What, Exactly, Is A Unit?

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The Quizzically-Named Blood "Unit"

Packed red blood cells are measured in the odd units of…”units”. 

There is very little meaning to this term.  Typically, we measure liquids by the King’s pleasure with terms like “quart” and “gallon”.  Or, if in a scientific mood (as we are in the hospital most days) with terms like “mililiter” or “deciliter”.  Of course there are similar words for solids. 

Each term boasts about as much tangible meaning in this world as any in the English language.  Similar to the idea that a dollar is actually a representation of a chunk of gold in some vault somewhere, so too are the words we use to describe matter backed by very specific – material – standards.

But a unit?  Even the guy I called at our hospital blood bank didn’t know what the term meant, exactly.  So, I done did me some research…

The term relates to the fact that blood is only partly liquid.  Really, human blood is nearly 50% solid matter – blood cells, clotting factors, platelets.  Lots of cool stuff, actually.  Blood is so complicated, doctors regard it as a human tissue.  

I also imagine that we describe blood in units because the substance looks so stark and bright and scary;  it just demands mad respect.  One of the most spectacularly beautiful things I ever saw in medical school was microscopic slides of red blood cells.  I used to stare at them for hours (which is why I nearly flunked histology).

A unit of blood typically is about 450 mL, which is about .95 pints.  If you order a unit of some component of blood, say, plasma, you will get the amount of plasma that would be found normally in a unit of blood.  Again, not especially exact.

BLOOD_0125_JRH_19516Here’s the thing:  A human body contains, roughly, 12 units of blood.  12.  That isn’t much.  So, when a person gives blood, they generally only give about 1 unit.  Any more than that and they’d have a pretty tired week.

The other day, we gave one patient 24 units of blood. It took 24 people deciding to take time out of their day, endure an IV, sit around with an outdated shallow magazine about surgically-enhanced humans…and donate part of their living body tissue to help this one person.

I order 2 to 4 units of blood for patients on a semi-regular basis.  I’d say I do it every other time I’m on a medicine week in the hospital.  As a doctor, I look at the patient’s needs; rarely do I actually think about where the supplies that I order come from.

Really, if you’re sitting around wondering what you can give away that genuinely, truly helps humanity.  Give a little blood.  It’s gross, the IV hurts and it takes up a not insignificant amount of your day.  And it’s measured in weird amounts that have no meaning so you won’t really know what it is that you actually donated.  

But you really do help others in dire need when you give blood.  Nobody “just kinda” needs a blood transfusion.  I’m not sure what we’d do if people didn’t donate regularly.  We really do save lives with the stuff.  So, when you get the chance, give it a try.

I Want It Thaaat Way

“Just…look under your seat.  I’m sure it’s there.”  Said Bobby, my driver.  We were rushing my ailing patient from Thomaseau to the general hospital in Port Au Prince when Bobby suddenly stopped our car to find a CD.

He made me get completely out of the car so he could check all around my seat, under it, inside the faux fur cover.  Nothing.

bobby“Daang, MAN!  I borrowed that from a friend.  Now I lost it.”  He sighed, “Ok, get in.  We’re in a hurry here.”

Thus began my first experience with the most famous man in Thomaseau.  Bobby grew up here.  His parents owned a general store that apparently did extremely well.  But with the rise of an anti-aristocracy movement when he was young, Bobby’s family found themselves in the grim cross hairs of a violent revolution.  So, his father pulled some strings (one very convenient perk of wealth in Haiti) and immigrated to the United States.

“I’ve never been to a public school,”  Bobby said as we bounced over a stretch of land that might be described as smooth for a Siberian rock quarry.  With Jedi-like reflexes, he swerved around some of the the bigger pot-holes and cranium-sized stones.  “Always private.  Even college.”

Bobby has a smile like a sun-flare and fashion sense straight from New York.  He knows English well enough to drop innuendo and colloquialism into his jokes.

“S-s-s-s-oh you went to c-c-c-c-c-ollege-ege?”  I chattered out as we pounded the Haitian “road” into submission.

“Yep.  Boston University.  Was getting a degree in…beer.”  He laughed.  “It was such a waste.  I dropped out and started my own contracting business.  Made a fortune.  I had money everywhere.”

But now he runs an orphanage in one of the poorest villages in Haiti.

Bobby's Mom
Bobby's Mom

When his parents decided to return to Haiti, Bobby followed.  Soon after returning, his Dad died and Bobby stayed to take care of his mom. Just like that.  Shut down his business, sold off the valuable parts and stayed.  It’s a family thing, I guess.

Bobby and his wife have been unsuccessful at having children, so they closed the family store and opened an orphanage in that building.  Mom lives in what was their house.  Lemons from lemonade.

“So, can you even make a living as an orphanage director?”

“A living?  HA!  Tell me another joke.  I don’t even know where I’m gonna get the money to pay my friend back for his CD.”

“Then,” I pressed, baffled, “clear this up for me: you left a few hundred-thousand dollar a year job to come back to Haiti and live on donations?”

Something like that, he responded.  “You do what you gotta do.”

I once heard a missionary talk about why they lived on pork and beans in a hut in Gambia.  “Love constrains us,”  he asserted.  Sometimes the call to service overwhelms the call for comfort and the pursuit of happiness.  Bobby seems to think the same way.

slum1That said, I myself do not believe in true altruism, with perhaps the exception of one perfectly selfless act somewhere around A.D. none.  Even the great works of Mother Teresa and Father Damien, most probably, have some selfish motive tied up in them.  The great Christian missionaries like Hudson Taylor and Jim Eliot were as much promoting their own worldview as providing service.  They probably would agree with me in this assessment on some level, too.  Great Christians are constantly in touch with their need for salvation.

And I wasn’t about to let some Haitian guy restore my belief in completely sacrificial love, but he certainly got me thinking about it, especially as we entered the inner city of Port Au Prince…

I wasn’t prepared for the hopeless destitution I saw there.  The place is a singular universe, filled with the dank and putrid entrails of human suffering.  The streets teem with staring hungry, lifeless eyes.  Hollow, gaunt faces watch expressionlessly as our car blisters by.  Breathe too deeply and you will retch, but you won’t know if it’s because of the stench or the scene.  Maybe both.  These slums fester like an abscess, limitless human pestilence stewing within the wound.  And instead of drinking with his buddies at Boston U, Bobby drives through this nearly every day.

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Some of the orhpans

As we bounced along, Bobby described some of the problems that led to such squalor.  I noticed his voice drop a pitch in the effort, and I could feel the sorrow in his countenance.  He described the floods, the fires, the rebellions and litany of misguided UN and WHO initiatives.  He outlined some of the self-serving and catastrophic policy choices by the French, and lately by – you guessed it – the United States.

We stopped at a stoplight and a child came to the window, asking for money, food, anything.

“Say something in English.”  Bobby told the child in Creole.  “If you want something from me you have to earn it.”

“Gim me dullah.”  Said the boy.

“Allright!”  Bobby exclaimed, “You’re on your way!”  He flashed his fantastic smile, the display of mirth some sort of anachronistic throwback to better times, handing the boy a US dollar bill.

Then my escort looked at me, reading my thoughts.  “I know about the handout thing,” he said.  “It just perpetuates poverty and dependency.  I know.  But you gotta remember…this is Haiti.  That kid isn’t going to go buy drugs or something stupid with that money.  He and a good portion of his family will eat with it.”

He paused as we asserted ourselves – alpha-wolf style – through a melee obliquely described as a roundabout.  “And anyway,”  He said swerving around a donkey and accelerating into oncoming traffic, “It’ll get that kid off the street for at least one night.”

Just as he said this, the expansive grill of an impressively huge white truck bore down upon us; clearly with no intention of stopping.  Deftly, Bobby yanked the steering wheel to the right at (what felt like) the very last moment, the blare of the truck’s horn bending into lower tones as we passed by.

But in avoiding certain death with the truck, even the Bruce Lee reflexes of Bobby couldn’t avoid two giant potholes now in our path.  I gasped slightly and dug my fingers into the IV bag I was holding for our patient.

Blam!  Followed quickly by BAMBAM!!

“No problem,”  he started to say, “we-…”  Bobby stopped, looking at me as he drove.  “Do you hear a crowd cheering?”

bbbExtracting my fingers from the ceiling, I listened.  “Actually, yes!  I hear it too.  Like, a real crowd.”

Just then the band kicked in, “Tell me WHYii!”  And then the crowd REALLY roared (screams, actually…it was mostly girls).  “III want it, thaat way!”

Bobby laughs.  The sound reverberates through the car, energetic and infectious.  “THERE’S my CD!  I knew I didn’t lose it.”  Apparently the shock of foot-deep potholes jarred the CD player loose from some track fixation and it just spontaneously started playing again.

I never, in the imagined space of 10,000 lifetimes, thought I would find such joy in a Backstreet Boys song.  But I did.  There we were, driving through a sorrow I will never forget, singing one of the cheesiest pop songs in American music history…together.

This child would not survive the Spring.

Later I would tour Bobby’s orphanage, a jewel of glimmering hope for forgotten children.  I would see the 40 foot well he dug through the hard dirt and rocks in his back yard.  I would listen to him describe his days that start at 5am so he and his wife can care for nearly a dozen kids with no home, no family and no safe keeping.  I would meet one of his orphan boys with cerebral palsy that would be dead within a month.

Through it all – with so much emotion and despair pressing me into ineffective stillness – Bobby is belting out American pop tunes, driving like Andretti with a midichlorian infusion and trying to save lives.

Sure, some part of what this guy does is self-serving.  He’d laugh if anyone called him a saint.  He’d probably ask that you dispense with the titles and donate t0 his orphanage instead.  But his life reflects a near-image of genuine altruism in ways that might inspire even the most jaded.

And he’s a perfect fit here.  This place is destitute and tragic to me.  But this is Bobby’s home.  He can see the hope that I can’t.  He waves to friends he knows as he barrels down the street; he looks with affection on the same things I see as symbols of misery and suffering.  With just a little help from people like me – so ill-fitting here – guys like Bobby will change the world.  They will change Haiti.

Even in a place like this, he still sings.

Left To Die On A Tile Floor

“Dr. SW101,”  said Father Larry, “There’s a woman lying unconscious in the church courtyard.  Can you go see her?”

With little more than a quick nod, I grabbed my interpreter and headed out the door. How, I wondered as harsh sunlight spilled into my eyes, is a doctor supposed to help an unconscious patient?  In Haiti.

I tried to think of all the reasons a woman might collapse, and what sort of assistance I might be able to offer.  Again…in Haiti.

Quickly, I reviewed ACLS in my head.  I tried to revise the arcane algorithms based on the fact that we probably did not have ONE SINGLE med used in a typical code.  I thought through hypoglycemic coma, and stroke signs and symptoms.  I tried to recall how I might distinguish between ischemic and hemorrhagic types (and would it help to know the difference?).

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Our team working on the patient

Also on my list of worries were seizures, pulmonary emboli, electrolyte disorders, dehydration and the difference between heat exhaustion and heat stroke.  Distantly, I pondered the probability of this being a simple “waiting delirium” where people fake a collapse to get to the front of a line.

I approach what must be the patient but of course I can’t see her.  All I see is a giant throng of people hovering in a circle; a shark frenzy of curiosity.

My interpreter helps me push through the crowd to a thin elderly woman lying with eyes half closed on a tattered blanket.  She was placed in the half-shade of a skinny, leafless tree on dusty cobblestones just outside the church offices.  People are yelling and pointing in all directions.  They give me space grudgingly.

I learn that the woman had a seizure sometime in the night, passed out, and has been seizing regularly ever since.  She is completely unresponsive.  Someone tells me she’s around 70 years old.  Someone mentions that she’s a grandma.  Someone says it’s hot out.

After a brief exam, I have her brought into our clinic and placed her on a army-issue stretcher.  I rummage around our supplies with the help of a spectacular nursing student named Kim.  Together we come up with an angiocath (for IV’s), a bag of normal saline…even some gauze.

We place the IV and get some fluids running to treat possible dehydration.  Kim and an OB nurse place a foley urine catheter we happen to have too.  Clear urine runs into the bag, ruling out dehydration.  We find urine test kits and note that there is no blood or glucose in the urine, thus arguing against diabetic problems or UTI.

The immediate problem was the seizures.  And we had no medicines we could give a patient who, every 15 minutes or so, had a full seizure on the entire left side of her body.  Kim and I riffled through the meds again and found some dilantin (good for seizures)…but in pill form, which made them totally useless.

Knowing the patient would die in her current state, I wrestled with the problem of how to get some sort of sedative – ANY sedative – into her tortured body.  At one point a group of us seriously considered IV Haitian Rum.  I thought about crushing up the dilantin and trying to trip a slurry down her throat, or pushing it rectally.

We eventually found liquid dilantin; made for oral administration.  The discovery felt like a ray of sunshine in a mausoleum.  Now all we needed was a naso-gastric (NG) tube.  Gotta be lots of those lying around, right?

None.  The patient is seizing again, Dr. SW101.  The family is getting frantic.  People are looking in at the patient through every window.  What do we do?

Kim and I did find a feeding bag. Looking at it, I envisioned how we could fashion some version of an NG tube out of the tubing from the bag.  I talked up my plan to Kim.  Seeming like this kind of thing was a daily occurrence for her, she retrofitted the tubing, reversed the adapter connections…lubed the thing up and slid it right down into the patient’s stomach.  Perfect.  I had my tube.

I dose out my best guess for the patient’s weight, not knowing her renal function, her hepatic status, her chronic diseases or her current metabolic state.  I gave it my best guess – shooting for safety and efficacy – and we started a regimen of dilantin.

Along with trying to treat this patient urgently, we knew this woman needed to be in a hospital, and Father Larry had been working on the weirdly complicated logistics of transporting a critical patient to General Hospital in Port Au Prince.  Father Larry also supported my desire to stay with my patient to make sure that someone on the receiving end knew the story and could adaquately take over for us.

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Our best effort at an ambulance

Not ungently, we put the woman in the back of a tough Isuzu jeep and then blasted out of Thomaseau over rocks and roots and dusty country roads, headed for the thriving city of Port Au Prince.  Nearly 2 hours later, sweaty and dusty, we pulled in through the hospital gates.

My driver and translator is something of a celebrity in the village and knows many people in Port Au Prince also.  He did some quick talking at a back entrance to the ER, and ran back to our car and told me to, “help me pick her up…quick!  They’re letting us in the back.  Otherwise we have to go through the front and it will be at least 8 hours until she is seen.”

We carry the woman through wards teeming with people.  I sense many stares as I pass as quickly as possible through hordes of sick patients, family members, hospital staff and equipment.  We enter an austere room made of tile and bricks, with windows high above us grudgingly tossing some light to the floor.  A kid of about 15 is walking back and forth, tears streaming down his face as he intermittantly screams and jams his hands down his pants (psych?  testicular tortion maybe?).

“Lay her here.”  Instructs Bobby, my interpreter, the celebrity-guy.

“Right here?  On the tile?”  I reply, looking around anxiously.  “Where’s the bed?”

“No beds.  There won’t be one for hours.  Maybe days.  It’s leave her here or we take her back.”

We lay her on the floor.  Two of her family members that came with us huddle on the cold linoleum next to her.  I tell her story to a bored and tired looking orderly.

“Ok.  They’ve got it from here.”  Says Bobby, already heading for the exit.  “Stay any longer and they’re going to demand more money to keep her.  We need to get out now while we can.”

Fighting a sense of revulsion at the place where I’m leaving my patient, and vicerally wrestling with nearly-overwhelming waves of guilt for abandoning her, I snap a quick photo and leave.

As we walked away, I knew she would die on that cold, lonely floor.  Her family trusted her to me, and I left her lying in a tile grave.

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Her Final Moments

Not long after we returned to Thomaseau, after a harrowing drive through some of the worst slums in Port Au Prince – and in the entire Western Hemisphere – after hours and hours of efforts to save a life…she died.  Probably from a stroke that occurred before we found her in the courtyard.  Within 2 hours of our return to the village we were notified that the patient was gone.  Please come collect the body.  We wouldn’t have given her a bed in the hospital anyway because you didn’t pay for food and supplies.

We did calm down the seizures, by the way.  By the second dose of dilantin, the repeated convulsions faded away and our patient clearly became more peaceful. 

A small consolation.

The news of this woman’s death was somehow devastating to me, even though I knew she had no chance.  I couldn’t help but get emotionally involved in something that required so much effort and focus. 

And for all that work, I ended up with a dead patient; her last moments spent in squalor, destitution and abandon. 

I have now spent hours trying to frame this experience in some sort of meaningful context; actively resisting raw emotions of fury and hopelessness and sheer nhilism.  So far, I know only this:  all I can really do for Haiti, is care about the suffering there. 

And never, ever forget…

Haiti Musings

jugI recently returned from a 2-week medical relief trip to the country of Haiti.  You will notice that my blogs mostly describe this topic these days.  Later, I’ll collect all of the posts and give them their very own Tab at the top of the page.

The independent country of Haiti shares a caribbean island with the Dominican Republic.  Unlike its relatively wealthy and stable neighbor, Haiti is poor.  Destitute.  The poorest country in the Western Hemisphere and one of 15 poorest in the world.  Haiti suffers from high infant mortality, devastating chronic diseases, illiteracy, poor education, over population, deforestation, soil erosion, rapid urbanization, high unemployment and a weak government that grapples with violent uprisings on a regular basis.  The country has been manipulated and abused over the years by the French, the U.S., the U.N., the W.H.O. and many others.  1% of the population possesses 97% of the country’s wealth.

The group we went with is called Friends of Haiti.  If you ever wonder where you can give money that will truly help humanity, check these guys out.  Led by a catholic priest named Father Larry Canavera – but ecumenical and non-evangelical in mission – this organization provides medical care and support to numerous villages in Haiti.  The volunteer teams return to Haiti every 6 months and stay for 2 weeks.  They work principally in Thomaseau, a town about an hour NE of Port Au Prince.  During the 2 weeks, smaller teams also move out into the Haitian countryside and work in rural villages with names like Grand Boulage and Noyo.

Friends of Haiti is based in Green Bay, WI.  Our WA contingent consisted of another 3rd year family med resident like myself, one of our full-time faculty members and two part-time faculty.  The costs of my trip were largely supplanted by a $1000 grant from two different foundations associated with my hospital and clinic.

hatI can’t describe this experience in singular words; can’t distill it into one major theme or valuable impression.  The time I spent there wove itself around me like a dense, intricate and finely-detailed tapistry.  Dozens of times a day I found myself thinking, in the midst of a nearly-overwhelming experience, “Somehow, you need to figure out a way to describe this in words.  Somehow you have to capture all this fury and sadness, this joy and passion and fear and loss and desire and music and…this incomprehensible hope.”

These stories are my best attempt at such an impossible task.

Jesus Christ EMR

Obama seems to have totally hit the Kool-Aid bong about EMR’s saving the American Health Care system.

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Go! Go! Go! Go! EMR! EMR! EMR!

He’s not the only one, either. I recently heard some analyst yakker on PBS proclaiming in breathless tones that instituting and EMR would lead to such better health in America that it singleRAMedly would lead to all the cost savings we’re looking for in our health system. She was so spun up about it at one point I thought one of the other interviewees might suggest she get herself a room so she could give herself a little tension-release (or at least re-powder her face).

EMR’s only barely improve medical care. The overhead costs – in maintenance and updates of both software and hardware – is tremendous. They worsen charting time because they have so many boxes and forms to click and fill out on every patient. They do nothing to prevent or protect against litigation.

Their biggest utility is, so far, a theoretical one. Connectivity. If everyone in our country had their medical record in the same system, you could see a doc in Tulsa one day and Tacoma the next, and both docs could essentially function as the same care provider because they could both see the same record and continue each other’s plan.

But the idea is a myth.

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Oooooooo. It glows....Bzzzz, bzzz...

This is a capitalistic country, so there’s dozens of EMR companies fighting for market share. There’s lots of venture capital involved because this is a big game with HUGE payoffs if you win it. Each EMR has some merits; NONE of them talk to each other. By none, I mean NONE. The EMR’s hate each other. They’re Mortal Kombat enemies. I’m being as genteel as possible when I describe the standoff with words like hatred, vituperation, caustic acid on mucous membranes. Get it?

Even if the EMR’s all went to counseling and became friends, the governmental obsession with medical privacy – so onerous it is now unreasonable – requires Pentagon-level encryption that nobody can afford in both time and money.

To log onto my EMR, for example, I have to enter a number from a digital keychain that refreshes itself every 3 minutes, plus my user name. I then have to enter my username and password at 2 other stages, all of which are preceeded by boot-ups, loading pages and security cross checks.

As mentioned, it turns out that charting in EMR’s takes longer than charting on paper. This means doctors will see fewer patients and spend more time charting.

Keep in mind that I’ve semi-rigorously calculated that I already spend at least 30 – 50% of my time totally avoiding patients and patient care so I can document. So, when you hear that we have a doctor shortage in this country, assume what is meant is that we actually have the right number of doctors… but because only half of their time is spent actually doctoring, we’re really about 50% short on docs.

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Still I love techololgee...TURN IT OFF! TURN IT OFF!!

If you look at good socialized health systems around the world, you don’t really see many EMR’s. In fact, obsession with glowing technology is what gets American medicine in trouble all the time. We already order too many high-tech tests that do nothing to increase life expectancy or quality.

The cost of our health care system isn’t a result of not having an EMR. Our costs are driven by all the extraneous junk that makes us uniquely inefficient.

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Follow the Liiiight, and You Shall Be Saved

Look at good health care systems, and the main thing you don’t see is entire industries piggybacking on the cash cow of medicine. Insurance companies are heavily regulated, and thus make reasonable profits. Some are government-administered and make no profit at all. Litigation is highly limited, preventing not only absurd payouts, but also preventing the much larger hidden costs to the system, which is excessive testing and charting meant to protect doctors and hospitals from dreaded litigation (the irony is, it doesn’t).

More technology is just more expense. What we need is less. Less specialization. Less litigation. Less technology. Less capitalizing on the sick among us. EMR’s are not the Jesus Christ of the American Medical system. They probably won’t help at all.

Technology won’t solve this problem, only common sense will.

Reply To ‘Dentist’ Comment

I recently wrote a blog (Sales In Dentistry) decrying a dentist’s attempt to sell me an expensive toothbrush while I sat helpless and captivated in his chair.  The blog generated quite a backlash from some dentist’s groups.

One of the comments on the blog, however, was so thoughtful and challenging, I decided I would turn it into a second blog.  Below, I’ve pasted parts of the comment and replied to them (in red).

Dear SecretWave 101

I read your blog with great interest.  It is an unfortunate commentary.  In my office we are constantly trying to help our patients get what they need, but it is always a challenge to not appear to be selling when one makes the diagnosis and has the solution for the problem at hand. That’s just it…THE solution is not a branded toothbrush, there are others on the market…my dentist should have pointed out pros and cons to each of them.

Some people call this convenience and others, like you with a half empty cup world view your half empty is my half-real, tomato-tomaghto, brother look at this type of presentation method as a “selling for profit” conspiracy.  To address the facts of your case experience:
1.  You were examined by a licensed hygienist that presented her findings to a licensed dentist that made a professional diagnosis of advanced periodontal disease and suggested a plan for treatment for the diagnosed problem. If they’d dropped the toothbrush infomercial, I’d believe that more easily.
2.  You perceived the diagnosis as patronizing because they had a solution to your problem at hand in the office in the form of an expensive tooth brush. As mentioned…A solution, not THE solution.
3.  You lost faith because it was “too” convenient a diagnosis and appeared to be in the best interest of the dental office and team. The problem wasn’t convenience, it was bias.  There are other options that weren’t presented.
4.  You did not accept treatment because of your lack of faith in the diagnosis and the apparent “selling atmosphere”. I might have given that impression in my blog, but in fact I actually did buy an electronic brush (Oral B – 80 bucks at Costco)…and then went shopping for a dentist I better “connect with” (read: trust)
5.  You posted your experience on line for all, including half empty people like yourself, to commiserate with you and to further cast a negative light on dental profession’s ethics.  True.  And your critique here is fair.  I’m willing to consider that my blog entry didn’t promote collegiality among professionals and potentially denigrates your profession to patients, which really wasn’t my intention.  But for the moment I can only meet you half-way on that point because I do believe my main points are fair criticism. Perhaps I chose the wrong venue.

Sounds to me like a lack of faith in yourself self-doubt is my constant companion…and we’ve become, if not friends, at least good neighbors, although I agree that it appears to be a conflict of interest to some people when a solution to a problem is proposed by the same person that found the problem.  My mother always taught me that unless you have at least a proposed solution to a problem, that you should keep your mouth shut.  I thought I outlined my very simple solution…don’t sell crap in a medical office.  Ever.  It’s available in stores everywhere.  There’s NO reason to do it except to make a profit and in the process eliminates competition between brands.  And this isn’t my solution.  It’s ILLEGAL for doctors to have a pharmacy in their offices for the same reason.

By the way, the meat hook “periodontal probe” is really a graphic perception and betrays your world view.  Fair attack on your part.  Graphic.  Unfair and a bit exaggerated, but I just can’t keep my hands out of the hyperbole cookie jar.

My team and I will have a great time discussing how we can deal with people like you “Mr. Half empty”. That’s doctor Half empty, pal There has been quite a bit of discussion about your blog on at least one dental forum *polishes nails on lapel*, and I appreciate all the positive comments.

I suspect that deep in your psyche you have some severe reservations about your own personal honesty see self-doubt comments above.  This is projected to others by you, and you perceive that others are trying to “rip you off”. Actually, I’m fairly gullible…

Trust is essential to any form of long term communication, and because of your deep seated insecurities, you are unable to trust Let’s see, this is deep seated?  Madoff, World Com, Lehman Brothers, Ted Haggard, Enron, Scooter Libby, Barry Bonds, Roger Clemmons, *sigh, inhale* Richard Nixon, ‘Iah did NOT have sex with that woman’, Bill Richardson, Baron Munchausen…who, exactly, should I trust? I suspect you have significant problems with long term relationships you are free to ask my wife of 11 years or 4 kids about that, or maybe my parents with other creatures actually, I”ve only recently managed to form a lasting relationship with a cat…I’ve consistently dropped a number of them off at the pet shelter in years past.

Since you posted this blog and have acknowledged a problem that I also recognize in organized medical and dental services “conflict of interest”, what is your solution?  Don’t sell stuff in your office.  Just don’t. Be a dentist, not a salesman.

As for all your patients that have chronic dental needs without treatment: dentistry and periodontal disease, it is usually a self inflicted disease secondary to poor personal habits and low self worth.   You are espousing classic conservative ideology, which I don’t always disagree with.  But in the realm of basic health services, I think people with a tooth abscess should be able to see a dentist.

How do you propose that medical practitioners help others without helping themselves?  I don’t.  We all have to make money, and health pros should be well-compensated for their expertise, management of responsibility, and years of sacrifice.  The thing is… they are.  Doctors and dentists salaries are in the top 1% of the nation.  Which is why there’s no reason to overdo it with value-added products that unnecessarily extend profit margins.

Good luck in formulating an answer if you dare.  Thanks.  My answers probably sucked.  But this was my best shot.

See?  There’s that self-doubt that once again keeps me from trusting myself.  You could argue that this dubious companion prevents me from getting too arrogant; that it forces me to carefully examine my motives.  But I suppose that perspective on the value of inner consternation would be far too “half-full” for some people to tolerate.

David S. Peterson DDS, FAGD

Med Web Yak – December ’08

I read primary care and health related discussions on blogs and discussion forums (fora?) around the web daily.  I figure that when I have the time and energy, I should make you privy a nice digest of those digital meanderings too, since they’re frequently so riveting:

kevinmdOver at KevinMD – a health blog generally focusing on primary care in the U.S. – a good discussion is brewing about making medical school free to anyone choosing to go into primary care.

Kevin says even this likely won’t save primary care in the U.S.  An annonymous poster counters that Dr. Nurses (try not to get hung up on that oxymoron) take over primary care.  I sent in the comment that I can’t imagine being unhappy with primary care if I were completely out of debt.  How can anyone be unhappy with $100,000 a year if they have no debt?!

At iMedExchange (have to be a doc to join, sorry), I’m watching a discussion among family doctors as they ponder quitting the profession if U.S. healthcare goes “socialist” under our new Dem leaders.  Most of the respondents says they’d stick around, but they wouldn’t be happy about it.

I won’t reveal much here because the whole point of a ‘doctors only’ message board is to allow docs to vent and rant among themselves, but the discussion is thoughtful and insightful….and tense.

My thinking is that a socialist system would work fine if it paid well.  The whole problem with socialized medicine is that the workers get ripped off and have no autonomy.

If I told the average family medicine doc that they would make $250,000 a year working 60 hours a week, they’d sign up in droves.  Given all the worthless costs in our medical system, I’m sure we could eliminate just a few things and put up this kind of salary for our primary care providers.

There.  Problem solved.  Everybody’s happy (except insurance billionaires and lawyers, which is fine with me).

wsj2 The Wall Street Journal Health Blog has an extensive discussion here, over frequent comments made by California Democratic U.S. Rep Pete Stark (he’s the author of ‘Stark Laws’ governing hospital interactions with community doctors…I’m not a fan) about how insurance companies are “the General Motors of the American Health Care industry”.  I’m pretty sure he didn’t mean that as a compliment.

One responder, Michael Proffit, claims that Stark is a socialist with no concept of the idea of “profit” (no pun intended, I assume).  A writer named Republican states that insurance companies cost the health care system too much money. macman2 says that Stark is “finally” a politician willing to state the truth that insurance and pharmacy industries have a stranglehold on U.S. Health Care.  So, it’s a nice, occasionally testy exchange going on over there.

My take is that insurance shouldn’t be a for-profit business.  Not with health care.  Everything else, maybe.  But not health care.  Not when the government – and many people – believe health care is a basic human right.  If health care is a right, not a commodity, then nobody should be getting rich by insuring it.

Also at WSJ is an article suggesting that yearly physical exams are useless and expensive.  They mention an article in the NYTimes from 2003 suggesting that the utility of yearly exams aren’t proven.  2003?!

Anyway, they also interview Ned Calonge, a family doctor and chair of the U.S. Preventive Services Task Force.  I use this group’s recommendations all the time to determine what sorts of screening tests a patient should get, and when.

Ned says that yearly PE’s aren’t proven to extend life or limit morbidity (bad happenings), and a patient should develop an individual schedule with their doctor regarding when they should be seen.

The write-in’s seem to generally support the idea that yearly physical exams, like much of American medicine, are added expense with little to show for it.

A commenter named Evidence suggests that “other countries” don’t give annual PE’s but their populations live just as long as ours.  That’s a little vague for me, but I do agree that we do lots of fairly dumb stuff in our medical system, often for no other reason than to be able to say we did it when the lawyers come calling.  And data does show numerous countries with similar or better health markers like life-expectancy, infant mortality, etc while our’s costs nearly three times more.

studentdocI’ve been a reader and contributor to Student Doctor Network since I was a med student weenie.  Their family med and general residency forums are throwing sparks, as usual.

Of the many topics I’ve scanned, a couple of primary care threads caught my eye.  One references an article written by an apparently bitter ER doc decrying primary care as a field of medicine.  The letter, an Op-Ed in Emergency Medicine News, is written by an ER doc at Case Western U – read here if you like ignorant propaganda.

The responses from the primary care docs and students on the SDN thread are rather level-headed and polite.  In particular, I appreciate the response by Ted Epperly, the current president of the AAFP.  You can read his letter in the discussion thread at SDN – to read it at AAFP you need to log in as a member (why would they do that?).  I’ve met the guy and he really is as cool as his response letter suggests.

Another concerning discussion thread is open at SDN citing an LATimes article that describes a failing FP doc in California.  The discussion is here, the Times article is here.

My opinon on this one is that the lady in the article just isn’t much of a businesswoman, and in today’s medical marketplace you need to be just that to survive.  If you want to provide medicine as a product or commodity, you better be able to work a balance sheet and pro forma.

The Times describes her pulling out her wallet and giving a patient cash for food, for example.  While kindhearted, that kind of gesture is colossally stupid from a business perspective.  You can’t survive in business with this kind of mentality, and in fact, this doc’s practice didn’t.  However, I don’t think the story really gives a good perspective on the state of primary care in America.


Tough Year for Global Warming Grants

I live in the Pacific Northwest, right on the waters of Puget Sound.  Of the many benefits that living near a large body of water brings, temperature stability is one of them.  It takes a lot of energy to change the temperature of water, and consequently, it doesn’t get super hot or super cold around here much.

It's BURNIN' Up Out Here!
Really, Trust Us, This Is All Part Of Global Warming!!

I bring this up because we’re currently experiencing both record amounts of snowfall and record low temperatures.  By ‘record’, I mean over the past 4-5 decades.  Quite impressive.

Aside from the fact that I love the cold and snow (to a point), I’m also a bit gleeful because all this blistering cold flies (like snow flurries) in the face of the global warming movement.  How is it that we’re breaking cold records if it really is true that we’re trapping hot gasses in our atmosphere with our carbon emissions?

There’s two answers, both are stupid.  One is, “Did I say global WARMING?  Huh.  That’s funny.  I meant global temperature fluctuations! And they’re just as bad – no, worse – than the global warming stuff I was preaching 10 years ago.”

The other answer is that this winter – a winter where every living organism north of the latitude of Phoenix, AZ is currently trying to unfreeze the snot from the inside of their noses – is just an anomaly.  A blip.  We’re getting warmer, you just don’t notice it.  You won’t notice it until your’re melting into the pavement of your local Dodge Durango dealership.

See?!  The Ice Is Melting Right Out From Under The Polar Bears!  Give Us Money, QUICK!
See?! The Ice Is Melting Right Out From Under The Polar Bears! Give Us Money, QUICK!

I will disclaim here that medical doctors are poor scientists, usually.  Our profession is filled with superstition and trendy medicine and popularity contests.  But, we’re trained as scientists, so I will say that we know the rules of empiric discovery.  As such, even as a para-scientist, I say that global warming is not science.  Why?  Because there is no real evidence to support it.  Furthermore, the phenomenon isn’t repeatable.  Both empiric evidence and repeatability are hallmarks of good science.  If you don’t have these things, you have no way of knowing truth from trend.

What global warming alarmists conveniently omit every time they prognosticate the end of human life is that, a) there is no way to determine a unique trend in temperatures on a planet that is thousands of years old (at least) when you only have about 150 years of data.  And b) there is strong financial incentive (in the form of grants) for global warming to actually exist.

I’m a believer in conservation.  I’m a stickered member of the Sierra Club.  I believe in waste reduction and recycling, I’m into alternative fuels and I’m warming (no pun intended) to composting.

But using the social myth of global warming is stupid, dangerous, expensive and disingenuous.

A few years ago, you may have heard about the controversy in Oregon regarding the Spotted Owl.  Tree-cutting was successfully halted because environmentalists claimed that the Owl – a protected species – had a mating radius of 50 miles.  In truth, they were just trying to protect old-growth forests.

I think we’re doing the same thing with global warming.  The problem is that using bad scientific principles to manipulate the public eventually creates an uncritical and intellectually lazy public.  A badly-thinking public is not to anyone’s benefit because over time, somebody will dupe everyone into much worse (see: Peoples Temple, AngkarEinsatzgruppen)

We need to limit our consumption of fossil fuels.  We need to reduce, reuse and recycle.  We need to protect our forests and rivers.  But it isn’t because of such a farce as global warming.  So far, there simply is no evidence to support such a brilliant, scary tale.

Sales in Dentistry

I’m losing faith in dentists.

Aside from never being able to get my patients with crummy insurance to in to see dentists, my growing distrust was heightened the other day when I myself went to my local toother-dude for a cleaning. It would be better described as a sales seminar.

The hygienist tells me she is going to poke my gum line in three places, giving a number to denote the health of the gum as she goes.  “Anything 4 or above we’ll have to talk about. N’kay?”  She says briskly and a little too brightly.

hookShe then proceeds to take her hook needle-thing and poke the gum at one edge of the tooth, then the middle, then at the other edge of the tooth.  If you like the idea of being nailed to a wall with thumbtacks, then I can say with some confidence that you’ll appreciate this exam.

Just before the spearing commences, I’m thinking, “I got this.  No problem.  We’re good if there’s 1’s, 2’s and even 3’s.  C’mon, gums, step it up.  Do me proud.  I brush you almost every night.”

The hygenist perkily launches in, “four, four, five, five, two, four, six, six, four, five, five, four, five, five, six, SIX!, SIX….”

My “gum” score, clearly, wasn’t going to win any golf tournaments.

sonicare-toothbrushHere’s my problem:  From my dismal performance under the spear-hook, the hygienist pivots deftly into a winning performance about the Sonicare toothbrush, available around town, she guesses, but ALSO RIGHT HERE IN OUR OFFICE.

This phenomenal testament to tool-using, opposable-thumb evolutionary Homo Sapien wonder will put those 4’s and 5’s (and SIXES, Good LORD!) right back into the respectable realms of 2’s and 3’s well before you’re evicted from your Homeowner’s Association.

Somehow, this lady’s urgency was a bit too cloying to feel genuine.

Suddenly, I was not only feeling rather sardonic about the “quick trip” speed mode (for those running-out-the-door moments) of the latest Sonicare – the Nimbus 2000 of toothbrushes – but I was starting to doubt all those 4’s, 5’s and 6’s too.

Judging by her elated demonstration of her toothbrush to solve all my ills – her solution to our global financial crisis would probably involve the electronic toothbrush – I’m pretty sure my high score would directly benefit our illustrious dental hygienist and her employer.  Said employer, by the way, was El Dentisto, who used part of his 2.75 minutes with me to also promote the freaking Brush of the Millenium.

I don’t need to spend the average yearly income of a native Paupan on an electronic toothbrush, of course.  It’s really just a question of whether or not I want my face to rot off.  My choice.  Entirely.  Total freedom.

I’ve occasionally lamented the No Free Lunch movement, which insists that drug reps quit bringing me free lunches and coffees from cool restaurants all over town.  I’ve at times accused the whole movement of arm-chair ethics.  I would never prescribe certain more expensive drugs just because I’m getting a MoooLatte out of the deal, right?

And anyway, I like free coffee, dammit.  Why’d they get rid of all the perks (no pun intended) just as I’m arriving on the scene?

But the problem was pretty stark as I sat in that dental chair, thinking about my 3 patients who currently need very basic dental care and aren’t getting any.  They go months or years with festering abscesses, and here I am being told in authoritarian low-register voice tones that my mouth was turning into a cesspool of decay.  Lucky for me, one really really really good way to halt the horror was a toothbrush conveniently sitting in full view on a counter behind my earnest and – was it gleeful? – dental professional.

If the process isn’t outright coercive, it’s certainly manipulative.

swaggertTruth is, health care providers really shouldn’t sell stuff out of their offices.  They just shouldn’t.  It’s impossible to exercise unbiased judgment when certain decisions about a person’s health directly benefits the provider.

These Wal-Mart doctors are no different than corrupt televangelists sweating into powerful sound systems and using Biblical authority to make money.  The white coat carries similar clout.  “Buy this, or you’ll die,” is the implicit message, and it isn’t just wrong, it’s evil.

Doctors make enough money.  Lord knows, so do dentists.

I did manage to claw myself out of there without Toothbrush Extraordinaire.  Somehow, standing my ground was worth the black hole of pus I’ll one day have for a face.  We all make our choices.

Ideal Micro Practice

I’m spending time with two different family doctors in town who recently graduated from my training program. They both run what is called the “Ideal Micro Practice”. This style of medical care is quickly gaining national attention and is becoming something of a national movement.

The basic idea is to return family medicine – any primary care specialty could do this, though – to the days where most of the visit is comprised of doctors working with their patients. The way to achieve this is to cut out ALL middle-men. And I mean everybody. As you might imagine, there are LOTS of people who make enormous amounts of money on doctors. The doc I was with today said that he’s pretty sure M.D. stands for people on whom you can “Make Dough.”

So, here’s how his practice works: He sees patients for anywhere from 30 minutes to an hour. There is no receptionist, no nurse, no medical assistant, no biller. The office is the same room as his single exam room. The computer is connected to a second monitor that faces the patient while s/he sits in a comfortable easy chair and talks about the medical issues they’re working on. Any labs, imaging or handouts are visible on the screen right in front of the patient, and all of them can be printed out or emailed at the patient’s request. The doc is available by email virtually all the time and has data-enabled cell phones that allow them to upload patient information when they are not in the office. Patients make their own appointments on-line. The cost is roughly the same as any doctor.

If the patient goes to the hospital, a staff hospitalist will do the admission and in-hospital care; the micro-practice doc will come see them socially. Both docs will have no more than about 400 patients on their panel, and they know each patient or family personally.

One of the doctors has limited his practice to ONLY the best insurance companies, which according to him is 4 of them. The rest suck. They don’t pay on time, they often don’t pay at all, and generally have no incentive to be honest with how they work with doctors. The flip-side is that he doesn’t have a full patient panel yet, but has no urge to allow anything but exactly the preferred companies because he works part-time for another practice that more than pays his bills. So, he is building his practice slowly and keeping total control over how things progress.  The other doc is subsisting only on his private practice and has thus taken on crappier insurance payers.  He recently acquiesced and hired a biller to deal with the paperwork and administrative overhead those insurance agencies generate.

Both doctors believe deeply in the IMP model.  They’re evangelists for the cause and they believe this will be the wave of the future.  Certainly I can see that they are both making money, although probably not as much as they would if they were pounding through 20-40 patients a day in a high-overhead typical practice.  In general, their revenues are miniscule to the typical family practice, but they keep so much of what they bring in that the differential is negligible.

Everybody’s trying to either fix American medicine, or they’re running scared as fast as they can to other fields.  I applaud these docs for trying to come up with a new world order.  I think the biggest drawback to practicing medicine in America today is the lack of freedom, largely due to influences outside the sacred doctor-patient relationship.  If I have to be kept from spending time with my beautiful children and wife, I would like it to be because I am working with a patient.  Most other reasons – generally some version of paperwork – just aren’t worth it.  IMP’s provide hope that medicine can return to it’s roots – to the days when doctors helped their patients, and nothing more.