A Very Good Day

I was asked to see a man in the hospital with a bad hip the other day. He's 96, lives in assisted living, still walks a little, has moderate dementia/Alzheimer's, and couldn't walk for the last 24 hours due to severe right hip pain. The x-rays showed severe, severe, arthritis. No joint left. The round ball of the hip reduced to a flattened mushroom. Far worse than the picture above.

When I walked into his room and said hello he could not say one sensible word. His eyes looked wild and he would yell out in misery about every 20 seconds as spasm would grip his painful hip. He couldn't offer one word of explanation and I couldn't be sure he could understand or hear one word of my questions. The man is in the Fast Pitch Softball Hall of Fame. The big ring still on his right ring finger.

I spoke to his medical doctor and told her there were two options: heavily medicate the man for pain and wait for him to die-- something that looked relatively close at hand-- or take him to surgery and replace his hip in an effort to gain pain relief-- an option that also held the very real possibility of death. She said she felt medication and hospice would be the wishes of his 92 year old brother. She'd check and let me know. His chances with surgery would be poor.

As it turned out, the 92 year old brother saw such misery in his older sibling he opted for surgery. "If he dies,"he said, "it will probably be a blessing." I had to agree based on what I was seeing. Seeing him in such pain was like witnessing the slow death of an animal struck by a car. My partner's eyes popped out when I told him I was taking the man to surgery but he was in such misery I felt it was the only humane option.

I operated him that night and replaced a very nasty old hip with a nice new shiny metal and plastic job. He did okay in surgery and we sent him to the intensive care unit after. At least he made it out of the operating room.

The next morning I go to see him not knowing if I'd find him dead or alive. There he lay: No moaning. No screaming. "How's your hip?" I yell at him. Big, big smile and a thumbs up. I saw him again yesterday, day two after surgery, and this time he says, "I should've had that done a long time ago!" "We'll have you running the bases in no time!" I tell him. "No." he says, raising his arm, "Pitching a no-hitter!" Big smile. Both of us.

That, my friend, is a very, very good day.  And, in a nutshell, that's the best part of my job.

Healthcare Reform: What About Him?

Sitting in a restaurant the other day I couldn't stop looking at a man at the counter. He was perched there on a stool-- a big man, tall and very over weight. He was noisy, poorly groomed, and he was wearing a C.R.O.W. walker. The latter is a custom boot designed to protect a foot that has been severely damaged by diabetes.

He ate an enormous plate of food, none of which appeared consistent with a diabetic diet, and polished it all off with a strawberry shortcake with whipped cream. Now, granted, I'm sitting 15 feet away and my view is not perfect but I can't take my eyes off this guy. His noisy attenion-getting banter with the kitchen staff was enough that you couldn't ignore him in the first place. His reckless eating was really the thing, however, and I just had to keep looking his way to see what else was going in that pie hole.

Problem is the CROW walking boot. Those are utilized in cases of severe injury to the foot-- injury that almost always stems from diabetic neuropathy, or loss of sensation in the foot. The combination of this man's diet, size, hygiene, and the appliance on his foot made me think: What's it like to take care of a person like this? How much does it cost? Who's paying? I'm guessing he was in his mid-50's going on 80 and, again, just guessing based on the visual evidence, probably on disability as is so common in my neck of the woods. So who pays for this guy? "The government" comes the stock answer. Hello "government," thank you for reading this today.

Let's pretend all of my assumptions above are true: If the cost of healthcare and entitlement programs are going through the roof how do we regain control? How do we reduce the expense of taking care of people who really don't give a rat's ass?

The above scenario is not isolated. I see people like him every single day in my office. They come in with back, knee, or hip pain. They're on disability. They smoke. They're diabetic. They show absolutely no sign of making any investment in their own health and well-being but they want to feel better and they want everything done possible to that end. Everything I can do. They're not usually too keen on hearing about what they should do.

I've thought about this quite a bit since leaving that restaurant and have come to this conclusion: Realistically we're not going to be able to do very much about that man and others like him. A few may respond to education and enlist in their health care. But most won't. Most will simply continue to show-up in the emergency room in crisis, show-up at their doctor's offices wringing their hands about how they try. No, the solution is extinction. Realistically there is very little we will accomplish trying to transform a lifetime of low self-esteem and poor habits into a vigorous healthy individual. What we can accomplish is succeeding in assuring this lifestyle disappears.

Healthcare reform will require education reform. A national healthcare plan will have to be developed to include education that begins in daycare; meaningful education. It will discard cartoon figures pitching the advantages of eating vegetables and, instead, sweep schools and daycares clean of all the prepackaged garbage that still gets served up to our children today. Nutrition education must take place by example.  The hardest part will be financial: McDonald's Corp. may slip off the list of best dividend performers.

Likewise, physical education classes have to become about lifetime activities like yoga, stretching, walking, and weight training. Sports are fine as electives. What I'm talking about is learning that every day starts with self-care in the form of exercise. There was a poster a few years back published by the American Academy of Orthopedic Surgeons showing a kid sitting in his room at a computer that featured the tag line: "Sure he can run the latest software, but can he run a mile?"

Not taking care of unhealthy people who do nothing to help themselves is not an option. We're stuck taking care of that guy at the lunch counter until he slurps down his last 16 ounce Mountain Dew. Our obligation is transforming healthcare into a system of care that includes the education needed to make certain that patient type disappears entirely. A system that begins in very early childhood and never lets off the gas. Unfortunately, if we can't find a way to commercially exploit the process it will probably never find the support needed to succeed in the good ol' US of A.

Parsimonious Doctors: Salvation for US Healthcare?

NPR reports that the American College of Physicians have published new practice guidelines calling for physicians to be "parsimonious" in the use of health care resources in an effort to rein in costs. According to Virginia Hood, president of the group, this recommendation comes in light of the fact that healthcare costs are twice that of other civilized countries when our outcomes are not as good.

The story is linked to another entry in which NPR comments on medical schools and academic medical centers, places like the Mayo Clinic, increasing their advertising budgets in an effort, in part, to capture more market. I see similar events on a local level: Driving down the freeway one sees billboard after billboard promoting birthing centers, cancer centers, orthopedic centers, heart centers.

It amazes me that, in discussions of healthcare, supposedly knowledgable people continue to look to the physician as the gatekeeper when it comes to cost control. If medical centers have to accommodate advertising budgets, if pharmaceutical houses spend billions on advertising, if insurance interests are beholden to investors and pay seven figure salaries to top executives, if many physician decisions are modulated by concern with legal defense, then healthcare costs will be very, very high. And outcomes will not correlate with the increased expense because these costs have little or nothing to do with providing care. I would argue that the lion's share of healthcare costs are generated by the desire to maintain healthcare as a very lucrative profit center. What's more, I would contend that, outside of practicing defensive medicine, doctors' decision making has very little impact on the bloated fiscal landscape of US healthcare.

Call me naive, but the math in all this appears academically simple and politically complex. Until the political is separated from the clinical and the commercial from the humanitarian, healthcare will be neither affordable or sufficient.

The Drug Culture

Seriously?

I watched the Obama interview Sunday on 60 Minutes. I enjoyed watching it and I like to think the man has the potential to accomplish an important human agenda. His biggest obstacle remains an opposing party that seems fully committed to obstructing any policy the President presents-- opposition that, in spite of all rhetoric to the contrary, appears to be opposition for the sole purpose of being obstructive.

The thing that killed me, however, was the fact that I saw two pharmaceutical ads, one for Lipitor and one for Cialis, aired during the course of the interview. I have to say, I don't think people outside of medicine really get it. Does anyone in all of the United States think pharmaceutical advertising to the public-- those sophisticated slick television, web, and print ads-- does anyone really believe those ads do anything other than add to the cost of healthcare?  Does anyone really think direct pharmaceutical advertising to the public makes American healthcare better, more informed? Seriously? Having Obama's interview sponsored by a pharmaceutical concern is like having Budweiser run ads on an interview with a raging alcoholic struggling to find the path to recovery. For a guy who is committed to healthcare reform the irony was too much to take.

What direct advertising to the public does provide is unrealistic expectations, unrealistic outcomes, and exceptional successes portrayed as routine, all the while adding millions of dollars to the industry budget. They aren't public service announcements, you know, they're enticements to buy. And they contribute to the obscenity that is the cost of healthcare in the United States. Pharmaceutical advertising is detrimental to America's health. The drug company ads need to saddle up and follow the Marlboro man off into the sunset.

Grumpy Old Me

I must be turning into a grumpy old pink-o, socialist, commie, hippie: I took care of a woman the other day and she tells me she is paying $1800 a month for health insurance for herself and her husband and they still have a significant deductible. What the fuh.....!

It just seems that in a modern society if you get sick or you need an operation or your teeth need care or you need medication...it just strikes me that you should be able to get that as a human being living in the United States in the year 2011 without having to choose between food-- or gas or housing or clothing-- and healthcare. Canada seems to be able to accomplish this along with a whole lot of other modern countries. And, yes, they do pay higher taxes.

I have heard the comments about access and quality and I don't buy them. I sat next to a man on a flight a few months back, a duel citizen of the U.S. and Canada. He teaches at the University of Saskatchewan and is a native of Illinois. His appraisal? "I just like being able to get care when I need it without having to think about deductibles and all that." I have also heard about the Canadians who cross into Michigan because they don't want to wait 4 months to get an MRI of their knee. Boo hoo.

Like I said, I guess I'm just getting grumpy. But every day 10,000 Americans-- 10,000!-- are turning age 65. I see older people every day and I cannot imagine how our present system of medical care is going to even begin to handle the volume of need that's coming. It's enough to really piss me off.