December 25th, 2008 by Dr. Val Jones in Announcements, Humor
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I’m visiting my husband’s family in Rochester, New York. If you don’t see any new blog posts in the next few days, you can assume that I’m actively digging my way out of their home to get back to DC.
Please check out this winter video to get a feel for life in snowy Rochester. It’s hilarious.
For more Christmas cheer, check out The Christmas Miracle story.
I wish you all a merry Christmas… and happy holidays!
See you on the flip side! (Don’t forget to sign up for my healthcare reform party on the 30th).
December 24th, 2008 by Dr. Val Jones in True Stories
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By Alan Dappen, MD
Twas days before Christmas and all through the house
The doctor was pacing, not telling his spouse.
“It can’t be my heart for it’s healthy and strong;
I exercise, eat right and do nothing wrong.
I’m hurting, I’m worried, have lingering doubt
I guess that I really should check this thing out.”
I did and the doc said, “Sadly it’s true,
That nobody’s perfect and that includes you…”
So starts my tale about life’s infinite ironies. This past week, I, “the doctor,” became “the patient.” My story is classic, mundane, full of denial, of physician and male hubris that it merits telling again. Like Christmas tales, there are stories that are told over and over again hoping that lessons will be learned, knowing they might not. I was lucky. I was granted a pass from catastrophe and this favor was handed to me by my medical colleagues and all who supported me.
My story began six months ago while playing doubles tennis with friends. Suddenly I felt the classic symptoms of chest pain. “This is ‘textbook’ heart pain,” I thought. “A squeezing/pressure sensation dead center in the chest.” Running for shots made the pain worse and stalling between points helped. My friends soon noticed a change in my behavior.
To my chagrin, they refused to keep playing. Instead, they wanted to call for help. Indignant, I informed them that the chest pain was caused by my binge-eating potato chips before the match – a fact only a doctor could know. The sweating was clearly from playing. I was younger and healthier than anyone there. The pain subsided while we relaxed and joked about “the silly doctor who thinks he doesn’t need help.”
In the next week, the discomfort returned often when I exercised, which I regularly do, including jogging, biking, swimming, and weekly ice hockey and tennis matches. Every activity provoked the pain. “Stupid acid reflux!” I thought, contemplating giving up my favorite vice –coffee. Keeping the secret from my wife was easy; she was traveling for business.
Over the next several days I started aspirin, checked my blood pressure (BP) regularly, drew my cholesterol, rechecked my weight. All were normal. Finally I plugged myself into an electrocardiogram (EKG), with the “nonspecific changes” results not reassuring me. I went to a colleague for a stress echocardiogram, and passed. “See!” I congratulated myself. “It was just reflux.”
For five months, all went well, with no memorable pain. But on December 10 “the reflux” came back. On the sly, I restarted aspirin, pulled out the home BP monitor again, and considered cholesterol-lowering drugs “just in case.”
Saturday night into early Sunday morning I played ice hockey. This time the pain was worse. With my team short on substitutes, I played the entire game. I dropped into bed exhausted and pain free at 2 a.m., only to be nagged throughout the night with persistent discomfort. I nearly slept through a morning meeting with a medical colleague at Starbucks. To avoid increasing my “reflux” pain, I passed on coffee.
By noon, a feeling of overwhelming inadequacy enveloped me. I withdrew, and my wife, Sara, asked what was wrong. I had to confess to her – and myself – of the reality of the pain in my chest. Sara coaxed my answers from me with non-judgmental techniques learned from years of experience.
“What advice would you give a patient calling you with these symptoms?” she asked.
“If it was anyone else, I’d send them to the ER,” I responded, wanting to stall longer. “I want to check my EKG at the office.”
Once there, she helped me with the wires, hooked up the machine. She turned the screen toward me with the interpretation to read: “anterior myocardial infarction, age undetermined, ST- T wave changes lateral leads suggestive of ischemia.”
“Stupid machine,” I thought, “there must be something wrong with it.” I insisted Sara redo the EKG. The second reading was the same. I leaned my head into my hand, not willing to believe what I saw. “Sara, let’s do it one more time…please.”
She asked, “What would you tell your patient to do?”
“Call 911.” I said quietly. The words hung there. At last I handed her the keys, saying, “Drive me to the ER.”
So went the gradual erosion of my denial, emerging into a new reckoning. After a catheterization, the cardiologist used a stent to open my 95% blocked coronary artery. Despite all I did to ruin my chances, modern medicine delivered me a “healthy” heart. This holiday season I got a second chance.
Eating healthy, exercising regularly, sleeping well, being happy, praying regularly, even being a doctor does not save us from the inevitable… sooner or later we are all patients. Healthcare is a critical social asset that must be done right, must be affordable, must offer as many of us in America a second, even a third chance. May we all be thoughtful and willing to compromise to achieve this end. Amen.
December 22nd, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Here’s my weekly round up of quotable quotes from my peers:
NHS Blog Doctor: Antibiotics do not cure snot. [Please go to the site for a fabulous illustrative photo.]
KevinMD: Since work-hours were restricted in 2003, there are no studies that have shown any marked improvements in patient safety or outcomes. Worse, errors have arisen from the so-called “patient hand-off,” the period of communication where rested doctors replaces those who are fatigued. Does increasing the frequency of patient hand-offs outweigh the benefit of better rested doctors?
Richard Reece, MD: The moral for doctors: Don’t expect as much leverage as in the past when negotiating with hospitals, even though you represent their main revenue stream.
Paul Levy: The medical community in Boston likes to boast about the medical care here, but we don’t do a very good job holding ourselves accountable.
Dr. Wes: Thanks to exorbitant costs of implementing EMRs in physician practices, the Medicare requirements for billing and prescribing electronically, and the prohibitive documentation requirements mandated by CMS in the name of “quality,” independent physician practices of all types will have no choice but capitulate to larger entities that have a fully integrated electronic medical record paired with collection software.
Heart found in a car wash (h/t Dr. Wes)
Ramona Bates, MD: I don’t think I would ever want to be part of doing a posthumous face lift or blepharoplasty or other cosmetic procedure, but I would be willing to debulk tumors if it would help families or individuals say “goodbye” more easily.
WhiteCoat Rants: For $79 you can blow into your iPod and it will play you a song if your blood alcohol is more than 0.08. You know this device wasn’t made for parents.
Just what we need. A bunch of drunk teenagers farting around with their iPods and getting into a “who can get the highest blood alcohol” contest.
The Happy Hospitalist: It frightens me to hear people say they want to work in medicine and work in a similar capacity as physicians, evaluating, diagnosing and managing disease, but not want to put in the time and sacrifice to be residency trained in depth and scope…
Science-Based Medicine: Our soldiers, grievously wounded in combat, deserve only the best science-based therapy available… If I were to propose treating our injured soldiers with bloodletting and toxic metals (both common methods in the 1700s and early 1800s) based on the concept that it would put the “imbalance of the four humors” back into balance, the Pentagon and the military medical establishment would toss me out on my ear as a dangerous quack–and rightly so. But introduce a method that claims “ancient Chinese wisdom” based on somehow magically redirecting the flow of a mysterious “life energy” by sticking small needles into parts of the body that correspond to no known anatomic structures through which “qi” flows, and suddenly the Air Force is funding a program to train medics and physicians treating our wounded soldiers how to do this method based on the same amount of convincing scientific evidence that qi exists as for the four humors (none) and in the face of no strong clinical evidence that it’s any better than a placebo.
Rural Doctoring: Hospitalists, take note: this is an example of why people go ape-sh*t crazy in the hospital:
• Her right arm is completely immobilized to protect the graft site.
• Her left arm has a heplocked IV in it.
• Half her head is shaved because the surgeon took the donor skin from the scalp.
• She’s vegetarian and the cafeteria sent her chicken for lunch.
• Dinner was vegetarian but she can’t really cut up a baked potato with only one hand.
• The hospital has double rooms and is running at capacity, so the staff is harried.
• Her roommate is an elderly, demented woman who keeps trying to get out of bed by herself and objects to the TV being on. So far, all she’s said to us is “Mind your own business!”
December 20th, 2008 by Dr. Val Jones in Announcements
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Tom Daschle and Barack Obama’s transition team have asked that Americans – interested in the subject of healthcare reform – lead community meetings to create a list of ideas for the new administration. So my husband took the invitation to heart and has decided to lead a group in our home right here in DC. Please respond if you’d like to join us. Here’s a copy of the email he’s been sending to friends:
###
Has our health care system failed you personally? Is it broken? I don’t want to hear about it….
….come join me for a Health Care Community Discussion (http://video.yahoo.com/watch/4122939/11107417) about what’s right with the U.S. Health Care System.
Be prepared to discuss one experience in which your interaction with the health care system was positive.
The goal will be to gather those observations and submit them to the Obama-Biden Transition Health Policy Team to be applied as best practices across the entire industry. Why do we always have to approach reform by looking at what’s wrong? Let’s discuss what’s right.
If you would like to attend this event, please RSVP to szlotkus at yahoo.com
Date: December 30th
Time: 7-9pm
Location: Dupont Circle, Washington DC (I will provide the exact address to attendee’s via e-mail)
Total attendance will be limited to 15 people.
Bring a friend, or pass on this web page to someone you think might be interested in coming.
Steve Z
December 19th, 2008 by Dr. Val Jones in Opinion
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I was reading a good blog post about ethics violations in clinical trials in India, and was reminded of an interesting case in the U.S. Several years ago a 21-year-old woman (Abigail Burroughs) with terminal cancer (who had exhausted all treatment options) was denied the option of purchasing a drug that was in the final process of receiving FDA approval. The FDA ruled that terminally ill patients should not be permitted to purchase drugs until the drugs have completed the approval process, citing safety concerns. Their arguments also included that:
1. Patients cannot make a truly informed decision regarding whether or not to try a medicine that has not yet been fully tested.
2. Allowing access to drugs before they are FDA approved would undermine the clinical trial process.
3. If terminally ill patients could buy treatments, others would soon expect health plans to cover these costs for others.
4. Allowing access to drugs before they were proven effective would add to the public’s general confusion about evidence-based medicine and promote magical thinking.
I don’t know how you feel about this, but it makes me squirm a little bit. Although I appreciate the FDA’s position (and my colleague Dr. Jim Sabin has blogged about his support for the ruling) it just seems a little heavy-handed, especially in light of the details of the Abigail case. Here’s what I wrote to Dr. Sabin:
About the Abigail case… I think they were trying to get access to Erbitux for Abigail, and it was in phase III trials at the time (so there was mounting evidence for its efficacy – their request to purchase it wasn’t scientifically unreasonable.)
I have very mixed feelings about the FDA ruling. I understand that we don’t want to 1) set a precedent that would lead to insurers having to pay for expensive experimental therapies 2) discourage people from entering clinical trials 3) allow drug makers to profit from “false hopes” in terminal cases. However, couldn’t we add enough caveats to make it reasonable to allow patients who have exhausted all other options to purchase (with their own money) drugs that have shown promise but are not yet FDA approved?
What if we said that the drugs had to be in phase III trials, with enough evidence to suggest a plausible benefit for the patient? Terminal patients are rarely good candidates for clinical trials (I don’t think we’d be poaching from the CT pool), few can afford to buy monoclonal antibodies (and the like) on their own so if there were trials for terminal patients, they’d still have great incentive to join, and I’m not sure that just because a patient can buy a treatment that insurance will HAVE TO follow suit.
Something about limiting personal choices (for those who have the means to make them) seems un-American to me. There are very low risks of harm in monoclonal antibody treatments (so the argument that the FDA must err on the side of patient safety doesn’t really fit the Abigail case). Yes, it’s sad for those who can’t afford to buy every possible therapy – but why should we deny access for those who can? With the right caveats, I think we could allow people like Abigail to try every remaining option. But of course I agree that phase I drugs are just not far enough along the research pipeline to make educated choices about them.
Maybe Abigail was a casualty of the one-size-fits-all, population-based rules that are appropriate most of the time, but fail in exceptional cases. I predict that this sort of thinking (where evidence-based protocols are applied in a cook book manner to all patients with a given disease) will dominate the healthcare landscape in the coming years as we seek to reign in costs and do the best thing for most. I just wish there were a way to bend rules on the edges a bit. What do you think?
I’m visiting my husband’s family in Rochester, New York. If you don’t see any new blog posts in the next few days, you can assume that I’m actively digging my way out of their home to get back to DC.
