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.