The Nervous Pool Cleaner

Ever heard of capitation?  In healthcare, it can mean that a clinic makes more money by following more patients.  Payments are per person, rather than per service.  I guess I shouldn’t be surprised, then, that they refused to dismiss this guy from their care.

He was a 32 year old young man who was diagnosed with an anxiety disorder.  He had been working independently as a pool cleaner but he couldn’t stand it anymore.  He was always nervous.  As a matter of fact, this man was nervous about everything he did.  Perhaps it was a generalized anxiety disorder, but surely something a great deal more.  He wasn’t having panic attacks, and he exhibited far more than the usual one or two things found in generalized anxiety disorder.

I tried to start him on some medications — as much as I didn’t like the medications he had been started upon.  He had been given regular Xanax in slowly increasing doses.  As nervous as he was, he wasn’t stupid.  He said, “It’s really funny.  The medication makes me sleep, but it sure doesn’t stop me from being nervous.”

I suggested that something else could be causing his anxiety and we should figure out what this was.  I offered him more information on the medications he had that made him most comfortable.  He was quite certain it hadn’t been the Xanax. It turns out that in this particular case, it had been Zyprexa.  It was a pediatric dose, but at least it had gotten him some sleep.  I educated him on the side effects, which I wasn’t crazy about. But it bought me a week or so to study his chart.

The most obvious thing missing from his chart were blood tests.  He had been followed for anxiety with virtually every medication I could think of that is supposed to have an anti-anxiety effect. But according to his chart and from what he told me, no one had thought of doing any blood work.

In general, I prefer to order blood work when I first start to see a patient — before they get settled into the idea of the diagnosis.  Both doctors and patients have a very strange way of getting attached to diagnoses.  I always thought a doctor was something like a woman who gave birth to a baby.  You just don’t want to let it go or believe anyone else can take care of it.  Like the old Jewish joke that the viability of the fetus does not come until after it has graduated from medical school.

He didn’t like the idea of blood work.  He had settled on the idea that his trouble was an anxiety disorder.  I assured him that there could also be a medical cause for his troubles, and he eventually gave me permission to move forward.

In general, I will test blood sugar and do a blood count to see if there is an infection or something similar going on.  I will also order as many thyroid function tests as I can.

In most continental health systems, people only test TSA thyroid stimulating hormone, which is the hormone that comes from the brain and controls the thyroid while it does its thing. About 85% of all abnormal thyroid functions can be detected in this manner.  However, to get a higher percent I usually like to get a T3 uptake and a 3T4.

This young man came back with what were — without exception — the most abnormal thyroid functions I have ever seen.  His thyroid stimulating hormone was essentially zero.  This means that the hormones coming from the thyroid were so active that they were literally sending instructions to his brain to stop stimulating the thyroid.  All of the hormones produced by his thyroid were present in amounts which were not lethal but were keeping his pulse a tad above what one would expect to find.  I remember even when we got him to relax that his pulse rate was 88 to 90. He told me that others had clocked him at 120 when he wasn’t able to relax.  And of course, the blood pressure was a little high too.

These results were all marginal and not enough that we would look at him and say he had a thyroid problem, an adrenalin problem, or a whatever problem.  But once I saw this, I told him, “Look, this is not a psychiatric problem.  This is something that is treated with chemicals that slow down your thyroid and I think you will be better.”  He looked at me very surprised and said, “My mother has a slow thyroid and she takes thyroid hormones to make it faster.  That’s not my problem is it?”  I said, “Not exactly, but the fact that she gave birth to you suggests there may be something going on with the thyroid that is common between the two of you. But you know something? I’m not the expert on this.  We’ve got to get you to a real doctor.”   This, by the way, is the way I always talk about doctors who aren’t psychiatrists.

At first, he didn’t want to go to a general doctor.  I mean, it took him a couple of months to get there.  Most patients seem relieved when we get a diagnosis that isn’t psychiatric for what’s going on.  But to my surprise, he was the exact opposite.  He had been working with —you guessed it, a psychotherapist — who told him his problem was insecurity and that he’d had a suboptimal upbringing.  I haven’t found anybody yet — including me –who’s had a maximally optimized upbringing.

After he got the guts to make an appointment to see a doctor, the doctor told him he had something that could be controlled.  He would be more relaxed and he would get better.  He was given a prescription for something, probably radioactive iodine or a radioactive version of some compound that would be taken up by the thyroid hormones and slow his thyroid down.  I’m not sure exactly what the treatment was.  The doctor also suggested he see a psychiatrist.

I’m the only person I know in that particular continental health system who is fairly compulsive about sending my diagnostic ideas and treatment results to other physicians.  Most often, it’s through phone calls and a letter.  But at any rate, after about 3 months I never saw this young man again. He went to see another psychiatrist, whom he had told me he didn’t like and whom he had seen prior to my joining the team.  He told that psychiatrist to tell me, “Say hello to Dr. Goldstein.  She gave me back my life.”

Huh? Well, he started taking whatever compounds he had been given.  He was slowing down.  He was sleeping and he was formulating plans for more education.  I thought at the very least I ought to tell the psycho-therapeutic team what was going on – but I didn’t even get to do that.  His psychotherapist told me he was going to continue to treat his insecure childhood.  I told him he could treat virtually the entire population in the city we were living in because nobody has a childhood that fills their needs.  As a matter of fact, it’s been said that what people choose in the interests of their adult life is a function of what was missing in their childhood.

But, they didn’t want to give up and he kept returning to the same psychiatrist.  I said to this psychiatrist, “You are not correct in prescribing psychiatric meds for this patient.  He does not require them.  He should not be seen in this clinic.  There is nothing more we can do for him.”  “We have to continue to follow him to see how he is doing” said the other psychiatrist.

I went and talked to the Chief of Psychiatry because this was not the first time I had “cured” someone yet was unable to dismiss them from the clinic.  The truth of the matter, the chief admitted to me, was something I had come up against a few times before and several times since. It’s called capitation.  It refers to the amount of money that a government entity or any agency that funds a clinic as being a function of how many patients are followed.  Nobody ever gets dismissed because it’s like giving away money.

The last I heard — after I had “given his life back” to this patient – he was continuing to have regular appointments for pharmacology and psychotherapy.  Appointments, mind you, for pharmacology that he never received and appointments for psychotherapy that he never needed