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.

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.


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