Posted by: notdeaddinosaur | July 21, 2014

Personae Public and Private

The house is done; we’re all moved in, mostly unpacked, and just starting to get organized. The guest room is my temporary writing room. No more excuses. Back to blogging.

My post analogizing car seats to vaccines has taken on second life thanks to a cool Australian site (Thanks, Mamamia of Oz.) This in turn has generated more comments (thanks, all!) including a long, thoughtful one from Patrick, who begins thusly:

I honestly believe there is fault on both sides of this debate. Vilifying and ridiculing each other doesn’t bring about good health results.

I feel the need to clarify something here:

I am not the same in person as I am on my blog.

In person, dealing with patients one by one, I neither vilify nor ridicule. I take my time, explaining in however much detail a given patient or parent wants to know, about anything and everything. How does this blood pressure medicine work? Where to kidney stones come from? Why won’t you give me an antibiotic for my cold? Is there any substance to these scary things I’ve heard about vaccines?

Even when people clearly do not believe what I am telling them (not “do not understand”, but “do not believe”) I remain polite, as I try to persuade by explaining. Analogies; stories; diagrams; articles; whatever it takes. I strive at all costs to educate.

So what happens when, after explaining AND ascertaining that the patient understands, she says in essence, “I don’t believe you.”

Nothing.

I don’t tie the kids down and vaccinate the m against the parents’ will. I don’t yell, I don’t wag my finger, I don’t shake my head sadly as I leave the room. Nothing.

Above all, I remain professional.

After a while, though, all those encounters begin to take their toll. Being called a liar tends to get me down. News flash: I’m human. So what do I do?

I take to the blog and hammer away at the idiocy of the antivaccine leaders and the sheeple who follow them. I flay the alt-med charlatans with words (though not nearly as eloquently as these guys.) Yes, I ridicule. Yes, I vilify. Yes, I shout from the hilltops, spreading far and wide the truth of science: vaccination works. But only online.

I find it amusing to intentionally adopt a far more curmudgeonly attitude here than I would ever dream of displaying in meatspace. It’s part of the fun of blogging, which is why I’ve been doing it now for almost eight years.

All I ask is recognition that my public blog persona is different from my personal, real self.

 

Posted by: notdeaddinosaur | July 12, 2014

Built a House (27): Final

House final

It’s done. We’re all moved in. So is our stuff; well, most of it. The piano arrives in a few more days. Then all we have to do is unpack, hang art, paint; you know, make it ours.

Once that’s all accomplished — or at least once I’ve cleared away a spot to sit down with a computer — real blogging will return. For all of you who followed along (three or four, I think) thanks so much for hanging in there with me.

 

Posted by: notdeaddinosaur | June 29, 2014

Not Just Tacky…

Wandering around Lowes picking up stuff for the new house, I came across this:

Tiki tacky

How tacky is this? Not just tacky. It’s….

 

 

 

…Wait for it…

 

 

 

Tiki tacky.

Posted by: notdeaddinosaur | June 25, 2014

Building a House (26)

House 26 (2)

Landscaping is in. Sod will be placed either the day before or the day of settlement, still on target for next week.

We had our walk through yesterday and everything looks great. Well, except for the dozens of sticky dots indicating painting and spackling imperfections to be addressed by yet another once-over by the painters and trim guys.

Moving day tentatively set for week after next. The journey is coming to an end…with a brand new one about to begin.

 

Posted by: notdeaddinosaur | June 16, 2014

Yahrzeit

Carousel 6-0057 (2)

28 years. Gone from our lives, never from our hearts.

candle

Posted by: notdeaddinosaur | June 15, 2014

“Energy” Does Not Mean What You Think it Does

Every time I think I’ve seen it all, something new blows me away:

Energy wataah

For those with trouble reading the fine print, this is “Energy Wataah”, on the shelves along with regular “Wataah”. As soon as I saw that word “Energy”, I thought “caffeine”. But no. Here’s what that green fine print on the label says:

Forget about caffeine and sugar. Ultra pure water with just enough oxygen is all the clean fuel your body craves.

WTF?

Water and oxygen are both critical for proper bodily functioning, but “energy”? “Energy” or “fuel” for the body comes from calories, found in carbohydrates (like sugar), fat, protein, and alcohol. Nothing else contains calories. Water and oxygen are necessary for burning them properly, but no matter how you twist the semantics, they’re not “energy”.

Here’s the thing, though: anyone know what you get when you add oxygen to water? Anyone?

Hydrogen peroxide. ( 2 H2O + 02 –> 2 H2O2)

Not really. That equation is thermodynamically backward. Bubbling oxygen through water will just give you water with bubbles of oxygen, which will probably come out of solution, collect at the top of the bottle, and escape into the atmosphere the moment you open it.

Besides, drinking oxygen isn’t going to do a thing. Oxygen is transported through the body attached to hemoglobin, a protein found in red blood cells. Red blood cells pick up oxygen when blood flows through the lungs, not through the stomach or the intestines.

This product makes no sense physiologically, chemically, or thermodynamically. Yet somehow this company figures it can get unsuspecting scientific illiterates to fork over six bucks for twelve little bottles of this stuff.

Unbelievable.

Edit: Clearly this is a New England based company. If it were in Philadelphia, they’d call it “Wooder”.

Posted by: notdeaddinosaur | June 14, 2014

Building a House (25)

photo (3)

The front door has been painted black, and the final trim/flashing/whatever-it’s-called has been added across the bottom parts of the roof line over the garage. Now the outside just needs some sealing and painting (mainly the half columns on the front porch), landscaping, and sodding.

Inside is practically done. They’re working hard on the final painting and trim; then it needs a really thorough cleaning. Everything still on schedule though.

 

Posted by: notdeaddinosaur | June 11, 2014

Driving While Hypertensive

The Second Law of the Dinosaur states:

It is impossible to make an asymptomatic patient feel better.

So true.

Chapter 2 of my book, Declarations of a Dinosaur, discusses how I handle a patient who may be asymptomatic at present but who will not remain so for long without taking my advice. Essentially, I explain in as much detail as necessary to create just enough anxiety, which can be relieved by doing what I say, be it taking pills, quitting smoking; whatever.

Another way of looking at it is that although the patient may not feel there’s anything wrong with him, my anxiety spikes when I see things like a hemoglobin A1c of 14 %*. All I have to do is find a way to get my patient to feel the same level of alarm as I feel.

This is what I did a few months back when I saw an African American gentleman with a blood pressure of 210/130. He hadn’t been to see me in quite a while (I think his BP had been a little elevated then and he was afraid of what it was going to be now). It also turned out that his LDL was 180, and his A1c was 12%. I felt like I was on the verge of a cardiovascular event just sitting there in the room with him! With that collection of risk factors, he was literally a heart attack waiting to happen. And that’s what I told him.

He felt fine. No chest pain; no headache; no retinal changes. No symptoms at all (which was why he didn’t meet the criteria for a diagnosis of Hypertensive Urgency with its attendant trip to the ER). Still, as I explained to him, if I were to get a phone call the next day that he had dropped dead of a stroke, I wouldn’t be surprised.

He hated pills. That was another reason he hadn’t returned earlier. Carefully prioritizing the situations, I prescribed two antihypertensives (in a single combination pill) and a statin. Hardly optimal therapy, but I wanted to start him as slow as I felt was safe, explaining at length exactly how scared I was, and how important the pills were.

He said he understood, taught it all back to me to show he got it, and thanked me, setting up an appointment the following month to see how he was doing.

Job well done! Or so I thought.

Next month he comes back.

“How are you doing with the new medicines?” I ask.

“Well, I didn’t start them.”

Aack!

“Why?”

“I don’t know.”

Double aack!!

Blood pressure was still over 200. Another month closer to that stroke. How could I have failed so utterly to get through to him? No idea. I had to try something else; some other way to communicate to him the emotions these encounters had produced in me.

I had an idea:

“Listen,” I began, “Have you had the conversation with your sons about ‘driving while black’?”

“Oh yes,” he replied. “Of course I have.”

“Okay,” I continued. “Do me a favor. Think for a minute about how you would feel if, after you had this conversation with your son, knowing what you know about the world we live in, he came home one night and told you that a police car tried to pull him over, but he managed to ‘get away’? Or that he was stopped, and boy did he give that cop a piece of his mind. Somehow, he lucked out, and got off without serious consequences. But wouldn’t your heart be in your throat, aware of the risk he had taken? Even worse, that he didn’t even seem to recognize it?”

My patient was nodding.

“Well, that’s how I felt hearing that you’re not taking any of the meds I asked you to. Seeing how high your blood pressure still is gives me palpitations. Please, please, please…please start taking the pills.”

This time I got through to him, and I’m pleased to report that three months down the road, we’re on the right track at last.

 

 

*(corresponding to an average blood sugar of 355; poorly controlled diabetes, with increased risk for heart attack, stroke, blindness, kidney failure, impotence, etcetcetc.)

Posted by: notdeaddinosaur | June 9, 2014

Building a House (24)

House 24
We now have trim over the garage and windows, a lamppost, and downspouts. The deck — really just a landing and a few stairs — out back is also done:

20140609-213137-77497056.jpg
Just a few more weeks to go.

Posted by: notdeaddinosaur | June 4, 2014

Building a House (23)

House w-shutters

Brick is completed and cleared from the front yard. Shutters are up. The deck is going on the back (really just an oversized landing with a small flight of stairs.)

Inside: tile is complete. Finishing is in progress.

Closing 4 weeks from today; on schedule.

 

Posted by: notdeaddinosaur | May 31, 2014

Building a House (22)

House (22)

Finally the brick is done. Actually, there’s still one small row of it to go under the front door, but clearly the vast majority is completed. The “holes” over the garage doors and window are where the trim will go. The front door will be painted and shutters will be added to the single first floor window.

Indoors; well, indoors is magnificent! Hardwood flooring is down (and protected with cardboard and duct tape), the kitchen cabinets are in, as are the counters (covered with protective plastic that makes them look weirdly blue.)

Still a lot to do: bedroom carpets, installing appliances, finishing up the tile, trim, painting, and fixtures. Outside there’s a lamp post that still has to go in (whenever the brick is finally moved out of the way), a light between the garage doors, and a tiny deck out back. Plus grading, landscaping, and sodding.

However we cut it, though, it’s definitely closer to the end than the beginning.

 

 

Posted by: notdeaddinosaur | May 31, 2014

American Rights

Americans have rights. Most of these rights have limits, though. For example, even though the First Amendment to the Constitution guarantees the right to free speech, Americans do not have the right to yell “Fire!” in a crowded theater.

There is one right, however, that would appear limitless. I’m referring of course to the right to be stupid. I suppose this means that someone can walk into a gun show and yell, “Bad guy!”

Posted by: notdeaddinosaur | May 24, 2014

Urgent Hypocrisy

I received a solicitation in the mail to apply for a position at a new company moving into my area, forthwith to be known as the “Facility for Urgent Care, Killer-Docs, that’s going to be opening a new office nearby:

FUC, K-Docs is looking for physicians who enjoy the practice of medicine, and the chance to focus exclusively on patient care. If you are looking for freedom and autonomy without the heavy financial and administrative burden associated with establishing and maintaining a practice, FUC, K-Docs may be right for you.

Cool. Unlike too many other primary care docs these days, I still very much enjoy the practice of medicine. It just so happens that I have found the greatest freedom and autonomy comes from having my own practice instead of being an employee. But hey; maybe this is something I should think about.

I read on:

Responsibilities include, but are not limited to:

  • Providing the highest quality* patient care while on shift.
  • Managing all patient care at the center while on shift.
  • Supervising all medical staff while on shift.
  • Ordering and reading all diagnostic x-rays and labs.
  • Ensuring medical staff follows proper protocols and conducts patient callbacks.
  • Ensuring pharmacy and CLIA approved laboratory compliance with regulations.
  • Ensuring center has all the necessary urgent care equipment, supplies, and medications.
  • Ensuring accuracy of ICD-10 coding.
  • Participating in the hiring and training of medical staff on shift.
  • Compiling quality data and addressing with medical staff as needed.
  • Participating in monthly conference calls with Chief Medical Officer
  • Ensuring all charts and medical records are accurately completed in a timely manner.
  • Ensuring patients are discharged with detailed instructions.
  • Collecting biological specimens and process them in the lab when needed.
  • Adhering to all center policies and procedures.

Excuse me? Only four out of the fifteen items on that list address actual patient care (bolded by me). Sounds to me like all of the hassles of running a practice — a pretty good-sized one at that — without any of the actual authority of ownership.

How could that introduction, followed by that list, be written without the author’s head exploding from sheer irony? It’s downright Orwellian.

It even turns out the guy opening the place isn’t even a physician. Figures. More money to be made getting doctors to manage, supervise, compile, ensure, participate, and adhere than by actually practicing medicine.

Sorry, dude. Not buying it.

* Defined as…?

Posted by: notdeaddinosaur | May 23, 2014

Building a House (21)

20140524-222326-80606026.jpg

Approximately one half of the brick done. It took three days, which means that the unofficial estimate of another three days sounds about right. Unfortunately, nothing is going to happen until after the holiday weekend, though we’ll probably still go out there and keep poking around.

Posted by: notdeaddinosaur | May 22, 2014

What if Car Seats Were Like Vaccines

What if a big TV station, say WTOP in Washington DC, came out with a blockbuster story claiming that infant car seats were implicated in cerebral palsy? After all, something like 99.7% of babies diagnosed with cerebral palsy had been brought home from the hospital in a car seat. In fact, every single time they went anywhere in a car, they were strapped into them. That’s an impressive number. There has to be some connection!

Imagine video of kids crying piteously as they’re buckled into the wretched contraptions. After all, car seats are restraining and uncomfortable. Kids hate them! But parents have been duped into using the damn things claiming it makes their children safer. Pshaw! How could a baby be safer anywhere other than in its mother’s arms?

Suppose this idea gained traction. Cerebral palsy is a dreadful thing! Why take the risk? Don’t use those nasty old car seats. Besides, don’t you know that the doctors who recommend them are all getting kickbacks from the manufacturers? [Less preposterous than kickbacks from vaccine manufacturers. Far more money in car seats.] Some Playboy celebrity reality centerfold comes out as the spokesperson against car seats. Suddenly there’s pushback from new parents who want to decide for themselves what the safest way is to transport their precious bundle. Never mind decades of car seat research. They may not be automotive engineers, but their parental gut feelings are good enough. Besides, no automotive engineer ever had to listen to their baby cry whenever she gets strapped in.

Facebook communities emerge where car seat refusal is supported and celebrated as the newest way to keep babies safe. Parents are carefully steered to “research” that hypes the dangers of CP. “Why take unnecessary risks?” becomes their mantra. Because the hype is scary. Parents of kids with CP conspire to sue the car seat manufacturers, because “Someone’s got to pay!” Why did this happen to their child? No one has any good answers [hint: It's not birth trauma] and vague discussions about prenatal injury to the brain like “Sometimes these things happen” is just not good enough.

Of course there’s no plausible connection between car seats and cerebral palsy. But that doesn’t matter. Studies are done to try and prove car seats don’t cause CP, which is technically impossible, since you can’t prove a negative. The anti-carseaters deny that they’re against car seats. They just want “safe” ones — defined as ones that don’t cause cerebral palsy. Do a large double-blind trial: randomly assign some babies to car seats and some to be held in mom’s arms and see how many in each group develop CP, they cry. It will take nothing less to convince them.

What happens? By and large, nothing much. Most kids don’t develop CP, however they travel in cars. And the vast majority of babies who ride in mom’s arms arrive safely at their destinations. There is a small uptick in infant fatalities that steadily grows as more and more people refuse to use car seats, but not many people take notice. The occasional family is devastated by the loss of a baby in a crash, and vow to tell their story high and wide. They do, but the only minds it changes are the ones that weren’t already made up.

Far-fetched? Sadly, not so much.

 

Edit: NOT plagiarized from this, which in turn is probably not plagiarized from this or this.

h/t TBTAM for the second 2 links.

 

 

Posted by: notdeaddinosaur | May 20, 2014

Building a House (20)

House 20

New mailbox.

Inside: Painting has occurred. Final electrical has begun. Most light fixtures are in, though not all. On track to close in about 6 weeks.

Posted by: notdeaddinosaur | May 20, 2014

To Refill, or Not to Refill?

I have an ethical dilemma, and would appreciate the opinion of the Collective.

Patient with controlled hypertension who hasn’t been in for a visit for over 2 years keeps requesting refills on her medications, despite multiple requests and decreasing quantities first of refills, then of medication quantities. We are finally down to my Note to Self in the Refill field, “No more refills without visit.”

Pharmacy request comes in for refill. No call from patient; no appointment on the schedule. Ideally, I like to see my hypertensive patients twice a year, but I’ll settle for annually. This patient hasn’t been in for over three years.

What to do?

First round of analysis: What are the harms of going off BP meds? Answer: potentially significant, in that patient is on several meds which are controlling BP well, and has other cardiovascular risk factors. 

Next, anticipating the patient’s objections to a visit: Why exactly to I need to see her? We call it “monitoring”; making sure her BP is still controlled, and that there are no side effects or other related (or unrelated) problems emerging. “But you never do anything,” I hear her responding, and it’s hard to argue. It certainly seems that the greater benefit comes from continuing to authorize the refills.

What’s the down side? This: What if something changes, and either the BP is no longer controlled, or something else happens as a result of the meds (kidney failure comes to mind)? I can just hear the lawyer bellowing, “Why were you continuing to prescribe these dangerous medications without monitoring them?” causing the jury to come back and strip me of all my worldly goods. 

So what to do? Refuse the refill and risk having her stroke out from uncontrolled blood pressure? Or keep on prescribing without seeing her? If so, how long? Four years? Five? Ten? 

Another option, of course, is discharging the patient from my care. But that’s not going to help her in the long run, nor me in the short run. (Discharging a patient is at least a 30-day process, and involves certified mail, which costs money and involves a post office run.) I would prefer not to go that route.

Thoughts?

 

Posted by: notdeaddinosaur | May 16, 2014

Building a House (19)

House 19

And garage doors.

Not sure why the brick hasn’t gone up yet.

We have reason to believe that painting will begin inside today.

Posted by: notdeaddinosaur | May 14, 2014

Building a House (18)

House 18

Now with a driveway.

Inside, the trim is virtually complete, and boy does it dress the place up! It’s still very white (which it will be for the first year or so; wait for the nail pops before painting is conventional wisdom) but oh so elegant. Seven weeks to closing, but with the final walk through a week before that.

Starting to get excited.

Posted by: notdeaddinosaur | May 13, 2014

Dinner

Veggie Meatloaf:

photo (8)

That’s meatloaf with veggies (almost more veggies than meat.) Not meat-free.

INGREDIENTS:

  • 1 lb ground turkey
  • 1 tbsp olive oil (for sauteing)
  • 1/2 cup chopped onions
  • 1/2 cup chopped celery
  • 1/2 cup chopped bella mushrooms
  • Leftover cooked corn from one cob
  • 1 egg
  • 1-2 tbsp barbecue sauce
  • 1 cup panko bread crumbs
  • Salt & pepper to taste

Saute chopped onions and celery in olive oil about 3 minutes until soft. Toss in mushrooms and saute another 2-3 minutes. In large bowl combine turkey, cooked veggies, corn, egg, BBQ sauce, salt and pepper to taste. Add panko, stirring just until mixture holds together. Turn into loaf pan and top with more BBQ sauce. Bake at 350 degrees 35-40 minutes.

Yum.

 

Posted by: notdeaddinosaur | May 12, 2014

Building a House (17)

House 17

The hardscape is taking shape; we have a front walkway, a sidewalk, and a driveway apron. Inside, the drywall is all done; taped, beaded, spackled, and sanded. Walking through it you can get a real sense of the space…and it is magnificent.

Posted by: notdeaddinosaur | May 7, 2014

All Physical Exams are Not Created Equal

Once again, I am in receipt of a letter from a specialist (a surgical subspecialty, of course) that has me alternately shaking my head in disbelief and trembling with fury.

The letter was clearly crafted with electronic medical record software to support billing as high a level office visit as possible. In addition to a complete specialty-specific organ system examination, a “Multi-System Physical Examination” was also documented:

  • Constitutional: well-nourished, no physical deformities, normally developed, good grooming
  • Neck: neck symmetrical, not swollen, normal tracheal position
  • Respiratory: no labored breathing, no use of accessory muscles
  • Cardiovascular: normal temperature, normal extremity pulses, no swelling, no varicosities
  • Lymphatic: no enlargement of neck, axillae, groin
  • Skin: no paleness, no jaundice, no cyanosis, no lesion, no ulcer, no rash
  • Neurologic/Psychiatric: oriented to time, oriented to place, oriented to person, no depression, no anxiety, no agitation
  • Gastrointestinal: no mass, no tenderness, no rigidity, non-obese abdomen
  • Eyes: Normal conjunctivae, normal eyelids
  • Ears, Nose, Mouth, and Throat: left ear no scars, no lesions, no masses, right ear no scars, no lesions, no masses, nose no scars, no lesions, no masses, normal hearing, normal lips
  • Musculoskeletal: normal gait and station of head and neck [whatever the hell that means]

This is verbatim, by the way.

If I saw this from a medical student, it would be a big fat fail. Oh, there are plenty of bullet points, and they’re arranged in enough lines to pass the billing clerk’s checklist. But it basically says next to nothing.

The really interesting thing about this writeup is that although the patient is being seen for an unrelated problem, it completely fails to convey that she is actually a heart-lung transplant candidate. This surgeon probably doesn’t even own a stethoscope anymore, because anywhere you’d care to put one on this patient’s chest reveals findings that are anything but normal. She’s missing a lobe of one lung, and her heart swishes and hums more than it lubs and dubs. Frankly, I doubt the specialist even realized there was anything wrong.

More proof, as if it were needed, that EMRs document for billing instead of medical care.

Posted by: notdeaddinosaur | May 6, 2014

Princess Dressing; or, You Can’t Fight City Palace

Princess

Daughter of a friend turns 7. Proud mama posts pic, with apologetic self-flagellation about having “given in to princess dressing.”

Question: What do you think mothers in the ’50s and ’60s would have done if they’d had things like Facebook, Twitter, and the Internet?

  • OMG! How is my poor little Agnes ever going to find a husband, going around in dungarees like that all the time?
  • All this pressure on young girls to “express themselves” by dressing however they feel like is preposterous!
  • This “women’s lib” is such a scourge. It’s not like when I was a girl!

I thought the whole idea behind raising girls (and boys, for that matter) was teaching them that it’s what’s inside that counts. Wasn’t there something about not judging a book by its cover? I understand that there’s still this pesky thing called “the outside world” populated by the ubiquitous “other people”, where external pressures and snap judgments are rampant. But isn’t the whole idea of parenting to instill that internal sense of Okay-ness that allows the child’s genuine self to shine through, however clothed?

I’m not talking about appropriateness. Certain venues call for certain modes of dress, which young children are not equipped to accurately judge. Party dresses aren’t worn to school, and jeans shouldn’t be worn to church. But if there are other times when kids are offered the choice of what to wear, the least we can do is respect those choices.

What’s the difference between telling a girl, “Oh no! Not a princess dress!” and “Oh no! That’s what boys wear!” Don’t both statements have the effect of devaluing the girl’s choice?

I have another friend whose daughter used to put together the funkiest outfits for school. The kid was a hippie whose mother had worn Catholic school uniforms. Teh horror! Bottom line: so what? Advice was given (and taken) to choose one’s battles, and the kid ended up a lawyer.

I understand that “society” (the collective version of “other people”) is doing terrible things to girls (and women): hypersexualizing them, objectifying their bodies, devaluing them as thinking, feeling, inherently worthwhile beings with a right to, well, themselves. I agree that it’s a fight that needs to be fought.

But it’s still okay for a seven-year-old to dress up like a princess from time to time.

Happy Birthday!

Posted by: notdeaddinosaur | May 5, 2014

What Gun Extremists and Anti-vaxers Have in Common

What kind of a masochist am I? Sticking my head back into the lion’s den snake pit and taking on the gun nuts again. Not the responsible gun owners, though. It turns out there really are such people, and apparently they actually outnumber their more vociferous crazy-heads compatriots. Nevertheless…

In medicine, we try to use scientific research whenever we can. Research is more than just someone saying something is so because they believe it to be so (see: Acupuncture). There are objective rules and standards by which people other than those doing the research can feel confident of the accuracy of the findings.

Every now and then, someone comes up with a research result significantly different from previous studies. (See: Galileo) Often this kind of result appears to make no sense at all, as it may be the complete opposite of the currently understood state of the issue. What to we do with this kind of confounding information?

First off, we try to replicate it. If the new findings are in fact true (that is to say, scientifically accurate) then properly done studies will have similar results. We call this “confirmation.”

What happens when studies fail to replicate the odd finding? The next step is to figure out (if possible) where the aberrant result came from. Were the researcher’s statistics flawed? Did he draw incorrect conclusions from his data? Might he just have made shit up? Did he have something to gain, financially or otherwise, from the unusual result?

Much of the opposition to vaccines, MMR in particular, stems from the work of Andrew Wakefield, whose Lancet article of 1998 purported to show that the MMR vaccine caused autism. It doesn’t. Many people tried very hard to replicate Wakefield’s results, without success, in the process pretty much proving the safety of vaccination, as much as a negative can be proven. Eventually the Lancet retracted the paper, Wakefield’s license to practice medicine was suspended, and the entire MMR-autism hypothesis was definitively refuted.

Except to an increasing number of hard-core antivaxers, who contend to this day that Wakefield was railroaded and that his findings were legitimate. Somehow they cling to the discredited results from a single researcher, denying the findings from numerous other sources that say they are wrong.

What does this have to do with guns?

Guns are dangerous. They have their uses, but only in the proper hands, with proper training, and with proper safeguards. Legitimate research has borne this out over and over again. (See Harvard Injury Control Research Center) And yet in any discussion when true gun extremists are called upon to cite evidence for their position that more people with more guns is a good thing, they always quote the same source: a book called More Guns, Less Crime (not linked; easily found) by a man named John Lott.

Turns out that the findings of this book (and this researcher) have been debunked over and over and over again. Furthermore, when confronted with inconsistencies in his research, Lott changes his story. This has gone on long enough that serious researchers in this field no longer consider his contributions credible.

Just like the anti-vaxers, this doesn’t stop gun extremists from clinging to the findings of a discredited academic as they go on insisting that the dangerous notion of “more guns means less crime” be used to guide policy. As dangerous as vaccine-refusal is, I daresay more people have died in this country from gun violence than from vaccine-preventable diseases.

There is something called Scopie’s law, which states:

In any discussion involving science or medicine, citing Whale.to [a known source of anti-scientific nonsense] as a credible source loses you the argument immediately …and gets you laughed out of the room.

I hereby propose Dino’s Gun Corollary to Skopie’s law:

In any discussion involving guns or firearms policy, citing More Guns, Less Crime or any other writings by John Lott as a credible source loses you the argument immediately.

I wouldn’t laugh at them, though. There’s nothing funny about guns.

 

Posted by: notdeaddinosaur | May 3, 2014

Building a House (16)

House 16

All the siding is now finished. Everything left wrapped in green will soon be brick, which has already been delivered to the front yard. Inside, the drywall is just about done. They still have a lot of work left on it, beading, taping, spackling, etc. But it’s coming along very nicely indeed.

We also have a new neighbor to our right (left in the picture). There’s another one on the other side that’s due to be framed any day now. Within a few months of moving, we’ll have neighbors.

Posted by: notdeaddinosaur | May 2, 2014

Home

Home

 

For almost thirty years, this was home. I secured the mortgage the same week I matched for residency. I moved right before medical school graduation.

Throughout my training, this was home. This was where I came post-call to lay my bone-weary head. Middle-of-the-night hospital calls rang here; this was where I came back to afterward.

I raised my family here. Babies brought home, watched as they learned to walk and talk, headed out to school (walking to elementary school around the corner), quickly becoming taller than me, and finally heading out into the world on their own.

This was their home.

This place saw its share of anger and fear along with love, joy, and triumph. My heart was broken here, though it mended with time as most things do. Love and joy returned.

It looked a little different at the beginning. Over the years it got new siding, an extra bedroom, a wider driveway, a new deck, a storage shed. It had more trees when I first moved in. Inside, every single room was eventually re-done. Twenty-nine years is a long time.

But no more. With kids gone, there’s no reason to bounce around in such a big place. Time to move on to smaller digs; someplace with an “open concept” and a first floor master. Near enough to get to work conveniently, but definitely a different neighborhood.

It feels strange. Even over these last four months of apartment living, I could still go over there whenever I wanted. But as of today, I no longer own the place. Make no mistake: it’s a huge relief to have the sale finally a done deal. But still; twenty-nine years is a long time. It will be a while yet, but I’ll get there. Watching the new house come together is exciting.

But today I pause to remember: Home.

Posted by: notdeaddinosaur | May 1, 2014

Healthcare Derivatives

I just realized what all these new insurance intermediaries and programs and organizations (all composed of people who don’t provide medical care to other people) remind me of: Derivatives! And we all remember how well that worked out for stocks a few years back.

Let me ‘splain.

A few years back, a bunch of Wall Street crooks financiers came up with a bunch of new ways to package various stocks and securities that were intended to be too convoluted for anyone to figure out that they were nothing more than a way to relieve gullible investors of their money. It worked. Really well. Well, until the housing market collapsed and the country plunged into near economic collapse. But hey; these things happen. Remember, it was all legal. It just wasn’t a very good idea. Take home message for investors: stick to owning pieces of real companies. Whatever else happens, there will always be people who need things like houses, cars, food, and other goods and services.

Now look at what’s happening to medical care: first we had insurance companies bully their way into the doctor-patient (financial) relationship, and over the years, boy have they thrown their weight around. “Administrative costs” have generated such enormous profits, many of them have cast themselves as major philanthropists in their markets. They have to; technically they’re “non-profit” organizations. Nice work if you can get it.

Back in the 1990s, they tried something called Managed Care. The stated aim was to improve patients’ health (whatever that means), but the real object was to shift financial risk back onto the doctors. Before this, if a patient visited the doctor five times in a year. the insurance company would have to pay five times as much as if he only went once. So they came up with something they called Capitation: they paid the doctor a certain amount per person per month, and that was it. The only other pay the doctor got was a small co-pay from the patient (they started at $2.00) whenever she came in. If a patient came in ten times a month, the doctor only got an extra $20. Sweet deal for the insurance companies.

They also instituted things like Referrals, turning physicians into Gatekeepers. They withheld part of the physician payments (called “withholds”, of all things) which the docs could earn back by not spending (technically but not authorizing spending) too much on labs and other testing, specialists, and hospitalizations. As a practical matter, money withheld was rarely seen.

This didn’t work. Well, it worked great for the insurance companies. Lots of people made boatloads of money. But doctors and patients hated it; so much so that it mostly disappeared. Mostly. There are still two huge capitated programs I’ve been with for twenty years now, and I can’t drop them because the companies’ standard contracts (summary of negotiations: options include taking it or leaving it) include something called “all products” clauses. Have to take the capitated plans to participate in the others. Also, I still have lots of long-term patients in those plans, and wouldn’t you know it: referrals remain the bane of my existence.

But doctors and patients hated it. Eventually, the large employers moved away from them as the prices increased. Because golly gee: turns out they didn’t really save any money. Imagine that!

Now here we go with round two. Apparently not content to just siphon off money paid by patients intended to pay for their medical care, now the insurance companies are trying to get the doctors aboard, mainly by paying the early adopters tons of money to recruit their gullible peers. Things like the Medical Home, Team Care, Accountable Care Organizations, and so on are nothing but a shell game designed to divert funds away from the people who provide medical care (doctors) to people who are sick or hurt (patients).

Now these huge companies (and some smaller ones, but the bigger ones have better marketing departments) have even got government suckered in. They use words like “evidence” and “data”, promising that somehow the more bits and bytes of information they collect (most of which are completely meaningless) will result in spending less money for medical care while improving outcomes (another term they never define).

Guess what: It’s not going to work. Oh, the companies are going to do great (defined as “making a boatload of money”; investors take note.) But patients are not going to benefit materially. Doctors (the ones taking care of the patients, not the ones who defect to Administration) are not going to benefit. The system will dissipate, hopefully without collapsing too badly. And the doctors and patients will be the ones left to pick up the pieces.

You want better medical care? Find a way to pay doctors a fair compensation for their services. (Single payer works well in much of the rest of the world.) Get the insurance companies and other middlemen out of medical care financing. Let Medicare negotiate drug prices (at the moment, by law, they have to pay whatever the drug companies charge.) Ban direct-to-consumer pharma advertising. While you’re at it, ban hospital advertising as well. Use the money to pay for more nurses.

You want healthier citizens? Increase tobacco taxes to decrease smoking. Find ways to increase seat belt and helmet use. Enact sensible firearm laws to keep kids from dying from rampant gun violence. Address income disparity to ease the intolerable socioeconomic stressors of intractable poverty. Notice that none of these things actually involves doctors or medical care.

But please: pay attention to the man behind the curtain. Keep your eye on the ball. Medicine is about people called doctors taking care of people who are sick or hurt. Always was. Always will be.

I had a silver-and-gold Passover. Hearkening back to the old Girl Scout song I learned from my mother:

Make new friends, but keep the old;
One is silver and the other’s gold.

With no space or equipment to have a seder myself, I was nevertheless the lucky recipient of not just one, but two invitations. The gold was thanks to a quarter-century-plus friendship; the silver was from a family we met the week before Passover. Who should I meet at the seder but a legitimate health policy guru, with whom I promptly struck up the first of hopefully many spirited discussions on the state of healthcare (or, as it is correctly called, “medicine”) in the US today.

How would you fix it? I asked him.

He responded that he would allow any payment structure at all, except fee for service, which he would outlaw.

Hm, I thought. What’s so terrible about fee for service? Doesn’t nearly every other private enterprise in the country operate on the basis of paying for services rendered?

Ah, he said. But with fee for service, there’s no accountability.

Whiskey, Tango, Foxtrot, I thought (because I was of course far too polite to come out and say it to someone I’d just met.)

Accountability. I do not think that means what you think it means.

Accountability, per Dictionary.com,  is “the state of being liable or answerable.” Being “answerable” presumably means that when something goes wrong, he who is accountable is the go-to guy for blame. The bit about “liable” would imply a monetary dimension to the exchange.

What does this mean in medical terms? “When something goes wrong, someone has to pay”? Sounds rather like a rallying cry for the plaintiff’s bar. The problem is that in medicine, the line between doing something wrong and something bad happening is far less straight than may be imagined.

Another issue is that bad things often happen to people which is no one’s fault. Tumors metastasize; organs fail; people even die. (Actually, all of them will eventually.) Where does “accountability” come into it?

The health care policy guru’s answer: chronic disease management. Diabetes, hypertension, chronic heart, lung, and kidney disease cost way too much; ostensibly way more than they should (according to whom, by they way?) When physicians are held accountable for the costs of the medical care they provide, so goes the theory, they will provide…what? Better care? More evidence-based based? More efficient?

We then run smack into the fact that so much of the response to treatment depends on the patient! What about people who keep smoking, refuse to exercise, eat whatever they want? To non-physicians, this is still our fault. “Education” is the perennial answer. Obviously if we had appropriately educated/persuaded/cajoled/etc, the patient would comply with our recommendations and get better. At what point are patients ever accountable for themselves?

Apparently the only kind of accountability that counts (at least to health care policy gurus) is for physicians to be associated with organizations that take financial responsibility (also known as “risk”) for the costs of medical care. And of course, the only reasonable way to take on that kind of risk is to be  part of a very large organization, and assume responsibility for a very large number of people (a population?) These Accountable Care Organizations nothing more than Managed Care 2.0, resurrecting the failed debacle of Managed Care from the 1990s, but with more money thrown at them this time around. I’m not holding my breath to see how many of those dollars trickle down to people actually providing medical care to people who are sick and hurt (known respectively as “doctors” and “patients”.)

When you stop to think about it, true fee for service makes me ultimately accountable to the only person who really matters: my patient. Once you take both government and insurance companies out of the middle (the so-called “direct pay” model, where the patients pay me directly for my services) and it’s just me and them, only then am I truly accountable.

Posted by: notdeaddinosaur | April 29, 2014

Words That Don’t Mean What You Think They Mean: “Quality”

Round and round and round we go yet again. The system is broken! Do something! Healthcare reform!

“Pay for performance” morphs into “measure (and pay) for quality.” The big problem is that no one has bothered to actually define the term, maybe because everyone assumes they know what it means — and that everyone else agrees with them. Wrong.

Quality is very much in the eye of the beholder, and can be surprisingly subjective. From my previous post:

Quality is like pornography; you know it when you experience it. But it cannot be measured; only assessed, and then only subjectively.

What does “quality” really mean in the context of medical care?

Some argue that when you have an operation, the surgeon shouldn’t leave anything inside you that shouldn’t be there. Others would say that everyone taking care of patients should wash their hands before and after every patient contact. Certainly all medical professionals should maintain proper licensure and credentials. I think of those things as basic expectations; more the difference between “acceptable” and “unacceptable”. “Quality” is different from “not unacceptable.”

Enter the idea of looking at “outcomes” (another meaningless word, also previously addressed by me here and here.) To reiterate: only certain kinds of illness and injuries have measurable outcomes. Fractures (should) heal. Surgically treated illnesses (should) resolve after operation. And so on. It’s generally accepted that there is a direct causal relationship between medical treatment provided and resolution of the condition, though this is not always so. Postoperative complications are not always preventable. Some fractures won’t heal. Cancers sometimes recur. So even the measurement of “outcomes” as a proxy for “quality” is fraught with hazard.

What about the relationship between “quality” and “Patient satisfaction”? Two words: Press Ganey. Short version is that there are times (lots of times) when what people think they want from doctors is not only not what they need, but can be dangerous, useless, and expensive. The patient is not the customer (and even so, the customer is not always right). When you actually look, it seems like the more satisfied people are, the worse their care.

So what does “quality” mean in the setting of primary care? Me again:

Quality in medical care has more to do with meeting the needs of individual patients and less to do with checking off boxes on a preventive care form. Some patients want detailed explanations of every facet of their medical care. Others prefer a more “Just the facts!” approach. 

What does it mean to be a high quality primary care physician? According to me:

[T]he ability to bring more than one style of communication to bear in meeting the needs of a varied patient base.

How do I and other skilled primary care physicians accomplish this? That’s simple (not the same as easy): time. Taking the time to listen, get to know what kind of communication the patient wants and needs from us, and then providing it. That’s quality. Find a way to pay for it (or at least find a way to not penalize it) and stand back while things fall into place.

How to measure it? No one has a clue.

Why not?

Because it can’t be done.

 

Posted by: notdeaddinosaur | April 28, 2014

There is No Such Thing as “Healthcare”

I do not provide “healthcare”. I don’t even provide “health care.” One word or two, what we physicians do is practice medicine, and what we do for patients is called “medical care.”

No one says, “I want some healthcare.” What they think is, “I don’t feel well. I want to see a doctor.”

People get sick and they get hurt. It’s true that many these conditions occur as a result of things they do (smoke, eat junk food, drink too much alcohol, go skiing) or don’t do (use seat belts in the car or helmets when riding motorcycles, exercise regularly.) But even if everyone in the whole country made perfect “choices” all the time, they would still need medical care for illnesses and accidents from time to time.

One of the wonderful things we can do these days is keep people from getting sick. This is called “preventive medicine” (or “preventative”, if you think it sounds more impressive with an extra syllable.) We have Primary prevention, such as vaccines to prevent certain infectious diseases, and Secondary prevention, such as taking aspirin and statins after a heart attack to prevent you from having another one.

We can also find some diseases before the patient has any symptoms of it. Sometimes (not always!) we can treat it then, preventing symptoms in the future and possibly (possibly!) prolonging life.  This is called Screening. It is still a form of medical care.

“Healthcare” is a made up term. It was invented by administrators, bureaucrats, and politicians (people who do not provide medical care) to insinuate themselves into the income stream process between people who are either sick or hurt, or who feel well and wish to avoid becoming sick or hurt, if possible, and the people whose care they seek. Their sole purpose is to siphon off as much of that revenue stream as they possibly can, leaving an ever shrinking pool of funds to pay the doctors and hospitals (meaning nurses, technicians, and housekeepers) who actually take care of people who are sick or hurt.

Sadly, they’ve done an awesome job of it. One of their strategies is recruiting doctors who are tired of fighting them to come join them…not coincidentally by greatly enriching them in the process. But every doctor seduced away from taking care of patients (our word for “people who are sick or hurt”) means one fewer available to make a real difference in the lives of real people.

What would I do to reform the “Health Care System”? Begin by abandoning the word (or words) “Healthcare” and going back to calling is what it is: Medicine.

 

Note: meme ca change…Already addressed this in March of 2012.

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