The Red Button

I don't post all that frequently (yes yes, durr, that's obvious), so perhaps as a result of that, I try to make 'em count when I do. My rant about arguing with the Billing department at my old job related to a guy we were about to release on a blood thinner (the practice didn't want to pay for INR checks, because the guy was behind on his bill) got linked by the AAPA's Twitter presence, for example, and I liked how my own subjective view of a larger problem got some small and fleeting light shone on it. Swear words and all, btw, so good for AAPA on that one especially.

I'm presently in the midst of a kerfuffle with a family member about childhood immunizations. And I feel kind of bad, because this person is a pretty amazing parent, all in all, and the young kids involved are great kids. Their shots are all up-to-date as far as I know, and I miss those kids like crazy whenever I don't see them for a while.

But tonight this family member said something on Facebook about "wondering if (they) could trust the pharmaceutical companies and doctors" and about "finding the other side of the coin," when it comes to measles. To be fair, I was the one who brought up measles, quoting some statistics about how deadly a disease it used to be, as a way of showing that the 90-some percent immunization rate we have now is, y'know, generally a very good thing.

That's when Family Member trotted out an unsubstantiated claim that there have been "a lot of" recent sudden-death reactions from shots, among babies and little kids. And that's when I sort of lost it.

I get little clinical updates in my email inbox all the time. From my employer, from SEMPA, and from the various clinical resources I subscribe to and use online all the time. If there were a rash of deaths, linked to anything, I'd be hearing about it. Plus, as I said in response over Facebook, if there really was a problem that seemed to be linked to a vaccine, those big bad Pharmaceutical Companies would be pissing themselves over potential lawsuits, and pulling vials off the market so fast there would be little vial-shaped Looney Tunes-style clouds of smoke whenever we opened a box of the product. If you call them weaselly and profit-motivated (which by the way I wouldn't argue against), then you have to accept all the consequences of that, and see them through logically.

Along those same lines, when Family Member said that there were supposedly more deaths per year from reactions than there are from measles, I laid a logical smackdown: the whole reason measles deaths are so damn rare nowadays is because of the immunizations. You can't compare the post-innoculation mortality numbers from measles to the number of hypothetical, unproven deaths from the injection, without also factoring in the number of deaths that would happen if there were not immunizations. Apples to apples, please.

And so, thinking about how to explain this to a layperson, a good parent, a concerned citizen, and an intelligent person who just isn't used to thinking about this problem as the public health issue it actually is, I came up with the following scenario. Try it sometime on your vaccine-averse friends and family, and see how you do:

Imagine you are standing in a room. In front of you, on a console, there are two buttons, one red and one blue.

If you press the red button, ten little kids will die.

If you press the blue button, one hundred thousand little kids will die.

Put it like this, it's horrible and it's sad and it should never happen, but the right thing to do is pretty damned clear, right? You press the red button. You press the crap out of it, then you press it again to be sure the blue button won't somehow get pressed by mistake. And that's, in a sense, sort of how public health questions are/ should be/ need to be approached. It's a way of thinking that, thankfully, most people don't really need to engage in; we get to enjoy the illusion that these sorts of choices are only hypothetical, and beyond the reach of modern science and public policy. For people who really do work in Public Health, I imagine this discussion is even more maddening than it is for me, a humble Urgent Care Bear.

But wait, excuse me, I left out one very important part:

If you press neither button, a timer will count down from 30 seconds to zero, and then the blue button will be pressed anyway.

This, I think, is a pretty decent analogy for what a lot of immunization-averse parents are doing. The timer has a much, much longer countdown, but the basic idea is the same. Parents who want the best for their kids, don't know whom to trust, and can't possibly have all the facts they really would like to have in order to be 100.00% sure will often simply retreat from the conundrum, throwing up their hands in frustration.

And as a result, they don't press the red button, while not exactly pressing the blue button either. Which helps explain why, as a result, herd immunity has been declining slightly but measurably, and some medical practices are actually starting to refuse to see kids whose parents refuse to immunize.

Tick tock, guys, you need to make a choice. And again, the better one, or at least the less-horrible one, is to press the red button. That's obvious to just about anyone.

Ahh, but if that's true, then what's the problem? How does Jenny McCarthy (who for me, by the way, is most famous for being naked in Playboy when I was in my early 20s) get so much traction with her anti-vaccination propaganda? Why does my otherwise kind-hearted, smart family member treat the sketchy, anecdotal evidence as if it were as legitimate and relevant as the actual data?

As a parent, I understand this one far better than I understand it as a medical practitioner, and as a practitioner I understand it pretty well. It involves a subtle but important change to the first part of the rules:

If you press the red button, ten little kids will die. One of them might be your kid.

If you press the blue button, one hundred thousand little kids will die.

I honestly don't know what I would do. I know logically that saving 9,990 kids is a good and noble thing, and something I'd be proud to do. I know I'd probably sacrifice my own life to do it, if I had to, and that it would be "a good death," as Crazy Horse, the Klingons, and Batman would say. That's what I'd consider heroic, under most circumstances.

But to take the beautiful, amazing little kid that makes my days so rich, the one that adds so much that's good to what I've contributed to the world (and easily makes up for all the stupid stuff I've ever said or done out of fear or ignorance), and potentially just snuff out all the incredible, wonderful life she has ahead of her? Fuck you, buddy, this just stopped being interesting.

And that, of course, is how the argument works. How dare you even think about causing my kid harm!, people say, choosing not to acknowledge that crossing the street or driving to the park is far more dangerous.

But that's parenthood. We're programmed by Nature to be fierce protectors of our offspring. This is why I don't look down on people who have doubts about immunization, and I don't think people are necessarily being stupid when they don't immunize. (Yes, they are being stupid, actually, but it's stupid in a way, and because of something, that I empathize with.) People are being selfish, is what it is, and I empathize with that as well.

It's to our credit, in a weird way, that in the world we have made over time, we haven't had to make these kinds of decisions. We've done okay, as a society, because we don't need to make Sophie's Choice on any sort of a regular basis. We don't routinely give birth to four kids but only get to raise two of them past the age of 3 years old, anymore. We don't tend to die in childbirth all that often. We don't have any real first-hand experience, anymore, with polio or smallpox. So it's understandable that we're so very bad at thinking this way.

But all it would take is a couple of generations beyond the present argument, and I suspect we'd regain the kind of clarity we would need. I really hope it doesn't come to that. And in the meantime, as I've said in the past, if your kid isn't immunized, that's a shame, because now my kid can't play with yours, and you aren't welcome in my house. If we're going to decide as a society not to slide backward, I figure it has to start somewhere.

I am pushing the red button.

Feb gets political!

So, how long did I get to do my job practicing hospital medicine before I had to argue with someone about finances?

Nine days. And what's weird was, I wasn't fighting with the party I assumed I would be.

We discharged a guy from the hospital last week, and because he'd had an unexpected event happen (I'm being intentionally vague about the specifics, but it's in that category of "maybe you can predict who's at higher risk, but you never know for sure if or when it'll get you"), he had to be discharged on a medication that was new for him. It greatly lowers the chances of future badness, but the med itself isn't exactly a glass of warm milk. You need to watch people carefully at first, test some blood, make sure the level is right. If it's wrong, things can go very bad indeed. This requires careful follow-up with the primary provider.

So I'm calling Scheduling to make sure this guy can a) get the appropriate blood test in a few days, and b) get in to see his regular doctor pretty soon. The scheduler says, "huh, that's odd" and "I'm sorry, but I'll have to have you speak with so-and-so." Then I find myself on the phone with someone who says the patient can't be allowed to schedule these future appointments, because he owes our practice group over $2000. I'm speaking not to some insurance company, but to our collections person.

Turns out, the guy had tried to schedule an appointment a few weeks back, and was told he couldn't, unless he paid some portion of his outstanding bill. Again trying to be as polite as I could, I wondered out loud if maybe this unexpected nasty thing that caused him to be hospitalized for three days maybe could have been avoided if he'd, oh, maybe seen his doctor a few weeks ago. The collections person was not impressed. Fair enough.

But this person's heart was not made of stone, and when I mentioned that the patient, sent out into the world blindly with no assistance beyond me wishing real hard for their med level to be correct, could potentially die, they did relent, and allow for one visit, for both the blood test and the primary care check-in. But no more!

From now on, when I discuss how messed up health care is in our country, I will tell this story. It's personal, it makes me crazy, and I can see several sides of it, all of which are totally and utterly, for lack of a better word, fucked. In my mind, it all boils down to a few key things:

1) Sure, this dude smoked, drank, and ate cheeseburgers; in short, acted like most Americans do. Sure, if he'd been jogging, avoiding high fructose corn syrup, cigarettes, and other vices; if he'd been eating bran muffins and celery sticks instead, he'd be better off now. But we play the hands we're dealt, and the guy in front of me is this guy, with this history. I have to treat him, not the version of him I would prefer to see.

2) According to what I could tell, he has insurance. I know a former Blue Cross claims agent who pointed out that lots of people have "80/20" plans, where the insurance only covers 80% of anything. That fits with the amount between $2000 and $3000. And of course, that bill is about to go up, from this recent hospitalization.

3) We're a private clinic group, so my own salary quite literally depends on the collections person doing their job, and doing it well. This person is, and I have no ilusions about this, on my side. God knows how many situations like this I'll encounter in my first year. If, hypothetically, my bleeding heart insisted on enough people in this situation being given care anyway, and if enough of them were unable to pay, then eventually we'd collapse and be able to help nobody at all.

4) And yet, when it all comes right down to it, I am not willing or prepared to say "screw this guy." I won't let him go out and die, or (worse for the system) get sicker and rack up more costs, just because he can't get in to see somebody. There are free clinics, but not enough, and anyway he earns too much at his job to qualify. There are a handful of sliding-scale clinics, but they have a waiting list that's months long, and he needs to be seen in a week. The walk-in urgent care centers don't do the ongoing primary care stuff, and the ER can do any test you want but it's ten times the cost so that's no solution.

And while it makes good sense in several different ways for my respected colleague the collections manager to aggressively defend the solvency of our business, how much would we have to pay his family in the event something bad happened and someone made a convincing argument that we could have done something to prevent it? (Ahh, but you can't reliably measure potential costs, and health care is all about potential expenses vs potential savings. Ask anyone who works in primary care why they don't make more money, and that's essentially the answer.)

So, for me, that's what the debate about a public option boils down to: somebody has to be willing to look that guy in the eyes and say "no." No, you can't get treated. No, you don't deserve a slice of these limited, expensive resources. No, the situation you are in, when stacked up against the situation others are in, and compared to what we have to work with, does not warrant you having this test, this visit, this intervention. And by the way, no, there is no reliable, consistent safety net we can allow you to fall into, so that at least there is a minimum standard you can count on. Have a nice day.

Because here's the thing: we say no to people all the time. We ration health care in the United States. We just like to pretend that we don't. And it doesn't go to the sickest first. In my opinion, getting anywhere near that truth freaks people out.

Well, the next person I encounter who doesn't believe in reform, or thinks a public option is Communist, is going to hear this story. And then I'm going to tell them I'm not willing to be that person who says "no, there's nothing, now get out." And then I'm going to ask point-blank if they would be willing.

Still alive, still awake

What's up?

You'll have to pardon my spotty posting, yet again. I was out of town, relaxing lakeside with friends. All my paperwork is definitely in, I made sure, so I'm waiting it out to see which comes through first, my temporary permit or my permanent registration (which I am given to understand they will soon be calling a "License" in my state, since it's the same board that approves MDs, with essentially the same process). And I've watched "the dog episode;" even took notes. I just have yet to write about it.

I've had little glimpses of future episodes, and there is indeed more Divya ahead. Okay, then, I'm doing it for Divya.

Which is not to say it's painful, exactly, to watch this show. Overall, Royal Pains is not bad, it's just not grabbing me the way its lead-in, Burn Notice, consistently does. And House, which is medically pretty silly sometimes, nonetheless gives what I think is a nicer, clearer idea of how medical thinking works, and how that changes the course of the story.

So I'm struggling a little to adjust my ideas about the show that RP could be, as opposed to the one we get each week. And that process is hampered a little by some quirks of the writing and plotting that I'll say more about as I go -- basically, I'd like it more if they took a firmer line and showed us what kind of show they want to be. For now, they're still kind of all over the place, and there's a lot of mush in between the fun, smart, or cool moments.

Naturally, this has become the highest-rated show on cable right now, and has been picked up for a second season.

Oy.

Champion of Justice

There's been this silver SUV parked in the apartment building's lot lately. The manager had told me there were painters coming and going for a while, but that was over with weeks ago. Yet the thing kept coming back like a fuel-inefficient bad penny. There's a bulletin board inside the building where the manager tacked a note stating that the MPD would be on the lookout for any cars parked in the lot without a permit, but that had no effect. I suspect the interloper was a friend of someone who lives here, or maybe just someone who hates to pay for parking. The SUV had no parking permit sticker, and tended to be right up along the row of signs reading 'FIRE ZONE' and 'NO PARKING ANY TIME.'

Except the other day, when I returned from my future wife's to find it parked in my spot.

I'm a generally easygoing and forgiving sort; in real life I don't usually get worked up as much as it might appear from reading my brain-spew here. But after I found a street spot and walked back home, I was ready to smack a bitch up, as they say. Or maybe slash some tires, or install some new after-market options. With a brick.

On further reflection, as a pending charge for vandalism isn't something that would help me much in PA school, I settled on the tamer, but by Minnesota standards still pretty aggressive, approach of "nasty note on the windshield." This, after the nice man at Gopher Towing explained that unless I was the apartment manager, I couldn't actually call them to yank a car out of the apartment's lot. At the moment, witty retorts about how Mark Yudof never needed to sign off on their fascist tactics all over the U of M campus circa 1996 did not occur to me. Alas.

So I fired up the printer, and created a flyer that proclaimed in big block letters that if this vehicle was seen in this lot one more time, towage would ensue. No fire lane, no stealing parking spots from residents. Grrraaah!

I walked my handiwork down, and slapped it under the SUV's windshield, hoping for an alarm to go off to draw the owner out, so I could confront the evil-doer in person. Again, alas. Then I went back up to my studio, which has a window overlooking the parking lot.

Ten minutes later, I noticed the offending silver SUV pulling in. It turns out my spot had been taken by yet another, unrelated silver SUV. This prompted a brief Homer Simpson moment. Then I rebounded, and threw my jacket around my shoulders as I picked up my keys and charged out the door. Vengeance would be mine!

I totally busted the guy in the SUV. Now that I looked at it, the thing was boxier than the one in my spot, and this was clearly our frequent visitor. He even pulled into his usual spot. I got the nastygram back from the new SUV, and assessed the situation. One guy, still in the car. I walked over to the driver's side, and he lowered the window suspiciously. I can't vouch for the expression on my face, but judging by the tone I heard in my own voice, it may have been the same hard-assed demeanor we use in the ED when our patience with belligerent drunks is juuuust about over, and physical and/or chemical restraint is one phone call away. The "I'm trying to help you, but you still have the power to mess it up for yourself" one.

I asked if the gentleman was planning to park there. I called him "sir." I explained that if the gentleman intended to wait in his vehicle -- I used the word "vehicle" like three times, god help me -- that would be no problem, but made it clear this was not a parking spot. This was a fire lane. Further, I explained, it's a problem for the people on this end of the lot who need to get in and out of their assigned spots, if anything is blocking their way. Finally, I told him about the sign that management had posted inside, and the looming threat of MPD intervention. I closed with the "it's your choice" tactic: do what you want, but you should know that if you leave this vehicle here, there's a chance it won't be here when you get back.

He nodded, and said "okay" a lot, and as I turned to go back to minding my own damn business, he asked "who are you, by the way?"

I did not say, "F%$@ you, is who I am." Nor did I say "somebody with a parking permit I paid for, asshat." If I had done either, it would have sounded awesome. Very David Mamet. I just shrugged, and said "I'm just somebody who lives here, and needs to get his car in and out of this lot sometimes."

By the time I got back upstairs, the SUV was gone. I didn't see when it happened, but a while later when I looked out the window, the other SUV was gone as well. I like to think the earth shook with Viking rage, just a little, and whomever had decided that my spot being empty all night and all morning was their invitation to use it had sensed in the air that they had overstayed their welcome.

Points for Grammar

I'll continue my budding rant about excellence vs. mediocrity, which is designed to turn into one about politics, soon. For now, I'm just going to whine about this idea of my career path being "Physician's Assistant."

The focus of my white-hot burning rage isn't the people who innocently use the wrong term. It's not really even the lack of careful thought that would reveal to any sane and intelligent person that if you go to school for eight years to be a doctor, you don't go to school for six years to be some doctor's "assistant." No, the problem I have is with the general fatigue we all seem to have suffered, which makes it all the easier to shrug our shoulders and be wrong about stuff without caring.

Oh, look, I guess this is the rant about mediocrity. Cool.

I'm going to keep politely correcting people. Accent on politely. I won't be deeply and personally offended, I won't hold it against you if you do it, and I'm not going to go out of my way to interrupt the flow of conversation to back up and fix the mistake. But I'm also not going to let it slide, if it can be helped.

Not for reasons of ego; if my ego were really that sensitive, I'd probably think it was worth it to do the time and get an MD. More because Judas Priest, people, the profession has been around since the 1970's, and the AAPA has somehow done such a horrible job of publicizing it that it falls to those of us who will actually be, you know, doing it to explain what it even is.

My job right now, the one where I work in the Emergency Department and get paid less than I did in 1998 as an office temp, that's an "assistant" job. I'm a nursing assistant, I'm a medical assistant, whatever you want to call it. In Ye Olde Days, I would have been called an "orderly." Which is kind of a cool title, because it reflects my function well. The ER gets disorderly in a hurry, and I help fight back the forces of entropy. Yes, I wipe some butts (although thank god I don't work in a nursing home). I push stretchers around to xray and up to the inpatient floors. I fetch stuff, I clean stuff, I stock things so they are there when clinical people need them. I generally make other people's jobs easier. And yeah, I get to do some cool stuff as well.

So I am the assistant to the nurses and to the physicians. Gramatically, I am right now a "Nurse's Assistant," and I am a "Physician's Assistant." (Okay, really I'm a "physicians' assistant," but go with me here.) I would never call myself that, because it would just make the confusion worse, but the point is the butt-wiping stretcher-pusher is the apostrophe-S assistant. The PA is somebody that sees patients and practices medicine.

The word "Assistant" is built right in to "Physician Assistant," so it's a logical and reasonable thing, if you're encountering the phrase for the first time, to assume there's a fair bit of assisting going on. "So do you pass instruments to the surgeon, and close up at the end of the surgery?" "That's like a resident, right?" Arrrrgh! But as I say, I can't get too wound up about it. It makes sense to think that.

After all, executive assistants are there to assist executives. Production assistants run around film sets, assisting people with random stuff that has to do with production. And physician assitants... practice medicine. Great. Thanks. Awesome.

In a nutshell, we "assist" physicians in kinda-sorta the same way a law firm's junior associates "assist" the senior partners. We do essentially the same job; true, the major cases and the really uber-high-stakes stuff will tend to go to the higher-ups, but that's fine because more training and more experience means you should handle more pressure. By handling a chunk of the cases ourselves, including mostly the stuff that comes in every day, with a little fun stuff mixed in, we reduce the workload. That's a mighty fine way to assist.

How awesome would it be if you had someone at your job who did the same thing you do (at a level a little under yours), and all you had to do was answer the occasional question or give some advice? This person does, let's say, 40% of your total work, and they do it as well as you do. Would you call that person your assistant?

Yeah, it's confusing, and yeah, it's vaguely insulting that the wrong idea persists. I saw a PA recently at the Target Clinic, for removal of some stitches, and as we were talking, I remarked that the poster outside in the little waiting area had an apostrohpe-S. She said "yeah, you kind of have to get used to constant little insults." Ohh, yay.

So if I've explained this to you already, sorry to be repetitive. I'd love to stop having to be.