First World Problems

The voters of the state of Michigan approved a law last year that allows the governor to appoint an “emergency manager” for cities he deems in financial distress. He did this for Detroit this year, effectively disenfranchising 3/4 million residents. Yesterday the EM said he would not rule out selling off some or all of the collection of the Detroit Institute for the Arts, one of the nations finest art museums. Suddenly, after voting for the law and watching the Detroit city government lose its power, the suburbs are enraged. Seriously, if you tell your poorer, darker-hued neighbors that you’re taking over the town and then complain when the cuts might actually inconvenience the lighter-hued citizens, you’ve got to re-examine your thinking.

Re-examine Your Thinking

The good people of the State of Oklahoma are no strangers to tornadoes, and can smell them from a mile away. Norman-based experts track dangerous storms and word gets out as quickly as possible for folks to take shelter. Only, most Okies (? PC) don’t have tornado shelters. They don’t have basements, safe rooms, or other places that might keep them from getting impaled by a two-by-four. But Oklahomans are an independent bunch:

“we are a pretty independent free people who don’t like being told what to do” ….

That’s great, but seriously, seriously misguided. If your ideology requires you to put you and your children at risk because of your ideology, it’s time to stop asking “why me?” and start digging. Yeah, there’s money involved, but this is a perfect situation for a little federal support.

Speaking of Federal Funds

A bridge collapsed in Washington State today. The bridge was, by all reports, a geriatric pile of stressed steel waiting for any excuse to collapse. And lots of our bridges are like that. Travel to any western European country and take a look. All those crazy taxes are doing something—they actually look like modern nations. Our infrastructure would look great to pre-DeLorean Doc Brown, but damn, how stupid are we?

Have a nice weekend. Watch where you drive.

There were almost two thousand names on the list. They had all stopped in my office over the years, and it was time to let them know I’d be moving down the street. But before I sent them all letters, I would have to shorten the list, removing the names that no longer hung on living bodies.

So many of them I hadn’t thought about for years, people from my early years as a doctor. I certainly remembered Syd, because I still cared for his wife. I also cared for his adult his children, who would also have to be struck off. I made a note of it. There was Mary, who was old, toothless and wonderful. She had grown up picking tobacco and cotton and didn’t much like it, but would still go south to visit her sisters and brothers every year at the family home. There was a Holocaust survivor who watched her greatest tormenter executed by an American soldier. There were so many names.

It’s easy to be forgotten when you’re dead, at least by those who weren’t used to your daily presence. I saw these people in sickness and in health, caring for them in the office and the hospital, but went home every day to my own family, putting as much of work out of my mind as was possible. But here they were, on a computer screen, glowing memories, daring me.

So I read each one, tried as hard as I could to remember them, remember the living things about them, remember that Jack liked to play tennis and make love, that Carole hated her kids. I pictured the lives they led while not in my exam room, lives full of the dull facts that make up a day, a life: making tea, having beer with friends at the corner bar, playing golf. Or worse, holding young children, saying long goodbyes to people who would have to grow up without you.

I struck off each name, the bytes disappearing from the list, shortening it significantly. I hoped that people remembered them all, the good, the bad, the silly. I would do my part; I would try. But I will strike them off just the same, making room for the living who need me more.

Since the day that twenty children and six adults were murdered by a heavily-armed man in Newtown, CT, I’ve been unable to get the “gun issue” out of my head. Someone could argue that I’m unhealthily obsessed, that my judgement is clouded, but evidence supports my beliefs. Guns are dangerous tools designed to kill, are marketed to children without regulation, and are easier to get than a driver’s license. We don’t let cigarette makers advertise to kids, and with good reason: cigarettes are responsible for almost half-a-million deaths yearly, in the U.S., and nearly 50,000 deaths due to second-hand smoke. If it were meteor strikes, we would probably shrug our shoulders and say, “well, it’s a tough universe,” but every cigarette-related death is preventable.

So are gun deaths. Cigarettes don’t kill people—unless people pick them up and smoke them. Guns also don’t tend to pick themselves up, point themselves and fire. Guns are simply tools that people use, tools that are responsible for more than 30,000 deaths in the US each year. Every one of those deaths were preventable. Suicide made up a large part of these deaths. Not all suicide attempts are successful, but the immediate lethality and ready availability of firearms makes it easier to try and succeed.

People can certainly disagree about the meaning of the Second Amendment, but facts don’t lie: our adherence to one particular interpretation is allowing tens of thousands of preventable deaths every year.

Whatever lawmakers may say, I will continue to ask my patients about gun ownership because it’s important to their health. I don’t tell them not to have guns, but I do ask them about their hobbies, hunting habits, and gun safety knowledge. I also let them know about the statistics that say that owning guns makes you more likely to suffer a firearms injury or death (obviously, really).

As with cigarettes and auto accidents, it’s likely that gun deaths can be prevented by regulation, but to take that step we ned to at least agree as a society that dead children make the question worth debating, examining, and voting on.

I hope to see many more evenings like this. I’m alone, sitting in my back yard. The sun has been down for a few minutes, the light is slowly draining out of the day. The previously skeletal trees are starting to look better-fed, some spectacularly so. I drove by a weeping cherry today and pink pedals drifted through the sun roof onto my dash.

It sounds a bit like morning, the same bird calls I expect will wake me. During the heat of the day, there were more woodpeckers knocking, red-winged blackbirds trilling, and black-capped chickadees, my local favorite, making me feel as if I were farther north.

Even with eyes closed, though, I’ll soon hear the evening. Spring peepers will slash through the relative peace, rivaling the cicadas I expect on a warmer week.

I learned a new flower on my walk last week: bloodroot. Despite all my time outdoors, I’ve never noticed it, preferring to keep my eyes out for trillium. The daisy-like flowers were nearly enfolded by a palmate leaf, seemingly birthing them into the spring.

The poison ivy’s not far behind though. The hardiest of hardy’s I’d say. They always look healthy and do not like to be removed. As soon as a bed has been cleared, they appear on a tree trunk, obscuring the bark, daring us to touch.

A cardinal a little ways away seems as happy as I am, enjoying the cool, dry spring air (although I suppose he’s a bit lonely).

The ducks though—the ducks. We have a pair in the backyard, but today, the female was surrounded by a group of drakes—a large group. They splashed, flapped, scooted, and eventually, two of them trapped the female long enough, I suppose, to make suspect the next generation’s paternity.

They can’t ruin this though. It’s perfect, and when I tuck in my daughter, I expect she’ll agree. I’ll never take spring for granted.

Yesterday I expressed some frustration at new hoops I’ll need to jump through in my career. That sort of whining is unlikely to garner sympathy from anyone other than my fellow internists. What I do hope is that non-doctors get a glimpse of what is going on behind the scenes. Given that we are all going to be patients at some point, it’s important to know what bedevils your doctor.

One of the complaints I most often get is from patients who want me to help them out but don’t want to come to the office. This is understandable. Doctor’s visits aren’t free, and with high-deductible plans becoming the norm, more of the cost is the responsibility of the patient.

But there are two very good reasons to practice medicine face-to-face. The first is simply practical: doctors, unlike lawyers and other professionals, cannot bill for time on the phone, email or other sorts of interactions. We simply cannot keep the lights on if people don’t pay for the services we provide. It’s also morally wrong to expect me to work for free. In our culture, payment shows you understand the value of a service.

I do provide free care through a local charity. They send me patients, but not so many that I can’t deal with it financially. Sometimes doctors will work out arrangements with uninsured folks, but when a patient is insured, discounting a visit can lead to legal trouble with insurance companies.

The most important reason to avoid phone-it-in medicine is that it’s “phoning it in”. If a patient needs a long-standing prescription refilled, it can almost always be handled over the phone. But nearly anything else is asking me to use my professional judgement to help a patient. Medically it’s a bad idea.

If you have long-standing hypertension, this needs regular monitoring. Hypertension often worsens over time and treatments need to be adjusted. Asking me to simply prescribe something indefinitely is asking me to practice bad medicine. A visit in person allows me to look for the signs of damage done by hypertension, and to spend the time talking to you about obvious and subtle symptoms.

It’s hard to tell the difference between bronchitis and pneumonia over the phone. Bronchitis doesn’t require antibiotics; pneumonia does. In the office I can listen to the chest and if needed get an x-ray. Sometimes just looking at someone helps tell me how sick they really are.

When your doctor puts off treating you over the phone, she’s doing it for a reason, one that is usually in your best interest.

A few months back I told you a bit about what internists do to maintain their board certification. I suggested that the American Board of Internal Medicine (ABIM) eliminate the expensive, time consuming process perhaps in favor of a less formal, ongoing education program. Well, you gotta watch out what you wish for.

Today I received an email from the Board—the board which just gave me a 10 year certification—that it ain’t over. After having been assured that my two year of preparation and examination, costing me about $2000 and endless hours, I will now be required to pay the board $200/year and engage in even more busy-work, such as taking quizzes and collecting patient data (oh, and BTW, is there some sort of IRB approval for all this data-gathering? DrugMonkey?)

When the Board implemented the 10 year certification process it grandfathered in members who had been certified by a certain date. This new process has no such provision: after having spent thousands of dollars and hundreds of hours with the understanding that I won’t have to do this again for several years, I’m now told that I will need to keep going.

This will take away from patient time and from other educational activities. Instead of choosing my own educational programs, I’ll have to use that time and money to do modules from the Board.

I know it’s not all that dignified, but I must tell the ABIM: you’ve jumped the shark with this one. Practicing internists don’t have time or money for your bullshit. Please fuck off.

A great miracle happened today: PalKid slept in. This is a “reportable event”, one that I’m likely to remember. She had good reason to need the sleep.

Saturday night she slept over at a friend’s house. When I picked her up, she said, “It’s a really nice spring day. Let’s do something outside. Can we go to the zoo?”

Yes. Yes we can. We went home, had a little lunch, packed a bag with snacks and took off. The zoo is a gorgeous piece of land, with long esplanades, gardens, and of course, animals. She wanted me to use the map, but it was much more fun to wander and let the animals surprise us.

She’s old enough to read the signs and learn about the animals and their habitats, and enjoyed teaching me. More important, she walked. A kid who prefers to sit walked for hours. Near the end of the day she did wear out. I gave her a piggy back ride, and she kissed the back of my head, saying, “I love you Daddy.”

I’m glad she slept in, but I’m ready for her to come down to breakfast.

I made the mistake of giving up on running during the icy months. Despite my best intentions, I didn’t substitute regular indoor exercise. But self-recrimination leads nowhere.

The last few mornings, the birds have sounded like spring. Cardinal songs are lovely but their incessant, randy singing can get a bit annoying. Blue jays’ musical tones are wonderful little surprises. But my favorite is the black capped chickadee. Its song always reminds me of the wilderness, so I took off onto the trail this morning for my return to running, and with the hope that the birds would provide a sound track.

I didn’t make it very far, but beside a pond I saw a movement in the bush. There it was, a small bird, perhaps just a random little brown thing. Then its small beak opened and out came the remarkably clear “yoo hoo” of my chickadee. Its camouflage is remarkable. Look how its brown body blends into the background, its black and white head mimics the light-dark of the branches and the spaces between.

Cry havoc and let spring the new season!

Someone is wrong on the internet! I read a tweet today that implied that doctors are indentured servants and should shut up and shop at the company store. Well, that’s how I read it anyway. Here’s the exact text:

If doctors stop taking medicare patients should they pay back 500k+ CMS http://www.aafp.org/online/en/home/policy/federal/issues/workforce/education.html … invested in training them?

Now, I’m not saying the tweeter thinks this is what should be done, but the premise is so completely wrong that…well, it’s not completely wrong, it’s just mostly wrong.

First, let’s chat about Medicare, the program that insures people over sixty five (and many disabled people). Medicare sets prices paid to doctors based on all sorts of formulas, but due to Congress’s inability to make financial decisions, these fees are unstable, requiring last minute fixes each year. This means that doctors that treat Medicare patients have considerable trouble planning salaries, hiring, capital improvements, and other expenses. Because of this instability and the generally lower fees paid by Medicare, it might make sense for some to simply opt out and stop participating. Medicare patients would still be able to go to the office, but they would have to pay out of pocket.

The interesting question raised by the tweet is this: since Medicare funds graduate medical education (residencies and fellowships) do doctors owe Medicare some sort of obligation?

Work has a value, and ideally the value is assigned at the time someone is hired for their work. If the worker doesn’t agree with the fee, they move on and management is denied her production. Ideally.

The ethic here is analogous to informed consent: contracts should explicitly state the obligations and benefits for both parties. Doctors pay for medical school, and exit with a debt averaging $200,000. They enter residency with the expectation that they will receive a modest stipend, one that usually doesn’t allow for loan repayment but at least pays room and board. To maintain a residency program, hospitals receive money from Medicare, and some of this money is used to pay this stipend (or salary, depending on whom you ask).

Residency is not a benefit given to young doctors: it is an obligation. In return for being taught and supervised, they take care of patient, working long hours and sacrificing years of potential earning and often family life. There has never been an expectation that they owe anyone anything.

This, then, is why I call “bullshit” on anyone who would suggest the system has other hidden obligations. To impoverish young doctors through debt, and then further impoverish them by having them pay for their training not only in service but in dollars is not consistent with how we create doctors in this country.

If we as a society decide that residency and fellowship are really tuition-based services rather than work, that would need to be explicitly agreed upon long before high schoolers enter college and decide to torture graduate students with questions about their organic chem grade.

If doctors are required to become indentured servants to Medicare, it should not be without an explicit understanding.

Dear Readers:

Hey, whassup!

Welcome back. I’m dusting off the furniture and moving back in—sort of. I’m having a great time writing over at Forbes (and I sincerely hope you’re reading!), but let’s face it: Forbes is a news outlet, and not a great place to put on the personal touches.

So, I’m re-opening WCU here at WordPress for my non-medical bits: family anecdotes, poetic musings, fiction, political rants, whatever. I invite you to follow both blogs for a complete look under the white coat.

Grand Traverse Bay. Yes, it’s that cold.

OK, that came out wrong, but you get what I’m saying.

So the other night my dad and I were talking about the latest cosmology story in the papers. PalKid, always the eavesdropper, asked what we were talking about. How the hell can I explain cosmology—something I barely understand—to a third grader? The first step, I figured, was ‘c’. Without understanding that light has a finite velocity, there’s no way to understand anything else.

As it turns out, third graders are capable of getting it. I started out with explaining how when we turn on the lights, it seems instantaneous but it’s not. Then we moved up to the sun. “It takes eight minutes?”

Then we moved up to nearby stars, and finally the edges of time. It was amazing. The kid soaked it up like a sponge. And then she went back to watching re-runs of Full House.

Anyway, spring is on the way. The blacked-capped chickadees are getting noisy, the robins fat. If the thermometer would just cooperate…

The whitecoatunderground.com domain will from this point forward direct here, and to get to Forbes, plug in my addy there, and thanks for reading.