Graham

Archive for the ‘Health’ Category

Observations on Health Care Reform

In Health on September 19, 2009 at 7:57 am

The proposed medical care reform program, for which the president is trying to find acceptance, seems to be the biggest fear most of us have, even more threatening than international terrorism. Yet getting access to the most skilled physicians of our time is more difficult, the more talented they are. In a managed care system, we at least have the potential for steering some of their time to those who need it, but otherwise would not get it. In a competitive system, such as our present model, we have the burden of being our own advocate with no guarantee that we will gain access to the experts we need.

The “better” doctors are difficult to enlist in our care because they spend a lot of time as inaccessible. These are the medical professionals who are pursuing fame and glory writing papers and presenting them at seminars, performing studies, performing consulting on the more interesting cases, i.e., those that provide the most interest in terms of career advancement (which is their right in the pursuit of happiness), and pushing many of their duties onto nurses and aids. This isn’t necessarily “bad” and may be what is necessary to encourage the pursuit of advances in medical treatments, but what it means for someone with a serious illness is that in a capitalistic society we compete for resources, whether or not we “manage” health care. The main question is, who will make the decision to allocate those resources?


Which brings me to one last observation before I get off my soapbox: free enterprise is not always in our best interest, just as selfish-self interest is not always our worst nightmare. To claim otherwise is naive. To write off the entire civil service, for example, because we are sure they will screw up the the health care system is ludicrous. From what I have seen over a 30+ year career in managing contracts with the government, the best results are obtained from fostering a “we’re in this together,” partnering atmosphere. If we sit back and expect failure, we will get failure. Better to deal with each individual case where we feel things could have gone better.

Let me summarize: A well-crafted health care program would not only make basic care available to those who can’t afford it, but also would make catastrophic care (i.e., the specialists) more accessible regardless of income. I suppose that’s too much to hope for, and the economics of such lofty goals would be potentially bankrupting, so the focus will remain on basic care issues—the lesser in importance of the two. But we have to start somewhere, and it’s difficult to argue against providing basic care to anyone who needs it.

Copyright © 2009 by Tad Laury Graham


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Musings on the Therapeutic Side of Golf for Movement Disorders

In Health on October 20, 2008 at 2:26 pm

Last year, or the year before, I played golf with a man I had never met who had Parkinson’s Disease. At first he was fearful of telling me why he could play some holes like a pro, and others like it was the first time. I guess he decided that I would understand, perhaps because I wasn’t critical, I wasn’t trying to teach him the game. The conversation that followed made me much more aware of the dimensions of this disease, and of the difficulties we all face, sooner or later, in trying to deal with our finiteness.

I told him I might someday immortalize him in a short story. He requested that I not identify him because he has enough problems without telling the world how “different” he has become. We agreed to use the fictitious name, Sam. I also included some observations (and attributed them to Sam, making him more like a composite) by two other Parkinson patients whom I have since met on a golf course. (Many physicians who specialize in movement disorders recommend golf as excellent physical and mental therapy.)

Sam was diagnosed 14 years prior to our conversation: he was 73 when I met him. The others (call them George-1 and George-2) were also male: George-1 was 62 and had few outward symptoms; George-2 wouldn’t reveal his age, but looked to be in his 80’s, and his symptoms were more pronounced. He only played 9 holes. Later I would understand how important those 9 holes were. They gave him something he could point to, even if only for a little while, and say, “It isn’t over, yet.”

Quotation marks in this blog only mean that I tried to use the words and phrases of the speaker, but some time has passed and I only have cursory notes (jotted down following each game). If I got it wrong, I apologize to Sam, George-1 and George-2, wherever you are, (and to the reader) for any misinformation in the article. However, I have a confidence level of 90-95% that it accurately reflects the intent of the participants, which was to talk about the things you won’t find in a book.

THE INTERVIEW

Sam: Parkinson is often referred to as the “nuisance disease,” as though it were only a matter of inconvenience. I can assure you it causes more than inconvenience in the average household. But because it has a very slow rate of progression, and even this is masked by some of the current drug treatments, it sneaks up on us slowly, allowing us to remain in denial for a very long time.

Graham: How long have you had the disease?

Sam: About 14 years. Yes, … I think that’s right. It sounds right.

Graham: You aren’t sure?

Sam: Sure I am sure, but I forget everything for a while, then it comes back.

Graham: You mean recall is slow?

Sam: Yes, that’s it. “Recall.”

Graham: You don’t appear to have dementia, but I notice you are slow to respond.

Sam: I do everything slower. I read slower, I talk slower, I dress and walk slower. Sometimes my legs freeze up and won’t move at all. Everything is affected … including thinking. Sometimes my brain locks up. I get it eventually, but people assume I’m retarded, so I don’t always try to join in.

Graham: Has there been a change in any of your mental abilities?

Sam: You mean, uummm … It’s coming, just a second.

Graham: For example, your “reasoning abilities.”

Sam: That’s it, “reasoning” … no, I can still reason, but I have lost memory skills. My IQ was tested a few months ago, and I haven’t lost much more than the average adult my age. I just process slower.

Graham: What was the actual diagnosis, and what are the symptoms the doctor used to determine the diagnosis?.

Sam: Idiopathic Parkinson’s Disease.

Graham: Idiopathic?

Sam: It’s the most common type. It means cause unknown.

Graham: They don’t know what caused it?

Sam: No. And that’s a problem.

Graham: Hold on a minute. I don’t understand. Isn’t Parkinson caused by pesticides getting into our drinking water?

Sam: Possibly, it certainly is one of the suspects, but the disease has proven to be more complex than originally thought.

Graham: How so?

Sam: We used to think the loss of dopamine producing cells was the cause. We now know that several genes, perhaps 6 to 8, and a few chemical messengers (including dopamine and norepinephrine) are involved. But we remain focused on dopamine because the dopamine system is involved in all of the major symptoms, and we have effective medicines for these symptoms. I take a lot of medicine.

Graham: What’s that about? I mean if you don’t know what causes the disease, why would you throw so much medicine at it?

Sam: Good question, but the answer is still symptoms. Parkinson symptoms can be very debilitating. There is no cure, and there is no medical procedure that can delay the progression. If we don’t know the cause, we can’t know the cure. But we do know the symptoms, and we can and have minimized them.

Graham: Can you tell me … ?

Sam: Wait. Let me finish. While there are no known medicines that can delay progression, coffee in moderation and even smoking cigarettes in moderation have been shown to slow progression. Nobody knows why, but for me it explains why I worked my way up to drinking 2 pots of coffee a day before my system couldn’t take it any more.

Graham: I guess you pick your poison with those choices.

Sam: Literally. And what makes it worse, dopamine, like all chemical messengers has more than one use. It not only affects fine motor movement, it also is used in the pleasure centers of the brain to reward behaviors. When we take our drugs, we can’t restrict delivery of dopamine to only the movement circuits, we also deliver a hit to the reward circuits. The result is, for some patients, the medication (especially the agonists) creates a stimulus for arousal, and sometimes inappropriate behavior. Only 5 or 10% act on these drives; more accurately, the reporting rate is under 10%.

Graham: Are we talking aphrodisiac?

Sam: Officially, no one in the business of medicating Parkinson patients would suggest what seems to be implied, and would be quick to point out that another behavior influenced by the drug is gambling, so maybe the issue is that the drug raises risk-taking thresh-holds.

Graham: I guess it depends on whether or not you can choose your poison.

Sam: All I know is that I have a much higher interest in sex than before I got the disease. You might think this is not much of a problem, but you would be wrong. My wife no longer trusts me because she knows its the drug, not me. She is angry at me a lot. This isn’t just a viagra-type drug, which works on the mechanics of sex. It’s a drug that turns up the libido, and simultaneously undermines the ability to perform.

Graham: They get you coming and going.

Sam: Double whammy. Particularly the agonists.

Graham: As interesting as this is, we still haven’t talked about the set of symptoms used to diagnose the disease.

Sam: I knew I was forgetting something, I’m sorry.

Graham: No problem.

Sam: There are over two dozen symptoms associated with Parkinson, but there are only three main symptoms: tremor, rigidity and bradykinesia. Parkinson tremor is most active at rest. If you have tremor in an arm that you are moving, chances are you have the yips, not Parkinson. Rigidity is stiffness in the muscles. They get harder and tighter, making it difficult to move about and maintain balance, causing postural instability. Bradykinesia is a slowing down of normal movement, and in advanced cases becomes akinesia or lack of movement.

Graham: So the main symptom is loss of motor movement?

Sam: You could say that, yes, but you can also have involuntary movements, or dyskinesias, which are caused by the drugs used to manage bradykinesia. For me, there are other problems that scare me more than losing the ability to move around. That’s the easy part. For a very long time, we can use walkers, motorized carts, or some other means to get around. It isn’t very pretty, but you can milk it for all its worth.

Graham: What would be worse to you?

Sam: The hard part is that Parkinson is a disease that takes away your ability to communicate. It affects speech, which gets softer and softer until you can’t be heard. It affects hand writing, which gets smaller and smaller until you can’t read it. It affects your eyes in a variety of ways, which makes it more and more difficult to read printed material. So while you are becoming more and more dependent on others to help you get around, you are becoming less and less able to communicate with them. You are alone, trapped in a body that is sentenced to watch its own death, unable to connect with either your world or the people in it. Ultimately, it destroys your personality, your relationships, and everything that you spent a life time building. To me, that is the closest approximation to living in Hell I can imagine.

Copyrighted © 2008 by Tad Laury Graham