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.
Thursday, January 29, 2009
Wednesday, January 21, 2009
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.
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.
Thursday, January 15, 2009
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.
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.
Wednesday, January 14, 2009
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".
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".
Thursday, January 8, 2009
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.
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.
Wednesday, January 7, 2009
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.
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.
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