Marcus Welby Is Dead: Now Who Is Your Advocate?

By Dr. Lowell Fisher

This book is about medicine then, now, and as it may become if the government takes over.

• Language: English
• Publisher: AuthorHouse
• Release date: Sep 15, 2011
• ISBN: 9781463468125

Dr. Lowell Fisher

Dr. Fisher is a board certified general surgeon with 40 plus years in rural medicine. He was trained in a time when the patient came first and the doctor advocated for his patient not the insurance company or the government.

Book preview

Contents

PREFACE

ABOUT THE AUTHORS

ABOUT THE TITLE

PART 1

CHAPTER 1

CHAPTER 2

CHAPTER 3

PART 2

CHAPTER 1

CHAPTER 3

REFERENCES

EPILOGUE

PART 1: How to survive modern medicine and

die trying.

PART 2: Never trust your health to anyone you would not trust your wealth.

PREFACE

Why would a practicing physician and a nurse write a book on how to survive modern medicine? Isn’t modern medicine the reason that life expectancy for women has exceeded 80 and narrowed the gap for longevity between men and women? Are not new technologies, new drugs, and new techniques responsible for increasing longevity? Are not specialists, subspecialists, and super subspecialists a major component in longer life? The answer for all three questions is yes, yes, and yes, or sometimes, maybe, and I hope so. How can you benefit from modern medicine and not become one of its unintended victims? This would not have occurred to me until suddenly my wife and I were converted from being healthcare providers to healthcare consumers. This occurred around 5 a.m. in late November, 2005. Since that time, a new question has occurred to us. How can the general public (nonmedical families) weave their way through our present system of modern medicine when we, with all our knowledge, experience, connections, and very good insurance, are hardly able to keep our head above water? Modern medicine seems to have established itself as big business based on science and technology. The medicine that we (my wife and I) grew up with was primarily an art and service profession that was steeped in the knowledge of science and technology, and your primary care physician acted as your advocate.

Late November in Michigan is usually a pleasant but chilly fall picture. The fall colors had started to find its’ way to the still green lawns. The early morning frost would disappear with the early rays of sunlight. Snow is not uncommon at that time of year in Michigan, but usually did not persist until after the usual Indian summer had passed. The 2005 Indian summer was in full bloom when the 5 a.m. alarm rudely awakened us. Bea rose to make coffee and I took our faithful Doberman, Samson, to the barnyard to let him run; and I fed, watered and passed out hay to the horses. I recall the pleasant and unseasonably warm weather. The horses were looking forward to a full day in the pastures. I recall wishing I could play golf, which would be unusual in late November in Michigan; however, I had surgery scheduled and truly anticipated the surgery as well. I’ve always told people that I never minded getting up early for three reasons, golf, fishing, and surgery. Bea also worked in surgery, but at another hospital. She worked three 12-hour shifts a week and liked the flexibility of her schedule. In 2005 we had been married some 35 years. We had no children, a dozen horses, and our devoted aging Doberman who ran the household. I was 62 years old and Bea was a few days short of her 60th birthday. We were both in excellent health with good genetics, and neither of us had any illness or took any medication. We were content, as only 35 years of a good marriage can facilitate. Life was good. As Samson and I came back into the house into the bedroom for our coffee (yes, the Doberman got his coffee too), I saw Bea sitting on the side of the bed with her hand to her throat. She was pale and anxious. I felt my stomach ascend into my chest. Something was wrong, and I knew it. She asked me to check her pulse, and it was bounding at 220 beats per minute, 3 times normal, but regular. Within a minute of carotid massage, her pulse dropped to 80 beats per minute. When I took her blood pressure, which was 240/140, twice normal, I felt the bile burn in my throat and chest. I was scared. Bea was scared. We knew our life had changed. I made an appointment immediately to see a cardiologist I knew. Early that morning, as we went to the car to keep that appointment, I felt a cold chill and noted a gray sky. The weather had not changed, we had. We did not know what lay ahead of us, but if we had, then, I think our emotions would have been best described as 2 parts fear, 1 part anger, and 1 part dismay.

ABOUT THE AUTHORS

Who are we, and why should anyone read this book? Beatrice Fisher, RN, born Beatrice Bellairs, on November 28, 1944, on a military base in Madison, Wisconsin (war baby and Army brat). Bea moved constantly around Wisconsin, Indiana, and Michigan because her father was an engineer and a troubleshooter for Western Electric. Bea always wanted to be a veterinarian, but mainly large animal (horses). She got no support in this endeavor and at that time vet schools discouraged women who wanted to practice large animal veterinary medicine. Bea’s first experience in people medicine was in co-op in high school. She worked as a desk clerk in a hospital in Pontiac, Michigan. Over the next few years, she worked in the lab, worked as an EKG technician (to this day, she reads EKGs much better than I). She enrolled in the surgical tech program at Henry Ford Hospital in Detroit and was working there during the riots in the late 1960s. Bea and I were married in December of 1969, during my first year of residency. During my residency, Bea went back to school and obtained her RN degree and returned to the OR, but also worked in the office over the years. Over the many years since, she has been primarily a scrub nurse and a surgical assistant in virtually all areas of surgery, vascular, open heart, plastic, neurosurgery, general surgery, urology, orthopedics, thoracic, and OB/GYN, transplant and harvesting. She has been an OR supervisor, has set up offices, including mine, and converted hospital ORs to computer use. She has been hired to troubleshoot both hospital ORs and private office practices that were dysfunctional. She is now working with me again as a private scrub and assistant. We have come full circle and are working together again.

Lowell Raymond Fisher, DO was born on April 1, 1942 (war baby and natural born fool), in Pittsburgh, Kansas. He was raised in Kansas City, Missouri, through grade school and high school. Grew up in the church. His father was a Baptist minister and believed sincerely in all that he preached. He went to the University of Nebraska in 1960 on a football scholarship and all the freshman football players were enrolled in a course in zoology. All of the football players passed this course, surprise, surprise! Although he didn’t like the course much, he loved the lab and animal dissection. At this point, he decided he wanted to be a surgeon and transferred to a small private and excellent college, William Jewell College, and declared as a chemistry major. Since he had had no previous chemistry in school, he figured that if he couldn’t hack chemistry, he wouldn’t get into medical school. Fortunately, he liked chemistry and survived. While most of his premed classmates went to med school at the University of Kansas or Missouri, he enrolled in the Kansas City School of Osteopathic Medicine and Surgery. His uncle was an osteopathic surgeon and his family had always been under the care of DO’s. After graduating from med school, he did a rotating internship, completed a general surgical residency, and then completed a general thoracic surgical fellowship. He practiced a few years just outside of Atlanta, Georgia (Stone Mountain), some 30+ years back in Michigan and the past few years back in his home in Missouri. His training and experience was varied and for most of his 40+ years in practice he has done about 40% general surgery, 30% gynecological surgery, and 30% thoracic surgery, mostly pulmonary. He is board certified in general surgery and continues in active practice at this time.

What is significant about this information? Neither Beatrice nor I were educated or trained at Harvard, Michigan, or Stanford, but at good small and accredited institutions. We have not served on any government committee or participated in any particular political party or endeavor. We are not published (not part of the publish or perish mentality). We have spent the last 40 years practicing medicine and surgery. We have been dealing directly with the healthcare of Americans in three different states. Between us, we have experience in patient care in the hospital, the office, and in the operating room. We have experience in the lab, radiology (x-ray) and cardiac monitoring. We have experience in the emergency room and in the intensive care unit. Between us, we have experience in practically every area of surgery; one of us has been in the OR for practically every type of surgery performed in this country. We have experience in primary care and specialty care. But, we are both essentially healthy and we have experience as patients in both surgery and medicine. So, why is this significant? In the real world, experience is everything.

SEEK WISDOM, NOT KNOWLEDGE. KNOWLEDGE IS OF THE PAST, WISDOM IS OF THE FUTURE. (That’s a Lumbee Indian proverb)

Experience tells us what happens and worked or didn’t work in the past. Wisdom allows us to anticipate what will work today and in the future. Original research is important in the practice of medicine. Original experience is essential in the practice of medicine. Experience is what we bring to the table. Experience does not require an Ivy League education; it requires the school of hard knocks. Daily living in the medical environment. We qualify.

ABOUT THE TITLE

For anyone younger than 45 years of age, Marcus Welby may not be a familiar name. When I was a kid, TV became a part of my life. I recall coming home from school and watching the test pattern until mid-afternoon TV came on the air. Howdy Doody and western movies were the staples. With progress, came more sophisticated programming. I remember three medical shows in those early years, Young Doctor Kildare, Ben Casey, and Marcus Welby, MD. Dr. Kildare was about a young doctor learning his trade. Ben Casey was a gruff angry neurosurgeon, sort of like Dr. House. His show ended when they ran out of neurosurgical diseases and they started to invent new diseases. The most influential was Marcus Welby, MD, a kind and concerned family practitioner who was involved in all aspects of his patient’s life and death. He had his office at home. Nowadays, family practice doctors rarely leave the office. They can’t afford the high cost of their overhead. Few have hospital privileges or even write orders on their patients. They no longer assist in surgery, and in many ways, they lack any first-hand knowledge of the practice skills of the specialist that they refer their patients to. They no longer deliver babies or even do minor surgery. I remember my friend, Bob Port, a dedicated family practitioner, riding in the ambulance to the hospital with is patients (Marcus Welby would have done that). Bob Port is retired and yes, Marcus Welby is dead, and not likely to reincarnate. Now, without any Marcus Welby to help, the public must survive modern medicine, and yes, die trying. Since we all die, the responsibility to look out for ourselves is life-long. No one that we can rely on is volunteering to help us. The admonition to never trust your health to anyone you would not trust with your wealth is worth strong consideration and makes common sense.

THE UNITED STATES WILL ALWAYS DO THE RIGHT THING WHEN ALL OTHER POSSIBILITIES HAVE BEEN EXHAUSTED. (Winston Churchill)

We will get it right, but the question is when, and at what cost. Since healthcare is a daily concern, we cannot wait until we get it right. If we trust our health and our wealth to the government, the lawyers, or clergymen, our employer, our family and/or friends, or even our doctors, while we sit back and watch, neither our health nor our wealth will survive until we no longer need them.

PART 1

How To Survive Modern Medicine

And Die Trying

I say and die trying because we all eventually die and we must try and work hard at taking care of our health

throughout our life.

CHAPTER 1

Survival Guide For The Patient

IT’S SUCH A COMFORT TO TAKE THE BUS AND LEAVE THE DRIVING TO US. (The quote is a Greyhound Bus advertising slogan.)

In the short time since I started in medicine, 1964, the general public has advocated more and more of all its decisions about their healthcare to their doctor, a hospital, the insurance company, their attorney, the government, and even their friends and family. The reasoning appears to be that science and technology have advanced so fast, they couldn’t possibly understand it all. The truth is that you don’t need to understand all of the advances of science and technology. All you need is a basic understanding of physiology and a little street sense to survive. If your doctor answers questions and you ask questions and insist on answers, you understand. In many and maybe most cases, the people making your decisions are either compromised or are less qualified to make those decisions than you are. If you want someone to drive your bus, you may not always end up where you want to go. In the 21st century mature adults must not only become involved, but must become committed to their own good health.

THE DIFFERENCE BETWEEN INVOLVEMENT AND COMMITMENT IS LIKE A HAM AND EGGS BREAKFAST; THE CHICKEN WAS INVOLVED, THE PIG WAS COMMITTED. (The quote is of unknown authorship).

If we now know that we must be involved, committed, and understand some basic physiology, what do I mean by street sense? Never trust your health to anyone you would not trust with your wealth. That should eliminate the government, the insurance company, the hospital, definitely your attorney, bring into question your friends, and even your family. This may also include your doctor and clergyman. Since you have to involve your doctor, find one you can trust and who answers your questions.

TRUST BUT VERIFY. (Ronald Reagan).

Don’t assume you’re entitled to good healthcare or because you are good everyone will treat you well.

EXPECTING THE WORLD TO TREAT YOU FAIRLY BECAUSE YOU ARE GOOD IS LIKE EXPECTING THE BULL NOT TO CHARGE SIMPLY BECAUSE YOU ARE A VEGETARIAN. (The author is Dennis Whaley)

Now that you know you are your own bus driver (patient advocate), let’s see how you can move through the system. First of all, let’s complete the story of how we stumbled on our journey through the system.

BEA’S STORY

I remember the incident in November 2005 pretty much the same as Lowell has stated. However, I had symptoms starting almost 2 months before, but they always had responded to carotid artery pressure. This time, the response was severely delayed. Approximately 3 months previous to this incident, I had a complete and extensive physical examination because the healthcare policy was being changed at the hospital where I was working. The exam was entirely normal except for a cardiac murmur that I have had since childhood. This was probably secondary to rheumatic fever as a child. I still remember the illness and the treatment; 2 large penicillin injections to my butt, both sides, every few hours. The diagnosis was never clear, but I recovered from the illness, but never recovered from the fear of the shots in my butt, or the cardiac murmur. Lowell and I both knew that our life had changed. A blood pressure of 240/140 does not just happen. There is always a cause. When the cardiologist told me I had essential hypertension because 95% of hypertension (elevated blood pressure) is essential. Essential hypertension means we don’t know or can’t determine the cause. I could not and would not accept this diagnosis, partly because a blood pressure is not normal in August and 240/140 in November, just because we can’t figure out what it is and there was no family history. The second reason is that the cardiologist did not look for a secondary cause of the hypertension. He just started to treat it. Lowell independently tried to pursue the secondary causes for hypertension. As we read, researched, and he ordered the tests. This is one of the advantages to being married to a doctor (unfortunately, there aren’t many). At the initial go-round, all the tests were normal. Most patients and with most doctors, this would be the end of the story. I was given a prescription for an antihypertensive medication and when that didn’t work, another was added, and another, and another, until I was on 5 different antihypertensive medications. I felt terrible, weak, nauseous, and except for some fluctuations, my elevated blood pressure was unchanged. When I complained, I was told I would get used to it (I wish I had a nickel for each time I heard this sentence over the next 5 years). A stress test was scheduled, and because my blood pressure was not well controlled, they decided to do a clinical stress test rather than exercise test. Lowell came with me to support and observe this exam. Lowell observed that with the chemical stress test my blood pressure dropped mildly, even with the elevated pulse rate that was expected. Though the stress test and the following perfusion tests were normal, the cardiologist recommended a cardiac catheterization (injection of dye into the coronary arteries). The cardiologist was just starting a stand-alone cardiac cath lab, hmmmm. We refused, politely. I fired my first cardiologist. I saw four; 2 thought a cardiac cath was a good idea, and 2 said there was no indication for a cardiac cath. I have never had a cardiac cath.

My next doctor was a kind family practitioner, honest, interested, and concerned. Since neither my husband nor I had any previous health problems, all doctors were new to us. We had been taking care of each other for the past 35+ years. Dr. Robinson agreed that there was a cause for the elevated blood pressure, but finding it was promising to be elusive. Lowell and I were both concerned about the possibility of a pheochromocytoma (an adrenal tumor of which caused elevated blood pressure spikes and has a malignant potential). Dr. Robinson referred me to my first endocrinologist who ran all the tests and ordered a CT scan. All the chemical tests were in normal range, but the CT scan showed a puffy adrenal gland. This was felt to be insignificant without any abnormal (catecholamines) chemical test. In the meantime, I felt terrible as I tried to take the medications previously prescribed and continued to be hypertensive. Both of my sisters and their husbands worked at the University of Michigan Medical Hospital and clinics. I saw my second endocrinologist at the University of Michigan and a special scan was ordered after an episode in the emergency room between two visits. The first visit with the endocrinologist was both uneventful and unproductive. A return visit was scheduled 3 months hence. When I woke up at 1 a.m. a few days later with severe headache and severely elevated blood pressure, my husband took me to the emergency room at the University of Michigan expecting the diagnosis to be pursued. He sat with me for 5 hours before being seen and a half hour later I felt my blood pressure drop to an acceptable reading. An hour later they gave me a dose of a medication I was already taking and sent us home. My husband was frustrated, dismayed and angry. My second appointment scheduled in 3 months got moved up to 1 week after I called my brother-in-law who worked in the endocrinology clinic. The scan got performed. They got excited, took a few more pictures, and never explained why. Two weeks later, we got a report of normal scan. In spite of our close connections to the University of Michigan through my sisters, I determined not to return to the University of Michigan. About a week later, a severe blood pressure spike sent me to Dr. Robinson and he admitted me to Foote Hospital as soon as possible. A drip was started and consultations were requested. A cardiologist changed Dr. Robinson’s orders and my heart rate zapped up to around 200 per minute. I was monitored and he was concerned if it was sinus (meaning normal heart pacer generated). I came down the hall with a strip that showed sinus rhythm and asked him to slow my heart. I fired my second cardiologist at this point. About an hour later, a second consultant entered my room and introduced himself as the candy man. He was a diabetic specialist and apparently was unaware that candy man was slang for drug dealer. When I showed him that my blood sugar was in the 80s and I had never had diabetes, he finally left. I immediately called Lowell and asked him to get me out of this hospital while I was still alive. My husband called my doctor and asked that I be discharged after starting me on a beta-blocker, the only category of antihypertensive medication I had not been given. Now I am on 6 medications. I got dressed and went home. Less than a month later, feeling worse than before, we discontinued the beta-blocker because we couldn’t get anyone else to do so, even though we sort of initiated it ourselves. Research showed us how to wean it off.

When I next saw Dr. Robinson, I was miserable and my blood pressure was unchanged. He arranged to send me to the Mayo Clinic. He was frustrated, I was frustrated, and my husband was frustrated. My Doberman was frustrated, and my horse, Fritz, was getting frustrated. Sometime during this frustrating time during our life, Lowell started this journal which has become this book.

When I arrived in Rochester, Minnesota, in the Mayo Clinic, my outlook improved. The organization and facility that is Mayo Clinic was and is impressive. I was called at home before I left Michigan and given instructions and all the appointments were scheduled, and in a day and a half I saw 9 doctors, had multiple lab tests and scans. I was assigned to the hypertensive department and once again, all the lab tests and studies were normal. Pheochromocytoma was suspected, but not proven; however, the serum aldosterone was in the normal range (high normal), but barely, and the renin was almost zero. Also, clean-cut CT scan showed the puffy adrenal on one side and a nodule (adenoma), small, on the opposite side. A suspected diagnosis of hyperaldosteronism was made and 400 mg of spironolactone was given to me. Within an hour I called back to the clinic. My blood pressure was around 75/40 and I almost collapsed. They got excited and wanted to admit me to the hospital, but within an hour or so I was able to walk and my blood pressure had climbed into a normal range for the first time in almost 2 years. Thus, Mayo Clinic made a diagnosis of hyperaldosteronism (elevated aldosterone) without a lab test showing elevated aldosterone (the balance between aldosterone and renin is the diagnostic criterion). Now, the question became, is the elevated aldosterone from one or both adrenals? If the one with the adenoma is the source (Conn syndrome), or are both secreting? A schedule to wean off the five antihypertensive medications was arranged and a dose of spironolactone was given me, and I was sent home to return in 6 months. Now the question changed. Which adrenal was secreting the elevated aldosterone? If they could determine which one, then surgical removal could conceivably cure the hypertension. If it is bilateral, then treatment would necessarily be medical (spironolactone). Although I had previously decided not to return to the University of Michigan, the procedure (bilateral adrenal vein analysis) was only performed at large hospitals, and thus I returned to the University of Michigan for this $14,000 procedure. Findings were apparently equivocal, however, less than one hour after leaving the University of Michigan I had one of my worst spikes and became nauseated and had severe headache. The test apparently was not performed completely correctly, because they did not discontinue certain antihypertensive medications that I was then taking. What does this mean? I’m not sure. How do you test for unilateral elevation of aldosterone when you have never actually had true elevation bilaterally or combined? I’m still not sure what this study proved. The spironolactone was slowly adjusted and the other medications were weaned off, and my blood pressure was controlled except for occasional spike (when I got upset or the temperature in the room became quite warm or anything that might stimulate the adrenals). For a period of time, I was on high doses of spironolactone, and unfortunately, no one warned me that hyperglycemia (elevated blood sugar) could be the result of the spironolactone treatment.

When a lab study showed elevated blood glucose, the diagnosis of type 2 diabetes was made. I told my husband, at that time, I would rather have leprosy than diabetes. After 2 or 3 years of trying to control my glucose, my opinion is unchanged. Maybe because leprosy is more biblical, but probably the fact that doctors seem to assume that poor control is the fault of the patient, while in my experience, diet is almost unrelated to my blood sugars.

When I returned to Mayo Clinic, the results from the adrenal vein sample were in my record with a note written by one of the doctors that said, What idiot did this test? I’m still not sure what the test told anyone. Since I had never previously taken any medications for any prolonged period of time prior to 2005, I was quickly learning that all medications have side effects, and I seemed to get all the more serious ones. I have since established a policy with my doctors. When they recommend any medication, I ask which medication they are going to discontinue. Imagine the unintended effects of multiple combinations of several different medications.

In May 2007 we moved to Rolla, Missouri, partly due to a bad economy in Michigan and a very poor medical environment in Michigan. We moved to Missouri where my husband’s family lived and he grew up. Rolla is a college town, University of Missouri Science and Technology, with a larger than expected regional hospital. Our intention was to practice there until we retired. Shortly after this move, Lowell and I started to work together again. I was his private scrub nurse as I had been some 30 years before. We were having fun again. Because we had left behind all the doctors I had seen in Michigan, an appointment was made with an endocrine surgeon at Barnes-Jewish Hospital in St. Louis. He stopped my spironolactone for 30 days so that we could repeat the chemical test (catecholamines), and obtain a more accurate result. Within a week I started to have blood pressure spikes of 200/100 or more at least daily. By the third week these spikes occurred 2-3 times a day followed by severe exhaustion. During a particularly severe episode, my husband took me to the hospital immediately and we drew blood to test the aldosterone-renin level. The results were normal aldosterone and essentially normal renin. I resumed taking the spironolactone; the spikes stopped immediately. With a change in insurance coverage, we next went to Springfield, Missouri, to see a surgeon. Once again, we were faced with a conundrum, lab tests normal. High dose spironolactone 4-10 times normal doses continued to be the only way to control the blood pressure. Diagnosis still assumed to be hyperaldosteronism. This was based on clinical evidence more than chemical evidence. About this time, I started to have nausea with each meal, only relieved with iced tea. I think my doctor thought I was crazy. Being a patient and a doctor’s wife is not an ideal combination. Doctor’s wives are not often treated like patients or given the benefit of the doubt. The general public and the majority of nurses seem to think that doctor’s wives have it made. If the doctor’s wife shows any frustration or displeasure, it is her fault. Doctor’s wives are not supposed to get sick, and if they do, it must be their fault. I never really wanted to marry a doctor and when I got sick, I really understood that doctor’s wives were considered either crazy or difficult. If they are sick, the diagnosis was not clear, they were just crazy. A gallbladder workup showed no stones on ultrasound, but the HIDA scan showed an ejection fraction of 6% (poorly functioning gallbladder). Dr. Voight, my husband’s partner, removed my gallbladder via laparoscopic cholecystectomy, and found a small stone impacted in the cystic duct. The surgery went fine and was uneventful, but the anesthetic was anything but. I ended up in the intensive care unit with spiking blood pressure and delayed metabolism of the muscle relaxants. Though I went home the next day and felt better, the gas and nausea, though improved, did not totally resolve. I resumed taking Prilosec, a medication available over-the-counter (needs no prescription)