Overkill

I decided not long after I started this blog – quite some time ago now – to never apologize for not writing.  I’m a doctor.  Stuff comes up.

So, I haven’t blogged in awhile.  If you’re still one of the regulars, my thanks.

This latest distraction involved graduation from my residency program.  Or rather, not graduating…the specter of it, at least.  And while the problem is resolved…the emotions on my side still simmer with grim ebullience.

Arriving in the infuriatingly innocuous manner of many catastrophic announcements, I received the news recently that I had not spent a required week with an orthopedic surgeon during this last year of residency.  Setting up that week is one of what feels like 4 bujillion stipulations that lead to graduation.  I’d missed this one, and it was too late to change my schedule to fix it.

Through some fuse-burning mental gymnastics on my part, and some heroic situation-framing on my advisor’s part, the faculty of my program have just decided that I will, in fact, graduate with my class.  In essence, we found a workaround that keeps me on-track to finish with my peers in less that 4 weeks.

This experience however, reignited an old resentment in me that essentially boils down to oft-repeated theme in the “Jason Bourne” movie series about being required to give vastly more than expected when signing up.

The frank truth is that all the permutations of mid-level medical providers – from ARNP’s to PA’s to Dr. RN’s – have one thing in common…they’ve been subjected to roughly 1/3 the amount of training as I have.  Subsequently, they have 1/3 the debt, and probably have 1/3 the family problems, health problems, and 1/3 the incidents of depression, substance abuse and suicidality.

The result of that limited training?  They do the exact same job as me…and get paid about 80-90% what I will make.

Calculate how much money I lose in training when they’re out actually working, and I probably make less than your average P.A. over the course of a career.

I was so upset over this graduation snafu, that I rammed my fist through a wall in our house, and ended up driving hopelessly around the beaches of Washington until 7am this past weekend.  Then, thankfully, I got with the program and figured out a way to address the problem a little more professionally.

No, working an extra week after graduation wouldn’t be the end of the world.  But in so many ways I feel I’ve reached the end of my rope.  And, for lots of logistical reasons, another week of “work” would have really been tough on me and my family (and probably our walls).

I should mention that what I was deficient in – observing an ortho doc – falls into my category of ‘watching doctors be doctors’.  I’m not sure where anyone came up with the idea that people learn from this particular brand of education-theory rack-stretching, but frankly at my level if I don’t have responsibility, I don’t care.  If I don’t care…I don’t learn.

Watching doctors be doctors is  easily the least valuable learning experience I’ve had in my entire medical training…and residency is rife with this vacuous requirement.  I’m quite sure that the endless hours I’ve spent delivering Oscar-level performances of intellectual interest could be completely removed from my training and I would still be the same doctor I am today…just less poor because I would have started working at least 6 months sooner.  Maybe a whole year.

Simply put, I believe that my medical training is outmoded.  It’s destructively expensive.  If people can do my job with 1/3 the training, then I’m effectively over-qualified. 

The backside to this is that M.D.’s themselves will eventually become irrelevant in the marketplace because we’re just too expensive.  We spend so much money on school and inefficient training, that nobody can afford to pay off all of our debts.  How long will it take me to pay off the $330,000 I spent on my training?  How much more do I owe on that since I’ve piddled away another 3 years on training – watching orthopedic doctors and acting interested – while a number that big generated interest on itself?

I’m deeply grateful to my advisor especially in this case, because he presented my situation to our residency faculty in a light that was very favorable to me.  He is probably the reason I’m not in a padded room at the moment. I don’t really blame my residency program, either. 

The problem is the system:  tone-deaf, needlessly arduous, inefficently stubborn.  The mid-level system was created by smart people who realized that it just doen’t take this much to make a doctor.  You shouldn’t have to sell your soul for the honor and burden of taking care of sick people.

In the end, I approach graduation almost devoid of any elation at all.  Instead, I feel like I’m sitting in a field, blood and feces spilling into my lap from the mortal shotgun wound I’ve received to the gut, looking plaintively up at the shadow hovering over me – at my colleague and killer – and wondering aloud, “Look at this mess…look at what they make you give…”

Ode to McDonalds and Cigarettes

You can say you saw it here. This family medicine doctor – supposed bastion of all that is healthy and wholesome – recently found himself encouraging a patient to keep up the McDonald’s and smoking. Instantly after proclaiming my support of these two great sins of the developed world, I heard my program director’s voice in the back of my head saying not unkindly, “Nice job, doctor, good work…we’ll most likely kill you in the morning.” Although never tempted by cigarettes, I frequently fight the urge to hit a McD’s and constantly rail against both as all that is disjointed and wrong with our society (celery is another problem, IMO, but that’s another discussion entirely).

I saw a patient this weekend who unabashedly describes smoking about a half-pack of cigarettes a day, and has been doing it for “goin’ on 50 years now, and I ain’t quittin’ no matter what you tell me.” The patient is 78 years old with advancing COPD. When she inhales, the wispy flimsy breath she drags down into her rapidly deteriorating lungs rattles around aimlessly like a blind baboon in Grand Central Station. She then forces the air back out; little of the oxygen actually used. She is on 14 medications to treat everything from her diabetes to the high amounts of fat in her blood.

“Smoking makes me feel…” She closes her eyes, her face taking on a distant, faraway look as if she just lost herself in recollections of her torrid love affair in Paris on a college philosophy tour, “like I’m surrounded by friends when I’m actually all alone.” How can I beat that?

This patient lived a full life, been smoking for a good majority of it. Now she is stuck in that impartial vice-like vortex of half-life and half-death that American medicine has so expensively provided us. Historically, people just died when they got as sick as her. Today, people linger, in a sort of daily, living suffering. The institutions they inhabit have innocuous-sounding descriptions like “assisted-living communities”, but everyone knows what they really are. Places where the clock of mortality hangs largest on every wall, where the clanging metal hammer pounding on anvil cannot go ignored, but can’t be rushed. It pounds in measured, inexorable rhythms, indifferent to anguish it causes. Hundreds of thousands of Americans waste away in these communal halls, most abandoned by their families, waiting for that final insult and staring droolingly at the wall in the meantime. But when this insult finally does arrive – a heart attack, hemorrhagic stroke, maybe a pulmonary embolism – it shows up with a slouch, hands in pockets, irresolute, nuanced and often as slow as a sadist. These days, the Reaper arrives in a robe of gray, eschewing the dramatic and abrupt pitch black somewhere around the time we invented beta-blockers.

So, go ahead, lady. Smoke to your heart’s content (or infarct). The damage is done, really. If you did stop today, the additional few weeks or maybe even year would be so miserable for someone who loves smoking this much it wouldn’t do much for you. Mortal time isn’t everything. There’s such a thing as life quality, too.

“The other thing I love,” She continued, “is Saturdays.”

Her face, looking like gravity used physical hands to pull her face to the ground for the past 200 years, suddenly filled with a smile. Her losing battle with age suddenly clamoring to a standstill. “My wonderful daughter comes every Saturday and brings me a McDonald’s egg McMuffin sandwich and coffee. I just love that. I look forward to it all week. Say, what day is it? Maybe she’s coming today. Do you know?”

“Well, it’s Saturday night at 11. Maybe she came earlier before your care facility staff thought you needed to come to the hospital.”

“Yes. This could be. You see dear, I can’t really tell the difference between days and weeks and months and years anymore. They’re all sorta the same to me anymore. I just know my Jerry comes on Saturday and we have breakfast together. And you know…that McDonald’s does a lot of good for other people, too. They hire young kids, old folks…give people a start in life, or help them do something worthwhile. The buy all kinds of ingredients from local grocers and farmers. Why, when they moved in here 30 years ago, my son was one of the first they hired. He has his own business today. Employs 30 people.”

“Wow. I’ve never thought of them that way.”

“And them McMuffins…ain’t so bad for you, either. They fill you up, keep you fed through almost a whole day. It’s good food.”

By any primary health care measure, someone who smokes daily and eats fast food at least once a week, is not healthy. But exceptions to every rule emerge in unlikely places. This woman did not come to the hospital to make me re-evaluate my unbending belief in the immutable evils of fast-food and smoking. But her defense of their place in her own life was unassailable. This woman won’t live to be 90 years old. The end may come in the next few days, in fact. But this is true for all of us. This very moment, our lives could be required of us. Should this happen, could you depart with the same gentle serenity?

If deprived of her simple vices, could she?

I found myself answering no to both questions. So this family doctor ended up departing the room, encouraging an overweight patient with COPD and hyperlipidemia to “keep up the smoking and enjoy your McDonald’s.”

I’ll start typing my resume. I hear there’s good jobs in the restaurant business.

Gestational Diabetes – What We Did

A while ago I wrote a ‘You Be The Doc’ regarding a patient with borderline gestational diabetes. That patient had her baby recently, and it was something of a white-knuckle affair. Here’s what happened:

The initial test for GDM is a 1 hour glucose tolerance test, and the patient was VERY positive with a score in the 190’s. In the medical world, it’s considered bad form to designate someone as ‘very’ positive, or ‘borderline’ positive. These numbers are cut-offs. If you are past the cut-off, you’re positive. That’s it. No rounding, no data massage. The cut-off for GDM is 140. So the test is positive.

There are lots of reasons why the 1-hour GTT is lame. You can eat virtually anything on the McDonald’s menu, then come to the clinic and take the test and have a pumped up test result. So, because you can’t really trust a 1-hour GTT, we follow it with a similar test that is at least a bit more rigorous (still lame, though). The 3-hr takes 4 blood glucose tests – a fasting, then 1, 2 and 3 hours after drinking a sugar-rich solution. Our patient had normal values for all but the 4th test, and it was only off by about 3 points. 3 points! Everything else was normal. In my last post, I pondered whether or not to bestow the diagnosis of GDM on this patient with this glucose profile.

We did not. We told her she was fine. No intervention.

Hey, we’re family doctors. We’re mellow. A coupla out of range values. So what? No big deal right? Actually, you might ask, what is the big deal? Well, the whole point is to determine if your body can metabolize (that is, put away) glucose correctly. Glucose – sugar – in your blood stream is a BAD thing. It doesn’t belong there, it belongs in your body’s cells. Think of it as energy. Like little burning, flaming, sparking packets of sun-beam radiation (that, incidentally, also taste really, really good). As this stuff flies around your blood stream, it’s like an average 2 year old boy left alone in a glass-blower’s museum (well, at least my 2 year old boy). This is, metabolically speaking, why eating high-sugar foods isn’t healthy…or at least risky. At any point, your body may look at all that glucose tearing apart your capillaries in your eyes and kidneys and brain, start wringing its metaphorical hands and just curl up into an useless whimpering pancreatic fetal ball and give up. If, for some reason, your body can’t vanquish the insane levels of glucose the average American pours into their arteries in a given meal, you have diabetes. High blood glucose levels cause all kinds of problems. The most important of which, in pregnancy, is HUGE kids. We call ’em “macrosomic”.

My patient – who we did not treat for GDM – went into labor around 8pm. Very little cervical change occurred through the first 10 hours. By noon the next day – we’re talking about 16 hours of labor here – she was finally ready to push. After pushing for 5 hours, the baby still wasn’t out, in fact, she hadn’t really moved at all. Imagine, after five hours of the hardest work you’ve ever done in your life…you get to hear your doctor say something oblique and vaguely encouraging like, “You’re doing GREAT! I’m sure things will progress if we keep working.” There’s a thing called the “labor curve” to mention here. Typically, if there isn’t continual cervical change, and steady descent of the baby once the patient starts pushing, the patient is said to be “falling off the labor curve.” When this happens, docs need to start looking for a problem. In general we look for one of 3 P’s: Power – mom just can’t push hard enough or uterine contractions not strong enough, Pelvis – is the “chute” too small?, and Passenger – is the kid too big? In this case, the patient was off the curve, and we couldn’t be sure that any of the P’s were adequate.

We were able to see the baby’s head well enough to allow us to use a vacuum, which did help bring the baby into the base of the pelvis. At that point, we had an OB in the room to evaluate for C-section. She was particularly concerned with our decision to not treat for GDM based on this patient’s glucose profile. Almost certainly, she said, this baby was macrosomic because she, by definition, had GDM (remember, our 4th value was out of range by 3). She also said that she would have treated the patient for GDM based on her very high 1-hour test, forgoing the 3 hr. entirely, since it had been “very” positive.

You can imagine my handwringing concern at this point. I let this patient sit around for MONTHS, cooking up a huge baby that was not going to get stuck in her pelvis. Bad things happen when babies can’t fit through pelvises. To think I could have prevented it by just being more aggressive early gave me the opportunity to experience some new emotion – as yet unnamed – that combines stark fear with wistful, sharp regret and a sticky sort of guilt all mashed together with insecurity and self-castigation. We’ll call this feeling FRGIS. Mid way through this experience, I felt extremely “Frgis-y”. That is, quite terrible. I’d, perhaps singlehandedly, resigned this mother to surgery (best case), or perhaps something more terrible due to shoulders, head or neck getting stuck in the birth canal.

In the end, the vacuum (which only adds about 10% more power than the uterus and mother already provide) created just enough extra oomph to get the baby’s head through. The shoulders were a tight squeeze, but there was no distocia (shoulders caught on the pubic bone…can be REAL bad). The mother hemorrhaged and required 3 different medications to get it stopped, and she had a pretty good-sized laceration that took about a hour to repair. But the baby did fine. Actually, rather cute. I usually think they look like aliens.

The upshot was that the baby weighed around 8 lbs. This IS NOT MACROSOMIA! This is a big baby, but not medically large. In the end, we had nothing more than a difficult delivery, which probably had more to do with the mother being new at pushing and not really knowing how to do it than anything else. More stringent glucose management may have helped keep the baby a bit smaller, but she wasn’t especially large even without management. And the patient got no shots, no medications and no extra worry about having a metabolic disease while she worried about just getting through her pregnancy.

In the end, the patient ended up with a beautiful, normal-sized baby. Yes, there was a pretty big laceration, but these are relatively common irrespective of the size of the baby. But in general, our management was within the standard of care, although there is room to debate whether or not we should have been more aggressive. True, the doctors lost hair and years from their lives (or, my life, anyway), and experienced the wonderful emotion called FRGIS, but hey, this is medicine, right?

Carl’s Jr. Confession

carls.jpgI’m not Catholic, so I’ve never formally confessed to anyone. But I feel the need to confess to a recent crime here in the blogosphere. Here, to you, dear readers.

I went to Carl’s Jr. the other night.

Worse, I took my whole family…indoctrinating my children to high fat, high carb, high calorie fast foods. And, I showed little restraint. It was like a multi-day Roman festival to the God of Girth. Yep…not just chicken strips and maybe a grilled chicken sandwich for me. It was fries, milkshakes and BURGERS.

And I loved it. Felt like I ate real food for the first time in about 2 years.

As a family doc, I’m constantly trying to convince people to give up their addictions, vices and bad habits. Chief among them is smoking, of course, but I’m also trying to get people to eat less, exercise more and watch things like cholesterol and lipids. Then look what I go do.

Let’s break it down:

Based on the awkwardly-named “Food and Nutrition Board, Institute of Medicine, National Academies”: The average human of my body size and activity should consume the following in any 24 hour period:

-total daily calories = 2884
-fat = 20-35 (let’s just go with the full 35)
-carbohydrates = 130
-protein = 56
-cholesterol = as little as possible (the geek-ball science freaks actually put this in their report)
-sodium = 1300 mg

Here’s what I ate, in one 30ish minute tribute to whimsy and sensual overload in the form of a burger, fries and chocolate milkshake:

-calories = 1830
-fat = 90
-carbs = 198
-protein = 51
-cholesterol = 185 (for the record, there is ZERO cholesterol in the fries)
-sodium = 2720

This means that in one meal I ate all but about 1000 of my alloted calories for an entire day.  Furthermore, those remaining calories could be composed of no fat, no carbs, absolutely no sodium and approximately 5 grams of protein.  IF I managed to gnaw at some cowhide for my last 5g of protein, I would still have gone over in fat by an eye-widening 55g.  I’d also have blown out the carb-O-meter by 68, never mind the cholesterol, and I overshot the sodium by, oh, let’s just round to 1400 mg.

This is unreal.  It’s so unhealthy I’d advocate placing automatic defibrillators in these restaurants before airports and hotels and malls.  Heck, forget seatbelts, helmets and all warning stickers of any kind.  This whole building needs to be wrapped in one giant warning sticker.

But the truth is, it isn’t just about hunger (for me).  It’s also about fun, and diversion and some deeply-housed food enjoyment gong that hasn’t rung for nary a moon.  It’s an emotional thing too, because 80% of everyone in the place was from California, where the chain got started back in the ’50’s.  I was re-living my days along the central CA coast, all tired out from surfing until my arms were rubber and then chilling with my best friends, eating great food at a Carl’s Jr.  It brought back the memories, and that alone nearly justified the visit.

I realize, after times like this, that I’m just as much an addict as smokers, drinkers, sexers, stealers, the overshoppers, overspenders and druggers.  My substance is food.  I’m not especially fat – yet – but that doesn’t matter.  I use food as a stimulus, an emotional emollient..as entertainment.  There are times I pretty much can’t say no to it, even if there is ample evidence that it will shorten my time on this earth with my friends and my beloved children.

So, what can I say to my patients, most of whom are battling one addiction or another?  I suppose nothing more than that I know the struggle.  And that I lose my own sometimes, just like they do.

You Be The Doc – Gestational Diabetes

One of the more difficult things to deal with in medicine – I think – is borderline lab values. A huge component of most medical decisions relies on the patient’s latest labs; often the decision is almost perfunctory. But what about times when lab values are just barely positive? For example, a normal blood pressure is 120/80. What if a guy has 122/80? Is that hypertension? Should I put this disease on his problem list…there for insurance companies to see and thus charge him more for life or health coverage?

gdm6.jpgMost lab values can be manipulated to some degree. The entire field of biofeedback starts from this premise. In biofeedback models, the lab values can be changed by effectively willing your body to change it’s own parameters. If effect, you can think yourself to a lower blood pressure, lower cholesterol, more hair…maybe even bigger sexual organs I suppose. Go for it. Imagine big, big gonads if you want. See what happens.

Anyway, some people consider this mere quackery – I think it will be considered a fad in a few years – but some swear by it. And yeah, I’m sure there is some bridge across the Cartesian mind-body quagmire we’ve been wallowing in since Modernism awoke, but I’m not sure biofeedback is that bridge. Aside from whatever volitional input we may have on our bodies, there is the fact that all lab tests have margins of error associated with them. You hear about “sampling” error in all these perpetual polls in the presidential primaries. Obama leads Clinton 47 to 42 percent…but the margin of error is plus or minus 8 points. So Obama doesn’t lead anybody. He and Clinton are tied. Many of the good polling companies actually do some real statistics to come up with these numbers, brainball.jpgbut it doesn’t really matter much because none of us voters really care. All we care about is who’s gonna win the stupid thing? Who’s the prez gonna be? And, (for me) WHO’S FINALLY GOING TO PUT AN END TO DYNASTIC, BOURGEOIS RULE IN AMERICA?

Sorry, this is a blog, so I can digress and feel only a little bad. The points are that lab values are manipulatable both physiologically and statistically. The statistical manipulation – the margin of error, for example – exists because determining something like the amount of glucose molecules in a sample of blood isn’t exactly easy. There’s 2 major ways to do it, and a 3rd less-popular way as well. Each way is different from each other, so if you determine glucose values using Type 1, and then use Type 2, you have to convert one to the other’s value to even determine if they’re equivalent. The conversion is a math equation, not observational science.

Why does an average doc like me care about all these details? Well, these facts play out in my mind when I get a lab value that is juuuussst barely out of range. A positive value means the patient has a new disease that can affect their ability to get health insurance (a quaint little reality of this American health system I admire so much), but also can affect their care. One little lab value can determine if a person suddenly needs to take expensive medicines – brand-name cholesterol-lowering meds are a couple hundred bucks a month, for example. Or it may mean that they now qualify for surgical exploration to find a possible tumor. Some people have had things cut off of them – like breasts – only to find that they didn’t have cancer at all. This is called the false-positive rate and is one of the biggest reasons why I try very hard NOT to do even little tests on patients unless it really looks like they need it. Breast self-exams are a classic example of dangerous false-positive tests that lead to sometimes catastrophic interventions occasionally for no reason. **Disclaimer on this one: major controversy exists about whether or not breast self-exam are good or bad. This was just an example. Keep doin’ em if you do ’em.**

When pregnant, one of the things we screen for is gestational diabetes (we call it GDM). This disease only shows up during pregnancy, and often vaporizes just after the baby is born. It more resembles Type 2 DM than Type 1 in that it won’t really kill you in the short-term, but deranged glucose values give the patient headaches and lots of nausea and makes them feel pretty much miserable. The problem is that high glucose in the mom can lead to huge problems with the baby. First of them being that the baby can be, in fact, HUGE. But they can also end up obese in life. They usually end up with REAL diabetes. Being so big, there are risks for the delivery that aren’t pretty too.

gdm4.jpgSo, we need to avoid GDM. We screen for it by giving the mother an oral glucose test at 28 weeks. She drinks this sugary solution – absolutely disgusting…I’ve tried it – and then testing her blood sugar levels an hour later. This is a classic screening test: It has lots of false-positives, but fewer false-negatives. It’s reasonably good for catching GDM. But because of the fasle-negatives, we do a second test to try to filter some of them out, which is basically the same test with more sugar solution and blood tests every hour for 3 hours. People who have out of range glucose values for both tests, probably have GDM and need treatment which can include testing glucose values 3-5 times a day (rather painful, a bit bloody, and not cheap). The might also get insulin shots, based on the glucose values. They are usually sent for nutrition counseling to teach them how to eat basically no-carb foods. They also get regular ultrasounds every month or less to determine if the baby is getting too big, which may lead to C-section. And while we’re on the topic of false-positives, ultrasound becomes less and less accurate for determining weight as the pregnancy progresses. By the end of the 3rd trimester, the US could be off by as much as 2 lbs! An alarming US can easily lead to surgery when in fact the baby is of normal weight.gdm3.jpg

So, my patient had a 1-hour glucose test of 199. The cut-off is 150. That’s obviously positive – she qualified for the 3-hour test easily. The first test of the 3hr is a fasting glucose test (arguably the most important) and she was well under the limit. Her second test, at one hour, was also well below the threshold for GDM. Third test – at 2 hours – also negative. Then, at 3 hours, her test was 164. The cut-off was 160. She has a positive value. She may very well have GDM.

You be the doc. What would you do?

Here’s some possibilities:

A.) Bring her back for another 3h test, since they can be falsely positive (and, actually falsely negative). In other words, they aren’t always accurate.

B.) Give her the full-monty: regular US, daily glucose monitoring, insulin, diet counseling, weekly visits, evaluation for c-section

C.) One or two elements of option B – a partial intervention, so to speak

D.) Tell her the test is “fine” and leave it at that. Effectively, regard the test as negative, and tell her this.

E.) Bring her in and just test her glucose twice a week. Treat her if one of those values is out of range.

**I’ll describe what I did in a week or so.**