Wherever you are, you weren't there before you got there.

Over the past decade the years have taken on a monotonous and tiresome pattern. In the frozen fog of January, I fire off a harshly written letter to our "so-called" public servants demanding that they repeal the entire month of February. Time and again my very reasonable request is ignored, forcing me to weather out the forty some-odd days of that foul month. This is followed by the false promises of March and April, with their faux-warming days fueling the discouragement of otherwise ceaseless frigid rain. The glorious festivals of May and June arrive; alas, their fleeting fairness fades after only three or four days max.

In July I finally run out of F's, sending me to remedial alliteration classes at our local community college. My family spends a week of bliss at the Carolina shores, and as I contemplate what I should be getting everyone for Christmas, the fearsome fatigue of Seasonal Affective Disorder descends on me as I reach deep into my dictionary for one or two more F's. In no time flat I find myself at Walmart late Christmas Eve, frantically ferreting out whatever presents I think will keep me out of trouble with my family.

Then the whole thing occurs again, year after year. Lather, rinse, repeat.

Not this year. Until just recently the weather in the Ohio Valley has been lovely: high of 80, 40% humidity, totally uncharacteristic of this area. So no computer last week, no TV, no drunken drivers. Just me and a variety of endophinogenic activities which involve non-virtual reality.

If this seems like some sort of excuse for laying off the blog, let me assure you that it is. I might have been linked by Glenn Reynolds in the past week for all I know. If I have been, please feel free to email me. I could use the encouragement.

Roid buffin' in the summertime

There are times in a young man's life when he has energy for blogging or strenuous physical exertion but not both. Then there are times when he has the energy for neither. That has been my status as of late.

My initial forays into the world of mountain biking consisted of taking a track going off into nowhere called the "Lachrymose Loop" or something to that effect. I feared for my life the entire time, so the next time I visited the bike shop I inquired about just how one goes about learning to mountain bike without, you know, getting killed.

"No probleemo", the LBG (local bike guru) says. "Just spend time on an easy course like the Lachrymose Loop and you'll be shredding with the best of them in no time."

Well, I'm 52, I've lived a good life and have plenty of insurance. Off to the Loop I go.

My last two trips to the Loop have been pretty exciting. For the first time I was able to hop a (very small) log, a thrill for someone who only a week before almost met his Maker by trying to hop a little curb. The last trip I went around the Loop twice, undeterred by trying to hop the (very small) log, mistiming it, slamming into it and bouncing back, landing unceremoniously upon my amply padded backside.

I figure if I'm not able to shred the singletrack like a pro, I can at least learn the lingo and sound like I know what I'm doing. These are some of my favorite terms:

horizontal bike rack:
that would be me when I come to a stop but am not able to remove my feet from the toeclips in time to prevent my bike and I from assuming the horizontal position.

pruning the half-tracks:
this refers to going through a trail that is heavily overgrown with vegetation, so that one emerges from it covered with foliage he has gathered from along the trail.

going endo:
one of my favorites as an endoscopist. One goes endo when he misjudges a jump and goes flying over the handlebars. See "giving blood" for further details.

Roid buffing:
my favorite, of course. When one goes down a steep incline, in order to keep from going endo one gets up off the bike seat and sticks his (or her, depending on ownership) butt way back over the rear wheel, acting as a counterbalance. Do that long enough and you've done some roid buffing.

Part II is coming, I promise. Or not.

Part I

Capitalism/the free market is a lousy way of getting things done in the healthcare arena.

Now before folks demand that I turn in my membership card to the VRWC, I should add this: having spent a brief time in Eastern Europe, I believe that socialism/the centralized economy is a catastrophic way of getting things done in the healthcare arena, or in anything else for that matter.

We're stuck with the free market for now. We might as well do the best we can within the system.

What are physicians' options in coping with the malpractice crisis? Our medicolegal system has been so corrupted that it is impossible to dream up a complaint that has not actually led to a lawsuit in our country. Even more telling, it is becoming increasing more difficult to dream up a lawsuit in which some jury somewhere in our fair land hasn't actually awarded damages to the plaintiff. Pay a visit to Overlawyered.com or sickoflawsuits if you need to be convinced of this point.

The free market understands supply and demand very well. Reduce the supply of a service and combine it with increased demand for said service and you will exert irresistible pressure on the way in which the service is delivered. Physicians (in contradistinction to lawyers?) are constrained by ethical and professional considerations in the way we supply healthcare. As attractive as some sort of collective bargaining action might seem, going on strike (for example) is illegal, unethical and ultimately counterproductive. We can strive to put more and more limits and boundaries on what services we provide; consider the number of OB-GYN's who no longer will deliver babies, or the number of specialists who refuse to have their names put on ER call rosters. We can try what I'm attempting, which is to limit severely the amount of services and numbers of patients I will accommodate and rejoice in being able to meet my overhead and pay for my health insurance coverage if nothing else.

None of the above protects us from the $23 million judgment and the financial ruin it would bring. The only way we can do this is to quit.

Yes, I'm aware of all sorts of methods to shield our assets from lawyers. This is like trying to construct a squirrel-proof birdfeeder: it can't be done. They're too clever. There will be a way in our system for the lawyers to get to the money. Charging "elder abuse" instead of malpractice in claims of negligence on the elderly is just one way that lawyers are now circumventing measures like malpractice award caps. Other maneuvers will come.

This is a problem for anyone who has put twenty or thirty years of training and practice into their field. It seems like a tremendous waste of human capital to toss it all. What I do ain't rocket science or brain surgery, but it takes a high-school graduate thirteen years of training to prepare for my field. Maybe they could condense it down to two or three years of training at a technical school. I wouldn't want to get a colonoscopy from one of them, but who knows? That might be the only option we have in the future.

To be continued.

Fake but accurate?

Some writers, by virtue of extensive training and/or native ability, have beautifully expressive styles that are a pleasure to read. Others of us erstwhile "new journalists" just fake it. The last formal training I had in creative writing was in 12th grade, when I had to write a "How did you spend your summer?" essay (mine was "Nothing but work on the dirt farm and I resent being reminded of it"). To get by I do what countless people have done before me: rip off as many styles from good writers as I can and throw them together in a melange that is so garbled that most folk don't recognize anyone in particular, and give me credit for at least some originality if nothing else.

There are some wonderful role models for us writers out there. I personally enjoy the style of the "legacy media", represented by such fine institutions as the New York Times, CBS, and Newsweek: report only those facts that further your agenda, distort the ones that don't, and just flat out make things up if it enhances the story line. This "fake but accurate" style is perfect for writers like me who are too lazy to check up on facts and links and who are too partisan to care much one way or the other.

As I reflected on my post entitled Free legal advise, I thought that readers might suspect that I got a little carried away. I mean, two lawyers who extort physicians out of their fees by threatening malpractice suits? No one's going to believe that. Even I began to doubt it until I ran into the doctor in question yesterday, quite by accident.

"Whatever came about that case?", I asked Keith.

"Yep, the lawyers' strategy worked like a charm. All of the doctors wrote off their fees over the threat of a lawsuit, even the ones who were only marginally involved. What's even better is that the hospital wrote off their charges, too. Here you have a guy who was admitted on an emergency basis, owned a small business but didn't bother to carry health insurance, required triple bypass surgery and a heart valve repair, and because he had a commonly described and accepted complication that resulted in at worst one extra week in the hospital, got the ENTIRE bill written off. Not even the hospital wanted to mess with it."

It turned out out that I got the facts right after all. I wish I hadn't, in a way; knowing it is that easy for lawyers to game the system these days isn't comforting.

By the way, complaints about lawyers in my state are kept secret until they are resolved. This allowed one sexual predator to molest several clients (all of whom complained to the Bar) with impunity until someone finally took out a criminal charge against the guy.

A colonoscopist's lament

A sonnet composed today at the MCE Butt Hut upon learning that there exists a group of my patients that call themselves "Bubba's Butt Club".

---

Basking in heaven's light we should reside
When we are in the blest Platonic realm.
But in the darkest cave we're forced to hide
When scope in hand we're stranded at the helm.
Medicine calls us as its holy Light
To rid disease from every human soul.
A shame that we're so limited in sight
That we see only up your exit hole!
The profit motive gathers us as one
As we gaze up into the colon's void.
And yet we know that when the hour is done
We'll see naught but a ripened hemorrhoid.
Know that our efforts shall not ever cease
Until the day that we run out of grease.

Free legal advise

One of the first lectures I heard in medical school was on gout. The professors enjoyed lecturing about it, in part because it was one of the first conditions for which a drug was specifically designed (allopurinol), and in part because it was a very fashionable disease. Not everyone would announce to the world that they had a bad case of tinea cruris, but anyone would take pride in having a good case of gout. You needed two things: the inherited trait, which was traditionally associated with only the very finest of families, and a diet that only the wealthy could afford, rich in red wine and red meat.

Some disorders are more fashionable than others. Here is my personal ranking of some of the more "popular" disorders, based on nothing scientific. Your list might look entirely different:

Disorders to be proud of:
gout (of course).
athletic injuries, especially skiing accidents.
"walking pneumonia" (a sure sign of toughness).
pilonidal cyst (I have absolutely no idea why).

Disorders with no stigma attached to them:
cancer.
peptic ulcer disease (especially since we realize you don't have to be a "type A personality" to get it).
coronary artery disease.
diabetes.
hypertension.

Disorders a civilized society wouldn't talk about:
PMS.
hemorrhoids.
erectile dysfunction.

Very serious disorders that nonetheless have a certain je ne sais quoi about them (I think because so many creative, talented people have had these):
bipolar disorder.
attention deficit disorder.
HIV.

Disorders struggling to escape an undeserved reputation:
depression (half the population has it, the other half belittles it).
Crohns disease and ulcerative colitis (sufferers were once thought to all be neurotic, but if some are it's because the illnesses take a tremendous emotional toll on them).
hepatitis.
panic disorders.

Disorders you still had best keep to yourself (so to speak):
sexually transmitted diseases.
sociopathic personality disorder.

As a societal disorder, medical malpractice has generally been in the "best kept to yourself" category, but that is slowly changing. You don't have to saw off a wrong limb or try to perform a hysterectomy on a guy to get sued these days. Something as seemingly innocuous as ordering a CT scan on a psychic can trigger a lawsuit if the plaintiff claims that the CT scan somehow damaged her psychic power (such a lawsuit occurred, and the jury ruled for the plaintiff and awarded her well over $2 million in damages). The stigma of a malpractice case is not so significant anymore, so doctors are a little more willing to disclose their experience with their colleagues.

As I'm a little more open about my suits than most doctors, I'm viewed by some as a bit of a legal expert, so I'm occasionally approached for free legal advise. My advise is worthless, and they all know it, but it's an oddly therapeutic exercise for us, and I'm always happy to share my opinion.

"Doc", one of my colleagues said, "could I get your opinion on something? A short while ago an older patient without health insurance came into the ER here with a serious heart condition. He required emergency surgery, and he had an extremely rocky post-operative course. To be honest, he was a real trainwreck. About five consultants were called in, and I was one of them. After a month and several touch and go moments he was able to go home. It was a bit of a miracle.

"It turns out that this gentlemen had two sons who are lawyers. They approached the cardiac surgeon and told him that they were very unhappy with his care and were strongly considering a lawsuit. If the cardiac surgeon wrote off ALL of his charges, and if he convinced all the other consultants to write off all of their charges, too, they might get change their minds and, who knows, maybe forgive the doctors for their slipshod care.

"The cardiac surgeon approached me and begged me to write off my charges. He was so fearful of a lawsuit that he personally went around to all the consultants and pleaded with them all to do the same.

"What do you think I should do? I mean, this is little more than extortion, but I also know that any lawsuit becomes part of your record and can affect your insurability for the rest of your career."

"It's a pity that the surgeon is not a little braver, although I hardly blame him. As for your charges, I'd write them off. Even if the case were dismissed, it would probably hang over your head for at least two years. Who needs it?"

And that's what he did.

Medical Grand Rounds XXXVI

Medical Grand Rounds returns! Check out Dr. Sanity's site. This is the second week in a row I've had a link. Glenn Reynolds still hasn't called...