Who cares about your health?

I love that patients have so many more tools to learn about their health. Between Google, TV, magazines and the thousand=word warning that comes with every prescription, it’s almost like you don’t need a doctor. This is especially true if you do the two most important things for your health: eat less and exercise more.

Except it’s not really that simple. There’s a reason it takes at least seven years to churn out a primary care doctor. There’s a reason your eyes glaze over when you ask me how a pill works and I launch into pathophysiology and pharmacology. I mean, I love this shit. I think about medicine all day and all night, and I’ve been thinking about it for about twenty years. When I see an interesting blurb in the news I hunt down the source to see if there is a new paper, a poster presentation, or maybe just a press release from a drug company. While you are stopping your life-saving medicine because your friend’s friend posted something on your facebook feed, I’m stopping by the hospital, reading up on new developments that will help my patients, and checking on lab results.

Google doesn’t care about your health. Some guy on facebook doesn’t care about what’s important to you. Dr. Oz doesn’t care if your depression is the reason you haven’t been taking your insulin. ¬†If you are worried about something you read about a disease or a medicine, why do you automatically believe “some guy”? I’ve been doing this for a long, long time (and I’ll be paying off those loans for a long, long time). Come see me sometime.


Another day at the clinic

Scene: Medical office, 9 a.m., waiting room full, chairs in hall full

Players: 2 nurses, 1 clerk, 2 doctors, lots of patients

Doc 1: “Hey, what’s up? I’m sitting on my ass here and there’s a room full of patients waiting.”

Nurse 1: “Hold on Doc, I’m almost done checking one in.”

“So, Mrs. Smith, do you feel safe in your own home?”

Patient 1: “It’s Sister Jan, actually. My convent is quite safe.”

Nurse 1: “And when was your last sexual encounter?”

Patient 1:” ??”

Doc 1 to Doc 2: “Oy. Why don’t you check up front, see what’s up?”

Clerk to patient: “I need to ask you a series of questions as part of our mandated check-in process. Is that OK?”

Patient 2: nods

Clerk: “I’m sorry, your answer has to be verbalized. Would you like me to repeat the question.”

Patient 2: “No, thanks.”

Clerk: “So you don’t agree to answer the questions?”

Patient 2: “No, I mean yes, of course I will. I was saying no about repeating the question.”

Clerk: “OK, that’s fine. First, are you here today as a result of an auto accident, an injury sustained at work or in the armed forces?”

Patient 2: “I’m not here for an injury. I’m here for my blood pressure.”

Clerk: “Sir, please don’t talk about your privileged health information in the lobby like this. I could get in big trouble. Can you just answer the questions yes or no?”

Patient 2: “Yes”

Clerk: “So you are here because of an injury sustained in one of the mentioned contexts?”

Patient 2: “No! I mean I’ll answer yes and no!”

Clerk: “OK, are you a dialysis patient?”

Patient 2: “No.”

Clerk: “Have you travelled outside the continental United States in the last 90 days?”

Patient 2: “Yes.”

Clerk, donning a mask: “Where did you travel?”

Patient 2: “Windsor, Ontario. I love the duty-free shop. Just a hop over the bridge and back!”

Clerk: “The government requires I ask you about your race. Can you tell me whether you are caucasian, African American, Hispanic, Native-Pacific Islander, Declines to Answer, or Other?”

Patient 2: “I’ll take ‘Declines to Answer’.

Clerk: “Now I have to ask about your ethnicity…”

Patient 2: “Wait, we just did that. I declined.”

Clerk: “That was for race, Sir. This is “ethnicity”.

Patient 1: “I’ll make it quick for you. I decline to answer.”

Clerk: “What is your shoe size?”

Patient 2: “Uh, 12”

Clerk: “Good, we’re getting there. As soon as we finish you can see the nurse.”

Patient 2: “What about my doctor appointment? It started a half-hour ago.”

Clerk: “The doctor cannot see you until the nurse evaluates you. Just a few more questions now. Do you eat meat?”

Patient 2: “Yes.”

Clerk: “Beef, chicken, fish, goat, or other?”

Patient 2: “Uh, any I guess.”

Clerk: “Please be specific.”

Patient 2: “I’ve eaten them all at one time or another. Except goat.”

Clerk: “Is there something special about goat that keeps you from eating it?”

Patient 2:”What do you mean?”

Clerk: “Is the reason you refuse to eat goat one or more of the following: I don’t like the flavor; I never got around to it; It’s against my religion; I believe goats are strictly for sexual satisfaction.”

Patient 2: “It doesn’t say that!”

Clerk, turning the screen around: “Yes, it does, see? Please just answer.”

Patient 2: “I’ll take the one that said never got around to it. That’s the last one?”

Clerk: Ok, the last one, “I believe goats are strictly for sexual satisfaction.”

Patient 2: “No! I never got around to it!”

Clerk: “Whether you’ve acted on your urges isn’t my business. I only enter your responses.”

Patient 2: “No, I meant that I never got around to eating goat. I don’t believe in goat sex.”

Clerk: “You should have been clearer. I’ve already exited that screen and you cannot change your answer.”

Doc 1 to Doc 2: “I don’t think we’re ever getting out of here.”


On the radio this evening they were arguing about the murders of the three Muslim students down in North Carolina, or rather how to refer to the crime. Was it terrorism? Or simple good old American gun violence over nothing at all?

If we judge by how other Muslim Americans report feeling, it was an act of terror. It made many Americans feel less safe. If we judge it by the scale of the atrocity and it’s likely long-term affects on Muslim Americans, I’m not so sure.

In the time that the three kids were murdered in NC, thousands in the Mideast were murdered, many in the name of religion and terror. In France the prisons continued to be populated 50% by Arabs/North Africans. In the U.S., black women were raped, black men were assaulted by representatives of government, and prisons continued to fill up with young African Americans.

Terrorism isn’t a simple thing. When Timothy McVeigh blew up the Federal Building in OK, most Americans were able to shrug it off as some crazy white dude. On 9/11, we all felt less safe, and allowed our government to make us so by engaging in domestic spying and unjustified foreign wars. I’ve spoken to Chaldeans whose families in Iraq are under threat by ISIS and are living in terror.

Terrorism is subjective. There are the individual acts, and the direct effects on the victims. There is the wider effect. And there are the imbalances of power.

What the discussion allows us to do is to identify systemic problems. Muslims are often demonized in the US. This leads to small-scale acts of terror, and to larger ones, some that we call wars. And these distract us from one of our biggest acts of societal terror: the continued subjugation of African Americans through our school-to-prison pipeline, our ghettoization of education, the Jim Crow job ceiling (which is not a “southern thing.”)

I’m no expert in race. I’m obviously not black, nor a scholar. But if we wish to make sense of the murder of the Muslim students in the south it makes sense to evaluate or domestic and foreign policy that is springs from. The only steps we’ve made toward our domestic terrorism is to ignore it. The only steps we’ve taken to avoid wars in the Mideast…well, we haven’t. We have a really big hammer, and everything from the Med to the Indus is a nail.

If we really want to make sense of terrorism, let’s clean house a little. That will only make us stronger to deal with very real external threats.


She arrived by ambulance in the middle of the night, awake, alert, and bleeding like crazy. We’d gotten a call earlier in the evening that she was on her way from a small hospital about forty miles to the north. We were the big city hospital, and an attending physician had agreed to have her transferred for a life-saving procedure, in this case a shunt that might stop her bleeding.

People who bleed from their GI tract can fool you. One minute they’re sitting up and talking, the next they are unconscious and in shock. This one didn’t fool anyone. When I spoke to the transferring hospital, they told me that they’d already given her eight units of blood, and another was hanging in the ambulance. I suggested they take her back in immediately, but the ambulance was already on the freeway.

When it comes to active bleeding, you can give all the blood in the world, but without stopping the bleeding, the patient will die. From the vague report we received, she had cirrhosis of the liver and was bleeding from a broken vein in her esophagus. Supposedly, she was coming her to get a shunt that would stop the bleeding.

No one knew anything about her. She was in late-middle age and was soon unable to tell us much more. The attending physician who accepted the transfer had never met her and knew little more. Still we were able to get a radiology team in to evaluate her for a shunt.

There were two of us on call in the ICU, one making all the phone calls, the other helping the patient. She didn’t look all that bad, didn’t have all the signs we usually see in a long-term liver patient. But she was definitely still bleeding. Blood coming from the rectum has a particular smell that stays with you forever.

While we waited for our experts to respond, we “resuscitated” her which in this case meant placing large IV lines and pumping her full of blood and saline. We stabilized her enough to get her to radiology, but they told us that the procedure wasn’t going to help. Someone mentioned a weighted balloon down her throat but I can’t remember what happened to that idea.

What I do remember is a woman, lying in bed, in a place she’d never been, surrounded by strangers and the scent of blood, waiting to die. I stuck a needle into a vein in her arm to collect some blood, but it looked like cranberry juice, not thick, red, life-sustaining blood. At this point she was unconscious.

All of us in the ICU struggled to keep her alive, but watched as blood continued to flow into a vein and out her bottom. We all knew what would happen, each nurse, the doctors. We saw she was losing her life in front of us, her consciousness occasionally making a brief appearance before diving back into oblivion. When her heart stopped there was no need for CPR; our chest compressions were only circulating thin, pink fluid through her arteries and veins, carrying no oxygen, no life.

We watched her bleed to death before the sun rose.

Practice good medicine, the rest will follow

Last week I got an incentive check from an insurance company. That’s how things are moving in health care. Patient out of pocket costs are going up, and doctors are getting reimbursed via incentives that no one seems to understand.

Some companies want special forms filled out, some want us to meet certain arbitrary-seeming benchmarks, and for the life of me, I have no idea how to even figure out all these different programs.

One company now lists me as “meeting quality standards” but not meeting “cost-effectiveness standards”. I requested the data on that one: I’m at the peak of the bell curve. Apparently I need a few more SDs to the left to make it. These results are posted on their website and sent to members.

My best doctor-patient relationships do not develop from an insurance website but from personal recommendations. Yes, patients are paying more of their health care costs, but the decisions whether to spend money happen in the exam room. If I think the patient needs a test, I recommend it. If they feel they cannot afford it, we discuss it some more and come up with a reasonable plan.

I’m not sure I care about what the insurance company thinks, but that’s probably naive.

My incentive check mentioned at the top was for $5.92. I’m going to go with a strange philosophy: practice quality medicine based on the latest evidence to the best of my abilities. Hopefully the rest will fall into place.

I might not be cost-effective when I suspect a cancer and get all the diagnostic studies done at once, but it’s better for the patient, so I’m going with it.

Surprises and space

Somehow winter surprises us every year. Yesterday’s white out on the way home wasn’t unprecedented, but it was all anyone was talking about today. At least for small talk. In the exam room, give someone some space to speak, some silence, and they’ll talk about more than the weather.

As the father of the world’s most wonderful ten year-old, I wonder what every parent does: how to protect her from harm, disappointment, sadness, grief. Of course it can’t be done, and shouldn’t be, and it’s probably selfish to try. I know she will experience sadness and it will become part of the her larger self, but I can’t stand to see her hurting. Nothing is worse than watching a child who can’t be comforted because you just cannot make some things right.

Maybe that’s part of the problem in the exam room. In some ways, it’s easy to take on a parental, or at least protective, role. Many doctors share the illusion–delusion?–that we share with parents, that we can make it all better.

Neither parents nor doctors can make alright all of the time. But we can give our children comfort and space to be sad. We can give our patients space to grieve with someone they feel is somewhat insulated from their pain.

If hospital patients were treated like office patients

Scene: Coronary Care Unit at Midwestern Hospital

First year resident picking up phone to call attending cardiologist after evaluating a new admission: “Dr. Heart, this is Dr. Doshi at MH CCU. I’m seeing Mr. Rubinstein who came in with chest pain.”

Dr. Heart: “Well, what did the EKG show? Are his enzymes elevated?”

R1: “I can’t tell you that.”

Dr. Heart, about to tear R1 a new one: “Why are you calling me before you have the relevant information, Doctor?”

R1: “Well, the ER wanted to get an EKG but Blue Globe Insurance doesn’t allow for ER doctors to order cardiac procedures. That’s why they transferred him to the unit.”

Dr. Heart: “For tonight, you’re the cardiologist. What does the EKG show?”

R1: “Well, that’s the thing. BGI only allows for a board-certified cardiologist to order an EKG. In person.”

Dr. Heart, about to lose his shit: “Well, let’s start with the basics then. Tell me his history and his physical exam findings.”

R1: “His chief complaint is ‘I feel like an elephant is sitting on my chest’. I can’t gather more information without a prior authorization.”

Dr. Heart, humoring the young doctor: “And I suppose you’ve gotten that authorization then?”

R1, starting to sweat, and speaking as if reading from a script: “A prior authorization can only be obtained from the member’s primary care physician.”

Dr. Heart: “And I suppose you’ve called this person?”

R1, sounding a bit embarrassed: “Yes. But…she said that she cannot apply for a prior auth tonight because it can only be done by computer from a verified HIPPA-compliant terminal between the hours of 6 am and 7 am…Guam Standard time. Which she said is impossible because that was yesterday, or it’s next week, or something. And besides, if she requests an authorization she’ll lose her incentive payment without which she will not be able to afford computers, and without computers she can’t request prior auths.”

Dr. Heart, sarcastically: “Can you at least tell me it Mr. Rubenstein yet lives?”

Uncomfortable silence lasting several seconds.

R1: “Um, no. He’s been discharged. Care management said that he didn’t meet inpatient criteria.”

Heart: “And why is that?”

R1: “There was no history and physical or EKG findings on the chart to justify admission.”

Heart: “Then why are you calling me?”

R1: “The Quality Committee is reviewing your actions in this case and they are meeting tomorrow to decide whether to revoke your privileges. Oh, and shiva will be at the Rubenstein home starting tomorrow night.”

I stand with Israel

I’ve never wanted to write about the Israeli-Palestinian conflict. It’s easy to come off sounding like a brainless partisan or a Friedmanesque utopian. And no matter what you write, someone is going to hate you. But the current conflict is making me crawl out of my little comfy North American hole.

The conflict itself is a painful, violent remnant of European colonialism, fed by hatred of Jews, apathy about Arabs, ignorance of complexity, and continued geopolitical gaming. It’s senseless to argue about which land “originally” belonged to whom—the entire region has been a battle ground since Biblical times. What matters most is the current reality on the ground.

The current reality: The region that makes up Israel and the¬†putative Palestinian state will eventually become two independent states, one majority Arab, one majority Jewish. Utopian visions of a single state are also a colonial pipe dream as can be seen with nearly every other state in the Mideast. When this will happen though is anyone’s guess, as the parties continue to play out their zero-sum game of futile militarism.

To “take sides” in this conflict as is shown in the media is also a fool’s errand. The people of both states have an absolute right to live safely and govern themselves. But they are in each others’ way and the world has made a decision: Israel, the stronger state-entity is the bad guy.

This is true. And it’s not. Israel has done some horrible things. That’s not surprising given that it is in a perpetual state of war, surrounded by countries that wish it dead and by non-state actors doing the actual killing. No one “wins” wars. It’s always the so-called non-combatants who suffer the most. But to paint this as a simple “Big Bad Israel” against the poor Palestinian refugees is incorrect at best, anti-Semitic at worst.

The classic “tu quoque” fallacy—“I know I did, but you did it too!”—is easy to fall into here, but there is truth to the complaint that while Israel has killed civilians in defending its citizens, its neighbors are slaughtering their each other in numbers unimaginable in Israel and Palestine. It is good and proper to hold nations accountable for their actions, but why this special focus on Israel’s misdeeds?

The origins of the State of Israel lie in Europe. While there has always been a Jewish presence in Israel, the greatest number of Jews until the mid-20th century lived in Europe. Mostly-secular Jewish intellectuals saw that Europe, with its endless pogroms and laws limiting Jews’ freedoms would not be a permanent home for the Jewish people, no matter how much they might wish it. They came up with a plan to form a state where all Jews would be welcome, and would survive by their own hands, live by their strengths, and fail by their own faults. The dissolution of colonialism along with the Holocaust gave birth to the Jewish state, and several kinds of hatred and prejudice gave rise to what will become a Palestinian state. Many Arabs were forced out of Israel during the War of Independence, many more fled, and those that did flee did not find welcoming homes in other Arab countries. Jews however continued to find relative safety in Israel, a safety they fought for daily.

In many ways the greatest tragedy of the conflict is the de facto partition that tore Jewish and Arab neighbors apart, and that exiled Jews from Arab lands, forcing them into the new Jewish state and creating more hostility between Jew and Arab.

But that’s history. The now is not so different for the people of the region. Violence flares often. The killing in Israel and the Territories, the limits on freedom, the daily humiliations are not nearly of the scale in Syria, Iraq, Iran, and Egypt. But the killing is real. And so is the hate that drives the world to focus on Israel’s culpability. Israel and the Territories fill a small bit of geography, and it’s a bad neighborhood. Distances are small. Hamas, a terrorist organization dedicated to preventing a two-state solution can easily attack Israeli civilians, keeping Israelis scared and alert. And wakening their military might. Hamas is also embedded in a very crowded strip of land, one that makes any fighting deadly to non-combatants. The problem here isn’t that Israel is killing civilians in its fight for survival but that there is fighting at all.

The only way to stop the violence in Israel/Palestine is to continue good-faith negotiations, but this is difficult when Israelis build settlements in traditionally-Palestinian lands and when those who claim to represent the Palestinians dedicate themselves to murder. And it’s not just terrorism used as a negotiating tool. Hamas’ goal is the complete annihilation of Israel and its Jews. This is why there is an “asymmetric” war, why Israel must maintain a powerful military, why Israel’s right manages to garner so many votes. Jews don’t want to lose their country, and they don’t want to be murdered.

And the pro-Palestinian demonstrations cropping up around Europe and the US, and the BDS movement, reveal the real feelings of the rest of the world. The greater world isn’t out to “save” the Palestinians but to destroy the Jews. To non-Jews this inevitably sounds paranoid, but we have a little bit of experience here. And look at the demonstrations around the world–they are not pro-Palestinian, not anti-Israeli, but anti-Jewish.

If the world is serious about helping bring peace they will give up their hypocrisy and recognize that as horrible as the situation is, the violence is minimal compared to the rest of the region. The violence in the Mideast is not a “Jew thing”. It is regional. It is horrible. It may be unforgivable. But it is not Jewish. There is a war, a war in which one side is divided as to how to live in peace with its impoverished neighbors living in unjust conditions. The other side simply wants to kill all the Jews. And it has found easy allies throughout Europe and the Mideast.

Israel has no real friends. The Jews never have. America is the closest thing, but politics are fickle. Europe made its feelings clear for centuries. Terrorists with a stated purpose to kill ALL the Jews are lobbing rockets at Israeli civilians. Any Israeli government that did not respond militarily would rightly fall. What else is Israel to do? If they were to suddenly lay down arms and recognize the pre-67 borders, recognize a Palestinian state, and pull out of the West Bank, what would happen? Would they suddenly have a valuable trading partner across the border? Would the two states suddenly become the economic powerhouse they could be together?

Clearly not. Palestinian politicians aren’t ready to keep peace with Israel, no matter the conditions. They probably couldn’t if they wanted to as one radical army or another would move in and set up bases to attack Israel. And as long as Israelis feel this threat, and see that they have no one in the world who will say, “Israel has the right to live in peace,” it will be politically impossible, and perhaps literal suicide to treat with the other side.

Those who are not intimately tied to this conflict, who are not Palestinian, Jewish, or Israeli, can have opinions but they cannot understand what we feel. Palestinians and Jews legitimately feel we are fighting for our survival, our very right to live. To judge us harshly is to participate in the colonialism that got us into this mess in the first place.

Want to help? Then help support Palestinians who aren’t anti-Israel. Support Israeli organizations that are pro-Peace. But don’t tell us to lay down our arms just because of ridiculous concepts of “asymmetry” or what have you. In war, people die, usually innocents. The way to prevent it is to support peace, not to demonize one side or the other.


On this day, a great battle

Once again, I ready for battle with an implacable foe. I prepare for the latest foray as best I can: cotton armor, leather gloves, boots of Spanish leather. My weapons are sharp though I know this will be a close quarters fight, main a main.

I approach the champs du bataille warily, my step slow. Had I a true squire, he would wipe the sweat from my brow; instead, i must be content to blink it away. I cannot raise my hand because the Foe is most unforgiving. His wounds seem light but the misery does come, if days after the encounter.

At the last moment I’ve brought my fickle friend Mont-de-Santo. He has failed me so many times, but he is the only one mad enough to join this folie a deux.

I pick my way through the hedge, my weapon lowered at first. And then I see the advance line: trefoil, edged by rubor of spite. And this is a warning, a shaking of spears, for its poisoned edge is a harbinger of erythematous misery.

I can delay no longer. I begin to hack my way through his ranks, but he seems unfazed. He bobs up and down, perhaps thinking me risible. He isn’t wrong. I look down, his line unfazed by my attack, no breach to sally through. I check my leather and cloth and bend down to do the work of a true knight. I grasp the enemy one or two at a time, by the neck, and pull, hoping to unseat him.

Have I found a weakness? Why does he seem to give way so easily? Oh! Woe! He has struck! I have unseated him, yes, but his hind has flown forward striking my wrist below the gauntlet. I should retire from the field and tend to this as I know it will inflame at a later time, but the heat of battle is upon me. I tear at him, no longer careful of his strikes but amok with rage. For each I unseat, more take their place to unleash their insidious poisons (not poissons for that is a different story altogether).

Finally, nearly surrounded, I retire and find my sometimes-friend Monte-de-Santo at the edge of the champs with that same look he always has, the one that says, “you may not want to but you will always return for my help and in return I will ask you for a favor.”

And it is done. The outcome unsure. Monte-de-Santo has returned to his place up high, my edged steel has been sheathed, my armor soaked in sweat. I strip it off carefully, not knowing where the Foe may have struck.

“A bathrobe?? Are you naked? In the laundry room? What the hell is wrong with you? You know the poison ivy is just going to grow back!”

Ah, a maid who cares more for my welfare than her gardens. I may just live to fight another day.


Every fall I bring flu shots home for my family. My wife has a hard time getting to the doctor, and my child uses wild, sadistic gestures to explain how it’s done at the pediatrician’s office. She reminds me every day to bring home the shots, and when I have it, she dutifully drops trou and takes her mediicne. My wife not so much—she requires a bit more wrangling.

Still, it has served us well. I haven’t had the flu in recent memory despite multiple exposures and the Pal Family has steered clear as well. But as of last week, I’m the captain of a plague ship.

MrsPal started coughing last week, then wheezing. Later my phone rang and she told me that her body was aching and she had a fever of 102. It was obviously flu, but I still had her come to the office for a test. Influenza b. Yuck.

So we sent PalKid to a friend’s house for the weekend to keep her away from the bug. This morning at 4am she came into the guest room (where I was isolating myself) to say, “Daddy, I’m shivering worse than when I get out of Lake Michigan.” Shit.

No reason to keep mother and child apart any longer, so I plopped her in bed with mom, hopped in the shower, and skedadled.

PalKid likely has influenza b as well. This year there were two basic flu vaccine formulations: a trivalent and a quadrivalent. Both vaccines contain two types of “a” and one of “b”. The quadrivalent has an additional “b” strain.

The CDC didn’t recommend one over the other. Both matched the circulating flu strains well. So there are couple of reasonable hypotheses as to why my family is down for the count.

1) The flu vaccine covered their strain but it didn’t work well enough
2) They both got the “b” strain not covered by their shots
3) The vaccine covered the strain but has worn off

All of these are plausible and it doesn’t matter too much at this point. Next year’s shots are likely going to be identical to this year’s, but next time, I’m bringing home the quadrivalent.

Meanwhile, PalKid is eating ice cream and watching Minecraft videos. She may end up liking the flu a bit too much.

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