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?