Posts Tagged ‘Jama’

Talking to Strangers: art appreciation from a medical journal

October 4, 2018

In Prince George our plane it did land

As our trip unfolded as planned

Tell me where have you been?

To the hill at Kao Lin?

Just for the learning first hand?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, my 50th High School reunion, and a 4-month assignment in northwest Iowa, I have returned to Canada.  Any identifiable patient information has been included with permission.

Our plane landed in Prince George on schedule.

When the engine noise stopped, people started to chat.

My area of the US takes pride in being friendly and polite.   I tell them to increase those two parameters by 10% from the most friendly and polite Midwest town on its most friendly and polite day, and you’ll get average Canada.

The friendliness shows in chatting with strangers, something I do a good bit but not as much as Canadian standard. As we stood to deplane, several other passengers asked us our destination.  So of course I gave more details than they probably wanted, but remembering the value of reciprocity I asked similar questions.

One of our fellow travelers just finished 5 months in China. I pulled out some Mandarin conversation openers; she told me it sounded like Cantonese.  So I asked what she’d been doing.

Ceramics.

I nodded sagely and asked if she’d been to Kao Lin Mountain.

Her mouth opened in surprise.

The Chinese perfected ceramics thousands of years ago, and some of the best clay in the empire came from Kao Lin, a texture so fine that the ceramics remain unmatched. The mountain there has provided so much clay that in English, china is synonymous with household ceramics, and kaolin is the scientific name of clay’s active ingredient (the over-the-counter anti-diarrheal Kaopectate, for example, has kaolin and pectin).

Kao Lin figured large in the first globalization of trade, with fully 1/3 of the world’s manufactured goods exported from China.

We agreed that few Westerners have heard of Kao Lin and fewer still know its significance.

I didn’t tell her I would have shared the ignorance if I hadn’t read the art column in Journal of the American Medical Association for decades. (Regretfully, M. Therese Southgate, MD retired, leaving the cover of JAMA bleak and frequently artless.)

She gave me her card. I told her I write a blog, and asked for permission to recount our conversation.

Let’s see what happens.

July 27, 2013

A matter of prognostic projection

When it comes to a diagnostic question

My pain management skills

Involve very few pills

And no longer my Enbrel injection

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

During my senior year of medical school I arranged to get credit for an elective rotation in acupuncture in January of 1979.  I studied under a very smart non-Asian internist for a month, and learned the vocabulary and the rudiments.

Before I had passed any Boards or actually obtained a license, I did acupuncture on a friend in a time crunch.  I applied a needle in each shin, close to the knee (the name of the point is Su Zan Li, but its nickname means three villages).  He responded well, and worked with tremendous efficiency for the next 9 days, turning out top-notch work.  The bottom dropped out of his energy three days later, and he slept for the next two days.

In retrospect, I had precipitated a hypomanic episode; his bipolarity would not be diagnosed for many years.  Nor did I realize the enormity of the power of those two needles for decades.

High-quality research with acupuncture showed mixed results.  A study published in a major journal demonstrated very good results in treatment of the most severe alcoholics (regretfully, the study didn’t detail exactly where needles went nor how they were placed).  Another, published in JAMA, showed acupuncture and sham acupuncture equivalent in the treatment of migraine.  Many docs point to that study and assert acupuncture has no validity; I look at the same data and conclude that you don’t have to be much of an acupuncturist to treat migraine; put a half-dozen needles anywhere you want and not very deep, on a regular basis and at the end of a year the patient will have half the migraines he/she used to.

I went to my acupuncturist today for a session because I’ve been off Enbrel for three weeks.  My sacroiliac joints haven’t fused despite my age, leading my rheumatologist to question the diagnosis of ankylosing spondylitis.  He would like to see if my sed rate (ESR) and my C-reactive protein (CRP) go up in the absence of therapy.

I can hope for a misdiagnosis, or for news that my disease has burnt itself out, but as the days go by the pain in my spine grows.  I’m now relying on the pain management skills I developed between 1967 and 2000, when I got my first injection.

I can do a lot of things to bring down the level of pain a notch or two; I can’t do anything to make the pain go away completely.    When I walked away from the acupuncturist/chiropractor’s office the pain between my shoulder blades had faded by about two-thirds, and I could sneeze without grunting.

Now I have to work on my sleep pattern.

Health care reform according to Gordon

February 28, 2010

Democratize medical education

Then insurance deregulation

            Then slowly with torts

            That clog up the courts

And raise tobacco taxation

 

Frequently people ask me what I think of health care reform.  I give my ideas.  Most people don’t want to hear what I have to say, declaring “We have to do something!” without realizing that the situation can be made worse.

Here’s what I think we should do, and for the most part these are not my ideas.

Reform medical education.  As a wonderful article in JAMA (Journal of the American Medical Association) pointed out, the current premedical sequence wastes two years, mostly to weed out the field because too many people want to be doctors.  At a time when we’re going to need a lot more doctors we shouldn’t be discouraging potential candidates.  If we need to weed them out, let’s democratize the first two years of medical school, which are the classroom years.  Put the content online, and let everyone who can pass Part One of the Boards apply for positions in the clinical years.   Those who don’t learn well from online courses could pay existing or specialty educational institutions.  The current educational sequence (four years undergraduate, four years medical school) could be shortened to four years undergrad followed by five semesters of clinical teaching.  You would need to have more medical schools and you would need to have more residency slots.  The resulting doctors would be willing to work for less money, but they would not want to work as many hours.  Which is OK, because there would be less burnout.   

A lot of people starting the sequence wouldn’t go on to clinical training.  They would be an asset to society on a lot of levels.

Reform the tort claims system.   The medical malpractice industry is alive and growing, and sucking time and money from the health care system.  Money that should be used to cure and heal is being used to pay plaintiff lawyers, defense lawyers, judges, and insurance premiums.  The vast majority of medical malpractice suits filed are dropped, but not before the doctor has lost a week of production, on average.  Lawyers currently name every doctor associated with the case with impunity, hoping that each one will settle for a nuisance amount.  I saw a case where the doctor performing the autopsy was sued (I’m not exaggerating). 

Lawyers need to have the same degree of accountability that they demand of everyone else.  While they get sued all the time now, they don’t get sued for very much.

But the change needs to be slow.

Health insurance needs to be health insurance.  My friend, Mike Bernstein, gets credit for this idea.  Car insurance doesn’t cover gas, oil, or spark plugs.  Home insurance doesn’t cover vacuuming the carpets.  Health insurance should be catastrophic coverage.  Instead of putting the money into the pocket of the insurance company to pay for things like bronchitis and athlete’s foot, we should have Medical Savings Accounts paid for with pre-tax dollars  and earn interest; the funds should carry over from one year to the next, and could be used for anything health related.  If you wanted to, you could use it for cosmetic surgery or gym memberships.  Such a plan would bring the idea of ownership of health and health care back to the individual, which would improve the influence of market forces in medicine.

Raise tobacco taxes.  Every year at the federal level, cigarette taxes should be raised by a dollar a pack per year.  Wait, you say, such a tax is unfairly imposed on those least able to afford it.  Yes, I say, and it should.  Because if you can’t afford your health care, you shouldn’t be smoking in the first place.  As a society we can’t keep pouring money into the largest single cause of death and disability.  The money we raise could go to pensioning off the oldest five or ten percent of the tobacco farmers, per year.

The Libertarians will scream Slippery Slope, if you do that to tobacco, what next?  My answer would be alcohol.  Or maybe high fructose corn sweetener. 

I can’t decide which.