NO VITAMINS PLEASE.


The encouragement to take a daily multivitamin continues to be strong. However, the accumulation of data suggests strongly that daily supplementation is not necessary. The reasons for fortification of specific foods with specific nutrients starting in the early twentieth century was deliberate and with good reason. The indications for Folic acid, VItamin D, Iron and Iodine were clear and scientifically proven interventions using prevention as treatment for neural tube defects, Ricketts, iron deficiency and goiter. For these diseases the scientific connection was clear and proven. Forward to today and vitamin and micronutrient fortification is touted as a panacea and treatment for all that ails. The evidence for the addition of most supplements is weak at best. Frankly, it is without merit and almost totally baseless.

The extrapolation that since we need small quantities larger quantities will be better is short-sighted and potentially dangerous. The evidence does not support that view. The industrial production and addition of vitamins to every conceivable food item is primarily a marketing tool. It is a waste of money for consumers. If we look at nature we can see a better paradigm to extrapolate from. The concentration of vitamins and micronutrients are small and very large quantities of whole foods would need to be consumed to approach the quantities in many of the marketed items. If there is not a proven deficiency there is no need to add to our foods. The proven need is for small quantities that is more than adequately supplied by a balanced diet. The evidence for benefit beyond that is none existent.

Although, the evidence for potential harm is small we must ask the question. Will super sizing the quantities we ingest be harmful in the long run? Like with the craze for copious quantities of bottled water we have been marketed a hook and we have bitten and are drowning in a sea of misrepresentation. Improve your diet. Make fruits and vegetables the base of all meals and stop wasting your money on bottles of urine coloring.

POSTOPERATIVE DELIRIUM


Life expectancy in the USA as of the most recent data is 78.61 years. Along with longer life span we have a every increasing number of surgery. With out-patient surgery rapidly growing year over year. The population over 65 years are living a more active life still and are requiring more surgical intervention. Our peri operative technologies have improved to allow us to provide safer care to those at the extremes expectancy range. WIth this improvement and comes many additional questions. The question of post op delirium continues to be a problem and will increase as the populations ages and more surgical procedures are available.

How the older patient is cared for in the peri operative time frame is and will continue to be of special concern to themselves, families and increasingly to payors. The process of getting from diagnosis to the surgical suite is basically divide in 2 routes, either via he emergency room or the physician office. The peri operative preparation is as import as the intra operative care and involves many, however as an Anesthesiologist i will present the process from my vantage point.
The care of any patient starts with the basics, taking a good history. For all patients under the care of an anesthesia provider taking a focused and directed history is vital to the safe delivery of appropriate care. For the older patient extra attentions should be placed on history of delirium in the post operative period which i would suggest should be considered to include the first 24 hours post PACU discharge. Other vital components to evaluate include vision impairment and hearing loss. For the visually impair consider how soon after arrival in PACU to return glasses. For the hearing impaired do they use hearing aids, can they be left in for the procedure. Does the patient lip read. Even for those that do on lip read, looking directly at them, speaking clearly with proper enunciation without shouting works very well to transmitted data.

Carefully look over medications for hints to treatment for early dementia. Ask about early dementia. What happened after last surgery. Who will be present in the post operative period?

There is no clear evidence that anesthesia specifically is the cause of post operative delirium. The choice of anesthesia should be based on what intervention will provide for the safest working conditions and facilitate a rapid low pain recovery.  For those with dementia the suggestion that regional alone maybe advantageous is not as clear to me as it maybe to others. From my experience regional as the sole anesthetic in a demented even for very minor procedures will be a challenge because of the lack of circumstantial awareness from the patient. The lack of awareness can and often leads to lost of cooperation and increased risk of morbidity to the patient. The primary anesthetic must provide the appropriate working conditions firstly. The demented patient like all patient must first be in optimal surgical condition. General anesthesia is often the most optimal choice. General anesthesia is not one thing but many varied combination of drugs and this is where the judgement of the anesthesia provider can be very helpful. From my vantage point the goal is to provide the most advantageous conditions using the lowest dose of the fewest drugs required. A monitor that was dependable in the judgement of anesthetic depth would be of great utility in the older patient. The BIS monitor is claimed by some to be such a monitor, but many others find it inconsistent and unreliable. I have not seen any evidence that convinces me that it provides and advantage. It may provide some advantage but that advantage is not clear to me. The traditional monitoring of anesthetic depth includes observation of changes in vitals and direct observation of the patient may be insufficient to guarantee adequate depth but is still the best we have. A vigilant provider is still the best monitor. I hope that one day soon we will have an even better monitor. Without that monitor the provider needs to be conscious to balance depth with risks of post operative delirium. The drugs that we use to maintain anesthesia are important potential risk point and one area that is especially concerning are the anticholinesterases. These drugs are used as apart of the cocktail for reversal of paralysis and can cause delirium and should be used with caution. The optimal situation would be to not need them, meaning if necessary we should avoid paralysis. However, if paralysis is needed full reversal should be used because incomplete reversal could make the post operative situation worse. Additionally making sure all our anesthetic if below therapeutic levels before going to the PACU is beneficial.

Once the optimal condition for surgery have been meet and the anesthetic is optimized to decrease the risk of post operative delirium the patient needs to be cared for in a PACU that continues to  optimize recovery. The environment needs to the at an appropriate temperature with appropriate lighting and quiet. Use the minimum required monitors to get the job done. The nurse in the PACU is a vital partner, she needs to orient the patient to date time and location. Orient, orient and orient again. Assurance of adequate hydration, pain control, empty bladder, treatment of nausea if present, prevent hypoxia are all vital. If delirium occurs, low dose benzodiazepine and family at bedside should be considered. The use of regional anesthesia is a great tool to assist the post operative period. I find the most utility of regional in the patient with dementia or at risk of delirium is in its ability to provide significant long-lasting pain control that decreases the amount of opioids needed in the recovery period.
Special attention to the needs of the older patient at risk for post operative delirium is a worthy goal. However, we must not be lead from first principles. We must provide a safe environment for the procedure. With careful planning and attention to detail we may be able to decrease the risks, but we should not lose site of the facts. Fundamentally, there is no good evidence that the type of anesthetic correlates with risk of post operative delirium. The only consistent fact is that the patient has had surgery. Teasing out the specific component of the peri operative environment that increases risk is still some way off. What anesthesia providers need to provide safe conditions that decrease risks based on the evidence we have.

MEASLES, REALLY?


The current rise in measles cases is a direct result of poor vaccination coverage. The current and pass trend in not vaccinating children is dishearten and threatens public health. How did we get from measles being almost completely eradicated to the highest numbers in decades? I want to suggest that this is emblematic of the poor scientific education of American society. We have allowed the principles and fundamental laws of nature to be undermined in the public discussion of societal problems.

The pervasive acceptance of the creation myth and the almost complete rejection of the pursuit of scientific knowledge is  at the root of the resurgence. The lack of understanding and rejection of the scientific method has led to a population that questions everything without the requisite background information.  Questions are healthy only when the questioner has a grasp of the context of the questions. We have lost our ability to objectively analyse the facts. The is not because the population is less intelligent that prior generations, but because we have had a 30 year campaign to undermine the foundations of scientific thinking. Scientific facts and precepts are attacked for economic reasons. The concerted and coordinated attacks have led to a wide-spread loss of societal scientific identity. We have lost our understanding of our place in the earth’s ecology. Instead of seeing our species as apart of the larger ecological system we have deluded ourselves into the belief that we are superior.

Many are under the miss-guided idea that creationism is an equal theory to evolution. This as lead to loss of understanding of the biology of life. Without a grasp of the facts of evolution an understanding of biologic life is not to be expected. The current concepts of biologic life are based on evolution and its essential component natural selection. Without a working understanding the general population is susceptible to the quacks that propagate the anti-science garbage that masquerade as alternative “scientific” theories. These vessels of idiocy need to be marginalized. They are the most dangerous threat to our society. Humanity will not be killed by global war or a rock from space. Humanity will be destroyed if we do not accept scientific facts and methods in our approach to the ecological system.  Science is the only route to understanding the physical world. We are a small part of a larger ecosystem. We are not essential to this system. If we do not understand that fact we will join the many other dead ends of evolution on our home planet.

Our ability to educate our people will determine over survival as a species. Let us drive the anti-science crowd from the places of power and consign them to the waste-bin of history.

GIVE ME ONE HOSPITAL BILL PLEASE.


A funny thing happened on my way to pay a medical bill. I have paid the same medical bill twice and as such have decided to not pay any bill until I get the second notice. So a few day ago I decided to pay the latest bill in the hospital instead of mailing a check to the billing company out-of-state. After much effort I found the correct billing office and presented my bill. I them got what I thought at first was a pleasant surprise. The clerk told me that she did not see a balance owed in the system. She repeated “You do not owe anything on this account”. I was perplexed since the bill I had in hand clearly stated that I owed a significant outstanding balance. As I left the office I began to wonder how many times this situation occurs. What would have happened if I had mailed a check to the out-of-State billing company? How many bills have I paid that were in a similar situation?

This experience has allowed me to revisit an idea that I have expressed to others in the medical community before. I would like to see the morass of medical bills be corralled and only one bill be sent to the patient. Broadly this is how I see it working:
a. all bills are processed by each provider or facility within 20 days of discharge of services,
b. all bills are presented to central biller within 30 days of discharge of patient,
c. one bill presented to patient within 60 days of discharge,
d. all patients have 30 days from receipt of bill to arrange payment.

 

WE WILL BE PATIENTS TOO.


As a consumer and provider of health care services I am not impressed with the level of service I see. I am disturbed by the lack of empathy and the poor efficiency of the system. Providing health care services can be a very stressful occupation, but if we have chosen to be participants we should put our best face forward everyday. The empathy and sympathy we show are major components in conjunction with efficiency and competence in providing the care that is required and that our patients deserve.

The system as currently constituted allows for wide variance in the quality of the service that is delivered. This is a problem that is often overlooked and under appreciated. We get distracted by the politics of our work environment and neglect to critically assess our function in it. I see providing great care as delivering the correct service in a timely manner. I do not consider giving the patient options as a service to them. Patients want us to tell them what the best choice is and why it is so.

Very few patients are equipped with the knowledge to make great choices. We need to refocus our discussion to providing the evidence that support our recommendations. We need to provide our patients with the option that the best evidence supports. When there is no known best option then we need to use our medical judgment and provide clear direction.

Discussing the best option is great, but only makes a difference if that service can be provided in a timely efficient manner. As a service providers I have the impression that many of us are not as concerned about the efficiency of the service provision. This lack of attention to the details of delivery is poor form on our part. We may think that providing the correct service is the important factor and we would be correct. However, providing the correct service is only as good as how timely that service is provided. We need to deliver quality service with empathy and efficiency.

The current system we have will never be able to provide this type of service delivery as long as providers are not engaged fully. We complain about the rules and regulations that hinder us, but they are not the problem. The problem is us. Instead of saying how can I get my job done, we have defaulted to how am I going to make them see that this rule is bad for patient care. This attitude is detrimental to patient outcomes.

I do not have hope for any improvement in the system. The irony is that the more we protest and passive aggressively resist the more change we induce. Providers are so lost in the echo chamber of passive resistance that we cannot see the good or the bad in the current system. We have given over control to the money changers while we are fighting for the crumbs. We are distracted from the essentials of our service. Let us be reminded that we will be patients too.

IT IS OUR MORAL DUTY.


The curious nature of the American electorate once again fascinates me. The ongoing discussion of health care coverage and delivery is schizophrenic at best. The most recent pools show a population in need of health care coverage but the same group most highly skeptical of the most recent attempt to improve their ability to access coverage. Furthermore those who are most in need, and treated the most poorly by the current system are still willing to hold onto the failed system. It is unfortunate but the same the tactics developed and used by the cigarette industry to convince us that cigarettes are safe are being used to undermine the ACA. Many are against the ACA without investigating the potential benefits.

The cable talking heads have succeeded beyond their wildest dreams. They have so muddled the facts that it seems no one has a grasp of the services that will be improved. The problem with that assumption is that it is far from being a fact. The data are there if we as consumers would only look beyond the imbeciles on cable T.V. The problem is that our attention is firmly planted on the imperfections and not the goals. We are not being true to the fundamentals of American cultural strength, the belief that we can do it if we want to. I can only suggest that the opponents do not want Americans to succeed. The success of American Corporates is not the same as the success of Americans.

The intellectual dishonesty of the talking heads and those in charge of the news media is disheartening. They have no regard for the uninsured. The consequence is that the people who need help the most have been convinced that there is no help to be had. The truth is not deceptive nor is it hidden. The ACA is good for Americans. The ACA aka Obama Care is good for American business and will be a success. Success will not be achieved overnight, but will be a long hard fight. The fight is against those who do not believe that government has any part to play in the delivery of services and those who do. The battle is against the deceitful. The battle is against the business lobby. The battle is primarily against the ignorance that parades in fine suits on 24 hour cable T.V.

Those of us objectively looking on need to not only look but need to shout down the liars and the dishonest. How do we inform those that need the information the most? I would suggest a grassroots election style campaign. We need to start by informing ourselves. Each of us needs to study the benefits and pitfalls of the law. Without in dept knowledge we cannot be effective advocates. Go advocate, it is our moral duty.

OBAMACARE


There is a time and place for everything and I think it is time for us to all look in the mirror. Our government has impaled herself on her own sword. The truth is that there is only one person to blame. No, it is not the President nor is it members of congress. You and I are to blame. We are the idiots that believe the garbage spewing from the despicable talking heads on radio and TV.

The continued pretense that there is always two sides to a story belies the continued mass delusion we live under. There is not two sides to every story. The imbeciles that continue to repeat that lie are in my view the worst thing that has every happened to our country. This pretense is used to confuse and demoralize the masses. This pretense allows the well dressed liars to continue to manipulate the low information voter. We all need to stop buying what the snake oil man is selling.

The current big lie is that Obamacare or the Affordable Care Act is going to bankrupt the country. The system as we have known it was doing that already. The honest among us will acknowledge that health care inflation was already running rampant. Obamacare has nothing to do with it. The honest among us will admit that there was always a problem and that Obamacare is an attempt to solve it. The most insidious lie of this whole fiasco is the that Obamacare is proposing something new. It is not. If we were paying attention to the health care debate of the mid to late 90’s we would recognize that this is exactly what was recommended by the right-wing think tanks. But the liars among us continue to deny and obfuscate.

The level of dishonesty is mind-blowing and disgusting. The people we expect to know more continue to disappoint. The dishonest continue to lie to the low information voter and said voter continues to send dishonest representatives to Washington. The deeper problem with our country is that the majority of the population lacks the willingness to do what is necessary to be considered a ‘informed citizenry’. Help us all.

TIMELINESS


All of us have our quirks. The question is, can the people around you live with them. On most days I think the people around me can survive. Mine is my drive for efficiency. I once was told that the fastest way to get a task done is to do it the right way the first time. If you work with me you have heard that before and you know that my way is the only correct way. Thanks for the indulgence. What motivates me is accomplishing a task in as few steps as possible. In health care that can be a challenge.

In the world of rising cost and decreasing reimbursement the imperative in healthcare is keeping cost to a minimum. My take is that patient safety is the first goal followed closely by efficiency. Some may wonder about that combination but I posit that they are one and the same. If your question is how so, let me expand by looking at one of the most frequent complaints in healthcare. Timeliness. What is timeliness and do you respect it?

The most offensive ‌thing to me is inefficiency. Inefficient use of time is the highest form of disrespect. The fundamental question is do you respect others. As importantly, do you respect your reputation. You first have to show respect for yourself before you can respect others. Respect motivates and challenges. It creates internal expectations that demand attention. The expectation that you must be the best at each task demands attention to the details of the task. Attention to the small details of the task shows others your commitment to success and will reinforce your reputation for succeeding at your goals. We all want the successful and self motivated on our team. Respect for one’s reputation means always doing ones best, including being on time. Respect for time, I posit carries over into ones preparation for treating patients and will result in better care being delivered.

Unfortunately many in our society have come to equate the cost of their time to value. Value is not defined by cost equations, but by the totality of benefit provided to others. Your time is not more valuable than that of others. As a physician I try to respect my patient’s time. However that attribute is not universally acknowledged and  that  leads to delivery of less than optimal care. The lack of preparation for our patients is reflected in lack of respect for the time of patients and results in us going for the easy fixes instead of the optimal. The easy fix is destroying the reputation of the Medical Profession. “ObamaCare” and Government regulation is just the latest scapegoat for the total lack of respect that physicians have for time and timeliness and by extension our patients. This directly affects our reputations, but too many don’t see the connection. Patients have become a number not because of the business of medicine but because physicians have not shown enough respect for our patient’s time. Too many physicians see patients as a captive audience. Even if our patients do not have many options we should still treat them with the respect they deserve. All of natures children deserve respect and humans no less than our cats or dogs. If we do not reverse this trend, one day we will wake up and find that we are not the only ones taking care of patients. Truth be told that reality is already here. Welcome to the evolving world order.

I AM IMPATIENT AND STUBBORN.


I am impatient and stubborn and I am working on it. Well, not really. I like being stubborn more that I like being impatient. In spite of that, I like being both. Both traits may seem to be negatives, but they are only negative if the full breath of human endeavor is not evaluated. My primary impatience is with how little respect many of us have for other people’s time. I hate waiting so I stopped using bank tellers in the late 90’s. Internet banking then was slow but still better than standing in a line.
I always opt to do it myself. It has to be done right the first time so no time is lost. I am not a master of all. I know when to call for help.
The people who work closely with me know I have an opinion on most topics and that I am sure that my way is correct. Truth is I am not always correct, but I am willing to do the work to ensure I am correct. I am accepting the stubbornness label because I have been labeled as such. I don’t really think that I am stubborn. I just know that I am right and I will defend my stance even if I am the only person that holds that position. I have done the work, have you. That’s my view, take it or leave.
One of the weaknesses of these two traits is that I don’t delegate well. I chose to become an Anesthesiologist so I would not have to delegate. I am a doer. The general direction of medicine makes delegation a larger and larger part of the practice. I am not sure what are the benefits, except for potential financial rewards. I would love to think it provides improved quality of care. However, that is questionable. Superior quality of care is provided by better trained providers. I am going to keep on being impatient and stubborn because it’s the only way to deliver a high level of care. Do you have a different answer?

ACCESS TO HEALTH CARE IS A BASIC HUMAN RIGHT.


2012-12-28-0242The current consternation in our country about the provision of health insurance for the entire population is somewhat baffling. The selfishness that says that ones lack of insurance is always your fault is truly inhumane. Maybe I am the selfish one because I want to get paid for my services. The dilemma we have is that most of us don’t understand the care delivery system and more problematic is that we don’t understand the concept of insurance. Neither is easy to explain in our 30-second 24-hour news cycle. The paradox of not wanting to spend hundreds of dollars to save hundreds of thousands is lost on the general population. More precisely, ‘a penny of prevention is worth a pound of cure’. It seems that the few that understand either gain from the broken system or are powerless to change it.

The conditions that lead to lack of insurance are varied and are sometimes self-inflicted. In spite of this, it is our responsibility to care for each other. After my last weekend on call I have come to the conclusion that access to health care including insurance is a basic human right. Some may disagree, but I say you are 100 percent wrong. My other conclusion is that I am not the selfish one. Sadly, that leaves you. Yes, I know I have no right, but I have seen too much to disregard the obvious and pervasive selfishness and disregard shown to the weakest among us. We claim equality for all but are quick to disregard the suffering of others so we can continue to consume more than we need. The obesity epidemic is the prime example. We buy more, consume more and throw out more food than we need many times over. At the same time we claim concern for the hungry. We however are oblivious to our own part in their deprivation. We, and that includes me, don’t really care about the others. We want to be seen to care without putting in the work.

For those that are now labeling me ‘one of those liberals’. Yes I am a proud Liberal. Yes I am a proud Capitalist. Yes I am a proud Libertarian. Yes selfishness is good, but greed is not. The selfishness of Capitalism looks to preserve individual advantage and caring for the weak is a part of that process. The problem is that most people are not informed enough to even look out for their own advantage. The low information citizen is easily manipulated into thoughts and actions that are not in their interest. The sadness I feel is enough to make me not care, but the truth is that some of us are not capable of not caring. We are the ones attempting to keep society balanced. Sadly in spite of the obvious we are still convinced that the majority of the population is caring and empathetic. I beg respectfully to disagree. Few people are truly heroic and even fewer are willing to tell the truth when they are the only ones who believe it. This is where we are. Our selfishness is self-centered, poorly directed and lacking in insight. This lack of insight will be the death of us all as a species.

What will we leave behind when evolution no longer has any use for our poor survival instincts? Are you planning on making a change this year?