Patients Gone Wild and Healthcare Reform

(I'm blogging from the operating room.  Here's my Saipan Tribune column for this week.)

I recently had the opportunity to read President Barak Obama’s letter on Health Care Reform, dated June 3, 2009.  There is one paragraph in particular that jumped out at me, because it seeks to identify the “root cause” of rising health care costs.  Here it is:

“At this historic juncture, we share the goal of quality, affordable health care for all Americans.  But I want to stress that reform cannot mean focusing on expanded coverage alone.  Indeed, without a serious, sustained effort to reduce the growth rate of health care costs, affordable health care coverage will remain out of reach.  So we must attack the root causes of the inflation in health care.  That means promoting the best practices, not simply the most expensive.… That's how we can achieve reform that preserves and strengthens what's best about our health care system, while fixing what is broken.”

First, let me say, that I agree with the gist of the statement.  Rising health care costs are killing our economy (well, that and a few other things), and medical care can definitely be improved so that it is more cost effective.

But here’s the truth.  The single best way to reduce the cost of healthcare is to reduce the need for healthcare.  We are a sick bunch of people, and for the most part, it’s because of our own behavior – we’re all “patients gone wild.”  The majority of us are sick, not because we’re out doing healthy things and suddenly get struck down by some horrific disease.  No, we’re sick because we eat too much, sit around too much, eat the wrong foods, smoke, consume alcohol, and generally ignore the things that lead to good health.  We’re sick because of the wild and crazy choices we make.  The vast majority of healthcare costs in America and the CNMI are tied to chronic “lifestyle” diseases.  The top ten causes of death in the US include heart disease, stroke, diabetes, and cancer.  And every single one of these has been incontrovertibly linked to how we live our lives – whether it’s what we eat, what we do, what we drink or what we inhale. 

To a large extent, we’re digging our graves with our spoons and forks.  Last year, we spent over $20 billion dollars on cholesterol lowering drugs.  That’s billion, with a “B”.  If you had $20 billion dollars, and decided to burn a million dollars a day, every single day, it would take you 55 years to spend $20 billion!  Why is our cholesterol high and why does it need to be lowered at a tune of $20 billion a year?  High cholesterol is a major risk factor for heart disease and stroke.  Our bodies produce some cholesterol, but most of the problem comes from what we eat.  Only animals have cholesterol in them.  Vegetables have no cholesterol at all.  We’ve known for decades that the most effective way (and the cheapest way) to lower cholesterol is to lower our consumption of animal products – animal flesh, animal milk, animal cheese, animal crackers, etc.  But you know what? We’d rather not make that kind of change.  We’d rather pop a pill and keep eating whatever we want to eat.  And that’s $20 billion dollars we spend so we can do what we want to do, which is to eat lots of animals. 

The same is true for diabetes, which is devastating our community, and growing at an alarming rate.  We know that for most of us, the adult onset variety can be controlled, or at least hugely improved, with diet and exercise.  Yet we choose not to make these difficult changes.  We choose to eat what we want, and take pills and go on dialysis and lose our vision and our feet and our erections.  And we spend untold billions on the cost of care for diabetes and its related problems. 

A diet high in animal fat is also linked to a slew of cancers.  Pass the processed meat that starts with “S” and ends in “M” and rhymes with “PAM”.  Or just pass a burger or wiener or any other chunk of meat.  Alcohol consumption is linked to many cancers.  Pass a Bud (better make that a Bud Lite).  Tobacco is irrefutably linked to cancer.  But we can’t seem to manage to pass legislation to ban smoking in public spaces.  Pass the votes. 

I admire efforts to improve the cost-effectiveness of the healthcare we deliver, but I know that the “root cause” of the mess includes our culture of indiscretion, of consumption, of sitting around.  Any serious effort to fix the healthcare mess must include a change in our culture – what we eat, what we do, what we drink and what we inhale.  These changes won’t solve all the problems, but they’ll make a huge dent in the demand for and the cost of healthcare.  A major portion of the responsibility to “reform” belongs on our shoulders -- those who end up needing healthcare.  Reduce the need, and you reduce the cost.  It’s simple.  But it’s not easy.  We humans typically don’t like change.  Yet failure to change our behavior will result in more and more people needing healthcare every year, rising costs, and eventually, not enough doctors, hospitals or other resources to take care of so many sick people.  We’re experiencing the fallout right now, right here in the CNMI. 

Addressing our behavior needs move to the front and center in the public policy discussion on healthcare reform.  It’s a nut we must crack.

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David Khorram, MD is the co-founder and medical director of Marianas Eye Institute.  He is the author of the book, World Peace, a Blind Wife, and Gecko Tails, which is available on Amazon.com and at Marianas Eye Institute.  Dr. Khorram can be emailed by visiting www.MarianasEye.com, or by phone at 670-235-9090. © David Khorram, 2009.

Seduced by a Stethoscope

It was the first week of medical school and Littman, the world-famous medical equipment maker was on campus giving brand new stethoscopes to every entering student. The free “little gray Littman” was unadorned – the disc to place on the chest, the tube to carry the sound, the hollow ear buds. Littman also brought the sparkling models with them, all making the little gray Littman look okay, but not very sexy, like a homely dress in a room full of evening gowns. The sultry knockout of all stethoscopes was the Littman 501. She could be seen draped around the necks of all great cardiologists -- in their clinics, hospitals, and family photos.

Ahh, the Littman 501. Her sound capturing device was like a warm hand that would lie gently on any chest. Her double tube body with dedicated conveyance to separate ear canals ignored all voices but the one she was intent upon. Her soft ergonometric buds were like lips that would whisper sweet lub-dubs into your ears. She was dressed in elegant black with silver accessories. Walk with her through the wards, and hearts throb, beats skip, murmurs rise for you and your 501. Your unbuttoned white coat flutters, leaving those with lesser stethoscopes gazing admiringly, with a twinge of envy, then hurrying to keep pace. Stay with her long enough and she would curl up into a perfect halo, illuminating your way.

I held the little gray Littman in my hand, and saw the 501 gaze seductively at me from across the room, promising love, happiness and the ability to hear a paradoxically-split S2.

“What do you think?” I asked the cardiology attending who was there to browse. His Kentucky drawl thickened the air before his lips, the words slowly making their way through it. His statement stayed with me throughout my career. “It ain’t what’s in your ears that counts; it’s what’s between them.”

I love the high-tech tools of my trade – my slit lamp, the ocular coherence tomographer, my phaco machine, the laser -- but the most valuable tool I possess is me: my brain, followed closely by my eyes and my hands, all held together by my soul which helps me work compassionately.

The doctor-as-tool may seem obvious, but it isn’t. We often give better care to our equipment than to our selves, thus growing dull, sometimes even broken, from lack of maintenance. People come to see us, because of who we are. They’re happy when we have the best equipment, but they know that without the talent to use the technology, and the soul to stay off grumpiness, the doctor isn’t much use.

Last week the new patient looked stunned when I said that the treatment for her lingering red eye would be, well, brain surgery -- that without it, she would die. She had walked in, expecting more drops. But my eyes had seen the tortuosity of her conjunctival blood vessels. My brain had noticed them and drawn a conclusion. My hands opened the drawer, dusted off the stethoscope, and placed it, oddly enough, on her skull. I heard the faint swoosh swoosh swoosh – a leak from a vessel in her brain, squirting blood with every heartbeat. The leak was raising the pressure inside the cavernous sinus, slowing drainage of blood from her left eye. This was causing her chronic “conjunctivitis” which no drops seemed to cure. I put my little gray Littman back into the drawer, and smiled, knowing that technology can be seductive, but it’s not what matters most.

SurgeXperiences 19 - Surgery Carnival

I'd like to thank Jeffrey Leow, the Monash Medical Student down in Australia, who found my blog and invited me to host the 19 edition of SurgeXperiences, the worldwide Surgery Carnival. As anyone reading my blog can see, the practice of medicine is just one of the activities I pursue, and so I have never really wandered the blogosphere looking for medical blogs. But now, through hosting this Carnival, I've found that there are some really fascinating ones out there. It's also inspired me to write a bit more about my own medical and surgical experiences.

I designated the theme of this Carnival,"Funny Operating Room Moments," and there are quite a few of them here, but many are just entertaining posts about various facets of surgery and medicine, and, well, the human condition. I'm posting them in the order they were received. Here we go.

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One of the most fascinating surgery blogs I came across is from Israel, and belongs to The Sandman, an anesthesiologist in Tel Aviv. (The Sandman -- get it? Puts people to sleep.) I found two of his recent posts quite compelling. The first is a story of having an elderly couple in his office. Because he took the time to get to know them better, they shared with him their story of arriving in Israel after the holocaust on the ship that was at the center of the story of the historical novel, Exodus. His second post that I enjoyed shares his thoughts on the calm face that seems to often be present on people who die violent deaths. It's a graphic post, but gives a peek into the task of pronouncing a person dead. ("I now pronounce you dead.")

You can also browse through his blog and get a different perspective on the violence in that country -- as seen from the inside of an operating room. The Sandman did send a post for this Carnival, "It ain't over til' the fat lady sings" which points out the importance of making sure your patient is asleep when you think they're asleep.

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Jeffrey Leow forwarded a few links to save me time finding them, including A Lesson (Not Just a Joke) From an Orthopedic Surgeon posted at The Differential: Medscape Med Students Blogs. It’s a story by medical student Ben Bryer that describes the unexpected use of a hand drill (instead of a power drill) to fix a patient’s leg. It’s just like here in Saipan, where improvising is a way of life. In fact, there is a sign hanging on our OR wall (by the former chief of orthopedic surgery) that reads, “If you have to have everything you need to do the case, you probably shouldn’t be here.”

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All of us have experiences of non-nonchalantly almost killing someone. I almost did it when I was an intern and admitted a patient who was experiencing weakness. I tucked him in for the night, thinking we'd deal with the problem in the morning. The resident stopped by to see him an hour later and diagnoses Guillane-Barre syndrome, a rare disorder that causes paralysis and therefore stops breathing. If the resident hadn't stopped by, the patient would have been dead by midnight. It was a learning experience I never forgot. In How We Learn posted at The Differential: Medscape Med Students Blogs, Anna Burkhead describes witnessing a surgical resident's similar learning experience.

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Jeffrey also brought my attention to the post, Surgery and the Blowfish, again by Ben Bryner, who gives proof that we surgeons are way smarter than blowfish chefs. Find out why.

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Pimping. Do other professions use the word the way we do? In medicine, it refers to the endless series of questions that will come the way of a "junior" medical type, by a "senior" medical type. Most commonly, it is a hapless medical student getting pimped into oblivion by the attending physician (the "professor"). It's usually conducted on rounds or in the operating room, and it's rare that there isn't a gaggle of spectators present -- the whole medical team -- silent witnesses with downcast eyes, folder arms and beaded sweat. Pimping ends when either the pimper runs out of questions, or the pimped doesn't know the answer. And the pimper never runs out of questions. So, the session will conclude when you're wrong, which is why pimping never feels like it has a happy ending. If you have a sense of humor, you can get away with a lot, especially if you know the answer. Once during rounds when I was being pimped, the attending, while studying an EKG asked me "What is one of the clearest indications of an elevated blood potassium level?" I answered, "The word 'HIGH' next the the letter 'K' [the symbol for potassium] on the lab sheet." Jeffrey Leow directs us to How to Survive Pimping in the OR posted by Anna Burkhead, where she gives some useful tips.

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Sid Schwab, who like myself is the author of a book, has written about a tube at an unexpected orifice. For some reason, whatever the conversation may be, orifices seem to be fertile ground for a giggle. Sid's post is Snakes on a Pan, over at SurgeonsBlog.

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When people move to Saipan (the island on which I live) and work for the government, they typically rant incessantly about the problems with the system, as if problems and inefficiencies are unique to this island. I usually respond, "Dude, you haven't ever worked at a VA, have you?" Dr. Rob Oliver paints some accurate (and funny) pictures of life at a VA at his post VA Voodoo Economics - Krugman wrong on John McCain posted at Plastic Surgery 101.

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Dr. Oliver also presents Dumb laws and smart laws re. plastic surgery. It regards legislation in California that will require medical clearance for all plastic surgery patients. Believe it or not, I get medical clearance for all my cataract patients, mostly because here on the island, you can rarely get a straight story about someone's medical problems. I send them all to see their internist, and we find some interesting things (like blood sugars in the 400's, just walkin' around). It's best in my opinion to leave medical decisions up to doctors, not legislators. We get medical clearance when we think it's necessary. And we're generally a careful group of folks, particularly in America where a lawyer with a briefcase is only a stopped heart (or an inconvenient rash) away. Thank-you, Dr. Oliver.

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All stereotypes are based on some element of reality. In medicine, we all know the stereotype of the orthopedic surgeon ("As strong as an ox, and twice as smart.") Dr. Val Jones shares some excerpts from a talk by an orthopedic surgeon, which I honestly found refreshing. I like these guys. They're the surfer dudes of medicine. Check out her post at Revolution Health.

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"I was filming a nipple reconstruction..." Thus begins a "Tale of Two... " um, no, I'm not going to say it... thus begins a tale by Norwegian surgical videographer, The Sterile Eye, who presents Yo mammae! That sentence is sure to become a classic in medical blogging literature. I give Sterile Eye the "Call me Ishmael" Award (which I just created) for week's best opening sentence of a Carnival post.

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Dr. R Bates, a plastic surgeon and quilter in Arkansas (who, by the way, is married to a wonderful man) is author of Suture for a Living. She explains the surgeon's "druthers" card, in her post appropriately named, Druthers. Her post, She's a Beautiful Girl! , which comes complete with it's own music video (is that Dr. Bates on the drums?) tells the touching story of a young girl who gains new self-image as a result of Dr. Bates skill. It's a reminder to all of us to pause and recognize how some of the little, "insignificant" things we do can so greatly affect the lives of others. Thank-you, Dr. Bates.

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South Africa's Bongi has some great posts at his site, Other Things Amanzi. If you're one of my regular readers who gets cheerfully grossed out by my "gory eye pictures," you're gonna love Bongi's writing. Here is a "taste" from his post, Fettuchini:

the patient came in after being involved in a car accident. he had an acute abdomen, but was otherwise stable. x-rays confirmed free air in the abdomen. easy call. the patient went to theater. we opened the abdomen. it was full of intestinal content. not too surprising. and then...lying in this soup, free in the abdomen we found a meter long tape worm! i'm not embarrassed to say i gagged. i threw it in a kidney dish where it entertained us with its peristaltic movements.

Bongi's hilarious post on operating in various states of undress deserves reading: Fashion Statements.

And what's worse than poop? Well, according to Bongi, it's poop that has gone rancid. Yep, rancid poop happens, and if you want to read about how it happens, and how to remain a macho surgeon in the midst of its indescribable fragrance, read this entertaining post, Tough Surgeon.

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Surgery has lots of "laws" -- dicta (that's apparently the plural of dictum) that give pithy bits of knowledge and wisdom. Many of them are specific to a particular institution. At the University of Kentucky where I went to medical school, there were "Five Laws of Surgery." I remember two of them: A bump in a breast belongs in a bottle; and Surgery, like sex, should be slow and gentle, and requires good exposure. (You're welcome to share your own opinion on whether or not good exposure is really required.) Bongi writes about this law of surgery: Eat when you can, sleep when you can, and don't f@*% with the pancreas. If you ever need advice on getting some sleep when little time is available, you can read this chilling post: Other Things Amanzi: Wakeup Call. Thanks, Bongi, I enjoyed your posts and I'm bestowing upon you a coveted Marianas Eye Funniest Medical Blogger of the Week Award.

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Doc Ness, an anesthesiologist not far from me, writes about the experience of being in the operating room, not as a doctor, but as a patient. Most of us will have to face the other side of the table sooner or later. You can read about Doc Ness' experience at random ness.

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And that's all folks. Thanks for stopping by. And buy my book, World Peace, a Blind Wife, and Gecko Tails. It's available on Amazon. (Yes, I know it's shameless self-promotions, but hey, I have four kids to put through college and Oprah hasn't called yet.) I hope you enjoy reading this Carnival as much as I enjoyed putting it together. I look forward to your comments and to regularly visiting your blogs.

The next edition of SurgeXperiences will be hosted by Dr. Sidney Schwab and will presented on April 27.

Doctor's don't know jack.

Okay, they know a lot about disease, and treating disease, but not one lick about health, and keeping someone healthy. I was at a medical staff picnic last weekend, and the potluck menu included a bucket of KFC, two Pizza Hut slabs, white bread sandwiches, and if you were there, you would have seen a toddler being given sips of beer. All the food tastes good, but the stuff is toxic to your health.

The vast majority of diseases in America and its outcroppings like Saipan are "lifestyle" diseases -- heart disease, diabetes, cancer. You get that stuff because of the way you live -- eat high fat foods and live a sedentary point and click lifestyle. The way to determine where a country is on a developmental scale is to look at their diseases. Developing countries deal with infectious disease. People die of things like measles, influenza, etc. When they reach a level of affluence where they can afford high-fat foods and a higher percentage of animal products, then they begin to experience diabetes and heart disease.

In medical school we had exactly one day of lecture on nutrition. But this is the key to treating almost every disease that we face. Even if you don't exercise much, if you eat well, you'll do well. All the new fangled drugs to treat high cholesterol, heart disease, diabetes, are really just a testament to the failure of American medicine and preventive health. Our new dialysis center is a beautiful building that is a monument to the failure of our system to prevent diabetes.

The hard part about preventive medicine is that you require people to make changes before anything goes wrong. They have to realize that the morsel of fat they're about to put into their mouths won't cause problems now, but will lead to a rotten life later.

In reality, it's pretty simple stuff. You gotta stop eating garbage (and honestly, almost everything you eat falls into the category of garbage). You can turn your life around in a matter of weeks. Pick up a copy of Eat to Live. It will change your life. By reading it, you'll likely know more about nutrition and health maintenance than 95% of the doctors you'll ever meet. But don't just read it. Knowledge isn't enough. You have to take action.

Let me know if you need help. If you want to lose weight or improve your health, Eat to Live is the path. I usually help my patients lose about 20 pounds within 10 weeks. I lost 30 pounds in 12 weeks and got down to my high-school weight. That was three years ago, and I've kept it off.

Lymph nodes, personality and the practice of medicine

Well, the mono test came back showing that Arman has been exposed to the mononucleosis virus (which is officially called the Epstein-Barr virus - EBV) at some time in the past, but not recently. There are different antibodies in the blood that can be measured. They measure antibodies to a molecule (or "antigen") at the core of the virus. The viral molecule is called the "virus core antigen" or "VCA". We produce different types of antibodies in response to an infection. The first one our body produces is immunoglobulin G, or IgG for short. In the graph above (don't get thrown off by the labels -- apparently French people have the same stuff in their blood as everyone else) you can see that IgG to the viral core antigen (the red line) rises and stays elevated. The IgG stays high for years and years, so if you have a positive IgG, you've been exposed to the virus at some point. IgM, on the other hand, rises during the acute infection and then goes away after a few weeks (the purple line). Arman's IgG VCA is elevated indicating past exposure to EBV, but the IgM is not elevated, indicating that he does not now (or anytime recently) have an EBV infection. Conclusion: They enlarged lymph node is probably not from mono. I say "probably" because sometimes, the IgM may not rise even in an acute infection. Go figure.

Being on the receiving end of the practice of medicine, I'm learning quickly that so much of the care that you receive as a patient depends upon the personality of the doctor, not on their knowledge. After seeing these results, the pediatrician recommended biopsying the node and discussing things with the pediatric oncologist in San Diego. I said, "With the node getting smaller, why would we biopsy it? After all, any of the bad things would not get smaller." The main question in my mind is, will a biopsy change the course of action at all? We already know it's not cancer. It's getting smaller. What could a biopsy show that would affect what we do? Answer: nothing really, but we don't want to miss anything.

That approach is one made on the basis of personality -- the need to not miss anything no matter how remote the probability. The pediatrician recommended that I at least come in and let the ENT specialist see Arman and make his recommendation. "Sure, I'm happy to do that." "Why don't you talk to him, he's standing right here next to me." He gets on the phone and asks me, "Is the mass getting smaller?" "Yes, definitely." "Then we don't need to do anything," he says. "Do you want to check Arman?" "No, just let me know if it gets bigger." "No biopsy?" "No, why would we biopsy something that's getting smaller?" His response also is based upon his personality. He doesn't need to have it proven to him that it's benign. His approach is pragmatic, like mine.

In medicine, many times (maybe even most times) there isn't a clear answer on the approach to take. The approach is based upon personality. In my practice, I do my best to let the personality of the patient make the decisions regarding the approach. When to start glaucoma medications for someone who has certain risk factors for glaucoma, but who has not yet developed glaucoma is one of these common situations. I'll often say, "What we do at this point, really depends on the type of person you are. Do you want to start this medication and use it for your lifetime, knowing that you may not need it, but that it will reduce your chances of developing any visual damage? Or are you the sort of person who would rather monitor things closely and see if any damage occurs, and then start the medicine once we are sure you need it?" Some people would rather take medicine and not worry about developing damage. Other people would rather wait to see definite indication that they need treatment. In my opinion, what I as the doctor feel (because in such situations, it is about what one feels, not what one thinks), isn't very important. I'll share it if asked, but I'll say, "This is what I would do because of the type of person I am. It might not be the best approach for you if you're a different type of person."

Of course, in lots of situations, the answer is clear, and I'll lay down the law and say, "if you don't stop smoking, you will go blind. You must stop smoking." That's the science. That part is clear. Doctors sometimes get confused because they lose the science in the midst of their approach, which is personal. That's why it can be so confusing to patients. Every doctor seems to have a different opinion of the best course of action. The important thing in my mind is to discover the best approach for the patient, based upon their personality. I teach them the science, and help them find their path.

So anyway, Arman's enlarged lymph node and spleen probably were not due to mono. And also, probably not due to lymphoma or anything bad. The lymph node is getting smaller. I was going to take him in for an ultrasound of his spleen to make sure that's getting smaller too, but I had forgotten that it was an "austerity Friday." Our government is broke here, so every two weeks all government employees get an unpaid holiday as a cost cutting measure. The ultrasound tech was on "austerity leave", so we couldn't get the ultrasound. I'll take Arman in next week, just to double check the size of his spleen.