Sunday, September 27, 2009


Basically taking pictures of the brain. You can't see AD on a regular x-ray. You can see the bones of the skull pretty well, but AD does not affect bones.
Then we have CT Scans Computed Tomography hence CT. or CAT scan. A state of the art imaging technique since the late seventies. CT scanners are quite common now, but were rather a rarity on the late seventies. You can see the brain fairly well, and you can do these with or without contrast dye. These are quite good for diagnosing bleeding in the brain for example.
Then there is MRI, or magnetic resonance imaging. This became state of the art by the late 80's. You can see the brain really well with these.
You can take CT scans or MRI's just about anywhere in the body. MRI's are generally more expensive than a CT but you typically get a more detailed picture with an MRI over a CT. This of course depends on what you are trying to look at.
A CT or MRI does not diagnose AD however, you do see more atrophy or shrinkage of the actual brain as the disease progresses.
This shrinkage is not specific for Ad but it is very very consistent with AD. As the disease moves to advanced stages you see more and more atrophy.
The CT or MRI is one diagnostic tool to help aid in making the diagnosis of AD. But as noted in the previous blog, the diagnosis can never be 100% accurate at this point without looking at the brain tissue.
Other more sophisticated scans are the PET scan positron emission tomography and the SPECT scan, single photon emission tomography.
The PET and the SPECT are generally not mainstays, in the clinical world, as they are very expensive, however they are quite prevalent in the research world. These are the pretty scans that are in color. Unless you are affiliated with a big university or research center, you primary care or neurologist is probably not going to order one of these. These scans are actually better at not just looking at the structure of something like the brain but actually measuring what is happening, in different areas, for example which areas have more metabolism going on and activity, relative to other areas.

Friday, September 25, 2009


Dr. Alois Alzheimer (

As we continue to look for a cure for Alzheimer's Disease, an interesting point must not be overlooked. The way we definitively diagnose the disease has not changed in 100 years since Dr. Alzheimer discovered the disease under the microscope.
To arrive at the definitive diagnosis of AD, brain tissue must be examined at the microscopic level. This can be done with a brain biopsy, (taking a piece of brain tissue and examining it) which is obviously not done in a living human being. The brain can't handle a biopsy, unlike say the liver or skin, or secondly an autopsy when the person dies, in which the brain tissue can be examined microscopically.
Other than that, the diagnosis still remains one essentially of exclusion. That is: you rule out other causes of dementia.
So how is it diagnosed with 80-90% accuracy in a living human being? Lab tests, ruling out things like thyroid problems, vitamin B-12 deficiency, syphilis, etc. Then imaging, CT scan, MRI, to look for other structural changes, e.g. brain tumor, vascular or blood vessel disease, you can see small strokes, (infarcts) on imaging, where the blood circulation of the brain was compromised. Sometimes an EEG electroencephalogram is done, that is generally to look for seizure focus (that is the test where they hook up all the wires to the head, and monitor the brain waves)
The first and foremost thing is that a very, very careful and in depth history must be done, (before the tests). Information from the patient, family members must be gathered. The more information the better. There of course are many commonalities in the history and onset of AD.
After the history, a thorough exam is done, (or should be done) This includes a physical, (often at the level of primary care, to rule out other medical problems that may be compromising ones mental functioning, and a THOROUGH neurological exam, testing ones sensory and motor function and a THOROUGH mental status exam. Testing one's short, intermediate and long term memory, concentration, attention, orientation etc.
In addition a THOROUGH psychiatric history should be done. Depression for example can mimic certain findings in AD. Complicating the picture more is that depression can co-exist with AD, and can be a presenting sign. Sometimes the depression gets picked up but the dementia missed, and vice versa. Of course there is the usual stigma and bias in society towards mental health, so this part can often be overlooked till it is of severe proportions. (bias and preconception and skewed views about mental health even exist in the health care field outside of psychiatry)
Another problem we forget about a lot is that AD can (and often does) co-exist with other problems such as Vascular or multi-infarct dementia (blood vessel disease and problems with circulation to the brain)
Despite the findings and research into causes, genetics, environment, etc, and all the clinical expertise and AD specialty centers, in the end that is still how you definitively diagnose the disease, just like Dr. Alzheimer did 100 years ago.
As we continue to look for THE CAUSE, THE GENE, we must consider this fact: Like many other problems such as heart disease, there may be many contributing factors and not just ONE CAUSE or ONE illusive gene.

Thursday, September 24, 2009


With all the health care reform debate, has anyone in recent memory seen anywhere in the media, print radio TV etc, President Obama actually mention the words ALZHEIMER'S DISEASE? Has anyone heard in the popular media any senator or congressman actually mention the term ALZHEIMER'S DISEASE? Any sound bite? Any comment? Just one specific reference? I'm sure there is. I'm sure I just missed it. There must be some unprompted reference somewhere with all this health care debate on AD.
I generally watch the NBC news when I can. I know there was a blurb on World Alzheimer's Day. Mostly in terms of the cost. Dr. Nancy S. did mention Health Care Reform and that AD was the "budget-buster". Given the number of affected individuals it would seem like this is a relevant sub-text to the health care reform debate.

getting out of the ER

So I got wheeled to another room and waited for the on-call plastic surgeon to show up. He finally did. He advised that I had a tripod fracture of my orbit. Three broken bones around my eye. The fractures were not displaced so there was no surgery or plating to do to hold the bones together. I asked him if I would have chronic headaches the rest of my life. He said lets not worry about that right now. I figured over a period of time the bones would heal, but I knew things would never be the same and wanted to know what the long term affects would be.

He proceeded to stitch up my forehead above my eye. About6 or 7 stitches, then my eyelid, those stitches were not melt away and would have to be removed in a week, Then my upper lip on the inside. none of this was very pleasant, the needle for the lidociane hurt, I had about 15 mg of morphine in me. My wife watched him stitch me up but then got light-headed and the plastic surgeon told her to go lay down on another gurney in the room There was a bunch of people in the room coming and going. My step-daughter was there, a tech trying to clean my knee, my friend and his wife, finally he moved to my elbow. Putting several internal and external stitches in.

My nice nurse who had been with me the last couple hours said good-bye as it was change of shift. I hated to see her go, as she was very kind and empathic. Now it was just about done, everybody left and I waited for somebody to come and discharge me. It was now about two AM. It seemed to take forever. Everyone had left except my wife and stepdaughter.

Finally some gung-ho guy in scrubs came in and had a bunch of paperwork. I said, "who are you?" I had to ask twice. He was the new nurse. He asked if I knew about Lorabs. I said I was a physician. He Said do you know about lortabs. I told him again I was a physician, he said, "so do you know anything about lortabs". Obviously we were in a power struggle.

I treat thousands of patients a year, who struggle with the addiction and problems associated with opiate pain medications. I did know about the pain meds.

I was already pretty beat up and did not particularly like this person who was being a narcissistic jerk. Like so many people that work in health care, he had a chip in his shoulder towards physicians, from what I could tell. Having a broken face, I was a pretty easy target to beat up.

He had me sign a bunch of forms, I could not see or read, then I went to the bathroom. I was dizzy and everything hurt. The nurse then decided to tell me about his sister who was in an psych hospital. In typical narcissistic fashion,the message was his pain and victimization was worse than mine. I just wanted to be left alone and go home.

but I had to reflexively be nice and tell him how sorry I was about his sister. Then I thought what a jerk this nurse was again. Unfortunately being a human being myself, the jerks stick out over all the good people that helped me at the ER. Being a narcissistic jerk who must dominate other people to feel better about himself, this health care worker nurse will never get it. He was too busy being victimized. Remember some great victims work in health care.

I had to go to the pharmacy on the way home, I was freezing and shivering, from the shock and the morphine. In the old days, not so long ago, somebody would have been admitted to the hospital for a week for something like this. I knew I had terrible road burns on my knees and arm and face. I knew that I would have to constantly drink fluids, since normally someone would have IV's for days on something like this. I was nauseated.

I made appointments that next week to see an opthomologist an ENT doc and an orthopod. I started spiking fevers every night. Finally a couple days later my orthopod put me on a week of antibiotics. He x-rayed my elbow and my chest, since I also had bad rib pain. My vision was OK, but I failed the visual fields evoked response test, which checks your optic nerve. I have to go back in a couple weeks to re-check since my eye was almost swollen shut.

I had to cancel about sixty patients, the problem with private practice, besides not having a 401-K or health insurance that costs 1000 dollars a month, when you work on your own, if you go down, your patients depend solely on you. I actually had to see one patient a few days later. I went back to work nine days later this past Monday at full time. I had to wear shorts because of the knee burns.

Now Things are healing a bit. I can't eat solid food, I have no feeling in my upper teeth or half of my lip. Basically on this type of fracture a branch of the trigeminal or fifth cranial nerve gets traumatized. The ENT doc was very confident that over time the feeling would come back.

My knees are still open wounds as is my arm. I get the stitches out of my elbow tomorrow.

My wife is doing OK except for her finger. It hurts very much. Her burns have cleared up nicely on her face. It is her right index finger and she is right handed, so that leads to problems. She has amazing fortitude.

Monday, September 21, 2009

being a patient

Somewhere in there I realized I had a head injury with loss of consciousness. I told my friend I had a broken zygomatic arch. That is the bone under and along the side of your eye. It is sort of the bony part around your eye. My friend said I didn't and I said I did, so he bet me. The Er doc came in and I told him I needed a CT (cat scan) of the head. Mostly I was terrified that I had a fractured skull and a bleed in my head, called a subdural hematoma. The ER doc said he was already going to get one, he also said I would get one of my face and neck. I remember being cold and shivering a lot in the ER. I started to come to more as I got wheeled over to the CT scanner down the hall. I was worried about leaving my wife who was in the bay next to me, and I wanted her to come with me. She reassured me she was OK and in fact was also going to X-ray to get her finger x-rayed.
When I got over to CT I started to come to a little more. I think I had an IV in by then. The CT went really quick. I knew there was nothing wrong with my neck as I sure could feel everything below that and move everything. But they had stuck a cervical brace on me to protect me from moving my neck anyway.
When I got back the ER doc said I had a tripod fracture of my orbit, basically the bone above my eye, alongside my eye and under my eye were broken. I asked about the head, what about cranium fractures, what about a brain bleed. That is the stuff that kills people when it is missed. The ER doc said no things looked OK, but was waiting for the radiologist to give a report.
The radiologists are the docs that you never meet and you get huge bills that insurance companies reimburse at rates of 20-30 times of what I make in the same time spent. You never recognize their names when they appear on the bill. I should have been a radiologist.
The ER doc would not take off the cervical brace while waiting for the radiology report.
I think the nurse who was pretty nice, (apparently I kept apologizing to everyone, for being so stupid and I was ashamed for crashing a motor scooter), kept hitting me with morphine through my IV.
I remember her standing over me and talking with my friend and telling him she was pretty worried about the laceration on my forehead.
Finally the ER doc came back and said we could take of the neck collar. I said, I told you there was nothing wrong with my neck. He advised they were calling in the plastic surgeon.
I asked who it was and if he was going to show up.
I then tried to listen to what the ER doc was saying to my wife in the next bay. She had lost her finger nail and had a fracture on the tip of her finger. I asked the ER doc if there was anything else and if she was OK. I think he said that she was.

Sunday, September 20, 2009

back to being a patient

So I did not have to get CPR, I do not recall much, as my friend helped me up; apparently I was bleeding a lot. I did not even remember being on the scooter or exactly where I was. We went into the house, and apparently I had a towel and was sitting down, at any rate my friend ended up driving my wife and I to the ER. I remember bits and pieces of this, asking if my wife was all right. I remember being really worried about my 14 year old son. He was not even with us the entire evening, but for some reason I was worried he was somehow hurt in the accident. That was the worst uncertain anxiety I felt, I just could not cognitively get it into my head that my son was safe. It was not totally registering that I had a head injury; I was so in and out of alertness. I don't remember much about getting into the ER. Generally it is a horrible experience checking in for any medical care, I have always found it humiliating, impersonal and generally awful, as medical assistants snap at you, calling out your address etc. They have no clue as to how they affect the treatment and influence everything by those initial contacts.
It is something I am profoundly sensitive to, as that initial contact at the front desk check-in or phone call, determines a lot about how the patient will feel going in to see the doctor. Since I have a private practice, it is one of the very last few things I can as a physician have any control over. We have true accountability over how empathically those other health care workers at the check-in desk treat the patient.
So if you have employees of a larger corporation or public health care system or whatever, often there is little accountability for how snotty or nasty or impersonal they treat the patient.
The worst part is the patient will usually take that interaction into the doctor’s appointment. THERE IS STILL SOME MAGICAL BELIEF that all those other people who work in health care actually work for the doctor or are accountable to the doctor. IT just is NOT true.
In a few very rare instances, like my office, since it is a private practice, the staff is accountable directly to me. Regardless of how good or bad of a day they may be having, they don’t get to treat any patients in any impersonal or disrespectful way. The most interesting part is in a private practice, I am directly accountable to my patients; not to a bunch of physician-despising health care executives. Sadly the system is set up to drive any would-be private practitioner out of their practice and into a larger health care bureaucracy.
I will come back to this later. As it stands checking into the ER after the scooter accident, my mental status was clouded, I remember more when I was lying on a gurney, a few minutes later

Saturday, September 19, 2009


Don’t Forget World Alzheimer’s DayTM , Monday September 21st. This year’s theme is:
“Diagnosing Dementia seeing it sooner”
This a trademark of Alzheimer’s disease International which is a Non-profit registered in Illinois.
Friends of ADI is a UK registered charity.

It is the Federation of 71 Alzheimer’s Associations around the World.

ADI notes to have official relations with the World Health Organization.

They Have Four Full time staff.

There are about 52 countries registered for World ALZ DayTM according to the ADI website.
Activities Range from Alzheimer’s Walks, to Conferences and Information Sessions.

Nepal for example is noted to be having a Memory Walk and Talk show

Poland is having a Street Campaign, open doors, and a picnic.

Cuba is having a memory walk in many cities including Havana, national and local meetings.

Canada is listed as having a national media campaign issuing a call to action to federal parliamentarians, online survey, Coffee Break® fundraiser across the country.

We of course in the States and the UK are having our memory walks mostly occurring now in September and Early October, usually on a Saturday.

The Alzheimer’s Association lists 23,357 walk teams so far across the States with a Goal of 30,000 teams.

The Link for ADI is:
Of Course the Alzheimer’s Association link is

You can find a local walk in your general geographic vicinity.
Raise Awarenss. Raise some money for a rightous cause.
So Get out and Walk already for crying out loud!

Alzheimer's Bill politics

A brief interruption on the "being a patient" odyssey
I think I should throw in a little AD news, on what our politicians are doing to stamp out this disease:

A little update from

There is a Bill in the Senate - S.1492 sponsored by Barbara Mikulski-D from Maryland on July 22, 2009. (30 copsonsors) It was read twice and referred to the Committee on Health, Education, Labor and Pensions. On that same day 7/22/09.

Senator Mikulski is 73 years old, by the way.

There is a Similar Bill in the House- H.R. 3286 Sponsored by Ed Markey –D- from MASS. (39 cosponsors) This bill was referred to the House Committee on Energy and Commerce. This bill was brought forth and referred to the committee on the same day that the senate bill was introduced July 22, 2009.

Congressman Markey is 63 years old.

This is the 111th Congress for the Senate and House, The 108th, 109thth (going back to 2004) had similar bills in both chambers. All of them were marked Dead and never got past the committee.

being a patient

Maybe it was a rock, maybe I hit the front brake maybe trying to turn, I just don't know, it was over in a split second. We could not have been going more than 10 miles and hour, but with the forces of gravity and inertia, you don't want to stop something with your face. I don't remember the fall. apparently I was unconscious for about a minute. I have never been knocked unconscious before for this long. I never had a traumatic brain injury. I never had a conconussion like this. It was dark and we were halfway down the driveway in a wooded area. My wife does not remember the fall either or exactly what happened. She remembers something was terribly wrong when she felt her face scrapping the gravel. She called for me, but I did not answer. She crawled to me and I was lying face down. I didn't answer. She screamed for my friend who came running, probably taking twenty seconds to get to me. He did not know if I was breathing and although no one knew if my neck was injured he had to carrefully roll me over, to make sure I had an airway. Apparently he did, and somewhere at that point I came to and started to move around.

Friday, September 18, 2009

Surviving being a patient

I want to preface my accident with this. A couple weeks ago, I was with my son in Moab, we went canyoneering and repelling, mountain climbing, rafted and kayaked and swam the Colorado River, 3 hours of horseback at the bottom of monument valley, hiked Hovenweep, climbed in the Abajo mountains, explored ancient ruins, even pilgrimaged to Four Corners, all in a weeks time, I did not get hurt. Granted for a guy crowding fifty, I had my opportunities, my fourteen year old son did fine of course. Mountain biking on the red rock, slick rock I crashed into a pricker bush, on the edge of a canyon cliff, but other than embarrassment and a few scrapes-no big deal.

So I come home and a feel later, have a nice dinner with my wife at a friends house, and he shows me his toys in his garage. One of them was a motorized scooter. Now I have only driven motorcycles a couple times in my life in college, and I figured this thing is more like a bicycle. How hard can it be?

I went around his driveway, as he lives in the country, and still not knowing what I was doing, thought I had it sort of figured out, I came back and told my wife to hope on and we took off, and that's about all I remember.

We were in gravel and these things don't do so well on gravel. I don't know if I was trying to turn, or hit a rock, but somehow ended up landing on the left side of my face. No helmet-everything we teach our children not to do- it was only his driveway,

Scooter Accident-Accessing Health Care

It only takes about a millisecond for things to go wrong and have a bad accident, facing death or severe injury. We do live in the moment, we can not really control the future and the past has already happened. Despite all this "pseudo-intimacy" or the Internet, which is really immediacy and not intimacy, we are still human beings who feel pain and joy, and there is simply no way the immediacy of the Internet can ever replace the support, compassion and nurturance one human being provides to another. I think the connectedness and the decrease in the feeling of isolation the Internet gives us is phenomenal, I think when we expect something else out of it, that is when it leads to problems. It is hard for me still to grasp how the generation under age thirty approaches the Internet as such an intimate thing, with all the social networking and such. We don't have to shake hands anymore, or look someone in the eye, or be in the same space as someone, and yet kids under age thirty consider this social networking intimate. My wife and I are reading a book by the founder of google, it talks about this a lot, generally putting a positive spin on everything. The bottom line is the Internet is changing society probably for better and worse.
Through all the immediacy and attention and exposure and support people crave, we are more exposed than ever. Yet paradoxically we are more invisible than ever, since everyone will be on the Internet and networking eventually, who will notice?
I am reminded of all this, as I was recently lambasted by my niece for "using her" to forward my blog address to people on a an email forward she sent me with 30 people, whom I did not know, who were in her address book. I thought I would just publicize the blog if anyone was interested. I was not making money, hurting or exploiting anyone. But apparently this is an emotional and Internet attrocity . I never really knew. Of course I apologized to her, but for the life of me, I still don't understand the new age of all this. In doing this blog I am still learning.
What does all this have to do with a recent scooter accident?
Well last weekend, I got really hurt. I have had to access much health care over the last week, and it has not been pretty. It is extremely personal and intimate. I debated all week whether or not to blog about it. What would be the point? Interesting read? Catharsis? It is hard for me to do any major action without considering the utility and if it would help anyone else.
Well as I see it, AD is related to health care, health care is a hot immediate topic, I had a head injury, etc. Anyways I think I will talk about it. ...

Thursday, September 17, 2009

Blog Content

When you have a blog, it is basically an expression of free speech. A mind journal if you will, to share over the world wide web. The title of the blog, determines the content. The title would help people looking for Alzheimer's Caregiver Support, if they find the actual blog.
I have no daily AD journal to share with readers, many caregivers are struggling with the day to day existence, caring for a mother or father, or grandparent or spouse.
Many blogs are to help raise awareness and get the word out, to advertise an Alzheimer's walk. Some are more scientifically and research oriented. Some are written by people who are themselves diagnosed with and dealing with the disease in themselves.
My mother died from AD 22 years ago. Why write a blog now? What does Minnesota provider tax and lighthouses have to do with AD?
Is this therapeutic for me to write this blog 22 years after my mother's death? Is this blog spreading any valuable information about the disease?
Just about every aspect of my life has been shaped and affected by my mother. Her AD robbed her of herself and her personality. It was a part of my childhood and adolescent process and my experience with my mother.
I went from being a caregiver to her to becoming a doctor. That's how I got my start with empathy and comparison and perhaps most commonly overlooked: that sense of responsibility for others.
Any AD caregiver knows that 'you are it' , the buck stops with you, you are in charge and it is your responsibility. It is a lot of responsibility. There are sometimes feelings like:
"I should have done this," "I could have done this", "What if?" "I'm not trying hard enough." "Why is this so hard?" "I feel guilty". "I should try harder". "I hate how caring sucks the life out of me some days, but more or dad needs me....except the harder I try the worse the disease is getting. "
"I do or did everything I can, but it still is not enough."
Some caregivers will identify with these feelings, it is not unlike a lot of the feelings a physician deals with - completely taboo to talk about of course.

So just about anything I talk about on this blog is connected in some way to my mother and her AD. It affected my whole life forever, personally and professionally.

Tuesday, September 15, 2009

Provider Tax

Well, I don't want to complain about things too much, for the sake of not sounding too negative.

This tax is 2% tax, for me it is an income tax paid every quarter, just like my estimated state income tax of 7%. It is called the provider tax, because only medical providers pay it on revenue generated directly from treating patients. So if you are a Doctor and you work for yourself and all you do is take care of patients all day and that is your only source of income, it is another income tax. It does not exist in any other State. They tried it in a couple other States but it did not work out. It was repealed.

The revenue generated is supposed to go into the fund called the Health Care Access Fund. That fund is supposed to cover the uninsured. Some years that revenue from the Health Care access fund has gone into the General Fund, and been used to cover other debts at the state budget level.

It would not feel so bad paying the provider tax if everyone in Minnesota had health insurance. averaging 2005-07 stats from the Census Bureau, about 8.5% of people in MN do not have health coverage at all. Mass. and Hawaii cover more percentage wise-they do not have a provider tax.

Some legislators like to say with the access fund we do pretty good at covering our uninsured. 21 other States are within 4% points of MN according to the Census. They do not have a provider tax.

It has been challenged at the level of the Constitution- the Minnesota Constitution and been found perfectly legal. No one with any interest, time and money has ever had the fortitude to take it to the level of the United States Constitution.

I have been told in a public forum by one state legislator that, "Well its an unfair tax, but what else can we do?"

The set up is this= as physicians when someone says what else are we supposed to do, as physicians we want to help and fix things, so instead of saying "we are not lawmakers figure it out" we start trying to help the legislature solve their problems. Basically docs believe in social justice, in fairness. Most want to do the right thing. When you back is against the wall, and some legislator says don't you want to cover the uninsured, almost all doctors are going to care and say yes.

The issue is further divisive of the few physicians working in private clinics and practices and those many salaried by huge and smaller corporations be it for-profit, non-profit, foundation etc. You don't really see or feel the provider tax. The institution pays it.

We are short of primary care doctors in rural areas, all things considered if you were a young doctor and you wanted to start a rural private family practice on your own, all other things being equal, and you could go to MN or Iowa, or Missouri, or ND, and you could pay 2% more tax in Minnesota to cover the uninsured, yet lots of you patients would not have health insurance,- it is sort of a disincentive. It is not a way to attract primary cares.

It is analogous to teacher's paying a 2% tax on the income they derive on the teaching they do with each student. Then putting that money back into education, except some years doing whatever you want with that money to pay the state budget.

Protecting the Health Care Access Fund and not use it for other debts besides health care becomes the partisan issue every year within the state government. There are threats to raise it every year, and that 2% has fluctuated a bit over the years.

Yet even with this progressive tax, (its not like a penalty tax or anything) we still don't cover 45,000 or so people in the state, about 8.5 %.

Yet it has been around for some seventeen years.

As doctors we are NOT allowed to complain about it. It is just unacceptable and makes you a bad person and a bad doctor if you even bring it up. What is the first thing the public would say and think if physicians actually got the intitiative and faculty to bring this to societies awarness? I think we all know hwat the public would say and think if physicians complained,
The legislators know this and key on physicians weakness, which is actually self-punitiveness, that is why the tax goes on.

I wonder how people would feel in the United States if everyone's income tax went up 2% to cover the medically uninsured, yet we still didn't cover the uninsured.

It works really well in Minnesota, (or does it?) yet you don't here much about it nationally.

Thursday, September 10, 2009


This weekend I want to tell you about a special tax on physicians and dentists and other health care providers. We like to think in Minnesota that we are pretty progressive, we have a special tax to help cover the uninsured, to help make sure everybody in Minnesota has health insurance.- Lots of people in Minnesota do not have health insurance though. It is not new, it has been around for a really long time, since the early 1990's. Most people in Minnesota do not know it exists. Most people in the United States do not know it exists. Lawyers do not have to pay it. Plumbers do not have to pay it. Teachers do not have to pay it. If you are a physician, but don't take care of patients, you don't have to pay it. If you are a physician and you derive income from taking care of patients, you must pay it. If you are a physician and you are salaried by a larger institution, your institution typically picks it up.

It does not exist in other States in the Union....................

Sunday, September 6, 2009

PART 2 - the rest of the New York Times blog comment submission-Unpublished

"For any clinician, it is profoundly frustrating not to have more effective meds. Although, until there is essentially a cure for AD the debate of how effective a med truly is will probably wage on. Aricept has been available for almost fifteen years. Last I checked the Federal Employees at the FDA do actually consider study design when reviewing the data. Why would the government whom we trust to take an active role in fixing the broken health care delivery system approve a useless med, or a dangerous med?

The article pays little attention to the inequities of Medicare, in covering Aricept which seems counterintuitive since Medicare has been used as a model and a benchmark for government run health care, or at least much rhetoric has been paid to this in the last three months. The article does simply imply that we need to put our resources elsewhere instead of into cholinesterase inhibitors.

In 1979, my mother at age 62 was diagnosed with AD. My family began to fall down the “rabbit hole” (as the author refers to it) of AD. I was seventeen years old and the Alzheimer’s Association was not even incorporated yet. It was still three years before National Alzheimer’s Awareness week began. AD was not a household word. I do strongly believe that I would have wanted to take the chance even at 20% odds of using one of these medicines to slow the progression of AD. One month or one day or one hour for most families having a more lucid conversation and the sparkle of their loved one present is well worth it. That for some may be a bit too humane and not utilitarian enough.

As a physician I have seen these medications albeit temporarily, improve one’s cognition, not just in Mini Mental status points but by patient and family report. That is significant. Is there utility in this? Yes from a humane standpoint. I have treated many patients, where the side effects are problematic and the medicine is discontinued. Those are simple reasonable facts and follow any standard of care. Is it easy to find families whom are angry because the med did not work? Of course it is, given the nature of the disease and the limitations of current pharmacotherapy. Doctors and meds and by default the giant nefarious drug companies get blamed as much or more as the disease process. This seems to be human nature and roughly parallels the decline of the physician-patient relationship and the uptick of the “consumer-provider” relationship in health care.

These types of articles further detract from the ancient physician healer- patient alliance. They seem to create more apathy towards AD that is already present in many physicians in the medical community, given the ultimate futility in stopping the disease with current treatments.

There really are few clinical scenarios that do not warrant a trial of these medications. The main reason to withhold a trial of these meds is about cost. With that said, we should stop denying our priorities and simply start rationing care. After all AD is fatal anyway.

Does the pharmaceutical industry spend ungodly amounts on marketing and advertising? Absolutely. Perhaps we can simply eliminate this. Perhaps the revenue used in Research and development can be shifted over to the government. Perhaps the government should take over the pharmaceutical industry.

In regard to research, the article did not cover how much the drug industry does spend on R&D. Moreover it did not cover the relatively minimal spending on AD research at the federal level. For example, compare AD to HIV and AIDS related illness. AIDS takes the lives of about 14,000 people a year. AD kills about 72,000 people in the same time period. Federal Funding for Research according to the Kaiser Foundation in 2006 was about 2.6 billion dollars for HIV/AIDS for direct research. Spending on AD research at the level of the NIH is about 659 million. (One quarter of the research dollars while killing five times as many people)

Perhaps we need a more utilitarian approach to rationing care, except it seems like research has already taken that approach. Is it any wonder why we don’t have better meds for AD?

As far as direct to consumer advertising, it is a well known and researched fact that most doctors do not approve of this. The debate on DTC advertising is 50 years old and stems from 1962 and the Kefauver-Harris Amendment to the Federal Food, Drug and Cosmetic Act. The issues of false and misleading advertising and fair balance were addressed back then. In the early 80’s the FDA placed a moratorium on DTC later to be lifted in 1985, with slightly more rhetoric in the guidelines. Perhaps the only positive byproduct of DTC advertising is that it has helped increase awareness. Increased awareness at least generates these discussions. Compare AD to Lewy Body Dementia (about as common of a household word as AD was in 1980). There are not a lot of meds in the FDA pipeline developed to treat LewyBody at this time.

The only aspect of the article that is not as misleading as the TV commercials themselves is the fact that the author has never had a close family member affected by the “rabbit-hole” of Alzheimer’s disease.” From that standpoint the tenor of the article makes good sense. My hope is that some day no person or family shall have to suffer through the devastation, havoc and heartache of Alzheimer’s disease. Right now this article proves that in the collective unconscious of America our hearts are not in the right place in moving towards this ideal."

Joseph J. Sivak MD

Saturday, September 5, 2009

New York Times Blog comment submission-NOT published (part one)

Here it is, the comment the NYT health blog did not see fit to print. It is kind of lengthy and I am sure that may be one explanation as to why it was not fit to print. As one can see if you read the entire article and posts, my comment clearly takes on a slightly different opinion and perspective. Luckily, the blog comments before my comment are fair and balanced, and their is no hint of of any quashing of any implied views that might not be in keeping with the PHILOSOPHY of the health blog.


"The article does not really present data, but opinions. Unfortunately the one sided opinions are about as leading and one sided as the Aricept TV commercial. The commercial seems to create visceral reactions in some that may have more to do with ambivalence towards one’s own mother rather than the treatment of Alzheimer’s.

It is well established in the scientific community that Alzheimer’s was discovered 100 years ago, and it is a progressive neurodegenerative disease that destroys neurons in the CNS specifically at the level of the cerebral cortex. The disease process happens to target cholinergic neurons. Acetylcholine has many functions within the nervous system. Memory is one of the many important functions. This is basic physiology and should not be dismissed. What is not understood in the clinical and research world is how and why this happens. Since acetylcholine has various other functions, artificially providing an influence through medicine on this neurotransmitter, can cause positive effects as well as side effects. Just about every pharmacological agent used in allopathic medicine and for that matter naturopathic, has potential benefit and risks (side effects) there are not many physicians who are interested in hurting their patients or causing more suffering through side effects. That is a concept that is instilled in the 15 year indoctrination process of becoming a doctor. It starts well before medical school.

Aricept is one of four cholinesterase inhibitors available to treat AD, Three are commonly used and one is even available generically. They simply work by blocking the enzyme cholinesterase that naturally occurs and is used to breakdown acetylcholine in the normal physiological equilibrium process. AD is not a normal equilibrium so there is a net loss of acetylcholine producing neurons. Using these medications has a net effect of keeping more acetylcholine around for longer. Since it is used in memory it may help with cognitive decline as well as have other potential side effects at many levels outside of the brain. These are the limitations of most modern meds.

Namenda has a different mechanism of action working to regulate the neurotransmitter glutamate at the NDMA receptor, resulting in a slowing of cellular destruction, and hence some preservation of memory for a relatively and varying period of time.

The degenerative process of AD is highly variable from person to person, like many diseases. The medicines do not work for everyone, and it is dogma that they do not stop AD or reverse the progression. In many patients it may slow the dementia process to one degree or another. Patients and families devastated by this disease need and want hope. It is easy to develop false hope through these meds. I have had the discussion with many patients and families over the years presenting the realistic expectations to families and essentially bringing down those unrealistic expectations that families develop about the medicines. Any competent physician that treats AD has been involved in this dynamic of setting expectations realistically."

Friday, September 4, 2009


I posted a comment to a New York Times Blog a couple weeks back. The NYT's decided apparently it was not publishable. It's interesting because there is tremendous variation between blog sites, comments and what apparently gets published on the internet. There are certain guidelines, and obviously certain things can not get published. Posts containing profanity, pornography, etc, would be deleted on most blogs. That makes sense. That is intuitive. However past all that, there is the issue of content that may not agree with the agenda, of the blog or the publisher.
The internet has blown things wide open. It is now considered like the old Wild West. No real clear laws on content etc. Do anarchy and power and money prevail? How ironic in a most politically correct world.
Where do we get our news? TV, newspapers, opinion polls? What I am wondering is if there was ever a time, when a reader got an objective news opinion. Things are slanted to the political right or left, Fox News and CNN and MSNBC fight it out. There is lots of money and power on both sides.
Interestingly enough, since the internet is wide open and someone expresses an opinion that the blog host or publisher might not agree is in keeping with their views, is it ok, to block it, to censor it?
What is the purpose of censorship? -To shape the minds and hearts of the people? What is the purpose of that? To control people like puppets?
Such things as book burnings by the Nazi's rising up come to mind. The Bolshevik revolution in Russia a century ago comes to mind. I think this was censorship. I think this was trying to control people and shape their opinions. In 21st century America in the political battles between the right and left how do we get our news? What does the internet mean? Everybody gets to have an opinion now. It is as simple as point and click.
I visited Communist Russia in 1988, right at the crux of Glasnost and Perestroika, I can tell you that the average citizen in the Soviet Union was not doing well economically, they were pretty beaten down. This is from first hand accounts of talking with Average Citizens. In fact one of the people I met, showed us his apartment, took us to a restaurant. We talked for hours. Ironically this person had been a journalist and lost his job because he was writing unpopular opinions. He had to take a job as a barber, and had his salon at his house, a small 6' by 10' room concrete floor that looked like a cave at his apartment. It was pretty sad. I wonder if good journalists that hint at publishing something not in keeping with the political views of the establishment loose their jobs in America in the 21st century.
Another interesting example is that long before the internet, there was a publication called Mother Jones’s magazine. It was considered to be very left by most readers. From what I got out of it, back in the day the left was considered too be pretty close to pro-communist. Interestingly after the Tiananmen Square uprising in 1989, (remember the Chinese guy standing in front of the tank, blocking it and risking his life) The student uprising was considered to be pretty anti-communist. It seemed like the magazine was all over this in support of the students. Yet this was anti-communism. As a reader it confused me. All I could take from it, was that the politically correct view was to side with the opinion of the oppressed, the underdog, - that seemed ok to me.
How do we get objective news? How do people assert their opinions?
Arguably from an intellectual standpoint, it has always been "cool" to be on the side of the left. It gives the appearance of sophistication, being "well-read" and you look way cooler at cocktail parties. You are thinking out of the box, you are non-conformist; you have intellectually "arrived". Interestingly enough, being non-conformist is simply a way to attract attention to oneself, and after a point nothing more than pathological narcissism. Are intellectual minds shaped and overridden by this? How ironic?
Can we think for ourselves, or are we busy thinking we are standing up for the underdog, so we can hold court with our editors, our students, our colleagues at the cocktail party. Perhaps we are deluding ourselves. Perhaps censorship in America in the 21st century does not exist. Who actually decides the political views of a billion dollar industry or publication? Some rich guys with several big houses? How ironic. Not very politically correct.
In 1988 Soviet Union, still very communist, I found that the "party bosses” had an awful lot of privilege that the average citizen did not have. Ironically we complain about our capitalist society politicians having privilege that the little guy does not.
Right or left: Do money, power, greed and connectedness always prevail? Does pathological narcissism always override?
I will post a link to the blog from the NYT; it was about meds and treatment for Alzheimer's disease. It was to me, more opinionated than objective. It painted a certain picture. I believe my comment that was not published was not in keeping with the painted picture. I will publish that tomorrow. It is all simply opinions, and the New York Times is allowed to do what they want with their blog. Fair enough. It is just kind of sad, because arguably the NYT's is kind of powerful and I would have thought all opinions count. Mine was probably too long.
You can judge for yourself.
Remember it is a link address to a NYT's blog. God forbid: I would never cut and paste anything from their blog. We get into lawyer stuff then.
Tomorrow when I post my comment on this blog, (my comment the NYT's did not see fit to print) remember it is just my views, and at this point in America, I am still allowed to own my own views. Thank God the NYT's is a private sector in the United States in the 21st century and allowed to publish what they want.
Here is the web address from NYT blog -topic Alzheimer's
If you can't get in the post was from Aug 5, 2009. Author is Jane Gross, titled "The New Old Age Hope With a Deductible" (Under Health tab Go to blogs)

Talking about the book with the Lake Superior wind....... a calm day