Migraine Medicine

Sad, scary, and awful story about a tiger who somehow escaped from her cage at the SF Zoo, killing one person and seriously injuring two others. Everyone was taken to SF General, the only level one trauma center in the city.

From Med Rants, about retainer medicine:

I urge these authors and their ideological colleagues to look beyond the trappings. I urge them to perform a thought experiment. Why are patients increasingly willing to pay? Why are highly ethical physicians opting for this style of practice? If they are honest, they will find some truths that knee jerk opposition obscures.

Some might argue that these “highly ethical physicians” aren’t so highly ethical by practicing retainer medicine. One ethical framework would suggest if all physicians just practiced retainer medicine, there would not be nearly enough physicians to go around. In that framework, retainer medicine would be viewed as unethical.

(I also don’t really get how Dr. Centor combats the classist and racist arguments he brings up. They’re totally valid, and I can’t help but draw a parallel between retainer medicine and insurance company cherry-picking, the latter I find to be despicable in its bottom-line philosophy. By practicing retainer medicine, you are selecting out for people who can afford to pay extra, and health and SES are intrinsically linked (and also race), so you’re essentially picking out people who are already healthier. If you look at things through an equality and social justice lens, who needs a physician’s help more: the poor, smoking diabetic or the executive with an HDL of 39 who bikes 20 miles a day?) (I however absolutely agree with Dr. Centor that health care financing is a complete and total disaster in the US, but I would argue we need to fundamentally change the system–yes, with all the turmoil and terrible problems and growing pains it would cause–than work within it and continue to try piecemeal approaches we’ve been attempting since the 1970s.)

A woman with chronic syncope needing pacemaker placement worries about future costs for replacement pacemakers on Ask MeFi. Most posters suggest she move to Canada; one even offers to marry her.

What a mess. Classic example of someone who clearly couldn’t buy her own insurance–it’s doubtful anyone would cover her syncope condition, so she’d be paying hundreds of thousands of dollars over her lifetime for her “pre-existing condition.” Just one of the many problems with an individual mandate.

Don McCanne points me to To Great A Burden (PDF), a report by Families USA which analyzes data on health care expenditures, and finds some pretty scary numbers and trends (my emphasis below):

• More than four out of five people in families spending more than 10 percent of their pre-tax income on health care costs are insured.
• 50.7 million non-elderly Americans with insurance are in families that will spend more than 10 percent of their pre-tax income on health care costs in 2008.
• More than three out of four people (75.8 percent) in families spending more than 25 percent of their pre-tax income on health care
  costs are insured.
• 13.5 million Americans with insurance are in families that will spend more than 25 percent of their pre-tax income on health care
  costs in 2008.

My point? These are the insured we’re talking about. The people who we quickly call “the covered.” And it’s gotten significantly worse in only 8 years:

Wake up, middle class. You don’t want to risk health care reform when you’re satisfied with your care, but how long until you’re part of the insured millions of families spending 25% of their income on health care?

And wake up, political candidates (and bloggers) that support individual mandates or continuation of the hodgepodge mess of private plans we have here–with their lifetime caps and pre-existing conditions, even the insured here are getting the rationing everyone’s so scared of under some sort of national system.

• Found some interesting methodology in this article exploring alcohol usage interventions in the ED. (Heavy but non-alcoholic drinkers were found to have decreased their drinking at 3 months.) For everyone that qualified for the study, they asked them on a scale of 1-10 how ready they were to change some aspect of their drinking (10 being fully ready). But this score wasn’t really that important–it was to secretly get at the patient’s own underlying concerns about drinking, because here were the follow-up questions:
  • if 2 or higher, ask: “Why did you choose that number and not a lower one?”
  • if less than 2, ask pros and cons: a) Help me to understand what you enjoy about drinking? b) Now tell me what you enjoy less about drinking.

  I love it. If you answer anything but 1, you’re indirectly acknowledging that there might be something less than optimal with your drinking. If you answer 1, you ask people to volunteer their own ideas about what’s good and bad about drinking. It’s essentially a sneaky way to plant discrepancy and cognitive dissonance in a patient’s mind.
  Now of course, duh, this won’t work for everyone. Just thought it was a very clever way to force the patient to come up with his or her own ideas instead of casting that whole “You shouldn’t be drinking so much” light onto patients.

• The “normal” body temperature, 98.6 degrees F has a fever, according to the LA Times. Turns out we base good ol’ 98.6 on experiments using mercury thermometers from the 1800s, and that depending on your race, age, gender, and time of day, your temperature is probably a couple tenths of a point lower than that. (Personally it would have been nice had the writer mentioned in the article that a person doesn’t have a fever until 100.4 degrees or higher, to do a little patient education out there in La La land.)