RIP Hans

I learned the other day that Hans Rosling, Swedish public health professor, died earlier this month of cancer.

I was walking down the street minding my own business, and I was so shocked by this that I stood stock still in the middle of Hamilton St listening to the rest of the podcast (BBC’s More or Less, if you are a fellow podcast fiend).

I never met Dr. Rosling, but everything I learned about global health in medical school, I learned from his videos on YouTube. (I think this says quite a lot about the quality of the global health curriculum at my school….) Yes, his presentations always had snazzy graphics, but his most important points were sound — that the data tells a story, and that the story challenges our preconceived notions about structural inequalities in wealth, health, and life.

Much of his work and legacy live on at Gapminder.org, but the world will miss you, Hans.

Behind

I spent the week in subspecialty clinics, which was awesome. Except for one thing: the schedulers.

Patients are usually scheduled for follow-up appointments, in 30 minute slots. Occasionally there is an initial visit, which gets an hour. So today, I got to work at 7, spent an hour reading about the 6 follow-ups on my schedule, because even though they are well known to the clinic, they are not well known to me.

My first patient was scheduled for 8, but of course did not show up until 8:15. So by the time I’d seen her, staffed her with the attending, and written her refills, it was nearly 9. (And she was the easiest on my list.) And so it went for the rest of the day, as I slipped further and further behind. I had 2 extremely complicated patients, each of whom took over an hour even before I talked to the attending. Both of them actually need psychiatric care, which I am not qualified to provide — one does not think he needs a “shrink” and the other has limited resources. But when someone tells me they are actively suicidal with access to weapons, I’m not gonna be like “Well that’s not my problem, see ya later!”

Meanwhile, some lady showed up on the wrong day (her appointment is actually later this month) and the schedulers tried to guilt me into seeing her. “Look,” I said, “I’m nearly 1.5 hours behind as it is. She can wait if she wants, but I’m going to see the people who have appointments today first, since they’ve already been waiting.” (She didn’t wait, thank god).

I deferred all my notes, which I hate doing because I worry that patients and plans will blend together. As soon as a patient walked out my door, I went to the waiting room to get another. I felt like a revolving door, and I was rushing slightly toward the end, because I had to get to the Main Hospital, 2 miles away, for a conference.

I saw my last patient, scheduled at 10:30, at almost noon. Skipped grand rounds, disappointingly, because it was on prion disease, and who doesn’t like prion disease? Drove back to the Main Hospital for conference, then had an observed H&P scheduled for 2, then holed up in an empty room for 2.5 hours to write all those notes. Luckily I had no afternoon patients.

It was like this on Wednesday afternoon, too, when they scheduled me for 5 patients between 1:30 and 4, except between a late start and a rather ponderous attending, I didn’t finish seeing people until 6. I was teaching a class that night, so I couldn’t stay to write notes; instead I came back to work at 6:30 in the morning to write them all before Thursday clinic started.

This issue doesn’t happen in the Resident only clinic, I think because the schedulers take staffing-with-attending into account; it nearly doubles the visit time because you have to catch the attending (They are usually staffing 3 or 4 residents at a time), present, and have the attending at least eyeball the patient. But I suspect this is what clinic is like in the Real World of private practice — this revolving door mentality, never feeling caught up, which is frustrating to doctor and patient alike.

(The other frustrating thing: when I left clinic at a little after 5, the support staff, including the schedulers who pushed me into this, were all long gone. As a matter of fact, when I was waiting for the attending on Wednesday, I asked one of the staff if I could bring my next patient back and then staff two together — she said no because “I’ve already cleaned all the empty rooms.” It was 3:45 and she was ready to go home.)

So folks, next time you are pissed that your doctor is running late, remember that she is just as mad as you at a totally broken system that serves no one but the administrators.

The Normal Heart

Friday night, I went to see The Normal Heart, a revival of a 1985 play about the early days of AIDS. (Starring Lee Pace! And Jim Parsons! More on them later.) It was quite shocking to us, for whom HIV/AIDS has become … well, not a commonplace, but a fairly straightforward chronic disease. I was on the infectious diseases service last January, and it was one of the most difficult months of my life, but we knew was wrong with these patients. We knew it down to the molecular level. We had drugs to extend their lives. We couldn’t cure them, not quite yet, but we could do something. 

And so forgive my naivete, but it was a shock to step back nearly 30 years (the play is set 1981-1984) and see a time when that wasn’t possible. The Normal Heart is basically a rant against the people that twiddled their collective thumbs while young men died. It’s happened before, and it will happen again. It’s probably happening now, and I just don’t see it because of the New York bubble. The title comes from a poem by WH Auden, which you should all go read because it’s Auden, nuff said.

The didacticism and emotional manipulation did get a little heavy-handed at times, but there was enough nuance to just save it. The relationship between Ned and his conservative brother Ben, for instance — love, uncertainty, and depth. The City government and the NIH bear the brunt of Ned/Larry Kramer’s diatribe, probably fairly, but they do come across as straw men. I guess it’s easy to attack institutions, but I would have preferred to see the people within those institutions.

And fantastic acting all around. Lee Pace as a jerk (though hints of backstory suggest non-jerkish behavior)! And Jim Parsons — holy crap. He had very few lines, but he just commands the stage in this understated and powerful way. Everyone was amazing, but he was just on point.

I was thoroughly impressed and should probably read And the Band Played On at some point. Why don’t we talk about this stuff in medical school?

Uphill in the snow, both ways

How Millennial physicians will impact disease management (opens in a new tab).

Apparently “Millennial” is the name for my generation, the post-Vietnam, post-modern, post-racism kids who grew up in the financial bubble of the 80s and 90s, watching Sesame Street and texting their little hearts out.  And according to this article, we are single-handedly responsible for the death of medicine.

Buh?

Honestly, this Dr. Sidorov comes across as more than a little curmudgeonly.

They don’t know about bomb shelters, walking to school, tape decks or having to get up to change a TV channel.

Oh, no!  Obviously we are inferior human beings because we don’t duck and cover.

(I will say, though, that this video made me feel very old.  But then, the kids are Canadian…. 🙂 )

I do think the author has a point about this generation being less concerned about rank, which doesn’t jive well with medicine’s rather entrenched hierarchy.  But then the rest of the article discusses how self-absorbed we supposedly are, how we will compromise patient care in the name of work-life balance.

I posted a comment on Kevin MD, but I think this deserves a longer rebuttal.

Vaccine Hoax

According to the NY Times, there’s a new report discrediting the Wakefield study.  Andrew Wakefield’s unethical science — including undisclosed financial gain and altered data — is one of the worst medical moments of the modern era, right up there with Tuskegee.

I once reported on an anti-vax rally for a summer internship, and it was one of the saddest moments of my medical education.  Hundreds of parents swarming around Capitol Hill, listening to Jenny McCarthy and Jim Carrey blather on about medicogovernmental conspiracy.  Oh no!  We actually want to prevent diseases that kill more than three-quarters of the world’s children! (Fun fact: Did you know that measles kills more children under age 5 than HIV/AIDS?)

Once, a long time ago, when I was in India, I saw a man crouching by the tourist gate of the Mughal fort we had just visited.  Then I looked again and saw that he wasn’t crouching at all.  His right leg was withered away, a crumpled bit of skin lying uselessly at his side.  Polio.  It seems like something so far away, so ancient. Until suddenly you see it and smell it and then somehow it’s not so far away at all.

Plus ça change

House Approves Senate’s 1-Month Medicare Doc Fix.

This dance happens with startling regularity, like the cycles of the moon or the flowering of the sukebind.  Medicare payment cuts are always looming; Congress always dallies; and at the last minute: swoop! cut revoked — until next month.  It’s Victorian melodrama for a the social network age, and we’re all Pauline, tied to the tracks.

This is the worst possible way to address the Medicare expense issue. According to the article above, Medicare is based on a 1997 formula tying Medicare payments to a percentage of the GDP. That’s crap. Why should physician payments be artificially pegged to the GDP? Shouldn’t the formula be revised to account for the technology-and-pharmaceutical explosion since 1997?  And would someone show me a breakdown of Actual Cost — of every health care dollar, how many cents go to prescription drugs, how many to running an office, etc? The whole process is shrouded, even from one who is in it and is actively seeking this information.

Lydgate, whose primary quality is his ability to rock some snazzy suspenders

Over Thanksgiving, I read Middlemarch, a provincial epic by George Eliot. (As I said to myold-lady-television-watching buddy, Cranford on steroids.) One of the characters, Tertius Lydgate, is a young physician, new in town and full of ambitious plans for revitalizing the practice of medicine. He’s a decent doctor and even manages (by luck or skill, it’s never quite clear) to save a young man from typhoid. But then he incurs the wrath of the town when he decides to charge for his services!  The nerve!   Apparently in the early 19th century, physicians would charge for the drugs they dispensed, but Lydgate prefers to leave that to the apothecary (pharmacist) and focus on what he has been trained to do: diagnosis.  But the town is up in arms about his chutzpah of demanding payment for something intangible like thought. (Never mind that Fred Vincy, the patient, is walking around town as tangible as you please.) The whole episode sounded exactly like the debates on health care reform.

Plus c’est la même chose.

Tinfoil hat

The new Crestor label says it may be prescribed for apparently healthy people if they are older — men 50 and over and women 60 and over — and have one risk factor like smoking or high blood pressure, in addition to elevated inflammation in the body…. An F.D.A. advisory committee had voted 12-4 in favor of expanding the usage in December.

-Risks Seen in Wider Use of Statins Like Crestor – NYTimes.com.

AstraZeneca must be rubbing their collective hands in glee right now.

My concern is that this will guide the standard of care (and thus reimbursement, malpractice, and all that good stuff) and that people with neither signs nor symptoms of hyperlipidemia will be labeled and prescribed a drug with a pretty significant risk of muscle breakdown, liver enzyme abnormalities, and Type II diabetes.  Don’t get me wrong, statins are great drugs, but they are not appropriate in the water supply.

It passed!

I have to say, I am pleased at the passage of the health care bill.  It’s a good first step in this long, hard struggle of health care reform.

I’m not convinced by the argument I have heard so many of my classmates make, that reimbursements will necessarily go down, or that a government-run option will by definition be inefficient.  Private insurance companies spend 30% of their income on administrators. Medicare’s overhead is in the single digits.  That sounds pretty damn efficient to me.

How a Bill Becomes a Law

Obama Calls Health Care Bill’s Passage ‘Courageous’ – NYTimes.com.

It would be nice if the vote had been less partisan, but baby steps.

Drug reps

My hospital, like many others, has a pretty strict policy about pharmaceutical representatives.  Back in the day, they used to tempt students as well, with food and drinks and offers of Caribbean cruises for Spring Break. (Taking their cue from the tobacco industry — get ’em while they’re young.)  That changed several years ago, and now drug reps are personae non grata — that’s Latin for “scum of the earth.” One of my attendings threatened to fail a student for using trade names in his presentation, that’s how serious the anti-pharmaceuticals sentiment is around here.

So imagine my surprise when I was accosted by two salesmen the other day.  I was just walking down the hall in my scrubs and white coat with a couple of classmates — easy targets, I’m sure — and these two well-dressed guys came up to us and started on their sales patter. “Wow, you are medical students? You must be soooo smart.”  The insincerity was palpable, and pretty insulting.

They gave us cards to fill out so they could contact us later.  I gave them totally incorrect information, including a fake email address.  (But wtf, I got a LinkedIn invite from one of them yesterday, which is just creepy.)  It did weird me out that they were just wandering aimlessly through the hospital.

In summary: pharmaceuticals = good. The cheerleaders who peddle them = sleazy.