Would you mind having an extra $900 a year? (You’d also get another $900 per kid.) What is that–about the cost of a really nice vacation every year? Going to a great restaurant once a month? Several pairs of shoes, clothes, and diapers for a child?

Often people don’t realize that they have something to lose from this inefficient mess we call “The US Health Care System.” Even if they have health insurance. See, because every time that your employer’s health insurance premiums go up, that’s money that your employer can’t pay you as a raise. So all that raise that you’ve been wanting to get? Oh, you’re getting it–but it’s in the form of higher health insurance costs, not a fatter paycheck. (And you probably didn’t even spend more on health care this year than last, either.)

One of the things I really enjoy about Joe Paduda’s Managed Care Matters is that it reminds me of how much health care really costs . We spend over $5200 per person per year in the US on health care. The next closest count, Switzerland, spends about $1800 less than us. And the Swiss have lower rates of infant mortality and on average live longer than us .

Granted, these are not perfect comparisons–even if I’m half wrong–that the Swiss aren’t as health as us, and they’d need to spend $900 more a year to compare with us–that’s still $900 cheaper than the US. Imagine if every person in the US could receive the same health care, but had an extra $900 in their pocket. As a student, I’d be happy to have it. I heard on the radio last week a guest describing employers that pay the “minimum wage” are actually paying a “subsidized wage;” that is, the public is subsidizing the employer, since the employee is receiving social services (including health care) from a public, tax-funded hospital or clinic.

But because we hold on to this insane notion that our health care system is the best, or that health care reform is politically impossible, we sit here, being inefficient, wasting our own money away . Until people realize that people will get health care, no matter what their insurance status, we’ll continue to chug along in a wasteful system. We are blinded to the fact that providing health insurance, and therefore, preventive, primary care, is more cost effective, and saves us all money.

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You don’t know how frustrating and condescending it is when you’re doing your best to speak your patient’s native language as best you can (and not doing half bad given that you haven’t really practiced in a couple months), and your patient’s mother and grandmother start laughing and making fun of the way you pronounced a word. Yes, I had my stethoscope on, ladies, but it ain’t exactly soundproof. And I can understand much better than I can conjugate.

I’m as obviously gringo as they come, but it’s obvious that I’m trying my best, and I’m making an effort. I don’t care if I’m a medical student or your doctor or the guy who cleans your toilet; it’s rude, flat out.

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I’m all for doctors and medicine trying to be as objective as possible, but it’s just so damn cute when doctors think they actually are objective. As if we don’t bring our own values and assumptions to the table. I’m doing well-child checkups this week at a county health clinic. I walk in, see a 9 month old baby, a 40-something year-old woman, and a 16 year-old girl, and immediately turn to introduce myself to the 40-something year-old woman, because clearly she’s the mother of this child; 16 year-olds don’t have babies!

I cringe every time I recall this story.

Next is the number of superstitions we go through as physicians (luck and superstition are clearly objective, too). For example, I will never, ever mention how a day or night of call is going smoothly, or how quiet the pager has been, or how empty the floor is. I will think it, and consider bringing it up for casual conversation, but it stops there; for if I mention anything to that effect, I will jinx the team and we’ll magically have 20 new admissions that night. I know this is totally crazy, but I totally, 100% abide by this. I don’t know that I totally believe it, but I’d much rather keep my mouth shut and hopefully have fewer admissions.

And it’s only medical things that I’m superstitious of, which makes it even more ridiculous–in the medical world, where we base everything on risk, benefit, and predictions from data and randomized, double-blind controlled trials, I truly act in a certain way, hoping my behavior will somehow influence the outcome.

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Busy learning Peds, which I’m really enjoying. A quick eval, starting with the pros:

• The people–doctors, nurses–are just nice . You don’t realize how not nice some people are on other services until you do Peds.
• Your patients are for the most part, cute.
• Kids are resilient, and can make it through some really serious disease that would probably kill an older person.
• Most have reeaaally short Histories of Present Illness (2 days of decreased bottle intake and 1 day of cough), reeaaaally short Past Medical Histories (full-term baby) and usually are taking no meds.
• Peds is pretty straightforward. Kid is dehydrated and can’t keep food down? Give IV until kid can keep hydrated on liquids, then discharge.
• For the parentless hypochondriacs like myself, if you don’t already have any of the terrible pediatric diseases, you won’t have them.
• There are many pediatric specific diseases, but most of Peds is medical management.
• Kids have nice clean arteries and veins and organs, and for the most part haven’t screwed them up with alcohol and drugs and cigarettes. (I screw mine up, too, just like any other adult.)
• You throw antibiotics at everything.

The cons:

• Kids are germ factories, and you will get sick while you’re on service. I can’t count how many times a patient has coughed right in my face.
• If they’re young, they can’t tell you what’s wrong with them, or what hurts.
• One word: parents. I’m astounded at how different parents can react to certain degrees of medical illness. Some parents are great, others need to chill out and/or stop coddling their children. (Yes, I know people have different styles, yes, I know you have to work with the parent where they’re at.) It just seems like too many parents want their kids to be their friend , when the kid needs a parent , not another friend.
• For the parent hypochondriacs, your kid could have or get any of the terrible pediatric diseases.
• It’s hard to get IVs.
• You see a whole lot of kids with congenital or lifelong diseases that have no treatment.
• It sucks making babies cry.
• It sucks having to calculate drug doses and fluids by kilogram.
• There’s a lot of turnover, so you honestly can’t remember a kid you discharged 2 days ago.
• You throw antibiotics at everything.

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The Lancet has a commentary piece arguing that is unethical for doctors to force feed patients:

We write regarding the forcefeeding and restraint of Guantanamo Bay detainees currently on hunger strike.1,2 The World Medical Association specifically prohibits forcefeeding in the Declarations of Tokyo and Malta, to which the American Medical Association is a signatory.

Fundamental to doctors’ responsibilities in attending a hunger striker is the recognition that prisoners have a right to refuse treatment. The UK government has respected this right even under very difficult circumstances and allowed Irish hunger strikers to die. Physicians do not have to agree with the prisoner, but they must respect their informed decision. Those breaching such guidelines should be held to account by their professional bodies. John Edmondson (former commander of the hospital at Guantanamo) instigated this practice, and we have seen no evidence that procedures have changed under the current physician in charge, Ronald Sollock.

The bf asked me if we force feed patients in any other case, and we most certainly do. In people with eating disorders, often the treatment for their complications (often very slow heart rates) is force feeding for nutrition. These patients (and others) are generally judged not to be competent to make their medical decisions, and so their family members, or their physicians, make their medical decisions for them. However, if a person is judged to be confident, it’s my understanding that they cannot ethically be forced to do anything, including eating. I have to agree with the comments from The Lancet. Dr. Sollock is breaching his code of medical ethics.

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Oh hellll yes. Did my first lumbar puncture (aka spinal tap) today. On a 5 year old. Champagne tap! (A “champagne tap” is when you get clear CSF fluid without any red cells in the fluid, as they can often contaminate your results.)

My attending, being the awesome guy he is, ran out and bought me a mini bottle of Korbel to celebrate.

I love procedures.

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ABC’s new reality show–if you can call it that–is already rubbing me the wrong way. It’s called Miracle Workers . (Here’s an article about the show with its host, a Miami CT surgeon . (thanks KevinMD ). From the show’s description:

Each week, the show will feature two stories of ordinary people who do not have the network, access to the necessary medical community or in some cases the resources to these procedures. Their seemingly overwhelming medical problems will be taken in hand by a renowned team of medical specialists. The patients’ lives will be transformed before viewers’ eyes as the professionals employ cutting-edge medical technology to heal those who need it most. The team will not only restore the patients’ health, but their hope in living a whole life again.

We’re apparently now leaving the really sick and uninsured to reality television as their care takers, as opposed to creating a better medical system where all “ordinary people” have “access to the necessary medical community or in some cases the resources to these procedures.” So, dying people without health insurance, I recommend either the really sad, depressing story, or perhaps the cute children perspective so that Miracle Worker’s producers will choose your loved one to live, while another’s loved one dies. If the producers are somehow able to figure out which patients “need it [healthcare] most,” I’d love to hear their algorithm.

I saw a commercial for the show last night, and I couldn’t be more frustrated with the portrayl of the physicians on the show. Physicians are not miracle workers. (I’ll include myself in the ‘we’ here, even though I’ve got a little over a year before I’m a doctor myself.) We’re not gods, as a patient’s mother told me and my attending last night. Physicians, contrary to popular belief, are humans. Falliable humans. We’ve devoted much of our lives to caring for patients, by means of understanding the intricacies of the human body, how it works in health, and how it dysfunctions in disease . This is the distinction. Gods and miracle workers snap their fingers, or wiggle their noses (wait, that’s witches ) or do whatever they do and make effect without any prior cause. Physicians figure out what the disease is, so they can understand its cause, so they can change something to alter the effect. They’re two entirely different branches of healing. The former is perfect, effortless, and instantaneous. The latter requires training, experience, and knowledge and is definitively human. That’s human all senses of the word, including “imperfect.”

Part of the reason I make such a distinction is because of the assumptions patients make about physicians, based on their understanding of how physicians work. After being told that physicians are “like gods,” my attending responded that “We’re no more like gods than any other person,” which was the perfect response. When patients assume physicians are perfect, or god-like, or saints, or miracle workers, they start having irrational expectations. When an error occurs, or a proper diagnosis isn’t made, it’s often hoped (and also assumed) that everything will go perfectly–that the error rate is 0% and the success rate is 100%. And that’s simply not the world of medicine that exists.

Physicians are taught to understand everything–I mean everything–as risk versus benefit. There are risks to giving a patient oxygen. There are risks to giving a patient some IV fluids–or even just giving a patient a meal or water. And physicians only do any of these things if they feel that the benefits outweigh the risks. This is what’s meant by “first, do no harm.”

I’ll repeat it: physicians are no more like gods than any other person. Yes, we had quickly figured out that the mother’s child had a malrotation that required urgent surgery, and that surgery was performed, and her child’s life was saved. But it was because the mother realized the child’s vomitting was of concern and brought the child to the hospital. And it was because the resident who saw the child recognized the child’s age and symptoms and made the diagnosis. And it was because the surgeon was able to repair the malrotation. And it was because the anesthesiologist properly monitored the child’s vital signs, and because the nurses caring for the child watched him closely, and because the respiratory therapist helped maintain his lung function. There was no snapping of fingers, no wiggling of noses.

Often, miracles seem like miracles because some of the treatments physicians give can rapidly take someone from dying to not-dying over the course of hours or even minutes. There’s a certain condition in the elderly that often causes them to have episodes of losing their vision–and if steroids are given, miraculously their vision can be spared. But it’s because the physician recognized the condition, understood why it occurs, and then understood the way to stop it from occuring.

And miracles? They’re statistical outliers. They’re luck. Listen: if my loved ones were sick in the hospital, I’d be praying as hard as the next man–but I’d realize the odds. The miracle involves being the one out of ten thousand that survives a disease. That’s just damn luck.

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Great music.

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It is really, really refreshing when your patients have no other medical problems, are taking maximum one other medication, have a short history of present illness, and are really cute and wide-eyed.

And don’t talk back.

Thank you, Pediatrics.

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Now would be a good time to wrap-up my long two months on my Internal Medicine clerkship, seeing as though I start Pediatrics tomorrow, which totally scares me because kids definitely don’t get my wry sense of humor and frequent pop culture references. In no particular, bullet order, because I’m just not in a paragraph writing mood tonight:

• After ranting for 20 minutes to my parents about how much I hated it, medicine turned out okay in the end, probably because I had a fun team and better attendings my second month. And okay, fine, I learned a lot, despite my best effort.
• No wonder people specialize. There’s just too much to freaking know.
• Man are we obsessed with data and risk and studies and evidence. Trial X found a Y% drop in Z when using Drug A dose B compared to Drug C dose D. This is the reason medical research and spending will always have a rationale. There will always be something a liiiittle bit better than the last breakthrough. Or sometimes studies suggest something reeaaaaally expensive for milllllions of patients. Are we really going to put pacemakers in everyone with heart failure?
• We spend an awful, awful lot of money on really, really sick patients, and often we spend huge sums of money on people in their last 6 months of life. In one study in LA, almost 50% of patients were seeing more than 10 doctors in their last 6 months of their lives. Is that how they really wanted to spend their time?
• Can someone please, please explain to me why nurses record a “normal” respiratory rate as 18 or 20? Because it’s not. It’s like 12-14.
• As a patient, don’t piss off your nurse, because if you’ve got an unprofessional one, he or she will turn all passive-aggressive. If this happens, tell your doctor; if nothing improves, go to the Patient Advocate.
• There is a nursing shortage in this country. If you need something as a patient, obviously ask for it, but try to be reasonable. A hospital is not a hotel. Try to make sure your loved ones are reasonable too. This will be help avoid the preceeding statement.
• As a patient, you will have better, more efficient medical care if you know the names of your medical problems and the names and dosages of your medications. A list is even better.
• Kate has been writing about medical malpractice and there’s been a lot of discussion about practicing defensive medicine, and their associated costs, but I would not be surprised if a large amount of spending is also devoted to repeating tests that have been done at one hospital but are not available at another. This is INSANE. I can now pay people money with my cellphone , but I can’t see images or lab values from a hospital 5 minutes away? You’ve got to be kidding me.
• For people that take multiple medications, automatically assume that they forget to take them. Ask: “How often do you miss taking these?” It will make patients feel less worried about trying to please the doctor.
• Trying to please the doctor is a normal human reaction. It’s why you brush your teeth extra well and floss before you go to the dentist. Just be honest, that’s the most important thing.
• I will never ever ever be an oncologist. They save so many people that they think everyone can be saved, and often lose sight of the fact that everyone dies. I don’t know how often patients were encouraged to undergo another round of chemo when it was obvious to everyone else they didn’t have much time to live. Then again, hindsight’s 20/20.
• Giving people a comfortable, safe, and supportive place to die is one of the most compassionate things one can do for another.
• The surgeon’s 30-day mortality statistic can lead to some pretty perverse incentives to keep patients alive.
• Many of the problems in modern medicine, like most other areas of life, are due to laziness. As my surgery resident told me: “You’ve got. To do. Your job.”
• There was a NYT article last week talking about how doctors are on such a different playing field from their patients that they seem like they’re from a different planet. I would have to agree.
• I came in thinking the differential was kind of silly, like that more cases than not are cut and dry. I now know why doctors are so damn skeptical and suspicious and often agnostic or atheistic. They’ve been burned too many times assuming one thing when it turns out to be something else entirely, or have been sure about a diagnosis, and then they find that they’re wrong.
• You really do need to understand the physiology to understand the pathophysiology to figure out the treatment. This makes it hard for me to believe in new agey healing stuff.
• Want to know why doctors are so unhealthy? Because we spend so much freaking time taking care of patients that we eat crappy food at the hospital and don’t have time to get to the gym. Also, because we are hypocrites. Or at least, that’s my excuse. Feel free to use it if you like. I seriously should go ahead and start a thiazide and a statin.
• Interns get freaking worked . I am trying to vigorously avoid this from happening, and am hence taking a year off to do “research.”
• More bullets to come.

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