PAIN PART 6

When I think about Frank, I have to smile.  Frank was elderly when I met him, meaning he was in his 70s as am I now.  Frank had a thick Italian accent and referred to his pain and body parts as “she.”  “My knee, she hurts me all the time,” was his usual complaint.

By the time Frank first saw me, he had seen a half dozen other docs and had lots of tests.  He was told he had arthritis and was on Advil.  “Doc, you got to help me, the pain, “she” is too much for me.”  “She” keeps me up all night.”

After reviewing all of Frank’s test and examining Frank, I told him the pain in his knee was most probably from his back and we would need to do a few more test.  “Doc, the pain she is in my knee, she no in my back,” was what I heard for months.  Frank finally consented to back surgery.  I’ll never forget what he said when he woke up after surgery, “Doc, the pain, she no is in my knee.  Now she in my back!”

The first lesson to learn is that pain can be referred from body parts remote to the one that hurts.  Renee’s shoulder pain may be coming from her neck.  My hip pain may be coming from my back.  The second lesson is that, according to Frank, pain is feminine in nature.

Seriously, diagnosing the source of any given pain is not easy and treating pain effectively is highly dependent on what the source is.  It’s important to keep an opened mind and explore all possibilities. 

Here’s today’s joke:

A couple was invited to a swanky costume party. Unfortunately, the wife came down with a terrible headache and told her husband to go to the party alone. He being a devoted husband protested, but she argued and said she was going to take some aspirin and go to bed and there was no need for his good time being spoiled by not going. So he took his costume and away he went. The wife, after sleeping soundly for about an hour, awakened without pain and, as it was still early enough, decided to go the party. Since her husband did not know what her costume was, she thought she would have some fun by watching her husband to see how he acted when she was not with him. She joined the party and soon spotted her husband cavorting around on the dance floor, dancing with every nice woman he could, and copping a little touch here and a little kiss there. His wife sidled up to him and being a rather seductive babe herself, he left his current partner high and dry and devoted his time to the new babe that had just arrived. She let him go as far as he wished…Naturally, (since he was her husband.) Finally, he whispered a little proposition in her ear and she agreed. So off they went to one of the cars and had a quickie. Just before unmasking at midnight, she slipped away, went home, put the costume away and got into bed, wondering what kind of explanation he would make for his behaviour. She was sitting up reading when he came in, and she asked what kind of a time he had. He said: “Oh, the same old thing. You know I never have a good time when you’re not there.” “Did you dance much ?” “You know, I never even danced one dance. When I got there, I met Pete, Bill Browning and some other guys, so we went into the den and played poker all evening. But you’re not going to believe what happened to the guy I loaned my costum

COST OF MEDICINE PART 3

A former patient wrote recently.  He was hoping I could give him advice as to what he could do to help control the price of medicine and medical care. He thought he would write his congressional leaders and ask for their help as well.

In the 45 years since I started in medicine, I have heard many congressional leaders promise to take on pharma and the insurance industry.  In the 45 years since I started in medicine, things have gotten worse, not better!  Is pharma more powerful than Congress and the president?  Or does campaign rhetoric simply fall by the wayside after our leaders are elected?

I believe we have many problems that effectively guarantee that pharma will continue to rake in obscene profits at our expense.  Today, I’ll address the top two problems. The number one problem is that pharma contributes large amounts of money to candidates running for office. 

According to an article in Newsweek, “The pharmaceuticals and health products industry has donated more than $5.9 million to Biden’s presidential campaign, according to OpenSecrets.org, a site run by the Center for Responsive Politics, which tracks political donations.”  Can I independently verify this information?  Of course not.  Does it surprise me?  Of course not.  Has Biden done anything to reign in Pharma?  Again, the answer is no! Imagine how much Pharma spends on political campaigns if they spent $5 million on Biden alone.

While we buy into campaign promises, there is no mechanism for assuring that the candidates keep their promises once they are elected.  To make matters worse, we tend to re-elect the same individuals despite their lack of performance. 

As I see it, the second problem is that our leadership is covered by the same insurance available to an average citizen but that their policies are at the “Gold” level; and they are reimbursed by the federal government for 72% of their costs.  Until they feel the pain of paying $750 for a months’ worth of medication, they will not be incentivized to pass legislation aimed at controlling the cost of medicine. Perhaps the answer is not only to assess the candidates platform but, if he/she is an incumbent, to pay close attention to how many of their former promises they have kept.

In a future article, I’ll address tort reform and the role lawsuits play in increasing medical costs across the board.

Joke of the day – If con is the opposite of pro, then is Congress the opposite of progress?

GENERAL PRACTICE

Would you believe me if I told you most ER and Urgent Care visits are inappropriate and that you would be better served waiting to see your family doc?  What, you don’t have a Family Doc? This article is designed to reinforce the idea that having a Family Doc is an essential element in keeping you healthy and that your first contact with the medical complex should be with your family doc.

Paul was in his early fifties when he died.  Today, he is well and lives an active life.  Paul’s heart stopped in his sleep.  His wife heard him die, started CPR and called the paramedics.  Paul was rushed to the ER where a neurologist pronounced him brain dead. I was notified and rushed to the ER to be with the family.  As their family doc, I was in a unique position to help them deal with the loss of their loved one.

I had recently read about the Artic Blank and its ability to save brain cells from dying during a cardiac arrest.  Luckily, the hospital had just received an Artic Blanket.  It was still in its original box. I explained that if he was brain dead, we had nothing to lose.  Having nothing to lose (actually, we could bring back a seriously damaged brain) and only potential benefit, we deployed the blanket and waited. The next day, Paul woke up and has done well since.

Had the ER not notified me, Paul might still be dead.  Had Paul not had a family doc who knew the family structure as well as I did, things might have been different.  Had Paul’s family been used to going to the urgent care center, I would have never gotten to know them. Find yourself a family doc and get to know him/her. Include them in your health decisions.  Finding a family doc is not easy.  You may need to try a few.  PS:  don’t forget to thank them for their care.  These days, the docs who practiced like me are retiring.  The new MDs are trained in corporate medicine.  Generalists like family docs and internists will never see the inside of a hospital.  Hospitalists will see you in the ER and hospital.  Knowing your physician and developing rapport is not going to be easy.  I’m in the

DISAPPOINTED

I took Renee to the right shoulder specialist.  Boy, was I disappointed!  The Doc is not really a right shoulder specialist, he can diagnosis either shoulder.  What he can’t do is anything else.  Renee also has pain in her wrist and asked her doc’s opinion.  “I can only do shoulder work.  I’m not trained in wrist,” stated the specialist.

I called him the “right” specialist because all the reviews and recommendations from friends and neighbors said he was the  “RIGHT” doc for Renee.  As it turns out, he was the wrong doc.  In my day, there was a doc referred to as an orthopedist.  As a resident, you’re trained in general orthopedics and then do a fellowship in a specific area of the body (like the shoulder), giving the right to claim a specialty.

My point is the following:  The doc either has the knowledge necessary to diagnose and treat wrist pain and was in too much of a hurry to assess Renee’s wrist or, for whatever reason, had a crappy residency and really can’t show competency if any other joint other than the shoulder.

We are still not certain where Renee’s shoulder pain is coming from. Although doubtful that the wrist pain is tied to the shoulder pain, it is possible.  A few extra minutes assessing my wife’s wrist might have revealed the diagnosis and probably a referral to a wrist specialist (or a curative intervention.)  

My training as a generalist taught me to do both a thorough history and a complete exam of whatever ails my patient.  I’ve been told by multiple patients and docs that I was an excellent diagnostician.  I did attract the difficult to diagnosis patient and, by being meticulous in taking a history and performing a full exam, solved many of them.  Today, I want to tell you about Sarah.

Sarah was a 34-year-old mother of four who had a history of severe attacks of right shoulder pain.  She had seen 3 orthopedists, including a shoulder specialist, a chiropractor.  She had received multiple prescriptions and had various injections all to no avail.  Sarah was miserable.  Her husband was scared, describing the attacks of pain as so severe that he thought they were going to kill his wife.

Since I failed to find an answer, I had Sarah, her husband and my staff publish Sarah’s history and findings and send copies to the heads of orthopedics at multiple major teaching programs.  I know it sounds nuts, but I got a reply from a doc in New York suggesting that we film an attack and send him the film.  Back then, the movie camera was expensive and huge; but Sarah’s husband went all in buying the best.

Six months later, Sarah experienced an attack while in church.  Her brother filmed the attack while her husband lifted her out of the chair and started for the car to go to the ER.  As per her usual, by the time Sarah got to the ER, her pain was gone. The following day, I watched the video and there it was, the answer.  Sarah’s shoulder was spontaneously dislocating.  Sarah’s husband reduced the dislocation while pulling her up to get her to the ER without knowing what he was doing.

A lot of extra effort and the use of new technology led to Sarah’s diagnosis and curative surgery.  I’m disappointed in today’s specialty-based care system. The future of medicine sure does look bleak. 

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