Tuesday, November 24, 2009

Well, much has been said about the impending health care reform. Unfortunately, little has been heard or has been published from the medical community itself. It is a shame.

After following the pros and cons arguments there are a few things that I belive are fundamental to the issue. No matter what the politicians say, health care cost are NOT going to fall. All could be attempted is to decrease the rate of expense growth.
There is a simple fact that is inescapable. Our population is getting older and with age comes increase in utilization of medical resources. So, as a jibaro used to say: "They(the pols) are thinking of pregnant birds" This is a literal translation of a puertorrican adage.

Let the actuarians calculate the staggering costs of caring for an increasing aging population and decide how much we are willing and able to commit in a fiscally responsible manner. Then allocate the resources to get more bang for your buck.

The recent published guidelines on mammography also illustrate a point.

In order to catch as many breast cancers as possible you have to cast a wide net. I remember from my training days working at the coronary care unit, we were having a discussion on the accuracy and the diagnostic acumen of the ED docs in cases of suspected cardiac ischemia. We concluded that a doctor who admits mostly patients with a later confirmed cardiac ischemia is likely to be missing some and sending home patients who needed observation. So, it is better to admit patients that end up not having ischemia so that you won't miss the real ones.
In an age of limited resources, is this acceptable? Or should we streamline the system to make it more efficient and less costly at the expense of missing diagnoses? And when a 42 y/o female mother of three, with no risk factors, vegetarian, non drinker, non smoker, physically fit, gets breast cancer that could have been diagnosed earlier with a mammogram not performed because of guidelines, who do we blame?
All this decisions carry a cost either monetary or in human life.

And still there will be breast ca missed and MIs sent home. There is a limit to everything.

Is it not this the meaning of "Shit Happens"?

It will kind of neat for my math whiz kid to design a formula that defines the limits on diagnosis.
All will be needed are the variables used in making a decision, say to admit or not admit to the CCU, find out the limits of the variables and then determine what is an "acceptable" rate of misdiagnosis. I wonder if you could use calculus formulas for this. Double, triple derivatives?Then again there is uncertainty........ Could you adjust for that?

Thursday, November 12, 2009

I have been told to listen

I have been told to listen by my soon to be wife.

It is funny that she says that since listening is all I do at work. Being a physician requires you to listen and a good listener makes a good doctor. Often I find myself telling my patients that my function for the most part is like a computer, the output depends on the input. My role is to analyze information provided to me and create sort of a picture of the patients problems which is the first step in finding a solution. The more detailed the information the better the picture and the chances of me being of help relieving symptoms.

At home, however, things tend to be somewhat different.

Frequently you could see me on top of a soapbox dispensing insights and advice about her job as an assistant principal and about the shortcomings of the school district and the school where she works. And really what she needs is a sounding board, someone that patiently listens to her gripes, sort of a punching bag taking the punches product of her frustrations and tribulations. She doesn't need advise nor insights just an ear, a friendly nod and perhaps some supporting comments. This I have found hard to do being trained as a problem solver.

So I have decided to create a blog to deposit all of those thoughts and use it as a release valve and who knows, it might be found useful by some lonely soul who may find him or herself in the same predicament.

I don't expect to get many hits from followers of my ramblings but at the very least this leaves an electronic imprint of the neuronal discharges that end up as my thoughts. And given Google's function as a repository of information and should the electronic impulses that generate this documentary survive for posterity, who knows if it will be useful to future cyber-anthropologists. At the very least it might help making me a better listener.