Boreal B[l]og

A recent op-ed in the New York Times (“This was not the good death we were promised”)  was a poignant piece written by a woman whose father recently died from pancreatic cancer.  Note: I use die and death here, not pass, pass on, pass away, cross to the other side or expire.  There is a reason to use die and death, finality.  Pass on and crossing over have the sense of traveling somewhere; when I die, someone else is going to be moving my lifeless body.  I’d like to believe I will travel to the Rainbow Bridge, but I will cease to exist.

The elderly man developed severe pain the night before, as it would happen, he died.  There was an hour delay reaching a nurse (not the physician) who told the family to give the man an extra oxycodone, the only pain medicine he had received.  The family became desperate and found some lorazepam and morphine from a prior hospitalization of another family member and gave them, too.  When the nurse came at midnight, she had no analgesics with her.  Eventually the morphine wore off and the crisis nurse who was supposed to come by in the morning didn’t because she was ill. The morphine pump that the patient needed, and one of the nurses was surprised that he never had one, came at 4 p.m., 8 hours after it was expected.  By then, the man was comatose and died shortly thereafter.

He died at home, in pain, although realistically, his last few hours were spent comatose. That doesn’t matter.  He became comatose while the family was trying to get help, they didn’t say their good-byes, and from their view, his last hours were spent in pain.  The author I suspect felt guilty that she failed her father, that she didn’t say good-bye, and that his last hours were so difficult.  That I can relate to.  My parents both died quickly and not in pain, but I still felt guilty about what I did and did not do.

This death should have been easier, recognizing that dying is not easy for any loved one.  The man should have had plenty of pain medicine available and the family needed to know how to give it.  We have a major problem with pain in this country: on one hand, we allowed an opioid epidemic to occur based on the idea that pain was a 5th vital sign, which it never should have become.  Chronic pain, especially “failed back syndrome,” should not be treated with narcotics, because they don’t work and risk addiction. I still am astounded the medical community and accrediting companies once felt that no patient should suffer pain.

On the other hand, we often under treat cancer pain, thinking, inappropriately, that patients will become addicted.  They won’t. This sort of pain does not lead to addiction; the patients will soon die. They should receive whatever necessary for their pain, even if it suppresses their breathing so that they may get pneumonia or even die.  I thought we had dealt with this issue forty years ago.  Palliative medicine specialists have told me that it is possible to deal with end of life pain without using Death With (DWD) laws, such as in Oregon and four other states.

I disagree, know of those who saw the deterioration of their body, felt the pain, and did not want to go through the long, difficult natural process of death.  I respect that; much of medicine is determining where nature should and should not take her course.

Nobody from palliative care physician saw this man in his final hours. The author wrote that she was never aware that 24/7 care was based on staffing, not a promise, as she had been led to believe.  Hospices self-evaluate their pain management, and this hospice weighed in at 56 per cent.  The head of the National Hospice and Palliative Care Organization was quoted as saying that “good hospice experiences ‘far outweigh’ bad ones.”  Their organization should remain silent on DWD until they have their act fully together on the “bad ones.”

End-of-life care is difficult, although there is lack of pressure of finding a cure or healing. The problems here were lack of planning, limited staffing, lack of follow-up, and lack of family education, to name four.  This man was close to death, since with virtually no care, he survived 22 hours after the crisis started.  It wasn’t like he would require many resources.

Am I being too hard on my colleagues?  No.  Do I have a bone to pick with some?  Yes.  Stories like this are likely to increase as more hospices become for profit, for staffing cuts are easier to make than system fixes that can address problems.  I know such, because I bet my latter medical career on helping medical personnel fix bad systems, and I lost. With family education and a morphine pump, this man would likely have had a peaceful death.

Back to DWD:  at their time of choosing, alone or with others, those who have been suitably screened want to be able to say “no more” and take something that puts them into a coma where they will die. This has been vigorously resisted as “assisted suicide,” but such  is pejorative, because the word “suicide” is interpreted to mean an otherwise healthy (but depressed, perhaps) individual ends their life and would not be expected to die soon. Instead of allowing someone to choose their peaceful end surrounded by family, we admit some terminally ill patients to hospitals, pump on their chests, do heroics, ignore Durable Power of Attorney papers, leading some, as the husband of a patient I once consulted upon to commit murder-suicide, dying alone.

I read about the double death weeks after I saw the woman.  She had a metastatic brain tumor, the treatment was minimal, other than radiation, which was going to buy her a short period of time. Her husband challenged me that if I couldn’t do anything, he would take care of the matter. They both survived the concentration camps but not cancer. Yes, we all have to die, but there are good deaths and bad deaths.  Theirs were bad.

DWD is for those who want control over the end of their days and don’t want to take their chances with hospices, whose care has more variability than it should, especially with the rise of for profits.  DWD has many safeguards, with two physicians—one not a treating one—certifying that the patient qualifies, and then having a prescription written for usually a barbiturate.  The patients are followed by volunteers, on call, who will be there if desired if the patient is ready to die.  Since 1997, since the law was passed, 1250 people have died using it.  One-third of the people who get the drug never use it, dying naturally.  The “thousands who would die” took twenty years to reach 1000, and every year in the state, 32,000 natural deaths occur.  Those are the facts.  DWD is fewer than 0.02% of the natural deaths in Oregon.

Richard Rettig, a medical historian, wrote, “the moral cost of failing to provide lifesaving care was deemed to be greater than the financial cost of doing so.”  He was referring to ESRD (End Stage Renal Disease), why dialysis is covered by Medicare.

The moral cost of failing to provide end of life care is greater than the financial cost of doing it.

I’ve looked at the Hospice Data Collection, and I don’t see anywhere how anyone determines the patient died a “good death.”  A German movie I know defined ein Schöner Tod (a good death) as not dying alone. I would add adequate control of pain, patient and family’s questions answered, no system failures in the final week of the patient’s life, and not dying alone.

About a month ago, I felt some scaling on my cheek, saw abnormal skin, and realized it was time to see the dermatologist long before my annual appointment.  Here in Oregon, I get annual appointments; in Arizona, I was seen every six months, which I needed, because I had lived there for decades, the sun angle is higher and there is more sun exposure in general.  Arizona is a hotbed of skin disease.  Worse, I grew up spending a lot of time outdoors, where my parents told me to go outside and play in the sun (along Route 20, I think the pediatrician told them).  Vitamin D was good: we all heard that. I developed many actinic keratoses as a result of all that “good” sun. The four basal cell carcinomas I had were more dangerous, but at least somebody found them in time and cured them with chemotherapy ointment.

Skin cancer is not a big deal if one has periodic checks and gets treated early.  That costs money, requiring insurance and access to dermatologists.  Unfortunately, in the scheme of needed body care, dermatology and dental are not high priorities. If one doesn’t have insurance or access—either one—there is a risk that a melanoma will be missed until it presents with a seizure perhaps, meaning it has metastasized to the brain, or a basal cell cancer presents by eroding deep into skin and bone, treatable only by extensive disfiguring surgery.  The father of a friend of mine died after surgery to try to clear a basal cell cancer that had eroded through his face. My actinic keratosis was treated in twenty seconds of liquid nitrogen therapy.  The blister on my face will be healed in a week.  I won’t discuss dental care other than it is necessary for good health as well as creating a good impression.  Americans are very teeth conscious.

Strep throats are nasty but are easily cured.  Left untreated, because someone cannot afford a doctor’s visit, they will still get better.  Unfortunately, untreated strep throats may have complications as peritonsillar abscess, mastoiditis, retropharyngeal abscess, rheumatic fever with subsequent scarring of the heart valves, and acute glomerulonephritis with kidney failure.  A big reason why I never saw mastoiditis when I practiced medicine was that American children get early treatment for strep.  Take away access to treatment and these diseases will return.  Syphilis has returned to Eugene.  Go to the Third World and you will see people with diseases we Americans never get (polio, tetanus, congenital rubella) and trauma that our “restrictive” safety regulations prevent.  No, we aren’t perfect; every fourth of July, 11 Americans die from mishandled fireworks.  A kid out here blew off his hand last week: “I thought I would have at least two to three seconds.”  He might have had that; people aren’t good judges of time. He now is young with one hand.

We need to ensure people at both ends of the age spectrum have access to affordable, good quality medical care, and then work on those in between.  I had thought we were making progress towards the first until these past few months, when there is now a real possibility we will go backward at least with children on Medicaid.  I would be very naive were I to think Medicare is immune from the chopping block in some form, either.  There are far too many who don’t think they should be taxed to pay for someone else’s medical care, even as these same people are medical care consumers.

I would hope that out of the shooting of Mr. Scalise, there might be an awakening in some circles that each one of us is one bullet away from an unexpected, unforeseen medical catastrophe.  A psychologist I know would have called this being hit with a two by four on the side of the head moment.  I would expand the list from a bullet to one malignant cell, one blood clot, one ruptured vessel in the brainstem, one bacterium, one virus, and one drunk driver.  While some of those have risk factors, virtually none is predictable.  We can screen for cancers, and we can eat right, and that will help, but I, like all doctors and nurses, have seen my share of horror stories: the 29 year-old with aggressive colon cancer, the 24 year-old runner who died after uncomplicated surgery for appendicitis, the 41 year-old man who died from a preventable heart attack, because he couldn’t afford to be screened, a 17 year-old high school student in my class, beautiful, smart, who died after routine thyroid surgery.  Bad stuff can happen to anybody, and not being able to get or to afford care makes a bad situation far worse.

Catastrophes aside, day to day preventive health care gives peace of mind if something isn’t found, and while peace of mind doesn’t have a dollar sign, it has worth: perhaps the pursuit of happiness that is discussed every July fourth.  If something is found early, like a melanoma, an unsuspected heart problem, a small malignancy in the colon, cervix, or prostate, it can be dealt with far more easily, successfully, and yes, cheaply, than waiting until the individual has Stage IV disease and is “found down” or struggles into an emergency department with extensive disease, a bad prognosis, and yes, very expensive, too.

I’m concerned about the 40% of our children covered by Medicaid.  The proportion is not surprisingly higher in the poor, especially in people of color.  A disturbingly large number of children have episodic Medicaid coverage, which is not good for those with chronic diseases, like asthma, who need regular monitoring.  I’m concerned about vaccination status, lead poisoning, and proper nutrition.  If we miss the timeline on these, these children will never catch up and be doomed to a second or lower tier existences.  If we have too many children in this country, which I think we do, then we need more available birth control, not defund Planned Parenthood or take away medical coverage.  What gives?  Let me say it right out:  Paul Ryan is a devout Catholic, and he is going to push the Church’s rules (hopefully not pedophilia, although that is a cheap shot, I admit) down our throats.  Let me keep going.  The Affordable Care Act was signed by a black (half black) president, and that is just too much to tolerate.  In one of my lesser moments in life, my father once accused me of being incredibly irrational.  Yes, I was.  And I learned from it.  (So was my father irrational when it came to the Catastrophic Care Act, which taxed the elderly.)  It’s one thing when I’m irrational.  I hurt the people around me, a very small number.  The Republicans in power are hurting a third of a billion (not counting the rest of the world), because they couldn’t stand a black president and any of his legacy.

What are they thinking?  Do they want more poor people who need more medical care?  Because that is where we are going.  Or do they honestly want to see people die because they aren’t pure in some form?  What is it that they want?  Is it government out of our lives altogether?  Why, when a majority of Americans want Medicare to be left alone, should it be changed?  Why, when a majority of Americans want background checks for firearms, should they not be allowed?  Keeping Medicare is not irrational; wanting background criminal checks before one purchases a weapon is not irrational.

Not making needed preventable and other medical care affordable to every man, woman, and child in this country is irrational.  Not only is it morally right, it will save money in the long run.  Want to save more?  Fund Planned Parenthood and increase family planning.  Wanted children are healthier and will be more productive citizens. It’s necessary, it’s fair.

It’s rational.

“Politics is not just about power and money games, politics can be about the improvement of people’s lives, about lessening human suffering in our world and bringing about more peace and more justice.”  Paul Wellstone

I miss Paul Wellstone.  The American Health Care Act (AHCA) was pushed through the House at lightning speed.  Fortunately, House bills don’t go directly to the President.  There is the Senate.  The idea, however, was to get this bill passed, so the representatives could go back to their districts without dealing with angry constituents.

Oh, there will be some angry confrontations to be sure, but unlike the roll out of the Affordable Care Act, there will be no debate at town halls.  Then representative Gabrielle Giffords had raucous ones, including one that ended rather quickly when a firearm fell out of a guy’s pocket.  This was, after all, Arizona.  I’d say that Giffords was shot by Tea Party activists, but that isn’t true, not that the truth matters much in today’s America.  No, she was shot by a mentally ill individual who had access to a gun (another story that is going to likely happen again in today’s America, but I won’t discuss that issue here).  The Tea Party was thrilled, I’m sure, since they have no shame, and they are thrilled that the hated “Obamacare” is again repealed.

It is obvious that the Republicans had no health care plan ready for rollout, or they would have had it on the table 3 January, had it passed and to the Senate on 21 January, if they worked on Saturday, which many of “the little people” do.  This bill was cobbled together with little input from many, including other Republicans, who are likely going to be wrong about the anger of their constituents, since the Senate will not pass this bill as it stands.  There appear to be three groups of Republicans: those who like the bill, those who think it didn’t go far enough, and a small, but important few who think what we had was worth preserving.

There is a lot about the AHCA that I could address, but I will stick to five comments.  First, what people call it is important.  A significant number think Obamacare and the ACA are different, and the Republicans succeeded in making “Obamacare” a hated name.  Shame goes to the Democrats and journalists who bought into that.  Currently, there is some effort to tell us not to label the AHCA “Trumpcare,” which Paul Krugman says we should.  I agree with him, even if I have to use the name.  I prefer Voldemort.

Second, the bill has a mandate that if somebody lets his or her insurance lapse, they must pay a 30% increase in premiums to get covered again.  This mandated tax—let’s call it what it is—will hurt many, those who don’t understand insurance, don’t get, open, or understand their mail, and may throw things out without realizing how important they are.  These very people—and there are many of them— stand to be hurt by an increase in premiums, and I suspect their health is normally not very good.  A lot them are poor, elderly, people of color, uneducated, unemployed or underemployed, who won’t be able to understand their coverage.

Third, the notion of à la carte insurance presupposes people know what medical problems they will have in their lifetime.  I’m a neurologist who trained until he was 32, knew a great deal about disease, and I would not have guessed the things I’ve had that I wouldn’t have suspected.  We don’t know what medical conditions we will have. Individuals don’t have that knowledge, Mr. Ryan. When they get ill, they want help and treatment, not to shop to compare insurance companies and enjoy a “free market” with “competition,” comparing plans in the comfort of their trailer home which isn’t paid for, and may not have food or heat.  People don’t have the knowledge to know what the insurance company is offering and more importantly not offering.  Those Mr. Ryan thinks will benefit from competition won’t, because they can’t understand the complexity of medical care.  No, I don’t want people trying to choose what medical conditions they want to cover. They can’t and shouldn’t.

Finally, catastrophic care should be covered, even if it once failed to pass, because it would have taxed only the elderly.  My late father, the epitome of a rational person, became totally unglued about the Catastrophic Care Act of 1988.  I didn’t dare mention it in his presence. Such conditions strike at any age and are almost by definition unpredictable. The biggest killer of people 15-44 is unintentional injury (read: accidents), double that of suicide, homicide, cardiac disease, and cancer, all of which are about the same.  The common causes of ED visits are fever, otitis media, open wounds, contusions, sprains and strains: 1 in 5 in the ED were not insured (in 2010), and given the heavy use of CT and MRI imaging, injuries are expensive to treat.

À la carte coverage, like insuring oneself for what one thinks he will need, should be banned.  As for those who believe men shouldn’t have to pay for women’s health care, this is a slippery slope for people like me who might say I shouldn’t have to pay for people who don’t eat right, smoke, chew, drink, have guns in their homes, don’t wear seat belts, are overweight, don’t exercise, take recreational drugs, and aren’t vegetarian, for a start.  It doesn’t work. We can vary premiums a little, but when we start treading into areas that people are genetically or physically unable to control, we are asking for trouble.  No, I can never get pregnant, but a woman can’t get prostatitis and has a lower incidence of cardiovascular disease than I do.  As for paying for birth control, I can’t think of many better cost-effective remedies, since fewer unwanted children takes pressure off young families, schools, jobs, and the whole health care system.  We ought to pay women for taking birth control pills and tax men who use anti-ED drugs, since we need fewer sperm floating around.

Finally, we need a single payer system, like the one John Conyers introduced again, as he has since 2003.  This would decrease overhead percentage dramatically, allow for standardization where it matters, require negotiation for drug costs, and track illnesses, treatment, quality, and yes—errors.  A single payer system wouldn’t cover everything, but it would cover what Medicare does.  It wouldn’t cover abortion, but it would cover contraception.  It would cover what is scientifically known and rapidly cover what appears to be known. Insurance companies could sell supplementals with varying deductibles, for those who wish them to cover those conditions not necessarily covered under the standard policy, ED drugs being my favorite for non-coverage, but hey, I’m willing to bargain.

My bottom line: repealing the ACA before knowing how many million would lose coverage  was heartless. People will die because of this bill, should it become law. Long term thinking would say providing medical care to the whole country would save money in the long run and be in keeping with our ideals.

At least the ideals we once had.

I had been satisfied with my internist.  She once saw me on short notice for a problem, which I really appreciated, but unfortunately left the mega-group to join a smaller local practice.  I decided to stay with the mega-group, since my records were there and I was seeing 3 other specialists there as well. A retired internist told me that a lot of doctors came to the mega-group and didn’t stay long.

On the appointed day, I arrived for what I thought was a Medicare Wellness Exam, taken back to the exam room by the medical assistant.  I gave her my unclothed weight, so as to avoid the issue I had at cardiology, where they took my weight fully clothed and then used that to compute my BMI to two decimal places.  One is plenty; too many feel that adding decimal places improves accuracy.  In some circumstances, it does.  This wasn’t one.

The medical assistant then took my history.  I am a surprised these days how many non-physicians not only have access to my medical information, but take it from me.  There was a time when we physicians actually did all this ourselves.  We didn’t have scribes, we dictated notes, and some of us even read them before signing.  It may have been slower, but all those people have to be paid, too.  I called people in from the waiting room myself, because neurologists learned a lot about a patient by watching how they arose from a chair, walked, spoke, shook hands, and sat down.  I diagnosed many with Parkinson’s before they ever reached the exam room.  I diagnosed myopathies when patients couldn’t get up easily from a chair, foot drops and hemiparesis from their gait.  Now, the exam room has become almost an inner sanctum, given by some of the routes I take to get into one.

Anyway, in these days of extremely busy physicians, I figured I better say whatever was on my mind in a hurry so it got into the record. The assistant then recommended a DEXA scan for my bones, which I thought odd, since I don’t have any risk factors I know of for osteoporosis except age.  But knowledge changes.  She finished and said the doctor would be right in, since the latter was done with the previous patient.

I waited 20 minutes.  That’s a lot in the inner sanctum.  Yeah, I know.  Doctors keep patients waiting.  I seldom did.

The physician came in and introduced herself.  I stood, as I always do, then sat down.  She then placed herself in front of the computer and started reading from the screen, first concern being my diazepam dosage.  I told her I took it for a GU condition where it was the only thing that worked (leaving out the story how I had discovered that, nobody else).  I told her I had tapered the original low dose more than 60%, but she was still bothered, because of federal regulations about this sort of drug.  She barely glanced at me, eyes instead fixed on the computer screen.

Diazepam is quite safe in low doses, yet we allowed Oxycontin to be marketed as a first line drug for musculoskeletal and chronic pain, which anybody with sense knew was a bad idea.  My internist, fixated on Diazepam, couldn’t find it in my records who prescribed it for me.  I finally said who had, but it wasn’t in the computer, and during this time, she continued to be look more at the screen than at me.  This is apparently the new medicine.  Everything is electronic, which can be good.  I get neatly typed records online, which are helpful, except for BMI to 2 decimal places and no comment about the little things in aging, like hearing, vision, sleep, and moods, affect me, and a diagnosis of Chronic Pelvic Pain, when I had no pain, only discomfort, which is a significant difference, trust me.  I almost didn’t get my needed blood work, because she didn’t appreciate that the last I had was in 2015, not this year. At least the DEXA wasn’t necessary.  Nobody asked about dental care.  It matters now, because we know now that periodontal disease affects health a great deal. The human cost of medicine by screen is failure to look at the patient, from whom much information comes.

Additionally, if something is inputted wrong, it tends to stay there. Imagine if you are my age, not a physician, with a lot of medical problems, and aren’t thinking clearly.  What happens to you if something is missing, not noticed, not picked up, not addressed?

At my age, I start answering questions like that with, “You die.”

By now, I felt like a major drug abuser.  I stopped mentioning my other concerns, like what she thought about statins. She dismissed my concerns about weight and waist with “do crunches,” which don’t fix the problem. She felt a little edema in my leg, assured me it wasn’t heart failure, which I knew, and said it was probably venous insufficiency, and I should lift my legs up when sitting. I decided that wearing support hose, like I did when I was an intern, was better.  She quickly listened to my heart and lungs and I was done.  At least I thought I was.  I was told to call a week prior to wanting the nasty drug I was taking, because these things took a week to fill.   Why? This stuff should be done electronically in seconds.  I filled requests the same day when I practiced, and I often called the pharmacy myself.

In her position, I might have moved from the computer to where I was sitting to directly across from the patient, asking about retirement, Medicare, money, meditation, depression, sleep, support systems, what it’s like when your body can’t do what it once did or does what it once didn’t. She would have heard a lot, and that’s the problem, because hearing a lot takes precious minutes that could be used to ….  well, do what, pray tell?  Help a patient?

A few minutes later, yet another medical assistant came in to hand me the papers that were printed.  I certainly get nice notes at the end of my visits, which my patients never did.  Indeed, if I had a question about my BMI to 2 decimal places with my clothes on, I could request a change at my next appointment.  The problem was I wasn’t given any other appointment.  I was told to see her if I needed to.  The appointment time to get into see a new internist in Eugene is 11 months.  Followups? For GI, 5 months.  For Derm, 4 months.  For GU 2 months.

Four days later, I got a call telling me that my doctor wanted me to come in in March—only four months’ distant—for a Medicare Wellness Exam.  I thought that is what I had had.  Did they want it in a new calendar year?  Or was there something else I didn’t know about?  I’m not sure what to do at the moment.

If I only had that screen, it would tell me.

“Hey Mike, you’ve got a little bulge in your stomach,” I heard, as I reached to the base of the final climb to Larison Rock.  At this point, I had climbed 2000’ in 3.5 miles. As hike leader I had bushwhacked around an impassable blowdown, found an alternative route, and made sure everybody got around it without difficulty.  I wasn’t even breathing hard on this hike.

Douglas fir blowdown, Larison Rock Trail; November 2016

Sun through trees, top of Larison Rock Trail; November 2015

I knew I had a waist bulge.  I have an apple pattern of weight distribution, and while I have never been overweight, and my Body Mass Index (BMI) is about 23 and change, I have a problem.  Turns out that waist circumference is an important risk factor for cardiovascular disease, more than weight itself.  Indeed, the waist:hip circumference ratio is more important than just being overweight. This is relatively new on the obesity scene, but it wasn’t just discovered yesterday.

The realization bothered me.  I looked for all the stats that said I was healthy, and I came up short each time.  I started to lose weight, from 170 to 165 at least.  I did it the way I have controlled my weight in the past— I looked at my diet and started finding how many calories I could easily remove.  In the past, it has been peanut butter, which I love, olive oil, fatty veggie hotdogs, all cookies and cake, and adding low calorie yogurt.  It takes a while, but I’ve always lost weight.  This time around, it was removing evening cheese, substituting dark chocolate for scones at lunch, again stopping the peanut butter, and changing the decaf white chocolate mochas I was having to decaf sugar free.   The last cut out 240 calories right there. My weight started to fall.  I was hungry at night; hell, I was hungry a lot.  It was the holidays, the worst time to lose weight, but each morning I got on the scale, I liked the numbers.

In 3 weeks, I weighed 165.  I don’t know if my waist had changed, because I didn’t measure it originally. My contour looked better, but still not right.  But I had reached my first goal, and I planned to go further.

During this time, I had my annual cardiology appointment.  I was weighed with my clothes on, and because there was freezing rain, I wore a lot, for I took the bus to the clinic.  I weighed 170, which isn’t bad with clothes on, but my BMI was listed as 23.71, which isn’t true.  It’s fine for doctors to weigh patients the same way each time, but if they are going to use that weight for BMI calculations, to two decimal places even, they either have to get rid of the clothes or subtract a few pounds.  That was only my first issue.

Everything had gone reasonably well this past year.  My Afib had recurred, as I knew it would, but I was doing well enough that the doctor didn’t think he needed to see me in a year.  I wondered, however, why he called the echocardiogram of my aortic root, 40 mm, “dilated”.  First, if it is a problem, I need to be seen annually.  Second, many don’t think it is dilated at that figure.  Third, if one looks at the recent literature using height, weight, body surface area, and age, I am below what is considered dilated.  Fourth, while I agreed we needed a second data point to see if anything has changed, he decided I didn’t need another echocardiogram for a year.  Yet, I am labelled as having a dilated aortic root, a big deal if I have a thoracic aortic aneurysm.  I don’t think I do, but I don’t like treating myself.  Nor do I like having my BMI measured to two decimal places with my clothes on and having to look online to learn about normal aortic root size. What do people do without a medical background?

I was told I was doing everything right.  True, I’m active, seldom drink, never smoke, don’t use caffeine, am vegetarian, not diabetic, have good cholesterol, normal weight and BMI (to 2 decimal places), and my systolic blood pressure is 110.  But I am concerned.  My waist-hip ratio is high, 1:1.035, and it should be less, the reciprocal.  My waist-height ratio was 0.538, and it ought to be closer to 0.5, less than at least 0.533.  I asked for a dietitian referral and at this point am waiting for a call back.  It’s the holidays, and maybe they don’t believe anybody is really serious about losing weight during the holidays.  Well, I am.

My weight continued to drop, holding at 165, and I counted all the calories I was consuming daily:  I measured the sunflower seeds on my salad, I was eating more carrots, cauliflower, and broccoli, not corn and peas, I ate apples, blueberries, strawberries, and tomatoes, and I watched the croutons I was putting on my salad, although how one measures a crouton using tablespoons is a mystery.  They are about 3 cal a pop. I used a teaspoon of olive oil on my salad. I found ways to cut calories I had never found before.

I think the cardiologist missed an opportunity.  He was busy.  I knew that as soon as he came in the room and stayed standing.  Bad form.  I always sat when I talked to patients.  Sitting conveys a sense of having time.  I realized I needed to say what I wanted and be quick about it. The waist issue didn’t bother him.  It should have. This stuff should be posted in the cardiology clinic, along with “know your BMI,” “Ready for the ratio test?” “risk factors to try to reduce,” rather than “we care about every mile of your blood vessels.”  Dietitians should be available, and frankly Medicare would do well to cover the cost, instead of only for diabetics and those with kidney disease or transplants.  Health is health.  I now know my Basal Metabolic Rate (1540 calories), how much walking for 3/4 an hour or hiking for an hour burns.  I know how to get a decaf sugar free White Chocolate Mocha and a 120 calorie Peppermint mocha at Starbucks.  I know how many calories many fruits have and that sunflower seeds have 170 calories per 2 tablespoons.  Hell, I should be counseling people.

I’m serious about weight, and it’s important to know what matters and how to count it properly.  BMI is almost always a good predictor of being overweight, but it is not a good predictor for wrong fat, fat in a bad place.  There are other numbers that address that.

I had showed up early for my appointment, but I knew the time was up.  The cardiologist didn’t even have to start walking towards the door. I have become good at reading people’s body language when they don’t want to talk to me.  At that point, I quit, because they likely haven’t been listening to me for some time.

This is now the fourth business day and I haven’t heard from the dietitian yet.  That worries me, because my original referral with the cardiologist got lost. How difficult is it to pick up the phone and take care of scheduling an appointment? If nothing else, a guy whose numbers most people would love to have thinks he should be even healthier.  Wouldn’t that be refreshing to be able to advise him, if you were a dietitian?

Maybe I will have better luck with my internist.  I will have to prepare carefully, however, needing to make sure I have all my ducks in a row and get through all my questions. I’d bring a list, but when I was in practice I hated it when patients brought in lists of things to ask.

Then again, I sat down when I talked to patients.  I listened without interrupting, too.

BMI calculator: 

Waist-hip ratio:

Waist-height ratio, BMR

On a long drive back from Nevada, I listened to the radio and heard about a function being given in a small town to support a young man who had been severely injured.  The money was going to pay for his medical expenses.  Two nights later, I saw on the news another function to raise money for an injured man who was in a wheelchair, who looked to me, a former neurologist, quadriplegic.

I’ve seen thousands of jars of coins in my lifetime to support children with leukemia, young boys vegetative after football injuries, or a young girl in a hospital after a retaining wall fell on her at a national park.  Quads?  Yes, them, too.  Awful.  Terrible. Unfair.  Devastating.

These functions, these jars, these attempts are futile.  Yes, futile. The amount of money they collect is minuscule compared to even one day in a hospital, let alone the fees charged by a surgeon, anesthesiologist, and the consultants that are part of everyday medical care. Go Fund Me will, for a 5% fee, allow crowd sourcing to help families of victims get money.  Even right wing sheriffs in Arizona used it, despite their past opposition to the Affordable Care Act, about as ironic as it comes.  We don’t have Go Fund Me pages for the millions of people who need medical care and can’t get it.  They can’t get it because we don’t have a national system of medical care that covers catastrophic as well as basic care.  We’re better than we used to be, despite 60-odd attempts to repeal the Affordable Care Act, but we have a long way to go.

Go Fund Me works for those who have connections with others who have money.  For those with identical medical issues without such connections, and that would be far more people, there is no recourse.  That is why we need a system that covers catastrophic and basic care, so everybody has a fair chance to get necessary treatment.  Ideal and equal?  Nope.  But it would be more fair and help many more people.

Another irony is that small town America votes Republican.  The Congressman representing this town voted against taxes, he voted against the Affordable Care Act, the passage of which may have given him his seat.  Despite the fact that the ACA has insured millions of Americans and has been a success, both in decreasing bankruptcies and improving the percentage of people who consider themselves healthy, that insurance isn’t enough.  And while the ACA is starting to cost more money, that is not bad, because it means people are finally getting care for things they once let slide, like diabetes, hypertension, Pap smears, skin checks, colonoscopies.

A national health plan covering catastrophic and basic medical care would raise taxes, but it would end the practice of saddling ordinary people with hundreds of thousands of dollars of debt they can’t possibly repay.  It would help hospitals and doctors, too, both groups delivering free care.  I did as a practitioner, and the hospital for which I was medical director did, too.  The problem with Go Fund Me is that some get help and some don’t, the help not proportionate to the medical need.  Pass out leaflets instead of jars, leaflets supporting the Democratic candidate who will work to bring health care reform to the entire nation, and we would see an end of the bankruptcies occurring because of catastrophic medical expenses. Medicare’s overhead is less than Go Fund Me.  While taxes would rise, medical costs paid out in personal budgets would fall.  I can’t put a price tag on the lack of worry whether a medical condition would have to be lived with, because the cost to get care was prohibitive.

Yes, it is you in rural America who ought to start supporting Democrats who vote for things you need.  The Democrats are not coming to take your guns, your liberty, and your land.  The first two have never happened, and as for “your land,” we the American people own it, you and us, and that includes a guy like me. who enters it, doesn’t trash it, shoot up road signs, foul the water, run an ATV across fragile parts, cut down trees, and despoil what should not be despoiled.  The American people own the Owyhee, we all own the Grand Canyon, the national forests, the parks and lands held in trust for us which we must hold in trust for those whose lives are yet to begin.

We cannot realistically help everybody deal with medical bills by crowd source fund raising.  You want to help?  Then vote in legislators who will give us national health insurance so that basic and needed care will be paid for by the people of this land, because each of us is one bacterium, one virus, one plugged vessel, one leaking vessel, one drunk driver away from medical bills that may lead to bankruptcy.  I am frankly less at risk than most, because I have Medicare and can afford my supplementals.  I have social security, which I don’t need and I am near the end of my life, older than 90% of the rest of you.

I am willing to vote and have voted against my economic self-interest to pay for what is needed nationally.  What I don’t understand is why so many in rural America support those who have more than 60 times voted to repeal the ACA, and if given a chance will take away Medicare and other safety nets.

Everybody deserves a chance to have freedom from fear–fear of choosing between medical care and food, fear of bankruptcy, fear of wondering what delaying care for oneself or one’s child might mean. There are many things to be afraid of in this world, but this fear we can and should address.

We’ll be a better nation and people for doing so.

Years ago, in the doctor’s lounge, one of my colleagues said, “I admit it.  I make money off CT scan referrals to the center where I invested.  I’m greedy.”

While honest, he was not fulfilling a fiduciary duty, a legal obligation to act solely in another party’s interests. Parties owing this duty are called fiduciaries.  That meant when I practiced, I had to act in my patient’s best interests.  I could not order a test to make money unless the patient needed the test. For example: I might see a patient with classic carpal tunnel syndrome, 5 minute history and exam. Confirmation, if surgery were a consideration, was a nerve conduction velocity, testing to see if the velocity of conduction were decreased through the carpal tunnel of the wrist. I billed either for a simple new patient visit, $95 then, or 2 nerve conduction (NCV) studies, one in each arm, to confirm, $86.  I could have billed for both and charged $181, but it was a 5 minute evaluation, and a 5 minute NCV, and that seemed excessive.

I knew some who charged an extensive new patient visit ($165), two NCVs plus sensory conduction (the other way) on both arms with electromyography (EMG) both arms, to see if the muscle were damaged (almost never, these days) done by the tech, while they were seeing another patient, nearly $800.  Physician time: 10 minutes.  We were paid by amount billed.  My wife ran a CT scanner back then, but I did not send patients to her.  Her readings of scans were better than other radiologists, but there was an appearance of a conflict of interest had I sent a patient to her.  Many colleagues did not have such worries.  They invested in CT scanners then sent patients to them, a nationwide practice so bad that the Stark laws, named for the California congressman who introduced them in the late 80s, were passed, limiting referrals by doctors to places in which they had invested.

The Oregon Health Plan is Oregon’s Medicaid plan, Medicaid being a joint federal and state program that helps with medical costs for some with limited income and resources.  In 1996, because insurers wouldn’t cover Medicaid services in Eugene, physicians created an IPA, not the beer one, an individual practice association.  Each physician ponied up $6000 for a set number of shares; many were not happy about doing it.

For-profit Agate Healthcare bought out the IPA, claiming in 2001 they had covered 30,000 Medicaid patients and had stayed within budget. For-profits do not have a fiduciary responsibility to their patients but rather to their stockholders.  Stated another way, costs to cover medical care from beneficiaries are called “Medical Losses,” the amount paid divided by the amount received called the Medical Loss Ratio, a term I dislike, because it has the sense that delivering medical care is bad.  Doctors with shares got dividend checks every year and they could buy and sell shares.  This is OK.  It’s capitalism, and for risking $6000, doctors got some reward.

Agate later contracted with Trillium Healthcare to manage the Plan, and now with 94,000 patients Trillium has rapidly increased their revenues from a quarter to a half billion in the past two years.  Over time, stock options, something most of us don’t have, exercise, or even understand, allowed executives to obtain more shares.

Successful companies are often bought by a larger one.  Centene, based in Missouri, with $16.1 billion in revenue and $261 million in net income, bought Agate. Yet in 2015, 13,000 Lane County patients still did not have a doctor.  Big problem.  Eventually, they did, but that’s not “high-quality care” that payers, hospitals, and doctors are often trotting out.  There was concern that Agate kept some of the Medicaid money to make them look like a cash cow, a company with a lot of cash on hand.

When the buyout occurred, Agate had marketed themselves well, their share price increasing 600% overnight.  My bank pays me 0.15% annually.  When Agate was bought for $109 million, the proceeds went to the shareholders, not for medical care for homeless or paying medical debts people had in Lane County, but rather to rich, connected locals, all white and mostly men.

The CEO got $5.7 million, the CFO $4.2 million, and the entire 13 member board of directors received $34.2 million.  Another 77 doctors got a total of $41 million; 128 shareholders got $34 million. For a $6000 investment, continuously compounded, the last received a 19% return over 20 years.  The whistleblower, an investor, felt he came by his half million “somewhat honestly,” whereas the board, he said, “well, that’s an awful lot of money.”  Yeah.  It is.  But “somewhat”?  The letters to the editor blasted the whole lot of them, not that much will change.

From medical loss ratios to “managing ED use and bed days,” for profits have dictated care.  We doctors put ourselves here by fee for service and cranking up the service. For profits manage the number of bed days by discharging patients early and denying some care, but in all fairness, I saw many patients who stayed in the hospital with either no visits on the chart during a long weekend, or a bunch of “doing well”  with no documentation why they needed continued hospitalization. This isn’t and wasn’t optimal utilization of hospitals. As for denying care, in my day, carotid surgery for asymptomatic narrowing was not indicated, heavily abused, with high complication percentages. I had the data.

There is too much money flying around in medicine, but fiduciary responsibility to patients must not be lost. Fiduciary responsibility to patients often requires one to leave money on the table, rather than taking all the groceries that were supposed to feed everybody.  Like not charging $800 for carpal tunnel workups.  Or doing unnecessary surgery.

How did the Agate issue become public?  The board president, a physician, put out talking points to defend its sale.  Who got how much was kept secret; the company hired lawyers to keep the sale results private.  The media sued, and all was to be contested in court, because Agate shareholder felt it was private information whereas the media felt the money came from public funds, which indeed it was.

The newspaper knew that prior to the sale of the company, many on the inside bought shares from others who didn’t know what was happening.  This is dishonest, but it is the way people work. The paper finally received 218 pages from a disgruntled member whose own share was about a half million (the somewhat honestly guy).  He was disgruntled because share owners were asked to fund the legal costs for a minuscule amount, enough to irk him to go public. When you stand to get $5.2 million, a little thing like asking others to pay legal costs tends to annoy people.  It’s remarkable how the whole secret house of cards came tumbling down over a buck a share issue.

We need a single payer system.  This sort of stuff is what Bernie Sanders railed about all spring.

We need to tax capital gains progressively, so that when somebody makes an investment that grows 6 fold overnight, they will pay a much higher rate.  I like 80%, but 70% would be acceptable.

Finally, I noted that every doctor named but one was a surgeon.  That one got individually blasted in a letter to the editor.  Seemed that he disappeared when a woman’s father was in his final hours. She never forgave him. Would you?

Fiduciary responsibility would have dictated different behavior there, too.