Lifestyle

Almost every day there is more data on the way that we behave. On NPR today they were talking about McCain's plan for health care. He wants to change tax rules so that individuals purchase their health insurance and there are more medical savings accounts. He thinks that if the consumer purchases health care directly they will utilize less of their money. We use more of other people's money than we use of our own. We want others to take care of our needs and desires.
There are two new important articles on alzheimer's and mild cognitive impairment. This isn't really news, since it just adds to an ever growing body of literature. People who exercise regularly had lower levels of cognitive impairment. People with cognitive impairment who exercise experienced significant improvements in thinking.
People who take more than two alcoholic beverages per day developed Alzheimer's on average five years earlier than those who were matched for other risks.
People who smoke experience Alzheimer's about 2.3 years earlier than those who don't smoke.

The news is shocking! If we take care of ourselves we do better than if we don't.
Health care costs too much and we aren't getting our money's worth. This is very complex. For one thing Insurance companies are just ridiculous. The whole concept is ridiculous. Their profits do nothing to help take care of people. McCain's plan completely ignores the true nature of health care. Actually, so do Clinton and Obama's. We spend most of our money in the last year of life. If you really want to get our health care costs down, you need to increase the notion that it's alright to die once you are very sick. That's where we waste the most money. We keep going when there's little point. The other place we waste money is that people generally don't have enough faith in physicians - in people in general. People are fearful and want tests to prove tha the physician is right. When I tell people they have Parkinson's they want to know what test I am going to do to show that this is the case. But there is no good test for Parkinson's. I constantly see Parkinson's patients for a second, third or fourth opinion. But the accuracy of diagnosis is very high. So fear causes a lot of the cost. So does litigation, which is driven by anger.
However, most of our cost comes from chronic disease. Chronic disease like heart disease and diabetes is driven by a failure of our society to take care of ourselves. Our lifestyle. We are more obese than other countries. We are sicker. We are a sick society. People here are isolated. I see a great deal of depression. There is no community. There is no support. People are alone. So they don't take care of themselves. So they get chronic illness. So it costs a lot of money. They are alone so they are scared. They aren't happy with the life they've had, so they don't want to die.
It's all about lifestyle.

Thinking Things are Good

A patient today told me that everyone is wanting to be a victim of circumstances, rather than realizing that they make their own conditions with their thoughts. I've had that sort of thinking many times. He was a very succesful business man. But I've seen a lot of people who just don't have that kind of opportunity. They don't have the ability to think that well. So they can't see that their reality is created by their perceptions. There is no alternative for them other than to be the "victim" of what happens. However, the notion that we create our lives is very limited. It fails to respect that there is a process that occurs over which we are powerless. That we just get to observe. Things happen. Then, we have to try to figure out (if we can) why they're good. It's harder in some jobs than others. It's hard in medicine. Why did my patient's wife get pancreatic cancer? How is that good? Why do I have a patient who keeps on getting shingles every four months? How is that good?
It's important to know that if I can't figure out why something is good that it's me: I can't figure it out. I'm not smart enough. That's different than deciding that the thing is bad. I'm not smart enough to know what's bad and what's good. So arbitrarily, everything is good. That's not to say that everything is all good all of the time. It's just that everything (the whole thing, not every single thing) is good. In that decision we create our reality to some extent.
Anyway, I saw that patient today. Then I saw a patient who is in her early thirties and has disabling Lupus. She's been my patient for about ten years. She's just sort of declining both physically and spiritually. And then I saw my ALS patient who can't move his arms and can very barely walk at all. And I saw my patient with post-traumatic spinal cord injury who is in a wheelchair. It's hard to help them with that sort of positive thinking. You can't just be a polyanna with the patients all of the time, because that's annoying. Sometimes it's important to acknowledge that things just don't seem fair. They don't seem right sometimes.

Six month Follow Up Visits

My last patient today was Mrs P. She was supposed to be a very easy patient. She has restless legs which are well controlled. She was here for a six month follow up, which means she's in pretty good shape. Nothing is better than a six month follow up except a one year follow up. Actually, the best thing of all is the "I hope I don't see you again" never follow up. But then again, those patients aren't really "in the practice". Anyway, her restless legs aren't that great, really. They're bothering her more. But she is under some stress too. Her husband is very ill. He is very weak and has been falling. He has had many surgeries. The VA eliminated his pension after review of his case, and they don't really have enough money. They are investigating a reverse mortgage to make ends meet. Anyhow, she got ill in October with coughing. She had no fever, but was very short of breath. Her doctor thought she had pneumonia, but her X-Ray and her Cat scan were normal. Another doctor thought she had bronchitis. But she hasn't gotten any better, really. She still coughs. She feels weak. She is always short of breath, and it gets worse if she lays down. It's not worse, really. But it's certainly not any better. And her restless legs is somewhat worse. I don't really understand why, but neither of the other doctors got her an examination of her heart. I think she really needs that, because all of these complaints could also indicate a heart problem. That wouldn't surprise me. The medicine she's on, Lyrica, is also a concern. It could do some of these things as well. Well, it wasn't really a routine six months follow up after all. You never can know what to expect. You can't really predict anything at all, it turns out.

Second Opinions

I sent M for a second opinion at a university teaching center. I had originally sent her to one of our local rheumatologists. He didn't think very much was wrong with her. I'm convinced she has a rheumatological issue. So I sent her to the university. They think she has Sjogren's syndrome. That makes sense to me. I have been dealing with her pain now for over a year. I keep thinking that it has a rheumatological basis. But the rheumatologist says no. It's frustrating. Now, I am terribly relieved. So is she. We can proceed with an intelligent treatment, and she's probably going to get a lot better.

Sometimes I don't like second opinions. I just sent someone else (one of my patients) for a second neurological opinion at a university center. They thought that I have it wrong, and gave him a different (much better) diagnosis. I think he has ALS (Lou Gherig's disease). They don't think so. They think he has Isaac's disease. However, I'm not sure yet that I'm totally convinced I'm wrong. Time will tell. Still - I hope I'm wrong. Even so, it's no fun to be the one that got it wrong. But here's the thing: if it helps the patient, who really cares?

Some doctors don't want the patients to get second opinions. Those patients should get a second opinion.

Giftim

R was here. He has had a stroke. He has severe chronic depression which he's had from his stroke for the last decade or so. He is weak on his left side, but still can walk fairly well. He can't use the left hand for much. I have another patient with nearly the exact same stroke, but he isn't depressed over it. My wife made up a word: "giftim". It refers to one who takes on the role of a victim as though it were a gift. She points to the fact that there are people who actually want to be victims. It justifies their lack of effort. It justifies their depression. It explains their circumstances. So then, they have nothing to do but suffer their victimhood. They go about telling their story, and everyone has to give them sympathy. The world is held hostage to their suffering. The world has to give them care and compassion. After all, if one doesn't have compassion for the person with a stroke, who is that person? The problem is when we see two patients with nearly the same stroke. One is great. One is independant and happy. One is dependent and depressed. It isn't the stroke, really. It's the giftim. It's a good word. It helps with insight into why there are some people who almost seem that they don't want to improve, don't want to be better, don't want to see the positive part of things. Whatever it is that we're faced with, we have to avoid being giftims.

Today

One of my patients -M came today. He has MS. He just found out that his wife has pancreatic cancer. Yesterday, C came in and his wife has pancreatic cancer also. That's too much pancreatic cancer. It's hard to watch them trying to be strong. Men try to be strong when their wives have cancer, but it's hard.
The staff is wonderful. They are doing great. It's a huge difference. The office is getting very organized.
Tomorrow I meet with the hospital administrator who wants to rule the town. One of my colleagues calls her "Queen ___". I'm very happy that after she got all of her employees to stop sending all of their patients here I am doing well. I think that will create a situation in which she has no power to influence me. Unfortunately, I don't think she'll have any influence over the other two neurologists in this town. I don't know how well her plans were thought through.
One of my patients called upset because I told him that the medication I was giving him would be inexpensive and it was $50.00. I have to be careful about that. To me, given what most medications cost that's inexpensive. I found it cheaper on-line for him. Still, I need to be more aware of what these things cost.
That was today.

Disease Burden

Today, there was too much disease. Some days are like that. It's not that I don't understand the purpose of disease or our need for it. It's just that there are days when there's too much to look at.
C came. He has been a patient for a long time. He has a severe pain syndrome associated with a stroke ("Dejerine-Roussy syndrome). Since I last saw him, his wife developed cancer - adenocarcinoma. She is not doing well. Therefore, he is not doing well. He is one of the people that will die shortly after she does. I know this. He loves her and they are no longer two. "The two shall be as one." So they are one.
J came. Her husband has end-stage Alzheimer's and he can't walk. He has severe constant back pain and he has severe heart disease. She does nothing but take care of him and hasn't been out for four months. I told her that she isn't helping him at all. That is shocking, but I said it with loving-kindness. If she were him and he were her, she wouldn't be happy at all that he was doing what she's doing. She would want him to take care of himself. She never thought of it like that. I've never explained it like that before. It works, though. It's the truth. If I'm like that, I want my wife to take care of herself. I don't want to know that I'm dragging her down with me. Anyway, I want her to think about letting him go. We don't use enough Hospice for Alzheimer's disease. We use it more for cancer, but this is wrong thinking.
R is a new patient I saw. She is 30 and describes herself as a "bitch". She has uncontrollable attacks of inappropriate rage. She has a fourteen month old child. Her marriage is struggling. She came to see me because she wants these episodes to be something other than psychological. She wants them to go away with a pill. She wants them to be explained by something that is not her fault. She has had plenty of head trauma, so it's possible that there is some "brain damage" (a useful English word that means very little to me). But I fear that this is far more likely just plain old "can't handle life well syndrome". She has had more suffering than she has suffering-healing skills.
Today is day two of new staff. They seem like they are going to be great and increase the patient's care.
The new "favored" Neurologist is now in town. All of the doctors who work for the hospital stopped sending their patients here. I'm still busy. I'm very lucky that it didn't really hurt. I know that the hospital CEO was really hoping to shake up my practice so that I would be influenced to try to get into the "good graces". She plays hard-ball business. She is good at it, too. I play take really good care of the patients. I'm good at it, too. We aren't playing the same game. I think I understand the rules of her game. But I'm not really sure that she understands the rules of my game very well.