Feb 18, 2010

40 Days and 40 Nights

As he mentioned last week, Doctor D is going to unplug from the internet for the 40 days of Lent.

Lent is an ancient Christian tradition when believers give up enjoyable distractions to focus on the more important things and prepare the soul for Easter.

Doctor D frickin' loves blogging!

It is lots of fun answering people's questions about the medical system and giving my odd perspectives on the doctor-patient relationship. Doctor D has met some very inspiring and cool doctors, patients, nurses, and med students through this blog.

Unfortunately, D has also spends most of his free time in front of the computer reading blogs, writing posts, and twittering.

So for the season of Lent D is going to escape from the internet:
On day one Doctor D will get some work done around the house.

But on day two he might get a little nervous and jittery.

On day three D's hands will be shaking and he'll ask to go check his Google Reader "just this once."

By day four Doctor D might just be howling obscenities and have to be tied down to keep from reading his favorite medblogs.

But... by day five D shall be totally Zen with a mind clear of all electronic distraction.

He will write and read on paper instead of blogs, he will learn to enjoy silence, he will take long walks in nature, and he will spend more time with his toddler, Little D.
After he has a purified mind and soul Doctor D will triumphantly return to answering your questions on April 5th!

How will you survive a long abstinence from all this Doctor D goodness?
  • Turn your attention to the blog roll: Doctor D links to some awesome blogs that will give you your medblogging fix till April.
  • Explore the Archives: There's some cool stuff back there to help you through the dark night of the soul Doctor D's absence is sure to bring on.
  • Subscribe: Instead of marking April 5th on your calender and counting the days in despair you can just plug AskAnMD into your reader and the new Doctor D shall magically appear on your computer after he has returned from his silent contemplation!
  • Send in Questions: Does reading this blog inspire you to ask a question? Email it to Doctor D and he'll add it to the list of interesting questions awaiting his sage answers.
Yes, despite all his blogless peace and harmony Doctor D will still check his email from time to time, so feel free to drop him a note.

Peace out! Doctor D is unplugging now.

See you in April!

Feb 15, 2010

The Medical Mafia (Price Fixing in Medicine)

Question for Doctor D:

Why does it cost so much to see a doctor?
Great question! There are lots of good explanations, but Doctor D's gonna give you a revisionist history lesson that will open your mind:

Doctor D's gonna take you way back to the US over a hundred years ago: There were lots of doctors and visiting them was cheap. Doctors made a middle class living and medical schools worked like apprenticeships. Doctors did their best, but they didn't have most of the cool lifesaving stuff doctors have now.

But big change was coming...

New biomedical research was going to alter medical practice forever, and "The Man" saw the opportunity to create a cash cow medical-industrial complex that would swallow the US economy whole.
But first The Man had to knock the little guys out of the action...

The newly incorporated American Medical Mafia Association made its move, hiring the intellectual hitman Abraham Flexner to execute their takeover.

That shady Mr. Flexner visited every medical school in the country. He knew exactly how to break the legs of the competition: Science.

The Flexner Report: An offer you can't refuse.
Medical science was bringing wonderful new knowledge into medicine, but in 1910 Flexner demanded that every doctor should be a scientist too. Every doctor must do years and years of basic science training before ever caring for patients. Flexner also recommended in his report that every medical school that wasn't associated with biomedical university research should be destroyed!

The mafia power play worked. The Flexner Report was hugely influential. The American Medical Mafia Association was given control over every medical school in the country. Don Flexner sent almost half the medical schools to "sleep with the fishes." With the little medical schools out of the way, the mafia now had complete control of who got to be doctors.

New Doctors: Nothing personal. It's just business.
The personable old "doc" of the past was replaced with the new scientific physician who knew more about organic chemistry than human interaction. New student doctors were taught to approach their patients with the cold objectivity of a scientist watching an experiment.

With the warmth and kindness of the doctor-patient relationship gone the study-weary doctors had no one to identify with but each other. Doctors became less a part of their communities and more a society unto themselvesmaking them easier for the medical mafia to control.

With total control the medical mafia cut supply to increase demand. With fewer doctors the price of a visit skyrocketed. Even doctors who might want to work for cheaper couldn't because of the massive debt from their new med-science education.

It's All About Control
The medical mafia keeps a tight stranglehold on medical schools. This country's population has gone way up in the last 100 years, but the medical mafia has been keeping a tight lid on the number of doctors. You might think with the current doctor shortage they would be begging every smart young person to go into medicine. Nope!

You want to be a doctor? You have to get excellent grades in lots of brutal courses, do a bunch of work on cells in a laboratory, be the president of some student organization, study like mad for the MCAT although it has nothing to do with medical practice, and promise them a decade out of the prime your life. Even still they're likely to say "No!" Every year thousands of bright students are refused entry to medical school even though they would make excellent doctors.


Refusal gives them power.
It makes the ones that do get into the club special, powerful, and always in demand. With a stranglehold on the doctoring business the Medical Mafia has its fingers in every clinic and hospital in the country.

Ever wonder why the United States has to import doctors who barely speak English? Now you know. It's the only way to circumvent the Mafia's blockade on doctor supply.

But couldn't we just train more American doctors, shorten the length of medical education and lower its costs, and allow medical visits to be affordable and doctors to return to the middle class? You think The Man would let us get away with that? Forgetaboutit!

Abraham Flexner
"Kiss the ring, bitches!"

So next time you or your insurance shell out $600 for a visit to a specialist remember the Medical Mafia and Abraham Flexner. Don Flexner has been dead fifty years, but trust me he still owns us little guys.

Show some respect! The Medical Mafia is just taking your money for your own protection!
So what do you think? Most of medicine still sees Abraham Flexner as a hero. Doctor D's story may be silly, but most of the facts are true. How do we undo 100 years of history? How do we recreate quality medical care that doesn't bankrupt the country?

Doctor D looks forward to your ideas and observations in the comments.

Feb 12, 2010

Neo Links Needed! (Friday Links)

Alas, one of the great patient medblogs is no more!

Neo-Conduit's Blog is gone.

Doctor D has really loved getting to know patients through the blogging medium.

D has spent a lot of time with patients in exam rooms and hospitals over the years, but he has often wondered, "What do they really think about doctors and medical care after they go home?" Doctor D always meets you in that very weird place they call the "doctor-patient encounter" where both people's behavior, perception, and personality are distorted by the odd roles we are assigned to play.

For healthcare providers, patient blogs offer a fascinating peak into the private thoughts of patients. Anonymous blogs allow people with medical issues to express their minds with a candidness they are rarely able to display face to face with their doctor or nurse. In blogs we see the humanity of patients through their stories, their triumphs, their frustrations, their fears, their angers, their rants.

Any healthcare provider that really wants to "help people" should read patient blogs on a regular basis.

Neo-Conduit was that sort of blog. Neo had suffered severe surgical complications resulting in chronic pain and multiple infections to her urinary system. Her blog told the story of her injuries, her frustration with doctors, her observations of other patients, and her personal feelings about life with illness. Reading Neo-Conduit was always entertaining and mind-opening.

Her blog has been gone for several weeks now. No hiatus or anythingjust gone! Leaving nothing but the dreaded, "blog not found" message. Doctor D tried to contact her, but got no response.

We hope that Neo is doing well and that much joy awaits her in her new blog-less endeavors. You can go to her twitter page (which is dormant but still there) to wish her luck.
Now AskAnMD requires a new patient blog for the Link List and needs your help!
Doctor D is about to take a Lent sabbatical and wants to leave you guys with some really excellent blogs to read. He is looking for a blog that is less technical (only info about diseases and treatments) and more of a personal experience in illness and healthcare. Take a look at the excellent blogs to the right for guidance.

Doctor D's favorite new patient blog shall take it's rightful place in the Link List space that once belonged to Neo-Conduit.

*This isn't a Big D Award contest, but all the blogs in the Link List will automatically qualify for the patient-blogger Big D Awards coming up in April or May!
So let Doctor D know your favorite patient blog!

And thanks to all you medical patients out there who have educated Doctor D!

Feb 8, 2010

Dr. D's Guide To Getting Worked-Up

The last few weeks Doctor D answered questions about work-ups that don't find answers and the proper work-up from a doctor's perspective. All that theoretical stuff is useful but Doctor D figured he'd hook you up with some practical tips:
So you go to your doctor with a problem. You tell the doctor your symptoms, and after examining you the doc shrugs and says, "To really figure out what's making you feel bad we might need to run some tests."
Here's how to handle this...
  • Take part in the decisions being made. Even if your doctor is awesome it is your body on the line.
  • Ask about the risks vs. benefits of each test done.
  • A useful question: "Is this test necessary?" If your doc is quick with a "Yes" or "No" then probably the evidence if overwhelming in favor of following the doc's suggestion, but often the answer is "maybe" and in these situations you want to understand the situation so your values can influence the decision. (Unless you are with one of those docs that never ever says "maybe" or "I don't know" in which case you should really find another doctor)
  • Ask your MD how serious these symptoms typically are for your situation: What is the most likely cause of my symptoms? What is the worst case scenario? (Hint: death is sometimes going to be worst case, which makes the next question more important.) How likely is the worst case scenario? How do most people with these symptoms end up? Are these "red flag" symptoms that must be evaluated.
  • Ask your doctor about the risks of the work-up itself. Some things such as certain blood tests are very low risk, and other tests may be higher. Part of the risk is the test itself, but part of the risk is that aggressive things we often do to follow up on results that are sometimes false positives.
  • Realize that your doctor may not be able to give you hard numbers on the risks of particular work-ups. We are only just beginning to understand how high the risks are for very common tests like mammograms and PSAs we've done on millions of people. We just don't have great data on the exact danger of each work-up, but your MD should be able to give you an educated guess about the risks of a test or series of tests.
  • If a doctor ever tells you any test is "risk free" run the other way. While a lot of tests are very low risk, all of them have some. Even the most safe and simple test runs the risk of misleading false results that put your care in danger. A physician that isn't thinking about the risks they subject you to is someone you don't want guiding your care.
  • Ask your physician how each positive or negative result you get affects the overall picture: Do these results make a concerning disease more or less likely? Do they clarify or confuse the picture? How do these tests change our concern about of my symptoms?
  • Ask about the end-point: Every work-up either produces a diagnosis or a point at which it would be unwise to go on. Ask where that end-point is and what it means to not find an answer with this particular set of symptoms.
  • Ask how certain a diagnosis that results from your work-up is: Sometimes the test results give an answer with a high degree of certainty. Sometimes the results just point us in the right direction and we make an educated guess.
  • Inform your doctor how you feel about the illness and the work-up: Are you more pleased or more worried based on how the work up is going? How much do the symptoms bother you? How much do you need to know the answer? How much risk are you willing to take to get a diagnosis? Your values make a difference.
  • Ask your doctor if he or she needs backup. MDs don't want to let their patients down, so sometimes we act on top of things when we are really in over our heads. In a big work-up for concerning signs and symptoms there is often a point where calling a specialist is the right decision. Let your doctor know that you will still respect him/her if they call in help.
  • Remember: you have the right to a second opinion. Even two very good doctors will likely approach a work-up and its risks/benefits very differently. If you are worried about a work-up that yields no diagnosis then you should get the perspective of another physician. Remember that different approaches don't always reflect a difference in quality of physicians, so don't badmouth the doctor that didn't find the diagnosis.
  • Don't ask your doctor to do something he/she doesn't feel is safe. It is pretty rare for a doctor to bluntly say, "I don't think it is safe to continue." If a doctor says this, listen. For a doctor to go against the grain and stop a work-up he or she must be pretty worried about your safety. If you want to proceed go to another MD who is willing to do it for you. If you can't find any reputable MD willing to do something then that should clue you in that you might be at a wise stopping point for your search.
  • Remember: More tests are not always better. Less tests are not always better. What is better is you and your MD working together to create a reasonable and thorough work-up for you.
What do you think? A lot of healthcare people and patients read this blog--let me know if I missed any important tips. Have any of you ever used these strategies? How did they work? Doctor D loves to hear your thoughts in the comments.

On a side note: Doctor D will be taking a brief sabbatical from blogging for the 40 days of Lent, which means that next week is your last chance to get your question answered before Easter.

Feb 5, 2010

And The Winner Is... (Friday Links)

Forget about the Superbowl: the real clash of champions this week has concluded! Thanks to everyone who voted in The Big D Awards. The dust has settled and it's time to announce the winners!

The Big D for excellence in Nurse Blogging goes to...

Nurse Me is a critical care nurse blogger who used to be a bartender. Although it sounds like an advocacy blog for breastfed infants Nurse Me is, in fact, a very cool blog on nurses, patients, and healthcare in general. (Doctor D feels free to have some fun at the expense of her blog's name after what NurseMe said about At Your Cervix!) Doctor D is very new to Nurse Me, only having found her blog a week before nominating it for the Big D. Now she shall take her rightful place in the Ask An MD blogroll.

Nurse Me won the title of "most awesomest medblog in existence" with 57 out of the total 200 votes. The runners up were At Your Cervix and Call Bells Make Me Nervous.

Now for the Big D Award in Medical Student Blogging:

Wouldn't you know it those fiercely competitive medical students managed to tie for the Big D Award!

Several minutes after midnight when Doctor D dragged himself out of bed to certify the results he found that both Journey to MD and Asystole Is The Most Stable Rhythm were tied with 55 votes a piece! Okay you gunnersyou can both be the awesomest. You shall both be able to display your Big D Award and you both get a mug! Now back to studying!

The runner up is Old MD Girl.

The final contest was to see who could nominate the best nursing or med student blog that Doctor D didn't include, and alas in this quest everybody got a big FAIL.

Out of 17 comments there was only one nomination, and that was Asystole nominating a friend of hers. He's a medical student but he mostly blogs about other stuff like strange masks. Okay, whatever.

So Doctor D went out and found a totally cool new blog on his own: Scenic Drive!

It is the fascinating life of a Pediatric ICU nurse who is also applying to medical school. Her blog is the perfect addition to the links today. Now she's in the nursing links but hopefully soon she'll be moving to the med student links. Go check her out. Who knows? You may end up voting Scenic Drive for the 2011 Big D Award.

Congratulations to all the nominees and winners! The prizes are in the mail! (or will be a soon as the winners send Doctor D their addresses)
Doctor D had lots of fun with these awards! We'll have to do them again soon. Which blogging category should we vote on next?

Feb 3, 2010

What Is A Proper Work Up?

Doctor D's post on Mystery Illnesses last week was pretty controversial. Some readers were concerned that D suggested we should sometimes give up looking for answers after a thorough work-up is negative. An intelligent reader remarked that Doctor D over-simplified because he didn't define what a thorough work up is. Excellent point:
What is a proper work-up?
Of course it's tricky to define because a good work-up varies significantly depending on the patient, the symptoms, and the situation. It would be tedious to go into the details of any specific work-up. Instead D will give you a simple answer:

The correct work-up is an investigation of your symptoms that is more likely to benefit you than harm you.

Work-Ups Are Dangerous
Okay, let's take a moment to consider a well-known but poorly-understood fact: doctors hurt people. I'm not talking about just bad doctors here, I'm talking about good responsible doctors. Yes, I know the whole motto of our profession is "First, do no harm" but doctors have to be reminded of that because the tools of our trade are inherently dangerous.

Running tests on a person is not harmless. We stick you with needles. We zap you with radiation. We inject stuff into you. Then we find abnormalities that require more tests. Don't get me wrong, this type of thing is often helpful and even life-saving, but every time we start down this path we risk hurting you. Even perfectly correct work-ups carry real risks and harm real people.

We have worked very hard to decrease these risks. In some ways the medical work-up is a victim of its own success: we have decreased the risk so much that we begin to assume it's harmless. Health care does a lot more good than harm, so we forget about the harm all together.

You can safely carry a weapon if you respect the danger it presents, but you'll end up shooting yourself in the foot if we forget it's a weapon at all.

Doctor D has seen enough people hurt by medical care that he has a healthy respect for the danger he puts you in every time he orders a test or a medicine. Unfortunately, most patients have little or no concept of the dangers posed by health care. Even patients who distrust doctors trust our machines and laboratories.

Work-up FirstAsk Questions Later
When faced with illness there is a natural urge to do something! You feel rotten and you go to a doctor for a solution. You expect the doctor will do something, and if that doesn't work the doctor will do even more.

There is a very old medical term called, Benign Neglect. It means that if the symptoms are not likely dangerous and the best course of action is just to watch patiently without doing anything. Doctor D has never heard a physician younger than 70 use this term.

Today's doctors are men (and women) of action. We have the tenancy to work up everything just because we can—because we are scientists and want to get to the bottom of things. Then the legal system reinforces this behavior. Doctors are frequently sued for not doing enough, but almost never sued for over-testing or over-treating although these things are also dangerous. We protect ourselves legally and keep our patients happy by ordering big work-ups for every symptom. More is always better!

Consequently US healthcare is the most expensive in the world, and Americans get more tests and scans than anyone else, but we aren't any healthier or live any longer. In fact, the opposite is true. We forget that healthcare should be used with caution.

The Proper Work-Up
Diagnosis is the heart of medicine. You come to Doctor D sick and he will do his best to give you a good answer. Keeping you safe, however, is more important than giving you answers, and no doctor should forget that our first duty is to "do no harm."

Seeing a doctor about your symptoms is like hiring a trigger-happy bodyguard. It might be worth it if you're life is threatened, but if you life in a safe neighborhood the jumpy security might be more likely to accidentally shoot you than save you.

Before your doctor goes nuts with a big work up you may want to ask, "Do you think these symptoms represent a dangerous disease or is it safer to ignore them?" Some symptoms need the big work-up and some need nothing at all.

If you come to me with an uncomfortable runny nose and low grade fever for a couple days you probably won't get any more work-up than a careful physical exam. If I don't find a problem I'll say "It's probably a virus" and advise you to ignore it. I could order a CT scan of your head, but that radiation that is more likely to harm you than provide any useful answers.

If you come to Doctor D with "red flag" symptoms like significant unexplained weight loss he'll probably keep testing until he finds an answerbut not every situation:

Doctor D once had a 97 year old that came to him with unexplained weight loss and weakness. Doctor D said, "This could be a lot of things, many of which are serious, but at your age aggressively finding and treating the serious ones are more likely to cause you pain than prolong your life. My advice is a few basic blood tests to rule out things that would be easy to treat. If that doesn't show anything then let's just treat the symptom with high-calorie shakes." The patient agreed and we did a tiny work-up that gave no answers. We treated the symptoms and he lived comfortably for several more years before dying in his sleep. I have no idea what finally killed him, and I really don't mind not knowing.

You Are The Boss
The harms or benefits of a work-up can extend beyond just the physical effects. Many comments on the last post mentioned the amount of personal reassurance people felt upon finding out the name of an illness. Personal values and perspectives on disease, diagnosis, and medical care vary drastically between people. Some hate the anxiety and discomfort of a work-up far more than their illness alone. Some hate the uncertainty of not knowing their disease and will undergo any painful or risk test just to find an answer.

Your work-up is a personal thing being done to your body and it should reflect your values.

Your body is yours and your doctor works on it for you. You are supposedly directing the care. Unfortunately, you don't always get to exercise your authority in the situation because your doctor is usually responding to what he or she guesses you want. First your doctor comes up with a large work-up because they assume you want it. Who wouldn't want lots of tests, right? If by chance the work up is inconclusive your doctor (or doctors) decide you must want it stopped, because further testing is risky without offering a lot of expected benefit (since most scary diagnoses have already been ruled out). Then if you say you want to keep going with the work-up the doctor suspects you are neurotic since you are acting against your own best interest.

A thorough work-up is complex, but your busy doctor may not take the time to discuss it. But the good news is you are in charge and don't even know it.

It is important for you to take charge of your work-up. Tell your doctor your values. Say what you want from your work-up. Ask about the risks and the benefits of tests. Remember the doctor is a dangerous ally, and communication is the safest way to take control of your healthcare.

What do you think? Do you think much about the risk of medical testing? Does your physician ever discuss risks of work-up? How would do you think your personal values would affect your approach to a work-up? Doctor D loves hearing your stories and thoughts in the comments.