Frail

Like most neurologists, I do EMG/NCV's. This is a test that involves needles and electrical shocks.

It's nobody's idea of a fun test, but we do get a lot of information from it, and for many disorders it's the best test there is for sorting things out.

As a result, it's not uncommon for me to get a fax from another physician's office asking me to do one on a patient. They send over the insurance info and all, and Mary calls the patient to schedule it.

About a week ago I received a fax from Dr. Livingston. It was an order sheet that said "Please do EMG/NCV on Mrs. Geri, possible hand pain." Mary called her number, reached her daughter, and set up the appointment.

Mrs. Geri came in a few days later. She was in a wheelchair, pushed by her daughter. Advanced Alzheimer's disease and incapable of doing anything other than mumbling gibberish. Frail, maybe 90 pounds. Occasionally she'd randomly wave one or the other hand back and forth.

I asked her daughter why Dr. Livingston wanted the test, and her daughter told me it was because of the intermittent hand waving. She hadn't complained of pain (or pretty much anything else).

And... I couldn't do it.

Sorry, Dr. Livingston. The $250 I'd get for putting this poor old lady through an unpleasant test that she couldn't understand seemed more like an exercise in greed and torture than a diagnostic medical procedure.

Not that I really blame Dr. Livingston. I'm sure he was just trying to find out why she'd occasionally wave her hands, but to me it was immaterial. Even if I found something, after putting this sad lady through unneeded discomfort, what would really be done with that knowledge?

I explained this to the daughter and sent them on their way. The billing sheet and her insurance info went into the shredder. I took a loss on the hour and sent Dr. Livingston a polite letter explaining why I hadn't done the test.

I'm sure he can find another doctor to do it. Maybe someone hungrier than I, or less willing to ask questions.

But I just couldn't do it.

Mary's desk

Mary: "Dr. Grumpy's office, this is Mary."

Ms. Caller: "Hi, I'd like to make an appointment with Dr. Grumpy."

Mary: "Okay, and what will you be coming in for?"

Ms. Caller: "I have Spritzgong-Fleagle Syndrome, and need to have an MRI done annually to check for new damage."

Mary: "Okay, let's see... This week is pretty busy, but I can get you in next Thursday, at 10:15."

Ms. Caller: "That won't work. I was hoping to get in this week so I can get the MRI done soon."

Mary: "Are you having new problems?"

Ms. Caller: "No, my regular neurologist will be back from vacation next week, anyway."

Mary: "Wait... you already have a neurologist?"

Ms. Caller: "Yes, I see Dr. Stevens, at Huge University Hospital. She specializes in Spritzgong-Fleagle Syndrome, but she's on vacation until next week."

Mary: "Then... why are you calling to see Dr. Grumpy?"

Ms. Caller: "I thought he could order an MRI, then I'd have it when I see Dr. Stevens next week."

Mary: "I'm sorry, but he doesn't cover for Dr. Stevens. You'd have to call her office to get the test done, or wait until she comes back."

Ms. Caller: "Thanks for wasting my time."

Click.

Parenthood

Dr. Grumpy: "How's she doing with the new medication?"

Mrs. Daughter: "Calmer, but she still treats me like a child."

Mrs. Dementia: "Are we at the doctor's yet?"

Mrs. Daughter: "Mom, this is the doctor."

Mrs. Dementia: "How do you do? This is my daughter."

Mrs. Daughter: "He's met us before, mom."

Dr. Grumpy: "How are you feeling, Barbara?"

Mrs. Dementia: "Don't talk back to me, young man!"

Mrs. Daughter: "Mom, he's the..."

Mrs. Dementia: "You don't talk back to me, either! Go to your room, right now!"

Dr. Grumpy: "Barbara, it's okay."

Mrs. Dementia: "And you're grounded, young man!"

September

Reminding all the guys out there that it's Prostate Cancer Awareness month. So be sure to get checked. And here's some special guests to say more.

Wednesday afternoon

I'm in line at the bank, and hear this conversation in front of me:



Teller: "Ma'am, I'm sorry, but we can't give you a cash withdrawal without any identification."

Ms. Deceit: "How about I just get the money today? I can come back tomorrow with ID."

Teller: "No, we need a form of identification before giving you the money."

Ms. Deceit: "Like I said, I left my purse at work, or I wouldn't be here in the first place."

Teller: "Well, you can certainly get it and return later."

Ms. Deceit: "Don't be silly. For that kind of trouble I might as well go to different bank. How about if I give you my cell phone number? You can call it right now, and I'll put my phone on the counter. When it rings that will prove it's me."

Teller: "We can't accept that. What we need is a photo ID and..."

Ms. Deceit: "A photo ID is easy. Don't you have a computer back there? I'll show you my Facebook page, so then you can see my picture and know I'm telling the truth."

Teller: "Ma'am, Facebook isn't an acceptable form of identification, and we'd also need to see..."

Ms. Deceit: "This is why I prefer online banking. Places with people in them, like this, just aren't customer-friendly."

(she leaves)

Phone calls

I'm with a patient. Mary interrupts me to say there's another doctor on hold, who needs to talk to me.


Dr. Grumpy: "This is Dr. Grumpy."

Dr. Call: "Hi, we have a mutual patient, Mrs. Memory."

Dr. Grumpy: "Hang on, let me pull up her chart... Okay. It looks like I haven't seen her since 2014."

Dr. Call: "Okay, you need to pull her driver's license. I don't think she's safe to drive."

Dr. Grumpy: "I really can't do that after 4 years without seeing her. Why don't you have her family call Mary to bring her in? I can see her tomorrow morning at..."

Dr. Call: "That's ridiculous. She needs to have her license cancelled today. Immediately."

Dr. Grumpy: "Why don't you call the state DMV? You can do it, too."

Dr. Call: "I'm very busy! I don't have time to do things like that! This is your problem!"

Dr. Grumpy: "I..."

Dr. Call: "Okay, since you don't seem to be able to, I'll take care of it. What is the DMV phone number?"

Dr. Grumpy: "I don't know it off the top of my head, but you can..."

Dr. Call: "I'll just have my staff do it. You're not very helpful."

She hung up.

"Stand back!"

Seen in a bladder-flow report:

All I need is a miracle

Aimovig is the first FDA-approved drug specifically developed to prevent migraines.

It’s getting a lot of press. Some articles talk about it as a breakthrough, some on how it shows the pharmaceutical industry is now focusing on migraine as a real disease, some on how it represents a new era in diseases that affect predominantly women, and many other spins.

Of course, it isn’t alone. There are 2-3 similar agents on the launch pads to join it in the next year.

From my daily office view, the phone calls (and drug reps) come in, and inevitably I hear it referred to as “the miracle drug.”

“I want to try the miracle drug.”

“I saw an ad for that miracle drug.”

“Someone at work told me about this miracle drug.”

Amgen, to their credit (not that the FDA would allow it, anyway), has NOT claimed it’s a miracle drug. The information they provide doctors is the usual glossy graphics surrounding dry statistics and obligatory legal wording. (Note - neither Amgen, nor their competitors, or anyone else, has paid me to write this post. These are my own thoughts).

People seem to need to think a drug is a miracle, in spite of all evidence to the contrary. This isn’t a slight against Aimovig - it’s human nature. Just as people thought of the Titanic as unsinkable (a claim never in reality made by her builders, owners, or officers) there’s a desire to believe human intelligence has somehow overcome a problem and cured it.

It’s not like Aimovig is the first drug to get that label, either. Botox is a miracle drug. So was Imitrex in 1992. Interleukin-2 in the 1980’s. Penicillin in the 1940’s. Willow bark in 500 B.C. (that's where Aspirin came from, people). And too many others to list.

Are these bad drugs? Far from it. But, like every other drug ever discovered, they have a lot of limitations. They work for some conditions, but not others. They ALL have side effects (if someone tries to tell you a drug or supplement doesn’t have any side effects, they’re lying). And, most importantly, humans are not a biologically identical group. No medication will work for everyone. If you read the stats on any med you’ll see that approval is based on a percentage of people who respond to it - and it’s never 100%.

There is absolutely no way to predict with 100% certainty who will - or won’t - respond to any given drug. For that matter, there’s no way to know who will - or -won’t - have side effects, or even which ones.

This is a trial-and-error crapshoot, people. We make decisions based on facts, but an educated guess is still just that - a guess.

There is no such thing as a “miracle drug. " And there never will be.

You won’t hear me, or hopefully any other reputable physician, ever tell you that a drug or surgery or whatever is guaranteed to cure you, or has no chance of harming you. Medicine is about as imperfect a science as there is.

If someone is making such a claim to you, run away. They just want your money, and don’t care about helping you.

I’m not knocking Aimovig. For some people it will be life changing. For others it won’t do a damn thing. Still others will have an unpleasant side-effect. The jury on it and its cousins is still out, and will be for at least 2-3 more years.

But don’t go into any treatment plan, for anything, thinking it’s going to be a miracle. There’s nothing wrong with being hopeful, but you can still do that and keep reality in mind. Because in this field, there are no guarantees.

Memories...

 

In the mid-80's I had a medical school interview in Chicago. It ran over and finished about 45 minutes before my flight home. And the drive to the airport was around 45-60 minutes.

I went out and hailed a cab. The driver was a dude with a scruffy beard. I climbed in and asked him if he’d be able to get me there on time.

He looked at me in the rear-view mirror and said “do you mind if I smoke?”

I said no.

He lit a cigarette, mumbled “fuck” then yelled “HANG ON!” and slammed on the pedal.

I discovered my seatbelt didn’t work, but just kept my mouth shut.

I made my flight.

I gave him a good tip.

Annie's desk

Annie: "Dr. Gumpy's office, this is Annie."

Mr. Consultant: "Hi, I saw Dr. Grumpy last week, and he told me to increase my dose of Flookadook from once a day to twice a day, and it hasn't helped my symptoms at all."

Annie: "Okay, did the increase cause any side effects?"

Mr. Consultant: "No. Why would it cause side effects? I'm still taking it once a day, and haven't had any problems with it."

Annie: "But you said you increased the dose to twice a day?"

Mr. Consultant: "No, I said Dr. Grumpy told me to do that. I didn't say I had."

Annie: "So..."

Mr. Consultant: "Anyway, my symptoms aren't any better. Can you please ask Dr. Grumpy what I should do?"

Bueller? Bueller?

Seen in a chart:

Sympathy for the devil

Please allow me to introduce myself. I’m Dr. Grumpy’s evil arch-enemy, neurological disease.

I’ve been around for a long, long year, stole many a man’s (and woman’s) soul to waste.

In the last year I’ve been in the headlines for my trifecta of stars with Parkinson’s disease: Neil Diamond, Alan Alda, and Linda Ronstadt.

The funny thing is that you people often believe life decisions or habits or activities can change your risk of meeting me. That may work for my friend heart disease, or for certain types of cancers, but me? Don’t kid yourself. Plenty of the things I do don’t have a known cause or risk factors, regardless of what some guy on the internet or TV tell you (and I bet he's trying to sell you something, too, claiming to cure it).

Others believe that a virtuous life will keep me away, or that I’m a punishment from God for being evil. You want good and evil? How about Pope John Paul II and Adolf Hitler (both Parkinson’s disease)?  You American evangelicals think you’re immune? How about Billy Graham (Normal Pressure Hydrocephalus). You think I care?

I especially love it when you try to attach political significance to me, like I’m here to punish someone on the side you disagree with. Let’s talk about Glioblastoma Multiforme, probably the most dreaded form of cancer there is. Here are 2 names from across the aisle, Ted Kennedy and John McCain. Here's another pair: Lee Atwater and Beau Biden. Political affiliations and age don't matter to me. The last pair were 40 and 46 respectively.

Before I forget, let’s talk about Alzheimer's disease: Ronald Reagan. Rita Hayworth. Charlton Heston. Glen Campbell. James Stewart. Perry Como. Jackie Fisher. Charles Bronson. Peter Falk. E.B. White. Rosa Parks. Burgess Meredith. Norman Rockwell. James Doohan. Fred Trump (yeah, his dad).

How about entertainers (besides those I mentioned above)? Slim Pickens. Gene Siskel, Ethel Merman, and George Gershwin (all Glioblastoma). Michael J. Fox, George H. W. Bush, Muhammad Ali (all Parkinson’s Disease). Terry Garr, Annette Funicello, Ann Romney, Richard Pryor, Montel Williams (all Multiple Sclerosis). Sir Laurence Olivier (dermatomyositis). Robin Williams (Lewy-Body disease). Dudley Moore (Progressive Supranuclear Palsy).

Let’s move to Amyotrophic Lateral Sclerosis, AKA Lou Gehrig’s disease or Motor Neuron Disease. This is probably the most dreaded disease in all of medicine. Obviously, Lou Gehrig and Stephen Hawking are the most well-known, but here are some other names: Mao Zedong. Catfish Hunter. David Niven. Stephen Hillenburg (creator of SpongeBob).

Epilepsy, while not usually fatal, can still have an impact on one’s life. Believed to be something to ashamed of for years, many places used to have laws on the books forbidding people with seizures from marrying or having kids. Here goes: Hugo Weaving. SCOTUS Chief Justice John Roberts. Bud Abbott. Vladimir Lenin. Neil Young. Lindsey Buckingham. Lil Wayne. Former U.S congressman Tony Coelho. Prince. Florence Griffith Joyner. Fyodor Dostoevsky. POTUS James Madison.

This list, of course, only covers famous people I’ve affected. There are far more who aren’t famous, but who are just as important. Somebody’s parent, grandparent, child, spouse, aunt, uncle, cousin, friend, co-worker, and many others. If I’ve touched them, then I’ve touched you. And you probably still remember both of us.

Years ago, I first met Dr. Grumpy when he switched from internal medicine to neurology, and I remember him telling me that it was a real shock. Back in medicine he saw mostly old people sick and dying, but in neurology it had shifted to younger folks. That discrepancy still bothers him after more than 20 years of doing this job. And it always will. He has me to thank for that.

So don’t go around making me a political, religious, age, cultural, racial, national, or whatever issue. I don’t give a crap about any of those things. I’m a human issue. If you think you’re special, and have done something that will guarantee I leave you alone, you’re wrong.

Seriously bad things, like me, can happen to you. Or anyone. Sometimes it’s just shit luck.

You don’t like that? There’s only one thing you can do. If you have some cash you don’t know what to do with, donate it to a reputable organization working to eradicate one of the diseases I’ve mentioned. Because research leads to knowledge, which leads to treatment. That’s the only way you may be able to get ahead of me.

'Cause I'm in need of some restraint.

Monday night, 11:18 p.m.

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Mr. Vasculopath: "Hi, you were my neurologist at the hospital last week, when I had a stroke."

Dr. Grumpy: "Yes, what's up?"

Mr. Vasculopath: "Well, I'm really worried. You prescribed Otquoobo to keep me from having another stroke, and I read about it on AllDrugsArePoison.com. It says it's really dangerous, and so I haven't started it, and now I'm worried I'm going to have another stroke, and I got all upset."

Dr. Grumpy: "Okay, let's talk about it. Are you okay right now?"

Mr. Vasculopath: "Yeah, I'm better. I just smoked a pack of cigs to calm down."

"Hey, what's that smell?"

Seen in a chart: