Posts filed under ‘Doctor’s Rants’

It’s much more complex than you think

It is not that I am surprised that people don’t know that medicine is complicated, but that they don’t seem to even have any suspicion that there may be alot more to it than they can appreciate.

After all, people do seem to know that med school is long and arduous, yet feel that with even a trivial effort that they can hope to figure out the workings of the body. I see this same effect in many places. It is a denial that the world could possibly be so complicated as to defy understanding or control.

As Isaac Newton famously said ( or was attributed to him) that despite being one of the most brilliant and accomplished minds of his time that he had barely examined one grain of sand on the beach of knowledge.

The levels of complexity boggle even me. The actual knowledge that has already been discovered is so vast as to be humbling if not overwhelming. Much of the time the body’s workings are counterintuitive and inconsistent.

The patient is the undeniable expert on what is happening to him/her as long as they stick to reporting what has happened. When they try to explain why it is so, is where the problems start.

 

as an example: Many times a patient will say something like, I have a headache some mornings, what is it? Sort of like my telling my mechanic, ‘my car makes a noise what is wrong with it?’

It will take me many, specific questions to even hazard a guess.

12/23/2014 at 5:05 AM Leave a comment

Natural, schmatural

What is it with this ‘Natural’ thing anyway? I have so many people simply assuming that natural must be better, as if it is a given, nothing to question, as fixed as ‘breathing is good’. This despite the overwhelming evidence against it. Furthermore, people are totally willing to believe that if it said to be ‘natural’ it therefore must be.
Nobody in this money driven society would ever consider lying about such a thing, surely that is taboo.
These are intelligent, educated thoughtful people. People that would never even hesitate to delete an email from a Nigerian prince. So why swallow such a bunch of hooey about ‘natural’?
The best answer I have heard in thirty years is that it is a holdover from the ’60’s back to nature movement and perhaps it is, but it sure should be wearing thin by now.
After all, consider the following:

Natural encompasses:

a hard difficult life full of tragedy ( think many childhood deaths) followed by an early death

Small Pox, Typhus, Malaria, Polio, Tetanus– the scourges and killers of untold millions before ‘unnatural medicines/ vaccines’ came to the forefront.

Performing labor manually, living by ‘the sweat of ones brow’ if you will, being hot in summer, cold in winter. No way cars and electricity are ‘natural’

Natural vegetables and staples before they were augmented/domesticated provided meager sustenance and did not allow for much storage, which meant cycles of famine.

Going to the bathroom in the open, the world smelling of a toilet.

Give me engineering and human modernity anytime. Certainly i won’t be the first to try something new but hey, were are a very bright and curious race and I enjoy and fully take advantage of all the fruits of scientists’ labor, whether it be transportation, Air conditioning (!!!), a robust infrastructure or advanced medicines.

A year ago I was routinely tested for immunity to a variety of diseases (Hep B, Polio, etc.) and was found to have no immunity to ChickenPox. How in the world is that possible ? I don’t know but I can tell you, I could not wait to get to the office and get a shot followed by a second one in six weeks.

12/13/2014 at 3:22 PM Leave a comment

Come on, folks, grow a pair

I should place a disclaimer that there are multiple factors in an ED (Emergency Department) with which I do not deal with, nevertheless, someone has to stand up and make decisions or we might as well give our jobs to a software package, who will do it error free (and health care free).

Case in point: 18 year old gets up one day and goes to the fridge. She becomes lightheaded, slightly nauseated and suddenly feels hot all over, she then faints onto the floor. She comes around very quickly and by report she was back to normal very quickly.

I understand the parent’s worry but calling the rescue squad seems a bit over the top to me, and it initiates a different protocol than simply walking into the ED, or better yet, calling her family doctor, this was daytime after all.

Did I mention that she had not eaten anything the night before? That her normal blood pressure (102/60) is on the very low side of normal? That besides a bump on her head she felt back to normal?

I do understand that since that wonderful actress (Natasha Richardson) had a subdural hematoma when falling on a bunny slope, the ED is more or less committed to doing a CAT scan of anyone that shows up from an ambulance with the slightest hint of head trauma. I do not fault them for that.

However, the Neurologist appointment the very next day?, The Cardiologist the day after that?, the Holter monitor two days later? Really, People? All of this under the guise of being proactive and caring? First of all, none of this is of any value. If we were monitoring her during her episode, then sure they would all conclude that she is a wonderfully healthy 18 year old that fainted because several things lined up ( her typical low blood pressure, probably low sugar level, perhaps poor sleep, etc.) Secondly, they are not decreasing their legal exposure for they sent her home. If they were truly worried that something horrible was going to happen, that these symptoms were a precursor of a life threatening issue they would not let her out of the building.

Now, she is seeing me because the patient and family are really worried. who wouldn’t be with all these appointments?

Why not simply send her to me (This is the Royal me, not me specifically)  and let me work the problem. This is what ED’s typically do, they rule out something serious and they punt to us primary care folk. I am sure it was purely a matter of coincidence that all of the specialists involved also worked for the same hospital. Also amazing how quickly she could be seen when we have trouble getting appointments within the same month. (Excuse my Cynic, he comes out from time to time.)

The EEG and Holter are utterly worthless in this case. There was no evidence at all that she has a seizure disorder and a holter after the metaphorical horse has left the barn is simply a way of making money.

Perhaps now they can send her to their mental health clinic to deal with her anxiety?

You have to wonder what their response would be if the income to the hospital was based on the actual problem and not on how many tests you can cram into one week ( before the patient or primary care doc decides they aren’t needed.)

We go to school precisely for this kind of decision making, to separate what is the right thing to do from what could be done and what would be paid for. The former requires training, experience and the willingness to make a decision, the second can be done by a geek ( I use that term affectionately, i used to be one)  that can program a computer.

11/09/2014 at 6:18 AM Leave a comment

Is that a religious issue?

A significant number of patients tell me that they don’t believe in flu shots, or even that the flu is a real issue . I presume they mean that they don’t think the flu shot helps or works. But when pushed they act much more like I challenged a cherished religious belief, which i would never do. But it never occurred to me that a common vaccine would be involved in such a belief system.

I see all kinds of people and their personal belief systems are only an issue when it comes in conflict with my recommendations, which in reality is nearly never. But no, they say it is not an issue of faith, but a fear that ‘The Government’ has put something in there to control them. How to respond to this? Where do these ideas come from? Not that i trust the government explicitly but I understand the entire production chain and the millions of people involved and the idea that a secret that large could be kept is ridiculous. Besides, I tell them, if the government was so disposed to poison its people it would be in the water or food, why go through the enormous effort to put  it in something people can choose to avoid?

At the end of the day i suspect that these ‘reasons’ are a proxy for “I don’t want a needle”. Which saddens me, for I don’t see myself as pushy; I offer the shot, stress my professional opinion that it is a good idea and perhaps mention that I won’t go a winter without my shot (32 years in a row now) and if they say no, then no it is.

10/29/2014 at 7:37 AM Leave a comment

Anti- vacines, really?

In the news there are reports of people not only choosing to avoid vaccines for their children but intensely promoting such behavior. I have of course seen this behavior since I started practice 25 years ago and have resigned myself to the myriad of reasons that come up.

Recently i saw the seven part series on the Roosevelts and of course FDR’s polio and the decades of misery and pain he endured because of it. I wonder how he would respond to the issue of not immunizing your children to a vaccine that would prevent such tragedy?

Are people really so removed from reality and history that they perceive this world to be a naturally safe place? When people tell me they prefer natural things rather than medicines, I ask them how they feel about Polio, Ebola, early death, high infant mortality rates–all of which are most definitely natural.

I could not wait for my two girls to receive all their shots. After thousands of years, humans have developed technology to avoid much ‘natural’ suffering and what in the world would compel me to avoid preventing it? I have seen HIB meningitis, polio, whooping cough and it is not a pretty picture. I have read the history of Typhus, Diptheria, Tetanus and those are unimaginable.

What should society’s reaction be when those people’s decision not to vaccinate endangers my own kids? Think Typhoid Mary, she was totally asymptomatic yet she was responsible for many deaths. To her death late in life she felt persecuted.

Perhaps this is a result of the immense success we have had as a society in eliminating these scourges to the point they don’t seem real anymore. This is not so in other parts of the world, right now, not  in some distant past.

If there was suddenly a vaccine as good against Ebola as the ones we have against polio, would these people also avoid that? perhaps someday I will ask one of them.

10/20/2014 at 7:50 AM Leave a comment

update on EMR

On the EMR (electronic medical records) front: things are not good. As anyone that has read my rants on this subject knows, I am not in any way encouraged to change my records from paper to digital bits and it is not a matter of being old and stuck in my ways. I like progress and have an iPhone, Facebook account, etc. I would even tweet if I had anything important to say in 144 characters. However the mass delusion perpetrated onto the primary care establishment that we should line up like lemmings to the cliff face and pay through the nose for the privilege of jumping off befuddles me. The link below is a third party report on the lack of success EMR systems have at the very thing they are supposed to provide.

Essentially, we are being recruited to be the ultimate Beta testers of a system that will not be ready for prime time for years. Without transparent standards allowing the easy transfer of multiple forms of data ( X-rays, reports, pictures) by all the different EMR systems, there is no point. What has become obvious is that the powers that be must know this but need to create the demand first. It should not surprise me that they are finding many willing (if not eager) takers. Providers are tripping over themselves to set a system up, costs be dammed.

At the risk of being the last man standing and being the last to purchase a fully functioning system at a fraction of the cost–so be it.

http://www.nytimes.com/2014/10/01/business/digital-medical-records-become-common-but-sharing-remains-challenging.html?module=Search&mabReward=relbias%3Ar

10/08/2014 at 6:21 AM Leave a comment

A mulligan please, I have earned it.

A patient who has been coming to see me for 18 years saw me yesterday . He clearly has been very happy with the care he has received (he stated as much) and for the most part the service at the office. He complained long and intensely about an event two weeks ago where he had trouble getting refills on two medicines. The problem started in that he had not been in the office for over a year. I have blogged before about this issue and a year is on the extreme end of what is acceptable, six to nine months is more typical. One thing led to another and my staff and him got into a verbal tussle, with him loosing his composure and my staff digging their heels in.

Although I will admit there was probably an easier way to handle it, my point is that after 18 years of excellent treatment I expect to have earned several mulligans. Many in fact. Yet this one difficulty let him to think of taking his business elsewhere! As if he can find another office that only has a bad day every twenty years!  Good luck with that.

I am not saying that my staff did things wrong, their point was valid as were the patient’s complaints. I am saying that it could have been handled much more simply on both sides, but nevertheless, I fell that for every year we do well by our patients they owe us one mulligan for a bad encounter. Perhaps a real bad encounter would use up two mulligans. Nevertheless this patient’s tolerance for frustration is so low that it was all I could do not to hand him the list of nearby physicians and wish him luck with his extremely low tolerance . The number of patients that do that and then come back is legion. They do not know what the norm is out there and when they discover that they return. The number of patients that move away, but still within driving distance and remain with us is also legion.  We are by far the most flexible and understanding office in our area.

Perhaps we have spoiled out patients and we need to reevaluate our policies and become more strict. Interestingly there are many patients to do ‘get it’. These are usually patients that have significant experience with the world and can appreciate how much we work with them to help them out.

Someone this fragile is scary to us. We are not perfect and occasionally we will mess up, how will they deal with that?

07/08/2010 at 5:20 AM Leave a comment

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