The yearly physical that isn’t

I realize that most of my readers are below Medicare age, but as goes Medicare, so goes the nation, so pay attention my friends.

Nearly all healthcare plans now include so-called preventative care, including some sort of yearly check-in visit. Medicare’s version of this is the “Annual Wellness Visit”. Most patients think this means they are getting a complete physical, and often they do, but this isn’t going to continue.

Medicare’s Annual Wellness Visit has a very limited set of requirements, including screening for depression and dementia, making a list of all the doctors someone is seeing, and calculating their body mass index. It’s really a brief visit, and doesn’t pay all that well.

Despite this, many of us have been including a more traditional physical. This adds on considerable uncompensated time to the visit. A time will come when AWVs are brief visits done by assistants, and the patient will have to come in for a physical on another day (which will not be covered at 100%, as the AWV is). I suspect many patients won’t like this.

The same may happen with non-Medicare plans. Doctors’ offices may have patients come in for a brief prevention visit with a physicians’ assistant, fill out any health screening forms, and make them come back at another time for a real physical.

It’s all better than being un-insured, but don’t be surprised when your doctor tells you that your yearly physical isn’t your yearly physical.

Pi day thoughts

Kids don’t get pi. Neither do most adults. For we non-mathematicians, it’s disturbing. Numbers are so concrete. You can hold two apples in your hands, but pi apples?

We humans like concrete answers, especially when they conform to our beliefs and worldviews. And this scares me.

Yesterday I was sitting at the cafe and the woman next to me struck up a conversation. Turns out her kid is autistic. “He got that stupid MMR shot, you know.”

Yeah, I do know, but what do I say to the irrational stranger about it? Do her friends also just sort of shut up when she goes off on the “MMR causes autism” thing?

There are plenty of nice people who believe destructive things. We don’t like pi. It doesn’t fit with how we see the world. Yet, it exists. So now what?

Let’s talk about your doctor’s office

Going to the doctor starts as a disconcerting experience: getting naked, physically and emotionally; talking about your weight, your smoking, your divorce. You count on your doctor’s ear and her discretion. Often enough, a patient will apologize for taking my time or for crying or whatever. I remind them that this is what the exam room is for, this is what they pay me for.

How far does this special relationship extend? Primary care doctors can’t bill for time with their patients unless it’s face-to-face. This is one of the reasons your doctor might not want to spend a lot of time on the phone or email with you. It’s also one of the reasons we may require you to come to the office to complete complex forms or change a prescription. These activities require work, and our main work is thought. Without you in my exam room, I’m not sure about that medication change or that disability form. And I can’t ignore the fact that I’m not paid for my time unless you’re in the office with me.

In my opinion, some doctors go too far, requiring monthly visits for simple prescription refills, but there are times when it’s necessary to drag someone in to make sure the drugs are working and not causing harm, or to make sure you are working on your dietary habits and exercise.

Saying ‘no’ to patients isn’t easy; we’re in this job to help. But it’s often the right thing both clinically and economically. This brings up another question, one we don’t often talk to patients about: how should we treat our time when the office is closed? The tradition has been to take patient calls after hours and on weekends, perhaps rotating this time on call between partners.

But there are murmurings out there about this uncompensated time. After all, what can I do for someone on a weekend? It’s not usually wise to diagnose someone over the phone. It’s also not so good to renew prescriptions on the weekend; it’s a poor use of time and for those of us with paper charts, it’s nearly impossible to know what’s appropriate.

For a primary care doctor, the answer to many phone calls is, “Call the office on Monday,” or, “Go to the ER.” 

As a patient I want to be able to reach my doctor on a weekend, but I would understand if he should decide to change his policy.

What say you? How can we maintain communication and deal with the problem of uncompensated care?


Many years ago, someone I loved was in the hospital and whenever I would visit, I would display my badge prominently. She wasn’t inmy hospital; my ID badge opened no doors; it didn’t get me free food in the cafeteria. It was a talisman, something to ward off the evil I would wade through, something that might have some magic—any magic—to help us through this hell.

Some people respond to this helplessness not with magic but with anger. It’s one of those things doctors have to learn to deal with. When families lash out, it’s not about you. Your white coat is the magic that wasn’t, the shield that let through the plague arrows.

Some get bossy—very bossy. They focus on the minutiae, the things that doctors and nurses know aren’t important. The shades aren’t drawn right, the medicine is ten minutes late, the meal tray is all wrong. What about that bandage, doesn’t anyone see it’s bunched up?

We are all at some point powerless in the face of disease, and we reach for what little power we have. We huddle together against the biting wind, cobbling together what shelter we can, and wait for the storm to pass.

Liberals: stop apologizing

If elections results are to be believed, about half of US voters are “conservative”. Why are liberals so apologetic? Why so willing to compromise beliefs?

Submitted as an example, abortion. Conservatives have no problem making it a dichotomous issue of good and evil. They are unapologetically against a woman’s rights over her own body. They continue to act as if humanity comprises two creatures: people, and women.

We liberals, as human beings, find this abhorrent, but we have diverse views. This diversity can sometimes lead to a willingness to compromise amongst ourselves, but that willingness sometimes bleeds into our interactions with conservatives.

“Abortion should be legal, safe, and rare,” is a common rallying cry on the left, and a stupid one. If you truly believe in a woman’s physical automony, then abortion should be “legal, safe, and none of my damned business.”

This wishy-washy bullshit opens us up to the bullying of the right. Many liberals may believe the “rare” part, but many of us see that as a related but separate reproductive rights issue. Access to contraception, something the right also abhors, does not guarantee fewer abortions; it is another layer of autonomy for women, one that shouldn’t have to be “added”.

If we really believe in human rights, in the right to work with dignity, equality of all people, freedom from hunger, access to healthcare—if we are to call these “rights”—then we cannot be apologetic. The Right succeeds with their base by being uncompromising in their defense of inequality and prejudice. We need to be equally unapologetic, unwilling to compromise on human rights.

Patients aren’t perfect and neither am I

I get it. I really do. If a patient won’t trust you on the most fundamental of medical facts, how can you be an effective doctor to them? An article circulating on social media argues this effectively–to a point.

If I were a pediatrician, I would be wary of allowing unvaccinated patients into my office. They may bring diseases into my office and infect kids who can’t get vaccinated for medical reasons. They may be more likely to catch diseases in my office. But that’s not what was argued. The argument was one of trust. How can I care for someone who doesn’t believe the most important things I tell them?

My answer to this “grow the fuck up.” People are imperfect and irrational. That’s how we’re built. The patient who believes they can can cure diabetes with cinnamon rolls may also take your advice to go on a statin for heart attack prevention. They may agree to medicine for blood pressure even though you think exercise and diet changes would be better.

Caring for other people is not about fulfilling your own needs but those of your patients and of public health. I do everything I can to persuade patients to take my advice, including getting recommended vaccines. I am blunt about the consequences of their decisions. But after that it’s up to them. Paternalism is a useful tool, but a useless rule. A good doctor must collaborate with patients and should only give up on their care if there is a real breakdown in the relationship.

If you choose only to treat rational people, your waiting room is going to be pretty quiet.

Online mishegos

So, my friends, flu is striking down the young, Obamacare has rendered a local medical charity obsolete, and I’ve become a lazy blogger unwilling to bother with hyperlinks (to be fair, I’m rarely at my computer and it’s all a pain in the ass on my iPad since I can’t open multiple windows).

I’m comforted by the fact that people are still people. They don’t want flu shots because they don’t want “to take a chance”, meaning they perceive the shot to be riskier than the flu. Bad reasoning, but the media isn’t helping us out much. People make decisions based on how they feel, and we have to help them to feel terrified of flu. A nurse was in tears the other day relating to me another flu death at the hospital. She feels it.

I’ll miss giving free care to the uninsured, but not really. One of the things our medical charity did was give patients cards that resembled insurance cards. This helped preserved their dignity, as will gaining actual insurance. Not only will my patients feel more financially secure, they’ll feel less humiliated. It’s a win-win, really. If you’re one of the people whose premiums went up, sorry. Your former plan was probably shitty, and you were paying that money in other ways as we treat the uninsured in hospitals and spread the cost around.

Meanwhile in illogical douche-baggery, Nature editor Henry Gee, over in Crummy-by-the Sea or something outed a blogger who had preferred her identity remain a bit more mysterious. At ScienceOnline and in many blogs and newspapers, writers have explained over and over why women might choose to remain anonymous or pseudonymous online. If, however, you suffer from the incredulity of privilege, it’s hard to understand what those girls are whining about. How can they sit there behind their Mighty Shield of Anonymity and hurl invectives? How is that fair?

Well, Microphallerati, this requires something called empathy and a bit of lack of whinery. When you choose to say things publicly from a position of privilege, people are going to call you out on it. Tough crumpets. Suck it up. Don’t blame a scientist halfway ’round the globe for your psychological problems. If engagement upsets your constitution, don’t do it. Leave the internets to those of us who are interested in communication, self-reflection, and change. Oh, and helping those who don’t stand on the lighthouse of privilege.

Cheerio, and get your damned flu shot.

Be proud, America.

I see uninsured patients through a community program as do other local doctors. Today I received a letter letting me know that as of May, my services will no longer be required.

The charity didn’t run out of money or doctors; they ran out of patients. Since the beginning of the year they began helping patients sign up for insurance plans through the Obamacare exchange and through the law’s expanded Medicaid access. They anticipate closing their doors by May freeing up resources for other uses.

Thank you, America. You got something right.

Obamacare: working hard to make it fail

I really wanted to put “clusterfuck” in the title, but a devil on my shoulder objected. Still, it is as clusterfuck. The launch of Obamacare has been hobbled by many impediments. First, the GOP has done everything they can to make it fail. They convinced states not to have their own exchanges, which, it turns out, is really, really stupid. I didn’t help that the most visible part of the rollout——was a disaster. A webportal is small potatoes, normally, but since this is the public face of the law, it feeds into the over-the-top anti-Obamacare rhetoric.

The insurance companies, who have been granted a gift by this insurance-reform law (it is not healthcare reform) seem to be doing all they can to suck advantage off the bone they’ve been thrown. My patients are getting letters warning them of the cancellation of their soon-to-be non-compliant plans and are being offered new plans at higher prices. These letters do not inform them that they may very well find a better deal by signing up at And the states that turned down local control of their exchanges received very little money to get out the word. The states smart enough to start their own exchanges have been given a lot more flexibility (i.e., money).

Any large-scale insurance reform is going to be a bit kludgey on launch, but with the landmines, tank traps and grenades tossed in the way, everyone here is going to get hurt.

Docs: don’t torture

Many Americans, especially minorities, are no strangers to arbitrary and capricious police behavior and abuse. But a case reported yesterday by Lowering the Bar had an extra horrid dimension: the willing participation of doctors in abusing a man in police custody.

There have always been doctors willing to collaborate with authorities in doing a great deal of harm, and not just in Nazi Germany. A report released this week details medical collaboration with torture in the US “War on Terror”.  There are still doctors who participate in executions in the US.

You would think these situations are no-brainers. If you are a doctor and a legal authority asks you to torture someone, say no, right? But humans are complex and can reason themselves into all sorts of horrible behavior. According to the complaint, police in Deming, NM picked up David Eckert and took him to the hospital in order to have him tortured (that wording is mine).  The first hospital they stopped at refused to cooperate, but the cops struck gold at Gila Regional Medical Center.

The doctors there reportedly subjected Eckert to multiple radiologic procedures, multiple rectal exams, and multiple enemas. And then a colonoscopy. Because the cops wanted it. And then they billed Eckert for their services.

While any rational human being would find this abhorrent, lets rehash the details:

1. Eckert’s abdominal area was x-rayed; no narcotics were found.

2. Doctors then performed an exam of Eckert’s anus with their fingers; no narcotics were found.

3. Doctors performed a second exam of Eckert’s anus with their fingers; no narcotics were found.

4. Doctors penetrated Eckert’s anus to insert an enema.  Eckert was forced to defecate in front of doctors and police officers.  Eckert watched as doctors searched his stool.  No narcotics were found.

5. Doctors penetrated Eckert’s anus to insert an enema a second time.  Eckert was forced to defecate in front of doctors and police officers.  Eckert watched as doctors searched his stool.  No narcotics were found.

6. Doctors penetrated Eckert’s anus to insert an enema a third time.  Eckert was forced to defecate in front of doctors and police officers.  Eckert watched as doctors searched his stool.  No narcotics were found.

7. Doctors then x-rayed Eckert again; no narcotics were found.

8. Doctors prepared Eckert for surgery, sedated him, and then performed a colonoscopy where a scope with a camera was inserted into Eckert’s anus, rectum, colon, and large intestines.  No narcotics were found.

There is no excuse for this behavior. There is no way to twist medical ethics to allow doctors to physically and emotionally assault a patient. There is no authority that can or should compel a doctor to do this.

It’s really quite simple: if, as a doctor, a police officer orders you to sodomize a patient, you say “no”. Doctors should never aid authorities, military or law enforcement, in torturing, killing, or maiming. No excuses.

Given the limp history of state medical boards, I presume the doctors involved won’t face official sanctions, but perhaps the legal system that allowed Eckert’s torture (there was a warrant, sort of) will help bring some measure of justice.

Addendum:  the local news outlet is reporting another case nearly identical to this one, with the same medical center serving as the cops’ personal torture service.


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