It was a beautiful day in the western suburbs of Chicago. I got in early to rearrange the doctors office (the feng shui was messing my day up) and the trickle of patients came in gradual. I remember hearing a "stat " overhead page for the emergency response team to assemble ......then the operator said to go the the sidewalk outside the office. A little unusual, but I kept on working. Soon came accross a patient who was complaining of a multiple body part injuries. If there was any space on the sheet for chief complaint, she needed to add about another sheet for everything that hurt her. In the ER, it's common knowledge that if a patient comes in with multiple problems all at the same time, they may be looking for strong narcotics. Now here comes the mentality of todays doctor; in the office where we are supposed to heal the sick as our primary goal in life, it has turned into practicing speed medicine as the primary goal. To pay for the nurse, receptionist, carpeting and all those other fufu things in the office that attracts a good crowd, I am supposed to be efficient with time. It boils down to the insurance companies reimbursing as little as possible for them to be profitable. (Then me seeing and billing as much as possible to stay afloat.) And they take their que from the government who pays the least of all insurance companies to doctors and hospitals -and until recently didnt pay for medicine. (What an irony........we work hard to get to retire but when we get their our health fails from neglecting it for so many years and the insurance we need, pays for the basic minimum.) It wont pay for a dietician for high cholesterol but it pays for a bypass surgery. It wont pay for exercise and physical therapy for obesity but it pays for diabetic insulin pumps. So to make my office and all the bills generated from hiring people to call the insurance companies for approval or paying for the guy thats sole purpose is to copy charts that are submitted for audit by the insurance company, to make sure I make these payments I have to see so many people in a block of time. Forget 9-5.....forget lunch....forget weekends with the family....I must pack as many people into an hour of patient care that I can. To be efficient, other docs have come up with streamlining a treatment plan once the diagnosis is made. That way I am in and out of the room and if a common treatment plan is established, my nurse can go in and discharge the patient. There are some young guns male docs who claim they can see 40-60 patients in an 8 hour day. Just calculate it yourself, thats 5-7.5 people an hour. Thats 10 minutes a patient. I have to get a detailed history, examine, order labs tests and discuss treatment and follow up all in 10 minutes. Well those young guns are sooooo good if its a cold or cough and nothing else is going on but wait....what about the elevated blood pressure in the guy who had a cold. "Oh, its just white coat hypertension" so "watch it". We can wait till an organ shows damage and you get symptoms, then we'll take more time. Or perhaps you can take time off from work and come in 2-3 more times so we can take care of the other 2-3 more ailments. Or get a babysitter so we can get you in to show you on paper that all your tests are normal even if we could have called but malpractice says you have to be scheduled in the office so we can document you received results
Wait....I digress. This lady had the audacity to have more than one body part to complain about in one visit! You guessed it, she was the one who fell outside on the side walk and couldnt get up due to her bone on bone left knee and multiple disc diseased lumbar spine and the fact she is obese and suffering from "fibromyalgia". (...in this disease state every muscle is stiff and painful, she gets no sleep and probalby depressed). Well, she was on her way to an orthopedic doctors office since her primary care doc couldnt give her more than 3 months of narcotic medicine and recently cut her down to one month with less pills and no other substitute for complaints. She has public aid and they dont pay for a pain clinic visit. The old orthopedic surgeon wouldnt operate on the left knee until she lost weight but public aid wont pay for a dietician, and physical therapy is also hard to find to accept the card.
Of course after I evaluated her, no fractures to left shoulder, elbow or back. Immobilizer wouldnt fit her knee, she felt little better with sling to the shoulder and a shot of toradol (injectable antiinflammatory) in addition to two darvocets (narcotic analgesic). She was able to stand with crutches and as she attempted to get to the bathroom she held her balance well, (even without the help of her son who was sitting in a chair with a blanket over him....what happened to chivalry?) I am well experienced with sportsmedicine and have multiple patients with fibromyalgia so I started her on a cocktail of morning steroids, evening antidepressant and darvocet......yes I gave a refill on the same drug that her primary care doctor wanted to deny her......but......I also gave her a script for physical therapy specifically to design a core exercise program and work on her gait. Also told her of a local herb shop where she may consider starting valerian and st johns wort in addition to a multivitamin and turmeric. Also told her about how neurotransmitters in the brain get depleated after a few days of stress and then the brain senses everything as painful. Not sure if she can afford everything but at least I was able to give her some options instead of going straight for pain medicine. This is one of those times when a little explanation may help the patient understand her own disease process and help them seek out alternatives since current economic status will not be able to protect her from spiralling downward. Not the American Dream she was envisioning when she was growing up!
Turmeric- is known for its antiinflammatory properties...excellent and is thought to stimulate some of the same pathways as motrin and celebrex without the side effects
St Johns Wort- approved to be used in mild to moderate depression. Mechanism is thought to be settling to the depressed mind due to its serotonin increasing properties.
Valerian- considered a tonic herb. One that works to settle nerve ending, thought due to gaba receptor action like benzodiazepines.
Fish oil would also be great for her with recent studies showing usefulness in depression and heart disease and arthritis/inflammation.
Omega 3 would be choice but it would have to be a balanced fromula between omega 3 and 6.
St Johns Wort and Omega 3 have been the most studied herbal supplements and you will notice I said "thought to work" because FDA doesnt do multimillion dollar studies on "food supplements" (the category herbal medicine falls under). Ther are many good supplement companies out there with excellent results but for every one there are 3 that are not putting the ingredients in the bottle stamped on the label. Bad people will always try to make money to get to their American Dream also, even at the expense of the sick.
