This Week in Mississippi

It’s the two year anniversary of Katrina. Two years ago today we were in our minivan, headed away from the terrible unknown, to the safety of family in Maryland. I’m trying not to dwell on it (too much), on the phenomenal failures of initiative and post-disaster planning, on the politicized quagmire, on the losses and missed opportunities. Instead, I present two news items from Mississippi. One is Katrina-related, one is not. I wonder if this will be all you hear about Mississippi this week; have we officially been written out of the Katrina story, as reported in the national press? Prove me wrong, people; prove me wrong.

(1) Mississippi is the fattest state.

Big surprise. Mississippi is also one of the poorest states. The cynics might scoff, “how can you be fat if you’re poor?” But there’s a difference between too poor to eat healthy, and too poor to eat. Fruits and vegetables are not cheap. Taco Bell, 2-liters of Coke, bags of Cheetos, and TV dinners are very cheap. Fried chicken, pork products, and bacon grease come from the cultural and historical roots of Southern cooking, using the cast-off parts and ingredients—again, directly related to poverty and lack of better resources.

Last week I was in the grocery looking for a post-lunch snack. Big ripe Georgia peach: $1.00. 5-ounce bag of Fried Somethings: $1.00. The Fried Somethings would have filled me up more, lasted longer. I did the healthy thing and had that scrumptious, juicy peach. But on a strictly cost basis, the Fried Somethings would have been a better buy. Unless Frito-Lay decides to raise its prices and sell fewer chips, taking a profit cut for the good of society—or if farmers decide to cut their prices and take a profit cut for the good of society (and in the process, go out of business, unless for government subsidies)—then I guess that’s that. Pity.

(2)How many licks does it take to get to the center of a Tootsie Roll Pop?

Reprinted from Waveland Ward 1 Newsletter, from Alderman Lili Stahler:
“An update on the ongoing projects are as follows:
Phase 1 Sewer & Water South of the tracks : completion October ‘08
Phase 2 Sewer & Water South of the tracks : completion January ‘09
Street Replacement South of the tracks : completion February ‘09
Water North of the tracks : completion May ‘08
Sewer North of the tracks : completion June ‘09
Gas : completion October ‘07
Garfield Ladner Pier : completion October ‘08
Library : completion October ‘08"

Four years. It apparently takes three to four years to get to the center of a Tootsie Roll Pop…er, I mean, rebuild the basic infrastructure of a town in these United States of America. Alderman Stahler writes, “Think back to last year at this time. How far we have come!!”

Yes, indeed. Oh, the Thinks you can Think.

Incidentally, a friend of mine is being featured on Oprah’s “Ask Dr. Oz” segment tomorrow (8/29), as well as on the Weather Channel, discussing Katrina experiences. I haven’t seen the interview, but I know the story, and it’s worth seeing if you can.

The End of the Ignorance: A Plea

As we approach two years out, a quick perusal of the blogosphere turns up more than a little Katrina backlash going on.

Much of it comes, sadly, from outright ignorance. Let's spend a few minutes, shall we?, responding to just a few of my favorite misconceptions:

"Isn't the Gulf Coast rebuilt yet? The government pumped in $100 billion already!"
Get on a plane to the Coast and you'll see for yourself the status of rebuilding. GulfCoastNews.com has a great article summing up where the Coast is and why it is so far from what any sane person would consider normalcy. They also correctly point out that $100 billion has been allocated; the actual amount being used is far, far less. A major reason I left the Coast was a belief that this recovery is going to take many, many years--I'll now say more than a decade--and I wasn't prepared to sacrifice my sons' childhood(s) to that.

"Those people living in trailers must be plain lazy if they haven't rebuilt their homes yet."
Ah, this one never gets old. For those who insist that there's been more than enough opportunity to rebuild, let's do the math, using some very rough estimates:
* Assume 5000 homes needing repair or rebuilding in Waveland and Bay St Louis (this, of course, leaves out Pass Christian, Long Beach, Gulfport, Biloxi, and New Orleans; I'm confining this example to the area I know best)
* Assume your average contractor has repaired and/or rebuilt 5 homes in the past 2 years (this might be generous, since my experience says a new home takes over six months to build, and almost nothing was started in Bay-Waveland until at least late winter-early spring 2006; then again, not every home needed to be rebuilt from scratch; maybe only a third? Which is actually a staggering number, so we'll keep that estimate where it is.)
* For all the homes to have been repaired within 2 years, that would mean 1000 contractors in the area. Now all of you out there who think there are 1000 contractors in Hancock County, please raise your hands. And that doesn't include the subcontractors and workers. By the time you add it all up, for all the homes to be rebuilt, the area population would have to be comprised entirely and exclusively of construction workers. And then you're left with wondering where they'd be living, since they're busy fixing other people's homes.

This little scenario also assumes that everyone received a fair settlement on their home and can afford to rebuild. Which leads to...

"If I was in that situation, I'd just pick up and leave."
Set aside emotional, historical, and family ties to the area. Financially, many residents are between the rock and hard place and Hell. They still owe a mortgage on a property which in many cases may be a slab. They can't afford to rebuild, since--oh, who knows why, maybe the insurance companies didn't give them a fair shake, maybe they didn't have flood insurance, maybe they didn't qualify for the Mississippi grant program, maybe they already lost a few thousand to a crooked contractor. And they can't sell the property since the real estate market has tanked. There are a record number of properties for sale--and a record low number of buyers. News flash, no one wants to buy a home in Bay-Waveland right now. Did I mention the astronomical price of wind insurance?
Your options? Keep trying to get by, sell the property at a major loss, or foreclose. That's about it. Which would you choose? Oh, by the way, it might be hard moving to a new place with no money and/or no credit...

And, finally,
"You people get what you deserve for living below sea level."
Um, Bay St Louis is 20 feet above sea level. It's actually the highest point on the entire frickin' Gulf Coast. That didn't mean much against a 30-foot storm surge. Which is pretty hard to imagine, but hey, it happened.

Why blame the victims? Why wallow in, and almost gleefully celebrate, the ignorance? Has anyone said those Minnesotans should have known not to trust an old bridge? Were New Yorkers at fault for living in the most prominent American city on 9/11/01? Why haven't we started yelling at the populations of Key West, Miami, coastal North Carolina, Galveston to pick up and leave, MORONS, before the next hurricane strikes and we have to clean up your mess, you crybabies? Why stop there--why should we feel sympathy or even responsibility for a post-earthquake San Francisco, a snow-bound Rochester, a flooded-from-broken-levee Fresno, a water-parched Las Vegas, a terrorist-hit Washington DC?

Is it simply Katrina fatigue? After the emotional drains of 9/11 and school shootings and war in Iraq, do we just have nothing left?

Is the dismal recovery simply too unbelievable to comprehend? Perhaps many Americans have a hard time accepting that the government of their great country could have been so callous and incompetent, and therefore they rationalize and project that the Coast's residents simply must have had a larger role in the current failures.

Or is it about southern rednecks of Mississippi hick-towns and dangerous inner-city blacks in New Orleans ghettos? Who must have been in their pre-Katrina situations due to their own slothfulness and moral failure? Are we in the throes of a neo-Puritanism revival that insists people's destiny is entirely self-determined and not subject to the earthly influences of the material world around them? Or even better, perhaps we'll just go all-out-Calvinistic (and no, don't go all Calvin-and-Hobbes on me, that's not what I'm talking about): these people are poor and uneducated because God has deemed they should be that way! We should no more feel pity on them or help them than we should try to improve the lot of a common dog!

Whatever the motivation behind the ignorance, perhaps the most concerning aspect is the fact that its adherents feel so free to profess it, with vehemence and self-righteousness. Perhaps we can thank Rush Limbaugh, and his protege, Bill O'Reilly, for the decline in courteous civil discourse in America today. Then again, the anonymity of the blogosphere certainly tempts many to more extreme emotions, outright provocation, and a lack of responsibility.

I enter a plea for tolerance, or at least, respect. In other words, stop the hatin'. Don't go spouting off on topics you know very little about; take the time to listen to the stories from the Coast. As anyone who has visited the region--let alone lived there--can tell you, it's all far worse and more overwhelming than you have been led to believe, or can even imagine.

But enough preaching, let alone to the choir. Good night, peace, and God bless.

Maybe they should call it SICK insurance...

Much in the same way that life insurance isn't really life insurance--it's death insurance (but who wants to buy something called that?)--what we call health insurance is really sick insurance.

Case in point:
This morning I was reading an article in the AAP (American Academy of Pediatrics) News describing new obesity guidelines to be published later this year. Truthfully, there was little groundbreaking in this article: treat obesity as a chronic disease condition, assess if the family perceives a problem, encourage a sensible diet and one hour of exercise daily (that last one is a little surprising, and potentially problematic: yes, it's recommended, but how many obese kids will do that much? I fear many will hear of such a lofty goal and fuggedabudit. I know I don't have time to exercise an hour a day...though I admit I should...)

The guidelines will also recommend checking up on obese kids every few months. Ah-hah, I thought, another ivory-tower academic recommendation, out of touch with the real world. Who will pay for these visits? Many insurers specifically do not cover office visits that have a diagnosis of "obesity." That's a lot of free care they're expecting us to write off.

Well, just a few paragraphs later, my concerns about ivory-tower recommendations were (partially) rebuked. The article went on to say that insurers need to start paying for visits related to obesity. It added that many insurers do not pay for obesity because they feel it does not directly cause health problems.

To put it mildly, pshaw. That's no different from saying that high cholesterol does not directly cause illness. The association between cholesterol and heart disease is pretty well established--granted, not in the course of days, but certainly over years. (I guess I missed that episode of E.R. where the man came in with a hypercholesterolemic crisis..."get me niacin, NOW, and some statins, STAT!") Let's see an insurer just try to deny coverage for our modern cholesterol-lowering pharmaceuticals.

Of course, paying for doctor's visits to treat obesity ultimately benefits the insurer in the end. Unless they actually don't mind paying for later treatment for metabolic syndrome and diabetes, heart disease, hypertension, bone and joint problems, not to mention the "incidentals" such as arranging for a specialized or open MRI machine that can handle our extra-large patients, extra-sturdy wheelchairs and beds and similar...

The administrators of these companies can't be that stupid. But they're also not that patient. They can't afford to wait 20 or 30 years to reap the dividends of investment now. Because their shareholders want to reap dividends next quarter. Wall Street needs to know what next year's projected revenue will be, and doesn't give much of a hoot about 30-year projections.

Then there's also the fact that there isn't a powerful obesity lobby waging a public relations war on the insurers. It's pretty much just the primary care doctors. Whereas, if the insurers decided to cancel coverage for cholesterol, you'd have the rich cardiologists and the mighty AARP yelling at CEOs within six hours, and the decision reversed in another twelve.

The insurers will cut costs, and coverage, where they can. And preventive care is one of the easiest things to cut. But then, since "health" is most effectively (including cost-effectively) guaranteed through preventive care, don't try to call it "health insurance." At least be honest and call it "sick insurance." And certainly don't try to claim you're in the business of "health care." As was said before, insurers are in business to make money, and it just so happens that they do it in the health care sector. Any health benefits to you, the consumer-slash-patient, are purely incidental.

A Tale of Two Centricities

In my old practice, I had an Electronic Medical Record system (EMR). The paperless office: all patient data entered in real-time into computers, all documents scanned, even digital photos transferred directly into the record. No more searching for lost charts, no more waiting for the front desk to hand the chart to the nurse who then hands it to me (who hands it back to the nurse, who then hands it back to me, who then returns it to the front desk); no more trying to decipher doctor's chicken-scratch handwriting; instant access to every patient's record from any computer with an Internet connection; and most importantly, near-complete recovery of every single patient record after the most devastating disaster in recent history.

That EMR was provided by a company called eClinicalWorks. They're a good little company with a good, nimble, customizable little product. It's far from perfect, but it did the job really well, and very affordably. I think of eClinicalWorks as a butterfly: small, delicate, and beautiful.

The practice I am now in uses a different EMR, called Centricity, from GE. Yes, that GE (you'd be surprised to learn how much GE is involved in health care). If eClincalWorks is a butterfly, Centricity is a hippopotamus. Big, lumbering, powerful, and utterly without grace. It's not going to listen to you unless it wants to.
I actually don't have much complaint against Centricity. Like eCW, it also does the job. It does many things eClinicalWorks never could (such as scale up to a massively multi-user, multi-site organization, the opposite of the solo private practice; also robust user-tracking, recording who entered and changed what in the record); I bet--though I haven't yet had the chance to find out--that it is much better at data collection and analysis. It's been fairly easy to learn and use, and hasn't significantly slowed down my work, or interfered with patient interaction.

But it does have some major drawbacks. Only one person can work on a record at a time, lest you risk crashing the program. The printed output leaves something to be desired. Small program changes have to be referred to the clinical committee, which then refers changes to the organization's IT department, who then sometimes has to work with GE's programmers.
Most interesting of all, the program's biggest strength is in collecting and recording patient background data: what language they speak, how they prefer to learn new information, if they have cultural concerns, etc. Combine that with its privacy features and user-tracking, and it seems that it was created with HIPAA and regulations first.

Privacy and compliance is important, yes. But I'm more than a little concerned that this product seems to have placed that area as most important--and physician input, management of assessment, plans, medications, immunizations, and such becomes second tier. I imagine a different Centricity, created first and foremost as an Electronic Medical Record: patient data, ease of entering and retrieving it, being the priority. Lay the compliance onto this template, add a pretty interface, and *boom*--you've got a revolutionary new product. However, that's not the Centricity that GE decided to create.
(It's all the more frustrating that this big expensive product was created by a big powerful company like GE. You'd think that GE would have the resources and insight to do it better. Of course, that might be part of the problem right there: hey, we at GE don't have to listen to those doctors or medical practices; we're smart enough to do it ourselves, with what we think is important. If you don't like it, that's tough, because we're big ol' GE, and we know best.)

And so we're still waiting for that hypothetical ideal EMR that satisfies all parties and concerns.

Yes, here in 2007 we still have a long way to go. (Though, did I mention that we're using the 2004 version of Centricity? There's an update, but it's still in beta. Our organization has, quite wisely, decided not to trust its patient data to an unfinished product.)

And some people wonder why doctors have been slow to switch to EMRs.

Blog Tag/Latest Update/Filler Post

Dr. Scott gets busy, again.
Just when the last post created a hullabaloo, we moved into our new house. Meanwhile, I also started work at my new practice. And as if that wasn't enough, I also had a meeting in Chicago, and I'll be in Washington next week.
Somewhere along the line--about 3 weeks ago, to be exact--Rebel Doctor tagged me in a game of Blog Tag, inviting his contacts to reveal 8 random facts about themselves. I was supposed to tag 8 more contacts to do the same. (Kinda like a chain letter, except without the promise fame and fortune. Just smiles. (Well, maybe a little fame. Very low-grade stuff though.))
While I've probably let the moment pass in terms of passing it on, I feel I owe it to Rebel Doctor to at least follow through on the first part of his request:

1. Like Rebel Doctor, I am not a Southerner by birth. (Of course, I'm now in Florida; does that still count as the South?) (If you must know, I grew up in Baltimore, Maryland, hon.)
2. Growing up, model rocketry was my hobby. (Geek!)
3. I met my wife when she and my sister were in a production of "Fiddler on the Roof."
4. Our oldest son is adopted from Kazakhstan.
5. My favorite alcoholic beverage is George Dickel Special Reserve whiskey. Closely followed by Knob Creek bourbon.
6. I once spent a summer in Frankfort, Kentucky working on a statewide health survey.
7. I am a member of the American Academy of Pediatrics' Section on Administration and Practice Management, Section on Adoption and Foster Care, and Provisional Section on Media (a call-out to Dr. Gwenn on that last one!)
8. If I couldn't be a pediatrician, I'd want to be either a journalist, or working for NASA.

More to come.
(P.S.: Anyone reading this is welcome to join the fun and post 8 facts about themselves too...)

Enough

A few weeks ago I hinted at a Big Project.
Enough waiting: The Project has culminated.
Dr. Scott has left the building.
Or rather, Dr. Scott has closed his doors. His practice is no more. He has had enough, and has left the Gulf Coast.

Some of you reading this blog admired me for staying. Staying wasn't about courage. It was about caring, and hope; nothing more. I still have my caring; indeed, if not, I would have left Mississippi long ago. In fact, that was the only thing keeping me, and it was a damn big thing, almost trumping all else. But the hope has gone.

I'm writing this to explain my actions, not for my own defense, but to give you some insight into the Gulf Coast, post-Katrina. To give insight as to what would make a pediatrician committed to his community finally leave, as to how even hope can be extinguished.

To let you know how much we have failed the Gulf Coast, and how this country as a whole (and especially its leadership) has given up on any pretense of caring. And I use "failed" in the past tense. The damage has been done. Indeed, that is probably the biggest reason why I decided to leave. If no one has come to help yet, and no one is planning to help, then no one will be helping in the future either. (Apologies to those individuals who did come, and gave time and sweat; I hope it's clear that my ire is dedicated to the greater government and the "compassionate conservatives" who support it and believe we on the Gulf Coast just need to hoist ourselves up by our own bootstraps and stop being such ignorant, lazy, greedy whiners.) We had so many chances to turn things around, to set it right. But instead we are condemning New Orleans and Waveland, Mississippi to poverty, third-class status, forever mired in what the rest of the nation thought they were like anyway; ah, the self-fulfilling prophecy. We have doomed a entire generation of children and we have crushed their chances of normalcy, of resiliency, of trust.

When George W. Bush spoke in New Orleans days after Katrina, he promised to do whatever it took to set things right. He gave us hope. He didn't have to say those words. He could have expressed sympathy, mentioned that "the nation stands with you as you rebuild," et cetera, et cetera, et cetera. But instead he promised action. The terrible tragedy would be met with just as equally awesome a recovery.

Perhaps the only thing worse than no hope is false hope. Hear me out: no hope leads to reasonable expectations. No one is coming; make your plans accordingly. False hope, on the other hand, encourages you to go to the brink, even over it. I may be near the end of my rope, my finances, my energy, but at least the cavalry is coming. Until you finally realize that it isn't. And then it's too late, and the anger comes forth.

Debate all you want about Iraq and if Bush lied about what he knew and how we ended up in that quagmire. I know this: Bushie lied about helping out after Katrina. A year and a half after Katrina we learned what many insiders knew all along. He had the authority to waive the Stafford Act's requirement of a local 5-10% match for recovery efforts. It was waived, by executive order, after Hurricane Andrew. It was waived after 9/11. Not for Katrina.

5-10% may not sound like much. But for Waveland, it was. When 90% of your housing is damaged, it's too much. When every component of infrastructure needs rebuiling--sewer, water, electricity, roads, government buildings, police and fire, should we keep going?--it's too much. When you no longer have a tax base to speak of, it's too much.

Ah, we should have just called it quits at that point. But our president promised to set things right, so we stayed.

The government has done NOTHING for healthcare after Katrina. No, let me clarify: it has done nothing for the private practitioner. There was an uncompensated care pool that helped hospitals from August 29, 2005 through January 31, 2006 (oh! so generous!). Hospitals and nursing homes can apply for part of a $160 million pool just released by Health and Human Services (though allocated from the Deficit Reduction Act of 2005--but what's two years among friends?) Oh, New Orleans also gets $10 million to recruit new "providers" into the area (whatever that term means). The ones already here get a big fat F*** You.

Not even a thank you.

Mere days after Katrina officials on the state and federal levels were being told--from people on the ground--what needed to be done. Increase Medicaid reimbursement for pediatricians treating Katrina survivors (both the ones remaining on the Gulf Coast and the ones dealing with the flood of evacuees in Baton Rouge, Houston, and the like). Reimburse for the surge of uninsured patients. Give government resources such as trailers for office space so local MDs can start seeing patients again. None of these suggestions--or others--has been even considered, let alone debated or implemented.

Here's my practice situation: since Katrina my office rent has doubled (I had to move out of my first office after it was destroyed). The rest of the overhead hasn't gone down any, what with added "fuel surcharges," inflation, and the like. My practice was 65% Medicaid--same as before Katrina, though it was still enough to keep the practice thriving beforehand. But the number of self-pay tripled. And the overall numbers? Not as many kids here now. And there won't be for a long while, if there is no affordable housing for families, and it's not the best environment for families anyway.

Oh, in the meantime, I just got the bill for my wind insurance premium, under the state wind pool. $6500. That is not a typo. Good thing we sold the house--though our realtor said we were miraculously lucky, since it was apparently the first house to sell in Waveland this year. Yes, one home sale in six months. No one wants to buy housing, no one wants to move in anymore, and certainly no one can afford the insurance to stay.

Prediction: look for the number of foreclosures to skyrocket in the next 12 months.

And then there is the obvious psychological stress and burnout. Seeing the debris every single day, the construction vehicles, the abandoned homes still waiting to be demolished, the streets being torn up for new sewer pipes and electric conduits. No relief, ever. Granted, everyone in town is in the same boat, which means at least we all understand each other's plight, but then again, it means it's the number one topic of conversation every day.

It hit home when I went to Washington last month for a conference. On the Metro, I didn't hear people asking, "how's your home coming along?" No one on the street mentioned about SBA, FEMA, or insurance. Oh, and things were green; trees weren't snapped; residential lots had nice houses, not abandoned concrete slabs; there were children playing in yards; malls and stores and farmer's markets to visit, restaurants to enjoy; the things that make life nice. That's not life on the Gulf Coast. The Gulf Coast is now a toxic environment.

If anyone from the Gulf Coast reads this, they might protest I am overlooking the good, the progress. Yes, the Coast is being rebuilt. The Bay St Louis-Pass Christian bridge just reopened in May, to much fanfare. (It may sound silly for those of you out of the area, but the importance of that bridge cannot be overstated; it's a real milestone in the recovery of both towns.) But let me remind you that the bridge took 21 months to open. The CSX railroad bridge across the same channel was rebuilt in only 6 months, by private industry. The Biloxi-Ocean Springs bridge isn't set to open until this November. Here we are two years after Katrina and we're still talking about rebuilding basic infrastructure. This is inexcusable. If we're at this point after all this time, it will be another 10 years before we're anywhere close to a normal town, a normal life.

Or longer. I've heard that Homestead, Florida still hasn't recovered from Andrew, now some 20 years ago. I worry that Waveland and New Orleans might never fully recover now. The people with the means are leaving, or working themselves into debt and exhaustion. The only ones left will be the working poor. Maybe some big condo developers will come in--though that in turn would utterly destroy everything that Waveland was.

And maybe the answer is, "so what?" So what if condos come in? Situations change, towns change. So what if Dr. Scott leaves town? (There are still two other pediatricians around.)

I think these things do matter. I do think my leaving has negative consequences for the community. I don't say this simply because I want to feel valued or self-important; I think even if one of the other pediatricians left instead the children of our town would be affected, and for the worse. The community as a whole is worse off.

We have the means to fix these problems, at our fingertips. But they require money. I decided to leave town for many reasons, but finances were at the top. I simply couldn't keep the doors open anymore--and I had the opportunity to leave for a better (and more pleasant and less stressful) life elsewhere.

Bush didn't say that we would rebuild New Orleans "if the budget allowed." I don't see Bush hemming and hawing about the bill for the war in Iraq. We can spend over a trillion dollars on a war of dubious necessity. But we can't find the money to restore healthcare or infrastructure to our own Gulf Coast.

Forgive me for playing the martyr, but I feel like I've been caring for the children of Waveland and Bay St Louis on my own back and on my own dime. I can't do it by myself anymore, and if no one is coming to help, it can longer be my problem. I have to think of the well-being of my own children, of my wife, and of myself.

This blog will continue; there's still more Katrina Story to tell, not to mention more insights into the whole big exciting world of medicine and pediatrics. And I won't forget those I've left behind. In fact, the intersection of disasters and medicine promises to continue to occupy my professional life for a while to come. But it won't be from Waveland, Mississippi. I leave the Gulf Coast with a heavy heart, but I'm excited to be leaving and starting new.

Bay St. Louis Pediatrics
February 22, 2004 - June 15, 2007

Easy or Hard?

Let's play "easy or hard." What would you do?
1. Mom brings in a 2-year old girl. The girl has been having a green runny nose for three days. She has been running a low grade fever (under 100). She is eating (though not as much as usual), sleeping, and still playing. She also attends daycare. Physical exam reveals mild nasal congestion; lungs are clear, eardrums look normal. Do you:
a) (Easy) prescribe amoxicillin for "sinusitis" so she can go back to day care and prevent mom from calling you in 3 days to say, "she's still not better!"
b) (Hard) let mom know that green rhinorrhea does not necessarily mean a bacterial infection, particularly in an upper respiratory infection of a few days with no other significant symptoms (e.g., fever, lethargy, findings on physical exam); explain that antibiotics are not indicated, discuss the role of over-the-counter remedies, encourage fluids, rest, nasal saline drops, and a humidifier or vaporizer; and ask that the mom call back in a few days if symptoms have not improved or if she is worsening.

2. Dad brings in a 6-year old boy. The boy was reportedly diagnosed with asthma by another pediatrician 4 years ago. He takes albuterol in a nebulizer when he gets sick. His "breathing attacks" consist of a junky rattle in his chest with coughing. He has no problems with breathing or coughing when he is not sick. He is now out of albuterol and wants a refill. On exam, his lungs are clear. Do you:
a) (Easy) write the refill and send them on their way
b) (Hard) explain that his current condition sounds more like a simple cold than an asthma attack; advise the father to use a humidifier at nighttime, watch the child's breathing for signs of retractions or respiratory distress; educate about the side effects of albuterol; and hold the refill unless symptoms change or progress
c) (Very Hard) same as "b" but also perform pulmonary function tests in your office to more definitively evaluate the symptoms; go over the results with dad and explain what it means and why

I could go on, but you get the idea. The Hard choices are good medicine; they bring the patient into the care, produce better outcomes, educate for the future, and are supported by clinical data and experience. But the Hard choices take time. They rarely, if ever, lead to better reimbursement (in fact, according to proper CPT coding, the simple act of writing a prescription can potentially increase the "complexity" of the visit and lead to mo' money; therefore, the education costs me both time and money!). Some patients don't want the education; they just want the prescription (this is called "convenience," and it's why CVS is betting that people will prefer to go to a nurse practitioner in a minute clinic instead of their regular doctor; it's not the best care, but that's irrelevant...)

It's been said that our current system therefore rewards mediocrity. Pay-for-performace (P4P) clearly isn't the answer, if only because "performance" means different things...and to a payor, it usually means "saving money." "Quality" is much more difficult to define, or at least measure.

I've heard that we should let the free market decide. Lawyers are free to charge whatever they want. The best lawyers charge the most. Can't afford it? Don't like it? Fine, see a cheaper lawyer. You'll get adequate representation. Which is fine for drawing up a will or contesting a small claim. Is that acceptable for multi-million dollar liability lawsuits? How about first-degree murder cases? Without giving an answer to that question, let's extend it to medicine. Yes, I know, concierge care is already a small example of this taking place. Does this mean that the poor are effectively excluded from the best care? Is that fair? Is that just? Is that simply the consequence of a capitalistic health care system?

Easy and hard, indeed. No answers here, not yet. Perhaps the lack of standardized incentives is actually an advantage: let everyone determine for themselves what they really do want. You want a quick scrip and no fuss? Find a doctor like that, or go to a minute clinic. You want 24-7 concierge care and 2-hour visits? Fine, just pony up. You want a doctor that takes time to listen, offers quality care, matches your personality? Listen through the grapevine and see who your friends and neighbors recommend. Don't like Doctor A? Go see Doctor B, maybe she's better. Everyone gets paid, everyone gets what they want--or at least compromises to get "good enough". So maybe the status quo is the best idea after all.

Towel Day

I just learned that May 25 (this Friday) is Towel Day.
Apparently it is in tribute to Douglas Adams and The Hitchhiker's Guide to the Galaxy.
As useful as a towel might be, I don't think I'll be bringing mine to work--I don't think my clientele would appreciate the reference--but I do think it's a cool idea and wanted to spread the word.
So there, I just did.

Lady in the...What? Er...

Watched M. Night Shyamalan's "Lady in the Water" last night.
Felt inspired to write a haiku about it:

Dear Shyamalan,
I gave your film a good try.
Want my two hours back.

L. commented that it would have made a pretty good anime, with teenage characters. But it's not that, so I warn you: it's dreadful schlock. I would urge you, watch something else instead.
Just to avoid being Mr. Negativity, I'll even recommend two recently seen, better movies:
1) "Flushed Away"
Laugh-out loud funny, great Aardman animation (you know, Wallace and Gromit?) Kate Winslet provides a great voice to "Rita."
2) "Tom Dowd and the Language of Music"
A little-seen documentary about a little-known music engineer who revolutionized the music industry and who worked alongside many of the greatest artists in rock and roll, soul, jazz, and more. And he seems like a really cool guy to boot.

Next on the Netflix list: Little Miss Sunshine. Dr. Dork has recommended it, so it must be good.

That's all for this week; until next time, we'll see you...at the movies.

Katrina in the News

1. From Kevin, M.D.:
Physicians at West Jefferson Medical Center in New Orleans are suing the state of Louisiana for $100 million in uncompensated care after Katrina.
I'm not sure a lawsuit is going to work, but I do admire their chutzpah. Because I don't see the state or federal governments giving any money willingly.
2. From the always astute Dr. Hebert:
The Washington Post reported this week that the federal government declined over $800 million from foreign governments after Katrina. Yes, you heard right. It was offered, and George W. said "no thanks."
Yet our government says it has no money for health care in the Katrina zone (or for waiving the Stafford Act's 10% local match, despite that having been the case for both 9/11 and Hurricane Andrew).
And of course, we have billions and billions for the Army in Iraq, but that's another story.
Which leads to our third and last item for today...
3. President Bush's veto on the troop funding bill was the lead item on the news a day ago. But a tip of the hat to the New Orleans Fox affiliate (Fox 8) for pointing out that the vetoed bill contained more than military matters.
In fact, H.R. 1591 contained billions of dollars for additional Katrina relief.
So yet again, the fate of the Gulf Coast is tied to the Gulf War, and not for the better.
As Nathan McCall said, Makes Me Wanna Holler.

Katrina Story, Chapter 8: Our House

(Dr. Scott's inner demons persuade him to return to Katrina Story at long last! My apologies if I repeat any details from prior chapters; I'm going to put pen to paper...er, fingers to keyboard...and write while I have the time and inspiration.)

After assessing the office and hospital, we turned from the professional sphere to the personal, and drove towards our house in Waveland. As we turned onto Jeff Davis Avenue (hey, this is Mississippi!) we saw a now-familiar sight: house after house with destruction, devastation, and the ubiquitous orange spray-painted "X." Immediately after Katrina, search-and-rescue teams went to each and every building across the Gulf Coast. The teams would tag each building (both residential and commercial) with an "X," and each quadrant of the X had a different piece of information: the date searched, the team that was there, the number of human bodies inside, and the number of dead animals (pets) inside. Fortunately, almost all of these orange Xs had zeroes or empty space in the last two fields.

The street was much narrower than it had been two weeks ago, due to the fallen trees and debris already starting to be pushed to the road. Power crews were also out in force, with their trucks in the road making the street just barely passable. Downed power lines crisscrossed the street and hung from tangled branches. At long last, we reached our house.

A massive tree had fallen across the front yard, completely blocking the driveway. A branch of the tree had punctured the side of the house, emerging in the master bedroom. The yard fencing on the other side was squashed under more fallen trees. Two beautiful magnolia trees in front had been stripped of leaves and now looked half-naked. A few towels and quilts were draped on the fallen trees, already bleached from the hot Mississippi sun.

We climbed the stairs to the screened front porch and tried to unlock the front doors. The doors were massive and made from solid wood, which meant they had warped stuck and refused to budge. I hopped the fallen fence and walked around the side to the back, climbing over a few more trees.

The back deck had been completely flipped over, concrete anchors up in the air. A huge tree that had been in the middle of the deck became uprooted during the storm; presumably the water loosened the roots while the wind pushed the tree down. When the tree fell, the roots came up, and the deck went with them. The whole process must have been terrific to watch: the charcoal grill landed neatly under the deck, only now upside-down.

With the deck out of the way, the back door was now four feet off the ground. I climbed up and unlocked the door and stepped into the mudroom, never more aptly named. The carpet was still sopping wet, squishing with every step.

I continued around the corner into the play room and then the living room. The wooden floors were horribly buckled. The glass screen of the television (bought only a few months ago) was marked with a horizontal line of dried debris, the water line, at about 3 1/2 feet off the floor--which translated to about 6-7 feet off the ground. We were about 1 mile north of the beach.

The boys' bedrooms were strewn with books and toys, while the beds had been neatly submerged, now giant wet sponges. In the master bedroom, our wooden dresser had tipped on its side and refused to be moved.

We opened some windows for ventilation, and to half-heartedly drive off some of the pervasive odor of mold. Back in the kitchen, flies buzzed around half-emptied juice bottles. I tried to take stock of what might be salvaged, especially before any looters thought the same. The wedding china was above the floodline in the cabinets, all intact. I wrapped it up in some of the boys' clothing, also preserved. A desk in the hall still held a book of blank checks, some photos, and personal trinkets. The jewelry chest from the bedroom fell apart like cardboard, but its contents were still present, if covered in muck. Most of our photo albums and my wife's wedding dress had been stored up high and untouched. Also saved were my collection of my father's cuff links, an audio tape of my wife when she was a toddler, and a few paintings done by my wife's grandmother. Lastly, I returned to the kitchen and grabbed a still-unopened bottle of Canadian whiskey, given to me by a medical student I had preceptored, and I tossed the remaining bottles of booze out of the window (lest they serve to attract vagrants into the house). We locked up the house, loaded the car as much as we could, and I walked two doors down, where our neighbor had Oscar the dog.

Nearing her house I heard a frantic barking. Oscar and two new canine friends were having a run of the place, cavorting and having a grand old time. The house's human resident came to the door, apologizing for the mess, at which I had to laugh. Oscar had been a fine houseguest and she had been happy to oblige. I offered my profuse thanks and asked if I could get her anything on my next trip down, perhaps in a week. "Fresh fruit," she said. "What I wouldn't give for a nice orange, or a banana." Her Jeep had been flooded, ruined, and she wouldn't be going anywhere, anytime soon.

We wrangled Oscar into the car, with much jumping and licking, and started to drive out. It was now about 4:30 in the afternoon. But we had one last place to go before returning to Birmingham.

The HIPAA in the room

With all the talk about HIPAA and its hassles and headaches, I had to share this little incident:

A few days ago I received a call from an irate mother. She wanted to know why we were blabbing her daughter's medical information all over town.

Excuse me?

"Well, I got a call from my baby's daddy's wife, and she heard from y'all that my baby had been to the doctor nine times, and she wanted to know what was wrong that a 3-month old had been to the doctor nine times."

Ma'am, first of all, why do you care what your baby's daddy's wife is telling you? Second, what is your current relationship with the baby's daddy?

"He's not involved, he's never been involved from day one and he's got no intention of being involved."

Okay, ma'am, but do you have a court order granting you sole custody, or another legal document excluding him from care?

"No, I haven't gone through that yet, but I don't want you sharing information with no one else."

I understand, ma'am, but he is still the father and he still has the right to information. We don't have to share information with his wife if you choose, but do have to release information to him, unless you have a legal document saying otherwise.

"You're saying that anyone can call up and say they're my baby's daddy, and you'll give them the information?"

Yes, if someone claims to be the baby's father we will take him at his word; we have no way to prove they aren't, and no reason to either.

"Well that's not right."

And, then, a few days later:
"I want a copy of your HIPAA policy."

Now, for all that HIPAA does and does not cover, it doesn't give you the right to keep the baby's daddy out of your baby's medical record, as long as he still retains legal status. Get down to the courthouse, sort it all out between the two of you, then come back with an official piece of paper, and my wish is your command. Nevertheless, I can just imagine a call from the feds:
"Is it true you gave out Protected Health Information against the mother's wishes?"
"Isn't it true that you don't verify the identity of parties requesting Protected Health Information?"
"Did you make a notation in the chart as to who has received information?"

For the record, my staff (both of them) denies ever giving any information to anyone about this baby. This is a small town. It's just as likely that someone was in the waiting room one day, overheard a couple things about "past appointment" and "next appointment", and then told baby daddy's wife. But it's all irrelevant, because this has nothing to do with HIPAA. This has to do with dysfunctional family arrangements. And yet, I can see HIPAA becoming the blunt club, the shotgun, the tool used to cause retribution.

Three more things:
(1) I'm not sure HIPAA ever solved any problem. Was there a serious epidemic of doctors releasing information to unauthorized parties? I am much more aware of privacy issues now, which is a good thing, but could someone show me that there ever was a problem before? If we want to discuss privacy, let's talk about corporations and federal agencies losing laptops with thousands of social security numbers...
(2) I realize the terrible meta-irony in discussing HIPAA issues by using the example of a patient who is already concerned about HIPAA. What if she comes across this blog and feels that her privacy has been violated yet again? Nevertheless, I haven't touched on medical issues (so it's doubtful that HIPAA truly applies here), and she would have a hard time proving that this little incident described here has now compromised her privacy and identified her to the world--unless she herself has been spreading the story...
(3) So, when will I be getting a call to appear on the Jerry Springer Show?

Another iteration of tragedy

My thoughts and prayers go out to those at Virginia Tech having to deal with unspeakable tragedy.

I cannot pretend to imagine what it must be like for a university to lose so many of its community in one day.

And yet...

I remember going out to dinner with my wife on a spring evening eight years ago. We were in an Irish pub in East Boston. The television in the bar was showing footage of a horrible massacre in Littleton, Colorado, at the local Columbine High School.

I was in my last year of residency, and I was working on a free-form elective rotation, looking at firearm injuries, where and how they were occurring, and different ways to address the problem: office counseling, community education, product design, legislative efforts, and such.

I remember saying to my wife that this country has a choice. We can sharply reduce the probability of another such event happening, but it would require a political turnaround, implementation and enforcement of strict gun regulations, and a massive grassroots clamor saying "enough is enough." Or we can continue to hold high our right to bear arms, our right to armed self-defense and recreation, realizing that events like this may be the price that we periodically pay for that freedom.

This is the choice we have made, and we must reluctantly acknowledge its occasional and tragic consequences. Let us express our sympathy, our condolences, our anger at this event. But let us not be so naive as to be shocked or indignant, both now and when it inevitably happens again.

The Last Generalist

Are pediatricians an endangered species?

This is the question that was recently posed on a listserv I read, as well as here and here and here. Stagnating or declining reimbursement for primary care and escalating financial pressures (particularly for vaccines) make it harder and harder for pediatric practices to survive. Meanwhile, nurse practitioners and retail-based clinics are claiming they can do the same thing we can, only with more convenience and less cost. The future doesn't look good.

A CEO of a Boston hospital believes insurers will eventually start realizing the value of preventive medicine, and start reimbursing, or shifting funding, accordingly.

But insurers--not to mention the government, via Medicare and Medicaid--have long known how good a deal preventive medicine is. There's even been data to back it all up, for years and years. Just look at vaccines. Yet insurers continue to pay ridiculously low amounts for vaccines (sometimes even under our purchase cost!), or similarly pathetic rates for infant check-ups. Because they can. They know (as I alluded to in my last post) that doctors--especially primary care doctors--are not businesspeople. We are here to help others, and if we have to shoulder some of that burden to care for our youngest and most vulnerable, we do it. The surgeons raise a proper stink if they don't get "fair" reimbursement for that gall bladder removal or tonsillectomy; we just suck it up and see another few patients per day.

There has been talk about creating value. Fight the retail-based clinics by offering evening hours, or open-access appointments (a type of scheduling that basically insures everyone who wants to be seen, is seen, that day). Show the insurers the data that our great care can keep the kids out of the expensive ER, and is therefore worth something to them. Or create programs that offer convenience and value to both patients and insurers--such as weight-loss classes, new parent discussion groups, or asthma education sessions.

These suggestions are great, but they can't be done by a solo pediatrician, or even a small group. Only a large group can do it. And many are doing it, or at least starting.

The days of the solo pediatrician are indeed numbered. The pressures are too great, and the innovations can't be reached, at least not without burning yourself out.

This doesn't spell the end of pediatricians, however. A good friend and colleague of mine likes to say that pediatricians are the last generalists. I don't mean your country doc, cradle-to-grave caregiver, delivering babies in the middle of the night at the Smiths' farm and being paid with a hog and a bundt cake. (There may be a few of those family practitioners still around, but they're not even endangered, they're basically extinct, outside of film or TV.) I mean the I'll-treat-anything-that's-bothering-you doc, the absolute-expert-about-the-whole-person physician. The Save-The-Day kind of doctor who, in this case, is the ultimate authority on kids. The doc who can resuscitate and stabilize a premature infant, start an umbilical line, calculate a drip, bag and intubate, and perform the spinal tap, all at 3 a.m. The doc who can differentiate ADHD from a learning disorder from a simple acting out, and start correcting any of the above. The doc who, even if he can't insert the ear tubes, can still keep straight a chronic serous otitis from a Eustachian tube dysfunction from an acute suppurative otitis media, figure out the right medicine, and--most importantly--explain it all to the mother who never made it past seventh grade. And the doc who might talk to the local PTA about newly licensed vaccines one night, and to the district attorney about a case of child abuse the next.

We may not do all of those things everyday, but we've been trained well enough that we can. If it concerns kids, we can handle it. Period.

And--I know this is going to get me some of my first hate mail--that Medical Degree means something. I'll say this with sincere respect: NP's can do great things, and bring wonderful perspective to the craft of medicine. Both NPs and MDs can follow protocols, develop judgment from a wealth of experience, and communicate well. But the MD has the base and the background to be the Authority. Only the MD has the training in biochemistry, psychology, pathology, pharmacology, epidemiology, research, the whole toolkit, and the mindset to be able to deal with the unexpected. A pediatrician's scope of practice is limited only by what he or she wants to tackle.

As long as that remains true, there will be a need for pediatricians. We are the generalists who specialize in children. We may be practicing in large mega-groups, or employed in government clinics, but we will be around as long as there are kids.

And maybe that's what I like best about being a pediatrician.

AAUGH!

Just like Lucy pulling the football away from Charlie Brown, Medicaid loves to play games with the pediatrician.

For the uninformed, a primer: Medicaid is the government's "safety net" insurance program for the poor. Many children are covered by Medicaid (in fact, here in Mississippi, about 3 out of 4 are). The federal government provides much of the funding, with the rest coming from each state, and each state also administers the program. Each state provides benefits as it sees fit--within certain broad federal guidelines--and can also set provider reimbursement in a similar way.

Medicaid represents government at its best and worst. The concept is wonderful, and enables patients to receive care at any willing provider. But the bureaucracy can be inscrutable, bizarre, and sometimes downright moronic, bordering on abusive and arrogant.

At the end of last week my billing manager was reviewing our past few statements from Medicaid, and she found that most of our newborn nursery visits were denied without payment. Late last year Medicaid started requiring prior authorization on many inpatient hospital stays. But babies born eligible for Medicaid don't receive their official Medicaid numbers until 4-8 weeks old.

You can't give a patient a "prior authorization" before they are born, and you also can't give them a P.A. before they have an ID number! The customer service rep agreed, and brought in her supervisor, who told us the grim news: a computer glitch was unexpectedly and incorrectly kicking out these newborn visits. Payment would be forthcoming when the problem was fixed--but that could take weeks to months.

I don't have a problem with providing charity care, as long as I determine the when and how. But I draw the line at systemically providing care for free, particularly when a payor tries to make it so. I can't pay my overhead on goodwill.

And so I am boycotting Medicaid babies until the problem is fixed. No more nursery coverage, unless I absolutely must (e.g., hospital call). I'll see them as soon as they are discharged, for an office follow-up visit. No payment, no care. Or, as others have said, "no margin, no mission."

This is not ideal care. In fact, some might even call it dumping on my colleagues, who will now see "my" babies on "their" nursery rounds. Of course, they have the option to do the same as me, in which case we all dump on each other, and it all evens out. They also have the option to suck it up and continue to provide free care, in which case you may call them "patsy," "sucker," or "loser."

Perhaps I'm deluding myself, but I like to think my profession entails doing some good in this world. I make sure kids stay healthy, or get healthy. This is not about "playing games" or pushing paper, this is about real-world results and making a difference. Compare and contrast with those who seem to erect barriers to said goals.

I'm not accusing Medicaid's bureaucracy of purposefully creating these computerized denials. But I think their response will be most telling, as to how quickly they fix the problem. And trying to deny proper due payment to providers for services rendered--especially contracted services delivered to poor babies--is most certainly "playing games."

Dog Days

Everybody, say hello to Denver Pickles!

The dog, the legend, here he is...

He would love to jump out of the screen and into your lap, if you'd only let him...He won't bite, he doesn't pee in the house (well, um, usually), and he's an adorable wiggle-butt and snuggle-puppy.

It's Denver Pickles!

We don't care how they do it in New York, and apparently the feeling is mutual

I caught a glimpse of the NBC Nightly News last week and was surprised to see a feature story about Dr. Persharon Dixon, a pediatrician who left Atlanta to work with the local community health center here after the storm. The health center has her riding around in a mobile van, a rather ingenious setup. The van and her work is sponsored by the Children's Health Fund out of New Yawk.

The broadcast gave me a peculiar feeling of pride, revulsion, and anger.

Only the first emotion is directed at Dr. Dixon. I've met her, and she's a wonderful woman and pediatrician, very sincere and caring. I have nothing but good things to say about her.

The latter two emotions I reserve for the Children's Health Fund.

A mobile health van is a good thing. A community health center is also a good thing. But so are local pediatricians. I don't claim to know the timeline or organization of CHF's involvement with healthcare on the MS coast after Katrina, but I do know this: CHF sure as hell never called me. Not to ask what I thought the kids might need, not to ask how CHF might integrate into the existing health structure, not even how we might work together.

All right, Dr. Scott: be reasonable! They have no obligation to call every pediatrician on the coast. You are a private practice, they hooked up with a non-profit. Besides, they're here helping out, just be grateful and appreciative!

First, there aren't that many pediatric practices on the coast. Here in Hancock County there are three pediatricians, and one of them already works for the community health center. How hard would it have been to pick up the phone and call the other 2 pedi's here?

Second, and more importantly, good intentions are no excuse for arrogance, particularly when intruding on someone's home turf. The CHF has a press release which notes that Mississippi already had pathetic medical care before the storm, and a shortage of primary care physicians. That may be true, but not on the coast. Me and my colleagues are not ignorant back-woods hicks who need us a little edumacation from the big city experts. We need help, not competition. Yes, we can learn from CHF's experience, but they can also learn from ours.

And so, once again, the locals continue to toil for (what somedays appears to be) naught while the out-of-towners grab the attention. "Look! Look at what we are doing for these poor Mississippi children! Look how we are helping when no one else will!"

Go ahead, call it sour grapes. I know I have it coming. But when the spotlight leaves, will the local providers leave also? Having exhausted our resources, with no outside help for us, what will happen then? I hope CHF has a fleet of those mobile health clinics ready, because that's all that may be left for health care on the coast.

Tweaking

"We should meet. And we will meet. But I'm in the middle of a project that needs...tweaking."
--Joe Fox (Tom Hanks), "You've Got Mail"

The accountant is perusing my tax information, perhaps as we speak. But Dr. Scott has still been quiet and neglecting his blog.

I am in the middle of a major project that needs...tweaking.

Actually, two projects. One is a conference next month. I have been invited to speak about Katrina. I had a talk already prepared, it just needed updating. Then the conference organizer asked if I would prepare a second talk as well. So now I am dividing my talk in two: the first, as a "general interest" for pediatricians and spouses and invited guests, tells the Katrina Story from the days before August 29 through the present (and the future). It describes my personal experiences, as well as what the community as a whole has faced (and continues to confront). And I thank y'all for giving me the impetus to put Katrina Story in writing (even if a meager 7 chapters so far); it has been great rehearsal and even better organization for my scattered thoughts.

The second talk will now be about the medical lessons from Katrina: the illnesses, injuries, and environmental hazards after the storm (including, but not limited to: "Katrina Cough," MRSA, mosquitoes, black widow and brown widow spiders, and formaldehyde in FEMA trailers), the mental problems (PTSD, depression, anxiety, and "Katrina Brain"), and...for the first time anywhere...a critical look at long-term healthcare delivery in a disaster area.

I'm getting psyched just thinking about it, but I've got a couple of work-heavy weekends ahead in preparation for this.

I mentioned a second project. That one is actually far bigger and more important. But I am not at liberty to share the details with you at this time. Soon. It needs...tweaking. A lot of tweaking. Sorry to tease you like this, dear reader, but when I reveal my secret you will understand all. For now, I just wanted to let you know that you have not been forgotten; I've just been preoccupied with other matters of importance.

TTFN.

Death and Taxes

Yes, the blog has been quiet recently. I spent last week (especially the weekend) gathering receipts and whatnot for my accountant. It took many many hours, to which my wife asked, "if you've spent this much time already, why not just finish the tax form yourself?" To which I replied:

1. I don't know enough about depreciation, nor the items that may have been depreciated over the last 2 years.
2. I'd feel more comfortable handing it over to the accountant (transfer of responsibility).
3. I've got more important things to deal with right now.

Now I have to find a way to pay for the taxes. And that was another thing I did this past weekend: signed the final paperwork on my SBA loan. (This is the "Death" part.)

I am now owned by the SBA. Or rather, in a few weeks, my house will be. The SBA requires they be listed on the mortgage and deed. They also need receipts to verify all money has been used "appropriately." On the last, I pointed out that the loan is "payback" on money that was spent over a year ago. Still: no receipts, no more money. And if I get any future insurance settlements related to Katrina, it gets applied against the SBA loan. None for me.

It took 18 months to get to this point. And all so I can get 4% interest on a 30-year note.

I realize the government is trying to limit fraud and to make sure that the money is spent only on replacement needs caused by disaster. But, consider this:

At the same time I completed my SBA application - October 2005 - I went to my local bank for a "GO Loan." These were special short-term Katrina-zone loans issued by banks, with no interest, but they were due in 6 months. The GO Loan had a two-page application. I was approved, and received $25,000, in about 2 weeks.

While the SBA officer was very helpful and friendly, the SBA as an organization brings to mind the worst of sadistic bureaucracies. It makes the IRS look like a model of efficiency and kindness. There has GOT to be a better way to get money to people. And don't forget, we're talking LOANS, not GRANTS. Why couldn't the local banks handle this, just like they did the GO Loans? Just a thought.

Meanwhile, I need to think how to repay the SBA Loan, which is paying my taxes, which are the price I pay for starting and continuing my practice on the Gulf Coast. My, don't I feel privileged being here right now.

Tourists, Go Home

Ever since Katrina passed through, tourists have been coming here by the carload and busload to see the devastation. On the whole, I've been a supporter of this idea of "disaster tours" or "disaster pilgrimages." As much as you might read or see of Katrina, I assert that words and pictures simply cannot convey the total experience. In order to fully understand Katrina, you must experience its aftermath first-hand: the 360-degree immersion, the assault on all your senses, the mind-numbing sight of block after block of debris and destruction. Even at this late date, 18 months after the storm, most outsiders would be shocked at the extent of what has not been done, and the further publicity of such can only help.

Besides, this event has become part of history, and it's only natural that people will want to come and bear witness, to tell their friends and family, just as crowds flocked to Ground Zero in New York City in the months after 9/11.

All the same, this is not a sterile museum exhibit, or an isolated preserve. People live here. People work here.

About once a week I'll be driving home, and a car ahead of me will stop. In the middle of the street. And people will step out and gape and start taking pictures.

Other times cars will creep along Beach Boulevard at less than 10 miles per hour.

Please, people! I wouldn't drive like that if I came to visit your town!

Yes, by all means, come and see the devastation for yourself. Contribute your dollars to the local economy while you're at it. But is it too much to ask that you obey basic driving rules? We've been through enough already. If you're going to come and visit, at least show some respect for the people trying to live semi-normal lives here. Not stopping in the middle of the street would be a great start.

Katrina Story, Chapter 7: Damage Assessment

We drove through the National Guard checkpoint and turned left on Highway 90, towards my office and the hospital. On the corner we caught a glimpse of the K-mart parking lot, now known as "Camp Katrina." Survivors and volunteers alike had congregated here and proceeded to take over the lot, which was now populated with RVs, campers, and tents.

The tire store in front of the K-mart looked like it had collapsed in on itself; the glass was smashed and the metal garage doors were caved in. Along the road, store signs were either down or the plastic blown out, leaving gaping rectangles. Some stores had their roofs torn off or fallen inwards.

We continued down Highway 90 and arrived at my office. The building looked largely intact from the outside, even though its neighbor had lost its metal roof. I peered in the waiting room and saw chairs and tables intact, on the ground, if not in the exact position where they had been 1 1/2 weeks ago.

I unlocked the front door and was hit by an overwhelming smell of mold. Wallpaper in the hallway was warped and buckling, and part of the hallway wall had actually given out, exposing the flooring store next door.

Picture my office as basically one long hallway. From the waiting room, the hallway went down the left side of the office. First room on the right was the reception and business office, followed by three exam rooms, and then my office, which was also the break room, which had a back door to the outside. The lab was across the hall from my office.

The reception/business office was trashed. Ceiling tiles had collapsed to the floor, covering a desk and bookcase with grey foam on the way down. The flood line was three feet off the floor, just above the desktop computers, laser printer, flatbed scanner, telephones, and all other electronic equipment. A horizontal file, which had been completely submerged, wouldn't even open anymore.

The exam rooms originally had white vinyl floors, but now they were just a thick brown-grey, covered with muck. The exam tables had also been submerged, and water still remained in the drawers. I couldn't even enter the third exam room; presumably a chair had floated between the exam table and the door, blocking the way.

In the lab, the refrigerator had tipped over on its side. Vaccine vials were strewn across the floor. But as I entered the back office, I realized the office had saved the worst for last.

The back bookcase, which previously held my medical textbooks, was now half-full, as its contents were strewn around the room and up the hall. My desk was tipped up at an angle, with a book somehow wedged under one corner. Whatever had originally been on, and on top of, my desk, was now also on the damp floor. The break room refrigerator had floated out of its corner into the middle of the room. The office server, placed up on the nurse's desk, was neatly covered with water, muck, and even dried leaves and grass.

I tried to open the back door to let in fresh air, but it wouldn't budge. On further inspection, I saw the back door had been wedged out of its frame. I wondered if a looter had tried to break in to the office. I then took a closer look at the door between the back office and the hallway. The door, including frame, had been torn out of the wall and was lying at the end of the hall. No looter did this. I realized the storm surge must have built up outside the back door, until it was breached; then the flood waters came in with such force, like a burst dam, that it swept books off the shelf and pushed the inner door completely aside, before tossing about the refrigerators and furniture.

I set to gathering a few basics, knowing that we had limited space in the car and had yet to visit the house. Salvaged from this first trip: office spirometer (purchased two weeks before Katrina, never used on a patient), cash box contents, damp office files (receipts, contracts, personnel papers), hard drives from desktop computers, and the office computer server. The latter weighed eighty pounds and drained water when we lifted it, but I hoped against better judgement that something might be salvageable--perhaps, if nothing else, the hard drives? Besides, if the drives were even remotely intact, they might have recoverable patient medical data, and I couldn't risk that information falling into the wrong hands.

We got back in the car to drive next door, to the hospital.

What used to be a hospital now looked like a military base. Army green tents covered the front lawn, and a black metal fence surrounded the entire military-hospital complex. On the road, a wooden sign painted green had a red cross letting people know that this was where they could get medical care. National Guardsmen milled about or walked to and fro. We drove up near the ER entrance, where we faced another guard post and more soldiers with M-16s. After producing my hospital badge, we were waved through and pulled up to the ER itself.

The waiting room had become a warehouse, where both donated and pre-existing supplies were being organized into neat stacks and piles. Here was the sterile gauze, there were boxes of gloves, that's the place for diapers and baby food. Extension cords snaked through the ER and the hallways, running from generators to construction floodlights. I found the hospital administrator in his new "office," a dark nook of the ER that used to be the staff lounge and library. He was talking to the head of maintenance on a two-way radio, hopeful that Mississippi Power might be able to restore electricity to the hospital this afternoon.

As it turns out, the hospital had not closed, but instead remained open during the storm. By the time they tried to evacuate some of the sicker adults, the storm was upon them and ambulance transports were no longer running. The wind ripped open a ventilation duct during Sunday night, but otherwise the building did fairly well until Monday morning, when the storm surge arrived. The first floor hallway became a stream. Then the generators flooded. As the water level continued to rise, the staff started evacuating patients up to the second floor, in the dark, in the heat and humidity.

After the storm, the worst was yet to come. Within a few hours, a steady stream of survivors began making their way to the ER. A nurse described it as a scene straight from "Dawn of the Dead," with an advancing horde of staggering, dazed people. Many had physical injuries: cuts, bruises, scrapes; others were trying to find food and water, though the hospital barely had enough for its own personnel. Some just wanted to be checked out after their ordeal. The makeshift ER ended up seeing 800 people in the first 4 days, before the federal Disaster Medical Assistance Teams finally arrived. Only then did the hospital close its doors and the brave, battered staff go off shift.

Needless to say, the hospital was in no shape to reopen anytime soon; the CEO thought it would take at least a month before even the basics could be provided. I asked about office space, since mine was completely unusable, as was just about every other building in town, and it might be two months or more before electricity and running water was restored. He said that FEMA might be providing the hospital some portable trailers in the next few weeks, perhaps by the start of October, and that the hospital would allow interested doctors to use the temporary space. I also learned that FEMA does not provide trailers directly to doctors; apparently, we are considered the same as any other small business, and our services are not essential to the community, no more than the local burger shop or clothing boutique.

Now we had some timeframe and direction: a hospital-provided trailer, in early October. This would be my new office.

Before I left the hospital, passing stacks of donated medicines arrayed in the ER, I realized I probably had some intact samples back in my office. The administrator said, "yeah, I don't think we went in your building." What did that mean? In the first few days after Katrina, the police and National Guard broke into some offices to commandeer medicines and create a small stockpile at the hospital. It was decided that the meds could better be kept safe, and distributed as needed, under appropriate supervision, at one central facility--which now happened to be also under armed guard. I should note that some offices stored not only antibiotics or cholesterol meds, but also controlled substances: painkillers, Valium, and similar.

We offered to add my meager pediatric samples to the pharmacy, since I wouldn't be distributing them anytime soon. We ended up collecting five boxes worth of medicines, all above the flood line, untouched and usable.

Outside the ER a truck from the Florida Department of Health was unloading bags of ice.

We walked back towards my office, about three blocks away. Just outside of the hospital grounds I saw a multicolored foot-long shard of hard plastic that looked vaguely familiar. It was a fragment of my office sign that had originally been by the road, perhaps 1/4 mile away. It was the only piece of the 4 x 6 foot sign I would ever find.

Jurisdynamics

The other day I received a blogosphere welcome from Jim Chen, Dean of Law at University of Louisville. Lest you think I routinely have friends in high places, I first made an "Internet connection" with Professor Chen through his blog, Jurisdynamics.

I don't remember exactly how I stumbled across his site, but I've found it to be incredibly insightful and thought-provoking on, among other things, the law as it relates to disasters. The site is actually about "the interplay between legal responses to exogenous change and the law's own endogenous capacity for adaptation."

Huh?

That sounds pretty heavy, but my interpretation (and I hope Dean Chen or his colleagues will correct me if I'm wrong) is that Jurisdynamics deals with the law's application towards, and evolution around, a rapidly changing and complicated society. Since we can't expect any single judge, lawyer, or lawmaker to be an expert on the many developments in technology, computers, communications, complex nonlinear systems, medicine and healthcare, even sociology and mathematics, we need to make sure that the legal system can be flexible enough to accomodate new situations. After all, at the risk of getting classically philosophical, what is the purpose of law, if not to serve the good of common society?

So Jurisdynamics is nothing if not interdisciplinary. But it's also fairly down-to-earth. You won't see (many) obscure Latin phrases, high-falutin' references to so-and-so court cases, and such. It's about ideas; it's about practical concerns. It's not concerned with impressing anyone; it is concerned with exploring issues.

And though I've never personally met the man, I get the impression that Jim Chen is much the same. Go to the site and peruse his CV: Fulbright Scholar; Harvard Law School; clerk for Justice Clarence Thomas; visiting professor in France, Germany, and Slovakia; 91 published papers or chapters; and now, dean of a law school. I stand in awe of this man's accomplishments in his field. But look at the papers he's written: the titles are full of witty cultural references: "A Vision Softly Creeping," "Come Back to the Nickel and Five," "Midnight in the Courtroom of Good and Evil," and my favorite, "The Sound of Legal Thunder: The Chaotic Consequences of Crushing Constitutional Butterflies." (Five points to the first reader who correctly identifies that last reference!) And I get the impression he has great respect for the English language, not as a crude tool for hammering out papers, but as an art form, as an elegant vehicle for complex thoughts.

I see Dean Chen and his CV and his intellectual curiosity and breaking boundaries, and I can't but help to admire him. That is what I aspire to, professionally speaking. That is one reason I want you to check out his blog. (Note: I say "his" blog, but in giving credit where it is due, I want to point out that Jursidynamics is not a solo effort, but rather the collaborative work of an exceptional cohort of scholars.)

The other reason? If you have any interest in Katrina, the failed response, and the stumbling recovery, you need to keep up with his site. It won't go into every breaking news item--just the important ones, and how the law can either help or hinder current and future efforts.

It's All In Your Head

I realize that making fun of Scientology's take on mental illness is an easy and cheap shot (much like Tom Cruise himself nowadays). Still, a patient yesterday reminded me of just how laughable/misguided/disgraceful such a denial is. For the few of you who don't already know, Scientologists believe all mental illness is curable through sheer willpower and exorcism of personal demons (the latter on multiple levels), and therefore they proclaim psychiatrists to be frauds who like doping up kids for money.

Of course, Scientologists believe the gospel according to L. Ron Hubbard, a hack sci-fi writer who invented a religion based on the evil space warlord Xenu and the "thetan" spirits that inhabit our bodies. Or something like that. No, really, look online if you don't believe me. Doesn't sound like they're in any position to judge the mental fitness of anyone else.

Anyway, without divulging too much detail, yesterday I saw a six-year old who was depressed. WAY depressed. Not like "I feel sad." More as in, "I hate everybody. Everybody is mean." Sitting on the exam table quietly, looking down, not cracking a smile, for the entire 30-minute visit. Mom says he's been like this every day for 2-3 weeks now, doesn't even want to play his video games.

So, Tom Cruise, want to try to clear his thetans? John Travolta, do you believe you can make this kid happy again?

It's fair to say, without being judgmental, that this is not normal for a six-year old boy. It also doesn't take a clinical psychologist to realize that there is something acutely screwed up in his brain chemistry. Adults with major depression will remind you that their condition is not simply a "bad mood:" it's more like being taken over, becoming physically and mentally incapable of rising above. Yes, there are many factors converging here: his home and family environment, his intellect and inherent ability, his experiences around Katrina. But none of this accounts for why a six year old boy would act like this for 2 weeks straight.

He needs to see a psychiatrist. Pronto. Unfortunately, there are none around here. I'm not averse to prescribing meds myself, when appropriate--but antidepressants are tricky. Last year the FDA became concerned about a few case reports of teenagers becoming agitated and even suicidal while on antidepressant medications (specifically, "SSRIs" such as Zoloft, Paxil, and Prozac). The FDA mandated a "black box warning" and urged extreme caution. So us pediatricians (already being told by many insurance companies that psychiatry was "not our area of specialty" and therefore not a reimbursable office visit) didn't want the extra liability, and we stopped prescribing SSRIs ourself, and referred all depression to the child psychiatrists.

Of course, the vital statistics released last month revealed a double-digit percentage increase in childhood suicides last year. Gee, who would have thought: if you don't give people antidepressants, they become--wait for it--depressed, and depressed people are at risk for being--wait for it, again--suicidal?

The perfect storm: politics, legal liability, and ivory-tower academics. But until the FDA decides to rescind that black-box warning, I'll be in BIG BIG trouble for any adverse effects from SSRIs that occur on my watch. I picture the malpractice lawyers licking their chops like ravenous wolves.

The mom assures me that she will watch and notify immediately if the child becomes a danger to himself or to others. In the meantime, we've spent 2 days trying to find a child psychiatrist (thank goodness he's not on Medicaid, or we'd be really screwed). We may have one an hour away, if we're lucky, who might be able to get him in one month from now (and mom will have to pay cash because she hasn't yet met her insurance deductible). And I guess he'll just have to suffer through it until then.

It's Mardi Gras Time!

The Waveland Krewe of Nereids held its annual Mardi Gras parade yesterday. For those of you not from the Gulf Coast, Mardi Gras is a BIG DEAL here. The Waveland parade may not be anything like you find in New Orleans, but it did have 80 floats, and it is one of the more family-friendly parades on the coast.

Afterwards, the streets looked like a giant pinata explosion, with colored beads and trash and smashed cups strewn everywhere. They're still cleaning it up as we speak, and by tomorrow it will be just another memory--but one of the happier ones as of late.

Pandemic Panic

Amidst the hoopla over the Gardasil (HPV/cervical cancer) vaccine this week, one news item largely overlooked concerned OSHA and the CDC issuing more pandemic flu guidelines. In the event of a severe pandemic, children would be largely quarantined; no school, no daycare, no spreading the nasty little hobbitses...er, I mean, flu viruses...until the pandemic started to abate.

By itself, that sounds prudent. Past studies have shown children to be the principal "vectors" for spreading the flu. Interrupt transmission by keeping them away from each other.

I'm curious if anyone on the federal level has considered the economic consequences of this. As a med school professor used to say, "if this is true, what does this imply?"

No school or day care means teachers and day care workers out of work, possibly for as long as 2 months. Parents will need to take off work themselves to care for their children. And parents' employers will no longer be able to function. Even if we prevent the flu from causing widespread death (which is very optimistic), the US economy would basically crash.

Has our government considered how they would bail out millions of small businesses? Pay for massive unemployment benefits? Would public employees still be paid?

On a personal level, what will happen to healthcare? Will I basically shut down my pediatric office for 2 months? Will I temporarily confine my practice to check-ups and children without fever or respiratory symptoms? Will I only allow one child in the office at a time? Will I leave my office to staff the ER? Note that none of these options leave me with a financially viable practice. After Katrina, I don't have any more financial reserves. A two-month shut-down--or even a slow-down--would most likely cause me to go under without state and federal assistance.

The devastation from Katrina will be repeated, but this time on a national scale. I'm not talking about the physical destruction; I'm referring to the economic fallout. The fact that we have still failed to address the Katrina recovery makes me very, very scared that pandemic flu would be far, far worse.

Have a nice day. >:)