I am mad at congress.

I don’t care if they are Democrats or Republicans, I am sick of healthcare being treated as a political football.  How much more of a crisis do we need before we actually start working on a solution?  Why does each party have to sit on its side of the aisle shooting spitballs at the other?  Each side has its pet issues that are tied to contributors, supporters, and lobbyists.  Each side will work to see the other side fail even if the other side is right.  Each side seems unable to do anything unless there is political value in it.  Power is more important than service, and power is a short-term project.

The real problem is that congress is thinking of short-term political gain while sabotaging the long-term.  It’s like the publicly traded company that works to maximize quarterly profits even if it damages the corporation in the long run.  Our society thinks in the short not in the long, and our congressmen are doing so in a way that harms all of us.

I thought of this while I was in the shower this morning.  I am not sure if it is the shampoo, but I have thoughts about blog posts while I’m in the shower.  I was getting filled with righteous rage about the stupidity of congress and how they mimic corporate America in short-sightedness.

Then I realized something: I do the same thing in my personal life.  I am trying to eat better and exercise, but that brownie in the break room looks awfully tempting.  A little indulgence now won’t hurt in the long-run, will it?  I start playing that damned Bejeweled game on Facebook instead of working around the house.  It’s only one night, and I am stressed-out about stuff.

Perhaps it’s the soap that gets me thinking this way.

Living my life making decisions based on my immediate feelings is the same stupidity that infects congress.  I indulge for personal gain in the short-term and let tomorrow’s crisis build.  I have had people younger than me have heart attacks and die; do I really want my last night on earth be spent playing Bejeweled?  Worse yet, if I survive and keep acting in this way, do I really want the measure of my life be how many brownies I eat or what my high score is on a game?  It’s not that I don’t realize I should spend my days better; it’s just human nature that thinks in the now in ways that harm the future.

Then I thought about my patients: they do the same thing.  My patients who are overweight, smokers, alcoholics, non-compliant, in bad relationships, neglecting their children, or hating others because of superficial differences – they are not all that different from me.  They are not different from congress.  They are living in the now because humans do that.  Humans overcharge their credit cards to the point that they can’t even afford the monthly payments.  Humans buy cars with money they don’t have just to get the warm feeling of having a new toy, and the joy of making others jealous.

It doesn’t justify stupidity, but it does explain it.  I feel righteous anger toward congress because I see the result of their inaction.  I see the harm caused to people by a dysfunctional system.  My paycheck is affected by it.  Congress can’t resist the brownies; they can’t stop playing Bejeweled.  Congress can’t stop smoking, or stop spending money on credit cards.

So how do we fight this battle that is all too human?  How do we get congress to act in a way that’s best for us, not them?  How do we get ourselves to spend time with the kids, not the blog?  How do I get my patients with heart disease to stop smoking?

I don’t know.  I had to get out of the shower.

Photo Credit

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It happens every year.

I try to get a little shut-eye, but then these guys in hats come around and yank me out of bed.  They proceed to parade me around a huge throng of people (most of whom are not wearing hats), obsessing about the presence or absence of stratus clouds.

What a strange group of people.  I seem to be the center of attention for the day, though, and that’s not all bad.  It’s my day on February 2nd, and nobody has ever taken that from me.

Until this year.

Let me back up a little.  My name is Phil, and I am a woodchuck who lives in western Pennsylvania.  Yeah, I know I was supposed to say “groundhog,” but I like throwing people off.  I am also called a whistle pig and a ground beaver, so it could be worse.  I personally prefer the woodchuck thing because I like the “how much wood could a wood chuck chuck…” poem.  Shouldn’t I be able to decide what I am called?  What’s wrong with “Woodchuck Day?”  It beats “Whistle Pig Day,” doesn’t it?

Sorry, that subject gets me emotional.  I live in a town known as Punxsutawney, which is an Delaware Indian (or Native American – see, it’s not so bad to have more than one name!) word meaning “town of sandflies.”  I can vouch for the appropriateness of that name.  It’s not much of a town otherwise; which is why I suppose they go around in hats and pester me each year.  What else is there to do?

There are a lot of llamas in our town too.  I think that’s why Dr. Rob came in the 1st place.

But this year we’ve been invaded!  Turns out that there is a whole other group of strange people who get all excited on a regular basis, and this year they invaded Punxsutawney!  They are lead by a guy named Steve, and for all the doting they do on him you’d think that this was “Whistle Steve Day!”  He took the much-anticipated day of my emerging and turned it into a way to show off a new thing he made; I forget what it’s called…something beginning with an “i,” I think.

So you see, I have be relegated to second-fiddle, which doesn’t suit me well.  That’s why I took Dr. Rob up on the offer to give my particular woodchuckian perspective on medical blog posts.  Plus, I thought he said “Ground Rounds,” and it seemed up my alley.  Ah well, you can’t blame me for wanting to get out of Punxsutawney as quickly as I could.  I’ll show you other pics of the day in Pennsylvania to prove it.  This guy is crazy!

Everyone thought last year’s stunt by the llama was crazy, but that was nothing compared to this year!

Since Dr. Rob inexplicably got a gazillion submissions, I am grouping them.  It makes things easier to digest.

Group 1: My Faves

Some of the posts stood out from the rest.  This is not to say the rest weren’t great, but certain posts just resonate with a large North American rodent.  I’m not sure if that’s good or bad.

The first on the list of Faves is a Post from the blog named Nourish: Living, Laughing, Whining (great name) which tells about Jacqueline du Pre’, a woman who played the cello but lost her ability due to Multiple Sclerosis.  Marie Cooper, the author of the post identifies with her in the pain of facing a horrible illness. Like the pain I feel facing Steve.

The next is from Dr. Charles, who writes about being a doctor and going to a patient’s funeral. Dr. Rob says Charles expressed the emotion perfectly.  Dr. Charles is a good writer.

The third of my faves is from Dr. Robert Centor, who’s a smart dude (so I am told).  He discusses the reason nobody is choosing primary care: it’s not because of what people say about it, it’s the job itself.  I think he is basically saying that primary care should suck less.  Dr. Rob agrees.

My final fave is from a psychologist named Will Meek.  He explains the difference between remembering and reliving hard things. Why do I like this so much?  First off, I have a lot of trauma to deal with, getting lifted out of bed every year (the whistle-pig side of me is quite sentimental, you know).  Second, there was a guy once who relived Groundhog’s day a bunch of times.  He should have read this post.

See!  He took over!  At least he wore a hat, though.  Even the llama wore a hat.

Group 2: What Docs Do

I get a skewed view of doctoring by just talking to Dr. Rob (he’s a skewed kind of guy), so reading posts about docs being docs was quite enlightening.

The Happy Hospitalist taught me what the difference between a hospitalist and an intensivist.  If there’s a Happy Hospitalist, is there an Idiosyncratic Intensivist?  I am sure there are lots of them.

Dr. D taught me how doctors diagnose the weird stuff.  It turns out you don’t have to be mean and abrasive (like that doc on TV) to be able to make “good catches”!  Who’d have thought?

Lockup Doc talked about how some doctors make you feel at ease, while others make you feel like you are a nuisance put on their schedule to give them justification to abuse illegal drugs (kind of like that mean and abrasive doc on TV).  The interesting thing here is that Lockup Doc takes care of prisoners!

Why do people need a thorough physical exam before getting surgery?  Dr. DJ (sounds like a rapper) talks about how people hide stuff that can hurt them later, necessitating a thorough physical exam.  He wonders if that is unique to India.  Dr. Rob says that it’s definitely not.

Kent Bottles…no, that’s his name…I am not saying he bottles things.  He might bottle things, but that is not relevant.  Dr. B talks about how some smarty-pants surgeon is telling everyone to use checklists all the time. Dr. B thinks that this guy may be right, but there needs to be room for imagination and deviating from the checklists.  I find that it’s very important to have creativity as a woodchuck.

Group 3: Yowza!

Some posts made me say “yowza!”  That’s woodchuck for “wow, what a controversial topic covered in the blog post.”

Dr. Wes talks about the healthcare legislation that has stalled in congress.  The amazing thing about this post is that the comments section is about 5 times as long as the post itself.  Great discussion, but Dr. Rob confessed that his Adderal ran out before he got to the end of the comments.

A blogger named Phil (good name!) on the Behaviorism and Mental Health Blog says that Schizophrenia is not a disease!  Dr. Rob was impressed by his bold stance that is definitely against the mainstream, and the way Phil put forth some solid points.  I was impressed by his name.

Mary Clark has a chip on her shoulder.  I think it’s a Pringles, but I can’t tell for sure.  LOL ROFL – That was a bit of woodchuck humor.  Anyway, Mary is very frustrated about two people who got surgery who clearly would have chosen otherwise.  Not all docs (or woodchucks) disagree with Mary.

Toni Brayer wonders about how doctors and hospitals get rated.  How can this information be useful to patients?  She says it can’t.  Of course, she’s from California, so you have to expect that kind of thing.  She probably got sick on some tofu or sushi.  (More woodchuck humor)

I have to admit, I was a little star-struck when I saw the iPad for the first time.

Group 4: Taking Care

What’s the best way to take care of people’s health?  There were some good posts on that topic.  If only they’d cover the best way to avoid guys named Steve.

Metformin for Type 1 Diabetics?  Amy Tenderich at Diabetes Mine once thought the idea ridiculous.  But then after looking into it more, there are definitely times it’s a good idea.  Who’d have thought of such a thing?  I am probably the only woodchuck with that knowledge.  Thanks, Amy!

What’s best, low carb or low fat diets?  The blog On The Wards discusses the research on the subject.  It turns out that they are the same.  I am glad about that.  Some woodchucks eat bugs and other yucky stuff, but I stick to the veggies to maintain my chuckish figure.

Bruce Siegel, who writes at the Robert Wood Johnson blog talks about some people from Minnesota who are working together to improve the quality of care.  He has the quote of the day:

You could dismiss this as another example of “Minnesota care”—where all the clinics are strong, the doctors are good-looking and the scores are above average. But Minnesota is only a harbinger of things to come in other parts of the country as the movement for high-value health care continues to pick up steam—with an extra boost coming soon (we hope) from the quality-related provisions of the national health care reform bill.

Group 5: Hah!

Some posts were either funny, or they were unexpected.  I usually like unexpected things, but Steve and his disciples are making me rethink this whole issue.

My first “hah” came when I read the post by Dear Dr. Ramona Bates on her blog, Suture for a Living. It turns out that there’s a surgery to make a navel!  I guess people would look funny without one.  Rumor has it that Dr. Bates learned the procedure at the Navel Academy.

Step aside Scoobie and Astro, the new dog darling is Ruppy – a genetically-engineered dog that fluoresces!  Jamie Newman at the ACP Hospitalist blog uses Ruppy, who’s a combination of beagle and sea anemone genes, as evidence that very different things can work together.  Pretty clever!

The spoof article in BMJ about evidence based medicine and parachutes made a lot of people (and woodchucks) say “hah!”  Not so for Jacqueline at Laika’s Medlib Blog.  She thinks that rejecting EBM is equivalent to rejecting science as a basis to medicine.  She’s right about that; I just hope she doesn’t bash the article on Ruppy.  She does have a picture of a dog using a parachute, so I’m optimistic for Ruppy.

From “Down Under” comes a post by Chris Nickson in the blog Life in the Fast Lane. He talks about a real mean dude who comes into the ER, goes to the ICU, and gets a rude surprise.  It’s not a funny “hah” at the end, but perhaps there’s a bit of justice in it.

Steve looked pretty smug when he found out I already own an iPhone.  I swear, I was borrowing it from the llama!

Group 6: Huh?

Understand this: I am a rodent.  My brain is not real large.  So there were some posts that made my brain complain to me.  Dr. Rob assured me that they were great posts, and that the smart people will get a lot out of them.  I wonder how Dr. Rob knows about smart people.

The first one is from David Williams on the Health Business Blog.  He interviews two real smart dudes who made software that improves the process of case-reviews. It seems like they are on to something good, because you can’t fix something if you don’t know where it’s broken.

The second “Huh?” was an article on the Health Care Law Blog by Robert Coffield, who is a Lawyer!  Does that surprise you?  Dr. Rob thinks some lawyers specialize in “huh?”.  But Mr. Coffield isn’t one of them, and he actually points to some really good resources for getting an idea about IT laws for different states.

Group 7: Feeling Better

Whew!  There are lots of submissions to cover!  My paws are starting to ache.  If only I had a tablet with a touch screen….  Well, the point of medicine is generally to make people feel better.  Here are some good posts on that subject.

The first one comes from the blog How to Cope with Pain.  I was interested in this because Steve is being a real pain to me.  Anyway, the article is about how values affect how people deal with pain.  Good stuff.  Useful.

Steve (no, not that Steve) over at the Funky Heart blog talks about being an adult survivor of childhood heart disease.  He sees how just his existence is an encouragement to parents of kids with heart disease.  Very true stuff.

Being sick is lousy, but a lot of times it’s harder on the people taking care of the sick person.  Barbara at In Sickness and in Health asks the question: Caregivers, do you tell your ill partners about your stress? Tough question.  I’ve already told you all about my stress (named Steve).

Group 8: Dumb Stuff

I was surprised to find out that Dr. Rob doesn’t have the corner on the “Dumb Stuff” market.  There’s enough dumb stuff to go around, and bloggers like to tell about it.

Dr. Val (who gets my vote for empress) writes on the Better Health blog about her experience getting licensed in Maryland and California.  Maryland took no time flat, while California is still working on it over 500 days later!  Perhaps they are all sick on tofu or sushi.  For a state that needs doctors, making it hard for Val is very dumb.

The ACP Internist blog brings up a very surprising fact: many medical students don’t have a clue when it comes to electronic medical records. Considering how hard they are being pushed, that’s a dumb thing to be happening.  Just ask Steve, a computer is your friend!

Scott Marshall is a Chaplain who has a bone to pick with Sanjay Gupta.  It’s not that Sanjay has fancy gig at CNN, and not that he has a cool sounding name.  It’s that in his book he compromises as a doctor for the sake of being a journalist. Scott says the book is a good read, but it could lead people to make dumb conclusions.  Scott’s no dummy.

I finally got my paws on the iPad, and what does Steve do?  Whoa, don’t drop the goods, buddy!

Group 9: Following Rules

Rules are there for a reason.  There is often a good way to do things that should be followed.  Other times there are just dumb rules that should be changed.  Steve certainly ignored all the rules in my fair town today.

Fee for service medicine is just the way we do things.  Is that right or wrong?  Lots of people want to change it.  Michael Kirsch at the MD Whistleblower blog muses about the pros and cons of FFS.  Interesting stuff, and he has a new spin on the idea of  ”putting an end to tonsillectomies.” Read it; it’s more woodchuck humor.

Dr. Ed Pullen’s blog has an article about taking medication correctly.  It’s not therapeutic to just want to take your medication, you have to actually take it.  He gives some good rules patients can follow to do it better.  It’s hard for me to remember to take medications during hibernation.

If you are in the hospital, the last thing you want is to go right back.  It’s kind of like Punxsutawney.  Amy over at the Health AGEnda blog writes a post with a link to a guide to prevent readmission.

Group 10: Reader Beware

Some posts are for mature audiences only.  No, they don’t have any gratuitous sex like they do on Animal Planet; they are just…well…I guess you should read them yourself to understand.  Maybe you should ask your mom first.

Elizabeth over at Life. Not Terribly Ordinary justifies the name of her blog, giving a recount of a very busy day.  It’s a great view into the very busy life of an academic doctor.  It also uses some words that would have had my mother washing my mouth out with dirt.

The Inside Surgery blog takes on a big controversy: the use of acupuncture for battlefield medicine.  It’s not a real graphic article (aside from gratuitously poking people with needles) and it uses no cuss words, but I suspect there will be some fonts a flying in the comment section.

Nobody ever accused Patient Anonymous for being subtle and reserved.  That’s pretty obvious when you read her post So, Is This What Medical School feels Like? Brace yourself for some strong words and stronger emotion.  I hope she doesn’t ever run into my mother.

Group 11: That iThing

OK, I confess: I am turning into a fan-hog of the new iPad.  Steve has this magnetic appeal that makes me want to go out and buy something I never thought I needed.  Even Dr. Rob uses a Mac!  I don’t really know what I’d use it for, but I still want to buy 50 of them.  Predictably, the Medical blogs had things to say on the matter.

Dr. Anonymous (who is, ironically, well-known) is the first to jump on the iPad bandwagon.  But wait!  He takes issue with the assertion that it’s a perfect device for healthcare.  Couldn’t cool aps be written for it?  Sure, but it’s not about the aps, its about the hardware.  Dr. A doesn’t think the iPad has what it takes for medicine.  Say it ain’t so, Steve!

Finally, Peggy over at The Blog That Ate Manhattan chimes in about the iPad.  Being an OB/GYN she first scolds everyone for snickering at the name.  I know for a fact that Dr. Rob snickered a lot – saying that the virus scan should be called the iPap.  Shame on Dr. Rob!  Anyway, the post analyzes the claim that the iPad is perfect for healthcare.  She too is mystified at where exactly it would be used.  But she should give up on trying to get Dr. Rob to grow up.  It will never happen.

Conclusion

It’s been a pleasure to get out of my hole and away from the hullabaloo in Punxsutawney.  You medical bloggers are bright folks and the world should pay more attention to you.  I read more common sense this week than I have heard in my entire life from Washington DC.

Pathetic Dr. Rob is now a fan-boy.  HE TOOK MY IPAD!!
I’m going to have to bite him (if the llama doesn’t get to him first).

Addendum:

After the deadline, I got an email from Paul Auerbach From Healthline.  I add this on because of the importance of the topic:

I just returned late last night from two weeks of medical relief work in Haiti, so apologize for the late submission. Please consider the following posts, which are a series of what we experienced, for submission for this week’s Grand Rounds. I realize that it would be highly unusual to list so many posts, but I offer it nonetheless. If you read them, you will understand.

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-22.html

http://www.healthline.com/blogs/outdoor_health/2010/01/from-haiti-thursday-january-21.html

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-23.html

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-24.htm

lhttp://www.healthline.com/blogs/outdoor_health/2010/01/from-haiti-january-25-2010.html

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-26-2010.html

http://www.healthline.com/blogs/outdoor_health/2010/01/from-haiti-january-27-2010.html

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-28-2010.html

Thanks for the opportunity!  Next week GR is hosted by Edwin Leap.

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Grand Rounds is a big event, and I have gathered together a star-studded line-up.  Do not submit any more posts, however, or you will be forced to go onto Dr. Phil to explain why you are such a dead-beat.  You don’t want that.

Obviously, with such a gathering, you don’t want to miss it.

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The deadline for grand rounds submissions is on Sunday at Noon EST.  EST stands for “Eastern Standard Time,” not “Estimated” or “Extra Submission Time” or “Even Steve Trounces.”

iSuggest you get things in as quickly as possible.

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I was talking to a fellow physician about a mutual patient.  I had information  that would help him in their care and he was taking the unusual step of asking me for my information.  I was impressed.

“Could you fax me those documents?” he asked.  ”Here’s my fax number.”

I scrambled to get a pen to write down his number.  Then I had a thought: “I could email you those documents much easier.  Do you have an email address?”

Silence.

After a long pause, he hesitantly responded, “I would rather you just fax it.”  He said no more.

This is a typical reaction I get from my colleagues when suggest using the new-fangled communication tool called email.  The palms sweat, the speech stumbles, and the awkwardness is thick in the air.  It’s as if I am suggesting they join me in an evil conspiracy, or as if I am asking them to join my technology nerd cult.  There is a culture of fear in our healthcare system; it’s a wall against change, a current of stubbornness, a root of suspicion that looks at anything from the outside as a danger.  Instead of embracing technology, doctors see it as a tool in the hands of others intent on controlling them.  They see it as a collar on their neck that they only wear because others are stronger than them.

It’s the only reason I can see for the resistance of a transforming technology.  It’s the only way to explain how they would favor a non-system that hurts their patients over a system that can improve their care immensely.  After all, what good is it to embrace a technology – no matter how good – if it will take away their ability to practice medicine?  ”It’s good for you!” they hear from politicians and academics, but they see it as a poison pill.

What gives me cause to use such strong words?  Surely it’s not that bad! It is, and what makes me so sure of it is the very high cost of their resistance.  The cost of this fear is huge, and so the fear itself must be bigger for a healer to accept that cost.  What is the cost?

Frustration

We see our patients without information.  The call from the specialist I described at the start of this post was a truly rare event.  Most of my consultants don’t expect to get information from me, and I expect to work without their input.  All of this has happened despite my repeated attempts to improve our system.

• I have offered to send our referrals with attached appropriate documents.  I can do this very efficiently using email.
• I have tried to send labs, x-rays, and other information to specialists when I felt they couldn’t do their job well without them.
• I have requested that they stop mailing their information to me, instead faxing them to our server.
• I have offered our hospitalist physicians after-hours access to our records for our patients.

Ironically, the only physician who has embraced my offer is an ENT at our local teaching hospital who specializes in parathyroid surgery.  I shoot him an informal email when I have a suspect calcium level and within the day I get a response.  In exchange, he gets consults with a full set of labs and can practice with greater efficiency.  He also sends me quick notes on my patients when he sees them, asking me questions to fill any gaps.

Cost

The total lack of communication results in huge cost to our system.  It’s not that the communication tools are not there, it’s that they just are not used anywhere near where they should.  Examples?

• A woman came to my office recently after being hospitalized.  I never was notified of her hospitalization, only finding out when she came for a “hospital follow-up” visit.  While in the hospital, she was found to be anemic and so had a workup for this condition.  This workup included a full consult by a hematologist and a gastroenterologist.  If my records had been looked at, they would have noticed that I did a workup 6 months earlier for her anemia.
• Specialists not accepting email copies of the labs I run usually end up repeating the tests.  For specialists like rheumatology – where the diagnosis is largely made on the basis of those labs – this elevates the cost by several thousands of dollars.
• I have had patients rebuffed by consultants who “didn’t know why I sent them.”  Nobody calls, and nobody accepts email.  I could send them whatever information they need in a matter of minutes if they would accept email.  Heck, they could even text me if they wanted.

The real cost, of course, is to the patient.  The Hippocratic oath says we should “first do no harm” as physicians.  Yet our non-system of communication does just that, and even kills people.

So why would presumably smart people reject a technology that could improve care, reduce cost, and reduce frustration?  Did any of them order gifts from Amazon?  Do any of them bank online?  I am sure they do, and they do so because it makes things easier and more convenient.   So why does that ease and convenience not apply in medicine, which is far more broken than shopping or banking ever was?  It’s not fear of technology.

To be honest, I don’t really know.  My best guess is that it is the overwhelming sense of pessimism most doctors feel about their profession.  Docs are second-guessed by lawyers, patients, TV shows, insurance companies, and the government.  The fate of medicine is not in the hands of doctors, it is in the hands of politicians, corporate executives, and malpractice attorneys.  It seems to me that the only way to avoid more scrutiny and to hang on to some control is to hold tightly to what we’ve got: our information.  Once that information is on computers it is far more accessible by others, and this is a bad thing if the goal is to retain full control.

So are docs just power hungry, wanting total control because of their inflated egos?  Some are, but most are not.  Even the most technologically-minded of us, however, have an increasing unease about the intrusion of others on our ability to do our job.  I don’t want to be thinking about attorneys when I am prescribing medications.  I don’t want to withhold information important from the chart because I know patients will be reading it.  I don’t want to be forced to include a lengthy justification of a procedure in my notes to make the insurance company happy.  As it stands, it sometimes feels like anything we include in our records “can and will be used against us.”

If someone like me, a physician who embraces technology, feels increasingly penned in by the increasing number of people peering at what I do, it is very understandable that other physicians reject technology outright.  They’ll quit before they give up their independence.

Is it stupid?  In some ways it is.  It certainly is a rejection of the centrality of what’s good for the patient.  But our system can’t afford to alienate physicians at this time.  If technology is going to be pushed, there needs to be a reassurance that this won’t be used against them.  I am frustrated at the lack of  acceptance of technology, but even more frustrated at a system that is hostile that forces docs into this foxhole.

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So you wanted more “Ask Dr. Rob.”  Next you are going to be asking for a colonoscopy.

Well, I guess I can do it.  It has been a long time since I have done one of these.  I thought I was being merciful.  Whatever.

Here’s a question from a moderately fictional person named Mike:

Dr. Rob:

What’s the deal with physics?  I heard that you have to take physics class to get into medical school.  As a doctor, do you ever use physics?

Sincerely,

Moderately Fictional Mike.

Wow, what a coincidence!  That’s the question I would have chosen had I written it myself!  What’s the chance of that?

To answer your question: yes, I do use physics quite a bit.  It’s a good thing, because my dad is a physicist.  This is a physical world we live in, with irresistible forces impersonally shoving us around without getting permission.  My father never told me about this dark side of the forces.

Force #1: Gravity

The first example of these forces at work is the ingrown toenail.  Toenails ingrow for one reason: they can’t grow out.  Instead of sticking out the front of the toe like any self-respecting toenail would do, they grow into the toe.  Why do they do this?  What causes some toenails to grow in while the others behave respectably?

Gravity.

Ever since Sir Isaac Newton suffered a head injury, gravity was felt to be related to the mass of an object.  The bigger the object, the bigger the gravity.  But then came Albert Einstein, and the trouble began.  Einstein’s theory of general relativity put forth the idea that gravity wasn’t even a force, but instead a curvature of the spacetime continuum.  Wikipedia explains:

Einstein discovered the field equations of general relativity, which relate the presence of matter and the curvature of spacetime and are named after him. The Einstein field equations are a set of 10 simultaneous, non-linear, differential equations. The solutions of the field equations are the components of the metric tensor of spacetime. A metric tensor describes a geometry of spacetime. The geodesic paths for a spacetime are calculated from the metric tensor.

Confused?  Yeah, well so is everyone else including the toes. What started out with a simple equation in Newtonian Physics:

became 10 simultaneous, nonlinear, differential equations! Yuck!!

Despite his lifelong battle with fruit, Newton remained
a gentle soul.

To get back at Einstein, the toes decided to take advantage of these changes.  Using a loophole in this new law, they increased the local gravity in his big toes, pulling the nail down into the flesh part, giving Albert the first ingrown nail in recorded history.  In foot-wracking pain, Einstein tried to recant his theory, but the damage was done.  This is why the presence of an ingrown toenail, which is evidence of a hyper-gravitational podiatric state, is invariably accompanied by the following:

• People step on them – scientists have proven that a foot with an ingrown nail is 10 times more likely to be stepped on than those without.
• Heavy objects are kicked – careful analysis has shown that objects such as coffee tables, lamps, and even large appliances move into the path of a person with an ingrown nail.

Why do these things happen?  Gravity.  Thanks a lot, Albert!

Einstein, on the other hand, was left embittered by
his chronic foot pain

Force #2: Opposing Forces

Following his head injury, Sir Isaac Newton (yeah, him again) decided to take the law into his own hands.   The result of this was the creation of Newton’s Laws of Motion.  His design was to prevent future fruit-related head injuries, and he was largely successful (except for one unfortunate Kumquat encounter).

Kumquats can be dangerous

Newton clearly had a lot more sense than Einstein, and he kept his toenails happier as well.  Take it from me: always keep your toenails happy.  The three laws that Newton made were about moving objects, the most famous of which was the 2nd law, with the formula:

Translated: Force = Mass x Acceleration.  This is a great formula because it is so simple (as opposed to Einstein’s ten differential equations), but sadly, it doesn’t apply in the doctor’s office.  The third law (the law of reciprocal actions) however, applies very nicely:

Which translates: “any force that is applied to object 1 due to the action of object 2 is automatically accompanied by a force applied to object 2 due to the action of object 1.” (1)

The application in medicine is not in the clinical realm, but in the interaction between doctors and nurses.  Since both doctors and nurses are important cogs in the machine of medicine, they commonly have significant effects on each other.  Believe it or not, they don’t always agree.  I am sorry if I shattered anyone’s image of a blissful cooperation and camaraderie.  That is true most of the time (if by “most” you mean “almost never”).   The Law of Medical Opposing Forces goes like this:

Any force that is applied on a nurse by a doctor is automatically accompanied by an opposing force applied by the nurse on the doctor.

The best example goes something like this:

Nurse: Doctor, Mr. Tucker’s wife wants to talk to you about the side effects of all of the 29 medications you prescribed.  I told her you were on the floor, so she’s expecting you

Doctor: Fine, nurse, I’ll do that.  Let me first write these three orders for enemas and the order to discontinue the sedative for the screaming lady in room 244.

Nurse: That’s nice.  Did I tell you that the Mr. Wafter has a large abscess that started draining?  I left it alone after explaining to him that you are an expert at wounds like that.  His roommate had to be moved, though, because he couldn’t take the smell.

Doctor: Wonderful.  I forgot to mention that I can’t discharge Mr. Whiner or Mrs. Screamer today.  I just want to wait another day to make sure they are stable.

Nurse: I’ll be sure to have the night shift nurses call you hourly through the night to give you updates.

These two children are in training.
This picture was taken before the hand-to-hand combat

This is a very important law to understand, especially for doctors in their residency.  Most residents assume that they are in charge since they have those letters after their name, but what they don’t realize is that they are weak forces.  Nearly all forces exerted by a resident on a nurse are met with much stronger opposing forces.

There are other opposing forces in healthcare, including surgical vs medical doctors, doctors and nurses vs hospital administrators, members of congress vs. people who don’t get money from drug companies, and insurance companies against anyone trying to get money from them.  Anyone dealing with healthcare needs to understand this very important law of physics.

Conclusion

I am just scratching the surface (which, of course, involves the force of friction), but the spacetime continuum is putting force on me.  But the bottom line (x-axis) is that physics is at the center of the medical universe.

Here’s to you, Dad.  May the force be with you.

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Emerging on February 2.

Llary says that you should submit your blog posts to grand rounds.  Llary also says that Dr. Rob really stinks at photoshop.  It’s a good thing you don’t need to photoshop to be a doctor or all of his patients would be in extreme danger.

Llary thinks they might be in danger anyway.

Obey Llary.  The email address is llamas.are.grand.rounds@gmail.com.

Deadline is January 31 at noon EST.
————————
Addendum: Several people have sent me the full articles. Grand Rounds is a summary of the best of the medical blogosphere. I read and link to your posts, giving summaries. Following those links gives traffic to your site (which is another big advantage). Submitting to GR is one of the ways this blog became widely known.

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“I thought you’d be over in Haiti,” a patient said when I walked into her room.

A pang of guilt hit me as I explained that I can’t leave work for long without risking not meeting payroll.  It’s a true fact about being in private practice: I am the commodity I sell, so my absence brings nearly all revenue to a halt.  Given the tight margins in primary care, that makes any day off be accompanied by the that hovering fact.

That sounds uncomfortably like rationalization.  Am I sitting comfortably here in America making excuses for my inaction?  A large part of me wants to help, but then there is my staff, my patients, my family – all of whom depend on me being at my job.  I feel tied by my responsibility and the needs here, but then I see the needs in places like Haiti, and it makes me ponder.  It makes me feel uneasy.

Maybe a conscience in this circumstance is OK.  Maybe it’s OK to feel powerless when I look at TV.  It’s fine that I am doing what I do now, and I need to be committed to first helping and serving those who are in front of me, but I shouldn’t ever forget that there is more.  We can help by sending money and prayers, but should always be looking for more we can do.  One of my greatest fears is that my comfort will turn into a sense of entitlement of the things I have gotten.  Pictures of Haiti remind me that much of what I have stems simply from the fact of where I was born.

So, my attention was piqued when I got the following email:

Dear Rob

International Medical Corps is a global, humanitarian, nonprofit organization, founded by volunteer doctors and nurses and dedicated to saving lives and relieving suffering through relief and development programs. Our emergency response team is in Haiti responding in force and I would like to ask for your help to get the word out to the readers of Musings of a Distractible Mind. There are still thousands of patients seeking treatment of which approximately 80% are in need of surgery and are running out of time – especially with the tremendous aftershocks still devastating this country. The team is treating crush injuries, trauma, substantial wound care, shock and other critical cases with the few available supplies – And they’re in it for the long haul.  I would love your help spreading the word by blogging or tweeting about IMC’s rescue efforts. We’ve put up a blogger friendly widget here on our site:

http://www.imcworldwide.org/haiti

With the widget it’s really easy to let your readers know that donating $10 to help the people of Haiti is as simple as sending a text message of the word “haiti” to 85944. If you have any questions just let me know and I will do my best to help you out. If you are able to post the widget or tweet, I would appreciate it if you could send me the link.

Thanks so much,

Ellie

Here is some information from their website:

International Medical Corps is a global, humanitarian, nonprofit organization dedicated to saving lives and relieving suffering through health care training and relief and development programs. Established in 1984 by volunteer doctors and nurses, International Medical Corps is a private, voluntary, nonpolitical, nonsectarian organization. Its mission is to improve the quality of life through health interventions and related activities that build local capacity in underserved communities worldwide. By offering training and health care to local populations and medical assistance to people at highest risk, and with the flexibility to respond rapidly to emergency situations, International Medical Corps rehabilitates devastated health care systems and helps bring them back to self-reliance.

International Medical Corps has gone on to provide life-saving care in more than 45 countries worldwide, responding to nearly every emergency in the last two decades. It deploys quickly in emergencies and then stays on to teach life-saving skills so that people locally can become self-reliant. Its training assures continuity and a new level of care for those impacted by conflict, tragedy and extreme poverty.

Over the years, International Medical Corps has responded to the world’s most devastating man-made and natural disasters, including famine in Somalia, ethnic cleansing in Bosnia, the Rwandan genocide, and atrocities against children in Sierra Leone. More recently, International Medical Corps was a first responder after the 2004 tsunami in southeast Asia, the 2005 earthquake in Pakistan, responded domestically following Hurricane Katrina, and is among the dwindling number of humanitarian agencies still working in Darfur and Iraq.

What I like about this is that this is a group of medical people providing relief.  These are people who can give care in the first person.

No organization is perfect, and no amount of giving on our part will fix the pain in Haiti.  But I think the medical blogging community should consider standing behind this organization.  If you have a blog, put the widget on your site.  Grab the one on the top of my sidebar.

And give what you can, but not to assuage your guilty conscience.  If your conscience is that easy to assuage, then you probably need to think a little more about your situation and that of these people.  It’s not wrong for us to have what we do, but it does give us a responsibility.

Everyone to whom much was given, of him much will be required (Luke 12:48)

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Huh?

Am I early?  I heard there’s something big coming up soon.  So much talk about llamas – I demand equal time!

Hah!  At least Dr. Rob will work for a change.

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One of my favorite patients died last week.

My reaction to this was not quite what you would think: I smiled.  No, I didn’t smile because of his death; I smiled because of his life.  I smiled because I got to be a part of that life.  His death wasn’t his tragic end, it was the exclamation point to his life.

I am around a lot of death – it’s one of the things that makes being a doctor different from other jobs.  My goal with all of my patients is to keep them healthy, to relieve their pain, and to do my best to keep them alive.  Ultimately, though, it’s a losing battle; 100% of them will eventually die.  That’s why I don’t like statistics about how many people who die due to inadequate doctoring.  Our job is to resist an irresistible force.  We are standing up to the hurricane, the avalanche, the flood.

If you only measure a story by its ending, we all live a tragedy.  Even a belief in life after death doesn’t remove the loss death represents.  (I often have to remind my Christian patients that even Jesus wept because of death). But being around death has also taught me that even seemingly tragic deaths aren’t always tragedies.  Sometimes being in the presence of the dying isn’t sad, it’s inspiring.  Sometimes I consider myself lucky to be with them.  Sometimes it’s an honor to be their doctor.  We don’t always stand against death, sometimes we get to stand with the dying.

My relationship with this patient started without distinction.  He was a few years younger than me, worked with his hands, and was generally healthy.  What made him different was his ever-present smirk.  He was subtle and soft-spoken.  It took me a few sentences’ delay for me to catch a joke he had slipped in without drawing attention.  I’d stop, smile, and his smirk would grow.

Then things started happening.  He came to me with unusual symptoms, and after running tests I still was without an answer.  I sent him to specialists, and they couldn’t explain his symptoms either.  His symptoms worsened, and he started missing work.

Eventually his picture clarified, and the news was not good: his condition was progressive and untreatable.  It was also rare – the kind of disease that happens in people three decades older than him.  It’s not supposed to happen in young, healthy men.

It was a tragedy: a man in his prime with a family is stricken with a disease he “shouldn’t” get.  I added him to my list of people I am going to ask God about.  Why does this kind of thing happen?  He should be living a long and healthy life, but that choice wasn’t given to him.  He just kept getting sicker and sicker from a disease he shouldn’t have had.  As time went on and as the disease progressed, the situation became clear: he was dying.

Standing helplessly while someone you like dies is usually hard.  The visits are uncomfortable and quiet, and I get a sinking feeling when I see them on my schedule.  But he was different; it was as if nothing had changed.  I never saw him sulk, I never heard the word “unfair,” and I still had to listen carefully for the subtle jokes.  When many would have been angry, frustrated, or depressed; he just smirked.

His attitude was infectious.  His wife never complained either.  I was always happier after his visits, and so was my staff.  Eventually he came to the office with a skilled nurse, and they were always smiling.

His death was not a surprise when it finally came.  But what did surprise me was my response.  I will miss him and his smirks and subtle jokes.  I do wish he had lived out a long and healthy life.  But he is no longer on my list for God.  He lived better while dying than anyone I have seen.  He inspired me, my staff, and anyone else fortunate enough to cross his path.  It was the fact that he was dying that made his life so remarkable and how he faced that fact that leaves me richer.

Perhaps we shouldn’t ignore death.  We are all dying, yet we always seems surprised when it happens.  Maybe we need to follow my patient’s lead and die well.  He didn’t ignore the obvious, complain about what’s normal, or bemoan his bad luck; he faced his end as he faced the rest of his life: with a smirk.

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