The Gift

By Richard P. Holm MD

Like a lot of men who make their way to my internal medicine office, Mark Ekeland came by the urging of his wife. He even put it this way, She told me to make the appointment because Ive been really dragging lately. This is classic guy.

During the examination I felt the liver and to my dismay it came down quite a bit below the rib cage, indicating that it was enlarged. The blood tests indicated bile duct blockage, liver cell destruction, no Hepatitis A, B, or C, and the ultrasound test did not show gallstones or tumor but only a large liver.

After a phone consultation with a gastroenterologist, a liver biopsy was done, which proved a rare liver scaring disease called Primary Biliary Cirrhosis. This kind of cirrhosis has nothing to do with alcohol but rather an immune system gone awry, and predicts a gradual worsening, eventual liver failure, and a premature death.

Over the ensuing ten years I watched as my patients condition worsened. Although never complaining, his muscles wasted, his color turned grey-green, his belly swelled, and he seemed to age right before my eyes. 

One day he came close to death bleeding from varicose veins of the esophagus, and although near the top of the transplant list, he still waited. Since there was such a great demand for organs, it looked like he might not get one in time. 

Then, a relative of his wife offered to be a living donor, an incredible gift of half of her liver. The transplant happened rather soon after, and it was a glorious thing to watch Marks general health come back to him over the next three or four months. 

Now four years later, Mark enjoys and savors every healthy day because of the courage and compassion of his donor, and the miracle of modern medicine. 

Take home message:
The advancement of science has offered remarkable treatments for what used to be terminal conditions;
All of us should do what we can to help those in need of organ transplant. Sign a donor card AND tell your family about your wishes to donate if tragedy should happen;
Living donors, and those willing to donate after brain death provide a gift for a lifetime of marvelous relief from illness and suffering.

Tom Daschle for Health and Human Services Advisor

By Shawn Vuong

Well its pretty much official, our own Tom Daschle will be the secretary of HHS.  What does this mean for doctors and patients in South Dakota?  What does this mean for doctors and patients nationwide?  

Some don't believe Daschle is the right man for the job.  They may be worried about his past voting history, his history of partisan politics, or even his wife's job as a lobbyist that may play in conflicts of interests.  Others think he's perfect.  Either way you look at it, he's going to be a key component of the healthcare reform that America is about to see.  

To get a good idea of what's in store for us, I plan on reading "Critical: What We Can Do About The Health-Care Crisis" by Daschle.  The book came out Feb 2008, and I think its going to be the outline of what's to come.

Are South Dakota's Current Abortion Laws Hurting Doctors?

By Shawn Vuong

While many South Dakotans are glad we are done with "Initiative 11" Zita Lazzarini thinks South Dakota has already taken it too far.  Today in the NEJM, Lazzarini says that the current law that was passed in 2005 known as the "abortion script" threatens the physician-patient relationship.

At one level this type of law pushes our state's beliefs onto doctors and patients.  Also, the abortion script may actually be keeping doctors from giving scientifically based information to allow for an informed consent.  Lastly, Lazzarini says that if we let the states push it this far, what's next?  Who knows what other ethical dilemmas the state will try to push onto doctors & patients.  

If legislatures can mandate that physicians provide women with ideological, vague, intimidating, and false information about abortion, what is to stop them from intruding further into physician–patient discussions regarding end-of-life decisions, the use of future stem-cell–basedtherapeutics, the efficacy of birth control, or the role of condoms in preventing sexually transmitted infections?

How important is the doctor-patient relationship to you?  Whether you are pro-choice or pro-life should not make a difference in this issue.  Imagine that you are in the hospital with your loved ones, and the doctor was mandated to tell you and make you sign paperwork that the end-of-life decisions you and your loved ones are making are wrong.  

Doctors Feeling Gloomy?

By Shawn Vuong

Yesterday I was talking about my worries of becoming a bitter doctor.  But why do doctors loose morale?  Today, Sarah Rubenstein of the WSJ gave me some insight on this matter.

Here are some of the bracing findings from 11,950 primary care docs and specialists who responded to the survey:

94% said the time they’ve devote to non-clinical paperwork in the past three years has increased. 63% said the paperwork has meant they spend less time per patient.

82% said their practices would be “unsustainable” if proposed Medicare pay cuts were made.

78% believe there is a shortage of primary care docs in the U.S.

49% said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.

60% would not recommend medicine as a career to young people.

42% said professional morale is either “poor” or “very low.”

17% rated the financial position of their practices as “healthy and profitable.”

6% described morale of their colleagues as “positive.”

Wow, if that isn't depressing I don't know what is.  Paper work, a shortage of doctors, and low morale possibly through low reimbursements, insurance controlling care, and less doctor-patient time.  I may be wet behind the ears in the world of medicine, but I can tell you one thing, I am going into medicine to take care of people.  If a primary care physician told me that all the paper work they do keeps them from seeing the patient, I'd dodge primary care like the plague.  Many other medical students already are dodging away from primary care.

A couple questions come to mind after reading this.  First and most obvious question, how do we fix this?  Also, since Dr. Holm is a family doctor himself, I would like to know what his general opinion is on this article.  Is morale really low here in South Dakota?  Are family physicians here feeling the pinch of administrative work, low reimbursements, and insurance control?

Healthcare Costs Part 1

By Richard P. Holm MD

Maybe it was ten years ago I heard a political reformer pose the question: What if we paid for groceries like we pay for health care in the U.S.& how different would it be? He described buying groceries where there would be no reason to look for a bargain, but rather motivation to buy the most expensive items, and everybodys basket would be filled to the brim.

I think there is still some truth to the comparison, because in this world of third party payers for health care, the consumer is still not driven to look for value. Rather it seems the employer who buys the insurance has to do that. But in 2008 there are some changes we would have to make to the grocery-store/health-care comparison.

Now you find that there are only three grocery stores in the state, and you have to go to the store your employer chose. Upon arrival to the store you find a very elaborately decorated and expensive building, the carts are robotic, the aisles are wide and beautiful, and there are way more managers than checkout people, due to government beaurocracy.

Looking around you realize that every customer in the store seems to have a different way of paying for the food. One person has a plan where all the food is free, once he reaches his deductible, but it pays only for certain food, and he cant figure out what that is, except to know that generic beans are always paid for. And then there are customers who have managed care advisers walking around the store with them pointing out which food is not available to them. What's more, there are many people outside the store that can't get in.

It is not a perfect metaphor but it makes one point very clear the system is a mess. In this age of healthcare reform, please be pro-active and contact your Washington legislators.

Primary Care Shortage Worsened

Med School to Doctor Transition

By Shawn Vuong

These last two posts highlighting some of the medical education we would like to give through this blog to the general public, has had me look back on my extremely short medical career (currently in week 17).  

Healhcare reform is in the air, and from what I've read and heard about the morale of health care professionals, it is at an "all time low."  Many professors and physicians come in to teach us different topics, and many say, "It looks bleak out there, I hope you know what your in for."  

What worries me is the transition.  What happens to the altruistic medical student who wants to save the world?  What beats him/her into submission and makes them into bitter doctors? Is it the troubles we deal with during our residency training?  

A recent article by Dr. Edwin Leap makes me think so.  He calls out to all residents and interns as medicine's last hope.  It is inspiring and really heartwarming, makes me want to go out and save a life.  Hopefully I can keep this in the back of my mind for the rest of my hopefully long and fulfilling career.  

Be our hope, my friends!  Be the hope of medicine, the hope of the wounded parents and febrile children, the gasping elderly and the poisoned teens.  And learn to see all you do through the eyes of a higher calling.  That perspective, if you can develop it and hold tightly to it, will keep you happier than any political reform or paycheck ever could.

The Hot Toe

By Richard P. Holm MD

It was 1972 and I was a green sophomore med student spending my summer shadowing a doctor in Watertown. As soon as we walked into the patients room, my hero-teacher told me the patient was suffering from an acute attack of gout. 

The crusty old German doctor explained we were seeing the classic signs of inflammation. He said that the great Celsius, a physician living in the first century, described inflammation with four cardinal signs and the definition still applies. 

"In Latin it's rubor, calor, tumor, dolor," is what he said. "Commonly inflammation means infection, but in this case there is no infection. Rubor is redness, calor is heat, tumor is swelling, dolor is pain, and add to that loss of function." There it was, a red, hot, swollen, painful toe. And the patient said, "It hurts so bad I can't stand for my wife to look at it." 

The patient was a 45 year-old man with a tendency to drink too much, a prior experience of similar bouts of severe single joint inflammation, and he came from a family many of whom also experienced this same condition. He was moderately over-weight, quite sedentary, and was taking a water-pill for high blood pressure.

"This is the classic picture of gout," my teacher told me. "His body suffers from too much uric acid, partly because of dehydration from the water pill, partly because of his weight and lack of exercise, maybe a little from eating too much protein, but mostly because he inherited the tendency. Too much uric acid causes the formation of needle shaped crystals in the joint fluid, and then comes inflammation."

"We need to treat the inflammation first, and then later get at reducing the uric acid level, or he may destroy his joints, develop kidney stones and destroy his kidneys," he instructed.

The complex treatment of gout made our patient better. It was the perfect lesson from a great teacher.

Take home lesson:
1. Inflammation is characterized by redness, heat, swelling, pain, loss of function, and can be due to reasons other than infection.
2. Gout most often presents as recurrent episodes of a severely inflamed single joint, most often involving the big toe but it can effect other joints as well;
3. This condition results from the formation of uric acid crystals in joint fluid;
4. Gout can progress to destruction of joints and kidneys, so it needs proper treatment.

That All Important Shoulder

By Richard P. Holm MD

One moment I was jetting down the ski slope unbelievably free, on the edge of control. The next moment I saw a bare spot under a bunch of trees  right where I was headed, but I thought too late and was going too fast.

When my skis hit the dirt, I went for one of those head-over-heels flips, struck my right shoulder on an icy hard spot and, finally, came to a stop, a heap of body parts just like Beetle Bailey in an old comic strip.

When accidents happen like that, I find myself wishing in vain to go back five seconds and do that one differently. But of course there was no re-doing it. I felt a burning pain coming from somewhere near my right shoulder, and it was not subsiding.

The doctor in the emergency room examined my shoulder for rotator cuff injury by testing, with resistance, three movements: 1) bring bent arm with imaginary mug of coffee to the chest, 2) rotate the arm out again, and 3) with straightened arm to the side, empty the mug away from the body. Luckily my rotator cuff was fine.

He also reviewed the X-Rays with me and pointed out a separated shoulder blade-collarbone, or AC joint, which ties the arm and shoulder to the chest.

Days later, my orthopedic partner reassured me that although I had torn the AC joint, it wasn't unstable. The only real problem was that I should expect it to hurt for maybe six months, which it did. 

The whole experience helped me appreciate the sudden and long lasting consequences of a reckless choice, helped me empathize with others in pain from any cause, and helped me learn about the value of the shoulder and all its parts.

And it helped me to avoid those bare dirt spots too.

Take home message:
1. Accidents can happen in a flash, and can result in long lasting suffering. Therefore it is wise to make good choices to avoid accidents when possible;
2. The shoulder has many important parts, and because it is so very mobile, is also more at risk for becoming unstable if injured;
3. The three movements mentioned above test the Subscapularis, the Infraspinatus with the Teres Minor, and the Supraspinatus muscles.

Alcoholism

By Richard P. Holm MD 

There is good science showing a glass or two of wine per night protects against heart disease. But what can be helpful to some, can be poison for others. 

One study found 53% of people in the US have a close relative who has a drinking problem. At last count 17.6 million in this country are alcoholic or alcohol abusive. Alcohol excess causing auto crashes, homicide and suicide, liver-heart-brain-kidney illness, and brain damage to the unborn, costs the US about 185 billion dollars per year, not to mention incalculable human suffering. 

"Alcoholic" means four things: craving, can't stop, withdrawal symptoms, and needing more and more to get high. This is different from "abuse", which means a pattern of drinking which results in failed work or school responsibilities, driving while drunk, legal problems or social and family problems. Although separate by definition, many alcoholics also experience alcohol abuse.

The CAGE questions help identify when there could be a problem: C stands for "cutting down", A for "annoyed" be criticism about drinking, G for feelings of "guilt", and E for the "eye-opener" in the morning to steady nerves. One yes is worrisome, and two means someone needs help. 

There is a myth that alcoholism is a sign of moral weakness, and to seek help is to admit some type of shameful act. In fact, alcoholism is a disease like diabetes or asthma, and not a sign of weakness or ethical deficiency. 

Why is it that alcohol will take hold of some people, and not let go until it's destroyed their lives or the lives of those around them? We dont know the answer to that question but we do know is that if there is a problem with alcohol, there is help to be had. You just need to ask for it.

Ethics & Alcohol

By Shawn Vuong

Today, Dr. Craig Uthe, a Family Practice phsyician in Sioux Falls, came in to talk to the medical students during their Introduction to Clinical Medicine class.  The topic for the day was Substance Abuse in General Practice.  We learned lots about the addiction process, and the tough road through recovery.  

Most interesting to me was the dilemma brought up near the end of the class.

Lets say there is a man named Mr. Jones.  Mr. Jones seems like he works non-stop, and today he finally has a day off to catch up on some things around the house.  He gets up early, fixes that dripping faucet that needed fixing, enjoys a wonderful lunch with his wife and children, and plays some ball outside with his kids in the afternoon.  Later that afternoon, he decides the grass is looking a little long.  Mr. Jones gets out the old lawn mower and starts cutting grass.  About half way through, he grabs an ice cold beer and drinks the whole thing before continuing to mow.  At that moment, he gets a call from work.  Its an emergency, and he needs to come in right away.  

Now lets say Mr. Jones is a maintenance man at the local hospital, and the power is cutting out in one wing of the little hospital.  Does the fact that he had a beer effect his work?  Should he be coming into work at all?

Now lets say Mr. Jones is actually Dr. Jones, and he is coming into the local hospital to deliver your baby.  Does the fact that he had one beer effect whether or not you want him to deliver your child?  Should he have been called in at all?  

Tough Questions About Death & Dying

By Shawn Vuong

In Dr. Holm's latest post, "When Should the Heart Stop Beating," some interesting questions are brought up.

1. When is a patient too old or too sick to receive expensive procedures?
   
2. How can we pay for expensive healthcare for so many people?
   
3. If we take away the "easier death" of an abnormal heart rhythm, how will people die?

These are extremely difficult questions, that I do not think many people are ready to discuss. But these are important topics for families, and are a hot topic in medicine. 

One factoid that has been cruising around the medical blogosphere for quite sometime now, is that 5% of our population spends approximately 50% of our healthcare dollars.  How can this be?  Some believe it is all of the expensive treatment we utilize at the end of life.  This time is a very difficult for the family, they may want everything done for their loved ones, when its obvious to the clinical team that there is just not much more anyone can do.  But more often then not, the clinical picture is in a "gray area."  How does a doctor decide that the act of performing surgery or giving the treatment may be worse for the patient than the benefits gained?  The Happy Hosptalist sums up the cost effectiveness of this problem quite nicely.   

How do you make a decision on how aggressive to be? We all want to sit here and say that age should not be an independent predictor for making medical decisions. I ask why shouldn't it be. Why should we not employ age in the equation of resource allocation. Let me ask you this:

Would you put a $30,000 defibrillator into a 60 year old patient with sudden cardiac arrest due to ventricular tachycardia and concurrent colon cancer with metastatic lung and liver lesions? How about a $5,000 pace maker? If you would, why would you. If not why not? What would be the basis of your decision? These are clinical decisions that are made every day. Judgement calls by medical professionals. You can't write guidelines for this stuff. Some doctors lose site [sic] of the big picture and do things to patients because they can. Because they lose sight of the big picture.  And sometimes, when you focus on the nail, it's just easier to ignore the house falling apart around you.

As a patient and a family member, you may be thinking "Why do these costs even matter? We want everything done for me (or my family member) because that's the right thing to do."  Researchers at Dartmouth argue that more interventions and aggressive treatment do not necessarily prolong patient's lives, and by doing less you may be "sparing patients the agony of unnecessary tests and reducing the risk of hospital borne infections."

The end-of-life decisions are not decisions for cost-effectiveness, insurance companies, or even doctors to make.  The patient and their family ultimately have to decide what is the best route for them. But I hope families realize, they can let their loved ones pass away with peace and dignity without demanding every possible intervention. 

The Picture of Health: A View from the Prairie

Just in time for holiday give giving.  A new book of highly informative medical essays by "On Call"  Dr. Rick Holm, Avera Brookings Medical Clinic, with accompanying photogaphy by Dr. Judith Peterson, Sodak Rehab, Sioux Falls.

A masterful work that will make a wonderful addition to your library, coffee table or patient Waiting Room...

"Wow, what a book! A mix of wisdom, beauty, practicality, and valuable insights into health and medicine."

-- Neil Shulman, MD, author of "Doc Hollywood," Associate Professor, Emory University School of Medicine

When Should the Heart Stop Beating?

By Richard P. Holm MD

In the end, we will all die of something. As a guy who has to fill out death certificates, it is interesting that when the cause of death cannot be defined I find myself stating that the person died of heart disease. Think about it, even when the ultimate reason is due to cancer, stroke, pneumonia, or a motor vehicle accident, when a person gets sick enough from anything, ultimately the doctor calls them dead when their heart stops beating.

Recently at a medical meeting I listened to a cardiologist speak about just that issue. He explained about the implantable cardioverter defibrillator (ICD). The device is a small-computerized battery buried under the skin, which is connected to the heart with a wire. It monitors the heart rhythm and automatically triggers the heart when the beat is too slow, or shocks it back to normal rhythm when the heart goes too fast. 

He explained we should be providing this for many more people than who are presently receiving it. He didn't tell us that the cost for putting in an ICD is roughly $50,000, and it needs replacement every 3-5 years.

It is pertinent that the very next lecturer spoke about health care costs. We listened in dismay about the ever spiraling out of control cost of health care. The expert explained that our country soon would no longer be able to pay for "everything for everybody right now". In order to provide for reasonable and basic health care for everybody, she explained we would have to limit some of the stuff that is so very expensive, especially when the value and benefit to the individual is minimal or unproven. 

The presentation was well received by the room full of doctors, and yet the real and scary future task of determining who gets what care when resources are limited, left us all uneasy.

The back-to-back lectures left me with several questions. When is the patient too old, or too sick to get one of those devices? How can we afford such a thing for so many people? And if we take away the easier death of an abnormal heart rhythm, then how will people die? These are tough questions, and we need to talk about them.

Take home message:
1. We have fabulous life-saving devices that can keep people alive when they shouldn't die.
2. How do we know when it is time to let people die?

The Effect of the Placebo

By Shawn Vuong

I find it extremely interesting that Dr. Holm would bring up the power of faith and hope in the relief of pain and suffering, so closely to the article the British Medical Journal recently published about placebos.  

The study found that nearly half of the physicians that responded claimed that they regularly prescribed "placebos" to their patients.  So any reasonable person should be asking themselves, 'Hey what's going on here?  These doctors sound like their engaging in some pretty shady behavior that could be effecting my health!'  

The New York Times also got wind of this journal article, and they question the ethical findings of the study's results.  A solo-family practice doctor thinks this maybe the media's "Gotcha Style" journalism at work.  The doctor points out that the survey in the BMJ study didn't use the word placebo even once.  

Kevin MD also stated that the effect of placebos can be very powerful, "however ethically incorporating the power of the placebo effect in everyday medical practice remains a challenge."

I believe that the faith that the patient has in his/her provider is just as important as the actual treatment.  While placebos have shown that they can have strong effects on many illnesses, this makes me question the real value of some medications.  Also, this brings up some questions about treatments.  Can some illnesses be cured through a mind over matter technique?  If so, do alternative medical therapies take advantage of this idea?  How does the traditional practitioner take advantage of this mindset?  Hopefully, it is not only through prescribing placebos.  

An Autumnal Festival of Faith and Hope

By Richard P. Holm MD

There is a very old Greek, then Roman, then Christian story of three pre-teen girls: Faith, Hope, and their younger sister Charity. They were tortured and killed with their mother while traveling along an early Roman highway. This apparently became the reason for an ancient yearly autumn festival to celebrate faith and hope in the face of suffering. 

The relief of suffering certainly was about the most important job of those first Greek physicians, and it remains so for physicians today. What's more, we are still using some of the same medicines they used back then, with opium-based narcotics to dull the pain of illness and injury.

We now know more about these important morphine-like pain relievers. Scientists have discovered that narcotics work by attaching to special pain relieving receptors in the brain, and we know that our brain makes its own pain relievers, called endorphins, when the occasion calls for it. 

We have even discovered an antidote to narcotic overdose called naloxone (Narcan), which works by displacing or pushing narcotics off from opiod receptors in the brain. I remember a big burly fellow, in a city hospital emergency room years ago, who was almost not breathing from what we presumed was heroin overdose. Right after I injected the naloxone, he came up almost off the table to try to choke me. I think he was angry for losing his "high".

One study about pain relievers has always intrigued me. In analyzing medicines for the relief of pain following childbirth, they found codeine gave about 80% relief, aspirin 70%, and placebo (a sugar pill) 60%. The amazing finding came when they gave naloxone to the patients receiving pain relief provided by a sugar pill (placebo) and it brought back the pain. 

How about that! Not just morphine, but also faith and hope work by providing pain relief through turning on the endorphin system, which we can measure and even reverse.& So when they say, "it's all in your head" you know that's the truth. 

Thus, in understanding narcotics and something more about Faith and Hope, we are better equipped to relieve suffering.

Take home message:
1. An autumnal festival of faith and hope came from an ancient story of suffering;
2. Narcotics have relieved suffering for thousands of years;
3. All kinds of narcotics and even the pain relieving effects of a placebo sugar-pill are reversible with a narcotic antidote or antagonist named naloxone;
4. Having faith and hope that a medicine will work is an important part of providing pain relief.