Wednesday, October 29, 2008

Why?

So, I have a few questions as to why people do things the way they do. See if you agree.

Why does the guy at Jiffy Lube stand outside when he's not busy and wave to me as I drive by at 8 AM as if he knows me? I mean really, its 33 degrees outside, snot is frozen on his mustache, and he thinks because he's standing out there waving to me I'll just "pop in" and get my oil changed, or maybe some 20 dollar wiper blades? Do they just put Jiffy Lube's in areas of low intelligence? Yep, as I passed by I thought, by golly, I think I need to have my oil changed, so I'll just pull in here and see friendly Hank and have him change the oil in my car while I enjoy some tea and crumpets and look at the latest edition of FHM (For Him Magazine). Really, why?

Why does our state mandate payment for neonatal screening tests for 29 conditions that have an incidence of less than 1 in 25,000 to less than 1 in 100,000? I mean really, would not the money be better spent on things that are more common, like preventing asthma and allergies from second-hand smoke exposure. There's probably enough money spent on these screening tests that eventually would be identified you could pay every new parent smoker to quit. Really, why?

I've had a few patients die recently and have attended their funerals. It is very interesting that a eulogy is given. You know, a eulogy is praise of a person. Would it not be better to praise them while they are alive? I mean, if the eulogy is about the person who died, what purpose does it serve to praise them when they can't hear you? Sure, it serves a purpose for those who are at the funeral, but they probably knew the person well enough that the praises being expoused were already known. It is, in essence, preaching to the choir. It's like going to the Sirloin Stockade, standing up in the resturaunt and announcing how succulent, tender, moist,and tasty the sliced roast beef is when everyone there has already tasted it. What I would propose are elegies (poems written about the dead), just because I like rhymes.

Need to grab a fast meal that looks after your abs? Heading for a "grilled" chicken sandwich? Well, guess what! Keep eating them and that 6 pack will become a 4 pack (or a 1 roll will become a 2 roll). I have patients that work at a certain fast food chain who tell me that sure, they're grilled, before they're frozen. But to thaw them and cook 'em up, they just throw them in the fryer, and whamo, after 90 seconds, they're done. So grilled chicken breast is what you call that? That's like taking a cholesterol lowering drug that acutally causes a heart attack, or ordering a diet pepsi and getting a regular pepsi. Or calling Britanny Spears a good role model (sure, she started out fine on Disney, but now? I guess with her you at least know what you're getting).


Our state has started puting government-funded TV ads on about getting out to vote and registering to vote. Really, you need to advertize to get voters? This is a good way to spend tax dollars? If you aren't educated enough to know to get out and register to vote and subsequently vote, I don't know if I want your vote counting in the election, because will it really be an informed choice your making, or will you always pick candidate C because that's what got you that passing D grade on your high-school geometry tests? Way to go state!

At the airport, do you really need a sign at the security check point that states "no guns." I think if you're dumb enough to go up there with a weapon, you deserve a good body cavity search. Maybe they'll find your brain up there before you're done and you head to the gates. That way maybe you won't board the wrong plane. See, it really is for your own good to not have that sign at the security check point!

Okay, so I could go on and on, but I have to wrap it up. Here are a few wasteful "really's" that are the result of the legal system.

McDonald's coffee cups warning that the coffee is hot and may cause burns.

Plastic bags with warnings to not put them over your head as they may cause suffocation.

Cigarette packages stating that their product may cause lung cancer and emphysema.

Gas station signs telling you to not smoke at the pump.

Hot tubs and swimming pools with a warning to not leave children unattended in them.

Beware of dog signs. Um, if it ain't your dog, don't mess with it.

Yard sale signs. Still can't get anyone to sell me their sod. What a farce.

Mattress tags. Um, took mine off and I've been on the run from the law ever since.

Menu warnings that eating raw or undercooked meat can lead to salmonella inection. Really?

Boxes of drinking glasses and dishes bought at stores that state on them "fragile: handle with care."

Budweiser Ad's that end with "Drink Responsibly."

Raw meat packaging that states: "Wash hands after handling."

Paint cans: "Do not inhale."

Herbicides: "Do not ingest."

Snow Ski resorts: "Not responsible for lost items."

If you're unfortunate enough to have suffered from the negative outcomes of not adhering to the above common sensicals, I encourage you to go to an airport security area packing heat. They'll help you become educated and you'll quickly learn the value of employing common sense.

Tuesday, October 21, 2008

Hey Batter Batter

So I just returned from a medical education trip at Las Vegas about obstetrical ultrasound in high risk OB patients. This is an area of interest for me since I do OB and do OB sonograms. I wanted to write a little blog about my educational experience and its application. I have to say that I walked away from the experience a little bothered. You see, this conference was taught by big-wig ivory tower doctors that do a lot of research from Denver, UCLA, Columbia (New York), and even Italy. The main theme of the whole 3 days was that we can diagnose things earlier and earlier with ultrasound so that termination of pregnancy can be offered by 22 weeks if there is something wrong with the baby. This theme just floored me! I can't believe that as medical costs rise and outpace spending in other areas, and as people's health insurance costs continue to rise, our educators were preaching to do more testing earlier to diagnose abnormalities earlier, mostly in the name of information for the mother so they could decide what to do with their pregnancy. The majority of these tests they are now recommending are primarily for the detection of Down's syndrome and congenital heart defects. Why diagnose these conditions earlier? Well, it does lead to being prepared at delivery with the appropriate staff and care, but why does it matter to diagnose it at 10-14 weeks versus 18-22 weeks when it can usually be diagnosed with other tests that are much less expensive? It is to allow a parent a choice to terminate the pregnancy if something is wrong. My friends, I have major ethical issues with this point as a doctor. As a family doc, I take care of lots of people with mental and physical disabilities, including people with Down's syndrome and congenital heart defects which have been repaired. Many of these patients are wonderful people who contribute more to society than fully functioning "well" people. For example, I have some patients with Down's syndrome who are now in their 6th decade of life, are rarely sick, are always happy, have utilized little health care resources, and have held various jobs for over 30 years. I also have patients who are in their 50's and have a diagnosis of fibromyalgia, have not worked in 15 years, who live off of our tax dollars in the form of social security/disability, who utilize more and more health care dollars, and have completely functional limbs and mind that allows them to go bowling, cook, clean, take week long vacations to the beach, but they just can't work. The point I am trying to make is that just because a fetus has a genetic problem doesn't mean that that "person" does not have a huge potential. Potential cannot be measured by any standard medical test that I know of. To base a decision regarding the life of a baby on whether or not that baby has a problem (genetic or not) is a fallacy. Don't get me wrong. The genetic testing is accurate, but the largest part of the equation is missing, and that blank cannot be filled in until potential has been given its proper environment and circumstance to reveal itself, at which time the point of termination is moot. If you did genetic testing on every person, you would undoubtedly find genetic flaws in every person's DNA (why do you think we get old and die?). It does not mean, however, that that flaw has any significant consequence. Perhaps those individual flaws are what makes us unique as individuals. Thus, genetic flaws do not always result in negative results, and when they do have known negative results, the degree to which they are negative depends in a large part on the environment in which they are expressed. I thus believe that in this case, more knowledge is not necessarily better. Knowledge does not always lead us to correct decisions. That requires wisdom, which requires knowledge yet is separate from it. My point is, my friends, that knowledge does not always help provide the correct answer. It is sad when in medicine we try to get more answers through more knowledge but it ultimately only leads to more questions.
My friends, medicine will never be able to provide you with 100% of the answers. We are not God. We can't explain everything, nor can we predict everything. There are no guarantees in this life in regards to health, and that includes pregnancy. There are risks, and a responsible person, which I believe is a requirement to be a parent, should recognize those risks as a possible reality when they decide to pro-create. Life is full of curve balls; you can't stop the pitch from coming and you can't leave the game. All that is left for you is to do your best with what you have.
So what did I learn from this conference?
1. Ivory, though white, is not completely pure (referring to the ivory towers of medical education, of course).
2. Knowledge does not always facilitate wisdom, but rather can hinder it.
3. There is a huge monkey on the back of choice and action, and its name is responsibilty.
4. In the words of Forrest Gump, "Life is like a box of chocolates, you never know what you're gonna get."
I look forward to your comments and opinions.

Tuesday, October 7, 2008

I'm sorry but I need that pen back

To all patients of the medical system (in other words, everyone),

I wanted to write you this letter of apology for my lack of not continuing to put your interests first and foremost in my day. I, along with the majority of my colleagues, are sorry that we have been so engaged in the day to day care of caring for the sick, dying, distressed and helping escort newlings into the world and elderlings into their new world that we have let the system of health care get out of control. The purpose of this letter is not to provide excuses, but to help you understand where we have failed you.

I am sorry that your coughing child who cannot keep down liquids because they are gagging on their mucus and that are fussy all day because they are up all night coughing can no longer get cough medicine. See, the FDA says they don't help, and because some parents were irresponsible in giving the medicine to their children and didn't follow the bottle's directions and their kids ended up overdosing on the medicine, they blamed the FDA for allowing these medicines to be marketed to children. The FDA reviewed the studies and said that since they don't decrease the DURATION of cough, they aren't useful. So now your insurance company won't pay for prescription cough medicine for your little cougher. I'm sorry we didn't go to fight for you with the FDA to show them that studies show it decreases the AMOUNT of coughing and night-time awakenings. I'm sorry that your insurance company is glad to not cover a medicine so it can make more profit off your insurance premiums. I'm sorry that the FDA is just worried about getting sued because <0.000008642358% of kids had problems with the medicine. I'm sorry that the paperwork I spend 15 minutes filling out explaining why it was medically necessary for your child to have the medicine was determined by them to still not be medically necessary. So as my solution, to show them that it is medically necessary, I recommend that the next time your child has a severe cough and snotty nose, and they can't sleep, eat, or drink well, that you take them to the homes of the FDA officials or the CEO's of your insurance company and leave them overnight. Then, I bet, you shall have your cough medicine for your child.

I'm sorry that we have not been able to provide the medical services that we decide are needed. I called your insurance company and talked with a nurse, who told me that the test was not medically necessary. I guess I should have been a nurse so I could make the decisions needed for your health care. I'm sorry that the medical review director of the insurance company left the office at 3 pm that day so I couldn't talk to them and tell them it was medically necessary for the tests I wanted to do to get done right away. I'm sorry that you ended up in the ER at 2 am with a ruptured appendix. I'm sorry you stayed in the hospital an extra week because your appendix ruptured and you are still off work. I'm sorry your insurance company only wants to pay for 3 days of hospitalization when you were still throwing up, not eating, and requiring IV pain medication on that day. I'm sorry they wouldn't cover your medication I sent you home on.

I am sorry that your formulary with your drug company is restricted and we have to use generics. See, I demand the best for the health of my patients, and when the concentration of a drug in a generic form can vary by 20%, I believe in some cases this makes a huge difference in the outcome of your health and you need brand name medication. I write your insurance company, but they deny the reasoning, as I guess they have more knowledge of your health and the health care decisions we make together. So I'm sorry that we put you on a generic medication and it doesn't work as we had hoped, or that you had an expected side effect. I'm sorry that for those three to six months your insurance company made more money from your insurance premium by not having to pay for a medicine that we decided was right for you.

I am sorry your insurance ran out and your cash cost for medical care is exorbident. See, we have no bargaining power with large insurance companies. I can't know what another practice down the street gets for a standard office visit, because it is illegal. Because of that, the insurance company can come in a give me a low-ball contract offer of payment based on a percentage of what I charge. I can accept the low-ball offer and jack up my charge so I can actually pay my medical school loans, or I can tell them it is too low and they will go down the street to the next doctor and sell your care to them for 1/2 a percent less. I just can't take that chance, since some income is better than none. Thus, I have to increase my charges so the insurance companies will pay me a decent amount for my time, training, education, and expenses. Well, just because you pay cash doesn't mean I can give you a discount. Because I accept medicare, I have to treat all patients equally, no matter who the payor (or lack of payor) is. Thus, I can't charge cash paying patients less or else I am committing a federal crime of fraud and can go to federal prison and lose my medical license. So I am sorry our office charge is so steep for a 7 minute office visit to tell you that you have a urinary tract infection and give you a script for a med to get you better.

I am sorry I don't have samples of medicine for you to try. See, the pharmaceutical industry is cutting back in order to preserve profits because the cost of new drug development is rising and they have investors to keep happy. For me to get you samples, I have to sit in front of a computer and watch a 15 minute presentation about the drug in order to order a 30 day supply of the sample you need. I just don't have the time to do this for 3 hours a day and still see patients, deliver babies, go to the hospital for emergencies, be on call, assist in surgeries, and still eat and see my kids.

I am sorry, but I can't let you keep that pen. See, the government for some reason thinks that because a pharmaceutical company gives me a pen that I will prescribe their medicine more often. So now they have created a regulation that we can no longer receive pens, notepads, or anything with their name or the product's name on the item. So I cannot relenquish my pen to you, for I need it to take notes and write prescriptions and instructions for you - it is the second most important instrument a physician uses. Every pen now affects my bottom line, what I can take home, and with declining reimbursements from the insurance companies (we don't want to loose you to the practice down the street, so we accept a reduction in percentage of pay nearly annually even though the cost of providing care goes up), every pen and piece of paper counts. Now I will admit that some big fancy institutions did studies in university medical centers (not doctors offices) which showed that when doctors received pens and menial gifts from pharmaceutical companies, they tended to prescribe their products more often. I can tell you that I would not risk compromising your care and a possible lawsuit because of a pen or a hot pack with a drug's name on it. Could it be that while they received that pen or menial gift they were talking to the representative about the product, learning more about it, and thus became more comfortable with the product and thus were more willing to prescribe it? Could it be that a person with 11 years of post-high school training through some of the toughest curriculum and training of any profession would actually make such a logical decision? Did they study this as the possible reason for increased prescribing practices when gifts are received? Nope. They just assumed because it influenced us that it must be the object itself that was the influencer, not the information that came with it. So sorry kids, I need my pen back, and please no coloring on my notepads. And I'm sorry that even though pharmaceutical companies aren't providing as many samples and we can't let you have those pens they give us that your drug costs are not going down. You see, they have investors to make happy and super bowl ads and magazine ads to produce. Welcome to being a financer of commercial advertising!

I am sorry that I won't prescribe medications (especially antibiotics) over the phone. You see, if I do that and you have a serious reaction to the medicine or you receive the wrong treatment because we did not diagnose the condition wrong, then I am liable, can be sued, and can lose my medical license and way of livelihood. Secondly, I would not want you to get misdiagnosed and end up in the hospital with something worse going on, which is not good for you, your family, or health care costs. Third, we have an issue in this country called bacterial resistance, and if we keep prescribing antibiotics for illnesses that do not require antibiotics, eventually none of the antibiotics will work, and you will be much worse off 6 feet under than enduring a few colds through your lifetime. Fourth, I do not have psychic abilities to tell what is going on with your body over the phone or through an email. Also, I could spend all day on the phone trying to help people and I would not earn one dime because your insurance company does not pay for phone consultation time. I have to meet a bottom line, and that line requires you to come in to be seen. I respect your time and understand you may have to miss work, but in all honesty it is in your and my best interest to do so. Thanks for understanding.

To my medicare patients, I am sorry that I can't spend more than 15 minutes of time with you. I'm sorry I ask you to come back to cover items 4-10 on your list of problems. You see, medicare doesn't care how much time I spend with you, they pay me close to a flat rate per visit. If I spend too much time with one patient, I don't see enough patients in a day to pay my nurses, my front office staff, the people that help fill out and fax forms for your walker, your non-approved medication, and your handicap placard, let alone my medical school loan for that month. I know your time is important. I respect that. I know it is hard to come to the office. I know gas is expensive. But I can't bargain with medicare for better pay. They haven't increased our pay for years. That's up to Congress, and Congress doesn't negotiate, nor do they care primarily about you - they care about the bottom line and the budget and getting re-elected. We don't get a cost of living increase, but we do get more paperwork and denials for payment. I don't want to loose you as a patient because I enjoy our visits and helping you, but I have to make ends meet. Thanks for understanding.

To the veterans who come to see me, I apologize for letting the government neglect your care through the VA system. I apologize for it taking so long to get the tests you need and the specialist care you need. I apologize you are seen as a number in the system. I apologize that you have a difficult time understanding some of the foreign medical graduates that work in the VA system to get in the door of working in the United States. I am sorry that you don't have the best medical care in the area available to you through the VA system.

I am sorry that our patient-physician relationship is no longer confidential. I am sorry that what we decide is best for you in the exam room is deemed to not be so by so many other entities. I am sorry that I have allowed insurance companies, pharmacies, pharmacy benefit managers, pharmaceutical companies, medical supply companies, the government, the DEA, and the FDA (I apologize if I missed anyone who deserves credit) interfere with your health care. I am sorry that medicine is no longer becoming your choice, but is being mandated to you. I am sorry that I have let socialism force its way into a capitalistic system. I can do no more nor yell any louder. I cannot strike for you, because that wouldn't be fair to you. I cannot go to Capitol Hill to fight for you, because I can't afford to and I need to stay here and care for you. Legislators will not listen to the minority. They may, however, listen to the majority. So I encourage you to speak up! Don't let the government or any other entity regulate and dictate to you and I what is in your best interest in regards to your health! Regulation is not freedom. We have a check and balance system for doctors- its called lawsuits. They don't need to watchdog us. We are the ones who care about you and your family. Our main motivation for going into medicine was to make a difference and to help people live long, happy and healthy lives. Do they go to the same restaurants we go to? Do their kids play ball together? To they have to answer to your family if you have a major problem? So speak up and keep the government out of our relationship and healthcare (would you trust Ted Kennedy to give you medical advice? Well, he wants to via a government-run healthcare system)! If you want a good look at government-run health care, talk to a veteran who goes to the VA. They can tell you what a debachle it is and how hard it is to get the care they need.
So to my patients, I apologize. I do promise, however, to do my best to continue to provide the care you need so that you can live a long, healthy life no matter who or what interferes in my ability to do so.
With all sincerity, anger, bitterness, resignation, indignance, and sorrow.

Monday, October 6, 2008

Doctor versus Daddy




So this past week my wife needed a break from the children and I took a day to be a dad. Now, the majority of my day is spent with patients, and afterward I had quite a bit of time to think about my day and compare it to my usual day. What I found was that there are some ironies and contradictions that are amusing, insightful, and incredulous. I hope you enjoy these series of realizations from my time of reflection.


My kids require my input for their health and safety.

My patients request my input for their health and safety.



My kids love McDonalds.

My patients, apparently, love McDonald's food (see previous blog).



My kids require verbal discipline for their normal development as people.

My patients require verbal discipline for their normal development as people.

I will pay if I don't give my kids advice and direction.

My patients pay me for my advice and direction.


My kids listen to my advice and take it to heart.

Many of my patients rarely listen to my advice and take it to heart.


I can spank my kids to get their attention and make my point.

My patients can fire me for making my point.


If my kids don't like what I have to say, tough. They still have to live with me.

If my patients don't like what I have to say, tough. They can fire me.


My kids love and accept me no matter what I do or don't do for them.

My patients accept me based on what I do for them.


My kids don't freely discuss bathroom business.

My patients readily and frequently discuss bathroom business.

My kids see another doctor.

I wish some patients would see another doctor.


My kids know which chair in the house is mine.

My patients in the office don't know which chair in the room is mine.


My office at home is a mess.

My office at work is a mess.


My kids smile when they see me and greet me with a hug.

My patients are apathetic when they see me and greet me with a list.

My kids go outside and get exercise when advised.

My patients don't go get exercise when advised.

My kids wash their hands before leaving the bathroom.

My patients, well...sometimes its a flush with an immediate door opening.

My kids don't text people and talk on the phone while I'm talking to them.

My patients do text and talk on the phone while I'm with them.

My nanny at home is my wife.

My nanny at work is my nurse.

I eat chocolate at home for comfort when my kids don't pilfer it.

I eat chocolate at work for comfort and readily pilfer it.

I am appropriately responsible for my kids behavior and actions.

I am inappropriately held responsible for my patients behaviors and actions.

Okay, so maybe this sounds a little synical. I do have to admit that spending the day as the primary care provider for my kids was very rewarding because I could see the payoff for the investment of time, which is not always true at the office. Medicine has become extremely frustrating, as I will detail in a future blog. I however, have a desire and drive to continue in the quest to help people, and a great appreciation for what my wife does day in and day out. I could not do it and understand why a sigh of relief occasionally occurs when I walk in the door in the evening. She is a great woman, a better person than I, who is making a true difference in this world by raising our children correctly while I struggle to do the same with adults at the office.