Top 10 lists are back!

I forgot about this kind of post, and a reminder by a reader is bringing them back.  They are really a fun and easy kind of post to write, so you may see a fair number of them (read: Rob is getting lazy).  I thought I’d start back with some suggestions for disgruntled patients (or grutled ones, for that matter) to make their doctor’s day much worse.

1.  Require the doctor to keep things secret from your child or your elderly parent. Insist that they can’t know about their cancer, depression, ADD, or foot fungus.  Call the medication the doctor prescribes “vitamins.”  Alternatively, you can threaten your child by saying that if they don’t behave better, the doctor will give them a shot.

2.  Disguise the real reason for your visit with something simple. For example, if you have depression or chest pain, set up an appointment for a sore throat.  Make sure you leave all of the office staff in the dark as long as possible.  It’s a bonus if you end the office visit asking them to check your hemorrhoids or help with a certain discharge you have been having.

3.  Call your children nicknames that have nothing to do with their real names. Let’s say you have a son named “James Wadkins Smith”; you should call them “Trent” or “Flippy.”  A daughter named “Anna Rose Jones” can go by “Jenny” or “Eva Marie.”  You get extra points if you change what you call them every few months.

4.  Smoke a pack of cigarettes or several cigars just before going to the doctor’s office. Then when you are asked if you smoke, say you don’t.

5.  Ask for doctor’s notes for anything. If your car doesn’t start and you miss work, call to get a doctor’s note.  If you don’t like fluorescent lighting and want incandescent lights at work/school, ask your doctor to write a letter stating that this is a medical necessity.  Asking for a few days off of work because of “stress” is sure to have the desired effect.

6.  If you are an employer or school district, make your employees or students get documentation for every single sick day. Make the docs fill out FMLA paperwork for sinus infections, and disability forms if it lasts more than 2 days.  School districts should require a detailed asthma management plan on all patients with asthma.

7.  Call frequently stating that you have a personal issue you need to discuss with the doctor, refusing to talk to anyone else. It’s best to call the office acting like you know the doctor well, referring to them by their first name.  When you do get the doctor on the phone, start talking about your anxiety, depression, or bowel problems.

8. Send your teenage son or elderly parent with dementia to the office alone. Make sure you don’t leave any contact numbers and don’t tell the boy what you are sending him to the doctor for.

9. Invite friends and family. Having as many people in the examination room as possible is the goal.  Having young children with ADHD is the ideal.  Think clowns in a Volkswagen.

10. Bring your spouse or child to the office so the doctor will convince them that you are right. Open hostile arguments are important for the doctor to see just how wrong they are.  Make it clear to your family member that the doctor is against them.

OK.

Some liked it, some didn’t like it.  At least my recent post that equated alternative medicine with magic wasn’t ignored.

Now, perhaps it wasn’t clear to some of my readers, but the purpose of that post was not to critique alternative medicine.  The point was that people like magic foot baths better than doctors who practice evidence-based medicine.  There is little flashy about what I do on a regular basis; I occasionally pull out my magic wand and dramatically help people, but most is little by little, day by day.  That is why some of my patients elect to go the foot bath route rather than follow my advice.

Oh yes, and I did paint all that is alternative in the light of magic foot baths, which isn’t really accurate.  But again, that wasn’t my point.

As I responded to those who felt I shorted alternative therapies, I saw that I needed to delve into a point I touched on in the post.  Here’s what I said: “The majority of healthcare dollars are spent on technological “miracles,” not the hum-drum treatment and management of disease.  When we in medicine go for the glamor, we sell our soul to the highest bidder and walk away from where we can do the most good.”  The more I thought about this point, the more I saw its significance.  Here’s what I mean:

1.  Magic Images

Have a headache?  You need your head imaged.  CT scans are passe’; MRI scans are OK, but PET scans are where it’s at.  The images are colorful!

I am sure that few physicians order PET scans for headaches, but I am also sure that few patients would complain if they did.  Doctors have ordered MRI angiograms, and ultra-thin slice CT scans when less expensive procedures would work fine.  Yes, these tests may have certain advantages, but is it always necessary to use the best possible procedure?  Is a test that costs 10 times more worth a 10% gain in quality of information?

The MRI scan of the back is a good example of “better”tests gone awry.  It took the heavy hand of insurance companies to stop the routine ordering of this test for simple back pain.  Patients didn’t object to getting the best technology has to offer, as it seems like they are getting better care.  But in truth, these MRI scans resulted in many people getting back surgery who did not need it.

“You have a bulging disc,” the doctor tells the patient who has back pain.

“Ah,” says the patient. “That is certainly the cause of my back pain.”

“Yes,” says the doctor.  ”If I remove that bulging disc, your problem will be solved.”

And so the neurosurgeon “fixes” the bulging disc in the patient’s back to “cure” the back pain.

Here’s the catch: just as many people without back pain have bulging discs as those who do have back pain.  The disc is an incidental finding on the MRI scan, but its presence with back pain seems to imply causality.  It is simply not true.

Did the patients complain?  They thought the smart doctor found the cure for their problem with the fancy machine.  Do the neurosurgeons complain?  They triple their business overnight, thinking the MRI scans are truly magical.  It took insurance denials of these unnecessary tests to eliminate this practice.  Yet I still have patients with back pain tell me about their “bulging discs,” as if these are clinically significant.

The technology makes the magic.

2.  Magic Tests

We need to get rid of cancer!  Cancer is causing all sorts of pain and suffering in our country.  What can we do to get rid of this scary disease?

Let’s do some magic tests!  Let’s screen the public with a test that shows the presence of cancer and then treat the cancer early.  Let’s call July national pancreatic cancer month and screen the entire population for this horrible disease.  We all loved that movie star who just died of it, and so now let’s prevent others from getting it!

That sounds great, but there is one tiny hitch: there are a pitifully small number of tests that are valid screening tests.  Most screening tests are flawed; they either falsely reassure people, falsely identify cancer, or cost a lot of money.

Yet with all of these tests we have celebrities campaigning on TV for us to urge our parents, kids, and coworkers to get them done.  They save lives. Well, at least we would rather spend a ton of money thinking we may be saving lives than sitting around feeling like we are doing nothing.  But there really are no good inexpensive tests.  Mammograms aren’t as good as breast MRI scans.  PSA testing will be replaced with a more expensive immunological test.  There will eventually be a line we can’t cross.

3.  Magic Drugs

I remember when Zantac was the wonder drug for heartburn.  It was amazing.  Then came Prilosec, and nobody was prescribing Zantac.  It just wasn’t very strong.  But wait; Prilosec goes off of patent and along comes Nexium to save the day.  Prilosec is now a weak drug and Nexium is all patients want, and all doctors want to prescribe.

Drug manufacturers have capitalized on the “new and improved” model.  This model works because it taps into the search people have for the “magic bullet.”  If these drugs were all the same price, why not get the best?  The problem is, of course, that Nexium is 10 times more expensive than Zantac.  But doctors and patients all want to spend more so they feel that the care given is better.

There is Nothing New Under the Sun

No, conventional medicine is guilty of the same magical thinking that they condemn alternative medicine by.  It seems far better to do the latest expensive thing than to do what has been shown to work: live a healthy lifestyle and take care of treatable diseases.  My job, primary care, is not at all glamorous.  I work with patients over decades.  I build relationships with them and try to help them to change.  But my patients will just as easily leave for the latest fancy scanner as they will the colored foot bath.

I do believe there is a basic difference between conventional western medicine and many of the alternative treatments: dependence on science.  Conventional medicine succeeds only as it depends on science to be its guide.  But if we forfeit the science and order expensive, unproven, yet glamorous tests or treatments, we are no different.  We forfeit our position for the sake of winning converts.

We also spend a bus-load of money.

I am holding a contest on my Facebook page to come up with a haiku about healthcare. I honestly don’t care what it’s about as long as it is clever (including llamas does not give you an advantage, though).

Head on over there and give me your best haiku! You know what is at stake here…

“Do you have any more questions?” I asked, wrapping up a routine visit.  She had been my patient for a long time, so communication was easy.

“Sure.  What do you think of those foot baths people are using?”  she asked with a little bit of embarrassment in her expression.

“The ones that change color as the draw out toxins?”  I said, waving my fingers downward in a wiggly pattern to emphasize the drawing-out process.  I have seen people describe this process, and they always do their fingers that way when they describe toxins coming out of the feet.

She nodded, and I grinned at her as I gave my response.  ”I am very certain that they will cause considerable weight loss in a specific area:” I paused for effect, “your wallet.”

She laughed, and we discussed the mysterious notion that somehow toxins would accumulate in the feet.  Her question wasn’t because she was herself considering the treatment, but because many around her were swearing by it.  My glib answer reflected the fact that I knew her purpose in asking.  I didn’t have much time to explain my feelings about these treatments, but I did assure her that I don’t really care if people spend their money as long as they don’t hurt themself.   If sticking your feet in water that changes colors makes you feel better, more power to you.  The placebo effect is a well-documented phenomenon.

The irony of this conversation is that it came almost immediately after I had a discussion with a colleague about the American obsession with alternative medicine.  Here are the facts:

• Americans spent $34 Billion on alternative medicine treatments in 2007 (1)
• 74.6% had used some form of complementary and alternative medicine (CAM).
• 62.1% had done so within the preceding twelve months.
• When prayer specifically for health reasons is excluded, these figures fall to 49.8% and 36.0%, respectively.
• 45.2% had in the last twelve months used prayer for health reasons, either through praying for their own health or through others praying for them.
• 54.9% used CAM in conjunction with conventional medicine. (2)

These statistics obviously hinge on what is considered to be “alternative.”  Because I pray for the health of my elderly parents, does that mean that I have engaged in alternative medicine?  Do people taking melatonin or glucosamine chondroitin qualify as well?

Still, nobody argues that the use of CAM (”Complementary and alternative medicine”) is widespread.  Websites and blogs such as Science-Based Medicine and Orac’s well-known blog, Respectful Insolence, have challenged many of the outrageous claims made by proponents of alternative medicine.  I will leave that job to them.  That is not the purpose of this post.

My question, and the question I discussed with my colleague, is this: why do people spend so much money on alternative medical therapies?  Are we practitioners of “conventional medicine” doing something wrong?  Is it bad PR on our part, or is it the smooth talking of the purveyors of alternative therapies that have made so many choose them instead of us?  Is it simply the stupidity or gullibility of people that gives an opening to alternative providers, or is there something lacking in conventional treatments?  Seriously, why would someone ever do a colonic if they weren’t forced to at gunpoint?

The answer, I believe, is summed up in a single word: magic.  There are three facts that explain why so many people turn to alternative therapies:

1. People want their problems to magically go away.
2. Conventional medicine is not magical.
3. Alternative medicine promises magic.

1.  People Want Magic

Life is full of pain.  We all face circumstances that are frustrating, confusing, and difficult.  If we are given the choice between explanations as to why things are hard or promises to fix things quickly, we tend to choose the latter.  It is human nature to seek out the easiest solutions to our problems.  This is not a bad thing, nor is it a sign of ignorance, it is simply a consequence of our desire to not feel pain (be that physical or emotional).  Magical solutions offer an easy way out.

There is another reason why people are drawn to magic: the appeal of the mysterious.  The child looks at his father in wonder when he produces a coin from behind her ear.  She wants her father to be magical and powerful.  The mystery doesn’t decrease her admiration, it increases it.  As she gets older and finds out that he is not magical, she still may admire him; but she won’t hold him in the awe she did as a young and naive child.

Which is the better state to be in?  It’s hard to say.  I don’t like being ignorant, but I do miss the wonder I had as a child.

2. Medicine is Not Magic

When one of my kids comes to me with a pain in their leg or a stomach ache, they are not coming for an explanation, a plan, or a differential diagnosis; they want me to fix their problem.

Unfortunately, medicine often does not work that way.  If someone gets an upper respiratory infection, the cure for it is to wait until it goes away.  If a person has diabetes, the main approach is not to cure the problem, but accept its presence and minimize the damage.  There are often people who come in with problems I can’t solve.  I go through my usual approach: rule out serious problems first, then work to minimize pain; but am often left without a solution.

3.  Alternative Medicine Promises Magic

Look at the testimonials of people who have used the foot-soaking therapy:

• A customer came to use our Aqua Chi Machine. She had recently retired because of severe arthritis in her hands. After one treatment She was able to open and close both hands. She commented her pain was 80% better. After five treatments, she had no more pain and 100% mobility back. She then asked her husband to try the Aqua-Chi treatments. He had Asthma and used oxygen at night and inhalers during the day. After two treatments he stopped using the oxygen and night and after five treatments was able to quit using the inhalers. He saw a remarkable change in his ability to breathe.
• “I have experienced kidney failure and poor kidney function throughout my life. I obtained an Aqua-Chi machine and had amazing results! Since using the Aqua-Chi Machine I have not had kidney failure.”
• “I was suffering from Candida overgrowth which was localized in my bladder and uterus. This was the cause of my low energy. After receiving a 35-minute Aqua-Chi foot bath, I felt much stronger. The therapist and I were shocked to find that the Candida seemed to have cleared out of my bladder and uterus. She stated that she had never seen anyone’s energy field shift so dramatically in such a short period of time! Since using the Aqua-Chi Machine on a regular basis, I have noticed that I have more energy and stamina and that I sleep more soundly.”

Before

After

This is what happens to blood cells in your feet!  Apparently, they do line dancing when they are sick!

You could find similar claims/testimonials on websites pushing MonaVie, colonics, and chelation therapy.  Alternative treatments promise magical results, curing problems for which conventional medicine doesn’t have answers.  You don’t find nearly as many alternative treatments for ear infections, ankle sprains, or appendicitis – things that conventional medicine handles quickly and effectively, in most cases.  Alternative treatments usually go after chronic symptoms such as fatigue, and chronic diseases such as arthritis.  They fix problems that I often tell patients they have to live with.

This is, by the way, why scientifically repudiating alternative therapies does little good.  They don’t require science since they are magical.

So What’s the Point?

What are we to do with this information?  Here are several things I get from this:

1. There will always be a market for magical treatments.  The desire for magic comes from a normal human desire – to be rid of pain as quickly as possible.  It’s fine to be critical of the hucksters that rob people of their money in exchange for fake magic; but portraying the people who seek alternative therapies as naive and silly is not productive.
2. Conventional medicine cannot and should not compete. We don’t offer magic, we offer applied science.  The majority of healthcare dollars are spent on technological “miracles,” not the hum-drum treatment and management of disease.  When we in medicine go for the glamor, we sell our soul to the highest bidder and walk away from where we can do the most good.
3. Medicine is what it is. We don’t offer miracles, and that is OK.  We don’t give guarantees and don’t pretend there are always simple answers to problems.  Since we take on a losing battle – every one of our patients eventually dies, and all of them will suffer – we will eventually feel and look powerless.  We will be powerless.  That’s OK, because medicine doesn’t try to deal with the metaphysical, mysterious, or unscientific.  We are focused on reality, and reality is often hard.
4. I am going to get one of those Aqua-Chi foot baths. I have toxins in my spleen that are causing me to ache behind my left elbow.  I am sure it will fix that.

I have a confession: I am cynical about Washington’s efforts to pass good healthcare reform.

Sorry for those of you who I just shocked; would those standing next to them please administer CPR?  I know most of you trust our government to do what’s best.  Sorry to burst that bubble.

The reason I am cynical is that I think the real problem has nothing to do with healthcare; it has to do with the way our government runs.  Here’s why:  let’s wildly imagine that one party came up with a plan that would actually fix the problem.  This plan would:

1. Ensure that all Americans have coverage.
2. Improve the quality of care, and set in place means to continue improving quality.
3. Fairly reimburse medical professionals for what they do.
4. Eliminate waste.
5. Save money.

And let’s say it did all this without pandering to special interests with deep pockets.

What would be the politically expedient thing to do for members of the other party?   They should oppose this plan with every ounce of their strength.   Politics is all about power, and if one party solved the healthcare problem they would be lauded as saviors.  They would have enormous political capital and would gain much more control of the government.  That wouldn’t be good for the opposition.

So here’s what the opposing party should do if they are thinking politically:

1. Misrepresent this plan to the public as something that would result in disaster.
2. Run commercials that would scare people.
3. Get special interest groups to harass and threaten those who support this bill.  Make it so supporting this good bill would be an end to their political career.
4. Try to influence members of the other party to vote against their colleagues in exchange for more power.

Politically, this would be the best thing to do.  It would also be the worst thing for our country.  It happens with regularity.

The reason this happens because nearly all of the members of congress are constantly campaigning.  They are constantly positioning themselves to get reelected, and this requires that they stay at or near the center of their own party.  If they break ranks and side with the other party, they stand to lose in the next primary election.  If the oppose the special interests with lots of money, they stand to have people spending that money to make sure they don’t get reelected.

The system encourages partisans and punishes those who go by conscience or work for compromise.  The system dooms us to legislation aimed at maintenance of power.  The system guarantees that the better the legislation put forth by one party, the more the other will misrepresent and smear it.

Just like the headache isn’t the main problem when a person ruptures an aneurism, the outward flaws of our government are caused by a much deeper problem: our legislators are far too vulnerable to abandon the greater good for the sake of political power.  To seek good is to give up power.  That dooms us to mediocre results at best.

There is one thing that would help undo this problem: term limits for members of congress.  Limiting senators to 2 terms, and members of the house to 3 would rid us of career politicians who are totally out of touch with the country they govern.

What’s the problem with term limits?  It will take an act of congress to make it happen.

Unless the people force the issue.

More people get it wrong than right.  I have more people coming to my blog doing the search “Musings of a Distractable Mind” than by the correctly-spelled version.  I made this same mistake when I started.  English is dumb.  Shouldn’t it be “able” because it means “able to be distracted?”  Nobody is “ible to be distracted.”

Sigh.

Sorry.  Got off track.   My podcast on ADD came out today.  In it I discuss the condition and give a personal narrative of my life with ADD.  I expect to be called by movie producers any day now.  Listen and let me know what you think.

Take the poll as well!

Bonus from the Onion:

FCC: All Programming To Be Broadcast In ADHDTV By 2007

WASHINGTON, DC—The Federal Communications Commission voted 3-1 Monday to require electronics manufacturers to make all television sets ADHD-compatible within two years.

To adhere to the guidelines, every program, with the exception of The Hi Hi Puffy AmiYumi Show, will have to be sped up to meet the new standard frame rate of 120 frames per second.

FCC Chairman Kevin Martin characterized the move as “a natural, forward-thinking response to the changing needs of the average American viewer.”

“In the media-saturated climate of the modern age, few have the time and energy to sit still for an entire episode of King Of Queens,” Martin said. “Although the FCC will leave it up to the television networks to make the necessary programming changes, we are recommending, in accordance with the ADHDTV standard, that all shows be no more than six minutes in length, and that they contain jarring and unpredictable camera cuts to shiny props and detailed background sets.”

(continues)

PLACE OF OCCURRENCE, HOME ICD-E849.0

6:00 AM

Alarm goes off.  Hit snooze button. CIRCADIAN RHYTHM SLEEP D/O IRREG SLEEPWAKE TYPE ICD-327.33

6:30

• Alarm goes off for third time.  Ready to hit snooze button, but knee in ribs from wife prevents more snooze button procrastination.  CONTUSION OF CHEST WALL ICD-922.1, ADULT MALTREATMENT UNSPECIFIED NEC ICD-995.8
• Feeling tired, go to make a pot of coffee. CAFFEINE ADDICTION ICD-304.40
• Fill bowl with Lucky Charms and start eating. UNSPECIFIED NUTRITIONAL DEFICIENCY ICD-269.9, HYPERGLYCEMIA ICD-790.29

6:45

• Realize that coffee pot needs to be turned on for it to make coffee. ATTENTION DEFICIT DISORDER, ADULT ICD-314.00, LISTLESSNESS ICD-780.79
• Turn coffee pot on and wander to check email, blog, Twitter, Facebook, etc. OBSESSION ICD-300.3
• Daughter wanders in with dazed expression and blanket draping shoulders.  STUPOR ICD-780.09
• Speaks only in soft, irritated grunts. SELECTIVE MUTISM ICD-313.23, E/M 99212 ENCOUNTER, ESTABLISHED, BRIEF

7:00

• Bring cup of coffee to wife in bed.  She moans when she looks at the clock.  Another morning headache.  E/M 99215, ENCOUNTER, ESTABLISHED, HIGH COMPLEXITY; OTHER COMPLICATED HEADACHE SYNDROME ICD-339.44, OTHER SPEC MENOPAUSAL&POSTMENOPAUSAL DISORDER ICD-627.8
• Wake up other children who return evil glares for gentle nudging.  CHILD EMOTIONAL/PSYCHOLOGICAL ABUSE ICD-995.51; E/M 99214, ENCOUNTER, ESTABLISHED, MODERATE COMPLEXITY
• Walk to shower and get frustrated at towels not hung up. ANGER ICD-312.00

7:25

• Shower, shave, and get dressed.  LACERATION, FACE ICD-873.40
• Walk downstairs to find kids sulking and wife frustrated.  UNDERSOCIALIZED CONDUCT D/O UNAGRESSIVE UNSPEC ICD-312.10
• Try to give her advice.  COUNSELING FOR PARENT-CHILD PROBLEM UNSPECIFIED ICD-V61.20
• Wife glowers.  MARITAL&PARTNER PROBLEMS UNSPECIFIED ICD-V61.10
• Say: “We have to leave in five minutes!” in an angry voice.  PROBLEMS WITH COMMUNICATION ICD-V40.1
• Children glower. FAMILY DISRUPTION D/T PARENT-CHILD ESTRANGEMENT ICD-V61.04
• Wife sighs and chides for the tone of voice.  COUNSELING FOR PARENT-BIOLOGICAL CHILD PROBLEM V61.23; E/M 99215, ENCOUNTER, ESTABLISHED, HIGH COMPLEXITY

PLACE OF OCCURRENCE STREET AND HIGHWAY ICD-E849.5

7:40

• Finally in car with daughter, driving to school.  CRITICAL CARE INTERFACILITY TRANSPORT EA 30 MIN CPT-99467
• Daughter still not talking more than mumbles.  OBSERVATION CHILDHOOD/ADOLES ANTISOCIAL BEHAVIOR ICD-V71.02
• Turn on iPod and play music daughter doesn’t like.  PASSIVE-AGGRESSIVE PERSONALITY DISORDER ICD-301.84

7:55

• Daughter dropped off, running frantically to not be tardy.  Angry that “we are always late.”  UNSPEC EMOTIONAL DISTURBANCE CHLD/ADOLESCENCE ICD-319.3
• Don’t attempt to explain that it is seldom the chauffeur’s fault.  HEARTBURN ICD-787.1
• Nod and smile.  FEAR OF WOMEN ICD-300.29
• Drive to work.  AGGRESSION ICD-312.00

OTHER SPECIFIED PLACE OF OCCURRENCE ICD-E849.8

8:15

• Arrive at work, greeted by a long list of unsigned charts that materialized mysteriously overnight.  DEPRESSION, SITUATIONAL, ICD-300.4
• Go to kitchen and pour another cup of coffee – mega jumbo size.  CAFFEINE EXCESS ICD-305.90
• First patient status is “arrived” even though appointment is for 8:45.  Sigh loudly.  AVOIDANT PERSONALITY DISORDER ICD-301.82
• Check email, blog hits.  DEPENDENCE ON OTHER ENABLING MACHINE ICD-V46.8

8:45-12:00

• See patients, answer phone messages, assess lab and x-ray results, and periodically check email, blog, etc. ADVERSE EFFECTS OF WORK ENVIRONMENT ICD-V62.1,
• Talk with drug reps who explain advantages of drugs which have been out for many years. AMNESIA, PSYCHOGENIC ICD-300.12; E/M 99213 ENCOUNTER, ESTABLISHED, LOW COMPLEXITY
• Get another mega jumbo cup of coffee. PREMATURE ATRIAL CONTRACTIONS ICD-427.61;  POISONING BY CAFFEINE ICD-969.71; EROSIVE GASTRITIS ICD-535.40

Note: This is a caricature, not my real life.  My wife and kids are generally very nice to me and I do like my work.

I was sitting in the third session of the medical blogger track at Blogworld Expo and noticed something.  On the screen to the right of the speakers was a live feed from Twitter.  It seemed that everything posted there had the word “Blogworld” in it, so I twittered the following:

Like magic, my tweet went up on the screen!

Then began a series of responses:

Which looked like this:

So all the world of Blogworld saw our antics; yet we were not Blogworld kicked out.  Clearly there was poor Blogworld monitoring.

Overall, the Expo was wonderful.  I have gone to medical and EMR conferences over the past 10 years and, truthfully, get bored in them.  I learn things in the medical conference, but having done EMR for the past 13 years, there are not a lot of new tricks to learn.  Blogging is a whole different thing.

The medical track was especially good, with excellent discussions on several very pertinent subjects:

• The history of medical blogging – Was just plain interesting.
• The ethics of medical blogging – I talked on this panel and despite that fact, it was good.  There are very big issues around being in a business that emphasizes privacy, and blogging – which is public by nature.
• How to influence healthcare through blogging – Very good discussion about what the point is of what we do as bloggers.  What is happening as a consequence of what we do?
• The value of blogs to corporations and hospitals – The issues around these institutions are much different, but are important for all of us.  How do pharmaceutical companies, hospitals, and the media handle medical blogging?  Where does blogging fit in and what are the pitfalls?

It was truly a joy to meet many of the medical bloggers I have read for years, especially my chance to meet the wonderful South African blogger Bongi and his fiancee Delre Roberts.

So what of the rest of Blogworld?  Here are some of the take-home messages I got:

• Google AdSense is not a good way to make money.
• Design of your blog will do a lot to retain visitors.  I changed the tagline of my blog because the haiku kept things mysterious to new visitors.
• Don’t apologize for advertising.  You work hard on your blog and good enough content will retain serious readers.
• Put things on your blog that will bring readers who get posts via RSS feed.  Things like contests, polls, and other interactive things are examples.  Increased traffic allows you to attract advertisers and increase your income.

Let me add, however, that medical bloggers are under a different level of scrutiny.  Our legitimacy is based on our independent voice.  Our job is to speak for our profession and for patients.  Just as people don’t want doctors’ prescribing habits influenced by pharmaceutical companies, our voice as a blogger should never be perceived as influenced by outside forces.

So, I recommend that (Blogworld) all of you go (Blogworld) to the Expo put on by….

You know.

I had a patient in the office today who doesn’t have insurance.  He told me that a recent prescription he got was too expensive.  This is not surprising, as many of the brand name, and even some of the generic medications are quite expensive.  What surprised me was the fact that the expensive medication was for hemorrhoids, and it cost over $100.  I certainly would never recommend anything but good care for that part of your body; and the symptoms of hemorrhoids can definitely have a big effect on your social life.  But come on, $100??

This medication had all of the usual components that most hemorrhoid creams have.  The real difference was the delivery system: it’s a foam.  There is no generic substitute for this, apparently.  As I spoke with this man, it became clear to me that this is a central issue in the crisis in healthcare.

What?  Hemorrhoid foam is the cause of the healthcare crisis?

No, that is not what I am saying.  The significance of this encounter is that the $100 medication is one that I prescribe frequently, and that insurance companies have never rejected.  The insurance companies are paying $100 for hemorrhoid medication.  True, they probably have wrangled some sort of discount, but the reason the company who makes this magic medicine can charge $100 is that somebody pays $100 for it.  I don’t think there are enough constipated millionaires to explain this phenomenon.

The main problem in healthcare is the total lack of value.  We pay a lot for care and don’t get a lot in return.  Costs are going up but we are not seeing an increase in quality along with those rising costs.  Why is this happening?  $100 dollar hemorrhoids show us what’s going on.  The medications contained in this concoction are not anything expensive – mainly cortisone.  The delivery system isn’t space-age.  The company spends very little money on marketing (I don’t think I’ve ever seen a drug rep for this hemorrhoid foam).  The R&D budget was probably spent on researching a way to get someone to pay $100 for hemorrhoid foam.

While in Vegas last week Dr. Wes told us about a patient he put in for 23 hour observation with a heart problem who racked up a $180,000 bill.  Insurance got a discounted rate but still covered $120,000.  How can they justify this?  How come there isn’t someone at the insurance company who says: “Hey, that’s an awful lot to spend on a 23 hour visit,” or “Wait a minute, why the heck are we paying $100 for hemorrhoid medication?”  The answer is at the root of our system’s problem: they pass on the cost to us.

If I was in the hemorrhoid foam business (my kids wouldn’t tell their friends, I am sure), I would accept the $100 check for each can of foam.  I’d even start singing “God Bless America.”  But I am not in that business (my kids are relieved), and instead I have people with insurance rates so high that they have to drop it.

Something is wrong with this picture.  $100 is more than I get paid for most of my visits, and congress is now arguing about whether they are going to cut my pay; yet nobody seems to be bothered by $100 for hemorrhoids?

Will I get paid better if I claim to shrink swelling and relieve itching?  Will it help if I deliver my care as a foam?

Zippy does not speak Tamil.  He doesn’t like curry.

Please post this request anywhere you can.  Please spread the word about Zippy’s captivity.

Let the insanity stop.