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. 

GOOD NEWS

It’s been a long time since I’ve written anything as the last 2 months have been tied up with preparations for my surgery.  I’m happy to tell you that the surgery went well; and, on last Thursday, the neurologist turned on my stimulator.  Wow, what an experience.  I was told to hold my medications Wednesday afternoon and Thursday.  I did as instructed and was miserable.

Thursday, Renee had to put me in a wheelchair and roll me into the office.  My Parkinson’s was in full bloom, and I couldn’t walk.  The neurologist then turned on my DBS and I was able to stand and walk better than I have walked in years.  It was truly miraculous, and I want to thank everyone for their prayers.

We’ve reduced my meds and I continue to do well.  I still have Parkinson’s but my motor skills are much improved.  I’ve only frozen twice since turning on the DBS and only napped 3 times yesterday.  At this point, I’ll see my neurologist every 2-3 weeks to fine tune the stimulator.  Like all interventions, the DBS can cause side effects and one of the more bothersome side effects are dyskinesias (awkward automatic body movements).  Last night I went on an eating binge which hopefully is not related to my DBS.  I’m already overweight and have to slim down.

The lessons I want you to learn from my experience are the following.  My surgeon and neurologist warned me, on multiple occasions, stating that DBS was indicated for tremor, NOT GAIT DISTURBANCES. At the same time, they gave me their warning (informed consent): they informed me that if the gait disturbance improved with medication, it should improve with DBS.    Giving “informed consent” is every physician’s obligation, even when it scares a patient out of doing a necessary procedure.  Having a trusted family physician is critical when you are getting mixed messages from your specialists. I understood the reasons behind the mixed messages and made the right choice.

The second lesson is that being scared of a medical procedure is both understandable and appropriate.  This surgery was scary!  I was awake throughout the entire procedure and it was intense.  Had I not had the surgery due to fear, I would have spent my final years in that wheelchair.  While I still have a progressive neurologic disease, my future is brighter.  I’ve been jealous of people who can walk unencumbered by illness.  Hopefully, we can balance my medications and my DBS so that I can walk and return to Rock Steady.

PHARMA WINS, WE LOSE

My war against PHARMA and the insurance companies is destined to fail.  In my first attempt to raise an army of patients, I enlisted NOBODY!  Yes, not one individual showed any interest in writing Congress, PHARMA or the insurance companies. While I was not surprised, I was disappointed.

Until people are willing to stand up against today’s healthcare complex, the only changes we will experience will be costly, increasing the cost of medication, labs, procedures and x-ray.  I will push on, working to expose price gauging and the inequalities between the private system and Medicare. 

My campaign will focus on uncovering just how much money PHARMA and the insurers pour into the campaigns of our political leaders and sharing those numbers with you.  My primary focus will be on those politicians who campaigned on the promise of lowering healthcare costs and reigning in the cost of medications.

Next, I plan on exposing the discrepancies in cost between what US pharmacies and foreign pharmacies charge.  I will tell you that        Canadians and Mexicans must be much brighter than U.S. citizens.  To understand what I’m talking about, all you have to do is read the package insert that comes with the product.  A US package insert is careful to tell you not to eat it, cook with it, put it in your anus, give it to children, etc.  The Mexican insert simply says take as directed.  I guess they don’t use anything rectally unless so instructed; and we, on the other hand, might shove something up our buns just to see what might happen!

As I’m writing this, I’m starting to realize how daunting a task this is going to be.  I’m going to need a lot of help. These companies are not going to say,” Wow, you caught me!  What do you want me to do?”  Instead, they’re going to fight back. Now I’m getting paranoid.  I wonder if using the word “army” puts me on a watch list.

Maybe I should scrap this idea.  What do you think?  I think I’ll fork over my $15,000 a year for my new medication and eat hot dogs at Costco.

Now for an update.  My DBS surgery is on Wednesday.  The last time I was this scared was when I saw “IT”.  I’M JOKING!  I’M REALLY NOT SCARED.

 I’VE GOT A GOOD TEAM.  OF COURSE, THE CUBS HAD A GOOD TEAM AND LOOK AT WHAT HAPPENED TO THEM.

One last thought.  Wouldn’t it be cool if some of you guys got together and started to do what I set out to do?

TIME TO FIGHT

On March 14, 2019, I died.  Retirement was synonymous with death!  At the age of 13, I decided to become a physician and I fulfilled that promise.  In my world, the patient came first.  I took the Hippocratic Oath seriously, advocating for my patients and treating them literally around the clock.

Once, a respected colleague of mine described me as a “bull in a China shop” as I plowed through any barrier to get my patient the care he/she needed.  I negotiated with the hospital, insurance companies, and pharmacies to provide my patients with whatever they needed.  I enlisted an army of healthcare providers who worked along with me.

In the early days, Good Shepherd Hospital stood at my side.  The CFO wrote off entire bills when necessary.  The medical staff established “The Sunshine Fund” (TSF) from which physicians could withdraw money to help hospitalized patients. TSF actually covered the expense of a babysitter so that a father could visit his wife in the hospital.

Wauconda Pharmacy and Osco Lake Zurich could be counted on to cut the price of essential medications when necessary.  PHARMA provided samples when patients could not pay for their meds.  I had a homeless and jobless patient on medication for a seizure disorder.  I spoke with the CEO of the company who made the medication he needed, and a year’s worth showed up a few days later.

My specialist referrals always responded to my call for help, often waiving their fees.  The local CT and MRI centers also offered reduced pricing to those in need. Local religious organizations helped finding counseling and durable medical supplies.

Then things changed.  Hospitals merged into “healthcare systems” that concentrated more on the system than on healthcare.  For the most part, charity vanished.  I will forever be indebted for Mr. T who, till the day he retired, would go out of his way to help my patients cover their bills.

The owner of Wauconda Pharmacy stood by my patients for my entire career.  He helped countless patients find the means to obtain their medications as did the pharmacists at Osco.  I often provided patients in need with full courses of samples and my pharma reps quietly worked with me.  Unfortunately, their employer, “Big Pharma, had an appetite for money and would feast on the elderly and sick.

I sat on national advisory boards for Glaxo, Astrazeneca, Pfizer, and others and worked hard to convince PHARMA that it needed to scrap the expensive and obnoxious TV advertisements, as well as getting rid of the discount programs (not open to Medicare patients) and simply cut the cost of their medications.  I failed.

I fought for my patients until the end.  Then I retired.  I didn’t really die, but I might as well have died.  The state of my once proud profession has deteriorated beyond belief.

Today, I found my new purpose in life.  Not surprisingly, my purpose in life is to become a patient advocate, only now I’m coming at it as both a doctor and patient.  I just got off the phone with the pharmacist at Humana.  He verified that the medication I needed was in fact going to cost $1500 a month.  He suggested that I try the Humana covered alternative at a cost of $1000 a month.  He also verified that a third of the patients on the alternative will have severe nausea and vomit.  The medication is used when the patient cannot ambulate. I think it works by making you run to the bathroom so you can puke in the toilet instead of on the family room carpet!

Congress and the President have promised to do something about the cost of medications and healthcare in general.  They have done nothing to remedy the situation while enjoying PHARMA’s campaign contributions.

To accomplish anything, I need an army. That’s where you come in!  I need you to write!  I need you to write to your congressional leaders.  I need you to write to the President.  I need you to write to PHARMA, your local pharmacy, hospital and doctors.  

I know what you’re thinking.  Isn’t that what AARP is supposed top do?  As far as I’m concerned, AARP is an insurance company.  AARP is an advertising agency!  AARP is . . .

Help me help you.  This old bull is ready to break some glass and make medications affordable and available to the masses. 

SHE’S RIGHT

The Triangle of Knowledge and its importance to doctor.  In reality, the pyramid of knowledge should play a major role in every decision you make, regardless of your vocation or lot in life.

The apex of the pyramid represents what you know.  As it turns out, no matter how smart or well educated you are, what you know accounts for a small percentage of all knowledge.

The midsection of the pyramid represents what you know that you don’t know. I know that I don’t know how to fly a jet.  I know that I don’t know how to insert an electrical conduit in a person’s brain.  Knowing what you don’t know is essential if you want both to avoid problems and find someone to fix them.  When I referred you to a specialist, it was because that individual’s job was to know about the things I didn’t know about and then to diagnose and treat those problems when necessary.

The third (largest) section of the pyramid of knowledge represents what you don’t know that you don’t know.  What you don’t know that you don’t know is what can hurt you the worst.  What I did my entire life was to “PRACTICE” medicine.  Delivering medical care has always been referred to as “THE PRACTICE OF MEDICAL CARE,” in recognition of the fact that there is much that we don’t know about the human condition and disease.  Over the last 40 years, my job has been to increase my knowledge and decrease the “I don’t know that I don’t know” portion of the pyramid.

Now for a true story.  I’ve been having trouble getting in and out of bed.  I’ve tried multiple interventions, including buying a new bed, all without success.  Renee is great at doing research and showed me a floor to ceiling bar that she thought would work.  I, a man of infinite wisdom, told her it wouldn’t work.  Further, I told her it would probably ruin both the floor and ceiling.  She, in her infinite wisdom, ordered it anyway.  Brian, my brother-in-law, and Abe, my brother from another mother, installed my pole yesterday.

Again, I was confident that a floor to ceiling pole by my bed would not help me (and that Renee certainly wasn’t going to take up pole dancing).  I was wrong!  The pole helped.  Time to eat crow! “Sorry for underestimating you.”  [Realistically, I was partially right; Renee is not going to do any pole dancing.]

Knowing what you don’t know and who knows it can save you a lot of grief.  As I grow older, the things I don’t know are becoming more plentiful.  Luckily, I have a brilliant wife whose job in life is caring for me.  Her knowledge base compliments mine, filling in the gaps.

I know I’m risking my membership in the Society of Men by admitting that my wife is right, but she is (and often).

Here’s your joke of the day:

Annoyed by the professor of anatomy who liked to tell “naughty” stories during class, a group of female students decided that the next time he started to tell one, they would all rise and leave the room in protest. The professor, however, got wind of their scheme just before class the following day, so he bided his time. Then, halfway through the lecture, he began. “They say there is quite a shortage of prostitutes in France.” The girls looked at one another, arose and started for the door. “Young ladies,” said the professor with a broad smile, “the next plane doesn’t leave till tomorrow afternoon.”

MY BROTHER, MY HERO

Usually, words come easy, spilling onto the pages I will publish. Originally, my articles were designed to teach individuals how to be better patients and how to care for themselves. I addressed current medical controversies and treatment protocols, as well as the importance of having a functional medical family. Eight years ago, I started on meds for Parkinson’s and everything changed.  My articles became more personal, giving my readers a front row seat from which they could witness the effects of chronic illness on the lives of those dealing with such devastation. While my original articles were meant to help my patients take better care of themselves, my recent articles should help the families of their chronically ill loved one better understand and care for their charge.

I have become more pessimistic and essentially capitulated to Parkinson’s.  In my role as a doc, I found that the patients that give up (such as myself,) don’t do very well.  In my case, every time I allow a smidgeon of optimism to sneak into my life, I find myself facing new source of pain and suffering.   It’s as if I have a roulette wheel with body parts instead of numbers.  Every morning I spin the wheel.  Whatever body part I land on is the one that will bother me today.

I Facetime with my brother every day and every day I see the benefit of hard work and healthy attitude.  I’ve started to write about my brother multiple times and find that doing him justice is beyond my capability.  Nonetheless, I’ll try.  Alan, in many ways, is my opposite.  He worked out in a gym while I worked out in the refrigerator. When he was faced with a debilitating stroke, he refused to capitulate, fighting to get the use of his leg and arm back.  I replayed images of my grandfather and father’s Parkinson’s, buried my head in the sand, and refused to admit that my foe was attacking or that there was something I could do to slow the disease process.  The list goes on.

I’ve always looked up to my older brother, but never really told him how I felt.  There wasn’t anything he couldn’t do.  As a rule, what disability you have at the end of the first post stroke year is what you are left with.  Not my brother! He continues to gain function by battling through physical therapy and refusing to give in to his losses.  He works at lifting my spirits while I write depressing articles and slide further into my disability.  I must embarrass him.

I failed to mention him or Martha, my other sister from another mother, in my last article.  Writing at 3 am is probably not a good idea. They are coming to see me at great personal peril.  Their major risk is that I take the wind out of his sail with my attitude. Traveling by car from Tennessee is not going to be easy. Not having your own chair, bed, and bathroom poses new problems. Our recent trip to Disney reminded me how difficult life can be when away from your usual abode.  Like Renee, Martha has become responsible for everything!  The packing and trip preparations Alan and I used to do have now fallen on our wives. They have become superwomen caregivers.  Frankly, I’m wearing Renee out.

I love my brother and sister.  Unfortunately, we lived our lives miles apart and never traveled together or spent much social time together.  Those who read my blog know I advise against playing the “would’a, could’a, should’a game”; but waiting until you are ill to see each other is insane.

It’s a pity that there are no do overs.  If you could play the “would’a, could’a, should’a game,” I would follow my own advice, spend more time with family, stress less, eat better, and exercise.  Oh, well.

THE BEST TREATMENT FOR WHAT AILS ME

Maybe there is a God however the devastation caused by war makes me wonder.  As many of you know, I’m having a deep brain stimulator (DBS) implanted in my brain on the 23rd of this month.  What you may not know is how scared I am! I shouldn’t be.  I practiced medicine for close to 40 years and have done or seen it all.  Years ago, I assisted my local neurosurgeon in a case of traumatic brain injury and even bored holes in a child’s skull.  She did great, as did the other patients I assisted with.   Even though our tools were primitive compared to today’s tools, our patients did well.

Nonetheless, I’m scared.  I worry about having a stroke or bleed.  I worry about becoming even more of a burden on my wife than I am today.  It may surprise you, but I worry about worsening and NOT dying.  I do not want to be a burden to my family or linger in a nursing home. Realistically, DB is going to help or it’s not going to help; and I’ll deal with whatever comes my way.

Just in case I don’t survive the surgery, I’m having a going away party over the next few weeks.  My family is trickling in from Virginia, New Jersey, and Georgia.  I have been blessed with two childhood friends/brothers.  I talk to them frequently and both had reasons why they couldn’t be here.  Internet hugs are just not as good as real hugs, but they would just have to do.

Maybe there is a God, and maybe He/She/or whatever pronoun you choose to use was looking after me today and recognized how badly I need an Abe hug.  Abe was scheduled to fly into Charlotte today and make a connection to his flight to the Virgin Islands.  Apparently, a bank of fog rolled in, closing the airport, and causing Abe’s plane to circle long enough to miss his connection. Yep, you guessed it. Abe and Linda are spending the night; and, having been able to hug them and tell them I loved them has alleviated many of my fears and concerns.

There is a Yiddish word, B’Shert, that translates to “meant to be.” What was unfortunate for Abe and Linda turned out to be a blessing for Renee and me.  I’ll drive them to the airport tomorrow knowing that their layover here was B’Shert no matter what happens in the OR.