Archive for August, 2009

You talk way too much

Sorry for all the quotes but they really are crackers.

From the journal of the college to which i belong – reasons why i find my job stressful and why i don’t sleep so well at night:

The emergency department (ED) is a complex and difficult environment in which to provide medical care and differs substantially from more traditional settings in healthcare organisations. Care is “unbounded” in the sense that the ED is the only part of the hospital where any number of patients can be admitted and held. It is the only “infinitely expansible” part of the hospital. Emergency caregivers typically treat many patients simultaneously and in a much greater variety than do caregivers in other settings; there are no limits on the type of complaint or condition that patients may present with; there are severe time constraints and often a paucity of information.

…This Government-set performance indicator target aims to increase the speed with which the patient moves through the emergency admission system, with 98% of patients being seen, treated and either admitted or discharged within 4 h. This has created huge pressures, not only on the ED but also on our support services and diagnostic services to increase their efficiency.

…Communication and decision-making are arguably the principal activities of emergency staff. In one study, 89% of emergency physicians’ time involved communication

…Observational studies have revealed that staff members working in the ED are dealing with up to 42 communication events per hour, with a third of these being classified as interruptions. Moreover, senior clinicians and nurses have been shown to be subject to the highest levels of communications and interruptions

I don’t even like people. I am so in the wrong job…

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Live forever

In a post on those with disabilities:

Unfortunately, our mortality makes a mockery of our pretension to be gods. This is probably why so many doctors in our hospitals run away from talking about death with their patients. As long as modern medical practitioners think of themselves as wonder-workers, and of their work as one of human engineering rather than alleviating human suffering wherever possible, they will always think of handicap and death as “failure”.

Just to make it clear – i think that this is a core part of what we do – alleviating suffering. Both doctors and the public have this perception that we make people better. Occasionally we do. But not very often. And we’re not very good at it when we do.

The view from your sickbed (some follow up)

I find this both scary and fascinating. Makes me look at my job in a whole new light. A slightly more positive light i mean.

The view from your sickbed

The Daily Dish (a sure way to monopolise all your RSS feeds…) has been running a series with the above title covering response to ongoing healthcare reform debate.

[When I get swine flu I might run a series titled, “the view from your swine flu”…]

To be honest I’m not entirely sure what Obama is suggesting but it seems to be some form of a nationalised health care system. This seems like a pretty good idea. Some don’t seem to think so.

Below is one of my favourite reasons for having the NHS. The whole American system just seems obscene.

For a few months, I worked at an electronic medical billing company. I was astounded at how complicated and convoluted medical billing is, and this is ultimately why we need to have significant health insurance reform. What happens is a doctor’s office will decide on a price for a procedure – for instance, a checkup typically costs around $180. Say I have Tufts. They might pay out $100 for a checkup – the rest the doctor writes off. Why not just charge $100 and not have to write off $80? Well, that’s because other insurance companies – say Blue Cross and AETNA – might pay $120 and $150 respectively. So it make sense for doctors to charge significantly more than they would expect from most insurance companies. However, if somebody doesn’t have good insurance or has no insurance, they are billed for the full amount -$180, even though the doctors office might expect to write off up to $80 dollars of that charge from somebody with good insurance. Given that the majority of the people without health insurance are lower income, this can cause crippling financial problems, or result in a denial of service. And why? Is someone with insurance “better” than somebody without? Are they more deserving of good health because they happened to not get laid off during a particular bad recession?

The problem with predicting medical expenses is that, even though you can find the codes (they’re called CPT codes and you can find them here) you would have to get the price from the doctors’ billing coders, which they would probably be loathe to give out- how can we expect the market to work when the consumers don’t get to know the price BEFORE consuming? And your other reader didn’t include that if you get an ultrasound, you’re billed for the ultrasound and the use of the ultrasound machine. If you have the time to sit down and do the research, it would be nearly impossible for the average person to make an accurate decision about the most cost effective doctor to have. Imagine trying to make that decision in a panic.

You know what i want to know

Sometimes i wonder what the medical profession did before the internet. One presumes they paid lots of money for expensive textbooks and went to medical school and stuff.

Virtually all my learning is done on line (some people would say that I should have done my learning while in medical school but i spent far too much time playing guitar and reading CS Lewis), trying to get my head around 9 or 10 different medical journals a month and the 2 gigabytes of plain text that is UpToDate.

Even in work I (and others) will frequently type symptoms and signs into google to see if there’s anything I haven’t thought of (usually quite a lot). I have looked up many simple and complex procedures on the internet before trying them out (just to be sure that the hip bone is still connected to the thigh bone…)

I also adore podcasts – some better quality than others. From the dull but accurate ACEP and SCCM podcasts to the excellent Albany Medical Centre (all be it with terrible sound).

My two new favorites are EM:RAP and the Persiflager’s Puscast

EM:RAP is presented by a bizzare but often entertaining hat wearing Aussie, who is actually a well respected Professor of emergency medicine.

The Puscast (what a title) is presented by a most sarcastic ID specialist who manages to make even MRSA funny. I also love the photo he uses to cover the podcast:

headUpArse

Says more about the nature of blogging and podcasting than it does infectious diseases.

Last days of my bitter heart

I have big issues with happiness. Not that I object to it in principle. Enjoyment is pretty much what Christianity is all about for me, joy is a moral good and all that.

What i mean is that i find myself uncomfortable with it. I am suspicious of it. I listen to too much miserable music, i read too many miserable books, i love miserable movies. But never mind this, i have eyes to see that life is a long (though occasionally brief) stream of pain and suffering interrupted by periods of peace and joy.

Perhaps i jest. Perhaps.

Not that i am describing my life. My life is a long stream of privilege and blessing interrupted by the odd major life event but mainly lots of melancholic wallowing.

But when I am joyful i always have one eye on the pain. You can’t have the sweet without the sour (baby) as i learnt from Vanilla Sky. Or rather, Vanilla Sky articulated what i already supposed.

This has become more of an issue in the past year. Since Da dying and all that.

I struggle to remember him without bitterness – not in the sense of anger or regret, more in the sense of sadness. I cannot have the joy and the thankfulness without the pain of remembering.

Yes i rant about this a lot. About memory and its effect on me. That the older I get the more memories i accumulate and the slightly more unhinged i become.

Lewis wrote in the great divorce about how people wanted to bring hell with them to heaven. That hell wanted a veto on heaven. That because there was pain, there could be no joy.

So why does my memory of pain (not only Da, but all the horrible things that happen to people i love every day) get to veto joy?

Surely it’s not a question of veto? That something or someone should be able to shout down the whole affair. Yes there is truth that it’s rare to find the sweet without the sour but they do at least get to co-exist, not one eliminating the other.

Anyhow.

I took a long walk here in the sun and i think i had my first purely joyful and thankful memories of dad. Toes in the ocean and all that.

Great expectations

Every time i meet a patient i make a judgement on them. I listen to how they speak, the words they use, trying to work out their level of intelligence.

I look at their clothes, make up, their address, trying to work out if they’re working or middle class, trying to scope out high or low income. I ask what they work at – for occasional pure pathological reference but mainly to judge them socially.

I check out the tattoos, the piercings, i look for the tobacco stained fingers.

I put all the picture together and use it to try and figure out what could be wrong with them.

Now you’ll be glad to hear that i also ask them about their symptoms and do that magical, mystical doctor examination thing (which is largely just poking and prodding them to see if it’s sore) – before i decide what’s wrong with them.

But the first bit still has relevance.

Virtually everything i do is a probability judgement. There are a few definites – the off ended bones going in different directions on your x-ray are definitely broken, but can i tell you that your tummy pain isn’t appendicitis – not unless i take your appendix out. All i can give is a probability judgement

The majority of what i do is guesswork. Expensive and highly trained guesswork but guesswork all the same.

And the guesswork is highly influenced by how i judge you as you walk through the door, by all the social and physical characteristics that i rate you by.

If you are from a poorer socio-economic background you will have poorer health. In America, if you are black or hispanic you will have poorer health. Or is that just cause you’re poorer with no insurance…

My job exists at the border of what in most circles is considered pure judgementalism – ‘they look dodgy, they might steal my BMW” and pure science, “yes your IV drug use makes you more at risk for infected heart valves and hepatitis C”

I ask more eastern european immigrants about cocaine use in relation to their chest pain than i do of nice looking middle class northern irish guys.

the question is not whether nice middle class northern irish guys in portadown use more or less cocaine (some do, though most don’t have access to it, different story in antrim and belfast and the rest of the UK. The eastern europeans are in a much smaller community where cocaine is more prevalent), my question is more about the morality of my judgements.

How do i divide the judgements i make – how do i work out which ones are bordering on racism and presumption and how many are “clinically justified?”

How is it different from a police man who pulls over more eastern European drivers on a sat night because he knows that “they’re all drink drivers” and me asking questions about sexual history and illicit drug use to guys with tattoos?


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