My Health is [Someone Else's] Problem

Filed under: by: Hey Doc Wait

Today in clinic, my attending got really frustrated with a patient. Patient was a middle-aged person with the usual outpatient cocktail of diabetes, hypertension, and hyperlipidemia. Patient had lost their insurance around 2008 and had stopped coming to clinic then; they also self-discontinued all their medications. Now in 2010, patient wants to resume treatment, having re-established health insurance.

My attending was furious.


Because in the intervening 2-3 years this patient had made absolutely no effort to eat well, lose weight, find a physician, get cheaper medication, or do anything regarding their health. Now, patient has insurance, and the doctor is supposed to magically fix the damage done in the past years.

Now, don't get me wrong, I know all about the barriers to care. I'm for expanding access, improving access to health insurance, etc. I know it is not easy to get to the doctor, that the visits aren't cheap, that labwork isn't cheap, and that medication isn't cheap.

However, so many people take absolutely no responsibility for their own health that if they lose health insurance it's like they have no health care at all.

There are free or pro-rated county health clinics available. Sure, the lines are long, but if you navigate the system you can get seen by a doctor, get your labwork done, and get your prescriptions written. You may even qualify for free or reduced-price medication.

Many of this patient's medications could have been changed into $4 for 30 or $10 for 90 type medications. If you can afford a Big Mac or a pack of cigarettes, you can afford a month's supply of many effective medications. Certainly the main treatments for Patient's conditions--diabetes, blood pressure, and cholesterol--are available in SOME form at very cheap prices.

My attending was mad in part because she would have worked with Patient to change their medications, had they asked. They could have worked out a plan to check in by phone, to change medications to cheaper ones if needed, to get labwork done at cheaper facilities if need be, or to spread labwork out. If Patient still had not been able to afford to see my attending, again there are other clinics that may cost less.

I find it amazing that being healthy is just not a priority for many people. We want a pill to fix our couch-potato drive-thru lifestyles that allow us to eat fast food every day and still be thin, beautiful, and heart attack free.

The plan that I've used my retrospectoscope to create for Patient would have taken effort, time, phone calls, etc. Sure, doing nothing was cheaper and easier, but now Patient will pay for it. Is that 2+ year period really going to do that much damage? I don't know, but it certainly didn't help.

No matter who provides your health care plan, be it private insurance or government-funded Medicare or Medicaid, health is still YOUR job (and my job, as I am a patient too, and I don't always practice what I preach). Your insurance can't guarantee that you see a doctor, can't guarantee that you take your meds, that you quit smoking, that you eat healthy, or that you exercise. And treatment isn't free with insurance. Health insurance is something of a misnomer; we expect all of our treatment to be covered, our doctors' visits free, our meds cheap or free, our tests free, etc. My car insurance doesn't cover routine oil changes, so I find it odd that we rely on "health insurance" to provide all of our health care.

Perhaps Patient didn't know what I know. Patient may not have known about $4 medications, or about free-standing labs, or about the county clinics. Patient may not have internet at home, and may not see the commercials for cheap meds. However, Patient did not ask the person who did know--my attending.

Certainly the opposite type of patient exists; my father-in-law has much the same cocktail of problems and is unable to get health insurance accordingly. So, he shops around, gets the best deals on his tests and meds, and even knows which hospitals he would go to if the occasion arises. He decided that it was his own responsibility to stay healthy, treat his chronic conditions, and live longer.

The current generation of elderly became adults in leaner times than us. My 70 and 80 year old patients grew up with the Great Depression and WWII; they did not grow up with easy access to burgers and fries at the window of their vehicle. The younger generations I see (myself included) did grow up with cheap, quick, tasty food available at all hours. I gained weight eating this stuff; at some point I realized I was killing myself. It was a big lesson to learn, unlike the young woman I saw today, with a BMI of 38 who said "I just have a slow metabolism" (despite describing a terrible diet and no exercise with a sedentary job). I wonder often if our long lifespans will start to shrink, as the fatter, less active generations start to age.

I'm now sitting on the couch typing, waiting for the heat to dissipate a bit so I can go jog without suffering a heat stroke. I'm not good at exercising, and I struggle with my eating habits every day, but I'm trying. I keep reminding myself it's worth it. Because it is worth it, to me, to be healthy, to learn healthy habits now that I can teach my kids someday. The government isn't going to exercise for me, nor is my health insurance company going to eat salad so I don't have to. Although sometimes, I wish they would.

It Figures

Filed under: by: Hey Doc Wait

As a lover of forensic shows on TV, I recognized the markings on my white coat as high velocity blood spatter. Not from a gunshot, but from splashing during a central line placement. I cursed a bit when I saw it, because I just cleaned this white coat, and it's kind of a pain in the ass to pull all of the crap out of the pockets (I roll with about 6 lbs of stuff in the pockets), use the bleach pen on all of the ink marks, etc, and get it washed without bleaching the embroidery.

I did this over the weekend, taking a lot of time to bleach all the spots (I'm terrible about ink spots), and I threw the coat into the wash with a couple of towels or somesuch--I'm not even sure what, just something that needed washing.

All went well until today, when I donned my newly cleaned white coat to wear to work. Halfway through the day, I look down, and the lapel is blue. Not white, blue.

I'm too lazy to wash the coat again right now, since technically it's clean, and hey, would you rather see a doctor with a mild blue stain on her coat, or one with bloodstains? Yeah, that's what I thought.

Better Regulation of Supplements

Filed under: by: Hey Doc Wait

Senator John McCain has introduced a bill in the Senate that would increase the FDA's ability to regulate "dietary supplements" and hasten the FDA's ability to quickly remove dangerous products from distribution. Better bloggers than I have discussed this here (at Science-Based Medicine) and here (at Movin' Meat). The law isn't very drastic, but it seems that it would require supplement manufacturers to report all adverse events to the FDA, and it would give the FDA the ability to issue cease production orders if a product is determined to be harmful; the company has the ability to appeal, but if the appeal fails the FDA can issue a formal recall.

When I talk to patients about supplements, I advise them to be careful. I tell them, you don't necessarily know what you are getting. You may be getting exactly what you pay for, you may get extra active ingredient, or you may get no active ingredient. For example, as red yeast rice supplements are growing more popular in lowering cholesterol (and studies are backing this up), some of the supplement tablets are being laced with statin medication to make them more effective.

I support people's rights to make choices, and if they choose a supplement that's fine. I take a few myself. However, I support the right to make informed decisions. How can a decision be informed when you don't know what's in your pill? If you have a bad reaction to a prescription medication, this is reported and monitored. If you have a bad reaction to a supplement, it's your tough luck.

If this is something you support, then go read the bill (found here), and consider writing to your senator. This will have a lot of opposition from Orrin Hatch, so if this bill is going to pass then people on both sides of the aisle will have to get motivated.

I'm No Longer Dead

Filed under: by: Hey Doc Wait

So maybe I wasn't dead. Just being an intern.

I had three months back to back of wards, so q4 call and 4 days off per month--and I got totally worn out. Pair this with ongoing concern for my sick family member, and I was pretty exhausted. I made myself a promise in mid-November that I would eliminate all extraneous stuff from my existence until I could handle it again. I didn't clean the house, I didn't send out holiday cards, and I didn't worry about updating my blog.

Not like it matters too much, as I don't really have an audience per se...

But I missed having an outlet for my thoughts and stories. I started blogging in 2005 and kept it up until October, so it's time to get back on it now.

What was the most interesting thing that happened to me this week so far? An 85 year old man kissed me on the cheek a few days ago after a clinic visit. I went to shake his hand and he leaned over and planted a shaky kiss on me. I didn't really protest--he's 85 freaking years old. I do think it made my husband wildly jealous, though...

Wii Active Kicks My Butt

Filed under: by: Hey Doc Wait

The EA Active game for Wii has thus far proven to be one heck of a workout (and proves what I already knew, which was that I am in poor physical shape). The first day I tried it, I did a 'demo' workout to show me how to do the lower body exercises. By midway through the series of squats, side lunges, and alternating lunge jumps, my thighs were quivering. I didn't actually complete the full series, instead moving on to arms (where I don't usually have any difficulty, especially when only using a resistance band. Therefore, the problem is for my poor legs, which have to heft my body weight around, and this is after losing 15 lbs! But I digress).

The following day at work, my legs felt strange and heavy. I had to push myself out of chairs, as my quads seemed strangely unable.

But the next day, when I was (of course) on call, was the worst. My leg muscles were weak and painful; my quads were tender to palpation and actually hurt just walking. I adopted a weird-looking waddle that didn't require my knees to bend much while moving, and my pace was about half what it normally is (I may be short, but I walk fast). I avoided the stairs and looked like a total douchebag, being a young, healthy-looking person taking the elevator up and down when I was only traveling one floor. I thought about asking the nurse to draw a CK level and hook me up to a bag of saline, in case I was having rhabdo, but I resisted my (well-developed) inner hypochondriac and instead made fun of myself all day.

This was all fine and dandy until I got called to a code. Try climbing a flight of stairs and walking as fast as possible doing a duck waddle and going "ouch, ouch, ouch, ouch" up each stair. The nurse I followed to the code gave me some crap for letting him beat me there, but he only beat me by a few seconds. (The code was short and successful, the nurses were already doing compressions when I arrived, and basically I did nothing useful except gather labs for the real doctor who showed up--the resident.)

Fortunately, after a couple of days my legs were fine. Just in time to do another round of Wii Active.

Let's Get Controversial

Filed under: by: Hey Doc Wait

I am going to delve into a scary topic here--yes, the A-word, abortion. Don't worry, I moderate my comments, and I am absolutely not interested in publishing long flame wars. This is my blog, and my opinions, and you can feel free to disagree with me and even to post disagreement in my comments, but if you call me or any of my other commenters ugly names I don't have to publish your comment. End of story.

Here's what I want to talk about. Oklahoma has passed a law requiring physicians to report to the state health department certain information about all abortions performed; this information will then be posted on the health department's website. The actual text of the bill, HB 1595, is here. The law has been challenged by a lawsuit under an odd provision in the OK Constitution that a law can only cover one subject.

Here's what makes me angry about this law. People on various websites are arguing back and forth about the women's rights being violated--and this is true, this law (I believe) directly violates a woman's HIPAA rights (which are federally guaranteed and, in my understanding, may not be undermined, only further protected, by the states). It is absolutely true that if you publish 'a white woman, age 35, married, from Y County [population 3000], with 2 prior pregnancies that ended in live births' you are publishing potentially identifiable information. But what really chaps me is when you read the law itself, it seems to be more a direct attack on abortion providers than an attack on the women who seek abortion. Because, you see, it is the doctors who must submit this information to the state.

This bill was championed under the guise of preventing abortion based on the knowledge of the gender of the fetus. Indeed, the first section of the bill deals with this: "No person shall knowingly or recklessly perform or attempt to perform an abortion with knowledge that the pregnant woman is seeking the abortion solely on account of the sex of the unborn child." (all quotes are from the bill unless otherwise indicated). The bill goes on to say that "any person who knowingly or recklessly violates a provision of this section" may be subject to injunction, which may be filed by the woman who had the abortion, "any person who is the spouse, parent, sibling, or guardian of, or a current or former licensed health care provider of, the female upon whom an abortion has been performed or attempted to be performed in violation of this section, a district attorney with appropriate jurisdiction, or the Attorney General." So in other words, anyone who knows a woman who sought an abortion based on the fact that she didn't want a fetus with XX or XY chromosomes may file an injunction against the performing physician, including the woman herself (whom we would assume knew her motives when she sought the abortion). The state penalties for violation (for the physician) will be $10,000 for the first time, $50,000 for the second, and $100,000 for the third and any time beyond, and if an injunction is brought against a physician and it is violated, the physician will be charged with a felony. Note: "No fine shall be assessed against the woman upon whom an abortion is performed or attempted". Because, clearly, it's all the doctor's fault.

Section 3 provides for the "Statistical Reporting of Abortion Act". They start off by saying the department of health must create a website that details all the pertinent state laws regarding abortion (not in itself a bad thing) and must have all forms available for electronic reporting on this website. Section 5 starts to get hairy. First, the physician has 30 days to submit the "Individual Abortion Form" for every abortion performed. Note, here they state "Nothing in the Individual Abortion Form shall contain the name, address, or information specifically identifying any patient." Yet, here is [part of] the form:

Individual Abortion Form.
The Department’s Individual Abortion Form shall be substantially similar to, but need not be in the specific format of, the following form: (TO BE COMPLETED FOR EACH ABORTION PERFORMED)
1. Date of abortion _________________
2. County in which abortion performed ________________
3. Age of mother _________________
4. Marital status of mother (married, divorced, separated, widowed, or never married)
5. Race of mother ________________
6. Years of education of mother ________(specify highest year completed)
7. State or foreign country of residence of mother ________________
8. Total number of previous pregnancies of the mother _____ Live Births _____ Miscarriages _________Induced Abortions __________________
9. Approximate gestational age in weeks, as measured from the last menstrual period of the mother, of the unborn child subject to abortion [emphasis mine]__
10. Method of abortion used: ...
11. Was there an infant born alive as a result of the abortion? ____If yes: Were life-sustaining measures undertaken? ___ How long did the infant survive? _____
12. Was anesthesia administered to mother ____ If yes, what type? _______
13. Was anesthesia administered to the fetus? _______ If yes: What type? _______ How was it administered? __________________
15. Reason for abortion (check all applicable):
Mother cannot afford the child ______
Emotional health of the mother is at risk ______
Mother suffered from a medical emergency as defined in Section 1-738.1 of Title 63 of the Oklahoma Statutes ______
Mother wanted a child of a different sex ______
Abortion necessary to avert the death of the mother ______
Pregnancy was a result of forcible rape ______
Pregnancy was a result of incest ______
Other (specify) ______
Patient was asked why she is seeking an abortion, but she declined to give a reason _________________________
16. Method of payment (check one): Private insurance __ Public health plan ___ Medicaid _____ Private pay ____ Other (specify) _________
17. Type of medical health insurance coverage, if any (check one): Fee-for-service insurance company ______ Managed care company ______ Other (specify) __
18. Sum of fee(s) collected ___________
19. Specialty area of medicine of the physician ___________________
20. Was ultrasound equipment used before, during, or after the performance of this abortion? ...
24. Were the informed consent requirements of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes dispensed with because of a medical emergency necessitating an immediate abortion: To avert death ______ To avert substantial and irreversible impairment of a major bodily function arising from continued pregnancy _____
25. Was the probable gestational age twenty (20) weeks or more? _____
26. Was the abortion performed within the scope of employment of an state employee or an employee of an agency or political subdivision of the state? ______
27. Was the abortion performed with the use of any public institution, public facility, public equipment, or other physical asset owned, leased, or controlled by this state, its agencies, or political subdivisions? _________
28. If the answer to question 26 or 27 is yes: Was the abortion necessary to save the life of the mother? If yes, what was the life-endangering condition? ____
Did the pregnancy result from an act of forcible rape? ____
If yes, list the law enforcement authority to which the rape was reported _____________ List the date of the report ___________ Did the pregnancy result from an act of incest committed against a minor? _________ If yes, list the law enforcement authority to which the perpetrator was reported __________ List the date of the report ___________
Filed this ____ day of __________, _____ by: ______________________________(Name of physician)

There is an awful lot of potentially identifiable information on this form. There are also some interesting tidbits. First, the bolded (by me) checkbox for "Mother wanted a child of a different sex." So, you're going to charge me $10,000 if I say yes? Hmmm... Second, the bolded (by me) wording of "the unborn child subject to abortion", which I think very clearly states the intent and purpose behind the people who wrote this law. Third, the almost disbelieving tone (later) when asking if the pregnancy is the result of rape, then demanding the law enforcement agency and date of the rape report, or to know the name of the life-threatening condition. Clearly, it's only rape if it gets reported to the authorities. Later on in the bill, they detail that if a physician doesn't complete this form on time, there is a $500 fine, and if the form is still not done after a year the physician's license will be suspended.

I think it is clear that the intention of the lawmakers who wrote this bill is to further hinder the performance of abortion by physicians. If they wanted to prevent abortion based on strictly the gender of the fetus, the opening few paragraphs would have sufficed (although I am still incensed by the lack of provision against another hugely responsible entity, the woman seeking the abortion based on the gender of the fetus). Also, this just occurred to me--unless you perform genetic testing, most ultrasounds to document the sex of the fetus are performed around 20 weeks, but [in my understanding, not being an expert in this subject] the majority of abortions are performed in the first trimester, when most women cannot be expected to know the sex of the fetus. As with the Partial Birth Abortion Act on the federal level, this is a law aimed at physicians designed to make it tougher to perform legal abortion.

The law does make provisions as to the reporting of certain statistical data on the website, but it is unclear in what form this data will be provided. If they post '280 abortions in YY county, 35% in unmarried women', etc, then it is hard to say that this will violate a woman's HIPAA rights. But if careful measures are not taken with this information, I could see it falling into the wrong hands easily. Also disturbing is the objective and private nature of much of the data. If I have to report a case of syphilis to the health department, I give the patient's name, age, and identifiable information (for tracking purposes); I do not have to report how many times they had unprotected sex, whether they got the disease by prostitution, or whether their partner was cheating on them and brought it home.

Abortion is currently legal in this country. I as a physician am not required to report to the state the illegal activity of my patients, including drug use, possession, or sale; assault; prostitution; weapons possession; or just about anything else they do on their time outside of my care (with a few exceptions, such as child abuse). Nor am I required to report on the immoral activity of my patients. Why, then, as a physician, should I be required to hand over such sensitive information on a legal activity? What does the state hope to accomplish by monitoring and tracking such data (which at least is more clear when tracking a condition like syphilis)? Why such punitive measures for physicians performing a legal procedure? What kind of idiot doctor would actually report to the state that the woman wanted a fetus of a different gender, knowing the fine is $10,000? [god forbid you make an error filling out the form!] Again, after reading the wording of this bill, I think it is less about violating the HIPAA rights of women and more about providing MORE hoops to jump through to provide a legal procedure.

Caveat: I am pro-choice, but not pro-abortion. I am not a fan. I think a huge number of abortions could be prevented by simply not having sex or using birth control, and I favor increasing education in BOTH arenas (and not the farce of abstinence-only education as it is currently implemented in this country). However, for the cases when this is not true, even though they may be rare, I consider it none of my business to confirm whether the rape was reported to the proper authorities. These are my views on a very touchy subject on which everyone has an opinion that is exquisitely personal; I do not mean to step on the toes of either the pro-abortion or the anti-abortion crowd, but simply to point out the misleading language of a law that does not really do what it portends to do (and sadly, passed 93 to 4 and was sponsored by a man running for lieutenant governor of the OK state). I think one should not fight an activity one considers immoral by going to immoral measures; to me, this kind of deception is immoral.

I Didn't Drink the Worm

Filed under: by: Hey Doc Wait

In our hospital, the isolation rooms have antechambers, rather like airlocks, that have sinks with gloves, masks, gowns, and other personal protective equipment that one may don prior to entering the isolated room. The other day, I left the room of a patient with severe immunodeficiency and stepped into the airlock to wash my hands. I lathered up and was on my second round of "Happy birthday to me, happy birthday to me"* when I noticed that there was standing water in the bottom of the sink, and that something was moving in the water. A small, thin, black, 1 cm long something that was clearly swimming.


I mean, I calmly eyeballed the thing, rinsed off my hands, and went to find a witness. The nurse looked at me like I was totally nuts (and to be honest, I was post-call, and was probably looking and acting a little nuts), but she came to see and was like "Oh my God! That is disgusting!"

I used a tongue depressor to gently move him out of the water and put him into a specimen cup, sealed the lid TIGHT and put it in a biohazard bag, then walked the thing down to the path lab. I may have brandished it in front of me, hoping someone would look in and go "EW!", or I may not, depending on which version of the story you heard. The lab tech was singularly unimpressed but promised they'd get back to me.

I got a call today from the lab: likely moth larva, not likely human parasite, but has been sent to the CDC for further testing. Apparently this is not uncommon, though I had no idea.

And still I think,


I only thought the cockroach in the ceiling light in the call room was bad...