even most of the people in the world don't get that. They can't even get medicine.
In South Africa, there was a company who made AIDS drugs generically. They were sued by about fifty different pharmaceutical companies for intellectual rights patent infringements. South Africa supported its right to make these drugs. They wanted to do this because in some areas almost all of the people are dying with AIDS. They can't afford the drugs. So they wanted to make them cheaply. South Africa ended up losing "most favored nation" status with the US, which costs a lot of money for the country due to trading priviledges. So the South Africans don't get medicine. And I'm lucky to be here because I get to use medicines for MIGRAINES! Never mind life-saving AIDS drugs. I'm actually able to help get rid of migraines, so how lucky is that?
Good days are important. They need to be noticed, savoured and remembered.
Work is good. Work is always good. It gives us meaning and productivity. It makes us feel that we have personal importance. It allows us to give our own personal contribution to the world. Work is what gives us meaning. When I say this, I also mean "work" involved in the care of others: children, spouses, family, friends, countrymen, and people in the world. Giving money to the victims of living in Africa where someone comes and burns the village and rapes the girls who are ten and cuts the achilles tendons of the men. That is "work" also. That is the work of taking care of our fellow man.
Some people think they can't work. That's because they don't have a paying "job". It is very hard. They think they lack value and meaning. They lack money, which is another thing that is good. But they have a wrong perception. They can't see what work really is. Work is not about money (which is nice). It is about the feeling that comes from success. Success can seem to be in a creation. I might be a builder. Then, I think that when I have finished building a building I have succeeded. I might be a banker who thinks when I have created wealth I have succeeded. But these thoughts are incomplete. Why does this mean there is success? Because a building helps people to live and work, things which are hard to do outside there is success. Because when we create wealth someone has more money and possibly more happiness (or more money to send to Africa or wherever). The "success" in reality is the possibilty of helping someone. Work is a form of socialization. The ants of the colony, who are just like us, work so that the other ants in the colony can survive.
It's amazing to be able to do what we do with our skills. It's amazing to see what we've created. We have jet planes and sky scrapers and cell phones. We have computers. And for me, we have medicine. The ants don't get all of that. Even most of the people in the world don't get that. They can't even get medicine.
In South Africa, there was a company who made AIDS drugs generically. They were sued by about fifty different pharmaceutical companies for intellectual rights patent infringements. South Africa supported its right to make these drugs. They wanted to do this because in some areas almost all of the people are dying with AIDS. They can't afford the drugs. So they wanted to make them cheaply. South Africa ended up losing "most favored nation" status with the US, which costs a lot of money for the country due to trading priviledges. So the South Africans don't get medicine. And I'm lucky to be here because I get to use medicines for MIGRAINES! Never mind life-saving AIDS drugs. I'm actually able to help get rid of migraines, so how lucky is that?
Good days are important. They need to be noticed, savoured and remembered.
Monday, August 13, 2007
Losing A Body
Today Mr.B came. He wasn't on the schedule. He had a 1:00 appointment, but they didn't put him on the schedule. I usually schedule him extra time, but instead he was scheduled for no time. I never like it when there's no time. I like time. It's good to have time to see the patients. A lot of doctors don't have any time to see the patients. But I think they tend to get frustrated. I once heard there was a doctor (in town here) who saw 100 patients in a day. I can't even imagine that. It's 7.2minutes per patient in a twelve hour day, assuming no bathroom or eating breaks. That includes the visit and the prescription writing and the dictations for the notes. It's probably roughly 4 minutes of "visit" time. Anyway, Mr. B has ALS (Lou Gherig's disease). It's a progressive loss of strength which has, in my mind, essentially no treatment. Riluzole is the only FDA approved medication, but it only prolongs life without improving its quality for about three months. To me, that's not meaningful treatment. I tell the patients about it, but few take it. On average, people with ALS die in about eighteen months. They die from too much weakness. They aren't strong enough to breath anymore. ALS affects people differently. Their weakness can be in any muscle. Mr. B has weakness in his arms. He can't pick up his arms at all. They just hang there at his sides. He can't dress, shower, feed himself, or clean himself up after going to the bathroom. He hates having his wife do all of it for him. Now he's getting leg weakness (right leg more than left leg). He fell. He has a lot of trouble getting up out of a chair. They just got a special high toilet, so he can get up off it. He doesn't have an electric wheelchair or an electric lift chair. He doesn't want to take any anti-depression pill. I think he's depressed. He says he's not. It's hard to treat someone for something when they don't want treatment, though. The last time he was here, he was talking to me about that he wants to die at some point. Not at this point, but he doesn't want to have to just lie in bed and not be able to "do anything". That happens with ALS. You lose the ability to get up and move. You end up just laying in a bed. Some of the ALS patients can't talk (mouth weakness) or swallow. He can talk and swallow just fine. His wife said today that it's a bad illness. When you have ALS you lose a body. I guess you lose a body with any terminal illness. Death is loss of a body. The thing is with ALS you lose a body very slowly. You just watch it gradually weaken into nothing over about a year and a half or so. Losing a body is a hard thing to do.
Monday, August 6, 2007
Perfection
I have a patient: "M" She suffers greatly from perfection. Most fittingly, she sees me for essential tremor. It is a "benign" condition, but I'm not sure why it's called that. Her employment as a sort of artist requires incredible fine motor skill. Especially her surgeries. She is a graduate of the finest schools in the nation where she achieved the highest grades and greatest honors. She is the best. Her career has used her seven days per week and most of her waking hours. Her business has flourished. She has great prestige in the community. Now, her stress is making her tremor far worse.
Medications for essential tremor are challenging. They help, but don't eliminate the tremors. They tend to have significant side effects. At times, the side effects are worse than the illness. The surgery for tremors is reserved for medication failures and disabling tremor. It is somewhat dangerous. Brain surgery tends to scare people somewhat as well.
Perfection is difficult. I think it comes for a sort of "emptiness". It is a cry for acceptance. It is a cry for someone to say "You are wonderful. You are the best." The perfectionist doesn't seem to think that they are "good enough". So there is an emptiness of "good-enoughness". "Good-enoughness" can't be achieved from actions of skill, prestige, hard work or admiration. It can't really come from another's love - neither erotic or platonic. It is internal: an internal knowing, satisfaction or fullness. Perhaps it is an inner peace of sorts.
I see "NGESI": "Not Good Enough Soul Injury". People get injuries to the body, mind and soul. Perfection is a response to this injury to the soul. It is an injury that may come from childhood, I suppose. If one has perfection they think that this will cause them to know that they are good enough. There is "proof" from going to this school, from this degree, from making this much money, from having this fancy car or house or something. But the proof doesn't penetrate our soul: it is only inside a brain. There are brain-soul connections. But not all that is in the brain goes to the soul. So perfection can't cure the injury. Perfection is "a place" where one hides from the suffering that feeling the injury brings. It is a distraction from Truth.
The Truth is, there is injury and suffering. I don't know of a cure. Perhaps someone else does. I think that there is suffering. Knowing that this is a suffering and recognizing the injury is unpleasant and painful and difficult. Often, I think, the harder the path the more beneficial it is. We can know that this pain is here. And we can say "Hello my NGESI." We can welcome the NGESI for a visit. It comes and goes. It isn't a friend. It is a visitor. Perhaps it is an enemy. Perhaps it isn't. It may be an unpleasant teacher. Many teachers are unpleasant, even bordering on abusive. I don't know what NGESI is. But if we sit with it, we become familiar. Familiar is also comfortable. This could decrease the pain. We don't hurt so much when we're comfortable. In fact, in a way, "Pain" is just a variation of "not comfortable". It's all about the linguistics.
But to cure someone I would need to find a way to have them "let go" of perfectionism. This, I don't have a pill for. And what's more I really don't know how I sign up someone for that. People don't like letting go of things, they like getting more things. I'm not supposed to encourage people to suffer: I'm a physician. What I'm supposed to do is decrease their suffering. Either that, or fix the tremor. If I could fix the tremor, then I could return "M" to her state of perfection. That is what she came to me for, after all. "Success" as a physician is making sure you listen to what the patient wants (usually, but not always, a cure) and providing that.
And I can't fix her tremor.
Medications for essential tremor are challenging. They help, but don't eliminate the tremors. They tend to have significant side effects. At times, the side effects are worse than the illness. The surgery for tremors is reserved for medication failures and disabling tremor. It is somewhat dangerous. Brain surgery tends to scare people somewhat as well.
Perfection is difficult. I think it comes for a sort of "emptiness". It is a cry for acceptance. It is a cry for someone to say "You are wonderful. You are the best." The perfectionist doesn't seem to think that they are "good enough". So there is an emptiness of "good-enoughness". "Good-enoughness" can't be achieved from actions of skill, prestige, hard work or admiration. It can't really come from another's love - neither erotic or platonic. It is internal: an internal knowing, satisfaction or fullness. Perhaps it is an inner peace of sorts.
I see "NGESI": "Not Good Enough Soul Injury". People get injuries to the body, mind and soul. Perfection is a response to this injury to the soul. It is an injury that may come from childhood, I suppose. If one has perfection they think that this will cause them to know that they are good enough. There is "proof" from going to this school, from this degree, from making this much money, from having this fancy car or house or something. But the proof doesn't penetrate our soul: it is only inside a brain. There are brain-soul connections. But not all that is in the brain goes to the soul. So perfection can't cure the injury. Perfection is "a place" where one hides from the suffering that feeling the injury brings. It is a distraction from Truth.
The Truth is, there is injury and suffering. I don't know of a cure. Perhaps someone else does. I think that there is suffering. Knowing that this is a suffering and recognizing the injury is unpleasant and painful and difficult. Often, I think, the harder the path the more beneficial it is. We can know that this pain is here. And we can say "Hello my NGESI." We can welcome the NGESI for a visit. It comes and goes. It isn't a friend. It is a visitor. Perhaps it is an enemy. Perhaps it isn't. It may be an unpleasant teacher. Many teachers are unpleasant, even bordering on abusive. I don't know what NGESI is. But if we sit with it, we become familiar. Familiar is also comfortable. This could decrease the pain. We don't hurt so much when we're comfortable. In fact, in a way, "Pain" is just a variation of "not comfortable". It's all about the linguistics.
But to cure someone I would need to find a way to have them "let go" of perfectionism. This, I don't have a pill for. And what's more I really don't know how I sign up someone for that. People don't like letting go of things, they like getting more things. I'm not supposed to encourage people to suffer: I'm a physician. What I'm supposed to do is decrease their suffering. Either that, or fix the tremor. If I could fix the tremor, then I could return "M" to her state of perfection. That is what she came to me for, after all. "Success" as a physician is making sure you listen to what the patient wants (usually, but not always, a cure) and providing that.
And I can't fix her tremor.
Thursday, August 2, 2007
Acceptance
I think that almost all of illness is acceptance. These days, acceptance is very hard to find. Some people are devasted when they acquire an illness. This may be a serious illness, or a mild one. So the severity of the illness is not what causes the amount of suffering that results. It's something about the person that dictates how much suffering an illness produces. There is ailment, disease, illness, sickness: all various terms with different nuances which reflect slightly different perceptions.
We go through life facing challenges. There are challenges almost every moment of every day. Events and our perceptions of them can be of two basic varieties: blessings and challenges. Or, we can have events that we just don't classify. But we rarely do that. We rarely say "This is like this." We say "This is like this, and that isn't good." or "This is like this, and that is good." It's our tendency, almost a reflex, to judge each event as good or as bad. Our entire culture is dedicated to that process. People make stuff and they love it and want to sell it. So they go on television and they tell us how fantastic this thing is, and that we need it because without this our lives cannot be complete. So we want that thing, or we go out and get it. Things that once were challenges have disappeared. We used to have to try to get a hold of someone. We would say, "I've been trying to reach you." We called them at home, and they weren't there. So we would have to call again later. Then, there was an answering machine, so we no longer had to call back later: we could leave a message. Then, since that was too much trouble, we all got cell phones. Now we can reach everyone everywhere, no matter what. Some people turn off the cell phone at the movies. But a lot of them just put it on silence. My daughter can't handle turning her cell phone off. She believes that if her cell phone is turned off, she will die or the world will end. It's an unacceptable notion.
There are things that we can't accept anymore: dial up modems take too long. Computers with a hard drive less than a billion trillion gigabytes, cars without defrosters, and almost all inconveniences. I can't be expected to work in outrageous conditions, like when the air conditioner isn't working right. I have to call the emergency air conditioner service right away.
So, when illness comes we expect that someone is going to eliminate that inconvenience for us. We have that power over the world. The television infotainment news with its thirty second or less "news" covers medicine in only two ways. 1) The medical community with brilliant science and incredible technology has miraculously cured this previously impossible disease and will be able to make us live forever within the week! 2) The medical community is nothing but pure evil and incompetence and the doctors are going around wrecklessly killing everyone and cutting off the wrong leg! You can't get upset with the media. Their job is not to inform us. Their job is to make money for the huge money making companies that own the networks by getting big ratings. Big ratings come from spectacular and fascinating events which are easy to understand. Medicine is not easy to understand.
But there is illness and disease that has no cure. It degenerates us and it is our nature to die, sometimes suddenly and sometimes slowly. Medicine, technology, and power and money can't change this. So we are left with being forced to accept how it is. There is no choice.
I have patients who can do it, and patients who can't. And I think the ones who can are the ones who suffer less. The purpose of illness is to accept our humanity and understand the nature of living and dying. It helps us to look at our true priorities, because it leaves us with nothing else. Disease destroy bodies. That's all. We are all very attached to our bodies. So when our bodies are being destroyed, we say "This is how it is; and this is bad." But if we could avoid that reflex, we would say, "This is how it is." Then what?
Then, we can ask "What happens when I lose my body? What is left?" Well, we are more than a body, I think. The question that really counts is if we allow the loss of the body to consume our minds and steal our spirit. If it doesn't, then it sharpens the mind and strengthens the spirit. That is how we accept our human physical frailty: we trade off the body for an increased spirit. Then we give up our body altogether and nothing but spirit is left.
We go through life facing challenges. There are challenges almost every moment of every day. Events and our perceptions of them can be of two basic varieties: blessings and challenges. Or, we can have events that we just don't classify. But we rarely do that. We rarely say "This is like this." We say "This is like this, and that isn't good." or "This is like this, and that is good." It's our tendency, almost a reflex, to judge each event as good or as bad. Our entire culture is dedicated to that process. People make stuff and they love it and want to sell it. So they go on television and they tell us how fantastic this thing is, and that we need it because without this our lives cannot be complete. So we want that thing, or we go out and get it. Things that once were challenges have disappeared. We used to have to try to get a hold of someone. We would say, "I've been trying to reach you." We called them at home, and they weren't there. So we would have to call again later. Then, there was an answering machine, so we no longer had to call back later: we could leave a message. Then, since that was too much trouble, we all got cell phones. Now we can reach everyone everywhere, no matter what. Some people turn off the cell phone at the movies. But a lot of them just put it on silence. My daughter can't handle turning her cell phone off. She believes that if her cell phone is turned off, she will die or the world will end. It's an unacceptable notion.
There are things that we can't accept anymore: dial up modems take too long. Computers with a hard drive less than a billion trillion gigabytes, cars without defrosters, and almost all inconveniences. I can't be expected to work in outrageous conditions, like when the air conditioner isn't working right. I have to call the emergency air conditioner service right away.
So, when illness comes we expect that someone is going to eliminate that inconvenience for us. We have that power over the world. The television infotainment news with its thirty second or less "news" covers medicine in only two ways. 1) The medical community with brilliant science and incredible technology has miraculously cured this previously impossible disease and will be able to make us live forever within the week! 2) The medical community is nothing but pure evil and incompetence and the doctors are going around wrecklessly killing everyone and cutting off the wrong leg! You can't get upset with the media. Their job is not to inform us. Their job is to make money for the huge money making companies that own the networks by getting big ratings. Big ratings come from spectacular and fascinating events which are easy to understand. Medicine is not easy to understand.
But there is illness and disease that has no cure. It degenerates us and it is our nature to die, sometimes suddenly and sometimes slowly. Medicine, technology, and power and money can't change this. So we are left with being forced to accept how it is. There is no choice.
I have patients who can do it, and patients who can't. And I think the ones who can are the ones who suffer less. The purpose of illness is to accept our humanity and understand the nature of living and dying. It helps us to look at our true priorities, because it leaves us with nothing else. Disease destroy bodies. That's all. We are all very attached to our bodies. So when our bodies are being destroyed, we say "This is how it is; and this is bad." But if we could avoid that reflex, we would say, "This is how it is." Then what?
Then, we can ask "What happens when I lose my body? What is left?" Well, we are more than a body, I think. The question that really counts is if we allow the loss of the body to consume our minds and steal our spirit. If it doesn't, then it sharpens the mind and strengthens the spirit. That is how we accept our human physical frailty: we trade off the body for an increased spirit. Then we give up our body altogether and nothing but spirit is left.
Subscribe to:
Posts (Atom)