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.