WhiteCoat

Open Mic Weekend

Haven’t had an open mic in a while.

Go ahead and rant about anything health-related that piques your interest in the comments section to this post.

Only rule is that there are no ad hominem attacks. Flames get deleted and I’m Smokey the Bear. Argue away, but be nice. Matt, behave yourself.

Taking the weekend off. Will provide my keen and witty insight to the comments on Monday.

69 Responses to “Open Mic Weekend”

  1. tracy says:

    Why do so few Psychiatrists do therapy? Is it because stupid insurance companies can pay less for other types of therapists to do therapy? What if one were willing to somehow come up with the cash, for a really excellent Psychiatrist? Why do doctors go in to Psychiatry if they don’t want to do the “talk thing” and just want to pass out pills all day or do research…or anything but TALK? “Drug Cowboys”!

    Thank you for letting me rave, Dr. White Coat.

    • I’m a psychiatrist and have always done therapy. I’ve only rarely taken on patients if they just wanted me to prescribe for them (ie they saw someone else for therapy, or only wanted meds). The medication part was never as interesting or challenging for me as doing psychotherapy. That’s the part of psychiatry I love.

      But…

      When I completed my training in 1989, my program (which had been totally psychotherapy oriented) got a new hot-shot chairman who was totally biologically oriented. The intensive supervision we’d gotten with therapists (mostly, but not all psychiatrists) in the community took a back seat. The “one-way screen” which was the highlight of our 4th year, soon ended. (One of the most esteemed analytically-oriented psychiatrists in the community did weekly therapy with a patient while we all watched behind a one-way mirror. In return, the patient got to be therapized by one of the best shrinks in the country for bupkas. Afterwards, the residents had a post-session discussion and analysis of the analysis with another great shrink who’d watched with us, along with the one doing the therapy. It was heaven.)

      Anyway…

      The majority of residency programs in the country no longer emphasize psychotherapy like mine did. Now, it’s all psychopharmacology. And yes, insurance companies generally don’t pay for psychiatrists to do therapy because they can get it cheaper from other disciplines. I suspect that both of those things, along with advances in diagnostic tests, medications, and a greater understanding of biologic/genetic causes of mental illnesses, probably drove the change from talk to meds.

      I don’t fault other psychiatrists for not wanting to do the “talk thing.” If pharmacotherapy is what rocks your boat (or, lights your cigar), fine. What I do fault them for is when they are completely uninterested in anything having to do with the patient’s psyche. If they’re doing meds only, a lot of them never bother to talk to the therapist and thus miss a lot of pertinent information about the concurrent, complementary treatment their patients are getting. If they’re seeing someone on an inpatient unit and you want to know the patient’s living situation or if family therapy has been done, the answer all too often is, “I don’t know. I’m not a social worker.”

      If you’re a psychiatrist and have no desire to do therapy, fine. But, you still have to be the captain of the ship and at least know what’s going on with your patient and what other practitioners are doing with them.

      • This is an exaggerated view of current conditions. In making a diagnosis, one must ask if the sad mood has a reason or has no reason. If the complaint is a mental disorder, it should apply across all settings. Even if a complaint is clearly about a mental disorder and not about stress, does stress have an effect, and how can it be attenuated?

        The best medical analogy is with diabetes, biologically based, but highly influenced by environment. The good psychiatrist will not miss these factors and will address them. If not, nothing will work well, and patient treatment failure will be a harsh teacher.

    • WhiteCoat says:

      Your problem is unfortunately a manifestation of cost cutting in the medical industry.
      “Talking” doesn’t pay the bills for the docs. So that function gets relegated to professionals who are lower on the totem pole who are still willing to provide the “talking” services for less money. But the downward spiral continues. When therapists get to a point where “talking” doesn’t pay their bills, then what happens? Either they stop providing the services or they engage in “group” therapy where they can get paid for treating several people at once.
      Think of how you would handle your job if your pay rate didn’t increase for the past 15 years – and likely decreased – yet you were asked to do more and more for lesser pay. Not intended as being a “snide” question, but one I really want you to think about. How would you adapt?

      • Matt says:

        Doctors have only themselves to blame for not getting paid by the hour. Every other professional does.

        Would you have the salaries you currently have if you hadn’t signed on to the current compensation scheme? Probably not. But you’re not going to have those salaries anyway in a few years it looks like.

        Being a physician from the late 60s to the early part of the last decade was mighty well paying work and impervious to the economic cycle, but the baby boomers are costing us too much and government pays too much of the tab for the gravy train to keep running.

      • Psychopharmacology represents a tremendous advance in psychiatric productivity. It has a 10,000% return on investment, guaranteed, with no risk of losing one’s capital. Its return is far larger than that of any crime, certainly any financial investment.

        You spend $500 on medication visits, and get to return to your $50,000 a year job, keep your family, and even your life, by the prevention of suicide. That story has not been told to the public.

        The idea on interminable chat sessions using concepts that are not facts in nature (id, ego, superego – all false bs), that puts a respectable specialty in the same category as fortune tellers (but more expensive than fortune tellers even those that attribute the problems to bad luck from cursed money – bring in all your money so we may burn it for you).

      • My husband, who is also a psychiatrist, often points out that when we finished our training and started our practices, what we made was on par with our accountant and lawyer (even though we had much bigger loan debt and several more years of post-grad training). Over the years, what we make has stayed the same or decreased, while our lawyer’s and accountant’s hourly charges have nearly doubled. Our overheads, of course, have only gone up.

        I have friends who are psychologists (PhD’s) and talk therapy is actually hardest for them to do. Insurance companies figure they can get the exact same service – only cheaper – from social workers and other therapists. PhD’s can’t prescribe, so they are really being left out and most of the ones I know in private practice – who are nevertheless excellent therapists – are struggling.

        To answer your question, WC (even though I realize it was directed at Tracy), how my husband and I are adapting to no pay raises and more difficult work conditions is we’re downsizing: We’re selling our house so we can retire, live in our RV and travel the country. We took a year off a few years ago to do just that. I thought my husband was crazy when he suggested it and demanded to know, “Why can’t you be like a normal husband in a midlife crisis and have an affair or buy a Corvette?” Obviously, he’s a much better shrink than I am, because we not only did the trip, but loved it so much, I was the one who suggested our current plan. If we were still getting the kind of satisfaction from our practices as we did years ago, I doubt we’d be planning to retire this early.

      • Matt says:

        “Think of how you would handle your job if your pay rate didn’t increase for the past 15 years – and likely decreased – yet you were asked to do more and more for lesser pay.”

        None of the rest of us professionals can imagine a job where we had a third party payer who would never run out of cash. The average physician is the highest paid profession in the world by 50% (Surgeons by 150%) over the next highest – how much more should you get from the government before you stop bitching that it’s not going higher? What’s more, you get paid regardless of your skill. The worst physician in the country gets paid at the same rate as the best!

  2. Marilyn says:

    I want to know why it is so hard to get doctors to do simple tests?

    My mom is 83, and they’ve written her off as a dementia patient even though her cognitive issues don’t fit a lot of dementia patterns. And why they won’t do simple things to rule out what might be obvious issues like a borderline thyroid problem? Her symptoms fit (as well as huge family history of autoimmune thyroid), but since she has a toe in range they won’t even do a trial of meds which are not dangerous, yet they will put her on:

    1. Aricept
    2. Lasix
    3. Ambien
    4. Anything for anti-anxiety
    5. anti-seizure meds (while ignoring below-normal calcium AND ABSENT PARATHYROID HORMONE

    They blew off requests for celiac testing even though celiac is associated with dementia and multiple myeloma/MGUS which she also has.

    I want to scream.

    If I would pay for the tests, WHY WON’T THEY DO THEM?

    • Nurse K says:

      “Borderline hypothyroidism” would not cause “dementia”.

      Looks like you’re not yet to the ‘acceptance’ part of the stages of grief. I would stay off WebMD and focus on hanging out with your mom.

      • Marilyn says:

        And, you would blow off hypoparathyroidism?

        She has NO detectable parathyroid hormone and is WELL BELOW the lowest threshold for calcium. Simple chemistry. Remember the importance of calcium to brain chemistry?

        She has a Free T4 of .8 (range .8 to 1.8), and a TSH climbing to the top of the range.

        When she was on calcium IV at hospital, jeez…funny thing, her “dementia” faded away.

        You are as bad as the docs that have seen her so far.

        Oh…I don’t actually READ webmd. Ever heard of the
        National Center for Biotechnology Information? or maybe you could read THIS from the British Medical Journal? (Not the only articles I have read by the way, just one example that you might just understand).

        Go back and study your biochemistry and physiology some more
        Everyone over 80 does NOT have dementia. Maybe the reason so many people are written off with it is because NO ONE WILL LOOK BEYOND IT.

        We’ve had a neurologist tell us it’s not Alzheimer’s, and that there are NO issues in her brain to show any damage or calcification or anything else that would cause what’s going on.

        I would accept dementia if there were not such glaring chemical imbalances in her blood. I won’t sit still until they address them.

        Don’t patronize me. I’ve told you that before. I am not an idiot, I taked lotsa biology in kollege. Just because you are an RN doesn’t mean you know everything and a non-medical person knows nothing.

      • Jeff says:

        I’m thinking that if the medical professionals that are working with your mom are met with the same reaction that Nurse K was just met with… well that just may be a large part of your problem. I don’t have enough information to weigh in. But just from reading this little exchange, I’m already on the doctor’s side in this. You are clearly not willing to even begin to consider anything that you don’t want to hear. I’m just sayin.

      • Marilyn says:

        Jeff,

        Nope. Not argumentative or angry with the doctors at all. Just trying to get them to do some tests.

        If I am willing to pay out of pocket for a couple of simple tests, why won’t they indulge? It is no skin off their nose, and no cost to the taxpayers.

        If they would do the tests, they might just see that a simple response is all that is necessary which in the end would save the taxpayers a load of money because then mom wouldn’t have to live on public assistance.

        As for my exchange with Nurse K, she thinks I am an idiot and has been not-very-nice to me on more than one occasion. I don’t like being put down by her.

        I can accept a lot. I have been through more different medical problems with different family members, and have been through a lot of untimely death, disease, and even others with dementia.

        Not trying to put my head in the sand, but also not willing to write off my mom when it was obvious that after 24 hours of lactated ringer’s she was almost herself again.

        Don’t think Ringer’s cures dementia.

        Sorry if you think I was harsh, but my question still stands and that is my rant. Why won’t they just do the non-invasive, cheap tests?

        My own doc at home (that’s where mom is going when she’s out of rehab) would do them in a heartbeat. She treated my thyroid when everyone else said it wasn’t a thyroid problem. And I got better.

        Docs killed my dad because they treated him for so many other things before they finally figured out he had cancer. No wonder I don’t trust them

      • Roberto says:

        I’m kind on the side with Marylin. Low PTH in highly unusual if malabsorption is suspected (celiac sprue), and is impossible if serum Calcium is low!!. In other words, low sCa should cause a spike of high PTH (secondary hyperparathyroidism).

        I agree that both TSH and sCa are simple tests that should be done. If the doctor is going to order them, I would also like to see the sPTH again and the 25-hydroxyvitamin D (25OHD; calcidiol). Unless Marilyn’s mom gets lots of sunlight exposure, I bet she’s got 25OHD levels in the rachitic range (10 ng/mL). That might also contribute to her so called ‘dementia’.

        The major question here is why both PTH and Thyroid hormones are in the low range. Marilyn argues that there’s a history of autoimmune thyroiditis. Could this also hit all 4 parathyroid glands? I think it’s possible.

        Go ahead Marilyn, convince your doctor to order sCa; PTH; 25OHD, TSH; thyroglobulin and repeat the free T4. Make sure the doctor rules out autoimmune thyroiditis. And do it just to prove doctors wrong!!.

      • JustADoc says:

        If she has no detectable PTH and is well below the lowest threshold for calcium then it sounds like those thests have been ordered. Of course you don’t state her albumin level so her Ca may actually be normal. And if it is than PTH should be low/normal.

        You also know her TSH and FT4(which were normal as you stated). There is controversy about treating subclinical hypothyroidism and the numbers presented don’t even meet that definition. And you say the treatments are benign. Guess you are lucky to have not seen atrial fibrillation from hyperthyroidism.

        So it sounds like some w/u has been done.

        I was going to write more but it started to border on medical advice, and I cannot risk that.

      • Marilyn says:

        JustADoc;

        I didn’t start my comment chain to work over my mom’s case, just to ask why it is so hard to get simple tests done!

        It’s not like I’m asking for all kinds of radical testing here! A couple of tubes of blood is NOT a cardiac perfusion and trip to the cath lab! Mom is willing to have the tests, and willing to pay out of pocket for it. Why won’t they just do it?

        As for the treatment of subclinical hypo, Iwas at first subclinical and was pretty sick. Thank God for the doc who decided to try thyroid meds or I’d have been really sick before my thyroid gave out completely. I had an endocrinologist tell me “I don’t treat thyroid till the TSH is at 10″. If I’d waited that long, I’d have dropped dead from a heart attack from the hypercholesterolemia and the arrhythmias I had going on. Or, I might have killed myself because I couldn’t stand the panic attacks (which started with the thyroid slippage, and disappeared after treatment). Funny thing too, I have Hashimoto’s disease but unlike most Hashi’s patients, I never developed a goiter. I wonder if it has to do with the early intervention of my doc…

        And you say the treatments are benign. Guess you are lucky to have not seen atrial fibrillation from hyperthyroidism.

        You don’t have to start a patient out on 100 mcg of thyroid med. My doc started me on 25. That was enough to stop my massive hair loss, something my doc could see…her comment to me when she saw me 6 weeks after starting treatment was “oh my gosh…you have hair.

        You all are too afraid of treating the thyroid. It is not rocket science to treat someone to a point where they are comfortable and functional. I am treated to a near-suppressed TSH where I feel quite well…I am nowhere near hyper, never have arrhythmia, and nowhere near suffering any kind of bone loss which everyone seems to fear.

        Everything I know about thyroid I learned at thyroidmanager.org. A textbook by docs for docs.

        You are aware, are you not, that the American Association of Clinical Endocrinologists is trying to reduce the upper limit of TSH? They feel that the current range is missing too many sick people.

        As I said elsewhere, medicine is no longer an art; it is now nothing more than a fast-food operation with limited menu. Or maybe it’s more like Henry Ford’s approach to automobile production: “Any customer can have a car painted any colour that he wants so long as it is black”.

        You can have any disease as long as it’s GERD or dementia.

    • Christine says:

      I believe that past the age of 80, dementia rates reach near 50%. I likely is dementia, and the doctor probably doesn’t see the point of an expensive work up to prove that to you.

      I’m sorry you’re going through this.

      • Marilyn says:

        I would certainly accept it if we did not find so much evidence that there might be a celiac connection. We have others in the family who are showing wheat/gluten problems, and why would it be so hard to simply up her calcium, and test for celiac?

        I do appreciate your sympathy.

      • Christine says:

        I may just be uninformed on this, but I’ve never heard of celiac causing mental status changes. Also, wouldn’t something like celiac be detected by age 83?

      • Marilyn says:

        Christine,

        The celiac does not itself cause mental status changes, it is the malabsorption of nutrients that causes the chemical imbalances that result in cognitive changes.

      • Mama On A Budget says:

        I would beg to differ, Christine. As a celiac who is part of a pretty big celiac support network, many of us experience pretty severe mental shifts if we are accidentally glutened. Some get depressed, some get hyper/manic. Me, personally, I zone out for a few days until the reaction clears (as well as all the unpleasant GI symptoms). Malabsorption isn’t the issues in a well-controlled celiac that is accidentally glutened by cross-contamination once in a blue moon – that’s caused by celiacs that aren’t eating a gluten-free diet.

        If your mother isn’t in a nursing home (ie, needing a diagnosis to get the to change her meals), why not just have her change her diet? What good does an official diagnosis do if a trial of gluten free living proves that she’s much better off the wheat, barley, rye and oft-contaminated oats?

      • Nick G. says:

        Celiac can have very powerful behavioral and emotional effects as Mama on a Budget shared. A friend of mine from my diabetic summer camp was seriously suicidal. Found out he had celiac, changed his diet, became his awesome self again. This isn’t across the board, but very possible and very real.

    • Hypothyroidism shows up in ordinary blood tests; TSH is one of the standard tests (which shows whether the pituitary thinks the thyroid is working). Slightly less frequent are tests for T3/T4, which would be done if there is reason to suspect the pituitary/thyroid interaction is busted. If you have access to the blood test reports, it’s probably on them.

      If she has multiple myeloma, both the metabolic cost of that cancer as well as the side effects of chemotherapies are much more likely sources of decreased brain function. Not to mention general aging issues.

      As for why the doctors won’t order tests – not all tests are harmless. Testing for celiac disease is one of those – a definitive diagnosis requires endoscopy and biopsy, far from harmless.

      Speaking as an amateur, but having watched a relative with MM and now lymphoma go through many courses of treatment.

      • Marilyn says:

        The MM is smoldering. Not active, growing, or being treated.

        The Igg and IgA wouldn’t be invasive. We’re going to put her on gluten free life when she gets out of rehab.

        As I said to Christine, what would be so bad about getting her calcium back into the range since she is so far below it? She has NO PARATHYROID hormone, and very low calcium.

        Isn’t that an obvious, and CHEAP problem to deal with?

      • Mama On A Budget says:

        TSH doesn’t show every thyroid imbalance. T3 and Free T4 levels can be off with a normal TSH.

    • CJ says:

      You don’t need a prescription for calcium. That’s something you can get OTC. Not a bad idea for anyone, especially an 83 year old woman who is at risk for osteoporosis just based on demographics alone.

      Another thing to think about is that MM/MGUS can screw up your calcium metabolism. Something to look into.

      Have you asked the doctors why they don’t want to test for these things? It would be interesting to have the whole story/hear what they were thinking.

      • Marilyn says:

        I’ve already started giving her calcium several times a day. I just found out about the low calcium a couple of days ago, though the tests were run weeks ago.

        The docs don’t think it is reasonable to test because her symptoms don’t fit their classic “approved” list.

        The hematologist was actually the best of the bunch so far (hematologist, internist, neurologist, orthopedic, naturopath) when he said “your blood is a confounding assortment of things”.

    • No offense….but how about because she is 83. EVERY 83 year old has some form of dementia.

      I’m more interested in why everyone wants to blame everything on the thyroid.

      And celiac….come one. You are going on zebras now. Celiac isn’t going to manifest itself in the EIGTH decade of ones life.

      You can put in your symptoms in any “symptom app” like diagnasouras or whatever and get a laundry list of diagnosis. It doesn’t mean they all fit.

      If you really want all those test done, then go to a concierge physician that is cash only. They would love to take your money.

      But maybe just let her be comfortable at 83 instead of putting her through a battery of tests, then treatment, then treatment side effects, then more tests, then treatment for the treatments side effects, and so on

      • Marilyn says:

        She wasn’t demented 6 months ago.

        I look at thyroid because every female in my family has (or has had) thyroid disease. Me, my three daughters, my grandmother, my great-grandmother, my aunts. Seems reasonable to me, especially since mom’s Free thyroid hormones are AT the number that is the very bottom of the ranges, and her TSH has shown a steady upward trend over the last 6 months.

        As I told Nurse K, celiac is not age-dependent.

        Let her be comfortable? I’d love to. But she is suffering terribly because she KNOWS she is in a terrible brain fog she can do nothing about.

        Age shouldn’t be the only consideration. If adjusting her chemistry would restore her independence, it should be done. It is simple, cheap, non-invasive. Saves the taxpayers money.

        They should not deny her the chance.

        I see a new career path for myself. Advocating for senior citizens. They are being robbed terribly.

      • Tracey H says:

        Every 83-yr-old has some form of dementia? Hmm. Tell that to my totally-with-it 86-yr-old Dad and 84-yr-old Mom. Not a sign of it in either of them. Lots of their relatives lived well into their 90s with no sign of impairment either. Sure, lots of 80-somethings have dementia, but lots don’t.

      • Esther says:

        My grandmother-in-law is 85. Two years ago she was diagnosed with Celiac disease and since being on the gluten free diet she has been doing extremely well. She was having infections and other problems before that. Now I’m not saying it cured her (she has pulmonary fibrosis and has to be on oxygen). And I know this is anecdotal. But it did improve her quality of life. Just because someone’s old doesn’t mean they can’t live well. I agree with Marylin. Dementia is common, but not necessarily a normal sign of aging.

      • Marilyn says:

        Esther,

        So your g-mother-in-law just got her diagnosis 2 years ago?

        Thanks so much for sharing.

        I rest my case.

        Just because someone doesn’t fit the expected pattern doesn’t mean they don’t have something.

        There is a lot of needless suffering going on out there because of short-sighted “gate-keepers”.

        Tracey;

        Great for your parents! Lots of mom’s relatives also lived to very strong 90s. NO dementia among them. Mom should probably have a reasonable expectation of the same.

      • Min says:

        In my family if you make it to 60 you are good for another 30 years. Heck the women who have had kids don’t even start menopause until almost 60! It is an informal tradition on your 40th birthday to get the calls reminding you to behave your self as pregnant at 50 is way too embarrassing. I had a great aunt who died last year at 107. Her older sister was at the funeral. A quick poll revealed that no one in recent memory (recent being very relative!) had dementia at 80 that hadn’t already been bit off since childhood, or some variant of abuse. Your comment about old must equal demented makes me think tunnel vision has snuckup upon you. Try to get away a little on the weekends road less traveled and all. Join an outdoorsy civic group and hang with older people who are well.

      • Esther says:

        Yes, my g-mother-in-law was diagnosed with Celiac that recently. I’m not sure which tests they did. I would add that several other members of her family have Celiac disease (my hubby for one).

        Also, Celiac symptoms are certainly not cut and dried. They really depend on the person. Celiac disease is both genetic and requires a trigger — usually a period of high stress — to start. So it’s perfectly reasonable that it might not show up until someone is elderly (or never).

    • BinkRN says:

      Marilyn-
      I can understand your frustration. I do hope that your requests to these doctors does not share the same tone that you are taking here, doctors, as well as nurses do not like to feel, or actually be, threatened by concerned, caring family members. We get that enough from a myriad of people we deal with daily.
      As far as having a ‘toe in range’ on a thyroid test- often, it is in the patient’s best interest to have that rechecked later, to see if there is a trend up or down. If it had been skewed to one end of the scale or another, treatment or further thyroid testing would have been warranted.
      As far as the celiac disease, I do not discount the correlation with many other conditions, however- being diagnosed at 83 is quite unusual, and probably unlikely. For someone who has true celiac sprue- you know they would likely be much sicker long before now.
      24 hours on LR? Maybe she was dehydrated…fluids are a great pick-me up.
      Has she been tested for UTI? Common cause for confusion and altered mental status in patients over 65.
      Serum calcium is not a fancy test- is is a normal part of a basic chemistry. If it was truly very low- they would address it- if they did not, ask them why they didn’t. You may be surprised of their answer.
      Is she eating well? If not, malnutrition can actually cause a cascade of abnormal labs.

      Most doctors will tell you why they did or didn’t do something. Do you have a medical POA for your mom? If not, might want to get one. Also- is your mom still making her own decisions? She may not want all this done, even if some of it is not invasive.
      The neurologist you saw was likely right, no Alzheimer’s, but there are varying forms of dementia, too.
      Not wanting to belittle your issues, just offering other ideas.
      Start with having the levels rechecked. And get a referral to an endocrinologist. After the results come back, then discuss differential diagnosis with the MD. Just remember, most patients are horses, not zebras. So you may not get the answers you are wanting.

    • JustADoc says:

      As I stated previously the labs you presented do not even qualify for subclinical hypothyroidism which is a controversial ‘disease’ to treat in its own right. And yes I am aware that the AACE is trying to lower the upper limit of normal for TSH. However you are currently asking a doctor to treat a ‘disease’ that doesn’t even meet the ‘not quite a disease’ criteria. Would it possibly be reasonable to do so? Maybe, but don’t make it out to be ‘just some simple tests’. As mentioned above testing serially is reasonable when the numbers are borderline. But then, that is being done from what you said. If the numbers continue to trend than it becomes far easier to justify treating as the risk:benefit ratio continues to slide to the right.

      I am glad that you didn’t have Afib or any other arrythmias when you were treated. You presumably aren’t 83 or even 60+ since your mother is 83 so you aren’t quite as prone to arrythmias in the first place. Because once you have Afib then we have to deal with Coumadin(or not and just have increased stroke risk but decrease bleeding risk) and all the problems that entails(frequent monitoring, interactions with almost everything, and sig. bleeding risk).

      • Marilyn says:

        JustADoc,

        I don’t mean to be cheeky, but I have to say this. My wish for you and others who think like you is that you would be imprisoned in an under treated hypothyroid body for two or three years, and that those in charge of your care would tell you there is nothing wrong with you and you must be hysterical or lying because your labs say you are fine.

        Some of the best thyroid docs got that way because they or someone they know lived that very nightmare.

      • JustADoc says:

        I am hypothyroid.

  3. Nurse K says:

    I would bet that the PTH level will be normal if re-drawn. Primary hypoparathyroidism is extremely rare, much more rare than a lab error.

    I’d tone down the ‘in yo face’/’I’m right/you’re wrong’ aspect of your requests if you want MDs to listen to you. I’m sure eyes are glazing over once you’re on the 5th or 6th test that you want to have done.

    Ask for the PTH level to be re-drawn and a referral to an endocrinologist if it is “undetectable” again. Leave out all the other doom and gloom with celiac and hypothyroidism. Maybe throw in an ionized calcium for good measure.

    • Marilyn says:

      I’d tone down the ‘in yo face’/’I’m right/you’re wrong’ aspect of your requests if you want MDs to listen to you

      The “in your face” attitude is reserved only for you because you throw it at me. I am perfectly sweet with the docs. Probably too timid in fact. I bite my tongue and simply ask questions, thank them when they give me their thoughts.

      PTH has been done three times. Below detectable limits every time. Thyroid antibodies can and do destroy the parathyroids. The doc won’t test for thyroid antibodies.

      Primary hypoparathyroidism is extremely rare, much more rare than a lab error. Multiple myeloma is rare too. But mom sure is going to be facing that.

      My issue, my frustration, is that doctors are assuming rather than observing simply because mom is 83. Her age is not a reason to simply not treat her! I might as well take her to a euthanasia clinic if that is how the medical profession sees her case.

      She was not demented 6 months ago. That should mean something. A neurologist has said he doesn’t have a clue what is going on. He’s the one who is supposed to know these things!

      The celiac and hypothyroid are not doom and gloom. We have too much Grave’s disease, Hashimoto’s disease and rheumatoid arthritis to let that pass.

      After a diverticulitis attack, I found that the only intestinal comfort I got was on a gluten free diet. Same for my daughter. There is a connection between celiac and autoimmune diseases, and there is such a thing as silent celiac. Not to mention that celiac is NOT age dependent. There is a connection between celiac and multliple myeloma

      Celiac can cause the malabsorption that leads to the anemia and hypocalcemia my mom is suffering.

      My rant, at the invitation to engage here in ranting, has to do with the unwillingness of medical professionals to do their job. Which of you would look at the legs of a woman which are so edematous they are breaking open and weeping, throw up your hands and say “gee…I sure don’t know what’s causing it and why the lasix doesn’t fix it…” and just send her home? (Don’t even say it…doc ruled out any kind of heart failure).

      I’m sure happy the government is taking over health care. Now everyone can face this fate.

      • ED RN says:

        “I might as well take her to a euthanasia clinic”

        We have euthanasia clinics now? AWESOME!!!!!!

      • Marilyn says:

        We have euthanasia clinics now? AWESOME!!!!!!

        Yeah. Come on up to Oregon. Actually, they are suicide clinics. Do-it-yourself euthanasia. There are lots of doctors standing by ready to speed you along to eternity.

        Interesting and sad attitude from someone who works in emergency medicine.

        Or, maybe not. Most of the people we see in mom’s rehab aren’t there because they want to help people, just there because they heard the medical field was a wide open job market. Like the nursing assistant who was supposed to help mom to the bathroom…”I’ll be there as soon as I finish my dinner.”

        Two hours later, she finally got there…too late.

        Medicine used to be a noble profession. Seems like just another “fast-food” operation now.

  4. Matt says:

    Please, I’m really quite polite if engaged in the same way. But I did find this interesting:

    http://www.boingboing.net/2010/03/10/most-adulterous-prof.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed:+boingboing/iBag+(Boing+Boing)

    Physicians are the most adulterous profession for men.

    • cynic says:

      Jealous ?

    • WhiteCoat says:

      That survey must include all the doctors that are getting screwed by lawyers.
      Bwaaaaaaahahahaha.
      Besides, it is from a biased organization, the study obviously didn’t meet statistical standards, California has had the same study for 40 years and no one pays attention, Texas has done similar studies and why aren’t people still happy … oh, and stop trying to shaft injured plaintiffs. That ought to cover it.

      • Matt says:

        Look at you – actually looking for facts before you reach a conclusion – (sheds tear) – you’re growing up before my eyes.

        And engaging in some slightly funny sarcasm. I’m so proud.

  5. Nuse K….you had until the ionized calcium!

  6. tracy says:

    Thanks for you input, Queen of the Road.

  7. tracy says:

    Nurse K……that’s kinda vicious…..

    • Pattie, RN says:

      Well, that is five minutes of my life I’ll never get back, all because someone went to the Oprah Winfrey School of Medicine!! I’m surprised that no one suggested the ONLY cure for Marilyn’s granny: Homeopathic treatments, bioequivalent hormones, and having her Chi adjusted. :~)

      There, fixed! Can we move on to medical discussions now???

  8. pharmgirl297 says:

    Who at the prescriber’s office enters electronic prescriptions that are sent directly to the pharmacy? Is it the prescriber? A nurse? A random staff member with a high school diploma? At the pharmacy, only a pharmacist can verify that prescriptions are entered correctly, and we are held responsible for our mistakes. I have never seen so many problems as I do with electronic prescriptions. I have to call for clarification at least twice a day. I appreciate the fact that I don’t have to decipher chicken scratch, but these errors are ambiguous and not always easy to recognize. I called on one yesterday because they had prescribed a drug twice daily for 30 tablets with three refills. I called to see if they wanted to give 60 tabs for a month, only to find out that it was the DIRECTIONS that were wrong, and the patient was to take it ONCE DAILY. I also am frequently sent two sets of directions, as it seems the programs don’t easily let the user deviate from standard directions (see my latest blog post).

    What is the problem? Is the software not user-friendly? Is it carelessness from the staff? Are these errors being reported to the software companies? Every error that occurs in the pharmacy has to be documented so we can learn from it. Does the prescriber’s office keep track? Someone please enlighten me.

    • VA Hopeful says:

      The software we use automatically enters the most common dosage schedule in the script when we send electronically. We have to fill in the disp# ourselves. I’ve caught myself numerous times having to change one or the other, and I’m a resident with more time per patient than most attendings. Rush + software that thinks its smart = mistakes.

    • WhiteCoat says:

      My wife’s office just converted to e-prescribing. Only docs can put in the prescriptions. One big problem with the software is that adding a medication pulls up every conceivable form of the medication from the formulary – “penicillin” gives you about 50 different choices. Our program lets us freehand the directions, but I could see how clicking the wrong button could cause the wrong prescription and more headaches.
      Is the calling for wrong prescriptions less than the calling for chicken scratch, though? May be a halfway decent trade off if so.
      Hopefully version 2.0 of e-prescriptions will have automatic checking for improper dosages at the point of entry. That will save time for docs and pharmacists.

  9. ER Murse says:

    I love all the Hugh Laurie fanboys and fangirls who want to be House, M.D., when Bertie Wooster is more their speed… So many extra-fun patients and especially extra-fun family members sitting in exam room with printouts of the google diagnosis of the moment. Someday they’ll let you bring your ipad into board exams so you can google them, and ya’all can go to medical school.

  10. paul says:

    something insightful i saw on sermo:

    >>No country that has significant government involvement could survive without three things: significant tort reform, strict guidelines for treatments for various disease (cancer, ortho etc.) and a nationalized strict formulary. I challenge anyone who heralds Obama’s plan as a triumph to explain how it could possibly expand coverage and reduce costs, without following the MAJOR tenets of every single other country with socialized medicine. It is an impossibility

    how true. our politicians are delusional if they think they can reduce costs while keeping the various lobbies all fat and happy. everyone has to make concessions if costs are to be brought down.

    • WhiteCoat says:

      I agree. Kind of like advertising new medicinal Kool Aid that will let you eat more food for less money and still let you lose weight.
      The FTC would shut down those business claims in a second. But when it’s the government making the promise, the government agencies just shrug their shoulders and look the other way.
      Glad I’m a doctor.

  11. WhiteCoat says:

    Holy Comment Thread, Batman!
    So much for taking the weekend off from blogging.

    Marilyn is right. First, celiac disease and dementia are definitely linked. Here are a couple of links.
    http://www.neurology.org/cgi/content/abstract/41/3/372
    http://www.webmd.com/news/20061013/celiac-disease-linked-dementia
    One of my kids has celiac disease. Her failure to gain weight, diarrhea, asthma and assorted other symptoms were all chalked up to various unrelated problems. One GI specialist at a well-known medical mecca diagnosed her with “sloppy stool syndrome” – even though we were giving her very little juice. Since she’s gone gluten free, all her problems have resolved.
    I’ve done the research about all the symptoms associated with untreated celiac disease. Thyroid cancer, thyroiditis, arthritis, infertility, strong association with Type I diabetes, dental problems, anemia, rashes, migraine headaches. The list goes on and on.
    Great book on all the diseases associated/caused by celiac disease is called “Recognizing Celiac Disease.” Definitely a good read for those interested.

    Celiac disease is undiagnosed or misdiagnosed in about 19 out of 20 people in the US right now. Could it be causing dementia is Marilyn’s mother – especially with all the other problems she’s having? Absolutely.

    However, Nurse K is also right. Cognitive decline is common in elderly patients. So once treatable causes of dementia have been ruled out, then it might be something that the family has to accept.

    One of my mentors once said that doctors should listen to their patients more – they just may be right about the diagnosis.

    If you aren’t happy with your doctor, then find another one. That doesn’t go just for Marilyn, that goes for everyone. Problem is that with increasing costs of medical education, decreasing job satisfaction and significant pay cuts, fewer people are going to want to be physicians, so finding a “good” physician will be tough to do.

  12. girlvet says:

    Does anyone really know how the health care reform bill will affect people? Who are the people who will be eligible for health insurance and how much will they pay? When will we get the details? Are there details some place on the internet that I don’t know about?

  13. throckmorton says:

    girlvet:

    At present no one really knows as all the rules committees have yet to say. In our area, private insurance is going up 17 to 23% to cover the unfunded mandates. This is for certain as they are writing the contracts for next year. There is an Obama Admin newsletter that touts insurnace for those who make up to 54K. This is an expansion of Medicaid but so far the states dont have the cash and as a result are cutting those enrolled. I would keep checking with your present insurance agent and secretary of state’s office and hang on, it is going to get real bumpy.

  14. tracy says:

    Any more comments about Psychiatrists out there? Hate to interrupt the coversation…..

  15. tracy says:

    Meds have certianly helped, but pills don’t “fix” everything. :( Annnnnnd, as i mentiond, we are hardly brimming with money, rather more the opposite, however, for the right Psychiatrist, i would certianly be willing to pay cash…and i KNOW it would not be “cheap”. i don’t mean to judge, but it seems that everyone who has replied has not been in this situation….and i don’t want Freudian Psychoanalysis….or “Voodoo” medicine.

  16. J says:

    Girlvet, find a local agent at nahu.org. Each state is different. I am an insurance agent in Colorado. We have a high risk pool for uninsurable people called covercolorado.org. Your state might have a similar program.

    None of the expensive things like ‘coverage for everyone’ will happen until 2014. Things like creating more high risk pools and guarantee issue for kids are happening now. Maternity, a pre-existing condition currently, will be a required benefit January 1 2010.

    You might try healthcare.gov, but it’s mostly BS.

    Your best bet is a good agent. The nahu website would be a good resource as well.

  17. SerenityNowHospital says:

    Marilyn,

    If you are so worried about celiac disease, then just home remedy it with a gluten free diet and dont worry about the formal diagnosis. If she improves great.

    I have to say, I am very disappointed to see so much about celiac on an ER blog.

  18. Helen says:

    I’m coming in late to ask Marilyn how her mother feels about all this testing. As a little ol’ lady of 70 with multiple health problems, I am sick and tired of dr. appointments, tests and screenings. Plus, it saddens me to think of the monetary impact on Medicare. I will continue to exercise and eat right, but at this point, I prefer palliative care and have expressed that to my children with a written directive.

    Luckily I am fairly lucid but that can change overnight. There comes a time when we have to say enough!

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