June 13th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Some bloggers’ clinical vignettes speak volumes about why doctors are exasperated with their day-to-day work lives. Here are a few good ones:
From White Coat Rants:
A patient from a nursing home was transferred by ambulance to our ED with the following chief complaint:
Mental status changes not responsive to albuterol [an asthma puffer].
Of course now we’re stuck trying to figure out how much this patient’s mental status has actually changed. I never could figure out how in the heck nursing homes can determine that an essentially non-verbal patient is having a mental status change. She sat in the bed, watched me walk around the room and smiled. So was she blinking less, or what?
I was waiting patiently on the next ambulance run for a patient with nasal congestion unresponsive to Ex-Lax.
From Ten out of Ten‘s Medical Jeopardy:
Answer: Massive Diarrhea
Question: What is the end result of eating nothing but beans and peaches all day?
People are so weird.
From Musings of a Dinosaur’s Anything Else?:
The perils of the open-ended question in a new patient interview:
Me: Tell me about your health.
Patient: I have hypertension and a little arthritis in my knees.
M: Anything else?
P: No, that’s all.
M: What medications do you take?
[presenting bag full of bottles, we find:]
Cozaar
Hydrodiuril
Lipitor
Zoloft
Ativan
Ultram
Celebrex
M: Why do you take the Zoloft and Ativan?
P: Oh, the Zoloft is for anxiety and the Ativan helps me sleep.
M: Anything else?
P: No, that’s all.
M: What about this Lipitor?
P: Oh, I stopped that about three years ago. It’s just for people who eat a lot of fat in their diet. I don’t think I need it.
M: Ok. When did you last have blood work done?
P: About four years ago.
M: And when did you last see a doctor?
P: About four years ago.
M: Any other medical problems?
P: No, that’s all.
M: Are you allergic to any medicines?
P: I get a rash with penicillin, and oh yeah! I have this weird rash that comes and goes. I’ve seen all the specialists downtown and no one knows what it is.
M: Anything else?
P: No, that’s all.
M: Anything run in the family?
P: My brother had a heart attack when he was 42, and oh yeah! I have a 30% blockage.
M: When did you find this out?
P: About four years ago.
M: Anything else?
P: No, that’s all.
M: Do you need any of these meds refilled?
P: Just the Celebrex.
M: Most of these other bottles also say “no refill” on them.
P: Oh, I have more at home. I just dumped them out and brought the bottles.
M: How much more do you have at home?
P: About two weeks.
M: How about if I write refills for all of them.
P: Ok.
M: Anything else?
P: No, that’s all.
M: Can I do some blood work on you today?
P: Sure. Oh, and I see a cardiologist, rheumatologist and orthopedist too. Can you send copies to them?
M: No problem.
Anything else?
P: No, that’s all.
M: Are you sure?
P: Yes.
Do you know why dinosaurs have no hair? It’s because I pulled it all out this morning.
We really do need a common, interoperable medical record system.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 12th, 2008 by Dr. Val Jones in Opinion
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I’ve written about raw milk before, but here again we find it making front page news. There has been a recent FDA raw milk crack down in California, and I believe that’s a good thing for public health reasons. Although raw milk enthusiasts ascribe mystical powers to the product (some say its natural microbial flora can cure everything from asthma to autism), I don’t see anything mystical about the pathogens that can grow in room temperature milk: e. coli, salmonella, listeria and even tuberculosis. If you like the taste of raw milk and don’t mind the risks associated with imbibing warm body fluids of manure-encrusted bovines… then go right ahead. But please, don’t put your children at risk.
The New York Times exposed the raw milk counter-culture phenomenon last year. Grocery store milk has been heated and packaged in a nearly sterile fashion so that no harmful bacteria are in it. Farmers collect raw milk from cows, then send it to a processing plant where it’s pasteurized (a heat treatment) and homogenized (blending the creamy part with the skim part) it before packaging the milk for human consumption. This process has virtually eliminated milk borne illness in this country, but now certain farmers are threatening to reverse that progress.
So why are people fascinated with raw milk and seeking out farmers who will sell them milk prior to heat treatment? Raw milk does taste very good, and there’s no doubt that the creamy layer that floats on the top is delicious. In New York City raw milk has a black market, cult following. Should you jump on the bandwagon?
As my regular readers know, I grew up on an organic dairy farm, and had the pleasure of handling cows up close and personal for at least a decade. In fact, their sweet-smelling grass breath, and not so sweet-smelling cow patties are etched permanently in my mind. Cows are curious, somewhat dim witted, and generally oblivious to the terrain upon which they tread.
Cows will stand in manure for hours without a moment’s regret, should you present them with fresh hay to eat or some nice shortfeed. They drop patties on the ground, in their troughs, and occasionally on one other. Their flicking tails often get caked with manure as they swish flies away and they scratch their udders with dirty hooves as well.
This is why when it comes time to milk them, farmers need to wipe their udders carefully with a disinfectant scrub before applying the milk machine. Mastitis (or infection of the udder teets) is not uncommon, and is a reason for ceasing to milk a cow until the infection has cleared.
And so, the cleanliness of raw milk depends upon whether or not the farmer removes all the excrement carefully, scrubs the teets well, and remembers not to milk the cows with mastitits. It also matters whether or not the cows are harboring certain strains of bacteria – which often don’t harm the cow, but cause very serious problems for humans.
Did I drink raw milk as a kid? Occasionally, yes. Were my parents super-careful about the cleanliness of the milk? Yes. Did I ever get sick from raw milk? No. Would I give raw milk to my kids? No.
I appreciate that epicures want to experience the flavor of raw foods, but for me, the risks are simply not worth it when it comes to milk. There is no appreciable nutritional benefit to drinking raw milk (in fact, store bought milk is fortified with Vitamin D, which is critical for healthy bones), and it caries a small risk of serious infection. I agree with the FDA’s ban on interstate sales of unpasteurized milk, and would not want to see raw milk available widely for general consumption. Of course, to get around this ban, some companies are selling raw milk and cheese under the label “pet food.”
It’s a crazy country we live in – anti-bacterial hand wipes, soaps, gels, plastics and an insatiable appetite for raw milk. As a doctor, I throw up my hands. Is raw milk getting a raw deal? Some farmers may feel that way – but this former farmer is pleased to have access to safe, clean milk. What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 12th, 2008 by Dr. Val Jones in News
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TRUE: New York City adults have more genital herpes than the national average (26% versus 19%). One commenter replied, “Well, that’s what you get from ‘Sex in the City.'”
FALSE: A practical joke sparks Internet health myth: cell phones can cook an egg or pop popcorn. People really will believe anything.
FALSE: Some folks in India swallow live fish to stimulate coughing and to “clean the esophagus” and cure asthma. Must be an interesting feeling to have a live fish swimming around one’s stomach! Of course this doesn’t work. h/t to Happy Hospitalist
TRUE: More and more Muslim women are having their hymens restored so that they will appear to be virgins on their wedding night. I wonder about those women who are born with small or nearly absent hymens? Will they be punished? And what about the men who made the women non-virgins? This NYT story is quite upsetting.
TRUE: The media misrepresents health information 2/3 of the time. Fewer and fewer people are willing to take the time to get a story straight. When perception is nine-tenths of reality, science and truth are in jeopardy.
TRUE: Marijuana smokers enjoy lax laws in Mendocino County, California. It’s legal to keep up to 2 pounds of marijuana and 25 live plants in one’s home. How much marijuana does one really need for medical purposes?
FALSE: Gummy bears do not have internal organs. However, this artist has a wonderful imagination.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 11th, 2008 by Dr. Val Jones in Health Policy
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Tom Daschle, former Senate Majority Leader from South Dakota, was the keynote speaker at the Fighting Chronic Disease: The Missing Link in Health Reform conference here in Washington, DC. His analysis of the healthcare crisis is this:
US Healthcare has three major problems: 1) Cost containment. We spend $8000/capita – 40% more than the next most expensive country in the world (Switzerland). Last year businesses spent more on healthcare than they made in profits. General motors spends more on healthcare than they do on steel.
2) Quality control. The US system cannot integrate and create the kind of efficiencies necessary. The WHO has listed us as 35 in overall health outcomes. Some people ask, “If we have a quality problem, why do kings and queens come to the US for their healthcare?” They come to the best places like the Mayo Clinic, the Cleveland Clinic, or Johns Hopkins. They don’t go to rural South Dakota. We have islands of excellence in a sea of mediocrity.
3) Access. People are unable to get insurance if they have a pre-existing condition. 47 million people don’t have health insurance. We have a primary care shortage, and hospitals turning away patients because they’re full.
His solutions are these:
- Universal coverage. If we don’t have universal coverage we can’t possibly deal with the universal problems that we have in our country.
- Cost shifting is not cost savings. By excluding people from the system we’re driving costs up for taxpayers – about $1500/person/year.
- We must recognize the importance of continuity of care and the need for a medical home. Chronic care management can only occur if we coordinate the care from the beginning, and not delegating the responsibility of care to the Medicare system when the patient reaches the age of 65.
- We must focus on wellness and prevention. Every dollar spent on water fluoridation saves 38 dollars in dental costs. Providing mammograms every two years to all women ages 50-69 costs only $9000 for every life year saved.
- Lack of transparency is a devastating aspect of our healthcare system. We can’t fix a system that we don’t understand.
- Best practices – we need to adopt them.
- We need electronic medical records. We’re in 21st century operating rooms with 19th century administrative rooms. We use too much paper – we should be digital.
- We have to pool resources to bring down costs.
- We need to enforce the Stark laws and make sure that proprietary medicine is kept in check.
- We rely too much on doctors and not enough on nurse practitioners, pharmacists, and physician assistants. They could be used to address the primary care shortage that we have today.
- We have to change our infrastructure. Congress isn’t capable of dealing with the complexity of the decision-making in healthcare. We need a decision-making authority, a federal health board, that has the political autonomy and expertise and statutory ability to make the tough decisions on healthcare on a regular basis. Having this infrastructure in place would allow us the opportunity to integrate public and private mechanisms within our healthcare system in a far more efficient way.
What do I think of this? First of all, I agree with much of what Tom said (especially points 2-7) and I respect his opinions. However, I was also very interested in Nancy Johnson’s retort (she is a recently retired republican congresswoman from Connecticut).
Nancy essentially said that any attempt at universal coverage will fail if we don’t address the infrastructure problem first. So while she agrees in principle with Tom Daschle’s aspirations and ideals, she believes that if we don’t have a streamlined IT infrastructure for our healthcare system in place FIRST, there’s not much benefit in having universal coverage.
As I’ve always said, “equal access to nothing is nothing.”
I also think of it this way: imagine you own a theme park like Disney World and you have thousands of people clamoring at the gates to enter the park. One option is to remove the gates (e.g. universal coverage) to solve consumer demand. Another option is to design the park for maximal crowd flow, to figure out how to stagger entry to various rides, and to provide multiple options for people while they’re waiting – and then invite people to enter in an orderly fashion.
Obviously, this is not a perfect analogy – but my opinion is that until we streamline healthcare (primarily through IT solutions), we’ll continue to be victims of painful inefficiencies that waste everyone’s time. It’s as if our theme park has no gates, no maps, no redirection of crowd flow, no velvet-roped queues, and the people who get on the rides first are not the ones who’ve been waiting the longest, but the “VIPs” with good insurance or cash in the bank. It’s chaotic and unfair.
Quite frankly, I think we could learn a lot from Disney World – and I hope and pray that next year’s healthcare solution is not simply “remove the gates.”
What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 11th, 2008 by Dr. Val Jones in Humor, Uncategorized
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Tom Daschle’s opening comment at the Partnership to Fight Chronic Disease conference:
One time I was introduced as a model politician, model South Dakotan, and a model husband. My wife looked up the definition of “model” in the dictionary and it read, “A small replica of the real thing.” I don’t aspire to be a model anymore.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
