Pain

RL, WH, AC, RS, DL, KS, WO, BK, JR, TW and MP: 11 patients today were pain patients. Back pain, head pain or leg pain is what they had. Except for one person with pain all over the place. There is a man in Worcester MA, Jon Kabbat-Zinn who runs the multi-disciplinary pain center. He teaches meditation. He believes that we should accept pain and welcome it. This relates to the process of labelling it as bad or good or neutral. We can have pain without suffering. People have made this distinction. The most famous time is in childbirth which is thought of as very painful. Generally, it isn't thought of as suffering. That's because the experience seems so meaningful that some people even "want" the pain component. They refuse analgesics.
I don't know what skill Kabbatt-Zinn has but I don't believe that I could get one of these patients to accept their chronic pain. I have some who would. These people just want it to go away. So we try with pills to make it better. Several of them are a great deal better, because we have such great medications. Several of them are not better. I wish that they could accept that they have pain and divorce it from suffering. It would be nice if I knew how to teach that.

Fascinating Information

Fascinating information has emerged. There have been several trials of medications revealing unexpected results. They keep on coming out. I know the reason: the sophistication in analysis of outcomes research. We are getting better at finding out what we want to know. Years ago they made up a new composite outcome measure. This means that when we do a trial we measure something. This is called the "primary outcome measure". The one we made up recently was "Vascular event". We now use this consistently in trials. It is the combination of either death or stroke or heart attack. Is this sensible? I don't know what this is. I know what stroke is. I know what death is. I know what heart attack is. But I don't know what the combination of all three of these is. What about very mild heart attacks? If I prevent many very mild heart attacks but very few deaths and major strokes is this the same as if I prevent many major strokes? I don't think so. We have another trend which is to measure the carotid artery thickness. If we prevent increased thickness (amount of athersclerosis) then this may indicate a reduction in "vascular events". So we don't even have to measure "vascular event". We also are using cholesterol levels instead of "vascular events" as a measurement of success.
A series of trials now is showing that our "substitute measures" are not working out as we had thought. Zetia was very effective at lowering cholesterol, but not the substitute measure of carotid artery athersclerosis. Now it's getting worse. Medicines that lower sugar more in diabetes are causing increased rates of death. Medicine combinations that lower blood pressure better than one agent alone are causing increased death rates than one medicine alone.
This is a problem because our insurance industry is getting very aggressive about measuring "quality of care". They are pushing "pay for performance" where physicians get paid more (or less) depending on whether they are meeting the appropriate outcomes. This pressures physicians to "perform". However, it's turning out that we don't actually know how we're performing. Things that we think are good are turning out to be bad. Perhaps there are a few "bad doctors" who are actually doing a better job at things. I've come up against some of my colleagues from time to time. I guess I don't know who is right and wrong. But a lot of times I want blood pressures "too high". That's because the medications are causing dizziness. They other doctor wants to have "high quality care". I want the patient to avoid falling and breaking their hip. But my quality of care is not good. Except now it's turning out more and more that we don't really know. There is no study on lowering blood pressure in dizzy patients.

Age

JF was late today because he was lost on the way here. He thinks he's losing his mind. He has neuropathy and tremors and back pain. He told me that he doesn't like the treadmill at all. He doesn't want to exercise and it's "hell" getting old. He thinks of aging as a series of giving up things. He's thought it ma be better to die young. I hear this.

Probably aging is our greatest challenge, and it's our final test. Things change. I wouldn't say that we just give things up. I would say that things change. We change. Our perceptions, skills, priorities and environments change. Still, throughout time we are either growing or we aren't. To me, if we aren't growing then we're shrinking. I suppose there should be a neutral option: non-growth. However, I think that non-growth is shrinkage. Over time, the challenges we are faced with increase in complexity and severity. So if there hasn't been growth there has been a relative decrease in our ability to handle our lives. A person with the capacity of a ten year old can't handle the challenges of a thirty-something year old person. So we have to keep growing to keep up. "Growing" isn't about skin or looks or athletic capacity. These things tend to degenerate. Our nature is such that bodies degenerate. Then, when they are old enough they die. Otherwise, they suddenly break and we die. The other option is that we break them through carelessness or war or something.

Aging has to be about growing. We have to be big enough to go beyond our physical existence. If the only point of it all is to be a body, a series of cells functioning to perform activities related to motion, there isn't much beyond youth. But it isn't that way because there is also cognitive and spiritual function. That is where the growth is. If we neglect these areas, then as the bodies degenerate we are left with very little. Interestingly, in the case where we also lose cognition (which in some sense is purely a physical process) there is nothing left except the spiritual component of a person. So we should grow that. We should spend some of our time - some of our lives - doing that. It gives aging purpose. Then, we aren't just going through a series of giving things up. We're going through a series of trading. We are trading lifetime for experience and growth. The trick is to get enough out of the trade.

The Healthy Journey Diet

The healthy journey book is at the editors. They e-mailed me today that the preliminary evaluation begins in three to four weeks. The guy who samples it to decide which editor to use thought that it lacks a little bit of "personal connection" with the author. So I guess I'll have to add that. What's so strange is that over the seven years I've worked on it I've removed a great deal of the personal parts of it, thinking that they weren't really relevant to what I needed to tell people. I know what he means, though. I guess it got off balance. I e-mailed the book to my brother-in-law. He said he would read it. It's exciting to be done with the writing part. I'm not sure how long editing takes, but I'm sure it's not as long as writing it takes.
I want to start on writing "Why Alzheimer's is Great". That's not an easy book, though. I suppose I should get this first thing published first. Also, it's that horrible time of studying for the re-certification boards. They ask a lot of very basic scientific questions that I don't keep in the inside-the-skull computer. I keep them in the books on the shelves and computer on the desk computers where they belong. So I need to do data transfer. It's very time consuming.
The office is starting to slow down a little for summer season, so time should start to appear.

Tough Days

Some days you get reminded that the universe can decide to be too difficult. Yesterday there was BG who can't probably live much longer. He has been in the hospital for about one week four times over the past six weeks. He has a very weak heart and bad lungs. I see him for very severe neuropathy that is hereditary and can't be treated. He is so weak that he can barely walk or use his arms. He needs a wheelchair to get around his house. I saw a truck driver for Waste Management who has destroyed his spine from bouncing in trucks for twenty years. He is young but has so much pain that he's going to have to go on disability. I saw PM who has MS. She now has a very severe cancer in her sinuses which will surely kill her soon. Her primary care doctor hasn't even seen her about this, and without any thought she has been shuffled into the cancer doctors for a chemo/radiation/surgery plan. But no one stopped her and told her that no treatment is also a very good option for her. That's the job for the primary care doctor. I was lucky because I was able to get someone to see her for me. It was extremely kind of him. I saw KC who is very young, having yet another severe flare up of her Lupus. She really needs to go to a big center for a second opinion, because the Lupus is eating her up. GL came in for his severe Alzheimer's with hallucinations. He has developed very severe dizziness now, which is threatening his safety since his judgement is bad and he tries to walk when he can't. It's very dangerous. I saw KS who is only twenty-one and was in a car accident three years ago. She's had severe pain which she's treated by buying narcotics from friends at work and is now addicted.
I see disease every day. It's my job. Some days are tough. There is too much illness in one day. It can make a person tired at the end of the day. There are these doctors who are just emotionally blank with their patients. They don't have to go through this sort of thing. But they miss most of what I consider the good part of medicine. So it's the price we pay. Luckily, these days are somewhat rare. It's rare that I get more than two "disasters" in a day.

What a Mess

BQ, MR and HN were here yesterday. All three of them have complaints about their physicians - either past or current. BS was here yesterday and he has a lot of physican friends. He is a businessman and spoke extensively (I ran late) about health care finance. Many physicians are leaving medicine or are frustrated. The economics are very challenging. I spoke with a physician friend yesterday who has stopped going to hospitals entirely and has stopped taking any insurance other than medicare. He is planning to stop taking medicare as well. He also has no malpractice insurance. Several physicians in this area no longer have malpractice insurance. Personally, it seems to me that it is insane to have for-profit health insurance plans. It should be illegal. All insurance plans need to be mutual companies, owned by the insured. Right now they are in a bind. They are supposed to make profits for the shareholders. The shareholders own the company. Physicians are now actually called "insurance implementers". We became "health care providers" a while ago. Some people now call us "prescribers". These names allow people to see us as cost centers or profit centers. This treatment changes our self-perceptions and behaviors. Our overall quality is decreasing. Patient satisfaction is decreasing. The democrats want universal coverage through some governmental agency. McCain wants increased competition. Unfortunately, no one wants to tackle the fundamental flaw in for-profit insurance. No one wants to tackle the fundamental flaw in having "consumers" (patients) use services that they don't pay for. No one wants to tackle the incentives that "providers" (Physicians) have to increase "utilization" (health care provided) including fear of malpractice and increased revenues. So nothing that the government is planning is going to help anything in the near future. Physician groups just want to protect their incomes. Patient groups just want to continue to pursue unlimited care without any financial incentives. Insurance companies just want to maximize their profits by decreasing the amount of health care provided while increasing premiums. Politicians just want to pander to the electorate.
It's quite a show. If it were a movie, it would be one of those suspense type of things where it just doesn't seem like things are going to end well. It's a little like "The Firm", I suppose. I wonder where this is all going to end up.

Another Day

Today there were three cancellations at the last minute. There were two patients who had appointments but weren't on the schedule. We give them an appointment, but we don't put it into the computer. So I ended up net minus one. It's a good reminder that the schedule can't tell you what's going to happen today. Sometimes I want the schedule to tell me who is coming and when. It's important to avoid that sort of desire. There is no order that we can impose on the universe. It does its own thing. We just have to be there when it happens.

I saw a new patient today who has been treated very aggressively for several years for nerve problems. She says "I have sciatica". This, in my opinion, is the greatest problem. It has really confused the doctors. They have imaged her spine and they have treated her with spinal injections. She came to me before surgery, which is her next step. The thing is, people are reacting to the term "sciatica" which is a term that we use. It's a medical DIAGNOSIS. People (several of them) have just accepted this as the diagnosis. I don't know how carefully she's been examined. I think she has a hip problem. That's because when I touch her hip, she jumps off the table. This is not a sign of a problem in the spine. It's a sign of a problem in the hip. This is nothing fancy. It's third year medical school simple stuff. I'm just glad she came in here. I told her not to have surgery on her spine. It's not a good idea.

I saw a patient today who has had horrible life-long migraines. She started accupunture recently and it has been very helpful. I love when that happens. It doesn't always work, but I love when it works. I use so many herbs and vitamins, and I'd like to use more accupuncture too. The only thing is that a lot of people are scared about the needle part of it. We have a chinese doctor in town who is very good.