That is most of it, being a physician—listening and seeing. The rest is technique.
—adapted from a quote by Schmendrick the Magician from The Last Unicorn, with apologies to Peter S Beagle.
I’ve continued plodding on in my re-read of Gödel, Escher, Bach° by Douglas Hofstatder (interspersed with *Little Dorrit by Charles Dickens, as well as The End of Time by Julian Barbour.
One of the things that struck me about Gödel’s Incompleteness Theorems is the resultant stratification of all human knowledge
true things that can be proven true
true things that can’t be proven true
false things that can be proven false
false things that can’t be proven false
One way to simplify this is (1) fact (2) instinct (3) lies (4) nonsense
Or perhaps (3) can be error, because it can happen unintentionally, too.
The point being, no matter how much any of these realms of knowledge expand, the basis of clinical medicine will always be the same: history-taking and physical-exam. The rough estimate is that at least 60% and up to 90% of the diagnosis can be derived from history alone. A good physical exam can probably narrow the gap by another 5-10%. Leaving lab tests and imaging to determine the last 5-10%.
So the skills to being a good clinician are exactly what Schmendrick says makes a good wizard. Being a good listener enables one to be a good history-taker. Always looking enables one to hone their physical exam skills. Everything else is mere technique, which can be easily overturned by adequately large clinical trials.
The Dragonfly Initiative suddenly took me back to those halcyon days of yore, when I could just sit for hours studying things that I find are of little-to-no clinical relevance. Chronic renal failure? Obsolete. It’s Chronic Kidney Disease. Congestive Heart Failure? Obsolete. It’s just Heart Failure, or Decompensated Heart Failure, now. There is no such thing as Non-Insulin-Dependent Diabetes Mellitus, either. It’s either DM type I or type II. Beta-blockers are standard of care in Decompensated Heart Failure. Digoxin is almost useless, except as a way to achieve rate-control in atrial fibrillation. The difference between Q-wave Myocardial Infarctions and non-Q-wave Myocardial Infarctions are academic and don’t make a difference in terms of treatment. What we care about are ST-elevations: STEMIs vs NSTEMIs/unstable angina. And it’s all called Acute Coronary Syndrome now.
Hell, I’ve had to unlearn things I’ve learned during residency already! Erythropoietin can cause serious problems. COX-2 inhibitors are a marketing ploy more likely to cause Acute Coronary Syndrome. LDL is not the end-all, be-all of risk stratification for Coronary Artery Disease. No one I know has actually ever seen warfarin cause a thromboembolism, and it’s standard-of-care to just start it without bridging as long as you know they don’t have a hypercoagulable condition and aren’t a super-high stroke risk.
I’m trying to think of a situation where medical student syndrome became an issue.
All I recall a couple of cases that my friends and family tried to get me to diagnose over the phone, knowing full well that I was just a mere medical student, and that diagnosis without actually seeing the patient is fraught with massive amounts of danger.
1:
My sister develops severe right lower quadrant pain randomly in the middle of the night. She’s puking her guts out, and one of her roommates tries to describe everything to me over the phone. She also has a fever. I’m thinking that it’s probably appendicitis. She ends up in the emergency room, and the urinalysis is consistent with kidney stones.
2:
My friend A calls me up and reports that she gets right upper quadrant pain about 30 minutes after eating meals, and that she ends up feeling bloated and nauseated. A diagnosis of gallstones flits through my mind, but it doesn’t make any sense. The mnemonic for gallstones is 40 years old, female, fat. A is (or was at the time) in her mid 20s and barely weighs 100 lbs. Gastroesophageal reflux disease (GERD) also floats through my brain. But why now?
Then I remember the old dictum: every female of child-bearing age is pregnant until proven otherwise.
I ask her when her last period was, and it’s like three months ago, and I’m like, “What?”
A laughs and tells me she and E are expecting. Now that was a forehead slapping moment that I won’t ever forget.
3:
My dad starts having bright, red blood in his stool and my mom is a little agitated by this. My dad, who is excessively fatalistic, doesn’t seem to care. He says it’s his hemorrhoids. My mom retorts: Didn’t you have surgery done on them? My dad laughs mirthlessly. We both know that surgery for hemorrhoids is no magic bullet. He eventually gets a colonoscopy, and, what do you know? It’s his hemorrhoids. At least he won’t have to have that done for another 10 years.
I’m glad I wasn’t in medicine yet when I had my chronic cough. I mean, this was really a chronic cough. It lasted from September to March. Non-productive. Non-bloody. No shortness of breath. Just this irritating cough that wouldn’t go away. I don’t really think anything of it at the time, but my mom freaks out and demands that I get a chest x-ray, which, predictably, comes back negative. And yet, for some reason, I don’t get a TB skin test done.
In retrospect, it turns out that it was probably a combination of a post-viral cough and my latent asthma. This is when I realized that there is no such thing as outgrowing asthma, and I’m going to have bronchospastic airways until the day I die.
Oh, now I remember. I got my testicles checked because I have this lump that turns out to be probably a spermatocele. At least, the urologist didn’t seem concerned.
I got my salivary glands checked out by two ENTs because I kept having (and keep having) face pain. One of the ENTs diagnosed me with sialolithiasis and extracted two stones from my Wharton’s duct. That’s probably what it is, and I’m not sure if I should get anything else done about it. The idea of injecting iodinated dye into the ducts to do a sialogram sounds unpleasant, and knowing my atopic history, I may even run the risk of having a contrast reaction, but I should probably get this taken care of while I have insurance.
Lastly, I remember getting motion sickness and feeling nauseated for days and days, to the point where I was basically just going to sleep after coming home from my rotation. I even saw a neurologist, and they found my exam completely normal, and chalked it up to some form of viral labyrinthitis that should wear off in another week or so. In retrospect, I realize that this was probably venlafaxine withdrawal. Damn that drug.
It’s funny how I feel reassured when the so-called experts can’t figure out what’s going on. Unfortunately, this also means that they can’t figure out how to make me feel better. I’m wondering if I should just get empiric treatment with parenteral penicillin, in case this really is an smoldering case of actinomycosis that’s causing sialolithiasis, although this seems pretty damn unlikely. Although it could explain some of the night sweats. (And, no, my last PPD was still negative, and while I may have converted sometime this year, the night sweats would pre-date the point of conversion. And my last CBC was perfectly normal, so I seriously doubt this is leukemia or lymphoma. But, you know what? You never know. How reassuring is that?)
Bayes Theorem is a powerful, yet oft-misunderstood, tool in medicine. Physicians are probably slightly better than average people at estimating probability, but we’re terrible at adjusting these probabilities in light of data accumulated from clinical diagnostic testing. So, despite the fact that very few people, even when considering people with hypercoagulable states, even when considering people with cancer, develop pulmonary embolisms, anyone with chest pain and shortness of breath that can’t be ascribed to Acute Coronary Syndrome, has a pulmonary embolism, no matter what the tests say. D-dimer negative? I don’t care. Get a CT angiogram of the lungs. CT negative? I think it’s wrong. Get a ventilation/perfusion scan with xenon and technetium-tagged macroalbumin. V/Q scan negative? Who cares. Let’s just anticoagulate the guy. This kind of flawed thinking goes on everyday, at the tune of hundreds of thousands of dollars. I think if they just taught Bayes Theorem for an entire year, we might get better at this prognosticating racket. But maybe not.
I suppose it was fitting that today Bn exhorted me to go the Bay Area once I’ve served my sentence completed my residency down here in S.D. While ostentatiously there are several reasons why I would want to stay here, there really was only one, and as of 7:59 pm, I’ve come to realize once again that such reasons are always perilous.
There is a part of me that is gnawing upon itself in agony, wondering why I keep getting trapped in these temporal loops of complete, utter despair. There is another part of me that is perversely rejoicing, because it saw this coming from miles away, like an ICBM arcing towards its target with the utmost accuracy.
My mom grilled me again this past weekend about whether or not I have a girlfriend. I hate that question. I hate it a lot. Enough to make me not want to come home very often. But it must be endured. As I’ve mentioned a multitude of times, my mom really wants grandkids. I don’t know why she keeps bugging me about them. My brother and my sister are both in long-term relationships. Let them take care of that filial duty.
Mχ asked me if I was going to bring anyone to Mχs and L’s baby shower. (That kid is going to be super-lucky to have them as parents, I swear.) When I told him no, he used the term “terminal bachelorhood” and I had to laugh out loud. It’s odd, that. That where I am now is where I’m going to be when I die.
Part of it is that I’m on a geriatrics rotation right now, and prior to that, I was on an elective ICU rotation. Either way you slice it, the people I’ve been interacting with are all pretty much on death’s doorstep. So certain songs have taken on some rather dark, deep, depressing, and morbid interpretations.
That there.
That’s not me.
…
In a little while
I’ll be gone.
The moments already passed
Yeah, it’s gone
and I’m not here.
This isn’t happening
I’m not here.
I’m not here.
—”How to Disappear Completely” by Radiohead
I thought of some really morbid, macabre imagery to go along with this song. I imagine someone in the ICU, intubated and on a ventilator, with multiple lines going in and out of him. Someone like the soldier in white from Catch-22, almost entirely covered by bandages, so much so that you can’t even tell if there’s anyone in there.
That there.
That’s not me.
The main drive of the short narrative is the decision to withdraw care. So they go through the process of terminal extubation.
In a little while
I’ll be gone.
The moments already passed
Yeah, it’s gone
As the patient goes into agonal respirations, scenes from his life/my life are interspersed. Going out with his girlfriend. Talking to his parents and siblings. Living life, being happy and healthy.
The other song I think about is “What Sarah Said” by Death Cab for Cutie (who is apparently currently having a concert at the Greek Theater in Berkeley.)
Christian Sinclair, M.D. deconstructs the song expertly, bringing to mind exactly all the things that I think of whenever I hear this song, and I seriously always cry at least silent tears whenever I hear this song, and if I’m in a really bad or vulnerable mood, it will leave me bawling.
But I sort of have a different take on the instruments in the final passage, relegating them strictly to ICU noises, and leaving the emotional aspect more muted
single guitar strum: inhalation/forced ventilator breath
random instruments: all the alarms going off dyssynchronously
doorbell: the elevator as they wheel the body away to the morgue
The cymbals are the first thing you hear, as your patient desats. The slowest rhythm is the single guitar strum, signifying a ventilator breath. The snare drum keeps time as code blue is called, but it also has the flavor of a march. It also happens to sound like critical aortic stenosis. The insistent continuous guitar strum reminds me of a tachyarrhythmia alarm, with the heart rate racing into the 200s, and then 300s-400s in v. flutter. The organ keeps the actual rhythm of cardiac electrical activity, which doesn’t match the bass drum because despite the flurry of electric impulses, the heart really isn’t pumping very effectively. As the code blue progresses, you start hearing the descending piano melody, as ventilation becomes compromised. One of the last thing you hear is the ascending piano melody as blood pressure tanks precipitously and irrevocably. Eventually, all you hear is the organ, now playing whole notes, reminding me of the asystole alarm. The cymbals start fading out, too, and they start sounding like unassisted breaths, or ineffective ventilator breaths. And then silence, and a quiet cacophony (is that even possible?) of dyssynchronous instruments as you take all the monitors off the body, letting the alarms go off willy-nilly.
Sinclair interprets the last sound as a doorbell, which may signify the arrival of the elevator car that leads to the morgue, but to me, it sounds like an old-school end-of-tape signal, both on cassettes and video cassettes.
So who’s gonna watch you die?
—”What Sarah Said” by Death Cab for Cutie
1. adj. post-call, referring to the time period when a physician is finished taking admissions or performing consults. This may refer both to time spent at work or time at home after a call period. Typically this is reserved for the time frame after working 24 hours in a row. Before work hour restrictions were in place, residents would typically stay at work for an additional 12 hours to ensure that all active issues were resolved, for a total of 36 hours in a row. In 2003, the ACGME mandated that the post-call period at work be limited to 6 hours maximum, for a total of 30 hours in a row. See also postal, going postal. 2. n. post-mortem examination, see also autopsy, necropsy.
Given all that tripe, I did have a decent day today. I managed to get in an arterial line after three tries. The attending that I’m working with—who has a reputation for making interns cry—thinks that I’m probably no dumber than a box of rocks. (Which, believe me, is a complement.)
Small triumphs. Little victories.
One of these days, I might manage to get a little self-confidence. What is this world coming to?
8 Asians introduces me to the acronym SDU, which means single, desperate, and ugly. I find this acronym highly amusing since I find it so self-applicable.
I am also reminded of something that I think S (not S.!) told me once: desperate is *so* not sexy. Or maybe it was N. I sometimes get all these women who rejected me mixed up.
So I have, in fact, tried to cultivate the demeanor of someone who is not desperate. It’s been so long that I’ve almost forgotten that I’ve been consciously trying to do it.
But sometimes reality pimp-slaps you upside the head. I mean, doesn’t the fact that I’ve been single all this time undermine the notion that I’m not desperate?
I suppose I could just put a spin on it. I just haven’t met the right girl yet. Riiight. That’s the ticket. My standards are just too high. Yeah. Or I just haven’t been looking.
I mean, there *is* some truth to that last notion. I have been living a sort of twilight existence this last half decade or so. I work all the time. I deal with death and disease. That alone is enough to sort of anesthetize the soul, really.
And then bad shit happens. When my dad had his big fat LAD, I took it pretty badly. Mostly because I held it all in for quite a while. I actually stopped blogging for almost two months. But that shit got me thinking about mortality big time, and I don’t think I’ve ever really gotten over it. My dad is doing pretty well, but none of us are getting any younger. The fact that there aren’t any little kids at Christmas kind of gets me down. If I were ever to have kids, I’d want them to meet my dad and remember him. But only Atropos knows when those threads run out, really.
But that reflex to just shut down and burrow in gets me every time.
What really threw my mind for a curve ball was the fact that my cousin D died about a year and a half ago. She was just a little younger than me, 29 at the time. I had gone to her wedding just a few years before. We weren’t the closest of cousins, but we pretty much grew up together. I still remember those days when we were all little kids and we’d go out to Fallbrook to my aunt-and-uncle’s place and play badminton or something. Or when they’d come out to Harbor City or even to Eagle Rock. When I finally moved down to San Diego, I saw her a bit more. We had sushi about two months before she died. That was the last time I saw her. We made a deal to hang out more.
That’s probably the last time I couldn’t stop crying. Even though I tried to let it all out, and not hold anything back, it still ached as I wept, like something was yanking my insides out. I remember that awful clawing feeling at my chest as they lowered her casket into the ground, as I watched her brother, her mom, and her dad just bawling, just trying to hold each other up. Just thinking about it fucking kills me.
I think about the people I’m taking care of lately. You would think, that after all this time, I would’ve gotten used to death. But maybe it’s just the reflex of the living, to fear death. There’s one poor woman whose lungs have just been obliterated by smoking, and now she’s on a ventilator. The chances of her getting off the ventilator are pretty much slim-to-none. It’s guaranteed to be slow, drawn-out, painfully protracted experience. Today, her brother saw her for the first time. The last he had heard was that she had gotten discharged and was actually doing better. Unfortunately, that lasted for all of twelve hours, and she ended up back with us. I had a hard time looking him in the eye, telling him what had been going on, and what we had been doing. That look of shock on his face kind of haunts me, to tell you the truth. You’d think I’d know how to deal with that by now. At least I don’t choke up any more and need someone to hold my hand and help me out.
Then there’s this other lady whose life has been seriously unnaturally prolonged. She showed up in 2006 with lung cancer that was already all over the place. Metastatic to the brain, the bones, the liver. When you’re at that stage, we usually measure life expectancy in weeks. Months if you’re extremely lucky.
But she persevered, and demanded everything that modern medicine could throw at her. And we probably crossed a line somewhere. That point when everything you’re doing can only hurt. Sure, you can intervene, but in the end, it doesn’t really mean a goddamned thing.
Somehow, she convinced a surgeon to open up her chest and lop off the part of her lung that was tattered and torn up by tumor. Never mind that the mets in her brain were getting bigger. She got hard-core quasi-experimental chemotherapy that left her weak as a kitten.
She got two extra years out of the bargain. Maybe it was worth it. But I don’t know. Ultimately, we’re just delaying the inevitable. She’s dying. Not in the existential way we’re all dying, but actively dying. The cancer has managed to chew it’s way through the part of the airway that the surgeons had to sew up after lopping off part of her lung. And she and her family aren’t even close to accepting the undeterrable fact that she just ain’t gonna make it. You always have the chance to die very badly—with ribs cracked apart, blood spewing from your mouth, shit and piss all over the place, and you struggling for air, or die well—peacefully, with dignity, and a chance for your loved ones to remember you at rest. I hope she makes the right choice. (Oh yes, there *is* a right choice.)
You would think, this far into things, I’d have gotten used to it.
Maybe, it’s because, ultimately, we’re all narcissistic, and I can’t stop thinking about that day when I finally come to a full, complete stop.
The idea of being able to review your primary care physician and leave a comment online is a little unnerving for me. I know for a fact that not everyone can like me, and many patients will just be put off by my approach no matter what I do. But you gotta be true to yourself, and you can’t please everyone all the time.
The problem is that these review sites attract the crazies. The borderline personalities. The guys who want to talk shit because we didn’t give them their pain meds. The narcissistic personality disorder folk. All sorts of dysfunction.
So it’s not surprising when you read a negative review for a doc you know is a great doc. Someone whom most of their patients love. At least they don’t let people just post anonymously any more. That was a disaster waiting to happen.
But seriously, if people can complain about their doc, I think docs should be able to complain about their patients (and their family members.) Oh, I know that the HIPAA regulations make this illegal, but we could easily make it pseudo-anonymous. Like take their name and birthday, and make an MD5 sum out of it. So you could search the database for bad actors, and it’ll give you their MD5 sum and a description of them.
As an example:
b656e0e9ab17d55353dd5e7b5f81eabc
45 yo male with end-stage liver disease, ethanol dependence, opioid dependence, who once decided to overdose on acetaminophen because his heroin dealer refused to give him heroin. He likes to “split”, hating some people for no good reason, liking other people for no good reason as well, and is highly entertained when he manages to get you and his nurse fighting with each other.
2104b0791e3d0bdc62413407b8927f1e
68 yo female with metastatic colon cancer, severe aortic stenosis, congestive heart failure with an ejection fraction of 25%. Her daughter frequently brings her into the emergency department, stating that her mother is dehydrated. If you refuse to admit her, she will threaten to sue you, and then will proceed to verbally abuse you. She will also demand that you page her mother’s surgeon, who doesn’t have privileges at St. Elsewhere Medical Center. He will, unfortunately, always side with the patient’s daughter and has a tendency to undermine any reasonable plan you can come up with.
This would be a stop-gap measure until we actually deployed a universal electronic medical record system in this country, but I’m almost certain it would cut down on the amount of morphine we dispense.
It only takes a couple of dicks to screw us all.
—Anonymous
I learned about the sordid history of health care and health insurance while writing a paper in college for a two unit class that was pass/not-pass (and therefore useless to my GPA.) It forever opened my eyes to the lunacy that we loosely term health care in America.
Back in the Dark Ages, before penicillin was available, doctors had free reign to charge their patients whatever they wanted. There was no such thing as health insurance. This is pretty much how most undeveloped and developing countries function. You have to pay cash, or you die.
Which, if you think about it, sucks big time, because most of the time they couldn’t really take care of your problem anyway.
Some ethical, socially-minded physicians charged reasonable fees and actually took care of their patients, but all it really takes is a few asshats to make a stereotype stick. So when the snake-oil salesmen came to town, a lot of people started figuring that most doctors were asshats.
Fast forward to the Great Depression, and FDR’s administration. The Social Security Act is created. It doesn’t have any provisions for health care. But a curious thing evolved. The government decided that employers were responsible for their employees health.
Which, I guess, makes some sense. I mean, it’s not too ethical to work your employees to the bone, and then discard them when they get sick from all the stress you put them under. In most civilized places, that is usually called exploitation.
This is where the bullshit gets really interesting.
So the corporations make deals with the insurance companies (which in some cases were merely one branch of a horizontally integrated corporation dealing with another branch of said company.) The corporations said, you give us cheap rates, and we’ll sign up all our guys with you. And when the choice is taking cut-rates, and not getting paid at all, the choice is pretty easy to make.
So the nascent health insurance companies get all this volume from the corporations, but their bottom lines aren’t doing so hot. Part of this is because it’s ridiculous to offer insurance on something that’s going to definitely happen more than once. I mean, not everybody loses their house in a flood, a fire, or an earthquake. Not everybody gets into a car crash. And while everybody dies, it’s generally a one-time event, so life insurance still makes sense, too. But health insurance? C’mon. Everybody gets sick. And the sicker you are, the more often you’re going to get sick. To bet on that (because if you think about it, providing insurance is just another way to gamble) is absurd.
At the same time, the insurance companies are trying to make a profit. So they go to the doctors, saying that if you accept our insurance for payment—even though it’s cut-rate—then we’ll refer all these patients to you. Win, win! So while the doc is only getting paid 50% of their normal fee, their volume goes up.
Then the Great Society opens up the late 1960’s and passes Title XII. Medicare and Medicaid are created. Health insurance for those who paid their dues, and for those who for various reasons can no longer make a living. This was a great idea! And then the piranhas came to town.
So my dad has apocryphal stories of this doc he used to work for. Let’s call him Dr. B. So Dr. B paid my dad a fixed salary and loaded him up with 30 patients a day. Meanwhile, he’s going on cruises, jetting off to Europe, driving his Mercedes, sailing his yacht. The secret to his success?
“All right. Today, we’re going to bill these people for their monthly visit.” Which seems pretty normal until you realize that he never really saw any of these patients.
In the end, my dad was subpoenaed to testify against Dr. B in the civil suit alleging Dr. B of insurance fraud. Fun times.
But this is where the on-going stereotype of the doctor who orders unnecessary procedures to fill their pockets comes from. Now, the insurance companies are in this to make money, and they looked at all this bogus billing as basically theft. The federal government and the different state governments were none to happy either. So the feds got busy with raiding doctor’s offices and fining them millions of dollars because they forgot to dot all their i’s and cross all their t’s. The guys who continued to make money made sure their charts were fully buffed, and sparkly/shiny, especially the notes for the bogus visits, and they never got called out. They may even be practicing to this day.
Meanwhile, the insurance companies came up with another idea entirely: HMOs. The docs were completely out of the loop on this one. Basically the insurance companies and the corporations colluded. The insurance companies were like, “All right, we’ll cut the rates you’re paying even more if you sign your employees up for this new plan we’re trying. It’s designed to cut costs by promoting preventive care, providing an incentive for making sure that people stay well (and prevent docs from billing for bogus visits.) The corporations were all like, “Deal!” and the rest is history.
Oh, sure, a lot of HMOs pay on the old fee-for-service schedule. Maybe 25% of your “customary charge.” But a lot of them do the whole capitation thing. What is capitation? In an effort to reduce the chances of billing for bogus visits, what this meant is that they paid you a set amount every month for every patient of theirs you followed, even if they never got sick and never came to your office. On the surface, it’s a pretty sweet deal! And when they show up and need to be seen, they pay a token fee ($5-$10, maybe) so that patients aren’t tempted to show up every day.
The problem is if you have to see them more than once a month. Because, guess what, you don’t get paid any extra. If the capitation fee is $10 a month, it doesn’t matter if they come zero times, once, or 30 times. You still only get $10. This can become a problem, particularly if you service an area full of needy people who feel entitled to health care.
A word about “customary charges.” Initially, the logistics of billing would go like this. You send a claim for $150 for your office visit. The insurance company will give you $75. You are expected to accept this payment as payment in full (you did read the fine print on the contract, right?) You can’t bill the patient for the difference. That’s all there is, there ain’t no mo’. So what some clever asshats did was figure they should charge $300 for their office visit, and then they’d get paid $150, and in some cases this actually worked. Of course, if a patient didn’t have insurance and paid cash, you’d only make them pay $150, because they’d probably kick your ass for asking for $300 for doing almost nothing.
When the government decided to get involved in all this, they weren’t amused. So the law of the land became that you could only ever charge your “customary” charge. So if you charged cash patients $150, you better charge Medicare $150, even if they only pay you $45. If they ever find out that you charge your cash patients less than you charge Medicare, or if you charge insurance companies differently as well, well, they figure you’re a lying piece of shit, and you have to go to jail. Do not pass go. Do not collect $200. Whoops.
But the docs of that era were a tenacious bunch. All they did was increase their volumes. 10 minutes, 7 minutes maybe of face-time with patient. Thirty to forty patients a day. They had grown accustomed to their incomes.
Fast-forward to the 21st century. The average health care CEO is now far wealthier than any doctor, when you correct for the number of hours worked. The average doc starts the game off in a big hole, on average $150k of educational debt, and climbing. And then there’s the malpractice game. Oh boy. Luckily, some states (like California) have come to realize that it does no one any good if every doc leaves the state because of astronomical malpractice insurance premiums. Look what has happened to Florida and Nevada, after all.
Don’t get me wrong. No doc is ever going to starve. You’re probably still going to be making six figures. Of course, no one ever points out that not only is that before taxes, that’s before you pay your student loans (at least a couple of G’s a month) and your malpractice (starting at $1k, and going up the more invasive and dangerous the procedures you perform.) But, hey, the American Dream!
Now I never did get into this for money. Part of it is the idealistic part of me that I never managed to kill, that actually finds joy in helping people. Even in small, unmeasurable ways. Even if whoever I’m helping doesn’t give a shit. I mean, I get to use my knowledge and skill to at least improve someone’s quality of life. It’s kind of cool.
The other part is that I was destined for a career in health care. My dad is a doc. My mom is a nurse. All my aunts are nurses. My brother is a nurse. It was what I knew. The hospital and the smell of Pseudomonas brings me back to my childhood, it does.
So my career choice was not made as some sort of compromise. I knew what this would entail. I knew the bullshit I would have to deal with. Most of the time, it’s worth it. Seriously. Even just a little thank you is actually rewarding.
So it gets me bummed out when I read stuff like this:
You can’t make me feel pity for Doctors - sorry. They choose that life, and they are generally very well rewarded for it.
And I’m like, great. Just what I need. Yet another guy as an adversary. Instead of someone I could co-operate with, to make their life a little better. The modern doctor-patient relationship is about partnership, these days. But if we approach each other as enemies from the onset, it’s just going to go wrong, sometimes in really terrible ways.
Oh, I don’t blame you for feeling this way. The old school asshat docs who were into fraud really screwed all of us. And now we have to pay for their sins.
You would think that almost 150 years after the Civil War, and nearly 50 years after the Civil Rights Movement, people would be a little more savvy with the race issue in America.
For one, you would think that most sane people would recognize that it exists.
It's a problem.
It's not something that's just going to go away by thinking happy thoughts.
So I told you about my little run-in with avowed Internet sock-puppet Amanda Chapel.
I mean, I have to admit, this was entertaining. She is the first troll I've met whose responses did not degenerate into random blathering. No. This was different. Instead, she decided to play the Ward Connerly card. Whoo-ah!
I will re-type the passage, in order to savor the flavor of it. Mmm-mmm.
amandachapel
Actually, I imagine you an adjunct professor for a CA State School brought in as part of some bullshit diversity program. (emphasis mine)
I'm not even going to bother pointing out that she misses the mark wildly on that guess. And I thought that Google was idiot-proof.
In essence, she charges me with skating in through the system through preferential treatment, when clearly it would've been impossible to do such a thing.
If someone said shit like that to you and you weren't offended, I gotta give you props. You're a stronger person than I am.
But to be faced with such bullshit was so preposterous that I laughed out loud.
Whatever. It's sock-puppet entertainment. Who hasn't baited a troll before?
But what kind of disturbs me is this response I get from a certain Mark Davidson:
markdavidson I just read your blog post about your exchange with @amandachapel. Straw man much? That was just an embarrassment. Study debate.
Fine. Whatever. It's still (mostly) a free country. You're entitled to your opinion. I've got no problem with that.
markdavidson Oh and I'm blocking you for being offensive. Every time someone inappropriately plays the race card, it diminishes the real thing.
Now that boggled my mind. Holy shit. A person who has no idea who I am, except for what I look like, decides to pull out the "bullshit diversity" line, and someone comes to defend her, and tells me I'm the one playing the race card? Uh. WTF?
Was I supposed to wait until they started throwing out epithets before I could call racism?
How fucked in the head do you have to be to not interpret "bullshit diversity" as "people-of-color don't deserve what they've got."
The thing is, I've always been wary of people who are privileged. Not that I'm not one of them, having grown up with two highly-educated parents with an upper middle class income. But privilege has always been an uneasy thing with me.
What I learned, growing up with it all around me, is that if you're privileged but are not compassionate, you're pretty much a sorry waste of protoplasm. I don't care if you're worth several million/billion dollars. You're essentially contaminated fecal material. I'm sorry. That's just how it is.
So when you get up and try to shout down the human dignity of people who are struggling and who are poor, I get the urge to beat the living shit out of you.
But why fuck with piss-poor protoplasm. What the hell is the point?
I'm thinking these things as I wait over in the pharmacy at one of the hospitals I work at and find myself amidst people who are clearly not in the same social class as the folks who gallivant around on Twitter, who have the same color of skin that I do. These are not iPhone owners. And it may be presumptuous, but I would hazard to guess that they are not as overly-educated as I am. I watch them as the pharmacy clerk informs them that their state insurance isn't active, and that the meds their prescribed are gonna cost about $500 for a month. We're talking about shit they need to *live*. You can't go walking around without your cyclosporine and Cellcept, you know?
And I think about my colleagues who, like me, are extraordinarily privileged, but at the same time, very compassionate. Don't get me wrong, there are some asshats among them, but even the most asshatish has more compassion in their pinky nail than some of the folks I've run across on Twitter. I mean, c'mon! No wonder this country is fucking doomed.
Seriously, though. When the shit hits the fan and the revolution goes down, all you privileged fucktards who do nothing but complain about how the poor are weakening your bottom line? You all are lucky that I'm constrained by primum non nocere and I won't be joining the firing squad. In fact, I might even be helping all your sorry asses. So when you start believing in your self-reliant bullshit, and how you made it through the world without anyone's help, I want you to meditate long and hard about who is probably gonna be on your side when you start having that anginal chest pain, or when the right side of your body goes numb and weak all of the sudden in the next few years or so. Deal?
There are two units in the hospital that tend to get a particular song stuck in my head.
The newborn nursery: because about half of the patients are named “Baby Girl”, Timbaland and Keri Hilson singing “The Way I Are” quickly pops into my head, and it is damn near impossible to get it out.
One of the wards where we overflow patients to is Ortho/Rehab. So Amy Winehouse starts crooning “They tried to make me go to rehab…” I especially find the Pharaoh Monch remix highly amusing.
The doctor replied, “Because I”m trying to examine you!”
This was a joke I found on my iGoogle front page, but the scary thing is that this an all-too-common occurrence on the wards. You don’t even have to be a female M.D. or R.N. to be treated to full-frontal nudity every morning.
This article in the Washington Post tries to argue that prevention is more expensive than intervention. The only problem is that they deliberately ignore two preventative measures that have clearly been demonstrated to decrease costs: immunizations, and colon cancer screening.
But even the idea that tight control of LDL using a statin is more expensive than performing urgent/emergent PCI or CABG is suspect. The argument is that giving people statins will cost approximately $160k/year of life in men and $240k/year of life, if you count lab tests and physician’s visits, and according to an old article in JAMA, the number needed to treat in order to prevent one death is somewhere between 163-639/year, depending on which statin and which dose you actually use. (For a back of the envelope calculation, we can use data from drugstore.com. A month supply of simvastatin 40 mg costs $27.99. A month supply of pravastatin 40 mg is $20.99. [These are the prices for the generic formulations.] So we’re really talking about somewhere between $41,056/year to $214,627/year to save a life, which, if you put it that way, doesn’t really sound like much, now, does it? I mean, I’d like to think that a life is worth more than $214k, you know?) And, in theory, you really don’t need to see your physician more often than normal. It makes no sense to check lipids more than every 6 months—and certainly no more frequently than every 3 months at the most. And you only really need to check LFTs a couple of times before you know whether or not they’re going to cause transaminitis. Once you’re stabilized and at goal, you can let it ride, pretty much.
Now compare this to an emergent ambulance transport to the emergency room, the activation of the cath lab, the GpIIb-IIIa receptor blockers, the fluoro time, and, God help you, the clopidogrel (a 30 day supply costs $135.99, and if you end up with a drug-eluting stent, we’re talking at least one year of this stuff, and sometimes, we’re talking a lifetime of Plavix.) Or maybe you need to get CABG’ed, so we’re talking about OR time, bypass time, probable ICU time +/- balloon pump, and I’m thinking that we’re easily talking about comparable costs, particularly when you add in the incidence of complications. And it’s a hell of a lot less convenient to have an MI than it is to take a pill for the rest of your life, if you ask me.
But we’re not even looking at opportunity cost: think about all the productivity that gets lost when someone has an MI in their 50s. I mean, we’re talking possibly up to a decade and a half of reduced productivity (and maybe more if we keep pushing the retirement age back.)
So, yeah, it’s going to be pretty damn hard to get me to believe that intervention is more expensive than prevention. Sure, we shouldn’t just put beta-blockers and SSRIs in the water to prevent MIs and major depression. You’ve still got to rationally target your preventions. And if you add in the cost to society in terms of opportunity cost, you’re bound to eventually start coming out ahead.
As I finish off my residency, I realize that no matter how awful some of the remaining hours and the minutes can be, this experience is finite and bounded. My senior resident on my very first in-patient intern month took a sardonic aphorism from the seminal medical novel “The House of God” and added a hopeful corollary which has become something of an unspoken mantra. “They can always hurt you more, but they can’t stop the clock.”
Pages from the Emergency Department that I would’ve reacted to with an apoplectic fit have started to become surreally ludicrous. Take one of the consults they had me see the other night while I held the neurology service’s pager. I am beginning to appreciate just how much insanity and ridiculousness the neuro service probably shields the medicine service from . They don’t necessarily diminish the number of painful, nonsensical (I think the technical term is “cockamamie”) admits we have to take, but they at least get the ER or surgery resident to focus and come up with a coherent reason as to why we should take the patient.
Still, it was with some trepidation and loathing that I walked into the resuscitation room down in that madhouse. One of the worst chief complaints we learn to dread is “patient found down”, because generally it means that we have absolutely no past medical history to go on.
Worse, their neuro exam was not very hopeful. Pupils fixed and dilated. Unresponsive to noxious stimuli. Serious badness.
Then again, the patient had just received massive amounts of sedative/hypnotics, with paralytics on top of that, for the alleged purpose of airway protection. Before I could even muster my sentiment of incredulity at having to perform a neurological assessment on someone who had just been drugged out of their mind, they were already apologetic. “I know the neuro exam isn’t going to be very illuminating, but we just wanted you on board.”
As I assessed the patient, I couldn’t help but sigh in resignation. They weren’t kidding about the fixed and dilated pupils. I couldn’t elicit a doll’s eyes reflex, either. I poked at her eyes with cotton swabs and got nothing.
I know it’s ridiculously early in my career, but I think the death and destruction is starting to get to me.
It occurred to me just how much pain and suffering occurs in the hospital. Me and the hem-onc fellow were bantering about the different levels of emotional damage that results from watching people die, ranking experiences according to how horrific they were. We never decided whether it was more awful to watch a baby die versus a young adult on the verge of attaining their goals and dreams. That’s when a “Code Blue” got called.
I think that it suffices to say that there is probably something wrong with you when you decide to go to a code because you don’t have anything better to do. So despite the fact that I wasn’t on the medicine service, I tagged along anyway.
It was with some horror when I realized that the patient who was getting chest compressions was a very sweet old lady whom I had admitted a few months ago. The family was in the ICU, weeping silently, and I grew painfully aware of the fact that it was a good 20 minutes before anyone went up to them to explain what was going on. I was tempted to do it myself, but they didn’t recognize me, and it seemed odd to be coming from an entirely unrelated service not at all involved in her current care.
I wouldn’t blame the ICU resident from wanting to kill us, though. As he got massacred by the sheer number of intubated people coming up from the emergency department, me and the back-up resident (who performs factotum duties between 1 am and 7 am) were shooting the shit about the recent study that showed that the concept of relative adrenal insufficiency is probably a farce, staying up until the ungodly hour of 3 am for no good reason. To be fair, the back-up resident did help him with putting in a central line.
The reason why I was loathe to go to sleep, though, was that housekeeping had neglected to fix the call room I was staying in. I ended up sleeping on top of the covers but that didn’t stop me from waking up feeling itchy all over. The thing that worries me and grosses me out is the fact that there’s some kind of lice infestation on the general medicine wards. They kept talking about this guy who was completely infested with lice, and the notion just gives me the heebie-jeebies.
And entirely unrelated to all this madness, this song kept popping up in my head last night:
No blinding light or tunnels to gates of white
Just our hands clasped so tight
Waiting for the hint of a spark
If Heaven and Hell decide
That they both are satisfied
Illuminate the NOs on their vacancy signs
“What is Real?” asked the Rabbit one day, when they were lying side by side near the nursery fender, before Nana came to tidy the room. “Does it mean having things that buzz inside you and a stick-out handle?”
“Real isn’t how you are made,” said the Skin Horse. “It’s a thing that happens to you. When a child loves you for a long, long time, not just to play with, but really loves you, then you become Real.”
“Does it hurt?” asked the Rabbit.
“Sometimes,” said the Skin Horse, for he was always truthful. “When you are Real you don’t mind being hurt.”
“Does it happen all at once, like being wound up,” he asked, “or bit by bit?”
“It doesn’t happen all at once,” said the Skin Horse. “You become. It takes a long time. That’s why it doesn’t happen often to people who break easily, or have sharp edges, or who have to be carefully kept. Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out and you get loose in the joints and very shabby. But these things don’t matter at all, because once you are Real you can’t be ugly, except to people who don’t understand.”
— Margery Williams The Velveteen Rabbit
