This Week in Mississippi

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

(1) Mississippi is the fattest state.

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

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

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

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

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

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

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

The End of the Ignorance: A Plea

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Maybe they should call it SICK insurance...

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

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

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

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

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

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

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

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

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

A Tale of Two Centricities

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

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

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

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

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

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

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

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

Blog Tag/Latest Update/Filler Post

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

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

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

Enough

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

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

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

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

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

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

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

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

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

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

Not even a thank you.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Easy or Hard?

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

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

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

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

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

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

Towel Day

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

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

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

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

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

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

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

Katrina in the News

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