June 11th, 2009 by DrRob in Better Health Network, True Stories
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I have to get some things off of my chest. A guilty conscience is something that can cause lots of problems, both emotional and physical. As David said in Psalm 32:
For when I kept silent, my bones wasted away
through my groaning all day long.
For day and night your hand was heavy upon me;
my strength was dried upas by the heat of summer.
Sounds like David lived in Georgia.
So here are my confessions:
I stole a bagel yesterday. I went to Pannera Bread Company yesterday and ordered a blueberry bagel (toasted and sliced). I have a cup that allows me to get free coffee, so when the woman at the counter was slicing and toasting I went got myself some dark roast. I chatted there with a woman about the fact that light roast actually has more caffeine than dark roast. As I went to the counter I saw someone I recognized, said “hi,” grabbed my bag and headed out the door. It was half-way to work when I realized I was now a criminal.
This morning I went back and tried to pay for yesterday’s bagel but she wouldn’t let me. I think she wanted me to live with my shame. I put the appropriate change into a can collecting money for a kids cancer camp.
I watch American Idol. Yes, I watched most every episode this year. Those who think I am all counter-culture can express their shock and disgust. I enjoy hearing them perform – they were especially talented this year – and we watch as a family. You must remember that I started college as a voice major, so I do like to hear good singing.
I was kind of pulling for Adam (his last name is almost the same as mine), but I thought Chris and Danny were worthy as well.
Sorry to those who now think less of me.
Our office allows drug reps to visit and give samples. We even have them give us lunch. I know there are some who think that this is the hight of immorality, but I have found them to be quite valuable. We have done our best to keep a limit on their access to us – they are not allowed to detail us in the hallway, only when they bring us lunch. Only 1 rep at a time and no more than 6/day (never more than one from one company).
We have a person on staff who is dedicated to getting patients medications when they can’t afford them. She will work with the reps to find a program for them and will give samples when possible.
Why do we do lunch? One main reason: for our staff. I actually skip it often because I get fat if I eat too much at lunch. Their finances are tight and so supplying them with lunch saves them money. The docs will generally tell the flat truth to the reps (”I dont prescribe your drug very much”). I do find that they have brought me good information at times.
Our practice has always been a lower utilizer of brand drugs when we have been measured (mainly United Healthcare), so I don’t think this has had an undue effect on us. Still, the conscience nags when others feel that pharma is the spawn of satan.
I have checked my blog in a patient room. During the more acute compulsive blogging phases, I have checked traffic during a lul in the exam room. I do actually feel guilty about this and have stopped doing it. I have NEVER twittered in the exam room, however.
There. I hope my bones don’t waste away now.
*This blog post was originally published at Musings of a Distractible Mind*
June 1st, 2009 by DrRob in Better Health Network
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Dear patient:
I am sorry you are so frustrated with me. I’m frustrated too.
People used to look on me as a good thing, but now everyone makes me out to be public enemy #1. It’s not my fault. I was made to give you what you need: medical care; but then they kept changing me and making things harder. One side doesn’t seem to know what the other is doing. Changes are made without realizing the consequences. Now instead of giving care, I just make it harder. Now instead of making people get better, I actually harm some people.
It makes me sick to think about it.
I don’t want that to happen to you. I don’t want you to get lost in the paperwork, rules, authorizations, and red tape that seem to define me these days. So instead of being lost in the system, take my advice to live by as you go through me. I mean that literally: these rules may just be the difference between living and dying, so listen closely.
1. Find a home base.
There has to be someone you can go to for trustworty advice. The rest of care is confusing, and you probably won’t know who to trust. Some people will lie to you and others will just confuse you. You need a translator. You need a mooring in the turbulent waters. You need somewhere you can go to orient yourself and know which way is up.
That person may be your PCP – that is the best-case scenario – but it may be someone else. Find someone who doesn’t intimidate you who can answer any question you have. Ask them lots of questions.
2. Don’t fragment your care.
Some people think that healthcare is like going to the supermarket. The shelves may be in different places and the prices may vary some, but the basic stuff they sell is the same anywhere you go. This is a dangerous way to get care. The more places you go, the less each place will know about you. Doctors who are seeing you for the first time can’t do as good of a job as those who know you well. Plus, the more places you go, the better chance that you will get bad care. Not all doctors are created equal.
So if something isn’t an emergency, don’t go to the ER. What constitutes an emergency? Not a baby crying during the night. Yeah, it may be more convenient to go to the ER or urgent care center (as you don’t miss as much work) but you may pay a big price for it. If you can wait to see your doctor, do it. If you can’t get in to see your doctor when you are sick, then maybe you should find another.
3. You are your own keeper.
One of the biggest mistakes people make is to assume someone is watching out for them. They get tests done and assume no news is good news. They go to specialists and assume their PCP knows about it. They spend weeks in the hospital and have all of their medications changed, and think that this information is passed on. It may be, but often it is not. The only one who knows about all of your care is you. The only one who can reliably watch out for you is you.
I know you like your doctor and think she is on top of everything. Unfortunately, good people are stuck in a horrible system. A ton of care is done blindly – without any inkling of what is going on at other locations. You must make sure these parties communicate. You must make sure news gets back to your PCP.
Does this suck? Yeah, it does. Big time. Why should you have to be the record keeper? Why should you be the watch-dog? It’s my fault. I give no reason at all for doctors to communicate, but instead discourage them from doing so. Everyone is working hard to do the job in front of them, and once you are gone from the hospital, specialist, or ER, they have no motivation to communicate. In fact, doing so loses them money.
Some are great at communicating, but many are not. Don’t gamble with your life in this area. Make sure that communication happens.
4. Don’t BS
If you can’t afford a drug, don’t act like you are going to take it. If you are scared about a brain tumor, don’t assume the doctor knows your fear. For some reason, some people feel the need to do PR work when seeing the doctor. They want to look smart and strong even when they are confused and weak. This is pure stupidity.
Tell the truth. Say what you are feeling. Express your fears, and ask as many questions as you need to ask. This also holds true if the patient is your elderly parent or your child. If you wonder about the advice you are getting, get a second opinion.
5. Famous people can be idiots
Oprah is fun to watch and she is a genuinely smart lady, but she isn’t a healthcare expert. I can’t be so gracious with other celebrities. Famous people like attention, and so they will usually get it any way they can. Many of them think that their soap-box makes them smart. None of them are likely to show ignorance – they are good at faking it.
The fact is, they are probably famous only because they are good looking. You don’t see many ugly famous people. This is a bad way to seek medical advice. Would you choose a surgeon based on their sex-appeal? Would you trust the life of your child to someone who got famous because they looked good naked? Don’t be a fool. Trust people who are trustworthy; not people who look good in front of a camera.
6. Don’t overdo it
I can only do so much for you. Everyone dies and most people suffer in life. Some people have bought into the American mindset that says all pain should be avoided. This is a bunch of crap. Don’t medicate every struggle or seek solution for all suffering. Some people seem surprised that life has these things in it. Don’t be; it’s normal.
I don’t say this because I like to see people suffering. I say it because people are putting unfair expectations on me. I can’t beat death. I can’t do the “happily ever after” thing, and I only have so much money. Plus, sometimes people hurt themselves by seeking too much treatment. There are docs out there who will give antibiotics for every runny nose and others who dispense narcotics like candy. Don’t go there. The price you pay is far more than monetary.
That’s just scratching the surface. There is so much more I could say, but the politicians are beating at my door and I have to go. Just remember that nobody else lives in your body. You are the bottom line when it comes to your care. Yeah, I may make it tough sometimes (sorry about that), but that should only make you fight harder to make sure you get the care you need. You can get good care, but it doesn’t happen if you are passive.
I am about to get a big make-over soon, so the walls of my maze will change. Chances are, however, the advice I just gave will still apply no matter what I end up looking like.
Stay strong,
Healthcare
*This blog post was originally published at Musings of a Distractible Mind*
May 27th, 2009 by DrRob in Better Health Network
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“That doesn’t make any sense.”
The patient sits across the exam room and looks at me with a combination of surprise and hurt. He had answered all of my questions to the best of his abilities, hoping that I would figure out what was causing the symptoms and fix his problem. A bit of doubt shows on his brow as he goes over what he feels and what happened in the past. Did he say things wrong? Did he mistake the way it felt? Is he just bad at explaining things?
“I am not accusing you of being untruthful. Your symptoms are your symptoms, and you felt what you felt. Unfortunately they don’t always read the medical textbooks and so make me earn my keep. I believe your symptoms are real; I just don’t understand how they fit together. It’s confusing.” I say this as reassuringly as possible. He relaxes visibly as I speak.
But that doesn’t change the fact that the symptoms defy logic. It’s my job to figure things out and fix things, right? Isn’t this an admission of defeat? Isn’t it a confession of my inadequacy? Won’t this undermine the thing that I have said is the cornerstone of a doctor/patient relationship: trust?
Some people seem impatient for an answer, but most are OK with me not knowing for a while. The thing that makes it acceptable for me to be confused is the longstanding nature of the relationship of a patient with their PCP. This is one page in the book, not the whole story. This concept – of the patient’s “story” – is one I actually use in this situation. I say:
You know when you see a movie that is really confusing in the start? You don’t know who is who, or why one person was mad at the other, etc. It is just hard to figure out what is going on. But later on in the movie things become clear. You say “Oh, so that’s who that guy was! That’s why she was so mad at him.” It all clears up over time. With your illness, we may just be at that confusion part of the movie. It may just take time for us to be able to make sense of what is going on.
I have to say that I actually am glad for those cases where things are confusing at the start. No, I am not happy for the patients, but the hard stuff is what separates the good docs from the bad ones. If I can sort through things and come up with an answer when one wasn’t apparent, I am showing the merit of all of my hard work. I justify my salary. I go home feeling like I am more than just a bunch of algorythms.
I don’t want everyone to be confusing, but just because things seem to not add up it doesn’t mean we won’t come to a good answer eventually.
*This blog post was originally published at Musings of a Distractible Mind*
May 17th, 2009 by DrRob in Better Health Network
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Before you get too “conspiracy theory” on me, let me assure you that I am not going to talk about how the influenza virus pandemic is the work of terrorists (unless the Napoleon and Snowball are trying to take over our farm). I am also not suggesting that children are terrorists (although some do raise my suspicion).
The virus that brought such worry and even panic seems now to be “fizzling out” and people are now questioning if the authorities and the press overreacted to the threat. Will this be a replay of the “boy who cried wolf” and have us complacent when a real threat comes? One writer questioned if the flu “overreaction” was “more costly than the virus itself.“ Another article cites an Australian professor (of what, the article did not say) who stated that “the country would be better off declaring a pandemic of some of the real health problems it has, like diabetes and obesity.”
The real din, however is in the countless letters to the editor and calls to radio talk-show hosts mocking the “alarmism” put forth by the WHO and others about this flu. This does appear to be in the minority, as one poll said that 83% of Americans were satisfied with the management of the outbreak by public authorities. Still, I suspect the volume of the dissent and sniping at the non-serious nature of the pandemic so far will only increase over time. The number of people who know better than public health officials will multiply.
This pandemic is a catch-22 for public health officials, as an excellent article on the subject states:
The irony is that the overreaction backlash will be more severe the more successful the public health measures are. If, for example, the virus peters out this spring because transmission was interrupted long enough for environmental conditions (whatever they are) to tip the balance against viral spread, CDC and local health officials will be accused of over reacting.
Which brings me to the connection to terrorism. If public authorities somehow thought there was a 10% chance that New York City would be hit with another major terrorist attack, how big should their reaction be? If they suspected that there was a reasonable probability, say 5%, that the subways would be flooded with sarin gas, should they shut them down? I would certainly hope they wouldn’t leave that many people open to the chance of death.
And what is the best outcome? The best outcome is that this is an overreaction. The best outcome is that the terrorists, in fact, have reformed and are instead joining the Professional Bowling tour. I would welcome this outcome (not to mention the exciting infusion of young talent to the tour). The problem is, the officials have no idea how it will play itself out. Truth be told, since 9/11, there have not been any major terrorist attacks in the US. Does this mean that the money spent on the department of homeland security has been wasted?
As a pediatrician, I am very accustomed to overreaction. If you bring in your 20 day-old child to my office with a fever of 102, I will do the following:
- Admit them immediately to the hospital
- Draw blood tests looking for serious infection
- Check a urinalysis to make sure there isn’t an infection (using a catheter to get the sample)
- Start IV antibiotics as soon as possible
- Perform a spinal tap to rule out meningitis.
This seems a little over-the-top, doesn’t it? The child just has a fever! The problem is that children this age with a fever caused by a virus look identical to those who have meningitis. By the time their appearance differentiates, it is too late. This forces me to do the full work-up on every infant with fever and treat each one as if they have meningitis or some other serious infection. I do this despite the fact that the cases of meningitis are far outnumbered by that of less serious problems.
If this is your child, don’t you want me to do that?
Knowing what we know about pandemics, the same caution was, in my opinion, absolutely the right thing to do. If the virus turns out to be nothing serious, hallelujah. I don’t want my patients (or family members) dying at the rate that some of the previous H1N1 viruses caused. I want this to be a lot of worry for “nothing.” Please let it be so.
But I still don’t think it is time to relax. As one commenter on an earlier post I wrote about this pandemic stated:
It’s still a bit early to relax. The 1918 flu went around first in the spring and was very mild – kinda like this. Then it came back in the fall after incubating and mutating and was a killer.
I think the CDC and WHO probably will be concerned about this until next year, at least. Just to be on the safe side.
Remember that that flu, which was mild in the spring, went on to kill 20-100 million people.
For this reason, I hope the voices of reason win out over the armchair quarterbacks that don’t have to make these decisions that could mean the life or death of millions. Will you tell me that evacuating the NY subways wouldn’t be a good thing on the threat of Sarin gas? Would you criticize me for “overreacting” if your infant with a fever turned out to just have an upper respiratory infection? I hope not.
If you would, then that gives us ample reason to ignore your opinions on how this flu was handled.
*This blog post was originally published at Musings of a Distractible Mind*
May 14th, 2009 by DrRob in Better Health Network
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I met a urologist from another city recently. Since it had been a much discussed issue recently, I asked him what he thought about PSA testing. His answer was immediate.
“I think PSA testing has been proven to save lives, and I have no doubt it should be done routinely.”
When I mentioned the recent recommendation that prostate cancer screening be stopped after a man reaches 70, his faced turned red. “That report is clearly an attempt by the liberal media to set the stage for rationing of healthcare. It was a flawed study and should not be taken as the final say on the matter.” He went on to recount cases of otherwise healthy 80 year-old men who developed high-grade prostate cancer, suffered, and died.
I chose not to debate him on the subject, but did point out that his view was that of one who sees the worst of the worst. I personally can recall less than ten patients who died of prostate cancer in the fifteen years I have practiced. My view is one that sees a non-diseased general public, and not worst-case scenarios. I also didn’t point out that even the American Cancer Society stopped pushing the test and states, and does not think as highly of the evidence as he does: “Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives.” (1).
But I digress. What really struck me in the discussion was the way he pulled out the idea of rationing as the end-all hell for American healthcare. It is regularly used as a scare tactic for those who advocate a “free market approach” to healthcare. They point to the UK and Canada where people are denied cancer treatment or delayed repair of a ruptured disc resulting in permanent paralysis. Rationing healthcare seems a universal evil, and any step that is made toward controlling cost is felt by some to be a push of the agenda of the Obama administration toward universal health coverage and ultimately rationing.
So what exactly is so bad about rationing? The word itself refers to an individual being given a set amount of a limited resource, above which none will be available. In healthcare, the idea is that each American is given only a set amount of coverage for care and above that they are left to fend for themselves. Those who are either go over their limit or are felt to have a less legitimate claim on a scarce resource will be denied it. This is especially scary for those who are the high-utilizers (the uninsurable that I have discussed previously), as they will use up their ration cards much faster than others. I certainly understand this fear.
But are all limitations put on care really a step toward rationing? Are limits put on care a bad thing? The answer to that is simple: DUH! Of course not! Of course there need to be limits on care! Without control over what is paid for, the system will fall apart. Here’s why:
- Limited Resources – Not only are our resources limited, they need shrinking. The overall cost of our system is very high and has to be controlled somehow. Different interests are competing for resources, and by definition whoever doesn’t win, doesn’t get paid. This means that someone needs to prioritize what is a necessity and what is not.
- Lack of personal culpability by patients – with both privately and publicly funded insurance, the actual cost to the patient is defrayed. They are not harmed by unnecessary spending, so they don’t try to control it. Only uninsured patients are painfully aware of the cost of unnecessry tests.
- Lack of personal culpability by doctors – If I order an unnecessary test or expensive drug, I am not harmed by the waste. For example, it is common practice by emergency physicians in our area to get a chest x-ray on children with fever. Most of this is related to defensive medicine which is understandable in the ER, but clinically the test is often not warranted. Yet the emergency physicians are not really affected by this waste, and the hospital and radiologists are actually rewarded by it if the insurance company pays for it (which they do).
- Incentives for other parties – As I just said, hospitals and radiologists have incentives to have wasteful procedures done. The urologist I spoke to has a huge financial stake in the continuation of PSA testing, as it generates enormous business for him. Drug companies want us to order their more expensive drugs than the generic alternatives. This doesn’t mean any of them are wrong, but they sure as heck won’t fight waste if it harms them financially to do so.
When I was a physician starting out, the insurance companies would pay for pretty much any drug I prescribed. At that time there were very expensive branded anti-inflamatory drugs that were aggressively pushed by the drug companies. When the first drug formulary came around, the first thing that happened was that they forced me to use generic drugs of this type. Before, there was no reason not to prescribe a brand, I had samples, and they were a tiny bit more convenient. But when I changed there was really no negative effect on my patients.
One of our local hospitals just built a huge new cardiac center. Statistically, our area is a very high-consumer of coronary artery stents compared to the national average. Yet there are many cases in which an asymptomatic person will get a stent placed simply because they have abnormalities on their cardiac catheterization. Logically this may make sense, but the data do not suggest that these people are helped at all. Do you think that the hospital wants these procedures halted? Do you think the cardiologists do? Yet if they are truly unnecessary, shouldn’t they be stopped? Couldn’t the $200 million they spent on their state-of-the-art facility be used in better ways? Someone has to be looking at this and making sure the money spent is not wasted.
Without cost control a business will fail, and the same goes for our system. Yet any suggestion at the elimination of clinically questionable procedures is met with cries of rationing. Right now we are not at the point of rationing, and the act of trying to control cost by eliminating unnecessary procedures does not necessarily imply that the end goal is rationing. The end goal is to spend money on necessary procedures instead of waste. I sincerely doubt there is a left-wing conspiracy to push us to deny care where it is needed. I doubt that the American Cancer Society is in favor of rationing.
Let’s just spend our money wisely. It’s just common sense; not an evil plot.
*This blog post was originally published at Musings of a Distractible Mind*
