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—healthcare.gov—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 healthcare.gov. 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.

Prevention: you keep using that word…

Preventing disease relies on an important principle: you have to do it before you get sick.  I bring this up because of the most common reason I hear for skipping the flu shot: “I’ve never had the flu before.”

Look, I don’t get in a lot of car accidents. In fact, I’ve never been in a bad one, but I still wear a seat belt.  You know those commercials for investment plans? You know how they always say, “past performance does not guarantee future results?”

It’s the same with health.  While your current state of health can certainly influence what happens in the future, many problems are relatively independent variables. Most people are susceptible to the flu, and not getting the flu is simply luck. It does not help predict whether you will get the flu in the future.

And just to remind everyone, the flu is not a benign little cold. It is a potentially fatal disease that, at its best, leaves you stuck at home miserable for a couple of weeks with fevers, cough, and horrible muscle aches.

Another common flu question regards the several different available vaccines. This year in addition to the usual trivalent vaccine there is a quadrivalent (it has an extra flu B strain covered) and an “old folks” high dose vaccine.  There is no preferential recommendation for any of these vaccines. None are known to be more or less effective, or at least not enough to recommend one over the other.  The most important thing is to get your flu shot soon. Which shot is less important.

If you don’t get the vaccine this year, I’ll pass on the bit of wisdom I give to my patients: good luck.

My continuing effort to avoid death

In my continuing effort to not die of a preventable disease, I’ve been running pretty regularly. Last winter was a bit of a disaster. The neighborhood I was living in wasn’t good for running, and the trail was covered in ridges of ice. That was my excuse.

This spring I felt like I was made of lead. Finally, I realized I should follow the advice I’d been given and try some intervals. I started with one minute each of walking and running and barely made it a mile. But it got better (except for one time when I tried to run after drinks with a friend. Bad idea.).

I ended up sticking with a 2:1 minute interval for a while, and watched my speed and endurance creep up. Up north I started running with a couple of friends. Normally I like to run alone, but I’ve found that when I take my regular Saturday run with friends, it goes quickly and easily. Yesterday I accidentally ran 3 1/2 miles (which for me is a lot. I’m quite happy with two.).

I don’t recommend running for everyone. Yesterday I ended up icing my shins for an hour. But no matter how crappy exercise feels when you first start out, it gets better (assuming no horrible medical problems). A walk to the mailbox and back counts. Do that enough times and you may graduate to half a block. It’s all good

I’ll see you on the trail.

Specialists gotta get it right

I am not a gatekeeper. As an internist I’m expected to know a lot about everything, and I try. Part of that knowledge is knowing when a patient needs a specialist. Most people don’t like thinking their disease is so bad that their doctor can’t handle it, so I really count on specialists to care for my patients well. Following are the pet peeves, or really, the basic things specialists need to do to be real physicians worthy of the respect of their colleagues and patients.

First hint: neither of us looks good when the patient doesn’t know what’s going on. Let me explain how this is supposed to work. I send you a patient with a problem. You may or may not have all the information you need, but it’s OK because you’re a doctor and you’ve at least seen this in a movie or something. You have to take a history from the patient, examine them and form an assessment. After that, you need to communicate your ideas to the patient in a way they understand and write me a damned letter, or at least give me a call.

When the patient asks what I think about your opinion and I tell them I don’t have anything from you, it’s not me who looks bad, and it’s not you or me who suffers. And no matter how good you think you are, I’m not likely to ask your opinion again, since you didn’t bother giving it to me.

While we’re on it, don’t refer the patient to a new internist as part of their pre- or post-operative care. I’ve known them for a long time and they trust me, and now I was foolish enough to trust you. If I send you a patient, and they don’t ask for a new doctor, have the courtesy to me and the patient to keep me on board.

If I send a patient to you for an opinion it’s because I’m not sure what to do. Don’t call me back yelling about how I should have told you more. I’ve told you all I know. And don’t ask to see an imaging study rather than a patient. No patient is summarized by an MRI. I want your opinion on a patient, not a film. I already have a radiologist.

Finally, I know we all hate EMRs: you don’t have to tell me, I get it. But don’t give me a note that is either so full of incorrect and irrelevant filler as to be useless (“tobacco cessation advice given”. Really? She never smoked in her 82 years.). And don’t give me one so short that it’s great for billing and useless for anything else (“Exam: blah, blah, plan procedure code number x.xx”).

Medical specialists are not technicians; they are highly trained and highly paid professionals, and they should be treated that way. And they should behave in a way that reminds us that this is true.

Medicine is easy

“What we do here, it isn’t that hard,” my pediatrics professor said in his Peruvian accent, an accent we came to associate with humor and brilliance.

The child’s cold hadn’t resolved with erythromycin, so the ER doctor changed her to azithromycin. The similarity in drug names is not coincidental; they are quite similar.

With a single sentence the lesson was taught: most upper respiratory infections do not respond to antibiotics, and if an antibiotic does fail, it probably isn’t all that sharp to switch to a nearly identical drug.

Medicine really isn’t all that hard. Once you understand the basic science, the clinical reasoning, and the necessary social skills, it’s pretty fun. This struck me today after my run. I felt great, and I ran into a guy who had completely controlled his diabetes through smart dietary choices and a vigorous exercise program. It wan’t rocket surgery.

What surprises me about much of the alternative medicine movement is how hard they make it look. Sure, they promote “easy” cures, magic pills, coffee enemas, but really, it’s all the same thing done over and over to a different tune. The diets are difficult to follow and based largely on how well they can sell a supplement or a book. Procedures such as chiropractic and acupuncture come with long, complicated, fictitious explanations.

Real medicine is a lot easier. The science is complicated to be sure, but armed with medical and statistical knowledge (and, once again, social skills), it’s not that hard. The guy who controlled his diabetes didn’t need to buy books or magic potions; he needed to want to get better and to work hard to achieve it (and importantly was in a position to buy healthy foods and exercise in a safe environment). If he hadn’t been able to make the necessary changes, he could have been treated fairly easily from a pharmacopoeia of effective and relatively inexpensive drugs.

These treatments—for diabetes, high blood pressure, heart disease—aren’t magic and don’t claim to be. They all follow the same science (unlike altmed where one person’s meridian is another’s subluxation). And they change as our understanding changes.

The magic pills “As Seen On Dr. Oz” are different every year, and not because of a change in our scientific understanding. One year, hCG is the magic diet medicine, the next year raspberry ketone, and so on. If the magic is so strong, why do these magic pills change every year?

When magic fails, people move on to new magic. Magic is attractive. But since none of these patent medicines actually works as advertised, sideshow barkers like Oz have to come up with new “scientific explanations” behind a disease to sell the new pill. Sometimes it’s “inflammation”, sometimes “toxins”, sometimes “unbalanced qi”.

When real medicine fails, we don’t have to change our basic understanding of the physical world, rather we tweak our understanding within the laws that govern our universe. It’s hard, but easier than making up a whole new universe to explain each new failure and each new potion.

An Unexamined Life

My “on-the-way-to-work” coffee shop sits at a busy corner in one of the wealthiest towns in the country. It’s a crossroads, though, and the crowd isn’t only parents on their way to yoga and kids sitting with their tutors. Construction workers, roofers, and tradesmen aren’t out of place—this is a union town, and everyone depends on The Industry. This part of Michigan is pretty democratic.

This afternoon standing in line for my afternoon joe I stood behind a small group of older teens. One wore a t-shirt for the “Milton Friedman Club”, the back bearing the quotation, “The government solution to a problem is always worse than the problem.”

The sentence is an abomination. I’m no notable quotable but I’d hate for my immortalized words to be so horribly written—which of course isn’t the big problem. Within a few miles of the cafe are two of the nations best public school systems and two of the best private schools. It’s foolish to make assumptions but it’s safe to say this kid never worried where his next meal was coming from.

Government solutions—you know, like social security or Medicare—have been wildly successful at protecting our most vulnerable, something that Ford and GM are not likely to focus on.

This kid’s mentor—the sponsor of his Uncle Milty club—is doing him a disservice if the only message delivered is, “Quick, pull up the ladder!” It’s easy to believe the government is useless if you don’t recognize how much you’ve benefited from your position of privilege, from your own sort of government largesse.

I hope these kids learn the easy way that real life for most people isn’t all Lacrosse tournaments, Land Rovers, and beer in the basement.

Food Allergies: An Open Letter

Dear Parent,

If I understand you correctly, my child’s food allergy is causing you great inconvenience. I wanted to let you know that I can completely relate. The first time my daughter had an allergic reaction I was quite busy on hospital rounds and had to leave before finishing. This ruined my Saturday night, which was spent with patients rather than my frightened family.

I’m not sure about you, but besides inconvenience, I also felt stupid and helpless. I didn’t recognize the reaction for what it was. I just assumed she had some bug causing hives, stomach ache, wheezing, and shortness of breath. Thankfully my wife figured it out and sent me to get an ingredient list for the cookie I gave my kid to get her through rounds. Boy, did I feel like an idiot!
It turns out to have been the walnuts, and now we’re quite careful. She hasn’t had a reaction since, but carries an epinephrine injector with her, just in case.

When you asked me why all the kids seem to have allergies these days, I didn’t have an answer, but your observation was right on target (although you sounded a bit sarcastic when you asked). Food allergies are more common, perhaps for a variety of reasons. This can give parents like me quite a bit of anxiety, and it doesn’t make my daughter feel all warm and fuzzy either.

So I understand you complaint. It’s tough to have a kid in a nut-free classroom. I appreciate how hard it must have been to remember to send in nut-free treats with your kids. The weekly classroom emails and newsletters are easy to ignore, as are the frequent reminders from the teacher. And it must be terribly hard, when making muffins, to leave out the walnuts. I mean, muffins without walnuts? Who does that?

I hold out great hope that you and your child will not have to suffer through another year in a nut-free classroom. Though my daughter will miss your kid, she does feel a bit less anxious knowing she’s a bit less likely to have to jab herself with an EpiPen while waiting for EMS.

Have a happy and healthy school year.



Sometimes you take a run…


Last week Up North I ran down to the water with PalKid’s friend. As we took those long, high strides that get you across the sand she said, “I feel like a superhero!” So did I. That dream you sometimes have (or at least I do) when I run effortlessly, floating—I felt that. And I was motivated to continue working on my intervals, increase my endurance.

But sometimes it doesn’t work. Yesterday’s run felt fine, although I had to do a bit more walking than I like, but today…

Rather than floating effortlessly, I was running through a thick fog, with my hands and feet in irons. I barely made it a mile-and-a-half, much of it walking.

It probably didn’t help that I had gone to see a bad movie and gorged on popcorn and coke. And then stopped for a pint with a friend. I suppose that could have had something to do with it.

Well, next time will be the charm, and if it’s not, then the time after that.

Too Darn Hot

This cold, rainy summer has gone supernova on us. It’s too darn hot. It’s so hot that people have lost their minds. I went out to do some yard work this evening and after about an hour I couldn’t even lift my arms. That was dumb. It wasn’t as dumb as hiring disease-promoter Jenny McCarthy to be a new host at The View. Jenny has promoted herself as a much better scientist than, well, everyone who is actually a scientist. Jenny is raising a child who, she believes, she has “cured” of autism through questionable diets, supplements, and lots of public foolishness.

The many problems with Jenny are just too much to go into in great detail but let me remind you of a little bit.

  1. She wants to “cure” her son of autism. As a parent, I understand wanting to have a child who is more like her peers, more typical. But there are a lot of autistic people who don’t feel they have anything to be “cured” of. Certainly some people on the spectrum are functioning so poorly that we should wish them “recovery”, but autism likely represents a huge number of neurologic conditions that superficially resemble each other. It is unlikely that there will ever be one cure for autism any more than there will be one cure for cancer. And some autistic folks are damned fine the way they are.
  2. It’s very possible her son was never autistic in the first place. She felt that immediately following some vaccinations, her son began to show neurologic abnormalities, but it’s never been clear that these represent anything on the autism spectrum. Also, if, as she and others have stated, that “it’s the toxins” in the vaccines such as mercury (sic), there is no biological way this could cause the neurologic signs typical of autism spectrum disorders.
  3. Her insane fantasy world based on her google-fu has helped promote a culture of vaccine phobia, allowing preventable diseases to sneak back in the crack she’s make in door.
  4. She makes my job harder.

And then there’s Trayvon Martin. The President spoke movingly yesterday, something I think he was required to do, and he did it well. The pundits are calmly reminding us that the justice system worked, that the State failed to prove Zimmerman’s guilt beyond a reasonable doubt. After all, we are a nation of laws, not men, and the laws worked, due process worked. Protecting people from the State requires we tolerate outcomes we may not agree with.

A few years ago I went to a talk by Jeffrey Toobin. After the talk he entertained questions and I asked about Bush v. Gore. Some have argued, I said, that the peaceful transition of power showed how well our system works, that despite the complexity and unfairness of the election’s outcome, there were no tanks in the street.

He replied that if we set our bar for a successful democracy at avoiding tanks rolling down the streets, we’ve set our expectations too low. The same is true for the Travon Martin case. Yes, the justice system worked on the micro level; a man was accused of a serious crime and the State failed to prove their case before a jury of his peers. Due process worked.

But that’s not the point. The “macro” problem is glaring; a man was able to pursue an unarmed black teenager and shoot him to death without legal consequence. Yes, Zimmerman got proper due process, but this due process was predicated on a system designed to allow for the murder and incarceration of thousands of black men and to protect those that harm them based on racist assumptions. Due process worked, and that is exactly the problem: the system within which we allow due process is fatally biased.

We need to raise our expectations. Allow scientists to set health policy, not actors. When actors are given a platform to betray public health, people, especially children, die.

When we have a system that allows—no, encourages—the murder of young, unarmed men of a certain hue, we need to do more than say, “well, at least we protected a defendant properly.” A safe justice system does require that some who are guilty go free, but when it is done systematically at the expense of a certain group, we’re doing democracy wrong.

%d bloggers like this: