Another Day

K came today. Her son died suddenly. She said that when you're "old" (she's in her eighties) you come to expect these things. She isn't really depressed about this. That is something that always surprises me. I've had a few patients who have lost children and were "OK" with it. I don't know how, but it's very inspiring. I'm pretty sure I couldn't do that. They have great strenght. I have one patient who comes every two months. He is 95 years old. He only needs to come here once every six months. He wants to come in every month. So it's a compromise. He asks me lots of advice, but doesn't follow most of it. I'm not sure why he likes coming in here so much. He always tells me how wonderful it is to come here and how important I am in his care. I can't really believe that, because he doesn't usually do what I tell him. That's a funny thing. My very obese stroke patient came in again. He has very severe apathy. He just doesn't care about anything. His wife prepares all of his meals. I've been talking to them about his weight for years. Today I told HER to stop giving him all of this food. He can't shop. He doesn't get his own food. So everything he eats, she gives him. I put all of the burden on her. We'll see how that works. She gives him ice cream every night before dinner. That's not good at all. I told her that's going to give him a stroke, so it's not worth it.

Buisness

There is a great new business opportunity for me. Most of the physicians in town are now employees of HMA, the company that owns the hospital. The new CEO came in and started buying all of the practices. Frank, my old partner, says that they want control. Anyway, they haven't had very much luck getting the Neurologists in town to do what they want. So they hired a new Neurologist to work for HMA. She is their employee. She starts on 1/28. Effective 1/28 none of their doctors have any patients referred to me. That is a little odd, since in a typical week that group would have about eight new patients here. But they are going to send people where their employer wants them too (obviously).
This gives me more time to find other business. That is a good thing. I never have enough time for my other interests. I've been trying to get this book on being healthy done for years. Perhaps I finally will have some time. Or maybe my self-referrals will pick up. Who knows. It's exciting. I am wanting to get more into the herbal side of medicine as well. That takes time. There's a lot to learn in that area.
When things change it is always an opportunity. Medicine is like everything else in that regard. As soon as the book on being healthy is done, I really want to write one on why disease is so good. There are a lot of books out about why death and dying are good. But there aren't ones on why diseases are good; especially particular diseases. No one thinks about that; no one writes about that. Everyone accepts that all illness is bad. But that isn't exactly true. It is easy for people to say it's bad that there is politics in where the patients are going to be referred. It's easy to say anything is bad. But it isn't bad. We just have to always work a little harder to see how things are good when we want to think they aren't.

Fear

People are afraid. There is so much fear that comes into the office. Mrs. H came in yesterday. She had urinary incontinence. She went to see a physician who was going to do a bladder suspension procedure. He had to send her for routine cardiac clearance. The cardiologist who saw her found an abnormal stress test, so he had to do an angiogram. After that, they wanted to do emergency open heart surgery for a 6-way bypass. She didn't even know that she had any heart disease.
That is scary.
She had surgery, and she is doing very well now.
We might suddenly die. That's the tricky thing. It makes people afraid. So we have to be able to accept this and still be happy from day to day. I don't really think this is a terrible thing. It's a constant reminder that we have to do whatever we have to do to be good right now. There's just no time to waste. I think the real problem is that too many of us are spending too much time wasted, thinking that we can't die right now. But that's a scary plan.

Money

Mr. T came in Monday. He is changing his primary care doctor and he is just not going to see his endocrinologist anymore (he has very severe diabetes). He stopped one of the medications that I give him for his neuropathy and spinal stenosis. He didn't have a scheduled appointment and he wasn't having very severe pain. He just wanted to come in to work out a payment schedule with me so that he can see me. He has joined one of the medicare HMO plans. None of his current physicians are participating in that program. They won't pay much (about five dollars) for those visits. He is allowed to still see these doctors, he just has to pay for it "out of pocket". The reason he went with the HMO plan is that they pay for his diabetic supplies, and traditional medicare doesn't. He gets about $1,000 per month from his social security. He had an IRA, but that just recently ran out. His rent is $400/month and his electric is about $100/month. He has a water bill and a phone bill. He also pays car insurance. He is complaining that there isn't really much money left over for food. He was spending about $160/month on his diabetic supplies. The HMO will pay for that. He makes too much money for food stamps. He is too proud to go to the All Faiths Food Bank. He is a WWII veteran. He used to work on the side as a handy man, but I told him to stop that about one year ago, because I was afraid it was going to be too dangerous for his back. When he stopped doing that, his back got much better.
I'll probably charge him about $20 per visit. If I charge him lower, it will hurt his pride. That's about all that I can do.
There's something wrong with medicare, isn't there?

Health Maintenance

Today I didn't see one patient who is adequately taking care of themselves. They are not exercising. They are all overweight (or obese). Some of them smoke. There is no health maintenance. Recently I saw a very heavy woman. Her cardiologist told her that she was "Fat and lazy." (He literally used those words.) Today, one of my patients told her that her internist told her to go on a 1200 calorie per day diet.

If every single one of my patients -- EVERY ONE -- that came in today has a problem with health maintenance, how can it possibly be the patients? If one person becomes a suicide bomber, he's insane. But when the entire village becomes suicide bombers, there is a social problem in that village. Clearly, then, there is something wrong in my village. In fact, I think, it's in my country.

Today was a little extreme. Usually I see a few patients who do take care of themselves. But in my practice, it's probably about 5%. That's lower than the national average: about 10% of americans exercise regularly.

It's difficult, because I treat back pain (which is caused largely by obesity) and stroke (caused by obesity) and neuropathy (often caused by diabetes which is caused by obesity). Parkinson's has nothing to do with lifestyle. ALS has nothing to do with lifestyle. Alzheimer's is interesting because there are studies now coming out that exercise seems to decrease the chances of Alzheimer's and that vascular disease has a lot to do with it, so it may partly be related to our lifestyle -- but only partly.

My society is creating too much disease. There is something very wrong with how we're doing things. People aren't being taught how to take care of themselves.

About time

I have fallen terribly behind on writing. There are too many patients to see. There isn't enough time. There is a great problem with this. It cuts into the time for reading and writing. In the academic world, when I was an assistant professor, we didn't really care very much about the quality of SERVICE. We cared about the quality of the care we provided. But SERVICE wasn't an issue. If people had to wait for four or five months to get a new patient appointment, it didn't matter to us. We had the prestige to demand this. Since we taught and did research, we didn't really care that much about patient productivity and our "practice". It was almost a side job. But now, that is entirely different. The patients are the priority. I still find that we don't service people well. We don't get people in here for weeks. It upsets them. The problem is, there just isn't the time. So now, the reading and writing are starting to suffer. Mostly, it's writing. Soon, it will be the reading.

I have thought before about time delusions. We have wrong perceptions of time. The time seems to come and go on its own schedule, rather than our own. We are always making choices about how we use our time. People are always telling me that they don't "have time" to exercise. But we have to make that time happen. We really "have" the time. It's just that we choose to use it doing something other than exercise. It's the difference between letting life happen and making life happen. Letting vs. Making. We just have to create the life that we want.

This is one of the things that is critical to a successful illness. When I have time, I do need to write a book on the good things about illness. (First I have to finish the one about being healthy). I'd better create that time. When we get sick, we tend to re-assess priorities. We make our decisions differently. We change the way that we use our time. I think if I were to get sick, then I would write more. Of course, the practice will suffer a little. People will have to wait, or another solution to seeing people will have to appear.

Focusing

Yesterday, I had an especially "difficult" patient. She was referred here for falling. She wanted to keep on talking about her stress. I usually can listen to patient's concerns. After all, I'm here for the patients. I am here to care for them. But with a referral for a particular problem, it seems that I should address that issue. She has fallen ten times in the past year. This is dangerous. She is elderly, and injury could occur. So I have to figure out why she is falling, and if there is treatment to improve her condition.
Her son had swindled her and her husband out of $100,000 a few years ago. He had stated that she had Alzheimer's, but an evaluation done by one of my colleagues revealed completely normal thinking. Now, he is apparantly trying to take advantage of them again. There are many details, but they aren't really that relevant here. She kept on telling me that she thought the stress she is under is the cause of her falling.
In order to figure things out, I do need some history. So I kept on trying to re-direct the patient; to find out more about this dizziness.
Now, I realize what the problem is. I wasn't really listening.
The problem with listening is remembering to hear what the people don't say. That's the tricky part. She wants this all to be related to the stress. That's because she can't handle anythying ELSE. There CAN'T be anything else. She doesn't have the ability to address another problem. She's here because her doctor sent her here. But in reality, she doesn't care about the falling. She doesn't care that she may fracture her hip. She doesn't care that she might hit her head. She only cares about the problems she's having with her son. So whatever is wrong, it HAS to be related to this stress.
I do think that there are stress related illnesses. I tell lots of my headache patients and my seizure patients about stress. I tell my back pain and neck pain patients about stress. I tell my obese patients about it.
But this balance problem was very clearly physical, and not stress related. So I was trying to explain that to her.
I missed the point entirely. There is nothing that isn't related to this stress for her right now. That's because this is the reality that she has created. So what am I supposed to do about this falling issue?