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.