Progress

GW was here today. He had a stroke last year. It left him with almost no deficits. However, it did leave him with the determination to stop smoking. He hasn't had a cigarette for nine months. Sometimes, people stop smoking. I'm not sure that it's because of anything I did or didn't do. I try, of course, to help people to stop smoking. I'm pretty sure that the stroke is really the thing that got him to do it. Strokes have a way of being very persuasive. They are even more persuasive than doctors. Anyway, it doesn't really matter what got him to stop it. He did it. It's inspiring and it makes the people who practice at medicine happy. We win little battles in medicine.
Well, anyway, GW tells me that he has purchased a treadmill. I suspect that the next time I see him he's going to tell me that he exercises. I did tell him that would be good for his health. His stroke told him the same thing, so that's two of us working together on the project. I asked him to go on it for five minutes a day. This is a great exercise program. It's great becuse it's manageable. Sometimes people want to have these giant undertakings. Nature isn't like that. It works slowly. It makes progress one step at a time. It's kind of similar to the practice of medicine: every once in a while there is a small success. Then we have to remember that it isn't that one person out of the twenty or thirty or forty (in some cases) patients that we see who is doing well. It's one person who has had a major change in their life. Someone's life has changed. There isn't any more than that can happen. That's progress.

The Other Thing

MW was here yesterday. She has been my patient since about 2000. She had several strokes. She is diabetic, hypertensive and obese. She had developed stroke-related Parkinson's at one point, but it cleared up. She has neuropathy from the diabetes. She has developed moderately severe dementia. Her husband is an excellent care giver. He keeps track of everything about her. He always brings her medication list and provides an excellent history about her. He is actually also a patient of mine because he had Guillain-Barre syndrome a few years back - I see him for his issues about once a year or so. He had a heart attack a few weeks ago. They wanted to do an angiogram but his nephrologist wouldn't let them because he thought that the dye would ruin his kidneys and cause renal failure (he only has one kidney). My wife is fond of saying that if you worry about something it will be the wrong thing to worry about. Well, Mr. and Mrs. W have always been worried about Mrs. She has been "clearly" the "sick" one that they need to tend to. I guess they should have been worried about "The Other Thing". Of course the trick is that we never know what "the other thing" is going to be until it is.

Everyone is very busy worrying about all of the wrong things much of the time. I know that worrying is not good for our health. I don't know if they worry everywhere or if it is a very "American" thing. It seems that there isn't enough "inner peace" around these days. There is too much "wanting" and "worrying". I think that they are related. With increased "peace" we can accept the illness that is there now without worry. Those of us who can do that seem to do better.

I told AM yesterday that she would do very well with her knee surgery. I know that because she is that way - she accepts the illness that is there without worrying about it. It's a rare trait among my patients.

Wednesday Sickness Levels

KW and FW (married) were here today. They are both having nerve problems: one in the hands and one in the feet. PN was here, she has Parkinson's with autonomic features. She is fainting again. She doesn't take enough fluid. BM (I know, bad initials) came in for pain from neuropathy which was a little worse. KC was here. She has Lupus, and I'm worried it may have affected her brain. Actually she has seizures from it, but now something else is up. VR came for follow-up from his stroke. He has aphasia, so he can't talk well and he gets frustrated at times. He went to speech therapy and that helped. LW came in - I don't know what happened to him or what he had. I had thought at one time he had Parkinson's, but I was wrong. I think he had drug-induced parkinsonism that I diagnosed wrong. I'm not seeing him again for a year because he is doing great. CL came in because she doesn't want to have back pain after surgery that she's going to have in two weeks to take out her kidney (she has cancer in her kidney). There's not much I can do for that, though. HN came. Her husband (he was my patient) died from Myasthenia Gravis (MG) because someone told her that his symptoms of swallowing trouble were not related to MG so he went into a "Myasthenic crisis". Anyway, she's doing better now. She gets migraines. There were three new patients today, all with nerve problems - either neuropathy or post-herpetic neuralgia.
Everyone who sees me is "sick", or they wouldn't see me. (Although there are a couple of people who insist on coming in even though they are REALLY not sick. I've tried to tell them that they don't have to come in here anymore and they just show up sooner than if I schedule them for a follow up. They develop some sort of new problem.) But there is a certain degree of "sickness" that I expect. In the morning I look at the schedule and see who is coming. Then I know how much "illness" there is. Today there was a lot less illness than expected. This is good, because it's harder when there is more than expected.
Anticipation is very interesting. It puts the reality we experience in context. We need to try to see what happens as what happens rather than as what happens compared to what we are expecting. Obviously, I don't do that very well with my days. I anticipate how much illness there will be. So at the end of the day today I am happy because the day was "easy". No one was "sick". For someone to be "sick" they would have to be worse than I expected. If they are better than I expected, then they are "doing well" - that isn't "sick". Perhaps my happiness is a "good thing" but it isn't really. It's there only because the events were favorable compared with the expectations.
I'm going to try not to anticipate how "sick" people are "supposed" to be.

Holiday Dying

Happy Thanksgiving! Two people died. Neither one was a patient. One died Wednesday and one Thursday. They didn't realize, I suppose, that they were dying during a holiday. One person had a ten year old daughter, the other a fourteen year old daughter. It was Mothers of daughters that died. One had very malignant cancer throughout the bones which was discovered only a couple of months ago, and the other one had very severe liver failure. The liver failure mother died in surgery receiving a liver transplant. That's always so difficult, because people get very excited that there is finally a liver. There is a severe liver shortage (actually, there is a shortage of all organs for transplants) so people wait a long time for a liver. It means hope, not death during surgery.
I don't really like mothers dying. It's a difficult thing. It's hard to see the good in Mothers dying. Of course, we all die and we all know that.
It's hard to see the good in people dying at Thanksgiving holiday.

The greatest challenge that we face is the dying. There is only one way to react: be nice. If we can go to the funeral and say "I was the best friend that I could have been" then we can do no more. I see many people who are near death and they know it. Either they know because of their illness or they know because of their age. Those who report that they are "ready" are those who were nice. They did everything that could have been done to be nice to those who they met. Those who fear death, on the other hand, are those that were probably not as nice as possible. This is how we deal with our personal death. It's like that for the death of the others.

The part that has really no obvious solution is the empathy-suffering for the children. Now there are these two young girls without mothers. Of course, there's nothing that I can do for either one of them. I guess that if I could be nice to them it would help a little bit, but only a very little bit. It is our nature to want to take away that sort of suffering. Of course, we can't. The only thing we can do is to be nice.
It's not always enough, it's just all that we can do.

Togetherness

I see a patient and the patient's wife (and her Mother) are also patients. Today I saw both the patient and the wife-patient. Soemtiemes it works like that. I actually have several married couples that are both patients at the same time. It comes with the territory of working where there are many elderly who tend to have lots of neurological problems. This particular couple isn't that elderly, though.
The wife is lonely. She doesn't really feel close to her husband.
The husband is lonely. He doesn't really fell close to his wife.
They both wish that they could be closer to each other.
One had a stroke, the other has migraines.

I'm so used to seeing people who are lonely because they are alone that it is a challenge to care for people who are lonely even when they are together. There are many widows and widowers in my practice. I suppose that some of them were also lonely when they were together. It takes a great skill and acceptance for the people who are together to avoid being lonely. This is very true when one person has a serious illness. It is even more true when a person has a stroke when they are young. It is not expected. There is such great disappointment. People get hurt and they get angry. Life isn't really fair, but when it isn't fair to you, it's upsetting.
I tried to get them to be alittle bit closer today. I don't know if it will work or not. Sometimes we have to try different things. We have to start with very small tasks and be satisfied with the rewards. Mother Theresa said: "There are no great acts. There are only little acts performed with great love."
So I told them to go for a little walk together every day and get a cup of coffee once a week. To some people that may not seem like a very good relationship. But for me, it would be wonderful. That's because right now they have much less than that. I just want them to take one step forward. One step forward is wonderful. Wherever we are, if we see where we want to go we can just go in that direction - we don't have to get there. It's not about getting there, it's about going the right way. If you have a stroke or get sick at a young age it can throw you in the wrong direction very easily.

Talking at Support Groups

I went to a diabetes support group this morning to talk about the diabetic complications of nerves - diabetic neuropathy and carpal tunnel syndrome and autonomic dysfunction. It was a very nice group. There are so many support groups that aren't good. They are "pity parties". Everyone goes there for the sympathy of the others who are also suffering. When people have feelings, they want "validation". That means that there is a need for someone else to understand. "Please understand my suffering." This makes it somewhat better. The difficulty is that if everyone sits around understanding everyone's suffering, it promotes that suffering in a way. It's important to get past that, though.
The support groups also educate people. Education, of course, is always good. That part I've always liked but it can be overwhelmed by the idea that it's OK to sit around and suffer because everyone else understands.
Whatever we're experiencing doesn't exclude a positive experience. We know this from Hospice people who are "enjoying" dying. Or at least who are dying with grace. We learn how to die with purpose and meaning. This is the key, I think, to illness. So support groups need to have an awareness of this. In this case, with diabetes: "It's OK to have diabetes."
This group had a sense of that. So it was uplifting to see that. It is OK to have illness. It's a part of being human. It is our nature to become ill. So we need to find a way to be OK with that. We need to accept this as a part of our humanity. In being "philanthropists" (lover of mankind) we need to encompass all of humanity within our capacity to love. That's also a part of that "for better or worse...in sickness and in health" thing. We love the person we married even though they may be human from time to time. We fall in love with them when we see their innner divinity. That's easy. Then, when we see their humanity we have to stay in love with them - that's the real trick.
We don't really get to see our humanity as well as we do when there is illness at any other moment. So it has to be OK to have illness.

"Dementia"

TR was here yesterday. He has complaints about memory loss. He is doing very well, despite his inability to remember things. On his Neurtrax, which is the instrument I use to measure thinking, he scores 104 which is just above average. Average is 100. One standard deviation below normal is 85, which is considered "abnormal" on the test.
We have a classification called "Mild Cognitive Impairment". We have "Normal". We also have the famous "Dementia". "Mild Cognitive Impairment" means (as close as I can translate), in English: "There's definitely something wrong, but it isn't bad enough to say that it's Dementia. We have guidelines set up to determine that someone has dementia.
The reality is that people "slip". They don't generally go downhill in steps. The slide one point (a made up point of some sort of unknown unit) per month. The course is a linear one. Although different people decline with somewhat different slopes of the line, there isn't a huge variation. Almost all of dementia is "neurodegenerative" which means either Alzheimer's or Vascular Dementia (many tiny little strokes) or a combination of the two. According to our current standards each year 10% of people with mild cognitive impairment develop dementia.
TR has been a patient of mine for about two years. When we started with his thinking he was 102 on the Neurotrax. That means he's had no change in cognition (he has a better score, but since it's only a couple of points that's basically "unchanged"). I have another patient who has had a somewhat larger increase in his score.
Most of my patients with thinking problems are on some sort of Alzheimer's medication. Very few of them can maintain or increase their thinking, though. So it isn't a matter of just the medications we're using. (I do think that Turmeric and Barcopa are especially effective, though). I know that there are some people with MS who can repair broken brain cells better than others. I suppose that's also true with the dementia illnesses. Unfortunately, no one has really written anything about these people who aren't "sliding". No one even seems to acknowledge that there can be people who are "climbing" instead of "sliding". I don't do research anymore, so I'm certainly not in a position to tell anyone what to do research about. It seems to me that this small group would be very interesting to look at. I want to know why they're doing what they're doing and how I get all of my patients to do the same thing.

It's kind of frustrating sometimes that we don't seem to know anything. Then it seems to me that the most important questions aren't even being examined very carefully.

Breakthrough

There's a "major breakthrough" in the newspapers this morning. Of course, there are only "major breakthroughs" in the media world. In reality, we learn incrementally. I've been in the medicine game for over twenty years. In that time, there hasn't been a single "breakthrough". Everything that we've learned (an incredibly enormous amount) has been a painstaking development of accumulated tid bits of information and hundreds of publications. Anyway, CRP is a protein that is not as famous as some biomarkers. It reflects a state of chronic inflammation which we know is probably an important part of what we now call "metabolic syndrome" which is possibly a pre-cursor state of diabetes versus a chronic "not healthy state" (that's my term). In essence, it's a sign of being an American: non-exercising and unhealthy eating. There was a study of 18,000 people with elevated CRP and normal cholesterol levels who were given statin drugs. There was a 50% reduction in the risk of heart attack and stroke. This isn't a huge surprise. There's been data on this published before. There is also data on reducing these cardiovascular risks by treating people with "normal" blood pressure with blood pressure lowering medications. The mediterranean diet and the effects of exercise, if they're additive probably have an equal effect. We seem to be getting relatively close to figuring out that it's good to be healthy. We are developing all sorts of medications to combat the poisoning that we're doing. Soon, we're going to be just as good at giving ourselves chemicals to stay healthy while we poison ourselves and neglect our well being as if we were just healthy. And we're also going to figure out that it's all a spectrum. The healthier the better. We "just found out" recently (in another "major medical breakthrough") that we can improve outcomes by treating kids with cholesterol lowering medicines. So we can start earlier and earlier. Treating CRP is just one step down the chain from cholesterol. It's a way of starting earlier, because 50% of people who have a first heart attack have "normal" lipid profiles. I think before I retire we'll start giving infants medication in their formula to fight off the effects of poor health habits. (Oh, wait. We do that already - it turns out that breast milk is better for babies, but we can avoid that healthy behavior, cause harm and then add chemicals!)
I try to get patients to exercise and eat right. But this is definitely not the American way. It's very hard in this culture to do that. We're not structured for it.

Quite a Compliment

MG came yesterday. She has some very odd ideas about what I've done for her. I admit that I have given her some good medical care. It has helped her. We've improved the quality of her life. She had great pain which we reduced, even after other physicians weren't able to. But my care wasn't extraordinary. I'm happy with it it. But it isn't one of the cases where I am so proud of how well I did from a medical standpoint. However, she has great gratitude. She thinks I have done great things for her.

We were discussing a new machine one of my colleagues has which I think is fantastic. I would love to have one, but it's beyond my reach. It's not a machine that we get reimbursed for. It absolutely should be. However, in the infinite medicare wisdom it's considered part of taking routine blood pressure (it's actually far from it). I was very shocked when she offered to split the cost with me.

I run a for-profit medical practice. Donations for non-profit medical clinics and hospitals are common. But donations for my practice are unheard of. Donations for any practice, I think, are unheard of. I've gotten some thank-you cards from time to time. I've even gotten a few little gifts from time to time. It's wonderful to know that some patients appreciate what I do.

Of course, I appreciate what I do. Even if no one ever said "Thank-you" this would be a good thing to do. That is because it is a great process. Actually, it's sort of a privilege to be able to do it. It's challenging, of course. But it's a good thing to do. It's a good endeavor. One can see directly how the work you're doing helps people. And there are times when you save lives and times when you do great things like make people in wheelchairs walk again. It's not an every day thing, but it's so much fun when you're a part of that.

This business of someone offering to help me buy a machine for the practice is entirely overwhelming. I'm not even sure I remember what I said. My wife asked me "What did you say?" I can't honestly say I know. Patients are surprising sometimes. People are nice. I like people. I like being a doctor. Sometimes the patients can give you strength in the face of what may seem like overwhelming challenges. It's actually a very rare day that I don't have at least a few patients who are grateful for their care and tell me. On the other hand, it's an extremely rare day (so far about once every fifteen years) that a patient offers to help me buy a machine that I can't afford!

Sick Monday

It was a sick Monday. M who actually is doing fairly well told me that his wife had died. I didn't know it. She had been a patient of mine for about five years or so. She had severe spinal stenosis and back pain. She died from a stroke. He's very depressed about this. It's made his tremors worse. That's a tough patient. Dying isn't easy for families. It would be nice if there were a way to make people feel better, but there isn't.
Then AB came in with a new diagnosis of brain tumor. It's not a metastasis, it's a primary brain tumor: a "glioma". That's tough because he's going to die pretty soon. Probably in a couple of months. He's going to have progressive weakness and thinking trouble. The weakness is on the left side. It started about one month ago.
PF was also here. She has diabetes with such severe neuropathy (she's had it thirty years) that she can't walk anymore. She can't even transfer in and out of the wheelchair. I was hoping she had developed some treatable neuropathy issue, which happens. So she came in for nerve testing, but that's not what happened. So she just can't get herself in and out of the chair now.
And CM was a patient with a new diagnosis of Alzheimer's.

Some days there are just too many sick patients. It's an excess sickness load. It can make a doctor feel tired. The curious thing is that if I do a great job and someone is totally cured, I never see them again. Of course, it isn't me as much as the illness that people get. There are days when rare things happen. Rare things have to happen sometimes. They aren't often, but they can't be never either. Otherwise, rare things would never happen and they wouldn't be rare things. So there have to be rare days when there are "too many sick people". Of course, everyone I see is basically see is sick. Every once in a while I have a patient who comes in and says "I feel great. I don't know why I'm here I almost cancelled this appointment." But this isn't something that is frequent. I guess most of the patients who feel this way cancel their appointments.

So what's so good about the "too sick days"? I suppose they test my strength and build my character. But they are a reminder to make sure you stay honest. It's always possible for the diseases to get the best of us. You need to respect that things aren't always easy. It's not good to get into a "groove". If you aren't shaking it up, then something will come around to help you with the shaking. Shaking is an important piece of living. Otherwise, it's boring. That's why some people go out and climb up mountains. I think being a doctor is better so I don't climb up mountains. Besides, I'm not a fan of great heights.

medicare - again

Yesterday the Senate passed legislation to prevent a decrease in medicare payments of 10.6% for physicians. A 10.6% decrease in PAYMENTS for my practice (overhead of 60% - which is fairly typical) would translate to a 75% loss in income.

The fight was between primarily Republicans backing the private insurance companies that handle medicare contracts (Medicare Advantage) and doctors (AMA). This time, AARP joined with the AMA because they were concerned about the possibility of decreased physician access.

I know two Internists who were going to stop taking new medicare patients (and still may) -- IN THIS TOWN! Others are considering retirement. Some are considering moving. I know many physicians who work in non-medicare saturated "markets" who already refuse to take medicare. The Mayo Clinic in Jacksonville doesn't take medicare.

Senator Kennedy showed up to vote for the doctors with a brain tumor. Nine republicans (including our not so illustrious Martinez) changed their votes due to too much voter pressure. Bush has vowed to veto this bill to protect his Insurance company friends. (Senator Frish as everyone remembers never had any conflict of interest despite the fact that his family owns Columbia health care).

Things are really getting out of hand. There is a major health insurance crisis here. Right now, the doctors are suffering. I know Internists working 80 hours per week making $125,000. That's a lot of money. Still, it's $62,000/job (they're working two full jobs). A medicare follow up visit charge of moderate complexity is $80 while cleaning the dryer vent is $90. Pretty soon medicare patients are going to start to suffer. A 25% pay cut to these friends of mine would have meant that they were supposed to be paid $46,000 for a full time (40 hours/week) job. I suspect doctors would be leaving in droves under those circumstances. They would have to if they have families.

In January 2010, doctors are now "scheduled" for a 20% cut in pay, and this fight is going to played out all over again. We have had no raises and several "small" cuts (one was 5%) over the past decade while costs just keep going up. People are either retiring, leaving medicare, or looking for other work.

It's time for people to start fighting against the insurance companies. We should have seen this when they refused to pay for the damage that was done during hurricane Katrina.

Pain

RL, WH, AC, RS, DL, KS, WO, BK, JR, TW and MP: 11 patients today were pain patients. Back pain, head pain or leg pain is what they had. Except for one person with pain all over the place. There is a man in Worcester MA, Jon Kabbat-Zinn who runs the multi-disciplinary pain center. He teaches meditation. He believes that we should accept pain and welcome it. This relates to the process of labelling it as bad or good or neutral. We can have pain without suffering. People have made this distinction. The most famous time is in childbirth which is thought of as very painful. Generally, it isn't thought of as suffering. That's because the experience seems so meaningful that some people even "want" the pain component. They refuse analgesics.
I don't know what skill Kabbatt-Zinn has but I don't believe that I could get one of these patients to accept their chronic pain. I have some who would. These people just want it to go away. So we try with pills to make it better. Several of them are a great deal better, because we have such great medications. Several of them are not better. I wish that they could accept that they have pain and divorce it from suffering. It would be nice if I knew how to teach that.

Fascinating Information

Fascinating information has emerged. There have been several trials of medications revealing unexpected results. They keep on coming out. I know the reason: the sophistication in analysis of outcomes research. We are getting better at finding out what we want to know. Years ago they made up a new composite outcome measure. This means that when we do a trial we measure something. This is called the "primary outcome measure". The one we made up recently was "Vascular event". We now use this consistently in trials. It is the combination of either death or stroke or heart attack. Is this sensible? I don't know what this is. I know what stroke is. I know what death is. I know what heart attack is. But I don't know what the combination of all three of these is. What about very mild heart attacks? If I prevent many very mild heart attacks but very few deaths and major strokes is this the same as if I prevent many major strokes? I don't think so. We have another trend which is to measure the carotid artery thickness. If we prevent increased thickness (amount of athersclerosis) then this may indicate a reduction in "vascular events". So we don't even have to measure "vascular event". We also are using cholesterol levels instead of "vascular events" as a measurement of success.
A series of trials now is showing that our "substitute measures" are not working out as we had thought. Zetia was very effective at lowering cholesterol, but not the substitute measure of carotid artery athersclerosis. Now it's getting worse. Medicines that lower sugar more in diabetes are causing increased rates of death. Medicine combinations that lower blood pressure better than one agent alone are causing increased death rates than one medicine alone.
This is a problem because our insurance industry is getting very aggressive about measuring "quality of care". They are pushing "pay for performance" where physicians get paid more (or less) depending on whether they are meeting the appropriate outcomes. This pressures physicians to "perform". However, it's turning out that we don't actually know how we're performing. Things that we think are good are turning out to be bad. Perhaps there are a few "bad doctors" who are actually doing a better job at things. I've come up against some of my colleagues from time to time. I guess I don't know who is right and wrong. But a lot of times I want blood pressures "too high". That's because the medications are causing dizziness. They other doctor wants to have "high quality care". I want the patient to avoid falling and breaking their hip. But my quality of care is not good. Except now it's turning out more and more that we don't really know. There is no study on lowering blood pressure in dizzy patients.

Age

JF was late today because he was lost on the way here. He thinks he's losing his mind. He has neuropathy and tremors and back pain. He told me that he doesn't like the treadmill at all. He doesn't want to exercise and it's "hell" getting old. He thinks of aging as a series of giving up things. He's thought it ma be better to die young. I hear this.

Probably aging is our greatest challenge, and it's our final test. Things change. I wouldn't say that we just give things up. I would say that things change. We change. Our perceptions, skills, priorities and environments change. Still, throughout time we are either growing or we aren't. To me, if we aren't growing then we're shrinking. I suppose there should be a neutral option: non-growth. However, I think that non-growth is shrinkage. Over time, the challenges we are faced with increase in complexity and severity. So if there hasn't been growth there has been a relative decrease in our ability to handle our lives. A person with the capacity of a ten year old can't handle the challenges of a thirty-something year old person. So we have to keep growing to keep up. "Growing" isn't about skin or looks or athletic capacity. These things tend to degenerate. Our nature is such that bodies degenerate. Then, when they are old enough they die. Otherwise, they suddenly break and we die. The other option is that we break them through carelessness or war or something.

Aging has to be about growing. We have to be big enough to go beyond our physical existence. If the only point of it all is to be a body, a series of cells functioning to perform activities related to motion, there isn't much beyond youth. But it isn't that way because there is also cognitive and spiritual function. That is where the growth is. If we neglect these areas, then as the bodies degenerate we are left with very little. Interestingly, in the case where we also lose cognition (which in some sense is purely a physical process) there is nothing left except the spiritual component of a person. So we should grow that. We should spend some of our time - some of our lives - doing that. It gives aging purpose. Then, we aren't just going through a series of giving things up. We're going through a series of trading. We are trading lifetime for experience and growth. The trick is to get enough out of the trade.

The Healthy Journey Diet

The healthy journey book is at the editors. They e-mailed me today that the preliminary evaluation begins in three to four weeks. The guy who samples it to decide which editor to use thought that it lacks a little bit of "personal connection" with the author. So I guess I'll have to add that. What's so strange is that over the seven years I've worked on it I've removed a great deal of the personal parts of it, thinking that they weren't really relevant to what I needed to tell people. I know what he means, though. I guess it got off balance. I e-mailed the book to my brother-in-law. He said he would read it. It's exciting to be done with the writing part. I'm not sure how long editing takes, but I'm sure it's not as long as writing it takes.
I want to start on writing "Why Alzheimer's is Great". That's not an easy book, though. I suppose I should get this first thing published first. Also, it's that horrible time of studying for the re-certification boards. They ask a lot of very basic scientific questions that I don't keep in the inside-the-skull computer. I keep them in the books on the shelves and computer on the desk computers where they belong. So I need to do data transfer. It's very time consuming.
The office is starting to slow down a little for summer season, so time should start to appear.

Tough Days

Some days you get reminded that the universe can decide to be too difficult. Yesterday there was BG who can't probably live much longer. He has been in the hospital for about one week four times over the past six weeks. He has a very weak heart and bad lungs. I see him for very severe neuropathy that is hereditary and can't be treated. He is so weak that he can barely walk or use his arms. He needs a wheelchair to get around his house. I saw a truck driver for Waste Management who has destroyed his spine from bouncing in trucks for twenty years. He is young but has so much pain that he's going to have to go on disability. I saw PM who has MS. She now has a very severe cancer in her sinuses which will surely kill her soon. Her primary care doctor hasn't even seen her about this, and without any thought she has been shuffled into the cancer doctors for a chemo/radiation/surgery plan. But no one stopped her and told her that no treatment is also a very good option for her. That's the job for the primary care doctor. I was lucky because I was able to get someone to see her for me. It was extremely kind of him. I saw KC who is very young, having yet another severe flare up of her Lupus. She really needs to go to a big center for a second opinion, because the Lupus is eating her up. GL came in for his severe Alzheimer's with hallucinations. He has developed very severe dizziness now, which is threatening his safety since his judgement is bad and he tries to walk when he can't. It's very dangerous. I saw KS who is only twenty-one and was in a car accident three years ago. She's had severe pain which she's treated by buying narcotics from friends at work and is now addicted.
I see disease every day. It's my job. Some days are tough. There is too much illness in one day. It can make a person tired at the end of the day. There are these doctors who are just emotionally blank with their patients. They don't have to go through this sort of thing. But they miss most of what I consider the good part of medicine. So it's the price we pay. Luckily, these days are somewhat rare. It's rare that I get more than two "disasters" in a day.

What a Mess

BQ, MR and HN were here yesterday. All three of them have complaints about their physicians - either past or current. BS was here yesterday and he has a lot of physican friends. He is a businessman and spoke extensively (I ran late) about health care finance. Many physicians are leaving medicine or are frustrated. The economics are very challenging. I spoke with a physician friend yesterday who has stopped going to hospitals entirely and has stopped taking any insurance other than medicare. He is planning to stop taking medicare as well. He also has no malpractice insurance. Several physicians in this area no longer have malpractice insurance. Personally, it seems to me that it is insane to have for-profit health insurance plans. It should be illegal. All insurance plans need to be mutual companies, owned by the insured. Right now they are in a bind. They are supposed to make profits for the shareholders. The shareholders own the company. Physicians are now actually called "insurance implementers". We became "health care providers" a while ago. Some people now call us "prescribers". These names allow people to see us as cost centers or profit centers. This treatment changes our self-perceptions and behaviors. Our overall quality is decreasing. Patient satisfaction is decreasing. The democrats want universal coverage through some governmental agency. McCain wants increased competition. Unfortunately, no one wants to tackle the fundamental flaw in for-profit insurance. No one wants to tackle the fundamental flaw in having "consumers" (patients) use services that they don't pay for. No one wants to tackle the incentives that "providers" (Physicians) have to increase "utilization" (health care provided) including fear of malpractice and increased revenues. So nothing that the government is planning is going to help anything in the near future. Physician groups just want to protect their incomes. Patient groups just want to continue to pursue unlimited care without any financial incentives. Insurance companies just want to maximize their profits by decreasing the amount of health care provided while increasing premiums. Politicians just want to pander to the electorate.
It's quite a show. If it were a movie, it would be one of those suspense type of things where it just doesn't seem like things are going to end well. It's a little like "The Firm", I suppose. I wonder where this is all going to end up.

Another Day

Today there were three cancellations at the last minute. There were two patients who had appointments but weren't on the schedule. We give them an appointment, but we don't put it into the computer. So I ended up net minus one. It's a good reminder that the schedule can't tell you what's going to happen today. Sometimes I want the schedule to tell me who is coming and when. It's important to avoid that sort of desire. There is no order that we can impose on the universe. It does its own thing. We just have to be there when it happens.

I saw a new patient today who has been treated very aggressively for several years for nerve problems. She says "I have sciatica". This, in my opinion, is the greatest problem. It has really confused the doctors. They have imaged her spine and they have treated her with spinal injections. She came to me before surgery, which is her next step. The thing is, people are reacting to the term "sciatica" which is a term that we use. It's a medical DIAGNOSIS. People (several of them) have just accepted this as the diagnosis. I don't know how carefully she's been examined. I think she has a hip problem. That's because when I touch her hip, she jumps off the table. This is not a sign of a problem in the spine. It's a sign of a problem in the hip. This is nothing fancy. It's third year medical school simple stuff. I'm just glad she came in here. I told her not to have surgery on her spine. It's not a good idea.

I saw a patient today who has had horrible life-long migraines. She started accupunture recently and it has been very helpful. I love when that happens. It doesn't always work, but I love when it works. I use so many herbs and vitamins, and I'd like to use more accupuncture too. The only thing is that a lot of people are scared about the needle part of it. We have a chinese doctor in town who is very good.

Lifestyle

Almost every day there is more data on the way that we behave. On NPR today they were talking about McCain's plan for health care. He wants to change tax rules so that individuals purchase their health insurance and there are more medical savings accounts. He thinks that if the consumer purchases health care directly they will utilize less of their money. We use more of other people's money than we use of our own. We want others to take care of our needs and desires.
There are two new important articles on alzheimer's and mild cognitive impairment. This isn't really news, since it just adds to an ever growing body of literature. People who exercise regularly had lower levels of cognitive impairment. People with cognitive impairment who exercise experienced significant improvements in thinking.
People who take more than two alcoholic beverages per day developed Alzheimer's on average five years earlier than those who were matched for other risks.
People who smoke experience Alzheimer's about 2.3 years earlier than those who don't smoke.

The news is shocking! If we take care of ourselves we do better than if we don't.
Health care costs too much and we aren't getting our money's worth. This is very complex. For one thing Insurance companies are just ridiculous. The whole concept is ridiculous. Their profits do nothing to help take care of people. McCain's plan completely ignores the true nature of health care. Actually, so do Clinton and Obama's. We spend most of our money in the last year of life. If you really want to get our health care costs down, you need to increase the notion that it's alright to die once you are very sick. That's where we waste the most money. We keep going when there's little point. The other place we waste money is that people generally don't have enough faith in physicians - in people in general. People are fearful and want tests to prove tha the physician is right. When I tell people they have Parkinson's they want to know what test I am going to do to show that this is the case. But there is no good test for Parkinson's. I constantly see Parkinson's patients for a second, third or fourth opinion. But the accuracy of diagnosis is very high. So fear causes a lot of the cost. So does litigation, which is driven by anger.
However, most of our cost comes from chronic disease. Chronic disease like heart disease and diabetes is driven by a failure of our society to take care of ourselves. Our lifestyle. We are more obese than other countries. We are sicker. We are a sick society. People here are isolated. I see a great deal of depression. There is no community. There is no support. People are alone. So they don't take care of themselves. So they get chronic illness. So it costs a lot of money. They are alone so they are scared. They aren't happy with the life they've had, so they don't want to die.
It's all about lifestyle.

Thinking Things are Good

A patient today told me that everyone is wanting to be a victim of circumstances, rather than realizing that they make their own conditions with their thoughts. I've had that sort of thinking many times. He was a very succesful business man. But I've seen a lot of people who just don't have that kind of opportunity. They don't have the ability to think that well. So they can't see that their reality is created by their perceptions. There is no alternative for them other than to be the "victim" of what happens. However, the notion that we create our lives is very limited. It fails to respect that there is a process that occurs over which we are powerless. That we just get to observe. Things happen. Then, we have to try to figure out (if we can) why they're good. It's harder in some jobs than others. It's hard in medicine. Why did my patient's wife get pancreatic cancer? How is that good? Why do I have a patient who keeps on getting shingles every four months? How is that good?
It's important to know that if I can't figure out why something is good that it's me: I can't figure it out. I'm not smart enough. That's different than deciding that the thing is bad. I'm not smart enough to know what's bad and what's good. So arbitrarily, everything is good. That's not to say that everything is all good all of the time. It's just that everything (the whole thing, not every single thing) is good. In that decision we create our reality to some extent.
Anyway, I saw that patient today. Then I saw a patient who is in her early thirties and has disabling Lupus. She's been my patient for about ten years. She's just sort of declining both physically and spiritually. And then I saw my ALS patient who can't move his arms and can very barely walk at all. And I saw my patient with post-traumatic spinal cord injury who is in a wheelchair. It's hard to help them with that sort of positive thinking. You can't just be a polyanna with the patients all of the time, because that's annoying. Sometimes it's important to acknowledge that things just don't seem fair. They don't seem right sometimes.

Six month Follow Up Visits

My last patient today was Mrs P. She was supposed to be a very easy patient. She has restless legs which are well controlled. She was here for a six month follow up, which means she's in pretty good shape. Nothing is better than a six month follow up except a one year follow up. Actually, the best thing of all is the "I hope I don't see you again" never follow up. But then again, those patients aren't really "in the practice". Anyway, her restless legs aren't that great, really. They're bothering her more. But she is under some stress too. Her husband is very ill. He is very weak and has been falling. He has had many surgeries. The VA eliminated his pension after review of his case, and they don't really have enough money. They are investigating a reverse mortgage to make ends meet. Anyhow, she got ill in October with coughing. She had no fever, but was very short of breath. Her doctor thought she had pneumonia, but her X-Ray and her Cat scan were normal. Another doctor thought she had bronchitis. But she hasn't gotten any better, really. She still coughs. She feels weak. She is always short of breath, and it gets worse if she lays down. It's not worse, really. But it's certainly not any better. And her restless legs is somewhat worse. I don't really understand why, but neither of the other doctors got her an examination of her heart. I think she really needs that, because all of these complaints could also indicate a heart problem. That wouldn't surprise me. The medicine she's on, Lyrica, is also a concern. It could do some of these things as well. Well, it wasn't really a routine six months follow up after all. You never can know what to expect. You can't really predict anything at all, it turns out.

Second Opinions

I sent M for a second opinion at a university teaching center. I had originally sent her to one of our local rheumatologists. He didn't think very much was wrong with her. I'm convinced she has a rheumatological issue. So I sent her to the university. They think she has Sjogren's syndrome. That makes sense to me. I have been dealing with her pain now for over a year. I keep thinking that it has a rheumatological basis. But the rheumatologist says no. It's frustrating. Now, I am terribly relieved. So is she. We can proceed with an intelligent treatment, and she's probably going to get a lot better.

Sometimes I don't like second opinions. I just sent someone else (one of my patients) for a second neurological opinion at a university center. They thought that I have it wrong, and gave him a different (much better) diagnosis. I think he has ALS (Lou Gherig's disease). They don't think so. They think he has Isaac's disease. However, I'm not sure yet that I'm totally convinced I'm wrong. Time will tell. Still - I hope I'm wrong. Even so, it's no fun to be the one that got it wrong. But here's the thing: if it helps the patient, who really cares?

Some doctors don't want the patients to get second opinions. Those patients should get a second opinion.

Giftim

R was here. He has had a stroke. He has severe chronic depression which he's had from his stroke for the last decade or so. He is weak on his left side, but still can walk fairly well. He can't use the left hand for much. I have another patient with nearly the exact same stroke, but he isn't depressed over it. My wife made up a word: "giftim". It refers to one who takes on the role of a victim as though it were a gift. She points to the fact that there are people who actually want to be victims. It justifies their lack of effort. It justifies their depression. It explains their circumstances. So then, they have nothing to do but suffer their victimhood. They go about telling their story, and everyone has to give them sympathy. The world is held hostage to their suffering. The world has to give them care and compassion. After all, if one doesn't have compassion for the person with a stroke, who is that person? The problem is when we see two patients with nearly the same stroke. One is great. One is independant and happy. One is dependent and depressed. It isn't the stroke, really. It's the giftim. It's a good word. It helps with insight into why there are some people who almost seem that they don't want to improve, don't want to be better, don't want to see the positive part of things. Whatever it is that we're faced with, we have to avoid being giftims.

Today

One of my patients -M came today. He has MS. He just found out that his wife has pancreatic cancer. Yesterday, C came in and his wife has pancreatic cancer also. That's too much pancreatic cancer. It's hard to watch them trying to be strong. Men try to be strong when their wives have cancer, but it's hard.
The staff is wonderful. They are doing great. It's a huge difference. The office is getting very organized.
Tomorrow I meet with the hospital administrator who wants to rule the town. One of my colleagues calls her "Queen ___". I'm very happy that after she got all of her employees to stop sending all of their patients here I am doing well. I think that will create a situation in which she has no power to influence me. Unfortunately, I don't think she'll have any influence over the other two neurologists in this town. I don't know how well her plans were thought through.
One of my patients called upset because I told him that the medication I was giving him would be inexpensive and it was $50.00. I have to be careful about that. To me, given what most medications cost that's inexpensive. I found it cheaper on-line for him. Still, I need to be more aware of what these things cost.
That was today.

Disease Burden

Today, there was too much disease. Some days are like that. It's not that I don't understand the purpose of disease or our need for it. It's just that there are days when there's too much to look at.
C came. He has been a patient for a long time. He has a severe pain syndrome associated with a stroke ("Dejerine-Roussy syndrome). Since I last saw him, his wife developed cancer - adenocarcinoma. She is not doing well. Therefore, he is not doing well. He is one of the people that will die shortly after she does. I know this. He loves her and they are no longer two. "The two shall be as one." So they are one.
J came. Her husband has end-stage Alzheimer's and he can't walk. He has severe constant back pain and he has severe heart disease. She does nothing but take care of him and hasn't been out for four months. I told her that she isn't helping him at all. That is shocking, but I said it with loving-kindness. If she were him and he were her, she wouldn't be happy at all that he was doing what she's doing. She would want him to take care of himself. She never thought of it like that. I've never explained it like that before. It works, though. It's the truth. If I'm like that, I want my wife to take care of herself. I don't want to know that I'm dragging her down with me. Anyway, I want her to think about letting him go. We don't use enough Hospice for Alzheimer's disease. We use it more for cancer, but this is wrong thinking.
R is a new patient I saw. She is 30 and describes herself as a "bitch". She has uncontrollable attacks of inappropriate rage. She has a fourteen month old child. Her marriage is struggling. She came to see me because she wants these episodes to be something other than psychological. She wants them to go away with a pill. She wants them to be explained by something that is not her fault. She has had plenty of head trauma, so it's possible that there is some "brain damage" (a useful English word that means very little to me). But I fear that this is far more likely just plain old "can't handle life well syndrome". She has had more suffering than she has suffering-healing skills.
Today is day two of new staff. They seem like they are going to be great and increase the patient's care.
The new "favored" Neurologist is now in town. All of the doctors who work for the hospital stopped sending their patients here. I'm still busy. I'm very lucky that it didn't really hurt. I know that the hospital CEO was really hoping to shake up my practice so that I would be influenced to try to get into the "good graces". She plays hard-ball business. She is good at it, too. I play take really good care of the patients. I'm good at it, too. We aren't playing the same game. I think I understand the rules of her game. But I'm not really sure that she understands the rules of my game very well.

New Staff

We have new staff today. We went from one employee in 2001 when I started the practice to two, to three, to two to three, to two. Then, we had three, then four. Then one left and we had only three. Now two started and we have five. This is very exciting. I am trying to get the staff to understand the notion of taking care of people. I think we have been generally "under staffed". This creates too much work per person which reduces the care output per person-patient encounter. People think that the doctor takes care of the patients. This is wrong thinking. The whole team takes care of the patients. I overheard one of the new staff talking on the phone to one of my patients. She was very - VERY - nice. That makes me feel good. I got to tell the checkout person that they are to check the patients out when they check the patients out. That means that they don't answer the phone and put people on hold. I'm optimistic that this is going to increase our happiness production for people who come. People who come here are sick. You can't go about doing a "job" and completing tasks when someone who is sick is here. You have to stop what you're doing and take care of them. Otherwise, they aren't taken care of. If they aren't taken care of, then what are we doing here? Anyway, hopefully this will work.

Drugs

I had two patients today of concern. One time, I dismissed a patient from my practice because of her husband. He wasn't giving her the medications that I wanted her to have. He was giving her the medications he wanted her to have. It wasn't working. I also think he was probably abusive. I have a patient with Parkinson's and it's very severe. He's old and he has severe dementia. His wife is giving him medications for delusions and hallucinations. His sons think she gives him too much medication. She asked me for something, and then she asked another doctor for something. It's never a good sign when there are two doctors trying to treat one condition. It's possible that she's treating him herself. Then, at the end of the day, I had a patient who has chronic headaches that don't respond to anything except narcotics. That's always a problem, because chronic headaches respond well to many other things. I think he just wants narcotics. I had to send him to another doctor, because anytime I don't completely trust a patient I know that I'm not really the best physician for them anymore.
There is a lot of abuse of prescription drugs by the patients and their families. It's actually very interesting. I'm not sure I entirely understand the whole thing. I think it comes from suffering and not wanting to be entirely aware of what reality is going on. Studies on drug addiction show changes in the way people's brains work. This is especially true with opioids. So at some point, the addiction actually changes the brain and promotes itself. It becomes its own disease. Then, it's very hard to sort out the psychological disturbance and the chemical imbalance. Some people can't function in our world. I wonder if there's something really wrong with these people? Maybe there's something wrong with the world because it can't fit them. Different cultures have different amounts of drug abuse. There is a high rate of drug abuse in America. Whenever there are cultural differences that are of a large magnitude, it raises the question of the role of the individual.
Anyway, these patients are not easy to treat.

I'm Ready

Spongebob Squarepants is a cartoon character. Cartoon people are great. They are uni-dimensional. Anyway, he is always going to work chanting: "I'm ready! I'm ready!" It's a sing-song type of thing. He is a grease cook. He loves his job. He's always singing and happy and ready. Today, I'm just not ready. What I want to do is go to Selby's gardens (a botanical garden) with my wife and roam around the orchid house for a while, take pictures, and read. We could sit and have a cup of tea there. That's what I'm ready for. It's not that I don't love my job. It's not that I don't like the patients. It's just that sometimes a work day comes on a day that should be a get away and rest day. Then what are we supposed to do? I think I'll be able to do a good job. I hope it will still be my best. I think, though, on days like today there is a slight sparkle that isn't quite there that you can't completely fake. I wonder how actors and actresses on Broadway do that? What do they do when they're not ready. Everything depends on that extra sparkle. There is a piece of your soul that is used to get certain jobs done. Being a doctor is piece entertainer. You have to make patients feel better somehow. That's what entertainers do: make people feel better. So they are the same. The difference is that entertainers take people away from reality into fantasy. Doctors make people feel better in the face of reality. It's a subtle distinction. But I think it's harder to have happiness in reality than in fantasy. That's why you make a lot more money as an entertainer: you create more happy people. Today, I think my wife isn't ready either. I think she'd rather go to the beach than come in here and run the office and make sure everything goes right. I bet I could talk her out of the beach and into Selby's though. Actually, she needs new shirts. I could talk her into going to buy new shirts. Sometimes, I wish that I could just cancel the day and play "hooky" like kids used to do in school. I did that once in my junior year of high school. I got caught. The problem with it now is that there are patients who need to come here. So it's not an option anymore. Perhaps I should call SpongeBob and find out his secret. Sponges don't actually have brains though. Actually, invertebrates don't generally have brains. They have collections of neurons. Anyway -- animal neurology is an entirely different issue. I digress.

Another Day

K came today. Her son died suddenly. She said that when you're "old" (she's in her eighties) you come to expect these things. She isn't really depressed about this. That is something that always surprises me. I've had a few patients who have lost children and were "OK" with it. I don't know how, but it's very inspiring. I'm pretty sure I couldn't do that. They have great strenght. I have one patient who comes every two months. He is 95 years old. He only needs to come here once every six months. He wants to come in every month. So it's a compromise. He asks me lots of advice, but doesn't follow most of it. I'm not sure why he likes coming in here so much. He always tells me how wonderful it is to come here and how important I am in his care. I can't really believe that, because he doesn't usually do what I tell him. That's a funny thing. My very obese stroke patient came in again. He has very severe apathy. He just doesn't care about anything. His wife prepares all of his meals. I've been talking to them about his weight for years. Today I told HER to stop giving him all of this food. He can't shop. He doesn't get his own food. So everything he eats, she gives him. I put all of the burden on her. We'll see how that works. She gives him ice cream every night before dinner. That's not good at all. I told her that's going to give him a stroke, so it's not worth it.

Buisness

There is a great new business opportunity for me. Most of the physicians in town are now employees of HMA, the company that owns the hospital. The new CEO came in and started buying all of the practices. Frank, my old partner, says that they want control. Anyway, they haven't had very much luck getting the Neurologists in town to do what they want. So they hired a new Neurologist to work for HMA. She is their employee. She starts on 1/28. Effective 1/28 none of their doctors have any patients referred to me. That is a little odd, since in a typical week that group would have about eight new patients here. But they are going to send people where their employer wants them too (obviously).
This gives me more time to find other business. That is a good thing. I never have enough time for my other interests. I've been trying to get this book on being healthy done for years. Perhaps I finally will have some time. Or maybe my self-referrals will pick up. Who knows. It's exciting. I am wanting to get more into the herbal side of medicine as well. That takes time. There's a lot to learn in that area.
When things change it is always an opportunity. Medicine is like everything else in that regard. As soon as the book on being healthy is done, I really want to write one on why disease is so good. There are a lot of books out about why death and dying are good. But there aren't ones on why diseases are good; especially particular diseases. No one thinks about that; no one writes about that. Everyone accepts that all illness is bad. But that isn't exactly true. It is easy for people to say it's bad that there is politics in where the patients are going to be referred. It's easy to say anything is bad. But it isn't bad. We just have to always work a little harder to see how things are good when we want to think they aren't.

Fear

People are afraid. There is so much fear that comes into the office. Mrs. H came in yesterday. She had urinary incontinence. She went to see a physician who was going to do a bladder suspension procedure. He had to send her for routine cardiac clearance. The cardiologist who saw her found an abnormal stress test, so he had to do an angiogram. After that, they wanted to do emergency open heart surgery for a 6-way bypass. She didn't even know that she had any heart disease.
That is scary.
She had surgery, and she is doing very well now.
We might suddenly die. That's the tricky thing. It makes people afraid. So we have to be able to accept this and still be happy from day to day. I don't really think this is a terrible thing. It's a constant reminder that we have to do whatever we have to do to be good right now. There's just no time to waste. I think the real problem is that too many of us are spending too much time wasted, thinking that we can't die right now. But that's a scary plan.

Money

Mr. T came in Monday. He is changing his primary care doctor and he is just not going to see his endocrinologist anymore (he has very severe diabetes). He stopped one of the medications that I give him for his neuropathy and spinal stenosis. He didn't have a scheduled appointment and he wasn't having very severe pain. He just wanted to come in to work out a payment schedule with me so that he can see me. He has joined one of the medicare HMO plans. None of his current physicians are participating in that program. They won't pay much (about five dollars) for those visits. He is allowed to still see these doctors, he just has to pay for it "out of pocket". The reason he went with the HMO plan is that they pay for his diabetic supplies, and traditional medicare doesn't. He gets about $1,000 per month from his social security. He had an IRA, but that just recently ran out. His rent is $400/month and his electric is about $100/month. He has a water bill and a phone bill. He also pays car insurance. He is complaining that there isn't really much money left over for food. He was spending about $160/month on his diabetic supplies. The HMO will pay for that. He makes too much money for food stamps. He is too proud to go to the All Faiths Food Bank. He is a WWII veteran. He used to work on the side as a handy man, but I told him to stop that about one year ago, because I was afraid it was going to be too dangerous for his back. When he stopped doing that, his back got much better.
I'll probably charge him about $20 per visit. If I charge him lower, it will hurt his pride. That's about all that I can do.
There's something wrong with medicare, isn't there?