Vindication feels nice.

Some time ago I saw a young woman patient who’d been feeling crappy for about a year.  She’d seen several docs but hadn’t managed to get a diagnosis.  She described an amazing array of diffuse, hard-to-characterize symptoms, and my initial concern was that I was going to have a hard time finding anything on this one, too.  The situation was worsened by the fact that she had some clear ideas about possible diagnoses, which was coloring her description of the problem to me.   So to get a clear viewpoint, I first had to look past her bias.

After some initial testing turned up nothing, I suggested that I needed to see information about her symptoms in much, much more detail.  I asked her to keep a diary of her symptoms, her diet, her sleep, and her activities for two weeks.  When I received the diary, I went over it with a fine-tooth comb and had a flash of inspiration – her symptoms had a fairly clear diurnal variation, with one set of problems in the morning and a different set in the afternoon/evening.  And, the afternoon/evening symptoms seemed to vary depending on her behavior that morning, in particular with how much salt she ate.

I concluded she may have an adrenal problem causing increased cortisol and mineralocorticoid activity.  Sent her for some initial testing and sure enough, her morning cortisol was about twice normal.  So I sent her off to the endocrinologist to see what was going on.

Well, he was really rude to her.  He laughed in her face, basically, and told her that her cortisol lab was high because she’s a hysterical little girl who got excited over the test.  He told her he’d order a backup test (24-hour urine cortisol) to “prove” that she doesn’t have this problem, and sent her home.  She was pretty upset. 

But today the urine cortisol came back and … guess what!  It’s nearly three times higher than the upper limit of normal.  Of course, his first line of action is to tell her something must’ve been wrong with the test, and ask her to repeat it…  but meanwhile he’s also ordered the additional tests (the ones my little lab can’t do) that will be needed assuming the original test is valid.  Which it will be.  She’ll get the diagnosis and get the appropriate workup and treatment to take care of the problem.

Why did he laugh at her?  Well, the symptoms caused by high cortisol are eventually very destructive on the body.  Someone with high cortisol will develop obesity, a hump of fat on their upper back, a widened, moon-shaped face, severe acne, and hair growth in inappropriate places on the body.  My patient has gained weight, seen increased acne, and feels like she’s seen some changes in the shape of her face, but these issues are all still very early – she hasn’t gained enough to be obese, hasn’t got enough acne to be disfigured, etc.  So she doesn’t “look” like she has the problem.

And I say, what’s wrong with believing a patient who knows her body is behaving differently, doing a diligent workup, and finding the problem before it leaves her permanently altered? 

So I’m feeling pleased that the patient will get the care she needs, smug that I identified the diagnosis on the basis of some very subtle clues – clues that several other doctors failed to see – and, well, rather guilty that I’m actively pursuing jobs other than medicine. 

OK, so I figure that we should look for the positive in everything… and celebrate the positives we find, so we don’t get all squashed down by the negatives.

So I just opened the envelope with results from a recent physical exam.  And I’m happy to report… I have awesome cholesterol.  Like, really great.  My total is fine, but the really cool thing is the breakdown of “good” and “bad” cholesterol, which puts me in the best possible risk category.  Last time I was checked I had pretty good cholesterol.  I think the difference has to do with exercising daily instead of occasionally…

I also don’t have TB, which is always useful.

That’s all, I’m done bragging now.

For some time now I’ve been overwhelmed by the insoluble problem that is healthcare.  There’s so much that we COULD do to optimize peoples’ health.  But many of the things we do now are long-term therapies, which are costly.  The US is one of the wealthiest nations in the world, we spend over 15% of our GNP on healthcare, and we’re still failing to provide care to a frightening proportion of our population.  It seems impossible to do everything for everyone without bankrupting the nation – and the cost of care is an even bigger issue for the rest of the world, that doesn’t have our financial strength.

The “healthcare crisis” is driven by this disconnect between what we want done, and what we can (or choose to) pay for it.  For the last several decades, the system has been weakened by efforts to make the current system deliver more for less money.  From the POV of a healhcare provider, expectations for what we should do have steadily increased, while real wages have dropped and working hours have expanded.  That’s just a little piece of the overall complexity that is healthcare – I sure wouldn’t want anyone quoting this as an exhaustive summary of the healthcare crisis – but it is a piece that threatens to destroy the entire industry as talented providers abandon the profession in droves.

The knowledge-leaders and politicos discuss what will solve this dilemma.  Universal healthcare?  Healthcare rationing based on complicated cost-effectiveness models?  I’m increasingly convinced that none of it will work.  Our only hope, I suspect, is that some amazing revolutionary breakthroughs lead to astounding changes in what we can do with peoples’ bodies.  Permanent cures for common and expensive chronic diseases, for example, would free up enormous sums of money for treating other people and other problems.

What’s got me thinking of all this?  Two of the biggest news topics of the day:

1.  The presidential election:  After listening to various candidates talk about how they’d “fix” healthcare, I’m convinced none of their plans will do much good.  When it comes to fixing the healthcare crisis, the most important platform item may be how much the new president is willing to restore to the healthcare research infrastructure, which has been gutted after 2 terms of W’s administration.

2.  Stem cells from skin:  News items like this one make me feel so excited and hopeful for the future.  Could this be *it*? Could this be the technique that changes the world we live in? Or will it just turn out to be another disappointment, a fraud or a flawed result or an intriguing but ultimately not-very-useful footnote in the path of medical progress?

This morning, I am working in a coffee shop.  Next to me is a couple women talking, one far more than the other.  Talker-woman has many opinions.  Actually her husband seems to have many opinions, and talker-woman’s goal in life is to share them all with her friend.

One of the opinions is about animal hospitals – T-W’s hubby feels it’s “wrong” to provide high-level medical therapies to animals, when some humans aren’t getting adequate medical care.  In particular he objected to a nearby facility with top-of-the-line cancer treatment equipment for animals.

It would be rude to approach talker-woman and explain why her husband is wrong.  So, I’ll write it here instead…

Anyway, I restrained myself from telling talker-woman that she could fix the health-care crisis if she’d go get a job and donate her entire salary to HHH, instead of spending her days in coffeeshops drinking $4 coffees and distracting those of us who work for a living… and she’s gone now so crisis is averted…

Hope y’all are having a lovely Friday.

***

The big cat seems to have a thing for paper.  On at least one occasion she came up and nipped a corner off the page of the book I was reading; piles of articles or mail have a way of getting thoroughly mauled; newspapers are thoroughly exciting events.  Just now she rather efficiently shredded the paper bag in which I collect paper for recycling.  I see I’ll need to start collecting recyling in a non-paper container…

I had a quilt over my lap with the end dragging the floor.  Felt a little tugging and came to realize the little cat had pulled it around and over her to make her own private little cave.  Only one ear is showing.

Problem is, the big cat hasn’t quite gotten past her tendency to assume a moving lump under a quilt (say, feet?) is something to be pounced upon.  So a short discussion ensued…

Someone was interviewing McCain on the TV as I did my treadmill time yesterday and I was finding him very interesting.  He was maintaining, somehow, that our status in Iraq was “military success” and maintained the “complete success” would follow.

I sort of thought that military success means your troops are no longer dying in hostile engagements, but there you are…

But I got to thinking about how none of the candidates seem to give any credit to the complexity that is Iraq – and Afghanistan, for that matter. It’s not just a matter of saying “we don’t seem to be able to succeed, so let’s leave”.  We went in there (wrongly, in my opinion) and we trashed their infrastructure.  If we just leave, they’ll be left without roads, schools, sanitation, power… And in their desperation, imagine their gratitude when those nice wealthy Taliban folk come in and build jihad schools and community centers…

So it occurred to me that invading a country is like adopting a puppy.  You think it’s gonna be a great idea but once you get the little guy home, you discover he chews up your favorite shoes, pees on the rug, and barks maniacally at your mother-in-law.  At that point, though, you’re stuck.  You committed to care for this little guy for the length of his life – so you resign yourself to ruined shoes and smelly house for years to come while you patiently try to teach him some manners.  You watch him like a hawk.  You shut him in the bathroom while you’re at work so he won’t ruin anything, then take him for long walks every evening so he will get the exercise the bathroom denied him.  (And with a secret smile you regretfully inform your mother-in-law that she just upsets the dog so much; maybe she should stay in a hotel when she’s in town?).

I’m not sure what the puppy-equivalent behaviors in Iraq are – I’m about as politically unsophisticated as they come – but I wish I heard our presidential candidates acknowledging the issue and discussing options.

When Koshka died, I was disappointed to realize that I had very few pictures of her floating around.  So I’ve resolved to be better about snapping shots for these two.  I have a little digital camera on my desk so I can grab it the moment they start to be entertaining  🙂

But sometimes those best moments are things that you can’t photograph because moving would spoil the picture.  When I woke up this morning, I was lying flat on my back with my legs sprawled in a sort of V shape.  And there between my legs, in perfectly parallel poses, were the cats – the little one in the point of the V, the bigger one further out.  Both wrapped in a ball with nose tucked under tail. 

There’ll never be a picture of that moment but it was pretty entertaining. 

I suppose that’s a good reason for journaling… now I’ll be able to remember this in the future…

The “Which 80s Movie Scientist?” Test

Your Score: Ray Stantz

149 Heart, 157 Genius, 126 Cool, 142 Excitability

Dr. Raymond Stantz – (Dan Aykroyd)

Ghostbusters (1984)

You are Ray Stantz! The heart of the Ghostbusters. You’re well-meaning, smart, and you have a childlike sense of wonder about the world. You might get taken advantage of, every once in a while, but it’s okay… You’re doing your part to help save the world.

“Gozer the Gozerian… good evening. As a duly designated representative of the City, County and State of New York, I order you to cease any and all supernatural activity and return forthwith to your place of origin or to the nearest convenient parallel dimension.”

I am scanning in a folder of old (junior-high and high school) papers and creative writing that appeared on my bookshelf.  I figured the mementos would be, if anything, safer and better preserved in a backed-up electronic form. We do live in flood and hurricane country, after all.

As I skim the work, I am concluding that I was a better writer between the ages of 12 and 17, than I am today.  Not that I was an especially great writer then, but I think I’ve gone downhill since.

Meanwhile, this month’s book club book is “Now, Discover Your Strengths”, which is one of those personality profile books where take a little quiz that tells you how to live your life and then read a book about the quiz results.  One of their contentions is that we start with a brain that has many diffuse neuronal connections, and over time you lose some connections in favor of reinforcing others.  They maintain that this translates on a macro scale to a lifetime of losing some skills in favor of strengthening others.

I want to disagree simply because I don’t like the idea of losing skills.  But – if they’re right – what skill have I gained in return for the loss of my writing skills?  And how can I parlay those into a career I really love, instead of just tolerating on the good days?

(Why yes, that’s a glass half-full thought but it IS Thanksgiving… why be pessimistic?)

I do feel like I accomplished a few things this weekend… some decluttering, some cleaning, some administrivia errands, and some general relaxation.

I scanned a pile of old documents – things I’d like to have records of, but don’t need hard copies*.  The total residue was a full bag of shredded stuff and an additional half-bag of stuff that didn’t require shredding.  That cleared out enough space that three file boxes became two, and shifting things around I now have three free shelves in the library.  I’ll move stuff from the guest room shelves out to the library – so I’ve furthered my goal of getting the free space in the guest room to do some built-ins.

I also got in some work outside and managed to clear enough trash off the patio and out of the garage that the enormous trash can is full… and there’s a pile by the recycling bin as well.  But I’ll need to do much, much more before the garage is usable as a woodworking space again. 

I find myself measuring progress in the square footage of horizontal space (shelves or floor) reclaimed.  I need to clear probably another 30 shelf-feet of stuff from the house before I’ll feel truly decluttered.  And I dunno how many from the garage.

I managed to work out both days.  I watched several entertaining home-improvement podcasts.  I answered a few emails. 

I read most of “Three Cups of Tea”, a novel about a guy who started a charity to build schools in rural Pakistan.  The backstory comments about the politics in Pakistan over the past 20 years have given me interesting insights into the current Bhutto/Musharraf (spelling?) confrontation – as Bhutto’s being painted by the press as a white-hat now, but it sounds like Pakistan under her and Sharif was rife with corruption and misery.

How is it Sunday night already?

* * * * * * * *

*Fr’ex, I scanned all my old electric bills.  I know I don’t need them for any documentation purposes, but I want the usage data on file so I can compare old to new when I do a home improvement that’s intended to save energy.   Comparing the pre- and post- data after installing the new, more energy efficient air conditioner, for example, was impressive.  In the summer months, it’s saved me up to a hundred bucks per month and that’s despite a sharp rise in prices during that time.