Just Practicing

This Week in Mississippi

2007-08-28T21:03:00.000-06:00

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

2007-08-21T18:59:00.000-06:00

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...

2007-08-08T19:35:00.000-06:00

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

2007-07-31T21:49:00.000-06:00

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

2007-06-25T18:33:00.000-06:00

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

2007-06-24T16:00:00.000-06:00

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?

2007-05-24T11:40:00.000-06:00

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

2007-05-23T17:29:00.001-06:00

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...

2007-05-07T09:51:00.000-06:00

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

2007-05-03T10:26:00.000-06:00

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

2007-04-30T13:30:00.000-06:00

(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

2007-04-27T07:55:00.000-06:00

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

2007-04-17T12:40:00.000-06:00

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

2007-04-06T13:43:00.000-06:00

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!

2007-04-03T18:09:00.000-06:00

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

2007-03-22T10:59:00.000-06:00

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

2007-03-21T09:31:00.000-06:00

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

2007-03-15T20:14:00.000-06:00

"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

2007-03-06T13:45:00.001-06:00

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

2007-02-26T13:40:00.000-06:00

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

2007-02-22T15:00:00.000-06:00

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

2007-02-19T13:34:00.000-06:00

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

2007-02-16T10:57:00.000-06:00

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!

2007-02-12T13:44:00.000-06:00

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

2007-02-09T10:40:00.000-06:00

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. >:)

Katrina Story, Chapter 6: Birmingham and Beyond

2007-02-08T14:54:00.000-06:00

One week after Katrina, we were back in the car, this time to our soon-to-be host family in Birmingham. By the time we would arrive at our new temporary home two days later, J. (all of 2 years old) clearly had become unsettled by the experience of, well, being unsettled. Over the past week we had driven hundreds of miles and spent the night in six different places. Little J. may have had some idea as to what had happened in Waveland, but that didn't affect him as much as the immediate lack of stability and his world turning upside-down. He began to associate the car with this turmoil and responded by kicking and screaming whenever he needed to be buckled into his car seat. The portable DVD player lost its calming effect (even with some new discs we picked up on the way), and we simply had to endure the noise until he tired himself out.

This would last for the next three months.

On reaching Birmingham (and exiting the car) we felt some semblance of calm for the first time since Katrina. Our host family (father, mother, 23-year old daughter, 21-yr old son, 14-yr old son, and 7-yr old son) were warm, gracious, accommodating, and almost eerily understanding. They let us know in no uncertain terms that, despite our protestations, we were not to consider ourselves a burden to them, and that we were welcome to stay as long as we needed. They asked for nothing in return, other than allowing them to help ease our way. Obviously, we would have none of that, and we tried to repay what we could, helping with groceries and meals and whatever else we could, but in the end, it would never be anywhere close to what we felt we owed this family.

In anticipation of our arrival, they had printed a local news item about previously unknown Waveland. A local pilot had flown his plane down with donated relief supplies, and he described massive devastation, but the specifics were otherwise scant. I was eager to drive in and assess the situation first-hand, and the father shared my sentiment, but how to arrange it?

The next day he came to me and asked if I wanted to drive down tomorrow. He, his oldest son, and I would set off before dawn, spend the day on the coast, and return that night.

The plan was set; I packed a backpack with some essentials, went to bed early, woke a few hours later, and we were off. I brought a notebook to remind me of my mission objectives: survey the office, talk to the hospital CEO about possibilities for returning to practice, visit our house, salvage a few valuables, and bring back Oscar the dog.

Approaching within 100 miles from the coast we saw trees snapped like toothpicks and stripped of leaves. We stopped in a Wal-Mart in Mobile, Alabama for last-minute food and water. Mobile had its fair share of damaged roofs but it had returned to being a functional city. As we continued west on I-10, the extent of destruction seemed to grow with every mile. More and more trees were down, as well as metal billboards twisted and folded in half. From the highway we saw only one or two gas stations open, identifiable by the cars lined up for up to a mile distant. (Thank goodness we took the family's fuel-efficient diesel.) Finally, we reached Exit 13: Highway 603, Bay St. Louis/Waveland. The hotel and gas station at the interstate exit were mangled wrecks of concrete and metal. We were about 5 miles from the main road through town, Highway 90, and another 2-3 miles from the water.

One mile from Highway 90, the National Guard was manning a checkpoint, complete with radio antenna and soldiers with M-16 rifles. Only locals or those on official business were allowed through, presumably to minimize looting; my hospital ID and driver's license were sufficient to let us pass.

We had entered the disaster zone.

Your Insurance Sucks

2007-02-05T14:06:00.000-06:00

A mother was in the office the other day, and her child was covered by a certain for-profit, commercial insurance...not to name names, but the company rhymes with "You lie, Ted."

Last year her co-pay on office visits was $20. As of Jan. 1 it rose to $40. She was not happy about this.

I wouldn't be pleased either. And I will go out on a limb and guess that her premium did not decrease. So this health insurance company gets the family to pay $20 more per office visit, and they get to pay $20 less.

That is an awesome way to make a profit: shift the cost to someone else!

Too bad I can't figure out a way to do that (legally, that is).

This same insurance company (whose letters can also be rearranged to form the phrase, "DIE, NUT") announced last year that it would finally start paying for both a sick visit and a check-up on the same day. Previously, it would only pay one or the other. Now most check-ups are pretty straightforward, and minor issues are expected: the baby has some cradle cap, my teenager has a little sniffle today. But every once in a while they present with something more complicated: a wheezing infant, a preschooler with bad behavior problems. If the insurance company won't cover both on the same day, I tell the parent: we can address the problem or do the check-up, but not both. (Expecting a doctor to do otherwise is like taking in your car for a tune-up, finding that your brakes are shot, and expecting the mechanic to fix the brakes for free, since "it's all part of the tune-up.")

Well, this nameless insurance company now says that due to computer issues, it won't start paying for both a check-up and sick visit on the same day until, oh, December 2007.

(Warning: sarcasm ahead.)

Dang, that must be a wicked bad computer problem. They must be getting some serious l33t hacker dudez to crack that code. Maybe they're asking both Steve Jobs and Bill Gates to work together on this one. I mean, how in the world would you program a change in a reimbursement rule? They must be outsourcing that one to, heck, every computer programmer in Bangalore and Boston combined. I hope they're at least consulting with MIT.

"Computer issues?" Really, couldn't they at least think of a better excuse? Though I admit it does sound better than saying, "we delayed the implementation to continue diverting money from the premiums to our shareholders."

I don't want to paint all health insurance companies with the same putrid brush, but as a doctor (or, as they say, a "health care provider,") I think the average person doesn't realize that these companies are first and foremost in the business of making money for their shareholders. If they can provide health coverage along the way, great, but they aren't in this for their health. Nor for yours.

The Secret Lives of Pediatricians

2007-02-01T20:00:00.000-06:00

When I first thought about creating my blog, I had to make a very important decision: use my real name, or hide my identity?

Some medical bloggers, such as Flea or Dr. Dork, prefer to stay secretive. Their nom de plumes write passionate about controversial issues, or reveal much about the men behind the facade. Others, such as Dr. Bryan Vartabedian at Parenting Solved, proudly post as their professional personae (yes, much like Dork, I like alliteration), preferring to speak with a calm, informative voice to the layperson. And some, such as Dr. Mary Johnson at Dr. J's HouseCalls, disregard these rules entirely, with blogs so personal and pointed they simply wouldn't work anonymously.

I knew my blog potentially would fall across all of these categories. My Katrina Story, for instance, can't be told without very personal and revealing details. Besides, a well-written blog can be an marketable asset for a practice, a source of information for patients. On the other hand, those same patients might be turned off by a particularly provocative tirade, or details of my personal life. I thought for a long time about what path to take.

I finally decided to go to the middle. So even though you all know me as "Dr. Scott," I've left enough clues on "Just Practicing" and in my posts that it would not be very hard to find out my Secret Identity. A couple of well-targeted Google searches should do it rather easily.

Now you might ask, why not just come out with it? Why make the general public work for it?

First, I do make reference in my posts to my wife and children, and the Internet can sometimes be an abusive place; I don't want to bring them any unwanted advances.

Second, and more importantly, is that I am a pediatrician.

It's part of my job to foster the wholesome development of children. And what better way to encourage healthy behaviors than model them? So, at least in the public sphere, I have to be careful of my image, whether online, or in the local Walmart.

When Pee-Wee Herman was caught, shall we say, partaking of some adult entertainment, the uproar was not because he was famous. He was the famous host of a children's television show. In theory, what the actor known as Paul Reubens did on his own time shouldn't have mattered. He didn't go to an X-rated movie dressed in his character's red bow tie and too-short pants. Pee-Wee Herman never hinted at such subject matter on his Saturday morning show (not even in a subtle, above-the-kids-heads kind of joke). Nevertheless, adults were now uncomfortable having him entertain their children, and so he disappeared for years.

In an even more dramatic example, the fledgling PBS Sprout network fired its eveningtime host last year. Sprout is a cable/satellite network with programming exclusively for the toddler and preschool crowd: Bob the Builder, Teletubbies, Barney, Dragon Tales, the whiny brat Caillou, and the like. Word leaked out that Melanie Martinez, of their "Good Night Show" segments, had acted in two commercial parodies six years before. The films, called "Technical Virgin," poked fun at abstinence-only messages for teens. No pornography, nothing illegal or even risque, just raunchy humor. Not only were the "Technical Virgin" clips far outside of wide release, but it's safe to say that the young viewers of PBS Sprout were unlikely to encounter this aspect of Miss Melanie, even accidentally in the wider world--unless the major media started making it a big deal, or these toddlers knew how to use YouTube. All the same, this unsavory past was enough to kick her off the show. (As a side note, PBS doesn't seem to mind that George Carlin narrates some of the Thomas the Tank Engine episodes. Perhaps they have a different standard for voice actors? Or just famous ones?)

I don't think I lead a particularly immoral life, but I do want the freedom to post about some of my interests, and receive comments back.

I like the occasional premium ethanol-based spirit. For the holidays my wife gave me a bottle of Bombay Sapphire gin. The word intoxicating was invented for this drink, in every aspect. I've also been working this past year on a bottle of Evan Williams Single Barrel bourbon, a truly sublime Kentucky whiskey. All the same, I don't advocate alcoholic beverages for children.

My wife will be glad to tell you that one of my other vices is video games. Another holiday gift, which I recently finished, was F.E.A.R. This is a first-person shooter that features telepathically controlled paramilitary clone soldiers. I couldn't make that up if I tried. It's bloody, excessively violent, and great fun. It's also rated "M" for a reason. I only play it when my children are fast asleep.

We're not talking about child pornography or something equally reprehensible. Nevertheless, I don't think the parents of my patients need to know these things about me. I don't think they really want to know. Why spoil the illusion of wholesomeness?

And so, if you meet me at a party, just don't tell my patients. And if you do, I'll just deny it all. It's all for the kids.

Katrina Story, Chapter 5: Witness to the Storm

2007-01-30T15:09:00.000-06:00

Maryland may have been a border state in the Civil War (or rather, as some here call it, the "War Between the States"). Nevertheless, it wasn't close enough to Mississippi, which was where we needed to be. My wife called a friend in Atlanta to see if she had any contacts or ideas. Incredibly, she in turn had just been on the phone with a friend of hers in Birmingham who wanted to do something, anything to help after Katrina. This friend-of-a-friend, our soon-to-be-rescuer, wanted to host our whole family for as long as we needed. We were taken aback; they already were a family of 6, and they were willing to host a family of 5, complete with 2-month old baby, asking nothing in return?

Were they for real? After Katrina, across this great country, they and others just like them answered, again and again, a resounding YES.

We made preparations to leave on the weekend, not even 1 week after the storm had changed our lives. Our family and friends in Maryland surprised us with a bag of Target gift cards. At first I refused the accept the gift; others needed this more than we did. We had savings, we had insurance, we would be okay. My wife persuaded me to reluctantly take the bag, which was a smart move: the cards were spent within two weeks, just on basics, and toys for the kids. And the insurance would soon fail us, while the savings would dwindle down all too quickly. Even those who thought themselves well-off had to swallow pride and accept, if not even ask for help. A pediatrician I know has said that at first after a disaster, people will give and give even when it's not needed or appropriate; only later, when you start realizing what you need, the donations will dry up.

Before leaving Maryland, we finally heard the good news for which we had been praying: the family that had stayed in our house was alive and safe.

Days later, they told us their story. Through Sunday night, the wind howled and the rain came down. At times they heard a rattling and a whistling, sounding like a nearby freight train (the tracks ran a block from our house); this was no train, but rather the wind rushing through the attic. Sometime in the morning, the wind started to ease. Then one of their sons looked out the front window and saw the water coming in. Our front yard had flooded before, during severe rains, but now the water was surging in and steadily rising. The floor of the house was about 3 feet off the ground, and soon the water was coming up through the floorboards. They tried to keep Oscar the dog in his cage on a table in the living room, but he was having none of that, so they let him out, whereupon he made straight for the couch. But the water--thick, brackish, brown, carrying debris and who knows what from the sewer pipes--continued to rise, and now the couch was floating around the room, with Oscar riding it. The family climbed up onto the kitchen counters, not knowing how high the water would reach, and Oscar followed.

Finally, the surge peaked at 3 feet inside the house (or about 6 feet off the ground), before receding. A brown muck covered every surface below the water line. The teenage daughter insisted on keeping part of the front hall clean, and was meticulous--even militant--about removing dirt as it was tracked in. This sounded ridiculous at first--with all of this debris and muck, she's worrying about cleaning the floor?--but gradually began to make perfect sense: she was fighting to hold onto a few square feet of cleanliness, of normalcy.

Yet normalcy was a relative term. Power, telephones, cell phones, water, sewage were all gone. The rains were also gone, and would not return for days, but the Mississippi sun was bringing a fierce heat. The meager stockpiles of water we had collectively stored in the house were quickly used, and the father walked about 2 miles up to the main road to get more from the distribution center. Food was running out as well, the house was smelling oppressively of mold, the children were having nightmares, and it would be weeks before the situation would change substantially. Their own house was even less of an option: it had flooded to the ceiling and was now partially collapsed. (Perhaps it was another instance of fate that they had stayed in our house after all.) By Thursday, the family decided they had to try to leave. Their car had flooded out and now was ruined. Somehow they contacted a relative who lent them a rickety van, and they moved out to his place in Wiggins, about 45 minutes to the north-east, a town with relatively minor damage. Like we had done a few days ago, they were now pondering their next move; remarkably, they would soon end up near Birmingham as well.

As for Oscar, he was in the care of a neighbor 2 doors down, sharing digs with her two canine companions. He was also safe, and purportedly waiting patiently to be rescued. All told, though Katrina had brought death with destruction, no one we knew personally had perished.

Resistance: Fall of Man

2007-01-26T19:30:00.000-06:00

Right after the stomach bug made its way through the household (as described in The Circle of Bleccccccch), my wife came down with lower abdominal pain, suspicious for a UTI.

(It's okay, I've received the necessary clearance to discuss this with you.)

So I brought home a urine dipstick from the office, confirmed (+) leukocytes, and wrote her a prescription for ciprofloxacin for 3 days.

Five days later, she was having back pain. Seems like the UTI bug fought the cipro and won, and was now moving on to the kidneys.

I consulted my Sanford Guide, wrote a new prescription for bigger, badder Levaquin x 7d, and soon enough, we were good again.

Last night, as the Levaquin started clearing her system, the back pain returned.

We called her OB-GYN, who recommended a repeat urinalysis, this time with culture, as well as a renal ultrasound.

(I suppose we could talk about the ethics of treating family members, but I think my treatment to this point was very standard-of-care. One of the unwritten perks of marrying a primary care physician is easy access to treatment and prescriptions, at least for (apparently) straightforward issues.)

The renal ultrasound was normal. (Levaquin: $25. Renal ultrasound: $694. Peace of mind: priceless.)

Meanwhile, the OB-GYN heard from her partner, who had been talking with a local urologist, who described the exact same thing in 3 other patients recently. UTIs that failed to respond to cipro, followed by Levaquin, finally cured with Augmentin.

The Sanford Guide notes "increasing resistance of E. coli to both TMP-SMX [aka Bactrim] & FQs [fluoroquinolones such as cipro and Levaquin] a concern." We should know in a couple of days exactly what the bug is, and its antibiotic sensitivities, but we are seeing the evolution of antibiotic resistance in almost real-time. The standard, first-line antibiotics are no longer working, and we have to resort to stronger and/or more unusual treatments.

In a similar manner, skin infections such as boils and abscesses used to be treated with Augmentin or first-generation cephalosporins such as Keflex or Duricef. The bug that commonly causes these infections is known as staphylococcus aureus, or staph aureus, or staph. Within the past 3-4 years a particularly hardy variety of staph has emerged, known as MRSA (methicillin-resistant staph aureus). It laughs at Augmentin. It eats Keflex for breakfast. Pediatricians are now being advised to use Bactrim as the new first-line therapy against MRSA, and there are only about 3 or 4 other antibiotics total that have any effect. In some parts of the country, about 20% of the staph is now MRSA. In other places, it is 50%.

I don't get a bacterial culture of every skin infection that I see. However, I can say this: in my area of South Mississippi, over the past two years, every single abscess culture has been MRSA. 100%. Without exception.

And people wonder why I am stingy with my antibiotics.

Foresight/Hindsight

2007-01-24T09:43:00.000-06:00

I really should have posted this yesterday, but I have my office staff as my witnesses. I gave 5:1 odds that Bush doesn't mention Katrina or New Orleans in his State of the Union address, and 10:1 that he doesn't mention the Mississippi Gulf Coast. And I was right on both counts.

I realize that this week I seem to have gone from "Just Practicing" to "The Katrina Blog." I promise I will get back to more medicine-related stuff soon. But you must realize that:
(1) For those of us here in the Katrina Disaster Zone, this is really all-encompassing. It affects truly every aspect of life here, every minute of the day, everywhere you go. I'll stop writing about Katrina when things are back to normal. That should be in about another 10 years or so.
(2)...Or it might be never. Katrina has been a life-changing event, not only for the residents here, but for our entire country. Disaster response and recovery has become a prime issue for people everywhere, but we obviously still have a lot to learn. In fact, even though citizens have taken many lessons to heart, I'm not sure our government has learned any lessons yet, and seems doomed to repeat them when (and not IF) the next disaster strikes.
(3) Don't ask us to "get over it." We haven't asked New Yorkers to "get over" 9/11. 9/11 changed America's entire mindset and priorities--as it should have. 9/11 was a man-made disaster with profound repercussions. Yet Katrina, a natural disaster affecting far many more people, has already faded into memory, as Bush's speech last night illustrates so well.
(4) Finally, things are not chugging along smoothly down here, despite what y'all might think. I'd refer you to this enlightening article at Gulf Coast News.

And besides, it's my blog, so I can write what I want. Ideally its focus is on the intersection between Katrina and health care, but it's going to veer back and forth at times. Hopefully, wherever it goes, it will continue to hold your interest. And I promise that there's lots more of Katrina Story to tell.

Katrina Story, Chapter 4: A Failure to Communicate

2007-01-23T10:45:00.000-06:00

The very first news out of Bay St. Louis came Tuesday night, when the ticker at the bottom of the screen on CNN announced that Hancock Medical Center was asking all available personnel to report in.

Wednesday morning I tried calling the hospital, but phone lines were out of service, as they would be for the few weeks or more. The Mississippi Emergency Management Agency had no information, nor did the Mississippi Department of Health. I managed to eventually reach a regional commander for FEMA, who said he had heard the announcement. He gave me the main number to the hospital.

I told him that number was of no help. Perhaps he had a satellite phone number, or he could coordinate a special patch-through. No, he said, and his own satellite phone was given to someone else earlier today; he also had no communication to the coast.

In retrospect, this was probably the first sign of things to come. And so, for the time being, Hancock Medical Center would have to survive without me.

Other than the CNN news ticker, there was no news whatsoever from town, which was more than a little disconcerting. Where were the news crews? Was the devastation so profound that no one could make it through? But what about helicopter footage? Or was it that no one cared about lil' ol' Hancock County, when Gulfport/Biloxi was a more recognizable name, not to mention the emerging crisis in New Orleans around the levees and the Superdome? A most grisly thought occurred: perhaps there were bodies strewn everywhere and the footage would be too shocking.

Finally, on Wednesday night, Anderson Cooper was on the beach in Bay St. Louis. For the first time, we had a glimpse into the destruction. Survivors talked about a monstrous storm surge and hanging on to tree limbs to survive as their homes and storefronts washed away. Every modern convenience was gone--electricity, phones, water, sewer. The camera crew showed stragglers gathering at the remains of the Bay St. Louis bridge, where some had found a strange little zone of cell phone coverage. We wanted to both cry and cheer when Cooper, in his now famous broadcasts, asked Michael Brown and the country where FEMA was. Why were our citizens going without basic food and water? If Cooper could get a CNN satellite truck down onto the beach in Hancock County, why couldn't any government agency do the same? For that matter, if Cooper had a satellite hookup to the outside world, why were FEMA, MEMA, and the MS DoH seemingly unable to duplicate the feat?

We called the Red Cross to see if they had any word about the family that had stayed in our house. Again, no news, but they would try to alert the search and rescue teams. We searched online bulletin boards, but the postings were too numerous and unorganized. We tried not to dwell on nightmarish visions of the entire family of six drowning in our home.

My office nurse, who was in Bay St. Louis for the storm, has commented that in some ways, it was easier to be a survivor in town than an evacuee on the outside. She knew that she was alright, whereas her family had no idea what had happened; all they could do was wait, and worry.

Eventually, later in the week, we received the first precious gems of communication from friends. Our office billing manager was safe in Louisiana with her two kids, having evacuated beforehand. Her boyfriend was my friend the Waveland cop. Despite rumors that the entire police force had perished, she found out he (and the others) had indeed survived, and she was going to drive to Oklahoma to meet him at his father's place at the end of the week. Apparently the Waveland police department building flooded to the second floor, and the officers climbed out a window and survived only by holding on to a scraggly tree. (*) She also mentioned that her sister had stopped by my office and reported, miraculously, that the waiting room looked largely untouched. Meanwhile, our office nurse--who had also left for Louisiana--had returned to Gulfport but now couldn't get out, since there was no gasoline. Her apartment off the beach was entirely, completely gone.

As anxious as we had been to flee the coast to the safety of family, we were now agitating to return to assess the situation first-hand. As a doctor, I also wanted to go back to help my patients and lend my skills. I called the Red Cross to see if a local team might be going down soon, but the training session was still a week away. I thought about just finding my way down to the coast, but I started to worry about being stopped by the National Guard because I didn't have the right clearance. When I contacted the Mississippi Department of Health, they informed me they would soon be collecting names and credentials of doctors wanting to help, but this was more for out-of-state volunteers; as a local, they didn't know what to make of my situation, and could offer no advice. Clearly this was not a situation they had ever prepared for, they were making it up as they went, and it showed.

The more I though about how to get down to the coast, the more my wife became concerned. In a pivotal conversation, she said: you are not just a doctor. You are a father and husband. Right now, we need you more than the hospital does. We may have lost our home and belongings, but we are not going to risk losing each other.

And so, by the end of the week, a plan had emerged: we would find a "staging ground" closer to the coast, from which we could drive in and out (possibly even commute, if close enough) yet still be safe and surrounded by basic amenities.

(*) This incident is detailed in Douglas Brinkley's masterful book, The Great Deluge. I wouldn't be surprised if it makes it onto film or TV someday. Or you can read more here.

A small indignation

2007-01-22T10:13:00.000-06:00

A parent called this morning asking to have her 7-year old daughter seen for a cough. My receptionist offered her 11:00am today, to which the parent replied, "well, I can't wait that long. I'll just take her to the ER."
The parent called back 10 minutes later asking for the 11:00am appointment.

In my office we do our best to get sick patients seen on the same day. We'll sometimes double-book or tell people to come in at 4:00pm--"You may have to wait, but you will be seen." Children who sound really sick are asked to come in right away and squeezed into the schedule.

I have no patience for parents that think a same-day appointment is unacceptable.

First, two hours might get you seen in the ED. If they're busy, it might not. So we get you in for an appointment before the ED--a walk-in facility--could even see you. (Aside from the fact that the most demanding parents tend to have children with relatively minor problems which don't even warrant being seen in an ED.)
Second, try this with any other specialty. Call up your internist and ask for an appointment today. I'd suggest you could use a stopwatch to see how long they laugh before they compose themselves and ask you, "are you serious? Our first available appointment is in 1 week."
Third, try this with any other profession. Call up your auto mechanic. I dare you to throw a hissy fit if they can't squeeze in your timing-belt replacement in the next 2 hours. See if your hairdresser will bend over backwards to get you in for a perm in the next 20 minutes.

I understand we are dealing with sick children, and anxious parents. But we pediatricians seem to get the least respect and the most outlandish demands, for reasons that tend to have little to do with the acuity of illness and more with the convenience of parents. ("I can't make it at 3pm, I have an appointment. If you can't accomodate me at the time I want, I'll just find someone else who can.")

One of these days, in a world without HIPAA privacy regulations, I'm tempted to ask one of these demanding parents: here is a list of the patients already scheduled this morning. You're welcome to call them, ask if they would give up their spot for you, and call us back when you find someone willing to do that.

There's no upbeat ending or silver lining to this post, just something I had to gripe about.

Katrina Story, Chapter 3: On the Road

2007-01-19T18:00:00.000-06:00

(With apologies to Jack Kerouac)
Sunday afternoon: the van and family are headed east to Florida as Katrina starts making its presence felt. Our policeman friend tells us that I-10 is already at a crawl, so we take Highway 90 along the beach. A quick lesson in the geography of the Mississippi coast: if you drive from west to east, you will go through Waveland, Bay St. Louis, Pass Christian, Long Beach, Gulfport, Biloxi, Ocean Springs, and Pascagoula, before crossing into Alabama and the outskirts of Mobile. We make good progress from Waveland to Ocean Springs until traffic on Highway 90 also slows to 5 mph. By 4:30--2 hours after leaving--we're only in Pascagoula, a long way from Florida. At this rate we will be riding out the storm in our car.

In the parking lot of a freshly boarded shopping center, we consider options, and decide to change our destination to Maryland, where our family is. My wife's uncle will host us when we arrive in a couple of days. My wife grabs the atlas and starts plotting side roads going north and east.

As we travel down country backroads, we're accompanied by many other drivers with the same idea. We pass through small Mississippi towns that probably have never seen this much traffic since...well, ever. At a particularly confusing intersection, we even pass by one of my patients.

The hour gets late, the boys are tired, and we finally reconnect with the interstate north of Mobile. L. tries calling every hotel in Montgomery (how did people manage before cell phones?) and finally reaches one with a vacant room. We arrive well past the boys' bedtimes and collapse into fitful but welcome sleep.

At roughly 6:30am my pager goes off. The security service on my office is notifying me that the office alarm was tripped and the police have been called to investigate. This has happened a few times before, so I'm not very concerned (though I do wonder a little if an audacious looter has taken advantage of the situation). Then I realize: the power is still on in Waveland. Communications are still working. Our town must have made it through the night okay.

(We later surmise that the power failed shortly after that page.)

So once again we turn on The Weather Channel, just in time to see Katrina over the southeastern Louisiana coast. The eye will soon cross the outlet of the Mississippi and make a repeat landfall somewhere near the Louisiana-Mississippi border. But after that, it will continue north-northeast, and Montgomery is too close for comfort--and we have many miles to go before Maryland. On the tv, reporters are in New Orleans showing footage of an empty French Quarter, and Jim Cantore is in Biloxi with strong winds coming off the beach, but on the whole, it looks like typical hurricane footage everyone's seen before. Winds thrashing palm trees, trash cans blowing by, driving rain; the worst is yet to come, we're concerned, but so far, so good. Anyway, gotta keep moving.

We leave Montgomery at 9:30 am, putting the portable DVD player to good use. The endless stream of Barney and Wiggles satisfies the boys--the things parents endure for the good of their children. As a respite from the kid stuff we listen to the radio up front, trying to catch some news from Waveland.

Gradually over the course of the day, the mood starts to change. Whether from the frantic evacuation, the stress of travel with small children, the single-minded goal of reaching Maryland, the lack of any communication from home, or the unfolding realization that what was happening on the Gulf Coast was becoming an event of unprecedented national and historical importance--and that our town was Ground Zero--we start to become less complacent, more concerned and agitated. We make it as far as North Carolina (it may have been Kannapolis, just past Charlotte--it's hard to remember now), settle in another hotel, but this one appears to be a temporary home to a lot of college students (maybe a local football game?). I remember thinking an irrational disgust that they could just carry on with the usual smoking, drinking, conversation, and laughter when our lives were now permanently disrupted. I almost wanted the hotel to be somber and respectful on this day of national significance, much like on 9/11. But the college kids were having none of it, with some of them throwing bemused looks at us, as if to say, "what's up with you?" Of course, it may have also been just my self-centered imagination, since I was unable to concentrate on anything beyond my immediate family and possessions in our minivan. It wasn't a completely unreasonable mindset, since this might be all that I had left in the world.

The next day, Tuesday August 30, we finally reach Maryland, spending the first night at my wife's father's house (we would go to her uncle's the next day). We were safe, with family. Now we could start to take stock of our situation and figure out: what next?

Score: NY Times 3, Katrina Recovery 0

2007-01-19T09:31:00.000-06:00

The NY Times scored a trifecta blast this week against the administration's so-called recovery and rebuilding since Katrina.

First, on Wednesday Jan. 17, in the Business section: a column discussing "What $1.2 Trillion Can Buy." The $1.2 trillion in question being, of course, the cost of the war in Iraq--so far, with more expenditures undoubtedly planned. (Actually, as the article explains, direct appropriations have been a mere $700 billion, with indirect costs making up the rest--the author, David Leonhardt, arrives at the $1.2 trillion as "the actual money that Americans would have been able to spend in the absence of a war.") Congress has spent a total of $100 billion on Hurricane Katrina. Even if you account for spectacular amounts of diversion, fraud, and waste (as has been the case ever since August 29), just think what even another $100 billion could do to finally get this recovery moving. There is a snide but apropos bumper sticker making the rounds here: it says, simply enough, "SCREW IRAQ, REBUILD THE GULF COAST."

Second is today's lead Editorial entitled, "Nowhere to Turn for Shelter." In a dead-on analysis, the Times holds the Bush administration to task for the shameful inaction on housing on the Gulf Coast. To quote: "...The response to the drowning of New Orleans has been a failure on every level...There has been no concrete action plan for reconstruction--only a patchwork of programs marked by dithering, bickering and bureaucratic finger-pointing throughout. The federal response was, after great delay, largely to cut a check and let overmatched local officials try to sort it out...The time is long past to turn from planning to action. And those in need of shelter today cannot take comfort in housing that won't be ready for another two years...That New Orleans remains a shattered city is a sad monument to impotence for the most powerful country in the world. Our grand plans were never laid, our brightest minds were never assembled, our nation's muscle and ingenuity were never brought to bear in any concerted way to overcome the crisis of the Gulf." (my italics)

Lastly is a Letter to the Editor also published today, strikingly forceful in its poetic elegance in tying together the above two thoughts. The letter reads, in its entirety:

Sometimes, I go to sleep and dream that I live in another America. One where we sent 140,000 able-bodied men and women, and one trillion dollars--to rebuild New Orleans.

A doctor watches American Idol

2007-01-18T16:03:00.000-06:00

I've been trading posts with Dr. Mary Johnson about American Idol, and I confess it's one of my guilty pleasures. Actually, once the season gets going it's not so guilty, since it is a showcase for some genuine talent and great performances (not in the PBS vein), and it's fairly family-friendly too. But the early "audition round" shows have been more of a freaks-and-geeks spectacle, bordering on mean-spirited. Last night's show in Seattle was fairly over-the-top even by Idol standards, and host Ryan Seacrest remarked as much. Unfortunately, it also offered a chance for my inner evil doctor--um, Dr. Evil?--to emerge and make off-the-cuff assessments.
That very tall woman, 6'4" (6'7" in heels), with a really nice voice...disqualified from the Air Force due to a heart condition...long spindly fingers...almost certainly Marfan's.
The guy at the end..."Big Red"...odd affect and speech...schizotypal personality disorder?
The dark-haired guy with delusions of N'Sync grandeur, who Simon thought looked like a lemur...well, ya got me there.

Oh, great. Now I feel doubly guilty about watching the show.

Katrina Story, Chapter 2: Preparations

2007-01-16T10:52:00.000-06:00

By the morning of Saturday, August 27, it was becoming clear that Waveland, Mississippi would have a hard time avoiding being hit by Hurricane Katrina. The predictions still carried a lot of unknowns: the exact where and when of landfall, windspeed and hurricane strength, lowest central pressure. At the local hospital, the administration asked doctors to discharge patients and get out of town in anticipation of closing the facility. I had one newborn in the nursery; I asked the parents, where will you go? The mother worked for the city of Picayune, about an hour north-west; she planned to take the baby to the city's command bunker. Normally I don't advocate exposing newborns to large groups of people in cramped, confined spaces, but I figured the baby would be as safe there as any place.

Sunday morning, my wife and I woke at 7am; she went to the computer, I went to the TV. Latest storm track and forecast revealed Katrina was now a full Category Five, on a near-perfect track for Waveland by tomorrow morning. Meanwhile, the satellite picture on The Weather Channel showed a massive cyclone filling nearly the whole of the Gulf of Mexico.

It was time to leave.

For those fortunate enough never to have evacuated for a hurricane, it is not an easy process. It takes planning, effort, and a lot of time--even more when you have a dog and 3 small children (our youngest was now all of 2 months old). We called family and let them know our plans (go east to Florida, vacation for a few days, then come back). Then we dragged out the suitcases and starting packing clothes, toiletries, and diapers, enough to last for about 6 days. We filled shopping bags with food and drink for the road. I grabbed the essential electronics: cell phones, chargers, portable DVD player, all of the kid's DVDs and CDs. My wife packed away toys, books, blankets, and pillows, and photo albums while I organized the essential documents: birth certificates, passports, insurance papers, medical credentials, copies of diplomas and licenses.

Then I went to my office.

My practice uses an electronic medical record. All patient information is stored on a server in the office, my receptionist and biller each use a desktop computer, and my nurse and I go room-to-room with tablet PCs. We are the medical practice of the 21st century, a paperless office.

Normally the tablet PC needs to be on the office network to access the patient data. But the computer program we use has a very special feature, one I had used just a few times prior. The tablet can be placed into "disconnected mode," where the data is downloaded onto the tablet itself. The tablet then becomes the computer system for the practice, until it's later re-synchronized with the server.

I set the tablet into the disconnected mode, grabbed a backup data tape from the server, disconnected the computers, placed them up on desks, and packed up some practice essentials: stethoscope, pocket reference, otoscope and ophthalmoscope. Time was running out, and I left most of the rest; if the office flooded, the majority of equipment was off the ground and should be safe. If the roof caved in or blew off, everything would be lost anyway. Leaving my practice to fate, I headed back home.

Our friendly neighborhood handyman was screwing plywood over the windows, making the house very dark, if more secure. Meanwhile, a change in plans had occurred regarding our dog, Oscar. We had every intention of taking him with us--until a family with which we were close decided, against all attempts at persuasion, to stay through the coming storm. If the family was that determined to ride out the hurricane, we convinced them to at least stay in our house, which was on higher ground (and, due to its older age, probably more solid) than theirs. They in turn volunteered to care for Oscar and keep him safe until we returned.

It was to be a fateful set of decisions on everyone's part.

The van was completely packed, it was now 2:30pm, and the skies were turning grey. Just before leaving, a good friend stopped by. He was a part-time officer for the Waveland police department, and he was required to be on-duty for Katrina. He assured us he would check on our house--and our family-friends--while we were gone. And so we drove out to Highway 90 and started east.
About a half-hour later, we pulled to the side of the road off the beach in Gulfport, to allow my wife to nurse the baby. I stepped out of the van and was pelted with rain blowing sideways as the wind whipped around. From the satellite pictures I had checked just before we left, I knew these were the first outer bands, even though landfall was still projected to be 18 hours away.

This was going to be a monster of a storm.

Expect the unexpected

2007-01-15T12:38:00.000-06:00

Remember the girl with Hepatitis A?
It's not Hepatitis A.

She seems to be getting steadily better, but after consultation with 2 specialists, and many tests, we still don't have a definite diagnosis. It's probably a viral hepatitis, just from an "unknown" virus. So the treatment and course remain the same, though the community as a whole gets spared.

This is what medicine is often about. This is why I like House, M.D.
No, I don't know why House and his lackeys do all the procedures themselves. And no, I don' t know if those lackeys are residents, fellows, or just visiting professors. But at least the writers get the process of medicine right. Problem leads to hypothesis leads to testing and/or treatment. Evaluate results. Rework hypothesis, start over again.
Granted, on the TV show, the patients usually have an inexorable decline towards death, with numerous evolving complications; patients don't just spontaneously start getting better again. But that's what makes it a television drama. It wouldn't be satisfying TV to end an episode with the docs escorting the patient out the door, followed by just sitting around with no good answer as to what just happened in the last 58 minutes, taking consolation in the fact that at least the patient is better.

Despite what patients may think, medicine is often without satisfying, definite answers. Learning to deal with that uncertainty is part of the art of medicine.

I also like House because the characters are compelling and very well-acted, and I have fun trying to guess the diagnosis. But I won't get to watch it for three weeks: American Idol starts tomorrow night!

Oh Will The Saints Go Marching In

2007-01-13T08:13:00.000-06:00

Normally I'm not a big supporter of professional athletics. I just don't care for immature, self-important boys being paid millions of dollars to go play games--nor the attendant revolving of the universe that follows around them. I'm not saying professional sports don't have some benefits; they can inspire children to exercise, even pursue dreams, and the true "good-guy" athletes can accomplish great things (raise money for foundations, create awareness of issues, even--*gasp*--be credible role models--as a native Baltimorean/Baltimoron I'm thinking of Cal Ripken, Jr as a shining example). A team can also create a groundswell of civic pride, particularly when they reach the playoffs. The New Orleans Saints have never been a powerhouse team; in fact, they've only won one playoff game in their entire history. Yet, somehow, this season has been one of their best ever, and they are now even contenders. So, in light of the suffering of our brothers and sisters in the Crescent City, it would be a Great Thing if this was finally the Saints' year to shine. Playoff game is tonight against the Philadelphia Eagles, 8pm EST/7pm CST, on Fox. Maybe I'll even watch.

GO SAINTS!

Katrina Story, Chapter 1: Prologue

2007-01-11T11:59:00.000-06:00

By popular request, I will tell my Katrina story. At one point I thought about writing a book about the whole damn thing, but I figure by the time I did that, the whole world will have had enough about Katrina and won't want to hear anymore. Maybe that's not quite true, since some of you out there still have interest. I expect this to be rather long, but a journey of a thousand words starts with a single step, or something like that. So, without further ado, here we go...

There's a morbid joke on the Mississippi Gulf Coast that Hurricane Camille killed more people in 2005 than it did in 1969.

When Camille plowed through the Gulf Coast in August 1969, everyone thought they had witnessed just about the worst fury that Mother Nature could throw. Camille made landfall as a deadly Category Five, one of only three to strike the United States in the last 155 years. Top winds reached over 190 mph, and some have estimated gusts as high as 210 mph. The NOAA ranked Camille as the second most intense US storm on record, the top prize going to an unnamed monster commonly called the "Labor Day Hurricane" that hit the Florida Keys in 1935.

Camille defined a generation on the Coast. People remember the apartment complex in Pass Christian, MS, where people supposedly partied through the storm until they drowned. Others recall the complete devastation afterwards, with entire city blocks leveled. Many Civil War era mansions in Pass Christian and Long Beach miraculously survived, a testament to their solid construction. What was destroyed was eventually rebuilt, and by the 1990s, the Coast underwent a commercial boom, thanks in large part to the new and opulent casinos such as the Beau Rivage and the Grand. Gulfport and Biloxi had gone from sleepy backwater beach towns to tourist destinations.

Further east, the towns of Bay St. Louis and Waveland were doing well enough for themselves, if not quite as popular as the larger cities to their west. According to the 2000 census, Waveland had nearly 6700 residents, with another 8200 in Bay St. Louis. Casino Magic brought jobs, revenue, and famous jazz clarinet player Pete Fountain to the county. NASA's Stennis Space Center complex, site of rocket engine development and testing ever since the Saturn V took America to the moon, also hosted aerospace corporations and military and government agencies. New Orleans residents tired of the bustle of the city retired to Waveland, one of the last beachfront communities in the country where even ordinary Joes could own beachfront property. The surrounding Hancock County, Mississippi was one of the fastest-growing counties in the state.

Thanks to that growth, the area needed another pediatrician. My family and I travelled to Bay St. Louis in October 2003 and immediately fell in love with the area. We moved down January 1, 2004 and opened my pediatric practice about 6 weeks later.

Living anywhere on the Gulf or Atlantic Coasts--from the southern tip of Texas, around to Key West, up to the rocky beaches of New England--means hurricanes are always a possibility from June to November. In mid-September 2004, Hurricane Ivan was approaching the Mississippi and Alabama coasts, with Waveland and Bay St. Louis on the western edge of the National Hurricane Center's predicted landfall. We decided it best to leave town; however, not having friends or family anywhere nearby, we drove west until we found a vacant hotel room. Unfortunately, much of New Orleans also had the same plan.

We drove 17 hours to Dallas, Texas. Me, my wife, our 2 boys, and 2 dogs were exhausted, but we were safe. My wife wanted to make the trip a mini-vacation, but I was anxious to return to our home and my work. And when we did return, we found 2 large tree limbs down in our yard. The house was untouched, our town was largely untouched, and life had continued uninterrupted. Ivan had made a last-minute turn to the east, which was very unfortunate for eastern Alabama and Pensacola, FL, but it meant only a tropical storm in Hancock County, MS.

And so, on Friday August 26, 2005, when the National Hurricane Center was showing a large hurricane crossing Florida and entering the Gulf of Mexico, we felt little urgency. We knew that it was still too early to make an accurate landfall prediction, and besides: even if it did hit our town, the area had already weathered one of the worst storms in recorded history. Our neighbor, an Emergency Room physician who endured Betsy in New Orleans in 1965, and then Camille in Waveland, offered this prognosis: "I probably wouldn't stay through the storm, but I think we'll be okay."

To be continued...

The Circle of Bleccccch

2007-01-08T10:11:00.000-06:00

The stomach bug that B and J had last week made its way through me (Friday night/Saturday), then my wife (Saturday night/Sunday). E has been fighting it on and off all week but yesterday Mr. Mom (uh, that would be me) didn't hydrate him enough during the day and he became worse; so Dr. & Mrs. Scott both stayed up all night pushing Pedialyte through a medicine syringe. True oral rehydration therapy in action, and it saved us from a trip to the ER for an IV. But now I'm at home trying to catch up on sleep before I see patients.

Well, not at this very instant. Though I would love to be able to blog in my sleep. It would be a great way to get all these thoughts out of my head.

In the meantime, thank you all for welcoming me to the blogosphere, and I hope not to disappoint. Too much.

Doo, doo, doo, looking out my back door

2007-01-05T17:47:00.000-06:00

Looking out my back door, I see:

3 occupied houses
8 empty property slabs
1 abandoned, empty house
1 house under construction
5 FEMA trailers
1 abandoned car, and
1 empty lot

The empty lot is right in back of our house, and it has become a small swamp after all these rains. "Swamp" meaning about 3 inches of standing water with nowhere to go except into the southwest corner of our backyard.

The view hasn't changed much in the past 6 months we've been in this house, other than the house under construction.
This is what it means to live in Katrina-land. Everywhere you go is a constant reminder of the destruction and loss.
This is not a healthy way to live, or to raise children.

Thank you!

2007-01-04T09:48:00.000-06:00

A hearty thanks to Flea for his shout-out today welcoming me to the blogosphere. Lately he's been running a great series on vaccine-preventable diseases. And he's also nominated for the 2006 Medical Weblog Awards (I've yet to check out all of the nominees, but I can assure you he's in good company). Of course, you probably already knew this since there is a good chance you came across my blog via his.
Speaking of vaccine-preventable diseases, yesterday I saw a child with what is most likely Hepatitis A. If it is, that's good, because it's a self-limited virus that just runs its course--for her. Her family and preschool face a different situation, with vaccine and immune globulin shots all around.
HepA is widespread in the west and southwest, but relatively rare here. In fact, I think this is the first case I've seen in seven years. I talked to a Pedi Gastroenterologist in New Orleans who confirmed he hasn't seen much either.
Just last year the immunization schedule was updated, recommending Hepatitis A shots for all kids 12-24 months. Prior to that, it had been just for children in high-risk areas. This is one of those indirect vaccination strategies, since infants and toddlers usually don't get sick or have severe symptoms, but the older kids and adults are the ones that end up suffering (and even face a risk of fulminant liver failure). The toddlers share and spread the disease, so you vaccinate them to protect the older folks. I can't comment on the public health costs and benefits of universal vaccination in term of dollars and cents, but I think it's fair to say that this one case is probably going to cause a lot of worry and work for a lot of people around here.

A medical practice is/is not a small business

2007-01-03T13:42:00.000-06:00

I love practicing medicine, which is good, because it's how I pay the bills. My patients often seem to forget that I charge for my services because I need to make a living, but I also need to pay my staff, pay for vaccines, pay for rent and utilities and office supplies and table paper and toilet paper and malpractice insurance and other insurance and what not. Just like any other small business, right? Post-Katrina, FEMA and the SBA have said so. Medical practices received no special treatment. So I try and pursue grants, loans, and other assistance to rebuild my practice. But my revenue is solely and entirely dependent on me seeing patients. So if I'm out of the office (say, for a meeting), I'm not making money.
That's not special, you say. Same as any other professional in a service field--lawyers, plumbers, electricians.
Yes, but an electrician sets his rate, gives you a bill, and you pay.
In healthcare, the insurer sets the reimbursement and pays what they feel is appropriate. This is like walking into Circuit City, seeing a TV for $1000, and saying, "no, I'll give you $700 for it. Thanks!" In theory, the insurer gets to take a cut off the doctor's standard prices in exchange for steering patients to the provider, enabling prompt and worry-free payment. In practice, it's done this way because doctors usually have no choice.
So unlike any other business in town after Katrina, I cannot increase my revenue by increasing charges, because it won't make any difference. I can charge Medicaid $65 for an office visit, or $650, and they still pay me $50.48. But I still have to pay an extra $2 for my $6 roast beef po' boy (mmm...roast beef po' boy). I still have to pay when Merck raises prices on its vaccines. In short, trapped. The only way to make more money is to see more patients.

And there's the final catch: there was an initial surge in population here after Katrina as everyone started coming back, and the contractors and workers started flooding into town. But now the population growth has slowed. Why? Housing. Here in Waveland MS about 90% of the houses were damaged or destroyed. As a result, people aren't coming to the area because there's no place to live. Few houses are on the market; the houses that are, are overpriced (simple market economics, supply and demand), squeezing out poorer working-class families. You can buy an overpriced empty lot, but you'll have to wait about 6-12 months before you can hire a contractor to even start construction.
So the doctors can't raise fees, can't see more patients, still have to pay the bills, and--oh yeah--try to recover all of the losses and expenses related from the storm and the loss of practice. (I'll try to post on that at a later date.)

Why does all this matter? So if I can't make it, shouldn't I just leave town?
First is the personal, community aspect. I feel a commitment to my patients. I want to be there for them when I'm most needed, and see them (and me) through this recovery.
Second: well, doctors are all rich anyway. Shouldn't I just sell off one of my 3 Lamborghinis, or my vacation home in the Bahamas? Actually, pediatricians are generally not rich. Most middle class 2-income families earn what I make--without the associated student loans, and with a good many years headstart on saving for retirement. I realize I'm doing better than many others, but I certainly don't have the resources to weather this for much longer. As is, I've taken out a $40,000 home equity loan and $60,000 SBA loan to cover post-storm and restarting expenses. That's $100,000 in new debt. OUCH. At least the SBA loan can be paid back over 30 years--just like my Stafford loan from med school.
Third, and most importantly, if I leave, who will see my patients? This is not a rhetorical question. There are two other pediatricians in town (one is now employed by the local hospital, the other works for a community health center). They could probably cover things, and patients could also see other pediatricians further away. But then what? A town without good medical care won't be very enticing to new families, or new businesses. And the recovery stalls out and the community never rebuilds.
Is that okay for little old Waveland, MS? How about New Orleans, LA? How about the next city hit by a major disaster?
I'm not even bringing in the moral arguments, that health care is a necessary community service and should be maintained for the good of the community. Or that doctors such as me are being not rewarded, but penalized, for staying on after Katrina. (Every week I get a flier for "Lucrative position! Starting income $200,000!" or something similar. Yet I'm still here????) Just on an economic basis, physicians face inherent difficulties unique to healthcare. We can't respond like other businesses can, yet we're expected to anyway. No special treatment, despite special circumstances.
So what to do? More to come.

You know, that Elvis dude

2007-01-03T13:05:00.000-06:00

B and J are at the breakfast table the other day.
B starts humming a song.
B: "Do you know that song, J?"
J: "Um, no. What is it?"
B: "It was on American Idol last year."
J: "Oh, yeah, I know that song."
B: "Yeah, it was sung by Taylor Hicks. Except he didn't write it. It was a song by some guy named Elvis."

An 8-29 commission?

2006-12-31T17:28:00.000-06:00

Nola.com is reporting that, with the Democrats set to control Congress, there is talk about establishing a Commission to investigate the government's response to Katrina. The panel would be modeled on the 9-11 Commission, leading this yet-to-be-formed body to be called the "8-29 Commission," referring to the date when Katrina hit the Gulf Coast.

FEMA is already getting defensive:

Aaron Walker, the national FEMA spokesman, said the agency has acted on "numerous reports from outside interests, Congress, and the White House on how to improve the agency and determine where the missteps were in our response to Katrina.
"At this point, it is doubtful that futher reports or commissions will reveal new, actionable insight," he said.

Well-spoken words from a man utterly disconnected from reality. You're doing a heck of a job, Aaron.

Apparently Republicans also feel that the current response has been adequate:

Frank Luntz, a Republican strategist, questioned how impartial a new commission could be.
"If you listen to the Democrats, the Republicans actually caused the storm, that they created the hurricane, and did all the damage," Luntz said.

No, the Republicans didn't cause the storm (unless you want to start talking about the possible contribution of global warming...) But the Republicans--excuse me, not all, just some very key Republicans, including the President, and his appointees--have shown an utter failure of leadership, an absence of clear thinking about recovery, a placement of bureaucracy over people, and a basic turning of the back and walking away from the Gulf Coast.

For those who don't know, more than a year later New Orleans and Mississippi are still just starting the recovery process. Every day that passes without a clear plan--and the subsequent steps to implementation, which includes funding--makes the recovery that much more difficult, if and when it ever gets underway. It also drags out the recovery since time and effort must be spent making up for lost time and in some cases undoing the damage that the inital delays have caused. Leadership and funding are in short supply, Mr. Luntz, and that is a problem for which the Republicans must take responsiblity. I don't know if Democrats would have done better, but I suspect they would have.

As far as FEMA's Mr. Walker, I suppose you don't need a commission if you know all of your mistakes and you are actively correcting them. In other words, we desparately need a commission because there are lessons that still haven't been learned. I know FEMA and President Bush could use a good schooling.

Happy New Year, everyone. May your 2007 be brighter and more fruitful than 2006.

Wet burps

2006-12-31T17:06:00.000-06:00

J woke up at 2 am on Friday morning throwing up. B followed about 1 hour later. So I cancelled out patients for that day, finished rounding at the hospital, and came home for daddy duty. The boys are feeling a little better now, but J is still having occasional bouts of, as he calls, it "wet burps." Without being too graphic, he'll be sitting comfortably, start a weak little cough, and then a small fountain erupts. Fortunately, it's mostly clear fluid, and he's still peeing okay, not having diarrhea or fever, and generally not uncomfortable. I hope this ends soon because we're getting tired of cleaning up puke spots. In the meantime, B has been spending his time in his room reading and playing on the Leapster, while J has been parked in front of the TV watching Disney movies.

My boys don't get sick very much. Partially because I try to be vigilant about washing hands before coming home, partially because they're not in school or day care. Of course, part of it may be the fact that I'm a pediatrician. Remember how Charlie Brown's father was a barber--while Charlie Brown was totally bald? (Alopecia areata?) That's me; a Charlie Brown father, where my profession does my kids no good. Well, I suppose I exaggerate; on the few times when they do get sick, my wife is very thankful to have a doctor in the house.

Introductions are in order

2006-12-28T11:07:00.000-06:00

A new blog. Why?
Does the blogsphere need another medical rant?
Do I have anything new and novel to contribute?
Maybe, just maybe. As a pediatrician, I like to teach. I teach parents not to panic about fever. I teach my staff to recognize what's serious and what's not (or what's snot?). And I have been known to teach medical students, Rotary Club meetings, fellow members of the American Academy of Pediatrics, etc. etc. etc. A blog is another way to teach, to the general public. Share some insights into this mysterious practice known as medicine. Let people know why we do what we do, why we don't do some of the things we don't, and just what's involved.
I don't claim to be a guru. I don't claim to be the smartest or the most eloquent blogger out there, let alone the smartest or most eloquent doctor. But I sometimes get philosophical about what I do. I think that's a good thing. I also have an angle: as a pediatrician on the Gulf Coast, I'm bearing witness to Hurricane Katrina and its recovery. Some of you may have "Katrina fatigue", in which case, skip my Katrina-related posts (or the entire blog if you want; we're all anonymous on the web anyway, I won't be offended). As much as Katrina has been in the news, the health care situation here has been largely ignored. I'm not seeing it on CNN; I'm not hearing about it on NPR; I'm not seeing it on other people's blogs; and only rarely will I read something in the New York Times. (Ah, I've just laid forth my liberal media-based bias; you now know I follow NPR and the NY Times! Conservatives beware!)
Maybe, just maybe, I can let others know what is happening here. And maybe awareness will lead to action. Because, to be quite blunt, there is no action happening. The health care situation on the Gulf Coast has been neglected even before the DMAT (Disaster Medical Assistance Teams) left. But more on that at a later date.
And maybe, just maybe, I can entertain you, enlighten you, make you think about things. Heck, maybe you can do the same for me in return.
Enough narcissistic rambling. This isn't a great American novel. It's just a blog. Enjoy, bookmark, and come back often.