Fraud in Medicine: Heartwood

Here in my neck of the woods, people are continuing to quit medicine. Two  managers who have worked in the clinics eaten by the hospital are leaving on the same day, after 30 years. And another woman doctor, around my age, is retiring from medicine. She is NOT medicare age.

Meanwhile, the Mayo Clinic is publishing articles about how to turn older physicians into “heartwood”.

http://www.mayoclinicproceedings.org/article/S0025-6196(15)00469-3/fulltext

“As trees age, the older cells at the core of the trunk lose some of their ability to conduct water. The tree allows these innermost cells to retire…. This stiffened heartwood core…continues to help structurally support the tree…. Here a tree honors its elderly cells by letting them rest but still giving them something meaningful to do. We non-trees could take a lesson from that.” Spike Carlsen

Oh, wow, let’s honor the elderly. Even elderly physicians. Instead of what, killing them? Currently we dishonor them, right?

But what is the core of the issue? Skim down to “Decreased patient contact”:

“Already, many physicians are choosing to decrease their work to less than full-time, with resultant decreased patient encounters and decreased institutional revenue. Prorating compensation to match full-time equivalent worked will aid in financial balance, but the continued cost of benefits will remain. However, when that benefit expense is compared with the expense of recruiting a new physician (estimated by some to approach $250,000 per physician), the cost of supporting part-time practicing physicians becomes more attractive.”

Ok, so the core of the matter. “Decreased institutional revenue” and the employer still has to pay BENEFITS. NOTHING ABOUT THE QUALITY OF CARE FOR PATIENTS.

Again, the problem is still that you can’t really “do” a patient in twenty minutes, and that full time is really 60 or more hours a week. To be thorough, I  have to absorb the clinical picture for each patient: chief complaint, history of present illness, past medical history, allergies, family history, social history (this includes tobacco, drugs and alcohol), vital signs, review of systems and physical exam. And old records, x-rays, pathology reports, surgical reports, laboratory reports. I fought with my administration about the 18 patient a day quota. I said: ok, I have a patient every twenty minutes for 4 hours in the morning, a meeting scheduled at lunch, four hours in the afternoon. When am I supposed to call a specialist, do refills, read the lab results, look at xray results, call a patient at home to be sure they are ok? The administration replied that I should only spend 8 minutes with the patient and then I would have 12 minutes between patients to do paperwork. I replied that they’d picked the Electronic Medical Record telling us that we could do the note in the room. I could, after three years of practice. But it nearly always took me twenty-five minutes. I would hit send and our referral person had so much experience that she could have the referral approved before my patient made it to the front desk. BUT I felt like I was running as fast as I possibly could all day on a treadmill. Also, the hour lunch meetings pissed me off. I get 20 minutes with a patient and they get an hour meeting? Hell, no! I set my pager for a 20 minute alarm every time I went into a meeting and I walked out when it buzzed. I needed to REST!

After a few weeks of treadmill, I dropped a half clinic day. But of course that didn’t go into effect for another month and I was tired and ran late daily. And every 9 hour clinic day generated two hours of paperwork minimum: nights, weekends, 5 am when I would not get interrupted and could THINK. Do you really want a doctor to review your lab work when they are really tired and have worked for 11 hours or 24 hours? Might they miss something? It might have been best if I had been quiet and just cancelled two people a day, since the front desk knew I was not coming out of any room until I was done, but I argued instead.

The point is, you would like to see a doctor who listens and is thorough. You do not actually want a medical system where there all these other people who read your patient history forms and enter them in to the computer and your doctor tries to find the time to read it, like drinking from a fire hose. If we want doctors and patients to be happy, then doctors need time with patients and we need to off the insurance companies who add more and more and more complicated requirements for the most minimal care. One system, one set of rules, we’ll fight over the details, medicare for all.

Diagnosis is only half the job

In clinic I have two jobs.

The first job is to diagnose. Chief complaint, history of present illness, past medical history, allergies, review of systems, medications (and vitamins and supplements and herbs and any pills or concentrated substances), social history including addictive substance use, family history, physical exam. What is my diagnosis? A clinical portrait of the patient.

The second job is to communicate and negotiate. I have to get a snapshot of the person’s medical belief system, their past experience with MDs, their trust or lack of trust, whether they are willing to take a prescription medicine. I have to try to understand their world view at this visit, at this moment in time. And it’s not static and may change before I see them again. If I can understand the person well enough to communicate with respect, with concern, with understanding, then we may be able to negotiate a treatment.

In clinic the other day I had a new patient who said, “I am not going to be pushed to take prescription medicine.” I responded, “That’s fine. I am not going to be pushed to do medical testing that I think is inappropriate, either.” She actually laughed and said, “Ok. That’s fair.” This is a patient who is coming from alternative treatment but wants medicare to cover her tests. After the visit she called and said that her provider wants a certain test before they feel comfortable proceeding with a therapy. I responded that I need a note and an explanation of the planned therapy before I will order the test. (Honestly, it’s an increasing trend that I get calls from patients with messages like “My orthopedist wants you to get my back MRI prior authorized.” and “My physical therapist wants my hand xrayed.” Our new office policy is: the provider has to communicate themselves, not via the patient. Also, it ain’t always so….)

I had patient once in the emergency room who said, “I have an antennae in my tooth. Get it out.” Her roommate nodded, looking terrified. This was after a fairly confusing complaint of tooth pain. I needed to think about an approach. I said, “I need to check on another patient. I will return.” I left the room in the emergency room and considered approaches. I went back in and said, “I am not a dentist. I can’t take out the tooth. BUT I can call a doctor to help with the sounds that you are hearing until we can deal with the tooth. The doctor is a psychiatrist.”

“Ok. Call them.” said the patient. The roommate practically collapsed with relief. Psychiatry said, yes, looks like psychosis and we have a safety contract and she will come in Monday. People HAVE actually had metal in their mouth that picked up radio sounds, but psychosis is much more common. Also, if you can say the station call sign that is a lot different than voices that are telling you to harm yourself.

I thought about my approach carefully. I did not want to argue about the tooth. I wanted her to agree to talk to psychiatry. So I told the truth: I can’t fix the tooth. It’s Saturday night. Here is what I can do. I never said, hey, I don’t think it’s the tooth, I think it may be a psychotic break. She may have known that it was not the tooth but been too terrified or too disorganized to tell me. And there was a small chance that in fact, it WAS the tooth.

It is not worth trying to “fix” or change someone’s world view. If they trust their naturopath more than me, that is ok. But it’s a negotiation: I am a MD and I will do treatments that I think are appropriate and safe and I may or may not agree with the naturopath or chiropractor or physical therapist or accupuncturist or shaman. But the goal in the end is NOT for me to be correct: it is to help the patient. Half the therapy is respect and trust and hope. And kindness.

The biggest problem with ten minute visits and the hamster wheel of present day medicine in the US is that the second job is often not possible. Complex diagnoses are missed or patients leave feeling unheard, not respected and frustrated. Time to make the connection and to understand is very important and is half the job. Physicians and patients are frustrated and it is only getting worse.

 

The photograph is my daughter and her wonderful violin/viola teacher, right before my daughter played for a music competition.

 

Does pain mean danger?

Does pain mean danger?

From a physician standpoint, sometimes the answer is “No.”

One example, sent by an alert friend, is a lump on the back of the neck, with pain radiating downwards.

This could be an abscess or an infected cyst, but since they didn’t mention infection, it is most likely an enlarged lymph node. This is one example where the doctor or nurse practitioner or psychic healer will look at it, say “Does it hurt?”, poke it and then be all cheerful while you wonder WHY they have to poke it* after you say, “Yes, it hurts.”

A newly enlarged tender painful lymph node is usually a reactive lymph node. It is swollen with cells from the immune system and is trying to heal something in the vicinity. A cut, irritated acne, a cold virus, that shaving accident, a low grade infection, an ear infection. Usually I talk about it and recheck it in two weeks.

The lymph node that will make your healthcare person worry is the one that DOESN’T hurt. A slowly or quickly enlarging lymph node that is not tender is worrisome for lymphoma or for metastatic cancer. Once it gets to 1 centimenter, I am calling the surgeon to consider doing a biopsy. We have lymph nodes throughout our body, but the ones that we can feel on the surface are only in the neck, the supraclavicular nodes, the axillas (aka underarms) and groin. The rest are under bone or muscle, though they can show up on CT scan or xray: enlarged mediastinal nodes along the great vessels and trachea in the middle of the chest.

So pain does not always correlate with the level of danger of an illness. The reactive nodes hurt because they swell quickly, and they usually go down quickly as well.

*They poked it to be sure that it is not fluid filled, that it is firm but not hard and fixed, so not an abscess or cyst, and doesn’t feel like a cancer.

I took the photograph last night with my cell phone, during a rare thunder and lightning storm here… beautiful.

Dream: home surgery

Yesterday I ask a friend to drive me to pick up my son, on his way home from college for spring break, an hour to a nearby pick up point and back. I can’t walk without limping horribly: apparently the recent stress in clinic has made my muscles mad.

F. drives. He has just finished reading Reinventing Collapse: The Soviet Experience and American Prospects, by Dmitri Orlov. Mr. Orlov says that I, as a physician, should start moonlighting as a midwife for barter to have a back up plan for when the economy collapses.

I laugh. “Not very helpful where the median age is 55.”

“Not to mention people want to use their pathetic health insurance.”

Home and I go to sleep. Dream: I am at F.’s house. There are two other men, one of whom needs abdominal surgery. We argue for a long time but he has no money and finally I agree to do surgery with F. assisting. The other man is to help hold the young man down. We do not, of course have anesthesia. I go over what I am going to do, force them to pay attention, discuss sterile technique, boil everything. Not ideal….

We don’t have a cautery or suction either. But there is almost no bleeding and the two things that need to be removed come out easily, I am very very  gentle, so I don’t cause other things to bleed. Never mess with the spleen.

Now I need to close the abdomen and I don’t have absorbablesutures. I am going to do a figure 8 from the surface, in skin, out the abdominal fat, across into the fat, down through the fascia, crossing very delicately up into the fascia on the other side, out the fat, in the fat on the other side and out the skin. Then slowly pull it tight, tight, and tie it off. It’s thick nylon. Nonabsorbable. Usually you would take the nylon out in 7-10 days but I am wondering how long I would need it for the fascia….I thought that would take 6 weeks to heal. I am worrying.

But now F. and the other man are not holding my patient, they are backing off and congratulating each other. My patient gets up off the table. “Lie back down!” I say, “Your guts could fall out the opening! We haven’t closed! F!” Surprisingly his guts are not falling out, but it’s because I have done such a beautiful low abdominal incision, bikini style. “Get back on the table or I will make you go to the hospital to have it closed!”

He reluctantly gets back on the table. F. and the other guy are still being morons but are calming down….

….I wake up.

 

The photo is in my yard during sunrise last summer: spring forward today….

music: https://www.youtube.com/watch?v=aEi_4Cyx4Uw

It’s about caring

I described helping a woman bring her bad LDL cholesterol down from 205 to 158 with two clinic visits the other day, and someone said, “I can replace you with a teacher who is much cheaper. Why should you go to medical school to talk about the things people already know? Let’s free you up to do heart surgery or something important.”

Well? What about that? Is my career as a doctor wasted because I am in primary care? I am in Family Practice and I spend tons of time counseling people about diet, exercise, lifestyle choices.

My work is not wasted.

If all we had to do was give people information, we have the information. Every magazine and newspaper screams at us: “Obesity! Stop smoking! Exercise for health! Eat right! Don’t eat junk food!”

Why do two visits with me make a difference?

People do not feel valuable and do not feel cared for in our culture. In the same magazine with articles about losing weight, getting organized, shouting “You can do it!” there are multiple advertisements for sugary desserts and things to consume. My spouse used to joke, “If I get (whatever he wanted at that time) then I’ll be a better person.”

I see pregnant woman who can stop smoking while pregnant, to care for the baby on board, but who often can’t extend the same caring to themselves after the child is born.

The history is often listed as the most important part of a clinic visit. I agree, but not just for diagnosing illness. I am listening to the person, and now with a laptop, I am recording their history. Why are they here today, what medical problems have they had, allergies, surgeries, do they smoke, are they married, do they have children? I want a picture of the person and I must listen hard. What do they reveal about their trust in medicine, about favorable or unfavorable medical interactions in the past, about what they understand or believe about their health? The visit is a negotiation. I need their view of what is happening and their questions.

The physical exam is often an interlude for me. I look at the persons throat, in their ears, listen to their heart and lungs. And part of me is collating the information that I’ve gathered, so that we can move to the next step: analysis and plan.

If I am doing a preventative check, a wellness visit, a physical, whatever you want to call it, I name the positives and negatives. Are they exercising regularly, have they stopped smoking, are they trying to eat a good diet? I name these. Are they lucky enough to have four grandparents who lived to 102 or do the men in their family die at 52 of a heart attack? A 55 year old man who has lost multiple relatives in their early 50s is surprised that he’s alive, and starting to wonder if it might be worth attending a little to his own health. He is a bit shy about hoping that he might not die tomorrow, and ready for encouragement in taking care of himself.

The visit is really about caring. Many people in our culture do not feel cared for. Moms are supposed to care for everyone else. Parents are very very busy, trying to take care of children and have jobs. People are afraid that they will lose their job, their insurance, their homes. We try to do the tasks of adulthood: have the career, find the true love, raise the children, achieve the lifestyle, home and place in our society. And many people feel that they are failing or fear failing. They have not gotten the job they hoped for. They have a house, but it is a huge amount of work. They are working very hard, but there are still so many things they would like to do or see or have. They have become overweight, they have gotten hooked on tobacco, their children are not turning out as they’d planned, the ungrateful wretches. And their parents’ health is crumbling, and in all the chaos, why would the person attend to themselves? The cell phone rings, the computer beckons, it’s time to work, to cook, to clean, to stay on the hamster wheel of life.

In clinic, for a few moments, this person is the center. They explain their health to me. They are painting a picture of their life. A patient will say, “I’ve been worrying about my mother, my son, my spouse, and I don’t take the time to exercise or eat right.”

And I say, “I hope that your mother, son, spouse does better. But you are important too. It is wonderful that you have stopped smoking, excellent! But we’re both worried about your cholesterol, right? It is too high. How are we going to take care of you? What can you fit in?”

Most people do not want to start with a medicine. They want to take care of themselves, too. They are willing to make lifestyle changes. They need encouragement and permission and to come back to see how it is going. What they need is my caring. And I do care.

I used to think that somehow complex patients would gravitate to me. But that is not true: the truth is that everyone is complex. Each person has layers and thoughts and feelings: fears and joys. I barely scratch the surface. It is the caring that is most important and each person that I see is important.

At the end of the visit, I print my note. I give it to the person. “Check it. Tell me if something is wrong. I cannot change the note, but I can put an addendum.” I see that people are shy and often show some confusion. Two pages? Single spaced? About me?

Yes. About you.

written in 2010 and published first here: http://everything2.com/title/It%2527s+about+caring?searchy=search

I took the photo in 2004, a school overnight trip to explore settlers 100 years ago….

Causes of Death in the United States in 2012

When I first started doing annual physicals I sat down and looked at the top causes of death and then organized the counseling part of the physical around them: starting with heart disease and working down the list. I think of the annual physical as my opportunity to “MOM” patients and say “STOP DRINKING LIKE A FISH OR YOU GONNA DIE EARLY,” though perhaps with a little more diplomacy. Sometimes without much diplomacy at all.

The top ten causes of death in the United States in 2012 were heart disease, cancer, chronic lower respiratory diseases, stroke, unintentional injuries, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide.

http://www.cdc.gov/nchs/data/databriefs/db168.htm#which_population

This is 2,543,279 deaths in 2012.

Let’s take the causes one by one.

Heart disease: This is number one. 599,711 deaths. 23.6% of total deaths all ages both sexes in the US in 2012. So that is where I start when I do the counseling part of a physical.

Let’s review heart disease risk factors:
hypertension
high cholesterol
family history
diabetes
kidney failure
lack of exercise
tobacco
alcohol
smoking other things…
illegal drugs
stress
obeisity
As you might guess, this part of the discussion can use up a lot of the visit….

Cancer: All the cancer deaths together are 22.9% of the 2012 total.
We can screen for a few cancers: lung cancer is now the number one killer for both sexes. A chest xray is useless for screening. There is a certain population of current or former heavy smokers where a screening CT is useful. No, I do not recommend a “screening full body CT”, that is crap. Yes, lung cancers do get picked up randomly when we do a chest film for some other reason.
We can screen for breast cancer, colon cancers, look for skin cancers, the prostate cancer screen is a counseling nightmare and I don’t recommend a PSA but will do one if the person wants and other cancers pretty much we have to watch for symptoms….stop smoking, ok? That’s what causes 70% of the lung cancer and breast cancer used to be number one in women but smoking made lung cancer beat it out….
If you want details about any screening test, go to the US Preventative Task Force site:
http://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care

Chronic lower respiratory diseases at 5.6%: ok, smoking again. Emphysema and chronic obstructive pulmonary disease, AKA COPD. Asthma too. This article is fascinating, that third generation children of smokers in a polluted part of California are worse and have inherited genetic modifications than third generation children of non-smokers who live in a less polluted part of California. Lovely. I grew up in a two pack a day camel household and no wonder my lungs are tricky.

Stroke, also called CVA, cerebrovascular accident, at 5.1% and then there are TIAs, transient ischemic accidents, the stroke warning symptom.

What are the risk factors for stroke?
Oh, smoking of course
hypertension
high cholesterol
stress
lack of exercise
obeisity
blocked carotid arteries
blood clots
atrial fibrillation

Unintentional injuries at 5.3%, also known as accidents.

Deaths from prescription medicines taken correctly outstripped deaths by MVAs, motor vehicle accidents and guns in 2007. The CDC declared an epidemic of overdose deaths, but it’s just starting to creep into newspapers and public consciousness.

Here: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

The unintentional injury counseling list includes:
wear your seatbelt
don’t drive inebriated
don’t get in the car with inebriated drivers
check your smoke alarms
in the elderly, decrease fall risk. don’t stack stuff on the stairs.
wear a helmet if you bicycle motorcycle ATV rollarblade ski or invent some new way of getting on the Darwin list. Base jump, for example.
don’t take a lot of controlled prescription medicines or combine them with each other or combine them with alcohol: opiates with benzodiazepines with alcohol with ambien or sonata with barbituates and hello, the drug dealer is not your friend and tells lies: they are cutting the methamphetamines here with tricyclic antidepressants and barbituates and my long term cocaine addict patient was getting methamphetamines with benzodiazepines when he was paying for cocaine. Really.

Alzheimer’s at 3%

This is moving up the list. Fast. Everyone dies of something. Alzheimer’s patients live an average of seven years from diagnosis….And the recent article about Human Growth Hormone transmitting not only prions but Alzheimer’s is really interesting, implies an infectious cause.

Here: http://www.nature.com/news/autopsies-reveal-signs-of-alzheimer-s-in-growth-hormone-patients-1.18331

That was HGH from cadavers. I still would not take HGH made in a lab for “anti-aging” either. Nope, nope, nope.

We don’t know how to prevent Alzheimer’s but that is not the only cause of dementia and we’re still naming different kinds. Very frequently a brain CT or MRI says “decreased white matter” or “small vessel disease”, so there is a contribution from all of the heart and stroke risk factors that can do bad things to the brain with the top ones being: tobacco, alcohol, hypertension, high cholesterol, stress, lack of exercise, diabetes, illegal drugs, and so forth. Keep your brain active and busy.

Diabetes at 2.9%
Ok, it can make you more likely to have a heart attack. Also the biggest cause of blindness in US adults and the biggest cause of lower limb, yes, foot or leg amputation and the biggest cause of kidney failure in adults. Also if your legs are numb from uncontrolled diabetes, you don’t feel injuries and are less able to heal infections. And if blood sugar is high, there are lots of bacteria and especially staph and strep that LIKE high sugar.

influenza and pneumonia at 2.1%

Get Your Flu Shot. Really. And if you are 65 or older or you have tricky lungs or you have a tricky heart, get the pneumovax shot. The pneumovax protects against pneumococcal pneumonia ONLY, not all the colds or influenza or hemophilus influenza. And get your Tdap, because that stands for Tetnus, Diptheria, acellular Pertussis. Pertussis is whooping cough. It’s back. We’ve had three outbreaks in our county in five years. It kills babies under six months. They don’t whoop, they just stop breathing, apnea. Other people whoop, but even with antibiotics, they can cough for MONTHS. The flu shot usually gives 80% protection by two weeks after the shot. Only 80%, people say? Well, are you perfect?

Kidney disease at 1.8%

Causes: kidneys get worse as we age, for one thing.
diabetes
supplements and drugs: kidney failure is on the rise! Everything that we absorb and metabolize is metabolized by either the liver or the kidneys. Liver function can be perfect at age 100: that is, if it has not been trashed by alcohol, hepatitis B or C, drugs, supplements, mushrooms, whatever. Kidney function usually drops by age 80 and I am there calculating the function before I choose an antibiotic because you have to use lower doses in the over 80 crowd and the early kidney failure crowd. If you take ANY PILLS you should have a yearly test of your kidneys and liver function.
infection can hurt kidneys
inherited disorders

Suicide at 1.6%
40,600 deaths in the United States in 2013

Risk Factors http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

Family history of suicide
Family history of child maltreatment
Previous suicide attempt(s)
History of mental disorders, particularly clinical depression
History of alcohol and substance abuse
Feelings of hopelessness
Impulsive or aggressive tendencies
Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
Local epidemics of suicide
Isolation, a feeling of being cut off from other people
Barriers to accessing mental health treatment
Loss (relational, social, work, or financial)
Physical illness
Easy access to lethal methods
Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

And for those who want in depth information, 15 leading causes of death by state:
http://www.cdc.gov/nchs/nvss/mortality/lcwk9.htm

Chronic pain and antidepressants

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