Maggie's Farm

No good deed goes unpunished.

Well, that is surely not always true, but with the economic downturn, the charity medical clinic at which I volunteer one day per week has seen a sharp upturn in lawsuits against us Docs and the clinic this year.

The medical defence lawyer we have now engaged (we have had no complaints or suits for 10 years until January 2009) tells us that we should now regard each patient as a potential enemy. (Our clinic's founding Christian philosophy is to regard every patient as a friend and neighbor.) 

He tells us that our notes must be guided by the principle of CYA (your notes are legal documents, not medical reminders as we had thought) and that every decision a doc makes contains some basis for a suit in the hands of a hungry lawyer because all medical decisions are judgement calls and every situation is unique.

He also told us that recessions tend to see more suits against doctors because more folks are looking for cash, and much more so in charity settings. Plus the tort lawyers are hungry too - but they always are. He also advised us to refuse to treat any patients with substance abuse histories for our protection - other than alcohol.

He actually said "Do not be kind. They will screw you whenever they decide to." He has been around the block a few times.

I do not like this at all. A Psychiatrist/Psychoanalyst cannot do the job under such conditions. Furthermore, I can not and will not endure any relationship in my life without mutual trust. I am considering resigning (even though I was one of the founders of the place) and finding some other outlet for my charity. Maybe prison work, where you can safely begin with the assumption that everybody is a liar and cheater and working the system - and take it from there.

My position on the Board, plus my volunteer time (all unpaid) doubles my legal liability. I just want to do my best, tithe and double-tithe my time, and avoid hassles that do not fit into my life - and legal fees that I cannot comfortably afford.

And no, I would never work for ObamaCare. Never. I did not go into medicine to be a government employee. I went into medicine to work for my patients, doing my best, with no intention of looking out for lawyers.

It's tough for doctors because we are often held responsible for people who either do not want, or do not accept, our help and advice. But, as long as their name remains on our rolls and as long as we persist in trying to be constructive, the lawyers can get us.

I have been burned several times by keeping them on the rolls in the charity clinic, only to be sued by them eventually for not doing a better job "taking care of them." What? I am not a professional mother and I do not "take care of" anybody. I am a doctor, not a caretaker and, despite the modern lingo, not a "care-giver" either.

Like all doctors,  I try to work with my patients - and do not take care of them, or I to try to bring them around to where I can work with them.

If I were more self-protective, I would not even try and would just say "I cannot help you. Good bye," but that is not my medical tradition. My medical tradition is that you are a friend to your patients, whoever they are.

Novalis presents such a case. More practical docs than I am would just throw them out of the office. However, after being punished and hassled legally several times by going the extra mile, my heart grows harder. 

Indeed, good deeds often are punished and yes, it does lead to some bitterness especially when it is performed on a charity basis. I have never been sued or hassled by a private, self-paying patient. 

The news mills are ginning up yet another medical crisis storm these days in an effort to pave the way for gummint medical care by the same good folks who run the DMV and the post office. They seem to imagine a problem with cost, access, and insurance. Maybe we are a nation of crybabies, because we have the best medical care in the world with which to pamper our so-called precious selves.

It's time we got beyond that self-love, and cared about the Greater Good. I have a few simple, rational, Utilitarian solutions.

Cost: Cost is driven by technology and modern pharmacology, cancer treatment, crocks (people obsessed with their health), gomers ("gomers go to ground"), and futile, guilt-driven end-of-life treatment for annoying old or sick relatives. The cost of American medical care can be dramatically reduced by forbidding all cancer treatment other than Oxycontin and at-home 10-gallon morphine pumps, all medical treatment for those over 57 (the children are our future!), all CT and MRI scans, all blood tests, and all medicines other than friendly, holistic, herbal organic ones. No more vaccinations - they cause Autism. No more antibiotics - everybody knows that they make people sick. Eliminate Dermatology (just stay out of the sun, people). Eliminate Opthalmology (bad eyesight is from masturbation - it's your own fault). Eliminate Psychiatry (mental illness is socio-political mind control). Eliminate Urology (do you want a #3 gauge tube stuck up your urethra?). Eliminate Surgery - it is physical assault on comatose victims. Eliminate Neurology - it's just nerves.

Access: Doctors are like waterfront trade unions: they limit their numbers to keep their payments high enough to join country clubs, to buy boats, and to take vacations. My idea: anybody who gets a C or better in Organic Chem is automatically admitted to a government medical school. Lots of good, caring people are weak in math and chem and bio and stuff, but that's who we need more of. My medical school flunk-out rate was 18%: what a waste of talent. Plus there are too many Jews and Asians in medicine anyway, and too few people of color or of gender identity diversity. So, with this increase in the numbers of docs, fees could go down to $5 per office visit and the docs who don't like it can open dry cleaning shops, cigar shops and wine shops like they do in Canada.

Insurance:  Medical insurance is a dumb idea. Why expect your neighbor to pay your medical bills when they will be so low under my plan anyway? They will be cheaper than your garbage pick-up, your newspaper subscription, your cigarette costs, your car payment or your monthly payment for your big screen TV. (Did you ever notice how nobody complains about the cost of their TVs, computers, or Life Insurance?) Or just save your money if you want and die quietly without complaint, dude, and make space for the next generation. Too many people on the planet and, let's face it, life isn't all it's cracked up to be anyway. A vale of tears and toil, a tale told by an idiot, full of sound and fury, signifying nothing. What's the big deal about death? Didn't your parents teach you that life is a bitch?

I opted out of Medicare years ago. I felt morally torn about doing so, but finally my bookkeeper refused to do any more of their paperwork. That settled it.

My compromise was to institute a generous sliding fee scale for Medicare-aged folks. (My general policy is to never decline a referred patient because of money.) From a young Doc, in the WSJ:

Here's something that has gotten lost in the drive to institute universal health insurance: Health insurance doesn't automatically lead to health care. And with more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have.

Consider that the Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients. The statistics are similar in New York state, where I practice medicine.

More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments.

Yesterday morning's NJ post on "Quality Care" from the WSJ was enlightening, and just gives me one more reason to stay away from Medicare (besides the fact that they pay me peanuts, and that their paperwork requirements are over my head and take more time than my patients take).

I see how government "Quality Care" works: the academic medical experts take a vote, and that becomes "Quality Care." That's not medical care: that's government policy. Forget the individual patient and his or her unique situation, forget the Doc's experience and skills and insight, forget the Doc's judgement, forget the fact that academic Docs aren't always practical, forget that next week's new data will completely alter the information at hand. Just Follow The Rules and stay out of trouble.

I have seen plenty of cases go bad in the hands of young Docs who strictly follow the rules. It's not a good example of that, but when I was a resident one of "the rules" of the time included strict limits on the use of pain-killers, even for terminal cancer patients. Didn't want them to become addicts, you know. They forgot that pain relief remains one of a handful of the greatest blessings medicine has bestowed on humanity (along with anesthesia, antibiotics - and Lexapro).

One of the best things about seasoned physicians is that they are a cranky bunch who do not take orders, who think for themselves, who feel that rules are made to be broken, and who do not like to take crap from anybody - especially anybody in "authority". Your patient comes first, or you are nothing. There is a "House" inside every Doc. In most lines of work, you can't get away with that sort of attitude.

When government gets involved in things, they tend to screw them up. The article's example of high blood sugars in the ICU was a perfect example. Even I, who have not cared for ICU patients for more than a decade, know that tight sugar control for critical patients is insane and dangerous. Not only that, but it doesn't matter: if the patient survives and gets healthy, a few days of higher sugars with a good margin of error will not have hurt them one darn bit. But I am a Doc with a practical mind.

Expertise always has to be taken with a grain of salt, and government-emitted expertise with a tablespoon-full. I am not disparaging expertise, which I respect enormously. I just distrust the combination of expertise with power over others: anointed experts who want power instead of simply to educate give me the willies.

Non-"experts" often have loads of common sense. We take an ancient oath, too.

Ed. note: Somewhat related: Socialized medicine: A warning from across the pond

That's the latest cardiovascular recommendation for brisk aerobic exercise. (It used to be 20 minutes three times a week, but new data has changed that recommendation.)

I have not asked whether 30 minutes of vigorous sex five times/week counts, but we hope it does.

For some today, and for just about everybody in the past, medical insurance was something everybody bought, just like life insurance or disability insurance, to cover extraordinary expenses. It is called Major Medical, and it is still readily available.

Over the past 20-30 years, governments, businesses, and union contracts began expanding their coverage by reducing deductibles and covering more routine things. Medicare, of course, was the model for that. During the same time, costly medical technology and new drugs were developed in a near-miraculous way, mostly in the US.

With those changes, folks began wanting "insurance" to cover their routine maintenance medical expenses instead of the things that would financially overwhelm them. When that shift was combined with the CYA style of medicine which results in $5000 work-ups for dizzy spells (fed by the ambulance-chasers), everybody expected everything.

That isn't sustainable, and will never happen. Medical technology has grown to an amazing extent, but those machines are expensive.

I have no idea what the folks in power are trying to plan for us, but I know it will be an entitlement disaster, filled with unintended consequences, that people would not be happy with. It will end up with politically-determined rationing.

Our family bought Major Medical insurance many years ago. It cannot be cancelled. It's more important than a cool car. Why everybody does not do that when they are young and healthy is beyond me, because it would seem like the logical and prudent thing to do. Over the years, we have increased the deductible so that it is quite affordable, and we keep a money market savings account specifically for medical bills to the amount of the deductible. As I recall, we began with a $2000 annual deductible, and now we finally have a dirt-cheap $20,000 2-year deductible on the original policy. It does not cover any routine or preventive medical care, which is as I think it should be. Nobody owes me medical care, in my view, any more than anybody owes me auto insurance.

We have kept this policy whether or not I or my husband had some form of insurance through work, because you never know how long you will want to keep a position - or when you will be let go.

Off-topic: Around 30% of Medicare expenditures occur in the last year of life. In other words, on failing and terminal people. Interestingly and unsurprisingly, when docs hold end-of-life conversations with these patients (as we should), the costs go way down.

General hospitals are increasingly relying on "hospitalists" to care for inpatients, freeing up office practitioner's time for their (steadily less lucrative) outpatient practices.

I have yet to be a hospital inpatient except for childbirth, but I think that, if and when I am, I'd like to see the face of my own Doc daily. 

This is a new model for medical practice. More time-efficient? Probably. Less comforting? Probably. Overall, better or not? I cannot say.

Internists, and what few GPs still exist, are having a tough go of it these days: Medicare, which is the bulk of their work, compensates them now at a rate lower than a plumber or electrician in Boston.

Your doctor may be so concerned about protecting you from alcoholism that he or she might not tell you that current research indicates that 1-2 drinks per day appears to reduce the risk of heart and arterial disease by 18-30%.

More is not better, however. Details at Medscape.

We have posted on statins in the past.

Here's further evidence that statins are helpful, regardless of your triglyceride levels. Maybe all guys should take them (per your Doc's advice, of course.)

David Thompson led us to a report about the evolution of the anus. How did critters get from one opening to two? One theory presented is that it entailed a connection between the GI tract and the reproductive system.

Many animals, like birds and reptiles, have a cloaca (or "vent" - hence the word "venting"), which combines urinary, defecatory and sexual functions. (Most birds copulate via a "cloacal kiss," but a few lucky birds, notably ducks, swans and ostriches, have penises.)

This reminds me of the Yeats:

Vl: Crazy Jane Talks with the Bishop

I met the Bishop on the road
And much said he and I.
'Those breasts are flat and fallen now,
Those veins must soon be dry;
Live in a heavenly mansion,
Not in some foul sty.'

'Fair and foul are near of kin,
And fair needs foul,' I cried.
'My friends are gone, but that's a truth
Nor grave nor bed denied,
Learned in bodily lowliness
And in the heart's pride.

'A woman can be proud and stiff
When on love intent;
But Love has pitched his mansion in
The place of excrement;
For nothing can be sole or whole
That has not been rent.'

A piece on the subject in the NYT notes:

The myth is that like magic, preventive medicine will simultaneously reduce costs and improve health.

Read the whole thing. Sadly, except at the margins, there is little we can to to prevent disease. The wishful thought that we can control fate and the gods never quits, though.

Yet one more manufactured, over-hyped  crisis is being debunked.

Nowadays you can define anything you want as pathological. And this whole new fashionable category of "at risk" silliness expands things to include everybody.

For example, at middle-age I am "at risk" for obesity. Not wanting to be fat, I decided not eat carbs and I do a tough daily workout. It's not too complicated.

Prosperous nations have lots of fat people. More of them than poor nations, although poor nations have plenty of them too. The reason is that humans have a weakness for carbs. Thus being trim and fit is a sign of self-control, but being heavy is a time-honored sign of prosperity.

If you want to see fat people, go to Disneyworld and get grossed out. There are Americans there so fat that they have to ride around in motorized chairs, like King Kamehameha. God bless 'em. The world needs more fatties, in my opinion. It means people have plenty to eat, but I don't like to have to look at them. To be evenhanded, however, I find anorectics even more disturbing.

I happen to feel that excess fat in women is unattractive, slovenly, and unsexy. Somewhat less so in men: some stout men are cool, like Teddy Roosevelt was. Anyway, we have been subject to much brouhaha about obesity in recent years. Big health crisis, etc.

You have surely read the news that being overweight is not such a big deal, from a medical standpoint. Even the WSJ covered the story, amusingly. Obesity - and that means much more than ordinary fatness and pudginess - is often quite benign.

And being overweight is fine, from a health standpoint.

Just like the the AGW fad and all such fads that governments are suckered into, there is fat money to be made from the obesity silliness. Follow the money: you know that somebody always wants some of yours. Careers. Respect. Pensions. Fat City.

Fact is, when I was an intern in NYC, I saw plenty of skinny, athletic guys in their 40s come into the ER and crap out with massive heart attacks. Also, skinny guys with insulin resistance. The reasons to be relatively thin are to be fully functional - and aesthetic. If an American lady wishes a decent sex life, it behooves her to be trim. Not so in some countries, however, where they prefer us gals Biggie-Sized.

Here's a good food story, from the Englishman:

His typical breakfast order from Pete's Grille in Baltimore, Maryland:

Start with three [white bread] sandwiches of fried eggs, cheese, lettuce, tomato, fried onions, and mayonnaise; add one omelet, a bowl of grits, and three slices of French toast with powdered sugar; then wash down with three chocolate chip pancakes.

According to his autobiography, growing up, lunch also consisted of 1 pound of pasta, 2 large ham and cheese sandwiches with mayo and 1,000 calories of energy drinks. Dinner’s another pound of pasta and a whole pizza and 1,000 calories more in energy drinks. No food hang-ups with him. He gets it. Food is fuel, not endowed with magical or evil effects.

What a fat slob he must be, bet he can barely get up from the sofa to get to the fridge, something ought to be done to prevent our youths ending up like him...

Let's all be relaxed and tolerant: being fat is a "life-style" choice. Let them eat cake.

Addendum: At Pajamas, Fast food restrictions fatten government

Here's an answer. Are men's nipples "sensitive"? Yes they are. Gals take note, for when in a playful mood.

There's a book with that title too: Why Do Men Have Nipples? Hundreds of Questions You'd Only Ask a Doctor After Your Third Martini

How many of you fellows out there are on statin medicines, like Lipitor or the others? Raise your hands.

Well, it's a good idea to take them. It may turn out to be a good idea even if your cholesterol and triglyceride levels are in the normal range.

Why? Because the way they seem to reduce arterial disease leading to heart attack and stroke may not be just - or even mainly - so much by altering cholesterol and triglyceride blood levels, but by stabilizing the endothelium (inner lining) of arteries. Here's a technical paper on the subject. One quote: 

Several clinical trials including Heart Protection Study (HPS), Collaborative Atorvastatin Diabetes Study (CARDS) and Treating to New Targets (TNT) Study have suggested that statins can offer protection to patients with normal lipid levels through various nonlipid-lowering effects.

The inflammation, clots, and plaque on arteries are the main cause of terrible events. American males already have visible arterial disease in their 20s. I saw it and touched it when doing autopsies in medical school, in young people who died of other causes.

Everybody dies. Statistically, if you reach maturity and don't die in a car crash, the odds are that half die of cancer and half of heart/arterial disease. So, if you can postpone that arterial disease, you get to die from a cancer.

That's today's cheery medical news.

I have no problem whatsoever with physicians easing terminal peoples' path out of life with merciful doses of morphine, but I have great problems with the Brave New World of government rationing of medical care, and the hustling of people into death to save money as they seem inclined to do in the UK, Canada...and in Oregon.

Dr. Bob discusses. One quote:

We have, at last, arrived. The destination was never much in doubt — once the threshold of medical manslaughter had been breached, wrapped as always in comforting words of compassion and dignity, it was only a matter of time before our pragmatism trumped our principles. Once the absolute that physicians should be healers not hangmen was heaved overboard, it was inevitable that the relentless march of relativism would reach its logical port of call.

In my view, easy abortion was the first big step in the direction of removing the annoying inconvenience of a human life. Perhaps it would be most expedient - or utilitarian - to do us in the minute we stop paying income taxes...assuming our function is to serve the "common good." Or at the moment of our birth, because it is certain that we will become expensively ill someday.

And when it comes to medical treatment in general, I like TigerHawk's idea much better than any governmental idea. WallMart! Just as long as I have my own doc who knows me and cares about me first.

Addendum: Father of Canada's medical system rejects what he created. "Woops. I goofed. So terribly sorry."

We have posted in the past about the role of natural Vit D - and the role of Vit D supplement, in cancer prevention.

Here's a piece at Pajamas on the subject. The take-home message is, I believe, get tan but not burned.

It's good news, because those of us who are pasty-white Anglos look better with some healthy color.

Columbia's Brain and Mind Symposium has archived (on online video) a wonderful and relatively non-technical series of lectures by the world's greatest neuroscientists.

These talks were presented in 2004 as a part of Columbia University's 250th Anniversary. (h/t, Neurophilosophy)

We said this a month ago. Will you believe it if it comes from Instapundit?

MORE VITAMIN D NEWS: "New research shows that people who regularly use sunscreen and avoiding sunlight may be sacrificing important vitamin D, which is made by the skin when it's exposed to sunlight. Now, the recommendation is to get 15 minutes of sun at the peak of the day three times a week to help avoid a vitamin D deficiency. . . . For years, Americans have been taught that as summer approaches, they should reach for sunscreen to protect themselves from a scorching burn - and the skin cancer it might trigger. But new research shows that by covering up, they may be sacrificing important vitamin D, which is made by the skin when it's exposed to sunlight. . . . Vitamin D deficiency is associated with reduced bone strength and risk of fracture; a twofold increased risk of some cancers such as colon, breast and prostate; an increased risk of both Type 1 and Type 2 diabetes; worse control of diabetes for those who have it; decreased immune function; and possibly also heart disease."

Which do you believe? Last year's expertise, or this year's? I am inclined to trust this year's, or God would have put sunscreen on our skin.

I know that it is trite to tout exercise, but it is worth mentioning that we keep learning more about its health benefits. I recently attended a talk on breast cancer in which daily exercise compared favorably with several widely-used chemotherapy protocols.

Humans were not designed to sit on their butts all day watching TV or reading ephemeral stuff on the Internets.

You name it, and exercise helps it, in the NYT by Jane Brody.

Thought I might share the data from a meeting tonight about vitamins, health, and cancer. The short version:

- Do not take folate-containing supplements unless you are bearing babies. (Unfortunately, the government in its infinite wisdom mandated its addtion to bread and other foods for the benefit of child-bearing women who eat terrible diets.)
- Adults should not bother with vitamin supplements, except...
- it's probably a good idea for most people to take 2000 iu of Vit D3 daily (which is actually a hormone, not a vitamin) even if you spend time outdoors, and...
- 20 minutes of daily exercise is a good thing.

That's just one researcher's opinion, of course.