Sleepless Patients, Difficult Choices

People need sleep and many are having difficulty getting it, especially with advancing age. Hardly a day goes by that I do not see a patient asking for a sleep medication. People think that all that is needed is to take a pill every night at bedtime and, like magic, they will get 8 hours of refreshing sleep every night for the rest of their lives. Life, and medicines, do not always work that way. When I tell patients the truth, that evidence is that long term sleep medications are more harmful than beneficial in patients over the age of 60, I am met with responses that combine disbelief and anger. Some patients have left my practice.

Sleep deprived patients are among the most desperate patients I see. By the time they come to see me they often have not slept well for months and are struggling to function. When they take a sleeping pill and it works it is an incredible relief to them. After a few weeks of treatment the thought of stopping the medication brings a sense of panic.

There are alternatives to long term sedative use but they require time and effort and we live in a world where things that require time and effort are undesirable. Cognitive Behavioral Therapy, a specific form of psychotherapy, has been shown to be more effective than medication in restoring normal sleep. It takes several weeks and is not inexpensive so many patients are resistant. Sleep deprivation therapy, an approach where patients limit time in bed to hours actually slept (sometimes starting at as little as four hours a night) can also be effective but is equally undesirable. When given the choice between changing behavior or taking a pill, Americans choose the latter.

What makes matters more difficult is that many patients are unwilling to change habits and behaviors that make sleep more difficult. When I bring up caffeine use, alcohol use, watching television in bed, use of iphones and tablets and other behaviors I am always met with a list of reasons why the patient cannot or will not follow my advice. They just want a pill. As my commitment to practice quality medicine is stronger than my desire to please, the visits become lengthy and difficult.

As frustrating as these interactions can be for both me and my patients I have learned that they are to be expected. I live in a world of people who have been conditioned to expect an easy fix to every problem,  a world where effort is something to be avoided and not expended.

I cannot change the world, but I can do my part to change the lives of the patients under my care. When it comes to improving their sleep, it means encouraging them to take the difficult but better road.

- Bart

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Unexpected Encouragement

Encouragement can come from unexpected places. After a stressful week that included planning memorial services for my grandfather and arranging placement for my grandmother, stress that caused my chronic jaw pain to flare and sleep to be elusive I found myself sitting on the sofa mindless watching television. Too tired to do anything more, I sat and listened to singer after singer miss notes but still be praised by the celebrity coaches. I felt I was giving away minutes that I would never get back.

Then Jordan Smith sang “Great is Thy Faithfulness.” In perfect pitch and with minimal accompaniment, he reminded me of the hope that has sustained me throughout my life. God never, ever, fails to keep His promises. Here are the words of the hymn he sang-

Great is thy faithfulness, O God my Father

There is no shadow of turning with thee

Thou changest not, thy compassions they fail not

As thou hast been, thou forever will be

Great is thy faithfulness

Great is thy faithfulness

Morning by morning new mercies I see

All I have needed, thy hand has provided

Great is thy faithfulness, Lord unto me

Years ago, as a child of 10 I memorized these verses from Paul’s letter to his friend Timothy

For if we died with Him, we will also live with Him;

If we endure, we will also reign with Him;

If we deny Him, He also will deny us;  

If we are faithless, He remains faithful, for He cannot deny Himself. 2 Tim 2:11-13

When God makes promises, He keeps them, and nothing in this life changes that truth. I was reminded of this tonight in an unexpected way.

-          bart

A Stranger in Your Exam Room

It is often difficult for patients to discuss personal issues with their doctors. Thanks to electronic records, it just got a whole lot harder.

Electronic Medical records have been a major disappointment. In survey after survey doctors tell stories of unmet promises and unexpected failures. While electronic prescribing, data collection and legibility of records are a positive, patients tell of doctors never looking up from the computer screen and of more time waiting and less time with the doctor. Doctors feel detached from patients, are stressed when they fall behind, and wonder when the promise of easily accessed data from other doctors will ever be realized. Some of these difficulties are understandable but there is one negative aspect of electronic records that is particularly troubling to patients, especially those dealing with intensely personal issues such as mental health and family conflicts. Many doctors are hiring “scribes”, people whose job it is to enter data into the computerized record on behalf of the doctor.

For some physician’s this is a matter of survival. Inefficient medical software and limited computer and typing skills have resulted in plummeting physician productivity. Declining reimbursements and rising costs make it impossible for doctors to cut back on volume to allow them to enter data themselves. They see no choice but to hire someone to do the work for them. When paying someone $25 an hour to enter data allows you to see an additional 6 patients a day, the math is easy. Spending $200 to make $600 is a return on investment that cannot be ignored.

While physicians are comfortable with an extra person in the exam room during the interview, patients are not always in agreement. Privacy laws and confidentiality policies do not change the fact that this extra person may learn things about a patient's marriage, sex life, depression or drug use that the patient wishes they hadn't. There is a real risk that as a result some patients may withhold information crucial to their care.

So what can be done? At the moment options are limited. Patients have a right to ask that a scribe not be present, but this may strain the relationship with the physician as it is essentially asking the doctor to fall behind in the office.

Some physicians have addressed the problem by charging extra fees to patients to cover the costs of longer visits. I have seen physicians charge from $900 to $3000 dollars a year per patient to be a part of a practice that schedules fewer visits per day, giving more face to face time with the doctor. Unfortunately these membership fees are not covered by insurance and out of the reach of many families. Doctors who participate in HMO plans are contractually banned from charging such fees.

As with many medical conditions, there is no readily available treatment or cure. For the moment, doctors and patients will need to learn to live with the pain and hope things get better over time. I am not sure they will.

-          Bart

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The Wisdom of Gramps

I have spent much of the last several days thinking about my grandfather. As is often the case when a loved one is lost, his words and stories have filled my mind. He was a man who loved to laugh and tell jokes but I do not think any of his jokes were new. I doubt if any of them originated after 1955. Here are some of his favorites-

Whenever anyone asked how he was his standard reply was, "I'm older than I've ever been."

When one of his grandsons would walk in he would often say, "You get any better looking and you'll look as good as me!"

If I asked him if he could afford anything his answer was always, "I've got money I haven't spent yet!"

A few days before he died, I suggested it would be easier to put all of his money into a single account. Gramps replied, "You want to put both dollars in the same place?"

He always introduced himself by saying, "I'm Les. With one "s"

He told me several times what he wanted on his gravestone- "Les is no more."

I still laugh at the silliness of his jokes, but it is a serious comment he made when I was 10 years old that has most been on my mind. One summer my cousin and I spent a few weeks with our grandparents. We spent most of our time trying to one up each other. One morning we were debating who was greater and telling stories about why and how we were better that each other. Gramps overheard our friendly argument and called out from the other room.

"If you really were great you wouldn't have to tell anybody. They would just know." That lesson about  greatness, that it is based on your actions and not your words, has never left me.

Thanks Gramps.

- Bart

A Love that Lasted.

I said good-bye to my Grandfather today. He was 97. His last words were to my Grandmother, the love of his life for 77 years, "I love you, Sweetie." My grandfather was not a perfect man, but if a man’s life is measured by the love he has for his wife, he was a good one.

It was just 12 days ago that Gramps was discharged from the hospital. As he was deemed too weak to return to his assisted living facility I scrambled to find a nursing home near me that would accept him and my grandmother. His long term prognosis was poor as the combination of age, a muscular disorder and perhaps some small stroke had rendered him unable to protect his airway when he swallowed. We all knew it was just a matter of time before aspiration pneumonia would take him.

He was admitted to the skilled nursing facility late on a Saturday. I took my grandmother to visit him the next afternoon. My brother and cousin were there with him when we arrived. Gramps had been dozing off and only marginally engaged in conversation. That all changed when I wheeled my grandma into the room. His face lit up when he saw her, he was fully awake and smiling broadly. I pulled her wheelchair up beside his bed. He quickly took her hand and said, “I love you more than ever!”

For the next 10 days they shared a room together, their beds side by side, TV’s turned on to Fox News, their favorite channel. During the days they went together to physical therapy sessions. She worked on regaining sufficient strength in her leg muscles, he worked to be able to sit up in bed. When she finished her exercises she remained for his session, acting as cheerleader to get him to work harder. The staff told me that he did better when she was there. He always did better when she was there.

She is still there, but he is gone. Now she will have to make do on her own, a daunting challenge after 77 years. It will be a struggle for her but I pray she will find comfort knowing that she was truly and completely loved. Even more, I pray she will rest in the knowledge that she will see him again. When God calls her home, I expect my grandfather’s face will again break into a smile. Heaven will be even more perfect, because she will be there.

Bart