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Patient: I know I already had the Covid. Remember when I was so sick in January? Couldn’t breathe without coughing, so weak? THAT was the Covid, I’m sure. 

Me: No, it wasn’t. Covid didn’t move from the bats to people until late 2019 and it really wasn’t here in Mobile. I think that was probably the flu

Patient: But the test said it wasn’t. Did you test me for the Covid? I’m sure I had it.

Me: No, we didn’t have tests yet in this country. But the flu test could have been wrong

Patient: Wait, you ordered the wrong test on me???

Testing in healthcare is rather more complex than one might think. Folks come to me as a physician and want a diagnosis. I order a test and then say “Have you had it before?” When they say yes I say “Well ya got it again.” Not really. Actually, before I order the test I need to know a lot of stuff, otherwise the results will not be useful.

The first thing I need to know is how the test “performs.” Take a pregnancy test, for example. What the over-the-counter pregnancy tests measure is a chemical produced by the body in early pregnancy. In order to be more accurate, it only detects a level that is consistent with a 3 1/2 week pregnancy. So if a woman gets up, has sex, and uses a pregnancy test to see if she is pregnant, the answer will be “Not Pregnant” even though she is “maybe” pregnant. Also, late in the pregnancy, the chemical goes away in some woman, So if a woman has gained 30 pounds and feels something inside her kicking and moving, and has an ultrasound showing a baby she is “pregnant” despite the negative test. The number of times the test accurately detects the condition (in this case pregnancy between 3 1/2 and 15 weeks) is known as the positive predictive value (98%) and the number of times it accurately tells woman “not pregnant” is known as the negative predictive value (95%).

The other thing is that if there is a lot of disease, a positive test is more likely to be a “true positive.” If there is little disease, a negative test is more likely to be a “true negative.” So, if you do a pregnancy test on a woman who has had a hysterectomy, a positive is almost certainly not a pregnancy and is a “false positive.” Conversely, if the young woman pours water on the strip because she doesn’t want her mom to know she is having sex, the negative is almost certainly a “false negative.” Here is a really good video explanation.

What, you say, does this have to do with Covid-19? Currently, there is  controversy over testing. Initially, in this country, there were no tests. In the absence of tests, all the doctors and patients had was their clinical intuition. This works really well in flu season EVERYONE in the house has the flu and then MOM gets sick (OH MY GOD, WHAT DO WE DO). Mom has the flu ,and no one needs a doctor to tell her or the other people in the family, who have to resort to eating Kleenex. This works just OK in strep throat season when, even under the best of circumstances, the child with the sore throat might have a 50:50 shot at having strep even if his best friend had strep. The possibility that the person has the disease prior to the test being run is known as “pre-test probability.” If that number is very low, then the a positive test will almost certainly be a “false positive.” So, before the plane loads of Italians and Wuhanians debarked, we needed 0 tests. All of the coughing and shortness of breath was not Covid.

Once the first plane loads of feverish (and pre-feverish) folks from Wuhan and Milan were in America, lots of tests would have really been nice for multiple reasons. First, one of the ways to stop an infection for which there is no treatment is to catch the potentially infected people and quarantine them until the risk of spread is diminished. Had we kept these folks separated from the rest of America until we had a “true-negative” test, the virus would have never come here. Secondly, there is no way to distinguish this virus from the influenza virus, the parainfluenza virus, or any of the other viruses that cause fever, chills, shaking chills, and the rest of the symptoms associated with Covid-19. The difference is that Covid-19 kills people over 65 and is spread by people who don’t know they have it. A positive test (whether true or false) in combination with paid sick leave could have kept meat plant workers away from their colleagues, infected visitors away from their family member in the nursing home, and allowed patients with infection to be treated by an appropriately dressed care team.

The timeline for the test for the virus is as follows: The gene sequence was known on January 12. Once this is known a test can be created. The first known infected person got off an airplane on January 15. We only had 200 test kits made by February 4th but they had a really high (almost 100%) false positive rate. It was another month before the CDC would let commercial labs create their own test. By March 14th we were collecting specimens in Mobile and sending them to a commercial lab in Birmingham that had just gotten permission to run the swabs. Problem was that the results took 5 days to come back. It was several weeks before we could get a result back in the same day.

If everything works right (the person has the right swab stuck up his or her nose and put into the right liquid and sent to the right lab) the virus test allows us to tell people if they are currently shedding virus with excellent certainty (it is a “true positive”). If they have fever, it tells us that they have the Covid. If they have no fever it tells us they have a 50:50 shot at developing the Covid fever. Either way, it also tells us that they can give it to folks they live with, work with, or cough on in a nightclub. It allows us to tell them to wear a mask and stay away from folks for 14 days or until they test negative. Even if it turns out they had a “false-negative,” their being quarantined would save lives and allow live to go on for others.

What we lost by not having good virus testing is control of the disease. We had people coming to the hospital who were potentially (but not certainly) sick with the Covid. We had their family members and the hospital staff who helped them exposed to the Covid, who they then went home to their families. We had people who were dying anyway catch the Covid and give it to their caregivers and we had no clue that they had the Covid. We had people come to the Mardi Gras because they had a scheduled hotel room and cough on people at the parade who then, with a little headache and muscle aches, went to their job at the nursing home. It came to funerals in rural Georgia, Easter service in rural Alabama, and Veterans Nursing Home where it killed 22 of our greatest generation. It is now in every county in Alabama.

Where are we now with testing? We, as a country, have tested over 10 million people since March 8th and found 1.4 million folks with the Covid. Although it sounds like a lot, since Covid is in every nook and cranny of the country experts say we need to test up to 35 million folks A DAY to find everyone infected. We also need to test more than people with fever or headaches. We need to test people who have contact with those who are sick to find virus shedders who are not going to run a fever. We need to identify those people who are infected and have them sit out the next 14 days so the chain of infection can be broken.

But wait, you say, if I already had it, can’t I be free to move about the country without fear? The answer is yes, but I’m 99% sure that you haven’t. That, my friend, is the story for next time.

As states in the deep South and elsewhere are starting to open up from shelter-in-place orders I think we need to get some things straight.

Things that the virus is not:

  1. A deep state conspiracy. It was not created in a lab in Wuhan. It almost certainly is a naturally occuring coronavirus that moved from a bat to humans via an intermediate mammal.
  2. Going to magically go away. Very few people have immunity right now. Summer does not make this virus go away. We are stuck with it until 60% to 80% of Americans get it (culminating in about 1,500,000 dead Americans), we get a vaccine (unlikely in the next year) or we take stopping the spread of the virus seriously as other countries have done.
  3. That thing you had in January. It is almost certain that only 1% to 5% of the population in any place in America except New York City has been exposed to the virus based in antibody testing
  4. Just a bad “flu.” In a really bad flu year in the United States we have 61,000 deaths over the entire season. We have had at least 75,000 deaths from this virus in 2 months.
  5. Not going to hurt me. Randomly people die in car accidents. Randomly people die of this virus. Less randomly older and chronically ill people die of this virus when exposed.
  6. A plot by big pharma to harvest your healthcare dollars. This is a virus that is killing people. It is not activated by masks. It is spread through coughing droplets on others.

What the virus is…The virus is real.  It  came over from China (west coast) and Europe (east coast). It has almost certainly killed almost 100,000 people in this country so far although the death toll will be artificially low due to the way we categorize deaths (I know, I fill out death certificates all the time). It is almost certain that a medication will not help with mortality. If you get the virus, your risk of death depends on your age (very few under 65 die as compared to a lot over 80), your underlying health (those with chronic illness and/or obesity fair much worse than those who are basically healthy), and your exposure history (if you do not come in contact with droplets of spit contaminated with Covid-19, you will not catch it).

The way it came into the United States is a follows. Initially people got off an airplane from either China or Europe with the virus growing in their upper respiratory tract. They may have had a fever, cough and body aches. They may have developed a fever and body aches once off the plane. They may never have done so and cleared the virus. The travelers then went to an activity where there were a lot of other people. A scientific meeting in Boston, A jet setter party in Connecticut. Mardi Gras in New Orleans. They coughed on people at these places and a lot of them got infected. Problem was we were not testing those folks who were coming from infected areas. No tests.

First 100 deaths in the US didn’t happen until the last half of March. How did it happen? The people at  Mardi Gras, at meetings, in New York, the ones who were young and healthy then went and infected a couple of other people and mostly, the virus stopped there. Sometimes, before these people got sick (or even after), they went and did another group activity. They went to a community sing along. They went to a funeral and cried on their sister’s shoulder. They went to church and coughed on someone. At these events, though, there were older and sicker folks. When these folks got sick, they got really sick. Sometimes they went to the hospital, who couldn’t test them. When they got to the hospital there may have been lack of concern because it wasn’t in the community (again, no tests), and/or a lack of protective clothing. Health care workers would get exposed. They would get sick but, because they are troopers, would continue to work through the “flu.” If their job happened to be in a nursing home, many older people who were at risk would get exposed and some would die (either in the nursing home or in the hospital), many other health care workers would get exposed, and then many more people died. The workers in the nursing homes then go back to THEIR families and the cycle continues. Although, as the saying goes, we all have to die sometime, it doesn’t have to all be in the next month. Even now, we do not have enough tests, the ability to administer tests, or protective gear for folks caring for nursing home patients. About 1.5 million people live in nursing homes in this country. That will be a lot of deaths that don’t have to happen

So, the country is opening up and, in the words of the President, “some people will be affected badly.” Assuming you do not want to be the proximate cause (or the 2 degrees of separation cause) of someone’s Papa’s death, there are some things you can do:

  1. Wear a mask. If we get infected we may not know it for 3 or more days. A mask keeps us from infecting someone else who may have an underlying condition or just be older and more susceptible.
  2. Wash your hands or use hand sanitizer. This will keep you and others from getting it.
  3. Stay physically active. Outside is usually safe with social distancing.
  4. Stay away from and don’t hold gatherings of more than 10 people now and 50 people until there is a vaccine. There is clear evidence that social distancing works and when it goes away people die. Stay 6 feet away from folks you are not quarantining with.
  5. Stay home when possible. Remember, you don’t know if you will become sick 2 days from now
  6. Most importantly, stay home if you are sick. If you have a new loss of smell, cough, fever, shills, shaking chills, or shortness of breath but are otherwise healthy, don’t go out for 14 days.

Unlike many countries, we missed the opportunity to control this virus before is became endemic. If we follow the above measures, become much better at testing and protection of healthcare workers and first responders, and learn how to give up some freedom so that those infected can be isolated, then we can get control of our lives back with minimal loss of Meemees and Papas. The alternative is to lose 2,000,000 folks. Guess we each have some choices to make.

 

My, how time flies when you are having fun. As president of our national organization of Family Medicine Department chairs, I had the opportunity to lead our group in a discussion regarding the response to Covid-19. As a work product (a great meeting BINGO word) we created a to do list for America (found here). We are now 3 weeks, 500,000 cases, and 20,000 additional deaths from the publication of this work product. How did we do?

  1. 4 week shelter in place order for all jurisdictions – as of April 7th, at least 316 million people in at least 42 statesthree countiesnine citiesthe District of Columbia and Puerto Rico are being urged to stay home. This is up from 9 states on March 23. While correlation does not prove causality, at least we were on the leading edge of recommendations. It is believed that this action saved (or will save) over a million lives in this country.
  2. Training and deploying a cadre of individuals capable of contact tracing and dramatically increasing access to testing – This will be vital to the SUCCESSFUL reopening of the country. As of today we have tested 3,000,000 Americans over the course of the outbreak. While a big number, in a country of 325 million people, not so many. We need to test close to 2,000,000 folks PER WEEK. We need to test people who have fevers. We need to test people who have been with someone with a fever. We need to test people who work in nursing homes. We also need to, once we find a positive, go and make sure that they are quarantined AND THEN TEST THEIR CONTACTS. This is a skill set that many in public health have allowed to atrophy since infectious disease became unsexy. If we were good at this, syphilis would not be a problem. For Covid control if we were to open the country, everybody would need to be tested approximately every 2 weeks with adequate investigators for the positives.
  3. Adequate personal protective equipment. – As someone who trains medical learners, this is near and dear to my heart. It is unclear how many health care workers, first responders, even grocery workers have been infected in their line of work. This is due to a broken supply chain, inadequate planning, and an inability to plan for the “unthinkable.” The CDC, on April 3rd, issued guidance on reusing “single use” equipment, One can only hope that we are working to adequately protect our health care workers. While there are many feel good stories about folks repurposing their plants to make eye protectors, there are many more about the lack of PPE and the fear that care delivery workers carry home with them.

So, now what? Hopefully we will continue to shelter in place, obtain testing and case finding to allow us to open the country, and obtain adequate PPE to protect vital workers. Fact is, Covid-19 is a disease that has no effective treatment and when fully manifested does not respond well to supportive care. It kills very few people in their 30s, more in their 40s, and so on until the population gets to be around 80, where 20% of those who develop an infection will die. For most of these older folks, besides protecting them from the virus we cannot alter the course of the disease

What can we do? To quote one of America’s great physicians, Sir William quote Osler, “Ask not what disease the person has, but rather what person the disease has”. The reality is we as caregivers are back in the era of “The Doctor.” I took some time today to read the bio’s of the Covid victims and I recommend you all do the same. Honor the victims. Let’s take some time to remember the people we care for, despite the isolation.

This is not about an invisible enemy except in that if you remain isolated you will not encounter it. This is about an insidious disease that is brought to our patients because of the efficient way we care for them (nursing homes, group homes), the way we ask them to work (low wages, no health insurance, limited childcare, no sick leave), and the limited information we give them (let’s reopen the economy). We need to fight THOSE enemies.

 

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As a family physician, one of the more fun conditions for me to care for is pregnancy, childbirth, and the well child checkups that follow.

I meet women at the start of their pregnancies and learn a little about their lives beyond their pregnant “condition.” I see them every month for a long stretch, meeting mothers, mothers-in-law, friends, and husbands along the way. As things progress I see them every two weeks, and then weekly.

By the time the weekly visits occur I find out what my patients are made of – and they get to know me, as well. Mama is very pregnant, and my job is to convince her that every day inside, even past the mythical due date, is good for the baby. I then get to witness the miracle of childbirth (and occasionally play a larger role).

In my practice, mother and baby come back to visit weekly, monthly, and then annually as the children reach toddlerhood. We continue to have conversations around the new family and the transitions up until the age of three.  After that, if the child is well, we are limited to an annual “Hi, how are you doing?” For the most part, they are moving on with their lives as a young family and fortunately do not need my help. In the words of the Lone Ranger,”My work here is done.”

However, it isn’t quite as easy as that. Doctoring is a funny gig when it comes to personal relationships. I’m sure there are others just as funny, dentistry probably being one. I see these folks back for a visit after a couple of years, or at a community activity, or elsewhere in Mobile and surrounds, and the mothers will proudly say to their (very embarrassed) twelve-year-old,  “There’s the first person who ever saw you.” We’ll make some small talk — what do you say to a twelve year old after nine years? — and typically the mother will ask about my family and my kids.

Because, as it turns out, while they were sharing a part of their story with me, I was sharing a little of my story with them. I used my children as examples for feeding and discipline problem-solving, as both good and bad examples. I discussed my wife’s meal-time solutions for feeding grown-ups and kids at the same table. In other words, I shared with them as they were sharing with me. A little piece of my version of how we put our kids to bed has entered into the bedtime strategy of many of the families that I have cared for. If “Good Night Moon” did become a successful part of their ritual, I hope they think of Dr. Perkins in a really good way (after the toddler is actually asleep, of course).

I don’t get to care for a lot of young families any more, given my other duties, but I do still see folks that I have cared for over the last twenty years, people with whom I have shared family anecdotes in this manner in the hope of leading them to better health.

It has been six months since my wife’s death. Many of my patients, coming in for a variety of reasons, or running into me around Mobile, have wanted me to know that they are here for me just as I, and our family, and some of my
wife’s child-rearing strategies, were there for them. It has meant a great deal to me.

Through pestilence, hurricanes, and conflagrations the people continued to sing. They sang through the long oppressive years of conquering the swampland and fortifying the town against the ever threatening Mississippi. They are singing today. An irrepressible joie de vivre maintains the unbroken thread of music through the air. Yet, on occasion, if you ask an overburdened citizen why he is singing so gaily, he will give the time-honored reason, “Why to keep from crying, of course!

Lura Robinson, It’s An Old New Orleans Custom, 1948

It is a month today since Danielle’s death. I had already planned to go to New Orleans for my 30th medical school reunion by myself prior to her death, as she was to be playing Amanda this weekend in a local production of Glass Menagerie. The play is set in St Louis. Tennessee Williams, the writer of the play, once said “America has only three cities: New York, San Francisco, and New Orleans. Everywhere else is Cleveland.” Clearly, he set it in St Louis for a reason. Danielle was a New Orleans native, and she understood those reasons.

I lived in the Faubourg Marigny (a neighborhood just outside of the French Quarter) while I was in medical school. After we married, Danielle and I moved to the Irish Channel, a neighborhood that is quite gentrified now but was much less so 34 years ago. For those of you who know New Orleans, we were one block off Magazine and spent many afternoons there walking and window shopping.

After moving to Mobile we found ourselves in New Orleans many times a year. We would go to Danielle’s mother’s house and, after a suitable time, we would make an excuse and go to Magazine Street. The children had valuable grandparent bonding time, and we had New Orleans time. This became less frequent as the children grew older. After Katrina, both of our immediate families left south Louisiana and so our visits were limited to special occasions. We still made it about three or four times a year, however, enjoying many delicious meals with our friends and extended family, and spending time window shopping on Magazine.

This weekend, I played hooky for much of my 30th reunion. Staying with friends of ours in their uptown home, we drank wine and remembered the old times. New Orleans being New Orleans, we went to the Boogaloo Festival and heard the Lost Bayou Ramblers. We spent time among the thirty-somethings, watching them  frolic in the old (not very clean looking) Bayou St. John canal. It was hot. All in all, a very New Orleans experience.

At the reunion events I did attend, word quickly spread about my wife’s death. Many came up to me and offered condolences. Most of them only knew Danielle peripherally, so I didn’t have many in-depth conversations. “So sorry for your loss,” they would say. “Thank you for your kind words,” I would mumble back. Since many of these old acquaintances are no longer married to the spouse they boasted in medical school, discussions of marriage and relationships are typically avoided at these reunions altogether. One of the more awkward moments, in fact, was when we toasted to those who helped us get where we are and the person next to me said: “Wait, am I toasting my EX-wives?”

I guess my loss really hit me when I was driving down Magazine Street on my way out of town. I saw all the familiar buildings that were built before we were born and will likely be there after our deaths, and I realized that my loss is not just the Danielle of today. My loss is the life we built together and the life we expected to continue to share. That loss includes our shared experiences and memories. Our stories. Our jokes. I realized that I had lost not only Danielle but our shared New Orleans.

“So sorry for your loss.” For those who knew us, it is a shared loss and I am sorry for your loss as well. For others, I really do appreciate the sentiment, even though I may respond less than enthusiastically at times.

 

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“Unless there is a public outcry, I don’t see any changes.”

Alabama Senate President Pro Tem Del Marsh on passing a Medicaid budget that reduced payments to physicians, hospitals, and would end all “optional services” including home health programs, hospice, outpatient dialysis, adult eyeglasses and PACE, a program to help some elderly people avoid having to be admitted to nursing homes

How do you create a public outcry? That is the question for the 500 dialysis patients who rely on dialysis to continue living.

Dialysis is a funny thing. When Medicare and Medicaid were established in 1965, renal replacement therapy (known by lay folks as dialysis) was known to save lives. People who had lost kidney function from diabetes, polycystic disease, or some other malady, unless they were fortunate enough to be a part of an experimental protocol, would die from a build-up of toxins in their body. If they were enrolled in a protocol or had the good fortune of living near a place that was experimenting with renal replacement therapy, they would live.

In the late 1960’s, a report came out that identified renal replacement therapy as established as opposed to experimental. In addition, because of the “experiments” funded through Medicare, the number of people on dialysis increased by a factor of 10 (from 1,000 to 10,000) and the number of physicians performing dialysis increased dramatically. This set the stage for the hearings in the 1970 where this testimony was heard:

I am 43 years old, married for 20 years, with two children ages 14 and 10. I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies. I tried to sell a non-competitive line, was found out,and was fired. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Should I go into the hospital under my hospitalization policy, then I cannot work? Please tell me. If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up? (U.S. Congress, House, Committee on Ways and Means, 1971b)

Following this, the house and the senate passed and President Nixon signed a bill creating a dialysis benefit for those eligible for Medicare.

Fast forward to today. In America we have 400,000 people on dialysis. They have to have their blood cleansed 3 times a week. If they do, they can live a relatively normal life. If they don’t, they can develop shortness of breath (pulmonary edema), feeling poorly (uremia), or a high potassium level (hyperkalemia) and when it gets bad enough that they’re deemed to be near death, they  are given dialysis via the emergency room.

Most people on routine dialysis have it paid for by Medicare. Who gets it on the federal nickel? To quote CMS, these folks are eligible:

  • You’ve worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee.
  • You’re already getting or are eligible for Social Security or Railroad Retirement benefits.
  • You’re the spouse or dependent child of a person who meets either of the requirements listed above.

If you don’t meet these criteria, and require renal replacement therapy, you pay cash (between $52,000 and $73,000 per year), obtain coverage from Medicaid, wait in a state of anticipation until you need emergent dialysis (costing about $300,000 a year as a strategy), or die.

Alabama would be the first state to take it away from ALL Medicaid recipients. Texas does not pay through Medicaid but instead pays through a separate fund.  They were able to take away dialysis from undocumented folks. Because of the pesky EMTALA laws passed by President Reagan, hospitals are required to provide EMERGENCY treatment. The consequence?  A bunch of folks who hang out at the hospital every day getting their blood drawn to see if they win the emergency dialysis lottery.

So, back to my original question. You see, Alabama is $100 million short on their Medicaid budget. On a budget of about $6 billion, that would seem like a small number.  Alabama legislators, though, are ready to make a stand. The 500 Alabama citizens on dialysis will either die or spend the rest of their days hanging out next to the emergency room so that we can prove the value of “low taxes”  unless there is a “public outcry.” How do you stop folks entrusted with the health and welfare of the citizens of Alabama if they are able to murder 500 people to prove a point? I can’t figure it out.

 

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Student overheard on interview tour: Boy, I really put one over on Perkins. I told him I wanted to be a Primary Care doctor…and he bought it. I’m sure to get in now.

What do we look for in medical students? No matter what, we want our physicians to be smart. The selection process is designed to weed out “not-smart” people. Unfortunately, we can only measure smart in a couple of different ways (grades and MCAT scores), ways that tend to benefit the wealthy  (60% of medical students are from the upper quintile of income) and non-minority folks (14% of medical students are from underrepresented minorities compared to almost 25% of the population).

Is there  another criteria we should  use for selecting medical students? Altruism in medicine is best described in the words of this medical student:

So, for me, I see it as always putting yourself behind the person that you’re with. So the patient comes first, no matter what. If it means spending extra time past normal office hours to stay, if it means going out of your way for somebody, if it means sacrificing something for yourself, I think that’s what it is. First and foremost, you’re taking care of the patient.

Can we assess this in a medical school application? Unfortunately, not very well and not in a reproducible manner. We tend to put value on things we can quantify, so an MCAT equivalent of 37 (99th percentile) would attract the attention of the admissions committee much quicker than a prolonged experience at a soup kitchen. As one of my fellow admissions committee members said, “You can’t assay for the Give A Crap gene,” but you sure want your doctors to have it. The MCAT predicts how well the student will perform on tests but has no bearing on how good of a physician they will be. The soup kitchen experience may take away some grade and MCAT points, but give me that doctor-to-be every time.

Another marker is not the number of experiences but the intensity and commitment shown. The best people I have interviewed have been folks who have decided on medicine after several years of Teach For America or similar life experience. These folks tend to be better able to communicate with patients and, not coincidentally, tend to seek careers in primary care.

The best way to assess this, so they say, is through the interview process. As an interviewer, I will look at the student’s activities and query them regarding each of the things listed. Although not focused on primary care, I try to focus on whether or not the person has the GAC  gene. To be honest, if in my opinion they don’t, I am not certain enough on my ability to assess to sabotage the application. If they do, I try to recruit them into our school. If not, I try to sell them on the other allopathic medical school in the state.

 

'Ms. Smith, I have a meeting in ten minutes and I can't find my hidden agenda.'

Discussion in medical school admissions committee:

Colleague: So I asked him “just why do you think you want to be a doctor” and he said, “Oh, you know, I like science, want to help people , like to problem solve.”

Me: I just learned about a new term called “the consent agenda.” In a meeting, if there is stuff everyone agrees on, you put it on the agenda as “consent items.” Then, with no discussion it can pass and you can move on to discussing something germane. I propose we notify all students that love of science, helping people, and problem solving are consent items. Then, we need to find out, how does this person know they REALLY want to be a doctor?

I just learned about this web site called DOC. DOC stands for “Drop Out Club” and it exists to help people transition from clinical medicine into a non-clinical arena such as management or sales. On their web site they say that the “name reflects the sentiment at our original gathering that no clear support systems existed for the paths we were pursuing.”

The site has about 10,000 members, although some may be lurkers like me. The forum at the site is full of folks who feel like they have made a terrible mistake with their lives and are looking for a way out. Many are in residency with statements like “I look around and can’t see myself doing this for the rest of my life” predominating.

Physician career dissatisfaction is a real problem. About 400 physicians commit suicide each year. Suicide is the number 2 cause of death in medical students (following accidents, some of which are also likely suicide). This is thought to be a consequence of underdiagnosed depression, almost certainly made worse by a rapid and monumental debt accumulation. In addition, I will concede that a love of science, a desire to help people, and a joy of problem solving are all good attributes. Unfortunately, they are not sufficient to combat an inchoate  fear that you are 5 years and $300,000 into a terrible, terrible mistake.  And it starts early, also:

A study of all medical students in the United States found that about 49.6% of medical students met the criteria for burn out and 51.3% for depression. Trust me—it’s not all from studying, but from being treated like crap, feeling like we can never make a mistake or ask for help and wondering if anything we do will help to change the status quo or are we just cogs in a wheel trying to crush us.

Approximately 15 years ago, Don Berwick outlined the triple aim for improving healthcare in this country – enhancing patient experience, improving population health, and reducing costs. Tom Bodenheimer recently outlined a fourth aim – improving the work life of health care providers, including clinicians and staff. He identifies the following as some of six things we can do in primary care to keep our colleagues engaged and off the DOC website:

  • Reduce the burden on the physician through team documentation: An encouraging trend I have seen among pre-med students is their being engaged as scribes. This way they get to learn what it is really like to be a physician by being a part of the team and the physician gets to go home without having to do two hours worth of charting after dinner.

  • Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders. Things that are automated should happen automatically with the physician not being a barrier to good preventive care. We need to model this for students

  • Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day. We have gotten rid of the office in our practice. The physician work space is a shared space where interaction can occur. It is really important to level the field.

  • To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice. This holds true for student members of the team as well. They need to understand their role in care delivery as part of the stress of being a student is constantly being thrown into a new environment.

In short, what we as educators need to do is make sure students understand what they are getting themselves into and make sure they have the tools necessary to do the tasks they are assigned. What students need to do is look away from the books and understand that this is not about science or helping people but is about acquiring the skills to enter into a very difficult profession. While interviewing a residency candidate  for our residency it came out that she had been to cosmetology school and had cut hair at Walmart for 2 years. I asked her what the best thing she had learned from that experience was, and she said “When people sit down in that chair and say ‘do whatever you want,’ they don’t mean it.” I suspect she won’t burn out.

 

download“If the entire materia medica at our disposal were limited to the choice and use of only one drug, I am sure that a great many, if not the majority, of us would choose opium; and I am convinced that if we were to select, say half a dozen of the most important drugs in the Pharmacopeia, we should all place opium in the first rank.”

Macht DI. (1915) The history of opium and some its preparations and alkaloids. JAMALXIV:477–481

Disabled, chronically abandoned

(Sign held by a young woman protesting in front of a pain clinic shuttered by the DEA last week)

Often in nature, a substance is found (or some believe God has placed a substance) that has serendipitous properties in humans. One of the first instance of humans discovering this was with the milky substance found in a flower now known as the poppy. Thousands of years ago, someone (we think an Arab adventurer) for whatever reason ingested that the milky substance in the “proto” poppy plant and found it relieved his pain. For the next thousand years, through cultivation and trial and error the opium poppy was born in China. Papaver somniferum. 

Pain is a funny thing in people. It is a mechanism almost all of God’s creatures have to tell them that if they stay in their current situation bad stuff might happen to them. One of the things we are taught in medical school is how to get people to describe their pain. We tell students to get people to use a 1-10 scale with “1 being a paper cut and 10 being an elephant sitting on your chest.” Did you know there are a lot of people whose paper cuts are a 10? Once the situation has resolved, we have chemicals in our body that connect with the pain receptors (there are 4 such receptors, with mu being one) to relieve the pain and give pleasure. The opium poppy, which likely could only move back and forth and doesn’t need a lot of pleasure materials, has been bred to have 12% of its latex made up of these pleasure drugs (morphine, codeine, and to a lesser extent thebaine which was used to make hydromorphine).

Having a drug that reduces pain is lucrative. Having a drug that causes pleasure is more lucrative. In the 1800s, German scientists were able to extract pure opium from the poppies. Although available for pain relief, the larger market was in euphoria production in shops (mostly in China) using water pipe technology. Ironically, it was declared illegal in China (where the poppies were grown) but was smuggled by the British into China and sold to the opium dens to offset the imbalance of trade they found themselves in from importing tea. Only fair, I suppose.

We don’t need flowers today. Thanks to the God-given ability of humans to reverse engineer, the world produces about 700 tons of narcotics. Most of this medication makes its way to the US. We have 5% of the population and account for 99% of the hydrocodone use in the world (active ingredient in Vicodan), 83% of the hydrocodone use (active ingredient of Oxycontin), and 37% of the world supply of Fentanyl. We consume twice as much per capita as the next highest nation. Within our country, even, there is much variation with Alabamians consuming 2 1/2 times (1 1/2 prescriptions per person) as much as Hawaiians. The misuse of these drugs contributes to 17,000 deaths annually, as many as ovarian cancer but without a ribbon to raise awareness. Deaths aside, there is the problem of diversion. Many people get a prescription for 90 Vicodan, take 60, and sell 30. There are willing markets of buyers and many physicians are unaware that their sweet little elderly lady patient (who has the medicine in her urine) has a side business.

It turns out opioids have a downside. They are addictive, meaning that they cause aberrant behaviors on people unable to get access to the drugs by buying pills from the guy down the street. They cause a physical dependence. People who are suddenly denied access will suffer from physical symptoms such as nausea, vomiting, and profuse sweating. Chronic use results in tolerance, meaning that it takes an increasing dose to get the same effect. If you are going to create a market, what better product to sell?

As detailed in this New Yorker article, this problem has been a long time coming, and we in the healthcare field are complicit. Beginning in the 1980s, scholarly articles encouraging the addition of narcotics to our inadequate pain treatment regimes have been published. Some very smart people believed that treatment of chronic, non-cancer pain with opioids could work  “with relatively little risk of producing the maladaptive behaviors which define opioid abuse.” In the 1990s makers of legal narcotics (Purdue in particular) began marketing their products to physicians and patients as safe for everyday ailments such as neck and back pain. With a team of 5000 sales people, a bonus system that encouraged “market growth,” and the assistance of the Joint Commission which began requiring hospitals to evaluate and treat pain, over $1 billion worth of Purdue’s Oxycontin was sold in the US in 2000.

So, God placed this wondrous drug in the proto-poppy for what reason? If used correctly, say for the pain associated with metastatic cancer, it is truly a miracle. If used by people to mask the psychic pain of living in America and written by physicians who are just too busy to talk to their patients, it is probably not what God intended. If given by physicians to folks in exchange for sexual favors thus feeding their addiction it is almost certainly not what God intended.

Perhaps God put the proto-poppy on earth to test physicians. We can make a lot of money selling these poppy derivatives but we can also get in big trouble. The test for us is to use it correctly.

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Dr Perkins, can you come see this baby? Something about it just makes me feel uncomfortable.

I walk into the exam room to evaluate the week-and-a-half-old baby that was being seen by our new nurse practitioner. The child had a late morning appointment, the mother having called at 8 because the baby “wasn’t feeding.” No fevers, nothing else out of the ordinary per mom (although the baby did up having a fast heart rate). But as soon as I walked into the room, I quickly agreed with the nurse practitioner. The child was sent to the hospital for a “septic work-up” and was indeed septic.

Dr Perkins, I just don’t feel good. I have this chest pain when I go to sleep at night. Not during the day, mind you, only at night. That’s right, it hurts right there when you mash down.Why, yes, I have been getting a little short winded when I walk the golf course but isn’t that just weight gain?

Despite the reassurance that reproducible chest wall pain brings, based on reduced exercise tolerance we went ahead and obtained an EKG. To make a long story short, 3 vessel disease.

It was quite the Monday.

Despite running a busy department, I do a lot of clinical medicine. Trained in the underserved environment where I continue to practice today, I care for all ages, do some minor procedures, deliver babies (and now the babies of the babies I delivered). As my practice has aged with me, I see a lot more older than younger folks and find myself diagnosing more dementia and less strep throat the older I and my patients get.

Being comprehensive defines my specialty along with continuity, coordination, and first contact care. We preach to our learners the importance of these attributes, we test our graduates on the comprehensiveness of their knowledge, and we criticize ourselves for allowing our scope of practice to shrink. Now there is one more piece of evidence that should make us think twice about that cushy outpatient job ($50,000 signing bonus, no call, no hospital, 15 minutes to the beach). The Graham Center has authored a very elegant study that links scope of practice with actual practice. They found that doctors who were able to do more (were more comprehensive in their approach) had Medicare patients who were less likely to be hospitalized and who had better care-seeking behavior. By better, I mean that they cost the system about 15% less.

Not measured in this study were quality and patient satisfaction. This is important. As one of the commenters points out, sometimes comprehensiveness can be misused.

[F]or some populations with higher disease burden, high comprehensiveness (or scope, as we say) may be counterproductive. PCPs that maintain “too much” comprehensiveness for patients who need more contributions by other providers may be doing so because of lack of coordination with specialists, inadequate supply of alternative providers, an inability to recognize limitations, or resistance to “letting go”. Whatever the reason, the decreasing value of expanded scope in high risk individuals is a phenomena we have seen in numerous populations.

Despite these limitations, this is important.  In the words of Kevin Grumbach (one of the smartest people I know) on NPR (one of the best sources for information I know)

the new study confirms a belief that had long been suspected, but has rarely been proven: Coordinated care, led by a family doctor who is judicious about referring patients to specialists, leads to cost savings.

“It goes from a matter of philosophical preference to actually showing that this saves money,” Grumbach says.

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