Dying

Sometimes I say that dying is good. People are confused by this notion because it's not what our culture celebrates. The problem is that there is a certain amount of magical thinking that we do. We think like there is an option. There is no option. There is only the choice of dying. There is no such thing as living forever. All things that live also die. In fact, since thought is generally dualistic ("either this OR that") one cannot really have the notion of life without the notion of death. They create their mutual existance, since without one there is no distinction between two states. In that sense, death permits or even creates life. Non-dualistic thinking is very confusing because in that format there is neither life nor death which is a reality so hard to perceive most of the time it just isn't worth it to consider that. So to me, in the most simplistic way I can, I say "dying is good". The magical thinking that we have is that we may live on. We don't necessarily think someone will live on forever. We just don't necessarily ever accept that the dying time is NOW. It has to be later. Of course, it can't always be later. We just refuse to ever have it be now. So it's magical thinking. To be completely honest, we DO want eternal life for ourselves and loved ones. We just aren't honest enough to say it out loud because it would sound childish and unrealistic.
The problem with thinking that death is not good as that we don't accept it. We don't look for the "now" that death should come. We refuse the opportunity at all costs. But what is the REAL alternative? There are actually only two choices. There is dying - a good choice. The other choice is refusing dying, which is the choice that leads to suffering. People will go through all sorts of torture in order to try to fight what is supposed to be. This is mostly driven by fear of having failed to live, having failed to love, or some form of guilt about how it's ending up. There is "unfinished business" when the "now" comes. So it can't be time. This causes great suffering.
Yesterday I saw JD whose father RD just died. He was a patient of mine. He has suffered for the last couple of years with severe pain that we just can't alleviate. He spoke to me several times about suicide. He wanted to die to relieve the pain, and at 80 years old, he didn't think that however many years he had left should be spent in agony. His wife wasn't willing to go along with suicide. She didn't feel that it was ethical. So I never helped him with it. Of course, it isn't legal to help with that. So I actually never help with it. Except that people sometimes end up dying accidentally if they have easy access to it and permission. RD never would have gone through with it without his wife's blessing, though. So he persisted with pain.
JD was not exactly glad that he is gone. But she new that the "now" was right. She said something to me that was very critical. RD had written a letter over the past three years for his family to put them at peace with his leaving. It's a fabulous thing to do. I have to do that. My wife did that and I have meant to do that. Of course, the time to do that is "now". Not because it is obvious that my time is imminent, but it is true that we never do know when it is. So we need to always be at peace with this. We need to make sure that all of the people we love are always at peace with this so that there won't be so much suffering when the time comes.

It was hard for me when RD died. He died only one week after PN died. I can't really have my patients dying, no matter how good dying is. Loving is not entirely different from suffering. We become attached to people. I am attached to the patients. I like them coming here. They give me something to do, and a sense of purpose. So when they leave there is suffering. JD made it easier for me because one of the most difficult things for me is the family of the patients who die. I can't really alleviate their suffering very well. So if they don't suffer then I am happy.

The Economy

I'm glad that my position is somewhat insulated from the economic crisis. Most of my patients are medicare age. That's always been a source of lower reimbursment for me. My colleagues who are in places that are only 10% medicare population have had a greater income than me. But now many people with non-medicare insurance are losing their jobs. My colleagues are all seeing dramatic declines in their incomes due to loss of patient base (no job, no insurance, no doctor). There is a difference here as well, but it is rather small. I have only lost a handful of patients from this crisis. I am seeing something else. I am seeing the toll on the patients. They are mostly retired people. Some are concerned about the lost value of their investments. Still, that doesn't seem that bad either. Today SS came in. She has a daughter who isn't working. Her son-in-law was just laid off. Now neither one of them has a job. Their house is worth barely what they paid for it or maybe less. Their child is in college. So she is very distraught. She doesn't really have the means to take care of this mess. So she can't help very much. It's making her arthritis worse and her MS worse. It's making it hard for her to sleep and she feels depressed and tired. This is what I'm seeing a lot of. I'm seeing a lot of parents and grandparents of people who are in real trouble. I don't really know what to say to these people. There isn't really very much that I can think of. It's very hard to sit by and watch your children suffer.

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.