CURSE OR BLESSING?

One of the best lessons I have learned is if you can make something good come from something bad, the bad was not so bad after all!  I have taught that lesson to countless patients over the last 40 years.  Today, I want to share my lesson with those readers who have been branded with “learning disabilities” (LD).

Yes, I said “Branded.”  Like those individuals with attention deficit disorder (ADD), individuals with LD often feel branded, even cursed.  During the formative years of life, patients with LD often struggle in school.  LD students receive “accommodations” in the form of special classes, tutors, and attend special testing centers.  Accommodations can make an adolescent feel inferior and damaged.  

I have a learning disability.  When I went to school, there were no special classes, accommodations; you either survived on your own or you failed.  I have a form of Dyslexia.  Reading has always been agonizing for me.  My disability is not readily apparent; I can read aloud to an audience and they will not detect a single problem.  I just can’t process what I read!  I always failed standardized tests.  Not because I didn’t know the answers, but because I could not process the questions.

I have the gift of being able to process and retain everything I hear.  Over the years, I have learned many tricks that help me deal with my dyslexia.  Modern technology has been a Godsent blessing for me.  My texts and journal are now available in audio format.

One of the most traumatic events in my life was my failure to get into the University of Virginia Medical School.  I was an honors student with a 3.5 something average and medical school was a slam dunk!  I was a cocky young man and only applied to three top East Coast schools.  Unfortunately, I bombed on my MCATs (entrance exam).  Scoring in the 14th percentile in English should not have been a surprise.  I can’t read!  Ultimately, I moved to Mexico and graduated from La Universidad Autonoma de Guadalajara Medical School.

Making something good come from something bad is today’s lesson!  Going to a Mexican medical school was an embarrassment.  It also was one of the best things to ever happen to me.  During my four years in Mexico, I learned a lot about myself and the world I lived in.  I learned to talk and think in a different language.  I learned that what Americans believed was not what the rest of the world believed.  It was a humbling experience and I needed to be humbled.

I also learned that I had a learning disability.  I learned that, if you work hard enough, you can learn to live with LD and you can make LD work for you and others.  This article is proof positive.  I have had a long career helping others and working with many of my patients and their children.  I help remove the stigma of ADD and LD by finding the good in the bad.  

If you have a reading disability, develop your listening skills.  If you have problems with the spoken word, thrive on the written word.  All of us are blessed with being unique individuals.  Within all of us is a gift.  Don’t get bogged down with being labeled LD or ADD.  Find your gift and celebrate it.  Don’t be ashamed of needing accommodations.  Use them as tools the same as I use the CD/DVD player.  Most of all, learn to be happy with yourself.  Yes, it may be harder for you to succeed but success will come.

If you are having problems coping, see your doctor or counselor.  If you are envious of others, recognize that they are unique individuals and have their own problems.  If others mock you, feel sorry for them, not for yourself.  They mock you out of ignorance and you are not ignorant.  

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OMG

September 26, 2019

It’s another miserable day.  Why?  Today I picked up my med refills from the pharmacy.  OMG (yes, I’m yelling)!  Despite having insurance, I’m spending a fortune on medications.  I use GoodRx.  I use Kroger’s discount plan.  Use my insurance.  I’m still hemorrhaging money every 3 months. I’m retired, getting older and sicker and have to have my meds.

I feel blessed to be able to take the financial hit.  I don’t know how people afford to live.  On New Amsterdam’s (TV show) season opener, they portrayed an out of control diabetic. She was out of control due to the outrageous cost of her insulin.  She could not afford to buy it!

The writers did a great job at portraying the sad reality of the situation.  The hospital administrator/Doc fired the drug company that provided the way too expensive insulin and tried to get it from Canada.  That failed miserably.  He enlisted the press in his cause.  That failed, too.  In the end, the pharmaceutical manufacturer of insulin bought him off by supplying his patient with her insulin for one year.  When the patient asked her doc what about all the other patients who could not afford their insulin, he had no answer.

Reality is depressing.  Patients need their medications and often are left with the choice of paying the pharmacist or paying the landlord.  Retirees living on fixed incomes get hit the hardest.

I wrote the following article 3 years ago.  The only thing that has changed is that now I’m spending too much of my retirement income and understand the plight of my patients firsthand.

February 24, 2016

Dear Pharma,

I’ve known you for years. We’ve been the best of friends.  You’ve brought me miraculous medications over the last 32 years and helped legions of patients enjoy longer and healthier lives.  In many ways, you’ve been a knight in shining armor.

It hurts me to say this, but you’ve been bad lately: really bad!  You’ve priced your medications so high that the average patient can no longer have them.  Your antidepressants eat up so much of a patient’s budget that it is depressing!

I know that there are many factors contributing to the outrageous cost of your most miraculous medication. I’ve previously written about the cost of liability insurance.  I know that the cost of bringing a new medication to market is massive.  I also know that your need to increase your corporate profits has led you down the wrong path!

As your friend and longtime admirer, I’m telling you it’s time to change your ways. It’s time to scrap the sample and discount card programs and reduce the upfront cost of your medications.  Everyone is coming after you.  You are Hillary’s villain.  She openly avowed that she was coming for you in her last debate.

The PBM (Pharmacy Benefits Manager) is your avowed enemy and they are all powerful.  They simply are denying access to your medications. You are the patients’ avowed enemy.  They see you, not as a knight in shining armor, but as a greedy pusher who has what they need but demands their life’s blood to purchase it.

Just how much do you spend on those Viagra commercials? Discount cards? How does a medicine that sells for nine dollars in Mexico, sell for fifty dollars here?  Why is a medicine that costs eight Euros sell for eighty dollars here?  As your friend, I’m telling you it’s time to think out of the box and sell more units for less, here, in the US.

As your friend, I’m warning you. My patients are fed up.  I’m fed up!  Time to buff up your armor and get on your stallion and rescue us!

(Unfortunately, Hillary, Obama and Trump have all failed us and there is NO relief in sight.)

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RETROSPECTOSCOPE

During the next few months, many of us will be busy preparing for the holidays, excited to be with family and friends, looking forward to the New Year.  The New Year brings many things, starting with the New Year’s resolutions.  While most of us look forward to a new beginning, hopeful that things will be better, many spend time pondering about the past and saying, “what if?” and “If only I had”.

Forty years in practice has taught me that ruminating on the past and the “What if” question and the “If only I had” reply, is detrimental to your health.  After all, you cannot change the past.  While you are busy regretting past errors, you may be missing future opportunity.  Today, a friend told me that one of the most important moments in her life was when I helped her through a moment of self-doubt and self-recrimination.  She had made a decision many years ago that had long term consequences for her child’s health.  At the time she made that decision, it was the right decision.  Many years later, it was still the right decision, but when viewed through the “retrospectascope” could be questioned.

All of us are called on to make decisions on a daily basis. As individuals and parents who do not have a crystal ball with which to look into the future, we make the best decision we can.  All of us, when looking back in time through the “retrospectascope”, realize that some of those decisions turned out to be wrong, some foolish, and some absurd.  What is critical is to remember they were right at the time we made them.  

When you make a decision that affects you or a love one, take the time to gather as much knowledge as you can.  Follow your heart and your mind!  Give pause, then decide and carry out that decision with great care.  Later, if the decision turns out to be the wrong choice, live with it.  Learn from it.  Do not do the “What ifs”.  “What ifs” serve no purpose.  They lead to self-doubt, anxiety and depression.  They make you less capable and, therefore, more likely to err in the future.  Residing too long in the past steals your future.  Look forward to the future and all of its possibilities.

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WHAT’S EASIER?

WHAT’S EASIER?

What’s easier; caulking and painting your house’s exterior or letting it rot and eventually replacing it? The answer is simple, isn’t it?

What’s easier; checking and replacing the brakes on your car when they are worn or dealing with the carnage when the brakes fail? Again, the answer is obvious!

So, what makes sense; taking care of your body by eating the right foods, exercising and seeing your doc for yearly physicals and routine maintenance or letting your body go to fat, your belly sag over your belt and your muscles atrophy from disuse. The answer should be obvious, shouldn’t it? Unfortunately, it’s not!

Many of my patients take their health for granted! They feel well! They’ve never been sick a day of their lives. They work hard at making a living but invest little in staying healthy. Then catastrophe hits and they are sick! Their blood pressure is elevated. They are diabetic or worse; they have a heart attack or stroke. Recovery is a bitch!

It’s no secret. It’s easier to maintain your health than to restore it once you’ve lost it. So, this year, work hard at maintaining your health. Make sure your spring-cleaning list entails cleaning up your diet, tightening up your waistline and exercising. The life you save may be your own.

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SMILES

Yesterday was a lousy day. My trip to Tennessee to visit my brother was at its end.  He is recovering from a stroke and I hated to leave him.  I also hate going to the airport (I used to love flying the friendly sky) as there are always delayed flights which leads to angry people. Angry passengers mean tension and stressed filled hours in the waiting area and on the plane.

In fact, the early flight to Chicago was delayed 2 hours and they had room for Renee and I.  I was hesitant to switch flights as I was in no mood to deal with others’ frustration and anger.  Nonetheless, we switched.  Sitting at the gate I realized, to my amazement, that there were no angry, complaining passengers.  If they had spiked Kool-Aid, I wanted some.

So, why weren’t people angry, frustrated, acting out and pumping up their blood pressure as usual?  The answer became obvious when I noted that the flight attendants, M.W. and B.H., were smiling.  Both had disarming smiles.  It’s hard to have a bad day when someone is smiling at you, engaging you while sincerely apologizing to you and keeping you updated on conditions. 

Once on the plane I looked around the cabin and found lots of smiling passengers. Apparently, smiles really are contagious and the flight crew had infected everyone.  So, what does this have to do with health?

In my case, they helped alleviate some of the sadness I was feeling as I left my brother to head home.  My depressed mood was lighter and my anxiety about being in a tin can with angry individuals vanished.

I have been a doc for 40 years and the one thing my patients and colleagues agree on is that stress causes illness.  I’ve seen people who looked like they were going to stroke out screaming at gate agents and flight crews.  I’m sure some have. 

All this brings me to my point.  Many of my patients seek relief from stress in a pill.  Today, it was obvious that the treatment for stress is to find a great smile and spend enough time with it to let it infect you.  Your job is to nurture that smile and pass it on!

I hope United Airlines recognizes how precious these two flight attendants are.  I certainly do.  If you work for United Express, pass this article on.

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Personal Responsibility

While this article was written in 2011, it represents an average day in a docs life and accentuates the point made in yesterday’s article.

All right, I admit it!  I was grumpy today.  I started the day 45 minutes early; and, by the time we opened, I was 30 minutes behind.  As very sick patients came through the door, I got further and further behind.  Not one patient had a simple problem today.  Everyone needed lots of time.  The further behind I got, the grumpier I became.  I don’t like to keep patients waiting.  There is a bright side to being grumpy.  My staff lobbied my wife to take me on a short vacation.  I’m going to see my grandchildren this weekend.  I should be grumpy more often!

Today’s topic is taking responsibility for your own health.  Today’s patients wanted me to fix years of neglect.  I treated an asthmatic who was angry because her cough has not gone away after 6 weeks of office visits and multiple treatment failures.  She blames everyone and everything other than her pack a day smoking habit.  She wants to see an allergist; it must be allergy related.  She wonders if gluten in her diet might be causing her cough.  

I treated a man who complained of erectile dysfunction who blamed it on his wife and not his heavy daily intake of alcohol and food.  Did I mention he is obese, hypertensive and has diabetes?  Today, I saw a fatigued mother of four who insisted her fatigue must be something medical rather than face the fact that she smokes, never exercises and binges on caffeine and chocolate.  Today, I treated a woman for headaches and sleep problems.  She did not want to know why she had headaches and can’t sleep; she just wanted pills.  She didn’t want a diagnosis as that would mean dealing with her many reasons for depression.  She would have to take responsibility for some of her bad choices.  It was one of those days.

Taking responsibility for being grumpy, smoking, drinking or eating excessively is the first step in getting healthy.  Taking responsibility for bad choices is the first step to healing.  The second step is doing something about it.  Changing lifestyles can be hard, but it also can be very healthy.  If you are ill, have health care issues that need work or are just unhappy, look first at the obvious causes, then at everything else.  When you can’t figure it out or you can’t change, see your doctor.  Hopefully, he is not having a grumpy day!

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WHY?

Everyone is interested in the “whats” and “whens”.  What do I have?  What are you going to do about it? What is going to happen to me? When will I feel better?  When can I go back to work?  While the “whats” and the whens” are certainly important questions to ask, the “whys” are the most helpful.

Today, I had a lengthy conversation with one of the brightest individuals I have ever met.  Conversing with him is intellectually stimulating.  During our conversation, he mentioned that most people skip the “why” and race to fix a problem before truly analyzing the issues involved.  It dawned on me that the “why” in medicine is often more important than the “what, when and where” questions.

While I can’t always answer the “Why?” of illness, the true path to health lies in finding the “Why?” and preventing it.  Over the last few days, I have been trying to focus on the known “whys” of illness.  “Why aren’t I getting well?”  Answer, “You keep smoking and the smoke is destroying you airway.”  “Why do I need all of these medications for my cholesterol and blood pressure?”  Answer, “You are not on a DASH diet; you are eating fatty red meats, salt loading and not even trying to change your sedentary lifestyle.”  “Why am I having problems getting an erection?”  Answer, “You are massively overweight and out of shape.  Sex might actually kill you!”

The answers sound harsh.  Reality is sometimes harsh.  The only way to stop the cascade into illness is to find the answers to the “whys” and then do something to change.  Am I frustrated?  Yes!  I often refer to myself as a fireman, pouring water (medication) onto a fire, trying to put it out.  My patients are often arsonists, pouring fuel on the fire and yelling at me to put the fire out.  As I increase my fire extinguishers (medicines), I get yelled at, “I’m on too many expensive medications.  I’m spending $500 a month.  You have to do something.”

I have witnessed the success of those patients who have found their “whys” and then done something about them.  On 11/23 and 11/30/10, I wrote about remarkable patients who found their “whys” and accepted the responsibility of doing their parts in healing themselves.  I have lots of success stories!  I also have lots of failures.  The failures frustrate me.  How do I motivate people to find their “whys”?  How do I convince my patients to tackle their problems head on, to take personal responsibility for their wellbeing? And, above all, how do I find my “whys” and what can I do to improve my health!

I’m working hard at answering my “why” and dealing with it in a constructive way.  Are you?

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TOO MANY MEDS

When I was in training at Lutheran General Hospital, my fellow residents and I used to meet in the cafeteria to commiserate and eat lunch.  One of the most frequent topics of conversation revolved around how the older attending physicians tended to prescribe way too many medications.

Our teachers were dinosaurs and we were the new king of the universe.  We marveled at how the old guys would prescribe 4 medications for an illness, followed by another 4 medications to take care of the side effects of the first four, and then a few more meds to counter the side effects of the 4 meant to treat the side effects of the first four.  Is your head spinning yet?

We swore that we would never do anything that foolish!   After all, we were the new generation of enlightened docs armed with the latest and greatest medications ever invented.  Jump forward 30 years and meet the dinosaur version of Dr. Segal.  Wisdom and age showed me that the old guys I was so quick to criticize knew what they were doing.

Ron, the waiter, stated that he was on too many medications.  I’m on ten, and yes, several are designed to treat the side effects of others.  I’m sure that today’s young residents in training would criticize my treatments.

As a young doc in training, I did not realize how complicated aging can be.  Each of my meds are essential.  Without my Parkinson’s medication, I’d sit frozen in my chair 24/7.  One medication causes nausea and one counter acts the nausea.  One medication potentiates the other.

One treats my hypertension and one treats the swelling in my legs.  One of the medications treats my arthritic joints and another protects my stomach from the stomach damage caused by the anti-arthritic.

While I complain about taking “too” many pills, I am thankful I have them.  I am also working hard at taking off some weight and increasing my exercise.  Hopefully taking off 25 pounds will improve my BP and joint pains and allow me to stop taking some of my meds.

So the next time you bemoan the expense and inconvenience of taking a lot of pills, count your blessings.  Medication, when appropriately prescribed, can save your life.

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FATE

October 17, 2019

Did you ever get the feeling that you were supposed to do something for someone, but you didn’t know what you were supposed to do or for whom?  I have.  In the past, solving this mystery was easy.  I was in the office 6 days a week and all I needed to do was sit and wait for that “someone” who needed special help to come in.

Now, it’s not so easy.  Last night I went to dinner with friends.  We were lucky, the waiter that we really like, had our table.  He’s remarkably good, entertaining and jovial.  Last night, he appeared to be dragging a little.

Yesterday, I published “Epiphany” and discussed how seemingly random events came together to give me a clear picture of something I had been pondering for a while.  Well, it happened again last night.  Two of my former patients (really, I consider them extended family) came over to say hi while the waiter was at the table.  Paul (I changed his name for confidentiality sake) recounted how I had saved/prolonged his life and thanked me for my care.

After Paul and his wife left, the waiter (Ron) confided in me that he was sick.   Apparently, he had been sick for a while and whatever he had was bad.  He’s under a doctor’s care and take lots of medicine.  He further stated that he usually is off Thursdays and that his change of shifts must have been fate! 

I explained that I also was on a ton of meds and chronically ill and, not wanting to delve further into his problems, gave him instructions on how to get to this blog.  I told him I blog in hopes of helping my former patients and others navigate through the complex world of medicine and illness.

If he is right and fate put my friends, wife and waiter together with a purpose, then somewhere in my prior articles or future articles, I’m supposed to provide him with the knowledge or support he needs. 

So, if you are out there and have a need, read on or leave a comment and I’ll respond.  If there is a topic you are interested in, let me know and I’ll try to address it.

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EPIPHANY

Sometimes things just come together and paint an undeniable picture that you had never seen before.  Yesterday, after posting my blog about physician burnout and suicide, I read an article on KevinMd that mentions the switch from pay per service to a quality-based payment system.  When I finished reviewing Kevin’s daily articles, I came across an expose on Bit coins and how they function.  These seemingly unrelated articles started me thinking and led to an epiphany.

What became crystal clear was that my generation is responsible for the demise of the medical profession.  I helped kill the thing I loved, my calling.  Let me explain.

“Value is in the eyes of the beholder.”  When you are clothes shopping and find a shirt you love, you buy it.  Yep, you go to the cashier, pull out cash or a credit card and, having paid take your new shirt home.  Can you imagine going to the cashier and telling her/him that you left your wallet at home and you would pay for the shirt later or that your insurance company would pay a discounted amount if you send the bill to them? Of course not.  The store functions on a fee for service basis.  The store sets the price and you decide if the shirt is worth it.

Can you imagine pulling up to the gas pump and filling your car’s tank to the brim, then driving off without paying?  Or eating a meal at your favorite restaurant and skipping out on the bill with your leftovers and a bottle of wine?  Of course not! You would be arrested!

“But judge, I would have eventually paid for those services.”

“They should have sent the bill to my insurance first.”

“It’s only $10 dollars.”

“I never got a bill.”

My staff has heard it all.  If the clothes store, gas station or restaurant were run the way the medical system in this country is run, they would all fail.  Not only would the businesses fail, but the people who owned and managed them would suffer from burnout and their suicide rate would rise.

So, how did my generation kill the medical profession I love?  It’s all about setting a “value” on an item.  When I started in medicine, physicians and patients set a high value on their relationship and practice.  Some placed physicians on a pedestal.  It was a fee-for-service relationship much like in the examples of the retail world above.  I set the fee, the patient decided if seeing me was worth it (my value) and paid on the way out the door.  If patients had insurance, they would submit a claim and be reimbursed according to the policy limits.  Billing expenses were minimal, and my wife handled the paperwork and billing herself.

At some, my cronies and I fell into a trap.  We allowed the insurance company to insinuate itself between the patient and the physician.  We no longer set our value, the insurer and government did. Over the years, we have lost much of our value, not because the patients no longer valued us, but because the insurer/government/middleman took over and devalued us.  The more the insurer devalued and controlled us, the more profit they made; or, in the case of the government, the less they spent.  The more the insurers and Medicare took over, the more office expenses increased.  At the end, I had two nurses and four full time individuals in the billing department.  My income went down and my patients’ cost went up as did the insurers’ profit and control.

Had we stood our ground years ago, we would not be in the sorry state we are in now.  We find ourselves at another critical intersection.  If, as a profession, we don’t take a stand against a “value” based system, we will finish the job started years ago: the complete destruction and further devaluation of the medical profession.

Remember that if you do not set your own “value,” the insurers and Medicare will, and I guarantee you that what you and I deem valuable will not be what they deem valuable.  A “valued” physician will most likely be a physician who checks every box on the electronic medical record, provides the least expensive care while following the insurer or Medicare’s protocols and avoids unwarranted treatment courses that involve thinking, tests and referrals. 

In other words, a “valued” physician will hate his/her job, be burned out and at increased risk of suicide.  What a pity.

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