Waiting and Seeing

I'm a sporadic participant in Grand Rounds. I don't submit every week, but now and then, when I've written something I think is especially cogent, I'll sent it along. This week, I decided one of my recent posts was Grand Rounds-worthy, so off it went.

Unfortunately, I missed the fine print about this week's theme, which is Health Care Reform.

I haven't bothered writing much on my blog about "health care reform" for a couple of reasons. First, no one's doing a damn thing about actual "health CARE reform"; the whole thing is all about health INSURANCE reform, and the sloppy syntax has really been pissing me off. Second, Americans don't seem to understand the concept of "insurance" in conjunction with health care, so the robber baron "insurance" companies are basically medical payment brokers.

The real problem with American health care is Americans, who demand the latest, biggest, and shiniest, balk at having to pay for it, and feel entitled to monetary gain through litigation whenever something goes wrong. I've seen enough things come and go (managed care, capitation, vertical integration) in my twenty years of solo practice that my tried and true strategy is to wait and see.

That's my take on the recent Federal goings-on.

100 Days Here, 100 Days There

I got a message from my representative in the Pennsylvania House:

This week, the state House of Representatives passed a proposed 2010-2011 budget 100 days ahead of the June 30 deadline.

Didn't we just go through this whole budget thing? Wasn't it just last year that our illustrious legislature took over 100 days to pass a budget? (Spoiler alert: uh, YES)

Wait, that means it's been less than 6 months since the Pennsylvania budget impasse of 2009 was finally resolved.

So on average, I guess they're right on time.

Never Saw That Before

Conclusion to a report of a cardiology consultation on a new patient with four dozen complicated medical problems and a whopping ass personality disorder to boot:

Will follow this patient with you, from a distance.

Message From my Father

I received the following:

I am directing a staged reading of a play...[dealing] with Sir Thomas More, who had many daughters and adopted more...as viewed by the women in his life. I take pride in having paralleled him, with three daughters plus two more acquired later in life. Of course I didn't serve as Chancellor under King Henry VIII...but then again, I was not beheaded for treason [ed: yet]. One thing that comes out in the play is that his oldest daughter...pulled his head off the pike where it was displayed after his beheading. Would you have done this for me?

My Dear Adored and Adoring Father,

If you were ever beheaded for treason (or any other infraction) I would be devastated. Not quite as devastated as you, obviously, but sufficiently so. I would most certainly pluck your detached head from its display pike, gently clutching you by the ears (since you don't have enough hair to get much of a grip) and surreptitiously spirit it away to be laid to rest with the rest of you. Most likely I would accomplish this task in the dead of night, because if I did it when someone could espy me, the overwhelming likelihood is that I would quickly share your fate, which I wouldn't want, and would hope you wouldn't want for me (despite the fact that you wouldn't care, what with already being dead and all).

I hope this answers your question.

Regarding the play: Break a leg.

The Truth

A couple of months ago, I got a call from a long-time patient, a man in his late 30s with an autistic five-year-old daughter.

"My wife died last week."

Obviously this was a shock; to us as well as to him. What happened?

"I have no idea. She got up out of bed, fell on the floor, and started seizing. By the time I called 911 and started CPR, I could tell she was gone. It was awful."

"Do they know why she died?" I asked.

"No," he answered. "They have no idea. They did an autopsy, but they said it could take up to twelve weeks to get all the toxicology reports back. They also said the only way I could get the results was through you. Will you please let me know as soon as you hear anything? This not knowing is terrible!"

"Of course!"

I saw him a few times over the next few weeks. He was coping as well as could be expected. I tried to help as best I could.

Finally I got the results in the mail. I tore open the envelope and began reading. I sighed deeply when I saw the cause of death. Then I asked my staff to call the husband and invite him to come in to go over it in person.

I escorted him into an exam room and we sat down together.

"I didn't want to do this over the phone, because I wasn't sure what your reaction was going to be," I began.

"Was it an overdose?" he asked.

"Yes," I said. "Cocaine."

I watched him carefully.

"Are you surprised?" I asked.

"No," he answered. "I knew it."

He sighed, and the words began flowing like a torrent.

"We did it together. It was our thing; alone together in our room. Always after our daughter was safely asleep; our door was always closed. We did it once or twice a month. You always asked me and I always lied about it. We never shot up, or smoked crack; we were afraid of smoking crack. We only snorted it, so we thought it was safe. We were doing it together. She had just snorted a line, and she started gasping, like she couldn't breathe. But she'd done that before. Then she just fell off the bed and began seizing. And I knew."

He sighed another deep, shuddering sigh, and I passed him a tissue for the tears that had begun flowing.

"Why her? Why not me? I did twice as much of it as her. That's why she was doing that line so fast; I was getting greedy, and she wanted some."

I waited.

"So what do I tell people?" he asked. "Help me. Make up a word."

"Why can't you tell them the truth?" I asked as gently as I could.

He looked horrified.

"I can't do that!"

"Why not?"

"I wouldn't want people to judge her. Even though she's gone." He teared up again.

I considered my next words carefully.

"You know, maybe among your friends there's another couple, just like you, who's doing this too. You never told anyone, so maybe they aren't either. And maybe they feel safe, like you did, because they're 'just' snorting it, not shooting it up or smoking crack. And maybe if you came right out and told people what happened, they might think twice about doing it again. And maybe if you didn't, if you lied, or said it was 'indeterminate', maybe this might happen to one of them too."

He sighed again as he dabbed at his eyes.

"You know, you're right. Besides, if I start lying, I have to remember who I've told what. It's harder to keep them all straight, isn't it."

He straightened up.

"You're right. Fuck it. I'm just going to tell them. It sucks, but...what the hell. Yeah. I'll just tell the truth."

"Do you feel better?" I asked.

"Yeah," he said. "Yes, I do. Like a weight's been lifted."

He turned to me and shook my hand.

"Thanks, doc."

"You're welcome," was all I could say as I watched him go.

The Stupid; it Paralyzes

I have a delightful patient in her 70s who contracted polio at the age of three. It left her with a somewhat weakened left leg and a lifelong pronounced limp, for which she very appropriately received a handicapped parking placard.

She complained that she had begun getting parking tickets of late. Apparently, there was some doubt about the legitimacy of her need for special parking accommodation. The process of getting the tickets dismissed included a telephone conversation with a person claiming to be a nurse.

"So why do you need a handicapped parking placard?" asked the "nurse".

"I had polio as a child," replied my patient.

"Ah," came the response (over the phone, remember), dripping with sarcasm. "But how do I know you still have polio?"

I Need My Goddamn Sleep

(Title from Chapter 9, Poor Planning on Your Part does Not Constitute an Emergency on My Part.)

I'm really tired this morning.

Why, you ask?

It's because I stayed up until nearly 11:00 last night.

Why, you ask?

Actually, it was a lot of fun.

I was a guest of Dr. Michael Sevilla, better known as Dr. Anonymous, on his weekly internet radio show. (Preview here; promo here; link here.) Now what on earth would two formerly anonymous now identity-revealed family doctor-bloggers have to talk about? Um, just about everything: medicine, writing, blogging, social media.

The show began at 9:00 and Dr. A told me it would run for about an hour. By 10:00, we had only just begun discussing the book! At 10:30, after Blogger Radio kicked us unceremoniously off the air, I logged into the chat room where Dr. A held court before a microphone, babbling on with increasing incoherence. (I guess he needs his goddamn sleep too, even if he doesn't like to admit it.)

So even though I'm completely wiped this morning, 'twas all worth it for my 15 minutes hour and a half of fame with Dr. Anonymous. Thanks, Mike.

Palliative Care: An Unnecessary Specialty

I love reading Dr. Bob Centor. He's sort of my inpatient counterpart, even though he's an internist and about ten years older than I. Still, what we have in common is a passion for patient care. That's why I was so tickled to read this recent post of his, where he says in so many words that the extensive sub-specialization that is the hallmark of American medicine is bad for patient care.

Dr. Bob also harps on the importance of making an accurate diagnosis before initiating treatment; the "evaluation" as opposed to the "management," immortalized in the expression "E/M". This seems so obvious as to be ridiculous, and yet failure to grasp it is the major confounder in the calculations of non-physician health care policy experts. Medical treatment isn't all that difficult. Really. I'm not going so far as to say that any trained monkey can perform surgery, or that driving this baby isn't tricky, but it's completely inappropriate to plug someone into, say, a congestive heart failure treatment algorithm unless and until you know that the patient actually has CHF. Much has been written about the complexities of the human body. and while some treatments certainly require a great deal of individualization, making an accurate diagnosis can be far more complex than any treatment regimen.

But there are two different kinds of treatment: curative, intended to eliminate the cause of the symptoms and restore patients to health (defined as not being under medical care), and palliative, intended to alleviate symptoms. These treatments often overlap; radiation that makes a tumor disappear relieves many of the symptoms directly caused by the tumor, such as pressure on surrounding structures. They also often overlap in time: salt water gargles and ibuprofen won't cure strep, but they will make the patient feel better while the amoxicillin is killing the germs.

So in a way, I was a little surprised when one of his posts as ward attending mentioned consulting with the "Palliative care team," a multi-disciplinary group of doctors, nurses, social workers et al whose sole purpose appears to be providing comfort care instead of curative care. As it happens, there was also a long article recently in my local newspaper about Palliative Care Teams, which emphasized their role in communicating with patients' families about difficult situations.

Excuse me: why do you need a brand-new "Team" to treat symptoms and talk to families?

True palliative care -- the management of symptoms -- is part and parcel of everyday medicine. Itching; nausea; constipation; pain. Work them up to make sure there is no serious underlying problem, of course, but for crying out loud, don't tell me you now need another specialist to actually come TREAT them! This is fragmentation of care taken to outrageous extremes.

As for talking to patients and families about difficult decisions when curative treatment is no longer an option, that too is part and parcel of my job. I do it every day in my office, and the only reason I don't come to the hospital to do it is because I can't get paid for it, and I can't afford to work for free.

Maria, a psychiatrist and blogger (Intueri) who completed a fellowship in Liaison psychiatry, has opined that doctors appeared to consult Psychiatry rather than talk to their patients. The reasons are legion. Psychiatrists are perceived to have more expertise with difficult conversations, probably because they have more of them. They aren't as afraid of them (same reason), and they have more time available for them (because they take it). There is a role for the psychiatrist, but it is not to take over the job of talking to the patient.

Likewise, the role of the "Palliative Care Specialist" is redundant in the setting of an informed, caring, up-to-date primary physician. I can see their involvement in cases where primaries are uncomfortable dealing with hospice situations, but by and large, the "Palliative Care" movement represents yet another attempt to carve out a piece of my practice that is well within my scope of knowledge and ability to care for my patients.

Americans don't seem to realize that they don't really need a pediatrician for the first eighteen years of their life, an internist and/or gynecologist for the next forty, and a team comprised of a cardiologist, urologist, orthopedist, and geriatrician for the rest, with a Palliative Care specialist stuck in at the end. It's called Primary Care for a reason. It comes first. And it's what I do.



(Full disclosure: I actually enjoy hospice and palliative care so much that if things continue to deteriorate, one of my possible exit strategies is to shift gears and certify in Palliative care. Think about the demographics. What's the next thing the baby boomers are going to all start doing? That's right: dying. And they're going to need a lot of Hospice docs to care for them.)