Saturday, February 21, 2009

I Agree, But Can't Comply

I received a thoughtful response to my recent over-the-top post about the difference between "consumers" and "patients" from a gentleman at HealthLeadersMedia.com. He raised some good points, but I am afraid that neither he nor I will get to see our ultimate vision of consumer- or patient-centered health care in the future. Here are a few snippets of what he had to say:

This is becoming one of those "get over it" moments for healthcare professionals. You can resist the notion all you want; the fact is patients more and more see themselves as consumers, and that's not necessarily a bad thing.

.....When it comes to my health, I have to do my own homework and make my own decisions. When it comes to my kids, I end up getting the best help and useful information from teachers and non-physician providers. The tired notion that as a patient I have some special connection with a physician who partners in my health is an alien concept. I don't blame physicians for this; it's just the way the system has evolved. As a result, I have no choice but to be a conscientious healthcare consumer.
I agree wholeheartedly --- it is important to be a conscientious healthcare consumer, and it is not necessarily a bad thing for patients to see themselves as consumers. But let's look at what a true provider of services-consumer interaction entails. Right now, my son is at swimming practice, and after spending the last hour catching up on paperwork, I am doing a little blogging. Where did I go for a cup of java and wifi access? I could have gone to Corporate Coffee Central; I like their coffee. I could have gone to my favorite coffee shop; it's pretty long drive, however. I chose instead to go to another locally-owned franchise, because it was convenient, has wifi, and serves a pretty good cup of joe.

I chose. Pretty simple concept in a capitalist society.

We had a simple cash exchange, a couple of bucks for a big, black cup of mud, and then a couple more for another cup. I had a menu of options to choose from, knew the price, and had the option of getting extras, such as a pastry that would make even Fat Bastard add a few inches to his waistline. Before I ever got here, I had seen advertisements for this and other places I could choose for coffee, all of which proclaim that they have the best tasting stuff. Some of them are running special discounts, which is really cool if you are a caffeine fiend like myself. If I became unruly, or refused to pay for my coffee, the shop owner can run me right on out the door, with no repercusions. If I ran a coffee shop, I would do all of these things --- advertise, make sure I offered the best product at a reasonable price, try to meet the desires of my customers, etc.

However, as a physician, I am not allowed to do these things. I cannot set my own price for providing care to patients ---- the government mandates what I can and cannot charge, with a list of rules that is so long it mirrors the tax code. I think that there are things that I do pretty well, and that I am caring and compassionate and very competent. However, I cannot advertise that I provide better care than my competitor across town ---- this is partly due to ethical standards, and partly due to the issues surrounding patient privacy. I cannot run a "special," giving patients a Mardis Gras discount for laparoscopic cholecystectomy ---- if I did so, Medicare or their insurer would demand repayment for the difference in price for all of the other cholecystectomies I did in the last three years. And if I have a patient who is rude to my staff, refuses to follow instructions, and doesn't pay his bill..... I still have to take care of him.

Realistically, Mr. Johnson and I are talking about two sides of the same coin --- or, more accurately, about two individual squares of a Rubik's cube, as there are many dimensions to this issue. Physicians are not allowed on the same playing field as other small businessmen. As a result, patients are not given all of the potential information that they may desire to be conscientious healthcare consumers. This problem will only worsen if we head to a single payer or totally government run healtcare system.

If Mr. Johnson and those at HealthLeadersMedia.com really believe in the consumer model of healthcare, then they must be at the forefront of the effort to prevent our headlong dash towards socialized/government run healthcare. How responsive are the folks at the DMV? The post office? How much help or information do you get from the DMV, and how much time does it take you to get it? Do you really think that the system that runs government offices will generate a more consumer-friendly, transparent healthcare system --- when they will have absolutely no competition? The answer is less government involvement in healthcare, with a decrease in the Byzantine set of regulations we deal with. This would allow physicians to negotiate with hospitals, labs, insurers, employers, etc., to form more efficient and integrated models of healthcare delivery. Then both Mr. Johnson and I would be happy, because he would be better able to get the data needed to make informed healthcare decisions, and I would have more time to devote to patient-centered care.

I do have one other question, though. At 2AM, when you are sick as a dog and need an emergency laparotomy, how are you supposed to be a conscientious healthcare consumer unless you have spent a considerable amount of time in preparation, studying all of the available surgeons in town?

Tuesday, February 17, 2009

Brush up on your German

I am not a "movie snob." I have a little talking statue on of Napoleon Dynamite on my desk, m'kay? But I must say that I enjoy a well made foreign movie now and again. No, I don't mind reading subtitles one bit, and kind of like hearing the actors speak in their native tongue rather than having some hack job overdub in English. Over the past several months I have had the great fortune of discovering four movies in German, and although they have literally nothing to do with medicine, I'd like to recommend them to anyone who is interested in movies that concern conscience and morality, and who understands the destructive power of government. All of these are available at Netflix, and all but "After the Truth" are available at Blockbuster.



Sophie Scholl (Die Letzen Tage) is a depiction of anti-Nazi resistance movement members in their last days in 1943. While their story may be well known in Germany, certainly it is worth telling to an American audience as a reminder of the true bravery of those souls who stand against the evil that men do to others, and of the price they pay. Well acted and well worth the time to watch.



The Counterfeiters (Die Fälcher) is another true story from Nazi-era Germany, this one told from inside a concentration camp where a hand-picked group of prisoners were forced to participate in the largest counterfeiting operation in history. This excellent film is based upon a book by one of the survivors, The Devil's Workshop: A Memoir of the Nazi Counterfeiting Operation, and won the 2008 Oscar as the best foreign language film. What struck me the most about this film is how well it portrayed a rather unsympathetic character who is able to eventually recognize the inhumanity around him and do the right thing when needed.


The Lives of Others (Das Leben der Andersen) is also an Oscar winner for best foreign language film, and probably one of the best movies I have ever seen. Set in the period before the fall of the Berlin wall and the collapse of the Soviet Union, this film explores the insidious way in which the continuous intrusion into the privacy of the populace -- an absolute necessity to maintain a socialist state -- destroys the souls of the spy and those spied upon. This is truly a great film; obviously, I'm in good company.



After the Truth (Nichts als die Wahrheit) is the most esoteric film on this list, and the one which has the least grounding in actual events. Imagine that the Nazi "angel of death" didn't eventually die in Brazil in 1979, but bided his time for a last chance at public redemption. I won't spoil it for anyone who wishes to watch this fascinating movie, but to have an elderly Mengele recount his deeds as "merciful," and accurately compare them to embryo experimentation, euthanasia, and the like is chilling. This is the kind of movie that should have gotten much wider distribution.


So, brush up on your German, or get comfy with subtitles. I promise you won't be disappointed.

Thursday, February 12, 2009

The Hard Sell

Amy Tenderich (@ Diabetes Mine) recently wrote a thoughtful post about the difference between referring to people as "consumers" or "patients" when they interact with the health care system. After I threw in my ill-conceived two red pennies, I started thinking about what the logical extension of the trend to label our patients as "consumers" would be. And, of course given the way my mind tends to work, what the far-fetched, illogical extension would be. This being America, I think we need look no farther than day-time teevee for the answers. After all, we approach consumers ........ with advertising!

Yep, I'm talking infomercials and TV pitchmen. I can see in the not too distant future these type of pitches.


"HI! BILLY MAYS HERE! IF YOU'RE HAVING PROBLEMS WITH HARD STOOL BUILDUP CAUSING DIVERTICULITIS, NOT TO MENTION HEMORRHOIDS, THEN YOU NEED THE AMAZING NEW BOHINEY BLASTER® COLON CLEANSE KIT! USE THIS STUFF ON FILTHY BOWELS AND IT GETS OUT CRAP THAT'S BEEN IN THERE SINCE THE NIXON ADMINISTRATION! IF YOU'VE GOT THAT HARD-TO-GET-RID-OF ROCK HARD STOOL, THEN BOHINEY BLAST® IT RIGHT ON OUT OF THERE! IT'S GOT THE POWER TO BREAK DOWN AND DISSOLVE: POOP, UNDIGESTED POPCORN, AND THE COIN YOU SWALLOWED PLAYING QUARTERS IN COLLEGE!

OTHER CLEANSERS HAVE TERRIBLE ODORS --- NOT BOHINEY BLASTER®! IT HAS A FRESH BUBBLEGUM SCENT WITH A HINT OF MERLOT! USE IT IN THE COMFORT OF YOUR OWN HOME, OR CARRY SOME TO WORK FOR THOSE TOUGH DAYS! YOU KNOW HOW HARD IT CAN BE WHEN YOU'RE CARRYING A LOAD AND YOU HAVE A MEETING WITH THE CFO TO GO OVER NEXT YEAR'S BUDGET!

THIS STUFF HAS THE POWER OF A SMALL THERMONUCLEAR WEAPON, BUT IT CAN BE SENT TO YOUR HOME TODAY FOR ONLY $19.99 A BOTTLE. BUT IF YOU ACT NOW, WE'LL SEND YOU TWO BOHINEY BLASTERS® AND THROW IN NOT ONE, BUT TWO OF OUR SPECIALLY PREPARED GRAB, YANK AND GO® HOME HEMORRHOIDECTOMY KITS!



Hi! It's Vince from ShamSurgery©! This is the self-surgery kit for the hernia. The perirectal abscess. The skin cancer. A regular surgery kit doesn't work wet. Not the new ShamSurgery©! It works wet or dry, whether you're performing self-surgery in the shower or on your kitchen table! Doesn't drip! Doesn't make a mess! When you're done, you wash it in the washing machine!

Here's a big perirectal abscess. That is going to be a real problem for the average surgery kit. Look at this --- with the adjustable set of mirrors, you can get back there in no time and get to work. You following me, camera guy? No other surgery kit is going to do that!

You're going to spend $20 every month on doctor copays anyway. To me, the ShamSurgery© kit is for everyday use! You get four ShamSurgery© kits for $19.95. If you call now, you get a second set, absolutely free. That's eight ShamSurgery© kits for just $19.95! It comes with a 10 minute warranty --- here's how to order!



Have you ever wanted to get that great, stretched-as-tight-as-Spandex-on-Roseanne Barr face lift? Well, I'm Ron Pepool, and I'm here to tell you today that your prayers have been answered! Today, we'd like to introduce you to the Robco Facial Carver and Dehydration System®.

This is truly revolutionary --- a device that allows even the most casually interested homemaker to become a surgeon par excellence. Let's look at the inner workings of this fabulous product. The knives are stainless steel, and sharp! (Crowd goes Whoo!) Why, without this you'd have to get pure obsidian to slice your skin that swiftly. You can carve off 4 and 1/2 pounds of fat from your face, or two 2 pound neck rolls! When you're done, the patented Facial Dehyrator will let all that left over juice and blood from surgery drip into the special collecting pan (whoo!), all while causing your skin to contract like Shrinky Dinks in a blast furnace!

Now, a system such as this is worth at least $500, but how much do you think you'd have to pay for such fabulous technology, and where can you get the set? First, let's review what you get -- Robco Facial Carver and Dehydration System® comes complete with a dozen stainless steel scalpels, a pair of sterile gloves, a dozen packs of suture, a Jackson-Pratt drain, and a one-size-fits-all facial burn dressing. Remember that the patented Facial Dehyrator is made of stainless steel-lined plastic, and comes with 3 reusable drip trays. So, how much is all of this worth? (A shout for $400). You know you're not going to have to spend $400! Not $375. Not $300. This revolutionary system can be yours today for just 4 easy payments of $39.95.

But wait! There's more! If you call today, we'll throw in the new Pepool Pocket Appendectomizer absolutely free. You know you'd rather be able to take care of a pesky case of appendicitis in the comfort of your own home than to head to an emergency room. This nifty device includes a veritable Swiss Army knife collection of tools, such as a corkscrew to stick into and lift the abdominal wall while you root around your belly trying to grab that little guy with the Robco Appendix Clamp. But you have to call now, because you know that this deal just can't last! (thunderous applause from the crowd)


Do you need surgery? Does the idea of forking over cash just to get that pesky coronary bypass out of the way irritate you? Well, for the last 30 years I have been working on ways to get YOU free operating room equipment! That's right! I went through all of the IRS documents, all of the Facebook pages of hospital CEOs, and every tax return filed in the past 75 years to make sure YOU get FREE SURGERY EQUIPMENT! How do you qualify? All you need is a Social Security number, $3,000 in annual income, and more gullibility than an Obama voter expecting a tax cut!



Tired of those other kitchen table surgery sets that get dull with use? Have a family member who is a little on the overweight side, and you just can't get down to the abdomen with your worn out, dull scalpels that constantly need sharpening? Well, YOU need the Ginsu Home Surgical Knife Set! It's the Sharpest Scalpel Set on the Market! Skin? Fat? Muscle? Bone? No problem! The Ginsu Home Surgical Knife Set will cut through it faster than Plaxico Burress goes through an ammo clip with his 9mm pistol.




How many times has this happened to you? Your kids all need their tonsils out! You are trying to come up with an exciting new way to get them to let you operate on them! You could go the standard route, tie them down, give them a slug of Everclear, and get to work. But why bother, now that you can use Rodco's amazing new home surgical tool, the Super Tonsill-o-matic 76! Yes, home surgeons, the days of roping your family members to the kitchen table are over because the Super Tonsill-o-matic 76 is so fast and easy to use you just need to give them a sniff of glue to briefly stun them, and away you go! The Super Tonsill-o-matic 76 will grab and blend those puppies into mush in no time!


Consumers. Merchants. Customers. Providers. Bullshit.

I dusted off my diploma, and put on my reading glasses (getting old, dammit), and looked hard. It says that I graduated from The University of Texas Southwestern Medical School (AKA The Best Medical School in the Country®). I checked their web site, and no, it still does not call itself a Provider School, churning out "providers" who deal with "consumers."

Although I am a small businessman, and have the tax headaches to prove it, my business is different than, say, selling shoes. It is my privilege and duty to care for people who come to see me ---- as patients. There is a respect involved with that term which is absent from the term consumer, and which is important in maintaining the dignity of the individual as he or she interacts with physicians, hospitals, and other places where medical care is delivered. When we lose that perspective ---- when physicians are seen only as "providers," or interchangeable widgets, and when patients are seen only as "consumers" ---- we will have totally lost any semblance of dignity as a profession, and by extension as a people.

Saturday, February 07, 2009

Shakin', Shakin', Shakes


The shakes. The shivers. The heebie jeebies. The jitterbugs. The jimjams. The horrors. The screaming meemies. The blue devils. Snakes in the boot. The DTs. All are expressions that refer to a clinical phenomenon known as delerium tremens ---- delerium associated with alcohol (or benzodiazepine) withdrawal. Why, pray tell, does a surgeon care about alcohol withdrawal? Because I see it, and not infrequently.

I like a good martini now and then. I've even enjoyed a glass of Delerium Tremens beer recently (oh, it was good). But I am not in the category of an Olympic caliber drinker, one who consumes a fair amount of alcohol on a daily basis. The dedicated drinker is the kind of patient who causes all kinds of havoc for us, and not just in the realm of trauma.

Alcohol can be a wonderful thing. A social lubricant, a relaxing tonic, a stress reliever, an enjoyable companion with a good meal, and in some forms possibly a good thing for your heart. It can also be destructive, a massive earthquake that destroys lives and tears apart families. I'll leave the social issues about alcoholism aside for this post, but I'd like to let you in on a little secret --- alcohol withdrawal is not a glamorous downward spiral or a simple hangover. It is an ugly, depressing, and potential deadly process. Unfortunately, we often see this when we least expect it.

Not surprisingly, many folks are a tad less than honest with their physicians. Alcohol dependence isn't as readily detected as, say, hypertension, a heart murmur, gallstones or appendicitis. We don't have a screening test available, and we thus must rely on a patient to be as forthright as possible when we ask the question "how much do you drink?" For obvious reasons, most answer with a miniscule fraction of what their real booze allotment really is --- I trained in Salt Lake City, where this question was frequently seen as an insult, but alcoholism knows no religious boundaries and I was given false information just as frequently there as here in Colorado.

For surgeons, especially those who work on the GI tract, an alcoholic can pose a vexing challenge. Basically, when a patient that overindulges regularly is hospitalized, the pint of vodka he usually downs on a daily basis is not readily available. For short hospitalizations of a day or so, this will generate irritability, nervousness, and shakiness ---- all relieved with a stop at the package store on the way home. For longer hospitalizations, it gets progressively worse, with nausea, headache, insomnia, excessive sweating, tachycardia, tremors and a variety of involuntary movements (such as constant picking at clothes, skin, and sheets) joining the display. This is the point where we generally pick up on the diagnosis --- basically the patient has the shakes.

A fault runs through the valley
It's long as it is mean
It starts to tear into the earth
And gets all in between
It shakes up through the mountains
It shakes down to the sea
It shakes up to the volcano
And then it starts to scream
And then it starts to shine
And Lord, it makes me tremble
And Lord, it makes me tremble
It's shakin' and shakin' and shakes

By this time, without a quick infusion of a couple of stiff drinks, the patient is well on his way to full blown withdrawal, marked by profound agitation, hallucinations, fever, convulsions, severe autonomic nervous system overactivity, and possibly death --> delerium tremens. We treat this by making a bargain with the patient's body --- if we give enough sedation, generally in the form of Ativan or another benzodiazepine, hopefully we can stave off the severe physiologic effects of alcohol withdrawal until the process passes. The tradeoff is that the patient must be pretty snockered, meaning ICU care, careful monitoring, a need for restraints, nutritional support, and a risk for aspiration. More severe cases may involve mechanical ventilation, particularly in the patient who has undergone major surgery or suffered severe trauma. Beta blockers and Clonidine also help mitigate the systemic effects of alcohol withdrawal, and though it seems a little bizarre, IV ethanol infusion has been used as an alternative to benzos.

Needless to say, it is often the case that alcohol withdrawal is often far worse than the other underlying reason a patient is hospitalized. It is also a big expense, one that is rarely reimbursed.

And Lord, it makes me tremble
And Lord, it makes me tremble
She's shakin' and shakin' and shakes