Healthy New Year advice: avoid the first operation
What many New Years greeting cards often say is "wishing a healthy and happy New Year.
Happiness is a state of mind, which no one can bestow upon you. The great Abraham Lincoln said: "You are as happy as you make up your mind to be". This is true. This essay will not dwell upon the initial part of a New Year's wish.
Instead: to your health.
There are so many disorders that it is absolutely impossible to list them all (even though ICD-10 attempts to do just that). Regardless of the disorder treatment usually comes in two forms: medical (i.e., non-surgical) or surgical, or a combination of the two.
Some times the type of treatment is not debatable, it can either medical, surgical, or none, depending on the patient's wish. Many times, a well-intentioned physician may recommend a course of action, which if she/he is truly well-intentioned will explain the risks and benefits (or as legally known "informed consent" [IC]). Now IC is a matter of considerable complexity, a discussion of which is a necessity in all cases except where the patient is in extremis--i.e., about to die if no action is taken. Such cases are a few on a percentage-wise basis.
Assuming the patient or his/her guardian is given the risk/benefit discussion, there are some general principles which you should know.
Whenever a surgeon (as opposed to non-surgeon) recommends surgery for a condition that could be treated either medically or surgically, get a second opinion from another surgeon. Don't ask your g.p. about a surgeon's recommendations--that's out of the g.p.'s expertise. Ask another surgeon.
It may seem strange to some of you that a retired surgeon (myself) gives such perhaps unexpected advice. Perhaps that is because I am old school. Back in the day, half century ago, I was taught that physicians should be patients' advocates. This bears repeating because this duty has gotten lost somewhere along the way: PHYSICIANS SHOULD BE PATIENTS' ADVOCATES.
Such an attitude is often antithetical to the profit motive. So be it. Most doctors did not get into medicine to get rich although an appalling number do have that intention.
Dictionary lesson for today (which many of you already know): Iatrogenic--meaning caused by physicians.
What is usually the worst result? Although I have a disputational anecdote, the usual answer is death. Chronic, unremmitant pain may come in a close second. There are other contenders for this "worst possible outcome" award, but they would be quite unique.
Rule number 1: Stay out of hospitals. Because this can be lethal.
Dr. Barbara Starfield was the author of that JAMA study, published in 2000, and her research documented how a staggering 225,000 Americans die from iatrogenic causes, meaning their death is caused by a physician's or hospital's activity, manner, or therapy. Her statistics showed that each year:
12,000 die from unnecessary surgery
7,000 die from medication errors in hospitals
20,000 die from other errors in hospitals
80,000 die from hospital-acquired infections
106,000 die from the negative side effects of drugs taken as prescribed
You name it--I've seen it happen.
Rule 2: Avoid the FIRST operation. If you do then you avoid the risks of a first operation. But even well-indicated and expertly performed operations do not rid the process of all risk factors.
This example, although shocking, is far from the only danger. I chose this reference because without instrumentation, even a butcher's knife, there can be no surgery. Other factors (partial list): dirty operating room, untrained assistants, improperly trained anesthetists, anesthetic errors, drug and blood product interactions, positioning mistakes, excessive unforeseen blood loss.
Scary? Yes, in my opinion.
From my post-retirement volunteer work at a medical clinic for which I charge nothing, I will cite two cases, one potentially surgical and one surgical if the misguided advice were followed.
I am sure many of you have personally experienced the operative situation--or friends or family have. These two cases are different but suffer from some joint errors.
The most common surgery for a neurosurgeon is not in the brain--it is in the spine. There are also fellowship trained orthopedic spine surgeons, some of whom are quite good.
Example 1: 40 year old very bright psychologist urged to undergo $4000 course of spinal realignment by a chiropractor. Note, I am not anti-chiropractor although that was the bias when I went to medical school. First I took a brief history. The gentleman had severe back pain radiating down one leg to the foot--typical case of sciatica--no diagnostic mystery here. Although a psychologist, this man's medical knowledge was close to nil. I reviewed his MRI scan and saw the second largest extruded disk herniation in my career. Extruded disks are completely separated from the main disk--no connection whatever. The chiropractor suggested a type of treatment which may work on non-extruded disks, called flexion-distraction. This treatment will never work on an extruded disk. Did the chiropractor tell him this treatment was not indicated for his condition? No. Did the chiropractor tell him that even if the patient completed the recommended course of therapy that he would still need surgery? No. I advised the gentleman to either live with the pain or undergo surgery.
So how does this comport with the title of my essay? Sometimes the first surgery is really necessary. When indicated back surgeries are delayed, the results are often compromised. How is the patient to know this, because all surgical delays are not necessarily harmful--they can be beneficial for several reasons. Partial listing of legitimate reasons to delay non-emergent but likely needed surgery: accepting the need for surgery, getting one's affairs in order, durable power of attorney, arranging post-recovery needs, getting into more satisfactory physical condition, initiating necessary pre-op drugs OR discontinuing current drugs.
Example 2: very vivacious, physically fit, intelligent horsewoman (or is equestrienne the favored term) in her early 50's. In view of her underlying medical condition, the incongruous surgical advice she was given was quite dismaying to me. Both of the two spine surgeons considered neither the lifestyle nor the actual underlying diagnosis, other than: "the indication for back surgery is a human biped". The first surgeon was Florida based but two days per month he flew to L.A. to harvest more suckers patients. His pitch was that he did "laser surgery", a half-truth because the laser was used only for control of bleeding, not the correction of the lesion. Allegedly this fellow took a look at the MRI and told the woman that she needed surgery "right away". That advice was untrue and completely self-serving. Being suspicious and performing due diligence, she consulted a neurosurgeon at Stanford. This doctor did take a brief look at the imaging and concluded, like the fist doctor, that she needed surgery but that it wasn't an emergency but was somewhat urgent (which it wasn't).
What these two physicians had in common is recommending surgery which was highly elective as no vital functions, such as ambulation or sphincter control, were compromised--nor were they likely to be in her particular case. Neither surgeon told the patient that there were any risks involved, and although neither guaranteed a good result, neither told her she could get worse, need further surgery, still have to change her lifestyle. After a brief evaluation followed by a lengthy IC, this very stubborn but not masochistic woman decided to change her lifestyle first. If that didn't work out, she could then undergo surgery with a better idea of what it was all about and what might go wrong.
Example 3: this one is from my private practice, and is discussed as it relates to IC. A middle-aged woman, none too bright, had a slowly-growing but benign tumor at the bottom of her spinal cord. She'd probably had it 20 years but it only became symptomatic within the past 2 or 3 years. She had no neurological deficit but couldn't tolerate the pain. I informed her that surgery might help her pain but was not emergent or even urgent. She was shown her pyelogram (as this occurred in the pre-MRI era) and explained the anatomy. Sensing she didn't register this information, I asked her to repeat it back to me, which she couldn't. So, I told her to come back in a month and we would go over all this in full detail again. After this second visit, again she failed to correctly repeat anything that I told her. This went on monthly for 10 more months. On the penultimate visit, she brought a more intelligent friend with her to again receive the "lecture". At 12 months, patient was able to acknowledge adequate information about the planned procedure. Only then did I operate.
Example 3 is presented for heuristic value, not to boast about my surgical prowess.
Lessons from the essay:
1. Is surgery emergent or urgent--if yes, ask questions. Why is this emergent or urgent?
2. Is there a non-surgical option available?
3. What are the benefits? Will I be cured or improved and what is the likelihood of those outcomes.
4. What are the risks? Get detailed answers, don't be blown off.
5. Ask about lifestyle changes, pre- and or post-op.
6. Get a second opinion from a qualified expert not your aunt or next-door neighbor.
7. Don't be afraid of asking questions for fear the doctor may think you are pain in the ass.
This has two consequences:
a) the doctor thinks you are a pain the ass--dump him/her
b) the pain might be in your ass if you don't ask the right questions
Comments
Thanks Doc !
This essay is priceless and could actually save lives.
My mothers cancer Doctor told her that, and I quote, 'The patient is the last line of defense, keep asking questions Gayle'.
Pay attention to what's going on around you and speak up if something doesn't seem right, especially when hospitalized.
I went under for a lung biopsy and ended up on a ventilator.
I woke up during Arterial surgery.
I was hospitalized briefly for an intestinal infection my Doctors said I probably acquired at the Clinic. (My smartest most trusted and renowned Doctor said 'There's no probably, you got here'.)
If you read and pay attention to only one thing this year, this essay should be that one.
It will save your life.
With their hearts they turned to each others heart for refuge
In troubled years that came before the deluge
*Jackson Browne, 1974, Before the Deluge https://www.youtube.com/watch?v=7SX-HFcSIoU
Nice essay, doc
Discussion taken to private message.
Snoopydawg is right, private for some. Big but:
My sister called me yesterday. Our mother, 97 next week, has been put into hospice (my educated sister is calling it 'hospirus' routinely, which I cannot correct, walk like an Egyptian). Mother may be eerily correct that her kidneys will do her in. Long Dxed with end stage renal failure, static, that has now accelerated. The Lewy body dementia will not kill her off, kidney failure plus dementia will. Our guess is that she will get it together and die on her 97h birthday. Someone who can no longer see real world due to AMD, can only vaguely hear (genetic). She has received a zoobie new wheelchair due to hospirus. Not sure now why End stage renal failure did not work by itself. She could walk +talk, not at the same time, mind you, she had to be seated to hear. Lewy body dementia. Beat myself up for not guessing two years ago. But beating oneself mentally is a useless task.
Within the first month of 2017 I expect to become an orphan. I last spoke to her less than a month ago. Obit I wrote, some may recall I passed it by here at c99 for suggestions, took one. An expected, but not so soon start to 2017.
Hey! my dear friends or soon-to-be's, JtC could use the donations to keep this site functioning for those of us who can still see the life preserver or flotsam in the water.
Thanks, RL
Caregivers have a particular malady which has not yet made3 it into ICD-10 nor DSM 5: caregiver disorder. The amount of guilt can be overwhelming. If the caregiver has done everything possible, while respecting the wishes of the patient, that is all that can be done. Blame and shame are natural but must be overcome that humans can only do so much. At the end of life, I have seen caregivers suffer more than the moribund patient. Talking to a friend or professional counseling can be quite helpful.
That is a really a good essay
I am reminded of my niece, who had Hodgkin's disease as a teenager and as a young women, was treated successfully, cancer came back in liver and breast, no metastases in the spine at her mid thirties. They didn't check for brain tumors. That was a medical mistake, imo, because while after treatment the liver and breast metastases disappeared, the treatment wasn't the right one for possible brain tumors. Sure enough later they discovered the brain tumors. She got surgery for those, but that was too late, too many smaller tumors in places that couldn't be reached. One big tumor for which she got successful surgery, but the little ones grew nevertheless and killed her in the end.
I just recap this shortly, because my niece was being "a pain in the ass" for some doctors, always asking a lot of questions. I still think, if she had paid attention, knowing aboug the blood brain barrier and knowing that the chemo she got for the liver cancer, didn't work up into the brain, so to speak. May be they would have caught the brain tumors earlier.
Well her case was a 'picture book medical case" of Hodgkins in early adulthood treated successfully (she had stage iv) when doctors told her that the average survival life-time of Hodgkin's patients is 38 to 45 years old. She died age 40.
Treated in the best hospital in NY for cases like that. And actually I think she had very fair and good doctors there. The failure to check her out for brain tumors, when the breast and liver cancer were treated was done at the West Coast, where she lived and worked before transferring to NYC. At least she fulfilled her dream to work on projects in NYC she always wanted before she died.
Thanks Alligator Ed. Both my sister and I believe now, if we should get cancer after age 75, we do not want treatment other than palliative care. I mean if you made it up to 74 and somehow you fall apart medically, it's time to accept to go. What do you think?
btw, that's her:
Remembering Beatriz da Costa (1974-2012)
It's hard to lose a child, niece and friend.
https://www.euronews.com/live
Mimi, you are welcome.
It is an individual's choice to make whether to extend life by any means possible or just to enjoy a shorter but more tolerable life. Palliative care is an excellent decision which can be made at any age (except for minors) if such is the patient's choice. A physician should NEVER force his/her own prejudices on the patient, but obviously should be willing to answer pertinent questions. My personal preference is that I want you around here but your decision is and must be yours.
of course, alligator ed,
just would have liked the opinion of others for how long they were willing to accept chemo- , radiation - and surgery for a predictable life-ending situation caused by various kinds of cancer.
People are very depressed these days for a variety of reasons. So, if you have to make choices like that as an elderly person, I wonder if one should fight the depression or fight the cancer at all cost.
Thanks for your kind words.
https://www.euronews.com/live
My Advice: Avoid the first DRUG.
Doc, good essay but my experience, which involves all my friends, is avoid the first drug people use to mask underlying problems in their metabolism. My doctor almost fell on the floor when i went to him after 15 years of no visits and told him I wasn't taking any prescription drugs. He acted as if I was an alien. It's like taking advil because you have a rock in your shoe instead of taking the rock out of your shoe. Way more victims taking drugs than undergoing operations even tho operation are a big problem too.
"Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho
No argument there, tpe
That subject (pharmaceuticals) would have made my essay too long but many of the same cautions apply here too. Last week at the clinic in which I volunteer, I met a woman who had 10 (ten) different physicians who had in toto prescribed 25 drugs! This is a horrible and unforgivable situation no matter what the illness or how desperate the patient is. What usually happens is that side-effects of one drug are treated with another drug, which in turn is treated with a third drug! etc.
That scenario is more common than people think.
It should be criminal. How can any living thing withstand the drug onslaught doctors subject us to? There's less liability for over prescibing than under prescribing.
"Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho
A reasonable argument, but not always possible
As a primary care internist, I very frequently have discussions with people who don't want to take prescription medications for common conditions like osteoarthritis, hypertension, hyperlipidemia or diabetes.
"I don't want to take pills," they'll tell me.
OK, that's great, I tell them. But your high blood pressure and your diabetes are going to significantly increase your risk of heart attacks or strokes, not to mention a lot of other risks, if they're not controlled. I'll endorse their decision not to take pills as long as they can reduce their risks in other ways. But then we talk about avoiding the hidden salt in their diet, moving to a less-processed, lower starch diet with no sugar and reduced saturated fats, and daily exercise with avoidance of long periods of sitting.
"Uhm, don't you have a pill?" is the common response.
Unlike our good doctor essayist, I'm not quite old enough to retire. But I remember training back in the days when hypertension treatment was rudimentary, when high cholesterol couldn't be controlled, and when diabetic treatment options weren't many. When a lot more people smoked and drank too much. In those days we used to see a lot more heart attacks among people in their early 60's or even younger, not to mention major strokes in people in their 60's and early 70's. For well treated patients who use medications judiciously, these severe cardiovascular events are much less common in those age groups than they used to be.
I tell my pill-averse patients that all medications can have side effects, and we need to watch out for those. And those lifestyle changes I keep nagging them about still need to happen. But not taking medications can have well known and often tragic side effects too, and you have to look at the risks of both sides of the decision about taking pills, not just one. The most important goal isn't necessarily avoiding pills -- it's living as long and healthy a life as you can, however you can manage it.
Please help support caucus99percent!
My object in treatment with drugs is the same as yours, DD
If a non-surgical condition can be treated with lifestyle changes, then it's the best approach and the best advice. As I pointed out in my essay, the same thing applies to potentially surgical conditions.
Great detailed instructions for what to do when surgery is
recommended.
Would make a good download on Amazon to reach a wider audience. Very good advice which is difficult to access in those circumstances when a surgeon tells one surgery is needed urgently - it tends to blind one's abilty to weigh information.
I don't think I've ever had 'urgent' surgery - just those which were cast as either elective or whatever they call it when it's already probably too late.
I asked for my first heart surgery *early* because imaging at the time did not show I was in crisis yet, and I was not able to function self-sufficiently. I asked them to repair my valve in order to delay having it replaced and causing me to be on heavy-duty blood thinners. Good thing they went in - wasn't enough left of my original valve TO repair. Was still able to delay the bloodthinning with the valve choice option I had request in case we needed a plan B. That, however, didn't end up serving me as well as I had hoped, but I still think it was the right choice for me at the time. I was, however, missing a piece of information which *might* have had me make a different choice. Water under the bridge. I did get a second opinion, and maybe a third, I can't recall. In my case, medical school might have been a good idea to keep track of everything I've survived.
'What we are left with is an agency mandated to ensure transparency and disclosure that is actually working to keep the public in the dark' - Ann M. Ravel, former FEC member
Your strategy was correct.
With cardiac and other similar vital organ problems it is best to intervene early while the patient is still in relatively good shape. Complications may be the same but a healthier starting point aids recovery.
FWIW looks like it just got easier to identify docs 'in the biz'
more for the money than for the patient's best interests?
I regularly visit the site of another medical group and take inspiration and become more informed about health care and related issues:
Thanks for the informative essay, and for your volunteer work. That's inspiring. Having read your comments here over time (experience them as sometimes biting and acerbic but often quite welcome) have to say it's nice to learn more about you and your life.
A truth of the nuclear age/climate change: we can no longer have endless war and survive on this planet. Oh sh*t.
I'm sure I'll be corrected but I see
the AMA as little more than a trade/lobbyist union. I have nothing against unions but lobbyists? I like them not so much.
"I can't understand why people are frightened of new ideas. I'm frightened of the old ones."
John Cage
Everything is a union
If you pay dues or taxes to belong, you are in a union.
If you elect leaders to represent you, you are in a union.
If you vote along with other members for policy positions, you are in a union.
U.S. Chamber of Commerce, AMA, BIg Pharma, Petroleum Institute, Actors Guild, ALL are unions.
The only "bad" unions seems to be labor unions.
IMHO.
Neither Russia nor China is our enemy.
Neither Iran nor Venezuela are threatening America.
Cuba is a dead horse, stop beating it.
Good to see those docs break away from teh AMA, which
has been opposed to improving our health care system if their profits were affected.
AMA not my favorite
A truth of the nuclear age/climate change: we can no longer have endless war and survive on this planet. Oh sh*t.
The AMA representing a minority of doctors has
been reported for years. The fact that this crowd supports tRump is not a surprise. A lot of them are specialists with bloated egos/incomes. Rec'd!!
Inner and Outer Space: the Final Frontiers.
Thanks D.O.
I have never been a member of the AMA*, which is nothing more than a lobbying agency also selling insurance and restricting medical practice. Not all of their activities are negative. They publish some fine, apolitical medical articles both research-oriented and clinical.
*I guess this is something like "I am not a Communist nor have I ever been one".
Haha good one.
Hope I am not distracting from your important essay here.
Have you ever checked out PNHP? http://www.pnhp.org/
Former HS teacher lay person meshelf, but I go to the PNHP site regularly to check out their 'Press Releases' and 'Articles of Interest' sections re single payer action.
We all make choices about life, and with the high cost of medical school physicians are bound to be torn.
The following is from a PNHP press release
A truth of the nuclear age/climate change: we can no longer have endless war and survive on this planet. Oh sh*t.
D.O., thanks for comment
I was unaware of PNHP as I avoided medical politics as opposed to civic politics.
This is my core belief.
This is an important secondary issue. Single payer will solve issue number two. Issue number one is much more complex that I have hinted at in this essay.
What is the "other medical group"
you mention? Is it open to non-physicians like myself?
Edit -- since the question is now answered.
Thanks Doctor Al
Great essay and very informative. I've had 6 surgeries in my life, non of them urgent, though one could argue the gall bladder operation due to severe cholecystitis came close. All the others fell into necessary (or believed to be necessary) category - a broken cochlea in my right ear due to head trauma (3 operations, first two to repair the cochlea, which failed, and the third to cut the balance nerve to end my vertigo issues), one for the aforementioned gall bladder, one for a broken and dislocated ring finger (had a hand specialist for that - quite interesting since they don't use general anesthesia, but some weird sort of local in the arm only, with a drug to keep you sedated while they drill into your finger; and one that proved to be completely unnecessary because two separate gastroenterologists misdiagnosed my autoimmune condition as Crohn's disease when it wasn't. But since the surgeon was in there anyway he took out my appendix which was perfectly fine. Not fond of surgery, but luckily, two were laparoscopic so that made for a quicker recover and exit from the hospital (next day I believe for the gall bladder, and within two days for the non-Crohn's/appendix removal surgery).
I certainly advise people to avoid surgery when they can. I've seen some very unpleasant results in other extended family members that didn't solve the issue (one was ovarian cancer) and one that made the pain worse (a back surgery).
I also second the idea to avoid the first drug if you can. I was put on a lot of high powered NSAIDs (indomethacin) to deal with recurring acute episodes of severe chest pain (not related to the heart function itself) after a bout of pericarditis when I was 17, for which the long term use of said drugs (25 years or so) I blame now for a lot of my intestinal issues (probably did some damage to a lot of other organs also, and may have masked an earlier, proper diagnosis of my long standing autoimmune issues). Also, I was placed on a variety of drugs as a young child for asthma - in the era of antihistamines that kept you dazed and confused - that made me constantly out of it (this was back in the late 50s and early 60s). It turned out moving to an arid climate (Colorado) solved my childhood asthma better than any drug.
Though to be fair, I suppose the doctors back then believed that throwing these new "wonder drugs" at everything was the answer for - everything. I recall my mother being prescribed amphetamines for weight loss after her third pregnancy, which led to a very bad result since she suffered from some form of anxiety disorder all her life, and they had to take her off them rather quickly when she became manic and paranoid.
The real problem as I see it with our health care delivery system (as opposed to how we pay for health care services) is that we have a reactive system dedicated to fixing what's broken after the damage has been done rather than a system focused on preventing disease through diet and better life habits (exercise, etc.) Our ingestion of heavily processed foods, that still include all sorts of chemical preservatives, dyes, flavor and texture enhancers, genetic modification, etc. doesn't help much either, nor the transition from small local farms to large industrial agricultural "factories" (as I call them) that are heavily reliant on chemical fertilizers, herbicides and pesticides.
I am convinced our diets, and for many of us our less our active but often more stressful lives, plus the way our food is "manufactured" (including the high usage of gluten, corn syrup as a sweetener and salt) have all contributed a great deal to the increase in diseases such as cancer, heart disorders, auto-immune disorders, mental illness, and diseases of the gastrointestinal system generally, which in turn fuels the pharmaceutical companies to create new and "better" drugs to deal with symptom management of these illnesses rather than the root causes.
Well, that's enough of a rant/ramble from me for now.
Thanks again Al.
"You can't just leave those who created the problem in charge of the solution."---Tyree Scott
Not a rant, Steven, but important observations
If you were treated 40 years ago for autoimmune disorders and this is the worst treatment you got--you were lucky. I'm not saying your treatment was ideal but there were worse in that era (and if you go to the wrong physician) you still might get poor treatment. If a specialist is unsure of the diagnosis, and hopefully honest enough to tell you of the uncertainty, please ask for a second opinion. An ethical physician should not hesitate to do so. If the physician balks at a second opinion, go somewhere else.
StevenD, I couldn't have said it better myself. Head hits nail.
Our doctors could take a lesson from someone who we thought they had already learned from, Hippocrates. A man who lived 2500 years ago. We need to transport our country back to his time and listen. Here is one of my favorite web pages.
http://www.azquotes.com/author/22138-Hippocrates
"Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho
Thank you for the Hippocrates quotes
One of my favorites:
This has been a problem perplexing me, even before reading the quote. Some physicians make me really doubt if they do love humanity. To make mistakes is one thing. Not to care about them is another.
My favorite is " Do No Harm". Not sure if I should laugh or cry.
So many people walking around suffering from prescribed drugs due to the metabolic ignorance of the entire medical industry. Pretty sure that ignorance is just plain corruption. I'm sick of hearing every doctor I meet claim they either forgot everything they learned in medical school about human metabolism or claim they never took any class that taught it. How 'bout maybe, just maybe, taking some time off from the professional sports games or refrain from one dinner out on a Saturday night and to look it up??? Is that not their job? It's down right criminal.
"Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies." - Groucho
As to the Florida surgeon who was in a hurry-
I wonder what he'd answer if the patient ask the Dr. to play a game of role reversal? Would you have the surgery immediately if you were in my shoes? And watch his facial expression.
Very helpful essay, Dr. Alligatoridae mississippiensis. Indeed!
"I can't understand why people are frightened of new ideas. I'm frightened of the old ones."
John Cage
Thanks sojourns
It's been a long time since somebody called me by given name.
Now to your comment: in my experience, charlatans like that--and I use the word knowingly because that's what he is--are usually arrogant, don't like to be challenged, and will dismiss you from his practice (unless he/she is really greedy). These physicians avoid questions. If a physician won't answer important questions, as I said in the essay, dump her/him.
Charlatans, AliEd
Have had interactions with at least two of those.
1. OB/GYN who rolled her eyes when I said I'd be having no pitocin, but using my own oxitocin during labor and delivery. (Opted for midwifery, for both babies after that, and "shopping" for doctors who wouldn't treat the births of my children like timed appointments with a cesarian when time's up, or me like an anotomy cadaver.)
2. Was prescribed a cream that literally ate away my skin and caused it to smell rotten. Called the office in duress, and Nurse Ratchet sighed, relenting to be bothered to allow me an office visit with His Highness. Took my mom, and because my pos ex husband accused me of not paying attention to doc's instructions, I recorded the office visit. Doc declared that we weren't a good fit, so I should go elsewhere. He was a specialist. My regular doctor was shocked and empathetic when he saw and smelled my skin.
Ugh!
BUT, I have had some seriously awesome Doctors, Physician Assistants and Nurse Practitioners over the decades. My current doctor actually wheeled me to the hospital, next door to the clinic herself just a few weeks ago. She's da bomb!
Another was a PA who actually talked down my BP 10 freaking points prior to a biopsy. Said she had performed the same biopsies in Central America with no electricity, and holding a flashlight in her mouth, with an assistant wiping sweat from her face. An angel!
You were smart and still are, Deja. Home delivery is often best
I am "shocked" that the OBG wished you to deliver YOUR baby according to HIS schedule. It was most impolite of you not to do so. (See my reply to another commenter in this thread about ER visits) s/
Avoiding complications of well-intentioned treatment is too common and often borders on malpractice. Avoiding iatrogenic complications IS malpractice.
The Unexpected Positive
We were pleasantly surprised when our doctor told us that the Catholic Hospital administration had no power to interfere with his operating theatre. Then he proceeded to create the conditions according to my wife's preferences.
This, in a one hospital town in a very conservative area. He did, so very much, enjoy the opportunity to tweak a few noses. As you noted (paraphrased of course): Angels are where you find them, and you just never know when you will find them.
Addition advice: Take an extra set of ears to every MD's visit
Medical visits are a high stress event and it is is easy to have trouble processing technical, highly personal (sometimes scary) information in a rational manner. Most of us in our day to day lives are not practiced in making fast medical decisions. If one makes fast decisions in a non-medical profession they may not have the base medical knowledge to make well formed medical decision within the 10 to 20 minutes of a physician visit.
Take a relative, friend or tape recorder with you. When you reflect on the visit the memory will be more detailed.
Also, take a 1 page (or short as possible) written list of your medications, supplements, allergies/adverse reactions, diagnoses and medical history each visit. Your electronic records may have been "upgraded" or transferred to a new program. The MD may have incomplete information. (short as possible). Most MDs process written info quickly and can then ask specific questions to identify or rule out a issues versus general info gathering.
Still yourself, deep water can absorb many disturbances with minimal reaction.
--When the opening appears release yourself.
Excellent observation, soe
Actually several very good points worth further elucidation. Even the most intelligent and observant individuals may fail to be aware of nuanced responses or information. Except for x-rays, nothing in medicine is black or white. A second set of ears is always a good practice, especially when change in treatment plans, new diagnoses, or proposed interventions are to be discussed.
My intake history form, which I verified line by line with the patient had questions pertaining to medications (even OTC) with request that the actual containers be brought in. I always conducted a thorough history (not the standard "ten-point review of systems" which is utter junk). I also requested that patients bring with them a list of questions for their follow-up visit. It seems that my office had a magic brain-wipe at the threshold, meaning that many people did not remember anything I told them, no matter how much time I took. I even had patients repeat back to me what they understood about the visit. Even that didn't work. If only I could patent that.
I've tried the teach-back technique too
Haven't found it all that helpful in my generally older patient population, for whom I manage several problems per visit. What has helped has been a remote medical scribe system using Google Glass which I employ, which allows me to talk directly to the patient (and attendant, if there) without keeping my nose buried in the computer. My scribe types out everything I tell the patient to do, and they receive a printed copy of these instructions (along with ordered tests, an updated medication list, and future appointments) when they leave my office. It's made a big difference.
Agree with the advice to bring a spare pair of ears, and to ask patients to write their questions down before the visit. I particularly advise this when they visit surgeons, and we review some of the considerations they should be thinking about if I see them before a surgical consultation.
Thanks for this valuable essay, and the peek under the hood it shows people who aren't in the biz. This is one of the most important relationships people have, and the more they know about how it works the better.
Please help support caucus99percent!
Dd what you do with Google Glass sounds great. Often one
goes to the doc not feeling well so written would be great.
Our doc down in Austin jokes about 'Dr. Google ' making his job somewhat more difficult when patients search based on their symptoms etc. Reading your comment immediately thought I would share what you do with him when we go in for appointments there next week.
Looked up Google Glass on Wikipedia https://en.wikipedia.org/wiki/Google_Glass and it seems went out of production but there are plans to reintroduce it?
A truth of the nuclear age/climate change: we can no longer have endless war and survive on this planet. Oh sh*t.
My group hooked up with a company in San Francisco
They have pioneered the remote scribe with Google Glass. The gadget has been withdrawn from retail business (there are rumors they're redesigning it), but it survives in "enterprise solutions" like this one. The scribe saves me a couple of hours a day, and I pay for it by seeing an extra couple of patients a day. More time with patients, a lot less time wrestling with documentation: what's not to like?
Next to having my notes pretty much done when I walk out of the room, handing the patient my verbal instructions transcribed by the time they leave is the best thing about it.
Please help support caucus99percent!
That rocks, DallasDoc! n/t
Got it, thanks. No brainer for you. Our guy is
interesting. Our GP for many years went Concierge after we retired, and we were without for some time, especially after we ramped up our foreign travels and our time in Santa Fe.
We learned about our current Austin doc from a friend who said that after the doc's wife passed away the doc converted his practice almost entirely to patients who have Medicare. He has told us not having to deal with all the different insurance companies makes his enjoyment of his job much improved. We love how he takes plenty of time with us. Really a pleasure.
A truth of the nuclear age/climate change: we can no longer have endless war and survive on this planet. Oh sh*t.
The prime problem with so-called private practice
is that the so-called practice is often dictated by insurance toadies who haven't graduated high school, don't know anything about medicine, can't pronounce the names of the disorders about which I am trying to treat and serve as a huge obstacle for obtaining needed patient treatment. To do so often required a personal conversation with the insurance doctor. Some of whom were well-meaning. Others probably had their feet up on the desk and couldn't wait for me to get off the phone.
Since I don't charge for my services, as my retirement is adequate, I enjoy my limited practice enormously--and because I don't need EMR, my nose isn't buried in a computer (it never was, by the way).
good advice
In New Zealand it is not that unusual to bring along whanau /ˈfɑːnaʊ/ (extended family) to medical appointments, job interviews, etc. The Maori and Pacific Island peoples are more likely to do this. We of European background are less likely to bring along support 'cos we have some weird attitude problem I guess.
Así pues, aquí estamos.
Great essay - thanks
I am considering an elective surgery and will rethink it after this article.
Here is a fairly long article by one of the regulars at Naked Capitalism on the medical care system in the US.
TrumpCare: ObamaCare, Medicaid, Medicare, and the Veterans Administration
The article quotes another article in the Denver post.
Way back in 1982, I was one of the first system engineers from Bell Labs leading the way for ATT to automate information systems in hospitals. Our effort failed. But way back then healthcare was around 10% of the GDP.
Can't believe that I was right on that one
That was from a long article on health care costs so I will put down the summary by their categories
History of Health Spending in the United States, 1960-2013
Don, thanks for the information
I have a few social, as opposed to medical opinions about this.
One is that the ONLY solution to our demented medical system is single-payer.
Obamacare was a train wreck waiting to happen.
Cost containment? What the hell is that.
Non-hospital physicians are penalized if they do not use EMR (electronic medical records). My experience with one program after I had researched 6, was to buy the one recommended by the American Association of neurologists. What a mistake. It was a piece of sewage--I had to sue the manufacturer for bait and swicth tactics--another story for another essay. None of the many private practice physicians with whom I discussed EMR was satisfied with them.
Thanks for that
Sounds like the biggest problem is finding the right medical advice.
Beware the bullshit factories.
Assessing the quality of advice being given is difficult
An essay on this topic might be useful in the future.
Regarding second opinions
I never tell the second doctor that it's a second opinion. Also, don't get your second opinion from the first doctor's associate.
I've seen lots of changes. What doesn't change is people. Same old hairless apes.
Excellent points.
Your advice is spot on. By the way, let the second opinion doctor make an independent assessment of the issues. Don't volunteer previous medical advice unless asked to do so. However if pertinent blood or imaging studies have been done, bring them with you--of course, this will tip off the doc that she/he is a second opinion--so you might not want to present the testing until the history and exam are completed.
I thought our medical records are now available
to all doctors electronically. Wasn't that part of Obamacare? So wouldn't the 2nd opinion doctor see the records and the first/original diagnosis?
Donnie The #ShitHole Douchebag. Fake Friend to the Working Class. Real Asshole.
Warning: bubble about to be popped!
Obamacare was supposed to enhance portability of medical records by forcing use of EMR. What happened is almost the exact opposite. With EMR, medical communication has not only become less accurate but the plethora of EMR systems, which don't "talk" to each other, has created a veritable Tower of Babel.
Thanks for the essay Ed
Backs up some things I've long suspected about modern doctors. To many of them it's just a job.
Had a middle aged doctor for a few years, then he retired early (in his late 50s) and his son took over the practice. Nine years later his son retires early(in his mid 40s).
Then some Indian guy took over and didn't accept Medicare patients.
Still looking for a primary physician.
Neither Russia nor China is our enemy.
Neither Iran nor Venezuela are threatening America.
Cuba is a dead horse, stop beating it.
Thanks for the compliment
The ethnic origin of a physician should not be a barrier unless speech is so unintelligible as to preclude adequate discussion. The finest physician I knew was Indian. Two of my children went to an Indian doctor because he was the best in town.
Unfortunately, your suspicion that to many physicians medicine is just a job is correct. My personal philosophy about the way I practiced medicine was that I treated each patient as if she/he were my only patient. The emotional rewards of so doing are enormous, even though outcomes can be disastrous (e.g., brain trauma).
This might sound like a Republican speaking here, but over-regulation is a definite impediment to medical practice and promotes early burnout.
A South American of Greek descent doctor
Once had a doctor like that. He had a booming, baritone voice, spoke fluent English, Spanish, and Greek. He also had such a complicated surname, everyone called him Dr. Papasaki. He was wonderful!
Great post Ed and my hospital story
I kinda group doctors and car mechanics into the same Trust category. Of course there are exceptions (like you) but lots that are in it for the bucks IMO.
The only time I ever went into the hospital was after an annual checkup. Told the doc I had a recurring pain at my solar plexis. He immediately assumed it was a heart problem and told me I had to go directly to the hospital. It was a friday and I had to lay in a hospital bed all weekend because they don't do heart stress tests on the weekend. And they put me on some kind of nitrogen pills as a blood thinner I assume -- which gave me a constant splitting head ache.
Come Monday all the tests come back fine. And they diagnose me with a stomach irritation. My girl friend (ex-smoker) loved to cook spicey food which I think was the cause.
Finally, the insurance company refused to pay the bill and told me not to pay if the hospital came to me looking for money. I'm guessing they thought the doc was just trying to fill hospital beds.
Donnie The #ShitHole Douchebag. Fake Friend to the Working Class. Real Asshole.
Dear CoE, your confusion as to the situation in which you
found yourself in, can be explained by the fact that YOU did not read the sign on the emergency dept. door which plainly says: "serious emergencies must be scheduled Monday through Friday between 7 am and 9pm--no exceptions permitted" Must have missed that one, huh? Well, there is a simple medical fact (warning: fake news alert) that no serious illnesses ever occur outside of the accepted time frame. Anyone suggesting otherwise will be prevented from seeking further emergency care at this facility.
Now that I have corrected that basic misunderstanding, perhaps we can discuss why you were late on paying your $15,000 bill for 3 days in the hospital (note, the ice water was gratis, no tipping allowed).
Ha. Yeah, I honestly didn't understand
why they couldn't staff the stress test machine on the weekend. They put some probe stickies on your chest, press the start test button and you walk on a treadmill for 10 mins. How hard can it be?
I didn't pay the hospital bill but I did pay for the over the counter Prilosec pills that calmed my acid-reflux. Hahaha.
Donnie The #ShitHole Douchebag. Fake Friend to the Working Class. Real Asshole.
Good for you!
You paid exactly what the non-treatment was worth. And the pills were overpriced too.
Stress tests must be performed by either a physician or trained technician with a cardiologist on the premises. Cardiac stress tests can be fatal and must be closely monitored, beat by beat. Now even my Podunk hospital had on call technicians (30 min. away) and on-call cardiologists (also 30 min. away) 24/7
Slightly Off-Topic
As the subject states, this line is going off the rail a bit, but I noticed something in your essay.
I guess I'm curious about this line, simply because a "psychologist" (specialization unspecified) doesn't generally have medical training. So, to me, his lack of medical knowledge isn't all that surprising. If we're talking about a psychiatrist, then well he definitely does need a strong grasp of a medical background since he is a medical doctor.
So when I was in college here a few years ago, I was debating between graduate and medical school. I was deciding between psychology or psychiatry (hence the above statement
) Anyway, started off the med track route. Going through all the pre-med and heavy sciences. There seemed (at least in my anecdotal evidence) quite a few...wealthier students who tried to breeze by to get into med school to make the bucks. I have no idea if they did get accepted or not, but some of the grades of those students...oofta.
No disrespect to psychologists intended
Depending on the budding psychologist's intended scope of practice, the amount of medicine and anatomy/biochemistry can be quite limited for those intending to go into counseling alone. Another psychological career course requires fellowship training for neuropsychology. These fellows (male and female) are quite knowledgeable about neuroanatomy, neurochemistry and physiology. The majority of psychologists do not opt for this subspecialty practice. Hence my statement above.
No problems
Right, I guess my point is that the majority of psychologists won't actually be that immersed within subjects such as anatomy and physiology, biochemistry, neurochemistry, etc. Industrial/Organizational, General, Forensic, Behavioral, Social, Cognitive, etc. etc. phew, many of the subsets of psychology often don't dive into the aforementioned areas. Clinical and topics such as neurology and what not would have people dive somewhat more into the branches that a psychiatrist would; but still not in the same depth as a psychiatrist would.
Overall point is that the field of psychologists having a more in-depth medical knowledge is more the outlier, not the norm. I'm not trying to go off on a rant or anything ha. When I've told say my grandparents I was trying to get into Clinical Psych, they started asking me about my medical degree and if I could prescribe, etc. But I would be a doctorate, a PhD ha, so sometimes a lot of folks (not pointing to you) often confuse or aren't often aware the differences between the grad route and med route. I was mostly just throwing in my two cents. And of course it was one sentence in a long essay. As I said, quite off-topic. But, it's an area I'm personally familiar with and my own anecdotal experience has shown people think a psychiatrist and psychologist are the same thing. Anyway, I'm sorry I didn't mean to potentially derail your essay here.
Glad for your comment
You delineated the rather wide scope of psychology quite nicely. For many of those specialties, advanced knowledge of pharmacodynamics would be much less important than sociology, anthropology, multiculturalism, comparative religions, etc.
While I have your attention
So you're a retired surgeon...an orthopedic surgeon? I'm taking a guess here since your cases you mentioned dealt with spinal and muscular issues.
Neurosurgeon, actually
Oh, Neat
Also, completely unrelated, but now can't shake the image of an alligator doctor now ha. Patients will always tell the truth when staring down the Alligator Doctor (copyright, 2018 TV series).
Very informative essay and comments
Neither I in my 70s nor my husband who is 80 take any RX drugs although we would do so if there were a medical need with no options. I never had any antibiotics until I was over 65 when I had a wisdom tooth pulled and they were recommended so I figured it was a good nonemergency time to make sure I wasn't allergic. I guess it's not that important now since antibiotics seem to be losing their effectiveness due to overuse.
I DID have increasing blood pressure after menopause plus a strong family history of cardiovascular disease, so after trying various nonmedical remedies decided to give low dose lisinopril a try. No nasty side effects I could notice but after a few months my white blood cell count, normally on the low side of normal, dropped rather precipitously. Since there were no other blood or physical indicators of a problem, my doctor said stop the lisinopril and wham! WBC returned to my normal. Rather than try another drug, and my diet and exercise regime already being very good, my doctor suggested a three month trial of a)a totally plant based diet and or b) acupuncture. Her recommendations were based on my family history and advanced blood work...not what she eats! I decided to go for both and have never looked back, attaining great results. For me (people are very different in some ways) it was the right answer. The acupuncture was expensive at first (not covered by Medicare nor my BC/BS) but now I just go to community (group) acupuncture once a month for maintenance so it's no more than a couple of copays would be. I have also loosened up VERY slightly on my diet, adding an occasional (once a month or usually less) small serving of some yummy artisanal cheese. I love vegetable gardening, cooking, preserving and culturing (and eating!), so that makes life easier. I don't really eat any added sugar except a square of dark chocolate every day. Thankfully I was raised on good home cooking and was never drawn into processed foods much at all. My husband's story was different but I'm tired of typing and I'm sure you are all tired of reading so will end it there for now.
My main gripe is that our current insurance based medical care does not really support people who might well WANT to try various non medical approaches (diet exercise meditation acupuncture etc) but just don't have the background or support to do it on their own. I always wondered at this penny wise pound foolish approach but then realized the insurance companies have no financial incentive to really encourage true health. How very sad. This is one reason amongst many that single payer is the only real solution....help people get as truly well as is possible for them now or pay big time for chronic illness later. And I do agree with AlliEd that overregulation is not the answer...that is what has led to much overprescriotion of meds as good medical practice IMO. We need instead to pay doctors for serious consultation and follow-up visits and not just procedures and drugs. Let various doctors become known and valued for their own areas of interest and expertise...our internist has said to me that she is only average when it comes to diabetes control and treatment ,but that there is another nearby internist who could be considered a "specialist" in dealing with it...she refers all her diabetic patients to that other one with no shame or false pride on her part. Her "specialty" is diet and exercise and lifestyle and as few meds as possible which is not for every patient either. Her patient load here is virtually all Medicare and when I saw the paltry remuneration she receives from them annually on a website, I was appalled, but she seems very fulfilled. It will be difficult to replace her when she retires for sure. Another problem is the cost of medical education, which may self-select too many stiudents who are interested in the money. That would be another very interesting discussion for another time. I think all of us want medical professionals who see it as a calling, not a monetary choice,but our current system does not improve the odds on that.
Zenza, you and your husband have adopted a wise course
of action. The less medicine one takes, the better. When I was in medical school, "alternative" medicine was considered quackery. So short-sighted. Revolutions in multiple fronts are occurring in medical practice. However many of them are being obstructed from general use by Federal Agencies (e.g., Medicare, medicaid, FDA), as well as Big Pharma (aided and abetted by the bribe-takers in Washington, District of Cash--oops, I got a little political there), and fear of being ostracized by one's colleagues.
Preventive medicine, which is THE best medical practice, gets under-reimbursed by insurance and Medicare. This is stupid. I may write another essay on that ridiculous notion.
So true:
Thanks for your sage comment.
Looking for that alternative med
essay. Far more helpful with blood sugar control, or not getting colds.
Brought in an excellent book on the former by Jenny Ruhl, and pointed to its ISBN. Doctor had no idea or what that was, and clearly no interest in reading or recommending it.