Archive for July, 2012

THE DEMENTORS AMONG US

July 22, 2012

On 5 June, I took my telescope, a camera, and a videocamera, all with solar filters, to the local medical society, and showed about 100 people the transit of Venus, at the same time shooting video, taking pictures, and answering questions.  This exceedingly rare event occurs in pairs, 8 years apart; the next pair will occur 105.5 years from now.  Only Venus and Mercury, inner planets, can cross the Sun as viewed from the Earth.  Of the 100 who came, nobody knew it would be the last time I would be involved in a local medical community event; from now on, before our move next year, I will be only a patient, and hopefully not too often.

The transit was not as beautiful as many astronomical events I have seen, but it is so rare that nobody alive today will see it again, including the baby who looked through the eyepiece of the telescope; his grandchildren, should they live long enough, will.

TRANSIT OF VENUS, 5 JUNE 2012, WITH SUNSPOTS VISIBLE

A picture I took of the transit appeared on the Society’s magazine where I was once a columnist until I resigned last spring, because of reasons explained in the link.  It was a beautiful picture, and it was a good way to leave medicine, as a volunteer, who took a good photograph of a rare event, and shared it with the members.

Everybody who came was nice, except for a few comments, that while were not nasty, I could have done without.  One man, whom I know well for his right-wing beliefs (even as he gets AHCCCS, Arizona’s Medicaid) asked me the distance it was to Venus, and I said about 26 million miles.  He said, “Wow, that is less than the national debt.”

Why does politics have to be brought up during an exceedingly rare astronomical event?  The distance to alpha-Centauri in miles is greater than the national debt.  So what?  We have the national debt for a lot of reasons, some of which I think are important (Medicaid, Social Security, Medicare, FAA, FDA, NIFC (National Interagency Fire Center, which saves lives, towns, and houses) FEMA etc.), some of which are not (Iraq, Afghanistan, aid to dictators, farm subsidies, tax breaks for millionaires).   But it sucked a little happiness out of me.  Dementors do that.

Another person came whom I consider a true enemy.  The person has never once laughed in my presence in the 35 years we have known each other.  Not once.  The individual does not believe in evolution, vaccination, climate change, and thinks there should be no government involvement in medical care.  Just seeing this individual depresses me.  That is a  Dementor.  I was polite, and while that person asked good questions, there has been “too much history,” and too many hateful comments from that individual for me to let down my guard.  Since this is likely the last time I will likely ever see this person, or anyone else there, I sucked it up for 2 hours.

A few months back, my wife and I had dinner with a neurologist friend and his sister, a retired nurse.  She had worked in emergency departments, and was vehement about those who misused them.  This happens.  I was up in the middle of the night a lot, caring for drunks, helmetless people who had motorocycle accidents, people who had not taken their anticonvulsants, and were in a state of continuous seizures.  Most of these people did not have insurance, and I didn’t get paid, although I could have been sued for everything I had, were I wrong.  That is part of a physician’s life–caring for many people come to EDs for conditions that they do unto themselves.

This woman we had dinner with felt that those patients wasted time, money, and effort, should have not been rescued, but left to die on the street.  Really.  A nurse said that.  My wife was shocked; I had missed that part of the conversation.  Well, Ron Paul also said that, too, and was loudly cheered by many, who if they have no insurance, are only a drunk driver, appendicitis, a kidney stone, or viral meningitis away from being in an ED without money and 5 figure costs.  My wife said if we again had dinner with the neurologist, and his sister came, I would go alone.  We left the dinner depressed.  Dementors do that.

Last March, in North Blind on the now dry Platte River, I was in my third year as a volunteer tour guide for the Sandhill Crane migration.  I was in the lower level of the blind; my co-guide had never been there and wanted the upper level, which had better views.  I had a family of four with two tweens, who were bored.  Their mother wasn’t interested, and only the father was taking a few pictures.  It was a good show–not spectacular–but good, and the kids obviously wanted to be elsewhere.  I couldn’t teach about Crane behavior, because they weren’t interested.  I guided 20 times during my stay, and this was the only time I left the blind depressed.  In a place where you can see cranes in fog, snow, close up, or 50,000 in the air above you, darkening the sky, with a haunting call that I simply love, who have been on Earth for nearly 10 million years, where it is one of Jane Goodall’s top 10 sights, and where the governors of Colorado, Nebraska and Kansas came one night, to have a bored family was a real downer.  They were Dementors.

EVENING ON THE PLATTE, MARCH 2012.

Twenty years ago, I helped a man on the Fall Lake portage in the Boundary Waters.  It was his last portage before returning home to Miami.  He had had rain, poor fishing, bugs, and not a good time.  I thought the weather had been fine, the fishing good, and the bugs non-existent.  I helped him get his gear across the portage and wished him well.  He was a Dementor, too, but the beauty of the Boundary Waters was strong enough for me to ignore his complaints.  Indeed, I parried every one of his comments; when he came to insects, he said “And the bugs!!!” He then looked at me and said, “Or are you ‘in’ to them, too?”  No, I am not “in” to bugs, but I recognize their presence, and I realize that they limit the number of people in the wilderness certain times of the year.

I’ve had my Dementor moments; many of us have.  But there are some who are always Dementors, and I try to avoid them if possible.  If they persist, I change the subject.  I had buttons made commemorating the Transit of Venus.  I didn’t make one for myself, for I only wear solar eclipse buttons,   The Dementor at the viewing got a button and liked his.  I almost wished I had seen that.  Harry Potter had the gift; maybe briefly, I had it, too.

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UNCOUNTABLE AND COUNTABLE COSTS

July 12, 2012

I needed a prescription refill for a medicine I have taken for 3 years.  My prior physician allowed calls to be made by the pharmacy to refill the prescription, so I didn’t have to go to his office to get one.  Unfortunately, he left practice to do concierge medicine.  I didn’t wish to pay $1500 annually for 24/7 access to a physician.  For years, I thought that went with the territory, along with not charging for the thousands of telephone calls I returned.  I can’t tell you how important it is as a patient to get a physician’s call.  I can’t put a dollar value on it, other than to say a big “Thank You” to the physicians who have called me back.  That has no dollar value, either, but I think they appreciate it.

Physician #2 left practice to become a hospitalist, because he was unable to afford continuing the practice he was in.  Physician #3 required a visit to refill this particular prescription, which is neither addicting nor dangerous.

We don’t have standardization in medicine for those things that need to be standard.  We disparage it as “cookie cutter” medicine, when in fact, cookie cutter approaches ensure good cookies.  “People are different,” I hear. No, we really aren’t as different as many would like to think.  Most men have similar anatomy; most women have similar anatomy.  Our physiology is the same, and our bodies react to insults in predictable ways.  That is why we study pathology.  Surgeons take out gall bladders the same way, and as a neurologist, I had a standard history and “cookie cutter” neurological exam.  I seldom forgot anything important.  What does differ is how we personally react to disease, and in a short office visit, time spent on that is virtually nil. I practiced for 20 years, so I know the difficulty in trying to diagnose, treat, and understand the patient’s reaction to an illness in a short office visit.

I drove to the physician’s office and asked for a prescription for 2 pills twice a day, 120 pills in all, with 5 refills.  I had my request written on a piece of paper.  I had to come back 2 days later to pick up the prescription.  The office could have sent it, but that requires something to be done by somebody else.  If I do it myself, it is more likely to get done right. Prescriptions can be lost and not sent.  It is only 45 minutes round trip, so it is nothing important, only my time.  When I returned, two days later, I was given my prescription, written for 1 pill twice a day, not 2, as I had asked for, but 120 pills in all, with 3 refills, not the 5 I had asked for.  I could have asked for the prescription to be written the way I had written it down, but the 120 pills a month was right, so I took it to the pharmacy, explaining carefully that this was a new prescription from a new doctor, who would be henceforth refilling future prescriptions.

The pharmacy normally calls me when my prescription is ready.  They didn’t call.

So, I walked to the pharmacy, 10 minutes fortunately, and was told that I could only get 60 pills, not 120, because the prescription was written for 1 pill twice a day. They said they couldn’t reach my doctor, but they mistakenly had called my previous one, who was no longer in practice, despite my having told them I had a new doctor, whose name and telephone number was on the prescription.

The pharmacy said they would call the doctor’s office.  I left the pharmacy empty-handed, because if I got 60 pills, I would have to explain to the insurance company why I needed a new prescription, should I again want 120 pills, which I do. The next day, the pharmacy said nobody picked up the phone.  I drove to the office, handwritten note again, and asked for another prescription, either to be called in or given to me to pick up.  While there, I asked if they had been called.  They said no, and they answer, so I am not clear whom the pharmacy was calling.

The following day, I got the prescription filled, a week late.  What would have happened if I did not have extra medication?  What would happen if I were 85, no medical background, not thinking clearly, because I was 85 and in ill-health, and on several medications?  I might end up in the hospital, which would be a five figure cost, because of breakdown of a really simple system.

I ask:  what is so difficult about writing and filling a prescription correctly?   Frankly, insurance companies should be trying to fix bad systems in medicine, which would save them far more money, than worry why a 63 year-old is taking 120 pills of Drug X every month, the same amount, and is doing just fine.  I am unable to refill a week in advance, should I go out of town during the time the refill is “allowed.”

No, insurance companies should fix bad systems, like ensuring antibiotics are given in a certain time window before elective surgery, which would save them far more money, as would standardizing the antibiotic. When I was medical director, we met the time window only a quarter of the time, and we had a post-op infection rate 4 times higher than Salt Lake City.  That amounted to about 20 extra infections a year, or a few hundred thousand dollars.  Those are all facts.  We had one doctor use a very expensive antibiotic for his patients, increasing the possibility of resistance, and I was unable to get the Surgery Department to deal with it.  We also had 3 wrong-side surgeries: on the head, knee, and bowel.  The first one was not communicated to the internist following the patient, who resigned from the case, he was so angry.  Bad systems cause trouble.

My pharmacy experience is is one reason why so many of us are so angry about medical care today.  It doesn’t work properly.  Systems are broken, and it costs money and time, and makes people frustrated and angry.  While time is supposedly money, it isn’t to me.  It has uncountable worth.  Unnecessary anger and frustration are uncountable expenses.  Being uncountable does detract from their importance, a fact lost upon many today.

Thirteen years ago, I bet my career on becoming one who taught people how to fix bad medical systems, and I lost.  Here is how medical errors have affected my small family:

My mother’s final illness began with a fainting spell.  She was taken to the hospital where we were told her CT head scan was normal. Five months later, 1500 miles from home, her rapidly progressive dementia led to a fall, breaking her hip, and she was delirious after surgery.  I had to fly to Portland, put my abulic (more than dementia, destruction of personality) mother, recovering from a broken hip, on a plane, and bring her home.  At the same hospital, we discovered she had refused the initial CT scan, and nobody had told us.  Worse, the attending physician later changed the note on the chart (the note that said “CT normal”), which is illegal.  Three more days (uncountable cost) were spent in flying to Portland (countable), to bring my parents’ car home.  My mother died soon after, so the error probably didn’t matter much, although the way she died still bothers me (uncountable cost).

My oldest brother’s meningioma was misdiagnosed until he went blind in one eye.  He is a professional photographer, so this is a significant issue (uncountable cost).   I am hoping the meningioma doesn’t grow further and kill him, because he refused surgery.  That might not have been a bad idea, given the location of the meningioma and given how complex medical procedures are.  After all, if we can’t deal with prescriptions properly, what is the probability of a successful operation?  Are there data? Or is it just anecdotal?

During my father’s final illness, he had low protein and edema so extensive that it literally wept through the skin on his legs.  Despite that, his nurses said he had heart failure.  I tried to explain to the head nurse that a lab test to measure protein was overdue,  that I was not the enemy, only wanting to ensure my father got the care he needed (uncountable cost, except for the lab test).  The response from the head nurse was “Let doctor take care of it.”

In my language, doctor takes a definite article.  For an unknown reason, omitting it annoys me.

I had a significant mistake made in my own medical care which led to 2 months of the worst misery I have ever experienced.  The medication for this condition is the one I have been trying to get at the pharmacy.

We argue about insurance reform, but we waste countable billions on bad systems;  suboptimal care, unnecessary deaths, and the uncountable cost of unnecessary frustration.  A family member of mine may need chest surgery and stay overnight in the ICU.  I will sleep there.  Many doctors would agree with my decision.  If you can possibly afford the time, and remember, my time is not important, you need to check everything that is done.  Medicine is complex, although we have other complex systems in society which work a lot better.  “We’re different from them,” say my colleagues.

Yes, we are different.  We don’t fix our bad systems, and we marginalize those who try.  I am proof of that.  Once I left medicine, I heard horror stories from just about everybody I spoke to.  Many of these may not be true, but tell me:  how many people each year die from medical errors?  We have estimates, but they are poor, which to me is a travesty.  With sampling or a census, ability to keep the findings from discovery, we could review each death from each hospital and sort it into:  definitely caused by medical error; significant, but not fatal, medical error; not significant medical error; no medical error.  Each chart could be reviewed, and we would have a superb estimate of the number for a calendar year by January 31 the next year.  Additionally, we would know what the errors were, and we could learn from them.  Legislation to do this was written by me, had 10 co-sponsors in the Arizona legislature, which was 8 more than the number of doctors who supported it.  The Hospital Association killed the legislation.

We physicians want malpractice reform, yet we act as if bad outcomes are just bad luck.  They are usually due to a concatenation of bad systems that can be fixed, not tolerated.  How many and what kind need only to be counted.  To people like me, who live and breathe numbers, “count” is always modified by the adverb “easily”.

Instead, I have encountered verbs: to marginalize, to ignore, to frustrate and to fail.

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METRIC FLUENT?

July 9, 2012

I happened to have the TV on, during the Tour de France, when I saw and ad for a $50 gold coin, which was going to be sold for $9.95.  The coin, which looked like the 1 ounce gold coin that the US Mint made, was clad in 14 mg gold.  “Clad” means to wear or to cover.  Fourteen milligrams of gold were used to cover the coin, so it looked like the real thing.

Looks mean a lot in today’s society.  We have to get rid of gray, have white teeth, be the right weight, have the right figure–in short, be debonair.  What is inside a person, which really gives them lasting beauty, does not appear to be to be nearly as important.

So, how much is 14 mg of gold worth?  If you are metric fluent, you know immediately this is a bad purchase.  I might call it a scam.  With a little work, you can determine how much of a scam it is.  Otherwise, you pay $9.95 for what you think is a real 1 ounce gold coin.  Don’t laugh; the company wouldn’t advertise if they didn’t think this was a good idea.  They will likely make a lot more money than I will this year.  After all, looks matter.

Let’s say gold is worth $2000 an ounce, an overestimate of course, but I want to give a clear overestimate of the coin’s value.  One of the problems with today’s math teaching is that many are so calculator dependent that they can’t estimate things.

How many grams in an ounce?  Oh, about 30.  The actual number is 28.35, give or take.  I’m writing this without looking up any numbers.  I know that a pint has 453.6 ml, and there are 16 ounces in a pint (which most students I teach don’ t know either, but hey, they look great in their miniskirts and low cut blouses and tight pants, right?)  Divide 16 into 480 and you get 30, so my estimate is not far off.  And divide 16 into 453.6 and you get 28.35.  Use a calculator if you wish.

Now, you have to get to milligrams, which means you multiply grams by 1000.  This is what makes the metric system so nice to use.  We don’t have 7/16 th of a meter in most calculations, but do any carpentry, and you find sixteenths of an inch all the time.  OK, 30 gm of gold is 30,000 mg, and that ounce is worth $2000, or 200,000 cents.  It helps to convert dollars to cents, but one does not have to.  One may disagree with my opinion,  but so far, this is not difficult math.  That works out to about 7 cents per milligram gold.  You don’t need a calculator and 8 decimal places.  You need the ability to make quick estimates.  If you want to be more exact, 200 divided by 28.35 is not far from 210 divided by 30, and the latter is 7.

Don’t laugh.  Last spring, I saw a math teacher write down the tangent of 67 degrees to 8 decimal places, when he only needed one.  Since the tangent of 60 degrees is sqrt 3, the tangent of 67 degrees ought to be at least 2 and likely a little more, but not 3.   I took a stab at it and was pretty close to the actual number.  Again, it is a matter of estimating, not looking up 8 decimal places.  I don’t expect many to know what the tangent of 60 degrees is, but I do expect high school math teachers to know, without a calculator.

Anyway, back to gold.  This coin has 14 mg or roughly $1 worth of gold in it.  The company is selling nickels with $1 of gold for $9.95.  I don’t know if shipping and handling is included).  How many people are going to buy this?  The guy selling the coin looked good, sounded earnest, and was absolutely sure you should do this.  Today, that counts for a lot.  All of us are subject to make bad purchases based on irrational approaches.  I sure am.

It’s just a question here whether paying more than 9 times as much for something than it is truly worth counts for you.

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WALKING AWAY FROM A BATTLE, SADLY AND QUIETLY

July 1, 2012

“When god created the horse, he said to the magnificent creature: I have made thee as no other. All the treasures of the earth lie between thy eyes. Thy shalt carry my friends upon thy back. Thy saddle shall be the seat of prayers to me. And thou shalt fly without wings, and conquer without sword; oh horse.” 

— the Qu’ran

And Ruth said, Intreat me not to leave thee, or to return from following after thee:  for whither thou goest, I will go, and where thou lodgest, I will lodge: thy people shall be my people, and they God my God.

–Ruth 1:16.

What is wealth? Being happy with what you have.

—The Torah

September 1963.  I begin 10th grade in a new school in Wilmington, Delaware, a southern leaning state.  Before class starts, we have the Pledge of Allegiance to the Flag.  We sit down.  Then, the homeroom teacher opens a Bible and begins to read.

I was stunned.  Bible Reading?  This isn’t upstate New York, any more, Mike.  You are in the South.  She read a few verses, then we all stood and recited the Lord’s Prayer.  Well (n-1) did, because having been raised Unitarian, I never learned it.  Within a week, I knew it cold.  Good thing, too, for the Supreme Court banned Bible reading after that.

Prayers in the school, before events were common.  Frequently, I would hear “let each of us in our own way, pray.”  I like that.  What I didn’t like was the leader ending it “in Jesus’ name”. when a good share of the school was Jewish, or me, a Unitarian, where it was said the only time the word “God” was spoken was when the janitor fell down the back stairs.

On Memorial Day, 2012, one of the Arizona legislators gave a speech, honoring “Christian veterans.”  I was appalled.  I was also angered.  I am a veteran who happens not to be Christian.  Did that make my service somehow less valuable?  What did being Christian have to do with military service?

Two months earlier, two Jehovah’s Witnesses came to my front door.  I listened politely, then told them that I did not foster my religious beliefs on others, and I did not appreciate their trying to convert me.  I asked them, using “Please”, to leave.  They did.  My late mother had a different approach, when the Witnesses said, “Don’t you want to live forever?”  My late mother, a Unitarian, said, “Certainly not.  I can’t imagine anything worse.”  The Witnesses were tongue tied.  That might have been a first.  My late father was fond of saying, “My prayers were answered, and the answer was ‘NO’.”

On a language Web site, a Muslim from Algeria looked at my profile, saw that I didn’t put a religion, only that “We are stewards of the Earth.”  He wrote me, saying while I had a good profile, it was a shame that I would be going to hell.  I seethed but stayed silent.  I knew I would never change his opinion, so why waste his time?  Not responding is one of the best ways to stop a conversation.

On this same Website, religion seems to keep appearing as a topic.  I was teaching English to a Russian woman from southwest  Russia, near the Caspian Sea.  One Saturday, I asked her what she was doing that day.  The answer was “Not much. I’m Muslim.”   She quickly followed with, “does that bother you?”

It didn’t….until later.  I am reading the Qu’ran, and I have found many Muslims on this language site who have taught me a great deal about their religion.  Unfortunately, this woman then said, “I hope you will convert.”  That bothered me, because I don’t ask people if they will convert to my way of thinking about religion.  I said, that I couldn’t believe in Allah, although I liked many other aspects of Islam.  She replied, “You’re wrong,”  two of the most charged words in the English language, almost guaranteed to make somebody angry.  I just said, “Whoa…..stop this right now.  This is your opinion and not mine.”  She did.  I wrote her later, and told her that a lot of Americans would have immediately ended the conversation permanently.  Little did I know I would be one of them.  I mentioned in my letter that 9/11 was devastating to how many Americans felt about Islam, to which she countered: “The US government caused 9/11 for oil.”

That was the final straw.  I had not brought up religion.  She had.  And in the space of 18 hours had managed to want me converted, said I was wrong, and espoused a conspiracy theory.  I told her that if she did not admit the possibility of being wrong, she would not hear from me again.  I got back, “You just don’t want to hear the truth.”

And so ended my teaching experience with her.

All religions offer solace to their believers.  The most beautiful writing from three of the world’s great religions is at the top of the page.  Those who live their faith are fine people.  Those of us who believe how we live our life defines us as human beings can also be fine people.

I have noted throughout history that was once God’s will is now understandable. People used to die from infected hangnails, or mild gunshot wounds, like President Garfield.  Now, we can treat these problems.  Rheumatic Fever and death from diphtheria or acute lymhoblastic leukemia were “God’s will,”  until the advent of penicillin and chemotherapy. Hemoptysis from bronchiectasis was God’s will until we discovered it was M. aviae complex, and treatable with triple therapy.  Untreatable cleft palates were God’s will, until plastic surgery.  We don’t see these problems much any more.

I believe in good science, which self corrects and moves forward, each generation standing on the shoulders of the previous generation and looking further.  I also believe there is a great deal that is unknown and to date inexplicable, There are many ways people deal with the unknown.  I am curious about it and want to know why.  Others use faith.  If I liked their way better, I would take it.  I don’t.  And I don’t ask them to take my way.  It is impolite, it is not going to happen, and it will make them angry.

To the legislator who honored Christian Veterans, I have these comments:  Jews, Muslims, Mormons, Buddhists, Wikkans, Atheists, Agnostics and others like me make up this country and have served honorably.  Honor those who serve.  Keep religion out of the discussion.

Faith, or lack of, is deeply personal.  Honor others’ views, unless or until they cross a line that you find you cannot tolerate.  Then walk away, sadly and quietly.

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