Those Journals Keep Coming

More than a year has elapsed since retiring.  My two state licenses remain active.  My professional liability policies do not so I have no interest in seeing patients.  Yet being a doctor is more than seeing patients.  Sometimes keeping the patients as inviolable top priority displaced other opportunities.  Now, no patients, but no research prospects, teaching, or committees either.  I am left with my knowledge and accumulated insight.  It can no be expanded for its own sake.

Currently I have two paid subscriptions, the New England Journal of Medicine and the Journal of Clinical Endocrinology & Metabolism.  The former comes weekly with a handful of articles.  I read all titles, abstracts of interest, and at least two articles ranging from core research to opinion.  I've largely stayed on track.  The JCEM arrives monthly.  It is bulky, fewer reviews, largely studies more appropriate to research groups doing similar investigation, but with clinical studies that are sometimes intriguing, more often pedantic.  It comes as part of my Endocrine Society membership.

Everything else is a freebie.  Mayo Clinic Proceedings, Cleveland Clinic Journal which is mostly topic reviews, JAMA Endocrinology, Lancet Endocrinology, and a couple of newspaper sized publications but glossier that have mostly news reports of current research or opinions of experts who seem to be interviewed by journalists.

All are available electronically but the only one I read that way is sometimes the NEJM. 

Clutter can get out of hand.  The ones I pay for stay for a year, the other journals three months, the newspaper sized publications the current and previous months.  They are recyclable.  I don't think I've ever retrieved one from the storage box to read it.  When I want to retrieve anything from the NEJM, I do it electronically. 

By now I know what I like to read, brief reviews, case of the week, and opinions on the experience of being a doctor.  For their own sake.

Medicare for All?

Among my Osher Institute classes has been a discussion session each week going on two semesters.  Topics vary as does level of expertise of the presenter and the presentation.  A medical professional, not physician though highly experienced in systems of medical care, selected Medicare for All as the topic.   It has made a ringing slogan for some political candidates, who I think really mean universal health coverage for all Americans, which expands the possibilities to a lot more than Medicare.  When Medicare took effect initially it replaced nothing other than some retirees having health insurance from their union or company pension.  It was also opposed by some important physicians organizations whose credibility never recovered.  Seniors and disabled people needed care that they couldn't pay for which means either they skipped what would be elective or their doctors and hospitals did not get paid for doing what could not be omitted.  It worked out well for the beneficiaries, for the practicing doctors, for the doctors in training, and for medical institutions.  The taxpayers did less well and the crystal ball gazers know the day of insolvency will come.

While Medicare beneficiaries are fairly secure except for prescription drugs which have supplanted a fair amount of surgery, and those workers or employers don't seem to mind their allotted contributions, most of the population is on the paying end.  If Medicare payments to providers do not adequately compensate the care given, then the cost gets shifted with higher payments from commercial plans and higher premiums or deductibles.  And we have a lot of Americans left out in the cold, people who may as well replace those seniors from the 1950's who could not forgo medical care but had no means of paying for it.

Most places around the world have bitten the bullet, offered universal medical benefits to their inhabitants, got some semblance of quality by accepted measures, and pay a lot less per individual than American aggregate costs, which don't cover everyone.  Medicare expansion sounds good.  An equitable system, something people are used to either for themselves or parents, and predictable if not economical cost.  Not a bad option if it didn't have to replace something, which is why some political candidates claim it as a promised initiative if elected.  However, it does have to replace something, and while uninsured or Medicaid or maybe even VA patients would do better, much larger numbers of people are already used to something else, often paid invisibly by employers supplemented by nominal payroll deductions that they never see.  Disruption never goes well, even when the status quo has a lot of room for improvement.  Siphoning off their care to create corporate infrastructure and profits does not register until the care fails, which it hasn't.

What struck me about the discussion with about a dozen Medicare age seniors of good intellect in the room was the shallowness of the understanding and the inability to articulate what they would want to accomplish.  From a patient perspective, it may be closer to VA or Medicaid for all though salaries would come from multiple employers.  Moving employees from their corporations to the Medicare rolls or people doing useful work for insurers to Medicare where the same work needs to be done but not necessarily by the same people or even the same number of people may not be worth the disruption.  And if everyplace else around the world has a process, the knowledge of those possibilities was non-existent, let alone how those places got from their starting point to where they are now.

The people in our room were 100% mullets but at least we have no influence on what happens.  The political candidates are also mullets and they can do a lot of harm.

While expertise has been gradually devalued, except maybe in the hi-tech world,this is one where people really need to defer to the experts who can examine other attempts,  determine intended upsides and downsides of multiple options, and pick one.  That's not a room of a dozen seniors and it's not a televised debate stage of ignoramuses seeking votes from other ignoramuses.

Intercepting the Asinine

My New England Journal of Medicine still arrives each week.  I pay for the subscription so I feel obligated to read two articles from it each week, roughly 100/yr, even in retirement.  They tend to be cases of the week or a review of something related to endocrinology, but I am as interested in the changes of how we practice, having lived through it.  One element that exploded during my final years as a clinician has been the number of directives and processes that differ from what an experienced physician would likely devise on his own.  Now, I may have gotten in on the ground floor of this, starting my post-residency career as a VA physician.  These guys didn't have the insight to allow me to receive a flu vaccine in my non-dominant shoulder.  One kabooby from the lab ordered, who didn't know what a patient looked like prior to autopsy, ordered that all the lab slips be placed in the chart without having been seen by the ordering doctor first, where they ended up in somewhat random order.  They used to transport World War I veterans 100 miles each way for their appointments, paying $700 dollars to the driver of a Ford Pinto that just squeaked by state inspection.  I had the transportation director price the cost  of a limo for the same trip.  For one-third of that, the old warrior could have travelled the breadth of New Jersey in style.  He would have to pay for what he took from the back seat bar, but if he drank too much, the VA would dry him out for free and hire the Pinto back to take him home.

On graduation to the university and private sectors, directives declined in number.  I am pretty hard pressed to come up with anything that matched the VA encounters.  Scheduling made sense.  Rules on charting were understandable.  We got our own parking spaces and as security became more important, ID tags enabled access to the places we needed to be to provide patient care.

And then came HITECH and the computer.  It all changed.  In an inner city area, it was common for patients not to keep appointments.  Any number of schemes were devised to either reduce the no-show rate or compensate for it, with scheduling bedlam when everyone came.  There was a directive to see everyone within seven days of discharge.  A schedule does not expand indefinitely, not everyone really needs to be seen sooner that three months by the consultant, and thinking about appropriate post-hospitalization is part of the competence that the residents are expected to acquire.  Meetings to discuss quality addressed non-problems to the neglect of what really needed more attention.

Intercepting the asinine seemed hopeless in this era of an expanded middle layer of managers charged with doing things that they don't really have the insight to do because they seemed like a good idea at the time.  Once there, they have a life of their own until the hospital is forced to reconsider by either legal allegations or loss of revenue.

It came as a welcome though unexpected surprise to learn that all elements of the inane did not have to become immortal.  A NEJM Sounding Board essay described an algorithm that can be computerized to identify and intercept the dysfunction, though not until it has become dysfunctional.

https://www.nejm.org/doi/full/10.1056/NEJMsb1900856

Based on importance, these mavens at NYU targeted processes that had no real basis but were intended to solve a problem.  If they didn't solve the problem, they were identified and sent back for rethinking.

Do we really need a computer algorithm for that or would a simple anonymous suggestion/complaint box suffice?  The big corporations probably addressed this decades ago.  A directive would come by or a customer would complain.  The VP's would hire people to address the concerns or deal with an external regulation.  Before you know it, you had people with significant salaries tweaking what would be better neglected.  Somewhere around the time of the 1992 election, they figured this out and pink slipped the capable high salaried people whose work wasn't worth doing.  Medicine has always lagged behind, which is why we are now being pummeled by insurers and product manufacturers.  They had their restructuring.  We have not.  If the algorithm really intercepts the many asinine processes imposed upon us, we might have a chance of catching up.

Harvesting the Old Office

It seemed like an essential need for space at the time.  Like many physicians or our era, by the close of the  last decade, a solo practice became nonviable.  Net revenues dropped far below what I could make as an employee, to say nothing of the burdens of operating the practice and investing in expensive computing capacity for what would likely be less than ten more years as an active physician.  An attractive job offer came my way and I accepted it.  After eight years in the new location I retired.

Ownership creates freedom, but it also creates expense.  A costly tail premium got paid.  Records went to storage with a monthly fee that became non-activity after about two years.  At the end of the legally required seven years retention, I arranged destruction, which priced at about another year's rental.  And twenty years of practice generates stuff, most of which could not be transported to my new digs.  As a result, my cleanout specialist recommended a nearby storage unit to house payroll records, old tax forms, a huge bookcase that cost $400 from IKEA, a laser printer, enough stationery to supply quite a number of poor children at back to school, a coat rack, and nearly 20 years of Franklin Planner refills in their annual storage binders.  The monthly fees came out of autopay so I didn't really notice it.  When I retired, more stuff from the final eight years belonging to me personally found it's way there.

One of the most stupid expenditures is to pay a monthly fee for stuff you don't want, which is virtually everything there.  Financial forms have passed their statute of limitations.  Our state will shred two boxes of paper a month, so I have become a regular at the site adjacent to the landfill the first Wednesday of every month.  Appointment and payroll logs gone.  Tax submissions now unreadable.  At the rate of three storage boxes a week, I should be done by year's end.  I can finally see the floor.  Copier cost $500 but it's bulky, missing a key tray and could be replaced for a lot less than I pay to store it.  Off to the state's electronic recycling bin.

Some stuff has personal value.  I had carefully wrapped a series of mugs in newsprint.  They are mementos, logos of my alma maters and places I visited with my son when we toured colleges.  I should be able to run them through the dishwasher and line them up for display in My Space.  I bought a big globe at a yard sale.  That will find a home in my house.  Along the way, I purchased three pre-insulin medical texts from book clearance sales.  Probably have little monetary value but tell me something about my medical roots.   Those come home.  And the big IKEA bookcase will fit just right in my bedroom, which never has enough shelf space.

There was a show on TV called "United Stuff of America", a series of mini-documentaries on how various usually unimportant museum artifacts summarize key events in history.  My son's college tour is in those mugs.  My interest in diabetes includes times before I was part of that care.  The countries on the globe were not there when I learned the geography of Africa at Kakiat Junior High School.  All moments of my adult life.  None worth a monthly storage fee.

Psychiatric Stigma

Among my courses at the Osher Lifelong Learning Institute is a weekly discussion group where each of the dozen participants is assigned a topic one week per semester to lead a discussion.  Medical related topics crop up, and even non-medical subjects often benefit from the expertise or experience of the doctors in the room.  One lady, now retired like the rest of us, was raised amid severe psychiatric illness with a father displaying bizarre and often controlling, paranoid behavior and the next generation including a sibling with a less clear diagnosis but chronic personal and social instability.  She is a survivor who could have escaped through bitterness but took a path empathy which has served her well, though from the discussion, maybe less efficacious for the two patients than it could have been.

Endocrinologists like myself are the most frequently consulted specialists in a psychiatric unit where the nursing staff cannot avoid bedside glucose monitoring and occasional lithium generated thyroid, calcium and electrolyte dysfunction.  All this needs to be coordinated with the psychiatric needs, always usually severe enough to require hospitalization beyond the 72-hour form #302 involuntary diagnostic commitment allowed by the Commonwealth of Pennsylvania with a subsequent length of stay, sometimes voluntary, sometimes court approved, that far exceeds length of hospitalization on other medical units.  I never saw any families there when I did my consultations and periodic follow-up rounds, though undoubtedly the psychiatrists and social workers would regard the impact on family as a core part of their medical advice.  I was shielded, making the discussion from a family perspective an interesting revelation for me.  I also have a medical perspective, noting what could have been many lost opportunities to achieve a better result for her father, her brother, and her family.  And as happenstance would have it, a review of schizophrenia, with a brief section on non-medical psychosocial support, appeared in the New England Journal shortly thereafter.

https://www.nejm.org/doi/full/10.1056/NEJMra1808803

As the doctor in the room among the dozen discussants in the room, my focus immediately gravitated to the medical, with some resentment on her part.  Like it or not, as the NEJM review indicates, the fortunes of these people depend on how well the medicines are managed, both their therapeutic benefits and the undesired effect.  If you pick up one end of s stick, you pick the other one up as well.  The obligation of the physician is first to the one designated as ill.  The family becomes a form of collateral damage, something to be addressed though not necessarily by the medical expert.  As she noted in her presentation, the medical community was not a reliable source of empathy or family repair.  These patients can function surprisingly well at the workplace, as her father did with a perceptive supervisor who minimized the employee's tenuous social interactions, focusing on productivity at work.  He supported a family economically for an entire career but inevitably the household lacks the resources of a medical institution or a major corporation so disruption emerged.

People with bizarre affect, socially marginal behavior, or atypical appearance get noted.  They also get avoided, and as my OLLI classmate noted, the close family gets avoided as well.  That aspect has not done as well as modern medical care.  She is a survivor, though not unscathed.  Her father has passed away, late life divorce for her mother's safety.  His death, found alone and unresponsive, took its toll on her, probably more than on him.  A sibling drifts along, unstable socially, managed professionally by the medical and correction communities, but leaving the lingering impression on her that her brother was basically written off for lack of the employable skills that her father had acquired that secured a better level of protection for him, if not for the other family members.

While the treatment of schizophrenia has advanced and the chronic psychiatric hospitals that functioned more as a warehouse have waned, the people are still amid the public, identifiable as outliers and largely avoided by those who do not have a direct professional or family responsibility for their welfare.  Good medical care, as her discussion noted, does not fix that.