Musings from the Disenchanted Doctor: an unscientific blog






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Spinach or Cheetos? You Decide!

Found an interesting website today. I'm not quite sure whether I approve of it or not but I certainly think it's worth a look. The site is called Center for Consumer Freedom and basically campaigns for people to use their common sense regarding health choices as opposed to "nanny" policies by the government. It vents a lot of wrath on the Center for Science in the Public Interest, the Robert Wood Johnson foundation, and PETA. Check out their Tarnished Halo Awards, in which the CCF...

awards prizes annually to America's most notorious animal-rights zealots, environmental scaremongers, celebrity busybodies, self-anointed "public interest" advocates, trial lawyers, and other food & beverage activists who claim to "know what's best for you."

The Tarnished Halo Awards highlight the winners' use of misinformation, duplicity and even violence to further a political agenda or fatten their own wallets.

Now I don't think the answer for obesity is to eradicate McDonald's from the earth, and if the Center for Science in the Public Interest is relying on flawed studies to make its claims (as the CCF claims it does) then I certainly don't approve of such tactics. On the other hand, it's true that diabetes, hypertension, and other lifestyle-related diseases are skyrocketing and that a large part of the population is making bad food choices. While I agree -- in theory -- with the CCF's position that people can make intelligent choices and that it's not the place of government to be your mother, the fact is that in many cases those intelligent choices are not being made. Some prodding from Big Brother might be a good idea. Then again, I think patients are more likely to pay attention to one-on-one counseling from a health care provider than to a billboard telling them to eat their peas.

Your thoughts?
posted by Dr. Alice at #

 
More From Malawi

Here is the next installment of my friend Chuen-Yen's adventures, in which we learn that one wife is worth five to ten head of cattle and that you should always book through a reputable Western Hemisphere travel agency if you want to try to climb Mt. Kilimanjaro:

Jambo (Hi in Swahili). I'm back in Blantyre for a day. Here's a brief update:

"Brushing your hair is a poor substitute for washing it."
-- Most profound thought at 5,895 meters

Summiting Mt. Kilimanjaro is an amazing experience. However, reaching the trailhead can be the most challenging part of the adventure. At Dar es Salaam airport, Jason, John and I were agreeably swindled into purchasing a package deal. However, our $250 per person deposit covered only local transport to Moshi, a good place to begin a Kilimanjaro trek. This hypothetically five-hour bus journey lasted twelve hours and left me crusted with dead insects, bird feces, shards of glass and a fellow passenger's blood.

Our first delay was Kili Express' brake failure. During the compulsory rest stop, I met Denas, a twenty-three year old Masai boy who had shirked traditional tribal life in pursuit of classroom education. He lamented that he was, at this mature age, unmarried and childless due to paucity of cattle. Denas limned that every Masai boy receives one cow at birth. With proper animal husbandry, he should own five to ten cattle by his eighteenth birthday. With these, he may procure one wife. As the herd enlarges, he will acquire more mates. However, Denas' family had consumed some of his stock while he attended school. With only three remaining animals, he was unmarriageable.

A few hours into the saga of Denas' tragedy, we splurged $12 more for seats on a passing bus with functional brakes. Unfortunately, this one grazed a lorry, explosively injuring the driver and shattering several windows on my side. Luckily, I was leaning forward to assess what items had been filched from my pack during the previous breakdown. While surrounding travelers were severely lacerated and had debris embedded in their skin, I was only stung by a mist of glass needles and showered with my neighbor's blood. The wounded, including our driver, were rushed to a local clinic as officials collected multiple reports, thus causing further delays.

Fortunately, the now repaired Kili Express caught up as we loitered outside "Barcelona Rhythms Nightclub," a roadside stand with a boom box. We scurried back onto the original bus. At 11 pm, we reached Moshi Central only to discover that Flugo Tours had paid for no further arrangements. I suppose $762 is a bargain for such priceless entertainment.

CY
posted by Dr. Alice at #

 
OK, I'm Back

Nice trip, but I got sick. My sister's youngest, William, is 11 months old and has a cold. He also has a charming habit of sucking on his fingers and then sticking them up the nose or in the mouth of whoever is carrying him at the time. Very sweet kid, though, and even-tempered even when sick. He has learned to crawl and just figured out how to go up stairs, which meant we had to keep an eagle eye on him and break out the safety gate.

Unfortunately, I came back to an avalanche of work. More later.
posted by Dr. Alice at #

 
How To Email? Type and Hit Send!

Are you a klutz when it comes to flirting by email? Have you sent embarrassing personal emails to the entire company by mistake? Then you need to take the Yahoo Email Master Class. Yes, apparently people actually do have this problem, as noted in this article. Pity the poor souls who describe email as a "huge burden."
posted by Dr. Alice at #

 
Okay, One More

I saw something in GruntDoc's blog today that reminded me of my experiences as an independent contractor, ten years ago when I first got out of residency.

This is how moonlighting works (and how residents get into financial trouble): after one year of internship, an MD is qualified to apply to the state for a license to practice medicine. Armed with said license, residents can moonlight in other jobs (usually after-hours clinics), where they can learn and get paid at the same time. Almost all moonlighters are paid as independent contractors, which means you have to estimate and pay taxes quarterly, as opposed to regular full-time employee paychecks which have taxes taken out as you go along. The good news is the paychecks look huge when you get them. The bad news is the tax bill can come as a nasty surprise if the moonlighter is a novice. This usually happens in the first tax season after the resident has started moonlighting and has not bothered to estimate quarterly taxes for the first few months.

One of my friends from residency was sitting in the doctors' lounge one April morning lamenting her financial situation as follows:

"I started moonlighting to pay off my credit card bill, and everything was great until I saw how much I owe in taxes! What am I going to do?"

"Put your taxes on your credit card and start all over again," I suggested.

I thought this was funny. She didn't.

posted by Dr. Alice at #

 
Google

Today, I hit the "I'm Feeling Lucky" button without entering anything - because, well, I felt lucky.

I got this.

So, it's not like playing a one-armed bandit. Damn!
posted by Dr. Alice at #

 
Name That Aneurysm

One thing I like about medicine is that you're always learning, no matter how long you've been in practice. It's no shame to admit you're unfamiliar with a disease or topic; instead, you're encouraged to read, investigate and ask questions.

Last week a patient of mine presented to the emergency room with abdominal pain. She was worked up and sent home, but I was called by the ER doc because the radiologist had found a splenic artery aneurysm on her abdominal X ray (it was an incidental finding and not the source of her pain). As an internist, I am totally unfamiliar with splenic aneurysms; in fact, I'm not sure I had ever heard of one before. So what do we do about this?

We check Google. Now that we have personal computers and Internet access at the office, I use Google a lot more than textbooks when I want to look something up; it's much faster. So here are the results of my search for "splenic artery aneurysm".

Hmmm. So they do rupture. Apparently one of the higher risk scenarios is during pregnancy - at least, there are several listings regarding pregnancy and splenic artery aneurysms. My patient is postmenopausal, so that is not an issue, but one of the articles suggests that aneurysms larger in diameter than 2.0 cm are at higher risk of rupture. According to the radiologist the diameter of this one is 2.0 x 2.5 cm, so now I email our surgeon for input.

"Get a CT scan" is the answer. The closer the aneurysm is to the branching point or origin of the splenic artery, the more likely it is that the entire spleen will need to be removed. In some cases, when it's further away, the surgeon can merely take out the dilated section of artery and anastomose (sew together) the open ends of the artery, preserving the spleen.

So now we're waiting for the CT, which should be done sometime this week. We will then have time to have the patient meet with the surgeon and get her vaccinations before proceeding to surgery. (Since the spleen is an important part of the immune system and helps fight off bacterial infections, we like to vaccinate people against things like Strep. pneumonia and H. influenza prior to surgery if possible.)

I also found a great article written by a man who suffered a ruptured splenic artery aneurysm - and survived. He ran thirty miles a week and was in great shape, which is probably why he lived despite several hours' delay in treatment.

Parenthetical note: blogging will be light or none till next week as I am going to be away for Easter. Enjoy your Easter/Passover, or just enjoy spring.
posted by Dr. Alice at #

 
Evil Grand Rounds: The Redux

Let's try a little humor here. In an attempt to get my mind off federal bureacracy, I present more Grand Rounds (and other activities) To Be Avoided:

All announcements are verbatim from my emails.

Department of Surgery sponsors
Surgery Grand Rounds
"Surgical Experience with 25 Conjoined Twins"
Chang and Eng, Orthopedists!

Department of Medicine
Division of Nephrology sponsors
RENAL GRAND ROUNDS
�The regulation of parathyroid growth in uremia�
A guaranteed cure for insomnia...

Cedars-Sinai Alumni Association sponsors
THE REVIVAL OF THE ANNUAL
Attending Staff Gomers
vs
The Housestaff Blues
BASKETBALL GAME

For those of you who don't know, "gomer" stands for "Get out of my Emergency Room" and is applied to elderly demented patients who turn up in the ER for no really good reason. I do not find it flattering to be referred to as a gomer.

Department of Psychiatry sponsors
PSYCHIATRY GRAND ROUNDS
"The New Role for Psychiatry In
An Age of Terrorism and Weapons of Mass Destruction"
New role? Try "tranquilizer dispenser"

�Lessons Learned from Litigation Against Oncologists�
Cancer is a very bad disease. Try not to get it.


posted by Dr. Alice at #

 
HIPAA Update II

This is rich... our risk manager has informed us of the following curve ball regarding faxes: we can fax patient information, but only if we fax from a "white-paper fax machine" to another white-paper fax machine. In other words, it has to be a freestanding fax, not a computer program that can send and receive faxes... because with the latter, the information could possibly be left hanging out there in the Internet ether, and therefore is not privacy protected!

So now we have to ascertain whether the receiving fax is a white-paper fax. This means we have to ask everyone this question before we fax anything anywhere.

I have to go kill myself now. Bye.

posted by Dr. Alice at #

 
HIPAA Update

We're already having problems. One of my colleagues is trying to do a preop exam on a patient who needs a breast biospy, and she can't get the results of the patient's mammogram or ultrasound. The surgeon's office is refusing to fax the information to her because of HIPAA. Now, this legislation is not supposed to affect the transfer of information from doctor to doctor, but in practice it is hindering it because now our staff is too damn scared to release any information at all.

More updates as they happen, if anything really outrageously stupid turns up.

posted by Dr. Alice at #

 
Well, HIPAA ("making your life better by making it worse") goes into effect today. It started out as health insurance reform - the acronym stands for Health Insurance Portability and Accountability Act - and, as originally postulated, was a good idea. (The key words here are "as originally postulated.") The purpose of this piece of legislation was to make it possible for someone to keep health insurance when they changed jobs; in the past, someone with a bad health record, or a family member with a bad health problem, could be denied insurance through their new employer when they changed jobs, since the new insurance company might not want to accept someone with high health costs.

So far, so good. Then someone decided to tack on "administrative simplification" to the bill, as follows:

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) require the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. Adopting these standards will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care.

Again, nothing really wrong here, either; it makes sense that simplifying the transfer of medical information and encouraging electronic record storage would be a good idea. Medical records, in large part, have not changed since the nineteenth century; notes are still hand written and stored in paper files. Record storage and retrieval is a constant bugaboo for hospitals and physicians. Patient privacy also needs to be considered, and this has taken over most of HIPAA; the most stringent and detailed regulations of the Act deal with this issue.

The problem here is that the regulations, as drawn up, are not a simplification, they are a complication. Medical centers and physicians' offices have had to invest a lot of money and time in training everyone on these procedures. This means residents, attending physicians, ward clerks/secretaries, medical assistants, maybe even janitorial staff. Everyone. The list of things the regulations affect are huge: I can't email my patients, for instance, because we do not have encrypted email. When I finish charts at night, I can't leave them on the counter at my nurses' station any more because the cleaning staff might walk by and see patient information. When I pointed out that the office cleaners would have the same access to charts in my room, I was told that the nurses' station was "public space" as opposed to my "private space"; equally vulnerable physically, but protected legally. You figure it out.

In addition, every patient coming in now has to be given a copy of our medical group's statement of compliance with HIPAA regulations and patient rights, and they have to sign a form stating that they've been given this copy, and if they refuse to sign we have to document that. We're trying to figure out how we can indicate that a patient has already signed off on this so they don't wind up signing multiple times and getting multiple copies (for instance, if we refer the patient to our gastroenterologist in some other office, he/she will be given another form to sign unless we can figure out how to let the office staff know that the patient has already been counseled).

Our administrative risk manager is buzzing around the office now making sure everything is shipshape, so I'd better sign off. If she catches me blogging she might have a heart attack, and I'd like to spare her that.

posted by Dr. Alice at #

 
It's A Zoo Out There is a website written by a doctor named Jen Jen, who works at Changi General Hospital in Singapore and is coping with the SARS epidemic. It's gripping reading. One of her posts begins, "How shall I put this delicately: I AM TERRIFIED." Thanks to Medpundit for the pointer, as well as for a link to this article on a new drug to prevent stroke damage. The drug is called caffeinol and combines coffee and alcohol.

I am not making this up. Go see the link. Wouldn't it be great if we could just hand every stroke patient an Irish coffee?


posted by Dr. Alice at #

 
May I Have This *zap* Dance?

To those of you who surf for medical content, I apologize for the number of non-medical posts... but as I have said before, this is a somewhat eclectic blog. Here's something just barely medically related that I had to post about: it falls more into the "I can't believe all this stuff is on the Web" category. It's a website that sells antique European dance cards. My favorite item for sale is the seventh card down which is rather elaborate and consists mostly of a model of a machine (three-dimensional). Description, and I quote:

No date or Ball name. Manufactured by Marton Alajos, Budapest. Again the "card" would have been located under the metal design. The "machine" was used for shock therapy treatment, so, we assume that this was a favor for a psychiatrist ball. Purchased on Cape Cod. Price:SOLD

Of course it's sold, I bet it was the first one to go. Oh, those crazy, romantic Hungarians! I wonder what they put on dance cards for psychiatrists' balls nowadays... probably models of Prozac or Zyprexa tablets.


posted by Dr. Alice at #

 
Odor Eaters Might Have Helped

Here's a silly Friday post for you:

Dutchman fined for smelly feet

[A] 39-year-old Rotterdam man was fined �70 for repeatedly going into the university library in Delft and taking off his shoes.

He was convicted of trespass because he kept going into the library despite the fact he had been banned for upsetting other users.

posted by Dr. Alice at #

 
All SARS, All the Time

SARS Watch focuses on the spread and investigation of SARS around the globe. Check it out if you're interested.

(via Tim Blair)

posted by Dr. Alice at #

 
Truth In Advertising

Candidate for worst slogan of the year:

"Hong Kong will take your breath away."

Could I just settle for being mildly impressed?

If you want to see the current report (for April 9) on SARS statistics from WHO, go here. Currently 2722 probable cases have been reported worldwide with 106 deaths. Two weeks ago the statistics were 1323 cases worldwide with 49 deaths. SARS continues to spread, but it is not growing exponentially at this point. Hopefully the quarantines and respiratory precautions will limit its reach. Unfortunately, it's too late for Hong Kong to benefit much from this.

posted by Dr. Alice at #

 
Sit! Heel! Pee!

If you ever want a dog to go where it's not supposed to go (unlikely, I admit, but you never know), read this.

"One-Take Nico" sounds like a pretty smart dog - and he's got his own suite at the Sofia Hilton!
posted by Dr. Alice at #

 
"I Sat on Saddam's Throne"

... is an interesting study of the function of the digestive tract during wartime. (Well, no, not really.)

Apparently the stories are true: the loo and fixtures have gold leaf all over them. Check out the picture.
posted by Dr. Alice at #

 
Robert Benchley Said It Best

Our medical center is now deluging the staff with information about preventing SARS outbreaks. By fax and email come documents: "SARS Screening", "Preventing the Spread of Severe Acute Respiratory Syndrome (SARS)".

V. responded to the latter announcement with this emailed suggestion: "Run away! Run away!"

But what I think of most is what Robert Benchley said when he was asked how to avoid catching colds:

"Don't breathe through your nose or mouth."
posted by Dr. Alice at #

 
Film Rant

One of my favorite movies is a French crime film from 1955 called Bob le Flambeur. It's about an aging gangster and compulsive gambler who comes up with a plan to rob a casino with some of his buddies when his gambling losses get too much for him, despite having sworn off committing crimes years before. This film is full of moody black and white photography, with great scenes of Paris at night. Bob is played by an actor named Roger Duchesne, who looks better in a trenchcoat than any man I have ever seen; he has a wonderful world-weary air about him. (I saw Bob le Flambeur in an art-house theater in LA about a year ago, and as my friends and I were exiting the theater I said, "If Duchesne had just stood in his trenchcoat and looked at the audience for two hours it would have been almost as good.")

So this weekend I picked up a copy of Entertainment Weekly and read that an American remake of Bob is being released this week.

Starring Nick Nolte.

Titled The Good Thief. (Why don't they just call it "Generic Title" and have done with it?)

Now let's be fair here. The film has gotten some favorable reviews. Nor am I trying to imply that Nick Nolte can't act. But...

It's just not right. For instance, why did the filmmakers make the Bob character a heroin addict? (Which they did.) The original film makes it clear that Bob has an addiction to gambling, and this addiction both precipitates his involvement in the crime and influences the outcome of the robbery attempt. It drives the plot, in other words. Now unless changing Bob's addiction sends the film in a whole new direction, I don't see the point.

And Nick Nolte, with all due respect, is no Roger Duchesne. I can't see the guy in a trenchcoat.

Oh, I'll probably see it for curiosity's sake. But the French are pissed off enough at us as it is without making films like The Good Thief out of classics like Bob le Flambeur. Chirac will probably never speak to us again.
posted by Dr. Alice at #

 
Photic Sneeze Reflex

Let us speak of an odd little phenomenon that you have probably either observed in others or suffer from yourselves: the photic sneeze reflex. What happens when someone with this reflex steps into bright sunlight from a darkened or indoor environment? They sneeze, usually two or three times, then acclimate to the brighter light and stop sneezing.

I find this interesting because I have the photic sneeze reflex, and I know exactly where I got it from: my dad. This is an autosomal dominant trait, which means that if a sneezer has children, each child has a fifty percent chance of inheriting the reflex. The photic sneeze reflex is most often seen in Caucasians, but it can be seen in other racial groups too.

The cause is felt to be some sort of crossover in nerve feedback between the optic nerves and the trigeminal nerve nucleus in the midbrain, sort of like a short circuit. Many people refer to the reflex as being "allergic to sunlight," and while this is medically incorrect, having experienced it myself I can see why they say this: the intense light makes your nose tickle as if you'd just inhaled a bushel of cat dander.

Have you experienced the photic sneeze reflex? And wouldn't "Photic Sneeze Reflex" be a great name for a rock band? Send me your comments!
posted by Dr. Alice at #

 
Whoa.

President Bush Issues Order Authorizing SARS Quarantine

Lock 'em up.
posted by Dr. Alice at #

 
Call Me Paladin*

Busy, busy, busy today. We had lots of doctors out at various medical conferences... either the ACP national meeting in San Diego or the Pri-Med in Long Beach. That means I'm covering for lots of people and trying to solve all sorts of problems. I got the office manager to distribute some of the phone calls to other docs, but I still had to review dozens of referral requests and...

Why am I burdening you with this??

Anyway. This weekend promises to be a busy one. I am taking hospitalist call tonight, which means I can expect to get pulled from my bed at some point this evening to admit one or more patients, and I'm also doing telephone call for the group Saturday and Sunday. I am doing this, of course, for money. Renovating one's home comes expensive.

When my medical director asked me earlier this week if I'd take telephone call, she quoted me a price and I said, "Done," and then realized that this was just like the bargaining scene in "Pretty Woman." I'm for sale... a medical slut. Or should I rather say, a hired gun?

*Which leads me back to the title of this post... Paladin was the lead character in "Have Gun, Will Travel." At this point I feel my slogan should be "Have stethoscope, will travel."
posted by Dr. Alice at #

 
Give Today to Stop This Illness!

There are many disease syndromes related to workplace exposures or work-related injuries. As I have mentioned in the past, the ICD-9 codebook is a great source for names of these illnesses. A few would be:

Farmers' skin (692.74)
Brickmakers' anemia (126.9)
Wool-sorters' disease (022.1)
Clam diggers' itch (120.3)

But what could surpass the heartbreak of guitar nipple?
(I'm guessing this code would be 611.7. Via Medpundit.)
posted by Dr. Alice at #

 
More From Chuen-Yen

Another delightful email from my internist friend Chuen-Yen, who is working as a volunteer in Malawi for a year: She has apparently become an expert on everything under the sun by virtue of her medical degree...

Hi again!

Every inhabitant of Malawi is a jack-of-all-trades by necessity. So, it�s only logical that, despite my background, I treat psych, ob-gyn, pediatric and minor surgical problems. It�s also plausible that I have become an endocrinologist, cardiologist, nephrologist, etc by default. However, since the advent of �Ask Dr. Lau,� my weekly column in The Daily Times, I have been increasingly obliged to address issues beyond the realm of medicine.

The newspaper advertises, �Dr. Lau, an Internal Medicine Specialist, will answer your questions about health and fitness every Tuesday.� One might, based on this information, speciously anticipate inquiries about common medical concerns. But given that an expert in one field must be a universal authority, I�ve received some amusing queries.

For instance, a hospital visitor recently accosted me with an urgent plumbing matter. After confirming that I was actually "the doctor", she began to unpack a large bag. Several feet of flexible metallic tubing materialized. Then emerged a showerhead at one end of the conduit and a portable electric heating device at the other. A relative had kindly sent this contraption. How she might utilize it? The lady was further confused about the accompanying item � a valve handle. I clarified that these were likely bathroom fixtures. The little thermal box should be connected to a water source, which the spigot would regulate. Delighted with this explanation, she thanked me for being a good physician.

This evening, another character approached me for advice about potato cultivation. Fortunately, I had recently discussed the topic and was able to describe the tubers� water, fertilization and six-week incubation requirements.

Readers are sending a multitude of interesting inquiries: How do you can foods? Where does salt come from? Why do frogs make that dripping noise? What makes a person feel happy? I didn�t learn all this stuff in school. But life is full of lessons that aren�t found in books. Hope you�re enjoying your education.

Any questions?
Chuen-Yen

posted by Dr. Alice at #

 
When the Interpreter Is a Child

The state of California is pondering a bill that would prevent children from interpreting for their parents to doctors or lawyers. You can read more about the bill here.

Children are often inappropriately used as interpreters for their non-English speaking parents in medical, legal or social service settings, said a San Francisco lawmaker who introduced a bill Tuesday to ban that practice.

"I think that all of us who come from an immigrant background have had an experience of having to translate for our parents," said Assemblyman Leland Yee, who immigrated to the United States from China when he was 3.

Asking a child to translate information about medical or legal problems can hurt the parent-child relationship, traumatize the child and can result in a less-than-accurate interpretation of health advice, said Yee, a Democrat.

His bill would ban state agencies and organizations that use state money from using children as translators. Those groups could instead turn to professional or volunteer interpreting services, community groups or ask older family members to translate, Yee said.

Now in theory I think this is a really good idea. Have you ever tried to take a sexual history from a patient using a child (or, indeed, any family member) as an interpreter? It destroys patient privacy. There's also no way to know that the child will be able to understand the terms the doctor is using, even if the problem is couched in layman's language. Unfortunately in a state like California, where there are literally dozens of languages spoken, there is no way to ensure that a non-family member will be available to interpret. We're not just talking about Spanish here - I have patients who speak Russian, Armenian, Hindi, Chinese, Korean, Tagalog... there's no way we can cover all those bases.

But people bring their family as translators because it's convenient and it's free. Often children are the only people available to the patient who are even partially bilingual. And doctors don't have the time or funds to find translators for patients in multiple languages:

Medical providers warned the bill could cause access problems for Medi-Cal patients in rural areas because doctors won't be reimbursed for the expense of hiring an interpreter.

Interpreting services cost about $1 per minute, said Heather Campbell a lobbyist for the California Medical Association. If a doctor has a 15-minute visit with a patient, Medi-Cal pays $22 for reimbursement, she said.

After paying for the interpreter, the doctor would be paid $7 for that patient's visit, Campbell said.

"It will probably stop physicians from taking patients who bring in a child as an interpreter," she said.

We shall see. I definitely think more interpreters should be available as a resource for doctors and patients - it could only improve communication between them - but if the bill passes and does, in fact, restrict access to health care for Medicaid and other patients by discouraging doctors from accepting them, it won't have done any good.

posted by Dr. Alice at #

 
Don't Forget Your Tetanus Shot!

Here's a little moral tale for you. Today I saw a new patient who was complaining of hair loss. When a patient (especially female) presents with thinning hair, something that should always be checked is the thyroid. Her thyroid exam was normal, but as I was evaluating it I noticed a scar at the base of her throat which could only have come from a tracheostomy.

"What happened here?" I queried, touching the scar. "Were you ever put on a breathing machine?"

She'd grinned when I noticed the scar. "Yes," she said with the air of someone who knows they have something to say that will get your full attention. "I had tetanus."

"Did you?" I echoed, stunned. I've never seen a case of tetanus or anyone who'd had it in the past.

"I was eight. It was when we were living in Jamaica."

"Didn't they vaccinate?"

"Well, they did, but when they came to my school I had a fever, so they said they'd give me the shot next year. But I got hurt over the summer, before I could get the shot, and that's when I got it. I was out of school for three years."

"I believe you. That's a really serious illness."

Quick Internet fact: Eleven percent of tetanus cases are fatal. I try to vaccinate all my patients who haven't had a booster in the last ten years. If you don't know when your last tetanus booster was, go get one.
posted by Dr. Alice at #

 
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.

posted by Dr. Alice at #

 
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.
posted by Dr. Alice at #

 
Arrr!

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.
posted by Dr. Alice at #

 
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.)

posted by Dr. Alice at #

 
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!"
posted by Dr. Alice at #

 
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?
posted by Dr. Alice at #

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

(Thanks to Dave Barry for this one.)
posted by Dr. Alice at #

 
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.
posted by Dr. Alice at #

 
"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.
posted by Dr. Alice at #

 
I Only Wish

Steve Martin:

"Aww, that's sweet... Backstage, the Teamsters are helping Michael Moore into the trunk of his limo."
posted by Dr. Alice at #

 
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.
posted by Dr. Alice at #

 
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,
Chuen-Yen
posted by Dr. Alice at #

 
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.
posted by Dr. Alice at #