More Clarification on "Balls"

I'd like to further clarify some of the details of my complaints about surgeons who try to get me to do their work. Some of the comments to the previous clarifying post began to get into a pissing match between surgeons and anesthesiologists, which was not the issue. Here's why:

Out here in the real world, things work somewhat differently from in a teaching hospital. The usual protocol is for the patient to have a separate anesthesia consult, often several days prior to the surgery, where the anesthesiologists do their own evaluation. They have their own patient questionnaire; they review the pre-op labs and EKGs, and they will often contact me independently if they have a concern about the patient's medical status. I have no problem with this. (Except when they call the morning of surgery with a 50 y/o diabetic's creatinine of 2.7 that's been stable for years, insisting that "she needs to see a nephrologist" before surgery. I call my nephrology colleague, am reassured that he is as incensed as I, and recite the magic words to Anesthesia, "Nephrology says it's ok.")

It is the surgical history and physical of which I speak. As my (good) surgical colleagues have explained to me, the surgical H&P goes over the surgical problem and physical findings, along with the surgical diagnosis and plan; including, of course, the informed consent and an assessment of whether or not a separate medical consultation is required. This is what the (lazy) surgeons are trying to foist off on me.

I would also like to point out something poorly understood (or ignored) by so many, from various commenters to Medical Economics magazine itself: the idea that I, as a primary care physician, can express my displeasure with a specialist by withholding future referrals is NONSENSE! In the sub-specialist-saturated area in which I practice, patients are referred willy-nilly from one specialist to another with no input from me at all. In the case that initiated the original diatribe, for example, the patient was referred by her ophthalmologist to a plastic surgeon who sub-specialized in ocular plastic surgery. And of course once a specialist says, "You need to go see this other doctor," no one cares about my opinion.

As if that weren't bad enough, in this age of information overload, patients often select their own specialists -- either from the internet or word-of-mouth referral -- and take themselves off to see them without even telling me. Worse, there are times when they do ask and I say, "I prefer Dr. A or Dr. B, but I've had some problems with Dr. C, so I don't recommend him," and sure enough, the letter comes back from Dr. C (that invariably begins, "Thank you for asking me to consult on Mr. Moron," thus insuring he can bill the visit as a consult for higher reimbursement.) Until (unless?) primary care in this country is strengthened to at least allow me to stay in the loop, this shit will go on. Obviously the strict gatekeeper concept failed miserably, but there ought to be some kind of middle ground; otherwise these ricochet referrals will only get worse.

Bottom line is that I have no power in these situations. As previously discussed, standing my ground too often means alienating the patient; another issue that only takes on real meaning after graduation from residency. Think about it: there's plenty of lip service paid to the importance of patients in the teaching hospital, but as a trainee, the people you really have to please are your superiors. Sad as it may seem, it doesn't matter if patients don't like you. They don't get a say in your evaluations. (Hmm: maybe they should.) The flow of patients is independent of your actions or behavior. They keep on coming, whether you're the nicest guy on the planet or a raving lunatic. It's only later that reality intrudes to the point of realizing that you have to play well with others if you want to eat. (Perhaps those who never learn this are the ones who remain as academic/teaching hospitalists.)

So thanks for the positive feedback. I just wanted to point out that it's not an anesthesia issue, and that all those textbook suggestions about "Don't refer to them in the future" are unhelpful in the real world.

Shamelessly Stolen

Partly to assuage blogger's block; partly because they're so good they need to be shared (and shared again, in some cases):

Maria, this is one of the most amazing essays on emotion I have ever read. I, too, find it easier in many ways to edit the writing of others than to generate my own, but the leap you make into the role of language in the interaction between emotions and behavior is nothing short of fascinating. Amazing.

Medblog Addict, you find the most amazing videos. How do you do it?:



You really have to issue beverage alerts; also known as spew warnings. That's why you're always broke from people hitting you up -- legitimately -- to replace keyboards, laptops and monitors.

In a similar but totally different vein, here's the first "funny video" I saw on the internet that way pre-dated YouTube, although it's now been uploaded there countless times:



Predictably, my writing production has fallen off dramatically since hitting the meaningless mark of 50,000 words. A word to the 101 Reasons to Stop Writing commenters: Sean's site is meant to be funny (I think; at least I find it so.) What I find amusing is his implied belief that people who do NaNo really think of it as "writing novels" and of themselves as "writers." It's a case of a joke not being funny if you have to explain it. Ah, well.

NaNoWriMo Winner

Not that it means anything substantive (just check out Sean's hatefest) but I am an official 2007 National Novel Writing Month "Winner":

I hit the 50,000 word mark this evening, Sunday the 25th; meaning I averaged about 2,000 words a day. Even better, my story isn't finished. It looks like it'll weigh in at about 80,000 words when it's done, which is a much better length for modern commercial fiction. Now, of course, it's even more incumbent upon me to finish it, even though it's going to take more than 30 days.

Don't go looking for "The Phlebotomist" in bookstores any time soon, though. First of all, I have to:

1. Finish it.
2. Let it sit.
3. Edit, revise, re-write and polish it.
4. Proofread it.

Then and only then will I be ready to:

1. Research agents.
2. Compose a query letter.
3. Write a synopsis.
4. Submit queries.
5. Wait.

where of course #5 is the most time consuming. The best possible course of events then goes like this:

1. Agent(s) ask to see a partial.
2. Agent(s) ask to see the full manuscript.
3. Agent offers representation.
4. Agent sells book to publisher.

Then, of course, it's only another year or two before the thing makes it through the glacial process that is publishing. And by that point, it's better than even odds that somewhere along the way, the title will have been changed.

So as I said, don't hold your breath to read it. Then again: I am a winner.

Futile Care: What a Difference a Species Makes

She's lived a long, healthy, happy, productive life, but now she's failing. Her eyesight is going, she can't get around as well as she used to, and she's started becoming incontinent from time to time. None of that changes your love for her, of course, so you help her get where she needs to go, and do what she needs you to do for her. You clean up after her as matter-of-factly as you can, so as not to embarrass her, because her company is as precious as it ever was.

But then you notice some blood, so you take her to the doctor. Not surprisingly, on the basis of age alone, she has a terminal illness. What happens next, though, depends on the quality of the doctors:

Are you told, "She needs an operation followed by some other treatments that are expensive, uncomfortable and may or may not prolong her life, but without treatment she will die," implying that of course you don't want her to die so this is what has to be done, or are you offered a compassionate discussion about comfort care and quality of life, allowing you the option of taking her home, making her comfortable and letting nature take its course?

AND: How much difference does it really make if we're talking about your aunt or your cat?

There was a time not all that long ago when the first option was the only one given for a person, and the second was the only option for a pet. To our credit, many physicians are coming around to recognizing the limitations of our wonderful craft, realizing that death is not the enemy and compassionately embracing palliative care. On the flip side, as veterinary medicine accelerates and catches up with human medicine in terms of what can be done, there are accusations of some young vets who begin to sound like old-fashioned human doctors: if we can do it, we should do it. After all, you don't want her to die, do you?

Here's the big question, though: Why is it only the veterinarians in this situation who are accused of being coldly calculating, money-grubbing scoundrels? Is it just because people actually have to pay vets for their animals' care, whereas Americans' dependence on the capitalistic system of medical payment brokerage (rendered in doublespeak as "insurance") has effectively allowed them to believe that medical care shouldn't cost anything? In the case of futile care, though, none of that ought to matter.

I am not saying that a human life is equivalent to that of an animal, nor am I espousing euthanasia for humans. But to the extent that ACLS is now an option for animals (despite the fact that cats, for example, don't get atherosclerosis so cardiac arrest is generally a terminal event) it seems that the line between futile care and heroic (ie care with a good outcome) is becoming as fuzzy in veterinary medicine as it is for humans.

Everyone needs to get together on the same page. Futile care is futile care, (edited to add: and shameless, money-grubbing appeals to guilt are, well, shameless) for man and for his best friends.

Shattered Lives - Part Three

(Click here for Part One and Part Two)

What do you do when lightning strikes twice?

What do you do when a brother, unable to handle the stress of his loss, is voluntarily admitted for his own safety and then found in cardiac arrest?

The full facts aren't yet known but none of it will change this: my friend has now buried both of her sons within ten weeks of each other.

I'm getting really sick of viewings: ornately decorated rooms filled with young people wearing memorial t-shirts; standing around outside funeral homes surrounded by cars with tributes written in soap on their back windows. Bodies of children I know, their faces caked with makeup in the most unnatural gray-brown tone I've ever seen, lying in boxes surrounded by white velvet padding, flowers and notes scribbled in a childish hand.

I'm getting sick of not knowing what to say, because there isn't anything to say. Of hugging sisters and aunts and cousins and grandmothers when there aren't enough tissues in the world to dry the tears that just keep coming. Of holding my friend as we take turns sobbing uncontrollably. Of trying to talk to a father of four who has seen his family literally torn in half. There is nothing to say except, "There's nothing to say."

I'm getting really tired of funerals.

This one, with a biting, wind-blown drizzle, was as cold and miserable a day as the last one was oppressively hot and muggy. The church was filled with kids who didn't quite know what they were supposed to do. There's no reason why they should. Kids shouldn't be burying their friends. And parents shouldn't be burying their children.

After losing a child, there's the expectation that things will be awful. You talk about it and you read about it. You go to counseling and support groups. You find out that everything you're going through is "normal," as if that helps. But there's also the expectation that things will gradually --oh, so gradually -- become perhaps a little less awful. The phrase "a new normal" is used, and even though you don't really know what that means, there's a sense that eventually something will change, and you won't feel quite as awful as you do now.

But then it happens again. The wound is ripped wider than before, when it hasn't even begun to heal in the first place. How do you even begin to pick up the pieces, ripped so small and scattered so widely you don't even know where to start?

I don't know.

I just don't know.

This is How "Balls" Works

I'd like to expand on my previous post about surgeons abdicating their medical responsibilities by explaining what happens out here in the real world when surgeons (some; not all by any means) try to get other docs (cough*me*cough) to do their work for them.

First of all, to elaborate on the specifics of the incident discussed, which is quite typical:

Yes, it was a "standard" H&P form from the facility. Surgeons -- or, more specifically, their "surgery coordinators" -- tell me that it's the hospital or outpatient surgery center that "requires" them to use the form, and that it must be completed by the patient's PCP. That is, they claim that someone other than the surgeon is insisting on my involvement. Frankly, if I were a surgeon I'd be insulted that my facility didn't allow me to do my own H&Ps or trust my judgment about whether or not I need a second opinion about my patient's fitness for surgery (if it were really the case that the hospital is requiring the PCP to complete the forms, of course.)

Here's what's really happening, though: the surgeon -- or more likely an office staffer -- says to the patient, "You need to have your doctor fill out this History and Physical form." No difference between a 75-year-old on a dozen meds or a 22-year-old having pins removed from an old fracture. No hint that the surgeon is requesting anything specific of me. No indication that I'm to do anything other than fill out a form. It's just another piece of necessary paperwork (totally glossing over the importance of evaluating a patient preoperatively) that they can foist off on someone else, because otherwise the surgeon would have to do it. And so the patient is left with the impression that "this is how it's done," which is how he comes to my office.

The problem is that when I throw a hissy fit, the patient has no idea what's going on. I'm stuck in the middle as the bad guy who won't cooperate with dear Dr. Surgeon to help the patient get the care they need. And how can I explain the problem to the patient without bad-mouthing the surgeon?

The real problem is that it's the patient who is inconvenienced when I try to stand my ground. I've tried calling surgery offices, rarely getting to talk to the actual surgeon. ("He's way too busy.") The surgeries tend to be technically "elective", but they're things the patients need; things that having to re-schedule wouldn't be fair to the patient. Of course the offices that do this sort of thing are the ones that tend to be the least cooperative, telling me the patients can't have the surgery if I don't do it, and that I have to explain it to them; basically playing a nasty little game of chicken. They know that I have more to lose by pissing off the patients than they do. That's why I often end up going ahead and just filling out the damn forms.

Besides, as is so often the case, there's the issue of money.

If a surgeon wants my opinion about a patient's fitness to undergo surgery, that is called a "Consultation." It requires several things, including:

• A written request for my opinion, and
  
• My written report back to the surgeon containing my opinion and recommendations.

Unfortunately, it is explicitly stated that a simple H&P on a healthy patient does NOT constitute a "Consultation." In point of fact, it's considered an integral part of the surgical procedure, supposedly covered as part of the "global surgical fee." What's the difference? Money, of course: Consults pay significantly more than simple "evaluation and management" encounters to fill out forms.

Regarding that line of text about having discussed the surgery with the patient -- which I had not seen on other forms: I don't really think the surgeons are expecting me to obtain Informed Consent. I believe it's there as a backup in the event of a lawsuit if the issue of consent should come up. If the patient complains that the surgeon's informed consent was defective, they've got that line to fall back on: "Blame Dr. Dino. See; that signature right here says that everything was discussed with the patient."

(More later on how I try to get what I need to code these as Consults, if anyone's interested.)

When They're Right, They're Right

Shamelessly stolen from 101 Reasons to Quit Writing because when you're right, you're, well...right:

TOP TEN REASONS WHY YOUR NaNoWriMo NOVEL SUCKS:

1. You hadn’t even thought about writing fiction until October 30.
2. You finish each writing session by typing "I’m going to bed now, see you later."
3. You read over yesterday’s output and discover you’ve typed, verbatim, an argument with your spouse about how the time spent writing is impacting your personal hygiene.
4. You left the datestamps in when you cut and pasted all your blog entries.
5. You left the datestamps in when you cut and pasted the entire NaNo forum thread about padding.
6. It’s a powerful, moving story exploring the inner turmoil of a copyrighted character.
7. It’s a powerful, moving story exploring the inner turmoil of two or more copyrighted characters who secretly love each other very much, and often.
8. You’ve only managed an average of 500 words per day so far, and 100 of them are about how hard it is to write 1,667 words a day.
9. Every 1,667th word is "CHAPTER".
10. The 49,999th and 50,000th words are "THE END", even though the 49,998th word is "and".

The Pitter Patter of Little Songs

Sid sent me a cute link in one of his comments, and it got me remembering how much I enjoyed the parody that his link parodied (reminding me of good times with both my father and my son.) So, since I'm still hip deep in NaNoWriMo (30,000 words to date) and don't have much time for blogging, I thought I'd do a post in which I follow the evolution of how a particular song that began as ridiculous morphed into outrageous, and thence to just plain silly.

It all started, as so much does, with Gilbert & Sullivan, a pair of seriously disturbed gentlemen who lived in England and wrote a series of operettas in the late 19th and early 20th centuries, most of which contained at least one patter song. Here's one of several versions available on YouTube of the Modern Major General's song:

(For anyone who may have trouble following all the words, the lyrics are here.)



A while later, an even more seriously disturbed gentleman named Tom Lehrer wrote a completely pointless song in which he set the names of the chemical elements to the music of the above song. Again, one of several versions available on YouTube:



(This version, not available on YouTube, is also cute.)

And finally (thanks again, Sid) we have this, which you have to go click on to watch.

Doing His Part

Had a conversation with the Jock this evening on the topic of Thanksgiving. I asked if he had any specific requests for dishes he'd like along with the turkey and stuffing we're planning to make. He made some suggestions, leading me to find a way to inquire about whether he would be willing to help out in the kitchen.

Unfortunately, what I actually said was, "Would there be any chance of you doing anything for Thanksgiving OTHER than sitting down at the table and eating dinner?"

Ever helpful, he responded:

"I can watch football."

I admit, it was a magnificent straight line that I lobbed gently to him; trust him to hit it out of the park.

Now This Takes Balls

I saw a patient today who had a History and Physical form she needed completed for (non-cosmetic) plastic surgery. The procedure was to be done in an outpatient facility, whose form was obviously being used for this purpose. It was a fairly standard, basic H&P form, until I got to the very bottom where it said this:

Surgery and alternative treatments were discussed with the patient. Complications of surgery and expected outcomes were also discussed.

WTF? Although it's just a little line of fine print at the bottom of the form (above the line for my signature) it states in essence that I am the one who has obtained the patient's informed consent for the procedure.

Bullshit!

Has anyone else noticed how lazy certain surgeons have become? I don't mind looking patients over for a podiatrist or an ophthalmologist (even though the latter did go to medical school once upon a time) but orthopods, urologists and plastic surgeons ought to be able to do an H&P. Failing that, if they want documentation from someone who actually deals with sick people on a regular basis that their patient is in good enough shape to survive whatever it is they want to do for them, ok I guess. But don't try slipping that little line in there, effectively leaving my ass hanging in the breeze when the lawyers come calling about informed consent.

By the way, before I signed the form I crossed out the offending line, initialed it, and wrote in:

Informed consent to be obtained by the primary surgeon.

So there!

Shooting Up the Cat

I had a very interesting day yesterday. The Mighty Hunter, who had been walking a little funny the day before, refused to put weight on his right front paw.

I tried my best to figure out what was wrong: I palpated the whole limb very carefully but didn't elicit any reaction from him. He wasn't particularly in the mood to be handled, though, so I wasn't sure I hadn't missed something. By the time I had showered and dressed, Darling Spouse was really worried about him. Our regular vet didn't have any appointments available so we decided to try a local emergency vet place we'd heard about.

TMH went into the carrier easily, something else that really scared the shit out of us. I drove; Darling Spouse held the carrier, crooning to TMH as we tried to find the place. The cat was crying; it's the only word for the sounds he was making. Then he started panting. Very uncharacteristic for this guy. Needless to say, we were getting more and more scared.

The logical, clinical part of me wasn't really worried. The overwhelming likelihood was that it was something musculoskeletal, and that we'd be sent home with anti-inflammatories instead of having to leave the dude there for surgery. I doubted trauma, even though he insists on going outdoors, because I would have expected an injury to start with symptoms at their most severe instead of the progression -- albeit fairly rapid -- that we observed. But the part of me that wasn't a vet thought, "What if it's something serious, like in his lungs?" I didn't know if an apical lung lesion could produce referred pain to a front limb or something like that.

We found the place after only a few wrong turns. Let me just say this: I'm in the wrong business. The facility was absolutely gorgeous; huge waiting room; coffee and cookies -- for the humans; a basket of doggie treats on the counter. The receptionist was awesome: friendly and attentive. I filled out the shortest form I've ever seen in a medical office. A nurse came out to triage TMH; making sure he didn't have something immediately limb-threatening like a clot, we were told later, but then we had to wait while another woman's critically ill dog was cared for.

Eventually we were taken back where TMH had his vitals taken. I have to say one thing for this cat: at least he's cooperative with medical care. He wasn't crying or panting anymore. In retrospect, I'd have to say he was taking his emotional cues from us, and we were feeling better about him now that we were doing something for him. The nurse set him down on the floor and sure enough, he began walking around on three legs, confirming that he was lame. (At first we were worried he'd walk perfectly normally and were reassured that that actually happens all the time. Not this time though. Definitely something wrong.) We left him on the floor while we waited for the doctor. After cruising the room he came back over to where I was sitting on a small bench next to the exam table. He carefully jumped up onto my lap and then back up onto the table; definitely guarding his right front limb, but we were encouraged.

The vet was great; young; very cool. Seemed to appreciate TMH's dudeliness. Did a complete exam. (Totally cracked me up later to read the documentation: "Neuro: cranial nn intact; proprioception intact; mentation good." WTF? He never asked TMH what his name was or if he knew the date or where he was.)

In order to do a very thorough exam of the right front limb we held the cat for him: on his back, cradled in my arms instead of right against the cold metal table; rubbing his belly. Once again, TMH cooperated beautifully. (Anything for a belly rub.) The vet was pretty sure the dark marks on the right paw pad were specks of dirt and not dried blood, but he said he couldn't be sure there wasn't something in there. He thought the metatarsal pad was a tiny bit swollen and a bit warmer than the other one. Darling Spouse and I looked at each other, suddenly remembering the broken glass in the street next to the driveway left by the garbage men. Had TMH stepped on some and gotten a piece stuck? I would have expected it to hurt a great deal more than TMH was letting on if that was the case. Still, x-rays were definitely indicated.

Off we went to the waiting room while TMH was radiated, but then we were invited back to view the films on a monitor in a gorgeous wood-paneled office area. The glimpses we got on the walk back showed that the rest of the facility was just as impressive as the waiting and exam areas. There on the monitor was an enlarged x-ray of a cat's paw. (Now, of course, I regret not taking him up on his offer to burn me a CD of the images. I wasn't thinking of blogging at the time.) "Right there," he pointed. Sure enough, the base of the fifth metacarpal had a small but definite non-displaced chip fracture.

How the hell had he done it? No idea. What to do? Let it heal. No cast or anything. Just three days of an anti-inflammatory. (It turns out cats' livers don't tolerate NSAIDs very well, hence the very short course.) Which one? Meloxicam; Mobic, for humans. Metacam for animals. Same stuff, of course.

TMH had already received a dose SQ (subcutaneously.) They were going to send us home with two more oral doses for him for the next two days. I looked at TMH. He was actually much better about letting vets handle him than us. The idea of catching him, immobilizing him (I couldn't squirt something into his mouth while rubbing his belly) and forcing something into his mouth that he didn't want filled me with something between trepidation and terror.

"Can I give it to him sub-Q?" I asked. I've had cats all my life and have seen all of them get shots. It really did look ridiculously easy.

I said the vet was cool. "No problem. They have so much skin, it's ridiculously easy." He showed me how to lift the skin of the back and inject into the V formed by pulling it up. "He won't even know you're doing it."

Back home, TMH looked almost stoned. I wasn't sure if it was the drug or the relief of being home. He slept very well all day.

This morning it was shot time. I took one of the two syringes they'd given me ($14 apiece; I told you I'm in the wrong business) each containing 0.1 cc of Metacam, then found TMH upstairs on our bed. I lifted the skin with my left hand and went to pull the cap off the needle with my teeth. The needle came off the syringe; it wasn't a Luer lock. I let the cat go, shoved the needle back onto the syringe and pulled the cap off.

Let me interject here that I give shots all the time; immunizations and allergy shots; obviously this is flu shot season. I usually use needles that are 5/8" long, going in at a 45 degree angle for SQ and a 90 degree angle for IM. (Yes yes yes; I've been told a million times I need to use longer ones; but I've hit bone going into a small toddler's arm with the 5/8", and I've also read that there's no difference in efficacy if it doesn't get into the muscle, so that's what I do.) This was a tiny little 1 cc syringe; I was expecting a similar sized needle.

So imagine my surprise at having uncapped a one inch, twenty gauge weapon I was supposed to stick into my cat! Ok; they have a lot of skin; the skin on the back -- where I was injecting -- is probably the thickest skin on their body (like humans; only place thicker is the soles of the feet.) Here goes nothing.

I lift up the skin on the back and poke the needle into the V, inject as quickly as I can (one whole whopping tenth of a cc) and get it the hell out.

The cat doesn't even notice. In fact, he rolls back over and waits for me to rub his belly. Which I did. Interestingly, within five minutes he's fast asleep. I go in to shower and when I come out of the bathroom, he's still passed out, spread-eagled on his back.

That meloxicam must be some great shit.

I've Always Wondered This Myself

A while ago there was (yet another) hullabaloo over at a The Underwear Drawer (neat blog; hat tip to RJS for the link) about the tired old "OMG" about admissions to exclusive preschools in NYC. I found the best answer to a question I too have often pondered in this comment:

How [can one] possibly determine a four- or five-year-old's chances of academic success based on an aptitude test or two and a 15- or 30-minute "interview"?

It turns out that this is the answer:

They don't. They look at the kid's parents. Not at how well they play The Game, but whether they seem caring, sane, intelligent, and likely to provide the kind of love and support that children need to flourish.

Good to know. Makes sense, doesn't it.

So True

Found on Facebook by the Nestling:

(New! Edited by the Nestling, via "someone on Facebook"; incorporating the comments:)

When Dumb Men do Smart Things

One of my employees called yesterday to tell us she would be late: she couldn't find her car keys.

She had scoured her house, purse and car; had re-traced her steps over and over; they were nowhere to be found. She swapped cars with her daughter (after numerous phone calls finagling the daughter a ride) and finally made it in, late and angry.

She had finally remembered that her husband had taken her car on an errand the night before and was certain he had gone off to work in the morning with the keys in his pocket. By the end of the day she had calmed down some, but I would not have looked forward to being him that evening.

Turns out he did indeed have the car keys. It also turned out that he was well aware of how upset she was about how inconvenienced she'd been (they've been married 25 years.) So on his way in through the laundry room, he met their older son, handed the keys to him and said, "Tell Mom you had these all day."

The kid had no idea what was going on, and is a terrible liar to boot. But a good laugh was had by all.

What Does "Solo" Really Mean?

Twice in recent weeks I've seen mention of "solo" docs...with multiple offices staffed by an assortment of PAs and NPs. One was a Medical Economics discussion of EMRs; the other was a recent comment about the inefficiencies of automated telephone answering systems for solo offices.

A practice with 1 doc, 2 NPs and 3 MAs may not be able to just pick up the phone, but it also doesn't seem to have much in common with my "solo" practice. Likewise, working out of two offices with 4 PAs and 3 NPs doesn't feel very "solo" to me.

Granted the practices above have only a single doctor in the practice, but the practices still have multiple practitioners. Perhaps we need a different term for "mixed level provider" offices owned and run by a single physician. Frankly, it seems to me that the practices above are misrepresenting themselves. Their management and financial issues are more in line with a single specialty small group practice, yet they're co-opting the "warm fuzzies" evoked by the words "solo practice" when they're really running is a full-fledged clinic.

To me, "solo" means "alone." One doc; one office. The rest of you: quit trying to convince patients you're offering the same thing I am.

Take That! (or: WTG Panda)

Panda Bear MD, in the usual humble, roundabout, beating-around-the-bush style of his, has just trashed the whole so-called CAM movement more thoroughly than I could ever hope to.

Unfortunately, I happen to have some pretty good friends who -- through no fault of their own (they live in California) -- happen to hold some pretty strong beliefs on the subject. Equally unfortunately, these friends (ok; it's "friend" singular) was recently invited to a gathering where she was treated quite shamefully. Within the context of trying to "debate" things that are patently ridiculous ("science" is not, or shouldn't be, a matter of "opinion") there's still no excuse for plain old rudeness.

Nevertheless, here's my take on it:

You are welcome to believe that the sun revolves around the earth, but you should not expect a warm welcome at a meeting of professional astronomers, nor are you entitled to whine about their "refusal to listen to opposing viewpoints." (Of course, if they invited you because they like your stories about riding the sun around the earth, they have no right to berate you.)

The difference is that in science, you can indeed change people's minds by using their own methods and techniques to prove when you are right. Granted it may take time, but when you're right, you're right; time is on your side and eventually people come around. They have to, if they're really scientists. When I graduated from medical school, no bacteria could possibly live in the extreme acid pH of the stomach. That was proven to be false in 1982. Voila! My opinion was indeed influenced, and now I -- like many other physicians -- prescribe antibiotics for ulcers.

There are some arenas where "opinions" are the issue at hand, such as politics and religion. But things like Holocaust Denial and CAM pull the cloak of "opinion" and "opposing viewpoints" around themselves with an intellectual dishonesty that is nothing less than shameful.