Medical Marginalia

Potpourri: WSJ, Coffee, and Why I am Still a Doctor

icedlatte@medmarg.com (IcedLatte) — Fri, 18 Dec 2009 01:14:00 +0000

Greetings, ah, Wall Street Journal readers. What a happy Christmas surprise to find in today's Google Alerts:

WSJ links to Med Marg!

To my dear friends and loyal readers, no, that was not Photoshopped.

There was EVEN MORE GOOD NEWS. Dr. Latte might not ever become diabetic. This is important, because Dr. Latte loves cookies and potato chips more than life itself, but slightly less than Jeni's Ice Cream. Why? What important medical break-through has Dr. Latte so juiced? This:

Coffee, Tea may stall diabetes.

A shout out to my peeps at MedPage Today! Every cup of coffee I drink a day lowers my risk of diabetes by 7%. (Okay, yes, I left out the "may". I was too busy adding half and half to my joe.) I think that this week alone I have reduced my diabetes risk by approximately 5,683%, which means I have lowered my risk enough for everybody in the State of Ohio. You're welcome, Buckeyes.

Now, to the meat. The New York Times (where my blog has not yet been extoled on high) doesn't always get health care right. Even when they're not right, they get credit for thoughtful, by which I mean "full" of "thought" which if you watch local news for 4.3 seconds you will see if often in short supply. Today they shot me in the gut.

I have been chatting at length recently with my comrade in arms, Dr. Beardy, about how we've changed. What did medical school, residency, and years of practice do to our brains? Dr. Beardy shrugs and rolls his eyes at my endless fretfulness.

But I wonder. I kept a journal regularly before I went to medical school and for the first year. Entries became more spotty as time went on. I read them now and it's cute, and I mean to be patronizing. Pre-med and -clinical me is so earnest and exciteable. A Richard Selzer essay sends me to the moon. "Oh, noble savage, I am here to lay my healing hands upon you;" I was chomping at the bit to unleash my skills and empathy upon the needy masses.

That was before two years of rote memorization, then many years of a first row seat at some of the finest suffering the body has to offer. Before abscesses exploded at me, on me. Before I got amniotic fluid in my mouth; before I beheld a newborn before anybody else in the world, even its mother. Before stinky diabetic feet met my wrath at 3am in the emergency room. How many times did I cry in the bathroom at how helpless I was to help, really help?

My earnest yearnings were before drug addicts, alcoholics, and prostitutes introduced themselves and their STIs and kept me busy on weekend calls. Before I stuck sharp things in prisoners who promised retaliation and held the hands of felons as they died. Before I pronounced somebody dead on Christmas who had been breathing and warm moments before, then had to turn to the family and think of something not totally stupid to say. I had listened to the slow thump of their hearts. Then I listened to nothing. Silent stillness.

I've held hands, smoothed hair, listened to hearts, thumped livers, ordered blood, checked ears, smiled, cried, worried, fretted, and laughed through thousands of encounters. I've listened. I've catheterized, immunized, yearned, grieved, smiled, giggled, joked, talked, and hoped with thousands of people, most of whom, in fact, I've adored in one way or another. Not all, but most. Listen, listen, I tell myself when I'm starting to dislike somebody; you'll hear the hook. That thing that the patient will say that will reel me into their world, still, to this day, astonished to find myself a tourist in a life and a body quite alike and different from mine.

I remember, like most parents, before my daughter, my beloved, adorable, sparkly, vibrant girl was born, my husband and I worried. We were deeply, completely in love with our quirky, volatile, funny, handsome, curious, brown-haired toddler boy. Could our hearts expand to include another with the intense, physical love we had for our first? Impossible.

But then there was this.

My Lu. In labor and delivery after my semi-emergent section, on mag, exhausted, uncomfortable, worried, a nurse--such a dear woman--brought me a picture of her, so tiny, with oxygen and a giant IV. I had seen my daughter for a few seconds in the operating room before she was whisked to the NICU. Someday maybe I'll take a picture that means as much to me as this picture did, still does. In the wee hours of the night, lonely and a little afraid, I fell hard for a premie in a picture and I haven't gotten up yet. May I never rise. (Look at that face. How could I?)

So. I can't tell you all the ways I've changed because I just don't know. But I can tell you this. I'm bigger. I'm stronger. I'm quieter. My heart grew--like the Grinch's. My brain grew. (May that continue, too.) I know from my kids and from my patients that really, my ability to fret, to absorb, to hope, to love, to grow (my husband would add "to opine" and "to bitch") will go on. And that brings me back to the New York Times.

A picture is worth a thousand words. I should have started with these pictures, because what keeps me coming back, what gets me out of bed in the morning, what flips my switch to "on", what I love about being a physician is to reach out and touch, to help, to listen, to be near. I saw these pictures today of a little boy, with brown hair and eyes like my little boy, with tetanus. (Woe! This dear little fellow didn't need to be sick.) Tomorrow, for some other mother somewhere I will reach out, listen, laugh, hope, and try to help.

Pictures of the day: December 17th

Turns out, despite the agonies of call and the endless needs of the Axis II patient, the earnest little pre-medical journal-girl has survived. (She's much, much older and grayer and wider, now though.)

The gassy winds of change

icedlatte@medmarg.com (IcedLatte) — Sat, 12 Dec 2009 17:09:00 +0000

So. The year is winding up. I am buffeted more by the winds of full-time working mommyhood at the holidays than I am by the winds of change in primary care. I am, though, getting cards and contact from old patients. Oh, how ambivalent I am about this. I am delighted to hear from these beloved folk, but so many tell me tales of woe. No callbacks about tests. Doctor in and out in five minutes. No explanation for an emergency referrals, sometimes no knowledge about the referral until the specialist's office called to find out why the patient missed the appointment. Inexplicable expensive tests based on miniscule probably benign findings. Where are the good primary care providers?

I know what physicians who are reading are thinking. "Iced, you weren't there. You don't know what happened." True, so true. But these aren't nutty patients. They're wonderful patients who never, ever brought anything but joy to my office. I'm only hearing the bad stuff, too. There's selection bias. Nevertheless, the stories make my hair and toes curl. I'm mad. I feel badly, and just a little guilty, not that I can do much about a corporation ramming an office closure down my throat with about 3 minutes notice. Grrrrrrr.....

In this context, I read this:

Primary care physicians spending longer time with patients.

Well, thought I, that's encouraging. Turns out it's only 3 more minutes, which isn't much when you're managing diabetes, hypertension, ordering labs, addressing depression and insomnia, arranging a mammogram, and asking about the kids, but it's something. But wait! During the time visits increased by 3 minutes revenue decreased by 10%. Physicians don't get paid by the hour, but by the patient. Spending 3 more minutes with each patient means I can see less patients in a day--20 patients a day times 3 more minutes=one whole hour lost. Can't make as much bacon. Oh, this burns my breeches. Bend over and receive a special award: Paycut. Yes, yes, but Dr. Latte, you still have a job. Many of your patients aren't having to suffer with paycuts 'cause of course, they don't have pay to cut. Yep. Read above, however, and see how your care is already suffering. The time has to come from somewhere. Didn't get a callback? Doctor had to see three patients rather than explain to you what happens now with your melanoma? Can't get in until three months from now? Have to go to Urgent Care because your doctor is 1. Out of business or 2. Out of appointments?

BUT! Help is on the way; change we can believe in. Two thousand billion pages of health care reform are coming our way sometime in the next hundred years maybe, and it's possible that if you don't have insurance now that you might be able to get insurance maybe in five years possibly and it might not matter than you had a pre-existing condition like fatigue 10 years ago. Here's my predication. Medicare works well for patients; not so well for physicians who are already losing money at it. Particularly if private insurance expands, more primary care docs--if they can without going to jail--will opt out. It's already completely, utterly impossible to know how to code 100% correctly for Medicare, and to not code correctly is to risk going to prison. Add 8000 pages of statutes and physicians rightly will run out of the room screaming.

That is, however, not to say that the present system shouldn't be napalmed, bulldozed, infected with H1N1 and left to die in a ditch full of vomit. To have to see a patient for a cold with 52 million pages of ICD-9 or -10, E&Ms and CPTs, Obama-Care EMR documentation laws attached just isn't going to be feasible for the average physician. Or even the super-human MD. I'm not hopeful. You can't get a straight answer now out of HCFA about some routine matters. How is that going to get better?

But here's something cool: Science. Pure, elegant, lovely, exciting science. From NPR an interview with a researcher who discusses the successful alteration of memory traces after they are accessed, and what that might mean for people with painful, traumatic memories:

Erasing fears by thinking about them.

Hats off! Wow. I'm smiling from ear to ear. Consolidation and reconsolidation. Shining the beautiful hard light of science at a nebulous subject, memory formation. Memory is a fluid, shifting thing, but here is evidence that it can actively be shaped in a more positive light. A little scarey with regard to the corallary--that you'd be able to shape a good memory to be bad--but to help all of us feel safe about traumatic episodes? That's powerful. I think there's some hope that I might be able to get over my medical school Gyn-Onc rotation after all.

One last thing. For now. First, let me be clear about my bias. I will use any excuse to continue to buy books often on Amazon. Here is proof that it is actually good for me and for my brain. I make my living using my brain. Thus, it is not just good, it is necessary for me to continue to shop:

Can neuroscience make you a better writer?

Yes, yes, you might be thinking, there are some caveats at the end about activation maybe not being an always all-good thing, but I'm going to ignore that because I want to continue to shop.

Oops, here's really the last thing. I see patients for a living, and usually twice in every patient encounter--before I lay my healing hands upon the patient and right after I am done--I use hand sanitizer. See twenty patients, that's ah, like 40 Purells a day. In reality, it's more, 'cause I reach for it reflexively after every sneeze or walk in the hall. I do WASH my hands, too, so don't go getting all jiggy on me, but I gotta tell ya. In the days I washed my hands 20-plus times a day the skin was falling off by mid-October and no amount of Vaseline, steroids, and socks would make it better until the following May. Hand sanitizer has made that better, although if you looked at my hands now, mid-December, you might be tempted to think that I am molting. So in my personal study of one, Purell isn't as bad for my skin as washing my hands 50,000 times a day. But how about the nails? The chemists at Beauty Brains have figured it out so you don't have to:

Are hand sanitizers bad for nails?

That's all for now!

USPSTF is mean to 40-49 year old boobies.

icedlatte@medmarg.com (IcedLatte) — Thu, 19 Nov 2009 12:02:00 +0000

Image via Wikipedia

The USPSTF, as you might have heard, recently recommended that women stop getting mammograms and just suck it up, because our lives apparently aren't worth enough to save. Especially women approaching the end of their reproductive lives--as nature casts you aside, so does the USPTF. Don't examine your breasts, and don't get xrays of 'em either. You suck. You probably went back to work and left your children at home to fend for yourself while you saved for a fur coat.

Or did they? If you listened to the news or read almost anything, that's the impression rabid, frothing at the mouth "journalists" gave. Yes, I'm talking to you, Sanjay Gupta. You're about to get your MD taken away by the IcedLatte Medical Excommunication Squad. You're an obnoxious little twerp and spouting nonsense from your bully pulpit about which apparently you know nothing is getting on my last nerve.

Prevention and screening are so lovely and warm to think about. You go in to see your doctor for your (almost always useless for detecting disease) annual physical and leave with a prescription for your mammogram and a referral for a colonscopy, and once those are done, you feel great because you know you're cancer-free. Maybe.

A screen is by definition for detecting a disease in an asymptomatic patient. When I order any screening test, I think about:

What is the prevalence in the population of the disease we're testing for? The less the diseases exists, the less the chance in general that a screen will be positive because most people simply don't have it.
How good is this test? How many people who truly have the disease does it pick up? That is the "sensitivity." How many people with the disease will it miss?
What are this patient's unique risk factors? For example, in a female who is 45 but still have regular periods with no sign of slowing down, is her breast tissue still going to be really dense making a negative mammogram not very helpful? What if her mother had breast cancer? What if her mother didn't have breast cancer, but a maternal aunt did at 35? Not all 45 year old women are created equal.
As noted above, there are technical considerations with a test. Mammograms are better screens for some types of breast tissue. A negative test is less reassuring in others.
What was the exam like? If then exam is negative, and only if it's negative, then I can do a screen. If it is positive, then forget the screen, we're going to do a diagnostic test. Screening guidelines don't have anything to do with that at all.
What will I do if the screen is negative? If I'm suspicious--but only if the exam is negative--will I believe the test? If not, should I skip the screen and consider a diagnostic test?

But wait, there's more. I turn to various screening guidelines--the American Cancer Society, the USPSTF among them--to help me figure this stuff out. They generally make thoughtful, well-reasoned guidelines (not laws) based on evidence. They don't always agree with each other, and I have to plug that into my math.

These groups look at huge numbers of patients over time and tell me things like "How many mammograms does it take in women 41-49 to save one life from cancer?" Turuns out it's about 2000. That alone isn't a value judgement, it's just a number. One of the variables I plug into whether I should screen or not.

To make matters more complicated, they all rate their evidence and level of certainty about the evidence, in sort of a "Great data and lots of it. Go for it." to "One study with one guy who was half asleep and possibly drunk when he did it. Proceed with caution." I paraphrase, but I think you get my drift.

Last, but certainly not least, like every other physician in the world, I'm always plotting my next move. If you have a mammogram, say, and it's a little positive, what am I going to do? If it's a lot positive, what is my next step? A little positive is a problem. There is increasing evidence that some breast cancers spontaneously regress, perhaps 20%. The screening tests we have right now can't differentiate who exactly is in that cohort who won't go on to develop an invasive cancer. FURTHERMORE, will early detection make a difference? If we pick up a cancer early, does it go without saying that it will make you live longer? As it turns out, not necessarily.

Confused? That's for your doctor and you to talk about, sitting in an exam room. The USPSTF isn't trying to get between you and your mammogram. The recommendations are just trying to clarify some of the variables in the giant screening equation. Their recommendations will change. The screening tests will get better. In the meantime, don't go burning your bra at your nearest mammography suite.

For an excellent discussion in exhaustive but terrific details, check out:

The USPSTF recommendations for breast cancer screening: not the final word (written by a breast cancer surgeon and researcher
Truth squad needed on breast screening quotes from Gary Schwitzer
Screen saver from Slate, written FIVE YEARS AGO about the perils of breast cancer screening

One last thought. Screens cost money. I think about that with regard to you (Do you have insurance? If you do, do you have coverage for preventative services?), but not necessarily with regard to populations. This isn't pretend money, though, it's real money. To save a life in a female between 40-49, it costs (assuming the mammogram is about $150) $300,000. Yes, yes, what price life? But you just got a new job at an insurance company. You must decidie what is covered and what isn't. What are you going to deny--vaccines for sweet little babies? Cancer treatments? Knee replacements? Grandma's small bowel obstruction surgery? If you put the money in one pot, which pot do you take it out of?

10 ways to be irritated by your doctor

icedlatte@medmarg.com (IcedLatte) — Wed, 18 Nov 2009 21:28:00 +0000

Hey, I'm a patient too. Here's my list. And by the way, my doctors, this isn't about you AT ALL.

1. Have stupid television playing in your lobby. I hate insipid health t.v. HATE. I don't want to watch Oprah, I don't want anything. Maybe I can listen to unobtrusive music, but nothing loud and nothing Brittny. I know the idea is that white noise or t.v. drown out the sound of actual patient care and decrease the odds of overhearing a dreaded convo involving protected health information, but really. Get a white noise machine and leave me some peace.

2. Have stupid stuff to read. Actually, given recent demonstrations of nasty disease-mongering germ covered magazines, don't have anything to read.

3. Ignore that I'm waiting. Listen, I know from personal experience that the 80 year old patient who scheduled for an upset stomach suddenly turns into a heart attack live and in-person, and suddenly you're six patients an hour behind, and suddenly it's two hours later and you're twelve behind. It sucks. When I check in, please have your staff tell me that you're really running late. Better yet, have them text me or call me to give me the option to reschedule. Leaving me to molder for 2 hours in your waiting room without so much as a "Could I get you a coke?" is rude.

4. Uncomfortable chairs are inexcusable.

5. Sure, I've walked out of a room and left the cap from a needle (not the needle). I've left the odd Bandaid wrapper on the floor. But dirty floors? Bugs? Not cool. Mice droppings?

6. Nasty staff. Your staff should not size me up like I am homeless and stinky, even if I am.

7. When I am back in a room at the OB/GYNs and I am sitting in a paper gown and paper sheet, please do have your staff tell me it's going to be an hour and a half of waiting in paper on an uncomfortable table. I will tell you that I would like to put on my clothes and reschedule.

8. When it's time for my pap smear, don't have your nurse come ahead of you, put me in stirrups so that you can walk in an go, "Spread 'em" and never look at anything but 'da business.

9. Seriously, I know margins are low, but get cloth. Gowns cost $0.25. Paper isn't that much cheaper.

10. GET ME A COOKIE!

11. Most of all, schedule appropriately. I understand if I come once or twice and you've had disasters, but if I come every time with my sick, cranky, twitchy children and I wait, please, please, stop overbooking.

10 ways to irritate your doctor.

icedlatte@medmarg.com (IcedLatte) — Fri, 13 Nov 2009 20:30:00 +0000

From Dr. Rob last week was this post:

Top 10 ways to annoy your doctor

Very amusing. My personal favorite is #8, send your teenage son or elderly parents with dementia to the office alone, without letting anybody know what the appointment is for. Sound crazy? Ha!

To be fair, the next post was:

Top 10 ways doctors can annoy patients

Here's my own personal top 10 historical, real-life ways I have been pissed off by patients. Have I covered this before? If so I do apologize, but it's Friday afternoon and I'm too lazy to look.

Lie about reason for appointment: Never, ever say, "I told the nurse I had a cold, but really, I'm having an affair, I want to kill somebody, and I haven't pooped in a week, and I'm addicted to my sister's Ativan." I'm still angry about that one.

"I don't know why my wife scheduled this damn appointment. Ask her." She's not here and I'm not interested in being in the middle of your marital conflict. Don't come if you don't know why the hell you have an appointment. I'm a doctor, not a psychic.

Give ME some drugs: A mom lied once about getting her daughter an appointment ostensibly for a rash. As I was about to walk into the room, the mom jumped out of the bathroom and demanded that I confront her daughter about her drug use. Screamed at me in the hallway.

Argue with me about dibby dab: I once gave an elderly gentleman Darvocet for some moderate arthritis pain. He came back a week later and told me I needed to refill the medication I gave him, then he handed me a bottle of Percocet. I told him I hadn't prescribed it. He told me I had. I pointed out that the name on the bottle wasn't mine. And wasn't his.

A gaggle of thieves: If you have six kids, DO NOT schedule an appointment for one, then show up with six and ask me (after my receptionist has already told you NO) to look at everybody's ears. Then don't ask me if I can examine your breasts and talk about your anxiety disorder.

Could you babysit? Don't schedule your pap smear and expect to get it if you bring your three small children with you. Don't. Don't tell me it will be fine for them to sit by me on the floor during the exam. No. No. No.

If you're a dude: Don't come to see me for pink eye, then tell me that there's something in your groin you need me to check out, harder, harder. Seriously, now. Do I look like I care, or that I was born yesterday?

Don't ever, ever call my staff a name, any name. Ever. Don't yell at them. First, they get the job done. They call in your refills, they phone you about your test results. They schedule your appointments. Wanna be at the top of the stack or the bottom? Want the office staff at the urologist's office to hate you before they've even met you? My staff tells me everything. I live with these people. They have my back, and yours, too. Here's an example of what not to do, "Listen, I'm coming right over there, BIT$H, whether you have an appointment or not, and if your directions are wrong, you're gonna pay." No, you're not going to be seen, and the police are going to take you to your car.

I can't get out. When you see me knee deep with EMS laboring over a patient who is struggling to breathe, don't yell into the room, jangling your car keys that you're parked in by the squad in the parking lot, and could they move because you have a lunch date. We are going to turn as one and yell, "NO!" at you.

Last, but not least:

But I'm disabled! Your first appointment is not the time or the place to get 50 refills and lay on me your SSDI paperwork done. DO NOT tell me that disability and FMLA forms were due in HR two weeks ago and if I don't do the paperwork today, right now, that you won't get your check. Too badksi for you.

Here's one for bonus points, just for my fellow providers:

"I haven't had good luck with my last few doctors. They just don't understand me. I've had to fire my last five, and I'm suing at least one. I hope you're better than the last. " I don't! This is a true story, uttered from the mouth of a perfectly healthy patient with a little dyspepsia. We're not exactly a Band of Brothers, but few words send chills through my spine faster than, "I have fired your colleague....." and "Malpractice" at your first appointment, particularly when they're the first words uttered from your mouth.

College

icedlatte@medmarg.com (IcedLatte) — Wed, 11 Nov 2009 02:42:00 +0000

So, as many of you know, I have joined the ranks of academia. Ha ha, no I haven't seen all ADD and STIs. You're funny. In fact, I haven't seen an STI in the four-plus months since I started. That makes me a little sad. I miss trich. I haven't seen a lot since residency and for some reason, the sight of that little protozoa swimming happily all over my microscope field always cheered me up. Our protocol for ADD/ADHD doesn't really involve initial diagnosis much. I write for less stimulants now than I did in private practice. Weird. Maybe two ADHDs in 4 month and no trich! No Chlamydia, no syphilis. Maybe some BV, but that's not exactly a world class sexually transmitted disease.

I find myself suddenly in possession of a lunch hour. A real lunch hour. I have oh, maybe 3 or 4 charts a day to do rather than 20-30 (on an easy day) and thus, I have time to kill at lunch. I stroll around campus and

I SEE DEAD PEOPLE.

No.

I SEE OLD PEOPLE.

Specifically, I see myself. I see my husband. I see old friends.

I'm working at the same midwestern university from whence I graduated from both college and medical school. I have gone home again. As I wander around in search of coffee, a sandwich, fritos, Columbian burritos, books, magazines, sushi, and kim chi at lunch, lost in my thoughts, I see myself. There I am, slinking along, 20 years old again, giant backpack at hand, giant sunglasses on, thrift store pants clad, flip flips on my feet (even then), on the way from skipping one class to skipping another class. I see my husband out of the corner of my eye, 20 years younger, NYTimes under his arm, smiling and overjoyed to see me (which, God love him, he still pretends to be). I see the guy I dated before Monsieur, riding his bike, rushing to his micro lab. "Yeah, sure, I can make some tuna noodle casserole on Friday. You wanna meet later at the library?" I see my sister dutifully trudging to class, pleasant smile on her face, cheery greeting at the ready.

It's a little disorienting. I snap out of my thoughts (no doubt mulling over how much I hate the flu) and for a moment, I'm 20 again. I compose my face to wave at my Monsieur, my sister, my friend, my organic lab partner. Then I remember my children. Huh? I have kids? What's the time? Oh, it's noon, 23 years later.

For just one moment, though, I am 20 years old again. It's a rather precious if fleeting interlude. How is it that my 20 year old state of mind is trapped and so easily called forth by my 45 year old brain? I can't remember my phone number half the time, but blam, there I am recalling a physics lab assignment and the nice guy (Michael) who was my lab partner.

I'm not alone. I saw a very depressed young student today who tranferred from the beloved undergraduate institution of her dreams to a college closer to home for financial reasons. She said, "I'm walking down the street and I see my roommate from last year out of the corner of my eye. When I look closer, she's not there of course, and I'm so sad. And I'm alone again."

I'm not so sad, but I do empathize. I see ghosts, too. I call forth younger, sillier, more fact-filled versions of me every day. Then I think of my children, my paycheck, my house, my comfy German blanket, my dear, old friends, and I wave goodbye to my ghosts of students past.

I think my depressed patient will make friends. She's adorable and charming but shy. I managed and I'm neither adorable nor charming. Until she does, my old bones will hold her young hand while we both watch for ghosts.

You might have too much time on your hands if you're doing this

icedlatte@medmarg.com (IcedLatte) — Thu, 05 Nov 2009 15:45:00 +0000

Toilet paper sculptures via Sprayblog

Maybelline for $5 or Latisse for $100?

icedlatte@medmarg.com (IcedLatte) — Thu, 05 Nov 2009 15:44:00 +0000

Grumpiness Rocks

icedlatte@medmarg.com (IcedLatte) — Thu, 05 Nov 2009 13:04:00 +0000

Three cheers to Grumpy Arugula, Esq. who alerted me to this little gem from the BBC News:

Feeling grumpy 'is good for you'

The details:An Australian psychology expert who has been studying emotions has found being grumpy makes us think more clearly.

In contrast to those annoying happy types, miserable people are better at decision-making and less gullible, his experiments showed.

While cheerfulness fosters creativity, gloominess breeds attentiveness and careful thinking, Professor Joe Forgas told Australian Science Magazine.

I'm seriously grumpy today, so I should be in great shape to overhaul pretty much everything. Send me your thorny problems. Your bad memos. Your personal catastrophes. I'm all over it, but I will complain bitterly and scowl about helping you.

Clinical Pearls from Mayo

icedlatte@medmarg.com (IcedLatte) — Fri, 30 Oct 2009 14:17:00 +0000

Kinda cool. Would love to see more!

Insurance 101

icedlatte@medmarg.com (IcedLatte) — Thu, 22 Oct 2009 11:18:00 +0000

Came across this working on a post:

Couldn't have said it better

icedlatte@medmarg.com (IcedLatte) — Wed, 21 Oct 2009 14:35:00 +0000

A great post on herbal and altie remedies and their potential inherent dangers. It was written by an organic chemist, which makes me feel very inferior. Wistful, too, for organic, which I did love so.

Herbal Fantasies

I've said it before, I'll say it again, just because it's all natural doesn't mean it's all good. Just because it's an ancient Chinese secret doesn't make it good, healthy, effective, or not harmful. Prove it. That's all anybody should expect of any treatment. There really shouldn't be such a thing as "alternative medicine". It's ALL medicine. If a product or procedure can't prove it's effectiveness (and that it is safe) then it is a haircut done by a blind man. It might make you feel better, maybe look better, but it doesn't make you better. It only makes you poorer and maybe it makes you look silly.

Along the same vein, a recent (but small) study and a review of copper and magnetic bracelets for arthritis. Flush your money down the toilet. That's apparently just as effective. Dr. Steve Novella reviews the date in Science-Based Medicine:

"Consumers using such products are prey to all of these placebo effects, in addition to others, such as regression to the mean. Arthritis, like many illnesses, waxes and wanes. People are likely to seek treatments when their symptoms are bad, and statistically likely to improve to a more average severity. This regression to mean severity is easily interpreted as a response to whatever treatment they initiated when their symptoms were at their worst."

Original post:

Copper and magnetic bracelets for arthritis

Moments

icedlatte@medmarg.com (IcedLatte) — Tue, 20 Oct 2009 00:36:00 +0000

The Onion and The Flu Vaccine

icedlatte@medmarg.com (IcedLatte) — Sun, 11 Oct 2009 22:58:00 +0000

Funny, "ha-ha" and "oh, God" kind of way.

Parents against the flu vaccine

Us vs. Them: Insurance edition

icedlatte@medmarg.com (IcedLatte) — Sun, 11 Oct 2009 01:07:00 +0000

Them:

Insurance companies have to maximize their revenue because they answer to their boards. They are in no rush to fix claims systems that make copious errors and delay payments to providers. There are hundreds of claims processing software programs out there. Some are acceptable, some are useless. None are really good or efficient. And there is the human error factor. A careless mistake by an apathetic claims processor can create payment problems that could literally last for years.

These generate hundreds of provider appeals, totally clog the appeals and grievances systems and breed enduring ill will on the part of providers who are trying to make a living

Us:

There are doctors doing cardiac catheterizations on patients who blatantly do not meet Medicare criteria for payment. The Medicare criteria are there for a good reason. Anyone who doesn’t meet them should not have a catheter snaked into their heart. There are other, safer interventions to try first. If the patient didn’t meet the criteria, the procedure wasn’t paid for. More millions in lost revenue.

Read more about it, via a depressing post on Dr. Kevin, written by a former insurance and hosptial executive:

Health care reform analysis

I'm a little gassy. I think I'll go to the emergency room.

icedlatte@medmarg.com (IcedLatte) — Sun, 11 Oct 2009 00:46:00 +0000

Image by indigoskye via Flickr

Think I'm joking? I'm not. Well, I'm not gassy, at least not right now, and I'm not thinking of going to the emergency room. Oh, God, no, not on a Saturday night when there's a big football game in town. Just leave me to die, please.

Lots of people do go to the emergency room when they're gassy, though. And when they've thrown up once. And on Sunday nights when Monday is looming? There are lots of people there with their sick (or not) kids who want work excuses for the next day.

There are also dying people. Psychotic people. Bleeding. Laboring. Infarcting. Fractured. You name it, an emergency room near you (hopefully) is taking all comers.

It's part of the American ethos, according to Dr. Edwin Leap, an ER physician. The ER is instant. It serves all. It's open all the time, better than McDonald's drive through. Dr. Leap writes:

And whether the our patients are paying or penniless, we examine them and review their X-rays and lab results. We order stress-tests, we call surgeons. We have a finite window of opportunity, so we answer questions as quickly as possible. And frankly, that’s the way Americans like it. Instant gratification is as much a part of modern American health-care as Penicillin.

I would add that it's one stop shopping, too. It's irritating to go to your primary care doctor for belly pain and find you have to wait for that appointment, then wait for some labs, a CT of your belly. Wait for an appointment with a surgeon, all the while not feeling so great. In the ER you get a doctor, labs, imaging, and maybe even a surgeon and if you're REALLY lucky an operation all in one shot. That's what we like. It's what we need. I don't have time for five appointments; I have a few hours for one.

Dr. Leap thinks that no matter how many primary care physicians we add, we'll still never keep Americans out of the costly ER. I think he has a point. It's not the way we're built. Primary care lacks 24-hour a day nearly instant access. It lacks efficiency, I mean, 99% of GPs are not going to have an MRI, CT, and lab waiting there for patients' immediate needs.

I agree with him to a point. Not everybody will use the ER in lieu of primary care, though, were they to have access. There are a lot of prudent people out there who just lack access to prudent, sensible, cheaper care. They get desperate and hit the ER. For example, a woman feels a lump in her breast. She waits, waits, waits, frets for weeks, then can't take the anxiety anymore. She tells her husband, her daughter, her friend; panic ensues. Off to the ER everybody goes. If only she had a doctor she could have called for an appointment weeks ago. Or the uninsured smoker with a cold which morphs into a pneumonia, waiting, waiting, waiting to see if it will go away on its own. It doesn't. Upon presentation to the ER by squad the patient is so sick he or she ends up hospitalized for a week.

Dr. Leap writes an interesting post. Check it out via Dr. Kevin:

Will more primary care physicians keep patients out of the ER?

He says no. I say some.

The doctor is in....Online. Visa Card # please.

icedlatte@medmarg.com (IcedLatte) — Sun, 11 Oct 2009 00:17:00 +0000

I ran across this NBC video from Clinical Cases and Images.

Visit msnbc.com for Breaking News, World News, and News about the Economy

I'm quite irritated by the physician who says, "Oh, I'd never use this not ever because golly, I'm just not sitting by my computer all day long." Oh really? Wow, I sure am. I'm using an electronic health record, which for better or worse keeps me not just sitting, but CHAINED to a computer ALL DAY LONG. I guess she's still a lucky Luddite who doesn't have to fuss with inputting orders electronically or using 50 clicks just to get an E&M code.

Has she ever handled a patient matter over the phone? Does she really make women who've had bladder infections before come in to the office EVERY TIME? Does she make every woman with a yeast infection from antibiotics come in EVERY TIME? I suspect she probably has, and that's the kind of thing being handled over the internet. Get used to it, baby! It's the way of the world.

Now, I haven't used RelayHealth, but it seems as though it be a way to get all that pesky phone-tag kinda things in one place, easily documented and thanks very much, billed.

That said, however, if you need to be seen by your doctor, you need to be seen. My standard analogy is this: Try to describe the smile on the Mona Lisa via an email or phone message. You could go on and on and on and I won't have any idea what you're talking about. BUT, let me see the painting itself for a few seconds and I have a very good idea. Any half decent physician can tell from the door whether or not you're sick; that's impossible nearly over the phone. It's way impossible using a checklist on email.

Ah, Bacon Flu

icedlatte@medmarg.com (IcedLatte) — Sat, 10 Oct 2009 22:30:00 +0000

I'm so sick of it already I could spit. And we've only just begun.

I'm on information overload about the Pig/Swine/H1N1/Bacon flu now, too. The Wall Street Journal Health Blog did succinctly bottom-lined a couple online NEJM studies published this week:

Swine Flu: Who is Most Vulerable

Can I take red yeast rice for my cholesterol?

icedlatte@medmarg.com (IcedLatte) — Sat, 03 Oct 2009 01:44:00 +0000

Sure, but you'd be better off with a PRESCRIPTION statin, because turns out red rice cozied up with yeast just makes Mevacor and other misc. HMG-coa-reductase inhibitors:

"When rice is fermented with the yeast Monascus purpureus, the resulting product contains numerous monacolins, which are naturally occurring HMG-CoA reductase inhibitors. One of these is identical to the prescription drug Mevacor (lovastatin)."

Hey, guess what? Same side effects, too, including hepatitis, rhabdomyolysis, and myositis.

Guess what else? Red rice yeast has EXTRA side effects:

"Some red yeast rice products contain citrinin, a mycotoxin that can cause kidney failure in animals. In one study, measurable amounts of citrinin were found in 7 out of 9 products tested. and in another study citrinin was found in four out of ten products tested, with the highest level found in a supplement sold by a major pharmacy chain."

That's SO COOL! You can take a potentially dangerous drug on your own, without a physician's supervision, and get yourself into serious trouble.

Course you can do that with aspirin, too, but don't. What exactly is the point of taking an unregulated, non-standardized drug? Oh, think it's cheaper? Probably not. Generic lovastatin is $4/month. And I'll be happy to watch your liver function while we both rejoice in your LDL going down.

Read all about it at Science-Based Medicine:

Red yeast rice to lower cholesterol

If you have a subscription to The Medical Letter, read all about it: Vol 51, Issue 1320, P 71-2, Sept 7, 2009.

A cross on our door, fibromyalgia

icedlatte@medmarg.com (IcedLatte) — Thu, 01 Oct 2009 11:46:00 +0000

It is quiet in my house at last. For the first time this week everybody is at school. The flu visited our house and I did not like it at all. It spanked my poor son, Little Latte. High fever, consumptive cough, a little delirium . . . It made for an interesting weekend with a soundtrack of nebulizer. Little Macchiato made out better. The flu was kinder to her. Nasty cough, low grade temp, sore throat. She kinda has a smoker's voice. Dr. Iced Mama has been swallowing Alleve and Tylenol by the bucket around the clock. I'm not sure how I feel.

I'm irritated with you, though patients! My poor husband had to go to five pharmacies to get Tamiflu for my febrile, wheezing, tachypneic, tachycardic, asthmatic son. Each of the pharmacists he saw told him a similar tale: shelves were cleaned out by healthy people last spring who wanted Tamiflu "just in case." Thanks for that on behalf of mothers everywhere with sick, at risk kids.

But back to just being grateful. We were spared the worst. During plague epidemics in the Middle Ages front doors were marked with a cross to signify that plague was in the house. Healthy people recoiled in horror, as they should! Who knew how it was transmitted? Nobody! What was to be done for victims? IV fluids? No! Ale or broth. Blech. I'll take normal saline. Blood-letting instead of antibiotics. Awful buboes and not much orally available for pain. Lack of decent anti-pyretics. No oxygen for the hypoxic.

Thank you for stopping by "Interlude with the Plague".

While I was awake in the wee hours Sunday night with my poor Little Latte, watching Spongebob, I was gobsmacked at how lucky I am. My sick baby sipped apple juice and sucked on his nebs. I have back-up. IVF, abx, O2, nebs.....whatever he needed. Fortunately all he needed this time was apple juice, Spongebob, prednisone (my dear friend), and albuterol. It makes me wonder. How agonizing to watch a child die for lack of IV fluids.

It still happens. For the sake of potable water 100,000 people died last year from cholera-induced diarrhea in 2004. For WATER. Understand that? There are hundreds of thousands of people in the world who don't have safe water! Who cares how the hell your water tastes? You won't die from your tap. You can drink it.

Or can you? The New York Times did a great piece a few weeks ago about water in these United States. EPA enforcement of the Clean Water Act has been less than ideal, and by "less than ideal" I mean pretty scarily bad at times.

Clean Water Laws Are Neglected, at a Cost of Suffering

Sure, drinking the water in your state might not give you cholera, but it might give you leukemia. Good Lord. Leave it to the United States to find a really serious way to screw up water. We can take your bacteria- and parasite- infested water, sterilize it, and make EVEN MORE DANGEROUS. This is unnerving. I'm all for public health care as an option, however, if we can't make WATER safe, for crying out loud . . .

(Deep breath.)

PalMD had an interesting post about fibromyalgia recently. It's worth a read:

Fibromyalgia, alternative medicine, and other bad ideas

Fibromyalgia is a vexing problem. It's not as vexing as it was way back in its heyday, like 10 years ago when rheumatologists and GPs were overrun with achy people, usually women, who all had the latest disease publicized by Big Pharma for whatever the drug du jour was at the time. For a time oh, Lord, how I dreaded seeing it on my schedule. Fully 2/3rds of the patients who purported to have it waived disability paperwork in my face, demanded narcotics, Soma, and refused to consider physical therapy, exercise, non-addictive medication, antidepressants or anything else. Then their sisters came in with the same diagnosis. And their neighbors. And babysitters, then dogs.

That's not such a problem anymore. Who can afford the copays for the Cadillac drugs Pharma is pushing for fibromyalgia now? HR departments aren't too sympathetic. Your disability insurer isn't fond of the diagnosis, either. I had a fair number of patients who called me shopping from the mall, or vacationing in Hilton Head, indignant that their disability claim for fibromyalgia was turned down. Boohoo, baby. I have ladies with breast cancer getting CHEMO working full-time. Suck it up. Especially when you wave your FMLA papers right under my nose and rip up the 90 prescriptions for Flexeril I've written.

But then there's that last 1/3. I still see them, and I wince still when they're on my schedule, but for vastly different reasons. They're miserable. They ache. They try everything I suggest, or by the time I see them they've already done everything. Twice. They come in all shapes and sizes. Many of them valiantly get up for work or school every day and desperately want to keep working. They take care of families and once the kids are in bed they crawl under the covers and try not to move. Medicine works for a few weeks, months. Yoga works for a while. Flexeril takes the edge off, but only a little. Heat helps. Cold helps, then it doesn't. Vacation is good for a few days, then the ache returns. They try massage; accupuncture; special diets; meditation . . . name it.

Are they depressed? Hell yes! Who wouldn't be? I'm depressed for them. I dread going in the exam room, seeing those searching eyes, haunted, looking for help. Anything. I twitch over my prescription pad. Should I give some narcotics just for a few hours of relief? What should I do? What do you do? These poor women--almost always women--have been to chiropractors, massage therapists, homopathatic doctors, integrative docs, naturopaths, dentists--everything! They're out of money for their "specials" and have to come back to little old me, and anyway, the other stuff only worked about as well as anything a boring old stuffy regular doctor like me prescribed. Works for a while, then peters out.

What is wrong with them? Hell if anybody with an MD knows! We do know that the severity of whatever this is--or whatever constellation of disorders it is made up of--waxes and wanes normally. Is anything we do helpful? So far the GOOD evidence for any intervention is pretty weak. Anything?

Good question. Perhaps you read about homeopathy and fibromyalgia? PalMD recalls the tooth fairy:

"Dr. Harriet Hall would remind us of Tooth Fairy Science. We can measure all of the important data about the tooth fairy, including average get per tooth, average age of visitee, etc, but if we forget to question the fairy's existence, we have failed to ask the most important question. It may be true that an RCT showed improvement in fibromyalgia patients using homeopathy, but since homeopathy is water, there is no reason to expect causality, and the results may be better explained by some other phenomenon."

If your data can't swim with the sharks get it out of the water.

I am so sad for these poor people. I have little to offer besides a little of this, a little of that, a sympathetic ear, and a strong shoulder. I'm a lot easier on the wallet, though, than the fibromyalgia tooth fairy, and just about as effective.

Specialists; Boosting the immune system; FLU 1918; and spitting coffee

icedlatte@medmarg.com (IcedLatte) — Sat, 26 Sep 2009 13:48:00 +0000

From Edwin Leap via Dr. Kevin this week an rather sad plea from a doctor who still actually touches patients. I feel his pain. I've treated thousands of patients now. I know pretty much from a glance who is sick and who isn't. If I call you, Dr. Smartie Specialist, it's because I need help; the patient really needs help. I really don't send patients to the ER who really don't need to be in the ER, Dr. Emergency Room. I'm really sorry if the "paper patient": the white count, CT, vitals, etc. don't seem impressive. The patient is. From Dr. Leap's post:

"We have made medicine into a series of check-boxes. Enough positive boxes and some other physician might get interested. But humans aren’t like that. Humans fool us; they ignore the boxes. And suddenly, they die without warning."

Thanks to hospital administrators and insurance executives for pushing the compartmentalization of the patient, too. Hope that I can look up from my streamlined, built-in ICD-9 coding, disease-diagnosing checklist when you, your mother, your wife, or your child is ill.

Is medical technology making doctors less relevant?

I would argue more, actually. It's a treat, an everyday miracle to be able to look inside somebody with labs, ultrasounds, MRI, PET scans, etc. No scalpel necessary. But even surgery doesn't always demonstrate function. Putting it all together is quite a challenge. Laying the paper at the foot of the patient takes some skill. And time. I'm biased, however.

Mark Crislip, the infectious disease specialist who blogs and podcasts at Quackcast, utterly cracks me up. I have a serious talent crush. He has an ID podcast, a journal-watch kind of thing, which I listen to while on the treadmill. Not only is it informative, it's hilarious. But Quackcast is something special. This week, on Science in Medicine, he reworked a Quackcast about boosting the immune system. Not only is it ridiculously informative, it's funny:

"The other popular phrase (made by vitamin and supplement manufacturers) is “support”. A product supports prostate health, or breast health or supports the immune system. It sounds like the immune system is sagging against gravity due to age and needs a lift . . .

. . . The immune system, if you are otherwise healthy, cannot be boosted, and doing those things you learned in Kindergarten health (reasonable diet, exercise and sleep), will provide the immune system all the boosting or support it needs . . .

. . . And there all the non specific parts of immunity that help prevent infection: platelets and cilia that sweep potential pathogens out and iron metabolism that keeps iron away from bacteria and the list goes on and on and on. The above is the briefest of overviews of the constituents of the immune system. It is almost like saying you have
described the works of Shakespeare by noting it contains the words ‘the’, ‘and’, ‘of’, ‘verily’, and ‘forsooth.’ But the purpose of this post is not to describe the immune system in detail as I would soon embarrass myself.

So when something allegedly boosts the immune system, I have to ask what part. How? What is it strengthening/boosting/supporting? Antibodies? Complement? White cells? Are the results from test tubes (often meaningless), animal studies or human studies? And if in human studies, what was the study population. Are the results even meaningful? Or small, barely statistically significant, outcomes in poorly done studies?"

Amen. Read his whole post. He throws just enough jargon around to keep you on your toes, but not to make you feel stupid.

Boost your immune system?

While you're wondering about boosting your immune system, think hard about aging rapidly and letting your immune system go to seed. From Clinical Correlations an interesting historical perspective on the flu, particularly the Spanish Flu epidemic of 1918. Consider this:

"It is estimated that for every American soldier who died in battle in World War I, 1.02 died of disease."

Chew on that--more soldiers died of the flu than the war--while you wait in line for your flu shot. With your kids. Later, while you're just sitting there appreciating breathing, picture this:

The appearance of victims’ lungs at autopsy gave the first clues to this question. Pathologists saw devastation of the lungs caused by the usual lobar and bronchopneumonias, but they saw something different in the lungs of 20-40 year old victims who died quickly during the pandemic. A pathologist was quoted as saying “[there was] essentially toxic damage to alveolar walls and exudation of blood and fluid. Very little evidence of bacterial action could be found in some of the cases.”[1] Whereas in bacterial pneumonia the infection rages inside the alveoli, in these lungs, the spaces between the alveoli were also filled, brimming with debris of destroyed cells, white blood cells, immune modulators, and blood.[1]

Ouch. Destroyed by your own immune system reacting to a new pathogen. Hey, I have an idea. Go get your damn flu shot!

The forgotten influenza of 1918: when a strong immune system becomes a weakness

Ben Goldacre at Bad Science tipped me off to a pretty neat PDF with nifty information in Q&A format about reading articles in the paper about health and healthcare. Anything which suggests spitting coffee might be an appropriate response to some health journalism warrants a read to me.

How to read articles about health and healthcare

My own rules: Is this article causing me to want to be prone and asleep? Are the statistics making my eyes glaze over? Are the numbers involved so big that I start to convert them to dollars and daydream about the cool appliances I could buy? If I want to be napping, if I'm thoroughly confused by the statistical analysis, and the "N's" involved are making me think, "Subzero" then I might be on to a good article.

That's all for now.....Dr. Latte

As long as Point A is Delusion and Point B is the hospital

icedlatte@medmarg.com (IcedLatte) — Sat, 19 Sep 2009 13:12:00 +0000

Don't take my health insurance away!

icedlatte@medmarg.com (IcedLatte) — Thu, 17 Sep 2009 15:25:00 +0000

All of you defending the status quo should read this. It's short, so stick with it. You can do it:

Dizziness and cough? We're dropping your insurance.

Now, those of you defending the status quo, have you ever had a cough? Have you ever been dizzy? Has your cholesterol ever been less than perfect, or GOD FORBID have you taken a medication for it? Have you ever been TIRED? If you saw me--or any other physician for that matter--for it, then I coded your chart with the ICD-9 codes for those things (which I know by heart, backwards and forwards, upside down, blindfolded, and locked in a closet BECAUSE EVERYBODY COMES IN FOR THOSE THINGS). Not to do so would be fraud, and I don't want to go to jail or pay fines for not calling your fatigue "780.79".

But now your lovely private insurer knows all about it. When you applied for private insurance, by the way, you signed over your rights so that the insurer could share every single thing you've ever been seen for with another insurer. Now, I'm completely, utterly sure that your private insurer would never drop you or any member of your family for costing them money because that wouldn't be nice. They care deeply about each and every one of their flock, right? They would never screw you, right? Not even if it meant they lost money. Their shareholders care deeply about each and every one of you, right? Those shareholders sure wouldn't care losing money if it meant doing the right thing by you, right?

If the goverment takes things over, or offers a private plan that private insurers have to compete with, then golly, getting insurance might be horrible and boring, like going to the BMV. Or getting unemployment. Or mailing a letter. Or getting electricity in your house. Oh my God, there might be forms involved.

The trouble with Wikipedia...

icedlatte@medmarg.com (IcedLatte) — Wed, 16 Sep 2009 00:53:00 +0000

Image by sunface13 via Flickr

...explored today over at the frighteningly intelligent Laika's blog. She's a medical librarian with a PhD in Medical Biology and the mother of teens and I'm not sure she ever sleeps, since she's ALWAYS on Twitter or posting on her blog or riding her bike to work.

But she's right on the money here re: the pitfalls of using Wikipedia as a decision-making tool. I'm ALL about Wikipedia at night on my Crackberry when I'm trying to find a picture of Katherine Parr, Henry VIII's sixth wife, who lovingly dressed Henry's gross, abscessed leg. I get art from Wikipedia all the time. Driving home from Amish country last weekend I read the Wikipedia entry about the Amish.

But you know, you get what you pay for. Free is free. I was talking at work about something I read (not medical) in Wikipedia and one of the other doctors said, "Hey, my kids edit Wikipedia for fun!" Her kids are teenagers. Smart teens, yes, but not skilled in the medical arts. Yet. I've had patients admit to me that they edit Wikipedia's entries on a whole variety of things they know nothing about. Just for fun. Which isn't to say that there isn't a whole lot of good, fun, accurate information there, too.

Several times a week I see patients who have attended the Wikipedia Unversity of Medicine and have convinced themselves they have something terrible: renal failure (urine smelled funny) or a brain tumor (little queasy the other day) or have colon cancer ("strong" brown poop). It's amusing only not really. Those patients suffer! They drive themselves crazy until they hear me pronounce, "Ah, yeah, probably not liver failure" or, "Yeah, well, I think probably you just ate some beets."

But okay, it's one thing if you're cribbing on Wikipedia as a patient. If you're a PHYSICIAN, shame on you. If you just need the lay of the land, or you want to see what it is your patients are up to, okay, but come on. Really? You're managing via Wikipedia? Don't believe your doctor is using it? Check out:

The trouble with Wikipedia as a source of medical information

British Medical Journal Says, Jesus, Enough Already America

icedlatte@medmarg.com (IcedLatte) — Mon, 14 Sep 2009 18:31:00 +0000

More than 100 NHS professionals and patients have added their names to an open letter to Senator John Kerry, who has called for the "lies" that have recently been circulating in the United States about the UK healthcare system to be refuted.

Dear Senator Kerry
Your reported call for "lies" about healthcare reform to be refuted is essential and requires an urgent response. To that end, may we—British health professionals and patients—respectfully expose those lies about our NHS, a service that our experience shows to work successfully for the benefit of all in this country.

Patient choice
There is no "death panel" in the NHS in the United Kingdom or anywhere else in the UK healthcare sector.
Termination of a pregnancy is a personal decision if approved by two doctors. No board or organisation of any kind makes any decision about termination for fetal abnormality. Such decisions are personally made by those seeking such procedures after counselling by medical and other health professionals.
Elderly people can get counselling and advice to help them determine their requirements for their future care but only if they wish it. It is a service that provides information about issues such as living wills. This is similar to section 1233 of the proposed healthcare bill in the United States, which provides counselling and assistance to those wishing voluntarily to make their own arrangements for their future, medically and physically.
Patients are normally registered with a family doctor practice of their choice. A patient is able to see a doctor immediately for urgent care in general practice, although seeing his or her own family doctor for non-urgent care may require waiting a few days. If patients require referral for specialist opinion or treatment, they can choose whichever hospital they prefer.
Care for those with pre-existing conditions
In the United States people with pre-existing health problems are rarely covered by private insurance companies for those problems. Many do not change jobs for fear of losing cover for such conditions from their new insurers. The NHS is literally a life saver for those with pre-existing health problems: they are not denied care. It is vitally important that the NHS—and any government financed health plan anywhere—undertakes the care of such people.
Care of elderly people
There is no cut-off age for health care in the NHS. Senator Edward Kennedy, like anyone else of that age or older and with health problems such as his, would have been treated by the NHS with the same high levels of care as someone younger. Care for the elderly includes free flu vaccinations, free medication, free operations as needed, nursing care visits, and help and adaptations for the home. Many hospitals now offer "hospital to home" programmes for palliative and end of life care to enable very ill people to remain at home.
Care of disabled people
Professor Stephen Hawking of Cambridge University, recently awarded the Presidential Medal of Freedom by President Obama, is disabled and has long been under the care of the NHS. Professor Hawking is an outspoken admirer of NHS care. Like thousands of others who are disabled, he is entitled to free medical care and medicine, and he can get adaptations, equipment, and home care to allow him to live at home.
Free medication
No one is denied drug treatment if they need it. All children up to the age of 16, pregnant women, adults over the age of 60, unemployed people, patients with cancer and many with chronic conditions don’t pay for their drugs from the NHS. Eighty eight per cent of drugs are dispensed without charge. For the minority who pay, there is a standard charge of £7.20 ($12; 8) per prescription, regardless of the real cost of the drug. Some parts of the UK have abolished prescription charges altogether.
Insurance
Like the Healthy San Francisco medical plan, people in the UK can also take out private insurance, if they can afford it, although fewer than one in eight currently do so. The coexistence of public and private coverage ensures complete freedom of choice.
The cost
The NHS is funded by taxes and provides universal coverage, while costing 8% of the UK’s gross domestic product (GDP). The US system currently costs 16% of GDP but leaves 45 million people without insurance and a further 25 million underinsured. (ed: emphasis added)

Background
The NHS was created in 1948. Its goal was to provide comprehensive medical care through taxation and universal coverage for the population that is free of charge at the point of care. It still does that despite the huge, and increasing, demands on its financial and practical resources.
The NHS is available free of charge to all regardless of ability to pay and does not discriminate against those with pre-existing conditions. Importantly it gives freedom from fear of the financial consequences of illness.
Survey after survey shows that British patients express a high degree of satisfaction with the care they personally receive from the NHS. On average, British users of the NHS live longer and have a lower infant mortality rate than people in the US.
The NHS has shown itself to be open to—and often the source of—innovation. How the US manages its own healthcare reform will doubtlessly provide us with new ideas about how to improve some aspects of our own NHS service. In the same spirit, we respectfully draw to your attention what evidently works well here.

Yours sincerely

George Alberti, past president of the Royal College of Physicians and dean, Newcastle School of Medicine

Alan Maryon-Davis, president, UK Faculty of Public Health

Anthony Costello, professor of international child health and director, Institute of Child Health, University College London (UCL)

Andrew J M Boulton, professor of medicine, University of Manchester, and consultant physician, Manchester Royal Infirmary

Mark B Gabbay, professor of general practice and head of Division of Primary Care, University of Liverpool

Rodney Grahame, consultant rheumatologist, University College Hospital, and honorary professor, UCL Department of Medicine

Ian Banks, president, Men’s Health Forum, and member of BMA Council

and so on.