medical *
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No analgesics needed in last 24 hours. I've accepted that I am dependent upon steroids, at least for now, and probably forever. My life quality has been excellent in the past day.
My sister Suzanne and brother-in-law Ed arrived on Saturday for a visit and we have been eating some wonderful Burmese curries and noodle dishes thanks to Jasmine.
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| Morro Rock. 46 Acre footprint. About 475' high. |
Drug Interaction Guidelines: At the beginning of 1974 I was at work on a book for consumers to help avoid drug interactions. I had sent a draft to Lippincott who wrote a gushing letter of encouragement but sent no money and made no promises. Well false hope is better than none, right? Isn't that a message being offered by a number of organizations in this world? As 1974 began, I was hard at work writing this in my spare time.
A Novel: Willing to do almost anything to avoid actually having to pick up a stethoscope and go to work, I had been developing a novel for several months. The idea came from a site visit that I made in 1973 to a environmental biochemist. He was showing me some typical gas chromatograph data from "normal" citizens. I asked him about a very prominent spike. He related to me that it was Phthallic Anhydride
He informed me that this compound was ubiquitous in the industrial world and that exposure to plastics such as auto trim and buffering resulted in inhalation of the compound and its presence in the blood. It was considered to be inert. The idea for the novel was an assumption that there could be infectious agents that would interact with pthalic anhydride with ill effects discovered by a real-time disease/diagnosis monitoring system. Trying to write this greatly increased my admiration for Michael Crichton. (To see his ability to explain complex systems, try Airframe.)
Thinking About Health Care Delivery Systems: While working for Dr. Waxman I had the opportunity to visit and speak with the advance guard who were creating new organizations for health care delivery around the United States.
The most charming was a young internist from Boston, named Jerry Grossman, M.D., who had a contract with Waxman and with whom I spent several hours at various times including a memorable evening with him and his wife and a walk to see Arthur Fiedler.
The most charming was a young internist from Boston, named Jerry Grossman, M.D., who had a contract with Waxman and with whom I spent several hours at various times including a memorable evening with him and his wife and a walk to see Arthur Fiedler.
In an era where people were thinking in terms of being able to absorb and display a patient's complete medical record, Jerry asked a simple question. "Eric, don't you think that you could practice pretty good medicine if you just had the patient problem list and current medication?" Yes, you could! He pointed out that the initial expectation for an automated record should pay careful attention to the "medical decision-making value" of what would be stored and transmitted. He was way ahead of the game.
This got me thinking about medical records themselves for the next year. Let me digress and discuss the current paper medical record. These are generally ass-covering treatises that are attempting to defeat the anticipated future scrutiny of lawyers. For more than 20 years I have worked in prisons. You would be amazed at the weight of these monsters.
The problem with these big records? Who has time to read them in a 10-15 minute office visit? Mixed in these tomes are important data, like drug allergies, and chaff, like information about the patient's bowel habits when confined in a lock-up 2 years prior. Most data is treated as equally important and gets carried along. Important stuff eventually gets lost in the increasing pile of useless, lawyer-intended bullshit.
A part of me believes that the useful medical record should never be more than 1 page...the one page could be used as an index to more detail about prior incidents of illness...but the page should start with the problem list, current medications, and other essentials. (I have some ideas about how one might best display an electronic medical record using the technology of the WEB as the foundation and if any developers are interested, send me a comment and I'll share.)
Most physicians will review thousands of pages of medical data only under duress, or when paid by the hour by malpractice attorneys to do so. But we could develop the expectation that every physician be responsible for knowing the content of the 1 page medical summary. Believe me, the medical visit would be a much safer adventure if data were organized in this fashion.
Jerry Grossman was involved with the Harvard Community Health Plan, one of a series of HMOs that came on line in the late 60s and early 70s as the Nixon administration attempted to promote HMOs. He had a strong technology background, was heavily involved in electronic record systems, and was constantly thinking about the purpose of information.
The Technology Division's favorite HMO was the Matthew Thornton Health Plan and its founder, Jim Squires, who was breaking new ground in medical practice. Generally surgeons are the high earners in medicine. In the current market, $500K to $1000K per year would not be an outrageous estimate of superstar surgical subspecialist earnings.
Squires was a surgeon who decided to associate with the low earners in medicine, the pediatricians and family physicians. They formed a group and began delivering high quality medical care. I think that their first office was in Nashua, although they are currently headquartered in Manchester. Instead of aiming for the bigger bucks of fee-for-service surgery, Squires used his extensive surgical skills on a salaried basis--quite a sacrifice. I wonder if a Herman Cain would have jumped at that chance!
Squires was a surgeon who decided to associate with the low earners in medicine, the pediatricians and family physicians. They formed a group and began delivering high quality medical care. I think that their first office was in Nashua, although they are currently headquartered in Manchester. Instead of aiming for the bigger bucks of fee-for-service surgery, Squires used his extensive surgical skills on a salaried basis--quite a sacrifice. I wonder if a Herman Cain would have jumped at that chance!
There are medical doctors, those of us who have acquired the M.D. degree and have gained state sanction to "practice medicine." Then, there are physicians...I'd say less than 20% of doctors.
Patients are said to judge doctors on the 3 A's. Availability, Affability, and Ability in that order. The doctor's ability to market himself is a key factor in success as measured by income. After all, this is America.
So, by 1974 I had been exposed to the current computer technologies in health care delivery, I had spoken with more than a hundred good minds who were out there trying to make things better, and I was sitting at a desk in Rockville, Maryland with access to an amazing library and I was keenly interested in how one would optimize the use of medical resources to promote health in a small general practice.
There was quite a bit of information about this in the British system. They had been struggling with a National Health Service for many years that attempted to remedy the problems of access to care for their population. It had meant a cap on doctors' pay and created an exodus of excellent physicians to the U.S. where pay was much better. However, the country was divided into "panels" of patients which were to be served by a single General Practitioner. The General Practitioner was to be community based and to remain outside of the hospital. When patients were too ill to be cared for in the community, they went to the hospital for care by specialists until they were able to be discharged back to care in the community.
The General Practitioner was expected to keep a chronology of visits and services provided for each patient. In the United States at the same time, you would have been surprised at the number of 8x5 index cards that were lined and used for the same purpose. There might be a one or two line entry such as
01/03/71 Cough, URI, no sputum, no pain, red pharynx lungs negative -- Fluids, ASA, rest
to describe a probable viral URI which was treated simply with fluids and rest.
However, a General Practitioner in Britain was also expected to track this visit in another way. There were logs for the more common diagnoses, particularly chronic illnesses such as hypertension, diabetes, nephritis, etc. If patient "Ian Hearst" was diagnosed with diabetes, then Ian's name or record number should also appear on a ledger entitled Diabetes.
Over time, it was possible for the GP in Britain to pick up the Diabetes ledger and quickly identify every patient in the practice who had the illness.
It was also possible for the GP to pick up the Birth Control Ledger and identify those women who had taken birth control pills during the past year.
If the National Medical Council wanted to study blood clots in women using oral contraceptives, the GP ledgers, called the EBook, had already identified the population to be studied. It was possible to use this very basic data as input to research about medical practice.
I Was Running Out of Options
In late spring 1974, Consumers Report called me about my book and asked me to come to New York to meet with their two medical advisors. Although they had a drug publication, it was much less ambitious than what I was trying to do with mine--to actually inform about specific common side-effects and drug-interactions for the 200 most commonly used prescription medications in the United States.
Molly and I drove up together and stayed in a nice hotel. The Consumers Report crew took us out to a fancy lunch and then they asked me the bombshell question while we were in a cab heading back to their conference room.
"What do you think the effect of a book like yours will have?" My answer was that it would do a few things. It might avert some illness and injury, maybe even some deaths. It might allow patients to question some of the doctor decisions about drug selection. Finally, it might increase the probability of certain kinds of lawsuits." The word "lawsuit" appeared to have an instantaneous negative effect on the medical advisors-- I came to the meeting thinking we were all consumers in consumer reports--that it was reasonable to expect doctors to understand the basics of what they were prescribing. We continued the discussions back at their headquarters but there was no longer any sense of camaraderie. The moment of possibility had passed.
So I wasn't going to have a long running book project for work. Strike One
I had sent out my novel to a few agents, none of whom were interested. Strike Two.
I had become too cynical about things like NIH Study Groups being old boys networks that made it harder for new researchers to enter the field without indenturing themselves to the existing people already funded at the trough. Was this any different than joining the military while knowing full well there was no personal danger to me but that I was assisting the government to endanger others? Long foul ball.
Finally, ball one, a consulting job with Opportunity Systems Incorporated, a minority business contractor.
I loved working for George the owner of Opportunity Systems Incorporated (OSI). At that time, a certain percentage of Federal contract work was "set aside" for minority companies--an attempt to right the previous wrongs and to give these companies an opportunity to develop a stable workforce and to build the necessary relationships within government for future successes.
So, Eric, recovering racist that he was trying to be, became the Token White Boy Physician for a contract that OSI had with the Bureau of Food in the FDA. The project was the standardization of the sanitation inspections within the restaurant industry. The Bureau of Food wanted to be able to compare sanitation levels in California with those in Oklahoma and other states. To encourage states to join such a cooperative venture, the FDA had agreed to take on the cost of the development of a standardized reporting form and a data base for reporting out sanitation inspection results. It would just give the capability to any state that wished to have it.
It was an interesting few months. OSI was a small company with a work force exceeding 90% African American. It was a pleasant working environment. Very little bitching. People didn't bring their troubles to work, and there were several very bright black technical experts and computer programmers. My role was quite limited, generally face to face meetings with health department directors in the few key states.
I made a deal with George and worked with his team on a few other proposals for contract work with the Feds with the agreement that he would employ me on contracts that were awarded. None were and we parted ways in mid-summer.
Ball 1, Strike 2. I left the Federal Government and cashed out my retirement account. There were some savings left from the previous 18 months of work and Molly was advancing well in a Survey Research Company. But I would have to start earning.
It had been four years since I had completed my internship and I had done no clinical work in almost two years. My last protracted stretch of writing computer code had been 1969. I may have learned a lot about theories of health care delivery, but my knowledge base for doing the actual doctor work was declining. I either needed to start doing medicine or to think about getting more training.
However, I am living in West Virginia in a county with a shortage of primary care physicians. I already own a house. I live about 20 minutes from the hospital. Maybe this is where I should open an office?
Scoping Out Medical Practice. Planning.
I was still fairly comfortable with my knowledge of emergency medicine. I had handled an emergency room caseload of 200 patients a week for 26 weeks of internship. I had seen more than 5000 patients come through those doors with a variety of emergent problems. So, I should be able to handle the day to day stuff.
What about the medical process? How does that work with a patient? I had been doing some thinking about this as well. If you look at the medical encounter, the patient becomes aware of a problem and eventually decides to consult a doctor. Let's say things go well, that a diagnosis is possible and that the patient believes that the doctor really has gotten to the bottom of the problem and has told the patient that a prescribed treatment plan will likely make things better. The patient then leaves the office. At this point one might say that nothing has really happened that is likely to make the problem go away. The patient must believe in and/or follow the treatment plan. After the medical interview, the burden falls upon the patient to do the necessary work, to take the necessary chemicals, etc.
Well, we know from studies that patients are unlikely to remember the treatment plan. And if there is an economic barrier to purchasing the necessary medication, any essential chemical treatment will languish as well. If this is not addressed, the whole visit is wasted.
So, for the twenty most common types of problems seen in medical practice, I must have written treatment plans that patients can carry away from the encounter and refer to at a later time. Patient Education! I will need a mimeograph machine.
Likewise, patients must be able to afford their medication. Generic medications are generally less expensive. Where possible and it is almost always possible, use generic medications.
For non-generic medication, particularly those expensive pediatric antibiotic suspensions, patients must know how much the drug is going to cost. Costs can vary according to drug store. Therefore, we need a list of the most common drugs and their costs at various pharmacies in the area.
The most good that I can do for patients is to make sure that immunizations are up to date. I call the health department. They will provide me with vaccines if I agree to keep a record of patients receiving the vaccine and if I agree not to charge patients for vaccines provided to me. I tell the health department, I will charge $1.00 for supplies and labor for each vaccine used but will not make any additional charges. They agree to that.
The second most good that I can do for patients is to screen for lifestyle variables and chronic illness. I can do this within a good medical history. I research several forms of medical history and rewrite one for about the 4th grade reading level. I can use that mimeograph machine to make history forms where patients can circle answers, fill in blanks, and write little summaries.
Once I can identify a chronic illness, I want the English EBook...an inverted list that allows me to go to a particular diagnostic entity and identify each of my patients with that condition. There is already plenty of data that indicates that more than 50% of people identified with hypertension are not taking sufficient medication and/or other treatment to reduce the pressure to desired levels--and these are patients seeing internists and cardiologists. Even in a general practice, it will make sense to look closely at blood pressure control. For those in whom regular treatment is ineffective in reducing pressure, the amount of treatment will need to be increased. Maybe it's just more medicine needed. But maybe the patient needs a little more motivation. Something to think about.
Finally
And so in a period of about 12 weeks, I put together the nuts and bolts of my first medical practice, using what knowledge I had acquired in the previous few years sitting in clouds in Rockville, Maryland in the National Center for Health Services Research.
Wow! A long time ago. I'm not sure if I were a bigger fool then or now. But it sure turned out to be a long step down the mountain from our little A Frame to a medical practice in Charles Town and Ranson, West Virginia.
-------------------------------------------
There was quite a bit of information about this in the British system. They had been struggling with a National Health Service for many years that attempted to remedy the problems of access to care for their population. It had meant a cap on doctors' pay and created an exodus of excellent physicians to the U.S. where pay was much better. However, the country was divided into "panels" of patients which were to be served by a single General Practitioner. The General Practitioner was to be community based and to remain outside of the hospital. When patients were too ill to be cared for in the community, they went to the hospital for care by specialists until they were able to be discharged back to care in the community.
The General Practitioner was expected to keep a chronology of visits and services provided for each patient. In the United States at the same time, you would have been surprised at the number of 8x5 index cards that were lined and used for the same purpose. There might be a one or two line entry such as
01/03/71 Cough, URI, no sputum, no pain, red pharynx lungs negative -- Fluids, ASA, rest
to describe a probable viral URI which was treated simply with fluids and rest.
However, a General Practitioner in Britain was also expected to track this visit in another way. There were logs for the more common diagnoses, particularly chronic illnesses such as hypertension, diabetes, nephritis, etc. If patient "Ian Hearst" was diagnosed with diabetes, then Ian's name or record number should also appear on a ledger entitled Diabetes.
Over time, it was possible for the GP in Britain to pick up the Diabetes ledger and quickly identify every patient in the practice who had the illness.
It was also possible for the GP to pick up the Birth Control Ledger and identify those women who had taken birth control pills during the past year.
If the National Medical Council wanted to study blood clots in women using oral contraceptives, the GP ledgers, called the EBook, had already identified the population to be studied. It was possible to use this very basic data as input to research about medical practice.
I Was Running Out of Options
In late spring 1974, Consumers Report called me about my book and asked me to come to New York to meet with their two medical advisors. Although they had a drug publication, it was much less ambitious than what I was trying to do with mine--to actually inform about specific common side-effects and drug-interactions for the 200 most commonly used prescription medications in the United States.
Molly and I drove up together and stayed in a nice hotel. The Consumers Report crew took us out to a fancy lunch and then they asked me the bombshell question while we were in a cab heading back to their conference room.
"What do you think the effect of a book like yours will have?" My answer was that it would do a few things. It might avert some illness and injury, maybe even some deaths. It might allow patients to question some of the doctor decisions about drug selection. Finally, it might increase the probability of certain kinds of lawsuits." The word "lawsuit" appeared to have an instantaneous negative effect on the medical advisors-- I came to the meeting thinking we were all consumers in consumer reports--that it was reasonable to expect doctors to understand the basics of what they were prescribing. We continued the discussions back at their headquarters but there was no longer any sense of camaraderie. The moment of possibility had passed.
So I wasn't going to have a long running book project for work. Strike One
I had sent out my novel to a few agents, none of whom were interested. Strike Two.
I had become too cynical about things like NIH Study Groups being old boys networks that made it harder for new researchers to enter the field without indenturing themselves to the existing people already funded at the trough. Was this any different than joining the military while knowing full well there was no personal danger to me but that I was assisting the government to endanger others? Long foul ball.
Finally, ball one, a consulting job with Opportunity Systems Incorporated, a minority business contractor.
I loved working for George the owner of Opportunity Systems Incorporated (OSI). At that time, a certain percentage of Federal contract work was "set aside" for minority companies--an attempt to right the previous wrongs and to give these companies an opportunity to develop a stable workforce and to build the necessary relationships within government for future successes.
So, Eric, recovering racist that he was trying to be, became the Token White Boy Physician for a contract that OSI had with the Bureau of Food in the FDA. The project was the standardization of the sanitation inspections within the restaurant industry. The Bureau of Food wanted to be able to compare sanitation levels in California with those in Oklahoma and other states. To encourage states to join such a cooperative venture, the FDA had agreed to take on the cost of the development of a standardized reporting form and a data base for reporting out sanitation inspection results. It would just give the capability to any state that wished to have it.
It was an interesting few months. OSI was a small company with a work force exceeding 90% African American. It was a pleasant working environment. Very little bitching. People didn't bring their troubles to work, and there were several very bright black technical experts and computer programmers. My role was quite limited, generally face to face meetings with health department directors in the few key states.
I made a deal with George and worked with his team on a few other proposals for contract work with the Feds with the agreement that he would employ me on contracts that were awarded. None were and we parted ways in mid-summer.
Ball 1, Strike 2. I left the Federal Government and cashed out my retirement account. There were some savings left from the previous 18 months of work and Molly was advancing well in a Survey Research Company. But I would have to start earning.
It had been four years since I had completed my internship and I had done no clinical work in almost two years. My last protracted stretch of writing computer code had been 1969. I may have learned a lot about theories of health care delivery, but my knowledge base for doing the actual doctor work was declining. I either needed to start doing medicine or to think about getting more training.
However, I am living in West Virginia in a county with a shortage of primary care physicians. I already own a house. I live about 20 minutes from the hospital. Maybe this is where I should open an office?
Scoping Out Medical Practice. Planning.
I was still fairly comfortable with my knowledge of emergency medicine. I had handled an emergency room caseload of 200 patients a week for 26 weeks of internship. I had seen more than 5000 patients come through those doors with a variety of emergent problems. So, I should be able to handle the day to day stuff.
What about the medical process? How does that work with a patient? I had been doing some thinking about this as well. If you look at the medical encounter, the patient becomes aware of a problem and eventually decides to consult a doctor. Let's say things go well, that a diagnosis is possible and that the patient believes that the doctor really has gotten to the bottom of the problem and has told the patient that a prescribed treatment plan will likely make things better. The patient then leaves the office. At this point one might say that nothing has really happened that is likely to make the problem go away. The patient must believe in and/or follow the treatment plan. After the medical interview, the burden falls upon the patient to do the necessary work, to take the necessary chemicals, etc.
Well, we know from studies that patients are unlikely to remember the treatment plan. And if there is an economic barrier to purchasing the necessary medication, any essential chemical treatment will languish as well. If this is not addressed, the whole visit is wasted.
So, for the twenty most common types of problems seen in medical practice, I must have written treatment plans that patients can carry away from the encounter and refer to at a later time. Patient Education! I will need a mimeograph machine.
Likewise, patients must be able to afford their medication. Generic medications are generally less expensive. Where possible and it is almost always possible, use generic medications.
For non-generic medication, particularly those expensive pediatric antibiotic suspensions, patients must know how much the drug is going to cost. Costs can vary according to drug store. Therefore, we need a list of the most common drugs and their costs at various pharmacies in the area.
The most good that I can do for patients is to make sure that immunizations are up to date. I call the health department. They will provide me with vaccines if I agree to keep a record of patients receiving the vaccine and if I agree not to charge patients for vaccines provided to me. I tell the health department, I will charge $1.00 for supplies and labor for each vaccine used but will not make any additional charges. They agree to that.
The second most good that I can do for patients is to screen for lifestyle variables and chronic illness. I can do this within a good medical history. I research several forms of medical history and rewrite one for about the 4th grade reading level. I can use that mimeograph machine to make history forms where patients can circle answers, fill in blanks, and write little summaries.
Once I can identify a chronic illness, I want the English EBook...an inverted list that allows me to go to a particular diagnostic entity and identify each of my patients with that condition. There is already plenty of data that indicates that more than 50% of people identified with hypertension are not taking sufficient medication and/or other treatment to reduce the pressure to desired levels--and these are patients seeing internists and cardiologists. Even in a general practice, it will make sense to look closely at blood pressure control. For those in whom regular treatment is ineffective in reducing pressure, the amount of treatment will need to be increased. Maybe it's just more medicine needed. But maybe the patient needs a little more motivation. Something to think about.
Finally
And so in a period of about 12 weeks, I put together the nuts and bolts of my first medical practice, using what knowledge I had acquired in the previous few years sitting in clouds in Rockville, Maryland in the National Center for Health Services Research.
Wow! A long time ago. I'm not sure if I were a bigger fool then or now. But it sure turned out to be a long step down the mountain from our little A Frame to a medical practice in Charles Town and Ranson, West Virginia.
-------------------------------------------
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| I will miss seeing this face. You are so lovely, dearest. |
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