Will Maranto's World

Reunion

So last night Molly and I went to my 10 year medical school reunion last night. Reunions are always things I look forward to with some trepidation: I knew I wanted to see my old classmates, but for some reason I was also dreading going. I've never been a hugely outgoing person and that was even more the case when I was younger.

But you know what? I had a great time. Perhaps I had forgotten how nice those people are? There was nothing but positive energy in the room last night. We were at Superior Steakhouse in Shreveport and had a nice-sized room reserved in the back. As you might imagine for a bunch of mid-late 30 year olds, lots of folks were now married and had multiple kids. These people have all grown up. Kinda like me!

I enjoyed talking to Shana and Eric Dupree. Eric and I not only went to med school together but spent three years after that at the LSUHSC Family Medicine residency program in Shreveport. I worked with him a lot and he's one of the people that I miss the most from those days. I think it had been seven years, but we picked up like no time at all had passed.

I also particularly enjoyed talking to Brad Vincent, Mike Benoit, Amy Johnson, Bradley Colvin, Joel Thibodeaux, Paul & Heather Bracey, Paul & Danielle Cooper, Kevin and Beth Valiulis-McGann (that's right Kevin, I hyphenated you!) and many others I'm no doubt forgetting at this moment. And there were tons of folks I didn't get to talk to that I wish I had!

More than anything I think it makes me appreciate the wonderful life I've got. Things like reunions make you take stock of your life and sum them up into brief soundbite-style summaries. In a nutshell, I'm happy, have everything I need, most things I want and a truly marvelous family to enjoy it with. Onward!

Sunday Tour of Duty

This fine Sunday finds me toiling away at the First Care.  For the uninitiated, this is the Urgent Care  facility that my practice operates for Christus Schumpert.  It's mostly easy: I like treating poison ivy, scrapes and cuts and runny noses.  They are a nice change from the deluge of congestive heart failure, COPD and diabetes that I tangle with on a daily basis in my regular practice. 

I've been AWOL from the blog since Molly and I are super-busy taking care of our new son James.  He's really a good baby, but he certainly requires more hands-on attention than our older son Ben, who is now 3 1/2.  This means more late nights and more daytime fatigue.  Oh well, I can do this one last time.  This seems like a good place to complain about being 30-something and "too old for this," but I actually feel really good.  And compared to the geriatric patients I see everyday, I don't feel too bad about being 36 years old.

On the musical front, 80% of Gypsy Mountain convened yesterday to work on some new songs.  I'm always struck by how painful it is to buckle down and learn new cover songs in the manner that we are forced to (one practice with only part of the band present, other practices later with other parts of the band present).  Though I wanted to pull my hair out at the time, it makes me miss the marathon rehearsal sessions that Wes and I endured through much of 2002.  We got everyone together weekly and slogged through tons of material.  That was for the first incarnation of Retroverb, but Gypsy Mountain benefits from that hard work even now.  Songs that we've played hundreds of time date back to those practices: "To Be Young" by Ryan Adams, "Aunt Avis" by Widespread Panic and "Driver 8" by REM to name but a few.

We Gypsies have a few shows coming up in May: Sam's Town Casino, Mudbug Madness and likely at a new club in Bossier, Code 3.  More details in due time.

Will

Thank God For Mixed Blessings (Or How I Put The Vulcan Death Grip On My Mother-In-Law)

I really am a complete slacker.  I accepted that many years ago, but it still annoys me from time to time.  When I was in college, I aspired to be King Slacker.  The King of Slackers is really good at what he does and you'd never expect him to actually be a slacker.  

But I digress.

The last week has been full of wonder and revelation.  Most notably, Molly and I had our second son (James).  This is both a wonderful and stressful event.  I don't think of myself as a world-class parent, but I do love my children and I would do anything for them.  More than ever I'm comfortable just being a dad.  Life and my psyche are ever-changing.  Imagine that.

So last night @ 9:30 Molly and I get the call from her mother's friend Brenda.  Kay is acting crazy, crawling around on the floor and saying she can't breathe.  Sounds scary, but unfortunately this is par for the course with my mother-in-law.  As an insulin dependent diabetic who has a tendency to not follow a consistent diet, Kay is all too acquainted with hypoglycemia.  It's kind of "her thing".  Think of it as a calling card.

So when I pull up at her house and walk inside, the M-I-L is sitting in a chair babbling.  She's fairly combative and this might be humorous if not for the fact that I had to take control of this situation.  After making her choke down some chocolate, using the VDG to keep her rebelliousness seated (as opposed to the fall-to-the-floor-and-break-my-hip alternative that she is threatening) and check her blood sugar a few times.  

What followed was about four hours of encouraging her to eat, keeping her from vomiting and lots of finger sticks.  The wonderful mixed blessing of this whole thing is that I was off yesterday and today to help with baby duty.  It all works out in the end.

More Thoughts on Healthcare

Doc Bass started a thread on Facebook about the state of healthcare reform.  I responded and then he asked me, as a physician, what changes, if any, I would make to the current system.  I responded with the following and I thought I'd put it up on Ye Olde Blog.

Glad you asked! This is something that my friends and I talk about quite frequently. I could go on and on about things, but let me be succinct:

The elephant in the room that all these “fix it” schemes are ignoring is the real problem with our healthcare system. That problem is the COST of services in modern medicine. If you reduce the cost of office visits and medical procedures, then you fix most of the problem. 

So if you focus on eliminating the things that make the costs of things high, you must target the following:
- Price Fixing. I bet you don’t know this, but the costs of most things in medicine are fixed by the government directly or indirectly. Medicare, the government insurance for the elderly or disabled, is used to directly set the reimbursement rate of office visits or procedures for its beneficiaries. What you might not know is that most private insurance plans reimburse at a percent of Medicare, say 120%. This sounds ok, but remember that this can lead to some bad things: MRI’s are a 25-30 year old technology. Unlike other 30 year old technologies, like say VCRs, the price of an MRI scan has barely decreased over 20 years. Why? Because the government fixes the price of an MRI. If you take this control away, who knows? $200 MRIs without insurance?
- Control No-Pay Patients. I’ll be blunt here: this mostly applies to illegal immigrants in the ER/hospital setting. Ever wonder why you’re paying $10 for an aspirin in the hospital? In my version of the world, if you were an illegal alien, you’d be treated in the ER/inpatient setting as needed and deported to your country of origin upon discharge. No exceptions.
- Allow/Empower consumer purchasing of insurance. The “allow purchasing across state lines” thing is good. I would also like to see people encouraged to buy health insurance with big tax credits. I agree with you that it is unconstitutional to require people to buy health insurance (with the threat of fines, etc), though. 
- Find a way to get people paying cash for most office visits. I’d love to see you being able to see a doc for cash for under $100 (and maybe $50) in primary care. But you’d have to cut 3rd parties out. This brings in competition and this is good.
- I think health insurance has to transition to actually being health INSURANCE rather than health FINANCING. That’s why I think high/mid deductible policies are more healthy than the kind of copay-driven plans you see. 

Just some thoughts for you…

Medical Wonderfulness

So I'm on the Facebook, where I can frequently be found hiding between patients.  My lovely and talented wife messages me the following:

"I thought you'd be interested to know that AOL is running an article called, "7 Women's Autoimmune Problems that Doctors Miss."  It will make you feel warm and fuzzy all over.

1.PCOS

2.Fibromyalgia

3. Chronic Fatigue Syndrome

4. Lupus

5. MS

6. RA

7. IBS

I'm sure you are glad this is in the news"

Oh yes, I'm glad articles like that are out there.  And while I'm sure that the person that wrote that article is as sweet as they are insightful, it does not make me happy to see.

I ask you, what are you supposed to take away from this article?  I would guess that the desired effect is to make you consider that your physician is incompetent and that you "know better what's wrong with [your] body" than your doctor does.  While I seriously doubt that statement is true in most cases, I get to hear it at least once per week.

I think it misses a key element in the nature of the physician's role in patient care.  When a patient comes to me, they are coming to ask my opinion and advice regarding their health or any ailments they may be having.  The above "article" would suggest that if you're having vague symptoms, then your physician is CLEARLY missing a vague or rare diagnosis.  More often than not, your physician is considering one or all of the above diagnoses (as appropriate), but you may not have anything like that.

Allow me to give you more common alternate diagnoses that can mask the above:

1.PCOS - You have diabetes (I'm not aware that PCOS is an autoimmune disorder).

2.Fibromyalgia - You are depressed and crave narcotics.

3. Chronic Fatigue Syndrome - You are depressed.

4. Lupus - You read too much on the internet and you crave narcotics.

5. MS - I can't think of anything sarcastic to say here.

6. RA - You have osteoarthritis and crave narcotics.

7. IBS - You are depressed and you channel your underlying issues into abdominal complaints (wait, that is the definition of IBS).

No, I don't mean all that literally.  But, thank you AOL for bringing down this wrath upon me from my patients!

Swine Flu Goodness

It's days like this that are slightly less than fun in Primary Care medicine.

So I roll into the clinic this morning at a few minutes before 8 am.  I've gotten up late because of a) friends at my house the night before b) two weak-ass chest pains that came into the hospital between 9 and midnight and c) I will not miss a night walking my dog on a nice night.  

There is a nice hospice rep waiting for me and Deere and Saucier.  She's brought us untoasted bagels for breakfast (sans cream cheese  or any other spread either).  Because I woke up late and was told we had food at the clinic, I also did not stop at Starbucks/McDonalds/Chick-fil-a/Sonic to get a nice warm dose of coffee either.  To fit with the theme of the morning, our massive percolator is not ready to offer up coffee either.  All the while I'm trying to wade through a mountain of messages, refill requests, prior authorization requests, lab results and various nagging pieces of paper.  And she's yammering on and on about their hospice.

I make it out of the breakfast.  Jan has filled up my room with people who know someone with swine flu.  Their stories all have holes in them, but they're determined, God love them.  They don't want to hear my advice.  Hell, they know better than me.  Maybe I just didn't get the memo.

Clinic rolls on.  More hypertensives and diabetics roll in.  This is good as it allows me to turn off my brain a bit.  

I look up and it's lunch time.  This brings another rep.  I like this one a lot because she's been calling on me a while.  By the time I get back to lunch, she's already eating.  I like this because it means she doesn't take this whole process too seriously either.  Thank you Jesus.  We obliquely talk about insulin and then transfer into politics or at least the politics of preschool.  This is good because I can't keep up the medical facade without a break.

Then the floodgates break loose.  Saucier is working lunch and even though he is the fastest of the bunch, he is getting rolled over.  I jump into the mix and start knocking out some sore throats and aching bodies.  After putting a hard hit on the influx of people with Kirk and now I'm leaving to get some Zen hot tea.  That's how I roll, you see.

The afternoon begins and I'm hitting my stride.  I do get the usual 14:30 dread.  After a while it fades.  I admit someone to the hospital and the clock strikes 5:15.  To the house.  

Hope y'all enjoyed that recap.  Telling or to blah?

No Rest For The Weary

This is the end of my sixth year in practice.  That's pretty easy for me to believe in all honesty.  On some levels, it feels like I've been doing the doctor thing for an eternity.  Most of the time it's pretty smooth: get up early, make my early morning hospital visits, see patients in the office in the morning, either round again at lunch or work through lunch in the urgent-care part of our clinic, see people in clinic in the afternoon and then go home.  Not too bad.

One thing that I've seen almost every year, though, is the pain and misery of mid-summer.  Why, you ask?  After all, it would seem that our patient volume should be slightly decreased because of less respiratory infection (relative to winter), right?  Well, sure.  But vacations get you every year.

As part of a five-man practice, it's my responsibility to pick up the extra load when one of my partners goes out of town.  Naturally we all cycle out for a while in the summer (though some of us WAY more than others) and then leads to increased volume and headaches on the folks that are still in town. 

Add to this stress that I'm always getting ready for my vacation to Gen Con (Gaming Convention -- yes, it's nerdy - deal with it) and you get an exhausting time of year.  I would say that August can't get here fast enough, but I've got so much to do yet...

If the mood strikes me tomorrow, I'm going to tell you a really hateful story about a patient I have in the hospital...

Jan has a Bad Attitude!

She says to me as she reads over my shoulder, "Oh bite me will you, don't put that on there!"  Then she pauses, slaps me in the shoulder and then says, get that off of there!"  "What am I going to do with you, Dr. Maranto?"

Meanwhile, Sharon says, "you've never read any of the things he writes about you on there?"  Jan says (wisely) "No, I haven't."

......

This is just a snapshot of the daily battle that goes on at Bossier Family Medicine.  A few minutes later Jan and I are fighting after she tries to put a smiley face on my back.  The confrontation ends when I stamp Jan's hand with a Cymbalta prescription stamper.  Take that old nurse!  And in case you have depression or fibromyalgia, well, I have you covered.

......

Please pardon the random nature of this blog.  I will leave you with the product of an altercation from last week!  Let's just say Jan could have walked into any pharmacy and gotten GOOD cough medicine.

A Medical Question I'd like to know the answer to

So last night I'm on call.  I'm not out to ruffle any feathers or start any fights.  I get a call from the LSU-Bossier ER and it's fairly standard fare: 74 year old woman with "chest pain."  My colleague in the ER informs me that her EKG is normal, her cardiac enzymes are normal (blood tests we draw to look for damage to the heart that you would probably see with a heart attack) and she's no longer having chest pain.  Of course he'd like to admit her to the hospital anyway. 

So I must know: why in God's name are our friends in the ER ordering tests if they don't care what the results are?  I'm not an absolutist and I can well-guess motivations for this but it's frustrating day after day. 

Similarly around 01:00 I get a call from Dr. Z, the most notorious over-admitter of patients from the ER.  He has one of my partners' patients who has a normal chest X-Ray.  She's finished a round of antibiotics but still feels bad.  Naturally she needs to be admitted. 

Don't get me wrong; I'm not for patients suffering.  I'm just a bit tired of inappropriate uses of the ER.  I mean, if you're really acutely ill, you'll find no one who wants to help you more.  As my good friend Dr. JMC once told me: our after-hours call services should be much less open than they currently are.  Do you know the sheer volume of calls for medication refills after 5 pm?  It's staggering.  But that's another post.  I'm going to jump into clinic...

First though, I'll leave you the explanation to a true medical mystery.  How do those narcotics manage to get washed down the drain?

Theory of Spontaneous Pill Destruction

Bad Medicine (or how we were all sold a false Bill of goods)

So if you buy the party line, the new administration is hard at work in Washington trying to cobble together a bill that will save this country.  The economic crisis we face is the "worst since the Great Depression," or that's what I heard my president say tonight.  I also head him say that the Bill that the Senate is working so hard on "contains no pork."  That sounds marvelous. 

I'd like to point out a few things to you, though.  While this Bill is ostensibly about "creating or saving 4 million jobs" (great thing to lump together - kind of like me saying "I'm either going to give you $10,000 or not take it from you" - not exactly interchangeable), there are a number of small things hidden inside that smack of liberal mondo-government bacon.  Bloomberg Article

The above article is really important since, even if you don't work in healthcare, you WILL be a patient someday.  I would like to point out a couple things from the referenced Bill:

• If I, as your doctor, am now bound to the standards and practices of a national Health Czar, what happens if the government decides that you should no longer be able to see me for sinus infections, sore throats, bronchitis and many of the minor illnesses that we treat regularly?  Sure, you may have private insurance, but the Bill holds doctors to national standards and creates a penalty for not following them.  If that doesn't bother you, what if the situation is that your grandmother is having a heart attack, but is 80 years old?  Currently, I, as a private practice doctor will throw every bit of skill and knowledge I have at the problem.  But as Obama Healthcare primary contributor Tom Daschle said in his book, this new bureaucracy will "guide your doctor's decisions" and help them to "learn to operate less like solo practitioners."  That's all well and good until common life-saving procedures are deemed too expensive.  It has happned in not-so-Third-World nations like Canada and England.
• A large portion of the Healthcare part of the Stimulus Bill centers around a single national Electronic Health Record.  While this is great in some situations, what if your sensitive (and formerly private - certainly from the government) health information is hacked?  Don't believe that this won't happen.  It will.  What if someday you wish to run for office, but say you were treated for an STD as a teen.  Think that kind of info can't be accessed? How long did it take a government employee to open up Joe the Plumber's old tax records?  Keep in mind this guy wasn't running for office, he only made the mistake of asking then-Senator Obama a very pertinent question about taxes.

I could go on longer, but these sorts of measures are pure bad news.  Ask yourself: if these are such great things, why are they hidden in a hastily-debated "Stimulus Bill?"  Why not have an open debate about them?  Perhaps there's a reason...