Prevention is in the Eye of the Beholder

I saw a new patient the other day for a physical. No complaints, he said. He was very healthy, he said. Wellness was very important to him, he said. He was interested in being as proactive as possible about his health.

Wonderful! What more could a primary physician ask for than a healthy patient interested in being proactive about wellness?

I begin by taking a complete medical history and performing a physical examination.

Any medical conditions? No.
Ever been operated on for anything? No.
Allergic to any medicine? No.
Family history? Nothing.
Do you smoke cigarettes? Yes.

Wait, what? Health; wellness; prevention; smoker??

You will all be very proud to hear that I was in fact able to keep a straight face.

Next up is the physical, which begins with the measurement of vital signs:

Weight: 210 lbs.
Height: 67 inches
Body Mass index: 32.9
Temperature: 98.7, orally
Pulse: 74
Respirations: 12
Blood pressure: 160/100

Remainder of physical examination was completely unremarkable.

Okey doke. So what we have here is an obese smoker with an elevated blood pressure. My proactive wellness recommendations would be to stop smoking, begin an exercise program, and lose weight with a reduced-calorie diet.

It turns out that what the patient's idea of proactive wellness is a chest x-ray and an EKG.

WTF?

Yes, he's aware that smoking increases his risk for lung cancer, which is why he wants the chest x-ray. This kind of makes sense (not really) but the mind-boggling thing is that he doesn't want to quit smoking.

I try to wrap my mind around this illogic (it's tough when one's brain is trying to ooze out through one's ears) and turn to the other major cardiovascular risk factor I have identified: his elevated blood pressure.

Yes, he knows that high blood pressure can lead to a heart attack. This is why he wants the EKG. No, he has no chest pain, shortness of breath, exercise intolerance, or any other acute symptom of coronary insufficiency at this time. And no, he is not particularly interested in changing his diet or exercise habits; and he doesn't think he'd be willing to take any medicine for his blood pressure (if it's still high after two more readings). He just wants the EKG. Because he's so proactive about wellness.

See what I'm up against?

Whose Medicine is it Anyway?

Hypertension, or high blood pressure, is one of the most commonly diagnosed chronic conditions seen in this country. What many people don't realize, though, is that a single blood pressure reading is not enough to make a formal diagnosis of hypertension. Technically, you need three readings on separate occasions -- preferably different days -- to make the diagnosis. Because I like to use sports analogies, I tell my patients that the diagnosis of hypertension doesn't happen until you have "three strikes."

What I usually do when I first measure a blood pressure higher than 140/90 is to explain this to the patient. I also discuss the role of weight loss, exercise, and sodium restriction in reducing it. Then I ask them to come back in a month to re-check the blood pressure. With any luck -- and with aggressive lifestyle modifications on the patient's part -- a mildly elevated blood pressure can respond before I ever make the diagnosis, coincidentally sparing the patient the official record of a "pre-existing condition."

I saw a guy the other day with "strike two". His blood pressure was still about 150/100. He wasn't all that overweight and his diet was already pretty good, so I started trying to prepare him for the fact that he would likely require medication to control his blood pressure. Like many people, he wasn't keen on that idea. He scowled as he said, "Okay, we'll give it one more month. Then I guess I'll take your damn medicine."

I thought, "What do you mean, my medicine?" My blood pressure is fine (as are my cholesterol and thyroid, thanks to better living through chemistry). I'm talking about medicine for you, Mr. Patient. Which got me to thinking:

Whose medicine is it anyway?

As prescribing physicians, we often talk about all the medications at "our" disposal. Is studying, understanding, recommending and writing for drugs enough to invest us with their "ownership"? Or does filling the prescription, paying for and swallowing the pills carry more weight?

I guess that's the source of the expression, "to take one's medicine."

One Quick Question

One quick question. What could be wrong with one quick little question? Just this: if I hear the words, "I just have one quick question" one more time, someone will be ripped limb from limb and fed slowly to the great Sarnack to be slowly digested over a thousand years, while I set my hair on fire, yank my fingernails out one by one, and shriek for mercy to the heavens above. Also, I may get a little upset.

Here's why.

It's flu shot season. This means that in addition to scheduling patients for regular visits, we have people coming in just for a flu shot. We pull the chart (so we can document the flu shot), but they're squeezed in and around the other patient visits. Given that it takes me about 15 seconds to draw up a flu shot and literally less than one second for the actual injection (not counting however long it takes them to roll up sleeves/remove jackets/unbutton shirts/whatever it takes to get to bare skin), we usually get these folks in and out pretty promptly. In fact, we count on it.

So when they start in with other stuff, like "I need a couple of prescriptions," or "Can you check my blood pressure?" or "Can I just see what I weigh?" or the infamous, dreaded "Can I ask one quick question?" my blood pressure starts to rise, as do the hairs on the back of my neck, and my hackles.

It sounds (and feels) so petty to say, "NO! You're just here for a flu shot. Not a blood pressure check; not a weight check; not for prescription refills; and certainly not for a visit, which is what we call it when you have questions -- quick, slow, long, short, whatever -- that require my professional expertise to answer. I mean, that's why you're asking me, right?" So I don't say that. Even if I'm thinking it; I somehow manage not to say it.

Instead, I swallow hard and say, "Sure."

And they ask their question, which often needs an office visit, which I try to get then to schedule. And I'll write a prescription or two; if there are more, I'll ask if they can come back later; they're usually okay with that. But I won't weigh them or check their blood pressure when there are other patients waiting for scheduled appointments. Mostly, they understand. I hope.

Because one quick question is seldom quick.

By Request

An email received from one of my two readers (who aren't related to me):

So - post something about the new health care legislation!!!

Huh?

Excuse me??

Um, what exactly are you talking about???

There was a ridiculously large, abstruse bill passed in Washington that no one actually read all the way through which included explicit provisions for payment for pseudoscientific religious nonsense (Section 125) along with financial incentives to states for not trying to address the issue of tort reform, among other provisions that don't actually mean anything until some unelected bureaucrats write the rules that will actually be implemented.

Once actually written and implemented, though, nothing in this bill does or says anything about health care. Rather, what is attempting to be reformed is payment for health care. Please note that I am even refraining from using the word "insurance" in this context, because "health insurance" as commonly used in this country at this time is not actually "insurance" in any linguistic meaning of the word. What we call "health insurance" is actually brokered payment for health care services.

Nothing about actual health care anywhere to be seen.

My bottom line response to the passage of this bill and other shenanigans currently being perpetrated in our nation's capital: move on; there's nothing here.

Saddest Words Ever

Overheard in a hotel lobby:

Obama makes sense, until you hear Rush Limbaugh and Sean Hannity explain what he really means.

That's it. We're doomed.

Tweaking the Tail of the Home Birth Tiger

Science Blogs has a new contributor: Dr. Amy Tuteur, an OBGYN who elicits, shall we say, very strong reactions among her readers.

Dr. Amy's debut post trumpets "The Tragic Toll of Home Birth!" (The exclamation point isn't actually there, but doesn't it sound like it should be?) Reading through it, though, sounds more like a screed against midwives -- specifically those who are not CNMs (Certified Nurse Midwives) -- than home birth per se. She includes this nifty chart to demonstrate her point:

Let's see. According to these numbers, non-CNMs do indeed have higher neonatal mortality rates than either MDs or CMNs, however MDs have nearly double the mortality rate of CNMs! Wow. If I really want to be safe, I should go to a midwife.

Then again, that table doesn't actually say anything about home birth. It just breaks down mortality figures by birth attendant. As it happens, the database Dr. Amy links is ridiculously easy to navigate. (Go and play with it.) In fact, I was able to come up with this breakdown of home birth vs. hospital birth, by birth attendant, using the same remaining parameters as Dr. Amy (2003-2004; white women, 37+ weeks, ages 20-45):

[Sorry I can't manage it in a nifty table format]

In Hospital:
CNM: Deaths: 107, Births: 292,422, Deaths/1,000 births: 0.37
MDs: Deaths: 2,118, Births: 3,498,447, Deaths/1,000 births: 0.61
Other Midwives: Deaths: 2, Births: 4,323, Deaths/1,000 births: Suppressed

Not in Hospital:
CNM: Deaths: 6, Births: 11,853, Deaths/1,000 births: Suppressed
MD: Deaths: 7, Births: 2.689, Deaths/1,000 births: Suppressed
Other Midwives: Deaths: 20, Births: 16,613, Deaths/1,000 births: 1.20

(Note: Rates are suppressed when the numerator is less than 20, because the figure does not meet the NCHS standard of reliability or precision.)

Source: United States Department of Health and Human Services (US DHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis and Epidemiology (OAE), Division of Vital Statistics (DVS), Linked Birth / Infant Death Records 2003-2005 on CDC WONDER On-line Database. Accessed at http://wonder.cdc.gov/lbd-current.html on Nov 5, 2009 11:45:58 AM

So what does this really mean? It means that a total of 33 babies who were born at home between 2003 and 2004 died in their first month of life. Yes, more of them had mothers who were attended by non-certified midwife than by a CNM or MD. By contrast, if you add them up, there were 2,227 babies born in hospitals who didn't make it past a month either. The rates for total mortality by place of birth including all birth attendants is 0.59 per thousand births for hospitals and 1.06 for "not in hospital".

Okay, then. Say we admit that, taking all comers, a baby is about twice as likely to die if born at home than in a hospital, or even three times as likely if attended by a lay midwife. Sounds pretty scary, no? Well, no.

It's the age old difference between absolute and relative risk. Take TBTAM's trick of using a piece of graph paper with 1,000 squares, and see what the difference is between having one square colored in, or two (or even three). Combine that with the tiny absolute numbers of women who want to give birth at home in the first place (I didn't want to have to clean up after it, frankly) and the whole thing starts looking more like the ideological witch hunt against midwifery that it actually is, and a whole lot less like a noble call to save large numbers of innocent babies from their mothers' intransigence.

News flash: people choose home birth over a hospital experience for many reasons, and will continue to do so even in the light of these statistics. Why? For the same reason they ride motorcycles, some of them without helmets. They feel that the advantages to them outweigh the risks. How can they best minimize the risk? By selecting a birth attendant with appropriate training and experience, for one. More training for midwives? I'm all in favor. But demonizing the entire home birth community by condemning their "Tragic Toll" is uncalled-for.

If you want to talk about "Tragic Tolls", Dr. Amy, check this out:

The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1,760 child fatalities in 2007.

Now that's tragic.

Bring on the Bets

One or two of you may be aware that there is something going on called the World Series. ("What world would that be?" asks this crotchety old guy in his 80's whom I've known for years.) It's the end of the baseball season, and this year it is being played by (my) defending champion Philadelphia Phillies and the New York Yankees.

As is traditional, the mayors of the two cities involved have engaged in a friendly wager. In past years, this has usually taken the form of a food exchange ("cheesesteaks or cheesecakes"). This year, though, you have to admit that Philadelphia Mayor Michael Nutter and New York Mayor Michael Bloomberg have really raised public service (and from "public servants", no less!) to a new level:

Regardless of the outcome, both mayors will host public arts projects. Nutter would join Mural Arts to paint a mural on the side of a recreation center. Bloomberg would partner with Public Color to paint the interior of a school.

If the Phillies win the series, Bloomberg will travel to Philadelphia to take part in the day of service while wearing a Phillies jersey. If the Yankees win the series, Nutter will travel to New York to take part in the day of service while wearing a Yankees jersey. The mayor of the losing city will also buy the mayor of the winning city and his fellow volunteers lunch.

That's just cool.

What it's really done, of course, is to completely reset the bar for all future mayoral sporting bets. Who's going to have the nerve to offer up a case of the local brew against some regional delicacy after this kind of event? Bravo to both of them!


PS: Breaking news from New York:

Suzanne Somers "Total Body Cancer" Debunked: The Cliff Notes Version

I love reading Respectful Insolence. Orac does a wonderfully meticulous job of tearing down all kinds of pseudoscientific nonsense. Go and read -- sometime when you have some extra time on your hands. The more time, the better; although he is good, he does tend to ramble a bit.

His current project is a review of the new book nonsense by the original ditzy blonde herself, Suzanne Somers. The problem is that she is too stupid to recognize the utter depths of nonsense she has plumbed in this tome. The "Doctors who are Curing Cancer" interviewed in this book are uniformly quacks whose techniques and treatments are either ridiculously implausible or scientifically proven not to work -- or both. Go and read Orac's archives for more detail. Also be aware that he will be posting more about the book; he's a better man than I. Then again, presumably if his brains explode he has his wife and/or laboratory cleaning personnel to clean them up after him. I have to do it myself, and brains are notoriously difficult to get out of carpet, not to mention all the little nooks and crannies of keyboards.

His most recent post is fabulous, but really long. I thought I would perform a public service by cutting to the chase and revealing what curious readers -- albeit those who have too much to do to peruse Respectful Insolence in its entirety -- are, well, curious about. At least I was.

Apparently in Chapter 1 of the book, Somers states that she was "misdiagnosed with total body cancer." Knowing that there is no such thing, Orac and I wondered what it could have been. Orac, who actually went and read the thing, reveals that it was disseminated coccidiomycosis, also known as Valley Fever. Coccidiomyces doesn't usually cause much in the way of illness in generally healthy, immunocomptetent people. On the other hand, one of the risk factors for dissemination is a suppressed immune system. Manfully resisting Leaving aside for a moment the I-told-you-so temptation (aka schadenfreude) to someone who took fistfuls of supplements supposedly intended to strengthen the immune system, what really was going on with her?

I knew that her supplement list included "bio-identical hormones" like estrogen. I also happen to know that chemically, estrogen is indeed a "steroid" hormone, however its protean effects do not include direct effects on the immune system. Ah, but it turns out that her regimen included "cortisol repletion"! Aha! She was indeed taking corticosteroids (unprescribed and unmonitored by a competent physician; funny about that)! And those can indeed depress the immune system.

The real problem with pseudoscience is that people's bodies neither know nor care what the person inhabiting them believes. Suzanne Somers' belief that she was "cortisol deficient" didn't make her so. She ate cortisone. Her body responded by making less of it, and by damping down its native immunity, thus allowing a usually indolent fungus to spread throughout her body.

Dumbass.

There you go: 550 words, give or take, compared with Orac's almost-9,000 word screed. Granted he covered far more material than I -- and I strongly encourage you to go read it -- but the more I think about it, the more I believe I have summarized Suzanne Somers effectively and accurately. In fact, I shall repeat it for emphasis:

Dumbass.

The Emergency Department EMR from Hell

Despite the fact that I am almost always available to my patients day and night, day in and day out, weekends and holidays included, there are occasions when they go to the Emergency Department*. Sometimes they call me first. Once I have ascertained, for example, that what they have is an acute surgical abdomen (I have indeed diagnosed appendicitis over the phone more than once), then they don't need me. What they need is a hospital and a competent surgeon, and the most expeditious way for them to connect with those two things is through an Emergency Room**.

Still, there are several other appropriate circumstances when patients head to an ER without calling me first. In these instances, though, it is a generally accepted responsibility of said ER to somehow let me know that the patient was there. A phone call is way above and beyond for routine problems, although there are occasions when it's appreciated (like when a patient comes in dead. It happens.) Failing that, some kind of written notification, either faxed or mailed, serves the purpose nicely.

The first step in the notification process, of course, is the patient admitting letting the ER staff know that I am their doctor. If the patient doesn't give my name when they check in, all bets are off. Once I am on record as their primary physician, though, the ball is in the ER's court.

I've been on staff at two different hospitals; one during my first decade of practice, and the other for the second. Despite the fact that the first one now has an electronic medical record (EMR), nothing much has changed in the notification process: I get a fax of the face sheet of the chart. What that means is that I get the patient's name, the date and time he/she signed into the ER, and all the contact and insurance information that I couldn't care less about. If they are then admitted to the hospital, I get a second fax identical to the first in every way, except that a previously blank space labeled "Diagnosis" is now filled in. If they are discharged from the ER, I get nothing. No idea what happened, what the problem was, the diagnosis, any prescriptions given; nothing. On the other hand, I do have that original sheet, which I leave in the patient's chart. Then the next time I see them or talk to them I'm able to say, "I see you were in the ER on such-and-such a date; what happened?"

The second hospital is a different story. Back in the olden days, they used a paper system called T-sheets. Every possible complaint had its own sheet, each with dozens of tiny check-off boxes allowing the ER staff to document out their asses in minimal time. They loved it. When the family physicians on staff began demanding requesting that they let us know when our patients were seen in the ER, they responded by faxing us the entire ER chart. This invariably added up to a minimum of 17 pages, of which at least three and up to six were completely blank. (For real; they faxed blank divider pages.) Not only that, but the tiny little print was essentially illegible when transmitted by fax. Usually the only way I could tell what the hell the patient was actually there for was by looking at the pre-printed discharge instructions (that were of course also included in the fax). As has been stated elsewhere, the signal-to-noise ratio of the information in this format was unacceptably low.

Furthermore, there were still many occasions when we didn't even get the 17-page packet of gibberish. The standard answer from the ER docs, recognizing our legitimate complaint, was this:

"Call us."

Um, let me get this straight. If a patient of mine goes to the ER, I don't know about it, and I don't get a report, I should call you. Hmm. So the next time you don't hear a tree fall in the woods, run for cover.

Recently this hospital has spent millions of dollars building a brand-spanking new hospital wing, including a brand-spanking new ER. This brand-spanking new ER also contains a brand-spanking new EMR. Hurrah! Never again will reams of paper be wasted generating illegible notes. This brand-spanking new EMR has the capacity to print out a concise summary of the patient's ER visit, and -- will wonders never cease -- to automatically fax said concise summary directly to little old me. Of course it turns out that although this brand-spanking new EMR can do this, does not mean that it does.

Receiving notification from the ER had been an ongoing issue with this hospital even prior to their multi-million dollar construction project and the acquisition of their brand-spanking new EMR

I recently got a phone call from a patient telling me he had been in the ER three days earlier and was told to call me to schedule a follow-up appointment, which is why he was calling. Because I finally had a situation where I knew exactly when I actually had a patient go to the ER, I called to see what happened to the brand-spanking new report from their brand-spanking new EMR. I actually had a lovely conversation with a conscientious and helpful ER doc, who asked me when the last time was I had gotten an ER report on one of my patients from them.

Because the answer was, "Never," I instead asked, "How long have you had the new system?"

Answer: "Since May."

Okay, then; at least five months.

After some rooting around on the part of the conscientious, helpful ER doc, it turned out that the only way their brand-spanking new EMR system would send me a nifty new easy-to-read report was if all of the following things happened:

• If I was in their system (I am)
• If the system had my correct contact information (it does)
• If the doctor clicked on my name from a pick list while he was writing the discharge instructions. Note: Not before (ie, the information wasn't carried over from the sign-in process when patients are asked who their doctors are); not during the visit (while the doctor was in the process of diagnosing and treating the patient), but SPECIFICALLY while the doctor was typing the discharge instructions.

Maybe that doesn't seem particularly onerous, but I think it's ridiculous. How many other things would I rather have an ER doc thinking about while discharging the patient, especially when MY F*CKING NAME AND OFFICE NUMBER ARE ALREADY IN THE GD CHART!!!

It turns out this brand-spanking new EMR has a few other little minor shortcomings:

• It doesn't let the physician access the nurses notes
• It doesn't let the physician access notes from triage
• It doesn't let the physician access the past medical history, family and social history already gathered earlier.

Um, excuse me, but isn't a computer's major strength its ability to eliminate repetitive actions? Hell, any time I want to order something from a catalog, there's this nifty feature that lets me check off a box that says, "Billing address same as shipping?" instead of having to enter my address again. (Not only that, but once I've done it, there's this thing called auto-fill that allows me to just point and click.) I thought that's what computers were supposed to do best!

But no. Here we have this brand-spanking new EMR -- did I mention that it's one of the largest and most popular EMRs (almost certainly among the most expensive too) nationwide? -- that basically makes the doctor duplicate all the nurses' charting.

Can't they fix this little bug? Surely it can't be all that difficult from a technical point of view.

Actually, it's not. The problem is that because it's such a large, widely used EMR, they can't make changes for just one user. They have to change it for everyone.

So...Why not do that? While they're at it, what's with having to make sure I'm "in their system"? We have these really cool new things called NPIs. The letters stand for "National Provider Identifier". Last time I looked, that first word ("National") pretty much applied to the entire country. So why can't they just incorporate the national NPI database into the system. That way, any time one of my patients went to an ER anywhere in the country, there's an easy-peasy way to identify me as the person waiting with bated breath to read the ER report.

Sorry, came the answer from the conscientious, helpful ER doc. We can't do that right now. So I'll just keep trying to remember to click on your name when your patients come in. I'll also make sure the other docs try to remember to do it too.

EPIC WTF.




* Happy now, Whitecoat?
** Sorry; old habits die hard.

Ask Your Lawyer If He Carries Malpractice Insurance; You May be Surprised

I've posted here and here about the responses of lawyers in two different states to the proposal that they be required to disclose to their clients whether or not they carry professional liability insurance. In general, the publicized responses have been against it.

I would like to share a modest proposal for dealing with this issue. Best of all, it doesn't even have to involve the lawyers at all.

Let me begin by pointing out that the essence of professionalism is responsibility; doing the right thing not because you will get in trouble if you don't, but simply because it is the right thing to do. Seen in this light, carrying professional liability insurance to protect your clients/patients against the financial ramifications of your inadvertent errors is the responsible course of action.

When presenting oneself to the public as a professional, it is to be hoped that one is representing that one is responsible. Therefore the vagaries of whether or not a given group of professionals (ie, doctors) is required by law to carry malpractice insurance is immaterial. It is not unreasonable for a medical patient, a legal client, or a patron of any other professional to assume that said professionals carry insurance appropriate for their business.

As came to my attention via the above linked posts, there are apparently large numbers of attorneys who do not take the responsible course of carring liability insurance. Here's what I propose we do about it:

I propose a large public service campaign to educate the public about the fact that many lawyers do not carry malpractice insurance. Just as consumers have been sufficiently educated to inquire of their doctors whether or not they are board certified, we should explain why it is important to ask their attorneys whether or not they carry malpractice insurance. The idea, of course, is to raise the question of why would one would want to engage the services of someone too irresponsible to protect his clients' interests.

Any philanthropist out there want to donate a couple of billboards?

More on H1N1 Flu; In Which I Call Dr. Anonymous onto the Carpet for Being a Wimp

The venerable Dr. Anonymous, although no longer technically incognito (like a certain dinosaur), has been busy of late. He's transformed himself from a full-fledged blogger into more of a media mogul, schlepping his trusty video camera hither and yon. He podcasts on Thursdays, and makes sure that Vegas is no longer confined to Vegas. He even has a regular gig on his local TV news. In the face of all this, he rarely writes true blog posts anymore. Leave it to me, then, to jump down his throat on one of the rare occasions when he actually does so.

His latest exposition is on the topic of H1N1 influenza. Bookended by a pair of very nice video clips, Dr. A sallies forth over well-explored territory, promulgating validated information about both the disease and the vaccine. After all that, though, here's where he falls down:

When it comes to immunization, it's definitely a personal decision.

Cut me a break! That's like going on and on about the risks of driving while drunk, and then saying, "It's definitely a personal decision." This is actually true. In fact, one drunk driver presents less of a numerical risk to the rest of the population than does one unimmunized individual during pandemic flu, especially if said individual works in health care. The DUI dude can only kill, at most, one or two carfuls of people, whereas the unvaccinated RN can wreak havoc throughout an entire institution.

Dr. A goes on to say this:

The only thing I ask is to just ask yourself this question - What is the risk to yourself (and your kids) if you DO get the H1N1 vaccine (mild side effects, in my opinion) verses the risk if you DO NOT get the H1N1 immunization?

Here's where I call WIMP*. Dr. A, you've just done an excellent job of explaining that the risks of vaccination are downright trivial, compared to the documented substantial risk of pandemic H1N1 influenza, especially to children. Why wuss out now and call on the patient to make the final determination of the balance of risk vs. benefit? You've just laid it all out for them. You need to take a stand and say that vaccination is the responsible course of action.

Patients are looking for our recommendations. When the issue is this clear cut -- and make no mistake, despite the pseudoscientific fear mongerers lurking around every corner, this is indeed one of the most straightforward decisions our patients are called upon to make -- we do them a disservice by wimping out and calling it a "personal decision".

Edited to add:

Every patient has the right to make "personal decisions" about whether or not to follow the doctors' recommendations. It is still our responsibility to come out and make those recommendations.

Man up, Dude.



(*Note to COG: that's not an acronym.)

Dino Road Trip, or: Tomorrow is the Day Yet Again

Tomorrow, Saturday, October 24th, Darling Spouse, the Rolling Peke and I will be heading back to where I was spawned for an author event at the Barnes & Noble in the Clarendon shopping center in Arlington, Virginia. If you're in the area and available, we'll be starting at 1:00 pm and we'd love to have you join us.

Texas Follows in California's Footsteps

The more things change...

Way back in June of 2007 I wrote this post, about the uproar in California when a rule was proposed compelling lawyers to disclose to their clients whether or not they carried professional liability insurance.

Now it's happening in Texas:

The Supreme Court of Texas has asked the State Bar of Texas Board of Directors to make recommendations in early 2010 regarding if Texas lawyers should disclose to the public whether they are covered by professional liability insurance (PLI)....Texas attorneys are not required to carry PLI. In fact, the American Bar Association reports Oregon as "the only jurisdiction that requires its lawyers to carry malpractice insurance." For some occupations, insurance is mandated, for others it's simply seen as a necessary (and responsible) business practice. While Texas attorneys seem to recognize the benefit of their industry's exemption from PLI, they seem resistant to the public being fully informed of this status.

(h/t Examiner.com, via WhiteCoat)

I'm not sure I can say it any better than I did before. I only hope that it's okay to plagiarize oneself:

From the [original] article [about the corresponding issue in California]:

Malpractice insurance protects clients who lose money because of a lawyer's negligence -- missing a filing deadline, for example, or providing incompetent representation that affects the outcome of a case.

A lawyer's insurance status is "a highly relevant piece of information that a new client deserves to know," said San Jose attorney James Towery, a former State Bar president and head of a task force that drafted the proposal.

The ultimate irony, of course, is their corresponding stand on medical malpractice insurance. Even as they go merrily picking our pockets with mandated levels of coverage, they bitch and moan about merely disclosing that they themselves can't be bothered to protect their own clients. Can you imagine the uproar that would ensue if doctors not only chose to go bare (if they had the option) but then refused to tell their patients? How dare they! How irresponsible!

Just to be clear: no one is proposing that lawyers be required to carry malpractice insurance, merely that they disclose to their clients whether or not they carry it. For those morons thoughtful individuals who claim they've never been informed whether or not their doctors carry medical malpractice insurance, it should be noted that in almost every state it is required as a condition of licensure that a physician carry certain minimum levels of professional liability insurance. Apparently in states that do not have this requirement (Oregon; Florida) doctors are indeed required to disclose the fact that they do not carry it.

This one continues to fall way beyond "irony", past "hypocrisy", and right off the chutzpah meter.Once again, lawyers are proving themselves to be the most outrageous assholes imaginable. (I guess it's true that everything is bigger in Texas.)

Epic WTF.

Published Again

I took my hospital up on the offer to write a column for a local paper. This was in yesterday's Daily Local News, serving Chester County, Pennsylvania:

Which Doctor Do You Call?

Edited for style, of course, but still all me.

One of These Two Actions is Illegal

Which of the following two scenarios is illegal under Federal antitrust law:

• Half a dozen family physicians (of about 50 on a given hospital staff) get together and decide to set all their fees for medical services to the Medicare allowed amount plus $10.
• Two large insurance companies (together covering 80% of the market in a given municipal area) somehow between them manage to pay between 88% and 95% of the amounts allowed by Medicare.

That's right. The feds would go after the docs. That's because the insurance companies are specifically exempted from antitrust legislation known as the Sherman Act.

Perhaps a better question might be, "Which action is more anti-competitive and more detrimental to commerce and society as a whole?" Ah, but when has the law ever bothered itself with common sense?

Health Care for the Unemployed

Appended to a note about how much she enjoyed my book, a friend asks:

I'd be very interested in any thoughts you have about getting healthcare to the unemployed and uninsured. Do you have some?

If she means, "Do you have any thoughts about large structural changes in the delivery of health care that decouple it from employment and insurance status?" then the answer is yes. However in addition to being the topic of my next book, these thoughts by definition have no chance of actually helping any of the unemployed and uninsured -- two groups that frequently overlap, of course -- right this minute. If, on the other hand, she means "Do you have any thoughts about getting health care to the unemployed and uninsured this very minute?" then the answer is also yes. Furthermore, they fit into a blog post.

I'd like to make it clear at the outset that I'm not discussing primarily charity care. There are several local clinics and resources available that provide care at reduced rates. The thoughts I have are about making medical care more affordable by thinking outside the box and off the grid.

Medical Care

First, find a good family physician you can work with. By this I mean someone whose opinions and abilities you respect, and whose advice you will follow. The well-trained family doctor can care for 90% or more of the problems you may have, and can do so far more economically than the collection of specialists most people in this country have come to equate with "the best medical care in the world". You do not need an annual visit to a dermatologist/gynecologist/urologist/cardiologist to check your moles/pap/prostate/blood pressure, even though they may tell you that you do. This will also spare you from undergoing expensive, unnecessary testing: annual stress tests and echocardiograms do nothing for stable coronary disease; once you've had three normal annual paps, the frequency can be decreased to every 3-5 years; and so on.

Tell your family physician about your uninsured status. Plan to pay for your medical care, preferably at the time of service. Rates are often substantially less than you think they will be. My regular fees work out to about $200 per hour (ie, $50 for a 15-minute chronic care visit; $100 for a half-hour physical, etc.) Most doctors near me would probably charge about the same, or accept that amount upon negotiation.

Drugs

We are living in the golden age of generics. There are really surprisingly few patients who absolutely require expensive brand-name drugs. In addition to WalMart's $4 generics ($10 for 90 days), Target and Genuardis have almost identical lists. Many other pharmacy chains (Giant, Rite Aid, and others) will match prices, but you have to ask. Costco usually has the best prices. By law, you do not need to be a Costco member to use the pharmacy.

Labs

Laboratory studies are among the most overpriced components of medical care. The markups between what labs charge patients and their actual costs are truly sickening. I know this because their charge to me as a physician client is a fraction of the direct patient charge. By charging only a small markup for myself, patients end up paying less than half of what they would be charged by the lab. Additionally, there are assistance programs available. Then again, a qualified, thoughtful family physician (like me) will limit lab testing by doing only those tests absolutely necessary for appropriate diagnosis and treatment.

Imaging

There is a free-standing radiology center near me that offers fantastic service, and completely transparent pricing. If you call them up and say, "I don't have insurance. How much is a chest x-ray?" they will say "That will be $62." (Actually, a rep stopped by the other day and told me the price for a chest x-ray had actually decreased.) If you need to schedule an MRI, they will say, "Can you come over this afternoon?" Again, competent family physicians (like me) will only order imaging studies if they are absolutely necessary to diagnose and treat you appropriately.

Immunizations

Every county has a public health department that includes immunization clinics for adults and children. Some are free; some charge (VERY reasonable rates; I purchase vaccines and I know what they cost). Pride should not be an issue: this is not charity. You pay for it with your taxes. (Montgomery; Chester; others easily googled.)

(Hospital Care)

This could be a project for venture capital: a cash-only, insurance-free hospital with transparent pricing. In the meantime (apologies for continually tooting my own horn), a qualified family physician ought to be able to keep you out of the hospital, and especially the Emergency Department. Aside from major motor vehicle accidents and complex trauma, a good family doc can take care of many things for which you may think you need an ER. Call first.

Other Ways to Save Money on Health Care

I would be remiss if I did not include a discussion of things NOT to spend money on when funds for health care are limited.

Supplements & Vitamins

Stop purchasing and consuming assorted vitamins and supplements. Things like CoQ10, antioxidants of all descriptions, and substances purported to "support" any aspect of your health should be avoided completely. They are completely unnecessary for your physical health, and downright hazardous to your financial health. All essential nutrients are readily available in high-quality food. Use the money you save to increase your consumption of vegetables, fruits, and fish.

Most Over-the-Counter Medications

Stick to generic acetaminophen (Tylenol), ibuprofen (Advil, Motrin) and naproxen (Aleve) for pain and fever. Just about everything else is useless. Cold meds like decongestants, antihistamines, cough suppressants, etc. have been shown not to work in children under 4. Originally, they were banned under age 2. That age is going to keep creeping up until it is finally recognized that they don't do squat. Saline nose drops/sprays/neti pots work best for stuffy noses. Use plain honey for cough. (Locally produced honey can help with allergies, too.)

When you get sick, you really do need to rest, increase your fluid intake, and be patient; not "a patient" (noun), but "patient" (adjective). Wait it out at least a week. Almost all minor illnesses will be improving by then.

Avoid Chiropractors

Intelligent chiropractors recognize that they are providing a form of physical therapy. The ones who still believe there is a vital force flowing from your brain to your spinal cord and out to the rest of your body, and that all illness comes from spinal subluxations disrupting these vital forces, are dangerous pre-scientific quacks who are nevertheless persuasive and effective at separating you from your benjamins. Save your money.

Avoid "Alternative," "Complementary" and "Integrative" Medicine

The more accurate term for all these modalities is "quackery". Acupuncture, homeopathy, reiki, therapeutic touch, and all kinds of other so-called "CAM" practices are collections of pseudoscientific nonsense that have been well studied (with your tax dollars, thank you very much) and shown scientifically not to work. Their practitioners are compassionate and persuasive, but their ultimate interest is their pocketbook and not your health. When you win the lottery and have more money than you know what to do with, feel free to waste it as you please. But if you're unemployed, uninsured, and/or worried about how to pay for healthcare, it is unconscionable to throw your money away on these services.

Drop the Gym Membership

Get out and walk, either outside in fair weather or inside in foul. Thirty minutes a day, a little too fast to comfortably have a conversation if you happen to be walking with someone else, is all you need for metabolic fitness.

Quit Smoking

Now is the perfect time. Cold turkey is the most effective, as well as the cheapest way to go. At $5.00 per pack, one pack per day is $35/week, $150/month, $1,825/year. That should easily cover a year's worth of routine medical care out-of-pocket.

Quit/Cut Down on Drinking

Alcohol isn't cheap, and it isn't particularly good for you either. Decreasing or eliminating it will do you no harm at all. While on the subject of liquid refreshment, the latest nutritional recommendations for drinks for children are "nothing but milk and water." Given that soda and most fruit juices are nothing but sugar water packed with empty calories, that's pretty sound advice for adults too. "Water" means from the tap, by the way. Your taxes go to make sure that it's absolutely perfect. Bottled water is a waste of money.

Stay Healthy with the Basics

They're called "basic" for a reason:

• Get plenty of sleep
• Eat well
• Exercise regularly

Nothing sexy, exciting, or expensive about any of it.

Marketing: It Works Both Ways

Seeing a new patient involves both of us getting to know each other. Not only do I have to take the medical history and get a sense of the new patient as a person, but the patient is also feeling me out and getting an idea about whether or not I'm someone they can work with as a doctor. Even if they've heard about me -- quite a lot about me, sometimes -- from family or friends, there's still the transition from stranger to friend that forms the emotional backdrop of the visit.

One thing I do to help patients get a better sense of *me* is invite them to read this blog. This is where I let it all hang out, pull no punches, say what I really mean, and generally reveal my true self to the world (scary as that may be to all concerned). People who know me have commented that I do it well; that is, what you read is what you get, both on the blog and in the book.

That's right: it turns out the book is just as good as the blog for getting to know me without actually meeting me. And that's precisely what happened last week.

A new patient came in for an appointment. I introduced myself, escorted him back to the exam room, and began with my usual opening line, "What can I do for you today?" And here's how he started:

I picked up your book in Barnes & Noble and really liked it. Then I looked at the back flap and saw that you were around here. I was looking for a new doctor anyway, so I looked you up. I really liked your philosophy, so here I am.

Actually, my head started spinning right after his first sentence. Here was someone I had never met, but who already knew me (after a fashion). That was unbelievably cool nice. The flip side, though, was that he already knew most of my stories. Whenever I started trying to tell him one, I stopped and realized that he'd already read about whatever it was I was about to tell him.

I must admit that I've been talking up the book like crazy to my patients -- along with just about everyone else I meet; I just see more patients than strangers in an average week. Still, this was the first time that the book has netted me a new patient. It turns out that marketing works both ways.

H1N1 Madness ( or: Crayzee is Relative)

I rarely link to Happy the Hospitalist any more because he's usually such a raving lunatic. However when Happy points out, albeit indirectly, that there are other people out there who actually make him look intelligent, that's saying something for the stark raving crayzee that's making the rounds.

Happy relates his recent experiences with H1N1 flu, and the near death of a previously stable asthmatic. He also links to a study from the Southern hemisphere about the results (not just the "risks", mind you) of H1N1 flu in pregnancy:

While pregnant women make up only 1 percent of the general population in Australia and New Zealand, 66 of the 722 ICU patients, or 9.1 percent, were pregnant women.

Countering this, we have Bill Maher, recent winner of the Atheist Alliance International's Richard Dawkins award (see here for full fisking), claiming that pregnant women should not take the H1N1 immunization, and that anyone who gets a flu shot is an idiot.

Furthermore, the Philadelphia Inquirer several days ago published a letter from not one but two women claiming to be registered nurses proudly proclaiming their plans to refuse the H1N1 flu shot, and encouraging others to do the same.

Listen up already, people:

• H1N1 is just another flu virus.
• It will kill many people, especially those with asthma and other underlying medical conditions.
• The shot is not "untested" any more than introducing a new color of paint for a car and not repeating all the crash testing renders it "untested".
• The virus doesn't care whether or not you "believe" in it.
• People trying to spread doubt and fear about the vaccines are not your friends (even if they're your friends).

Flu shot naysayers are like people refusing to leave New Orleans as Katrina comes roaring ashore. Listen to them, and you or your children could die. Period.

Just Saying "No" to Colonoscopy

Just when you thought you'd heard it all; just when you thought you'd heard every unbelievable, incomprehensible, illogical policy* imaginable; just when you thought it was safe to champion preventive care, comes the Darwin Award for the lowest an insurance company can go.

There's this patient whose father, sister and aunt all had colon cancer in their 40's, so you recommend a screening colonoscopy. The patient is perfectly willing to go (only about 1 in 10 patients right there!) but is told by her insurance company that they don't cover screening colonoscopies.

That sucks, especially since the company prides itself on its comprehensive preventive care that covers annual mammograms over 40 (shown to cause more harm than good, when anxiety from false positives is factored in) and PSAs for men over 50 (never shown to lengthen life). Still, patients often have symptoms like fatigue and changes in bowel habits, which allow the procedure to be coded as a diagnostic colonscopy instead of a screening one.

Ready for the kicker?

This company won't cover diagnostic colonoscopies either.

Epic WTF?

Let me get this straight: whatever the symptom, whatever the history, whatever the possible diagnoses, under no circumstances will this particular company ever cover the specific non-invasive procedure known as colonoscopy?

Yep.

How can they do this? By including this language in their "Plan Exclusions":

Colonscopy both screening and diagnostic is considered a non-covered service under this plan. This test may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this procedure is the most appropriate choice for their situation, they are encouraged to proceed with the procedure at their own expense.

Apparently, this is how the insurer transfers liability for non-coverage; it seems that this is permitted under the Supreme Court decision handed down in regards to insurer liability for non-coverage of an accepted level of care.

It turns out that this is considered purely a cost-containment measure.

What the hell next? There are plenty of other ways to save significant sums of money:

• CT scanning is considered a non-covered service under this plan. This test may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this test is the most appropriate choice for their situation, they are encouraged to proceed with the test at their own expense.
• Levaquin is considered a non-covered therapy under this plan. This drug may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this drug is the most appropriate choice for their situation, they are encouraged to receive this drug at their own expense. [Not all that bad an idea, actually. In addition to being hideously expensive, it's rarely the best choice.]
• Chemotherapy is considered a non-covered treatment under this plan. This treatment may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this treatment is the most appropriate choice for their situation, they are encouraged to receive this treatment at their own expense.

It seems that in order to effectively contain costs, insurance companies are moving away from actually paying for medical care. And this is the private insurance that "most Americans are happy with"?

Un-fucking-believable.

h/t to BS


* Aside from Medicare paying for kidney transplants, but discontinuing coverage for anti-rejection drugs after three years.

Another Book Mention

Thanks to my agent, Janet Reid, for directing me to set up Google Alerts for all mentions of my name and book on the internet, which is how this little item came to my attention. In response to this well-commented-upon post about why the Doctor-Patient relationship cannot be 50-50 comes this, from The Patient Report:

On this website, TPR, we write a lot about the doctor-patient partnership. It is our goal to be clear that it is not possible for it to be a 50-50 partnership because one of the partners has been to medical school and the other has not—-and may feel rotten, besides.

That said, it still is a partnership, each doing the best he or she can. Let’s also remember that it often is the patient who gives the doctor the diagnosis, although not in Latin. Repeated takings of the history of the problem may enable the patient to refine a pattern or spot a symptom which, at the time, meant nothing. So, patients are no slouches in helping out in the diagnostic department—-they just may be not be expected to.

Many doctors have argued that “informed consent” is an ideal, not a reality.

This marvelous woman is making the same point but more bluntly.

Don’t give up on your partnership with your doctors no matter what she says.

But also know that she is right about who actually must make most of the decisions.

Thanks to Cheree Cleghorn for the kind words.

Colonoscopy Complications

Fighting a cold for the last week, I've still got this annoying little cough once in a while. Ran into a neighbor while walking the dog who heard me cough, and offered up this story:

She had a colonoscopy a few weeks back which was complicated by aspiration. As a result, she had been coughing up a lung ever since, although it was getting better. Her germophobic sister-in-law, upon hearing her cough, drew back in alarm, arm drawn over her face in fear.

Neighbor: You know I'm not contagious.

Germophobic sister-in-law: No.

Neighbor: Yeah, this is from my colonoscopy.

GSIL: Did they go up too far?

Tomorrow is the Day (Again)

Anyone and everyone in the vicinity of the Valley Forge Barnes & Noble (150 West Swedesford Road in Devon, PA 19333) tomorrow, Sunday, October 4th at 2:00 pm, please feel free to join us for another reading and signing event for

DECLARATIONS OF A DINOSAUR;
10 LAWS I'VE LEARNED AS A FAMILY DOCTOR

(which you may or may not be aware is the name of my book.)

You Know You're Getting Old When...

Heading out to watch the Jock's Ultimate Frisbee team (which includes a sophomore with the same given name as the Jock) play a tournament, I arrived a little after they started. This meant he was busy, so I didn't go bother him. Instead I hung out on the sidelines, where there were a number of new players I hadn't yet met.

One of them asked me who I was, so I replied, "I'm the Jock's mom."

Her response: "Sophomore Jock? Or the other Jock?"

"The other Jock"? The other Jock. The *other* Jock.

There you have it. The poor kid only missed graduation by one year, and he's already "the other" Jock. Four years he's put his heart and soul into this team, and now he's just "the other Jock." Last year he was the team captain; this year he's "the other Jock."

Heh.


(In case you hadn't figured it out, the title of this post refers to the kid, not to me.)

Twenty Years

Happy Anniversary to me! Twenty years ago today, I hung out my solo shingle.

Last year, I forgot to post anything about it. Two years ago, I wrote about it here. Much has happened in the last two years, yet much has remained the same. Happily, my family is still all well and happy. Sadly, my income hasn't budged.

Twenty years ago, I saw three patients that first day. Today I begin the day with 16 patient visits scheduled, plus 27 others for flu shots.

I'm still blogging. I'm not checking the site meter nearly as compulsively as I once did; this is a good thing. I now have a laptop on my desk at work, though, so I check Facebook several times a day; this is probably not such a good thing.

I'm still writing; and now I'm published. I even have an agent, so I know that as I continue writing, there's at least one person who doesn't think my stuff sucks. This is an extraordinarily exciting time in my life, and I'm really looking forward to seeing how this writing thing develops as an ancillary career.

But now as then, what I look forward to most is the people. They're usually called patients, but what they really are is people who have done me the tremendous honor of allowing me into their lives at their most vulnerable; the best and worst moments of their lives; the beginnings, the endings, and everything in between. When I think of twenty years in practice, I don't think about the three locations, the comings and goings of assorted staffers, or even the hospital staff and committee meetings. I remember the patients; my patients; my friends. Now as then, they are the reason I do what I do, and why I love what I do. Now as then, I thank you all.

Me and the Rolling Peke,
both with fresh haircuts

The Dirty Little Secret about End of Life Care

Since the first in my series of "Dirty Little Secret" posts went over so well, here's the next one. Unlike the first, though, this one really is directed at patients as well as doctors, so listen up everyone:

Unlike Sarah Palin the politicians and talking heads discussing non-existent "death panels," I have had many conversations over the years about options for medical care at the end of life, with lots of patients of many different ages and situations. Interestingly, just about everyone ends up saying one of two things.

1. Just keep me comfortable and let me go; no heroic measures; etc. or
2. I want everything done.

The problem is that very few patients really understand what "everything" means, in all its gory, grotesque, excruciatingly painful detail. The needles, tubes, drugs, restraints, surrounded by all the machines; the blinking lights and beeping alerts that never stop (there are so many, there's always one or more going off at any given time); the cracking of ribs and smell of singed hair at the final resuscitation, with the same inevitable result. Who in their right mind would want to go through that?

The answer, of course, is that no one would. The only reason they say otherwise is because they don't understand what it is they are asking for. It is therefore our job as physicians to explain to them -- as bluntly as necessary to ascertain comprehension -- why "everything" is not really what they want.

Think about what this means. It means that once everyone fully understands the horror that is "everything," it becomes safe to make the default assumption, when presented with a stranger in extremis, that they want to be kept comfortable and allowed to exit this world with dignity.

A significant problem arises when people conflate the issues about medical care at the actual end of life -- when it is medically apparent that death is inevitable -- with questions about quality of life. Is life worth living tethered to a ventilator? How about dialysis three times a week for five hours? What if you couldn't eat or talk, sustained by tubes in your stomach and neck, but were able to see, hear, communicate (via computer or even pen-and-paper), walk, drive, etc.? How much discomfort would you be willing to tolerate from chemotherapy side effects for another month of life? How about six months? A year? These are different questions that deserve different discussions.

Interestingly, when those discussions are held in advance of their actual need -- ie, in the hypothetical -- people who say things along the lines of, "I would never want to live like that," frequently find themselves with different views when faced with the reality of the situation. (Ironically enough, these same people are often reluctant to accept other people's decisions. I once had a ventilator-dependent patient who requested its removal, knowing it would lead to her death, and was confronted by medical professionals appalled at my plan to accede to her wishes.)

So where does that leave us in terms of "advance directives"?

It is meaningless to discuss "how would you want to live?"-type issues in the purely hypothetical, because the discussion will always be repeated when the actual situation arises. It's like discussing college with a pre-schooler. It can be discussed in generalities, with the understanding that actual decisions can't be made yet, and that opinions expressed now are very likely to change.

As for actual end-of-life care, informed patients just want to be kept comfortable. Uninformed ones, those who want "everything" done, need to be educated as to why they do not, in fact, want to be tortured to death between CPR and the ICU. Ultimately, the default becomes what it should be: dignified comfort care for all.

At this point in time, we physicians need to concentrate our efforts on expanding the general public's understanding of the limitations of aggressive interventions at the end of life. Some may wrongly construe this as an attempt to limit patient "choice" inasmuch as a specific course of action -- "doing everything" -- needs to be actively discouraged. As physicians, we have an obligation to prevent our patients (and their families) from inadvertently increasing the suffering that ensues from futile end-of-life care. This is best accomplished with compassionate education. Whether this occurs in the context of an office visit or a concerted public service campaign matters little. We need to change the cultural default in this country from "do everything" to "comfort care only." Americans have to grow up and realize that they are not immortal.

Op Note

That Hatchling sure is enjoying his senior year. Look what he just sent me:

Date: 9/24/09 12:30
Patient ID: Surgical Medical Student
Preop Diagnosis: Cellulitis with abscess, R medial ankle
Postop Diagnosis: Same
Procedure: I&D R medial ankle pustule
Surgeon: Surgical PA
Assist: Surgical Medical Student (aka the patient)
Anesthesia: Beer was requested and denied by the PA
Blood Loss: none
Urine: not measured

Procedure Note: Patient removed right sock to display prominent 1.5cm diameter pustule overlying an erythematous region of approximately 10cm in diameter posterior and inferior to the medial malleolus. The procedure and risks were discussed including loss of sensation, generalized sepsis, and possible need for amputation should complications arise; informed content was obtained. Liability was discussed and patient agreed to waive all liability for the procedure.

Patient requested a beer for anesthesia but this was deferred due to location and unavailability. Patient proceeded to drape in a non-sterile fashion with absorbent chux. He then prepped his own foot with rubbing alcohol and betadine.

At this time the PA instructed him to lie back and relax. She then attempted to shield the incision site from the patient. The patient proceeded to call the PA an ass, and promised not to move during the incision; he remained seated upright so he could see. The PA proceeded to make a 1cm postero-inferior incision across the middle of the lesion. Immediately purulent material flowed from the wound causing the two nursing students observing the procedure to say "ooh". Despite the stoic demeanor of the patient, no phone numbers were obtained.

In total about 2-4cc of purulent material was expressed from the wound with not so gentle force. Pressure was again used to ensure hemostasis. It should be noted that the PA seemed to take pleasure in causing the patient to grimace with excessive pressure. The wound was dressed with a 2x2 gauze and the patient was told to return to work immediately because they needed the room. Patient was discharged with a script for Keflex 500mg QID to treat the remaining cellulitis. Patient was instructed to keep the leg elevated when possible and continue using warm compresses to treat the remaining cellulitis. Patient is expected to be noncompliant and lost to follow up.

Signed: Surgical Medical Student 4

I have seen and attest to the above statement as the attending
practioner: Surgical PA

The Problem With "Quality"

Many other people have addressed this issue many times over. Here's my latest essay on the subject, that also appears here:

Imagine a town with two barbers. One of them sports a magnificent haircut; the other’s head resembles the nest of a psychotic bird. Which one would you choose to cut your hair?

If your first choice is the immaculately coiffed one, stop to think about how things must work in this town. Since there are only two barbers, obviously they cut each other’s hair. If you’re looking for a great haircut, wouldn’t you prefer the person who created it to the one sporting it?

Now imagine a town with two doctors. All the patients of the first doctor have perfectly controlled blood pressure and diabetes. They all exercise regularly, none of them smoke, and all of them have received all age-appropriate preventive health screenings. Many of the other doctor’s patients, on the other hand, have blood pressure and glucose readings off the charts. Smokers are well-represented in the practice, and preventive health screenings are hit-or-miss.

Medicare’s recent “pay for performance” (P4P) initiatives purport to reward doctors financially for so-called “quality” care. According to the data, the first doctor in the above town would be raking in the bonus money, while the other would be facing stiff penalties.

But which one do you think is the better doctor?

What if the first doctor decided that the best way to improve his P4P data was to discharge all the patients from his practice who, for whatever reason, failed to achieve acceptable control of their blood pressure and diabetes? Or who didn’t stop smoking? Or who refused to get a flu shot, or go for a mammogram, pap smear, or colonoscopy? As it happens, there’s nothing in the Hippocratic Oath against discharging patients. With enough money at stake in a P4P arrangement, this is inevitable.

What happens to these people? They’d be in big trouble if the other doctor in town also refused to take care of them. By continuing to work with patients whose diseases are not as simple to control, who may be reluctant or unable to take time off from work to undergo preventive testing, or who are too ornery to follow medical advice even as they continue to seek it out, that physician is also providing “quality” care.

The biggest mistake made by Medicare, private insurers, and other entities seeking to improve medical care by rewarding “quality” is mistaking it for “performance”. One of the most egregious examples of this is the so-called “four hour rule” for antibiotics for pneumonia. Medical evidence does indeed support the idea that when patients have pneumonia, they do better the sooner they are begun on antibiotics. But by tying hospital compensation to a rigid four-hour rule, many more patients end up receiving unnecessary antibiotics when the diagnosis of pneumonia takes more than four hours to establish. The financial penalties from failing to meet the standard are significant; they can include risking the institution’s accreditation status. Thus, a “performance” standard results in a lower quality of care for many patients without pneumonia exposed unnecessarily to powerful medications.

Quality is like pornography; you know it when you experience it. But it cannot be measured; only assessed, and then only subjectively.

Quality in medical care has more to do with meeting the needs of individual patients and less to do with checking off boxes on a preventive care form. Some patients want detailed explanations of every facet of their medical care. Others prefer a more “Just the facts!” approach. The mark of a high quality physician is the ability to bring more than one style of communication to bear in meeting the needs of a varied patient base.

How well we succeed in controlling diseases that are primarily dependent on patients’ lifestyle choices is measurable, and therefore tempting to use as proxies to reward, but ultimately irrelevant. We need to be very careful when we talk about “quality” in medical care, because patients can easily end up with much more than a bad hair day.

Everything Else You Need to Know About the Flu

After posting this, which ended up being mainly about the H1N1 flu shot, I realized there were a few more things you really ought to know about the flu.

How do I know if I have the flu?

As I said before, it isn't subtle. In addition to a fever, headache, and body aches that make the day after five games to 15 that all went to universe point feel not so bad, the onset is often quite abrupt. You wake up feeling fine that morning and by lunchtime you can't stand up anymore.

You don't need to go to a doctor or health center to "make sure" you have the flu. The diagnosis is usually made on the basis of the medical history (what you tell the doctor about how you're feeling and how it started) anyway, so the best thing you can do is to stay away from other people (as are often found in a doctor's office or health center). There isn't much they can do for you either.


What do I do if I get the flu?

As I also said before, most people who are young and generally healthy get over the flu just fine. The most important thing you can do is REST. This does not mean going to class just to get the notes. It does not mean going to practice just to impress everyone with how dedicated you are. It definitely does not mean having a few brews with your buds because if your head is pounding anyway you may as well get a buzz on as well. It means stay in your room, preferably in your bed. If you live close enough to school, call your parents to come get you and stay in your room at home instead.

You can take acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). It really will make you feel better. Not perfect; not well enough to get up and do stuff anyway; but better. So will drinking lots of fluids like water, juice, and chicken soup. NOT beer.


How can I keep from getting the flu, or spreading it if I have it?

Because the flu is spread by respiratory droplets, containing them is the key. The first thing you have to do is re-learn how to cough. You know how your mom taught you to cover your mouth with your hand when you cough? DON'T DO THAT. It just gets all those flu-virus-filled respiratory droplets all over your hands, which then touch door handles, keyboards, as well as other people and things that other people touch. Unless you're going to wash your hands with soap and water for 20 seconds every single time you cough or sneeze, DON'T COVER YOUR MOUTH WITH YOUR HANDS.

What should you do? You boys are going to love this, because you've been doing it for years and now no one can yell at you for it anymore: cough into your arms, which are hopefully covered with sleeves. If you're wearing just a t-shirt [and what the hell are you doing wearing only a t-shirt in the middle of winter when it's frickin' COLD outside!?!?] then cough into your shoulder.

You should still wash your hands frequently, preferably with soap and water for 20 seconds (the latest thing is to call it the time it takes to sing the "Happy Birthday" song), but those alcohol-based hand sanitizers are better than nothing.

The other really important thing to do is to stay away from sick people if you're healthy, and healthy people if you're sick. It's all about those stinkin' respiratory droplets.


What about school?

Many schools and colleges have developed policies to deal with flu this year. The Pennsylvania State system (includes IUP, Penn State, West Chester, Kutztown, etc.) has a policy encouraging sick students to "self-isolate", ie, stay in their rooms or go home. It looks like they're also going to be pretty liberal about excusing absences and allowing make-up work. For what it's worth, though, this should not be looked at as open season for slackers. I have no doubt that plenty of students will abuse the relative laxity of these policies, and absenteeism will probably be ridiculous even if the flu is really mild. Still, I expect better of the Frisbee team. I'm happy to bring you homemade chicken soup if you get sick, but you know I'll be just as quick to come kick your asses if you start acting like a bunch of lazy slackers.


What's Tamiflu?

Tamiflu is the name of a medicine that can be prescribed for people who get the flu. All it does is shorten the duration of illness by only about a day, on average. It needs to be prescribed within 24 hours of the onset of symptoms to do even that. It has side effects like nausea and vomiting. All in all, it's not much of a trade-off for young, generally healthy people, so I'm probably not going to be using it much for them.


When should I worry?

If you get a really bad cough that's bringing up a ton of stuff (called "sputum") of any color along with a very high fever, trouble breathing and/or bad pains in your chest, you might have pneumonia. Call a doctor or go to the health center.

If you have a really bad headache AND your neck is so stiff that it hurts to move it, call a doctor or go to the health center.

I usually tell people to call me if they feel really really bad, but the problem with the flu is that it can make you feel pretty bad, and people who don't get sick much don't know just how "bad" is bad enough to worry. Leave it at this: If you have anything in addition to fever, headache, body aches, slight sore throat and cough, get them checked out. If that's all you have, suck it up and wait it out.

Anything else?

Not that I can think of. Email me or ask in the comments.

Everything You Need to Know About the Flu

Dear Innuendo Ultimate,

Earlier today I promised to tell you all about the flu, but those first two games were so close and hard fought -- and we were all so wiped by the end of the third one -- that I never got around to it. Here's what I wanted to tell you:

Influenza -- flu -- is caused by a respiratory virus. That is, a virus that comes into contact with the inside of your nose or mouth (the top of your respiratory tract). It's passed from person to person through "respiratory droplets" produced when you cough, sneeze, or wipe your nose on something that someone else then touches, and in turn touches to their own nose or mouth.

The disease it produces is different from just a cold. More than just a little sore throat, runny nose, and cough, flu usually produces a fever (temperature over 100 degrees, taken by mouth), body aches, and headache, along with a scratchy throat, cough, and stuffy or runny nose. It's not subtle. Patients often tell me they feel like they've been hit by a truck. "Body aches" means everything hurts; lots of people say, "Even my hair hurts." Flu really knocks you on your ass. If you're not sure you have the flu, you probably don't.

Most people get over the flu just fine, though it can take longer than you want it to (up to 10-14 days), but it can weaken some people enough so that they get other infections (like pneumonia) on top of it. About 30,000 people a year, on average, die from the flu; usually the very old, the very young, and people with medical conditions like diabetes and asthma that make them susceptible to flu complications.

The flu virus mutates a lot. Even through the regular flu season (fall/winter, when it's cold, and people -- and their respiratory droplets --cluster inside together) the virus can mutate slightly. Once you get a specific flu virus, you form antibodies to it; this means you can never get it again. Other mutations of the virus can still make you sick, though. Still, over a lifetime, you accumulate immunity to the various versions of the virus that circulate each year.

Different mutations of the virus act differently. They may be harder or easier to catch ("infectivity"); they can cause a milder or more severe illness ("virulence"). These variables are independent of each other.

Every year the CDC chooses three flu strains they think will most likely circulate that year, and they make a vaccine against those three. We call this the "seasonal flu vaccine", and it changes each year. In general, it is recommended for those groups above (old, young, and with certain medical conditions). I tell people who ask me that I recommend it for anyone who doesn't want to get the flu.

Here's what's different this year:

Back in the spring, a new ("novel") flu virus mutated from a version that infects pigs (hence the "swine flu") and began infecting people. Named for the proteins on its surface, it's known as H1N1 (also called "hinny" by morons who think that's a word). So far, this version of the virus is very contagious (highly infective; easy to catch) but not terribly virulent (causes mild disease). Because this form of the virus hasn't circulated for many years (probably since the 1950's), it turns out that younger people are more susceptible to it than older people. Lots of people have been getting "swine flu" all summer.

So what's the big deal?

Back in 1918 there was a huge pandemic (pandemic = worldwide epidemic) of H1N1 flu that killed an estimated 50,000,000 people. What was worse was in addition to the very old and very young, an unusually large number of young, otherwise healthy people died from it. No one is quite sure why. Probably a lot of it had to do with the general state of medical care back then (no antibiotics, ventilators, and all sorts of other fancy supportive care). Also, it was the height of World War I, with troop ships moving lots of soldiers all over the place, spreading the virus like crazy while they were all crammed together. Many people think it was because the virus was novel, so very few people had any immunity to it. Still, there seemed to have been something about that particular virus that made it much more virulent than others.

Remember how I said that the virus can mutate even during the same flu season? There is the concern that although the current version of H1N1 isn't all that virulent, it could mutate and become much more so. We're unlikely to see 50 million worldwide deaths again, but it could certainly get pretty bad.

It takes about 6 months to make seasonal flu vaccine, so by the time H1N1 was identified, it was too late to include it in this year's mix. They did manage to make a separate H1N1 vaccine, though, and it should be available by mid-October. It's recommended for everyone aged 6 months to 24 years, pregnant women, caretakers of babies under 6 months old, and anyone with medical conditions that make them more susceptible to flu complications. (Also health care workers; I'm not sure if that technically includes athletic trainers.)

The flu shot does not contain flu virus. It cannot give you flu. It may make your arm sore for a few days, and it might cause a mild illness, but you cannot get the flu from it. It takes about two weeks for it to work completely, so if you happen to get the flu before then, it wasn't from the flu shot. (There's also going to be something available called a "live attenuated" version of the vaccine that you shoot up your nose. That's a little different, but is still hugely safer than getting the flu.)

The government is purchasing the vaccine and distributing it for free. There should be plenty of doses for everyone in the recommended groups, so there are no expected availability issues. Doctors and clinics can charge you an "administration fee", but that shouldn't be more than about $10, and I strongly suspect many places won't be charging it.

So please, even if you don't want a regular (seasonal) flu shot, find a way to get an H1N1 vaccine. The whole thing may very well turn out to be a bust, but this is truly a case where it is better to be safe than dead sorry.


Please pass this along to all your friends.

Looking forward to the rest of the fall Ultimate season.

Love,
Mother Hucker

You Know You've Arrived When...

...While watching your kid's Ultimate Frisbee team play at Sectionals, the kids want to chant a somewhat more risque cheer than usual. The captain glances around furtively and, while looking straight at you, says:

Good, there are no adults around.

Etiology

I've learned something new today, courtesy of the NinjaBaker, who has just discovered the following:

Mad cow disease is caused by E. coli zombies.

Edited to add:

Explanation, per NB:

It was a thought process about E.coli zombies.

Cows get it by being fed their own entrails and feces, which contain E.coli. Prions are mutated proteins which ... could theoretically be from dead E.coli. They attack other proteins, convert them into their own, zombious form and eat BRRRRAAAAAIIIIIIINNNSSS.

I love the logic of scientific offspring.

Looky Here

Check out page 6 of the current copy of Keystone Family Physician, the official publication of the Pennsylvania Academy of Family Physicians.

For anyone without Adobe Flash player and to flesh out this post a bit, here's what it says:

Lucy Hornstein, MD (Valley Forge) is known to many simply as “#1 Dinosaur.” That’s her blogging moniker for “Musings of a Dinosaur,” which she has authored since August 2006. The blog built a huge following and she was asked to write a book about her almost 20 years as a “so-called dinosaur” or “solo practice primary care physician.”

“Declarations of a Dinosaur; 10 Laws I’ve Learned as a Family Doctor” hit the bookstore shelves in August. Published by Kaplan, the book offers advice to others who hung out the shingle, musings to help them survive and, hopefully, thrive in a profession that some think is on its way to extinction or already there.

Not so fast, says Dr. Hornstein, a PAFP member since 1988, who notes her first book is just that and not a new career.

Here’s the opening now posted on her blog….“They say the solo Family Doctor is extinct; gone the way of the dinosaur. Well, I've been in private practice for nineteen years and I'm still kicking, so here's my blog. Until they drag my cold, dead body off into the tar pit, read about my trials and tribulations -- and the joys and triumphs, which are what keep me going. I'm also embarking on a new career as an author. You can read my first book by ordering it below. If anyone worries that I may become so successful with my writing that I will give up my medical practice, rest assured: writing is something I do; doctoring is who I am.”

Read her 10 laws and more at http://dinosaurmusings.blogspot.com/

The actual article also has a picture of the book, and another one of moi. Plus it makes a nifty "whooshing" noise when you click to turn the pages.