The Gods of Blood

A comment posted to Bevel Down:

I hate it when I tell people that I'm a hard stick. They look and SEE and say Nah! You'll be easy.

No, I'm not, really; I get monthly lab draws...for almost 13 years. Trust me. I'm not an easy stick. I don't care what you SEE when you look.

Then they start to feel; "Oh, here's a good one!"

Please make sure that's not the scar tissued area.

"Nah! this is a good vein! Whoever told you you were a hard stick didn't know what they were doing!"

Stick (as the JAB feels like I've just been jabbed with needle the size of the Seattle space needle)

Hmmmm ... it collapsed. No blood is coming. Odd, funny, you looked like you were an easy stick.

"yea, gee ...funny. Told you I was a hard stick.

Humility is a lesson I've learned the hard way. Here's the spiel I use as I'm tightening the tourniquet and carefully palpating for a vein (when I can push on it and tell from the give that it's a fluid-filled structure and not scar):

"Outside these four walls I'm fairly religious. I believe in one Gd; I'm active in my synagogue. But inside this room I am a shameless pagan; I worship the Gods of Blood. The Gods of Blood are jealous gods, easily angered. And what angers the Gods of Blood is hubris. Overweening pride. So I try never to say, 'Oh, that's a great vein. I can hit that; no problem.' Because the Gods of Blood will hear me; and they will strike me down and make me miss. Never fails."

By now the blood is usually rushing into the tube and I'm getting the other tubes ready. I go on:

"One time there was this guy who said, 'I'm a terrible stick', and I said, 'Nah. That's a great vein. I can hit that; no problem.' I push the needle into the vein, push the tube onto the needle, and...nothing. I said -- out loud -- 'Gods of Blood; I apologize for my arrogance. I promise I will be humble from now on.' I withdrew the needle about a millimeter and -- WHOOSH -- in rushed the blood."

At this point I usually have the tourniquet off and a cotton ball ready to press over the puncture as I withdraw the needle. I interrupt my narrative to say, "Press on this. Don't bend..." as they try to bend the arm, (bending the elbow to apply pressure after venipuncture has been shown to stretch the hole in the vein and increase the chance of hematoma) "...just press," and I continue:

"Now you probably think I'm kidding about this. But I have to tell you: I've been doing this long enough that I'm not sure how much is actually kidding anymore."

And that's why I never brag. And why I humbly approach everyone as if they were a hard stick. I've sometimes disconcerted people by looking at a huge, fat, juicy vein and saying, "I'll try." They say, "What the hell do you mean 'try'? How can you not hit that?" I just answer, "It's about my religion," as I launch into the spiel above.

It's my genuflection to the Gods of Blood.

(Oh yeah: the other way to anger the Gods of Blood is to write someone's name on the tube before their blood is in it. It implies you don't think you're going to miss. So I never write the name until the blood is in it; BUT it's the VERY FIRST THING I DO after the tape is on. The tubes never leave the room unlabelled. Sounds crazy, I know; but like I say, I've been doing this a long time. And the only times I miss are the times I get overconfident. It's kinda scary.)

Please Stop Talking to your Doctor Already

This Viagra ad, and others on TV and elsewhere, imply that patients are embarrassed to discuss erectile dysfunction with their doctors. Those poor, shy patients need all the encouragement they can get, so they are urged on radio, TV, magazines, newspapers, and Muzak for all I know, to "talk to your doctor."

Wrong, wrong, wrong! And it's just getting wronger through the years. They ALL ask about it. NO ONE seems the least bit embarrassed.

They want samples.

What they get, of course, is a history, exam, lab work (usually) and a detailed and extensive discussion of what the drug does and doesn't do, how to use it, and so on.

One guy came in, early 40's, and said, verbatim, "Is Viagra right for me?" I successfully kept a straight face, and began taking a history.

Me: What kind of a problem are you having with sex? Trouble with erections?
Him: Oh, no. No problem with getting an erection or anything like that. It's just that the second and third times aren't what they used to be.

(That was where I lost the straight face.)

I can't make this stuff up.

The Right Thing at the Right Time

I have been fortunate several times in my life to come up with just the right thing to say at just the right time -- instead of three days later, which is what usually happens. Please note that these were all people I knew well enough to be confident that my comments would be taken the way they were intended, and appreciated; which they were.

To the distraught mother of a seven-year-old who had swallowed a ball bearing:

"This too shall pass."

To the oral cancer patient at a checkup; I asked if the bronzing of his arms was from radiation therapy, and to which he had responded no, he had been sitting out on his deck getting a little sun:

"You'd better be sure to use sunscreen. You wouldn't want to get cancer."

To the double amputee as I was about to tell her something surprising:

"Are you sitting down?"

To the patient with longstanding dental problems who woke up one morning unable to find one of his teeth (it fell out regularly; he kept taking it to the dentist who kept shoving it back into the socket) and was pretty sure he'd swallowed it:

"Well that'll come back to bite you in the ass."

Bevel Down

(Edited: Marble Dinosaur Egg #3; whoever said dinosaurs could count?)

I've noticed that several of my readers are medical or nursing students still learning basic clinical skills. I'd like to share something that, once I got around to trying it, has stood me in very good stead indeed.

More years ago than I care to disclose, when I was a 4th year student on an "outside" rotation, I met a crusty old FP with a tic disorder we never spoke of, and a zillion little clinical pearls he was eager to share.

Here's one: when drawing blood or starting an IV, go in with the needle's bevel down.

Yeah. Right. What does an old guy like him know about drawing blood anyway, I thought. Just like all of you, I was taught that the bevel (the hole in the needle cut at an angle) should be up so you can see it as you go through the skin and into the vein.

Fast forward to the present: I cannot for the life of me remember when or why I decided to try it (I know it took many years) but I seem to recall a diagram like this one changing my mind:
(This is just a crappy hand-drawn sketch, but the needles are outlines of the same cardboard template flipped over, lined up as parallel as possible.)

As you can see, entering the vein (at any angle) with the bevel down instead of up vastly increases the area of the bevel that gets into the lumen. It's also much easier to avoid damaging the back wall of the vein with the tip of the needle, especially if you concentrate on exerting upward pressure once you've entered the vein.

Nowadays I draw all my own bloods -- bevel down -- and have developed an amazing reputation among my patients for hitting veins no one else can. (The other tricks are not even to start looking until after the tourniquet is on, and going by touch. Always go for one you can feel even if you can't see it, instead of one you can see but not feel. You'll miss the latter every time. If I can't feel it I won't even try.) Granted my near 100% success rate at this point may be just from sheer experience, but almost every patient who's ever had blood drawn by another phlebotomist says my sticks hurt less. Some even claim they don't feel it at all, a phenomenon I have actually experienced drawing my own blood. (Don't ask.)

I know it goes against everything you've been taught, but consider trying it sometime; maybe when you're not being watched/graded. Or you can do as I did and wait an extra decade or so to fine tune your skill. You have nothing to lose but a hematoma.

Still More About Money

More with the comments:

OK, so you're a good doctor and you are smart. Here's a test for you... do you make more money seeing patients or analyzing reimbursement from certain payors?

I know lots and lots of very astute business people who are also physicians. My wife is one of them. The reason they are good business people is that they realize where they make money... in the exam/treatment room.

Hire someone who is good at watching over things, stay in the loop, but generate more revenue and you'll be happier and more financially successful

How the hell am I supposed to "hire someone" when I can't even pay myself!

What you don't seem to grasp is that there are places in this country where a completely optimized medical practice still doesn't generate the kind of revenue you're talking about. It is a myth that if a practice isn't doing well, it's the doctor's fault for either not working hard enough or smart enough. "Just get into that exam room and see more patients" = "Why can't they eat cake?"

Again, an apparent solution would be "so move." But doctors are not fungible; a commodity easily interchanged by physician recruiters (oh, lookie: another lucrative middle-man industry that doesn't actually provide healthcare.)

There is more to business than being astute. Perhaps one could say that my only bad decision was in setting up practice in an area like this, but as it happened when I began the practice it wasn't like this. The environment (the BUSINESS environment) is what has deteriorated over the years. This is not the kind of thing that even business people can predict (though now that I think about it, they're the ones who caused it.) What they can do, though, is move on to other industries, whereas I'm "stuck" because there are 2000 people here I care about and who need me.

I'm Still Not Convinced

The numbers in my anti-Gardasil (HPV vaccine) rant have been challenged.

So be it. I confess: I'm a doctor, not a statistician. But I still don't think it's a particularly good value, nor an appropriate use of increasingly scarce health-care funds. And I've come up with a better analogy:

If there were a very expensive rain hat that would lessen your children's chance of being hit by lightning, would you buy it for them? I'm betting most parents would say no. The baseline risk is ridiculously small, and is reduced even further by common sense, such as not standing outside in thunderstorms.

Likewise, even relatively minimal attention to regular preventive GYN care will pretty much catch all HPV infections at least a decade before it advances to invasive carcinoma. If you want to start attacking me by pointing out all the money and anguish saved by reducing the overall burden of HPV disease in the form of treatment of dysplasias and the like, at least you're on steadier ground.

Bottom line, though, is that I don't believe the vaccine itself will truly save a single life in the US. That is, the women who get the vaccine (ie, that have insurance that pays for it or the ability and willingness to pay for it out of pocket) are not the ones who will then waltz on through life without ever submitting to stirrups. The women who get the cancers -- the poor, the immigrant, the marginalized, and the doctor-phobic -- will never get the shots. I believe it would be a better use of resources to use all that money Merck wants us to spend on Gardasil for GYN outreach, making sure every woman has access to this basic healthcare right.

Internet Intimacy and Betrayal (or My Take on the TNT Affair)

A long, long time ago -- about a month -- just before the dinosaur in me decided it wanted to blog, there was a bit of an uproar over a blog called The Naked Tomato (no link.) To summarize the saga, an 18-year-old woman posed online as a Pediatrics Resident, became close to several other bloggers, disclosed some very personal stuff (now uncertain how much was true) and led at least one other blogger to disclose a very personal trauma of her own. When the truth finally came out completely (after the denials and the accusations) several bloggers felt betrayed.

Flea has found himself upset when families transfer their child out of his care. On one occasion he blamed himself for a minor mistake that he felt caused the rift, but the same thing has happened to me many times over the years, even when everything seemed fine. I have felt betrayed when a patient unilaterally ends our relationship.

Ripple of hope, formerly Difficult Patient, has elaborated on her blog about a doctor who dismissed her from his practice -- unjustly, in her opinion and the opinions of others, including me -- for her supposed misuse of controlled substances prescribed by him. Her doctor told her she had betrayed him; he blamed her for his possible liability, and told her she had "put his wife and family at risk."

I have had patients come to me seeking drugs, lying to me to obtain them. I have been fooled. Other doctors in this situation have told me of their anger at "having been betrayed" by these patients.

There must be an obligation in order for there to be a betrayal, so who exactly is betraying what in these scenarios?

The doctor-patient relationship is inherently asymmetrical, emotionally speaking. As much as we doctors derive deep emotional satisfaction from our relationships with our patients, they -- our patients -- don't really owe us anything emotional. They are free to transfer their care to other doctors if they wish, for any reason(s) they choose. It's a painful lesson that, with luck, gets learned early in a career (cough*Flea*cough) and even when learned well, doesn't prevent a pang on seeing that "Please send my records to..." note from a long-term patient. But I'm not so sure I could call it "betrayal."

What about folks who lie to me to get drugs? I quickly realized that the anger I felt was actually at myself for having been fooled. Over the years, I decided to be nicer to myself. I'm only human, and as hard as I try not to be, I'm going to be caught up in someone's sad tale from time to time. (Much less now than when I was younger, so obviously I'm doing something right.) Rather than getting angry at the patient for "betraying" me, I've learned to take it in stride.

And Ripple's doctor? That was emotional blackmail, pure and simple. It is never legitimate to invoke one's feelings or those of one's family in the context of a doctor-patient relationship. If anyone was betrayed, it was the patient.

What about TNT? What did she owe a bunch of strangers in the blogosphere? That gets into the concept of intimacy (thanks to Moof for an enlightening series of emails.)

Here on the internet, all we have are our words (and pictures; see TundraPA) and despite the ubiquitous warnings, we also all begin with the presumption of honesty. We are presumed to be real people telling the truth about ourselves, and as it turned out, TNT wasn't; this despite the fact that the bond others forged with her was real. Here's how I phrased it to Moof: think of "internet intimacy" as a "promissory relationship". I could say to her, "Hey I'm going to be in your neck of the woods; let's meet for coffee," and know that the relationship would be the same nose-to-nose (her words) as it is nose-to-screen (mine.) The kicker is that this potential has to be real. I really am a family doc in solo private practice, as Moof could discover beyond a shadow of any doubt if we were to meet. As it happened, TNT could not do the same.

Here's one more analogy I came up with: paper money is backed by the full faith and credit of the United States Government. (Leave it for now, please; this isn't a political post.) Dollar bills aren't the same as gold, but they are, for all practical purposes, readily exhangeable enough so that they are functionally identical. The existence of counterfeit bills does not undermine that basic equivalence. Likewise, internet friendship -- intimacy, if you will -- can be similarly assumed to be real until disproven. Running across the occasional faker doesn't invalidate the rest of the gifts the blogosphere has to offer.

Wait Just a Minute!

From the comments:

...Unfortunately doctors are not good businesspeople...

How about these statements:

• Unfortunately, girls are not good at math.
• Unfortunately, surgeons are assholes.
• Unfortunately, poor people are lazy.

Even:

• Unfortunately, doctors have lousy handwriting.
  

Can you say "generalization"? Can you say "stereotype"? Hell, can you say "prejudice"?

The problem with stereotypes of all kinds is not only that they aren't true, but that without careful attention some of them can become excuses. "I'm a girl, so I can't do math." Bad behavior by surgeons is tolerated. And doctors feel that medicine and business are mutually exclusive.

Many factors are out of the control of the people who run a business. The problem with doctors is that we are tied to an industry in which businesspeople (those without a real profession) have discovered they can extract large sums of money without actually doing anything useful within the industry itself. They do this by diverting the flow of funds from those who receive medical services to themselves instead of directly to those providing the services. Is this a great country or what.

I'm may not have an MBA, but I enjoy the business side of my practice, and frankly I'm pretty damn good at it. What others may call "good customer service" I have been doing from day one, only I call it "patient centered care". It doesn't mean giving people prescriptions for unnecessary antibiotics because they think they need them, but it does mean answering the phones promptly and courteously, being flexible about scheduling, helping patients out with paperwork, and all the other crap involved in navigating the nonsense that is our healthcare system. Believe me, I squeeze every last dollar there is to be squeezed out of my business, consistent with the practice of good medicine.

I also do calligraphy for fun. When I handed a prescription to a patient who, without even looking at it, said, "I can't read this" (no, illiteracy wasn't an issue) I laughed and said, "Bullshit!" (Again, it was someone with whom I had enough rapport to get away with it.) When he did look at it he agreed with the rest of my patients that I have beautiful handwriting.

Forgive the rant, but every time I see that old canard, "Doctors are not good businesspeople" it annoys the hell out of me. And beware of the annoyed dinosaur.

L'Shanah Tovah (Day Two)

(An oldie but goodie in Jewish High Holy Day lore; credit Rabbi Richard J. Israel)

On Rosh Hashanah there is a ceremony called Tashlich. Jews traditionally go to the ocean or a stream or river (moving water; ie, not a pond or lake) to pray and then throw bread crumbs onto the water, for the fish to symbolically eat their sins.

There has been discussion over the years about what kind of bread crumbs should be used. Taking a few crumbs to Tashlich from whatever old bread is in the house lacks subtlety, nuance and religious sensitivity. I would suggest that we can do better:

For ordinary sins: use White Bread
For exotic sins: French Bread
For particularly dark sins: Pumpernickel
For complex sins: Multi-Grain
For twisted sins: Pretzels
For tasteless sins: Rice Cakes
For sins of indecision: Waffles
For sins committed in haste: Matzah
For sins committed in less than eighteen minutes: Shmurah Matzah
For sins of chutzpah: Fresh Bread
For substance abuse/marijuana: Stoned Wheat
For substance abuse/heavy drugs: Poppy Seed
For committing auto theft: Caraway
For petty larceny: Stollen
For committing arson: Toast
For timidity: Milk Toast
For being ill tempered/sulky: Sourdough
For silliness: Nut Bread
For not giving full value: Shortbread
For jingoism: Yankee Doodles
For risking one's life unnecessarily: Hero Bread
For excessive use of irony:Rye Bread
For telling bad jokes: Corn Bread
For hardening our hearts: Jelly Doughnuts
For being money hungry: Enriched Bread or Raw Dough
For war-mongering: Kaiser Rolls
For immodest dressing: Tarts
For causing injury or damage to others: Tortes
For promiscuity: Hot Buns
For promiscuity with gentiles: Hot cross Buns
For racism: Crackers
For sophisticated racism: Ritz Crackers
For davenning (praying) off tune: Flat Bread
For being holier than thou: Bagels
For unfairly upbraiding another: Challah
For indecent photography: Cheese Cake
For trashing the environment: Dumplings
For sins of laziness: Any Very Long Loaf
For being hyper-critical: Pan Cakes
For political skullduggery: Bismarcks
For over-eating: Stuffing Bread or Bulky Rolls
For gambling: Fortune Cookies
For abrasiveness: Grits
For sins of pride: Puff Pastry
For cheating: Baked Goods with Nutrasweet and Olestra
For being snappish: Ginger Bread
For impetuosity: Quick Bread
For incompetent child rearing: Raisin Bread
For negligent slip ups: Banana Bread
For dropping in without warning: Popovers
For trying to improve everyone within sight: Angel Food Cake
For being up-tight and irritable: High Fiber or Bran Muffins
For sycophancy: Brownies

Thanks, Dr. Sid

New Dinosaur Law:

Trauma survival is inversely proportion to the patient's value to society.

More About Money

From the comments (posted by a headhunter physician recruiter):

Most physicians who complain about money fall into two categories. The first don't see enough patients and aren't efficient with their schedules. The second live in poverty-stricken areas (either inner cities or remote, rural areas.) There are hundreds of thousands of doctors who do extremely well. What do they do differently than you do?

Here's what some of the hundreds of thousands of doctors who do extremely well do differently than I do:

• They're not practicing in areas dominated by one or two giant insurers who offer take-it-or-leave-it contracts paying sub-Medicare rates.
  
• They're specialists who order and perform lots of procedures, often without regard to their clinical utility.
• They spend five minutes with a patient and charge for a level III or IV visit using an EMR to generate reams of meaningless documentation.
• They bring patients back for return visits to review all tests regardless of the results, producing visits like, "The MRI was negative; you don't need surgery on your knee; just keep going to physical therapy" (and then see above.)
• They use consult codes exclusively, even for follow-up visits and when patients self-refer, when they should be using Evaluation/Management codes (which don't pay nearly as much.)
  
• Their malpractice premiums are less than 40% of their net pay.
• They're practicing "concierge medicine," charging $2,000 per patient a year to do exacty the same things I do for non-negotiable "negotiated" insurance rates.

As for "most physicians who complain about money" falling into two categories:

I have open access and see all patients the day they call, if they wish. Physicals are accomodated within the week. August was great because of this; the phones have been slower this month, so we sit. Don't go talking about marketing to get "more people in the door" because:

1. There's no money for it,
2. I'm seeing 1-2 new patients a day on average, because
3. Word of mouth -- as you know, the best marketing there is -- is going great guns thanks to my patients.

It's not volume; it's revenue per encounter, which in primary care isn't nearly as elastic as you seem to think. Surely you're not suggesting I perform unnecessary procedures or recommend extra immunizations just for the money, all the while justifying it with "creative coding"? As for impoverished inner city and rural areas, are you implying that people who live there don't deserve medical care since they can't pay for it? Or that doctors who take on the challenges of practicing in those areas shouldn't expect to make much of a living?

You are oversimplifying and blaming the victim.

I will not let you pin this one on me.

L'Shanah Tovah (draft title was: Punched in the Gut)

Earlier this week; beautiful, bright sunny morning in the office; listening to the messages on the machine.

A cancellation; a refill; then,"This is the ER calling to let you know your patient GF was brought in dead on arrival this morning."

Suddenly I find it hard to breathe; did the sweet, cool morning air just become thicker? Did a cloud move over the sun, or is it my eyes abruptly filling with tears?

First thought: What the hell happened?

He was only 45, diabetic for about six years, but under good control with insulin and orals. He was also on a pile of psych meds for some kind of schizophreniform diagnosis, and he drank -- though he only admitted it to me off and on. His latest meds were Lyrica for neuropathy, recently added to Neurontin (planning to taper.) So it could have been anything from a massive silent MI to respiratory arrest from the potentiation of alcohol and CNS depressants.

Second thought (fleeting): Did I screw up? Miss something? Do something? Not do something?

Check the chart. Last visit in August with an A1C of 7.1. Only notes since then are letters from the neurologist about meds. Clean conscience there.

Third thought: Sadness

Now the tears threaten to well over. He was a little odd, but he always shook my hand firmly at each visit, both on coming and going. Looked me straight in the eye despite his flattened affect. Never failed to offer an appropriate greeting for whichever Jewish holiday was approaching. Often brought me Mishloach Manot (food gifts) at Purim. Apologized whenever he called on a Saturday for disturbing me on Shabbes (not "Shabbat"; "Shabbes" -- emphasis on the first syllable.) He may have been a time consuming "difficult" patient off and on through the sixteen years we knew each other (back when I still admitted to the hospital, he came in regularly with pancreatitis) but in spite of his limitations he was a good man. A friend as well as a patient, and I know I will miss him very much. Out the window I look differently at the sun, knowing now that it shines on a world without GF.

Final thought: Is this beautiful day his way of letting us know he's ok?

Postscript: I had three calls in to the coroner's office trying to get more information, but Mr. F, the patient's father, calls me first. I know him well; he takes care of G's prescriptions for him and gives him his insulin shots. We've met in the office many times.

I tell him how sorry I am. He speaks in a soft, high-pitched voice; very precise, with a Yiddish-like accent. He thanks me and asks if I've heard anything more. I haven't, but he has: the coroner's office has told him that they found a lung abscess at autopsy. GF died of sepsis.

What the hell? (Later in the day I did get to talk to the coroner, a pulmonologist and old friend. Lung abscesses can indeed be totally asymptomatic; until they break through into the bloodstream and produce septic shock and death. Still weird, but I suppose it's worth knowing that it wasn't an MI or something else.)

I tell the father I'll try to get a copy of the autopsy report when it's done and let him know if there's anything else; answer any questions he and his family may have. He thanks me.

He tells me the service will be today at 3:00, graveside. He begins talking about how much he is going to miss his son. Despite his psychiatric issues, they were close. He had recently talked G into coming with him to the gym. His voice begins to waver.

Then, in the middle of telling me of his shock and pouring out his grief in the wake of this unbearably sudden and unexpected loss, his voice steadies, as if he's just remembered something very important. He says to me, "Oh, and Dr. D; I'd just like to wish you a Shanah Tovah, a healthy and happy New Year to you and your family."

I didn't bother trying to stop the tears as I thanked him and returned the greeting.

(Rosh Hashanah, the Jewish New Year 5767, begins at sundown tonight.)

Curses; Tagged Again

Thanks for nothing, Ripple. I'll play along with this one, but I'd rather sit out more Internet tag for a while.

The Seven Songs Tag

Instructions:

List seven songs you are into right now. No matter what the genre, whether they have words or even if they’re not any good, but they must be songs you’re really enjoying now. Post these instructions along with your seven songs. Then tag seven other people to see what they’re listening to [My Edit: or not.]

I have a high schooler too, and he dominates the sound system. Luckily his sister burnt him a CD with a great mix of songs, so that's what gets stuck in my brain:

1. Earth, Wind and Fire medley (my son's marching band field show)
2. Piano Man - Billy Joel
3. Where in the World is Carmen Sandiego - Rockapella
4. Soundtrack from Wicked (the whole thing) (last year's marching band show)
5. Margaritaville - Jimmy Buffett
6. American Pie - Don McLean
7. Changes in Latitude, Changes in Attitude - Jimmy Buffett (our family's "vacation" song; the first one we play as we leave home to get us in the mood)
   

Anyone who wants to play, feel free to consider yourself tagged. Sign up in the comments; first seven "count."

Check This Out

This is so true.

Check out this blog (blogrolled on my sidebar.)

It will make you laugh. It will make you think. It will generate equal parts admiration and jealousy for the person who thinks it up. And all by looking at it for about two seconds.

It is called "Indexed." It should be called "Not a Thousand Words."

Coda to The New Patient

Thanks to Tundra Medicine Dreams for including a post of mine in this week's Grand Rounds. There's a funny postscript to it.

After posting, I read both the original post (at Ripple of Hope) and my answer out loud to my son, age 17. He scowled, and with no irony or sarcasm at all he blurted out, "That sounds like a relationship."

Me: "Yeah. It is. They call it the Doctor-Patient Relationship for a reason, you know."
Him: "No; I mean a real relationship."

Whatever. (Exit: to school)

Obviously it is a real relationship. And just like a relationship with a lawyer, accountant, car mechanic or hairdresser, we seek out people we can trust, with whom we can communicate, who we can get ahold of when we need them. Most folks are thrilled to find a doctor they can relate to, but what's the first thing you look for when you move to a new community? Car mechanic and hairdresser usually come even before doctors. All good relationships are priceless.

Follow the Money (Guest Rant)

One of the reasons we dinosaurs have three feet in the tar pits is the increasing difficulty we're having making a living. Only in this country do we have de facto price controls on doctors' fees (ie, Medicare) and over which we have no control. What to do?

There's a growing rumbling about in the land. "Cash only", the rebels intone. One by one, a few docs here and there throw up their hands and bite the bullet (often to do quite well, but obviously with a different patient mix. Some of my personal reluctance to go that route stems from my sense of responsibility to my present patients. But I digress...as it appears we dinosaurs are prone to.)

How might this be accomplished more systematically? This, too, has been discussed in assorted circles, both public and private. My friend Dr. P says it well:

We ALL together DROP all insurances. We announce a D-day, nationwide. We dump tea in the harbor; taxation without representation, off with King George's head!

We tell the patients that it's a new day. Forego one dinner and movie out and you can pay for your doctor visit. Payment due at time of service, unless there's real financial hardship. Hello? If you're too poor for that, we'll see you for nothing. Those of you with six-digit incomes can subsidize the difference.

Everyone buy a rock-bottom catastrophic policy for duh? insurance (what insurance is supposed to be: spreading risk of accident or severe illness, not everyday gas and oil). And sock some money into the now-allowed HSAs tax deferred. Keep your money instead of p---sing it away to "insurance" companies.

What a concept. Sound familiar? Sound retro? Sound like the rebirth of common sense? (Have you read Philip Howard's The Death of Common Sense?)

Forget about coding. It's useless for its original purpose: to collate real disease. It's useless because we have to code for the disease in order to test for it. We have to assign a code even when we haven't a clue what's wrong with the patient. No one's codes are believable anyway. They're all fudged and we know it. (Admitting is is a different story.) Hospitals fudge for highter reimbursement -- we sign and go along as we look the other way.

It's also useless for equalizing reimbursement bewteen primary care and procedures. The RBRVS was a valiant attempt, but all that emerged were armies of coding specialists who now earn more than the family doctors, and whom we now have to hire and pay. Forget about studying real Medicine: time to learn Business Management.

Everyone wants to know the way out -- this is it.

But it all depends on the public being led, step by step, to understand that this is best for them, not just for us. And it depends on our not being afraid to do it. Courage.

It would only work as all-or-none, but I'm just on the edge of being ready to give it a shot.

Anyone else?

I've Been Tagged

Thanks, MedStudentGod (feel the sarcasm.)

I've been tagged, but at least it's about books; a subject closer to my heart than I can reveal without jeopardizing my surprisingly easily assumed disguise.

1. One book that changed your life:
The Jewish Catalogue (now known as the "first" Jewish Catalogue, or the red one, as there have since been two sequels.) It was given to me as a confirmation gift when I was about 16, and I devoured it. To me, it read like a do-it-yourself guide to a much more observant version of Judaism than I had been raised with, and it resulted in my deciding to live the rest of my life much more Jewishly.

2. One book you have read more than once:
Too many to count. I have a habit of reading books over and over and over; I call it "over-reading" them. Granted it was worse when I was younger, with more time and less access to new books. But a partial list of books I "read 'til they shred" would include: To Kill a Mockingbird; I Never Promised You a Rose Garden; The Other.

3. One book you would want on a desert island:
The bible. Maybe I'd finally get the chance to actually read it cover-to-cover.

4. One book that made you laugh:
Eats Shoots and Leaves. How on earth can punctuation be funny? Read it and see, but not in bed at night. You'll wake your bed partner laughing out loud.

5. One book that made you cry:
Marley and Me. No animal person can read the last few chapters of this without Kleenex handy.

6. One book you wish had been written:
The bestseller I'm working on.
No; wait; I don't wish someone else had already written it. I mean I want to write a book that others will wish had been written.
Aw, hell; you know what I mean. (I hope.)

7. One book you wish had never been written:
Protocols of the Elders of Zion. There would probably still have been the same amount of evil done in the world without it, but it might have been a little more difficult.

8. One book you are currently reading:
The Dante Club; a historical about a serial murderer in 19th century Boston whose crimes are modelled on The Inferno.

9. One book you have been meaning to read:
The Kite Runner. Not sure why; I've been told I "should", and it's sitting on my dresser.

As for passing it on, I politely decline, but if Flea, DP, and Sid think they might enjoy it, they can be my guest.

The Party That Wasn't

Today would have been my parents' 50th anniversary.

My mother died after 30 years of marriage (she actually died in June, but no one objects to my dad claiming the extra three months), and at the end of next month my dad and my step-mom will celebrate 19 happy years of marriage. So life goes on.

Two weeks ago we were all together having a wonderful celebration of my step-mom's 70th birthday, but I hope I can be forgiven thinking wistfully that the big party should have been today. Not that it wasn't fun doing another college visit with my son, but I wish there could have been somewhere else we should have been.

My mother gave my father a gold Patek Phillipe watch that day, engraved:

With all my love, Always
September 16, 1956

He sent us an email telling us about his feelings reading that inscription today; musing (tearfully at times) about their 30 years and five children together; the eight grandchildren she never knew, and how much he still cherishes all the memories.

I also spoke to him on the phone. He told me that after a meeting at his club today, he came across a wedding reception in progress. He cornered the bride and groom and showed them the engraving on the back of his watch as he explained that he was married fifty years ago today. He wished them as much happiness as he had shared with my mother. And he asked a favor of them: that on their golden anniversary, September 16th, 2056, they also seek out a couple on their wedding day and pass the blessing on.

The New Patient

I saw this post at Ripple of Hope (formerly Difficult Patient) following the link from Grand Rounds. Edited and posted here with her permission:

The New Doctor

Well, she's new to me. She is Dr. Barbie, and I have an appointment with her today for a physical. I'm nervous. How much do I share with her? How much does she really need to know? How do I tell her not to ever give me sleeping pills or anti-anxiety meds or anything stronger than ibuprofen for pain--how do I tell her these things without telling her why?

There is no way I'm going to transfer my medical records from Dr. G. I have a personal copy of my official records (no, I'm not going to share it with her) but I can only imagine the negative remarks Dr. G would make about me.

Yep, I think Dr. Barbie would drop me like a hot potato if she ever spoke with Dr. G. I really wouldn't blame her, but those records do not accurately reflect me (then or now)--they are defensive assumptions because Dr. G didn't have all of the facts. Yes, I know it's my fault that he didn't have all the facts, but that doesn't exactly help me now. I think I'll keep my answers brief and to the point. I like her, but I don't know her, and I don't really trust her.

Yep, I'll just leave the past in the past for now. Any suggestions on how to communicate with my new doctor without scaring her away?

Here's my response (expanded upon from the comment I left on her blog):

I hear you. I'm the doctor on the other side of that door. I wouldn't dream of comparing my anxiety to yours; I'm well aware that I wield the tools of authority, pain and humiliation (white coat and stethoscope, needles and probes, stirrups and gowns.) But anxiety is contagious; and just seeing you check in at the desk and sit in the waiting room, your obvious nervousness surrounding you like a cloud of worried gnats, makes me nervous just to walk into the exam room. So I'll take a deep, cleansing breath as I open the door, and resolve to project enough serenity so that at least some gets back to you even through your anxiety.

I'll introduce myself and shake your hand; then I'll sit down, put your chart to one side, look you straight in the eye and say, "What can I do for you today?"

And then I'll listen. Talk as long as you need to; tell me whatever you want.

I'll want to know why you're really here; there's no such thing as "just a physical." New to the area? (Welcome.) Old doc died/retired? (Sorry about that; I'll try to pick up where s/he left off.) New insurance? (Bummer, but I'll do my best with the new plan.) If you had problems with other doctors I'll want to know about it, mainly so I can go out of my way to make sure you don't have another.

As for your medical history, I'd like to have all the information, but if you'd rather wait and see instead of dumping it on me all at once, that's fine. I can wait. I don't mind giving you the time you need to get comfortable with me. In fact, spreading the whole story out over several visits is easier on my schedule.

If you're playing me for drugs you're going to be disappointed eventually, but I'll give you the benefit of the doubt to start with.

As for communicating with Dr. Barbie, here's my suggestion: be yourself. Tell her whatever you want, however you want to tell it. If you scare her away then she just wasn't good enough to be your doctor. Then again, you may be surprised to find her competent, caring and understanding. Consider giving her a break; it's what you'd like her to do for you, isn't it?

(Back off, all of you in your time-stressed, seven-patients-per-hour-or-else practices. This is what I do and how I do it, because I can. What anyone else does is irrelevant. This is the stuff that seems to be going the way of the dinosaur.)

Fun & Games

Doctor walks into an exam room to find an elderly couple waiting.

He asks, "What can I do for you today?"

They say, "Just watch us, please."

They proceed to strip down, climb onto the table and go to town. They dress, thank the doctor, pay the bill and leave.

Next week the same thing happens.

The third week the doc stops them and asks what the hell is going on.

The old man answers, "We can't go to her house because her husband is there. We can't go to my house because of my wife. A hotel room costs $95. Your office visit is only $90, and Medicare reimburses us 80%."

Screening 101

Words are my friends, so it bothers me a great deal to see them abused. One word that gets beaten up a lot these days is "screening".

As we all (should) remember, "screening" means something very specific: as I describe it to patients, it means looking for a disease or condition when you don't expect to find it. If there are symptoms you're trying to explain or history that suggests the presence of a certain condition, you are not "screening" for it.

Screening tests are very carefully evaluated in terms of prevalence of the disease or condition, the ease and availability of the test, the sensitivity and specificity of the test, the costs of the testing, and perhaps most importantly, how much of a difference in the natural history of the disease can be made by earlier detection. These criteria are what have been used to determine that colonoscopy is a good idea for colon cancer and routine chest x-rays are a bad idea for lung cancer, counterintuitive as it may sound.

My problem is the confusion of screening with diagnosis. Mammography is a great screening test for breast cancer, but when you're evaluating a palpable mass you are no longer doing a screening test. You are evaluating the mass you can feel. (Actually, what you're really doing is making sure there isn't another, non-palpable abnormality in the contralateral breast, since you're obligated to further evaluate the palpable abnormality with ultrasound, biopsy or both; it still isn't "screening", though. But I digress...)

Another problem with screening is that we do a great number of things as de facto screening tests that haven't been subjected to the rigorous analyses required to determine their value. Treadmill stress tests -- especially with nuclear imaging -- on asymptomatic patients, cardiac risk factors notwithstanding, are probably the one most demanded by the non-medical public, and/or pushed on them by doctors with equipment in their offices as revenue generators. Echocardiograms on anyone with a pulse fall into the same category. Is anyone aware of a cardiologist who has not ordered an echo on any given patient? I'm not.

The real problem with this is that valuable and proven opportunities for meaningful screening fall by the wayside as we try to educate patients about why whole body CT scanning for calcified arteries doesn't mean squat, and why "Virtual Colonoscopy" -- nothing more than fancy computer processing -- isn't ready for prime time.

It all just goes to prove the Fifth Law of the Dinosaur: A patient's acceptance of any screening test is inversely proportional to its necessity for that particular patient.

More Dinosaur Laws

Many thanks to Flea and Shinga:

Fourth Law:

No good deed goes unpunished.

Fifth Law:

A patient's acceptance of any screening test is inversely proportional to its necessity for that particular patient.

Keep those cards, letters and comments coming.

Two Little Numbers

It may not yet be possible for anyone to blog about anything on this date other than the obvious. So despite the fact that others are sure to be far more eloquent, I must try. I occupied space on the planet that day, so I was part of the world as it changed forever. Where were you?

I was at work that perfect Fall Tuesday morning. Someone came in for an appointment and said something about a plane and the WTC. For some bizarre reason, the image in my head was of a small private plane inadvertently crashing into the building, damaging mainly itself and threatening only its pilot. One of my employees' husband called with more information.

There was an old black and white TV upstairs. Someone dragged it down and set it up in the front office while I went on seeing patients. I didn't see either tower fall. The rest of the surreal events of the day continued to trickle in. Patients cancelled. By afternoon the planes were grounded, and although no one was at all certain of what had actually happened, it was clear enough -- even to me in my far-off sequestered corner of the world -- that life had been divided into two distinct parts: all of time up to this day, and all of time yet to come.

I've been playing with this idea for a couple of years now: thinking about things that permanently divide life into before and after.

Some things seem like it at the time we are living with them: exams; boards; proms; holiday parties; championships. But in the grand scheme of things they really aren't; within a few years, how much difference does a big organic chem exam really make (whatever grade you got on it, if you even remember.)

Some other things that feel like it (graduations; weddings; babies) actually are. But because these things are usually planned and thought about and endlessly contemplated a thousand times before they occur, when looked back on later feel more like a process than an event.

The things that really divide our lives in two are the things that catch us by surprise: auto accidents; broken bones; sudden deaths; an ultrasound showing twins (our first pregnancy); and 9/11, a simple pair of numbers that when put together like that have come to mean "the day the world changed forever."

As that day went on I found myself in shock, not even fully sure why. In fact, I felt almost guilty: I didn't know anyone who had perished; I didn't have any direct connection with anyone who was directly affected. I don't live anywhere near New York. But I still felt it.

I had a date that night. We had dinner at home and spent the night together. I remember feeling strange having sex when it felt like the world as I knew it was coming to an end and what might replace it was far from certain. But in the end we agreed it was a validation of life, and symbolic of life going on. We've been married over four years now, so life certainly went on. Funny how it almost always does.

I've already written some benzo prescriptions for patients who were in NYC that day, who saw the planes hit and whose PTSD will be acting up on the anniversary. For myself, though, I don't plan to watch any of the TV shows or participate in any of the memorials. But I will think about it every time I write the date on a script or a note or a lab slip. Who would ever have thought of two little numbers having such power?

They Like Me; or at least They Like (some of) What I Have to Say

Thanks so much to Shinga for including me in the latest Pediatric Grand Rounds. What a nice welcome to the blogosphere.

What Comes Between Primary and Tertiary?

The definition of Primary care is easily understood: it refers to the first stop in the health care system for the average person confronted with accident or illness, as well as preventive care. Also fairly straightforward is the "tertiary care center", which refers to the big city medical center with high-powered specialists and expensive equipment that can nail down that elusive "zebra" diagnosis and treat patients with very complex problems.

Those who have mastered the concept of numbers may have noticed something missing. What is "Secondary Care"? The answer is specialists, and the care they are trained to deliver.

So what's the problem?

During specialty and subspecialty training for Cardiology, Gastroenterology, Pulmonology, etc. physicians are taught that they must make a diagnosis. Every possible condition -- no matter how unlikely -- must be ruled out. Cost should not be an object, because some rare condition could always be present. That is their job as the specialist after all.

Here's the thing: specialty care assumes a preselected population. When patients are properly evaluated first by a trained primary care physician, many will find themselves correctly diagnosed and treated without the need for specialty care. When specialists see only those patients whose diagnosis escaped the family doc or who didn't respond to the Primary's treatment, their "spare no cost" approach is perfectly reasonable. In fact, their greater expertise is the rationale for their higher fees.

But when applied to a general population -- people off the street who haven't seen another doctor first -- medicine as practiced by specialists is expensive at best and inappropriate at worst. How many times has a patient with chest pain and no other cardiovascular risk factors gone directly to the cardiologist and, after an EKG, echocardiogram and nuclear stress test, been found to have GERD? To the cardiologist, the fact that the patient came to him is all the rationale he needs to perform his full work-up, when in fact the patient, whoever is paying for his care (be it his employer, himself, or an insurance company) and the specialist himself would have been far better served if this patient had been seen by a family physician first to be appropriately evaluated and treated.

So why aren't the specialists our biggest cheerleaders? Wouldn't their lives be far more interesting seeing patients far more likely to actually have those zebra diagnoses, not to mention more lucrative? (Consultations pay significantly more than evaluation/management codes. Then again, Consult codes are often abused. But I digress...) Specialist care can get ridiculously expensive, mainly because of all the procedures they recommend for diagnosis and treatment.

The specialists need to get their act together, quit poaching our patients, and go back to what they were trained to do: Secondary Care.

Just Drag Me Off to the Tar Pit

It's raining and dreary and miserable. My foot hurts (plantar fasciitis.) My head hurts; I've just taken two tylenol. And people are being really stupid today.

I go around and around and around with a guy who wants an antibiotic. I tell him it won't help because he has a virus. He says, "So you don't know what's wrong with me."
me: Yes I do; it's a virus.
Him: Then why can't you give me something for it?
me: Because it won't help.
Him: Oh, ok. But how about an antibiotic?

Then there's the lady with a TSH of 1.5 on 0.1 of Synthroid for 10 years, but has swollen feet, fatigue, dry skin, a pain under her ribs, and about six other general symptoms. How long has she had these problems? "A while." A week? A month? Since the Carter administration? "Oh, it's been quite a while." Extracting the history, one precious nugget of information at a time, wheedling, cajoling, repeating and re-phrasing every step of the way.

Another lady comes in, talking continuously, telling me about her terrible sinus infection for which she needs Biaxin. Nothing else will do. Just give her some of that Biaxin, please. I don't really need to take her temperature (98.5) or her blood pressure (168/96) or examine her (gorgeous pearly TMs, throat perfect; pinkest, clearest nose I've seen all day; bang on her cheeks with a sledgehammer and she's fine; never even stops talking.) She just needs that Biaxin. Ten minutes of careful explanations about bacteria, viruses, upper respiratory infections, antibiotic resistance -- not to mention side effects, though of course I do -- and she refuses to be swayed. Not only that; she literally won't leave without it. I strike a bargain: three days of Biaxin AND a blood pressure pill, and she has to promise to come back in a month so I can see how she's doing. She thanks me profusely on her way out. I won't see her for a year. I know this because every word of this visit is identical to her last visit -- a year ago. (And my office manager has to explain to her why there's yet another $110 Medicare deductible she has to pay.)

Next there's the 11 year-old girl who had a cold last week. She's fine now, but her dad wants me to "check her out." While there, he mentions a spot on his leg that was there a few months ago. It's gone now, but he wants to know what it was.

And finally there's an older gentleman whose blood pressure was decently controlled on moderate doses of once-daily generic meds. He said he wasn't feeling quite right, so he stopped taking them and switched to something over the counter called "Blood Pressure X". He's not sure what's in it (he forgot to bring in the bottle) and it's kind of expensive, so instead of taking it three times a day he's only taking it twice. But he feels great. Just great! His BP is 190/100, but he feels great. Just an illustration of the Second Law of the Dinosaur: It is impossible to make an asymptomatic patient feel better.

Guest Rant: The Crux of the Problem

Discussing the value (or lack thereof) placed by patients on primary care and preventive medicine, my friend and fellow dinosaur Dr. G puts it so well:

It all seems to boil down to "How do we make sure that people get the things they need but don't value enough to pay for themselves?"

No wonder primary care is in the mess it is (and specialists thrive.) Here comes the the light bulb: the real reason for the demise of Family Medicine is that people don't want us. They do if someone else pays for it, but not if they have to pay out of their own pockets.

Specialists get paid for the things people value: "Bail my butt out of the jam I got myself into" care. People want the angioplasty and they'll raise the funds for a specialist to do a procedure, even if it only adds a week to their life. Yet they won't pay a $20 copay to discuss preventive care with us.

Patients often make these same kinds of decisions in the face of dismal prognoses: full court press with the chemo, ICU, etc. The oncologist, thoracic surgeons, intensivists, pulmonologists, cardiologists and others all get rich billing desperate people who were too busy to think about preventive care, or didn't care enough to pay for it before they got sick. The statistics on how much of our healthcare dollar we spend in the last few months of our lives escape me, but they point to why our system is in the state it is.

Couldn't have said it better myself, and believe me: I've tried.

Laws of the Dinosaur

First Law:

The art of medicine consists of amusing the patient while nature takes its course.

Second Law:

It is impossible to make an asymptomatic patient feel better.

Third Law:

The urgency of the test is inversely proportional to the IQ of the insurance company preauthorization clerk.

Anyone have more to add? (And no fair snarfing from House of God, which I know by heart.)

People Who Used to be Doctors

Is "doctor" something we are or something we do?

Although attainment of an MD degree forever confers the title of "Doctor", once you decide to make your living doing something else -- even if you use your medical knowledge or background in some way -- you cease to be a "real" doctor.

I'm not talking about our colleagues in research or teaching, but about those who chose careers subsequent to or instead of one in medicine. Careers which don't necessarily need the skills and knowledge of a physician to succeed in, even if an MD does confer an advantage; careers where the majority are in fact not doctors. That is the point at which a doctor is no longer a physician, and more importantly, should not hold himself out as such among his peers -- us.

Michael Crichton graduated from Harvard Medical School, but is now a wonderful writer and successful television and movie producer and director. He used to be a doctor.

Bill Frist also went to Harvard Medical School and practiced for several years as a cardiothoracic surgeon. But since 1995 he has served in the United States Senate as a powerful legislator, and in fact has recently even let his CME lapse. He used to be a doctor.

The lawyer who sued me in the mid-90's had an MD degree as well as a JD. Seven years after my "failure to diagnose" a base-of-tongue cancer in a non-smoker, the patient was alive and well and free of disease; the jury took 15 minutes to find me Not Liable. He used to be a doctor.

Robin Cook, who went to Columbia University Medical School, invented the fiction genre "medical thriller" in 1977. He used to be a doctor (although Flea points out in the comments that Cook never intended to be one.)

William McGuire got an MD from the University of Texas-Austin. He has since used his credentials as a pulmonologist to rake in well over a billion dollars in salary and stock options as the CEO of UnitedHealth Group without having seen a patient in 20 years. He used to be a doctor.

And then there's Joel Fuhrman, who caused such a hubbub over at Pediatric Grand Rounds a while back. He attended the University of Pennsylvania Medical School and is a board-certifed FP in New Jersey, where he specializes in "nutritional medicine." Not Family Practice; not Pediatrics; not Preventive Medicine; "nutritional medicine", an urecognized specialty whose practitioners reject what they were taught in medical school and concentrate on selling non-FDA approved products (products specifically "not intended to diagnose, treat or prevent disease") to their "patients". Fuhrman's major source of income is the books and products he hypes on his website and other media (He has "appeared on hundreds of radio and television shows including: Good Morning America, CNN, Good Day NY, TV Food Network, CNBC, and many more.") So don't waste any more time worrying about him, and whatever he may say, don't feel compelled to accept his views as that of an actual medical colleague. He isn't really a doctor anymore.

Pick up That Phone

I had a dream a while back. I don't remember all that much about it; it was something about handling a difficult patient, or doing something I didn't want to do but knew I should. Something like that. One of the characters in the dream was a man I'll call Dr. M, the associate director of my residency program. I woke up remembering yet again how much he meant to me.

I've been out of residency for more than 15 years now, solidly ensconced in practice. When I have questions about a diagnosis or treatment, I have a rolodex of referral specialists who have been great about answering me over the years. I know who's willing to answer general questions and which ones will hem and haw and insist on seeing the patient (so guess who I prefer to call) but I've pretty much moved past my residency faculty as a clinical resource.

But I still find them with me every day, especially Dr. M. His is the voice in my ear when I see what I'm sure is HSV but really ought to be cultured, just so the patient can be absolutely certain. I remember squinting at a sheep's blood agar plate trying to discern whether the colony of strep had a ring of beta-hemolysis and hearing his voice behind me saying, "Positive as the day is long, Dr. D; positive as the day is long." When a patient is being unreasonable, his voice in my head is the one pointing out that the patient is probably scared, worried about what I might tell him, so his belligerance isn't really directed at me. Dr. M was my ultimate model of a family physician, and I still find myself regularly thinking "What would Dr. M do in this situation?"

He's not dead. Last I heard he's the Director at another program, so I checked online and sure enough he's still there. I copied the phone number down, and early the next morning, right before I began seeing patients, I picked up the phone.

His voice was as happy and excited as I remembered. No one was ever as excited about Family Practice Service rounds every morning as Dr. M was. He asked about my kids and I about his. Then I told him why I was calling, saying something like this:

"I just wanted to let you know what an important part of my life you were -- and are. More days than not I think about what you taught me -- not just the clinical minutiae of family practice, but what it means to really be a family doctor. I find myself modelling what I do, what I say and how I say it after you. I just wanted you to know that. And I wanted to thank you."

What about you? If there's a Dr. M in your past whose voice still echoes in your head, why not just pick up the phone and make his or her day.

Not Yet Evidence Based Medicine

Don't get me wrong; I'm a huge fan of EBM. Call it silly, but I do think the things we do and recommend to patients should actually work. Let me also say that as a rule I am not what is known as an "early adopter." I prefer not to be the new guy on the block with new drugs and treatments. Let other doc's patients find out the hard way that Vioxx causes heart attacks.

That said, as new evidence from research comes down the pike, there are times when a pattern can be seen emerging distinctly, and following the curve ahead a bit feels like a good idea. So let me tell you about some of the non-evidence based ways I am treating type 2 diabetes.

For starters, I am explaining to patients that I no longer think of diabetes as a "spectrum" from non-diabetic to pre-diabetes to borderline diabetes to full blown diabetes. I'm check a lot of A1Cs with so-called "screening" blood work; anyone with a family history of DM, anyone who has been told their "sugar was a little high", and any woman with a history of any degree of gestational diabetes. Anyone with a glycated hemoglobin over 6.0% has "it".

Insulin resistance, potential diabetes, whatever. What it says to me is that if/when they eventually develop DM according to whatever the future standards might be (because they have been tightening relentlessly over the last 20 years) whatever damage to the blood vessels in their hearts, brains, kidneys and eyes will have already been going on for who knows how long. So I have decided to get ahead of the curve, even though there's no "evidence" formally promulgated as of yet.

As we all know, the metabolic syndrome is more than just DM ("glucose intolerance"; whatever.) So what my diagnosis if "it" does is raise the bar for BP and cholesterol control. What do I do with someone with an A1C over 6% but under 7%? Even if I call them "diabetic", they're still "well controlled" by whatever lifestyle modifications they've already implemented. Many of them already have an optimal exercise regimen and diet.

What it does is change the targets for blood pressure and cholesterol control. I try to get their BP down below 110/70 instead of 120/80, preferable with an ACEI or ARB. I'll try to push their LDL down below 100. I don't give them all metformin, but I'm sure someone somewhere is researching it.

Evidence based? Not really. Not yet, anyway. But it's what I would do if my A1C were over 6%. And I tell patients that up front. Your BP is 118/78; why do you need lisinopril? Because I think 10 years from now the "guidelines" will have changed (again), and I'd rather they get the 10 extra years of protection for their endothelium.

Robin Cook Writes Fiction

I wasn't going to write about Robin Cook's op-ed piece in the New York Times the other day, partly because so many others already have, but mainly because it really pissed me off and I didn't want to go back to the *angry primary care* thing just yet. Still establishing my persona out here in the sphere, yanno. But all the buzz going around is only about FP's getting paid less because we're less educated than internists and peds; which is wrong, but focusing on that part of it is like responding to someone who calls you lazy, stupid, cowardly and ugly by saying, "Whaddya mean 'ugly'?"

For the record, the piece was about Primary Care being undervalued in the marketplace. No quarrel there. But when I read this part of it:

As it is now, insurance companies — following Medicare’s lead — pay primary care doctors according to the number of patients they see. Each patient visit is generally reimbursed at a flat rate of slightly more than $50. The payment is the same whether the patient is a healthy, young person with a runny nose or an elderly person whose multiple chronic illnesses require many tests, referrals to specialists and detailed explanations to both the patient and his or her family.

I thought WTF. Insurance companies and especially Medicare sure as hell doesn't pay a flat rate -- certainly not "slightly more than $50" -- per patient regardless of how much time I spend or how complex a case it is. Shit, if I got $50 per healthy young person with a URI, I'd be quietly raking it in! Hasn't he heard of CPT coding? E/M documentation guidelines? What the hell is he talking about?

And then he adds this:

A lawyer in general practice is not expected to accept the same low fee he gets for writing a simple will when he writes one that involves complicated business circumstances. Nor does an accountant charge the same amount for a difficult tax return as for an easy one. Why should the work of doctors be assessed this way?

Hey, dude: lawyers and accountants ARE paid by the hour. The simple will or tax return costs less because it takes less time. They charge this way because they can; it's their clients who actually pay them. Hello! Remember why insurances are called "third parties"?

So don't contract with insurance companies in the first place. Sounds reasonable and logical, but there are at least two trivial little problems with that:

1. It assumes that each party to the contract is able to negotiate terms to its benefit. In places like Colorado the major players (who all happen to pay the same fee, but it isn't anticompetetive because the insurance commissioner has said it's just coincidence) refuse to negotiate, telling doctors to take it or leave it, and
2. (the bigger problem) Somehow we have come to a point in this country where patients -- people; citizens -- seem to feel that they shouldn't have to pay for medical care. The "ideal" is insurance paid for entirely by one's employer, with minimal (if any) employee contribution, co-pays, etc. Although most people claim they don't expect all of that, their behavior still reflects the mindset that someone else is paying the bills.

Back out here in the real world, sure we can opt out of all the contracts. The only problem then is getting patients to come to us if they actually have to -- GASP -- pay. Unless (or until) all of us do it, there's always going to be someone up the street they can go to "without" paying (as in, "But doc, they take my insurance.") Still, things are getting bad enough that more and more of us are contemplating exactly that.

Bottom line is that after 30 years as a writer, the only things Robin Cook has in common with practicing primary care physicians is friendships from residency and an MD degree. He may be trying to help, but with premises so outrageously inaccurate he should stick to writing fiction. Oh, wait; I guess he has.