Politics, Parasites and a Proof-of-Principle

Now that Max Baucus and Senate Finance have finally pushed their bill out of committee, there are at least five legislatively viable approaches to healthcare reform floating around on the Hill. (Also see this, but quickly, it's all getting dated even as I write.) Given the current political picture, there’s every reason to believe that Congress will push through some sort of healthcare reform legislation, perhaps before the end of the year.

President Obama will sign it, and I’d like to think that he’ll be holding his nose when he does so. That’s because the bill he gets is almost certain to be at least 50% fecal matter by weight.

Oh, sure, there will be a lot of laudable stuff in the final bill. It will cover more people by making healthcare coverage more affordable, it will possibly put something remotely resembling a leash on the for-profit insurance companies, it will probably mandate EMR (which I consider to be a Good Thing) and, most importantly, it will demonstrate an incredibly important proof of principle: health care reform is actually possible.

Remember, a huge array of powerful actors were dead set against any reform at all, right from the git-go-- extremely well-monied and reactionary interests, people who don’t know the difference between a pneumonia and a blister, who would be perfectly happy to let you die in the street if it saved them a dollar on their taxes, the kind of folk who are generally in it for themselves and eat their young. The fact that anything even got out of committee, given the carefully staged town hall outbursts, gazillions spent on disinformation, and hysterical bullshit about "death panels," is something akin to a legislative miracle.

So yeah, the final bill will have a lot of reasonably tasty stuff in it. It will also be at least 50% shit. And what happens, exactly, when you mix tasty stuff with shit?

Still, I’m one of those guys who likes to think that the glass is only half full of shit, and there is a glimmer of hope that the complex, corrupt, mysterious and intensly Kabuki-like process of legislative reconciliation now underway will actually improve on the bills that have come out of committee.

I also play Mega Millions on a regular basis. (I won $3 this morning, woo-woo!).

But hey, there’s always next time (see Proof of Principle, above). And so, for next time, and for the Mega-Millions part of me who hopes against hope that something useful will come out this time, I humbly offer, in all its glorious simplicity, Sullydog’s Overriding Principle for Meaningful Health Care Reform.

Ready, Nancy? Harry? Barack? Olympia? I know you’re reading this.

Brace yourselves.

Here it comes.

Don't spend health care money on people who don't do health care.

That’s it. That’s all there is to it. And from a physician/patient perspective, it really makes a lot of sense. It’s really just a polite way of saying that parasites are very bad for you and must be exterminated without mercy. Huge segments of the health care economy are parasitical, sucking resources out of the system without giving a damn thing back, except increased costs, perverse incentives, and toxic administrative burdens. If a new health care system were to put even a few of these helminths out of business, that would be a prime indicator that something had been done right.

Just to be clear, I'm not talking about people who run hospitals and clinics, critical administrative and support personnel--although truly meaningful reform would reduce the need for administrative support. It takes a lot of people to do billing and wrangle with HMOs. No, I'm talking about the real bloodsuckers, the people who line their pockets with American healthcare dollars and don't actually do anything to promote or support patient care--people who, in fact, weaken the entire system and put our patients in jeopardy.

There are plenty of barnacles on the hull of US healthcare, but two groups deserve special attention. I don't think I'll get any argument from most people on the first genus of tapeworms that should be in our crosshairs: malpractice lawyers.

Now, from my tone, you might prematurely surmise that I'm hostile to all malpractice lawyers, or that I think the medical malpractice tort system is a bad thing in and of itself.

So, just to be sure there's no mistake, that nobody misconstrues what I'm saying here, let me just clarify by saying that you would be absolutely right. That's exactly what I'm saying.

This is a destructive, malignant, greed-based industry that has been capitalizing on human suffering and sucking the life out of our health care system for quite long enough. The entire enterprise deserves to leave skid marks on the bowl. Our medical malpractice tort system does notimprove the quality of care, does not justly redress errors, has been a principle driver of increased waste and costs, and has poisoned the art of clinical decision-making almost beyond recognition. Other, more rational, more effective, and more just alternatives are readily at hand to mete out justice and provide compensation and care for injured patients. These are not opinions, they are facts, and they constrain malpractice attorneys, as a class, with a direct and categorical moral duty to find a way to serve the public interest rather than harm it, as they are doing now. They can do this by evolving into homeothermic chordates and working on new methods for just and proportionate patient redress, or by devoting their skills to another branch of the justice system. Or they can remain in an evolutionary cul-de-sac, in which case we should force them to trade in their pin stripes and Porsches for a nice shelter and a soup kitchen. Either will do. If health care reform puts thousands of ambulance chasers (and malpractice insurers, and professional expert witnesses, and various and sundry other vermin) out of business, I will not shed one bitter tear. They're bloodsuckers. They deserve to be eradicated.

The second superfamily of parasites that needs to be exterminated make up that vast, vile and suffocating biofilm known as the Health Insurance Industry. It's time to don hazmat suits and go to work on these guys with a pair of pliers and a blowtorch.

A lot of sturm und drang has erupted over the now-moribund prospect of a Public Insurance Option, much of it having to do with such a public program's ability to insure more Americans at less cost by undercutting premium margins and exploiting unfair advantages (such as lower marketing costs) over for-profit insurance. Horrors! These “unfair advantages,” it is said, would gradually suck all the oxygen out of the insurance market, and ultimately put HMOs and other private health insurers out of business.

Really? Wow. When can we get started?

Let's review the physiology and life cycle of a typical member of the species insurances profitales parasiticus, shall we? This loathsome creature spawns in that celebrated, dog-eat-dog, Darwinian space known as the Market, which is a great ecosystem for predators and even for wary herbivores, but a really shitty environment for sick people. Once it has affixed to a host (also known as a policyholder), it will feed on premiums until the host sickens, is injured, or is weakened by lack of employment. At that time, the worm detaches and scurries away as fast as possible, to search for another victim while its decimated erstwhile host is consumed by the various scavengers and saprophytes of the Market (and the malpractice tort system—an excellent example of synergistic parasitism).

That's it. That's how this whole system works. For-profit insurers collect premiums from policyholders. That's their blood meal. If they can keep it in their belly, they get nice and fat and rich. And the only way they get to keep it is by limiting or, better yet, denying compensation when somebody gets sick. Think about that: they've already got your money. The fundamental incentives of the free market mandate that theykeep as much of it as possible. As private corporations, it is in fact their duty to their stockholders to keep as much of it as possible--no matter how sick you are.

There is just no getting around it: anybody who has private health insurance places their insurance company in an immediate fiduciary conflict of interest the minute they get sick or injured. That's because the duty to compensate the patient's care is at direct odds with the duty to maximize profits. And that's how we end up with a system like the one we have now--a system in which the insurance marketplace is supposed to provide coverage, but the overriding economic incentives of the insurance marketplace are to deny or limit care. It's perverse. It's immoral. It's evil.

Of course, if Congress cared whether something was perverse, immoral or evil, we'd be living in a different world. Instead, let's focus on the fact that this system doesn't work, that it leaves millions without access, and that it's also stupid and wasteful, because it means that billions of dollars a year are spent lining the pockets of an industry that doesn't actually provide health care--people who actually deny health care for a living.

It's so simple. Don't give healthcare money people to don't do healthcare. What's so hard about that?

Why do we put up with a system that’s dysfunctional and wasteful and immoral, just because it makes a lot of people insanely rich and powerful?

Oh. Yeah, right. Never mind, don't answer that. I'm off to buy another Mega-Millions ticket.

Turkey, Tinea and a Touch of Death

The Rapid Care clinic hasn’t opened yet, and the acute care mods are beginning to feel like the protracted combat sequence at the end of Children of Men. Yet another patient pops up on my congested list: “scalp rash x 3 mo.”

Unbelievable, I think to myself. Who could possibly think that a scalp rash was an emergency? After 3 months? And what person not at death’s door would come to the ED on a beautiful spring day like this, the first warm day in what seems an eon?

My resident is tied up with a complex lac. That’s okay–on the face of it, this doesn’t look like a teaching case. When I enter the module, I am confronted by an obese, anxious lady with a rip-roaring case of tinea capitis that I diagnose from across the room.

Tinea. Pilfered web image. Not my patient. HIPAA is no fuckin' joke.

I manage a smile that is marginal at best, and squelch my impatience with this silly lady by reminding myself that this case is likely to be quick. Diagnose, treat, street, and back to the “real” patients.

“Hi,” I say, and introduce myself. “I’m one of the emergency doctors.”

She looks me in the eye, and there’s a hint of terror in her expression. “Doctor, I just want to know if I’m okay. I don’t want no aneurysm or cancer.”

Huh? I’m closer now, and I’m 100% certain that this is tinea.

“Um…no,” I tell her, a bit bemused. “That’s not…cancer.” I immediately double-check myself and look again. I squint at it to see if I can make it look like cancer. Nope. That’s tinea.

“I had cancer,” she tells me. “I had cervical cancer.They almost didn’t catch it in time.”

Not only am I sure that this thing on her scalp isn’t cancer, I’m absolutely positive that it isn’t cervical cancer.

“No,” I tell her. “It’s just tinea.”

The unfamiliar word frightens her. Her eyes get wide. “What’s that?“

“It’s a fungus. It’s just ringworm. We can clear it up.”

She starts to relax. “It’s not an aneurysm, either?” Her mother, as it turns out, had an aneurysm, something in her head that killed her. She’s heard that they’re hereditary.

“No, that’s not an aneurysm, I’m sure.”

She grimaces and shakes her head. “I just want to know if I’m okay.”

“I have to ask,” I tell her. “If you were that worried about it, why didn’t you come in earlier?”

She looks at her feet and nods, a sort of silent mea culpa. “I know,” she says. “Stupid.”

Uneducated, I think, but not stupid. By now I’m starting to forget that this lady’s appearance in my ED is cramping my style, messin’ up my rhythm. She’s gone from being a treat-n-street to a person. It’s a humbling moment, of the kind that come–or should come–quite often in emergency practice. There’s no such thing as a good slow emergency doc, but sometimes we do need to slow down a bit just to remember why we’re here. I sit next to her. “No, it’s not stupid,” I say.

“I was just scared. I thought it was cancer. I mean, not really, but I thought it might be.”

I’m suddenly awake to what’s going on. This lady–not particularly knowledgeable, and with limited resources at her disposal–has been trying for three months to work up the time, energy and, most of all, the courage to come down here and just find out whether she’s okay…or if maybe she’s going to die.

Because, you see, she’s had brushes with death before. Unlike many of our younger patients, convinced of their own indestructibility, she’s got the age, the experience, the scars and the innate wisdom to know and fear her own mortality. She watched her mom die young of some mysterious thing called an aneurysm, which had something to do with her head, a genetic demon that might possess her as well. And she herself had to fend off a cancer that had come for her. Now she thought another monster was stalking her, and after three months of hiding from it she’s worked up the fortitude to come in and find out just how bad it is.

She just wanted to know that she was okay.

You and I are the same, I think, and at that moment she is the most important patient in the module.

Let me back up before any of you Bozos think I’m getting all soft and cuddly on you. Not likely. But about three months ago, I did have an interesting experience.

I started my shift at 1pm. It was the standard Mod 4 “afternoon overflow” shift. In all, my residents and I saw some thirty patients over the next ten hours. I had two very long codes during the shift, and most of our patients were complex, difficult, bizarre, drunk and demanding. It was a typical inner-city ED shift. I ate almost nothing, and drank far too much coffee.

At about 1130 pm, after my module had closed to new patients, I came to realize that I had not been taking very good care of a patient who had arrived many hours earlier. I was attempting to correct the deficiencies in my care and was having some difficulty getting the overworked nurses to recognize that he was sicker than I had thought. By midnight, my orders for additional fluids and repeat vital signs had not been carried out. My request to ICU that they admit him had also not been received favorably. All, ultimately, my fault; if I had made the relatively elementary recognition of his need for care hours earlier, I wouldn’t have been playing catch-up.

I stood at the bedside of my patient, painfully aware of the untimeliness and deficiency of my care–not an unusual circumstance for any emergency physician, certainly not for me. I was using my sergeant voice, imploring the staff to hop-to. I was upset with them, with ICU, and mostly with msyelf. And of course, I was exhausted, some 15 hours after rising, some 11 hours after starting shift. I suddenly felt flushed, which for an instant I attributed to my dissatisfaction with the situation and the dismay of letting my patient down. I have experienced this before, this sudden reddening and warming, the adrenal blush that accompanies stress in the ER. Flushing gave way to a sense of profound weakness and fatigue and a sort of vertigo. “I need to eat that sandwich I brought for lunch,” I thought. “I need to sit down and eat.”

Then I was in a dream, looking at a faraway TV screen displaying the faces of my colleagues arrayed in a circle. Then I was inside the screen, and I was in pain, and I fought back against them, and they were holding me to the floor. The Man With The Red Shoes, Dr. Phil, was shouting at me. It took some time to understand what he was saying, that I had passed out, fallen, and struck my head. Now he was flushed and upset, as were my other co-workers. I had really frightened them. Soon I was on a backboard and then on a gurney, with O’s in the nose and an IV and monitor leads on my chest. I was a patient in my own module.

The story became more clear as time went by and they filled me in. I had told one of my favorite nurses, in what she called a strange, sing-song voice, in a very automatic and rehearsed way, to do several things she had already done. “I need him on a monitor.” He was on a monitor. “I need him to get fluids.” He was receiving fluids by then. “We need to prioritize.” I remember saying none of this.

Then I went straight back, like a felled tree, and my head made a resounding crack that, allowing for some exaggeration from my excitable coworkers, was allegedly heard throughout our department. There was apparently some “Smurfication” of my complexion, and I had that empty, blinkless stare we don’t like to see in patients. The nurse could not find a pulse, probably because of profound bradycardia, and CPR was initiated. I woke up some thirty seconds into this code, physically combative, apparently with the words “Get the fuck up off me.” I do not recall that, either. I do recall that my head and neck hurt, and my first quasi-lucid thought was to confirm to myself that I could wiggle my toes, extend my thumbs, shrug my shoulders, exercise my ocular muscles in all planes, and squeeze my own butthole. This I did. A relatively sophisticated clinical self-evaluation, at a moment when I could not recall my own birthday or phone number when asked.

I was scared.

I needed to know if I was okay.

But my ED workup was negative, my colleagues and coworkers were wonderful, and an overnight in the CCU yielded little besides a bill. Cardiology told me to set up an appointment for a perfusion stress and an event monitor. I went home. (And no, contrary to all the rumors I’ve heard, I did not sign out AMA.)

Ultimately, I believe this was an incident of little practical consequence, though it was a tad embarrassing. But I am awe-struck at how how precipitously and inexorably my sensibilities were taken from me. One moment I was suddenly overwhelmed with fatigue and dizziness, with barely an instant to reflect upon a sandwich before consciousness left me. If it had been a lethal arrhythmia, my last worldly thoughts would have been of honey-roasted turkey and Swiss cheese. I did not register what was about to happen to me, much less did I have time to marshal what would have been an ineffective defense, or even a clever parting quip. My last words would have been “We need to prioritize.” Better, I suppose, than “I know what I’m doing, dear,” or “I need my diaper changed,” but hardly worthy of a tombstone.

Just that quickly, death might have tapped me on the shoulder and taken me. Of course, I have been aware of this possibility for some time, but to experience this small taste of the Reaper’s power, so palpably and vividly, can really change one’s outlook.

Doctors tend to think of themselves as fighters against pain and disease and death. And I for one always fancied that I had a better personal chance against untimely death than the average Joe, simply by virtue of being an ED doc and in relatively good health. Of course I should have known better, and now I realize, as never before, that death need not face me like a combatant and grapple with me for my life. He can slip up behind me and cut my throat without a moment’s warning, whereupon I have barely enough time to register my own confusion before consciousness is gone. We are fighters, yes, but he is not. He will brook no opposition, and has no compunction about exercising his office without warning or trial.

My patient with tinea knows this better than I did just a short time ago, because she has had her own brushes with death. And she knows something else, too. She knows that death and disease are mysterious, even to doctors. Sure, she may not know how to tell tinea capitis from a skin cancer. But neither can my colleagues in the ED and in the cardiology clinic tell me why I zonked out in the middle of the module that night.

So even after my CT and my EKG and my serial troponins and my other labs all came back 5/5, I, the big smart academic MD-PhD, was left with the same question that haunts my patient: Am I OK? Thereafter, every twinge of minor thoracic pain, every brief instant of fatigue or dizziness, every caffeine-induced palpitation made me wonder: Am I OK?

Two weeks after my episode, the resident who had been working with me that night approached me and asked me how my perfusion stress and event monitor had turned out.

“Well,” I said. “I…uh…”

Her eyes got wide. “No. You didn’t get them!”

“Well, now, look…”

“You didn’t follow up! I don’t believe it. You didn’t follow up!” She’s gaping at me.

Another resident overhears this. “What the fuck, Dog?”

I am well-rebuked. Yes, I feel dumb. For two weeks I’ve been wondering: Am I okay? Do I have a renegade coronary? Some weird channelopathy that doesn’t show up on a cardiogram? Some insidious valvulopathy? Sick sinus? Epilepsy? Glioma? Oh, fuck–do I have brain cancer? Oh yeah. That’s it. It’s brain cancer. Or a valvulopathy. Or it’s a brain cancer and a valvulopathy. Do they go together? I bet they do. I bet there’s some weird syndrome of brain cancer, valvulopathy and syncope. A classic triad. Probably named after Quincke.

The only difference between me and my patient is that I can dream up far uglier and more ridiculous scenarios to explain my mysterious condition than than she can, by virtue of my training. But I’m apparently no more capable than she is of getting out from under the bed to do battle with these phantasms. It takes two weeks and a tongue-lashing from a couple of residents to get me to pick up the phone and make an appointment in cardiology clinic.

I put my hand on my patient’s shoulder. “It’s not cancer and it’s not an aneursym,” I tell her. “It’s just a fungus infection. It can be a little stubborn, but I can give you some medicine that should clear it up.”

She takes a deep breath and holds it. I can read her mind. She wants to hear the words.

“You’re okay.”

I can see the tension go out of her shoulders and her jaw muscles. She lets out a huge sigh and smiles. I’ve given her a reprieve from a sentence that we all must face eventually, a sentence that, in her mind’s eye, has hung over her head for weeks. I’m pretty sure I can help her tinea, but looking at her, I think that with two words I’ve already relieved more suffering in this one “non-teaching case” than I have all month. Something akin to the relief I felt when my cardiologist showed me the negative results of my perfusion stress, or when my three-week event monitor (what a pain in the ass!) came back negative. My world was exceptionally vivid after that clinic visit, my coffee quite bitter and delicious. I suspect my patient will find the fresh air outside today more pleasant than most of us would, the sunshine just that much more golden.

I shake my patient’s hand and go to write her prescription. You and I are the same, I think, feeling more like a doctor than I have all morning. But we’re okay.