Little pieces of RK

RK died this morning. He just fell down and his heart stopped. I took care of him for myasthenia gravis. He had a terribly challenging myasthenia. He didn't have the usual findings, because his blood tests (antibodies) for myasthenia were negative. His chest CT scan was also negative. He was very difficult to treat because the medicines didn't work very well. He did well with plasma exchange, but that didn't last very long. I did send him over to Mayo for a second opinion. I'm not really sure that they helped. I tried to send them over to a friend of mine who I think is a really smart neurologist for a second second opinion, but he and his wife didn't want to go. I tried treating him with a few different things, but none of them really helped until we came up with plasma exchange. I really expected him to do well and gain his strength back. I was totally wrong, though. I don't think he died from anything I did wrong. I reviewed his chart and I think I did OK at treating his illness. The only thing I can think of is that he could have had a pulmonary embolus which is a clot in your legs that then goes to your lungs that then causes a low oxygen in the blood which leads to an irregular heart rhythm. He didn't show any signs of a blood clot in his legs, though. Also, he still walked a lot (with a walker) which means that it wouldn't have been sensible to put him on a blood thinner to prevent that. So if that's what happened, then I couldn't have really treated it. He could have died from an aspiration which is when your weak swallowing muscles (which he had) mess up and your saliva blocks up your airways. I was trying to get him strong enough to avoid that, though. I had a pulmonary doctor helping me with his breathing at night, but that doesn't prevent this issue. He could have died from something I don't even realize that is related to his illness also.
He might have died from an unseen heart condition - his death may have been unrelated to the myasthenia gravis that he had. He was fairly young, but he was overweight. I wasn't treating his cholesterol levels or his heart. Sudden heart attacks are very tricky. We're lousy at predicting them, especially the ones that start off with a rhythm problem.
RK was definitely one of the best patients that I've had in my practice. I'm not sure that people think very much about how much the patients give the physicians. I know that a lot of the doctors that I know don't really think about it very much. I think they give the doctors as much or more than the doctors give them. I'm not talking about the money part of the practice: patients (and their insurance companies as a proxy for them) pay for services. That's business. I'm talking about the other part: the people getting together with people and "giving" each other some of themselves. We give people little pieces of us, and they give us little pieces of them. That's what happens when we "socialize". Socialization changes people in this way. It causes "group behavior". I and many of my colleagues work very hard to avoid taking the pieces of our patients that they have to offer; the offered pieces contain so much of the negative and draining parts of us that they aren't really good to "take". It's really nice when there are patients who come in and make up for that by giving us the pieces that are good. Those pieces can sometimes be a truly wonderful gift. Those are the little pieces that make people happy as doctors. Without those, it clearly isn't worth it at all.

What are things worth?

AM didn't come today. He had a confirmed appointment. However, his wife came without him to his appointment just to talk with me about his condition. This is a sensible idea, and it's good care. AM has dementia and there isn't really that much that I need to see him for. Mostly I need to help his wife to take good care of him. However, this is a medicare issue. Medicare doesn't allow billing for "family conference" with outpatient care. That's a silly thing, but that's what they do. So people have to pay for that themselves. I don't mind the conferences, but I mind not being paid for things, so I tell people that they'll have to pay for it without medicare. Usually, they don't want to have the conference if they have to pay for it. Of course, that's what Mrs.M chose to do. She "can't do that". The charge for that service is $80. This is a little less than what medicare pays for a patient visit. It is $10 less than what I am charged to clean out my dryer vent once a year. I'm not sure how we can fix a "broken health care system" under these circumstances. If the patient's wife "can't do that" (spend $80 for a consultation about how to take care of her husband) when that costs less than what most people who smoke spend on cigarettes, then we have a problem. There is a huge difference between what people are willing to TAKE and what people are willing to SPEND in terms of health care. I don't think that the service in question is worthless. However, my thoughts on the matter are irrelevant. Things are only worth whatever the market will bear. If no one will pay for whatever it is then whatever it is isn't actually worth anything, regardless of what your thoughts are on the matter. My new dog needs hip surgery (dysplasia). The vet said it would be about $500. To me, it's worth more. I don't know how he came up with his fee schedule for that procedure, but I'm very happy to pay what he's asking (I'd pay more, but I didn't offer that to him). Since I'm willing to pay him what he wants it's worth $500. On the other hand, if he were charging $2,000 (which I think a lot of Vets do) then (in my case) it would be worth $2,000. Of course, he'd do less operations (some people just "can't do that") so he could end up making less.
Next year, medicare will pay $150 for a new patient visit for a physician (it's $225 this year). That means that a new patient visit will be "worth" $150 next year. How did that visit lose all of this value this year? It's worth whatever medicare says it's worth as long as I continue to take medicare. I take medicare because if I don't I can't practice in this town and I don't want to leave. I take medicare because right now, I still make more than I could doing something else with my training. However, that is very rapidly changing. Soon, I will be able to make more by working at Publix. At that point, it will become more difficult to explain to my family why I am doing what I am doing. Next year, a lot of physicians will stop practicing because it isn't "worth it". I will still do it, but I still like being a doctor very much. I haven't had to cut down my patient visits to five minutes and see forty people a day yet. The guys who have already done that just don't have any more cushion left. They also don't like being doctors anymore.
Worth is very funny, and very complicated.

Everything is Good

I saw TB today. He is Cymbalta for depression. It seems to be helping somewhat. He has had intermittent bouts of depression for the last twenty something years following the death of his son. When his son died, he stopped going to church entirely. His wife (who is also a patient of mine) still goes. He tells me that he'll never get over it. I suppose it's hard to figure out that dying sons (and daughters) is good. There is such a tremendous loss and negative impact. I have another patient who has lost three children (actually I have two different patients who each have lost three children). It's bewildering. I don't really want to lose any of my children. I'm a very big believer in the notion that everything is good. That theory helps me to get through the day. When things happen that seem "bad" I decide that I don't understand these things properly. If I only understood more, then I would be able to see the good through the bad. It's a strange belief structure, I suppose. Still it seems to work most of the time so I use it. I learned it from my wife who is far better at it thanI am.
The good thing about disease and dying I understand. I realize that this is the only thing that gives any of us any value. It is the only reason that we actually HAVE TO be nice to each other and have compassion. We can break the law and go to jail. But that isn't always a bad thing, like in the civil rights era with civil disobedience. There is always the possibility of justification: "The law is not a good law". However, when we hurt other people we have to know that there is a consequence. These people have value. All people are frail and susceptible to disease and death. This makes them precious which is why at the end of the day we have to make sure that we were nice. Most of us don't get that until we have someone who is sick or dead. Then we tend to become nicer people. Most people become nicer over age. They understand their personal vulnerability more, and therefore the vulnerability of all of the other people. So disease and death do that for us.
I just don't understand why some of the people who die have to be someone's children. Now that's a very silly thing indeed.

Happy Being Sick

George Akerlof said "Happiness is knowing what you want to do and doing it." He is the 2001 nobel prize winner for economics. He wrote something important about the economics of lemons. The link between lemon economics and medicine is immediately obvious. People want to have lemons. However, people don't want to have illness. This is why the people I see here (who have illness) are not happy. The people I see at Nokomis Groves (where they grow lemons and sell ice cream) are happy (sometimes, of course). Then again, lemons (and ice cream) don't always make people happy.
I'm not really sure that Akerlof has it completely right. He has it mostly right. Reading the quote this morning I knew that this was one of the greatest problems facing my practice. "Knowing what you want to do" refers not so much to action in his comment. It refers to adherence to a moral code more than anything. It refers to behavior that generally conforms to one's thoughts of what is appropriate. In THAT context, happiness is possible with illness. We are not wanting to have illness, but we are wanting to behave a certain way under the conditions of illness. This is an important distinction. Many other people have pointed out that our response to the situation is paramount and the situation itself is secondary. My favorite quote on that topic is "Nothing is neither good nor bad but that the mind doth make it so." - William Shakespeare. Victor Frankl who was a concentration camp survivor was also very big on the idea that we choose our response to situations. He wanted to choose to not be too upset about being in a concentration camp (a lofty goal).
We are all going around doing some of what we want to be doing. We are also doing some of what we don't want to be doing. I'm not talking about what we're doing in terms of activity (golfing, etc.). I'm talking about living up to our own ethical code of conduct. Of course, some of us don't know our own ethical code of conduct, in which case we can't live up to it. The blend may favor more of one or more of the other - more doing what we want or more doing what we don't want.
This is the key to our response to illness. This is also the key to our response to dying. Illness are dying are not really different. People generally die from illness. Those patients who are mostly happy with life are mostly happy with illness and death. Those patients who are mostly miserable with life are mostly miserable with illness and death. So the only way to fight against illness is to develop the ability to do what you want to do under whatever circumstances are present.

Dying

Sometimes I say that dying is good. People are confused by this notion because it's not what our culture celebrates. The problem is that there is a certain amount of magical thinking that we do. We think like there is an option. There is no option. There is only the choice of dying. There is no such thing as living forever. All things that live also die. In fact, since thought is generally dualistic ("either this OR that") one cannot really have the notion of life without the notion of death. They create their mutual existance, since without one there is no distinction between two states. In that sense, death permits or even creates life. Non-dualistic thinking is very confusing because in that format there is neither life nor death which is a reality so hard to perceive most of the time it just isn't worth it to consider that. So to me, in the most simplistic way I can, I say "dying is good". The magical thinking that we have is that we may live on. We don't necessarily think someone will live on forever. We just don't necessarily ever accept that the dying time is NOW. It has to be later. Of course, it can't always be later. We just refuse to ever have it be now. So it's magical thinking. To be completely honest, we DO want eternal life for ourselves and loved ones. We just aren't honest enough to say it out loud because it would sound childish and unrealistic.
The problem with thinking that death is not good as that we don't accept it. We don't look for the "now" that death should come. We refuse the opportunity at all costs. But what is the REAL alternative? There are actually only two choices. There is dying - a good choice. The other choice is refusing dying, which is the choice that leads to suffering. People will go through all sorts of torture in order to try to fight what is supposed to be. This is mostly driven by fear of having failed to live, having failed to love, or some form of guilt about how it's ending up. There is "unfinished business" when the "now" comes. So it can't be time. This causes great suffering.
Yesterday I saw JD whose father RD just died. He was a patient of mine. He has suffered for the last couple of years with severe pain that we just can't alleviate. He spoke to me several times about suicide. He wanted to die to relieve the pain, and at 80 years old, he didn't think that however many years he had left should be spent in agony. His wife wasn't willing to go along with suicide. She didn't feel that it was ethical. So I never helped him with it. Of course, it isn't legal to help with that. So I actually never help with it. Except that people sometimes end up dying accidentally if they have easy access to it and permission. RD never would have gone through with it without his wife's blessing, though. So he persisted with pain.
JD was not exactly glad that he is gone. But she new that the "now" was right. She said something to me that was very critical. RD had written a letter over the past three years for his family to put them at peace with his leaving. It's a fabulous thing to do. I have to do that. My wife did that and I have meant to do that. Of course, the time to do that is "now". Not because it is obvious that my time is imminent, but it is true that we never do know when it is. So we need to always be at peace with this. We need to make sure that all of the people we love are always at peace with this so that there won't be so much suffering when the time comes.

It was hard for me when RD died. He died only one week after PN died. I can't really have my patients dying, no matter how good dying is. Loving is not entirely different from suffering. We become attached to people. I am attached to the patients. I like them coming here. They give me something to do, and a sense of purpose. So when they leave there is suffering. JD made it easier for me because one of the most difficult things for me is the family of the patients who die. I can't really alleviate their suffering very well. So if they don't suffer then I am happy.

The Economy

I'm glad that my position is somewhat insulated from the economic crisis. Most of my patients are medicare age. That's always been a source of lower reimbursment for me. My colleagues who are in places that are only 10% medicare population have had a greater income than me. But now many people with non-medicare insurance are losing their jobs. My colleagues are all seeing dramatic declines in their incomes due to loss of patient base (no job, no insurance, no doctor). There is a difference here as well, but it is rather small. I have only lost a handful of patients from this crisis. I am seeing something else. I am seeing the toll on the patients. They are mostly retired people. Some are concerned about the lost value of their investments. Still, that doesn't seem that bad either. Today SS came in. She has a daughter who isn't working. Her son-in-law was just laid off. Now neither one of them has a job. Their house is worth barely what they paid for it or maybe less. Their child is in college. So she is very distraught. She doesn't really have the means to take care of this mess. So she can't help very much. It's making her arthritis worse and her MS worse. It's making it hard for her to sleep and she feels depressed and tired. This is what I'm seeing a lot of. I'm seeing a lot of parents and grandparents of people who are in real trouble. I don't really know what to say to these people. There isn't really very much that I can think of. It's very hard to sit by and watch your children suffer.

Less Cost, Better Quality

JW was here. He was sent to me for complaints about his memory. His young - in his fifties. He was alcoholic and developed a case of severe esphageal varices which caused bleeding in the esophagus. He went to the ICU with some liver failure, and shortly after that (or maybe when he was in the hospital) he developed severe thinking problems. He lost all of his ambition and drive. He sat in the chair all day long. He couldn't concentrate. He was treated for a few months with anti-depressants. He did stop his drinking due to his near death experience. He just wasn't getting any better, so his physician sent him here to evaluate if maybe this wasn't just depression. His wife was at wits end. His sister was also at wits end. He had already checked an MRI of the brain (at their request mostly). I checked his EEG which showed severe slowing, so I told them that this was just not from depression since that doesn't cause severe slowing on the EEG. I told them that we had to look at several issues, but first I wanted him to stop his opiate medications including methadone and oxycodone which he was on. He had been on pain medication for years, so we were all skeptical that this was the cause of the severe thinking. In fact, even I was skeptical that this was the cause. Normally, I would have ordered a lot more testing. However, he didn't have medical insurance. I didn't think we should spend a few thousand dollars before making sure that this wasn't medication related. Every once in a while someone is on a medication for a long time and then the side effects suddenly turn up. It's unusual, but it happens. So we tapered him off pain medications. He came in a new man - he thinks like he used to. He is in a lot of pain, but his thinking is back. He wants to go back on pain medication because he is in so much pain. His wife wants him to stay off the pain medication because he is himself. I don't know what they'll end up doing.
This is an interesting case. I am often upset about all of the nonsense about better quality care for less money that is always talked about. I'm upset about it because it ignores all of the major realities that create such an expensive system. But this was done out of the necessity to save the patient's money. It was excellent care. It was very cheap. If he had insurance, it would have cost several thousand dollars more, and it would have taken a few weeks longer to find out what was wrong with him. I usually think that I'm pretty quick, but the need to cut costs in this case actually made me quicker. This is the first time that I feel like I improved quality by being driven to decrease cost. I'm not sure how much this goes on, but I can see that it is more than I have previously suspected.
For my practice, this pales to what I spend that I know doesn't really need to be spent to either 1) please the patients or 2) prevent being exposed to a law suit in the event of something extremely rare and unlikely. I suspect that's true for most practices. Still, I have definitely under-estimated the effects of trying to decrease costs as a factor in improved care. Now I will have to open my mind to this issue.

Healthy food

Yesterday I saw PJ. (Hey, those are funny initials). Her husband has a bad family history and was overweight and had high cholesterol. He decided to start exercise and to eat healthy. He also lost sixty pounds and dropped his cholesterol by 40 points. His behavior caused her to also change her habits - especially her eating habits. In fact, the other day she had a cheesburger at McDonalds and got sick from it! (That's what happens to healthy people who are not used to eating such toxic food).
She has found that her chronic pain syndrome has improved significantly. She just has less pain. This is very interesting to me. I don't understand this, but I believe her. I do know that with inflammatory situations food is important. There is a dietary need for a product called arachadonic acid. This cannot be produced by our bodies. It is an essential component of inflammation processes because it is used to make the chemicals that produce the signals for inflammation. Duke University has taken advantage of this issue. They have a program for Rheumatoid Arthritis where they put people on a fast for ten days to improve their arthritis. It is very effective. Arachadonic Acid is found in polyunsaturated fats, particularly animal fats. So diets that are very low in arachadonic acid (vegetarian + fish + olive oil) produce less inflammation. So I would expect a "healthy diet" to produce less inflammation. In fact, I often recommend it - for those situations.
PJ doesn't have (I don't think, anyway - maybe I'm wrong about this) inflammation. According to everything that is written and thought about most of these chronic pain syndromes, there isn't any local inflammation. The pain is mediated through different pathways in the nervous system. That means that the arachadonic acid process is not involved in her pain mechanism. There is no reason that I understand why her pain should have improved. It's a mystery to me.
I'm glad her pain decreased. This is one case, though. I can't go around telling all of my chronic pain patients to go on a healthy diet to decrease their pain. I just don't know anything about this situation (I do tell the arthritis people to change their diets). Perhaps one day I will find the connection. I should probably put this question on my "look up" list, although I doubt I'll find something written about it. Sometimes it's frustrating to know that there is something there that we definitely don't know but we should know, and to also know that I'm most likely to not find out.

Waiting

Yesterday I saw a new patient: JW. She is a retired lawyer who became an author. We had a long philosophical discussion about language. It was fun. Unfortunately, it was long. So the patients after her were waiting for me.
I work very hard to stay on schedule. Patients shouldn't have to wait for me. Patients don't like waiting. No one likes waiting.
The medical practice is complicated. People are willing to wait for me because they understand that "things happen". A person is scheduled for only fifteen minutes because it is a routine follow-up of an easy problem. Then it turns out that there is something new wrong, or there has been some major development in their life that needs to be addressed. Then I'm late for the rest of the day.
Everyone I had to see yesterday after JW was very understanding. But they all made the assumption that there had been such an occurrence: an unexpected problem with a patient. I didn't volunteer to everyone that I had just been taking my time. I could have seen JW quickly. I could have averted the conversation entirely.
It's hard to say how much taking that extra time may have helped her, but I really don't think it helped her enormously. I know that there are some people that just need to talk, though. Perhaps she was that way. The "art" component of medicine goes largely unseen - even to me. I do many things out of a subconscious frame rather than a conscious frame.
Honestly, I think I was just "having fun". I do have fun doing my job, although some times are more fun than other times. The thing is that if I was just having fun and it wasn't so much of a great help to the patient I shouldn't have really caused people to wait.
I have some patients who I always schedule extra long visits with because they require more time. That's rarely due to the complexity of their illness. It's usually due to the complexity of the way they relate to the universe or the fact they're just more fun and I like to go slower with them. Some people just move at a different pace. So I change my pace to suit them. Again, it's part of the "art" - I don't exactly know why sometimes.
It's really important that I keep having fun at this job. Otherwise I'll turn into one of my colleagues who doesn't like what he or she does. That leads to not caring about the patients. That leads to not listening to the patients. That leads to missing details in the history that help with the diagnosis. It also leads to unsatisfied patients who know that their doctor doesn't really care about them. The problem with the schedule is that you can't really schedule fun. It isn't amenable to structure.
So yesterday, the patients had to wait for me to have fun at work. It wasn't quite right. Maybe it wasn't quite wrong. I don't know. It's hard to stay on schedule sometimes. The schedule is quite rigorous.

Medications

I saw a seventeen year old yesterday for a seizure. She had a generalized tonic-clonic seizure. She went to the emergency room, but they didn't find any cause for it. Her primary care physician sent her here for further evalution of new onset seizures. She takes Ultram and Prozac. Both of those medications can cause seizures. She takes the Prozac because she has "outbursts" where she gets very upset over "nothing" at her mother. She takes Ultram for chronic back pain. I asked her to stop both of those medications. It seems to me that her back pain and her outbursts are both caused by stress from her home life. I don't think medications are likely to solve either of those problems. She is also upset about being heavy. She has gained thirty pounds. She takes Lyrica (for her chronic pain). Prozac and Lyrica make people gain weight. So I think the weight gain she has is from the medications.

I don't think her social life can be easily fixed. I don't think her stress can be easily fixed. But I think that the medications are just going to make matters worse. In fact, they are already doing that. People sometimes think that if there is something wrong there is a pill for that. But there isn't a pill for everything. This needs to be seen sometimes.

Sick People

GL has to go to a nursing home. I saw him this morning. His wife wants to put him in a nursing home due to his Alzheimer's. He doesn't know who she is. He hasn't known that for the last year or so. Now, he doesn't remember how to get to the bathroom from the bedroom. He can't get dressed or undressed either. I thought he needed to be in a nursing home some time ago. I told her that about a year ago. Her back is bothering her, and she has sciatica. That's the thing that made her finally realize that she can't really take care of him anymore.
CG came in today. He has a very severe chronic pain due to stroke and also neuropathy that I can't fix. I actually got it to go away once for a while but then he was allergic to the medicine that made it better (he got a rash). I just put him on a new medicine (I keep trying him on things). It hasn't helped, but I want to try increasing the dose. It is expensive, so he said he won't be able to take it. I'm going to have him try the high dose for a week anyway. I don't know what I'll do if it works. I've tried almost everything trying to fix this pain for the past few years. If I find something that works and he can't afford it, I'm going to be extremely frustrated.
TY came in today again. He fell down and broke his foot. He sees me for seizures, which are well controlled. He wants to be on less medication because of the side effects. One of the side effects is clumsiness, but that's not why he fell. He fell because of an insulin reaction from his diabetes. I'm not sure how we're going to figure out if his clumsiness improves when we reduce his medication if his foot is broken and he's in a cast with a crutch.
People are sick today.

Violence

A patient told me that another patient that he knew was my patient was afraid of her husband, who is also my patient. That is because the patient of mine who is the husband had been violent. He knocked down my patient who is married to him. The knocking-down patient has dementia. The knocked-down patient has blindness due to macular degeneration and had a TIA.
I told the patient who told me the story nothing. I'm not allowed to (HIPPA rules).
I called the wife and had her come in. She came today. I told her that I'm not sure she's safe. She wouldn't completely come out and say that she IS safe. She doesn't want to put her husband in a nursing home, but understands that cognition is required for impulse control. He wasn't violent prior to his dementia, and the cause of the violence is dementia. She is managing this with behavioral therapy at the moment: she makes sure that he never gets upset and that he always has things his way. She isn't sure how long this will work. She doesn't want him to go to a nursing home, but doesn't really know if she would want her daughter to behave the same way that she is currently behaving. She isn't sure about that. She hasn't told her children that he hit her and knocked her down. They are going to visit the children in June, and she may tell them at that time.

I don't know what to do about violence. I am generally opposed to violence. This sort of violence is very challenging because it comes from lack of capacity. It is very unpredictable. I'm not entirely sure that she is safe right now. On the other hand, if we were to force her husband into a nursing home (that is the only other realistic alternative) it would really destroy their marriage. That would hurt both of the patients in a very significant way. I don't know that it necessarily hurts more to get knocked down and hit than it does to lose your husband. So I don't really know what is best for her. I think it might be best for him if he doesn't go to a nursing home, although I can't be completely sure of that either.

Unknown

I have a patient RK who has something. I don't know what that is. It's a lot like myasthenia gravis. So I checked him for that. He didn't seem to have it, at least not by testing. Still, it looks a lot like that illness. I thought about treating him without knowing what he has, because whatever it is that he has it is causing great disability with very severe weakness. I sent him to Mayo Clinic. They said he has something. They don't know what it is. It looks like maysthenia gravis to them, but his test is negative. So they thought I should try treating him.

I treated him with what we thought we should treat him with for whatever it is that he has. It seems like it probably didn't work. It maybe worked a little. I saw him back and thought he was a little bit stronger. His wife thought he was better. He didn't think it made a difference. I saw him back a couple of weeks later, and I think it didn't really make any difference. It's not clear at all.

At this point, we're going to try treating what we don't know this is with another treatment that we don't know if it will work. He and his wife wanted me to advise them about how he's going to do - of course, we don't know that.

I saw a patient today and he has Lumbar Spondylosis with Scoliosis and Spinal Stenosis associated with a mild L5 Radiculopathy. This causes pain and weakness and will progressively get worse. Treatment is difficult. Right now, things are not that bad and I would prefer to wait until later. Later on, he will almost certainly have severe pain that may be disabling. Then, we can start treatment. I told him basically this. He was quite happy to have a clear cut definitive diagnosis, the poor prognosis and limited treatment available not withstanding. It's much nicer for me to see someone like that than someone like RK.

It's amazing how much we hate the unknown.

Reality

I keep on wondering how it is that so many of us see so little of what is real. There have been many discussions this week with patients about health care financing. I guess this is just becoming an immense issue. People are losing physicians due to changes in insurance. There is concern regarding the socialization of medicine (which is almost surely coming). There is concern about the cost of insurance premiums. People seem to think what they seem to think. It's interesting because the basic reality isn't even up for discussion.
One thing that is problematic is that no matter what anyone says, no one actually knows how to measure quality of health care. We can't measure the quality of care that a physician provides as a physician to his patient population. We don't even have honest discussions about what are the criteria. For example, if I caused the death of a patient through error, what does that mean? How many deaths per patient encounters can someone have? If I save a life that no one else could have saved (how would you know that, of course) what does that mean? I pick on that because we all agree that we can actually measure if someone is alive or dead. We don't have agreed upon standards for how to measure overall pain levels. So we can't actually compare whether I alleviate more pain or less pain than another physician who tries to alleviate pain. We could easily measure patient satisfaction and quantify it, but we don't routinely do that, nor do we accept the notion that overall patient satisfaction is relevant or important in measuring physician quality. This is reality, but it is unpleasant.
What about system-wide quality? We can measure infant mortality pretty well. Ours is too high. We can measure lifespan of a population (ours isn't high enough). We can measure vaccination rates. These things are in fact important to some extent. They are actually what is used to measure quality of population health care systems. Patient satisfaction is not considered an important measurement of population health. Neither is access to "elective" surgery or procedures.
If we change our system to a socialized one we will have less infant mortality and more vaccination. Our population lifespan will increase (because less babies will die). The people who have no insurance now (50million) will have access to basic health care, including primary care (which may be done by nurses mostly). Their health will DEFINITELY improve. The people who are currently in medicare or receiving private health insurance care, however will see a decline in certain things. They won't get to use so many fancy tests, see so many doctors so quickly, have so many specialists take care of things that are complicated, or get so many fancy medications (which are sometimes superior to the older ones). The older people will die a little more often a little sooner with a little less care. The patient satisfaction with the system and with their own personal physicians will decline. This is what will happen. Is it good? Is it bad? I don't know any of that. I'm just stuck on the fact that no one seems to look at the reality of things. It isn't free. There are trade-offs. It's very hard. There are ugly questions about value. The politicians and the thirty-second spin artists want to have one-liners about nothing. They want to claim things like "better quality" when no one even knows what that means!
It's frustrating. I would like to see someone in the public arena actually have a real discussion about health care because it's important.

Quality

I am seeing four new patients today that were sent from one physician - an orthopedic surgeon. Three of them are for nerve conduction tests, one for Restless Legs Syndrome. That is a lot of referrals from one person. I guess he thinks I'm taking good care of his patients. I used to have a lot of physicians who sent a lot of patients over here before the politics changed so dramatically. Now there are less. It was difficult to think that people wouldn't send the patients here over business reasons rather than who would take the best care of the patients.

I changed the practice to try to be able to get patients without relying on physician referrals, because I had no choice. Now I don't depend on them. I'm still working on practice building. It's hard, but it's good. It's good to do it on your own.

Now I find myself happy that this physician is loyal and lies sending people here. I feel "proud". This is something I have to watch. It isn't any better to think good things that depend on others than bad things. I have to be responsible for the determination of my quality. I have to know that I'm good at what I do because I'm good at what I do - not because someone else thinks so. Of course, some people have to know that they're right even when the whole world is against them. I don't think I have that sort of insight or that sort of strength. But history teaches us that this happens sometimes. Ghandi must have seemed ridiculous at the beginning, claiming that he could gain independence from Britain with non-violent protest. He changed the way the world thinks about non-violence, though. He somehow knew that he was right in the face of everyone thinking he was wrong.

There is still no reasonable way to measure physician quality. People try to do it all of the time. It's just about impossible.

Today's Patients

Yesterday I finished late and didn't get to do all of the paper work. My last patient of the day told me that she was feeling unsafe at home due to prior instances of spousal abuse. She took extra time. I think people should feel safe at home. I told her to call one of the organizations that help in these circumstances. I don't know if she will or not. There is too much spouse abuse. It is usually related to alcohol as in this case. It's surprising how little we can do. It wouldn't surprise me at all if she doesn't call for help. That's very common.
PN has had Parkinson's for a very long time. She has severe dementia, and very severe anxiety. Toady her husband told me he's considering putting her in a home. He doesn't really have adequate support and is worn down.
I saw a woman today who needs to see a Neurosurgeon. She has severe spinal stenosis with spinal cord compression. She told me why two of the neurosurgeons in town whom she has met with before are terrible people. I recommended a third one, but she didn't want to meet with him. She is very angry and very arrogant. It's interesting that someone is in danger of developing spinal cord damage but would rather discuss why she doesn't like the surgeons she's seen in the past than working on the problem that she has.
I saw JB today. She is a complete mistery. For reasons that I can't understand she acts exactly like someone who isn't getting enough blood into her brain even though she has enough blood pressure. She is dizzy. I can't seem to make her better, even though I've taken her off more than half of her blood pressure medications.
MB was here today also. She is quadraplegic from a trauma about fifty years ago. Her husband died last week. She didn't really want to talk about it though.

Friends with Death

I just returned from New York. My Grandmother died so I went there for the funeral and everything. You have to be there for your family. You don't do anything. You're just there. She was very old and she died in Hospice in her sleep without suffering. I like death. I've gotten friendly with death. My Aunt died a couple of years ago. I was worried that I would be horribly sad about my Grandma dying. I tell the patients always that I believe death is good. It's interesting to be tested, though. You can say anything you want. The trick, though, is to live it. I think it would take an entire book to try to explain, if it's possible, why dying is good. We don't think of the good in dying in our culture.
In the end, though, it's the only real test we have. You can cheat on everything, but not on death. We will all die. Then, there's nothing left but the way we lived our lives. You can't take it back. You can't re-do it. Whatever mistakes you made you made. Whatever ways you cheated you cheated. The hurt you caused others was caused. People forget about it. They go about their business as usual and forget that the final exam is coming at the end. Some people pass and some people fail.
I don't want the people that I love to go. I love them. All I know is that it's death that forces me to be there now. It forces me to be real and to be good. When I have to face my death I have to look at myself with open eyes. Because of my business, I face it every day. So when it comes, it comes. I do the best I can, and I don't forget death. It's with me every day. Every time I write a prescription - no matter how silly the prescription is - I might cause death. So I have no choice in the matter. Of course, my patients die and their families die.
At funerals, people are very emotional. You can see people clearly at these times. You can see if they are friends with death or not. I think if you live well and try hard and have little to account for, then you can handle it better when the loved ones you have die. That's because you know that you did the best that you could do.

Guardianship

The state of Florida is in need of money. I understand that. They are raising some of their fees to get more money. I understand that also. Taxation is a complicated issue. "User fees" are justified because they burden those who use specific resources with their costs. This is the principle behind toll roads. The people who drive on THAT road pay for its cost. The people who go fishing pay for whatever the state does to provide fish (I'm not really sure what that is). In reality the system doesn't work all that well. The money all goes into one pot. Also, people who buy lottery tickets don't really require any more education than those who don't buy lottery tickets. Furthermore, the services that the state provide are supposed to all "work out in the wash". In other words, we all need a "state". Some of us use some things more, others use other things more. So we may not have a child in school, but the presence of a school helps us anyway. That's because we don't use the school but we do use the grocery store. There is a connection. The person in the grocery store has a child in the public school. This is why they can afford to work there for so little. If there was no school, that person couldn't live in this state. They would live in a state where there were public schools. That means there couldn't be a grocery store in this state. Grocery stores can't afford to pay the checkout people enough money to send their kids to private school. They need the state to provide certain services to their employees. So if I eat food, I need a public school. The "non-users" of public schools get "indirect" benefits. It's the same for the toll roads. Even if I don't actually drive on the toll road, I still need it. I need it because someone else who is in my state needs it. I need everyone here to succeed so that they don't end up on welfare (which comes out of my taxes). Therefore that road helps me every time it helps anyone to do their job or be more productive. This is the essence of the state. We are all in it together. Now we can debate how together we want to be and how separate we want to be. We pretty much all agree that we need roads. Some of us think we don't need schools, but most of us think that we do. Most of us want to pay for that - one way or another. On the other hand, most of us want someone else to pick up more of the tab because it seems like our share is too high. So this is where things get a little tricky.

There is now a proposal for the state of florida to increase some of its fees. One of these is the fee to apply for guardianship. There is a proposal to increase this fee to $2000.00! This is a "user fee". If you want to be a guardian for someone it will cost $2000 to "use the court". Most court services are fee based. Every time we use the court for something, there is some sort of fee. This fee is insane. If someone is incompetent they need a guardian. That is a person who can legally control another person, just like a parent controlling a child. Very often it is a child controlling a parent. When a person with dementia is told not to drive they may listen; or they may drive. If they lack the capacity to drive and lack the capacity to understand this a person who loves them may want to force them to stop. However no one has that right. In order to sell someone else's property or force them to act against their will a guardianship is required. CLEARLY this helps the "non-users". It helps me when John Doe gets a guardianship in order to stop his demented father from driving around and killing me.

This fee is clearly going to stop some people from obtaining guardianships. It is a big mistake.

Depression

I have read about the "great depression". To me, there has been a great depression in the practice since coming back from the boards. Monday and yesterday it seems like almost every patient I had was having depression. Neurology is not one of the easier fields. People are very sick. The illnesses I help patients with are serious ones. They are often disabling. So I am used to having to play the cheerleader role. It can get to anyone to have stroke, neuropathy, parkinson's disease, chronic pain, Alzheimer's, Multiple Sclerosis, weakness or whatever I'm seeing people for. This is not the depression I'm seeing, though.
I'm seeing a systemic depression. The "practice" is depressed. I think the whole town is depressed. Perhaps the country is depressed. I don't mean financially depressed. I mean that it's taking a toll on people. There is just a decrease in the happiness level.
It seems to me that too many people are far too attached to the economic well being in order to have happiness.
The internet dating sites are experiencing huge growth. People can't go out and spend money, so they're turning to having relationships. I think relationships with people are probably far more likely to produce deep and longstanding happiness than wealth. So to me, this is a great benefit of the economic downturn.
There is a G-20 summit, and there is talk about having global regulation for the large mega-coorporations that run the world. This seems like a good idea to me also. These companies are bigger than countries. They have our country under their control because they basically pay off the legislators. So maybe this is another part of the silver lining.
The thing about the difficult times is that the silver lining in the clouds is never clear at the time. So there has to be faith.
I spoke recently to a patient's daughter who was very hostile towards me. She expected me to call her after every visit with the patient to update her so that she could ensure that her mother was getting "the best medical care". It is a manifestation of the lack of faith we have in each other.
People are not doing well with these economic difficulties. It is causing too much depression because there is no faith and people lack deep relationships. It is going to create disease. Stress leads to disease.

Boards

The neurology boards are coming up on March 24. I have to take those every ten years. They test me to make sure that I'm a competent neurologist.
Hyperkalemic Periodic Paralysis is a channelopathy in which there is a problem with sodium channels whereas Hypokalemic Periodic Paralyis has a potassium channel defect. Thomsen's disease (Paramyotonia Congenita) has a chloride channel problem. The other one is something something with myokimia. It is a calcium channel disorder.
I can bet my house that I will never see any of these diseases. I can bet my car that there will be at least one question asking one of those facts. So I've memorized it. I have to read twenty books that are between two hundred and three hundred pages and memorize most of them for this very annoying test. About 30% of it will be about these types of things. The other 70% will be about things like Stroke, Epilepsy, Neuropathy, Parkinson's and other things we actually see in practice.
The people who become very prominent academicians do research most of the time. They spend their entire lives researching something like Periodic Paralysis. So they find it kind of hard to imagine that someone exists who doesn't know the details of it. It's hard to ask them not to write any questions about it.
It's annoying to study for this test though.
One thing that no one wants to accept is this: it's pretty much impossible to figure out which doctors are good or not. You can "board certify" us. But that really only means that I'm pretty good at memorizing these twenty books. It doesn't mean anything about how good I am at what I do. You can measure patient satisfaction. It's been shown that this is a valid measurement. But that doesn't tell you anything about diagnostic accuracy. You can measure if people follow guidelines or not. But guidelines have been studied and shown to not necessarily reflect best medicine. (Guidelines don't take into account patients, which may have multiple conditions). I guess there is some degree of satisfaction that there is some minimal degree of competence if a person passes a test. But the problem is that people don't really know how well the test reflects the quality of care someone can provide.
How are we supposed to know if our doctors are any good? It's a really vexing question. As "consumers" (patients) we're really not in a very good position to evaluation this because we can't judge the fund of knowledge required. There isn't a consumers report either.

Yesterday

JF was here first yesterday. She is doing so great. She came to me about six months ago, I think. She had very severe pain. She was truly upset and very anxious. She was calling me neally every day. She was on pain medicin (narcotics) and xanax and high dose anti-depressants. She has a very strange variant of trigeminal neuralgia. I got her somewhat better with an anti-convulsant. I was trying to wean her off the xanax with great difficulty. I got her off the narcotics. One of the psychiatrists who is amazing saw her and told her to just stop the xanax. She did, and she was great. Then, she had a reaction to the anti-convulsant so we had to change that to another one. Now, she is doing even better. It was a great joy to see her improvement. She is truly a "new person". That was my first patient yesterday.

DT came second. She was told by Dr. M that she shouldn't drive due to cognitive problems. She went for a driving evaluation with an OT who specializes in this and said that she shouldn't drive. So she came here. She is here only so that I will let her drive. I did a thinking test which shows decreased attention and information processing speed. The OT who said she couldn't drive said she lacked attention, especially with divided attention (requires speed). DT may have Alzheimer's because her MRI shows some hipoccampal atrophy. However, the thinking test is still pretty good. I told her that she needs to come of two medications: Paxil and Ambien which could be contributing to her decreased attention levels. Then, we can re-evaluate her thinking test and if the attention and speed scores increase, we could repeat her driving evaluation. I thought that was great. She didn't. She just wants to drive. She doesn't really care about anything other than the fact that she feels she is capable of driving. I asked her if she thought that both Dr. M and the OT were incompetent. She thought they were just wrong. So I asked her how we know that she's not wrong. She just repeated that she just thinks she can drive. She doesn't really want to answer the question about how much certainty we need to have in order to have her drive. She didn't want to answer what she would do if she killed someone after the question of her capacity was raised. In this town, when you can't drive it really ruins your life. The public transportation exists, but that's really about all I can say for it.

LD was here. He's worried about the economy.

I saw a new patint, DF. I have no idea what he has. It's some kind of really unusual sleep problem. He is truly fascinating. I e-mailed a friend of mine who specializes in Sleep medicine. I don't think he's ever heard of anything like this either. It's exciting to see something that no one has really described before. Maybe I'll be able to make him feel better.

BS came. He is 96. He goes to the YMCA to work out four times a week. He lives alone in his house independently. He isn't happy.

RK came. He has been a patient for about a year. He told me that his sister was burned to death. He thinks that her husband killed her, but that was never proven. He raised his two neices. It's surprising what happens to people.

LL was a new patient. He is a retired accountant. He worked as an auditor. He doesn't think very highly of some of his colleagues.

I got very behind on paper work yesterday. I ended up staying at the office too late.

Pain and Suffering

CS died. He was a patient of mine for about seven years. He had a stroke that had damaged his "motivation center". He had severe apathy. He was very pleasant, but always sort of "blank". He didn't try very much. He didn't walk. He was very overweight. He just basically didn't care about anything. I liked him. I like most of my patients. I like people and I like patients. I will miss him.
JM was in today. Her son is in hospice. He is dying from a brain tumor. She is very sad about it. I can't help her. She has Parkinson's disease, which is why she's my patient. Her Parkinson's is doing well, but I just had to stop her Azilect. Her blood pressure is high, and I think it's from that. That's too bad, because her Parkinson's will get a little worse.
There's been a lot of dying this week.

I saw BS today. He fell in a grocery store. It was a "slip and fall". He fell in just exactly the right way to completely crush his Sciatic nerve. I think he fell around the end of 2007, so it's more than a year, maybe close to a year and a half. Anyway, his nerve isn't going to heal so he has permanent pain in the leg. He has such an upbeat attitude for a person with nerve pain. I like him because I think he is one of my happiest patients. I have several people in the practice who have constant chronic pain every day but they are happy. It is very important.

People don't understand that there are different things that are "unpleasant". There is the simplest form: "noxious stimulus". Even a single-celled organism (ameoba) can move away from something. But it can't really experience "pain". "Pain" doesn't happen until there is a fairly advanced nervous system, nearly a "brain". Jelly fish don't really experience "pain". Pain (in humans) happens at the level of the thalamus. Then, there is a higher order of experience called "suffering". This is a critical distinction. "Suffering" happens at the cortex. It's not in the thalamus. They are different experiences that happen in different parts of the brain. This is why there can actually be "masochism". That is where a person "enjoys" a "painful" experience. The translation from thalamus to cortex doesn't prouce suffering, it produces joy. If we could "induce masochism" we would turn pain into pleasure. It would be a very good treatment for chronic pain.

I saw MM today, who has chronic pain that creates enormous suffering. She is a complete "anti-masochist". No one can figure out why she has all of this pain (including me) and she won't go to Mayo Clinic even though I keep asking her to (I don't think they're going to figure it out either, I just want to check). However, her pain makes her suffer greatly.

Anyway, CS never really cared about anything. So he didn't really have the ability to "suffer". He didn't care enough about the hurting leg or the hurting arm. BS doesn't suffer that much because he refuses to let the pain in the thalamus become suffering in the cortex. It's like there is a block. JM doesn't have pain right now, but she will because she is having such great depression over her son that her transmission from the thalamus to the cortex is going to be enhanced. And MM has actually augmented her transmission of pain in thalamus to suffering in cortex.

I had lunch today with my wife. We don't have lunch that much anymore, because it's not really in the schedule. We were talking about how much can people change themselves, change their brains. CS had a stroke that robbed him of all motivation. So she wanted to know how we can be upset with the people who are homeless in the streets but aren't motivated to get themselves going. (She is always sticking up for the poor and the wretched.) What if they have a "weak" motivation center in their brain? Still we all try to change ourselves and to some extent succeed. We have some limit, of course. I can never be totally different than me, I can only change me a little. Of course, if I'm persistent a little change at a time adds up after a few years.

I think that too many people don't realize that they have the power to change themselves. They don't even realize that there are these huge differences in people's perceptions. People think that the pain and suffering they have is similar to the pain and suffering that others have. But everyone's pain and suffering is different. Everyone is different and they experience different realities.

Losing Things

WM came yesterday. I haven't seen him for months. He has MS, but a very mild form. His wife died, and he's been grieving. RS has also recently lost his wife. Wife-losing is a very difficult thing. BP just came back down from Ohio, she lost her daughter (esophageal cancer). Daughter-losing is also a difficult thing.
If the bank can take "my house" then it isn't really "my house". It was always the bank's house. They bought it. Their money bought it. I borrowed the money. If I pay off my mortgage or if I buy my house with cash money,then the bank can't take it. Nobody can take it except the government. They can take it with "eminent domain". So even if I "own" it, I only own it provisionally. It is mine as long as the government says it's OK for it to be mine because they don't really need it right now. These days a lot of people are losing "their" house (which wasn't really theirs).
If somone else can take the thing that it is "rightfully" then it isn't really my thing. It's on loan. People are on loan. They can be rightfully taken by nature or God, whatever you want to call it. We forget that. We forget that these people are just a temporary loan. They get taken back. It's so hard because we don't want it to be like that. We want them to be ours because we have no connection to what's not physically here. We don't develop those connections. Then we have too much loneliness.
I can't really imagine getting through days without my wife or my children. I see a lot of people who do it. They really don't know how they're doing it. I think it's important to go through the exercise of reminding ourselves that our people are on temporary loan. It helps to appreciate them while they're here. It helps us to deal with their "loss" better because we know they were never really ours. More importantly, we need to know that when we "had" them we never forgot their value, their impermanence. We do way too much of not being aware of how near death is to all of us. It can be here in a moment.

Our Community

Yesterday I saw two new patients RM and CT right after another. They were both very difficult. RM is an 85 year old man with blindness from macular degneration and dizziness who was sent ot me for peripheral neuropathy. He has been telling his doctors for years that he has a great deal of pain in his feet, in his back, and in his neck. No one seems to be addressing it. He tells them about it and they tell him that he's old. It was depressing. I can help him, and in all likelihood I'll get rid of his pain. But I was upset about the past: about his previous neglect.

CT came right after him. She is a 44 year old who can't walk. She lost her walking ability fairly quickly for unclear reasons. Her mother is a double-amputee diabetic, so her daughter, who is 17 years old, dropped out of school to help take care of the two of them. She has no medical insurance (of course). I don't think I'm going to be able to make her walk. I think she has sensory AIDP. I would normally try IVIG therapy on her to see if it works and it usually would. IVIG costs about $15,000. She doesn't seem like the type of person who has that laying around (she used to work at Albertson's before she lost the ability to walk). I was upset about the insurance issue - or lack of insurance issue, to be more accurate.

I know that I shouldn't get upset about these challenges; I am supposed to be optimistic in the face of disease. I try to like disease because of its tremendous positive effects on people. But this isn't about disease. This about the way that people are treated. We aren't treating each other properly. We aren't caring for each other the way that we should. The bonds of our community aren't right. Even doctors are a part of this - the ones that didn't listen to RM; the ones who didn't address his problems but just said, "You're old." What relevance does his age have? There is only one question: "Can I help make this better?" If the answer is no, then there is only one follow-up quesiton: "Who can help make this better?"

I don't understand why we have seventeen year old girls dropping out of school to take care of her mother and grandmother who both can't walk. What chance will she have as a high school drop out? What choice does she have? Why do we put a young girl in that kind of predicament? There were five people in large banks who make over 250 BILLION dollars while they ran them into the ground so we could bail them out. But we can't help this girl. It doesn't really make any sense.

I know I shouldn't be complaining and having a negative attitude. But this just really stinks.

Missed!

I have a "mystery patient". She developed a very strange type of "rash". It's not a rash, actually. She had "purpura". These are little tiny bleeds that occur into the skin for no reason. It has absolutely nothing to do with Neurology. She has a "great" internist. She went to see one of the Oncology (Cancer) people about this, because it can be related to a problem with clotting (usually a platelet problem). She had a bone marrow biopsy, and he gave her a chemo drug, but it didn't help. She also went to an Arthritis doctor because sometimes this is from an auto-immune disease (diseases like Lupus and Rheumatoid Arthritis). She had two skin biopsies and a trip to Moffitt Cancer Center and Mayo Clinic. She came back to see me yesterday, still with no diagnosis.
I told my wife to figure out what was wrong with her. I said it's one of three things: Cancer, Immune problem or drug reaction.
Five minutes later she asked me "Please don't make fun of me. I came up with something, but I know it's really stupid". Then she asked me if it could be from Hydrochlorothiazide.
Hydrochlorothiazide is one of the oldest and most commonly used medications for hypertension. It is practically like aspirin in terms of how well known and commonly used it is. It is right on the list of side effects: "purpura". Not one of the at least ten doctors she's seen who are "purpura" experts has taken her off this medication. Last night, I spoke with a hypertension expert. He said he was shocked. He told me that this is so important that it is a question on every medical boards examination. The first thing that should have been done is to take her off the medicine. He was certain that this is the cause.
I don't know if the purpura is from the Hydrochlorothiazide. I suspect it is. We'll know pretty soon (I told her to stop it). However, even if she doesn't get better and it wasn't from the Hydrochlorothiazide, it's prett scary that this was missed. The really scary part is who missed it. It's really amazing how usually it's the simplest things that people make mistakes about. Everyone forgot to look up the side effects of the medications she was on. It's one of the first things that we're supposed to do. That probably should have been done before the bone marrow, chemotherapy, and skin biopsies.
Things can really get missed!

Not Sure

Sometimes, you can't really be sure about what the patients are saying. They will tell you things that they want you to hear. However, how can you know if what they are saying is accurate? It's certainly not good to have to wonder about the validitiy of th einformation that you are given by a patient. People who take narcotics are always suspected of dishonesty. It is very common in the practice of medicine. Usually, I try to give people the respect that I expect. People do have pain. They do need strong medications. However, it is very rare that people actually drop their medications down the drain. Of course, it does happen. It's also very rare for people to have to get theri prescriptions filled in a different pharmacy than usual because of vacation. Sometimes, these things make me feel unsure. After a while, though, I can get pretty sure. No one drops their pills down the drain three times in one year. It's just not something that happens. I know this because in twenty years of practice, no one has ever dropped their entire prescription of antibiotics down the sink. In fact, non-narcotic medications seem to very rarely get lost in any way.
Some physicians have absolutely no tolerance for this. Everyone is lying if they tell you something that you don't want to hear. The problem is that there are too many people who ARE lying. It makes some people very cynical.
I try very hard to believe the patients. But lately, I'm not sure. I'm just not sure these days. I had a very difficult to understand patient today. The pattern of illness is just so strange. I always try to think that if something is very hard to understand it's because it's very hard to understand. The other way to think is the more common way. "If I don't understand it, then it must not be so." However, that assumes that I understand everything, which we know is definietly false. If I don't understand then there are TWO (definitely two) possibilities. Either that is how it is and I don't understand it OR that isn't how it is at all and I'm being deceived. So then you have to ask youreself if you really want to believe the patient or if you even CAN (assuming that you wanted to.)
Today I had a car accident patient who I'm just not sure about. They aren't "narcotic seeking" people. They just want to have a bigger injury than they have for a variety of reasons, the worst of all being deliberate desire to acquire a large settlement. They may tell us (physicians) things that exaggerate their illness. Well, this patient was clearly moving much better when I looked at her out of the window walking outside after our visit than she was in the office. She looked very different. So this makes me pretty sure that there is some exaggeration going on. At this point, I now don't really know what I'm going to do. Initially I just wasn't sure about what was wrong. Now, I'm just not sure about what exactly to do with the patient. If you tell a patient, "I don't think I can help you" they may still insist that you try. The option of telling them directly that there is a lack of trust always exists. But that creates a problem with your "caring" since it causes harm to the patient ("Above all, do no harm"). It is a small harm, of course. Still, it is a deliberate harm, and, in the event that you are wrong despite your certainty possibly a bigger harm than you realize.
I'm just not really sure.

Primary Care

I had a patient today who brought his wife who doesn't want to have a primary care physician. She has one now, but doesn't like him. She wants to see me for a neurological issue, but she wants me to "be her doctor". She doesn't want a primary care doctor. This is the third person this week who had this sort of discussion with me. One patient told me that his cardiologist told him he doesn't need a primary care doctor.
A lot of the "primary care" doctors are starting to refer the patients to specialists for almost every concern that comes up. They are also not seeing patients urgently. They send the patients to the "walk-in" clinics or "urgent care" centers. They also don't care for the patients in the hospital, because we have "hospitalists" now - physicians who specialize in the care of patients in the hospital.
The Walmarts and Publixs and CVSs are starting to have clinics with Nurse Practitioners and Physicians Assistants attached to the pharmacy. In Hawaii, they have started ten minute computer-interface physician "prescribing consults". You never actually see a doctor, you just communicate via computer to get a medication.

We are creating greater and greater efficiency in everything. The "encounter" with the patient is now an "event" that can be quantified and expedited to the point that there are physicians who see eighty patients a day! Today, I saw eleven patients. I am clearly not getting the point of it all. (I know a way to increase my income 7.3 times, though). This is great efficiency. I am not good at "primary care". I don't do it all of the time. I didn't train in it. I tell people this. I do think that there are other people who do it far better than I ever can. The problem is that the patients don't care that much about what you're doing if you don't care. They can't get past the fact that you don't care. The problem is that if you care, you can't see eighty people a day, and it isn't efficient "enough".

In the great rush the "primary care" physicians are rushing themselves out of a job. I don't even know what to say.

Changing our Likes

This morning was all Alzheimer's. There were five Alzheimers or MCI (Mild Cognitive Impairment) patients. There was a pinched nerve in the back patient, a Parkinson's patient, a chronic pain and seizures patient, one Migraine patient, and a woman who clearly has a broken hip and has been walking around with it for a week. Well, she hasn't really been "walking" around. She's been limping. I had to do one LP for a woman who may have MS this afternoon. It was annoying because the lab lost her spinal fluid the first time. I had one patient who wants his muscle cramps fixed right away, so he's going to see a surgeon (I told him I don't think surgery will help). He has to have this pain fixed before his wife dies, because she gets him his pills when he gets a cramp. If she isn't there to get him his pills, it will be a problem. (Sometimes people amaze me with their deep compassion and love.) I had a new patient this afternoon who was really an old patient. He counts as a "new" patient because I haven't seen him for six years. He has pinched nerves in his arms. He was mostly talking about his wife who has Alzheimer's. I think he's more worried about that than his arms. He was supposed to be here for his arms, though. That was the day.
The most interesting thing today was chosing what we like. It really is important that we decide what we want to like and don't want to like. We create who we are if we want to. I can change me. You can change you. Sometimes, if things are all set up correctly, I can change you. You can change me. People change. That means we can change how we think, how we act, and what we like or don't like. So if you don't like something that you should like you can change your liking. When people say "I don't like to walk" I pretty much always say something like, "Oh, you like being in a wheechair better?" It's silly, of course. But it isn't really possible to not like walking. It isn't possible, at least, if you consider it as an option. Do you like walking or not walking? "Not walking" (paralysis) is not pleasant at all. So we have to like walking. Then there is the nuance of wanting to walk just for the fun of it, or just for the exercise of it. Still, people don't want to be unhealthy. So they want to be healthy. This means that they want to exercise. Exercise is a requisite part of being healthy. If we say, "Do you like to be healthy or unhealthy?" People say "I like to be healthy." Being healthy includes doing exercise. It is a part of it. It is not separate, it is a subset within the larger whole. One cannot like being healthy if they don't like being a person who exercises. This is like someone saying, "I like being alive, but I don't like having a beating heart." It can't be. Even so, people sometimes don't see the logic clearly.
I need to learn how to better explain the process of changing ourselves to like what it is that we want to like instead of sitting around passively and noticing what we like as if we have no control over it. We sit around "resigned" to our likes and dislikes. This prevents our ability to create the person we want to be.

Empathy

I remember once reading somewhere something from someone. It was about the beauty of our fellow man. It was about his actual divine nature. It was sometihng sort of like this: "If we were to see the divinity within each other we could do nothing but bow down before our fellow man." Obviously, my mind is failing us on the details. Nonetheless, the essence of the thought remains couched inside the vague notion of what I once read. Looking very deeply into others we know well we at times can see their "divine nature". (It's harder with some people than with others.) But what does this mean for our empathy for others. There is this issue of many (is it most?) men living out their lives in quiet desperation. There is a great discrepency. We have divine creatures living out their lives in desperation. They aren't recognized any more for their divinity or their unique and inherent value. We no longer (as a culture, that is) appreciate a good person the way we appreciate a good orchid. How is this possible if the person is a divine entity? Certainly there is no shortage of suffering.
If we proceed with empathy towards everyone we meet then there is this sea of suffering that comes in. This is hard to deal with internally. Yesterday I saw sixteen people. One or two at most had what I call a "reasonable degree of happiness." This isn't to say that I can sit here and say: "That person was truly happy." I just can say that they had a "reasonable degree." The rest of them are suffering some or suffering a lot. That is the way the patients were yesterday. That is the way that the patients usually are.
So physicians have no choice but to lose empathy. It is hard to continue to see these people and feel for their suffering for ten years. Of course, seeing sixteen people in a day is ridiculous. These days physicians see thirty at least and sometimes as many as eighty people a day! There are physicians who see eighty people a day! Forty is typical. This is mind boggling to me. However, it can be understood if you know that they don't see any PEOPLE. Certainly they never get a chance of glimpsing into their divine nature. In fact, they rarely even know the people they treat. They only know a disease state. "Here comes the gallbladder." "Here comes the diabetes." It's a way to survive the "practice of medicine". It's a way to get through the system (mostly in quiet desperation). There's very little empathy left in medicine these days. Patients come to see physicians because they are suffering; so they need empathy.
It's interesting to see all of the discussions about "quality of care" and "healthcare costs". Patients need to have tests because when a doctor orders a test it means he cares. Patients need to have tests done because they can't trust the doctor to be right if the doctor doesn't even seem to care about them, or if she is seeing eighty people a day. Doctors want to put patients throught tests to generate more money because they don't really care about the people that they can't even see if there isn't empathy. The physicians are unhappy because they don't have a connection, because they can't because if they did, they would drown in the sea of despair. But no one is talking about the real issue - the lack of empathy in our "medicine".

Mercury

BB was here yesterday. I have seen her for a few years. She has dementia. Dementia probably means (it's nearly impossible to translate from medicine language to enlish) "progressive trouble with thinking ability." The most "popular" dementia, by far, is Alzheimer's which is a specific disease. I'm not sure if she has Alzheimer's. If she does, it's an unusual one. However, since 85% of the cases of dementia are due to Alzheimer's disease, an unusual case of Alzheimer's is more likely than an unusual dementia. Someone I respect who is a neuropsychologist thought she has Progressive Primary Aphasia. That's a very rare form of dementia. Maybe she has that.
She has a caregiver who is a joint custodian for her with a charity group. Yesterday I spoke with her at length. BB has been going for chelation therapy. She is being treated for high fecal mercury levels. This has been going on for fourteen months. There hasn't been significant benefit from this so far. Yesterday was the first time that I was asked the questions that made me discuss the potential benefits of this type of therapy. So I did.
It is sufficient to say that I don't really have faith in the theraputic value of this treatment, although the financial benefit (to the provider) is significant.
I don't believe in taking away people's hope. It's not right. It doesn't really help anything. If people want to try things that I'm pretty sure don't work, that's alright. If people want to try things are just dangerous, I object. So sometimes when people are doing certain things for certain diseases, I keep quiet about it.
There is a lot of "alternative" therapy that sounds very good to me. Some of it has very good research behind it and I really believe in it. I take Barcopa because it's pretty clear that it makes thinking better. I recommend it, and I even sell it in the office. I do the same with Salacia. It's crazy to think that herbs don't do things. How some people come to this conclusion is mind-boggling. The "herb" marijuana has very clear and potent effects. It's even illegal. The "herb" (it's a bean really) coffee clearly has a significant physiologic effect. So there's no doubt that some plants produce chemical effects in our bodies. It has to be that way. It's just a matter of understanding what they are and the risks and benefits. There is also the issue of our degree of certainty about the purported benefits.
Then, there are things that are most unlikely to help. I'm pretty sure that "fecal mercury" for which BB was treated never had much of a chance. It was an expensive therapy. Now, it turns out that BB is "running out of money". The charity that helps be her "custodial guardian" required $53,000 last year to manage her finances (pay her bills). Maybe that's part of why she's running out of money. It is a church-related charity. I don't know how charitable it is to charge that much money, though. Maybe the chelation is part of it too. Maybe I should have opposed the chelation more vigorously at the start - to help save her money. I don't know, though - it would have reduced the hope and decreased the faith in me. People want to believe what they want to believe; they need to learn from experience more than from lectures.
So that's the story on Mercury.

Control

A new patient was brought here by his wife. His doctor told her that she thought she could handle his severe Alzheimer's disease. However, she just wanted to have a neurologist so that she could find out about new developments. It's a little odd, since she's very intelligent and belongs to the Alzheimer's association and is on the web and was a lawyer who just recently retired and (I know this is a grammatically incorrect run on sentence) she certainly knows that any major development in Alzheimer's would be all over the news. However, she just wanted to have a neurologist to find out about new developments in the field. She recounted his history for me. They just moved here from Arizona. He is an an assisted living setting that she feels is very good for him. She brought some of his records for me to review - those from his second neurologist. She didn't bring the ones from his first neurologist who she mentioned had made some mistakes which were confirmed by their primary care physician. She also said that there was a significant conflict between herself (she's "the second wife") and his daughter. They had agreed that the daughter shouldn't be visiting him with many people all at once because (according to the wife and her research - she was able to research this issue extensively, but wouldn't be able to find out about new developments) many people all at once agitate people with Alzheimer's in generally and especially him. This had required lawyers and negotiations. She had letters from his last neurologist stating that she was the only one who should dictate his care, and letters that he shouldn't be exposed to multiple people. It was probably a detail oversight (lawyers commonly miss the details) but there were multiple copies of these two letters, which is why I say "letters". There were only single copies of the medically relevant information. Anyway, what she wanted is that I write letters saying that his daughter shouldn't be allowed to take him out on her own. She wanted this "for her files". It was all very confusing to me. It turns out that she was concerned to some extent about a cabin that he owned. Also, she had left Arizona without discussing it with his daughter. I mentioned this many times, but she didn't want that. Anyway, when there is a family dispute about who should be a guardian, courts typically appoint a "neutral" party. There are professional guardians who take on this responsibility for people. They just do what's best for the patient when it appears that people in the family want to do what's best for them.
Obviously, this wife wants to have complete control. She came here to try to get my assistance. I told her that I couldn't really help her, because I really don't know that it isn't good for the patient to go out with his daughter. I don't know how any doctor can know this. I don't know how a neurologist in Arizona knew that going out to lunch with his daughter was harmful for the patient - ahead of time. I also told her that this sort of decision making was usually made by a custodian.
There is a lot that goes into the control of people who lose thinking. I'm notsure what happened with this family. There is a great conflict between the patient's wife and the patient's daughter. I don't blame anyone. I won't take any sides. The situation is sad and frustrating. There was a failure in planning. This is something that the family should have discussed very early on - the minute that the diagnosis was made. The patient should have set out clearly how things should have been handled: who should become the custodian if one were necessary. He should have prepared an irrevocable will that couldn't be modified by a custodian. None of that, it seems, occurred. She is a lawyer, so it's not a case of ignorance. It's just a case of control. People want control.