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Diagosis Unknown: An Orthopedic Mystery

For more than a decade, I successfully avoided a visit to the orthopedist for a chronic elbow problem. Today I reluctantly decided, on the advice of a friend and orthopod, to go to the hospital and find out once and for all what could be causing my elbows to lock during certain exercises.

The process took 4 hours, all told. I registered at the clinic, then proceeded to the radiology suite to wait for some X-rays. There was a long line of legitimate-appearing X-ray candidates before me – some in casts, others in slings, still others limping pitifully. I was just fine and pain free, feeling a bit guilty – as if I might be wasting resources.

I glanced at the films as I put them in a folder to take back upstairs to the clinic – they looked perfectly normal. “Oh, boy.” I thought, “young Caucasian female complaining of elbow locking for 15 years, now with normal X-rays.” I bet the orthopedist is going to roll his eyes at me. I was escorted to an examining room where I sat on a table across from my normal X-rays, clipped on a light box.

A trim and athletic gentleman in his mid 60’s introduced himself to me. He had crystal blue eyes and short white hair… and disproportionately large hands (kind of the way Michelangelo’s David does). I was sure that I was the healthiest person he’d see that day. He glanced at my totally uninteresting elbow X-rays, took a deep breath and raised a skeptical eyebrow as he asked me to describe my difficulty.

“Well, when I’m at the gym, my elbows lock at about 15 degrees from full extension during certain exercises. It’s always during the eccentric phase of muscle contraction, and usually during a lat pulldown or seated row. If I rotate my forearm there’s a snap and the discomfort disappears and I can resume the exercise.”

He was impressed by the specificity of my description, and asked me to demonstrate the problem. I felt a little bit silly, but attempted to keep a straight face. Seeing that we were not going to be able to reproduce the problem without counter weight, the good doctor jumped in to simulate the exercise by pulling on my arm. I pulled back, and we soon realized that he was unable to apply a force strong enough to trigger the problem. In fact, I pulled the poor man off balance and nearly dropped him on the floor.

After a few more maneuvers he concluded that he had no idea whatsoever what the problem might be. He told me that since the X-rays were normal there was probably nothing to worry about, and that I might consider avoiding lifting weights in “clanky gyms filled with smelly, sweaty people.”

He dictated his note in front of me, highlighting my excellent health, unusual strength, and completely benign X-rays. He seemed to relish the whimsy of the fact that he was no physical match for me (a smallish blond woman) and added that I was unlikely to be damaging my elbows at the gym.

His advice, as I had anticipated, was to “stop doing the things that trigger the locking” and to consult him if I developed any neuropathic pain or effusions. He added that I reminded him of his daughter.

Well, it was an amusing interaction – but somewhat unsatisfying. It made me think of all the times that I wasn’t sure what was wrong with my patients, and how disappointed they were when I had to tell them this. Medicine is an inexact science at times – and the best that we can do is rule out the really bad stuff, and shrug when the rest remains unclear.

Have you had a problem but couldn’t find a diagnosis? Do tell…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

End-of-Life Care: Healthcare’s Big Ticket Item

More healthcare dollars are spent on end-of-life measures than perhaps any other single expense. About 25% of Medicare’s 2.8 trillion dollar budget is spent on care for people in the final year of life. That works out to be about $2500/person/year that we spend on government funded end-of-life care. Medicare spending overall is closer to $10k/person/year in this country… and given that the average household pays $6K in taxes/year… you can see that we’re in a real pickle when it comes to healthcare spending (and that’s just for Medicare).

In a recent blog post, PandaBearMD suggests that it’s time to “put granny down.” This gallows humor speaks to what the medical community has been been discussing in more academic terms. Here are some interesting sound bites (click on links for full references):

Terminally ill patients should be treated outside of acute care facilities. …Acute care hospitals are, by definition, set up for handling acute conditions – trauma, childbirth, orthopedics, heart attacks, etc. Terminal illnesses are not acute conditions, and therefore should be treated in a facility or setting that is chronic-care oriented.

The technological advances that medicine has witnessed in the last few decades are no more apparent than in the ICU. Yet when used inappropriately, this technology may not save lives nor improve the quality of a life, but rather transform death into a prolonged, miserable, and undignified process.

Hospice care can reduce the cost of end-of-life care by 30% or more (though this is debated).

We don’t operate in a closed health care system, where there is a fixed number of dollars for health care, and thus the need to choose how to allocate those dollars,” said Dr. Weissman. “Our health care system is open-ended, which is why the cost of health care goes up every year. So we’re not making a tradeoff of spending more on the elderly and thus not using those resources on children’s care.

While it is fairly obvious that we deliver a lot of unnecessary, costly, and heroic medical care at the end of life, determining how to ration this care is fraught with moral and ethical dilemmas.

What sort of population-based rules should we institute to govern access to acute care services at the highest level? Would limiting care to people based on age or comorbidities sit well with Americans? Imagine that you’re 65 – just entering retirement and expecting to enjoy another 20 years of life – and you’re disqualified from top tier medical treatments because of your age. Who has the right to judge your worthiness of top medical technology?

I know of an elderly woman who accidentally took too many diuretics over the period of two weeks. She became delirious and was admitted to a hospital where the doctors assumed she had end stage Alzheimer’s disease and sent her home with hospice care. Another doctor later discovered the error, rehydrated her and she returned to her usual state of health. It was a close call for that “granny.”

My parents are in their late 70’s and in excellent health, enjoying book writing and traveling. I asked them to read PandaBear’s analysis of end-of-life care in the United States – and how billions of dollars are spent on heroic measures for the frail elderly.

My mother said tersely, “I hope I die in Europe.”

My father replied, “Whether you’re old or young, it’s nice to be alive.”

But I can’t help but think of that patient who was sent home with hospice care for delirium caused by severe dehydration. Will we turn our backs on the elderly and not carefully consider their differential diagnoses simply because of their age? As long time tax payers, are they not the most deserving of access to top technologies if so desired?

This is one tough dilemma – and the best I can advise is that we each create living wills, and save our own money for that rainy day when we need critical care, but are ineligible based on some future population-based rule to save money on futile care. In that case, the wealthy would always maintain access to the best care available.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The Christmas Miracle

My sister Vicki lives in Grand Rapids, Michigan with her husband, three children and
an alarmingly large and slobbery Saint Bernard named Gilbert. Several Christmases ago she decided to teach her then 5 year old son, Harrison, about Christmas tree decorating. She took him to a Christmas tree farm and helped him select a tree. They hauled it back to the house and my sister managed, with no help whatsoever from Gilbert, to set it up in a nice corner of the living room. The tip of the tree reached the ceiling and its full figured branches spread from icy window to window.

Vicki and Harrison spent hours and hours winding lights, tinsel, ornaments, paper angels and popcorn strings around the tree. Little Harrison couldn’t wait to see the final product, with glittering lights and a magical star to top off their fine work. They decorated into the early evening, and the living room grew dark as the sun set over the snow covered neighborhood. At last it was time to plug in the tree lights.

As Vicki plugged in the lights for the first time, Gilbert roused himself from his resting place in front of the fireplace and shook off his drowsiness. Harrison held his breath in eager anticipation of the twinkling display that he had helped to create. My sister turned off all the overhead lights.

As the plug entered the outlet, the tree lit up with thousands of tiny glittering lights. Harrison
marveled at his glorious creation. “Mom, it’s the most beautiful tree in the world!”

My sister sat down on the couch and hugged her son tightly in her lap as they relaxed and enjoyed the view. Suddenly, Harrison’s eyes fixated on one of the branches.

“Mom… look! There’s an icicle on the tree!!”

My sister squinted and followed the direction of Harrison’s pointing finger.

Sure enough, there was a glassy, 5 inch long, icicle-appearing object perched in a tree branch in the middle of the tree.

Harrison’s raised his voice with glee: “Mom! It’s a Christmas MIRACLE!!”

The little boy broke free of his mom’s grasp and ran up to the tree to inspect the icicle at close range. As he reached out his hand to clasp it, his look of amazement turned to horror. The icicle was in fact a long
string of dog drool that had flicked off of Gilbert when he shook himself out of his sleep.

“Ewww!!!” Harrison screamed. My sister slowly realized what had happened and started laughing
uncontrollably. Gilbert wanted to get in on the fun and began barking and running in circles. He became tangled up in the extension cord and pulled the tree right out of the tree stand. At that moment, Vicki’s husband returned from shopping with the other 2 children. As he turned on the lights he found my sister
trapped under an unraveling Christmas tree, a hysterical child frantically wiping his hands on paper towel, and a barking, drooling Gilbert in the midst.

“What happened here?!” he shouted, attempting to rescue Vicki from underneath the tree.

“It’s a Christmas miracle” was her muffled cry.

And this story will be in our family for a long time to come.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Beating Colon Cancer: One Woman’s Journey

A few months ago I wrote about my dear friend who was diagnosed with stage IV colon cancer just after having her first baby. Her optimism and positive focus was inspirational to me, and I marveled at her ability to live life unencumbered by prognosis.

Today I am happy to report that she has completed her 7th round of chemotherapy (with avastin, oxaliplatin, 5FU, and leukovorin) and her liver tumors have already shrunk by two-thirds. She is bothered by neuropathy (burning sensations in her hands and feet – a known side effect of this drug regimen) and has lost the ability to taste food fully, but otherwise she is maintaining her weight and her blood counts are good. She told me that her plan is to complete 12 rounds of chemo and then meet with a liver surgeon to consider surgical removal of the remaining tumors. Miraculously, her doctors believe that she may be a candidate for liver resection and eventual cure.

This couldn’t be any better news and I am so pleased to be able to celebrate my friend’s success. I have learned a great deal myself about the journey, and about how many people are willing to reach out and help those who are struggling. As for my friend, she has greatly benefited from:

1. CarePages – an online gathering place where friends and family can find out the latest news about her progress, and leave well wishes and virtual gifts. CarePages is part of the Revolution Health family.

2. The Colon Cancer Alliance (CCA) – this wonderful non-profit organization linked my friend up with a mentor who has been through a similar treatment regimen and diagnosis and can speak to her about what to expect. The CEO of CCA has even taken time out of his busy schedule to make sure that my friend gets the best support available and has put her in touch with top liver surgeons.

3. Dr. Lenz’s Colon Cancer Blog – Dr. Lenz is a leading medical oncologist and Co-director of both the Colorectal Center and the Gastrointestinal (GI) Oncology Program at USC/Norris Comprehensive Cancer Center in Los Angeles. He also prepares 3 fresh blog posts per week here at Revolution Health, to make sure that cancer patients have access to the latest research and information about colon cancer.

With incredible advances in evidence-based cancer therapies and these terrific online resources, colon cancer patients have a brighter future than ever before. I’m so pleased that my friend is doing well, and I’m grateful for the many people and organizations that have touched her life. Expect another update on her progress in March!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Could You Die From A Cold Virus?

I was troubled by an article that I read in the Washington Post today. Apparently a common cold virus (adenovirus) has mutated unexpectedly into a killer strain (with a death rate as high as 23% for those infected in Oregon). The CDC has been carefully tracking this virus over the past year, and has noted outbreaks in Oregon, Washington State, Texas, and New York. Genetic studies of this virus suggest that it is similar to adenovirus 14, first described in Holland in 1955, but has very recently mutated into a more virulent form.

The interesting (and frightening) thing about this virus is that it’s so strong that it can kill young, otherwise healthy people, rather than the usual “at risk” populations of the very young and the very old. There’s no way to know if this virus will spark an epidemic, or whether it will die down and disappear for now.

Those who have had the virus, and lived to tell about it, say that it came on like a usual cold but then instead of getting better at the usual 4-7 day point, their symptoms got worse, and high fevers, cough, and difficulty breathing ensued. Some folks have even required mechanical ventilation in the ICU setting to help them breathe.

This virus reminds me that we are very vulnerable to unexpected attacks from infectious diseases. All the while we docs had our eyes on bird flu and SARS, this little cold virus mutated into a killer. If you have a high fever with difficulty breathing, please see your doctor right away. Let’s hope this epidemic threat dissipates before it can gain a real foothold.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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