Musings of a Dinosaur

I've Moved

2010-04-21T16:02:00.003-04:00

I've taken the plunge: come visit at my new WordPress site:

(For those who are cut-and-paste-challenged, all you have to do is change "blogspot" to "wordpress" in the URL.)

Same rants; same writing; different look (but still no ads).

Buggy Blogger

2010-04-20T06:03:00.002-04:00

Breaking one of my rules here ("Blogging about blogging is boring,") to apologize for buggy Blogger hiding posts. Looking into migrating to another platform, and hope to be up and running ~~my mouth off~~ again real soon.

More on Palliative Care: Be Careful What You Wish For

2010-04-13T14:44:00.003-04:00

My previous post has generated a gratifyingly large response that has been remarkably civil, for the blogosphere. I half-anticipated commentary along the lines of, "Dino, you ignorant slut," which is par for the course on the internet, and frankly, half the fun, given that none of it (for the most part) is intended or taken personally. In fact, it can be quite amusing to watch the fur fly publicly while exchanging warmly professional emails behind the scenes.

The major thrust of several comments was along the lines of, "Sure, it would be nice if all Primary Care docs could do palliative care, but with the current payment system, they just can't manage it." That's straight out of the 10th Law of the Dinosaur, "A bad idea held by many people for a long time is still a bad idea." The system is stacked against us, so we shouldn't even try? Sorry; I refuse to give up that easily.

Medicare and other payment systems have a provision for time-based billing. When more than half of the face-to-face time is spent counseling the patient, reviewing treatment options, etc. then the total time spent in the encounter can be used as the determining factor for payment. News flash: the topics discussed are NOT REGULATED. "Death panels" (ie, the proposed payment once every five years to discuss end of life issues) aside, I can and do (and always have) bill specifically for those visits.

The point was also made that although Family physicians could provide these services, too many of them don't. Point made; shame on them.

The whole "team" concept is also a red herring. I utilize all kinds of other professionals to care for my patients. I regularly call upon psychologists, visiting nurses, social workers, chaplains, and others for their help and expertise. Calling us a "team" is nothing but a semantic boost to the morale of professionals insecure in their role in patient care. Perhaps in the highly hierarchical hospital setting where contemptuous physician attitudes may be more on display, enforcement of the Team concept, complete with meetings and name tags, may seem useful. But out here in the real world, I able to communicate extensively with my non-physician colleagues -- including how much I value their expertise --without wasting their valuable time with "team meetings."

The real issue is the "Specialist" label. While not denying that the increasing body of knowledge about the relief of symptoms and management of patient care at the end of life may warrant specialty status, what are the actual advantages to patients of this further fragmentation of medical care? In fact, a recent article in the New York Times (discussed here and here) seems to point out the enormous disadvantage of palliative care physicians' proud assertion that they love to care for dying patients: if that's what they do, then a referral must mean the patient is dying!

Added to this is the American obsession with "the best;" the newest, the shiniest, the most expensive must be somehow "better." Better than what? Why is the concept of "good enough" so difficult to grasp? Although the fellow who places last in medical school is still called "Doctor," there are hundreds of fully qualified students for every spot. I firmly believe that grading medical students (and residents, for that matter) on any basis other than pass-fail is meaningless for that very reason.

Once you set Palliative Care up as a "Specialty," complete with board certification and all its administrative falderal, you are presenting to the public that you are the only ones qualified to provide this care. After all, if you're Board Certified in Palliative Care, the care you provide must by definition be "better" than that provided by someone not so accredited. It's similar to the unfortunate perception that only a cardiologist can manage high blood pressure, you need a pulmonologist to care for asthma, and you must be getting suboptimal care for diabetes if you don't see an endocrinologist.

How much more compassionate might care be at the end of life if, instead of being seen as yet another distinct specialty, palliative care were viewed as a vital, integral part of primary care. There would be no shifting of emphasis from "curative" to "just" comfort care, because symptom relief would be part and parcel of all phases of treatment. And who best to care for people at the end of their lives than those who have cared for them through the rest of it?

I do believe that self-designated Palliative Care Specialists should have important roles in academic and consultant capacities. Rather than a knee-jerk "referral to palliative care" when the going gets tough and the end may be approaching, I'd love to see primary care physicians in the forefront of caring for these patients, with consultant backup from our Palliative Care colleagues. Recently having dived into the archives at Pallimed, I've developed a new appreciation for the academic study of death and dying. But I still don't think Palliative Care needs to be an independent specialty.

Answers to Questions No One Asked

2010-04-07T15:59:00.002-04:00

Do you have to be a man to be a mensch?

Absolutely not!

Rest in peace, Linda. You were deeply loved, and you will be greatly missed.

Stating the Obvious

2010-04-06T05:46:00.003-04:00

There's a question that keeps popping up all over the place when the obvious mismatch between the dearth of physicians practicing primary care and the upcoming flood of newly insured patients thanks to the recently passed health INSURANCE bill:

What's going to happen when all those people can't find a primary care doctor to take care of them?

It is usually stated rhetorically. On the rare occasions when someone tries to answer it, they come up with something obvious:

People will go to Emergency Rooms.

Non-heathcare types may understand that ER care is far more expensive than that provided in doctors' offices and clinics, but the downside to ER care for non-emergency problems goes beyond that. ER care is more expensive because the ER mindset ("Don't miss anything," as opposed to the primary care mindset, "Don't miss anything important") results in lots of unnecessary care: blood tests, CT scans and other x-rays, etc.

The other piece of this puzzle, rarely stated, is that many, many patients, perhaps the majority, will recognize that the ER is not the appropriate place to seek medical care for their longstanding problems even though they now have insurance. (ER docs won't believe this, because they only see the people who come to the ER. It's hard to believe that what you don't see really exists, and I can vouch for the fact that there are lots of reasonable patients out there who do NOT think to rush to the ER for every little thing.)

The problem is that in the absence of sufficient numbers of primary care physicians -- and with no mechanism to filter access to specialists -- patients will self-refer to specialty care. Again, to non-healthcare types, this doesn't seem to be much of a problem. The American perception is that specialty care is "better," presumably because it's "special". And this is a huge mistake.

Specialty training is designed to focus on "not missing anything," because in an ideal world, anyone who clearly has "nothing important" going on would never have darkened the specialists' doors in the first place. When their comprehensive approach is applied to an unfiltered population, their extensive (and expensive) workups are not only useless and time-consuming, but dangerous to low-risk patients who have no need of exposure to the risks of useless testing.

What's really going to happen when those 30 million newly insured patients can't find Primary physicians is that the specialists offices will explode! Everyone walking in off the street will get the full workup of whatever that specialty office has to offer. Then, when no answer is forthcoming, they will get shuffled onto the next specialist, and the next, and the next. By the time they finally get into my office, multiple thousands of unnecessary dollars will have been spent to rule out everything I could have told them they didn't have.

This is the real reason health care costs will explode under the new law.

What to do about it?

Perhaps if there were a requirement that newly insured patients' first encounter with a non-primary-care physician be treated differently from an actual referral, we could find a way to get specialists to reign in their natural inclination to rule out everything under the sun (and then refer to their other specialty friends, to rule out everything else). I'm not sure precisely how this would work, but make no mistake: if something isn't done to address this issue specifically, the unintended consequence of insurance coverage expansion will be a surge in health care expenditures of unimaginable proportions.

It Happened Again, Dammit!

2010-04-01T11:08:00.004-04:00

Why do people keep doing this?!?

I got a call from the cheerful chippy at the cardiologist's office:

CCCO: Your patient, 28-year-old Joe Bloe, has an appointment to see us tomorrow. Would you please fax over any recent blood work or EKGs he's had at your office?

Me (after pulling chart from cold storage): We haven't seen this patient since 2002, so we don't have anything "recent" on him. But I do see that he saw you for palpitations in the past. Don't you have that information in your records?

CCCO: No, I'm afraid I don't. Could you please fax them over?

Me: Um, I guess so. What is he coming to see you for anyway?

CCCO: I don't know.

Me: What?

CCCO: There's no Presenting Complaint written down.

Let me get this straight: a patient calls up and says, "I'd like to see a cardiologist," and you say, "Sure, come on in," WITHOUT EVEN DETERMINING THAT HE ACTUALLY NEEDS A CARDIOLOGIST?!? What the fuck! Whatever his complaint actually turns out to be, you'd better believe that these ~~idiots~~ cardiologists are going to do a bunch of "screening" tests (blood, EKG, echocardiogram, probably a stress test) on him because, well, because they can. Because they're cardiologists.

And if they don't find anything (as they're perilously unlikely to on a 24-year-old guy who hasn't seen a doctor in eight years), they'll ship him off to at least three other specialists; probably a gastroenterologist to see if his chest pain is GERD, a pulmonologist to evaluate his lungs, and an allergist because, well, he may have allergies. The GI will do an endoscopy and give him Nexium, the pulmonologist will order a chest x-ray and pulmonary function tests (probably before even seeing him), and the allergist will skin test him. By the time all is said and done (and the patient winds up with a diagnosis of anxiety) he will have generated thousands of dollars in medical care for literally no reason at all.

No wonder medical care in this country is so fucking expensive.

Waiting and Seeing

2010-03-29T06:08:00.003-04:00

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

2010-03-26T14:17:00.002-04:00

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

2010-03-26T11:42:00.002-04:00

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

2010-03-25T05:41:00.001-04:00

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

2010-03-24T05:36:00.000-04:00

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

2010-03-23T20:24:00.004-04:00

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

2010-03-19T06:50:00.006-04:00

(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

2010-03-18T08:37:00.003-04:00

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.)

All Together Now: "Aww"

2010-03-15T14:10:00.002-04:00

DS hates to travel. He doesn't sleep well away from home, even with his CPAP. (Funny. You'd think having enough room to stretch out your legs without impinging on anywhere from one to three cats would be downright restful.) Although he enjoys sampling assorted global gastronomies, his GI tract doesn't share his enthusiasm. He doesn't mind traveling for pleasure, but business trips really knock the stuffing out of him.

So it was that he sent me an email, titled "Good news/Bad News" which contained the bad news that he was almost certainly going to have to go to the UK for a week in April, and to Japan and Singapore, probably in the fall.

DS isn't usually all that demonstrative verbally, yet this is how his email concluded:

Good news...I have my job, I have my health and I have you!

Aww; I love you too, DS.

The Latest and Greatest

2010-03-09T12:33:00.000-05:00

Want!

Polar Bears in the Amazon

2010-03-06T15:36:00.005-05:00

I have a patient who has done quite well for the last several years with metastatic breast cancer. Every week or so she comes in for a blood test before her chemo. Every six months the oncologist sends her for a repeat staging workup of scans and blood work. And every six months, the patient tells me how anxious she gets awaiting the results of all these tests.

So every six months, in addition to the regular blood tests, I send off tumor markers at the request of the oncologist. Three different blood tests; they have always been normal.

This time around, I asked the patient if any of those tumor markers had ever been positive, even prior to her treatment. I checked the chart to confirm her impression: no, she had never had a positive tumor marker test.

This isn't particularly unusual. Not all cancers express proteins that can be measured in the serum. But the point of "tumor markers" is that when a tumor actually produces one, it should decrease (or disappear) after treatment, and its later reappearance ought to correlate with recurrence.

So what's the point of following tumor markers when a given tumor never produced them in the first place?

Sometimes oncologists sort of go on autopilot. Time to re-stage: order tumor markers.

Testing for things you can't possibly find. I suppose it's reassuring for the patient to hear that all the tests were negative, though it seems to be akin to setting up an early warning system for polar bears in the Amazon.

Excuse me while I make a phone call. I have to knock some sense into a certain oncologist.

Always See the Patient First

2010-03-04T10:25:00.000-05:00

There's a very important rule to remember when rounding in the hospital. Personally, I would think that it's self-evident, but apparently not, according to a recent trainee in my office, who told me the following story.

Rounding on patients in the hospital has several components. In addition to seeing and examining the patient, one generally peruses the results of lab tests and other new studies, collects the most recently measured vital signs, consults with the nursing staff about the patient's status, and documents the encounter.

I well remember my student and resident days, when the major goal felt like collecting material for the progress note. After a patient had been in the hospital for some time, figuring out how to write something other than, "Continue present management" gets to be a real challenge.

It turns out that after perusing the current results of lab tests and other studies and getting the vital signs from the nurse, my new friend began writing the patient's progress note. He spoke with the current nurse who confirmed the patient's stable status, and duly noted same in his progress note-in-progress. Finally he went to see the patient...

Who was stone cold dead.

Suffice it to say, he had some re-writing to do.

Hence, the very important rule of rounding in the hospital: Always see the patient before writing the note.

Regarding today's date: thanks for all the good wishes. DS is taking me out for sushi, which is celebration aplenty.

Joined at the Karmic Hip

2010-03-03T08:51:00.002-05:00

One of the coolest things about family practice is the opportunity to take care of people for a long time, through various stages of their lives. Birth, death; marriage, divorce; friendship, estrangement, and often back again. It can be a wild ride, this thing we call Life(tm).

There's a patient I met over fifteen years ago. Ten years ago she got married, and her husband started coming to me as well. After about five years they divorced, and both of them have continued to come see me.

Here's something royally freaky: even now, years after their divorce (amicable, but it's not like they're in regular contact with each other) whenever one of them calls the office, the other one inevitably calls too. Often the same day; sometimes within the hour.

The calls are always appropriate; each has individual (albeit quite different) issues. It is entirely possible that we disproportionately remember the times they both call while forgetting many other occasions when one calls but not the other. Certainly this is the kind of thing that can be put down to coincidence, a phenomenon that occurs with far more regularity than is intuitively obvious to the oddly wired human brain.

But I don't think so.

It's like they're still joined somehow; through me.

Freaky.

Last Schmuck Standing

2010-03-01T19:54:00.003-05:00

Much has been written about the doctor-patient relationship. How to start one (call for an appointment); how to end one (ask to have your records transferred if you're a patient; send a registered letter if you're a doctor). If you're a specialist enlisted to treat a specific problem -- an orthopedist consulted for a fracture, for example -- you can discharge the patient from your care once the problem is resolved. I can never do that. The last line of every progress note reads, "Re-check" sometime; two weeks; six months; or the all-purpose "as needed."

I try never to discharge (also termed "fire") patients. Before I'll send someone that certified letter, return-receipt-requested, telling them that I'm only available to them for thirty days more (and then only for emergencies) they have to really piss me off. Usually lying to me about their narcotics (repeatedly; I'm awfully forgiving of lost prescriptions, pills down the sink and so on) is enough to do it. See, my view of these patients isn't that they're just out for the drugs. I know a lot of them have real pain, and I feel responsible for treating it. In fact, most of the time I don't actually discharge the patient from the practice altogether; I just refuse to write narcotics for them. Granted they usually then switch physicians voluntarily; still, I remain available to them if they decide what they really want is medical care.

But what happens when the patient has already been discharged by every other practice in town? Not just in town, but in the entire region. What if they've even been discharged from Pain Management, for heaven's sake, for a positive urine test for illicit drugs? She comes back to me, begging and pleading for the pain meds without which she cannot function, care for her home or her kids. Although I've already been around the block with this woman in the past, I agree to resume her care with the explicit understanding that my goal is to find modalities other than chronic narcotics to manage her back and leg pain.

For awhile, everything is fine. She keeps appointments. She claims to be following the tapering dosage schedule for her medications. Then she starts missing appointments. (They only have one car and she can't get a ride.) She calls for early refills. (The pain was so bad this weekend she just had to take a couple extra.) Finally, she shows up for an appointment with obviously slurred speech. Has she been drinking? Just one beer, although her blood alcohol level is more consistent with four, given her body weight. She has driven to my office while legally intoxicated to receive a prescription for over one hundred narcotic tablets that will only last her two weeks.

Find another doctor, I say.

But doctor, she sobs, where can I go? No one else will take me. You're the only one left.

Finally I manage to come to the obvious conclusion: That this is not my problem. Your situation is entirely of your own making. It is not my fault. You are responsible for the results of your own actions.

Yet it takes weeks longer than it should have. It's tough to be the last schmuck in town.

Responding to the Challenge

2010-02-26T09:06:00.005-05:00

I received the following email from the NinjaBaker:

I had a really odd dream last night. It included Glenn Beck. One of the first things he said to me was "I got your Mom's haiku". I then wondered how he recognized me as your son (especially cause I imagine you might have emailed it to him), and he said something about how I breathed or spoke.

Anyway, upon waking and remembering this, I was wondering what kind of haiku you would write to Glenn Beck. I imagine it would have something to do with firmly disagreeing with his beliefs, including a few choice words, but I couldn't picture fitting it all into merely 17 syllables.

Consider this a challenge from my subconscious.

One ~~way to cheat~~ trick to getting around the strict 17 syllable limit is to use a series of haikus:

Dreaming of Glenn Beck,
the idiots' idiot:
subconscious challenge.

Word: "Conservative."
I do not think that it means
what you think it means.

Too stupid for words;
So wrong he's not even wrong.
Not worth the effort.

Ice Rorschach

2010-02-20T16:51:00.002-05:00

What do you see?

Best answer so far:

A curling match gone horribly awry.

Enough with Curling Already

2010-02-20T12:36:00.002-05:00

Curling: the most ridiculous "sport" *ever*. And now it's in the Olympics?? For crying out loud, it's just shuffleboard on ice!

Since when has MSNBC become the all-curling, all the time station?? Enough!

It's just fucking shuffleboard. On ice. With big stones instead of little disks. And people running down the ice next to them sweeping the ice trying to make the stone go j-u-s-t where they want it to.

There are people watching this stuff. Live. And cheering! Chanting U-S-A, as if it were a hockey game or an actual athletic competition. Watch; next thing you know, someone will be petitioning to add tiddlywinks to the summer games. Or jacks! Now there's a sport! I excelled in it at summer camp. Maybe I can try out for the team!

But no. Instead, we have Curling.

WTF??

IT'S JUST FUCKING SHUFFLEBOARD ON ICE.

Bus Stop Diagnosis

2010-02-18T13:50:00.006-05:00

Sometimes patients present with diagnoses that are so obvious, you know what the problem the moment you see them. Some call these "bus stop diagnoses," because, um, you can diagnose them standing at the bus stop*. Hyperthyroidism with exophthalmos is one; acromegaly and achondroplastic dwarfism are others. Obviously, many skin conditions can also be readily diagnosed from cursory inspection at a distance.

Now and then, though, a diagnosis and a cliche come together like soap and water.

I saw a lovely young lady today with what was probably one of the worst cases of rosacea I have ever seen. Her cheeks were bright red, as was her nose, and sections of her forehead and chin that had also broken out. Even my staff was able to diagnose it, telling me afterward that they, too, had never seen such a severe case.

Surprisingly, though, that was not why she had come to see me. In fact when I asked about it, she claimed that she had never actually been diagnosed with rosacea before.

I slammed my hand over my mouth as the response jumped into my head, but eventually, I couldn't resist, and this is what slipped out:

You've never been diagnosed with rosacea?
Why, it's as plain as the nose on your face.

* (Thank you, Mr. Frank.)

Fake, but Funny

2010-02-17T09:39:00.004-05:00

For anyone who missed it, back in January a Jewish teen's tefillin set off a bomb scare on a commercial flight.

h/t to SG, but according to the comments on this source, it's fake. Still funny, though.

What's the Difference?

2010-02-16T07:48:00.005-05:00

I have a friend with widely metastatic cancer. He's been in and out of the hospital recently, along with a stay at "rehab," after which he became strong enough to return home. I've tried calling him, but the word he has put out is that he doesn't want to see anyone right now. He's reserving his strength to "fight this disease!" He did leave me a voice mail a few weeks back, thanking me for my message of love and support, closing with the assurance that, "I will beat this thing."

His oncologist is totally on board with this. My friend is continuing to receive chemotherapy and radiation, complete with their devastating side effects. Recently, he became so weak he had to leave his beloved wife and home to back to the "rehab" facility again, to make up "all the gains he'd made" during his first stay. He's had multiple conversations with his family about his wishes. Nothing has changed. He doesn't want to see friends yet, because he's still fighting. He is adamant that he will win this battle.

But he won't.

My fear is that his refusal to acknowledge this undeniable fact will end up robbing him of the last part of his life, as he spends it "fighting," rather than living. There are many people who love him dearly, and while I understand his loathing of the idea of people coming to visit to "say goodbye," I'm terribly afraid that the next time they gather will be for the funeral. That's the way he wants it, though.

Armed with the insight from OncRN that "patients don't want treatment, they want outcomes," I realized that what my friend really wants is for the disease to be gone and to go back to life as it was. Back to his home and his work; back to his family and his garden; back to watch his grandchildren grow up and dance at their weddings. The oncologist knows (or ought to know) that none of the treatment he has to offer is going to result in that outcome. So he has the choice between trying to help the patient re-align his expectations to make the best use of the rest of his life, or continue to offer "treatment," tacitly agreeing that the patient's desired outcome is possible; anything not to undermine the patient's "hope." But isn't it far more important at times like these to redefine "hope" for the patient, as has been so eloquently expressed elsewhere?

This was the context in which this thought occurred to me:

What is the difference between oncologists who never stop treatment, and the alternative/biomed/quacks who push endless, dangerous, uncomfortable (and expensive) treatments on children with autism spectrum disorders?

Both of them have patients (or families) who are desperate.
Both of them have patients/families who desperately want/want them to get better.
None of these patients ever will.
Both feed into their patients'/families' false expectations in the name of "don't give up hope."
Both believe they are doing the right thing.
Many other people have dealt differently with the same situation, finding satisfaction and fulfillment in dealing more realistically with their circumstances.

Some may say that the difference is that autistic children aren't choosing to undergo useless "biomed" treatments, whereas competent adult cancer patients are, supposedly, fully aware of the pros and cons of the treatments to which they consent. Still, it isn't really treatment they want; they want a specific outcome. And when no treatment can provide the outcome the patient wants, what good is it doing?

My friend remains fully convinced that the treatments he struggles to tolerate will indeed eliminate his disease and return him to his previous state of health. He clings to that, and refuses to discuss any other outcome of his condition. Not really much different from parents who insist that they can "recover" their autistic child, if only they believe hard enough and pay enough money for scientifically useless treatments. What's the difference between their doctors?

Maybe not so much.

What Patients Really Want

2010-02-14T12:49:00.003-05:00

Once again, the incomparable OncRN nails it:

nurse - 'wait, why are we offering this super difficult treatment to this super old person with super crappy disease?'
doctor - 'because she wants treatment'

i so desperately need a game show buzzer for my pocket....because we're sorry - that is incorrect
i have yet to meet a patient who wants treatment.
patients want an outcome.
big difference.

Seldom have I ever seen the point made so cogently. By and large, patients have little to no idea what "treatment" really entails. From chemotherapy, to breast reconstruction, right down the line to the nasty side effects of antibiotics; no one really wants to undergo any of these treatments. They just want their disease to go away, and never come back. They want to feel better, though they may settle just for feeling a little less crappy than they feel now. Rarely will any of our treatments make anyone feel better while they are undergoing them. Patients are taking us at our word that once they recover from the treatment, they will feel better than before. That is why it is so important that we as physicians make pretty damn sure that they will, before we undertake the surgery; the chemo; the radiation; the medications. And we'd better be damned sure to do everything in our power to mitigate the discomfort of the treatment, which starts with recognizing it. Because OncRN has it right: No patient wants treatment.

We Don't Miss You...

2010-02-11T07:34:00.004-05:00

...except when we do.

Dear Jock, DinoDaughter, DenverDaughter and NinjaBaker,

Most of the time, DS and I have no problem with the fact that you're all out of the house, away at school and off on your own. We don't miss you at all. Really; we don't. Most of the time.

Then there are times like these:

We still have five shovels. Come home anytime.

Later that day:

(Let it be known that when DS went out for milk, he crashed the right side of that carefully carved snow cavern out to the street -- despite there being PLENTY of room on both sides of his car. Furthermore, upon his return, he crashed the left side.)

Just to give you a better idea:

I'm told that the terminology for this stuff is as follows: First there was Snowpocalypse, followed by Snowmageddon. This was "Snowverkill".

Snow Idiocy

2010-02-10T15:43:00.002-05:00

It's snowing here. Not just a couple of flakes here and there, enough to heap scorn on those wimps who batten down the hatches and refuse to emerge until Spring. Rather, it's a nasty nor'easter that's got the entire northeast part of the country pretty much shut down. Not only have all the schools, businesses and government folk canceled out for the day -- and probably tomorrow as well, in order to shovel out, as this isn't supposed to stop until late tonight -- but several local highways have officially "closed," meaning fines for anyone venturing out onto them. In short, it's a mess.

DS and I went out this morning at 6:00 (we wake up early even without an alarm) and shoveled the first six inches off the driveway during a break in the precipitation. Now we're ~~snuggled~~ stuck here at home, waiting it out. In between cooking, eating, cleaning up, deciding what to have for the next meal and when to have it, plus reading, blogging, and ~~other time wasting computer activities~~ working on the new novel, we're watching television. The problem is that the weather is such a mess, it's preempted all the local network television affiliates' regular programming for "all weather, all the time."

The main message these and other news outlets are trying to convey is, "It's a mess out there; stay home if you possibly can." Of course, in addition to the talking heads and perfectly coiffed meteorologists in the studios, each station has people out in the community (usually at a Wawa), bundled up in parkas monogrammed with their station's logo, standing out there in the blowing snow, bringing us up to the minute news that basically consists of, "It's a mess out there; stay home if you possibly can."

Given that there's so little on TV, I must confess that we've been watching some of this coverage. One reporter at a super-Wawa (one that sells gas) was interviewing ~~idiots~~ drivers who pulled up, because hey, who wouldn't want to be on TV! Naturally, the first question the reporter asked was, "Why are you out in this mess?"

Here's the response that blew out my idiot meter:

I went to the gym.

You went to the gym? You went to the GYM?!? You needed to work out; fine, I get that. Exercise is important; possible even addictive. But why the hell don't you stay home and shovel your damn snow?!?!!

Idiots. They're everywhere.

Master of the Analogy

2010-02-09T07:22:00.005-05:00

I have a patient in his 60s who is riddled with metastatic lung cancer. He isn't on hospice (oncology refuses to let him out of their clutches just yet; actually, the problem is that around here Hospice won't accept patients still on palliative chemo or radiation) but is aware of what they have to offer. He and his wife have assured me that they will let me know when they feel they need their help.

In the meantime, he comes to me for a visit because he is worried about his blood pressure.

Up until his cancer spread, I had been treating him (successfully) for high blood pressure. Pretty routine; good control; no big deal. The problem of course is that now he is extremely unlikely to live long enough to have a heart attack or stroke. I have already told him to stop his BP meds, and he has. At this point, his blood pressure isn't even all that bad, but he occasionally gets readings at home in the 150s over 90s. This has him concerned.

My gut reaction was a combination of, "Why?" and "It doesn't matter."

Although I have explained this to him and his wife several times before, either the chemo-brain or the whole brain radiation for metastatic disease has left him a little foggy. I need to find another way to explain this without coming right out and saying, "You're going to die of cancer before your blood pressure has any chance of hurting you."

So I said this instead:

Imagine there's a house with a leaky faucet. You know that it's important to fix leaky faucets, because they can cause big problems with the plumbing down the road.

He nodded his understanding.

Now imagine that the house is scheduled to be demolished next month.

"Ah," he said, smiling with comprehension. "It doesn't matter."

Exactly so.

One of the greatest pleasures I have in my job is watching things click. That "Got it!" moment when a vaguely abstract concept is presented in terms just different enough to trigger comprehension instead of confusion is exhilarating for both of us. Nothing beats the effectiveness of a great analogy.

Best Part of the Day

2010-02-07T15:18:00.004-05:00

It is well known that there are a number of other events held annually in conjunction with this evening's football game. Here in Philadelphia, for example, the Friday before the Super Bowl has become known for Wing Bowl, an event the likes of whose masculine debauchery is seldom equaled.

But our favorite here in DinoLand -- especially beloved by the Rolling Peke -- is, of course, Puppy Bowl:

complete with aerial views from a hamster-driven blimp, bunnies as cheerleaders, and a halftime show starring kittens. Cuteness abounds.

Yes, she really is entranced by it; and yes, I really got a shot of the screen with the logo. No photoshopping here.

There Might be Some Football on Tonight

2010-02-07T11:04:00.005-05:00

Today's email from this crotchety old guy I've known for years:

I've been reliably informed that today is Superbowl Day, and CNN is trumpeting the news that nearly a billion people worldwide are expected to watch it. To your amazement and surprise, we will have the TV turned on for that event, too, so when people talk about it tomorrow, I will know what went on. After all, I love water polo -- what else would one play in a bowl? -- and will be glued to the set for every chukka. (I know there are no innings in that game.)

His ignorance of sports is exceeded only by his lack of interest in them. Still, I want to help him make sure he doesn't miss the parts everyone is really going to be talking about. Hence my response:

The real reason my friends and I will be watching is for the commercials. Of course we never turn our noses up at a chance to get together and gorge on scrumptious pot-luck food while enjoying each others' company either. Still, the rhythm of the event is very much talk-eat-talk-drink-talk-here-have-some-more while the football part is on, then "Shush everyone, here's a commercial!" -- resulting in everyone's rapt attention -- at appropriate intervals. So if you want to be in the know, all you need for the football game is the final score, but scrutinize the commercials carefully. (ie Time your bathroom breaks counterintuitively.)

That's what everyone's really going to be talking about.

HIPAA be Damned

2010-02-05T08:14:00.005-05:00

We can be pretty informal in my office. Sometimes patients would rather sit by the front desk and chitchat with the office staff instead of going back to the waiting room, lovely though it is, and read magazines.

One of those regulars was in the other day. As she sat there filling us in on the latest goings-on with her grandchildren, the next patient walked in. As it happened, she was another lovely lady who preferred the company of the staff to the more comfortable chairs in the waiting room, so she also perched next to the check-in counter and joined the conversation.

After a few minutes of this informal give-and-take among us all, I found myself feeling ever so slightly rude. I realized it was my home training asserting itself, as I heard my mother's voice in my ear saying, "Introduce them."

So I did: "Mary, Jane; Jane, Mary."

First names only, of course. Including their last names would make them uniquely identifiable. This would constitute "Protected Health Information," which needs to be zealously guarded from inadvertent disclosure. That's what HIPAA says.

The first lady had been looking carefully at the second, but now she said, "What's your last name?"

I had to bite my tongue not to scream, "NOOOOOOOO!! HIPAA says you can't tell her that. It's Protected Health Information!"

But of course there's nothing in HIPAA that says a patient can't tell another patient her last name. They ended up exchanging not just current last names, but also maiden names -- and discovered they had gone to high school together fifty years ago. They caught each other up on their families: one was widowed; both had grandchildren. They laughed and had a lovely visit, foreshortened by me, party pooper that I had to be, to actually provide, yanno, medical care to them.

The take-home message is that privacy is the patient's. They are the ones who can choose what to do with it, including breaching it to reconnect with an old friend. It was a lovely encounter to witness, and the hell with HIPAA.

New Look

2010-02-03T09:29:00.002-05:00

Some people change their blog templates like their underwear. Unlike underwear, though, blog templates are not subject to staining with bodily secretions containing aromatic compounds causing people to whine, "OMG, haven't you ever heard of SOAP?"

For the record, I love my old template. I think maroon and gray go together wonderfully. The look was classic. So why the switch?

Hat tip to the oxymoronically well-known Dr. Anonymous for this bit about branding. Reading it, I realized that my brand is, of course, the Dinosaur. For better or worse, whatever else I end up publishing (and yes indeed, there are plenty of other non-Dino works in the pipeline), I am ~~Sparta~~ Dino.

Hence the switch to a more saurian-appearing (ie, green) template. Rest assured, this portends no change in content, which is good news for all three of you regular readers, and bad news for this crotchety old guy in his 80s I've known for years. (Which is to say that yes, four-letter words will continue to appear on occasion.)

A Gentle Reminder

2010-02-01T15:22:00.004-05:00

Many thanks to dzineprof:

One Simple Question

2010-01-30T09:38:00.002-05:00

A patient of mine brought her father down to live with her because he was having some problems living alone. She called me in a panic to tell me he was having trouble swallowing, so I rushed over to make a house call (yes, I still make house calls) to see what needed to be done.

It turned out that he'd been having the problem for months. He'd complain (loudly) he couldn't swallow -- yet was able to speak just fine through the episode. Then it would stop as abruptly as it started and he'd be fine, eating and drinking with no problem.

With that history, it was extraordinarily unlikely that there was something seriously wrong organically. Symptoms of an esophageal tumor wouldn't come and go like that. Nothing else really bad came to mind either. Still, it deserved at least a cursory workup, even though the guy was in his 90s. The daughter even told me that she was certain her father had seen the doctor for this problem, although she couldn't remember what testing, if any, he had already had, at his previous doctor's at Geisinger.

As anyone who reads anything about health care economics knows, Geisinger is one of the large multispecialty organizations specifically mentioned as the epitome of efficiency, delivering high quality care with better outcomes at lower costs. These accomplishments are attributed both to the corporate culture of cooperation between specialists and primary care physicians, but also in large measure to the fabulous efficiencies provided by their system-wide electronic medical record system. It should be a fairly simple matter to find out if he had had either a barium swallow and/or an endoscopy to evaluate his swallowing issues. Either of those negative studies would be enough to reassure us that there wasn't anything immediately life-threatening going on.

Piece of cake! The patient signed a release. Three weeks later* I get a half-inch thick sheaf of papers printed out from Geisinger's EMR. I wade through page after page of beautifully documented outpatient visits, complete with nurses notes, medication reconciliation, exam findings; all kinds of crap. Yes, dysphagia (difficulty swallowing) is listed as a diagnosis, but I can't see any record of it having actually been addressed at any visit. I couldn't find any labs, x-rays, other imaging studies, or procedures anywhere in the records.

Hm. Seventy-five pages that didn't say jack.

Then again, there were some notes about a hospitalization. Too bad all it said was, "Hospital follow up visit." Perhaps he had had studies done in the hospital, and those records, although not included in my printout, were easily accessible to someone actually on the system.

So I picked up the phone.

Actually, I had to do it twice. The first time around, my call was dropped somewhere between the voicemail system and any actual liveware. When I called the second time, I tried a different tack. Instead of asking to talk to an actual doctor, I decided to try letting the system do its thing. After all, I just had a very simple question: has this patient had either an upper endoscopy or a barium swallow?

Guess what? She can't tell either. There's nothing written anywhere in Geisinger's much vaunted EMR about the workup of a medical problem this patient has had for the better part of a year.

Riddle me this, boys and girls: what the hell good is a medical record if you can't tell what tests a patient has already had?!? Just by way of comparison, previous studies -- or specific notations about what the patient has NOT had -- are part of my history of present illness (HPI) every time I see a patient for a new problem. Not only that, but because of the way I keep the papers filed in my chart (that's right: still paper), I can put my hands on the report of a barium swallow or endoscopy in about six seconds (and that's only because I have to be careful of sharp paper).

And this is Geisinger; one of the groups identified BY NAME as a model that the rest of us should emulate. Really? When they can't manage to answer one simple question about a patient's care?

I don't think so.

*By comparison, I usually get medical records in the mail the next day; by the end of the week at the latest.

Why Bother Blogging?

2010-01-27T11:22:00.006-05:00

Why bother ever writing an incendiary blog post ever again?

This says it all.

(The comments are hilarious, too. I actually added one. It's in there, three or four hundred down.)

h/t to Overlawyered

(Edited to add: I swear I posted this before I saw it at Orac's place!)

The Power of Prayer

2010-01-25T10:51:00.003-05:00

This is for all those fundamentalist atheists (who are just as intolerant and hateful as all other fundamentalists) who scoff at prayer. Not prayer in lieu of taking actual action; that's just stupid. Demanding logical consistency of religion, an endeavor properly undertaken (and believe me, I quite understand how frequently through the eons religion has been used improperly, to say the least!) to comfort inconsistent humans in times of pain and suffering, is trivial and irrelevant. Yes, it is possible to thank Gd for allowing some to survive, without holding Gd responsible for those who perished, just as I thank DS for taking the trash out without berating him when he forgets. Remember that bit about foolish consistencies and small minds.

What brought this ~~rant~~ thought to mind?

I received an open letter from a surgeon at my community hospital who was on his way back from Haiti after spending a week there, hip-deep in relief efforts. He describes hospital scenes:

Many [patients] had their original dressings on, their wounds filled with dust and debris. Some no dressing at all. Within the next 24 hours there would be 18 rooms labeled Post Op with close to 80 - 100 patients who had had their surgery but were receiving little or no care. External fixation devices everywhere. Amputation stumps with dressing that had gone unchanged. IV sites that were occluded, bottles empty. Some patients crying, some quietly resolute. Occasional screams. Post op orders written on sheets of paper, no charts. Most orders not being carried out. No way to know if someone had gotten pain meds or antibiotics. No blood pressure cuffs. Only your hands and a stethoscope to determine pulse and blood pressure. Very little oxygen, no ambu bags, no suction, no ventilators.

and this:

I can't remember all of their names, but I can see their faces. I can also see the face of the mother who had just delivered whose baby died within her sight as [an ER doc from Miami] and I tried to resuscitate him without a laryngoscope, pediatric endotracheal tube, oxygen or even an ambu bag. Or the patients in Post-op room 18 who watched as we coded a young woman who had had her femoral fracture reduced, had been lying in bed for 3 days without heparin prophylaxis, and upon her likely massive pulmonary embolus, no crash cart, not even an ambu bag and no oxygen. Then they watched as we wheeled out her stretcher, and out in the courtyard, those waiting for triage watched as we put her in a body bag and carried her to the makeshift morgue outside.

But here is his closing paragraph:

Finally, please know that I felt the presence of every single one of you each time I knelt by the side of an injured Haitian patient. Because for strength and prayers, because of the support of all of the organizations, I quickly felt that I was there on behalf of each one of you. I had the privilege of bringing care, comfort and hopefully some healing directly to these people, but in truth I was acting through you. You have touched many, many Haitians' lives. Patients and families. So please do not feel helpless. You have already done so much.

This is what prayer accomplishes. Strength and support for those who are actually doing the painfully difficult work of helping. Relief from the helplessness that comes with being able to do nothing more than write checks. Validation that caring matters.

Could he have done it without "all that sky fairy nattering"? I'm sure you atheists will point out that of course he could, since those prayers weren't actually "doing anything". Maybe; but maybe not. Who knows what heights of human endurance can be enhanced by the knowledge that others are keeping you in their hearts and minds?

I was deeply touched by the letter, only brief snippets of which I've posted.

That is the true power of prayer.

American Health Care; Vew from Afar

2010-01-24T10:43:00.006-05:00

I received the following email from an expat friend of mine from college who now lives in Israel:

I thought of you when I read this, and would be interested to hear your take on it. (I'm one of those pessimistic types that think that America's health care problems will only begin to be cured when a majority of the public realize that their "insurers" are truly robber barons. Guillotining comes to mind as an option. But that's just me.) Trying to sound rational I usually say that it's high time the US took a look around at countries that have dealt successfully with providing health care (Denmark springs to mind) -- but I doubt the American political system or the American voter are ready for that.

My response:

Yeah, don't get me started on all that "Patient Centered Medical Home" shit. Basically, it's a way to get large impersonal multispecialty practices to work like me, from the patient's perspective (ie, everything they say they want to accomplish is precisely what I'm already doing).

As for systems in other countries, forget it. You know what the main problem is with American health care? Americans. If you could magically impose any other country's health care system on the US, I guarantee it would crash and burn in 6 months. Mostly because of the unparalleled litigiousness found here, but also because of patients' generally unreasonable expectations of medical care, coupled with an appalling refusal to take responsibility for modifiable lifestyle factors.

So yeah, if everyone recognized that the "insurance companies" are basically robber barons, and made rational decisions in their own financial best interests (which would involve paying cash for quite inexpensive primary care, true insurance for catastrophic illness, and programmed savings for end-of-life care (a la retirement)) then sure, we'd be fine. Just remember that this is a country of Limbaugh dittoheads who think Sarah Palin has more than two functional neurons in addition to a hyperfunctional uterus [edited to add] and left-wing nanny-staters who think it's their civic duty to wipe everyone's ass from cradle to grave. Believe me, there are times when guillotining sounds downright sensible to me too.

RIP Marvel Battle Van

2010-01-19T07:36:00.006-05:00

Also known as a 1999 Plymouth Voyager, with over 100,000 miles (not bad for a Chrysler product with the original engine and transmission), the Marvel Battle Van owes us nothing. For seven years it served me well; the remaining four years of its driveway tenure were in service to the Jock, who found it "convenient" (large and red enough to find in any parking lot; plenty of room for a team and its gear). It had begun sucking down money over the last few years, accelerating at a greater rate than it ever did on the highway -- which is saying something. For anyone who hasn't ridden a Voyager on the highway, that puppy can move!

The quest for new wheels is on, as the Jock and I bid a fond farewell to the last automotive vestiges of adolescence. To the Marvel Battle Van, we say Adieu; safe journeys to that great parking lot in the sky (or wherever Purple Heart takes it).

I Didn't Know You Could Get Them That Small

2010-01-14T09:00:00.003-05:00

True story:

Healthy five-year-old boy in for an annual checkup:

Dad: Tell the doctor why you wear boxers.

Kid: I like the way it feels when it flops around.

Consult Codes: Goodbye and Good Riddance

2010-01-13T15:41:00.002-05:00

Consult codes have just gone the way of the dinosaur! And none too soon, I might add.

For all you non-medicos with no idea what I'm talking about, allow me to enlighten you:

Medical care comes in two flavors. The first kind, so-called cognitive services, involves the doctor talking to you, examining you, perhaps ordering some blood tests or imaging studies, figuring out what's wrong with you and what to do about it. The other variety, "procedural services," is when the doctor does something to you, like cutting something off of you or out of you. There's plenty of overlap, of course. The most important part of any procedure is deciding whether or not it needs to be done (which usually involves thinking), and procedures of some kind are required to establish many diagnoses. The problem is that procedures pay far more than cognitive services.

It began about 25 years ago, some Harvard economists came up with the idea of quantifying the amount of "work" in a medical encounter. This allowed them to calculate a Relative Value Scale of everything a doctor does (cognitive and procedural). Add some geographic fudge factors (to make it "resource-based") and a "conversion factor" (a dollar amount) to turn it into a fee and you have the Resource-Based Relative Value Scale, the infamous RBRVS. Leaving aside the subsequent actions of the specialist (read: those who do procedures)-heavy RBRVS Update Committee (RUC) that have made procedures more and more lucrative than cognitive services, I have a problem with the idea that the amount of "work" can be quantified for any given medical procedure, cognitive or procedural.

Take the so-called Level 3 (of 5) Office Visit. This has an actual definition:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coodination of care with other providers or agenies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

Here's my take on that: NOT ALL LEVEL 3 VISITS ARE CREATED EQUAL. Believe me, 15 minutes reviewing three chronic problems, performing a brief physical, and renewing ten prescriptions for a pleasant, informed, cooperative patient is a very different 15 minutes from those spent with a cranky, demanding, loudmouth who has no idea what meds he's taking, much less whether any of them need refilling, and who insists that I order an MRI because he had a headache last night. In fact, that I can manage to accomplish what each of these patients need (not counting a swift kick to the behind in the case of the second patient, but I have a bum foot) in only 15 minutes is a testament to my skill, tact, and efficiency. Nevertheless, I still believe that for cognitive services -- the so-called Evaluation and Management, or E/M services -- the most logical and equitable proxy for "work" is TIME. By and large, the 20 minute visit is generally twice the work of the 10 minute one.

But I digress.

It turns out that specialists have another ~~mechanism to increase their take~~ set of codes they can use for what are essentially E/M services: Consultations.

Here's the way the system is supposed to work: everyone sees their family doctors for all their concerns. Family doctors are perfectly able to take care of 90% or more of the problems they see. The remaining 10% are either too complex or severe for our skill set. Those we refer to the specialists, who, by virtue of their longer and more detailed training, are better equipped to deal with this small proportion of the general public. For this (a specific request from another physician who was unable to handle the problem) it is generally accepted that specialists deserve greater compensation. The purpose of Consultation codes was originally to identify this specific service, to distinguish it from any old garden-variety E/M visit. Logical; fair; economical.

Two things are necessary for this system to work as designed, though:

Everyone has to go to their primaries first, and
There have to be more primaries than specialists.

Instead of having the accepted ratio of 70/30 specialist to primary care, this country has exactly the opposite. This is only part of the reason why people don't go to their primaries first; in too many cases, the too-few doctors are too busy. Then again, Americans are notorious for demanding "the BEST." In the case of medical care, this usually means the specialists. (The really sad thing about this situation is that for the unselected, self-referred patient, the specialist's approach is much more expensive than it needs to be, and subjects the patient to all kinds of inappropriate interventions.)

So when you have 70% of physicians using codes intended for 30% of them, to care for medical conditions that do not require their full expertise, you're going to be spending far more money than necessary.

This is why the Centers for Medicare Services (CMS, ie, "Medicare") decided to stop paying for Consultations. Weep bitter tears for the poor specialists who are now stuck with the same paltry selection of E/M codes as we Primaries. If nothing else, maybe it will help them work together with us to increase compensation for cognitive services.

h/t to my good friend TBTAM, with whose post on this topic I respectfully disagree.

What You Can Do with Your Pink Ribbon

2010-01-09T18:22:00.004-05:00

For those who may not be aware of the goings-on at that massive time waster known as Facebook, there was a bit of a tizzy over there the other day. Simply put, women were encouraged to post the color of their bra in order to "raise awareness of breast cancer."

Note to those whose opinion of me is inversely proportional to the amount of time I ~~waste~~ spend on Facebook and other internet frivolities: I did not find out about this online. Rather, the patient I was seeing apologized for the fact that her phone kept buzzing. Apparently, she had it set to alert her when anyone updated their Facebook status, so it buzzed constantly as all her friends played along.

By today, there was commentary galore, both pro and con, throughout the blogosphere. For the record, here was my response:

Lucy doesn't care what color your bra is. If it contains two healthy breasts, consider yourself blessed.

As DenverDaughter puts it, all the pink ribbons in the world won't bring her mother (or mine; or anyone else's) back again.

(Apologies to my Facebook friends for the redundancy.)

So True

2010-01-09T07:33:00.001-05:00

If you don't read Indexed, you should.

Fun on the Radio

2010-01-07T14:05:00.004-05:00

Whenever I am in my car I listen to WOGL. It's a nice oldies station (kind of sad that "music of the 70s, 80s, and 90s" -- my music -- is considered "oldies") with an affable morning crew. In addition to music, news, weather, and so on they have assorted games that people can call in to play. One of them is called "Buck-a-Bark," and (no surprise, I would hope) requires that the caller have a dog. The goal is to get your dog to bark as many times as you can in 15 seconds, and they then send you the corresponding dollar amount.

What fun. I listen to it regularly on Thursday mornings. Usually the dog barks like crazy before the timer starts, then won't make a sound for the critical 15 seconds. Other times it won't bark at all. Occasionally, the dog goes on at the right time. The most I've ever heard was a Pomeranian who got in 44 barks.

The best part is watching the Rolling Peke react to the dog barking on the radio. Since she adores d-o-g-g-i-e-s (I have to spell it out; just hearing the word sets her off) she goes nuts during the feature. I have to stroke her and tell her that there really aren't any d-o-g-g-i-e-s out there, and she should shut up already.

Ever since her surgery almost five years ago, RP has come to the office with me. For a small dog, she is unusually quiet. Most patients and visitors to the office are amazed that there's a dog there at all. Most of the time, that is.

For some truly unfathomable reason, there are certain people who drive her crazy. She barks like crazy at them from the instant they walk in the door until the moment they finally leave. Sometimes she sits at the door after they've left and barks a few more times, as if to say, "And STAY out!" These people have nothing in common. For a while, I thought it might just be old people; but not always. Or smokers; nope. Dog-haters? Not at all. Dog-lovers? Sometimes yes, sometimes no. It's random! But once you're on her "bark" list, you stay there.

A few weeks back, a patient of mine was burned in an awkward location on his back. He lives alone and was having some trouble changing his bandage. Because I've known him such a long time, I started having him come in every morning right before the first patient so I could dress the wound for him. (It's healing beautifully, by the way.) As it happens, he's one of those people who drives the dog nuts. Every morning. All I have to do as I pull into the parking lot is say to her, "He's here!" She sits up and starts the little huffing noises dogs make before they burst into full-throated barking. She runs after him, barking her fool head off. She follows us into the exam room where she finally shuts up. Then as he's leaving, she chases him out. It's hilarious.

So this morning, they invited folks to call in for Buck-a-Bark just as I was heading out to work. It occurred to me that if I called in, I'd end up arriving at the office just as they'd be getting us on air. Assuming my patient was there (he's only failed to beat me in once), my 15 seconds of fame could very well coincide with the RP's giving him a very vocal piece of her mind.

So I did it.

And it worked!!

I'm bummed beyond all words that I can't find a way to podcast the piece, but the Rolling Peke let loose right when they started the timer. She barked like a champ as ~~the mean, nasty man~~ my patient goaded her.

The official Counter of the Barks, Mr. Bill Zimpfer, declared that the RP had barked 19 times. Frank Lewis (the weird guy) rounded it up to 22 (I said he was weird), and I had the time of my life chatting with Ross Brittain and Valerie Knight.

Thanks for making my day, WOGL's Breakfast Club!

Yet Another Reason Why Assumptions are a Bad Idea

2010-01-07T13:17:00.003-05:00

Because of various insurance requirements, I am forced to use a certain lab (call them "Mission" Laboratories) for almost all my patients. For us dinosaur offices, the lab still provides us with a large doorstop of a book that contains all the information about how to order the various tests they offer. Although we have lab forms pre-printed with the vast majority of things we frequently order, there are times when I still have to go to the book to look up a specific test. Which I did the other day. And got a phone call from the lab:

"What test do you want?"

"I wrote the name and the number from your book," I answer, reciting the name and number back to them.

"That's an obsolete test number. It's not in use anymore. How old is your book?"

"2008."

"Please call Client Supplies and have them send you a new one."

So we did, and they did. All was fine (so I thought) until today, when I get another call about a test ordered yesterday:

"What test do you want?"

"Test number @#$%. I wrote it on the slip, and I got it from the new book I just got. It's right there on page 186."

"I'm looking at page 186, Doctor, and there's no such test on that page."

WTF?

Finally, DinoStaffer "D" notices that the book, while announcing "2009" in large friendly numbers at the top of the cover, says "New York/New Jersey" in smaller letters further down.

Epic WTF?

Why on earth would "Mission" Laboratories send a New York/New Jersey reference book to a Pennsylvania office?? The DinoStaff came up with a thought.

DinoStaffer "B" is a lovely person, but her native origins are clear the instant she opens her mouth. Our suspicion is that upon hearing her heavy New Yawk accent, "Mission" Lab immediately assumed that they knew her location...and sent us the wrong fricking book.

We have requested a replacement. This time, DinoStaffer "D" made the call. She is Pennsylvania born and bred.

We shall see.

Stupid is as Stupid Does

2010-01-06T07:21:00.004-05:00

If you're planning to leave your wife of thirty years,
and if you wait until just after Christmas to tell her about it,
and if you already have plans for New Years with your new girlfriend...

What kind of idiot are you to put it all on Facebook, where your kids can see everything you're doing (and therefore find it all the more difficult to believe you when you deny everything)?

How stupid can you get?

Thank You, Westboro Baptist Church

2010-01-05T10:11:00.003-05:00

For those of you stuck off in an underground bunker with the great good fortune never to have heard of them, the Westboro Baptist "Church" (no link) is a family-run cult that specializes in disrupting military funerals and staging protests at schools, churches, and municipal institutions that dare to show any kind of tolerance and acceptance of anything their two neurons can conceive as having anything to do with homosexuality. One of the deeper ironies of the universe is that their founder is a lawyer who began his career with great success in civil rights litigation. He has since been disbarred and has begun a new phase of his life as founder and leader of the Westboro Baptist ~~cult~~ "Church".

I know what you're thinking: why on earth would I be expressing thanks to one of the most disgustingly vile hate groups masquerading as "Christians" in this country today? Here's why: yesterday, they held an early morning protest outside my niece's high school.

Still don't get it?

The community's response of peacefully gathering and ignoring the protesters, while providing a buffer between the hate-filled rhetoric and the students, was a source of deep pride to my niece and her family. I called her last night, and she told me that the incident sparked a great deal of discussion in school, both in formal classroom settings and among friends. All told, it sounded like the incident generated a fair amount of positivity (including this).

Although the world would certainly be a better place without all the hate spewed by WBC and its ilk, if it has to exist -- and if it absolutely has to invade the loving and tolerant world my family is trying to provide for our children -- the very least it can do is generate the warmth and community spirit as was found in New England yesterday.

I love you all, RFS et al.

Worth the Hype

2010-01-02T19:03:00.003-05:00

I am generally pretty cynical when it comes to movie reviews. In fact, I find that my impression of a film is inversely proportional to how many stars it receives in the paper. The less everyone else thinks of it, the more I like it, and vice versa.

Today was the exception that proves the rule.

Avatar.

The IMAX was sold out, but the regular theater with the 3D glasses was good enough.

It has everything: a functional if predictable plot; engaging acting; an appropriately dramatic soundtrack that managed to stop short of inducing cephalgia; and of course, knock-you-out-of-your-seat visuals. Despite its length (two hours and forty-two minutes) I was never bored or fidgety. (I've been known to fall asleep in movies. As an adult.) Not this time. Every moment captured my attention. The opportunity to be immersed so fully in such a well-realized and executed world/alternate reality was nothing short of exhilarating!

Go and see it if you get the chance. You won't regret it.

Ten Years Ago

2010-01-01T18:23:00.002-05:00

Ten years ago, my children were in Middle school. We were planning a joint Bar and Bat Mitzvah for the Jock and DinoDaughter. I was so proud of how grown-up they were.

Today, all my kids have traversed the High School graduation milestone with ease, navigated the bulk of their college years, and are now actively planning for life beyond schooling. I believe this is called "adulthood."

Ten years ago, this crotchety old guy I've known for years was taken off a cruise ship with ruptured diverticulitis and flown to Miami for emergency surgery -- including a colostomy -- in the middle of the night. I flew down to be with him for several days, and to spell his wife, who was caught in the middle of the rioting over Elian Gonzalez (remember him?) When the COG wrote a poem about his colostomy, we knew he was going to be fine.

Today, we're all still basking in the warm glow of last year's trip to Bermuda to celebrate his 80th birthday. His colostomy is history (when the doctor closed it, all the guy wanted to hear was, "Mr. COG, you have your asshole back." Instead, the doctor told the wife, "Mrs. COG, you have your asshole back.") although his abdominal wall is a scarred battlefield of assorted repaired ventral herniae. His mind is as sharp as it ever was, though.

Ten years ago, I was single, dating frequently, and hating every moment of it.

Today, I pinch myself every morning as I wake up next to the most Darling Spouse anyone could ever wish for. (I have another kid, too.)

Ten years ago, an orange cat was pissing off his original owners so thoroughly that they brought him back to the shelter where they got him.

Today, nine years after attaching himself to Darling Spouse and DenverDaughter when they went to select a cat at the behest of DS's late wife ("so he wouldn't have to come home to an empty house"), the Mighty Hunter lounges in the sunshine between presenting us with small former rodents and getting shot up with NSAIDs.

Ten years ago, everyone was getting their panties in a wad worrying about the ramifications of the Y2K bug, which turned out to be a whole lot of hot air over nothing much.

Today, everyone is all in a tizzy over health care reform, which I predict will, in retrospect, have exactly the same impact as did Y2K.

Ten years ago, I was busy berating the arithmetically challenged hordes insisting that a new decade was dawning today, instead of a year from today.

Some things don't change, even after ten years.

Happy New Year, everyone!

The Dinosaur Speaks

2009-12-28T07:36:00.003-05:00

You've read my words; you've seen my face. Now hear my voice. Many thanks to Greg Friese of Everyday EMS Tips (and to Rogue Medic for the referral) for interviewing me on his blog, as well as for the very nice write-up.

My recent lack of writing in general (and book-related activity in particular) is a source of shame. I understand that virtually all writers have day jobs (as I opined they should; listen to the interview), but I don't think the words "flu season" have quite the same impact on those who don't have to worry about disappearing needles. Still, my promise to all you sharks out there (well, one in particular) is that I will be getting back on the stick, butt in chair, and fingers applied to keyboard post haste.

Out of Network

2009-12-23T14:08:00.003-05:00

Last patients today: a husband and wife with an infant under six months of age for their H1N1 shots.

Wife: "Can I ask you a question?"

Sure, why not. Turns out her neck had been bothering her for a week or so. Nothing much to get excited about (nor was there much to do for it), but I rubbed it for a few moments with moderate relief. She sighed and said, "Can you please write a prescription for my husband to do that for five minutes every night?"

Husband's response: "I don't take your insurance."

This One's for AD

2009-12-21T14:11:00.005-05:00

Saw this and thought of you, dude:

Hinny Shots and Anal Puckering

2009-12-18T22:58:00.002-05:00

As some of you may know, there is a novel flu strain out there called H1N1, or, less accurately, Swine Flu. As others of you may also know, there is a vaccine available that is recommended for the following high risk groups:

Children/young adults between the ages of 6 months and 24 years
Household contacts of infants less than 6 months old
Pregnant women
Health care workers
People with health conditions (asthma; diabetes; etc.) putting them at high risk for flu complications

For those of you who have been hiding under a rock since Fall, the vaccine is being purchased and distributed by the government. This is as good an explanation as any as to why I have not been able to get ahold of any of the stuff.

Until now.

Finally, at long long last, I received an email from the state department of health notifying me that my order of 200 doses of H1N1 vaccine had been approved. Unfortunately, they were unable to provide me with a shipping date. They also sent me another mass email informing me that as of 12/11/09, they would be suspending all shipments (ostensibly, "for the holiday") and would resume 1/4/10.

Shit.

Then two days ago, I received a box from UPS. Inside, I found a plastic box. It was a sharps receptacle, a container specifically designed for safe disposal of hypodermic needles. I examined the package at length; the only other thing in the box was a sheet of paper naming the company that had sent the thing. The name rang a bell; sure enough, it was the company distributing H1N1 for the state. Given that the government was not only going to be providing the shots but also all the equipment and supplies for its administration, this was a very good sign indeed.

The next day brought another good sign: another delivery consisting of one box containing two plastic pouches, each containing one hundred syringes with attached needles, alcohol wipes, and little cards upon which flu shot administration could be documented and given to patients. This was an excellent sign!

Then earlier today, UPS came again. This time, the cardboard shipping box contained another box made of styrofoam. Hidden within, nestled among half a dozen cold packs, sat two shrink-wrapped packages of ten little cartons containing vials with 10 doses each of H1N1 vaccine. I'm in business!

(Eventually, I got back to check my email, and discovered that I had to print out and complete reporting forms for each dose given, and then send them back to the health department "in a timely fashion." I knew it couldn't be that easy.)

I was just finishing up with a patient as the vaccine was being delivered. Realizing what the package was likely to contain, and aware that the patient was undergoing cancer chemotherapy (a definite indication for H1N1 vaccination), I grabbed her before she could leave so I could get her immunized.

I tore open one of the government-supplied packages of syringes, and freed it from its paper overwrap. It was an unfamiliar design, but I figured that the basic idea is pretty universal. I drew up the first dose, half a milliliter of the treasured serum, and approached the patient's bare left upper arm.

I need to interject at this point that I'm damn good at giving shots. What I do is say, "Count to three" AS I'M GIVING THE SHOT. By the time they start to count, it's already done. I've given out about 300 seasonal flu shots this year so far, and the most common response to my injection technique is, "Was that it?" Even though I hadn't ever used this particular model of syringe/needle combo, I saw no need to alter my technique.

I swiped the site with alcohol and inserted the needle as I began to say, "Count to three." I depressed the plunger and watched as the vaccine disappeared into the tissue where it belonged. Suddenly, there was a loud SNAP as I finished the injection, and to my horror, there was no needle at the end of the syringe!

It is the essence of professionalism that the expression on my face never changed as the words, "Oh my fucking god, where did the needle go? Oh my fucking god, did I break the needle off in her arm??!? Oh my fucking god please no no no no no where did that fucking needle go???!?" raced through my mind, and my lab coat sucked all the way up to my splenic flexure.

I peered carefully at the patient's arm. Nothing out of the ordinary. But how could I tell if there was a needle broken off all the way under the skin? I poked at it gently.

"Does that hurt?" I asked the patient.

"A little," she answered.

I've had tiny glass shards stuck in my foot and they hurt like a mofo with the slightest pressure, so I thought it was unlikely that a broken-off needle would hurt just "a little."

Next I examined the syringe in my hand. I noticed that there was a stretched out spring within the barrel that I didn't remember seeing there earlier. Eventually, after a great deal of quizzical staring, I finally made out the needle and its clear plastic hub nestled safely within the syringe's hollow plunger. Clearly a brilliant design from the point of needle safety. On the other hand, it was downright hazardous to my cardiac health. The time it took to convince myself that I hadn't left an inch-long metal sliver in my patient's arm was marked by asystole and an adrenaline burst the likes of which I hadn't experienced in decades.

Finally, I began breathing again. First, I exhaled. Then I broke out in a sweat. Eventually I calmed down enough to get on with my day. I used the new syringes to give out several more shots, and even though I now knew what to expect, that SNAP still got me every time. I can only hope that I get used to it.

In the meantime, though: Hey everyone, I have H1N1! Come and get it.

Miscellaneous Observations about Sweden

2009-12-14T22:28:00.003-05:00

First miscellaneous observation about Sweden: They really do have style.

Everywhere you look, the little details on buildings, furniture, and clothing all scream Scandinavian sophistication. Sitting in the hotel, whether the restaurant, the lobby or the room, feels like you're sitting in an Ikea store. The curved benches in the airport waiting areas; the clean, simple lines of -- well, of everything! There's the inescapable sense that these people know how to put things together visually.

Second miscellaneous observation about Sweden:

Although the hotel room had one large bed (queen size), it was made up with two individual twin-sized down-filled duvets, folded neatly on each side of the bed. At first, I thought it looked like they had just shoved a pair of twin beds together, though closer inspection revealed the truth. What a fabulous idea for sheer comfort it turned out to be.

See, one of the problems sharing a bed -- or more specifically, bedding -- with a larger individual is that the shared blanket doesn't drape down all the way around the smaller body (in this case, mine), allowing in drafts of chilly air. Whereas with this particular configuration of bedding, one can still share a bed yet still be wrapped comfortably against the elements. This needs to be further explored upon the return home.

Third miscellaneous observation about Sweden: People-watching is universal.

We spent a lot of time watching people. Alone in the airport the first day, I had ample opportunity to observe all kinds of travelers in assorted phases of travel. Once Darling Spouse arrived and we trekked into Stockholm, we watched people in train stations, on buses, walking the streets, and perusing museums. Both of us were struck by the variability of heights, weights, hair color, dress; everything. Until you heard people speaking the lovely, lilting, vaguely Germanic-sounding language that is Swedish, you wouldn't have been able to tell you weren't in any other city on earth. Commuters; tourists; teens; indistinguishable from those in the good ole US of A. The trains may have been cleaner, but the people were all the same. Reassuring, in a curiously humanistic way. Just helps to reinforce the old truism: Wherever you go, there you are.

Thus endeth the travelogue. We now return to (ir)regularly scheduled blogging.

One of the Biggest "Oh, Shits!" in Maritime History: The Vasa

2009-12-13T06:00:00.001-05:00

The time: 1628
The place: Stockholm shipyard
The event: the launching of the magnificent warship, the Vasa, commissioned by King Gustavus Adolphus

Majestically it begins its maiden voyage, all sails deployed, flags flying proudly! The shore is packed with spectators, including the curious, the well-wishers, and the foreign dignitaries there to pay homage to the great and mighty Vasa, the greatest and mighiest warship of the great and mighty Gustavus Adolphus.

Meanwhile, back on shore:

Whiny little assistant to the Chief Designer in charge of the Vasa: Sir, Accounting needs you to sign off on these invoices for the final material delivery for the Vasa.

Chief Designer (peering over the sheaves of paper): Hmm, let's see: that looks like the right amount of timber for the masts and decking. The bill for the sails looks right. Wait a minute; how much ballast was put in?

WLATTCD: It says so right there, sir. What's the matter?

CD: It's missing a zero.

WLATTCD: So what? A zero is nothing, isn't it?

CD: No, you idiot. It's missing a zero at the end.

WLATTCD: What does that mean?

CD: It means the ship may not have enough ballast.

WLATTCD: So? What's the worst that can happen?

CD: What's the worst that can happen? If there's not enough weight in the bottom of the hull to balance the weight of the ship, the masts, sails, rigging, provisions, the sixty-four cannon with all their ammunition, and everything else, it can tip over in the slightest wind, letting water pour in through the gunports. It could even sink!

Meanwhile, back on shore:
The ship starts to heel over, water pours in through the open gunports and:

the whole thing sinks in over 100 feet of water, all sails rigged, flags flying proudly.

Here is a depiction of the general reaction to the event*:

Fast forward to 1961, when the Swedes spend another shitload of money to raise the thing, preserve it, put it into a building shaped like a ship:

and call it the Vasamuseet.

Actually, it's pretty cool. The central hall is dominated by the actual ship, surrounded by exhibits about the disaster itself:

life aboard the ship (dominated by the military; the crew consisted of 164 sailors and 300 soldiers),

the artwork (hundreds of carvings originally painted in brilliant colors),

and the restoration (including fascinating reconstructions from the bones of some of the 30 people who died when the ship went down).

So, to recap the history of the Vasa:

Two years to build the thing
Five minutes of sailing
Submerged in over 100 feet of water for 333 years
Raised to the surface and painstakingly restored over 17 years
Enjoyed today by Dino and Darling Spouse

And that's the way it was.

* Actually, that's a reconstruction of the carving inside the gunports, visible to the outside when said gunports are open for business.

Greetings from Stockholm

2009-12-12T14:16:00.010-05:00

Today was our first day in Stockholm. That is, if you don't count yesterday, when I spent the entire day having quality time getting to know all the ins and outs of the airport from the time I arrived at 10:30 am until DS's plane arrived from Manchester at 10:10 pm (except that his flight was canceled so he had to fly through Copenhagen and didn't arrive until 1:00 am today). What can I say? It's an airport.

Today, though, was a day of fast trains, city buses, subways, sights, museums, and aching feet.

Here's the fast train:

Here's a lovely shot of downtown Stockholm across the water -- of which there is plenty, given that the city is built on several hundred tiny islands:

Here are some pictures of museums:

into which we did not go. The museum in which we spent most of the day (and took most of the pictures) will be getting its own post.

After dark, ie about 4:00 pm, we made our way to Stockholm's Old Town, a cobblestoned island called Gamla Stan. We toured the Royal Armory (or, as they call it, the Armoury) and the Christmas Market, by which time it had begun to snow. Interestingly, this did not change the status of the weather, which remained "perfect." Not much wind, and brisk without being uncomfortably cold.

In between those adventures, we wandered the city in search of the subway stop where this was filmed:

We found the right place,

but alas, the keyboard had vanished. Still, the expedition allowed us to travel by subway and wander several other interesting neighborhoods. DS commented that it could have been Philadelphia. I demurred, feeling that although one of the large boulevards we walked did bear a passing resemblance to the Ben Franklin Parkway, many of the architectural touches were so quintessentially European: the high, wide doorways; the external downspouts; the sequential numbering as we walked up the street (as opposed to odds and evens facing each other). It didn't feel American; which is to say, it was somewhat exotic.

Trudging through the snow as the flakes got bigger, we found our way back to the train and made our way home(ish):

reflecting on our wonderful day.

It's All Terry's Fault

2009-12-10T05:54:00.003-05:00

Blame Terry.

Darling Spouse had to go overseas on business about two months ago, and it was a long, difficult two weeks. I felt like all I ever did was walk (roll) the dog, take care of the cats' I/O, and work. Not much sleep (since the dog needed to be rolled twice a day), and not much in the way of cooking or eating either. Just keeping the house and office going singlehandedly. I've done it before (albeit with only a single cat and no dog), but it's so much nicer not to have to. It was a rough two weeks.

Then they told him that he had to go again! Same deal: a week in the UK and a week in Sweden, in early December this time. Bummer!

So I tell all this to my friend Terry, who lives around the corner from my office and comes in once a week for allergy shots. And Terry begins to berate me: "You have to go with him this time!"

I roll my eyes and invoke my reality. I can't go with him. I'm self-employed; no work, no eat. I have the dog, and the cats, and the house. Besides, he'll be working. What would I do all day for two weeks?

"Those are nothing but excuses! You have to go!" continues Terry.

I smile.

Then I go home, and I tell DS about seeing Terry, how Terry yelled at me, and so on. We agree that I can't get away for two whole weeks, but we begin to hem and haw a bit; see what we can work out. He sits down at the computer and researches (really cheap) flights; he realizes he can shift his hotel arrangements around a bit, and voila!

The dog is being boarded; the cats and house are being sat; coverage is arranged; later this afternoon, I am outta here. I've got my camera, and this adorable little netbook for surfing, blogging and the like. It even has a port for the card from my camera, for convenient picture posting.

I'm going to Stockholm for the weekend.

And it's all Terry's fault.

Thank you, Terry.

Best Answer Ever

2009-12-09T18:39:00.002-05:00

Facebook exchange:

Friend F (gay) requests an explanation of what the homosexual "agenda" consists of.

Response from Friend L (straight):

It starts with an appetizer of baked brie and whole wheat crackers, then a refreshing sparkling drink, then a discussion of possible Oscar-contenders and finally, the last item on the agenda is a vote to determine which restaurant will be patronized that evening. At least, that was the agenda for all of the homosexual events I've been to.

Self-Linking

2009-12-09T11:06:00.002-05:00

Many thanks to KevinMD for publishing my Guest Post on his blog the other day. Stay tuned for a somewhat snarkier take on the issue of the new USPTF breast cancer screening guidelines.

Another Idea to Limit Unnecessary Testing

2009-12-09T09:00:00.004-05:00

Defensive medicine, defined as "additional and often unnecessary tests to avoid lawsuits"(1), is widely acknowledged as one of the biggest factors in spiraling health care costs. The problem is more than just testing specifically to defend against potential litigation. At issue is what to do when patients request/demand inappropriate testing. This has been driven home to me at least three times just in the last week.

From patients with no family history of anything and perfectly normal blood tests (cholesterol panels, blood sugars) a year ago who "really want it done again" despite the USPTF recommendation of 3-5 year intervals for these screenings, to women who demand annual paps "just to make sure everything's okay in there," I find myself struggling to explain the downside of unnecessary testing. "But the insurance will pay for it," they respond. "What's the harm?" Sometimes I do it; sometimes I stand my ground; but the encounters often leave me drained and upset. How much is my inability to explain these things adequately, and how much is it the deeply ingrained American idea of "more is better," "better safe than sorry," and so on? There seems to be no way to tell.

So how about trying out this idea to reduce expenses from unnecessary testing:

Third party insurances will only pay for tests not designated as "medically indicated" by a physician if they are abnormal.

Although one might propose requiring a physician's version of a "certificate of necessity" (which we sort of already have; you can't get a test without a physician's order) whereby patients can get any test they want if they pay for it themselves, it looks really bad when that test comes back showing something unexpected. If insurance companies only pay for abnormal tests, patients have a little more skin in the game by taking on the risk of having to pay for negative tests. As most of them claim to only want the testing for "peace of mind," it stands to reason that many of them would also be willing to pay.

This is philosophically similar to the concept of "loser pays" litigation, although a more familiar and less arbitrary-seeming example would be the NFL rule for charging coaches a time-out for challenging penalties that are subsequently upheld. However you look at it, increasing the potential risk -- even only financial -- to patients demanding unnecessary testing, while not penalizing them for the occasional accidental finding, is at the very least a novel idea for controlling health care costs that I believe deserves serious consideration.

Footnote:
(1) Baker, Ninja; Malpractice Tort Reform; 1 December, 2009; policy paper for HS104a American Health Care, Professor Altman; Brandeis University; page 3 (comment from TA HKI: "good definition.")

Requesting Blood Tests: The Right Way and the Wrong Way

2009-12-02T15:43:00.002-05:00

Attention Partialists*; listen up!

Despite what you were taught in training, patients have more than just one organ. Yes, yes; I know your organ is of course the most interesting and important. Still, there is more to most patients than an eye, a heart, a pair of lungs or kidneys, or even a prostate.

Most of you have learned that there are times when findings in your organ implies that something may be wrong with one or more of the patient's other organs. Although your usual response is simply to shuffle the patient off to your buddy, the OtherOrgan specialist, there have been occasions out in the community when, your hands tied, you send them back to me instead. As a public service, I would like to take this opportunity to describe the right way to do this, as well as the wrong way.

Right way

Pick up the phone and say:

Dr. Dino, I saw this weird ditzeloma in the back of our mutual patient's eye. It can sometimes be associated with diabetes, so could you please take a look and see if that might be the case here?

Wrong way

Send me a fax on a safely prescription pad (which comes across the fax as almost completely black) saying:

Complete blood test to rule out metabolic diseases.

I'll give you a hint: "Rule out [a whole freaking class of conditions]" is not an appropriate way to format a request for either a blood test, or a consultation to evaluate for the condition about which you are concerned -- which is what this patient really needs.

Oh, and while we're at it, could you please refrain from recommending that my patient with no cardiac risk factors ought to be on a cholesterol medicine for a total cholesterol of 255, when I have already determined that her LDL is only 120, her triglycerides only 125, but her HDL is a whopping 110, and I have told her she is fine? Remember you're a surgeon; it's not like you're a doctor anymore. M'kay?

*A fabulous term from one of the AAFP ListServes referring to our colleagues who only take care of portions of patients.

The Plural of "Anecdote"

2009-11-29T11:11:00.002-05:00

Not offering an opinion of my own about the state of the economy based on the observation that the King of Prussia mall made a zoo look sedate this weekend, but comparing and contrasting some other proffered opinions from around the blogosphere:

From The Well-Timed Period:

On Broadway early this morning, all the stores on the Upper West Side--Loehmann's, Barnes&Noble, etc.--were open but the traffic was puny. The one notable exception was the new Apple store, it was packed. But, the odd thing was that half the people were store employees. There was almost a 1:1 ratio of shoppers to red shirts.

Couple the observation about store traffic with the fact that I just saw, for the first time ever, an "Apartment available" sign on both West End Ave. and CPW and my sense is that we still have a way to go with this economic recovery.

From Happy the Hospitalist:

I snapped this picture [picture of checkout line wending perhaps 30 yards from store entrance; can't really tell much from it] while waiting in the checkout line at Shopko during the greatest recession in more than 50 years. Based on the number of people waiting in this checkout alne, I'd say the recession is over.

There you have it.

(Then again, considering the sources I'd have to say the economy is still in big trouble, given that HH is reliably full of shit.)

Love

2009-11-24T18:37:00.004-05:00

Dear DenverDaughter,

Your father and I have been together now for eight and a half years. As you know, we have been trying to work our way through the accumulated detritus of the past. Thanks in part to the huge shipment we sent you, we've finally gotten rid of the garage-sized storage locker, though the last few boxes wound up in our living room. Now I'm going through them one last time, ruthlessly culling, even as I take care to preserve the important stuff.

What counts as important? Photos. Several albums have found their way into boxes that will remain on readily accessible shelves. Pictures aren't going anywhere.

I also came across the sign-in book from your grandfather's funeral in 1965. As you know, he died when your dad was 15, so neither of us ever met him. Still, as I leafed through it, I was impressed to see page after page after page of signatures of friends and relatives. Clearly, he was loved. I slipped the book alongside the one from your grandmother. It's not going anywhere.

Then I came across a small bag, silver-and-white striped, containing several things:

Six unopened, unused boxes of "Thanks for your expressions of sympathy" cards.
An unused, unburnt shiva candle
Three large manila envelopes stuffed to overflowing
A silver-and-white striped box holding another book from another funeral, this one from 2001.

As you know, it was for your mother. That book isn't going anywhere.

As for those overstuffed manila envelopes, they held all the cards and letters sent to you and your father after she died. When I saw what they were, I stopped what I was doing and went to find your father. I sat down facing him, took his hands, and asked simply, "Do you want to keep the cards from the funeral?" He sighed heavily as he considered. Finally he said, "Nine years is enough. They can go."

I pulled those stacks of cards and letters out of the envelopes and held them in my hand. There were a lot of them. They formed a stack at least six inches high:

I spread them out over the kitchen table. They covered it easily, several layers deep:

You have told me in no uncertain terms that you are not sentimental; that you have no use for stacks of old papers and cards filled with cliched platitudes. Neither does your father. Never fear: they have not been put into the mail to you. They have been duly discarded, as requested. Their purpose has been served. Hopefully, they brought you comfort at the time.

But know that each piece of paper, each bit of card stock, each tattered envelope, represents someone who loved your mother; someone who thought well enough of her to set pen to paper and stamp to envelope just to let you know that. Know that there were so many of them, they covered a kitchen table; spread out, they would easily have covered a banquet table.

Your mother was loved. By you; by your father; and by many more other people than you probably realized. The cards may have been discarded, but that love will always live on. And I now have the unfathomable good fortune to be the subsequent recipient of your father's love. Know that I will spend the rest of my days trying to be worthy of that, and to love him back with every fiber of my being. I'm not going anywhere.

If you are ever moved to doubt, just enlarge that picture of all those cards spread across the kitchen table, and know that you are loved too.

All my love, always.

Count Me In

2009-11-23T14:39:00.003-05:00

I received an email from a needlephobic friend acknowledging my generally negative stance toward ~~quackery~~ alternative medicine, but asking me to make an exception for this:

Dark Chocolate: The New Anti-Anxiety Drug?

The results of this new study are intriguing and shed more light on the biochemical basis behind dark chocolate’s health benefits.

Okay; I'll bite (pun deliciously intended). The idea that consumption of dark chocolate could have a favorable effect on high-anxiety individuals seems plausible. Theobromine and other compounds found in chocolate are structurally similar to other psychoactive compounds such as caffeine. Thus, the hypothesis isn't completely out there. However the study was very small, comprised of only 30 subjects. In the face of these promising preliminary findings, I think the only responsible response is to call for further study.

Lots of it. Study, that is. With chocolate. Dark chocolate. Very dark chocolate.

Furthermore, because of the debilitating nature of anxiety and the vital importance of following up on any possible breakthroughs in its treatment, I would even be willing to volunteer for these very important studies.

As long as there is lots of chocolate.

Prevention is in the Eye of the Beholder

2009-11-19T12:58:00.003-05:00

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

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

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

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

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

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

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

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

Remainder of physical examination was completely unremarkable.

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

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

WTF?

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

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

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

See what I'm up against?

Whose Medicine is it Anyway?

2009-11-18T18:36:00.002-05:00

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

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

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

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

Whose medicine is it anyway?

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

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

One Quick Question

2009-11-13T07:48:00.002-05:00

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

Here's why.

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

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

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

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

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

Because one quick question is seldom quick.

By Request

2009-11-10T13:46:00.002-05:00

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

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

Huh?

Excuse me??

Um, what exactly are you talking about???

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

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

Nothing about actual health care anywhere to be seen.

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

Saddest Words Ever

2009-11-08T19:50:00.003-05:00

Overheard in a hotel lobby:

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

That's it. We're doomed.

Tweaking the Tail of the Home Birth Tiger

2009-11-05T12:23:00.004-05:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now that's tragic.

Bring on the Bets

2009-11-04T07:27:00.005-05:00

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

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

Regardless of the outcome, both mayors will host public arts projects. Nutter would join Mural Arts to paint a mural on the side of a recreation center. Bloomberg would partner with Public Color to paint the interior of a school.
If the Phillies win the series, Bloomberg will travel to Philadelphia to take part in the day of service while wearing a Phillies jersey. If the Yankees win the series, Nutter will travel to New York to take part in the day of service while wearing a Yankees jersey. The mayor of the losing city will also buy the mayor of the winning city and his fellow volunteers lunch.

That's just cool.

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

PS: Breaking news from New York:

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

2009-11-03T15:30:00.003-05:00

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

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

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

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

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

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

Dumbass.

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

Dumbass.

The Emergency Department EMR from Hell

2009-11-02T15:07:00.000-05:00

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

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

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

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

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

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

"Call us."

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

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

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

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

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

Answer: "Since May."

Okay, then; at least five months.

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

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

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

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

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

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

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

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

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

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

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

EPIC WTF.

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