Tis the season; of college acceptances, that is.

I treated a high school senior today suffering from acute depression, anxiety, and panic attacks all precipitated by the fact that he was not accepted to any of the four Ivy League colleges to which he had applied, but several of his friends had. It wasn’t that he had been rejected everywhere. In fact, he had multiple acceptances at excellent schools. Nevertheless, he was beating himself up over his perceived inferiority. He just couldn’t understand why his friends with identical grades and test scores were somehow more worthy than he.

I explained to him that in this day and age, all of the Ivy League schools — as well as many, many other top tier colleges — have enough ideally qualified candidates to fill their entire classes ten times over, or more. After a certain point — a point well passed by my patient and many other students — acceptance to any of these schools is basically a lottery. Although my patient understands this intellectually, emotionally he still doesn’t quite believe it. His friends must have had something he didn’t to receive that coveted thick letter.

So here is my modest proposal. Listen up, Ivy League admissions folks:

Go through your regular admissions process. Evaluate each applicant according to whatever criteria you want. Decide whether or not each one has what it would take to succeed at your institution, and whether or not you would want him or her there. Sort them all into two (and only two) piles: Yes, and No. Go ahead and send out your graciously worded rejection letter to the kids in the “No” pile, bearing in mind that the group almost certainly includes future presidents, entrepreneurs, Nobel and Pulitzer prize winners, etc.

Next: Take all the names in the “Yes” pile, throw them into a hat, and run an actual lottery.

If you have 40,000 applicants for 6,000 places, go ahead and pull out 6,000 names (plus however many extras you want.) Send them those nice thick letters. Then — and this is the important part — everyone else on that “Yes” list gets a letter telling them that they were good enough. They were fully qualified; there was nothing wrong with them, with their application, with their qualifications. Their number just didn’t come up, you’re so very sorry, and you wish them well.

There are several advantages to this scheme.  In addition to preserving the sanity of the poor high school seniors stuck in the middle of this mess, the job of the Admissions Committee will be infinitely easier; all you have to do is decide yea or nay on a truly individual basis. Additionally, it’s much more intellectually honest. All that crap about “balancing” your class, fine-tuning the precise makeup of your student body is all a bunch of bull anyway, since as you know, you can’t control who accepts you once you send out those letters. Just run the damn lottery and let the thick and thin letters fall where they may.

You’re welcome.

 

Mediterranean sea bass with roasted fennel, tomato, fingerlings, and garlic herb sauce:

Florida grouper with parmesan ramp risotto, asparagus, spring ramps, shaved crimini mushrooms, lemon vinaigrette:

Desserts: Signature chocolate tower:

 

Vanilla creme brulee:

No, I didn’t make any of it (though my creme brulee is better.) We are in Cape May, NJ celebrating our anniversary, beginning with dinner at the Washington Inn, attentively waited upon by the delightful Godfrey of Uganda and London.

Guy goes to see a doctor for a skin rash, stomach ache, cough, knee pain, trouble peeing, and is found to have high blood pressure. He’s seen at his team-based medical home and sent to a dermatologist for the rash, gastroenterologist for the belly pain, pulmonologist for the cough, orthopedist for the knee, urologist for the urinary problem, and a cardiologist for the high blood pressure.

The dermatologist diagnoses eczema, gives him a prescription for a steroid cream, and tells him to follow up with GI, Pulmonary, Ortho, Uro, and Cardiology.

The gastroenterologist orders blood tests, a CT, does an EGD and colonoscopy, diagnoses him with GERD, gives him a prescription for a PPI, and tells him to follow up with Derm, Pulmonary, Ortho, Uro, and Cardiology.

The pulmonologist orders a chest x-ray and PFTs before even seeing him, then diagnoses cough-variant asthma and gives him a prescription for an albuterol inhaler, Advair, and singulair, then tells him to be sure to follow up with Derm, GI, Ortho, Uro, and Cardiology.

The orthopedist orders x-rays and an MRI of the knee (again before seeing him), diagnoses osteoarthritis, and gives him a prescription for Mobic and a pamphlet about knee replacement, telling him to think about it, but also to follow up with Derm, GI, Pulmonary, Uro, and cardiology.

The urologist orders a PSA (because he’s breathing; the urologist, that is), does a rectal exam, diagnoses BPH, gives him prescriptions for Proscar and Urotraxal, and tells him to follow up with Derm, GI, Pulmonary, Ortho, and Cardiology.

The cardiologist diagnoses him with hypertension, sends him for a nuclear stress test and echocardiogram, then starts him on Exforge and tells him to be sure and follow up with Derm, GI, Pulmonary, Ortho, and Uro.

Each of these doctors also brings him back for a checkup annually for the rest of his life.

Same guy comes to see me. I proceed to:

1. Take a complete history, do a thorough physical exam, and order some basic blood work (including a PSA in this case) which allows me to:
2. Diagnose eczema, and tell him to start by trying moisturizers
3. Suspect that his stomachache is actually heartburn, tell him to consume less alcohol, caffeine, and tobacco, lose some weight, and try some antacids first (then OTC H-2 blockers, ie first generation anti-acid meds)
4. Realize that the cough is probably coming from the GERD and tell him to wait and see if it persists after treating his heartburn
5. Diagnose osteoarthritis and tell him to start by trying two extra-strength Tylenol (1 gram total) four times a day, and that losing weight will help his knee as well as his GERD.
6. Diagnose BPH and give him prescriptions for generic finasteride and flomax, and
7. Tell him to come back and re-check his blood pressure, as the diagnosis of Hypertension requires that elevated readings be found on three separate occasions.

Total cost for the first: Multiple thousands of dollars.

Cost for my care: a few hundred dollars at most.

Total time available in the specialty appointment books for patients who actually need to see them: you do the math.

Why on earth do people voluntarily board this ridiculous runaway referral-go-round instead of seeing a good family doctor (and paying us appropriately) first?

I’ll never know.

How do you know it’s all worth it?

For years, nay, literally decades, you remind and cajole and bug and nag them: please pick up your stuff. Please throw that away instead of just leaving it on the floor. Please, please, please.

Eventually, (if we’re smart) we learn not to worry so much about the bedroom. It has a door that can always be closed. So we concentrate our efforts on the common spaces.

Please don’t leave your shoes lying around.

Are you done with this soda can?

Is this junk mail that came for you, or do you want to hang onto it? (And if so, could you please take it up to your room.)

On. And on. And on.

Months dragging into years blooming into decades.

Then one day it all ends. They’re gone. Really gone. And you finally have a chance to clean up the house once and for all; and then savor the joy of watching it stay picked up. Because there’s no one but you and a well-trained spouse living there who enjoy the clutter-free ambiance of trash in the can, folded laundry in drawers, and old newspapers in the garage.

Bliss.

What could be better?

This:

Coming by after a week in the new house with the new roomies, you overhear him lament,

“I wish Frick and Frack were neater.”

I would say it brought a smile to my face, but that’s not exactly true. What it brought was a 10-minute laugh to my belly.

This is a true story. I say this up front because if I don’t, the whole thing will look like nothing more than a set-up for a really bad pun. It is, of course; but it really happened. And the pun was mine.

There is a large group of urologists in my neck of the woods. Actually, it began as many small groups of urologists who joined forces and became a “group practice without walls“. One of the desired effects of this new arrangement was increased clout in dealing with large insurance companies to negotiate better payment rates.

As it happens, one of these large insurances took umbrage at their requests, so when it came time to re-negotiate, they played hardball, and in a full-blown game of chicken, ended up walking away from the table. Letters were sent to patients informing them that they had to find new urologists. I had one guy in his 90s who’d been seeing the same doctor for decades who called asking me what he should do. I told him not to worry, go ahead and keep any scheduled appointments, pay the guy out of pocket for one or two visits (if it came to that). Mainly I reassured him that the standoff wouldn’t last.

It didn’t.

After a short time, the insurance company caved, agreed to the urologists’ contract terms, let the patients go back, and all was right with the world.

While discussing the situation with my patient’s urologist (who happened to have been the chief negotiator for the group) I realized that the moral of the story was this:

Never get into a pissing contest with a bunch of urologists.

(Documentation here and here.)

Grilled scallops with stir fried asparagus, mushrooms, and red onions with Wegmans Garlic simmer sauce:

The first time I made this, I used a package of Wegmans pre-cut veggies because I thought it was an interesting combo. It was. But this time around, I bought the veggies separately and cut them myself. Not only was this (a lot!) cheaper, it also allowed me  to make the vegetables more uniform and a little smaller. This helped them cook more evenly. I also did the onions alone for the first few minutes before adding the asparagus and mushers; another advantage of prepping them separately. My original thought was to toss some small bay scallops into the pan, but we couldn’t find any (in packages under two pounds), so DDS did the big ones on the grill.

Yum.

Man comes in for a physical. Thanks to the new healthcare law, there is no longer a co-pay for this preventive service. He is pleased.

We notice that he has an unpaid balance from an earlier visit a year ago. We have billed it to his insurance, which denied the claim, stating that the visit was for a pre-existing condition and was therefore not covered. We explain this to the patient. He is not pleased.

He states that the previous visit was not, in fact, for his pre-existing condition of asthma (for which the documentation clearly states the visit was scheduled), but rather to discuss his erectile dysfunction, which he states is a new problem. Because it is not a pre-existing condition, the insurance should pay it. He is pleased to explain this.

Never mind that we evaluated, discussed, and managed his asthma during the visit (clearly documented) as well as his ED (also documented). Never mind that neglecting to include the asthma diagnosis on the claim would constitute insurance fraud. Never mind that we’ve gone round and round with the insurance company for six months, and then billed him for the next six months. Never mind that he has been told that his insurance contract is between him and the insurance company, whereas we are merely the ones actually providing him with medical care.

We request payment owed for services rendered. He is not pleased.

His precise words:

“I don’t think I should have to pay.”

Really? For services already rendered? Does he think the water, electric, and phone companies would be perfectly happy to continue providing me with services if I decided randomly that I shouldn’t have to pay for them? My lawyer and accountant would have me in small claims court in a jiffy if I decided after the fact not to pay up. Why are doctors any different?

Why do people seem to think that the terms of their contract with their medical insurance company doesn’t really apply to them?

Talk about entitlement!

 

 

The expression “Empty Nest” in the context of parenting generally refers to sending kids off to college [one of my very best pieces of writing, if I do say so myself.] There is no denying that this is a definite milestone. They’ve graduated from high school. They can vote, enter into contracts, legally consent to medical care and sexual relations, even enlist in the Armed Forces. Technically, they are adults.

And the emptiness of the nest is legitimate. Less laundry to do; not as much noise; lower grocery bills (often counterbalanced by tuition, but that’s another story.) I don’t deny that it’s a big adjustment.

But it’s not entirely real, because it is often not permanent. They still come home for holidays, vacations, and summers. Their driver’s license still lists our address, as does their car registration and insurance. Their legal residence is usually still “home”.

Sometimes that changes after college graduation.

Sometimes they go off to graduate school confident that they are finding their own way in the world. Even when you go along to help find that first apartment, they take the lead. After a year, when they buy themselves a condo and get a cat (all the while refusing to take money from you), you know they are well and truly launched.

Sometimes they get married and set up housekeeping, including their own menagerie of cats, snakes, and other reptiles. Even if we happen to be helping out with student loan payments, it still counts. They’re not coming back.

And then there are the boomerangs. The ones who come back home after college or grad school and stay a while as they get started on their life. Nothing wrong with that, especially when they have a full time job, their own car, friends, activities, and schedule. It’s more like having a housemate than a kid, when general consideration (noise, hours, etc) is practiced by all parties. The difference is that this time, it’s more open ended.

But eventually the exam is passed; certification achieved. The soul-killing retail job is eagerly ditched in exchange for the professional one. Life continues, even while living at home. But however you cut it, however pleasant (and cheap) the situation may be, it’s still anathema to be “living with your mother.” And so the next steps begin.

House hunting ensues. A property is located. A deal is struck. A mortgage secured. Settlement is made and a truck is rented.

Moving day: the truck is loaded, unloaded, and re-loaded again for a final trip. This one is truly final, though. This time, he’ll be filing change-of-address forms for his driver’s license, car insurance, credit cards, and so on. He is moving to his new home. His. Not ours, which is to say mine. He’s outta here.

He’ll be back of course. Tonight, in fact, to watch the season finale of the Walking Dead, since he doesn’t get cable until Tuesday. But never the same. He’s gone.

I know they’ll still come to visit, but it’s just to visit. Home is elsewhere for all of them now. Now the nest is empty in a way it hasn’t really been before. There’s a new freedom to clean up, clear out, re-arrange, discard; maybe even consider downsizing.

Melancholy? Bittersweet? Regrets? Actually: no.

Because it’s time. They were all ready, and now the first to come is the last to go. Even as they fly away from my arms, I will always hold them deep in my heart.

But now I get to order new carpeting.

A crunchy friend of mine on Facebook re-posted something from an even crunchier friend of hers who was shocked — SHOCKED — to find that many naturopaths sell supplements. Actually, she feels that selling them is okay; so is prescribing them. But selling what they prescribe apparently tips her Ethics meter over into “unacceptable”.

As I read her screed against  the ND who conducted a cursory history and exam before checking off $750 worth of supplements on a pre-printed sheet (Visa, Mastercard, and Discover accepted, I’m sure) I felt my heart lift. Yes, I thought. Now you’re getting it. When she advocated hiring a naturopath who doesn’t do this, I found myself telling the screen, “Good luck with that.”

The poster was also, rightfully, concerned about “the heart of the practitioner.” She places great emphasis on intent. Question for her: what about the practitioner who really, truly feels that the only supplements good enough for her patients are the ones she is selling? You’d probably think she’d been hoodwinked by marketing, and you’d be right.

Here’s the thing, though: you yourself have been hoodwinked by the marketing of the entire “Natural Health” industry. Naturopathic medicine, energy healing, homeopathy, chiropractic, acupuncture, and all the rest are nothing but non-scientific hokum.

Some of it emerged before science had developed sufficient understanding of the human body. Others, like chiropractic, were actually invented in order to make money selling them to practitioners (who were understood to then turn around and use them to take money from patients.) There is no way to learn — and really understand — chemistry and then turn around and believe in homeopathy. Emerging consensus reveals that acupuncture is nothing more than an elaborate placebo.

Recognizing the ethical shortcomings inherent in the sales and marketing of supplements is the first step. The next is the painful understanding that those who sell “education” and “training” to become a “Natural Health care provider” are just as unethical, selling nonsense in lieu of science to people whose disappointments with “regular” (ie, real) medical care leave them vulnerable to the wish fulfillment that is “holistic” care. I’ve written about this before.

It’s important not to confuse the message and the messenger, or rather the material and the teacher. It’s possible, even likely, that the vast majority of natural health practitioners really believe that what they’re doing is legitimate; just like that Naturopath who really feels that her supplements are so much better than cheaper alternatives.

This friend of a friend goes on to give this advice:

Bottom line is this – if you are in the natural health field, or are planing a career in it – choose which side of the coin you want to be on – 1) patient care, consulting, advocating and teaching, or 2) retail, sales, product marketing. Both of these are perfectly fine when apart – it is the mixing of the two that causes my heart to sink.

The existence of the whole “natural health field” is what causes MY heart to sink. I ache for those whose bad experiences with “conventional medicine” — that is to say, medicine — have caused them to look for alternatives. But for anyone looking for a career in the health field, make it a real health field, like nursing or medical school, EMR/paramedic/first responder training, or become a doula or lactation consultant. As for those already there, please take a long, hard look in the mirror, and think about what you are really selling.

Tonight is the first night of Passover, the Feast of Unleavened Bread. Around the world, Jews everywhere sit down together around the table for the seder, a special dinner with very special foods, prayers, and rituals that go back centuries.

Over the years, I’ve been to all kinds of seders: at my home, at someone else’s. I’ve done Seder with a hundred people at synagogue, and six people around my table. I’ve done seder with my family, my children, siblings, friends, and every combination thereof. I’ve had a former nun, and a priest at my seder.

This year, first seder falls on a Monday. (Outside the State of Israel, many people have a full seder on each of the first two nights of the eight-day Passover holiday, the thinking being that outside Eretz Yisrael we can never be absolutely certain exactly when it begins. This way, we’re covered. It also comes in handy for families of divorce, allowing kids to have seder with both parents each year.) DDS had been asking me for weeks what I wanted to do for Passover.  Options included making a seder in our home, traveling to family in another city, or soliciting an invitation from friends.

I didn’t feel like doing anything. Not this year. I’m not sure why. I’ve been a little down lately, and the work involved in pulling together what is basically an elaborate dinner party was just too daunting. I don’t want to do anything this year, I said. Fine, he replied. He made chicken soup over the weekend, and we planned for nothing.

But then the day arrived. And the thought of sitting around watching NCIS while chowing down on a nondescript dinner knowing that virtually every other Jew in the world was sitting around a table with loved ones breaking matzah, blessing wine, making horseradish and chopped-apple-and-nut-relish sandwiches (maror and charoset, known as a Hillel sandwich)…I couldn’t bear it.

So I threw together some matzah balls, made the smallest batch of charoset ever (just one apple and a small handful of pecans, as it turned out I was out of walnuts), and laid it out with some parsley, lettuce, horseradish, and a hard boiled egg on a simple plate. I stirred some salt into water, folded a napkin around three matzahs, got out candles and wine, and just two copies of the Maxwell House Haggadah, and sat down with just DDS. We sang the blessings, lit the candles, drank the wine, told each other the short version of the story of every Jewish holiday (“They tried to kill us; we survived; let’s eat”), and had a delicious dinner together, just the two of us. The matzah balls were exquisite (natch!); DDS made a wonderful farfel stuffing to go with our feast of roasted chicken.

It was different from every other seder I’ve ever been to. Yet in every way that matters, it was pretty much the same. The dry, sandy texture of matzah on my tongue; the crunch of the nuts in the charoset; the wonderful sweet alcoholic grape juice that is Manishevitz Concord Grape. This is Passover. This is freedom. It is sweet, which is good to remember; this night, just like every other night.

It’s happened again.

Reading the gut-wrenching news that yet another of my child’s childhood friends will never marry, have children, or grow old. Taking off from work to help a friend bury a child. Danny and Derek and Steve and Jimmy. Enough.

Enough. We always say “enough” when we mean “too much”. Too much sadness to bear. Too much grief to carry.

The worst part is when it’s no one’s fault. This is not a screed about motorcycles or helmets, or impaired older drivers. Nothing like that. No one to blame.

Nothing to do but ache. And hold your kids close, however old they are.

You know how you can tell when it’s getting to them too? They hug you back.

You may have heard of the “Dean’s Lie“, the artificial padding of numbers allowing medical schools to claim ever-increasing percentages of their graduates are going into Primary Care medicine. This is accomplished by counting everyone going into Internal Medicine, Pediatrics, and Med-Peds, in addition to Family Medicine as “Primary Care.” It makes their schools sound more attractive by seeming more progressive, but it does nothing to enhance the supply of actual physicians who take care of undifferentiated patients at their entry into the medical care system, because as it turns out, significant percentages (90% or higher for IM, 60-70% for Pediatrics) end up specializing and subspecializing after their initial postgraduate training. But I see another problem: Obstetrician/Gynecologists, who are typically thought of as providing primary care to women.

OBGs are not primaries.

Obstetrician/gynecologists are surgeons. Surgery is hard. It takes a long time to learn to do it well. There’s a reason why General Surgery residencies are five years long. OBG’s get four. Their training curriculum is all surgical. Oh, they have their clinics, but by training and temperament, they are surgeons through and through. The only time I ever had my knuckles literally rapped was in a c-section, when I commented that the resident was doing something “just like a surgeon.” He whacked my hand with a clamp (it hurt!) as he retorted, “We ARE surgeons.”

Over time, many OBGs become competent at outpatient medicine. Still, their knowledge base and skill set are limited to the female reproductive system. News flash: there’s more to women than lady parts.

Primary care for women is more than just pap tests and mammograms. Sure, the OBGs check blood pressures and order studies. But they don’t diagnose or treat hypertension, hyperlipidemia, thyroid disease, or diabetes. Many of them think they’re diagnosing osteoporosis when they order DEXA scans. Then they write for bisphosphonates and order the DEXA every year or two (the test should not be repeated for at least 3-5 years, and the drugs don’t do anything more after 5-7 years) and pat themselves on the back for providing such “comprehensive” care.

Women also get sick and hurt in ways that have nothing to do with their reproductive systems. OBGs have no clue how to deal with these kinds of conditions, even in pregnant patients. Swimmers ear is not treated with amoxicillin. Coagulopathy workups are not the first thing to order for slight bleeding of the gums. And ordering blood work for diabetes is not particularly useful for corns on toes. Real primary care physicians take care of problems like these, as well as many others — the figure quoted is 90% or more of what walks in the door.

Family docs who do office gynecology (like me!) are the right way to do real primary care for women. I’m happy to refer when my patients need procedures beyond my training (colposcopy, biopsy, and obstetric care, although many of my Family Medicine colleagues provide these services), just like other specialists. But when they don’t need surgery or gynecologic specialty care, I diagnose and manage their blood pressure, diabetes, asthma, allergies, and tend to all the rest of their general medical needs. I can also diagnose and (appropriately) treat acute conditions for them; their pneumonias and ear infections and sprained ankles. I can even keep them healthy by offering age appropriate immunizations, diet, exercise, and lifestyle advice for which I have been specifically trained.

I can’t perform a c-section or a hysterectomy, and I appreciate the knowledge and skills of my OBG colleagues who do. But they are not Primary Care physicians. I understand the ramifications of the primary care shortage in this country, but roping surgeons with specialized expertise into serving as “Primaries for Women” does them — and women — a disservice.

I’m so glad I was able to generate so much traffic for The Health Care Blog (with this post), where I am currently being eviscerated for hating on PAs. Clearly, all of the hullabaloo is from folks who have never read any of my other posts. In the six and a half years I’ve been blogging, I’ve also ragged on nurse practitioners, radiologists, podiatrists, cardiologists, orthopedists…I could go on and on (I really have been doing this for a long time.)

At any rate:

The post in question was about a patient with a rapidly progressing infected cat bite on the hand who needed to be admitted for IV antibiotics who was “sent to the ER.” A valid criticism of my (administrative) handling of the case was that because the diagnosis and plan were already known, the patient should have been admitted directly to the hospital instead of going through the ER.

Good point. And in the good old days of outpatient family docs routinely admitting and caring for hospital patients (before we got elbowed out by hospitalists and decreasing payments) that’s exactly what I would have done. Things have changed, though.

Ceding inpatient care to a generally competent cadre of physicians took some getting used to. And like most other hospital based groups, they pride themselves on “communication” and “customer service” to the referral base (that would be me and my outpatient colleagues). I have laminated cards from each local hospital listing phone numbers for getting in touch with them with any questions or concerns about my patients in the hospital. But what about admitting them directly?

Turns out that on paper, there is a mechanism for doing so. Granted it involves two phone calls to different places followed by callbacks from each before being able to tell the patient (sick and/or in pain) where to go. Because it’s been so long since I’ve had occasion to do this, I ran this by the chief hospitalist when I happened to run into him the other day. His response:

Better just to send them to the ER.

Further rationales quoted included ease of getting labs, starting IVs, and (of course) the billing.

No problem. I send the patient to the ER to be admitted. Does that mean they can bypass triage?

Oh no. Everyone who walks into the ER needs to go through Triage, where they will be asked if they feel safe at home (thank you, requirements for universal domestic violence screening) after waiting in line behind everyone else who didn’t come in on an ambulance.

If I call ahead and arrange everything with the hospitalist, does my patient still need to be seen by the ER doc?

Welll…They like to eyeball them just to make sure they’re stable.

Great.

So apparently the ER has now become the de facto Admissions Department for anything other than pre-registered elective surgery (more and more of which is being done at free-standing surgicenters; I wonder why?) Talk about mission creep.

Here’s a thought: They’ve already added Fast Track many places to punch through some of the bottlenecks. How about reserving a bed or two for “direct admits” coming through the ER. Give them (the admitting physician, that is) all the conveniences of the ER (nursing assistance, stat labs, etc.) without technically calling it an ER visit.

Because for better or worse, it looks like there is no longer any such thing as a Direct Admission.

Mazel tov on your new Pope.

Modified Beef and Chickpea Toss:

Original recipe from Family Circle:

Makes: 4 servings Prep 10 mins

Directions
1. Drain and rinse 2 cans (15 ounces each) chickpeas. Combine with 3 tbsp each olive oil and raspberry balsamic vinegar, 2 tbsp mayonnaise, 1/2 tsp fresh chopped thyme and 1/8 tsp each salt and pepper. Serve in Bibb lettuce cups with 1/2 pound roast beef, sliced into ribbons. Top each serving with 2 tbsp crumbled blue cheese. 

I made this a few days back and it was okay. The chickpeas weren’t my favorite, though, so I modified it as follows:

Ingredients:

• roast beef sliced into fine ribbons
• 2 tablespoons hummus [nothing more than ground seasoned chickpeas, right?]
• 2 tbsp mayo
• 2 tsp EVOO
• 1/4 cup balsamic vinegar
• 1 romaine heart
• diced celery
• 1/4 cup cooked quinoa, cold [I'd made the whole package for something else, and had about two cups left over]

Directions:

Coat the roast beef ribbons with the hummus. Toss into a salad with the lettuce, celery, and quinoa. Whisk together the mayo, EVOO, and vinegar; pour over, toss, and serve.

 

Hypocrisy drives me crazy, even if it’s inadvertent. The topic today is anti-vaccine breastfeeding proponents.

There’s lots of good science behind breastfeeding. So much so that there isn’t really any controversy over it. Nursing is a good thing. There’s still plenty of room for advocacy, of course, but the science is pretty settled. Breastfeeding advocates have no difficulty accessing, interpreting, and applying this science which is readily available from the literature.

If someone were to come up with a rogue study claiming that breastfeeding is dangerous, what do you think their reaction would be? What if they were able to discover that the guy who did the study was so unethical, he eventually had his license to practice medicine revoked and the study rescinded? I’ll bet you dollars to donuts they’d have no trouble using their scientific acumen to call bullshit on such a study, and on anyone with the audacity to use it to say anything negative about breastfeeding.

Why, then, are so many of these same individuals confirmed anti-vaxers?

The science behind vaccines, and the dangers of vaccine-preventable diseases, are just as settled as the advantages of breastfeeding. Yet when I try and point this out to my vaccine-resistant parents, they hide behind the plaintive cry, “But I’m not a scientist.”

News flash, folks: if you are able to do a literature search about lactation and understand it well enough to have a cogent discussion about it — as do the vast majority of nursing proponents  – then you clearly have the intellectual chops to understand the reality-based science behind vaccines. What you need is the integrity to recognize the intellectual dishonesty of the anti-vaccine movement.

Your kids’ health depends as much on vaccines as on breastfeeding.

Comment from my flash fiction post, GUN LAWS:

You called it.

with a link to this:

A city in Georgia is considering a proposal as soon as next month that requires every homeowner to own a gun. Citing limited police resources and slow response time, Nelson City Councilman Duane Cronic said armed residents would deter crime instead:

“When he’s not here we rely on county sheriffs–however it takes a while for them to get here,” said Nelson City Councilman Duane Cronic. [..]

“It’s a deterrent ordinance,” Cronic said. “It tells the potential intruder you better think twice.”

Another city, Kennesaw, Georgia, already has a mandatory gun ownership law, although it is not enforced. And outside of Georgia, a Milwaukee, Wisconsin sheriff recently urged residents to “get in the game” with a gun for emergencies, rather than call 911.

Cronic and others tend to argue that more guns mean less crime, based on scant evidence from two methodologically flawed studies. But academic consensus finds the opposite to be true: A survey by researchers at the Harvard University School of Public Health makes a strong case for the idea that more people die from gun homicides in areas with higher rates of gun ownership.

(HT: Buzzfeed)

All I got wrong was the state.

h/t JH (math teacher/friend of mine):

Students who slack off in math class become mediocre mathematicians; mediocre mathematicians create bad weather models; bad weather models FORECAST 3-6 INCHES INSTEAD OF ZERO. Lesson learned: do your math homework, kids.

Also:

Credit: Jason Butterhoff, via Pat Dransfield (whoever they are; ain’t Facebook grand?)

 

Following up on this post.

From the comments:

There are mid levels, and then there are mid levels. Just like there are doctors and then there are doctors.

Of course there are mid levels, and then there are mid levels; there are doctors and then there are doctors. There are also patients, and then there are patients, and there are specific problems occurring in specific scenarios and then there are specific problems occurring in specific scenarios.

Face it: most of the time, people seeking medical care (even in supposedly higher acuity settings like ERs) do not have anything seriously wrong with them. Most people will get better whatever is done for them. This means that most of the time, the care provided by mid levels is indistinguishable in terms of outcome from care provided by physicians.

Life is all about playing the odds, and the vast majority of the time, they are very much in your favor. 

Problems occur erratically. That means you don’t know when they’re going to happen. I’ve seen a guy with a fever and sore throat who turned out to have leukemia. Does it happen a lot? Of course not. Am I glad I’m the one who saw him and not the Minute Clinic PA who would probably have given him amoxicillin without even bothering to do a strep test? (Yes, I know they have protocols that say they’re not supposed to do that, but I’ve seen them do it anyway.) Hell yes. And so was the patient.

All I’m saying is that the more you know, the more you know you don’t know. Doctors by and large know more than mid levels (bell-shaped curve understood; some midlevels know more than some doctors, especially when the former are older and the latter are younger) which means that doctors have a better handle on what they don’t know. Which means that in situations more likely to be dangerous, it’s probably a better idea to be dealing with a doctor than a mid level.

As always, Peggy nails it:

The problem seems to arise when care is being managed by an MD who refers and then the patient is seen by a non-MD who then usurps the judgement of the MD who first saw the patient.

That’s exactly it. Although in this case, the PA didn’t seem to realize I had already seen the patient (even though the patient told her so; it’s the ER. Why listen to the patient when you can get a CT scan?)

Another option in this case would have been to call ahead to the ER and speak to an MD there to be sure the patient got the care he [needed].

I thought about that. Sadly, I’ve found I often have similar problems even when I call ahead. They usually pawn me off on a nurse, so I rarely get to talk to the actual physician. Frankly, I get less reliable followup that way then I do by asking the patient (or family) to call, as in this case.

Beef and Mushroom Dashi stir-fry:

Served over rice. Yum.

Recipe here.

“The more you learn, the more you realize you don’t know.”

You will hear this statement not just from physicians, but from lots of other folks engaged in scholarly work of all stripes. That’s because it is not merely true; it is a deep and universal truth that permeates all of mankind’s intellectual endeavors.

The implication of this for the practice of medicine is that a little knowledge can be very dangerous.

What do I, as a fully trained, extensively experienced primary care physician bring to the evaluation of patients who seek out my care that cannot be matched by so-called “mid-level providers” (PAs and NPs)? It is not (always) my knowledge, but rather the experience to know when I do not know something. In short, I know when to ask someone else’s opinion in consultation or referral.

I had a scary experience lately with a PA who didn’t even know what she didn’t know (and who still probably doesn’t realize it.)

The patient had been bit on the hand by a cat. I saw the injury approximately 9 hours after it had occurred. The patient had cleaned it thoroughly as soon as it had happened, and by the time I saw it,  it was still clean, bleeding freely, not particularly red or swollen, and only a little painful. Still; cat bites are nasty, especially on the hands. Therefore I began treatment with oral amoxicillin-clavulanate, and told the patient to soak it in hot water several times a day.

Six hours later (after one oral dose of antibiotic) the patient called me back: the wound was now much more painful, red, swollen, and there were red streaks going from the hand all the way up to his elbow. Frankly, I was a little puzzled. He was already on antibiotics; the single dose probably hadn’t had enough time to make much of an impact. And yet the infection was clearly progressing.

I called my handy dandy Hand man, my friend the hand surgeon I have on speed dial, whom I love because he answers my texts. This time, though, I picked up the phone and spoke to him. I explained the situation and my puzzlement. Here’s what he said:

Send him to the ER. He needs to admitted for IV antibiotics for 24 hours. If it’s not getting better by then, he needs a debridement [surgical procedure].

Okay then.

I called my patient and relayed the message. Just to be sure, though, I asked him to call me if they did NOT admit him.

On I went with my day.

Phone rings; it’s my patient calling from the ER:

They’re sending me home.

What?

They’re giving me a dose of IV antibiotics and sending me home on the one you gave me. They gave me the number of a hand surgeon to call tomorrow if it’s not better.

Hm.

I get on the phone to the ER, and ask to speak to the physician seeing my patient. Turns out it’s a PA, who proceeds to tell me that the hand doesn’t really look all that bad, she’s seen worse, and treated them like this before, sending them out with the blessing of the hand surgeon.

Hm. This is a fast moving infection that has worsened markedly in the last six hours while on oral antibiotics.

Did you consult Hand? I ask.

No.

Hm.

Long story short, I get the PA to call Hand Surgery (“Though I doubt they’ll come in,”) who successfully convinces the ER to admit the patient on 23 hour observation status with IV antibiotics. By morning (and 4 doses of IV antibiotics), the red streaks are resolving, the swelling and pain are decreasing, and the patient is good to go, to complete the course of orals.

I was concerned enough about this encounter to call the ER and speak to someone *in charge*. As part of our go-round, I was informed that there was always an ER physician available while the PA was seeing patients if there had been any concern, to whom the PA could turn. It was surprisingly difficult to convey the idea that the problem was that the PA did NOT have a concern. She did not believe that she needed to consult either with her supervising physician, or a specialist.

If I had not explained the (expected) plan to my patient, or specifically asked him to call if the plan was not carried out, or if I had meekly acquiesced to the “provider” on site since she was looking at the patient and I wasn’t (though the patient did take and send me a picture, which I was able to compare to one I took of the same injury 6 hours earlier), frankly I shudder to contemplate the outcome.

Primary care isn’t just about knowing stuff, and knowing what you know; more than that, it’s knowing enough to know what you don’t know.

Mid-level providers do not know enough to know what they don’t know. This makes them dangerous. Admittedly these situations are few and far between, which is what allows complacency to flourish. But make no mistake. Their education emphasizes what they know, leaving them with enormous blind spots of hubris into which more and more patients will fall, with predictably disastrous results.

 

 

Osso buco in crock pot, with boiled potato:

Recipe here (except made with lamb instead of veal.)

Two words: Dee. Lish.

 

I met a man with one leg.

He told me he had once been engaged to a double amputee, a woman with no legs.

He had to break up with her because she was running around on him.

Guaranteed 100% really happened. DDS can vouch.

So it turns out that we are discovering that all kinds of previously thought “vestigial” organs have actual, useful functions. Tonsils and adenoids, yanked with impunity in ages past, have been discovered to be important parts of the immune system. And now it is time for the appendix to take center stage:

The appendix may not be useless after all. The worm-shaped structure found near the junction of the small and large intestines evolved 32 times among mammals, according to a new study. The finding adds weight to the idea that the appendix helps protect our beneficial gut bacteria when a serious infection strikes.

Cool.

This conclusion was reached primarily as a result of anatomical studies comparing appendices of various species. Nothing really medical about it all. It occurs to me that the next step towards validating the hypothesis is quite straightforward, and not particularly involved or expensive. Additionally, because it can be done entirely via retrospective chart review, there isn’t even a smidgen of risk to patients.

I propose that someone review hospital records and see if there is any relationship between diagnoses of serious GI infections and appendectomy status. If the hypothesis is true, then patients admitted for serious GI infections would be expected to have undergone previous appendectomy more often than patients admitted for non-GI conditions.

I would love to do it, but some of us have to go see patients.

So come on, you ivory tower types: get cracking!

I called it! Almost three and a half years ago, to be precise.

• The date: September 24, 2009.
• The topic: Defining “Quality” of medical care
• My take:

What if [a] doctor decided that the best way to improve his P4P data was to discharge all the patients from his practice who, for whatever reason, failed to achieve acceptable control of their blood pressure and diabetes? Or who didn’t stop smoking? Or who refused to get a flu shot, or go for a mammogram, pap smear, or colonoscopy? As it happens, there’s nothing in the Hippocratic Oath against discharging patients. With enough money at stake in a P4P arrangement, this is inevitable.

Now along comes this, a question to Dr. Lin, the Common Sense Family Doctor:

For the past two years, I have been searching for a primary care physician who will not require that I undergo prostate cancer screening as a condition of accepting me as a new patient. Usually physicians don’t admit this directly when I ask them in the initial interview; sometimes, they actually agree with me that the PSA test and digital rectal examination are neither necessary nor beneficial. But something strange and frustrating happens after I leave each office: these physicians decide that they require screening after all and send me a letter, telling me in a short sentence that they won’t or can’t accept me as a new patient.

The comments reflect bafflement at what is going on here. Isn’t it obvious?

I’ll bet you dollars to doughnuts that most of these practices participate in some version of an Accountable Care Organization, or are beholden to insurance companies, which provide financial incentives too juicy to risk by accommodating patients with perfectly reasonable requests to forego needless health screenings. The real reason doctors have begun “requiring” that patients undergo all manner of screening interventions is to enhance their compliance ratios. After all, the quickest way to get to 100% is to get rid of everyone who falls short.

At first, I admit it sounded a little far-fetched. Would doctors really be so blatantly unethical as to “sneak” in unwanted screenings? Why on earth would they do it? It’s downright disgusting, but frankly, it’s the only (semi) legitimate explanation that comes to mind.

FSM help us as we continue our slide down this slippery slope. Today, it’s just reporting that we measured A1c’s and blood pressures; tomorrow, we doctors will be on the hook for the actual results. Watch as the trickle of discharge letters becomes a deluge.

Remember: you saw it here first.

My blogging has been going very well of late. I’ve gone from 5 regular readers to 7. And they write comments! With questions, no less:

My [spouse] and I are 63 and childless. We are thinking of spending $99 to get genetic screening…on the theory that it could help us plan a little better for our old age. Just as a random example, if I knew my chances for getting Alzheimer’s disease were high, I might want to move into assisted living sooner rather than later. We have many questions. Is this testing accurate? Does it raise more questions than it answers? What are the chances for our information remaining private in a real world where data leaks occur all the time? As a doctor, is this something you would consider for yourself?

Excellent questions. Here are the answers:

• Depends what you mean by “accurate”
• Yes (actually: Hell, yes)
• Iffy
• No way

Here they are in more detail:

Accuracy of genetic testing

We now have the technical capability of sequencing the entire genome of any given human. This is time-consuming, expensive, and not what commercially available genetic testing does. What they do is test for a panel of specific genes and gene variants. This they do “accurately”. What is still very much in the not-ready-for-prime-time phase is the relationship between those specific genetic variants and the emergence of actual, diagnose-able conditions like Alzheimers or diabetes. Even so, finding various genetic variants will never tell you that you will develop a certain disease; the best it can do is give probabilities. And even if those probabilities are high, it still can’t tell you when or how the condition will manifest.

Questions vs Answers

Because all you’re going to get is probabilities, you’re always going to have more questions: When is the disease going to show up? How will I know it? Is there anything I can do to prevent or delay its onset? How about minimizing its impact? Again, the relationship between the presence of certain genes (or genetic variants) and specific diseases is far more fuzzy than Marketing will ever admit. The specific site you reference appears to be geared more toward ancestry and family genetics, so I wouldn’t even be sure of the specific utility of any given result, especially in the context of financial planning.

Privacy Concerns

In general, my take on Internet Privacy is what I call the YouTube rule: yes, anyone can see anything you put up, but because there’s just…so…MUCH…of it, as a practical matter, no one can find anything unless they’re actively looking for it. The other piece of this is that yes, anyone can find out anything they want about you if they really want to, but by and large, unless you’re George Clooney, no one really cares enough to do so. Then again, you may very well run into the problem of insurance companies coming across (or worse, requiring you to provide) the information and then using it against you, either in terms of refusing to issue a policy or affecting your premium. So yes, that’s a very real concern.

And finally:

Would I spend the money to do this myself?

Absolutely not, and certainly not in the context of financial planning. My take on the current state of commercial genetic testing is that it provides no better medical information than a good family history. Are there situations when it may make some sense? Sure: adoptees with no access to medical information about their birth families may find it useful. Exploring one’s genetic heritage? Sounds like fun. But as a financial or estate planning tool? Worse than useless. My advice is to take the $99 and put it towards a good accountant or attorney with experience in end-of-life financial planning who will sit down with you and craft a strategy that makes sense for you.

Alt-text (extra caption) from this xkcd:

A human is a system for converting dust from billions of years ago into dust billions of years from now via a roundabout process which involves checking email a lot.

Single payer. Some love the idea; others not so much. Either way, there’s a picture supposedly in favor of Single Payer that is making the rounds on Facebook with a caption that proclaims:

THE USA DOES NOT HAVE A HEALTH CARE SYSTEM. IT HAS A DISEASE MANAGEMENT SYSTEM.

THERE IS NO PROFIT IN HEALTHY PEOPLE…DUH.

I hate to break it to them, but whatever you may think of Single Payer, there’s plenty of profit to be had from healthy people. Especially when you find ways to convince them that giving you their money is the only way they’re going to stay healthy.

There are legitimate ways in which healthy people can produce a revenue stream. Screening, by definition, is testing or procedures performed on healthy people. Mammography; colonoscopy; pap smears; well child exams; all profit-generating endeavors in and of themselves. Despite the drumbeat of “they just want to find more stuff they can treat,” bona fide screening programs are hardly loss leaders.

Then there are the less savory ways to extract money from healthy folks: chiropractic, naturopathy, homeopathy, acupuncture, nutraceuticals…the list is nearly endless. And that’s not even counting things like organic food, vitamins, supplements, and weight loss products directly marketed to the gullible public.

Somewhere in between those two extremes are what can most charitably be called “unnecessary care,” marketed to folks with more money than common sense when it comes to medical care, whose mantra is an unshakable “More is always Better.” The “Executive Physical”, annual stress tests, coronary artery calcium scoring, carotid artery testing, portable bone mineral density testing; procedures ranging from useless to unvalidated to debunked, still directly marketed in retirement communities and senior centers around the country.

Clearly there is plenty of profit in healthy people.

Duh.

Punxsatawney Phil, the famous groundhog of winter procrastination, failed to see his shadow today, anecdotallly predicting an early Spring.

Cool.

Only problem is that apparently, the renowned weather rodent has only a 39% accuracy rate in his seasonal prognostications.

Bummer.

Wait a minute, though: if you were to make the prediction randomly, you’d expect approximately a 50% accuracy rate. At 39%, Phil is more often than not wrong in his forecast. This means that he is (somewhat) reliably incorrect. Therefore by essentially switching the polarity of his prediction (in other words, break out the short sleeves if he DOES see his shadow) you will have a better than average chance of being correct, ie, not freezing off your buns in a too-light sweater.

Everyone got that? If not, I can always run through it again…

I’ve said it before, I’m saying it again: this girl can flat out write. Not only that, she promulgates wisdom beyond her years in bulleted lists: 19 Things I Learned in College.  Kaleigh, some people will never learn all those things, no matter how many degrees they hold nor how long they live.