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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Monday, March 31, 2003
    What About Generic Meds?

    Hmm, looks like drugs are today's topic. The Wall Street Journal has a great article today about pharmacy-benefit companies (like Medco that I ranted about the other day); unfortunately, no link is available. They profile Express Scripts Inc., one of the big middleman companies that handles pharmacy benefits for employers and health plans. Apparently, this company and others like it have found a way to make money -- lots of money -- on generic drug prescriptions. Their markup on these drugs is huge. In the most blatant example, a review of billing documents showed that Express Scripts made a profit of $170 on a single 90-pill prescription of fluoxetine (generic Prozac).

    This is possible for several reasons. When these companies buy in bulk, they are able to purchase drugs at well below the AWP, or average wholesale price, which is used as standard pricing in the industry. These companies offer drug prices at well below the AWP (like 60% price cuts), which naturally sounds like quite an attractive deal. But AWPs are wildly inflated and in many cases are not really a reliable indicator of the actual cost of the drug. In the example given by the Journal, the AWP for fluoxetine is $2.66 per pill. Express Scripts, offering a 60% discount, offers the health plans a rate of $1.06 per pill - but they purchase it at a cost of five cents per pill.

    That's a markup of 2100%, if my math is correct.

    Express Scripts claims that they take a loss on many brand-name drugs to keep prices low for their customers and that their average profit is only 46 cents per prescription. Maybe so. But if I were one of these health plans, I'd start auditing my drug bills PDQ.

    More on Canadian Drugs

    Well, the FDA is dusting off its boxing gloves. They've sent a warning letter to Rx Depot, a storefront business that helps U.S. citizens purchase drugs from Canada, telling the company to cease and desist. Rx Depot has twelve stores in various states (Florida, California, Oklahoma, Texas, Arkansas and Colorado). They send prescriptions written by U.S. physicians to a pharmacy in Manitoba, which fills the prescriptions and ships them back. Rx Depot has indicated that they plan to stay open... this will probably culminate in legal action against the company by the FDA.

    In a separate but related development, the Canadian Competition (antitrust) Bureau announced that it would not take action against GlaxoSmithKline for stopping shipments to Canadian pharmacies that export to the U.S. This probably means that more pharmaceutical companies will follow GSK's lead.

    So the search for less expensive medications will be stymied, but (as I keep saying) this issue is not going away. Now that Americans have found a source for cheaper meds, to have it taken away from them will anger them enough to impel the government and pharmaceutical companies to do something about this issue.

    Friday, March 28, 2003

    Hurrah! Disney is releasing Treasure Island on DVD next month. This almost makes up for their hideous animated fiasco/remake, Treasure Planet. If you've never seen Treasure Island, you're in for a treat - the best scenery chewing ever by Robert Newton, the man who patented the phrase "Arrr!" Also, Disney wasn't afraid to throw in some rough stuff on this one... apparently the original print had some violent scenes cut from it when it was re-released to television, which have now been restored. I think this is appropriate because Long John Silver, one of the greatest villains ever created, has a real dark side. He has a soft spot for Jim Hawkins, but he's a meanie.

    If you've never read the book - get it. Any library has it and it's one of the great stories, perfect for a weekend read.

    Thursday, March 27, 2003
    Primary Care Providers: An Endangered Species?

    This week the national internists' association, the American College of Physicians, reports the following sad news regarding residency matches: primary care continues to decrease in popularity as a career choice among medical students.

    For the sixth year in a row, fewer U.S. medical school seniors chose primary care residencies in the Match.

    According to results posted last week by the National Resident Matching Program, 3,040 U.S. seniors matched to categorical, primary and medicine-pediatrics internal medicine programs. That represents a drop of 194 medical students over last year, or a one-year decline of 6%.

    Since 1999, the number of U.S. seniors matching to the three internal medicine tracks has declined by a total of 14.5%.

    That's not good news. Most people receive most of their care from primary care doctors; more worrisome still, many specialists have to complete an internal medicine residency before going on to do a fellowship in the specialty of their choice (think cardiology, gastroenterology, infectious disease and nephrology to name a few), which means we'll likely be facing shortages of specialists in these internal medicine-based fields. Meanwhile, the residency positions in ophthalmology, dermatology and radiology are no doubt filling up. Which is all well and good, if that's what you want to go into... one's quality of life and economic bottom line are probably better in those fields, to be honest.

    But people need doctors. Primary care doctors. With proper training and educational background. Where are we going to get them? What's going to happen to our aging population in the next decade as more docs retire and there are fewer to take their place? Probably more and more of us are going to settle for seeing physicians' assistants or nurse practitioners. I know some excellent and dedicated PAs and NPs, but I feel that primary care docs provide better care for complicated patients with multiple medical problems - our training is focused on this very issue.

    Two factors in this problem, of course, are time and money. Providing primary care takes more time - and we are reimbursed less - than the specialist who does procedure after procedure all day. Read DB's Medical Rants for more on this topic. (She also has a lovely post about me.)

    To Boldly Extrapolate What No One Has Extrapolated Before

    So last night my endocrinologist friend V. and I were sitting in my office. We had each finished a bruising day of patient care and were commiserating with each other, as well as chuckling over an weblink I had sent her (a humor column from Esquire featuring sex tips from Donald Rumsfeld!) This naturally led to some talk of the war, and of the Bush cabinet. V. is not a Rumsfeld fan: she likes Colin Powell much better.

    "You're going to think I'm crazy," I said, "but when I think of Rumsfeld and Powell I think of Star Trek."

    Not surprisingly, V. started giggling.

    "Hear me out! Think about Shatner in the middle, with Spock and McCoy on either side giving him advice from two different points of view."

    "I like that!" said V. "But who's Spock?"

    "Powell. Powell is definitely Spock. Rumsfeld is McCoy. And George Bush is Captain Kirk!"

    Wednesday, March 26, 2003
    Now I'm Really Mad

    Last week I saw a patient who had GERD (severe acid reflux and heartburn), who I'd placed on ranitidine (generic Zantac) at the maximal dose of 300 mg daily. She was doing well with it, but noted that if she missed her dose by even a few hours her symptoms would return. She was having symptoms of reflux during the daytime as well as at night.

    She showed me a letter she'd gotten from her pharmacy benefit manager, Medco Health - yes, I am going to name names here. These people make me furious. I quote here partially from the letter:

    We are offering a new digestive health management program, called Positive Approaches, at the request of your plan sponsor (that would be her insurance company: Merck Medco contracts with several insurance providers to provide pharmaceutical benefits).

    As part of this program, your medications may be reviewed with your doctor or other healthcare professional to determine the most suitable and cost-effective treatment for your condition.

    Then followed a list of two generic medications: ranitidine and cimetidine, as well as Pepcid (famotidine). These are the three "H2 blockers," the original anti-ulcer drugs. Now that more advanced drugs, the "PPI's" (proton pump inhibitors) are available, the costs of H2 blockers have dropped significantly... especially cimetidine and ranitidine. They continue to be excellent methods of treatment for GERD, and very inexpensive.

    The point of the letter was to tell the patient that, without getting special authorization, the patient could not continue on the maximal dose of the H2 blockers (in my patient's case, 300 mg) but would have to cut back to the mid-strength dose (150 mg). This for a generic medication. PPI drugs are limited in many cases, and rightly so, as many patients don't need them but will do fine with the less expensive H2 blockers - but I have never seen an insurance company quibble about H2 blocker dosing. (The patient said of the letter, "They sent it the minute I filled my prescription... I got it later that week.")

    I called up Medco to make my case for continuing to maintain the patient on 300 mg. During my conversation with the pharmacist, I told them how ridiculous I thought this was and that I had never seen such a request before. "Is it really worth it to do this?" I asked. "How much money can they possibly be saving?"

    The pharmacist stated that he didn't know, but that the company must be saving a significant amount of money or they wouldn't have begun this protocol.

    Later that day, to satisfy my curiosity, I called the pharmacy downstairs from me and asked for a price quote on a month's supply of ranitidine, both for 150 mg and for 300 mg.

    Thirty 150 mg tablets cost $13.
    Thirty 300 mg tablets cost $15.

    Let's do the math here, folks. That's two dollars a month.

    Granted, if someone only needed 150 mg daily, they could get that dose by buying 300 mg tablets and cutting them in half for a total cost of $7.50 - but to put it in perspective, a month's supply of the PPI drug Protonix costs $130 for thirty 40-mg tablets.

    I don't see the benefits of fighting over seven dollars a month when the company could be saving $115. Do you?

    Tuesday, March 25, 2003
    You may sleep with the fishes, but don't try to swim with the seals.

    (Thanks to Dave Barry for this one.)

    SARS Update

    Today the CDC is announcing that they think they've isolated the causative agent for SARS - and it's not a paramyxovirus. They think it's a new variant of a coronavirus (a family of viruses that usually causes the common cold).

    This illness has spread rapidly. Currently up to 487 cases have been identified worldwide (in 14 countries) with 17 deaths. The death rate so far is running about 3.7 percent, relatively low. Hong Kong has had the most cases. All cases seem to involve either travel to infected areas or direct contact with patients with the illness (several cases seem to have stemmed from one man, a Hong Kong physician infected with the disease, who was staying in a hotel. Several people staying on the same floor of the hotel were infected). Spread into the community at large, however, has not been seen - though it is worrisome to note that a patient in a Toronto ER, in the same holding area as a patient with SARS, got sick and later died.

    Stay tuned.

    Monday, March 24, 2003
    "Why I Collect Cookbooks"

    For those of you who are interested, follow this link to read a more extensive piece I wrote on cookbooks. It was published online about a year and a half ago at DigsMagazine.com. It's quite good, if I do say so myself.

    I Only Wish

    Steve Martin:

    "Aww, that's sweet... Backstage, the Teamsters are helping Michael Moore into the trunk of his limo."

    More on Canadian Drugs

    Here's a link to a story in the L.A. Times, via Yahoo, about companies opening stores in the U.S. to act as middlemen in obtaining prescription drugs from Canada. These stores may fold awfully fast if the FDA goes after them, but I think Pandora's box has already been opened. If these companies are put out of business there will be a major backlash of popular opinion against the US pharmaceutical industry and something will have to be done.

    Another email from Chuen-Yen, my friend in Malawi. This is a heartbreaking story about trying to treat pericardial tamponade without resources or equipment.

    Hello again...

    Thrusting a needle into someone�s heart is rarely a good idea. It is an especially bad proposition when requisite tools are unavailable and neither you, nor anyone around, have experience doing it. Nonetheless, circumstances occasionally necessitate such perilous undertakings.

    While dissecting through an infant�s leg, I was called about a fifteen year-old girl suffering shortness of breath. I couldn�t see her immediately. So, the consulting general practitioner offered a tad of information. Lekelani had been admitted for chest pain three days prior. She was increasingly dyspneic. Chest x-rays and electrocardiograms had been done, but were reportedly uninterpretable.

    Actually, a massive heart was conspicuous on the radiographs. And, though muted in amplitude, EKG strips clearly showed alternating large and small waveforms. Lekelani was in tamponade. I requested a cardiac ultrasound while finishing with the baby. Due to equipment issues, the patient was sent across town for the study and returned hours later.

    By the time I received Lekelani, she was gasping for air, confused and dropping her blood pressure. Ultrasound had confirmed a massive pericardial effusion, which needed immediate removal. Our surgeon refused to attempt such a high-risk procedure. The only person known to have done one previously was in Geneva. Fortunately, pericardiocentesis instructions are on my computer.

    Since no semblance of the recommended needle was available, we improvised as usual. I inserted an angiocatheter under the ribs and successfully withdrew a liter of fluid in twenty ml increments. (BAH�s largest syringes are 20 ml.) After evacuation of the first deciliter, Lekelani started to converse. She laughed, said she was studying to be a secretary and even ridiculed her condition. Everyone was delighted.

    Later, I was called to see Lekelani for recurrence of her symptoms. This time she didn�t recover. Might the outcome have differed with better facilities and experienced physicians? Probably.

    On a daily basis I do what is considered malpractice in the developed world but exceeds Malawi�s standard of care. Such shenanigans, which are tremendous experience to me, make the difference between life and death for the locals. It sucks to be sick in Malawi.

    Stay well,

    Sunday, March 23, 2003
    Altar Guild Made Ridiculously Simple

    Friday night my next-door neighbor Susan called to ask if I wanted to go walking with her the next morning. We usually walk two miles on Mondays, Wednesdays and Fridays. I said sure, but we'd have to leave at six because I had to be at church at eight.

    "Church? On Saturday?"

    "Yes, I've got Altar Guild this week."

    "Oh. Okay," she responded blankly. The next morning, after puffing up the first hill, she reintroduced the topic: "So, what exactly is it that you're doing at church today?"

    "Well, I'm a member of something called the 'altar guild.' We're in charge of setting up the church before services." Susan was raised Mormon and has renounced organized religion ever since she was old enough to have a say in the matter, so I tried to keep my explanation basic. "We set out the votive candles, put up the hymn numbers, set up the chalices and other stuff for Communion, and wash up afterwards. We also clean the church linens. There is ironing involved. It's not very exciting, but I find it kind of relaxing."

    "I see," she responded dryly. "So it's like the housework you pay other people to do... and you find it relaxing."

    I started giggling. "Yes, it's sort of the same.. but it's, you know, different. The other thing is, it's flexible. It's something I can do for the church on a weekend, and there aren't set hours for it as long as it gets done." One hill later, I added, "Being a little eccentric helps, too - we've got a lot of obsessive compulsives in the Altar Guild."

    We left it at that, but the conversation stayed on my mind as I let myself into the church later that morning.

    My Altar Guild rota schedule is every fourth Sunday. I usually work with George, who has been head of the group for years. He likes things done in a very specific way, but his attitude is laid back enough that I don't find this to be a problem; I've learned a lot from working with him. After being on the guild for over two years, I still haven't memorized the way the chalices and other items are to be set out for Eucharist, so I usually limit myself to washing the votives and putting out fresh candles, putting up the hymn numbers, putting out the kneelers, and fetching and carrying generally. This week as I unlocked the sacristy I was greeted by a nasty smell of mildew - we'd had heavy rain the week before and the ceiling had leaked badly. We had to stop our usual duties to deal with the problem of the overhead light fixture, which had taken the brunt of the rain; several light bulbs were half-filled with water and these were removed after we found the church janitor and got him to shut off the power to the sacristy for a few minutes.

    Saturday mornings in the church are very peaceful. Tom, another member of the guild, is usually there early to practice playing on the organ (he's taking lessons) and I enjoy hearing him play while I'm wandering around the church trying to see what else needs to be done. Tom had been on guild duty last weekend: "The hymn numbers got soaked and I had to take them home and put them in the oven to dry!" (We use an old-fashioned system of cardboard numbers placed on wooden racks around the church to post the order of hymns in the service; we still do this even though the numbers are also printed in the service leaflet.)

    Our church was built around 1920 and has really not been renovated since, except for the installation of a new organ. We still rely on radiators in the winter and freestanding fans in the summer - there's no air conditioning. The wooden pews have been there for eighty years and still bear numbers on them, from the time when families who were contributing members of the church had reserved pews. I love our church building, archaic as it might be, and I do enjoy Altar Guild. The next morning it's always nice to sit in church, look around, and see the results of our work - the hymn numbers, the candles fresh and ready to go, everything properly set out.

    Since there had been a funeral in the church a couple of days before, we had to change the frontal cloth on the altar, the Lenten veil on the cross, and the cloth drape on the pulpit from white (for the funeral) back to purple (for Lent). This reminded me of the upcoming funeral for my friend who had worked with me on the school board - her funeral is the 28th. I knew George would be coming to church the night before to set up for this event, and to change the frontal cloth and so forth back to white. I asked if he'd be needing any help: it was something I wanted to do for her and it would be an opportunity for me to learn how the church is prepared for funerals (something I haven't done before). George said he'd be glad of the help, so we agreed to meet Thursday night.

    Later this week: Episcopalian funerals - more than you ever wanted to know.

    Friday, March 21, 2003
    The last three days I've been thinking, while surfing the Web to get the war news, that in 1991 during the last Gulf War we didn't have this luxury. The Internet as we now know it really didn't exist.

    I look around at all these websites: eager, enthusiastic, good writers, many well-informed with great insights about what's going on, all sharing their impressions and thoughts. This is unbelievable. Who would have thought people all around the world would be able to communicate with each other with such ease, basically instantaneously? And it's either free or incredibly inexpensive to do so!

    This is the defining cultural phenomenon of the twenty-first century. The Internet existed prior to 2000, yes, but it wasn't being used like this. No global event will ever be quite the same, as our ability to analyze and comment on them grows. I'm not trying to sound pompous here, but I think this is not so different in importance from the invention of the printing press in terms of improving communication.

    Glenn Reynolds Nails It:

    "They protest in the name of the working people, but they don't actually like working people."

    Have I mentioned how glad I am that I don't live in effing San Francisco anymore?

    Friday night. I'm tired. I have been coping with some bad news over the last ten days: I recently found out that a classmate of mine from high school died after a brief illness; a member of my church, a very nice woman who I got to know fairly well (we both sat on the parish school board) died of a brain tumor; a long-time patient of mine who I have a really good relationship with told me a week ago that he'd been diagnosed HIV positive.

    Oh, and that giving-up-coffee-for-Lent thing? That is so not happening. But I have stayed away from Starbucks and have saved quite a bit of money, and will be donating that, so I hope that will make up for it.

    In other news: the latest on the SARS pneumonia - the virus has been identified.

    TORONTO, March 21 (Reuters) - Canadian researchers said on Friday they were able to identify a virus related to measles and mumps in six of eight cases of a deadly globe-trotting form of pneumonia that has baffled world health officials.

    The researchers said six Canadian victims of the infection, known as severe acute respiratory syndrome (SARS), contained evidence of the human metapneumovirus, part of a family of viruses called paramyxoviruses.

    More than 300 people have fallen ill with SARS and at least 10 have died, according to the World Health Organization, which issued a global health alert about the outbreak last week.

    The outbreak, which may be linked to a wave of similar illnesses reported in China earlier this year, has spread through Hong Kong, Vietnam and other parts of Asia.

    Hong Kong health authorities said most infections could be traced to a single doctor who treated patients in China before becoming ill and dying from SARS.

    The U.S. Centers for Disease Control and Prevention said on Friday that 22 people in states stretching from Maine to California were suspected to be infected with the disease.

    Wednesday, March 19, 2003
    In an attempt to distract ourselves from the upcoming war for a moment, consider the following:

    Somebody won $1000 playing Rock, Paper, Scissors in a national competition.

    More Codes

    Medpundit uses the ICD-9 code book to her advantage, too!

    Thanks to GruntDoc for this pointer to QFever, a medical humor/satire site. There are some real gems here:

    Global Warming and Rising Sea Levels Linked to Obesity - the sea isn't rising, the U.S. is actually sinking

    And so forth.

    Tuesday, March 18, 2003
    Work continues on the mystery respiratory infection originating in Southeast Asia. Looks like we're down to nine reported cases in the U.S. We now know it's a virus, but it will be interesting to see if it is a variant form of influenza or some other type of virus. There's some evidence that it may be a paramyxovirus, but this has not been confirmed by the CDC. These bugs cause various respiratory illnesses known as parainfluenzas - meaning like the flu, but not caused by the flu virus. Most parainfluenzas are pediatric in nature, and adults don't seem so subsceptible to them. The classic example would be croup, which is a parainfluenza. If that's what this is, it seems to be a more virulent form than the usual respiratory virus.

    Monday, March 17, 2003

    Read this for more about the choices docs are facing in medicine these days. Dr. Bradley is a family practice doctor who closed his practice and now works "fast track" shifts in the ER. Want to know why? Read his blog. I like. Oh, and the book he named his blog after, "Kill as Few Patients as Possible," is excellent. I highly recommend it.

    Got this email from a reader:

    I thought I would give you insights from an employer who has to pay for
    those expensive health insurance premiums. Health care costs are
    reducing wages, increasing prices and increasing unemployment.

    Here are the percentage increases Blue Cross has charged our company
    for the last four years-20 percent, 22 percent, 25 percent and 27 percent. 10 years ago, the
    annual cost to the company for family coverage was 1500 dollars. This year the
    cost is 9000 dollars. That is 4.33 per hour added to the cost of having an

    The employers have put pressure on insurance companies to reduce their
    premiums. The insurance companies have responded by prescribing
    treatments, limiting fees and approval for certain treatments....

    All true. In some situations now, employees are getting nasty surprises for treatments they thought were covered (as per the Wall Street Journal last week). One patient was trying to get a bone marrow transplant for cancer. The transplant and meds were covered, but the search costs for the donor were not. She spent several thousand dollars on a donor search. In another case, a patient developed breast cancer, which was treated... but when a tumor developed in the other breast, treatment for that was not covered. Insurance companies may be partially responsible for these scenarios, but the employers' coverage choices are part of it too. They're desperately trying to keep costs down so that they can stay in business. So that means that even people who are "covered" by insurance aren't completely covered.

    When things get this out of control, something has to give. I don't know what it's going to be - but I think that health care will be different in five years, and really different in ten years.

    Sunday, March 16, 2003
    OK, let's talk Medicare reform. God knows we need it. With the population over age 65 continuing to increase, and the cost of drugs which can keep people alive and out of the hospital also increasing, something has to be done. As it stands now, many elderly have no drug coverage or insufficient drug coverage and are faced with very high drug costs; reimbursement rates to doctors for many procedures as well as general preventive care are being cut annually; many patients are being cut loose from their senior managed care plans (which offer drug coverage) with minimal warning, as insurers are leaving this market due to high losses.

    The plan as currently proposed by President Bush would offer three options:

    1. Stay in traditional Medicare. For those of you who don't know the details, currently Medicare has no drug coverage whatsoever. It also does not cover long term or "custodial" care. It will cover up to 100 days per year of skilled nursing care, if the patient qualifies (in other words, if the patient needs tube feedings, IV antibiotics, physical therapy, or special nursing care for wounds). Many screening blood tests and examinations are also not covered by Medicare - you must show medical necessity (in other words, certain blood tests will be paid for by Medicare if you have diabetes, but not if you don't). It mainly covers hospitalization costs, and most outpatient medical costs. It has a reputation as being the universal coverage that all doctors will accept; lately, however, that is no longer the case. Many doctors are refusing new Medicare patients due to falling reimbursement rates.

    Medicaid, the state health coverage plan, will cover drugs and also covers long-term custodial care. It's a backup plan and can be very useful, if the patient qualifies financially (essentially, you have to be broke). It's also possible to buy backup insurance for drug coverage, but this costs about $400 per month.

    Under the Bush plan, patients who stay in traditional Medicare would get little in the way of drug benefts. They'd get a discount card which would reduce drug costs by 10 to 25%, and annual drug costs would be capped at some amount between $5500 and $7000.

    2. Switch to "Enhanced Medicare," a proposed plan that would have patients join a private plan with some elements of managed care; would probably offer more drug benefits than traditional Medicare. There would be some restriction of access to specialists, namely, if patients chose to see an out-of-network doctor it would cost them more. The health plans would be able to design their own menu of drug benefits as long as they met a federal standard of required benefits (which hasn't been designed yet).

    3. Enroll in "Medicare Advantage" - an updated version of the Medicare+Choice program. This plan was begun in 1998 to offer managed care to seniors at a lower cost. This would be the cheapest of the programs to join. There would be fewer choices among physicians. This could work, but only if the government commits to offer insurers a guaranteed level of reimbursement; otherwise we'd see the same scenario as noted above, with insurance plans fleeing en masse from senior managed care due to financial losses.

    Meantime, in the news this week we now see that the FDA is backing the pharmaceutical industry in restricting the purchase of drugs from Canada. It's looking more likely that patient access to this means of reducing drug costs will soon be denied.

    So, Dr. Alice, how would you fix this problem?

    Uh. Well. I have a few ideas. Blogger keeps eating my posts, so I am going to try to condense this. The first thing is to face facts and realize that increasing coverage for health care will increase overall costs, pure and simple. So I would look at ways to reduce the cost of providing care in other ways.

    First, tort reform. I don't think this is the biggest cause of high healthcare costs, but it certainly is one of the main causes. Soaring malpractice rates are forcing doctors out of practice in some areas. Obstetric care is essentially unavailable in places like Nevada, where OB-GYNs are refusing to deliver babies (they can't afford the insurance; it can cost upwards of $200,000 per year). Tort reform would keep docs in practice and improve access for patients. It would also lower the cost of many valuable medical treatments such as vaccines, IUDs and pacemakers.

    Next, and I realize I may get flamed good for this... take a serious look at rationing care. I am serious. Let me give you one example: during my stint working in the hospital two months ago, one of my patients was an elderly woman who had been in Intensive Care for some weeks. She had been admitted with pneumonia, intubated and placed on a ventilator, then developed renal failure and was begun on dialysis, then developed fungal pneumonia (a death sentence). Every doctor involved in her care (and believe me, there were several) agreed that further treatment was futile. She was kept alive for another two weeks simply so that her son could fly out from New York to Los Angeles to make a decision on her care. By the time I picked her up, the unit team was marking time waiting for the son. I was there the day he arrived and spoke with him; it took him five minutes to make the decision to withdraw care.

    How many thousands of dollars were spent on this Medicare patient the last ten days of her life, in the knowledge that none of it would do any good? How many other people could have been helped with that money? I've discussed this issue with a lot of other doctors in the past few months. Every one of them has said, essentially, "The only way to lower health care costs is to lower our standards of care." Maybe that means we prioritize things like mammograms, vaccinations, well baby checks and Pap smears. Maybe that means that organ transplants go to the bottom of the list. Maybe that means that patients over 80 don't get the option to be intubated or put in the ICU or dialyzed.

    If we as a nation really want to reduce health care costs, that's what it's going to take. But it would be political suicide to admit it.

    Saturday, March 15, 2003
    Worrisome news today: WHO has released information about a serious atypical pneumonia which seems to be originating in Asia. It's not known yet whether this illness is viral or bacterial in origin.

    15 March 2003 | GENEVA -- During the past week, WHO has received reports of more than 150 new suspected cases of Severe Acute Respiratory Syndrome (SARS), an atypical pneumonia for which cause has not yet been determined. Reports to date have been received from Canada, China, Hong Kong Special Administrative Region of China, Indonesia, Philippines, Singapore, Thailand, and Viet Nam. Early today, an ill passenger and companions who travelled from New York, United States, and who landed in Frankfurt, Germany were removed from their flight and taken to hospital isolation.

    Due to the spread of SARS to several countries in a short period of time, the World Health Organization today has issued emergency guidance for travellers and airlines.

    �This syndrome, SARS, is now a worldwide health threat,� said Dr. Gro Harlem Brundtland, Director General of the World Health Organization. �The world needs to work together to find its cause, cure the sick, and stop its spread.�

    There is presently no recommendation for people to restrict travel to any destination. However in response to enquiries from governments, airlines, physicians and travellers, WHO is now offering guidance for travellers, airline crew and airlines. The exact nature of the infection is still under investigation and this guidance is based on the early information available to WHO.

    The latest news is that there have been nine deaths due to this illness.

    My friend Chuen-Yen is an internist, doing a year's volunteer stint at a hospital in Malawi. Her emails never fail to entertain, educate and inform. Today we take a look at life without water.

    Without. Water.


    Though I stopped taking electricity for granted long ago, I have always expected water to run from the faucet on demand. Even when Blantyre�s hydro plant was down, storage tanks ensured an uninterrupted flow. This week, taps ran dry across the country. Based on experience, nobody believed the supply would resume in the projected two days. Thus, in the interest of self-preservation, people fought desperately over what remained.

    At the hospital, inter-appointment hand washing has ceased. Spirit swab rubdowns could be used instead, but most of us just ceased touching patients. Floors weren�t mopped. Linens weren�t washed. Stenches fermented. In town, the effects were more substantial. Stores rapidly sold-out of buckets. Hygiene went to the wayside. Cooking was nearly impossible. Thirst was rampant.

    My neighbor Darryl and I are lucky enough to share a fairly large water tank with the dental clinic over which we live. So, we weren�t so worried when the shortage began. With a little conservation, our supply could last several days. However, droves of people materialized to fill containers from an outside tap. As darkness set in, clandestine arguments over who should fill their vessels first pierced the air.

    Though inclined, we couldn�t overtly deny water. However, Darryl did put the dogs out as a deterrent. And, as a precaution, I filled three water bottles, my only bucket, a rubbish bin, all four of pots in the kitchen and eight cups. I also collected my bathwater and dishwater for toilet flushing.

    To make matters worse, an inconstant electrical supply exacerbated the water shortage. �Power sharing,� by which only a few areas can simultaneously use electricity, meant water stagnating in unclean vessels often couldn�t be boiled.

    Fortunately, the hospital is considered a high need locale. Water resumed ahead of schedule here. Now we�re more relaxed about sharing with those whose pipes are still dry. And we are enjoying the luxury of suppressing our survival instincts.

    Bye for now.

    Friday, March 14, 2003
    Coming Soon

    On the weekend, when I have more time, I want to do some writing about the situation we're facing with the U.S. healthcare system. Sorry about the light blogging this week, it's been busy.

    Thursday, March 13, 2003
    Code Update

    Today I've got 307.45 because I was on hospitalist call last night.

    ("Irregular sleep-wake rhythm, nonorganic origin")

    I wonder how that would look on a disability form.

    Tuesday, March 11, 2003
    Code of the Day

    One of the minor irritants of practicing medicine these days is coding: in an effort to improve the efficiency of insurance billing, disability evaluations and the Medicare system (among other things) a system of code numbers has been assigned to all diseases and procedures. The standard medical/disease code system is ICD-9 (International Classification of Diseases, ninth edition). Every doctor's office has a copy of this codebook somewhere; every office visit, lab test and disability form has to have an ICD code attached to it for diagnosis. Sound bureaucratic? Yes it is, but that's not why I'm writing about it: I adore the ICD-9 codebook. Yes, I do. Pick it up and you won't be able to put it down; it's more addictive than leafing through an encyclopedia or a dictionary. It's perfect bathroom or rainy-day reading. Many old-fashioned disease names are still included in the codebook, along with syndromes I've never heard of. The perfect example? 784.49 - clergyman's throat (also known as "voice disturbance, unspecified").

    The system also sometimes takes exactitude to a ridiculous degree. Under visual loss, we have for blindness 369.0, but for "better eye: total impairment; lesser eye: total impairment" it's 369.01. Then follows every permutation and combination you can imagine of the visual acuity of each eye, all with a different code number.

    A few months ago I decided to share my love of ICD-9 codes and started a code of the day mailing list in my medical group. It was received with enthusiasm, more than I had dared to hope for... I just hoped people would find it amusing instead of the final reason they needed to admit me to the psych unit.

    Let's look at some examples. In order to play I suggested that the members of my list arm themselves with an ICD-9 codebook and look up the answers, but obviously that's not workable here so I will simply append them.

    Hint: Mary had this (V02.1) Answer: Typhoid carrier

    I joked that we all had patients with this problem. (301.51) Answer: hospital addiction syndrome, similar to Munchausen's syndrome: a chronic factitious illness, self-induced.

    I will leave you with a final thought: 309.23...
    Answer: Adjustment reaction with specific academic or work inhibition, also known as spring fever. (Yes, it's really in there.)

    Sunday, March 09, 2003

    It happened just before six yesterday morning. I was up early, thinking about going to the gym when I suddenly heard sounds of yelling and smashing glass a few houses down. I wondered if someone was fighting and hurried to get dressed, thinking, should I call the police?

    Suddenly from my bedroom I heard explosions - three dull, percussive sounding thumps - and saw red flames reflected in the windows of the house across the street. Simultaneously I heard sirens.

    I ran to grab the phone and call my next-door neighbor - I knew it wasn't her house but thought it might be the house on her other side. It wasn't... it was just across the street, a house on the corner. I ran outside to see what was going on.

    They got there fast. There were three fire engines and an ambulance, and a few minutes later a fourth engine pulled up. I joined a little group of spectators on the sidewalk, most of whom were in robes and slippers. One person I recognized was Irv, an older guy who lives across the street from me. He knows everybody on the block, it seems. He told me he'd been worried about this woman for a while, that she was elderly and lived by herself with a dog. I remembered the dog, I'd often seen him at the front window or barking at the front door. Irv muttered, "If she's lost that dog, she's gonna die." He told us that she used to be the secretary to the mayor of Beverly Hills; he also said she'd had a drinking problem.

    We stood there watching the firemen on the roof, using chainsaws to get through the roof to vent the fire straight up. Then we saw the woman being brought out in a wheelchair. One of the people on the sidewalk, who knew her, ran over to see if she was OK - she came back looking worried and told us she'd been burned all over the neck and chest.

    Then we saw the dog, lying on the lawn. One or two of the firemen had been crouched over the dog earlier, but now they moved away. The dog didn't move, and we realized it was dead; a minute later, someone put a tarp over its body.

    We all gradually moved away, back to our houses, knowing the fire was out. Later that morning I heard a mention of the fire on the radio: the cause was smoking. I can't help wondering if she'd had oxygen in the house and if that was why the fire exploded the way it did. If you need another reason not to smoke - there it is.

    Friday, March 07, 2003
    Canadian Prescriptions Under Fire

    Some of you reading this in the U.S. may either be getting prescription medications from Canada (where they are cheaper) or have a friend or relative who is doing so. I recently got a notice from one Canadian company regarding a GlaxoSmithKline crackdown on this process, which I'm putting out to the BlogUniverse:

    (edited for conciseness)

    ... we may not be able to serve your needs much longer, because of attacks by the pharmaceutical industry. We urgently need your help to ensure that we can continue to provide you with this service.

    Earlier this month, Glaxo SmithKline... had announced a ban of its Canadian drugs from being sold by Canadian pharmacies to any American customers. While Glaxo says they're taking this step for safety reasons... Canadian pharmacies believe that the drug company is really concerned about their profits.

    Importantly, if Glaxo's ban goes unchallenged, other drug makers may follow Glaxo's lead.

    Please show your opposition to this major threat to your low-cost Canadian drug resource... by taking these "Action Steps" today:

    1.a. Email your U.S. Senators by using the direct, free links found at the www.capwiz.com website... ask them to stop Glaxo's ban against Americans buying Canadian drugs, and prevent other companies from doing the same.

    1.b. Do not buy any GSK over the counter medications, such as Coactifed, Neosporin, etc.

    1.c. Email all your friends and acquaintances to do the same.

    2. Call Glaxo's toll-free consumer line at 1-800-825-5249. A recorded voicemail will lead you through several prompts before you can give your comments to a live operator. When the operator answers, we recommend that you tell them that "Glaxo's ban against Canadian drugs is hurting American seniors, to lift the ban immediately, and that you will tell your doctor to give you a therapeutic substitute from another company."

    3. Write to Glaxo's U.S. president to share your feelings:

    Mr. Christopher Viehbacher, President
    GlaxoSmithKline US Pharmaceuticals
    5 Moore Drive, P.O. Box 13398,
    Research Triangle Park, NC 27709

    I offer this as an option, speaking as a physician with many patients who have been driven to order drugs by mail, since their insurance is no longer covering many medications.

    Thursday, March 06, 2003
    Thanks, Mr. Blair! And thanks to everybody who stopped by. Hope you like the site. Come back again.


    (no, this is not a misprint)

    Recently I had a new patient come in complaining of some unspecified gastroenterologic problem. I work with a resident twice a week; that afternoon she happened to be there, so I sent her in to evaluate the patient.

    She came back looking green. "She says she's got worms!"

    "What exactly did she tell you about her symptoms?" I asked. This elicited a lurid story -- hold on to your gorge -- of the patient feeling worms crawling in her abdomen, seeing worms in her stool, and having some sort of rectal blister that burst "and worms came out."

    The reason I'm going into such detail is this: I knew this couldn't be true. Parasites do not behave like that, at least not the types most likely to be picked up in North America. Also, with symptoms like that she'd had to have had a huge parasite load - she would have been really sick and possibly developed an abdominal obstruction. (As a side note, I was once privileged to see an upper GI X-ray of a patient from the Third World who presented with symptoms of abdominal obstruction; the study showed a mass in the small intestine which turned out to be a worm ball. Ugh.) Taking advantage of our computer system, which taps into the local medical center, I saw that she had had a stool study for parasites within the last few months... negative. With the symptoms she was describing, that would have been almost impossible.

    Back to the resident. I explained to her that I found this story highly suspicious, told her why, and sent her in there to gather additional information: "Does she have a travel history? How big were the worms? How many were there? What did her previous doctor say? Push for as much detail as you can and watch how she reacts."

    I already had my suspected diagnosis: formication. This isn't a common phenomenon, but it is well-known and seen most often in patients taking drugs (it's also referred to as "coke bugs"). However, it is also seen in patients who don't take drugs... usually the elderly. It's felt to be a manifestation of mild psychosis. The patients are preoccupied with the idea that they have parasites in their body, usually under the skin, and often present with abrasions or excoriations on their skin where they've dug into themselves trying to get the "worms" out.

    My resident came back and reported that the more questions she asked, the more evasive the patient got. Diagnosis confirmed - or almost. I went in, evaluated the patient and elicited much the same history, did an exam and found nothing. She did look to have a local dermatitis in the area, possibly fungal, so I gave her some cream, explained what I thought was likely to be going on, pointed out that she had a recent negative stool study and asked her to follow up in a few weeks. So far, no follow-up, but we shall see.

    Wednesday, March 05, 2003
    Ash Wednesday

    Welcome to Lent.

    Around here, we have a little Ash Wednesday ritual. It's called, "OhmyGodshegaveupcoffeeagain! Get the hell OUT OF HER WAY!"

    No coffee or booze for the next six weeks (excluding St. Pat's of course). I'm a little... edgy.

    Tuesday, March 04, 2003
    Feet First: The Cheap Laughs Edition

    Hey, I'm not proud.

    Story Number One: The Mad Pizza Eater, or "I Told You Not to Give Me any Damn Anchovies!"

    Courtesy of Yahoo, we have this:

    Axeman Attacks Chef over Pizza

    FRANKFURT (Reuters) - Unhappy with his pizza and not content with a refund, a man in Germany has gone after the chef with an axe.

    Frankfurt police said the 57-year-old man was restrained by customers after he drew the axe from his coat and started swinging it at the cook.

    "Apparently, the pizza didn't agree with him," said police spokesman Manfred Feist. "He wasn't a regular customer."

    And then there's this:

    Story Number Two: Brothel for Sex-starved Dogs

    BERLIN (Reuters) - A German artist has applied for a license to open a brothel in Berlin for sexually frustrated dogs and says it will be the first of its kind anywhere.

    Karl-Friedrich Lenze, 54, said he planned to charge dog owners $27 per half hour of happiness.

    "If dogs can't get what they want, they get cranky -- just like people," Lenze told Reuters.

    Who you callin' cranky?! You son of a... uh, never mind...

    The establishment would offer patrons a variety of carefully vetted "employees" of both sexes, rooms for private encounters and even a "bar" where customers could sniff out their preferred partners.

    Aren't there enough unwanted puppies in the world? What are they going to use, condoms or something?

    Cute! Cute! Cute!

    Got this e-mail from a friend this morning:

    These are the contents of a lunch bag prepared for me by my 5 y/o son:

    1 can of Campbell's soup
    1 apple
    1 orange
    1 baggie of peanuts
    1 baggie of candy hearts left over from Valentine's Day (I've been
    instructed to read the sentiments)
    1 package of cookies
    1 napkin

    I couldn't help it, I had to share.

    Monday, March 03, 2003
    This weekend I did something doctors almost never do any more. Two things, actually.

    One: I made a house call. Two: I pronounced a patient dead in her own home instead of dragging her off to the hospital. (At the family's request, I might add.)

    Here's what happened. I've been following this patient since 1999, when she had the bad luck to fall and break her hip. She was admitted, the hip was surgically repaired, and she was then transferred to a skilled nursing facility for physical therapy and rehab. She hated it there, and demanded to go home. Her sister, still functional and the person who held her power of attorney, backed her up. The woman lived in a second-story apartment in West Hollywood -- she'd been there for decades -- which had no elevator access. But she deeply wanted to be in her own surroundings, and seemed disoriented in the unfamiliar facility. After many conversations, home she finally went. Since she never again was able to walk (she failed physical therapy), it was clear that getting to the doctor's office was going to be an impossibility; transportation to outpatient appointments is not covered by insurance, and there was no wheelchair access since there was no elevator. The patient literally had to be carried downstairs whenever she left the apartment, and that meant an ambulance. So, I started making house calls. I do occasionally do this, but I don't exactly advertise the fact.

    It was rather interesting, actually. This woman had traveled the world and was a gifted painter. The walls of the apartment were covered with pictures she had done over the years, as well as the occasional award from various art competitions. She frequently offered to sell me one, but I always declined. (I was secretly hoping she'd give me one, but that never happened.) On one visit I found a volume of an encyclopedia set dating from the 1930's which I skimmed through, fascinated; I wouldn't have minded having that, either. She was always willing to chat, though our conversations were limited as she was 1) stone deaf and 2) somewhat demented.

    Last spring things began to change. I had not seen my patient for several months when I got a call from her caregiver, who informed me that the patient's healthy, functional sister had fallen downstairs and broken her neck. After several months in a nursing home, she finally passed away. My patient's new power of attorney and next of kin was a relative in Alaska. About this time, my patient developed a large skin cancer on her face; this clearly required treatment. After mammoth negotiations with the family, they finally hired the ambulance - at a cost of several hundred dollars - to bring the woman to the dermatologist to get her cancer treated. Fortunately, the office treatment seemed to work well and the cancer did not recur.

    Last week I got a call from the caregiver that my patient was coughing and running a fever. I called in some antibiotics, intending to see her later in the week... but she jumped the gun and got very sick, very fast. I diagnosed pneumonia by listening to her breathing over the phone. At this point I called the relatives in Alaska and gave them the choice: either I call 911 and get her to the hospital or we keep her home with the understanding that she will almost certainly die.

    "Keep her there," they said. I agreed. So Friday night I went over to see my patient. She was shaking with rigor, covered in cardigans and blankets, and the heater was on. The apartment was like an oven. I had called in some Tylenol with codeine syrup but the caregiver hadn't been able to get it yet. The minute I saw her I knew she wouldn't last another twenty-four hours.

    "This is what we do," I told the caregiver. "When she dies, call me and I'll come over and pronounce her. Does she have funeral arrangements?"

    "Yes," was the answer, and I was shown a neatly organized file including the business card of the mortuary. Attached to the file was a Post-It: "Remove opal ring." Wow, I thought, somebody thought ahead.

    "Just one thing," I added: "If she dies in the middle of the night, please don't call me till six-thirty. I am not coming here at two o'clock in the morning to pronounce her; a couple of hours won't make any difference." I felt I had to add this, since the caregiver looked quite nervous (understandably).

    As things turned out, the patient didn't die until nine the following morning. I got the call, and back I came. She was now shrouded in the blanket and looked quite peaceful.

    "Was she comfortable last night?" I asked.

    "Oh, yes, doctor. As soon as we gave her the medicine she quieted down."

    I phoned the mortuary and gave them all the relevant information, and told the caregiver to turn off the heater. As we looked in the desk drawer for her Social Security number, I found her birth certificate which was marked "Delayed" and dated 1942; this gave me pause, as I knew my patient had been born in 1911! As I read it became clear. She was born on a farm in North Dakota, and the birth was recorded in the family Bible and sworn to as accurate by her family doctor. In that place and time, many births were probably not registered for years. Truly another era!

    As I left I felt that I had actually accomplished something. I had done something most doctors hadn't done for decades; something most doctors of my generation never will experience. More important, I had helped this woman die comfortably in her own home and had not jammed her full of intravenous tubes and lines she didn't want (she had told me many times over the last three years that she was ready to die). So, though it may sound strange, it was a really good experience.

    I don't know what it is about me and cats these days, but I have another great feline-related site for you: Piddle Pants for incontinent cats. The best part is the sentence that says: "Please measure carefully." (Have you ever tried to measure a cat?)

    Saturday, March 01, 2003
    Oracle of Starbucks says...

    Goddam it! I'm either lame or I'm a freak! I mean, Starbucks says so, and how could they be wrong?