MRIs as screening tools

I have really come to enjoy the world of blogs! I was doing a little catch-up reading today of several that I enjoy, and I found a disturbing bit of news on one of my favorites, http://thecountrydocreport.wordpress.com/2008/11/23/today-show-plugs-mri-screening-for-brain-tumors/. This show was aired on 11/17. I don't watch the Today Show, as I tend to get my news online and on NPR, and somehow I missed this story.

Briefly, it appears that there is a push to use MRIs as a screening tool for brain tumors. As the Country Doc points out in his excellent discussion, there are no data supporting this type of use of MRIs. I'm just appalled at the Today Show for airing such a piece! I realize that the mobile MRI traveling around NYC was only charging $169, but that is not a realistic price, just like no-money down house financing...

Our health care system is in shambles; we outspend every other country in the world, yet we have worse outcomes than most 1st-world nations. It seems that finally we may get universal health care, but if it is going to work, we need to make some difficult choices. Fortunately, we have established a few evidence-based guidelines we can use to help make decisions, but we need to use them. There are also studies from foreign countries we can use to help guide us. Please don't get me wrong, I am grateful to live in one of the most scientifically innovative and creative societies! And I do worry that if/when we cut health care spending, some of it will come out of research funding. However, we need to take responsibility and use our limited funds wisely. Perhaps if we place more emphasis on preventive care, we'll avoid some of the huge costs of preventable diseases. I know I'm not saying anything remotely new, but I feel strongly that our American mindset needs to change; in other words, we may not be able to save every life regardless of cost, we may not be able to give every single citizen access to the newest, most expensive, and not necessarily the best drugs! As a medical provider, I share in this responsibility, and it is a heavy burden. I went into the medical field because I like to fix things, make people better, but I too need to accept that there are limits.

The Desert

I grew up on the East Coast, and I always loved all the trees, all the green, the lush green lawns. I also remember driving from Flagstaff down to Tucson for the first time, thinking how brown and dreary the desert was. Shortly after arriving in Tucson, I visited the botanical gardens and started my education about the desert. Slowly, I began to learn the names of desert plants, such as creosote, mesquite, and ocotillo. The more I learned, the more variety I started to see in the landscape. Where I'm going with this is that I have come to love the desert and see more colors in it than in the green landscapes of the east.

Last year, on Christmas Eve, we camped out on the dunes of White Sands National Monument, under a full moon. We were the only ones camped in the park and were utterly alone in the vast expanse of the stunning gypsum sand dunes. The silence was deafening, the light was breathtaking, and the air was sharp. Although we were quite cold, it was one of the most incredible camping experiences I have ever had!

I decided to look up some poetry about the desert to share with my readers, hopefully conveying some of it's beauty and loneliness and power. Enjoy!

The desert has many teachings

In the desert,
Turn toward emptiness,
Fleeing the self.

Stand alone,
Ask no one's help,
And your being will be quiet,
Free from the bondage of things.

This is an excerpt from a poem is by Mechthild of Magdeburg, a German mystic from the 13th century. Although she did not live in a desert, and the desert in this poem is likely not a physical desert, I feel that these first two stanzas of this poem captures the spirit of being in a desert.

The following is a poem by Lord Byron which appealed to me as well!

Oh that the desert were my dwelling place,

With only one fair spirit for my minster.

That I might forget the human race,

And hating no one, love her only.

This next poem is by Bernard Howe, a poet who lives in Tucson, which is part of the Sonoran desert, quite different from the Chihuahuan desert where I live. It is lighthearted and quite descriptive of the terrain.

Way out west where the prickly pear grows,

lived an old man who only had 9 toes.

Seems a javelina wanted one for lunch,

when it got the chance it took it with a munch.

Life in the desert is different from the city,

for out in the sonoran no one gives you pity.

With the hot sun beating down upon your head

if you run out of water the next thing is your dead.

The snakes are hiding quietly amongst the desert rocks,

if your not to careful one may bite you through your socks.

And if that ain't enough there's scorpions that will sting,

then there's monsoon storms that always come in spring.

Yes that old sonoran desert that runs through the southwest,

is home for me old sam the old man thats possessed.

The desert cactus that flowers are pretty to your view,

but if you step on one, the thorn goes through your shoe.

It seems everything grows wild within this here desert,

along with the critters that make sure you stay alert.

But there is still beauty in all of this here land,

like the setting of the sun which is always grand.

Many colored wild flowers cover everything in spring,

the splendor of a sunset which makes your heart just sing.

Yes mother nature protects all that she has made,

and all that lives out here knows where to find the shade.

Yes the desert sage may dry up and become a tumbleweed,

and with a dust devil they can pick up lots of speed.

The road runner runs along like the quail with her young,

and our Native American brothers speak another tongue.

All these things live in harmony along with mother earth,

I hope nothing destroys this for it is beyond any worth.

God made this desert land with all its natural beauty

and we must protect its balance because it is our duty.

The final poem is one that I wrote. Now I put it at the end, with the hopes that my readers don't actually get to it...Poetry is not a strength of mine, and I've probably broken every rule/convention in writing it. It is about White Sands National Monument.

Vast and undulating
Glistening and rippled
Interrupted by lone yucca

The power is overwhelming
The silence roars

I am alone in the vastness
My footsteps are my only past
Adjacent dunes are my only future

Connections

I've been a bit slack with blogging through the holiday, enjoying a break from work, then coming back to a flood of phlegm!! You know how it is when you take off of work, you end up paying for it in spades.

I live in a fairly small town in a state that is not known for it's good schools. I myself was fortunate enough to grow up in areas with excellent public schools, and this was primarily due to my parents' choices of where to live; they sacrificed a lot for us to be able to go to good schools. I also enjoyed school and did pretty well.

Sadly, it seems that a lot of the high school teenagers here are not particularly ambitious and don't work very hard. For example, the first year we lived here, there was no valedictorian in the graduating class because no one had fulfilled the requirement of taking at least three honors classes in four years of school. This was stunning to hear. However, this week I had the pleasure of interacting with a junior who I could identify with a little better. She loves school, is taking the hardest classes she can possible take, and wants to go to college. She hates to miss school, and she feels stressed when she gets behind. It was just such a pleasure to chat with her about school and AP classes! When I saw her a couple of days ago, I felt like we really connected. Today, she came in to see me for some mental health issues, and she was really able to articulate her feelings, and so I felt like I could help her in a way that I can't the teens who simply grunt!

Seeing her reminded me that I do enjoy working with teenagers, I love the conversations, I like listening to their thought processes, I like hearing about their plans for the future. Sometimes I lose sight of this when I have less meaningful interactions, but I was pleasantly reminded today with my last patient of the day.

Paying for labs

Last month, we received news at my clinic from "the bosses" that we were to use only one particular lab company for all our labs except for a few types of private insurance. This news came as a surprise, and the medical providers had not been asked for any input on choosing the company. I was very disappointed, as the one that was chosen just happened to be one of the slowest in processing times. When I questioned the administration about the decision, I was told that they offered our organization the best prices for our uninsured patients. End of discussion. Since there was nothing I could do to change the decision, I tried to improve the speed of processing through our customer service representative. Needless to say, nothing has changed on that front either.

So, I went about my business, grateful each time when I had a patient who had the kind of insurance which allowed us to use a different company. But, then, last week, bammm!!! out of the blue, another dictum. This lab company who had contracted to take on the organization's uninsured patients decided that they were losing too much money on us; understandably, they cannot do thousands of labs for free. And our organization decided that we cannot keep losing money by writing off the bad debt. Keep in mind that we are a group of federally-funded community health centers (CHCs), so we provide healthcare for any and all, regardless of insurance status. The policy on labs now has changed, and our patients who don't have health insurance have to pay cash up front for labs. As a provider, I do have the ability to say that a particular lab must be done, regardless of the ability of the patient to pay. However, someone from my staff has to inform the family of the cost of the lab, ask if they can afford to pay, then let me know if they can or can't, and then I need to note in several different places whether the lab is critical or not. I already try not to do unneccesary labs on my patients since for most kids a blood draw is very frightening, so when I order a test, it is generally very important! I suppose I am disappointed because I chose to work for a CHC so that I could provide care to all. I already have to choose medications by whether they are covered or not by each particular Medicaid program, I often have to get prior authorizations for medications and radiologic procedures!

I am very bothered and saddened by this new policy. Many of the families in this community are already struggling to make ends meet. My worry is that they will stop coming in when word gets out about this policy. Fortunately, most of the children I see are covered by Medicaid, but there is a fairly large population of adults who can't afford health insurance. I also understand that our organization cannot continue to provide essentially free care indefinitely. The patients know that we do not send out bill collectors, and some of them have large unpaid bills. However, if they can come in for preventive healthcare, which sometimes includes labs like lipid panels, we end up saving money on them in the long term. I really don't know what the solution is, except that we need to address the healthcare crisis immediately.

Along those lines, I happened to come across the blog of the country doc, Dr. Cohen, discussing President-Elect Obama's choice of Tom Daschle for head of the Department of Health and Human Services, which seemed quite relevant to me, as I continue to struggle with this new policy. I admire Mr. Daschle, but like Dr. Cohen, I am concerned that he may not truly understand what is going on the ground level of healthcare. Both Mr. Daschle and his wife have ties to healthcare firms. Now, I know that healthcare firms are not inherently evil, but they are businesses which want to make money. I'm also not against making money, but I think that sacrifices will have to be made on everyone's part. I am simply hoping that Mr. Daschle will seek input from all participants in our broken healthcare system, including families, primary care physicians, specialists, pharmaceutical companies, and health insurance companies. We need a comprehensive team approach if reform is going to succeed. As a country, we have a lot on our plate right now, and I frankly don't envy Mr. Obama's position one tiny bit!

Brain Power

When I was eleven years old, one of my cousins had an aneurysm which left him a quadriplegic. He had been in medical school, was an avid mountain climber, and an outstanding violist. He had had some non-specific neck pain for a couple of days, and one night, it was bad enough that his mother took him to the hospital. The short story is that he went to the operating room with the hopes that the aneurysm could be repaired but woke up paralyzed, on a ventilator. This really impressed me, as he could speak, but he had to use a computer to write, using his tongue to move a cursor. Ever since then, I have been afraid of a similar thing happening to me, especially after learning about multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS) a few years later. Of course, when I was a first year medical student, I had every disease we learned about, including MS and ALS! Fortunately, I survived intact.

For those of you who may not know what ALS is, it is a rapidly progressive and always fatal disease which attacks the nerve cells that control voluntary motor function. Eventually, the upper motor neurons (those in the brain) and the lower motor neurons (those in the spinal cord) stop working, so messages do not get transmitted to muscles, and the muscles eventually shrink and waste away. Oddly enough, most patients retain control of bladder and bowel function, eye muscles, and the senses of smell, taste, hearing, and touch. Usually patients die within three to five years from the onset of the diagnosis, although approximately ten percent live for ten or more years. For more information, I found the website from the National Institute of Neurological Disorders and Stroke to be very informative.

These memories of worrying about various illnesses came back to me last week when I watched the CBS news show, Sixty Minutes. There was a segment called, "Behind the Scenes: Brain Power" (http://www.cbsnews.com/stories/2008/11/04/60minutes/main4570731.shtml) which just blew me away. It focused on a neuroscientist by the name of Scott Mackler from the University of Pennsylvania. He was diagnosed with ALS, and the disease has progressed to where he is ventilator-dependent and unable to speak. However, he is now able to communicate using Brain Computer Interface Technology, which basically allows a person's brain to be connected to a computer using EEG electrodes attached to a cap which is placed on his skull. So, in order to write a letter or to speak, Dr. Mackler looks at a computer screen with flashing letters, and the computer writes the letter that he is thinking of. Absolutely amazing!! The neuroscientist who was "locked in" by his disease now can write journal articles and goes to work in his lab where he conducts research. The story also talks about a woman, Cathy, who suffered a brain stem stroke which left her only able to move her eyes and with some facial expression. She volunteered to participate in a clinical trial where the Braingate system was implanted directly into the motor cortex of her brain. Cathy is able to move a cursor on a computer screen by thinking about how she would move her hand; she is able to turn off lights, for example, using this technology.

Advances in the science like this are always so exciting to me. Yes, I'm a nerd, I know. But the potential for this Braingate technology is limitless, and there are so many people who could benefit from this. Obviously, it would be even better if we could find the causes of neurodegenerative diseases so that we could prevent them, but even if we did, it could be used for stroke victims, accident victims, and many others. I am concerned that with our healthcare system in shambles, along with our economy, that funding for research will be cut, but I hope that our amazing, creative, dedicated science community can continue to thrive somehow.

I'm back! It's been a busy few weeks since I last wrote, between an onslaught of strep throat infections at work and the election, I'm utterly exhausted! Even though the election was decided fairly early on Tuesday evening, I was up too late because I was too stirred up to go to sleep. I was so excited but also apprehensive about our future as a country. Anyway, I'll stop talking about the election, since I have no new and/or amazing insight to add to all the discussion, except that I am very proud of the people of the United States.

On a completely different note, I had a patient this week that reminded me of Stuart from MadTV. For those of you who don't know what I'm talking about, here it is:

http://www.youtube.com/watch?v=U02xbYhhjxQ

My patient was a little younger, fortunately, and I was not thrown out of the window, only because we don't have windows in our exam rooms. But his mother just stood there and watched, then reinforced his behavior by comforting him. She then proceeded to threaten him with a shot if he wasn't good, asking me to back her up on that!! The boy had already dismantled the exam room and managed to pull down almost all the stickers off of our sticker boxes...all this within the first few minutes before I even walked in. The first thing he did, actually, when he arrived at my office, was set off the fire alarm in the patient bathroom. As soon as the alarm went off, I knew he had arrived - it's one of his favorite things to do!

This boy can be well-behaved, I've seen it. When he comes in with his grandmother, he's fine. We've come to an agreement with the physical exam: he holds the stethoscope for me on his chest, I hold it when I listen to his lungs; he holds the otoscope with my hand on his, same goes for the ophthalmoscope. So, needless to say, when I see how he behaves with his mother, it frustrates me. When I ask her about it, she explains to me that his feelings get hurt when she disciplines him, so she's given up. I offered her a session with our social worker to help her understand how she can be her son's friend but also his mother...she was interested, now we just have to see if she shows up; until then, I can only hope that he comes with his grandmother!

We all have our Stuarts, be they children or adults. Sometimes we can work with them, sometimes we can't. They can be difficult to examine, and I always worry about missing something, a murmur for example, when I have one of these wild screaming ones. But, when I'm ready to pull my hair out, I just think about Stuart, and I start to laugh, and think, in his voice, "I can do it...."

ADHD and Nature Walks

I was perusing the NY Times today when I came across an article on Tara Parker-Pope's blog on wellness about a small study conducted at the University of Illinois at Urbana-Champaign about nature walks for children with ADHD.

Here is a quote from her blog which can be found at http://tinyurl.com/5lqqhm

"A small study conducted at the University of Illinois at Urbana-Champaign
looked at how the environment influenced a child’s concentration skills. The
researchers evaluated 17 children with attention deficit hyperactivity disorder,
who all took part in three 20-minute walks in a park, a residential neighborhood
and a downtown area.

After each walk, the children were given a standard
test called Digit Span Backwards, in which a series of numbers are said aloud
and the child recites them backwards. The test is a useful measure of attention
and concentration because practice doesn’t improve the score. The order of the
walks varied for all the children, and the tester wasn’t aware of which walk the
child had just taken.

The study, published online in the August The
Journal of Attention Disorders, found that children were able to focus better
after the “green” walks compared to walks in other settings."

I did not find this discovery to be at all surprising. This was a suggestion given to me when I was diagnosed with ADHD, and it's one I always recommend to parents. Whether a child is on medication or not, I recommend twenty to thirty minutes of outside play immediately after school before homework. Unfortunately, not all parents seem to believe me that it works. I am happy to have a study, be it small, to quote, rather than only my own experience.

For myself, I have learned that I am able to focus much better when I get home when I have gone for a run, once I recover a little...To help motivate myself, I like to sign up for races, it gives me something to work towards; if I don't, then I can come up with one hundred excuses not to exercise on any given day! I cherish my runs outdoors, breathing in the fresh air, having quiet time without interruption, and working my muscles. I also get a mental boost from the sense of accomplishment.

On a different note, I worry about "kids these days," to sound like an old lady. Most of them have such busy schedules, going from school, to soccer, to music, home or out for dinner, then homework. Does anyone play kickball on the street anymore after school? Does this over-scheduling have something to do with the increase in the diagnosis of AHD? I also wonder what happens to some of these kids when they get to college, and suddenly they are in charge of their time after classes. Do they know how to allocate their time wisely? I don't know, but I'd love to hear from some readers!