Take Your Own Pulse

My Health is [Someone Else's] Problem

2010-06-16T17:30:00.003-04:00

Today in clinic, my attending got really frustrated with a patient. Patient was a middle-aged person with the usual outpatient cocktail of diabetes, hypertension, and hyperlipidemia. Patient had lost their insurance around 2008 and had stopped coming to clinic then; they also self-discontinued all their medications. Now in 2010, patient wants to resume treatment, having re-established health insurance.

My attending was furious.

Why?

Because in the intervening 2-3 years this patient had made absolutely no effort to eat well, lose weight, find a physician, get cheaper medication, or do anything regarding their health. Now, patient has insurance, and the doctor is supposed to magically fix the damage done in the past years.

Now, don't get me wrong, I know all about the barriers to care. I'm for expanding access, improving access to health insurance, etc. I know it is not easy to get to the doctor, that the visits aren't cheap, that labwork isn't cheap, and that medication isn't cheap.

However, so many people take absolutely no responsibility for their own health that if they lose health insurance it's like they have no health care at all.

There are free or pro-rated county health clinics available. Sure, the lines are long, but if you navigate the system you can get seen by a doctor, get your labwork done, and get your prescriptions written. You may even qualify for free or reduced-price medication.

Many of this patient's medications could have been changed into $4 for 30 or $10 for 90 type medications. If you can afford a Big Mac or a pack of cigarettes, you can afford a month's supply of many effective medications. Certainly the main treatments for Patient's conditions--diabetes, blood pressure, and cholesterol--are available in SOME form at very cheap prices.

My attending was mad in part because she would have worked with Patient to change their medications, had they asked. They could have worked out a plan to check in by phone, to change medications to cheaper ones if needed, to get labwork done at cheaper facilities if need be, or to spread labwork out. If Patient still had not been able to afford to see my attending, again there are other clinics that may cost less.

I find it amazing that being healthy is just not a priority for many people. We want a pill to fix our couch-potato drive-thru lifestyles that allow us to eat fast food every day and still be thin, beautiful, and heart attack free.

The plan that I've used my retrospectoscope to create for Patient would have taken effort, time, phone calls, etc. Sure, doing nothing was cheaper and easier, but now Patient will pay for it. Is that 2+ year period really going to do that much damage? I don't know, but it certainly didn't help.

No matter who provides your health care plan, be it private insurance or government-funded Medicare or Medicaid, health is still YOUR job (and my job, as I am a patient too, and I don't always practice what I preach). Your insurance can't guarantee that you see a doctor, can't guarantee that you take your meds, that you quit smoking, that you eat healthy, or that you exercise. And treatment isn't free with insurance. Health insurance is something of a misnomer; we expect all of our treatment to be covered, our doctors' visits free, our meds cheap or free, our tests free, etc. My car insurance doesn't cover routine oil changes, so I find it odd that we rely on "health insurance" to provide all of our health care.

Perhaps Patient didn't know what I know. Patient may not have known about $4 medications, or about free-standing labs, or about the county clinics. Patient may not have internet at home, and may not see the commercials for cheap meds. However, Patient did not ask the person who did know--my attending.

Certainly the opposite type of patient exists; my father-in-law has much the same cocktail of problems and is unable to get health insurance accordingly. So, he shops around, gets the best deals on his tests and meds, and even knows which hospitals he would go to if the occasion arises. He decided that it was his own responsibility to stay healthy, treat his chronic conditions, and live longer.

The current generation of elderly became adults in leaner times than us. My 70 and 80 year old patients grew up with the Great Depression and WWII; they did not grow up with easy access to burgers and fries at the window of their vehicle. The younger generations I see (myself included) did grow up with cheap, quick, tasty food available at all hours. I gained weight eating this stuff; at some point I realized I was killing myself. It was a big lesson to learn, unlike the young woman I saw today, with a BMI of 38 who said "I just have a slow metabolism" (despite describing a terrible diet and no exercise with a sedentary job). I wonder often if our long lifespans will start to shrink, as the fatter, less active generations start to age.

I'm now sitting on the couch typing, waiting for the heat to dissipate a bit so I can go jog without suffering a heat stroke. I'm not good at exercising, and I struggle with my eating habits every day, but I'm trying. I keep reminding myself it's worth it. Because it is worth it, to me, to be healthy, to learn healthy habits now that I can teach my kids someday. The government isn't going to exercise for me, nor is my health insurance company going to eat salad so I don't have to. Although sometimes, I wish they would.

It Figures

2010-03-08T20:58:00.002-05:00

As a lover of forensic shows on TV, I recognized the markings on my white coat as high velocity blood spatter. Not from a gunshot, but from splashing during a central line placement. I cursed a bit when I saw it, because I just cleaned this white coat, and it's kind of a pain in the ass to pull all of the crap out of the pockets (I roll with about 6 lbs of stuff in the pockets), use the bleach pen on all of the ink marks, etc, and get it washed without bleaching the embroidery.

I did this over the weekend, taking a lot of time to bleach all the spots (I'm terrible about ink spots), and I threw the coat into the wash with a couple of towels or somesuch--I'm not even sure what, just something that needed washing.

All went well until today, when I donned my newly cleaned white coat to wear to work. Halfway through the day, I look down, and the lapel is blue. Not white, blue.

I'm too lazy to wash the coat again right now, since technically it's clean, and hey, would you rather see a doctor with a mild blue stain on her coat, or one with bloodstains? Yeah, that's what I thought.

Better Regulation of Supplements

2010-03-04T19:23:00.000-05:00

Senator John McCain has introduced a bill in the Senate that would increase the FDA's ability to regulate "dietary supplements" and hasten the FDA's ability to quickly remove dangerous products from distribution. Better bloggers than I have discussed this here (at Science-Based Medicine) and here (at Movin' Meat). The law isn't very drastic, but it seems that it would require supplement manufacturers to report all adverse events to the FDA, and it would give the FDA the ability to issue cease production orders if a product is determined to be harmful; the company has the ability to appeal, but if the appeal fails the FDA can issue a formal recall.

When I talk to patients about supplements, I advise them to be careful. I tell them, you don't necessarily know what you are getting. You may be getting exactly what you pay for, you may get extra active ingredient, or you may get no active ingredient. For example, as red yeast rice supplements are growing more popular in lowering cholesterol (and studies are backing this up), some of the supplement tablets are being laced with statin medication to make them more effective.

I support people's rights to make choices, and if they choose a supplement that's fine. I take a few myself. However, I support the right to make informed decisions. How can a decision be informed when you don't know what's in your pill? If you have a bad reaction to a prescription medication, this is reported and monitored. If you have a bad reaction to a supplement, it's your tough luck.

If this is something you support, then go read the bill (found here), and consider writing to your senator. This will have a lot of opposition from Orrin Hatch, so if this bill is going to pass then people on both sides of the aisle will have to get motivated.

I'm No Longer Dead

2010-03-03T20:59:00.002-05:00

So maybe I wasn't dead. Just being an intern.

I had three months back to back of wards, so q4 call and 4 days off per month--and I got totally worn out. Pair this with ongoing concern for my sick family member, and I was pretty exhausted. I made myself a promise in mid-November that I would eliminate all extraneous stuff from my existence until I could handle it again. I didn't clean the house, I didn't send out holiday cards, and I didn't worry about updating my blog.

Not like it matters too much, as I don't really have an audience per se...

But I missed having an outlet for my thoughts and stories. I started blogging in 2005 and kept it up until October, so it's time to get back on it now.

What was the most interesting thing that happened to me this week so far? An 85 year old man kissed me on the cheek a few days ago after a clinic visit. I went to shake his hand and he leaned over and planted a shaky kiss on me. I didn't really protest--he's 85 freaking years old. I do think it made my husband wildly jealous, though...

Wii Active Kicks My Butt

2009-10-12T21:10:00.002-04:00

The EA Active game for Wii has thus far proven to be one heck of a workout (and proves what I already knew, which was that I am in poor physical shape). The first day I tried it, I did a 'demo' workout to show me how to do the lower body exercises. By midway through the series of squats, side lunges, and alternating lunge jumps, my thighs were quivering. I didn't actually complete the full series, instead moving on to arms (where I don't usually have any difficulty, especially when only using a resistance band. Therefore, the problem is for my poor legs, which have to heft my body weight around, and this is after losing 15 lbs! But I digress).

The following day at work, my legs felt strange and heavy. I had to push myself out of chairs, as my quads seemed strangely unable.

But the next day, when I was (of course) on call, was the worst. My leg muscles were weak and painful; my quads were tender to palpation and actually hurt just walking. I adopted a weird-looking waddle that didn't require my knees to bend much while moving, and my pace was about half what it normally is (I may be short, but I walk fast). I avoided the stairs and looked like a total douchebag, being a young, healthy-looking person taking the elevator up and down when I was only traveling one floor. I thought about asking the nurse to draw a CK level and hook me up to a bag of saline, in case I was having rhabdo, but I resisted my (well-developed) inner hypochondriac and instead made fun of myself all day.

This was all fine and dandy until I got called to a code. Try climbing a flight of stairs and walking as fast as possible doing a duck waddle and going "ouch, ouch, ouch, ouch" up each stair. The nurse I followed to the code gave me some crap for letting him beat me there, but he only beat me by a few seconds. (The code was short and successful, the nurses were already doing compressions when I arrived, and basically I did nothing useful except gather labs for the real doctor who showed up--the resident.)

Fortunately, after a couple of days my legs were fine. Just in time to do another round of Wii Active.

Let's Get Controversial

2009-10-11T22:00:00.002-04:00

I am going to delve into a scary topic here--yes, the A-word, abortion. Don't worry, I moderate my comments, and I am absolutely not interested in publishing long flame wars. This is my blog, and my opinions, and you can feel free to disagree with me and even to post disagreement in my comments, but if you call me or any of my other commenters ugly names I don't have to publish your comment. End of story.

Here's what I want to talk about. Oklahoma has passed a law requiring physicians to report to the state health department certain information about all abortions performed; this information will then be posted on the health department's website. The actual text of the bill, HB 1595, is here. The law has been challenged by a lawsuit under an odd provision in the OK Constitution that a law can only cover one subject.

Here's what makes me angry about this law. People on various websites are arguing back and forth about the women's rights being violated--and this is true, this law (I believe) directly violates a woman's HIPAA rights (which are federally guaranteed and, in my understanding, may not be undermined, only further protected, by the states). It is absolutely true that if you publish 'a white woman, age 35, married, from Y County [population 3000], with 2 prior pregnancies that ended in live births' you are publishing potentially identifiable information. But what really chaps me is when you read the law itself, it seems to be more a direct attack on abortion providers than an attack on the women who seek abortion. Because, you see, it is the doctors who must submit this information to the state.

This bill was championed under the guise of preventing abortion based on the knowledge of the gender of the fetus. Indeed, the first section of the bill deals with this: "No person shall knowingly or recklessly perform or attempt to perform an abortion with knowledge that the pregnant woman is seeking the abortion solely on account of the sex of the unborn child." (all quotes are from the bill unless otherwise indicated). The bill goes on to say that "any person who knowingly or recklessly violates a provision of this section" may be subject to injunction, which may be filed by the woman who had the abortion, "any person who is the spouse, parent, sibling, or guardian of, or a current or former licensed health care provider of, the female upon whom an abortion has been performed or attempted to be performed in violation of this section, a district attorney with appropriate jurisdiction, or the Attorney General." So in other words, anyone who knows a woman who sought an abortion based on the fact that she didn't want a fetus with XX or XY chromosomes may file an injunction against the performing physician, including the woman herself (whom we would assume knew her motives when she sought the abortion). The state penalties for violation (for the physician) will be $10,000 for the first time, $50,000 for the second, and $100,000 for the third and any time beyond, and if an injunction is brought against a physician and it is violated, the physician will be charged with a felony. Note: "No fine shall be assessed against the woman upon whom an abortion is performed or attempted". Because, clearly, it's all the doctor's fault.

Section 3 provides for the "Statistical Reporting of Abortion Act". They start off by saying the department of health must create a website that details all the pertinent state laws regarding abortion (not in itself a bad thing) and must have all forms available for electronic reporting on this website. Section 5 starts to get hairy. First, the physician has 30 days to submit the "Individual Abortion Form" for every abortion performed. Note, here they state "Nothing in the Individual Abortion Form shall contain the name, address, or information specifically identifying any patient." Yet, here is [part of] the form:

Individual Abortion Form.
The Department’s Individual Abortion Form shall be substantially similar to, but need not be in the specific format of, the following form: (TO BE COMPLETED FOR EACH ABORTION PERFORMED)
1. Date of abortion _________________
2. County in which abortion performed ________________
3. Age of mother _________________
4. Marital status of mother (married, divorced, separated, widowed, or never married)
5. Race of mother ________________
6. Years of education of mother ________(specify highest year completed)
7. State or foreign country of residence of mother ________________
8. Total number of previous pregnancies of the mother _____ Live Births _____ Miscarriages _________Induced Abortions __________________
9. Approximate gestational age in weeks, as measured from the last menstrual period of the mother, of the unborn child subject to abortion [emphasis mine]__
10. Method of abortion used: ...
11. Was there an infant born alive as a result of the abortion? ____If yes: Were life-sustaining measures undertaken? ___ How long did the infant survive? _____
12. Was anesthesia administered to mother ____ If yes, what type? _______
13. Was anesthesia administered to the fetus? _______ If yes: What type? _______ How was it administered? __________________
15. Reason for abortion (check all applicable):
Mother cannot afford the child ______
Emotional health of the mother is at risk ______
Mother suffered from a medical emergency as defined in Section 1-738.1 of Title 63 of the Oklahoma Statutes ______
Mother wanted a child of a different sex ______
Abortion necessary to avert the death of the mother ______
Pregnancy was a result of forcible rape ______
Pregnancy was a result of incest ______
Other (specify) ______
Patient was asked why she is seeking an abortion, but she declined to give a reason _________________________
16. Method of payment (check one): Private insurance __ Public health plan ___ Medicaid _____ Private pay ____ Other (specify) _________
17. Type of medical health insurance coverage, if any (check one): Fee-for-service insurance company ______ Managed care company ______ Other (specify) __
18. Sum of fee(s) collected ___________
19. Specialty area of medicine of the physician ___________________
20. Was ultrasound equipment used before, during, or after the performance of this abortion? ...
...
24. Were the informed consent requirements of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes dispensed with because of a medical emergency necessitating an immediate abortion: To avert death ______ To avert substantial and irreversible impairment of a major bodily function arising from continued pregnancy _____
25. Was the probable gestational age twenty (20) weeks or more? _____
26. Was the abortion performed within the scope of employment of an state employee or an employee of an agency or political subdivision of the state? ______
27. Was the abortion performed with the use of any public institution, public facility, public equipment, or other physical asset owned, leased, or controlled by this state, its agencies, or political subdivisions? _________
28. If the answer to question 26 or 27 is yes: Was the abortion necessary to save the life of the mother? If yes, what was the life-endangering condition? ____
Did the pregnancy result from an act of forcible rape? ____
If yes, list the law enforcement authority to which the rape was reported _____________ List the date of the report ___________ Did the pregnancy result from an act of incest committed against a minor? _________ If yes, list the law enforcement authority to which the perpetrator was reported __________ List the date of the report ___________
THIS PORTION TO BE COMPLETED IN CASE OF MINOR
...
Filed this ____ day of __________, _____ by: ______________________________(Name of physician)

There is an awful lot of potentially identifiable information on this form. There are also some interesting tidbits. First, the bolded (by me) checkbox for "Mother wanted a child of a different sex." So, you're going to charge me $10,000 if I say yes? Hmmm... Second, the bolded (by me) wording of "the unborn child subject to abortion", which I think very clearly states the intent and purpose behind the people who wrote this law. Third, the almost disbelieving tone (later) when asking if the pregnancy is the result of rape, then demanding the law enforcement agency and date of the rape report, or to know the name of the life-threatening condition. Clearly, it's only rape if it gets reported to the authorities. Later on in the bill, they detail that if a physician doesn't complete this form on time, there is a $500 fine, and if the form is still not done after a year the physician's license will be suspended.

I think it is clear that the intention of the lawmakers who wrote this bill is to further hinder the performance of abortion by physicians. If they wanted to prevent abortion based on strictly the gender of the fetus, the opening few paragraphs would have sufficed (although I am still incensed by the lack of provision against another hugely responsible entity, the woman seeking the abortion based on the gender of the fetus). Also, this just occurred to me--unless you perform genetic testing, most ultrasounds to document the sex of the fetus are performed around 20 weeks, but [in my understanding, not being an expert in this subject] the majority of abortions are performed in the first trimester, when most women cannot be expected to know the sex of the fetus. As with the Partial Birth Abortion Act on the federal level, this is a law aimed at physicians designed to make it tougher to perform legal abortion.

The law does make provisions as to the reporting of certain statistical data on the website, but it is unclear in what form this data will be provided. If they post '280 abortions in YY county, 35% in unmarried women', etc, then it is hard to say that this will violate a woman's HIPAA rights. But if careful measures are not taken with this information, I could see it falling into the wrong hands easily. Also disturbing is the objective and private nature of much of the data. If I have to report a case of syphilis to the health department, I give the patient's name, age, and identifiable information (for tracking purposes); I do not have to report how many times they had unprotected sex, whether they got the disease by prostitution, or whether their partner was cheating on them and brought it home.

Abortion is currently legal in this country. I as a physician am not required to report to the state the illegal activity of my patients, including drug use, possession, or sale; assault; prostitution; weapons possession; or just about anything else they do on their time outside of my care (with a few exceptions, such as child abuse). Nor am I required to report on the immoral activity of my patients. Why, then, as a physician, should I be required to hand over such sensitive information on a legal activity? What does the state hope to accomplish by monitoring and tracking such data (which at least is more clear when tracking a condition like syphilis)? Why such punitive measures for physicians performing a legal procedure? What kind of idiot doctor would actually report to the state that the woman wanted a fetus of a different gender, knowing the fine is $10,000? [god forbid you make an error filling out the form!] Again, after reading the wording of this bill, I think it is less about violating the HIPAA rights of women and more about providing MORE hoops to jump through to provide a legal procedure.

Caveat: I am pro-choice, but not pro-abortion. I am not a fan. I think a huge number of abortions could be prevented by simply not having sex or using birth control, and I favor increasing education in BOTH arenas (and not the farce of abstinence-only education as it is currently implemented in this country). However, for the cases when this is not true, even though they may be rare, I consider it none of my business to confirm whether the rape was reported to the proper authorities. These are my views on a very touchy subject on which everyone has an opinion that is exquisitely personal; I do not mean to step on the toes of either the pro-abortion or the anti-abortion crowd, but simply to point out the misleading language of a law that does not really do what it portends to do (and sadly, passed 93 to 4 and was sponsored by a man running for lieutenant governor of the OK state). I think one should not fight an activity one considers immoral by going to immoral measures; to me, this kind of deception is immoral.

I Didn't Drink the Worm

2009-10-01T20:33:00.000-04:00

In our hospital, the isolation rooms have antechambers, rather like airlocks, that have sinks with gloves, masks, gowns, and other personal protective equipment that one may don prior to entering the isolated room. The other day, I left the room of a patient with severe immunodeficiency and stepped into the airlock to wash my hands. I lathered up and was on my second round of "Happy birthday to me, happy birthday to me"* when I noticed that there was standing water in the bottom of the sink, and that something was moving in the water. A small, thin, black, 1 cm long something that was clearly swimming.

OH MY GOD WTF IS THIS ARE YOU FREAKING KIDDING ME?????

I mean, I calmly eyeballed the thing, rinsed off my hands, and went to find a witness. The nurse looked at me like I was totally nuts (and to be honest, I was post-call, and was probably looking and acting a little nuts), but she came to see and was like "Oh my God! That is disgusting!"

I used a tongue depressor to gently move him out of the water and put him into a specimen cup, sealed the lid TIGHT and put it in a biohazard bag, then walked the thing down to the path lab. I may have brandished it in front of me, hoping someone would look in and go "EW!", or I may not, depending on which version of the story you heard. The lab tech was singularly unimpressed but promised they'd get back to me.

I got a call today from the lab: likely moth larva, not likely human parasite, but has been sent to the CDC for further testing. Apparently this is not uncommon, though I had no idea.

And still I think,

EW OH MY GOD IT WAS IN THE SINK IN THE HOSPITAL!

I only thought the cockroach in the ceiling light in the call room was bad...

Egregious Lies

2009-09-30T19:59:00.002-04:00

Sorry for the delay in posting. Sick family member, busy intern, blah blah blah.

I wanted to make sure this link got attention: CTV News

The part that I'm focused on is toward the end.

Shona Holmes appears Friday at a Republican event on Capitol Hill.
Holmes, a 45-year-old mediator from Waterdown, Ont., has become a poster child for conservative opponents of health-care reform in the U.S. for her claims she would have died if she'd stayed in Canada for treatment of a brain tumour.

"If I had relied on my government for health care, I'd be dead," Holmes said in a television commercial for the anti-reform group Patients United Now.

In fact, Holmes didn't have a cancerous brain tumour, but a benign cyst that threatened her vision.

Nonetheless, she travelled to the Mayo Clinic in Scottsdale, Arizona, and spent US$97,000 for treatment rather than wait 36 days for insurance-paid care in Canada. She's now pushing for the Ontario Health Insurance Plan to reimburse her for the money she spent on surgery, tests and follow-up.

The organizers of the Capitol Hill event say she will be among several patients who will "share stories of overcoming life-threatening illnesses and explain their concerns about the president's plans for health-care reform."

This really upsets me.

Here's a woman who could have had a legitimate claim against socialized care--I was losing my vision and they wanted me to wait. However, she had to go and exaggerate on TV--"I'd be dead"--which made it onto all the television commercials. The reason this makes me mad is because people have used her example as reasons not to pursue health care reform. I'm not pushing for a Canadian-style system, necessarily, and certainly they have their problems. But it makes me angry that legitimate claims are overblown to sway vulnerable people who don't know better who then get the message "If you change our healthcare system then you'll be dead!"

Here's her Mayo Clinic "Success Story" where they talk about the benign tumor that was indeed threatening her vision (and I'd have had sympathy if she'd left the story at that). And here is her statement to factcheck.org as well as her testimony to the US House of Representatives Energy and Commerce Committee. Again, it sounds like her situation was concerning, but I do not think she was in a life-threatening condition (and adrenal crisis is certainly treatable, especially if the doctors know you are adrenally insufficient and give you steroids, so I don't buy that; also, how can you have Cushing's disease, which is an overproduction of cortisol by the adrenals, and adrenal insufficiency at the same time?). Certainly, in her testimony, she raises good points about the Canadian system, points which go along with why I don't support a single-payer system. However, as she is currently suing the Canadian government for her health care costs (when she is the one who went outside the free care), I think her motives are suspect. Clearly, she (and many people) wants the free care of Canada with the luxury and speed of American private care--in other words to have her cake and eat it too.

I realize that no side of this argument is free of propaganda and attempting to sway opinion through sob stories and exaggeration. This one happens to be a TV commercial I've seen in my own living room, so I felt I should comment. Junk like this is why I hear perfectly well-educated people say things like "you people just want to make us like Canada, where they wait months for treatment and die". Well, maybe not so well-educated, or they'd look this up themselves.

Ignorance is Difficult to Treat

2009-08-31T16:21:00.000-04:00

These two articles point out that the American public and the medical establishment do not see eye to eye at ALL on health care. Kent Bottles' article refers to this Kaiser Family Foundation article comparing polls of "experts" and "the public" regarding health care costs.

I realize it's a tough sell to ask someone NOT to undergo screening for cancer. The very word "cancer" strikes such fear into our hearts that people rush out to get tested. It is a tough sell to say to people that they may be in a low risk group, and that even if they test positive the cancer may not kill them, etc. A gentleman patient I treated a while back had asked for (and received) a total radical prostatectomy for localized, lower-grade prostate cancer, thus leaving him with erectile dysfunction and urinary incontinence for the rest of his life. His risk of dying of this cancer was low, but his fear was such that he traded his ability to hold his bladder for the rest of his life.

Another patient I treated as an outpatient came to me after a lengthy hospitalization. This person has moderately severe dementia (able to know their name and sometimes where they are, unable to dress themselves, bathe themselves, or otherwise care for themselves). This person came to my clinic after receiving a screening test for colon cancer--screening because this patient was asymptomatic--that was positive. Patient had a small cancer removed by the colonoscope but was referred to the oncologist "just in case". Onc recommended simply observing by scope, but somehow the patient was already referred to surgery. Surgery inexplicably (to me) performed a colectomy on this patient, who now has a colostomy and spent a long time (months) in rehabilitation. This patient's life expectancy was already likely less than 3 years, given the advanced dementia. This patient was also asymptomatic from a small cancerous polyp, which would not likely have started causing any problems for several years. Now, the patient is cancer-free, but also has a colostomy bag that requires extra care. We did not improve this patient's quality of life or extend their life by this procedure; in fact, you could argue that we decreased the qualify of life by adding the colostomy and depriving the patient of time spent outside the hospital. The patient did not likely ever understand the diagnosis, and was unlikely the one pushing for radical treatment... *sigh*

I don't mean to say that patients with dementia, or any other condition, or simply elderly patients, should be discriminated against. If this patient had been symptomatic, fine, do what you need to do. Life-saving treatment should be offered unless there is a valid DNR order or it is refused. But screening should be used judiciously for those who may actually benefit from it--the otherwise healthy and asymptomatic who are likely to survive for some length of time into the future AND who are likely to have increased survival odds should a small cancer or disease be found early. The diseases where this is the case are few and far between. There is a reason we don't routinely screen 20 year old women for breast cancer--the odds are extremely small (though non-zero) that any one of these women will have cancer; we are not doing the population as a whole any favors by overscreening this group. For that matter, health care dollars are limited. If we spend all of our money screening every single citizen for every single disease we can think of, we will have no money left for treatment or prevention (perhaps an over-dramatization, but you get my point). Screening should get the biggest bang for the buck.

Let's put this article on the front page of the NYT: "Overscreening Causes Hairy Palms, Anxiety, Insomnia, Heart Disease, and Hemorrhoids". Perhaps the public, and we as citizens of this country with such a large amount of debt, should be taught to be more afraid of over-using screening tests, and less afraid of the bad cells hiding in our bodies whether we find them with screening or not.

"Common Sense"

2009-08-30T16:17:00.004-04:00

In case you haven't read it, this is a very funny piece by Uwe Reinhardt about a "common sense" approach to health care reform.

God Bless ICU Nurses

2009-08-18T20:35:00.000-04:00

A person near and dear to me was recently hospitalized and in intensive care. I can say that I personally saw so many things that are RIGHT in our system with regards to this person's care that I guess I can partially understand why some people don't want to make any changes. In particular, I want to sing some praise for the ICU nurses I met. They were all kind, patient, answered all our questions, and took excellent care of our loved one. They all had critical thinking skills and thought quickly on their feet. As awful as the whole experience was, the nursing staff was a shining point, and I will make sure I write to the hospital to say so. The doctors were all fantastic, too, and explained things to all of us, even teaching me a little after I said I was an intern. However, I see what people mean when they say the nurses are their main contact and that they are grateful more to the nurses than the doctors.

So, ICU nurses at XXX Hospital, thank you.

An Excellent Comment

2009-08-17T20:29:00.002-04:00

To whomever "TB" is (I hope he/she doesn't have tuberculosis!), I am going to post your comment here, because I thought it was great:

If someone thinks that our healthcare system isn't... If someone thinks that our healthcare system isn't flawed, than they are either selfish, ignorant, or blind. I have heard enough from O about that. For the last year whenever he talks about healthcare he talks about how it needs his "change". I'd like a lot more open discussion about what he is trying to push through and a lot less about what is wrong. How are his "changes" going to fix the problems we have today?If he is creating a government plan that doesn't reject based on pre-existing conditions, a few more people who can't get private insurance (like myself) who don't have a job that provides insurance (unlike myself) than some more people will be covered.But what about the 20-something who thinks they don't need it. What about the unemployed who can't afford it. Who pays for them when they get in a wreck or cut off their fingers trying to unclog the lawnmower? I hear a lot of talk about the number of millions of uninsured, but how many are uninsured by choice?Healthcare is expensive for a lot of reasons. There is medicolegal risk, there is defensive medicine to prevent that risk, there is abuse of self-referral, there are large back-end operating costs, and there is a large cohort of non-payers. If any hospital approached your suggestion of collect 50% of what they bill then they would be collecting more than double what most hospitals do.How about we fix the abuse of litigation (which is going to be hard considering most senators and congressman are lawyers). How about we fix back end costs of pharmaceuticals, medical grade equipment, and billing departments. How about we fix the waste of defensive medicine. How about we fix medicare/medicaid abuse in self-referral of unnecessary procedures.Once those are done and the cost of providing healthcare is reduced, it might be an easier feat to then fix the problem of who actually pays for whose care.

Very well said, ma'am/sir. It's entirely true that the costs in our system are driven up by a wide variety of different things--the number and variety of costs is astonishing. Truly doing "health care reform" is going to be so incredibly complicated that I'm not sure it can happen all at once. It's also entirely true that some people are uninsured by choice--they're banking on being young and healthy (usually) but when something unexpected DOES happen the cost of their care is often covered by everyone else, not them.

And to TB, I can sympathize with you; I am also a person who has private health insurance through an employer, but I would not qualify for health insurance (or only at very high rates) due to a couple of pre-existing conditions that don't bother me on a daily basis but that have disqualified me from disability insurance.

So forgive me for posting your comment like this, but I liked it, and I did not want to take credit for it. Thanks!

Just in Case You Were Wondering, Part II

2009-08-14T22:08:00.000-04:00

Lest you think I only pick on my patients...

The other day, I went to clinic, and I was sitting in my clinic room waiting for my patients to show up. The door was open, and I was alone, and I'd eaten a burrito... Let's just say it was a good thing no one walked in on me unexpectedly.

And yes, the patient I referred to earlier was ill, but you know what? Farts are funny. Baby farts are funny, old people farts are funny, my farts are funny, my dog's farts are funny. I didn't laugh at the patient and I didn't embarrass them by saying anything, but the fart itself was still funny to me. Yes, I am about four years old, and feeling slightly bad about my previous post.

But if you don't think farts are funny, don't watch this.

Propaganda

2009-08-13T21:39:00.000-04:00

We saw this commercial (on the home page) the other night, and immediately started asking what was this group that made it. According to Source Watch, this "60 Plus Association" is largely funded by the pharmaceutical industry and has campaigned in the past in health care matters. They advertise themselves as "the conservative alternative to the [AARP]"; their membership form includes this statement: "Contributions to the 60 Plus Association are not tax deductible for income tax purposes.", indicating that they do not have non-profit status, despite the ".org" in the website title.

Like any political propaganda ad for any topic on any side of the debate, this ad is deliberately misleading. Playing off the "death panel" fears, they state clearly that "the government, not doctors will decide if older patients are worth the cost". This has been debunked multiple times (he's a bit partisan here, but he's correct).

If the ad had been from AARP, I'd have sighed and gone on with my life. If Pfizer had directly sponsored the commercial, it wouldn't be so bad, either. The fact that it was made by a PhRMA front group is what hacks me off. It's the subterfuge that gets me. It's like commercial Continuing Medical Education being sponsored by shell corporations directly funded by pharmaceutical companies who still get creative control over the content being taught.

Of course, I also think that this emphasis on the end-of-life counseling clause turns the whole health care reform bill into a debate worthy of abortion debate in this country. It's already become so emotionally fraught that we can no longer have intelligent debate about this reform bill, because people start hollering about Down's syndrome babies being euthanized. Way to go, 60 Plus Association, for continuing in a grand style what Buckeye Surgeon calls "an all too frequent quintessentially American archetype; the uninformed, strident, unwavering voice of righteous protest." When I read that, I giggled out loud. And then gave a huge sigh.

Death Panels

2009-08-12T21:02:00.002-04:00

I'd like to find the actual wording of the health reform bill that describes the "death panels" and tattoo it on my forehead, or be in on the secret meeting where Obama and Pelosi discuss the final solution to get rid of anyone over the age of 65 or without perfect health.

Oh wait...

I'm reiterating what many have said before, but people, come on. It's totally awesome to have a rational debate about healthcare reform, and to hold opposing viewpoints, and to disagree with a public option, or to worry about rationing of care. What is not awesome is reading a debunked chain email with all the veracity of a Nigerian bank fraud and then screaming that you'd better not let the government mess with Grandma's Medicare!

I did like this post at Movin' Meat: the message is that if you don't think health care is rationed, that's because it hasn't happened to you yet.

I understand if utilitarianism isn't your thing. It's a way of approaching the situation, but it isn't necessarily the best way. It is, however, useful to approach the situation by acknowledging that healthcare resources are finite. Even if there were an abundance of livers available, not every American could get a liver transplant if they needed one today, because the cost is astronomical. The surgery takes hours, the pre-op testing takes weeks, the post-op recovery takes weeks, and then you go on immunosuppressive meds for years. So, then, how to decide who gets a liver? Right now, we do it in several ways, often based on money. If you're a VA patient, you have to meet their service connection criteria, or no liver for you. You'd better have insurance or cash if you are a civilian. If you're a patient in a large county system without Medicare or Medicaid, and you're unable to cough up the dough, then you don't get the liver. Today, this is considered fair--by those who have insurance or cash, who don't like to think about the person without. Or they say, this person is likely unemployed and therefore doesn't deserve a liver. Isn't that a form of utilitarianism, though, to judge a person's worth to society by saying they're uninsured, therefore they're unemployed and a burden to society and don't deserve treatment?

Ahem. Sorry for the soapboxing. What I'm getting at, though, is utilitarian principles may help to distribute limited resources among the population. In our country, we don't act like health care is a limited resource. That is a big part of our problem. If you go to a fancy private hospital for treatment because you have good insurance or good money, it's easy to ignore the plight of the patient in the huge county system, waiting 7 hours to be seen in clinic or >24 hours to be seen in the ER. I am lumped in this category, so I'm including myself in my criticism.

The way I see it, though, our whole health care system is a giant pyramid scheme. There are real fixed costs in health care (although these are buried under a morass of billing schemes created by insurance, Medicare, clinics, doctors, and hospitals) that require payment. If you crash your car and you are uninsured, who pays your hospital bills? If you cannot pay, the hospital eats the cost of your care. The doctors who saw you, if they bill by procedure or hour of consultation, do not get paid for that care; in essence they are paying for it.

Those who have insurance are counting on paying less in premiums than they will rack up in costs should they get seriously ill. This is how all insurance works. The insurance companies are counting on you not getting ill, but if you do they might just cut you off as a "pre-existing condition" or raise your premium so high you cannot afford it.

Medicare refuses to pay for certain things that should be covered, like known complications of being sick (under guise of the "never event" policy). Medicare, Medicaid, and private insurance ALL play billing games, denying claims for a misplaced comma in the hopes the hospital or clinic won't refile the bill, so they won't have to pay the claim; this in turn leaves the cost on the hospital or clinic, who then attempt to make the patient pay, which may or may not happen.

Everyone is trying to get someone else to pay. It's a mad scramble, as we use more and more health care but seemingly have fewer people actually paying for it. What ends up happening is the burden of paying for people who cannot pay ends up spread over the paying patients (increased fees for Tylenol in the hospital, increased insurance premiums), insurers (who aren't currently hurting, because they can raise their rates), hospitals (who often collect less than 50% of what they bill), doctors, and ultimately the government. As our health care costs spiral out of control, and consume more of our GDP, money that could have gone to other things is sucked into health care.

One reason I support universal coverage (not single payer, or truly socialized care) is that it spreads the burden over more people, hopefully more equally than we do now. The young, healthy person who forgoes health insurance may not cost the system anything initially, but if they become seriously injured or very sick we all end up paying for them anyway. The key is that they didn't put anything in to pay for themselves or anyone else. The system will take care of them anyway, but they had no skin in the game; they bet on the system providing for them even though they paid it nothing.

Of course, if we don't drive down the costs in health care, all of this discussion may be moot, but I'm tired now, so that will be another post...

Rationing: A Four-Letter Word

2009-08-03T21:32:00.002-04:00

A great article by Uwe Reinhardt on what it means when the word "rationing" is used in health care. We who have insurance fail to recognize the "rationing" instituted by the health insurance company when they deny our claims, force us to pay co-pays, tier our prescriptions, etc, but we get awfully upset when the government suggests that it will not pay for certain tests, procedures, or medications that have not been shown to be effective. If you want an unproven test or procedure, and you can pay for it or get your insurance to pay for it, and you can find a doctor to give it to you, fine. But why should the government pay for your unnecessary back MRI any more than your private insurance pay for your elective breast enlargement?

What we will essentially move towards is a multi-tiered health system, where there is a basic level of care at the government/public plan level and tiers above paid for by private insurance or, ultimately, cash. Some people think this is wrong, but some of those people forget (or choose to ignore) the fact that our system now is not exactly a level playing field. We already have multi-tiered care in this country, we just prefer not to think of it that way. If my insurance covers the back MRI, or a screening coronary calcium scan (despite the fact that routine coronary screening is not indicated), then I will demand it and insist that if I don't get it I'm being rationed. Many of the people I hear using the "R" word in vain have good, comfortable insurance (and many have the cash to cover if their insurance didn't provide them what they wanted), so even if the evil of government rationing came to pass they would be largely unaffected.

While I think there are worthy arguments against cost comparisons, and I'm all for constructive debates on these subjects, I am not personally opposed to rational rationing of care. We cannot continue to have our cake and eat it too: have the most expensive healthcare for ME while denying it to YOU because your small business employer does not pay for insurance and you cannot afford a private plan. I get all the back MRI's I want while you cannot afford blood pressure medication.

Besides, something good that could come out of doing effectiveness research would be finding out when too much care is not actually a good thing. Getting doctors and patients to buy into this idea will take a lot of convincing, but if the evidence is good I think it can happen.

ACLS

2009-08-02T22:10:00.004-04:00

Just spending one of my nights on vacation going over the ACLS material so I can try to recertify this week. It's terribly exciting, this life of the resident physician--I can see why they make so many TV shows about it!

Death is Not the Worst Thing

2009-07-27T22:31:00.002-04:00

Death is final. It is scary. There's no turning back. It may be painful, but then again, only the living can feel pain.

It is also going to happen to all of us. With 100% certainty, I can say that I will die someday. You will die someday. All of my patients will die someday, some sooner rather than later.

I quit looking at medical treatment as "saving lives" a long time ago, if I ever did. We postpone death, that is all. Hopefully, when we delay the reaper, we buy the patient a little time that is good. If we're really lucky, we buy them a lot of good time--hence the reason people still go into pediatrics, even though the pay sucks (for a medical specialty).

And if the time left is not good, have we done the patient any favors by keeping them alive?

This is a tough question to answer. Utilitarians attempt to answer this by using "QALY"s and working out long, complicated formulas. Ultimately, I think only the patient can answer this. I might look at the way a patient lives and think "I would never want to be alive in those circumstances", but I don't necessarily know if the patient agrees.

However.

If a patient has made an advanced directive that states they would not want to be artificially kept alive, and has never made a statement to the contrary, and has multi-organ failure with multiple serious infections resistant to most major antibiotics, and is kept alive on a ventilator, and is in constant pain, then death is not the greater evil. This shell of a person is not your loved one any more. The constant sepsis and hypotension have destroyed the brain parenchyma wherein lived the intellect that made them who they were. If there is such a thing as a soul, where is it now? If you believe in an afterlife, is the soul stuck clinging to this wretched body, unable to go to a better place? Or, is the soul already departed, meaning that the body is just a body?

For a country in which a majority of people believe in Heaven or an afterlife, we are also utterly terrified of death. If it's such a lovely place, why are we as a culture so afraid? Medical science can sometimes keep a body "alive" for great lengths of time, but what kind of life is it spent in the ICU? If there is no mind left, no soul, then why are we prolonging this kind of suffering?

And, to be utterly callous, why are we paying for it?

In the ICU setting, one of the functions of the doctor in training should be how to greet death with a patient. How to discuss the end of life with patients and families, how to properly address risks, how to explain the limits of our care and the limitations of our science. I am not talking about euthanasia here--I don't really know how I feel about that, but it's not an issue where I live. I am talking about when to withdraw treatments and when to never initiate them in the first place. Just because we CAN dialyze the 95 year old with advanced dementia (not oriented to self) and multi-organ failure doesn't mean it is indicated. And if the patient has an advanced directive and has never made clear statements to contradict it, we should obey their wishes no matter how many lawsuits their relatives threaten--and we should be protected from lawsuits in these cases.

At some point, actively prolonging a terrible life should not be our goal, and we should be taught that we don't always have to prolong life. After all, prolonging life is not saving it.

Just in Case You Were Wondering

2009-07-25T20:51:00.000-04:00

Most doctors do, indeed, have senses of smell. Mine happens to be particularly sensitive. So if you just laid a massive fart in your hospital room 30 seconds before I walk in to examine you, yes, I will notice. I may also later make a blog post about the eye-watering smell I encountered, and how I was noticeably breathing through my mouth during the first 10 minutes of the H&P. I will, however, refrain from commenting on what may have died in your room, or inquiring what you may have eaten, or singing any of my favorite bits of the "Diarrhea" song. You're welcome.

Health Care Courts

2009-07-23T22:20:00.001-04:00

This is absolutely brilliant, in my opinion. If we completely revise the way malpractice suits are handled, it changes the whole equation. Malpractice suits don't properly compensate victims (but they do compensate their lawyers, who have their own bills to pay), and drive up health care costs both directly (cost of claims and malpractice insurance) and indirectly (defensive medicine, etc). If we had a way to make the system more fair to doctors (who can have their livelihood taken away even when following best available guidelines) and to patients (many of whom do not ever file for compensation, even when they have truly been harmed), then we all win.

Are health courts the only answer? No, of course not, but perhaps they are an answer that works, which is what matters.

Public Service Announcement #1

2009-07-23T20:50:00.000-04:00

It does not matter how lovely your Power Point presentation is, how well-written your morning report is, how intelligent your points are or how many references you pulled in...if you are chewing gum while delivering the talk. I do not remember what you presented the other day, or what fabulous teaching points you made, but I definitely remember you smacking your gum around. I kept wondering if you had braces, or a speech impediment, because I just thought there was no way a person who graduated from high school, college, and medical school and is currently a physician in training would be dumb enough to chew gum during a public presentation. I was obviously wrong.

Elective vs Urgent vs Emergent

2009-07-22T21:48:00.000-04:00

Just a quick thought, inspired by these propaganda ads I've been seeing tonight. The ad I'm referring to bashes Canadian health care and threatens that "Washington" wants to enact Canadian-style health care in the US.

I'll get further into all of this at another time. My current beef is this: a lot of what Americans find appalling about Canadian or UK health care is the idea of rationing or waiting for procedures. When you look at the procedures that, on average, people are waiting months for, they are elective, non-emergent procedures. I'm not saying that these systems are perfect, or that problems don't happen--there have been a few well-publicized cases of people with cancer diagnoses waiting months to start treatment in Canada--but overall, people with cancer or other life-threatening diagnoses usually receive timely treatment.

What they're waiting for are things like knee replacements. While knee arthritis is certainly painful, it is usually not life-threatening. I'm not arguing that it's not a quality of life issue--I like to be able to walk--but when we're talking about an elective issue, if you want it faster you should have to pay for it yourself, and if you're unable to pay for it yourself and need the government to do it for you, then you may need to wait.

I think our inability to tell life-threatening from urgent from non-urgent is something that is helping to drive up our healthcare costs in this country (amongst the 99 billion other things doing so). People going to the emergency room with "I had asthma symptoms yesterday but not today", whether they are insured or not, are helping drive up our costs. People who demand their elective procedures NOW--and can pay for them--are helping drive our healthcare system towards specialists and proceduralists, as graduating medical students can attest.

Perhaps it should be like 911. If you call 911 and it's not an actual emergency, and you abuse the system repeatedly, you can be fined or even arrested in most places. I think regardless of whether you have insurance, Medicaid, or nothing, if you abuse the emergency room you should pay a fine. Or, maybe the answer is to charge a fee to come into the ER at all. After all, with my insurance, I have a copay to use the ER (and it's not little). So, I have to decide how emergent things really are. Now, this copay is waived if I get admitted to the hospital from the ER--one way of potentially gauging the severity of my complaint. There are some things that may need treatment in an ER that may not require an admission--broken bones that can be set, abscesses that can be drained, lacerations that can be sutured, etc--but would be totally worth the copay, in my opinion.

Anyway, there are a lot of problems with the ad and it's premise, but I wanted to go off on a tangent. Because I can.

Never Event

2009-07-21T20:47:00.000-04:00

I once treated a patient who experienced a deep venous thrombosis while in the hospital. This unfortunate person was being treated for acute MI, on heparin drip until they went to the cath lab, so heparin was held that morning prior to cath. That night and the next day, the patient was at risk for bleeding after the cath, so heparin was held, and started at a low dose for DVT prophylaxis that night (just over 24 hours post-cath). Patient received 2 doses of subcutaneous heparin, and on the second morning after the cath began to complain of leg pain and swelling. Ultrasound revealed a DVT. The other kicker? This patient has a below-the-knee amputation of one leg, and the DVT developed on that same side. I'm not sure what the evidence is for using sequential compression devices in patients with only one leg (and terrible peripheral vascular disease) but we had elected not to do so.

Other than the SCD (which we considered, and rejected), there really wasn't anything else we could have done differently. We were stuck between the risk of bleeding (the cath was done from a "high stick" to go above a femoral stent and therefore was at higher risk of bleeding, at least according to my attending) and the risk of DVT. Patient did not bleed, but did have a DVT. If this patient were a Medicare patient, none of the treatment (which includes IV heparin drip with nursing protocols, extended hospitalization, starting warfarin treatment, etc) would be paid for under the "never event" policy. But is this a never event? This patient had terrible peripheral vascular disease, HTN, diabetes, and history of previous DVT--their risk was extremely high to begin with. The patient did not receive anticoagulation for less than 48 hours, but was still taking aspirin and Plavix during this time, which (one would hope) provided at least some small amount of protection against platelet aggregation and clot formation. If we had treated the patient more aggressively with anticoagulation, would they have bled out onto the cath table or developed a large hematoma at the cath site? Would Medicare cover these complications of the anticoagulation?

I think the never event policy is really stupid. Amputating the wrong leg? Fine, don't pay for that, I completely understand. But a hospital acquired UTI? Pneumonia? DVT? Pressure ulcer? Show me the clinical guidelines that tell me how to prevent 100% of these known risks and I'll buy the never event thing. But until we know how to prevent 100% of these complications, they cannot be considered "never" events.

Oh, and I am a resident, paid a salary; my attending is on salary; we do not get paid extra for causing complications in our patients (which was one reason behind the "never event" policy).

Law Number 3

2009-07-20T20:45:00.000-04:00

Law #3 of The House of God: "At a cardiac arrest, the first procedure is to take your own pulse."

This comes in particularly handy in many stressful situations, not just during codes. I tend to get particularly overwhelmed and flustered when my pager goes off again while I'm answering the first page that I got while talking to a patient or family and I still haven't written any of my notes and there's a new admission to see and I haven't peed all day and I promised my husband I'd cook dinner but it's already 4 pm and it will take me an hour to get home once I'm finally done and and and...

So here it is, July, and I'm a brand new intern on call. Except I'm not really a brand new intern, because I've already been doing this for a while. I'm a detoured intern, intern v2.0, sidetracking through a first residency until I realized I was stuck in the wrong place doing the wrong thing, now playing a little catchup for 6 months. Thank god, this gets rid of the worst part of being an intern: the sheer panic of the whole thing. My first night on call was one or two years and two days ago and I dropped my pager into someone's coffee cup (that was very un-JHACO-like, btw, to leave a cup of coffee in the nurse's station in the ER, ahem!). I still get just as flustered, and I know very little of what I'm only considered to be 6 months behind in (namely, all of adult general internal medicine), but I'm not really afraid of it at this point.

But at some point, I could still use a reminder to take my own pulse.

About

2009-07-20T10:38:00.000-04:00

About me: switching residencies so I'm currently a repeat intern. Or am I? As far as teh interwebz are concerned, I don't actually exist. This site is purely fictional (or if I've drawn from something in my experience, I've modified any patient information, drawn from several patient scenarios that are mashed together, and generally modified any HIPAA-type information). Do not use anything on this website for your own health care--go see your doctor.