I'll be on a medical mission for the next two weeks with doubtful internet access for posting.
Until then, hassle Happy (see sidebar).
Sunday, June 28, 2009
Treating Me In Dementia
I had a long-time patient tell me last week that she had a solution for her own future dementia.
She would rig a bomb and wrap it as a gift to herself. If she ever developed dementia, she'd forget what was in the box and open it.
A nurse told me her advance directive includes a provision that if she cannot remember to ask for her medicines, she's not to receive them.
I'd add the exception that the care provider should give me morphine, antiemetics, haloperidol and lorazepam as needed.
Any other ideas?
She would rig a bomb and wrap it as a gift to herself. If she ever developed dementia, she'd forget what was in the box and open it.
A nurse told me her advance directive includes a provision that if she cannot remember to ask for her medicines, she's not to receive them.
I'd add the exception that the care provider should give me morphine, antiemetics, haloperidol and lorazepam as needed.
Any other ideas?
Tuesday, June 23, 2009
Does Canada Really Make Patients Wait?
In the debate about a Government-run National Health Plan, impressions of the Canadian system loom over any proposal. The influence can be subtle, educated, or not. Often it degenerates into the exalted format of childhood arguments:"Does!" "Does not!" "Does too!" etc...
Waiting times for certain tests and surgery are thrown about and highlighted or trashed, but rarely is any data offered. Here is the 2008 Fraser Institute report "Waiting Your Turn", which provides a comprehensive look at the numbers. Take a look at it, some of the best graphs of the overall effects are on pages 57 and 58.
Waiting times for certain tests and surgery are thrown about and highlighted or trashed, but rarely is any data offered. Here is the 2008 Fraser Institute report "Waiting Your Turn", which provides a comprehensive look at the numbers. Take a look at it, some of the best graphs of the overall effects are on pages 57 and 58.
Highlights of the report include an average 8.5 week wait from referral to seeing a specialist, and another 8.7 weeks to receive the treatment recommended by that consultant. One of the shortest waits was medical oncology (think chemotherapy) which was 4.6 weeks from referral to treatment. Overall the wait times nearly doubled compared to 1993 (referral to treatment went from 9.3 weeks to 17.2 weeks in 2008).
One can well argue whether these waiting times are medically significant or not, whether this person or that person might have "had an untoward outcome" as a result.
My point instead is that Canada's medical system is not the health care nirvana that some claim. Canada has rationing by an ever lengthening queue.
No national health care system can afford to pay for everything, for everyone, always. All the handwaving about 'efficiencies' and EMRs will not conjure enough cash to prevent rationing, whether open or covert.
Tuesday, June 16, 2009
When The Consultant Is Non-Compliant
Pay for Performance (P4P) and the Patient Centered Medical Home are two of the schemes being touted to save the nation from nefarious, inept and greedy doctors. Chief among arguments for these ideas are that more structured routine medical care will "increase quality" and "reduce health care costs". In essence, reward docs to do what 'someone' wants them to do (and imply future penalties if they don't).
An example of this approach is to reward (or not penalize) primary care doctors(PCP) for blood sugar and A1c "targets" achieved by their diabetic patients, typically A1c <7 and fasting CBGs <120. The PCP is rewarded or not based on the group performance of patients with the condition as though he/she is the only variable in the equation.
I have a middle-aged patient who elected to seek and receive surgical treatment for obesity in part because he had inadequate control of his diabetes (A1c 7.5-8) despite multiple medications, etc. He had no A1c (7.9) and CBG (~140 fasting) improvement after surgery, so the surgeon obtained a medicine/endocrine consultation(I was not involved). My patient is motivated and compliant with both medications and lifestyle choices.
The consultant recommended that my patient discontinue his diabetic medication as long as his fasting CBG stays below 180!
Now, if my patient chooses to follow the consultant's wisdom instead of my recommendation leading to worsened A1c and CBG numbers, should I be held financially responsible, as the PCP, for my patient's failure to meet the goal? Should my name go on the bad doctor list? Should I fire the patient?
An example of this approach is to reward (or not penalize) primary care doctors(PCP) for blood sugar and A1c "targets" achieved by their diabetic patients, typically A1c <7 and fasting CBGs <120. The PCP is rewarded or not based on the group performance of patients with the condition as though he/she is the only variable in the equation.
I have a middle-aged patient who elected to seek and receive surgical treatment for obesity in part because he had inadequate control of his diabetes (A1c 7.5-8) despite multiple medications, etc. He had no A1c (7.9) and CBG (~140 fasting) improvement after surgery, so the surgeon obtained a medicine/endocrine consultation(I was not involved). My patient is motivated and compliant with both medications and lifestyle choices.
The consultant recommended that my patient discontinue his diabetic medication as long as his fasting CBG stays below 180!
Now, if my patient chooses to follow the consultant's wisdom instead of my recommendation leading to worsened A1c and CBG numbers, should I be held financially responsible, as the PCP, for my patient's failure to meet the goal? Should my name go on the bad doctor list? Should I fire the patient?
Friday, June 12, 2009
Why Should I Care If Physicians Lose Autonomy?
How does the loss of the conscience clause threaten physician autonomy? How would that affect me?
The loss of the conscience clause is simply one more nail in the coffin, but a crucial one. It marks the transfer of decision making from the doctor and patient to 'someone'.
The someone will be a government medicrat.
If the medicrat has the power to determine what services the doctor must provide, he/she has the power to determine what the doctor cannot provide.
If the doctor is forbidden to provide a service, the patient cannot receive it.
Where does this already happen? Look to Canada, where all medical care comes through the government system, and physicians are prohibited from operating outside the rules. Most Americans know that Canadians can wait months for many tests and surgeries because Canadian doctors have been prohibited from providing care except by the medicrat rules (although a recent court decision has led to cracks in the concrete). If someone wants the hip surgery sooner, they must leave the country rather than wait.
Currently in the USA, a government program or insurance company can decide to "not cover", that is, not pay for a service. The doctor may recommend, and the patient may decide to have a service and pay for it out of pocket. Although this can be inconvenient and expensive, the final decision is made by the patient. The patient preserves his/her autonomy, as does the doctor.
No national health plan can pay for everything, all the time, for everyone, although the politicians will pretend for a time. As expenses run away, the pressure to lower costs will lead to intensified hidden rules and restrictions (covert rationing) and eventually to explicit rationing. The current "not covered" will increasingly morph into "not medically necessary". Will it become forbidden?
Insist that any plan protect this freedom: that when your surgery/test/procedure/consultation is denied or delayed, you have the liberty to pay out of pocket without leaving the country.
Otherwise, expect your bladder difficulties to be treated by Vogon poetry.
The loss of the conscience clause is simply one more nail in the coffin, but a crucial one. It marks the transfer of decision making from the doctor and patient to 'someone'.
The someone will be a government medicrat.
If the medicrat has the power to determine what services the doctor must provide, he/she has the power to determine what the doctor cannot provide.
If the doctor is forbidden to provide a service, the patient cannot receive it.
Where does this already happen? Look to Canada, where all medical care comes through the government system, and physicians are prohibited from operating outside the rules. Most Americans know that Canadians can wait months for many tests and surgeries because Canadian doctors have been prohibited from providing care except by the medicrat rules (although a recent court decision has led to cracks in the concrete). If someone wants the hip surgery sooner, they must leave the country rather than wait.
Currently in the USA, a government program or insurance company can decide to "not cover", that is, not pay for a service. The doctor may recommend, and the patient may decide to have a service and pay for it out of pocket. Although this can be inconvenient and expensive, the final decision is made by the patient. The patient preserves his/her autonomy, as does the doctor.
No national health plan can pay for everything, all the time, for everyone, although the politicians will pretend for a time. As expenses run away, the pressure to lower costs will lead to intensified hidden rules and restrictions (covert rationing) and eventually to explicit rationing. The current "not covered" will increasingly morph into "not medically necessary". Will it become forbidden?
Insist that any plan protect this freedom: that when your surgery/test/procedure/consultation is denied or delayed, you have the liberty to pay out of pocket without leaving the country.
Otherwise, expect your bladder difficulties to be treated by Vogon poetry.
Monday, June 8, 2009
Friday, May 8, 2009
Doctor Automomy Vs. Patient Autonomy
What should happen when patient autonomy and physician autonomy appear to conflict?
What if my patient requests a procedure which I believe is wrong to perform? Which is against my conscience?
The Obama Administration has recently proposed removing the new Bush-era regulations concerning the "Conscience Clause" protections for health-care personnel and abortion. Many electrons have been rearranged in internet debates in discussions (usually) narrowly focusing on whether doctors may refuse to provide or refer for abortions.
Limiting debate to abortion allows the many venting spleens to miss the critical point: there is no conflict in reality, rather a division of responsibility.
My position is straightforward. The patient has autonomy and the responsibility to decide what legal medical services to seek. The physician has autonomy and the responsibility to practice in the manner s/he chooses. As a physician, I choose whether to provide or refer for any legal procedure or service for my own reasons. If I decline to refer for a procedure, the patient is free to seek care elsewhere in this very commercial society. If it's abortion, must I walk her fingers through the Yellow Pages?
"But doctor, don't you have a duty to provide what the patient wants"?
No. I have a duty to provide medically necessary care to my patients within my scope of practice under the conditions I determine within the law. If a patient, an insurance company or the government requests my services otherwise, I have the right and, at times, the duty to refuse.
My conditions include obvious items such as my training, skills, location, payment and time of day (I have voluntarily limited myself in some contracts and agreements), but also include my belief systems and ethics.
My responsibility is to answer these questions in each individual case:
What can be done?
What needs to be done?
What should be done?
These answers cannot be separated from either my clinical judgement or my ethics. Many similar situations have critical ethical differences we hide in other language. For instance, how many pronouncements against the "octomom" fertility doctor were couched in medical language such as "it was not indicated" when meaning "it was wrong and should not be done"?
Is it wrong to refuse "octomom" multiple embryos on moral grounds?
Is it wrong to refuse clitorectomies?
To assist suicides?
To refer for abortions?
The patient is free to seek these services. I am free to decline.
As I would not be a slave, so I would not be a master. This expresses my idea of democracy.
Abraham Lincoln
What if my patient requests a procedure which I believe is wrong to perform? Which is against my conscience?
The Obama Administration has recently proposed removing the new Bush-era regulations concerning the "Conscience Clause" protections for health-care personnel and abortion. Many electrons have been rearranged in internet debates in discussions (usually) narrowly focusing on whether doctors may refuse to provide or refer for abortions.
Limiting debate to abortion allows the many venting spleens to miss the critical point: there is no conflict in reality, rather a division of responsibility.
My position is straightforward. The patient has autonomy and the responsibility to decide what legal medical services to seek. The physician has autonomy and the responsibility to practice in the manner s/he chooses. As a physician, I choose whether to provide or refer for any legal procedure or service for my own reasons. If I decline to refer for a procedure, the patient is free to seek care elsewhere in this very commercial society. If it's abortion, must I walk her fingers through the Yellow Pages?
"But doctor, don't you have a duty to provide what the patient wants"?
No. I have a duty to provide medically necessary care to my patients within my scope of practice under the conditions I determine within the law. If a patient, an insurance company or the government requests my services otherwise, I have the right and, at times, the duty to refuse.
My conditions include obvious items such as my training, skills, location, payment and time of day (I have voluntarily limited myself in some contracts and agreements), but also include my belief systems and ethics.
My responsibility is to answer these questions in each individual case:
What can be done?
What needs to be done?
What should be done?
These answers cannot be separated from either my clinical judgement or my ethics. Many similar situations have critical ethical differences we hide in other language. For instance, how many pronouncements against the "octomom" fertility doctor were couched in medical language such as "it was not indicated" when meaning "it was wrong and should not be done"?
Is it wrong to refuse "octomom" multiple embryos on moral grounds?
Is it wrong to refuse clitorectomies?
To assist suicides?
To refer for abortions?
The patient is free to seek these services. I am free to decline.
As I would not be a slave, so I would not be a master. This expresses my idea of democracy.
Abraham Lincoln
Friday, April 24, 2009
Doctor Autonomy
Just as a patient has autonomy (self-rule) for health decisions, a doctor has autonomy in practice decisions.
A doctor has autonomy to decide the mode and scope of his/her practice of medicine. Mode, in this context, refers to employment, location, associations, etc. Scope of practice is simply what services the doctor provides. Some conditions of practice are prescibed or regulated by national or local law (such as non-discrimination statutes), and some conditions and practices are prohibited, otherwise current U.S. law allows freedom for doctors to decide these things.
Employee or self-employed? If employed, by whom and under what conditions? Where?
Solo or group practice? Locum tenens? Staff model HMO? Government?
Doing which procedures? Under what conditions? For whom?
(Scope of practice enters into the mode of course, as a doctor needs to perform within the requirements of employment).
A doctor has autonomy to decide the mode and scope of his/her practice of medicine. Mode, in this context, refers to employment, location, associations, etc. Scope of practice is simply what services the doctor provides. Some conditions of practice are prescibed or regulated by national or local law (such as non-discrimination statutes), and some conditions and practices are prohibited, otherwise current U.S. law allows freedom for doctors to decide these things.
Employee or self-employed? If employed, by whom and under what conditions? Where?
Solo or group practice? Locum tenens? Staff model HMO? Government?
Doing which procedures? Under what conditions? For whom?
(Scope of practice enters into the mode of course, as a doctor needs to perform within the requirements of employment).
When I chose solo, rural, self-employed practice I accepted certain conditions which came with that decision and are different from other modes of practice. For instance, I have more independence and flexibility to follow my own values, but more responsibility for the business side of practice with less security.
My scope is based on my training, experience, preferences and belief system. It has changed with time, mostly I have reduced the procedures I perform after my skills atrophied since training (e.g. most joint injections). I no longer do obstetrics for financial reasons. I received no training in procedures I intended to not perform for whatever reason.
My next post will address one threat to this liberty.
Monday, April 20, 2009
Make Your Own Parabiotic kit
The NEW! ALL-NATURAL! ORGANIC! Way to Maintain Health!
Introducing the
PENSPORE SYSTEM®
Make-Your-Own -PARABIOTIC Kit
From the Eliminates Network
Makers of Cuzco Copro Gold®!
Stay Healthy with Food, not Chemicals!
Parabiotics enhance your protection from harmful bacteria.
Biotic means living thing. We all know how anti-biotics are anti-living things!
That means anti-biotics are Anti-You! The Synthetic Chemicals which kill!
Recover from Anti-biotics!
Fix your Flora!
Fight Infection!
Feel the Force!
In recent years probiotics have been used to help your own natural good bacteria and to recover from anti-biotics. Although probiotics are helpful they are incomplete. Our Penspore System® Parabiotic comes alongside (para) you and your bacteria and attacks bad bacteria trying to assault you and your good bacteria. Unlike anti-biotics, the Penspore System® has No Harmful Synthetic Chemicals, and is an All-Natural and Organic FOOD!
Our kit is easy to use with these simple steps.
1) Take a loaf of Organic Whole Grain Bread and wet with pure bottled spring water
2) Sprinkle with the contents of our PENSPORE® packet and seal into HyphLife® Bag
3) Place in a warm location for 3 days until it’s green(color of Life) and white(color of Purity)!
4) Eat one slice twice daily for health maintenance and 2 slices four times a day for illness
The Penspore System® is optimized for use with Cuzco Copro Gold®. Both Products are available from your nearest Eliminates Network Associate or at www.peruvianpasture.com.
SPECIAL INTRODUCTORY OFFER!
Buy 3 months supply of the Penspore System® for only $89.99 when you buy 3 months of Cuzco Copro Gold®!
As always with our products, your complete satisfaction guaranteed or no money back!
Not to be used by those with a penicillin allergy
Introducing the
PENSPORE SYSTEM®
Make-Your-Own -PARABIOTIC Kit
From the Eliminates Network
Makers of Cuzco Copro Gold®!
Stay Healthy with Food, not Chemicals!
Parabiotics enhance your protection from harmful bacteria.
Biotic means living thing. We all know how anti-biotics are anti-living things!
That means anti-biotics are Anti-You! The Synthetic Chemicals which kill!
Recover from Anti-biotics!
Fix your Flora!
Fight Infection!
Feel the Force!
In recent years probiotics have been used to help your own natural good bacteria and to recover from anti-biotics. Although probiotics are helpful they are incomplete. Our Penspore System® Parabiotic comes alongside (para) you and your bacteria and attacks bad bacteria trying to assault you and your good bacteria. Unlike anti-biotics, the Penspore System® has No Harmful Synthetic Chemicals, and is an All-Natural and Organic FOOD!
Our kit is easy to use with these simple steps.
1) Take a loaf of Organic Whole Grain Bread and wet with pure bottled spring water
2) Sprinkle with the contents of our PENSPORE® packet and seal into HyphLife® Bag
3) Place in a warm location for 3 days until it’s green(color of Life) and white(color of Purity)!
4) Eat one slice twice daily for health maintenance and 2 slices four times a day for illness
The Penspore System® is optimized for use with Cuzco Copro Gold®. Both Products are available from your nearest Eliminates Network Associate or at www.peruvianpasture.com.
SPECIAL INTRODUCTORY OFFER!
Buy 3 months supply of the Penspore System® for only $89.99 when you buy 3 months of Cuzco Copro Gold®!
As always with our products, your complete satisfaction guaranteed or no money back!
Not to be used by those with a penicillin allergy
Monday, April 13, 2009
Doctish-English Phrase Book
Doctish-English and English-Doctish Travelers' Phrase Book-- Introduction and Initial Lesson
Doctish is a dialect of Medicalese in wide use, however misunderstandings commonly occur with its use. Despite CMS mandates, there remains insufficient availability of translators due to scarcity and expense. Many phrases seem to have the same meaning in English but mean something else entirely. In addition, a superficially similar but unrelated language with many dialects (Alternivarian) causes confusion through similar terms with bogus meanings [ed. note. Although Alternivarian often has Medical or Medicalese appended to its name, it is an Alien toungue from another universe with scant connection with physical reality].
This guide will be published in installments so as to maximize your learning experience and our revenue.
Lesson 1 Common expressions
Doctish phrase / Plain English translation
Hello, I'm Dr. ______. / Let's get on with it. I only have 7 minutes
Who referred you? / Who is to blame?
How can I help you? / What can I do to you?
How did it happen? / You did what?
Which toe is it? / I'm blind.
Where do you hurt? / Where will you hurt even more in a minute?
Lemee feel it. / Minute's up.
Does that hurt? / Stop screaming!
We need to run some tests. / I'm hear lawyers' hoofbeats.
We need to do a diagnostic procedure. / I have a Porche payment due.
This won't hurt a bit. / This will hurt.
You will experience some discomfort. / This will hurt a lot.
I'll give a few pain pills for home. / This will hurt more than you can imagine.
The results are back. / Oh, oh.
I'm not certain, but... / I'm certain.
Do you have an advance directive? / You're toast.
Is there anyone else I should talk to? / You're toast and I need to butter up the next of kin.
I'll send a report to your regular doctor. / I've run out of procedures to do on you.
You can follow-up with your PCP. / Not my problem!
Doctish is a dialect of Medicalese in wide use, however misunderstandings commonly occur with its use. Despite CMS mandates, there remains insufficient availability of translators due to scarcity and expense. Many phrases seem to have the same meaning in English but mean something else entirely. In addition, a superficially similar but unrelated language with many dialects (Alternivarian) causes confusion through similar terms with bogus meanings [ed. note. Although Alternivarian often has Medical or Medicalese appended to its name, it is an Alien toungue from another universe with scant connection with physical reality].
This guide will be published in installments so as to maximize your learning experience and our revenue.
Lesson 1 Common expressions
Doctish phrase / Plain English translation
Hello, I'm Dr. ______. / Let's get on with it. I only have 7 minutes
Who referred you? / Who is to blame?
How can I help you? / What can I do to you?
How did it happen? / You did what?
Which toe is it? / I'm blind.
Where do you hurt? / Where will you hurt even more in a minute?
Lemee feel it. / Minute's up.
Does that hurt? / Stop screaming!
We need to run some tests. / I'm hear lawyers' hoofbeats.
We need to do a diagnostic procedure. / I have a Porche payment due.
This won't hurt a bit. / This will hurt.
You will experience some discomfort. / This will hurt a lot.
I'll give a few pain pills for home. / This will hurt more than you can imagine.
The results are back. / Oh, oh.
I'm not certain, but... / I'm certain.
Do you have an advance directive? / You're toast.
Is there anyone else I should talk to? / You're toast and I need to butter up the next of kin.
I'll send a report to your regular doctor. / I've run out of procedures to do on you.
You can follow-up with your PCP. / Not my problem!
Subscribe to:
Posts (Atom)