Archive for: May, 2011

Journeys

May 29 2011 Published by under Medical Musings

This is a re-post of a piece I just happen to like a lot. Seemed fitting for Memorial Day weekend somehow.  --PalMD

I met this beautiful woman the other day. She had a sad, glowing smile, was dressed impeccably, and had this wonderful accent. I imagined her voice would be at home in some small corner of Europe where the pastries are always fresh, the coffee fragrant. She was sitting in a chair next to man, or what used to be a man. He lay stiffly in a bed like a bundle of fallen sticks---one of the sticks was being held gently by the beautiful woman, his wife. The room was too big for them, the high ceiling and white walls almost deafeningly empty.

They belonged to another time, this couple. The light poured through the window, stopped by a single IV pole which left a long, thin shadow on the wall, like a tree in winter. I pictured them in a different light, one a little richer, maybe browner, the colors subdued but present, not washed out like this day. They must have held hands then, too, but less delicately, with less fear. The young doctors stood by, also dwarfed by the room, but somehow less out of place. It's not just that they were doctors, and this a hospital---they were more a part of this life, this place, this time. They were near the beginning and middle of their journeys, not the end. It was palpable. They thought, "where might I be tomorrow? In bed yet? Answering a call? Drinking?" The questions hanging over the couple in the room were, "Will I be tomorrow? Are there any left? Why?"

It's strange---to be in the middle point of my own journey, surrounded by people nearly at the end, or perhaps past the end. Some live for the moment, never thinking it will end. Some mourn for the sepia-past that never was. But mostly I think they just cling to each other and to the moments, waiting, unsure, and watching as we middle-folk go about as if there will always be another day, another cup of coffee, another kiss.

20 responses so far

Eavesdropping

May 29 2011 Published by under Medical Musings

Last night PalKid really wanted to sleep with Mommy, so after getting the kiddo washed up and heparinizing MrsPal's IV, I tucked them in, turned out the light, and backed away slowly.

This gave me a little while to browse the Twitters, and I started eavesdropping on a conversation between authors Tom Levinson and Jennifer Ouellette.  These are both authors who take the geekiest of topics (obscure history, physics, Joss Whedon, zombies) and turn them into compelling narratives in which story and science blend seamlessly----no, they don't blend, they are the same thing.

Much of what occurs in science and medicine is fascinating in the hands of a good story teller.  The everyday dramas in science, the every day giggles and horrors, those that we on the inside share only with each other----these can be translated successfully into a good read, one which is a good read because it is scientifically and medically true.

(See Samuel Shem's House of God which helped immortalize truthful, dehumanizing conditions, simultaneously making us laugh and making us hate ourselves for laughing).

Any conversation based on typed 140 character statements can be easy to misinterpret, but from what I could gather, they were trying to parse out the difference between striving for accuracy in drama, and creating drama that teaches accurate science.  My take is that drama that happens to incorporate accurate science teaches without being didactic.

I love to tell stories.  I may not be up there with Tom and Jennifer, but the whole blog thing has given many of us who have stories to tell an outlet, and while I like to know that people read,  and I love the feedback, it is the writing that I really love.  My favorite category is the one I call "Medical Musings," a place I tend to put less scientific pieces, but stories that are still set in the world of medicine.  But I also like to share brief tales of medical discovery, stories that share with others my love for what I do.

My stories tend to be medically accurate, even though the patients are amalgams of various people I've seen, and they form the framework of what I'm trying to get across, but there is no reason a real writer, someone who writes professionally and is damned good at it, cannot learn about the real drama in real life, life that is based on science and affected every day by medicine.

While I stick to non-fiction, there is no need in fiction to make up medical facts,  no need to invent implausible neutrinos or new diseases.  Real life tosses us enough drama.  I work in a thousand-bed hospital.  There are at least that many stories here, real, engaging stories of real people with real diseases.  And these people go home, and have families, and friends, and the stories are right there, waiting to be told.

3 responses so far

Real outreach

May 24 2011 Published by under Medicine

It's no secret that doctors don't often look like their patients.  This simplistic observation hides a more complex set of effects: in addition to the economic problems faced by minorities seeking medical care, there is a quieter, dirtier history, one of forced sterilization, institutionalization, research abuse (and, one might argue, murder).  It should then be no surprise that when it comes to getting proper health care, minorities are often at a economic and cultural disadvantage, and have valid reasons not to trust the health care system.

For many minorities, the emergency department is the landing zone when preventable illness finally becomes impossible to ignore.  Internists like me see case after case of advanced heart disease, kidney failure, and stroke that could have been prevented with good primary care.

As a recent study has shown, when suffering signs of a catastrophic illness such as stroke, African Americans may reach out to friends before calling 911.  This is one of the many good reasons for looking into ways to bring prevention directly into trusted minority community institutions rather than waiting for minorities to seek out care that may be unavailable or alienating.

Hypertension is a potent risk for heart attack, stroke, and kidney failure, common ailments among African Americans. Investigators went to Dallas County, TX to see what effect if any outreach at black-owned barbershops might have on patrons' blood pressure.  Shops received one of two interventions: either standard pressure pamphlets, or an intervention group where patrons were screened with their haircuts and offered peer-based intervention, and encouraged to get medical follow up.

The results were both frightening and encouraging.  Forty-five percent of men screened had hypertension, and of those, only 38% had their disease under good control.  Both groups in the study had improved blood pressure control, with the more intensive intervention group experiencing a slightly greater increase in blood pressure control.

This study shows the great potential of community-based interventions for important health conditions, especially in communities with less access to standard health care.  It is important that programs like this continue to be studied for validity and strength of effect, and if widely implemented, that they remain science-based, and do not become a profit opportunity for more charlatans to prey on the poor and on minorities.

 

References

Hsia, A., Castle, A., Wing, J., Edwards, D., Brown, N., Higgins, T., Wallace, J., Koslosky, S., Gibbons, M., Sanchez, B., Fokar, A., Shara, N., Morgenstern, L., & Kidwell, C. (2011). Understanding Reasons for Delay in Seeking Acute Stroke Care in an Underserved Urban Population Stroke DOI: 10.1161/STROKEAHA.110.604736

Victor, R., Ravenell, J., Freeman, A., Leonard, D., Bhat, D., Shafiq, M., Knowles, P., Storm, J., Adhikari, E., Bibbins-Domingo, K., Coxson, P., Pletcher, M., Hannan, P., & Haley, R. (2010). Effectiveness of a Barber-Based Intervention for Improving Hypertension Control in Black Men: The BARBER-1 Study: A Cluster Randomized Trial Archives of Internal Medicine, 171 (4), 342-350 DOI: 10.1001/archinternmed.2010.390

3 responses so far

It's Quiet

May 22 2011 Published by under Fatherhood

I'm sitting on a chair in my family room listening to Blood on the Tracks and it's peaceful.  Six hours ago, my wife was sitting in this same chair while a brave nurse tried to find one more vein to get an IV in.  In the last six weeks, all of our routines, every simple act we count on have been upended.

When I see a patient, I barely get the Cliff Notes; behind every worried look is a drama, one affecting many more people than the one sitting in the room with me.  My usual task is to understand it, not to live it.

Our little drama has had some repercussions of its own.  I normally work three nights a week and every weekend, and with MrsPal at home ill, this hasn't always been possible.  I miss my residents.  I miss the work.  But suddenly I'm spending far more time with my kid and my wife than I'd ever expected.  Much of that time is basic care-taking:  showering, changing dressings, hanging IVs.  But when routines are thrown off so quickly, all sorts of strange things happen.

This morning I woke up at seven.  I cursed, rolled out of bed and got into the shower.  In the shower I realized two things: first, it was Saturday, and I could turn off the shower and go back to bed.  Second, my bed (not my marital bed---that's a bit full of spouse and supporting equipment at the moment) was empty.  Since this journey began, my daughter hasn't been able to sleep alone.  Every night she climbs into bed with me, follows me around in fact until I'm ready to go to sleep.  Once MrsPal got back from the hospital the pattern continued.  She could not, would not go to bed alone, would not be alone at all in fact during the evening.

Last night, after a long evening at a school event, she folded over and snored her way home, and fell asleep in her own bed.  Tonight, she asked for a sleepover at a friend's house.  I was so worried about my kiddo, so concerned that the fear about her mom would overwhelm her, but she's a lot more smart and resilient than I'd realized.  It probably helps that mom looks a lot more like mom and is back to bugging her about her homework.

She's even resilient enough to turn on some more complex scams.  Yes, she's gotten pretty much everything she's wanted the last month or two, but we've been starting to reel her back in.  Tonight she batted her big brown eyes at her friend's mom and asked if she would go with her to get her ears pierced, an activity that we have not endorsed.   The layers of her aborted scam weren't quite The Usual Suspects, but not bad for a six year old.

So it's quiet around here tonight.  MrsPal is comfortable enough to have fallen asleep (and her IV is done for the night), and PalKid isn't here at all.  I'm grateful for the solitude.

But it's really, really quiet.

One response so far

To pee, or not to pee

May 21 2011 Published by under Medicine

Folks, I am so tired of not writing every day.  I knew with the new job I'd be cutting back quite a bit, but then with MrsPal's illness, all my writing time has gone right into the Foley bag.

By the way, a Foley catheter is not something one should try to remove on their own.  Many men and some women have had the pleasure of hosting a Foley catheter because there are times in a person's life when they may not be able to pee for themselves. This is particularly true of males.

Men are more frequently invaded by urinary catheters because of an anatomic accident, but women have their own anatomic annoyance, the urinary tract infection (UTI).  To understand how people's sexy bits can become so un-sexy, we need to learn a little anatomy (and this is about to get clinically graphic so I'm putting in a page break.  You've been warned). Continue Reading »

8 responses so far

Lessons

May 14 2011 Published by under Medical education, Medical Musings, Medicine

One of my early lessons in medicine was "listen to the nurses".  This isn't to say that nurses know everything and doctors nothing.  But we have very different knowledge sets, and it would be easy for a young medical student to simply dismiss anything told them by a "mere nurse" (in this case, "mere nurse" meaning someone who they think---often erroneously---cannot affect their grade).  Not only do nurses spend more time with the patients, but the have skills that med students need to learn.  Some of the essential skills taught to young physicians by nurses include how to draw blood and place IVs, how to turn patients, how to lift people safely.  At many hospitals special teams take care of IVs and blood draws, but many of us trained at hospitals where we were often responsible for these tasks.  During emergencies, it helps to know how to do everything---if someone's heart has stopped, waiting for the IV team would be a pretty bad idea.

In addition to the nurses, at least a dozen pregnant women taught me to place IVs.  Pregnant women often have nice, plump veins, making it easy for the novice to slip in a needle.  Getting in the needle and catheter is only a small part of it though;  you have to learn the preparation and the dance.  You have to learn how to tear the tape you need ahead of time, how to secure the IV and flush it, and all the other bits of knowledge that surround getting the needle into the vein.  Most important, you have to remember that the vein is attached to a human being, one who may be frightened and in pain, and needs your confidence, your ear, and all of your empathy and compassion.

I made it my business to learn as many of these lessons as I could.  I volunteered to start IVs and get blood from the most difficult "sticks".  I wanted to be the one people would call if they couldn't get the job done themselves.  While I rarely use these skills anymore (an excuse often tossed out by young docs who don't want to bother to learn them) I still value them, and especially now I need to send out a "thank you" to all of the doctors, nurses, techs, and patients who taught me.

This morning I hung a bag of IV fluids for my wife.  It seemed familiar.  It took me a second, but the understanding, the comfort with the process came back to me quickly.  Because of this, we can sit together at home instead of at the hospital.  This is worth every night I spent on call alone and tired, surrounded by other people's loved ones.

14 responses so far

How much would you pay to see your doctor?

May 01 2011 Published by under Medicine, Uncategorized

We pay far too much for health care in this country, spending ridiculous amounts and getting outcomes no better than countries that spend a fraction of what we do.  But most efforts at reforming the system have been aimed not toward better, more cost-effective care.

The last twenty years have seen all sorts of experiments arise in how to fund health care in the US.  One thing many of these models---such as HMOs---have in common is being loathed by patients and doctors alike.  It seems as if each new incarnation of private health insurance is designed solely to maximize insurance company profits rather than to deliver safe, timely, evidence-based care for which doctors are fairly compensated.

One of the experiments of the last ten years is so-called "boutique" or "concierge" medicine.  In this model, patients pay their doctor a retainer and in return, the doctor takes on fewer patients and uses the reduced patient load to make herself more available to her patients.  In addition to collecting the retainer, the doctor can still charge for individual visits and she or the patient can send the bill on to the insurance company.

Something about this model has always rubbed me wrong, but in truth, there appear to be few ethical problems with this model, at least in theory.  However, the model requires a pool of patients willing to put out a retainer for their care.  Is the care actually any better?  To my knowledge, this hasn't been well-studied, but I would make an educated guess that patients are in general more satisfied, but that there is no reason to expect better medical outcomes.  My diabetic patient with proteinuria should be on an ACE inhibitor whether or not I see five patients a day or twenty.

It certainly can work out well for the physician.  It is much more satisfying to care for a fewer number of patients and to make money from the choice (e.g. 250 patients paying a $1500 retainer each, plus insurance reimbursement).  But in the present economy, it can be difficult to recruit enough patients willing to shell out the bucks for this sort of care.  Some doctors have prosed a hybrid model, in which some patients are part of the concierge patients, others standard fee-for-service or HMO patients.

This model seems fraught with ethical dangers.  To have a practice where patients are inherently unequal, where a few bucks insures better treatment for some will inevitably lead to poorer care for both groups.  Concierge patients may not have the access they expect (although presumably this is set out in some sort of contract), and more important "regular" patients may end up at the bottom of the to do list, having less access to their doctor, less of their time.

In a free market, a patient unsatisfied with this arrangement can walk away.  But in reality, it is not always easy to find a primary care physician, and insurance and geography may place significant restraints on choice.

Given the failing model we currently have, where primary care doctors are reimbursed poorly and are forced to see increasing volumes, hybrid practices and other questionable models will keep popping up, and our already inequitable health care system will continue to divide us into haves and have-nots, with both groups encountering sub-standard outcomes and excessive costs.

References

Lucier, D., Frisch, N., Cohen, B., Wagner, M., Salem, D., & Fairchild, D. (2010). Academic Retainer Medicine: An Innovative Business Model for Cross-Subsidizing Primary Care Academic Medicine, 85 (6), 959-964 DOI: 10.1097/ACM.0b013e3181dbe19e

Alexander GC, Kurlander J, & Wynia MK (2005). Physicians in retainer ("concierge") practice. A national survey of physician, patient, and practice characteristics. Journal of general internal medicine, 20 (12), 1079-83 PMID: 16423094

13 responses so far