When Will They Ever Learn?

Health 2.0 is having a big convention that everyone is getting all excited about, and yet at the same time, RevolutionHealth is on the block.

Hello?

When are all these ridiculously rich people with money burning a hole in their pockets (which they use to entice other people who perhaps aren't quite so rich to part with as much of their hard-earned cash as they can convince them to, to further enrich themselves) going to finally figure out that health care is something that by definition cannot happen in cyperspace? All those personal health records might enhance communication (only if people decide they want to use them) but the bottom line is that sick and injured people can only be cared for face to face by a physician (not a provider; not an assistant; not a doctor-nurse) who knows what the hell to do for them right then. No computer will ever replace that. No insurance company will ever be able to provide that.

Not only that, but doctors are not willing to provide that care without being paid for it. Enormous sums of money are being wasted on vast networks of computer advertising that do nothing but shunt bank balances from one billionaire to another, rather than providing any actual health care for American citizens.

The health care system in this country isn't the least bit broken. It's working just fine. It's doing precisely what it's designed to do, which is to enrich those who know how to game the system by purchasing legislative influence to pass laws which allow them to accumulate ever more vast sums of money. The saddest thing is that those individuals are trying to fill a deep emotional hole in their souls that no amount of money will ever satisfy; it's just too bad so many other innocent, hard-working souls have to pay for their emotional ignorance.

Heaven help anyone who actually dares to think that the American health care system has anything to do with sick people and the doctors who care for them.

Two Things They Never Taught Us in Medical School

First thing they never taught us in medical school:

When they taught us to "go where it hurts last" (ie, examining the non-painful parts of the limb or abdomen before palpating the area of discomfort) they never taught us to EXPLAIN TO THE PATIENT that we were taught to go where it hurts last. I discovered this the hard way when patients thought I was an idiot, for example, for beginning the exam in the left upper quadrant of the belly when they had specifically indicated that the pain was in the right lower quadrant.

Second thing they never taught us in medical school:

When discussing certain specific causes of an overactive thyroid gland, they never told us to WARN THE PATIENT that a certain condition was named after a doctor; a doctor with a coincidentally unfortunate name. Imagine the reaction to being told you have a Grave disease, which is what too many patients hear when we refer to Dr. Graves and his hyperthyroidism. No other condition has probably produced more unnecessary panic than this eponym.

Politics Can Be Hazardous

Driving back from a satisfying and productive shopping trip in the beautiful state of Delaware (home of tax-free shopping; nice touch when purchasing computer equipment) Darling Spouse is zipping along in the passing lane of a two-lane portion of northbound route 202. I see a white SUV in the travel lane moving a bit slower than we are. As we gain on it, I note with some alarm that it's drifting towards the center line and in fact appears to be encroaching on our lane. I grip the armrest, but DS manages to maneuver safely past it.

As we pass, I see the source of the problem. There is a decal on the rear window that says, "Obama '08."

Although I didn't have the nerve, what I really want to do was open the window and shout at the driver, "I respect your politics, but for the moment, PLEASE KEEP TO THE RIGHT."

Anatomical Confusion

Grandmother comes in with kid and mother. Kid has "glue ear;" fluid behind the ear drum so thick and dessicated that it's like partially dried rubber cement. Hard to hear if your ear drum won't move because it's all socked in like that. Kid and mom both want to look (mom, obviously to compare "normal" to kid's ear; kid because she's just curious) so I use grandmom as my "normal" model. Unfortunately, grandmom has some wax in her right ear.

As it happens, she (grandmom) starts complaining that she's having trouble hearing, and can't I take the wax out.

Which ear are you having trouble hearing out of? I ask.

This one, she says, pointing to the left.

Since the left ear is clear, her hearing issues clearly aren't from wax. I suggest she see her own doctor for an evaluation. She isn't pleased.

She points to her left ear again and says:

But this is the one I use to watch TV.

In Which I Must Brag (Because I Rock!)

I am thrilled to pieces to announce that not only did I pass the Family Medicine Recertification exam that I took back in July, but I did it with a higher score than I got on my original Certification exam back in 1989 and BOTH my re-certs in 1995 and 2001.

I'd read somewhere that the usual pattern is for scores on this exam to decrease somewhat with each recertification cycle, which sort of makes sense. The more time away from training (and the In-Training exams we took annually, created by the same Board) the rustier one's grasp on the basics might be expected to grow. This is indeed what happened to me the first two times I took the test (technically the second and third times.) But as of seven years ago, I was still at the 80th percentile, so I wasn't really worried about failing.

Still, I have to admit that I was as surprised as I was pleased to find out that my composite scaled score put me in the 94th percentile of everyone who took this exam.

So to all my patients reading this blog: See; I really do know what I'm doing.

[Off to do the Snoopy dance of happiness!]
(Many thanks, SS!)

Welcome to the Paperless Office --NOT--

Some of my charts were reviewed today by a very nice lady working for a company that reviews medical charts for insurance companies. I was told they need to justify medical care received by patients with information from their medical records. One example was that everyone who has ever had their serum protein measured (meaning everyone who's ever gotten liver function tests, which include serum protein, and a comprehensive metabolic profile, which includes liver function tests) need to have their chart reviewed to see if they have documentation of a bedsore. (She tried to explain it; I still didn't get it.)

She came. She sat. She unpacked her laptop computer, set it up and plugged it in. Then she unpacked her spiffy little portable scanner, about the size and shape of a three-hole punch, which she used to scan progress notes from my paper charts into her computer. It was the only way she was allowed to enter the information into her computer, she said.

I mentioned how much easier her job would be in a paperless office. If only I had an electronic medical record, all I'd have to do would be copy the information she wanted onto a CD, or even a thumb drive, if her laptop didn't have a CD drive. Then she could plug it into her machine, click and drag a few things and she'd be all done. After all, wasn't that the promise of the paperless office? (Actually, such an office could just email the information directly to the reviewing company; never mind having to pay for the reviewer's gas and expenses to come all the way out to my office.)

Oh no, she replied. Here is what she is required to do in offices with EMRs:

Each entry in the medical record within the designated time frame must be printed out (on...say it with me, boys and girls...PAPER) for her to feed through her spiffy little portable scanner, one page at a time, to enter the information into her computer.

Guess what happens next? (You just know what's coming...)

All those printouts must then be shredded.

Someone tell me again how much more efficient and environmentally friendly the paperless office is going to make us all?

Another Cool Analogy

Saw another patient today with blood pressure just a little too high; same as it was the last time I saw him. I told him to come back in a month; that was four years ago.

This time he's back because he's (rightfully) proud of his recently improved diet and exercise regimen. Much to his dismay, his blood pressure is still just a hair over 140/90 -- and he really doesn't want to take medications.

I asked him what kind of work he does: he's a real estate agent.

Once again, I came up with an analogy specific to his line of work to help him understand why I was recommending we medicate his blood pressure:

I pointed out that he was like someone wanting to sell their house who had already spent a great deal of time and effort preparing the house for marketing; the last thing they'd want to do was something else, especially if it cost more money. I told him to imagine the sellers had already done a wonderful job, but that he as a professional was obliged to point out that a few more little details -- perhaps painting the crown molding to make it *pop* -- could make the difference between getting an offer close to or even above their asking price, or having to settle for less money to avoid having the house languish on the market. I pointed out how his suggestions might sound to the sellers; they could easily take it as criticism that they hadn't done enough.

That was the context of my suggestion for blood pressure pills. He had done such a good job with his lifestyle modifications -- he was at his ideal weight -- that all he needed to optimize his health was a little help, even though it was something he was loath to do (take pills.)

I saw the same "Aha!" reaction from him as I had previously. Unfortunately, he still wanted to wait a few more months before admitting that meds were what he needed. Oh, well; one for two ain't bad.

Why Are You So Surprised?

• Polypharmacy is bad, especially in the elderly.
• Try to limit the number of drugs your elderly patients take.
• The elderly take too many pills.

I hear; I agree; and I obey.

So my lovely little sharp-as-a-tack 85-year-old lady is only taking three pills -- a BP pill and a pinch each of a diuretic and a thyroid pill. Everything is fine. She's happy. I'm happy. Presumably the writers of guidelines regarding polypharmacy in the elderly are happy.

So what happens?

She gets a call from her insurance company (I won't say which one, but it's named for a color and a shape) offering her their health counseling services. She's not quite sure what they're talking about, but she agrees; and another nice woman comes on the line.

She asks for the patient's street address; the patient gives it.

Then her birth date; she complies.

What medicines does she take? She names them.

Is that all? Yes.

Is she sure? Yes.

Pause.

You don't sound like an 85-year-old lady.

After deciding they really didn't have anything of use to offer her, the patient had a great laugh over it, while I was left wondering what the hell an 85-year-old is *supposed* to sound like.

I also wish this particular, nameless insurance company would stick to doing what it's supposed to be doing (pay for health care) even though it doesn't do it very well, instead of trying to justify its bloated premiums by offering all kinds of other -- mostly useless -- services.

While I'm here...

Twelve-year-old girl with a fever of 102; headache; stomachache; miserable. A careful exam turns up nothing, so in this part of the country at this time of year we do a test for Lyme disease. Draw the blood; comfort the kid. Review symptomatic care with tylenol and ibuprofen. Discuss how long the blood test will take and make arrangements to call once the results are back; etc.

Finally, on the way out the door, the mother says,

Oh! While we're here, can I have a note saying she's ok to play field hockey?

What? The kids is sick as a dog and you want a note for sports?

This way I don't have to come back and bug you next week.

You know what? As a busy parent, I understood. And I gave her the note -- undated. She can fill in the date once the kid is better. (The Lyme test was negative, and she was good to go within the week.)

Best Line of the Day

You have to know Pennsylvania politicians to appreciate this but:

Letter to the Editor in Thursday's Philly Inquirer by Sophia Demas:

This last surrealistic week I watched a scary version of My Fair Lady unfold as Sen McHiggins introduced Sarah Palin, his political experiment, to the world as a "reformer."

In fact, she is a fighter for what she wants -- drilling in Alaska at the cost of environmental damage -- and her no-choice family-values stance will be forced onto every American.

The transformation of small-town spitfire into national reformer is now in the process, and if people fall for the spin, it is possible that we will all wake up one morning and find our president to be Rick Santorum in drag.

Whew!

My Litmus Test

Apologies for a political post. I try not to do them very often, but current events have intruded on my generalized political apathy. Although I have tried my hardest to avoid the recent conventions, some of their drivel has leaked through, rather like a tiny gap in a window frame lets in enough moisture to fog the windows. As I read about the candidates and their positions, I realize that I have a personal litmus test.

The expression "litmus test," by the way, comes from elementary school science classes where we first learned about acids and bases; the concept of pH. Litmus paper is either red or blue, and turns red when dipped in acid (meaning that red paper stays red) and blue when dipped into a basic, or alkali solution. There are no degrees of acidity measured; every solution is either considered an acid or a base; red or blue. Simple; clear cut.

The concept of a litmus test as applied to politics refers to a single issue whose importance to a given voter is so crucial that a candidate's failure to agree with the voter's position will cause the voter to refuse to vote for that candidate. I suppose there are some people who also use the term to refer to the converse: voting for people based on their views on a single issue, regardless of where they stand on all other issues. In my case, the former applies.

My litmus test is that I cannot bring myself to vote for any political candidate who believes in magic instead of science, and who uses those beliefs to determine policy.

Homeopathy is magic. "EverCleanse" colon cleanse (advertised daily on the radio) is magic. Enzyte is magic, and it's inventor/marketer is on his way to jail for fraud. Chiropracters run the gamut from those who understand that they're glorified physical therapists to those who don't believe germs cause disease; in general, chiropractic is magic.

Creationism is magic, but because it is cloaked in the trappings of religion, it gets treated with kid gloves. Religion needs to stay out of the science classroom, and I cannot bring myself to vote for anyone who doesn't understand why.

I think it's a shame that ignorance has become not only prevalent but desirable in this formerly great land of ours. I suppose hypocrites are so popular because they make people comfortable with their own hypocrisy.

I can't even tell if my dominant emotion is fear or sadness.

All I can do is apply my own private, non-partisan litmus test in the privacy of the voting booth. Magical thinking is a thought process of childhood. It's time this country grew up.

Guidelines Gone Wild

Hey! Everyone stop what you're doing right now and PAY ATTENTION!

This is "Important":

The American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) will issue the first comprehensive clinical guidelines to help health care practitioners identify patients with cerumen (commonly referred to as earwax) impaction. The guidelines emphasize evidence-based management of cerumen impaction by clinicians, and inform patients of the purpose of ear wax in hearing health.

(Um, they're actually *not* the "first" such guidelines. I found some pretty comprehensive ones here, at a Guideline Clearinghouse, dated 2007.)

Dear dog in heaven! A group of specialists putting together guidelines (and presenting them at their annual meeting, no less) on the diagnosis and appropriate management of SOMETHING MY FAMILY PRACTICE ATTENDINGS TAUGHT ME THE FIRST WEEK OF RESIDENCY!!!

I suppose this means that the ENTs now officially know everything. If they're actually bothering to waste their time promulgating stuff every family doc, internist and pediatrician learned before they knew how to get to the call room, they must not have much else worthy of study.

What next? The American Gastroenterological Association writing guidelines telling us how to wipe our asses after taking a shit (complete with prospective, randomized, double-blinded studies on folding vs. bunching the TP)?

(Thanks to the AAFP ListServe, whose comment trail demonstrated far more and funnier sarcasm than I am at liberty to replicate here.)