“Knowing that here on earth God’s work must truly be our own. John F. Kennedy, 20 January 1961
From Sombrero, October 2009
My mother once answered the front door and encountered two Jehovah Witnesses. She was a Unitarian but remained polite, calmly stating she was not interested. One of the Witnesses then said, “Don’t you want to live forever?” My mother, not having a good day even before the doorbell rang, looked the Witness in the eye and retorted, “Certainly not. I can’t imagine anything worse.” She then witnessed speechlessness of two Witnesses.
I am appalled at the lies stating the health care plan will have “Death Panels” deciding the fate of older Americans. I’ve euthanized 12 companion animals; I allowed my parents to die naturally. I know the difference far better than those who argue against the plan. I was respected as a neurologist with the knowledge, skills and willingness to deal with families of patients with severe or irreversible brain injury, issues where a patient’s death was either likely or the best option. It was tough, thankless work that wasn’t paid for, often unappreciated, but I took charge and did it well when it needed to be done right. The elderly are far more worried they will be kept alive on machines too long than having the plug pulled too soon. A family friend with severe neuropathy feared he would suffer the fate of Terri Schiavo and be kept alive against his wishes. Government run medicine? How about the Republicans trying to bypass the legal next of kin and dictate Ms. Schiavo’s care despite the American Academy of Neurology’s amicus curiae brief? Where was the outrage? I was an expert in dealing with coma and knew cold the probabilities of improvement. Frist should have lost his license and been fined after his video diagnosis; he and those who voted with him should have been censured. To those who still maintain this was a wrongful death, Schiavo’s brain weighed 615 grams at post.
Many state “high quality care” as if repetition established validity, rather than definitions, measurements and improvement. We need local outcome measures for central line insertion and care, ventilator and catheter-associated infections, pre-op antibiotic timeliness and post-op wound infections, hyperalimentation, carotid endarterctomy (CEA) and other high risk procedures. Alone, in 1984, I discovered major CEA complication rates averaged 15% in 3 hospitals; knowing that, I dramatically decreased my surgical referrals and only to the surgeon with the best outcomes.
The above procedures should be standardized, because cookbook medicine gives predictable quality. Surgeons have their own op trays; each of us dictates a standard way. Isn’t that cookbook? Want liability reform? Standardize, prove effectiveness with data, define outliers, learn from outcomes and errors and share the learning among the profession. That means count, analyze and improve.
I call upon all physicians to count something in their practice that bugs them. Count it fairly, but count. Send the counts to me (qssm@comcast.net) or Steve Nash. For a defined period of time, count formulary hassles. Count the minutes spent on hold or talking to insurance companies. Count the dollar cost of tests you do that are defensive medicine. Count the number of days of futile care in ICU or days’ hospice care is delayed. Count the per cent of patients in the ED who should have been seen elsewhere. Count the number of true life saves in the trauma unit. Count the number of people sent to the trauma unit who could have been handled elsewhere. Count the number of patients whose problems relate to their lifestyle. Count the number of post-op infections. Count the 15 day non-elective re-admission rate. Count the per cent of your patients with no health insurance. Count the dollars of your billings that aren’t paid. Count the number of patients who admit to alternative medicine. Count the number of times a day you say you are quitting.
The way I see it, we can be “poor me” victims or we can take control with hard data that we collect. The data won’t be perfect, but it beats complaining and doing nothing. And I promise you this: if Steve and I get enough decent data, we’ll go public.
If we resent insurance companies or the feds getting into medical practice, then we must prove what we do and prescribe works. If we disagree with a formulary or non-coverage, then we need clinical data, not polls, for proof. Ineffective treatments must stop, even if it costs money or referrals. Alternative medicine should be held to the same scientific standard that we should be abiding by. We all know procedures and treatments that shouldn’t be done, but still are, because nobody wants to be the enforcer. Count those, too. I’m counting the percentage of obese middle schoolers and the number of teenagers who die in MVAs, about 12 annually in Pima County.
I enjoy tutoring math (7 years), backpacking in Alaska (5 trips), chasing total solar eclipses (11 seen), canoeing the boreal lakes and rivers of North America (83 trips), hiking the AT (530 miles) and visiting the National Parks (41). I would enjoy helping improve medicine using my unique skills. But I have to do it now, while here on earth, because like my mother I don’t believe the Witnesses.
Boreal B[l]og 
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