Thursday, November 19, 2009
Neglect
Diabetes is an interesting disease. There are two types of diabetes. Type I occurs in early childhood, is unpreventable, is very severe and requires lifelong therapy in order to not develop the severe complications associated with diabetes. Type II is more prevalent, is potentially preventable, and requires escalating treatment as the disease gets worse.
In the category of Type II diabetics, there are really two styles of patient responses to the diagnosis of diabetes. The first type will almost immediately change their habits. They will lose weight, check their blood sugar religiously, modify their diet and eating habits to control their blood sugar and get regular check-ups to make sure they don't have the long-term problems. Not surprisingly, these patients invariably do well. We never see them in the hospital because they have decided to control their disease.
The second type is more common in my experience. These are the people who don't feel any different and therefore don't believe or don't understand that they have a disease, don't trust the doctor, don't have the requisite willpower to change their habits, or just don't really care as it doesn't affect their lives immediately. These people come to the hospital commonly and have limbs amputated, are put on dialysis, have heart attacks, and are going blind. It's sad to walk into a room and know that a person will be dead within a year or two from a disease that is very preventable and controllable.
This is a strange parallel, but I worry that our society is heading down the second track in regards to climate change. It doesn't bother us currently, therefore we don't believe we have a problem, don't technically understand that we have a problem, don't have the requisite willpower to change, or just don't really care as it doesn't immediately impact our lives.
Climate change is different in that it is well established what is going to happen to a diabetic if they don't control their blood sugar. We have no idea what is going to happen to our planet as it warms. It could just be mild warming and secondary homeostatic mechanisms kick in to compensate, or it could generate a positive feedback loop that turns our planet into Venus within a century. We really just have no idea. The similarity is that there is something we can do right now to help prevent this problem, but we aren't doing it because we don't really believe that we have a problem. Sure hope we don't end up on that hospital bed in couple decades.
In the category of Type II diabetics, there are really two styles of patient responses to the diagnosis of diabetes. The first type will almost immediately change their habits. They will lose weight, check their blood sugar religiously, modify their diet and eating habits to control their blood sugar and get regular check-ups to make sure they don't have the long-term problems. Not surprisingly, these patients invariably do well. We never see them in the hospital because they have decided to control their disease.
The second type is more common in my experience. These are the people who don't feel any different and therefore don't believe or don't understand that they have a disease, don't trust the doctor, don't have the requisite willpower to change their habits, or just don't really care as it doesn't affect their lives immediately. These people come to the hospital commonly and have limbs amputated, are put on dialysis, have heart attacks, and are going blind. It's sad to walk into a room and know that a person will be dead within a year or two from a disease that is very preventable and controllable.
This is a strange parallel, but I worry that our society is heading down the second track in regards to climate change. It doesn't bother us currently, therefore we don't believe we have a problem, don't technically understand that we have a problem, don't have the requisite willpower to change, or just don't really care as it doesn't immediately impact our lives.
Climate change is different in that it is well established what is going to happen to a diabetic if they don't control their blood sugar. We have no idea what is going to happen to our planet as it warms. It could just be mild warming and secondary homeostatic mechanisms kick in to compensate, or it could generate a positive feedback loop that turns our planet into Venus within a century. We really just have no idea. The similarity is that there is something we can do right now to help prevent this problem, but we aren't doing it because we don't really believe that we have a problem. Sure hope we don't end up on that hospital bed in couple decades.
Thursday, August 27, 2009
Just Say No to Drug....reps
Third year of medical school is a glorious time. You have absolutely no responsiblity because you have hardly any competence. Therefore, you can sit and talk with patients for hours and get to know them. Third year is this idealistic time where you have all the time in the world with patients and their families. This is how medicine is supposed to be. In holding with that idealistic tenor, I am endevouring to avoid all gifts and influence by drug reps this year.
This is really hard. These little vermin are everywhere. They permeate our medical system with their free lunches, pens, clipboards, mousepads, notepads, and other assorted Chinese junk. They come in the middle of lecture with their steaming hot bags full of Panera Bread, or Chipotle or some other chain restaurant and slowly lay it out on the table in the back. The smell drives you partially mad with hunger and you can't listen to anything the presenter is saying. Then they stand there in their perfumed business-skirts and 5 inch heels and greet you with sparkling teeth as you pass by and grab the food before you have too much time to contemplate just how much of your medical integrity you sold.
I do get some enjoyment out of though. Their large, thickly makeuped eyes rise a little in shock when I sit down and pull out my peanut butter and jelly sandwich and carrots. They look at me with a mixture of confusion and fear like I am some rabid, anti-social lunatic for refusing their generous hospitality. I just sit there placidly listening to the doctor on the speakerphone, secretely seething inside that a fellow medical professional could stoop so low as to become a peddler of drugs. Albeit a sophisticated peddler, but a drug peddler nonetheless.
I know, I know...it's more complicated than that. The researcher has to get his funds from somewhere. If the drug companies didn't do these studies no one would...blah blah blah. It still doesn't change the ethical implications of a medical practictioner selling a drug and funding his research into that drug.
It sucks to have so much anger and loathing built up inside you for someone. Since I don't enjoy those feelings, this discipline is slowly teaching me to stay away from these drug lunches altogether. I think if I can keep it up for the rest of the year, then I will easily be able to avoid future lunches as I will find them a waste of my valuable time.
This is really hard. These little vermin are everywhere. They permeate our medical system with their free lunches, pens, clipboards, mousepads, notepads, and other assorted Chinese junk. They come in the middle of lecture with their steaming hot bags full of Panera Bread, or Chipotle or some other chain restaurant and slowly lay it out on the table in the back. The smell drives you partially mad with hunger and you can't listen to anything the presenter is saying. Then they stand there in their perfumed business-skirts and 5 inch heels and greet you with sparkling teeth as you pass by and grab the food before you have too much time to contemplate just how much of your medical integrity you sold.
I do get some enjoyment out of though. Their large, thickly makeuped eyes rise a little in shock when I sit down and pull out my peanut butter and jelly sandwich and carrots. They look at me with a mixture of confusion and fear like I am some rabid, anti-social lunatic for refusing their generous hospitality. I just sit there placidly listening to the doctor on the speakerphone, secretely seething inside that a fellow medical professional could stoop so low as to become a peddler of drugs. Albeit a sophisticated peddler, but a drug peddler nonetheless.
I know, I know...it's more complicated than that. The researcher has to get his funds from somewhere. If the drug companies didn't do these studies no one would...blah blah blah. It still doesn't change the ethical implications of a medical practictioner selling a drug and funding his research into that drug.
It sucks to have so much anger and loathing built up inside you for someone. Since I don't enjoy those feelings, this discipline is slowly teaching me to stay away from these drug lunches altogether. I think if I can keep it up for the rest of the year, then I will easily be able to avoid future lunches as I will find them a waste of my valuable time.
Saturday, August 01, 2009
Controlling Health Costs
A fellow medical professional stops by this blog every once and a while and leaves his thoughts. He's a smart fella and it's fun to read his stories, but we are on opposite sides of the political spectrum and have a rather abusive relationship if you really get right down to it. Maybe that's par for the course with bloggers :)
Anyway, he peaked my interest when he left a comment on my last post about controlling medical costs. The ironic thing was the example that he used was about medical helicopters. Medical helicopters are probably one of the most visible examples of medical waste and why our system costs so much. Do they save lives? Yes. But they also transport many people who don't need to be transported by a helicopter. My father was an ER physician for 23 years in one of the busiest ERs in the country and in that entire time he only transported 1 patient to a tertiary center by helicopter. It was a young man with a subarrachnoid hemorrhage and my father, the helicopter (and the brain surgeons on the other end) surely saved his life. It worked out well for that patient and it makes a great story, but the vast majority of patients transported by medical helicopter don't really need it
I went on a helicopter ride once because I thought it was cool. We transported a patient with preterm ruptured membranes 60 miles to our hospital. I'm not saying ruptured membranes isn't bad, just saying she more than likely would've survived the hour ambulance ride and didn't need the 20 minute helicopter ride at almost twice the cost. These kinds of stories are shockingly common. I'm sure if you did a cost/benefit analysis of helicopter transports in the US, it would be a high number. This also doesn't even factor in the stupidly high risk of crashing the helicopter before it ever reaches the hospital.
Back when my father first started practicing medicine, there weren't any air ambulances. These evolved after the Vietnam era and were popularized and glamorized by shows like MASH. Our state had one of the first air ambulances. It barely got off the ground (pun intended). There just wasn't much use for it. Now there are three air ambulance services in my state, all competing with each other to carry critically ill patients from hospital or roadside accidents. They are literally competing with each other. They have turf battles and run sophisiticated marketing campaigns, and this situation exemplifies what is wrong with our medical system.
These kinds of services are reimbursed because they are big, visible, sexy and look like they take a lot of work. They are all those things, but they really don't add value to the overall health system. In other words, it may look like it, but you don't get a lot of bang for your buck. For the $20,000 it took to take that lady with ruptured membranes to the hopsital, we could've provided vaccines to 70 kids. For the $120,000 it takes to give an 87 y/o man a new heart and two more years of life, you could get a primary care doc to work in a underserved area for a year and take care of hundreds of kids and their parents.
Sanitation, vaccines, preventative care, and good primary care are the key to an effective health system at the population level. Unfortunately, we are not reimbursing any of these things. I think we believe that we have these things already pretty well figured out and we're more focused on the next big thing. The helicopters, brand-name pharmaceuticals, medical robots, specialist consults, amazing imaging, and surgeries have all replaced primary care as the backbone of our medical system, and that's why it's so expensive. Do we need all these things? Yes. Do we need as much of them as we are using right now? No, and it's not where the money should be focused.
Anyway, he peaked my interest when he left a comment on my last post about controlling medical costs. The ironic thing was the example that he used was about medical helicopters. Medical helicopters are probably one of the most visible examples of medical waste and why our system costs so much. Do they save lives? Yes. But they also transport many people who don't need to be transported by a helicopter. My father was an ER physician for 23 years in one of the busiest ERs in the country and in that entire time he only transported 1 patient to a tertiary center by helicopter. It was a young man with a subarrachnoid hemorrhage and my father, the helicopter (and the brain surgeons on the other end) surely saved his life. It worked out well for that patient and it makes a great story, but the vast majority of patients transported by medical helicopter don't really need it
I went on a helicopter ride once because I thought it was cool. We transported a patient with preterm ruptured membranes 60 miles to our hospital. I'm not saying ruptured membranes isn't bad, just saying she more than likely would've survived the hour ambulance ride and didn't need the 20 minute helicopter ride at almost twice the cost. These kinds of stories are shockingly common. I'm sure if you did a cost/benefit analysis of helicopter transports in the US, it would be a high number. This also doesn't even factor in the stupidly high risk of crashing the helicopter before it ever reaches the hospital.
Back when my father first started practicing medicine, there weren't any air ambulances. These evolved after the Vietnam era and were popularized and glamorized by shows like MASH. Our state had one of the first air ambulances. It barely got off the ground (pun intended). There just wasn't much use for it. Now there are three air ambulance services in my state, all competing with each other to carry critically ill patients from hospital or roadside accidents. They are literally competing with each other. They have turf battles and run sophisiticated marketing campaigns, and this situation exemplifies what is wrong with our medical system.
These kinds of services are reimbursed because they are big, visible, sexy and look like they take a lot of work. They are all those things, but they really don't add value to the overall health system. In other words, it may look like it, but you don't get a lot of bang for your buck. For the $20,000 it took to take that lady with ruptured membranes to the hopsital, we could've provided vaccines to 70 kids. For the $120,000 it takes to give an 87 y/o man a new heart and two more years of life, you could get a primary care doc to work in a underserved area for a year and take care of hundreds of kids and their parents.
Sanitation, vaccines, preventative care, and good primary care are the key to an effective health system at the population level. Unfortunately, we are not reimbursing any of these things. I think we believe that we have these things already pretty well figured out and we're more focused on the next big thing. The helicopters, brand-name pharmaceuticals, medical robots, specialist consults, amazing imaging, and surgeries have all replaced primary care as the backbone of our medical system, and that's why it's so expensive. Do we need all these things? Yes. Do we need as much of them as we are using right now? No, and it's not where the money should be focused.
Tuesday, July 21, 2009
I finally have stories again
The first 2 years of medical school make you an utterly boring person:
"What did you do today?"
"I studied."
"What did you study?"
"I don't really remember, something about the kidney"
"Anything else?"
"Nope"
Nothing interesting happens to you. You sleep, eat, study, go to class, and work out. You hang out with your friends some weekends, but only if there isn't a test coming up. You learn a hell of lot of information, but it is all cerebral and none of it is practical yet.
Now I finally have stories again. Getting the crazy patient who hears voices and asks if you do too, having my cell phone go off in the middle of my first pap smear, seeing interesting patients with benign diseases that you can help and horrible diseases that you can't do anything for. It's a breath of literary air after 2 years drowning under textbooks.
I saw something today that really struck me. I spent the day with the social worker, and we saw several sad cases of people who were not naturalized citizens, but really needed the healthcare benefits that naturilized citizens are entitled to. A wheelchair bound man of 34 and a man going blind were scrambling to find any medical resource they could that would help them. That wasn't the part that struck me though. A woman with four children in tow came to the clinic to have her diabetes checked. While she was in the lab, she left her stroller outside in the waiting room and when she came back, the stroller was gone along with her cell phone which was in a pocket in the stroller. She eventually arrived at the social worker's office and he immediately set out on a mission to find money to help this poor woman buy a stroller.
He wandered from room to room, looking in drawers and cabinets until he found an envelope in the drawer labeled "jean money." He explained to me that this was money that the clinic workers donated in order to wear jeans on Fridays. That made me smile, but the smile quickly evaporated when he opened the envelope and only $35 fell out. He counted it meticulously and then quickly pulled out his own wallet and added another $5 to the stack to make it $40. It was a touching gesture seeing a man who dedicates his life to helping people donate some of his own money.
Think about $40 for a second. Most of us stop by the ATM and pull out at least that much every other week or so to buy small things like food or gas. But, this little clinic with one social worker had struggle and scrape to come up with $40. These are the places we should be trusting our money to. This is why it makes me angry when we talk about million dollar bonuses to executives and then they complain that their taxes are too high. Real people are struggling to find $40 to give to a poor mom with four children who just had her stroller stolen. Where is the justice in that?
"What did you do today?"
"I studied."
"What did you study?"
"I don't really remember, something about the kidney"
"Anything else?"
"Nope"
Nothing interesting happens to you. You sleep, eat, study, go to class, and work out. You hang out with your friends some weekends, but only if there isn't a test coming up. You learn a hell of lot of information, but it is all cerebral and none of it is practical yet.
Now I finally have stories again. Getting the crazy patient who hears voices and asks if you do too, having my cell phone go off in the middle of my first pap smear, seeing interesting patients with benign diseases that you can help and horrible diseases that you can't do anything for. It's a breath of literary air after 2 years drowning under textbooks.
I saw something today that really struck me. I spent the day with the social worker, and we saw several sad cases of people who were not naturalized citizens, but really needed the healthcare benefits that naturilized citizens are entitled to. A wheelchair bound man of 34 and a man going blind were scrambling to find any medical resource they could that would help them. That wasn't the part that struck me though. A woman with four children in tow came to the clinic to have her diabetes checked. While she was in the lab, she left her stroller outside in the waiting room and when she came back, the stroller was gone along with her cell phone which was in a pocket in the stroller. She eventually arrived at the social worker's office and he immediately set out on a mission to find money to help this poor woman buy a stroller.
He wandered from room to room, looking in drawers and cabinets until he found an envelope in the drawer labeled "jean money." He explained to me that this was money that the clinic workers donated in order to wear jeans on Fridays. That made me smile, but the smile quickly evaporated when he opened the envelope and only $35 fell out. He counted it meticulously and then quickly pulled out his own wallet and added another $5 to the stack to make it $40. It was a touching gesture seeing a man who dedicates his life to helping people donate some of his own money.
Think about $40 for a second. Most of us stop by the ATM and pull out at least that much every other week or so to buy small things like food or gas. But, this little clinic with one social worker had struggle and scrape to come up with $40. These are the places we should be trusting our money to. This is why it makes me angry when we talk about million dollar bonuses to executives and then they complain that their taxes are too high. Real people are struggling to find $40 to give to a poor mom with four children who just had her stroller stolen. Where is the justice in that?
Thursday, February 05, 2009
The Definition of Irony
While studying about different viruses that can infect humans, said medical student contracts said virus and is now at home typing up some blog entries and posting pictures to facebook.
Saturday, August 23, 2008
Trickling down- you gettin' kinda thirsty?
Why Trickle-Down Economics Doesn't Work.
I'm no economist, but I've been getting in a lot of conversations lately about the state of the economy and basic economic theories. I am of the opinion that trickle down economics doesn't work. I think it's a construct made up by the rich to help them hold onto their power and influence and I give them credit that they've managed to convince so many people so that it works. If enough Donald Trumps say that the only way to economic growth is relentless (and reckless) tax cutting, then eventually people are going to start to believe it.
The theory (as I understand it) is that if we cut taxes for the richest members of society, then they are going to have more money, and they are going to spend that money and that spending is going to "trickle down" to us as sales, jobs, and giant bonuses. Unfortunately, it doesn't really work like that. Rich people don't get rich by spending money. They get rich by investing it and saving it. Maybe the theory would hold up if rich people were really investing a much greater percentage of their money, but mostly they are just accumulating it and holding on to it.
This is shown by the huge gap that we have right now between the have's and the have-not's. Rich people just keep on getting richer and resting on their laurels of the past few years, while middle class people keep getting poorer as their wages remain the same and food and gas inflation eat into their paychecks.
I have nothing against rich people. I admire them for taking enormous risks and having them pay off. Who knows, I might be an entrepreneur someday. They are the people who really drive progress and economies forward. But the theory I don't subscribe to is the one where people who earn more don't have more of an obligation to pay for services in our government (i.e. taxes). If you earn more than $100,000, you are in a much better position to help pay than someone who makes 20,000 a year. Trust me, you're not really going to miss that $30,000 as much as the low-income earner is going to miss $5,000. One is whether you can take that trip to the Florida this year, the other is whether he can put enough food on his table to feed his three kids.
Another consequence of this relentless tax cutting is how short-sighted it is. We are accumulating trillions of dollars in debt...for what? So we can have cheap plastic toys from China. So we can wage war in a country that doesn't want us there? Where is the long-term investment in the money we are spending right now. I am spending a lot of money right now, but it's with the idea that it will pay off in a couple years with a good job and income. I don't see that strategy being employed by our government or our society in general. People around the world are starting to see this and it has lead to the decline in the dollar. The rest of the world is losing confidence that we are a good long-term investment. We are just spending right now and not investing. This is bad for our long-term prospects and for our children's.
The element that makes a really strong economy is a strong middle class that has a good income and upward mobility. Why do you think China's economy is growing so fast? Their middle class is surging upward as all the factory workers bring home a good income and want to spend it. There are rich people in China and there will be a lot more, but their middle class will be the biggest factor in the coming decade. Meanwhile, our middle class is declining. People are falling into the have or have-not category and that is eventually going to be bad for everyone.
There is one candidate that is talking about helping the middle class and the other is talking about continuing the current economic policies. I think we all know the current policies aren't working very well.
The theory (as I understand it) is that if we cut taxes for the richest members of society, then they are going to have more money, and they are going to spend that money and that spending is going to "trickle down" to us as sales, jobs, and giant bonuses. Unfortunately, it doesn't really work like that. Rich people don't get rich by spending money. They get rich by investing it and saving it. Maybe the theory would hold up if rich people were really investing a much greater percentage of their money, but mostly they are just accumulating it and holding on to it.
This is shown by the huge gap that we have right now between the have's and the have-not's. Rich people just keep on getting richer and resting on their laurels of the past few years, while middle class people keep getting poorer as their wages remain the same and food and gas inflation eat into their paychecks.
I have nothing against rich people. I admire them for taking enormous risks and having them pay off. Who knows, I might be an entrepreneur someday. They are the people who really drive progress and economies forward. But the theory I don't subscribe to is the one where people who earn more don't have more of an obligation to pay for services in our government (i.e. taxes). If you earn more than $100,000, you are in a much better position to help pay than someone who makes 20,000 a year. Trust me, you're not really going to miss that $30,000 as much as the low-income earner is going to miss $5,000. One is whether you can take that trip to the Florida this year, the other is whether he can put enough food on his table to feed his three kids.
Another consequence of this relentless tax cutting is how short-sighted it is. We are accumulating trillions of dollars in debt...for what? So we can have cheap plastic toys from China. So we can wage war in a country that doesn't want us there? Where is the long-term investment in the money we are spending right now. I am spending a lot of money right now, but it's with the idea that it will pay off in a couple years with a good job and income. I don't see that strategy being employed by our government or our society in general. People around the world are starting to see this and it has lead to the decline in the dollar. The rest of the world is losing confidence that we are a good long-term investment. We are just spending right now and not investing. This is bad for our long-term prospects and for our children's.
The element that makes a really strong economy is a strong middle class that has a good income and upward mobility. Why do you think China's economy is growing so fast? Their middle class is surging upward as all the factory workers bring home a good income and want to spend it. There are rich people in China and there will be a lot more, but their middle class will be the biggest factor in the coming decade. Meanwhile, our middle class is declining. People are falling into the have or have-not category and that is eventually going to be bad for everyone.
There is one candidate that is talking about helping the middle class and the other is talking about continuing the current economic policies. I think we all know the current policies aren't working very well.
Tuesday, July 22, 2008
6310
There are many people who see God everywhere. They see God's action in all things, and in all of creation. But, I have trouble seeing God in all these things. When I look at life I zoom down to the smallest cell and wonder at it's intricacy, but never really believe that it was created. When I look at the stars I wonder at how far they are, but don't really see the need for a creator. When I go to church, I see people getting in touch with a spiritual need that we all feel, but I don't really see God.The place I really see God is in the hospital. That nexus of humanity that swirls with grief, joy, rage, pity, and all other shades of human emotion. Weird things happen that don't seem to make any sense at first, but then a pattern emerges that just screams out for an explanation beyond coincidence. I'll give you an example.
I was getting off my shift in the ER and strolling lazily behind a bed being taken into the hospital. I don't know if it was idle curiosity or just boredom that made me ask where they were headed.
"6310," replied the tech who was pushing the bed. I turned down another corridor and started to walk away without saying anything else when the patient in the bed called out,
"Why, you gonna come and visit me?"
I turned around and smiled at the lean, black girl in the bed. Her hair was disheveled her teeth were a little crooked. Like most hospitalized patients she looked like she was having a rough day. But, she had an infectious smile and I couldn't help but grin too.
"No, I just had to find out," I said. I turned around and continued to walk away wondering why I had said that. Technically, it wasn't a lie, but I felt kind of awkward saying it because I really had no reason to find out what room she was going to. I kept walking and my mind shifted gears to something else.
I was just about to unlock my car in the student lot when another car pulled up and huge lady leaned out the window.
"Excuse me, do you know where we can find visitor parking around here?"
I had never had that question before but I felt like I should know where it is. I stood there in a mental fluster trying to think of where they could go for parking.
"My daughter was just admitted from the ER for a sickle cell attack and we can't seem to find parking anywhere," said the lady. The image of the grinning girl flashed into my head and before I even thought about it I blurted out,
"6310!!"
"Huh?" Said the huge lady in the car.
"6310, that's where they are taking your daughter. I just saw her. Pull right around here and check that big parking garage there and then go to room 6310 and you'll find her. She looked pretty good."
"Thanks," said the lady as she pulled away with a puzzled look on her face.
I don't know if they ever found visitor parking, but 6310 is now firmly engraved in my memory as my prescient number. Experience cries out for explanation.
