Ruminations on our healthcare and our government

I think it's pretty obvious from the posts here that I love what I do. So when I have a chance one of my favorite things is to just talk with my patients. Lately, the most common comments I receive are about Obamacare and the childlike behavior of our government.

A very satisfied patient came in today. For years he was suffering from fatigue, eye itching, and generally just miserable. He had gone to doctors with no help. Once here I diagnosed allergies. But since he didn't have classic symptoms it took a while to convince him to do treatment. A year in to allergy shots and he's doing great.

Today was his annual visit. Just so happens he was one of the government furlough victims but fortunately he was called back to work after just one week. We were talking about the government and we both were shaking our heads. After all, we have to maintain a budget, please our customers and we are subject to feedback regarding our performance. We aren't able to just disagree and shut down businesses. We have to work!

Somehow, the folks in congress, who are elected to create and execute a budget, refuse to do the primary job they are required to perform. And this weak performance is rewarded with lifetime healthcare and a retirement program even if they only serve a single two year term. Even better, they get to gerrymander their districts so they can maximize their chance of reelection. On top of this, once they finish their service they oftentimes are hired by lobbying companies for huge salaries. Quite a deal for a group that doesn't even execute their job.

So, what does this have to do with healthcare? The second thing we talked about is whether the Affordable Care Act, aka Obamacare, is going to affect me. For a long time I told people I just didn't know the answer. But now I do have some answers, and they are a bit unsettling.

My office has provided good quality health insurance to the doctors and the employees for over 15 years. This year we received notification that in reward of this long history of dedication due to Obamacare our premiums would INCREASE 30%. The only silver lining is that they were allowing us to renew our plan from last year with pre Obamacare mandates if we signed up this week.

Now, here is the kicker, we just received notification that due to Obamacare if we were going to be on panels to treat these newly insured patients were are to take a 30% REDUCTION in payments. Hmmm! I may not have won a Nobel prize in mathematics but something here does not add up.

So, I am now wondering if the impact on my medical practice is an increase in my insurance premiums as well as a reduction in reimbursements how will this impact other physicians in the country? Now, I know that someone out in the ether is going to tell me I should thank the Republicans in Congress who are trying to shut down Obamacare.

I have a different perspective. If the Republicans in Congress recognized they can do a great deal of positive change by not shutting down Obamacare but demanding some corrections they could make this much better for all of us. I highly doubt the President and the Democrats are going to allow this program to be shuttered but I do believe they are starting to see the warts and might be willing to make some change.

Therefore, I ask all of you to ring the bell out there and encourage some reasonable civic minded discussion on how we can get our Government to do its job. In exchange, I promise to tell some new stories about my wonderful patients. And yes, despite all the insanity I still love what I do.

Noises In My Head

I was sitting in the doctors lounge the other day and I overheard two physicians talking about a patient. One doctor was telling the other how his patient had ringing in his ears. He said it was causing a lot of discomfort but he didn't see anything wrong on the exam. He went on to say that there wasn't anything we could do for it and so he told the patient to live with the problem.
So is that true, do you have to live with noise in your ears?
I would like to talk about about this disorder of hearing sound in the head and share my thoughts about what can and should be done. First of all, we need to be using the proper terminology. The sensation of a  sound in the head is called "Tinnitus". A diagnosis of tinnitus is just a medical way of acknowledging how to describe the problem.
There are many causes of tinnitus but most essentially relate to the same general problem. The inner ear communicates with the brain constantly by sending signals back and forth. When a problem occurs in that path such as when you have lost hearing the signal increases in intensity and frequency and you hear ringing. If hearing is restored or the path is repaired then hearing goes away.
We have all experienced this when we have been exposed to a loud noise and we have a sudden loss in hearing with the onset of ringing in our ears. A few of us may have experienced this at July 4th celebrations yesterday. Fortunately, healthy ears will often times recover over the next few hours.
We have a problem when the ringing never goes away. So, if someone develops ringing in the ears what should they do? First of all, don't panic. Second, be wary of what you read on the internet. Third, don't let your doctor dismiss your problem without an adequate evaluation. An adequate evaluation includes a complete look at the head and neck area.
I often times find the culprit of the ringing when I look in the ears. One very common cause is wax impacting the ear canal or touching the eardrum. Fortunately, this is easy to fix. I even had a patient this morning whose main cause of her tinnitus was wax. Another common cause is fluid trapped behind the eardrum from a recent upper respiratory infection. Once the fluid resolves most times so does the tinnitus.
Unfortunately, looking in the ears doesn't always identify the cause. Usually I will proceed with a detailed hearing test. Most patients who have tinnitus will have hearing loss and that hearing loss is usually in the frequencies that the sound is heard. If the hearing loss is due to injury to the eardrum, the middle ear or the tiny bones then surgery may be offered. More commonly the loss is to the sensory apparatus itself. This is called sensorineural hearing loss.
The next question I usually get asked is what can be done. This is where the frustration was expressed by that physician I was mentioning at the beginning of this article. Since we can't cure sensorineural hearing loss what is the benefit from going through this whole process? Most hearing loss can improve with hearing aids and up to 70% of people who use hearing aids who have tinnitus will have improvement in their tinnitus symptoms. There are even hearing aids that have the ability to place a sound in the ear that helps quiet the tinnitus.
Some of my patients don't have poor enough hearing to benefit from a hearing aid. I had a middle age woman present with that scenario today. We talked about the various ways to try to handle the tinnitus.
In addition there are several things that can exacerbate tinnitus or trigger it. Any medication that affects the nervous system can be trouble. Also aspirin in high doses and in some people even low doses. Stress, anxiety, tension and fatigue all will worsen symptoms. Jaw clenching and teeth grinding is another source of trigger.

Currently I recommend several things to try to help mitigate the symptoms:

1) Play masking sounds to quiet the tinnitus. This could be a water fountain or a music player. You can download masking sounds in the Apple and Google app stores.

2) Consider meditation and relaxation exercises when the tinnitus worsens.

3) Supplements known to improve symptoms include zinc 40-50mg/day, Gingko Biloba, and bioflavinoids often called "Tinnitus Relief Formula" in pharmacies. A well known version on the internet is Arche's Tinnitus Relief. With these supplements changes may not be felt for 30 to 60 days but if there is no relief by 90 days they probably aren't worth continuing. In addition, I have had some success having patients start melatonin about 1-2 hours before bedtime to help you fall asleep.

4) Tinnitus suppression-This is based upon the idea that if sound is presented in the ear at the frequency of tinnitus it can help with the feedback loop between the ear and the brain to calm the ear down. There are studies that show that if the sound is played up to 2 hours per day for several weeks, long lasting suppression can occur. I have recommended that patients try downloading an application from their smart phone. A number of these are free and are found by searching "Tone Generator". Once installed on your smartphone find the tone that matches the frequency of your tinnitus and play it at a low volume, just loud enough to be louder than your tinnitus. Start off at a few minutes per day and increase based upon your tolerance up to 2 hours per day. If you begin to observe the tinnitus improving then continue with the program as long as you wish. Most studies suggest 2 to 6 months of treatment.

5) Don't give up, new ideas are coming up every year and most people will have some spontaneous improvement in 3-6 months after symptoms start.

I strongly recommend my patients check out www.ATA.org The American Tinnitus Association puts out a quarterly journal that is understandable and relates the latest research and ideas for tinnitus management.

I hope those of you who have tinnitus or know someone who suffers will find some comfort in reading this article and you are welcome to print this and share it.

An Answer for Dizziness and Headaches

A few days ago a patient of mine came in and had no dizziness or headaches. What's special about this is that when I saw her about ten months ago for her first visit she described headaches occurring every day for at least five years and intermittent dizziness causing vertigo and nausea and increasing in frequency.

All of this had gotten much worse a couple of years ago after she had been treated for lymphoma with chemotherapy. Fortunately the cancer was cured but her symptoms were disabling. Examination revealed a pleasant articulate and engaging young woman. She had moderate swelling of the nasal tissues. More revealing was that during a balance test, "Romberg Test", wherein she stands heel to toe with her eyes closed she kept falling off balance. This test is very sensitive for an inner ear balance disorder.

Because of her dizziness I ordered a specialized balance test, videonystagmography or VNG, to evaluate inner ear balance and because of the migraines and nasal swelling I ordered an allergy test. Of note, I have learned over the past 15 years that patients with poorly controlled migraines often have at least a partial allergy trigger. I learned this a number of years ago when I was treating patients with  allergies who also had migraine headaches and when they would come in for a recheck they would have dramatic improvements in both symptoms.

For this patient her VNG revealed significant weakness in one of her ears. We did an MRI of her brain which was  normal and I began to suspect a disorder called Meniere's Disease. Meniere's is an autoimmune type disorder of the inner ear that causes intense dizziness with hearing loss ringing and ear pressure. What was also interesting is my patient had other autoimmune diseases she was being treated for at the same time. The standard treatment for Meniere's is dietary restriction of salt, alcohol and caffeine. Which ironically is also important for migraine headaches. Another thing I have learned over the years is that patients with Meniere's may also have an allergy trigger. So I encouraged my patient to complete the allergy testing.

The allergy testing was positive to nearly everything.  So she initiated sublingual immunotherapy, which involves placing allergy drops under the tongue every day, and allergy medications.I think it's important to remember that she was still having her headaches and dizziness when she returned after completing her allergy testing.  Normally I see patient's 3 months into therapy but she did not schedule her 3 month appointment.

Therefore, I was surprised to see her a couple of days ago.  I was curious about her progress and I was happy to hear her reply to my questions. She hasn't had a headache or dizziness for several months! With a smile she told me she was moving out of the area to attend college. She was concerned about stopping therapy, but one advantage of using sublingual immunotherapy is that we can mail her drops wherever she lives. There might be a few changes in her sensitivities in her new home, but overall I have had very good luck maintaining successful therapy in patients who have moved away and maintain the sublingual drops.

This patient really illustrates for me that experience can truly lead to significant improvements in patient care. For example, I have noticed the trend over the past 10 or 15 years that patient's who undergo immunotherapy can have dramatic improvements in headaches and dizziness symptoms.  But there are very few studies that are available to confirm this.  And in a small practice such as mine developing a double blind placebo controlled study is nearly impossible.  Therefore much of my treatment is based upon experience and would be considered anecdotal.  Perhaps one-day I can look through my old charts and present some analysis that would be publishable. Until that day I will continue do my best to find creative answers to difficult problems.

Danger in the Medicine Cabinet

One never knows the dangers that lurk in the medicine cabinet...

One month ago I was referred a patient who had dizziness symptoms. He initially was having spinning symptoms and he also had significant allergies with nasal congestion. he was taking Benadryl and a nasal steroid spray. His primary care doctor suspected benign paroxysmal positional vertigo, correctly, and treated him with the Epley maneuver (described in a previous post). Now he was complaining of lightheadedness. I suspected the Benadryl. Benadryl may seem innocuous since it is an over-the-counter medication that has been around for decades but a single dose has the equivalent mental impairment of two alcoholic drinks and it is the chief ingredient in most OTC sleep medications. This patient was taking it four times daily.  I told him to stop it and to try Allegra for his allergies since it didn't have these side effects.

He came in to see me a couple of days ago completely cleared of his symptoms of dizziness and very satisfied. When he and I were talking he reminded me of a very interesting patient I treated a few months ago.

An elderly gentleman in his mid eighties was referred for imbalance. I introduced myself and was confronted by an ancient looking man who was in a wheelchair and fairly confused. His examination didn't identify any focal abnormalities in the ear, nose or throat. He did have a tremulous voice and hand tremors. I suspected a neurolgical source of his imbalance as well as age related causes.  In my experience no one is really happy treating these patients and they tend to get bounced from doctor to doctor. This patient had already seen the neurologist who hadn't been able to contribute much.
I tried to do a balance test in the office with him but he couldn't even stand up. I ordered a special balance study we do in the office called VideoNystagmography (VNG). In this test we look at eye motion tracking lights in the dark, and we place the patient in various positions seeing if it stimulates dizziness, and finally we place first warm and then cold water in the ears which will stimulate some vertigo which we can measure and compare to see if the ear is having a normal reaction.

In our pre-testing instructions patients are advised to stop medications that my impact balance. A review of this gentleman's medication list was daunting and he was on several medications that could affect the testing. Sometimes when the patients are advised to stop these meds for 48 hours we have poor compliance because they don't like the side effects of being off medication. I had a concern that would be the case in this situation. Either way we scheduled him for the test.

A few days later I heard my audiologist shout down the hallway, "Dan come here and take a look!"
What I saw was hard to believe. This patient who looked days from death just a few days earlier was smiling, bright eyed and walking into the exam for his testing. Needless to say his test was nearly normal and the only treatment he needed was to be taken off the meds that were messing both his mind and his balance.

I saw him again a few weeks later in follow up and asked him how he was doing. He told me he was great and that he had thrown our every medication in his medicine cabinet except for the ones he absolutely needed for maintaining his health. Ironically, many of the meds that had caused him his troubles had been progressively added because he kept on having various side effects from each of them. The problem started with the first anti-anxiety medication but from there he kept getting medications added on one after another until all the side effects resulted in a person who had lost balance, self confidence, and independence.

The Hippocratic Oath says "Do no harm" and in trying to follow that I rarely give patients over the age of 75 medications that impact wakefulness, mood, or balance. Unfortunately, the pharmaceutical industry doesn't agree with me and markets very aggressively to patients now. I suggest that we be wary of over prescribing and we should all make sure we don't pressure our providers into giving us or our loved ones medications that aren't truly necessary.

A Story For My Mother

Oftentimes my interactions with my patients can be funny and sweet. I would like to share one of these with you. A few months ago a woman came in to see me for hearing loss. She was about 60 years old and during the exam I noticed that she had a pinched appearance to her nose on her left side. She related to me that she had a rhinoplasty (nose job) forty years ago and ever since she had trouble breathing. Over the years she had talked to doctors but was told there was nothing that could be done.

In my experience this is not an unheard of problem. A surgeon that is trying to make a dramatic change in the appearance of someone's nose will resect a good deal of cartilage. Sometimes this results in the nose losing its structural support. Essentially the nose collapses just like a building would if you weakened the supporting beams. Correcting this can be tricky. One has to open the nasal skeleton and place cartilage support in the areas of weakness. The surgery doesn't always work and I believe that is why this was never offered.

We discussed the procedure in detail and we scheduled a surgery date. In the operating room I could see that there were very specific areas that had weakened and I harvested cartilage from a hidden incision behind the ear. This was then trimmed and placed in key areas around the sites of collapse. She was sent home with a plastic implant in her nasal cavity for support for one week.

At the one week recheck I removed the plastic in her nostril and it looked like the nose had healed correctly with good support. She took in a deep breath gave me a big smile and said "You're a Genius!" I laughed and said she better wait a little bit longer before being convinced of our success. I told her I wouldn't brag to my mother about her until I was sure she had at least one month of healing. This is because scarring can contract and shift the cartilage implants out of position.

One month went by and she came in for her recheck. I opened the door and with a big smile she said, "Ok, now you can tell your mother you're a genius!" Well, I don't think I'm a genius but I am glad that I could help this patient. And Mom, if you're reading this, I hope you get a smile from this story.

Let's trade, I fix your dizziness and you'll teach me...

We all know that it's called the "practice of medicine" and everyone has heard that a doctor is always learning. In fact, I bet that you have heard at least once in your life that your doctor learned from you. Usually we think of this in a different way, for example, a unique disease teaches us, or maybe a patient responds in a special way to a treatment and we learn and log that experience in our memories. But, today I have a very different story to tell.

First, I want to tell you how I helped my patient. A gentleman in his sixties presented with a month of significant dizziness. He would have severe rotational vertigo when rolling over in bed lasting several seconds and leaving him with a feeling of imbalance. He could pinpoint the exact time andplace when his symptoms developed and ever since he had been uncomfortable and actually fearful of motion.

On physical exam he was completely normal except for one abnormality. When I did a Dix-Hallpike maneuver he became rapidly vertiginous on his right side. The Dix-Hallpike maneuver is done by rotating someones face to either their left or right side while sitting up and rapidly laying them down flat. When one experiences intense vertigo that starts after a brief delay and lasts for about twenty seconds they are diagnosed with a disorder called benign paroxysmal positional vertigo, or BPPV.

BPPV occurs when very tiny crystals in the inner ear in the balance portion fall off and become lodged in one of the three semicircular canals. Those semicircular canals are oriented in the X, Y, and Z axis. When crystals become lodged in there when ever you move your head the crystals slide around and cause vertigo. The disorder is very common yet very strange. Whenever I show a patient a diagram of the inner ear and explain how this occurs everyone is amazed how the problem occurs.

Before 30 years ago people suffered until the brain learned to ignore the problem. They would be given exercises to practise. If they didn't improve surgery would be done to plug or destroy the balance portion of the ear to stop the problem. But then a ENT doctor in Washington ,Dr. John Epley, was doing doing surgery on someone with the problem and he could see the little crystals floating around in the semicircular canal. He took a model of the inner ear and figured out that if you placed someone in just the right position and rotated them 360 degrees you might be able to cure the problem.

His idea was slow to catch on because everyone thought it was kind of hokey. I attended one of his lectures and I was impressed by the idea. I was in residency then and my professors thought the idea was silly and wouldn't let me try it. But when I was in practice a few years later I did the maneuver on a nurse who had been dizzy for over a year and cured her.

So, with this gentleman I identified the likely offending ear and took him through my modification of the "Epley maneuver". As I was taking him through it I discussed with the patient that he might be skeptical but that I had a 90% chance of helping him. He promised me that the next time I saw him he would teach me something as well.

Two weeks later, a few days ago, he showed up and said his dizziness was cured. He hadn't had a problem again since he saw me that day. So now he was ready to teach me his trick. When he was young he was frequently afflicted with hiccoughs. Nothing would help. One day he saw an elderly woman that he described as gypsy like. She put her finger on each side of his face just in front of his ears and held them there for a few moments. And, his hiccoughs were instantly cured. Amazed, he asked her exactly how to do this and she taught him. Ever since then he would cure people who were afflicted. He said it was a great barroom trick and earned him more than one free beer. He explained to me exactly how to do the trick.

Just my luck an opportunity presented itself a couple of days later. My three year old daughter Ellie, developed hiccoughs. I did the maneuver and Voila! She was immediately cured. Granted this was just one time and it may have been coincidence so time will tell if it really works. But, either way, this is a patient who really did teach me something new and unique.

Virestorm Chapter 8

Chapter 8

Ann Arbor

Alex awoke with a start. She could hear a knocking on her door. At first she was disoriented. She started to raise up and realized she was unable to. As the fog in her mind began to clear she could hear Stephanie in the background calling to her over the music playing. She reached up and remembered she was still in the tanning  booth. “Oh shit” she thought to herself, how long had she been there? She raised the clamshell top and pulled out the earbuds.

“Stephanie I’m fine, I fell asleep. Sorry”

“That’s ok Alex, it happens all the time.” Stephanie rolled her eyes and backed away from her door and returned to her desk.

Alex grabbed her watch. Uh oh, it was already nine o’clock. How could she have slept for an hour on that bed? She could feel the sticky sweat in the small of her back. She grabbed a towel, wiped the bed down and a with a fresh towel wiped her back arms and legs. She must look like a disaster. She pulled on her panties and bra and went over to the mirror. She brushed her hair, applied make up and then put the rest of her clothes on. Paula was going to kill her. If she decided to stand up and do her routine she would have been first up like all of the newbie first time performers. Alex headed out the door and into the main room. Stephanie looked up at her.

“Alex, you owe for an hour and you only paid for 30 minutes.”

Alex rolled her eyes, reached into her purse and pulled out the punch card. “Fine, just punch it I’ve gotta go!”

“Fine, not like it’s my fault you passed out in there you know. Maybe you should be getting your sleep at home.”

Alex was perturbed by this latest comment, partly because it was rude but partly because she really wasn’t sleeping well at night and Stephanie’s comment hit a chord. Alex headed down the narrow wooden staircase and bounded out onto South University Street. She speed walked down the side walk toward State Street. She passed the undergraduate library, better known as the “Ugly” from the old days before they replaced the 1950’s boring brick structure with the new modern glass and brick structure. She saw the undergraduates heading in and out with their back packs full starting their Spring term studies. She made it to Main Street and headed up the steps to the Union building.

The Union building is a red brick structure with peaking roofs and a traditional old school East Coast appearance. Built in the early 1900’s for men only the building is now used for all sorts of University student functions and is very popular for its lounge with frequent band performances and on nights like tonight amateur comedy hour.

Alex entered the heavy wooden doors and went up the hallway to the lounge. She could hear the tail end of laughter followed by applause. She headed through the crowd and could see a table just in front of the stage where Paula’s boyfriend Malcolm was sitting and next to him two empty chairs. She walked up and looked up at the stage. Paula was bowing to the audience and waved and said thank you. She caught Alex’s eye and raised her eyebrows quizically. Alex sat down next to Malcolm. He looked over at her. His ice blue eyes cut straight through her.

“I can’t believe you Alex, you’re her best friend and you missed her entire act.”

“I know Malcolm, look I feel like a total shit ok? I didn’t plan on missing her debut. Today was crazy, I raced over here and I know I blew it, but I didn’t mean to. I wanted to see her too you know.”

“Well, she did great, and you better make her feel like you were here even if you weren’t. She’s been behind you through all of your issues and you owe her more than this. Oh, here she is.” Paula ambled up, she was smiling although her lips were a little tight. When she leaned over to give Malcolm a kiss Alex could see that she was shaking.

“I hope I didn’t make a complete ass of myself.”

“No babe, you were great. We were all laughing. You totally had us. Great job. Didn’t you think she did great Alex?” He gave her a kick under the table.

“Oh yeah, great job. I missed some of it but you totally had everyone eating out of the palm of your hand.”

“Really?” Paula was starting to relax, her tremor in her voice began to settle down. “I wasn’t sure if the joke about Bush nuking the “liberal country of Hawaii” carried well. You know how everyone’s so sensitive.”

Alex didn’t know what to say but Malcolm stepped in and saved her, “You nailed it right on. Maybe the junior national guard didn’t quite get it but everyone else was totally with you. You did great. Do you want to stick around for the other acts or go out for a beer?”

“I could really use something a bit stronger. Let’s head to the Full Moon and get some chili fries and drinks. I’m starving, I never ate, I was way too anxious.” She reached over and gave Alex a hug. “I’m so glad you caught part of the act. I was so pissed I thought you missed the whole thing but you must have been out of my sight. Those bright lights distort, like, everything. Come on guys, let’s get out of here.”

They headed out of the club and turned onto State Street and again on South University.  Students were heading out of their dormitories, apartments and houses and heading in loosely amalgamated groups toward the various bars in town. A few were heading out with stuffed backpacks to pull all night study sessions at one of the several libraries but since the term had just started most students remained in party mode. As they navigated the streets Alex struggled to keep up with Paula and Malcolm. She could over hear the two of them dissecting the monologue to refine and improve it. Even though Alex could practically recite the routine herself she didn’t feel she was invited to contribute.

Eventually the streets became quieter and they reached Main Street. This area was more of a graduate level group of students who tended to be more serious. Evening festivities tended to be less noisy and more intellectual. Branching off Main Street were a number of establishments catering to this crowd for several decades. Most of the bars and restaurants maintained their early twentieth century architectural style with tin ceiling tiles, old wooden floors, and brass railings.

They turned into the Full Moon restaurant. At the entrance outside was an iron gate enclosure and behind it were several tables. Sitting at one of the tables was a thin guy with thin light blonde hair. He was surrounded by a couple of other guys and girls who looked to be graduate students and at least ten years younger. They were watching the thin blonde guy closely and he was gesturing with his left hand which was holding a partially burned cigarette, the right was holding a pint of a dark beer. He looked over to Alex, Paula and Malcolm as they entered.

“Hi Alex, how are ya doing tonight?” He opened his arms and Alex leaned in to give him a kiss on the cheek. One of the woman who was sitting across the table looked Alex up and down and not with a look of approval.

“I’m doing pretty good Vince. They totally bombed me in the lab today. Nine specimens to process from Pakistan, well really only eight arrived. Tomorrow will be marathon part two so I hope you don’t have too many plans for tomorrow.”

“No problem, we’ve been light lately. Hey, you want me to get you a beer?” Now the girl sitting with Vince was really glaring.

“No, it’s okay, I’m going to help Paula and Malcolm celebrate her debut at the Union, but I’ll catch you up tomorrow.” She headed in after Malcolm and Paula who had already navigated past the narrow bar area to an available table. As they walked through more than one of the men at the bar turned to look at Alex. Her near hip length blonde hair was always a potent visual stimulus and was a source of both good and bad fortune depending upon your perspective. Paula caught several of the visual shakedowns in mid view and projected one of her “concerned friend” looks to Alex who was happily sashaying in the midst of the attention.

“Oh, don’t worry, I haven’t anytime for games tonight. With the work load I have tomorrow I only have just enough time for a basket of chili cheese fries and a beer. I still don’t get why you guys just blow past Vince every time we see him.”

Paula rolled her large brown eyes to the ceiling, shrugged, and shook her head a little. She probably understood Alex’s need for masculine attention better than Alex did and she wasn’t convinced that Vince was a “good friend” like Alex was always saying. Paula didn’t really think it took a Ph.D. in psychology to recognize that Alex was eventually going to have to discover a better method of dealing with her father’s absence in her life. Because of this she gave Alex a lot of free space and support. She knew deep down Alex would eventually confront these demons, a few weeks ago after a night of copious alcohol consumption Alex began to discuss her dad. But, the discussion was just the tip of a very deep iceberg.

“Look Alex, he plays this Mayor thing every night. He closes the place down, surrounded by his disciples and the rest of his “city council”. You’d think he’d grow up by now. These girls he dates are like at least fifteen years younger than him. Anyway, I’m not so sure his intentions are true with you.”

“Oh Paula come on, we work together sometimes but besides that he’s totally harmless.  It’s not like I’m going to sleep with him or something.” Just as Alex said this Malcolm walked up.

“Hey ladies I got a pitcher of the draft  weissbeer.” After Malcolm poured three tall glasses he raised his to Paula, “To your triumph at the Union, may we all laugh until our buttons pop and our trousers rip,” with that they all crashed their glasses together in unison.

Moments later Malcolm and Paula were dream talking about her great future career of physician by day and comedienne by night. Alex’s mind slowly wandered to the day’s work and the inconsistencies in the lab specimens. Paula reached over and punched Alex in the shoulder busting her out of her thoughts.

“Oww, what was that for?”

“Well, for like ten minute Alex we’ve been asking you what’s going on in your head and you haven’t responded. Malcolm was ready to call the paramedics.”

“Ha ha. Today was just very strange. There was another flu outbreak, this time in Pakistan. Looks like nine people died but they only sent eight specimens. Anyways, tomorrow I have to process everything. Looks like the weekend might even be burned. We’ll just have to wait and see.”

“Bummer, I was hoping we could take a canoe out on the Huron River together. This will be one of my last weekends for a while since clinical rotations have us doing Saturday Grand Rounds and Sundays we have to work. Let me know if you end up getting any free time.”

Just then the food arrived. Alex hadn’t even thought about eating today, with the frantic work pace she just realized the last thing she ate was that cinnamon raisin French toast at breakfast. She voraciously dug into the fries and half of Paula’s blue cheese bacon burger.

“Wow Alex, I’m glad you didn’t mistake any of my digits for a fry or I would be ruling out surgery as a specialty. I think your enthusiasm for the meal scared away half the single guys at the bar who’ve been eyeing you all night. Of course the other half are wondering if you could do that to a burger, hmmm.”

Alex made a limp chuckle. Her eating habits were a common topic of humor to Paula and admittedly there had been some pretty funny times but she didn’t always like being the butt end of some of Paula’s humor. Anyways, right now it didn’t really matter, she was tired and she knew she better head home and catch up on her sleep, tomorrow was going to be a very long day. Alex broadened her lips into a smile leaned over and gave Paula a hug and a peck on the cheek for Malcolm.

“With that, I must go. Those of us who work for a living get few chances for rest. Ciao guys.” Alex quickly headed for the door, no sashay this time, only one brief eye contact with an attractive twenty-something long light haired guy in a tie-dyed shirt, and out into the Spring night.

Can a talk show change how I treat my patients?

Every day is an oportunity to learn something new and medicine is full of a
 tremendous amount of complexity where the information changes on what seems a daily if not hourly rate. I'm always trying to keep up with what's new and there are many sources of information. Of course there are journal articles, meeting updates, and even the newspaper can be a source of knowledge. The trick is to integrate that information in a way that has a meaningful impact on patient care.

One of my more surprising sources of information is from a colleague of mine, Dr. Dawn Motyka. Dawn has a radio call in show on public radio in my community. She starts off with information about journal articles or publications she thinks may be of interest and then she takes calls from patients. People call her about a wide variety of issues and interestingly some call from quite a distance. I recall one person calling from Florida. Dawn is a Family Practice physician so she often times introduces topics of interest that without her talk show I would be unlikely to have any exposure to.

One phenomenon that has been increasingly recognized in medicine is the increasing number of patiets diagnosed with elevated calcium levels associated with an elevation of a hormone called Parathyroid hormone. Parathyroid hormone is secreted by four small glands that surround the thyroid. When they sense a low calcium level they secrete parathyroid hormone which tells your bones to breakdown a little and secrete calcium into the blood stream.

Sometimes the system goes haywire and the hormone is secreted when it isn't supposed to be and one ends up with elevated levels of calcium in the blood stream with demineralized and weakened bones and elevated levels of the hormone. For an unknown reason we have been finding more patients with this condition in the past several years. This has been attributed to the fact that doctors are more frequently ordering routine blood panels that include calcium levels now than they did in the past and therefore have uncovered more people with the condition.

So, a couple of years ago I was referred a patient with this exact same issue. Since she had elevated calcium levels and had a high parathyroid hormone level the concern was that she needed surgery to remove the glands that were over secreting the hormone. When I see patients with these findings I think of three possible sources of the problem. First is that this is seen in people with renal failure, but that was not the case here. Second, is that there is a single gland that has developed into a benign tumor called an adenoma that is the source and the third possibility is that the glands have just become defective.

To further evaluate I did some imaging studies to see if one of the glands had a tumor but the result was negative. I was considering surgery for the patient but I was uncomfortable because her calcium level wasn't terrible elevated and she wasn't having problems such as evidence of bone loss or kidney stones from the high calcium level. The surgery involves removing three and a half of the glands, thereby leaving just enough tissue to kick the body into a normal level. But if one removes too much the opposite occurs and the patient is stuck with low calcium which can be even more dangerous. So just to be sure I repeated the blood testing for her third time and surprisingly, everything was normal. The situation was strange, I advised her to have monitoring and I placed the experience in my library of unsolved mysteries.

Now, back to the present. Last week I was listening to Dawn and she was discussing another problem we are well aware of in medicine which is that we are prescribing large quantities of very powerful antacids called proton pump inhibitors which are more familiar to most of us as Prilosec and Prevacid among others. In fact currently those two are available without a prescription. The usage of these medications has gone up probably in direct correlation with the increase in obesity in our population. Unfortunately, these medication are not used without risk. They have been shown to be asssociated with poor calcium and vitamin B12 absorption as well as increased levels of osteoporosis.

But, interestingly Dawn found an article with some new information. Apparently these medications are also associated with an elevation in the secretion of parathyroid hormone. This recently published study immediately caught my attention because it may explain why my patient had the combination of elevated calcium and parathyroid hormone and then spontaneously returned to normal. Of course, now that three years have gone by I have no recollection of the name of the patient so I can't review her records to see if she was on this medication at that time.

But, I wonder if this mini epidemic of patients being found with high calcium levels might be a result of these now very common medications. Ironically, a couple of days after Dawn's radio show I bumped into her and shared my thoughts with her. She certainly was intrigued and we both agreed it was something we were going to share with our colleagues and monitor for among our patients.

So, in answer to the title of today's blog. Yes, a talk show can change how I treat my patients and I view every source of information as valuable as long as it comes from a legitimate background.