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.
Thursday, June 26, 2008
Monday, June 16, 2008
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.
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.
Tuesday, June 10, 2008
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.
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.
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