<![CDATA[BERTRAND LIANG, MD - Blog]]>Wed, 10 Apr 2024 12:38:46 -0700Weebly<![CDATA[David:  Some patients fight demons beyond their diseases.]]>Sat, 16 Mar 2024 16:47:12 GMThttp://bliangmd.com/blog/david-some-patients-fight-demons-beyond-their-diseases​David was referred to me because of a severe neuropathy secondary to being treated with a platinum-based drug for his germ cell tumor.  He was fairly young but looked much older than his years.  He’d lived on the streets for a very long time and had a history of being in and out of halfway houses and shelters but somehow managed to meet his appointments with his doctors over at the cancer center.  Surprisingly, he’d completed his courses of chemotherapy pretty much on time despite his social situation but by report he often showed up drunk to clinic appointments, or to his chemotherapy treatments.  He was a quiet drunk, as he termed it, one allowing him to delve farther into a world where he needed not deal with reality of health and the challenges of the street.  So it was no surprise that his neuropathy was very profound, with significant loss of sensation, with the painful muscle cramps in his feet and legs associated with significant and advanced disease.  When I first saw him, he was sitting in the clinic, in a disheveled state.  His walking was clearly that of someone with a lack of sensation in his feet, picking up his legs very high with subsequent slapping of his feet when they came down.  We walked together into the clinic room, and I noticed his flat affect of minimal tone and inflection of his voice.  As we sat down to discuss his case, he brightened somewhat, noting that he hoped I could help him, which I found to be a good sign.  
As we delved into his history more, I was surprised to learn that he had been a good student in high school and had started college at one of the state schools in the area.  He then began having as he called it, issues, which he would not specify, and he left school and began wandering.  He didn’t know his family history, as he hadn’t talked to his parents for years.  He started drinking, in his words, because that’s what you do in the shelters.  While he knew the date and where we were, he was lacking in his knowledge of current events; but then, he performed calculations with alacrity.  I became more interested in his mental status and tested him further; while he could write and read, he couldn’t draw a clock or a time on a clock, and he was unable to imitate certain hand movements. He could tell left from right but had difficulty with consistently naming his index or pinky finger.  And pointedly, sometimes during these tests and questions he would start answering, and then stop, making a face like he was being bothered by something, and then continue on again.  He could recall during these episodes when I’d ask him something, but when I would query what was going on during those events, he’d just say something like “I’m thinking,” or “nothing”.  
His neuropathy was indeed severe. He had minimal feeling in his feet, including a lack of position sense to the ankle.  I could see his sneakers had wear marks where he’d been scraping his feet.  During the exam, his feet also cramped up, causing him significant pain.
I asked him about any mental changes that he’d noted in the past, and he said that he felt he was just getting older, and that his memory wasn’t what it used to be.  I hadn’t really seen any memory issues and told him so.  His response was interesting; he said, “I get along.  What else do I need.”  And then he became almost morose, silent for the most part with only yes and no answers to most things.  
I prescribed some medications to try to alleviate both the neuropathic changes in his feet and the painful cramps he was experiencing.  I was aware that with his alcohol issues, I would need to be careful about him using morphine derivatives due to potential for abuse.  I was frank with him about that concern, but his notation was that “Pills aren’t my thing.  I like Jim Beam.”  I did warn him that alcohol would make things worse, to which his response was that alcohol makes everything worse, saying it without a smile.
I also told David that I’d like him to undergo neuropsychometric testing to define better some of the abnormalities found on his examination.  He refused, citing that his brain was his business, and he didn’t want anyone poking and prodding his mental state.  This was somewhat surprising to me - not that he refused, but that he had the insight to understand that the assessment would be to examine why he was able to do certain mental tasks, and not others.  I pushed him a bit on this, but he became sullen and I didn’t bring it up again.  
When I saw David again, his neuropathy was stable, but the cramps were worse.  As well, his personality was much more aggressive, and his speech was more pressured and urgent, but low in volume almost like a loud whisper.  He refused some of the mental status examination but did allow me to assess his neuropathy. I asked him if anything had changed, and his response was almost paranoid - he said, “Should there be?”  I was concerned about this change, and again suggested further evaluation and work up, this time with psychiatry, which he flatly refused, with the same type of intonation that he noted previously.  I asked if he would be willing to change some of his medications to address the cramps, to which he acceded, but only with some cajoling.  I scheduled an appointment for David to come back to see me in less time than usual, as I was concerned about him.  Usually, we’d be able to call the patient for an interim assessment if needed, but since David had no mobile phone, and had itinerant status otherwise, the challenge was to ensure his continuous care.
Six weeks later David came back to see me.  I didn’t recognize him at first.  His hair was combed, he was wearing a button-down shirt, khakis, and suspenders, although he still had his old sneakers on.  He greeted me like an old friend, and his friendliness was almost alarming.  He was cooperative with the examination, but I found that his neuropathy was not improving, and he still had painful cramps; his mental status exam was slightly worse, with concentration somewhat off.  However, I took advantage of this mood to again suggest additional tests, from neuropsychometric testing to a visit to psychiatry.  This time he agreed to be seen, and rather than taking a chance of a change of heart and mind, I called in a consult for the patient to be seen right away - at least for the psychiatric assessment.  I was able to get one of the residents to come to my clinic for evaluation.  I went to use another room and allowed the consultation to take place, and started seeing other patients.
Close to the time at the end of my clinic, one of the Psychiatry attendings called me - he wanted to ask questions about David, and talk about the consult.  He listened as I related his mental status exam, his history of school performance, dropping out of college; his homelessness and drug abuse.  My Psychiatry colleague noted these things were important, and also noted that the resident had found not only these things but also some psychotic tendencies as well.  He asked if I noted that the patient would stop mid-sentence, then continue after a pause, to which I noted I had.  He asked what I thought, and I said of course I was concerned about a seizure, but he apparently heard what I had been saying during that time and could recall it.  What my colleague then noted was definitive - he said, “Yes, that’s what I would’ve thought.  But what the resident found is that David is hearing a woman’s voice - asking him questions.  Accusing questions.  Questions of why, motivations; of his worth.  Pretty specific.”  
Obviously, I knew this was a very bad thing.  My Psychiatry colleague asked about family history since the resident couldn’t get any.  I noted my lack of success as well.  “We think he’s schizophrenic.  Obviously we need to assess other things like manic-depression etc., but his history and behavior is pretty clear.  Amazing he’s made it this far for so long, especially with cancer.”
As a neurologist and cancer doctor, it was somewhat embarrassing to have missed putting together the pieces of the puzzle.  I could treat his neuropathy the best I could, but the struggles David was undergoing on a daily basis was far more than a history of cancer and side effects of therapy could be.  We arranged for David to be followed in the Psychiatry service, particularly with the schizophrenia expert group there, and I continued to see him for his neuropathy.  With time, I could see David improving, although the only thing I did for him was to decrease his painful cramps; the neuropathy never really changed.  
I always remember David for what I need to consider as the whole patient to be evaluated, rather than a historical disease and needed treatment.  The patient may be fighting more things than our subspecialties can imagine or consider.
<![CDATA[Mr. K: Treat the patient, not the numbers.]]>Sun, 11 Feb 2024 22:33:42 GMThttp://bliangmd.com/blog/mr-k-treat-the-patient-not-the-numbers​Mr. K
I walked into the examination room, to be greeted by Mr. K, a big, burly man of about 35 years.  He had a work shirt on, indicating his place of employment, where apparently, he was a truck driver.  As we got to talking, it was clear that Mr. K didn’t really know why he was seeing me, and it was going to take some detective work to figure it out. 
His chart was somewhat difficult to access since he was a workman compensation case.  Regardless, with Mr. K and what I could discern from the previous doctors who’d seen the patient, I could at least piece together what was going on and the need to access neurologic input for Mr. K.
Mr. K had noticed that, over the past few months, that he’d been losing strength in his left hand, and although he was right-handed, it was acutely obvious.  “I fashion metal art from old coins,” he noted somewhat proudly.  “Totally self-taught.  I learned from YouTube videos, and with some background in the trades, just put together one plus one.” 
He showed me his wedding band, which was fashioned out of an old Liberty Dollar, of which his ring and his wife’s were from the same coin. 
“But now, I have a really hard time with it.  My hand is so weak sometimes, I can’t keep my machinery steady.”  His artwork was really impressive, and he’d been able to create quite a remarkable adornment of things.  He showed me some of his advertisements, and he could do everything from fishing lures to money clips to almost anything a client would want. 
“Most of the business is really custom,” he continued, “although everyone sees what’s been done in the past.  It’s mostly about the year - something makes it special, and I can identify some coinage at that time, and make something they can remember it by.  It keeps me busy,” said the patient, with a smile.  But then a cloud returned to his face.  “But I really haven’t been able to do anything for the past three or four weeks.  Just can’t keep my hand strong enough.”  I nodded, looking at some of the reports I had been able to pull up.
Mr. K also noted that he was numb in his pinky and fourth finger as well.  This also had been going on for several months.  Just looking at Mr. K’s hand, I could see the prominent atrophy of his first dorsal interossei muscle, the muscle between his thumb and forefinger. 
It wasn’t subtle.  And, similarly, on the palmar surface, the muscle under his pinky finger was also flattened, which wasn’t unobvious either.  The patient had seen a local doctor, who had noted that these findings in his hand, but discounted that the sensory findings had anything to do with his grip strength, nor the apparently earlier atrophy which probably was less obvious than before. 
When he continued to complain of symptoms, he was sent to an occupational medicine doctor, who also discounted a relationship between the sensory and motor symptoms but ordered an EMG/NCV study for further assessment.
Passing papers
When I looked at the neurophysiology studies, I was surprised to see it hadn’t been done by a neurologist, but by another service.  Moreover, it was frankly, incomplete, and really focused on looking for carpal tunnel syndrome, rather than looking for all three major nerves in the hand. 
And, not surprisingly, the conclusion of the study was that the patient had carpal tunnel syndrome, and there was indeed some slowing across the carpal tunnel, but it was very mild, and, on the right hand, not the left, which was called normal. 
As I followed the subsequent follow up, the patient had been told by a physician that all he had was carpal tunnel, and that he’d be followed up with Physical Therapy.  When that hadn’t really been helpful, and his symptoms were worse, he’d been sent to Neurology for further assessment.  This was over a month ago, and according to the patient, wherein he’d gotten worse with his sensory changes and weakness.
Just by observation, it was clear that the patient had an ulnar neuropathy, and that the studies he’d had done were inadequate to help in the diagnosis.  His neurologic examination localized to the nerve, and in particular, distal to the carpal bones, in that this was past the point where apparently the EMG/NCV study was done, at least for the most part. 
The sensory changes, the areas of muscle weakness, and atrophy - all of it could be localized to this one nerve.  The occupational physician had done what he could - he’d only trusted the conclusions of the other physician who’d done the examination, but that exam and the numbers weren’t either complete or even correlated to the clinical course. 
The patient had told a clinical story which was localizing, his current exam was not only localizing but unfortunately stereotypical, which means probably later stage than it should’ve been and the patient had suffered as a result. 
It was a classic case of just playing with numbers, and not looking at the patient, something in busy practice can happen since it’s more reflex rather than consideration of the entire patient. 
Beyond the numbers
We were able to send the patient to a specialist hand doctor, where after seeing my examination notes, took the patient to surgery right away to relieve a compression on the ulnar nerve.  The last notes I saw in follow up with the hand surgeon was that the patient was beginning to be able to grip well again, and the sensory changes had stabilized, if not improved several months later with the assistance of physical therapy. 
I did get a note from the patient letting me know that he was “back in the saddle”, and was doing his side business again, in case I had any requests.  I could only smile - I was just happy that hand surgery and follow up PT was able to get the patient back towards recovery. 
And again, made me feel fortunate with the realization that I had the luxury of understanding that just playing with numbers isn’t what the art of medicine, and Neurology, was all about.
<![CDATA[Tony: Hearing what’s said.]]>Mon, 29 Jan 2024 17:49:59 GMThttp://bliangmd.com/blog/tony-hearing-whats-said​Tony
Tony came into clinic with his wife, who was dominant with respect to her demeanor - talking nonstop to her husband, as I entered the room.  She didn’t stop despite seeing me, and Tony actually arose to greet me as his wife continued speaking to her husband.  “Nice to meet you,” I noted to the patient after shaking his hand, and said the same to his wife, who continued to speak to her husband and just nodded her head at me, with the concluding clause, “...and you need to remember that.”
After sitting down, I asked the patient why he was in the Neurology clinic.  His wife began speaking, and I asked her to stop, so that I could speak with the patient and get his perspective.  After a strained silence of a couple of seconds, the patient began. 
“I think I have dementia,” noted the patient, quietly.  Looking up, I asked the patient why he thought that. 
“Excuse me?”  I repeated myself, louder this time. 
“Well, I don’t remember things anymore.  My wife here tells me that.” 
His wife added, “And he has family that has dementia.  His dad’s dad had dementia, and his mom’s brother.”  I asked Tony if this was true, and he confirmed that it was.  “How old were your family members when they were diagnosed?” 
“Well, I think grandad was at least 80, and my uncle was probably around that age.” 
“Any one else?”  “Not that I know of,” said Tony, shaking his head. 
I then explained that familial dementia was rare, and that at Tony’s age, in his early 60’s, if it was familial, it might follow the same pattern.  But usually that familial dementia presented itself early, and it was the spontaneous type that presented late.  
Tony’s wife spoke up.  She’d looked up Alzheimer Dementia on the internet, and that Tony exhibited all the symptoms of the disease.  He was forgetful, and often sullen.  He didn’t speak as much as he used to, and when he did, only a few words. And sometimes he just didn’t answer he when she asked him a question, and just continued to read or watch tv or do whatever he was doing. 
“His behavior is very much like the website I was reading,” she concluded, with finality.  “We scheduled this appointment since his primary care doctor wouldn’t prescribe the Aricept that I wanted for him.  She said we needed to see a neurologist first.  That’s why I, I mean why we, are here.” 
I listened, dutifully writing things down, considering how Dr. Google had made yet another diagnosis for me, and all I needed to do was to write the prescription.
I asked Tony some questions, regarding getting lost, or being found in an unfamiliar environment, or wandering - all of his answers were negative, noting that he knew his memory wasn’t what it was.  I asked about his wife’s report, and whether he was ignoring her. 
“Not intentionally,” he said, somewhat hesitatingly. “I just don’t hear her sometimes.” Looking up, I saw Tony’s spouse roll her eyes.  “I just don’t, really.“ 
I asked the patient what he used to do for a living, and he had worked in a canning factory for about 20 years.  They would regularly test hearing, and unfortunately one day, when his hearing was tested, his boss sent him out and had him go to the clinic at the company, then took him out of the plant.  He was told he’d need either to retire or to take another job, which would be in the adjacent offices. 
“I just took retirement,” said Tony.  “Biggest mistake I made.  But I didn’t want to learn how to be a clerk.  I just wanted to be with my friends.” 
Changes and discovery
“He was miserable,“ noted his wife.  “But he started to volunteer at the high school, but stopped after having problems understanding what was going on.  That was a few months ago.” 
I asked Tony what he perceived about that, and he just said he just didn’t recall being told things or hearing what needed to be done at the school’s shop.  “I just decided I wasn’t all there anymore and quit.”  There was a silence.
On examination, Tony actually did well on virtually everything except concentration abilities; he didn’t even try to spell or name or other things within the exam.  However, his memory and constructional abilities were intact. 
His exam did show something which I had suspected through the interview - that he did have a significant loss of hearing. This was both for higher frequency, as well as volume.   And, he was depressed, probably a reactive depression, given the lack of pleasure of doing activities that he’d previously found pleasurable, and rather, would just sit around the house, staring blankly at the tv.  Tony’s wife noted that she would try her hardest to get him to do things, to get him engaged, to motivate him.  But to no avail.
…And hearing
“I’m not sure you have dementia,” I told Tony, and his wife after his examination. 
“At least nothing classic as a dementia syndrome.  I think you’re more likely depressed, and that you have another issue - you’re hearing is affecting your life dramatically.  We need to address both of these.” 
Tony’s wife began articulating her efforts once again, and I held up my hand.  “I appreciate it but we need to rule out these causes before making any diagnosis.  That’s something we always do.”  Tony spoke up, asking what we needed to do next. 
“Well, minimally, I’d like audiology to see you, and the ear, nose and throat (ENT) doctors, and as well, psychiatry in order to assess all of these issues.  I’d also like to get some neuropsychometric testing, to evaluate your cognitive, or thinking, abilities, but only after you’ve seen everyone else first.  Once you’ve seen all of them, we can get together again and go over all the results together.  Tony nodded, and his wife, to my surprise, also just nodded.
A new day
Tony was seen by the hearing service, who fitted him with hearing aids, with the ENT doctors noted just presbyacusis, or being hard of hearing due to age.   The psychiatry service did feel that he was depressed, and started him on an antidepressant. 
After a few months, Tony and his wife came back to see me.  He was a changed person.  From being actively engaging with his wife, who was much less vocal, to seemingly brighter and more forthright, he greeted me heartily as I came into the exam room.  I told him he looked better, and he noted he felt a lot better. 
“He’s still forgetful,“ noted his wife, with a smile.  “But it’s selective.  Like when I want him to empty out the dryer.  Or take out the trash.  But other stuff he seems much more with it.  And he doesn’t ignore me as much anymore.” 
I asked Tony his thoughts.  “It was the hearing, I think, doc - I just wasn’t hearing things.  I didn’t think it was that bad, but the audiologist said it was - I was missing half the conversation most of the time.  And I didn’t even know it.” 
He’d started again volunteering at the high school and told the lead teacher about his hearing aids.  They even used this as a subject on safety on hearing for kids going into the trades.  In the end, I didn’t bother getting the neuropsychometric testing, since his examination was entirely normal.  I still see Tony since he wanted to be followed in Neurology, but he’s clearly better now. 
I was happy that I could appreciate what was going on with him and hear what he was telling me when we first got to know one another. 
No need for Dr. Google’s Aricept, after all.
<![CDATA[Mr. E:  Cognitive Bias]]>Fri, 05 Jan 2024 19:19:24 GMThttp://bliangmd.com/blog/mr-e-cognitive-bias​Unintended consequences of our thought processes. 
Mr. E.
Mr. E was referred to me from the internal medicine group because of seizures.  He’d had a long history of apparent epilepsy, followed by his local doctor initially at a health maintenance organization for some time, and then by our fee for service group once he’d changed jobs to become a finance manager for one of the local businesses.  He was young, in his late 20’s, and he noted to me that his seizure diagnosis had been from when he was about 5 years old, when he’d start getting facial twitching, and then felt that he’d lost some time.  Twice when he was young he’d noted that he’d wake up having wet the bed, and feeling sore all over.  His local doctor had diagnosed him with epilepsy, which was by report confirmed by EEG.  Although he’d not been followed by a neurologist, the last note from Internal Medicine was that the patient’s “longstanding epilepsy” wasn’t particularly well controlled, and since he was starting care with our group, seeing Neurology was a good next step.
Beginner mind
When I spoke with the patient, he noted that he’d had seizures for years, and he could name all of the seizure medications he’d been on - Dilantin, phenobarbital, primidone, Tegretol, Depakote etc etc - but they only helped a little bit.  He noted to me that he was getting the seizures weekly, maybe because sleep was less due to a 6-week-old at home, and that he’d learned to “hide” them, so that only the most observant persons from his family could tell what was going on.  This was, to say the least, not what I expected to hear, and we spoke further about the details of his spells.  “Well, doctor, it’s like this.  I know something is going to happen, maybe that morning.  A few hours later, my face starts to tingle, and on the right I feel like my face is twitching.  Sometimes I ask people if they can see it, like my wife; she says at times she can, but I can feel it all the time.  My vision gets all blurry, and my head fogs.  Then I get a real bad headache, like someone is pounding my head with a sledgehammer.  I gotta go lie down.  Sometimes I throw up.”  I asked Mr. E whether he’d lost consciousness, and he noted that no, he hadn’t as far as he knew, since he was a kid.  And how long would these episodes last?  “Twenty, thirty minutes - but the headache lasts all damn day, doc.  I gotta go lie down in a dark room.”  Any loss of bladder contents recently?  “Nah, not since I was a kid.”  Apparently, his former doctors had put the patient on valium if he’d experienced the spell, and the patient noted he didn’t take it anymore, since he was a “robot” through the next day with it.  “So, what do you do, then?” I asked, trying to remain open minded.  “Sleep, make sure I take my anti-seizure medication, and that’s about it.”
Thinking, and not thinking
There are many manifestations of seizures, and many types of seizures that we see as neurologists.  As well, there is a relationship between epilepsy and migraine headaches.  From Mr. E’s description, it sounded more like he was experiencing migraines, rather than epileptic seizures.  While having a seizure could evoke a headache, the pattern the patient was describing really didn’t fit this particularly well, and in fact, again was associated with migraines.  When asked about the blurry vision, the patient noted that it was like wavy lines were in his eyes, and the queries about ice cream headaches and motion sickness were also acknowledged – he’d had both since a chjild.  I told the patient that I wasn’t sure that he was suffering from epilepsy, but that I thought that migraines were more likely the cause.  “But all my doctors have said it’s been seizures; I’ve had them since I was a kid,” said the patient.  “Although none of these medications seem to work very well.  And my brother - he’s a colon surgeon, he wanted me to see you since he wasn’t sure these were seizures either.  But he said he didn’t know.”  I told the patient that some of the epilepsy drugs we do indeed use for migraines, but not really the ones he’d used in the past, and even more recently.  “I think we should put you on a regular migraine medication,” I concluded, ‘since you’re having these headaches relatively frequently.  And we can give you a migraine rescue medication as well.”  
Understandable doubt
The patient was momentarily silent.  “Ok, I think that’s ok.  But I’ve never been off my seizure medications before.  Is that going to be alright?”  I assured the patient it would be, but that he still shouldn’t be driving, which he knew not to do.  The patient was started on the medications, and when I saw him again in two months, he was smiling, and had brought along his wife.  “At first, I did have a couple of the face twitches, and I took that medicine you gave me,” said the patient.  “I didn’t get the headache like before - just a bit of a dull ache. But I haven’t even had that in a month.  It’s fantastic.”  The patient’s wife noted that, “He’s even been able to get up with the baby as well,” noting they’d been sensitive to sleep for the patient because of these spells.  I was also obviously happy for the patient and his wife, and then the patient noted to me that he'd found the EEG report at his parent’s house.  When he showed it to me, I wasn't surprised to see that it was noted the pattern was consistent with Rolandic epilepsy, which can start in early childhood, but typically goes away at puberty.  So it was most likely that while Mr. E did indeed have childhood epilepsy, it was the type that went away.  Mr. E was speechless.  But then said thoughtfully, “Ya know, it’s weird.  I’ve been told that I’ve always had seizures.  It’s like a part of me.  But now...I don’t.  I need to wrap my head around that.”  His wife noted that it was better than the reverse.  Nonetheless, I knew what the patient was saying - while a relief, it was almost like a loss. But I hoped that he’d get through it alright, which is what I told him.  
Cognitive bias
In the back of my mind, I was thinking he’d been tagged with a diagnosis of epilepsy for so long, and it was just promulgated throughout his history.  We doctors had just continued to label the patient with a diagnosis and attribute his symptoms to something that we already knew was in his chart.  I know this is something that occurs all the time, not only in medicine, obviously, but it has great ramifications in our field, given that it can create unneeded treatments or inappropriate medications for patients.  It’s why I like to have other services involved in a patient’s care since we’re better at assessing things independently, to avoid our own biases. 
Mr. E once again makes me remember that we always need to listen to the patient who’s trying to tell us what they're suffering from - and to be aware of our own cognitive biases for the benefit of the persons sitting in our exam rooms.
<![CDATA[Ms. M:  An Educated Consumer]]>Wed, 27 Dec 2023 23:13:53 GMThttp://bliangmd.com/blog/ms-m-an-educated-consumer​Ms. M
Ms. M was 67 years old when I first met her in my general Neurology clinic.  She’d been evaluated by a number of different hospitals and medical centers in the past, given her 30+ year history of multiple sclerosis, or MS.  As she relayed to me, she’d been initially like many other MS patients, with a relapsing and remitting course, which had gone on for about 10 years, and which she’d tried a number of different medications.  She’d actually had done quite well during those years and had continued to raise a family and been quite productive balancing a professional life as well, with only mild exacerbations of the disease. 
Clinical changes
However, after that, her course turned much more intense, and she’d moved from being a relapsing remitting course to a chronically progressive one, where she was losing function and not getting better after each neurologic setback.  “I tried everything the doctors had to offer,” Ms. M told me.  “I even volunteered for experimental therapies and was in a couple of clinical trials.”  She had also been quite involved in the local MS society and had a very sophisticated understanding of the newest medications on the market.  “It's so frustrating,” said the patient.  “All these things take so long to get through the FDA after the clinical trials.  Why can’t we try things if we as patients are willing to?  Does the government know better about how safe these medications really are?  Sometimes we don’t know for years if a medication actually turns out not safe.”  I didn’t say alot, although certainly there was part of me that agreed with her.  But she was uniquely informed, and not everyone is.  
A Wealth of information
Ms. M had just come back from an evaluation from one of the most well-known academic centers for MS in the country, and they had suggested she be treated with a specific medication that had been approved by the FDA recently.  Ms. M was well-aware of the medication, and actually described to me the benefits of the medication, as well as the issues with safety that had come up during the trials that had been performed.  I was prepared to allow for the transfer of care of her case to that academic center, when the patient surprised me, saying “But I decided I really don’t want to have that therapy. All the tests I have to go through, all the travel back and forth and being away from home.  I just want to be treated here, where I have the support of my family and friends.  And I think the best drug for me is the one that was approved last year.”  
Courage of convictions
I was a bit taken aback with Ms. M’s clinical plan.  I had assumed, given her knowledge of her disease, the therapies available for it, and that she had sought out the best physicians and centers that she’d be taking advantage of all of it to create the treatment plan she wanted.  And I told her this.  “Well, Doctor,” said Ms. M, looking at me intently.  “I know the therapy that I want isn’t for people my age.  And that there’s a chance I might die because of it.  But you know what?  I’m not afraid of dying.  Of course, I don’t want to die.  But I’ve heard great things about this therapy.  And I know and trust you all here, and my support is here.  It just seems right in the end.”  I acknowledged the comment, and she continued.  “The fact is, it’s about going for it, you know?  I don’t want to live not knowing I didn't do what I thought would be the best thing to treat my disease.  Even if I die from it.”  All I could think of was how courageous Ms. M was, and how hard she had worked to investigate the available therapies for the disease.  As well, she knew the data - she was cognizant of the pro’s and con’s of the disease.  This wasn’t, what has been such the catchword, of patient “shared decision making”, which frankly has been what we doctors have been doing for decades.  This was an occasion of patient decision making, no sharing from my end at all.  Except, I had to agree to prescribe the medication, which I had not agreed to do, as of yet.
Making a decision
“Ms. M, you know all of the potential side effects, better than I do, of both the therapy from the other hospital, as well as the one you want. Are you sure this is really what you want?  There are all sorts of warnings about this medication that you’re so adamant about.”  
“I know the side effects, I know the issues, and I know that given my secondary progressive MS, this has the most data around benefit out there.  And even you admit I’m a young 67,” and smiled.  To that, she was right; I had said that when I first met her.  I asked what her family thought, and she noted that, as usual, this was her decision.  Her family had also noted that she knew more about this than anyone else, and other patients sought out Ms. M for her thoughts on their therapy.  “I never say I’m a doctor, just that I know the results of studies,” said the patient.  “That’s all I tell people; the results.  They have to make decisions for themselves.”
An educated consumer
“You know what you want,” I said, as I signed off on some of Ms. M’s paperwork.  “I’ll prescribe and arrange for you to get the treatment that you want.  You know the risks.  But you also know the data better than any else that at least I know.”  The patient thanked me, and we arranged for her to receive the therapy at one of the nearby hospitals.  I actually had to transfer her care to another neurologist who could actively monitor her at the other facility, which was more convenient for the patient.  The last I heard, she was tolerating the treatment well.  Whether she would get better with it was anyone’s guess, and it would take months or even longer potentially to figure that out. 
But it brought to mind the quote from a clothing store from the east that I used to hear, which still rings true to me in many ways, and certainly with respect to Ms. M:  An educated consumer is our best customer. 
For Ms. M, this certainly was the case, indeed.
<![CDATA[Ms. Y: To “suck out all the marrow of life.”]]>Tue, 12 Dec 2023 21:13:30 GMThttp://bliangmd.com/blog/ms-y-to-suck-out-all-the-marrow-of-life​Ms. Y greeted me in the hallway as I was walking into the examination room to see her.  She was walking in her walker, and I had seen her moving briskly down the hall before we’d both arrived at the doorway.  She moved well for a patient who was 93 years old, and had a history of over 20 years of Parkinson’s Disease.  “Good morning,” I noted to Ms. Y.  She sniffed, and as she shuffled her walker to move into the room before me, said “What’s so good about it?” and laughed.
I had known Ms. Y for some time, and she’d lasted through a couple of neurologists, me being the third one.  Her first one had retired, her second had moved on, and I had inherited her subsequently.  She was, to her own description, a crusty old bird, ornery, and with a rapier wit toward basically anything said around her.  I replied to her query.  “Well, I get to see you today!” I noted with enthusiasm.  She sniffed again and smiled.  “Your pleasure, not mine.”  But she smiled.  I asked her how she was doing, and she tilted her head back, look to the two children in the room, and pointed her chin toward them.  “Ask them,” she noted wryly.  “They’ll tell you.”
Her two daughters laughed, but they noted that Ms. Y had been doing well.  She still lived with her two attendants, otherwise independent, at the home that she had moved into over 60 years ago when she had gotten married.  She still went weekly to church to play bingo, had recently travelled to South America, on a four-country combination flight, boat and car trip, with a travel group of friends, a number of widowers who’d kind of created a club who’d pick travel destinations every six months – one trip inside the US, and one outside.  Of course, it was Ms. Y who had been one of the founders of this club after her husband had passed away of a heart attack.  As her eldest daughter noted, “She doesn’t stay still for very long – she’s busier than both of us put together!”
As I was doing my examination, I did notice that the tremor in Ms. Y’s hands really hadn’t changed with time, and the low dose of thrice daily Sinemet was doing its job well.  The patient also noted this.  “That drug is a miracle – I love it.” I nodded, noting how some patient’s do incredibly well with it.  “I’m lucky.” She responded.  “Girls in my club sometimes stiffen up really badly.  I never had that.”  It was true; Ms Y had about the most mild, very slowly progressing course of Parkinson Disease I had ever seen.  She had initially had tremor in her hands, then her left leg, but this responded well to treatment, and she had gone right along with her activities.  “I’ve been to all the major continents, including Antarctica,” she had said to me once.  “And I don’t intend to stop.”   She was the paragon of a woman with a thirst for adventure, to experience, as she would quote Thoreau, to “suck out all the marrow of life“.  As she told me, “When Henry, my husband passed, it was a wakeup call.  I’d lived for my children all my life. But I’d never really lived.  So I was determined to live.  To experience.  And I have two wonderful kids who have allowed me to do it.”
Ms. Y also volunteered for her church, and led the annual charity sale that took in lots of items from parishners and beyond and sold them to raise dollars for the food bank that bought groceries for those who couldn’t afford it.  “We give out about 1000 bags of well-balanced groceries a week,” she once told me.  “And it’s not junk – it’s nourishing stuff, and things that kids and adults can use.”  Ms. Y should know, since she was a former nutritionist for the school system and worked as a consultant to the all the schools in the district in the past.  After she retired, she provided her services gratis, and was quite the advocate for school lunches and finding ways for kids to get at least two meals a day if they couldn’t get something at home.  It was quite the story.
After I’d finished examining Ms. Y, and told her I thought she was doing great, she smiled, and then asked if there was anything at issue if she went to very high elevations.  I asked what she was planning to do.  “Well, the girls and I want to, and do some of the ‘14ers’ in Colorado – but we’d need to get used to the altitude first.”  I told the patient that I’d been a doctor in Denver once, and that they needed to be extraordinarily careful if they were going to go up and down in those altitudes, but as long as they acclimated, had good medical care around them, it was doable.  “Of course it’s doable,” said the patient, “we just need to make sure we come back down with our hearts still beating.”  It was my turn to laugh, but told her and her compatriots to be careful, but who was I to prevent the club from having their next adventure.  As she shuffled out of clinic, she noted, “Until we meet again, Doctor.  And it was a pleasure to see you.”  I called back – “Of course, Ms. Y, the pleasure was mine.”
<![CDATA[Mrs. M:  A Short Memoir]]>Mon, 27 Nov 2023 21:32:36 GMThttp://bliangmd.com/blog/mrs-m-a-short-memoir
 All patient circumstances are unique.  But sometimes there are those you just can’t forget. 
It’s all too frequent that patients come in very late in their course, due to the circumstances of life. As doctors, regardless of field, we all have seen cases that can be challenging after the fact, and treatable with earlier diagnosis. As an oncologist and neurologist, I’ve seen tough as nails farmers come in with literally the worst headaches of their lives, and only agreed to go to a doctor because they couldn’t use their left arm at all to drive the tractor and their kids forced them to come in.
One of the worst cases was Mrs. M.  She was the penultimate busy mother with four kids, working at a local retail store, whose husband was deployed in the reserves.  She was busy from sunup to sundown and after, and had an amazing energy and disposition. 
Only in retrospect did she admit to herself that her aspirin use had gone sky high because of headaches, but she’d ignored it due to her busy schedule - she still needed to get to work and be a mom and insisted on being a positive influence on her kids’ lives despite essentially being a single parent. But the headaches progressed, and one day she noticed she’d lost her ability to calculate and make change (so she “borrowed” her daughter’s calculator); days later, she forgot how to tie her shoes (so she bought Velcro strap shoes), and after that, lost the ability to recall how to button a blouse (so only began wearing pullover shirts). All through this she was trying to juggle things and keep everything going in her family life. Finally, she had a seizure, was brought to the emergency department (ED), and of course there was a mass in her brain frontal lobe with diffuse swelling. With aggressive therapy, she survived longer than most, but certainly not very long, with accumulating deficits in her function mentally and physically, that were as frustrating to her as it was heartbreaking to see for everyone who knew her beforehand.  
It is she who always reminds me of the challenge to be a patient, the social aspects which create circumstances we doctors just cannot know. I remember all of my patients, but she is perhaps one of the most memorable.
<![CDATA[Mrs. B:  The Second Patient. It’s often stated the second patient in any disease is the caregiver.]]>Sat, 11 Nov 2023 16:40:48 GMThttp://bliangmd.com/blog/mrs-b-the-second-patient-its-often-stated-the-second-patient-in-any-disease-is-the-caregiver​Mr. B
Mr. B was a major executive in one of our town’s key industries, and exuded confidence and gravitas when I first met him in clinic with his wife.  He was inquisitive and questioning about his therapeutic options, and asked incisive questions including other centers where he might be treated that I would recommend.  He did note he’d prefer to stay in town, of course, since he’d prefer to be home and not interrupt work.  I asked what his surgeon had told him about his disease, and what his expectations were. 
“He said that I had a bad cancer, and that I’d need a lot of treatment.”  I asked if the surgeon had talked to him about prognosis.  “Not really.  He just said it’s a bad cancer.  But I know it must be very bad, if I need treatment as severe as radiation and chemotherapy treatments”. 
After pausing, I noted that neither the radiation oncologist, nor I, would be able to cure his disease – a malignant brain tumor.  We might be able to stem the tide, but it would in all likelihood come back.  And then we would be faced with less certain therapies. 
Without any hesitation, he said “Well, then we’d better get started!”  It was an amazing response, said with pragmatic confidence. 
That’s when Mrs. B noted, “If anyone can beat this, he can.  I’ve seen him do some amazing things.”  To which Mr. B just nodded.
Radiation Therapy
Regretfully, Mr. B did not do particularly well with radiation therapy.  Radiation has different degrees of effect on people - some tolerate it with just mild fatigue; others exhibit tremendous fatigue with at times depression; others get significant fatigue and irritability.  Mr. B had the last.  His mood swings were severe, and he was one day angry at everyone and other days depressed and silent.  During each daily visit to the radiation suite, his wife would be by his side, supportive of his moods, warning the technicians of what to expect, and trying to assuage the situation in any way she could. 
She confided in my nurse, “Sometimes he just wants to give up, and then sometimes he blames the entire world.  But it’s really mostly to me - he’s used to tempering things with the outside world.”  If this was tempering, noted my nurse, she’s really taking the beating at home.
When Mr. B started on chemotherapy his moods seemed to stabilize.  With each course, his stern countenance and gravitas returned.  But it was clear that his wife was wearing down; she began to look haggard, and clinically her fatigue was palpable. 
She spoke to my nurse often, always without either Mr. B or myself present.
“Everything that he thinks or feels is different, he worries about; he’ll wake me up 3, 4 times a night to ask if he looks different, or because he’s thought about something that’s happening.  I haven’t had a good night’s sleep in weeks.”
First Recurrence
After Mr. B’s second round of chemotherapy, his cancer came back, heralded by a seizure with weakness of his right arm.  We changed his treatment regimen and sent the patient to physical therapy to try to maximize his right arm function as best we could.  Understandably Mr. B was extremely frustrated, and he stopped going to the office - his wife related that he was too embarrassed to be seen as weak. 
Mr. B’s wife would go back and forth as messenger and communicator during her lunch break and after her job, noting that, “I have to keep him sane.” 
I asked my nurse if we needed to have social work involved in the situation.  She replied that of course that would help, so of course, both of them would refuse.  Sighing, I left it at that.
Second Recurrence
Mr. B’s tumor recurred again after the next round of chemotherapy, and as I walked into the room to discuss the results of the MRI, I noted that Mrs. B was in very bad shape.  She was disheveled, with dark circles under her eyes; her hair was barely combed, and she was wearing very casual clothes - the first time I had seen her in jeans.  Mr. B now appeared a shadow of his former self - no longer the confident executive I had seen 11 months earlier; his right arm weakness now also involved his left leg, and he needed a cane to walk.  
“What’s next, Doctor?” asked Mr. B after explaining to him the results of the last scan.  I could see his wife was fighting back tears - but I wasn’t sure whether this was from the discussion, or the obvious strain and fatigue she was enduring.  I told him that there were several clinical trials that were available, both locally and on a national basis, and these would be the ones I would recommend. 
“Let’s do the local one,” said Mr. B.  “It’s too hard to travel anymore,” and he glanced at his wife with a degree of affection, that I haven’t ever forgotten.  I thought I saw a tear drop from Mrs. B, but then she turned away.
Going Home
Mr. B didn’t make it to the next clinic appointment to set up his clinical trial therapy.  He died later that week at home, with his wife by his side.  She had weathered the storm with him, being the constant companion on a difficult ride, but which had now concluded. The last I heard from my nurse, was that she had had some guilt at the end - she was happy that the journey from hell, called cancer, was over, but was overwhelming sad that a pillar of existence - her husband, was now gone. 
And yet, without her, Mr. B would never have been able to weather the storm himself.  Her unwavering strength had carried him along.
It is, unfortunately, not an uncommon scenario.  I have always been grateful my nurse and Mrs. B had such a great rapport.
In all the diseases we as a health care team encounter, it is the second patient we must always remember needs care as well.
<![CDATA[Remembering the artist:  An artist shining through his dementia]]>Wed, 25 Oct 2023 17:42:58 GMThttp://bliangmd.com/blog/remembering-the-artist-an-artist-shining-through-his-dementia​The Man
Mr. T was 90 years old when I first met him, accompanied by his partner as well as another young man, his caretaker.  He was tall, with a flowing white head of hair and a pale lined face, which was stern and quite the contrast to his fairly high-pitched voice. 
After introducing myself, the patient responded with very hesitating speech, sputtering out his name, as well as some numbers.  “Those were his dog tag numbers,” said his partner, smiling.  “He does that pretty much every time he meets someone new.”  I nodded and noted that the patient had been referred to me for management of his dementia, which apparently another doctor had noted was Alzheimer Disease. 
Smiling at the patient, I started to ask him questions, and Mr. T seemed to fiddle with his hands, and spoke out occasional words and sentences, which mostly were questions back to the partner and provider.  They were almost pleas for help to understand what was going on around him, but at the same time without any aspect of fear or discernable discomfort, except for the fiddling with his hands. 
Noting to the patient that I was going to address his partner and the caretaker, I asked about how well the patient cared for himself, what he did throughout the day, did he wander at night and other such questions associated with the different types of dementia. 
“He really doesn’t speak much, except to ask for things,” said the young caretaker.  “But he does manage to do a few things around the house.  Sleep is the worst issue - he naps during the day and is up all night.  Can be really hard.”
A Day in the life
Apparently, both the patient’s partner and caretaker allowed Mr. T to sleep through the day, watching TV for countless hours alternating with napping, despite trying to get him to do other things.  The patient’s partner noted they had a park across the street, and while it was sometimes possible to get the patient to cross the street, he’d prefer to sit on the bench near the swing sets and just stare off into space, falling off to sleep most of the time. 
“I can’t seem to get him to stay awake at all,” he noted, sighing.  “He’d rather be up at night.” 
I noted to both Mr. T’s partner and provider that this could happen in Alzheimer’s Dementia, where the patients reverse their sleep wake cycle. Having good “sleep hygiene” is the fundamental aspect to try to reverse this trend back to more normal hours. 
“That would be a relief,” said Mr. T’s partner, after being informed of this.  “We just thought letting him sleep would be the best thing for his brain.”  Noting that sleep is important, I just pointed out that obviously for everyone’s sake, having the patient return to a normal sleep-wake cycle would do everyone good.  “That’ for sure,” noted both Mr. T’s partner and the caretaker provider.  “Avoid this sleeping in shifts thing.” 
I tried to do some of the standard things in the examination which help assess a patient’s mental status, but Mr. T didn’t really engage very much. He seemed to pay some attention to what I was saying, but then would lose interest fairly quickly in answering my various questions, sighing, then looking at his partner who’d try to get him to answer the question once more. 
Most of the time I didn’t push it.  Then, as I usually do, I asked the patient to draw a clock. 
The response I received, was to put it mildly, remarkable.  The patient drew a circle, but then instead of putting numbers in, like the face of a clock, he drew a man, who appeared to be pushing the side of the inside of the circle. 
Then, he drew a man outside the circle, who was pushing the circle as well from the opposite direction.  He drew other circles, with stick figures inside, doing various things like sitting, standing, bending arms and other things. 
I just watched, as he continued on.  In the midst of this Mr. T’s partner started to tell the patient to start drawing a clock, but I just held up my hand, just observing.  Then Mr. T just put a couple of letters at the bottom of the page, and put down the pen, staring off into space once again.  
The Artist
“He was an artist,” said his partner, wistfully.  “You name it - he drew things for the New Yorker, had shows in the Bay area, worked for the most sought-after advertising agencies in the UK.  He could draw anything, and did.” 
It was of course fascinating, and sad at the same time.  “Does he still draw?” I asked, still looking at the piece of paper in front of me. 
“No - he’s not awake long enough to do anything.  And we don’t leave out such things since they’re sharp.”  I asked if it was possible if he could use something like an iPad or other touchscreen.  “He always hated those things,” said his partner.  “I love them, but he used to say ‘you can’t feel what you’re doing with them.’”  
“Well, perhaps what you can do is to try keeping him awake by having his old drawing materials available while under supervision,” I said, hopefully.  “That way, you might be able to reverse the sleep wake cycle and provide him an engagement that he might be willing to stay awake for.  Just a thought.” 
Both Mr. T’s caretaker and partner agreed to try to do this as well as re-try using some version of a tablet computer to see what he might be willing to do.  The next time I saw Mr. T and his compatriots, they had some sketches to show me, which quite frankly were just incredible. 
There was a pencil rendition of a park with swings (“from across the street, like I told you,” noted his partner), a large leaf with smaller leaves covering it, and an old rotary telephone, with the receiver hanging off the hook, with the intricacies of the lines of a twisted cord noted. 
“These are simply stunning,” I replied when shown the drawings. 
“Yes, he’s quite talented.  He did things similar before,” replied his partner matter-of-factly.  I just nodded with the acknowledgement of his talent.  “By the way, he threw my iPad across the room when I gave it to him to try,” laughed Mr. T’s partner.  “Modern technology has no place with this artist.”  No, indeed. 
And his sleep?  “It’s gotten better, but not perfect,” said the patient’s caretaker.  “He sleeps about 4 hours a night, but that’s a lot better than none.”  I encouraged both the caretaker and partner to hang in there, and that hopefully with continued good sleep hygiene and his engagement with his artistic endeavors, he’d sleep at least 6 or more hours at night. 
“We’re on the right path,” said the patient’s partner.  “And thanks for the suggestion to let him pick up a pencil again.”  “Indeed”, I replied. “I’m really happy it helped.” 
To which his partner noted, “Yes - we all really need to remember the artist in him.”  
<![CDATA[Carson:  Being in "Our" System]]>Wed, 18 Oct 2023 22:31:14 GMThttp://bliangmd.com/blog/carson-being-in-our-systemAbandoning a society and its health care system
I only saw Carson once in my clinic, but he’d made quite an impression on everyone there within Neurology. 
He was about 40 years old, although he looked quite a bit older.  His face was darkened from the sun, creased heavily, and with splotches which I thought might represent early stages of keratitis or squamous cell carcinoma.  He was dressed in what appeared to be old clothes, patched in many places, covered by a coat with crisscrossed strips of fur, matched with a dark untrimmed beard. 
His shoes were more conventional, which were workman’s boots, and had appeared to be worn through to the steel toe at least on the left, and had been repaired at least several times in the past.  He seemed to squint most of the time, but when his eyes were open they had a greenish shade, like the color of lily pads at dusk.  As I walked into the clinic room, he stood up, and reached out to shake my hand.
I introduced myself, somewhat hesitant given the rampant biases in my mind given the patient’s appearance and what I was expecting to hear back. 
To my surprise, Carson spoke clearly and concisely, with a bit of a New England accent, “Nice to meet you, sir.  Thank you for seeing me today.”  Recovering from what was a somewhat shocking breakdown of my expectations, I asked the patient what I could do for him. 
“Well, Doctor, nothing really.  I’m not particularly interested in medical care.  After being in the Emergency clinic yesterday, they suggested I come to see you just in case there was something that needed to be done before I’m on my way.”  When I asked Carson what had been going on, he noted that he’d been getting weaker on his left side, but that he didn’t make much of it. 
“As you might have noticed, I live off the land. I built a cabin up in the mountains.  My dog, Stone, and me - we farm and hunt.” 
I’d heard of people like Carson, who were industrious enough to be able to live by themselves off the grid.  I asked him why he had become such a person.  “Oh, a mountain man?  I gave up on society, on people, years ago.  There’s too much materialism, too much need for money, and not enough connection with what surrounds us.”  He continued that it was a choice, and one he never regretted. 
“Well, sir, then why are you here, then?”  I asked again.
Man of the land
Carson relayed that he grew plants, and set traps for game, and that he would often walk 10 to 20 miles a day for these opportunities. 
“I have a degree in horticulture, so I’m pretty familiar with the plants here. And the small game – they’re plentiful.  But I have to get to them.” 
 Apparently, Carson was having issues hiking in his usual routine, that he noted he used to be able to do in every season, during the day, namely in sunlight.  “Now, it’s starting to get dark as I turn up toward my cabin past the creek.  I know I’m late.” 
He had tripped near one of the dirt roads, and apparently had lost consciousness, and had been found by some hikers, who insisted he come with them to the emergency room (ER).  “I had no desire to go.  But I was scared, and tired, so I went.  The doctors there think I may have had a stroke.  I don’t know. I thought strokes happen all of a sudden.  They told me to come here afterward.  So I stayed in the park down the street, and came here this morning.” 
I marveled at the inconsistency of Carson, but also his resolve.  I talked to him about his weakness, and he told me how it seemingly had evolved over several months, thus less likely a stroke.  We went through the differential diagnosis, in which he just shook his head. 
His examination showed a clear weakness of his entire left side, and increased reflexes.  I told the patient he really should be evaluated with imaging, to assess this further.  “Doctor, I asked the other doctors in the ER, what can be done now?  I mean, you listed all sorts of things this could be.”  
I noted to Carson that this could be a whole host of things; that he could be having seizures, that he might have something in his brain, that certainly he could’ve had a stroke and the like.  He asked if this could be treated holistically, since he didn’t take medications.  I told him that to my knowledge most of these things could not, but somethings might be surgically treated. 
“No, and no,” said Carson definitively.  “I don’t take medicines, although I do drink tea that I make from herbs.  And I don’t believe in surgery.” 
Shaking my head ever so slightly, I asked again why the patient had come to see me then.  “Maybe it was just that I wanted to know what might be going on.  I won’t change my life.  If it’s my time, it’s my time.” 
Although I knew it would be futile, I tried convincing Carson that the best thing to do for his health was to get evaluated, get a diagnosis, and potentially be treated so he could go back to living the way he wanted to live. He just shook his head. 
“Doctor, like I said, I’ve given up on this society.  Why would I go and get lots of tests that I can’t pay for, engage in the greedy system, and take medicines or worse - and have to deal with all of this…” he gestured to our room as he looked up, “…again?  I’d be falling into the same trap you all have.” 
After a slight pause, I said to the patient that it was his choice, and that we would be here if he changed his mind and wanted to take advantage of our system’s care structure. 
“That’s just it, doctor - your system.  It’s your system that I’ve been lucky enough to get away from.  And I will, again.”  He smiled and thanked me. 
Then Carson got up, and shook my hand, and left the clinic without checking out.  My medical assistant came up to me and asked what we were going to do with him. 
After a moment, I answered quietly, “Nothing. He’s going back to his system.” 
And as I walked back to my office, I wondered what was going to happen to him. 
And, who really was getting the better deal.