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The Times They are a Changing

I am blessed by the fact that I really do love what I do as a physician.  I love seeing folks every day and seeking to sort through the problems they’re struggling with, figure out what malady is underlying their symptoms, effectively treat it, make plans with them for preventing other big problems down the road, and along the way, get to know them personally.

At the same time, I can’t help but notice that many of my colleagues feel hassled and unfulfilled and are retiring early.  Likewise, patients feel that medical care is more and more frustrating with big bills, short visits, and impersonal, distracted interactions with physicians.  With insurance they pay more and more to get less and less coverage while losing more and more control over how and what they receive in medical care.

For my part, I feel those same pressures on both me and my patients.  When I began practicing medicine, I could still readily focus on my patient, take the time I felt was needed with them, decide what further tests were necessary to arrive at a diagnosis for them, choose which prescription or course of treatment would be most effective, document a note in a minute or two, and charge a reasonable fee for the service.

Now my patients and I feel competing, resisting, and frankly annoying forces at each step.  It’s harder to focus attention on my patients because insurance companies and government agencies require massive, multi-page notes full of minutia that helps neither me nor my patient and takes my eyes off the patient and on to a computer screen.  To try to solve this I finally hired a full time medical scribe to help keep the notes so that I could focus back on my patients.

Next when, after hearing from and examining my patient, I decide which tests are needed to help diagnose their problem, I often need to battle with the insurance company to convince someone who has never seen my patient that the test is necessary.  This involves more time from me and my staff and often delays diagnosis for my patients.  Next comes the course of treatment.  It is no longer just which treatments or prescriptions would be best, but the all-important question of what insurance will allow and cover.

I could go on but you get the picture, and as patients you’ve experienced it.  The personal doctor – patient interaction is being taken over by distant, impersonal entities steadily engulfing every step of medical care.  Time, attention, and cost are increasingly going toward satisfying these entities instead of taking care of individual patients.

So what’s the core of the problem, and is there a reasonable fix?  The answers to those questions are larger than a column this size can fully tackle.   But maybe with this and another in two weeks we can make a helpful start.

We can count on the fact that the one paying the bills for medical care will eventually control the care.  When we moved to a system of insuring medical care at every level we started down the road that has brought us to this place where patients and their physicians are no longer in control of care.

Normally insurance involves many people pooling their resources to be able to afford to pay for an unlikely but expensive event.  So catastrophic medical insurance makes sense. But we don’t use our homeowners insurance to cover repainting a room, or our car insurance to cover an oil change.  Likewise, we shouldn’t use medical insurance to cover every physical or strep throat.  These are routine, expected services.  When we began to use insurance to cover all of them, the total cost began to go up and the control of the visit began to be taken away from the patient and their physician and given to the insurance company or government agency.

Each time a large entity such as an insurance company or the government promises or implies that they will take care of us, we need to remember that sooner or later there will be a very substantial cost, sometimes in dollars, and sometimes in loss of control over every level of the medical care we receive.  Experience has borne this out.

Ok, so that is a very brief picture of some of the problems facing us in getting affordable, effective, personal medical care.  It is not at all intended to be a rant a whine or an idle complaint, just an objective look at where we’re at in medical care.  It is an attempt to diagnose the cause of our problem.  And I believe there may be a cure for the cancer that is eating up medical care, or at least some steps that can put it into remission.  But, as you so often may hear from your physician, we’re out of time and that will have to wait for two weeks from now.


Poison Ivy

Sarah, one of the young ladies in my practice in her late teens, sat on the exam table looking just a bit like a picture I once saw of a frog that had been stung by a few dozen bees.  Her eyes were almost swollen shut.  Her ears, lips and cheeks were puffy and red.  The transformation of this normally wholesomely pretty young lady was striking to say the least.  And she was itching terribly almost from head to toe.

Yes, she had inadvertently walked through a good patch of poison ivy, to which she was extremely allergic.  About 80-85% of people are allergic to poison ivy and 15% are extremely allergic.  Poison ivy causes a reaction that medically is called allergic contact dermatitis (ACD).  Other plants such as poison oak and poison sumac can cause similar reactions but are not as incredibly common to Tennessee woods, yards and hillsides as poison ivy.

When the plant oils come in contact with human skin, they begin to trigger an allergic reaction which usually starts to show up about 48 hours later.  Within 20-30 minutes of contact with human skin the oil of the poison ivy plant is essentially neutralized.  Until that point, if the oil is on your hand, for example, anywhere else you touch can get the reaction because the oil is transferred.  So if you know you’ve come in contact with poison ivy, the quicker you can wash it off with soap and water the better, ideally in less than 10-15 minutes.

The allergy-producing oil of poison ivy does not get neutralized when it is on clothes, other inanimate objects, or pet fur.  So if those things have been in poison ivy, even days previously, and come in contact with your skin, you can have a new poison ivy outbreak.  So pets, clothes, etc. that have come in contact with poison ivy need a good washing to avoid future trouble.

One myth is that the fluid from poison ivy blisters can spread the poison ivy, or that you are contagious when you break out in poison ivy.  By the time you are getting blisters or a rash the poison ivy oil has long ago been neutralized by your skin.  The rash just sometimes appears in different places over several days due to different amounts of oil and thickness of the skin in those areas.  It’s not truly spreading in any contagious manner.

The appearance of poison ivy plants is pretty well known to most who venture into woods and fields.  The typical three-leaved shiny plants with notches on the leaves and growing either as a ground vine or a hairy vine going up a tree is easy to recognize.  The five-leaved vines on many trees are the generally harmless Virginia Creeper, not a five-leaved poison ivy variant.  Just Google poison ivy, oak and sumac images to get a refresher in what these look like.

So suppose despite your best efforts, you’ve gotten into poison ivy and are breaking out.  If it’s mild, just use cool compresses, a cortisone cream (or Sarna or Calamine or whatever your favorite topical anti-itch cream is), and an oral Benadryl when you’re going to try to sleep.  Don’t take hot showers or use lots of soap once the rash has started; you want the natural oils in your skin to remain and reduce the itching.  Oatmeal baths can be soothing as well.

But if you have a more intense outbreak, see your doctor and get either a shot of cortisone or an oral course of it.  The typical length of a poison ivy outbreak is two weeks, so the treatment generally needs to be for that length of time.

Even with poison ivy around, it’s worth a little risk to get out and enjoy the beautiful creation God has put around us here in East Tennessee.  Just get to know the appearance of these bad boy plants, keep a little distance, and if they still manage to jump on you, deal with them smartly and as quickly as possible.


Egypt and Us

Last week I had the opportunity to visit Egypt and, among other things, take part in some medical clinics.  The medical care in Egypt is reasonably good in many areas, but not so much in the very poor section we served outside of Cairo.  Looking out of the window of the little bus as we rolled into town, it was hard not to notice garbage everywhere; it floated over the little canal that divided the road and littered the road itself.  In the end, it was part of the health challenge of this Egyptian town.

At the end of seeing a day’s worth of patients filing in, I was struck with the fact that there health challenges are similar in many ways to ours.  Like us, they suffer from arthritis, congestive heart failure, diabetes, headaches, hypertension, and bronchitis.

But there are some different challenges as well.  At least in these poorer towns, access to routine care for some of the more chronic problems is almost impossible.  So while we could identify high blood pressure, diabetes or heart disease, we could do little to effectively manage it with our one-time visit.

Another challenge these folks face that is not major for us is routine access to clean water and food.  Many of the children and adults had parasites sapping their energy and giving them various gastrointestinal complaints.  An anti-parasite medicine, albendazole, was one of my most frequently prescribed medicines; I can barely recall prescribing it while in the states.  And when I prescribed it in this little town in Egypt, I knew I was only temporarily reducing the worm burden in these patients.  Without a change in their water supply and food handling they would quickly be re-infected.

A couple of children were covered from head to toe with red bumps and blisters.  It took me a good while to realize this was not some infestation of mites but just severe chicken pox.  Here in the U.S. I rarely see chicken pox anymore and they are usually very mild cases.  Likewise Egypt still has some of the more serious vaccine-preventable diseases like polio.

So while the people were in many ways similar to those I see here in Tennessee: many delightful and a few a bit more cantankerous, some very sick from advanced congestive heart failure and others just needing reassurance that a small skin lesion wasn’t cancer, there were some clear differences in the overall systemic health challenges they face.

It left me with a heart for these folks and a thankfulness for the blessings we have in this country: ready access to clean food and water, a sanitation and waste system that works, availability of effective vaccines against many of the diseases that used to plague our children and adults, and access to routine health care to manage and minimize the complications of serious chronic diseases.

Our challenges are more of excess – excesses of food, entertainment, alcohol, and tobacco.  Choosing the healthier foods in reasonable portions, finding ways to bring regular physical exercise back into our crowded lives, not neglecting or mistrusting the available vaccines, and avoiding toxic habits – these are more the challenges of our world in the U.S.  They don’t account for every illness, but good choices in these areas drastically impacts the epidemics of chronic diseases in our country.  These are not meant as judgments, just observations to focus our efforts and count our blessings.