Patient Stories from the Topahkal

Case 1:
47yo male with newly diagnosed diabetes mellitis. Married, no children. Initial lab workup revealed a significant dyslipidemia (triglycerides 880, cholesterol 306) and a fairly strong case of diabetes (hgb A1C 10.8, mean blood sugar level 268). Initial approach was to start the patient on a standard dose of Gemfibrozil to control his severe hypertriglyceridemia, Glipizide to control his sugar, and a baby aspirin daily to minimize cardiac risks. This is fairly routine medical care. Some folks will also start their patients on Statin drugs to control the high cholesterol and maybe choose a different diabetes pill. I'm not a fan of statins in the first year or two of a treating people with diabetes or dyslipidemia. While some data indicates these drugs have a benefit there are real issues of compliance past a few months and a focus on pills instead of nutrition.

The patient understood that the medications were being started to stabilize his illness and improve his symptoms. We talked about using the medications for 6-12 months while he made lifestyle changes that would optimize his health, using food and exercise as medicine. There was no promise made about stopping the drugs, his body would decide that, but it was our goal. We spent about an hour talking about dietary changes, the role of sugar as a poison for the pancreas and other organs, the utility of certain foods and herbs. We also talked about the patients fears of the diagnosis of diabetes.

He left terrified (I later learned) but with some clear steps he could take and easy access back to the office if any questions arose. About two months later I received some labs by fax and I was flabbergasted. It took me about five minutes to realize what I was seeing. This man's triglycerides were now 80, not 880. His cholesterol was 140, not 306. His hgb A1C was 7.3, not 10.8. His mean sugar was 140, not 268. I called the patient and asked him to come in and see me to review the labs. I was fairly certain that the Gemfibrozil could not have accomplished such a significant change and I wanted to know what happened.

Turns out that he had stopped the Gemfibrozil after a month and had cut his dose of Glipizide down to half a pill because of side effects. Almost all of the lab changes were due to dietary and exercise changes. He had incorporated flax seeds into his diet, as well as oatmeal (not instant) each morning. He had cut out all lard, fat and white flour products as well as almost all sugar products. He was still eating meat but in balance with alot more vegetables. He was exercising every other day for at least 20 minutes.

And he felt great! He also looked great. all his symptoms of diabetes and fatigue were gone. I stopped his Glipizide and we'll check his blood levels again in 2-3 months to ensure that this wasn't a fluke and that his diabetes is controlled with diet and exercise alone.

This man earned his independence from the medical system by taking the challenge of creating his own health. He recreated his relationship to food and physical exercise with minimal consultation. The total cost of this transformation was under $100.00 for the doctor visit, the labs and the intial medications. The folks who calculate the GNP won't be happy but you can't please everyone anyways... 2 months.

A Reality Check is in Order - I've been a student of medicine now for almost 10 years and have rarely seen this kind of transformation happen. I tell this story not to set some standard but to to share the possibilities with folks. As providers, it gets easy to become discourged or pessimistic during our training or on the job when so many patients are unable to care for or invest in themselves. There are many real issues that contribute to this reality. In any healing process there are at least two participants. The person who is healing him or herself and the person who is facilitating that process. My personal challenge now is to explore the relationship between how we build our health systems, what our clinics look and feel like, and how our attitudes as providers INFLUENCE the POSSIBLE for our patients.

aziwa

Freaks come out at night (carnival of the uncapitalists)

I had no idea how many carnivals exist online these days. There's a carnival of the cats and a carnival of the dogs; a carnival of the medical folks and a carnival of the indian folks; a carnival of the capitalists and a carnival of the revolutions...and even a carnival of the carnivals.

Well why not a carnival of the uncapitalists? Fret not, there is one! The carnival of the uncapitalists focuses on the "excesses of capitalism and its alternatives" (not the benefits of communism, as some jumpy readers may interpret such a gathering of views). Check out THIS week's edition, on "Markets and Health", hosted by the wonderful Lindsay at Majikthise. Two of the many fascinating posts -- Charles Todd's a right to enchiladas and Effect Measure's it's a bit like farming.

Civil rights Lawsuit - Interpretation / Translation Services at our Public Hospital

This week marks the launching of a legal challenge 8 years in the making. Advocates for Native Americans (Navajo), Spanish speaking immigrants/citizens and Vietnamese refugees announced publicly this past friday that with the help of the NM Center on Law and Poverty and the ACLU the University Hospital will face a legal challenge for it's poor performance in providing interpreter and translator services.

To put it plain and simple, in the words of Kieth Franklin, advocate for Navajo Nation members living in Albuquerque - "We do not want to be treated as second class citizens."

The legal challenge is based on data from the hospital showing that over 40,000 requests for language interpretation per year are not met. Patients leave the hospital with large bills with no understanding or explanation of what was done, what the future might hold, what the treatment plan is, etc. Parents go for days or even weeks without knowing what is happening to their child. Pregnant moms have lost their babies in natural miscarriage and not been given the basic information about what had occurred, leaving the hospital believing their fetus is still alive. Children are expected to interpret complex medical and emotional realities for their parents and grandparents when they might not even be truly bilingual or old enough to understand the implications of the information.

I participated in alot of bad interpretation medical encounters as a resident. I didn't know then or understand the depth of the implications every time I let a situation pass without calling in for backup. I spoke limited proficiency Spanish at that point and thought myself adequate to the task. Now I understand with better language skills and more access to seeing the mistakes made in the system how wrong that was. Of course at the time there were no viable solutions. there were no interpreters to call for help. we did have access to a phone system that was burdensome to use if your time was limited, as well as not being easily available in key places like OB testing and triage and the ER.

What i realize now is that it was beyond my power at that point to fix the problem. Now after four years of working on this problem at the economic and political level outside the hospital, aware of all the data and studies and laws, I realize that the problem is PREJUDICE, not economics, not lack of knowledge. Simple logic would tell you that having adequate interpretation services would save people's lives, would diminish their fears and worries greatly, would help them feel respected, feel dignity, express themselves intelligently. it would certainly cost some money. health is an investment. kindness is an investment. it's not free. it would mean the hospital would have to balance their budget with a different set of priorities. bottom line human dignity, not profit, corruption and greed. this is doable.

We'll see where this legal action takes us. It is my hope that the hospital will choose an alternative pathway, one of respecting their communities needs, invest some money in interpreters and not spend a dime defending an indefensible position of racism with out public tax dollars.

aziwa

Physicians of power -- prescribing power

This week, Bob Goodman, founder of No Free Lunch -- took the American College of Physicians (ACP) -- the organization that represents physicians trained in internal medicine -- to TASK.

Here's some of the press release from No Free Lunch, an organization that educates physicians (and other health care professionals) about the influence of the pharmaceutical industry on our clinical and other decisions:

New York, NY – The American College of Physicians (ACP), the nation’s largest medical specialty society, will convene its Annual Meeting—billed as the “most comprehensive CME event in internal medicine,”—at San Francisco’s Moscone Center on Thursday, April 14th. In addition to its Scientific Program, the meeting will feature an exhibit hall almost 3 football fields long. The hall—which the ACP’s website calls “an extension of the learning environment of the ACP Scientific Program”—will be filled with enormous industry exhibits and countless sales reps displaying their wares and handing out trinkets to the physician-attendees. Additionally, there will be daily industry-sponsored symposia—from a breakfast session on the treatment of overactive bladder (supported by Indevus Pharmaceuticals, manufacturer of Sanctura,TM a treatment for overactive bladder) to a dinner session on the treatment of GERD (sponsored by Astra-Zeneca, manufacturer of the ubiquitous Purple Pill, Nexium.TM), daily raffles, and of course, free lunch. And in case all this is not enough to get the promotional message across, companies may sponsor just about every minute and inch of the program—from the morning coffee break ($6,000/day) to the Annual Session Tote Bag ($60,000). As the website boasts to prospective exhibitors, “The American College of Physicians Annual Session stands out from all other meetings that you attend because it offers an unparalleled opportunity to meet with physicians of power - prescribing power.”

Why is this newsworthy? Because in 2002, The ACP—whose stated mission is to “enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine”—published guidelines on Physician-Industry Relations that include the following:

“The dictates of professionalism require the physician to decline any industry gift that might be perceived to bias their judgment, regardless of whether a bias actually materializes.”

“The potential for bias in industry-prepared information becomes especially precarious when such information is accompanied by a gift or free service.”

“It is not just lavish amenities that are in question. The acceptance of even small gifts can affect clinical judgment and heighten the perception (as well as the reality) of a conflict of interest.”

“Ideally, physicians should not accept any promotional gifts or amenities, whatever their value or utility, if they have the ability to cloud professional judgment and compromise patient care.”

Well, you can have a gynormous exhibit hall filled with pharmaceutical industry folks and their expensive gifts to docs, and you can have policy that clearly states that physicians should decline gifts that may bias, but ya can't have it both ways (unless you want physicians to take "personal responsibility" to not take bias-ing gifts from the exhibit hall).

This week, the Wall Street Journal published an article by Scott Hensley on this very issue, entitled "Doctors, Drug Makers too Cozy?". Mentioned in the article was a February survey of consumers and physicians that found that 75% of consumers believe that the pharmaceutical industry is so flawed it needs to be overhauled, while only 40% of docs believe that. There can be a number of reasons why, but I'm sure conflict-of-interest has something to do with the difference in beliefs between consumers and docs.

Also, yesterday's New York Times has a piece about an upcoming meeting of physician experts who will recommend to the FDA whether or not to lift a ban on silicone breast implants. Documents show that up to 93 percent of such implants rupture within 10 years, and not enough is known about the health effects of silicone leaking into bodies. But:

Dr. Mark Jewell, president elect of the American Society of Aesthetic Plastic Surgery, said he was surprised that the agency had estimated that silicone implants failed so often.

"That's certainly news and does need to be addressed," said Dr. Jewell, who has consulted for Inamed and Mentor [companies that produce silicon breast implants]. "But I feel that the devices should be approved."

Hmm...

Anyway, back to medical organizations and pharmaceutical sponsorship. I'm proud that the American Medical Student Association's national convention last month had NO pharmaceutical influence in its exhibit hall or otherwise (and that AMSA has a Pharm-Free initiative too). Medical students passed such policy years ago, and thus they walk the walk instead of only talking the talk.

Lastly, at each of my interviews for residency, I inquired about the residency program's relationship with the pharmaceutical industry (free lunches sponsored by them, interactions with sales reps, etc). I heard a range of responses, and appreciated each of the program's reasons for either allowing or not allowing interaction with pharmaceutical sales reps, but I was especially pleased to hear from EACH program that more and more students are asking this question of them.

(thanks to the helix for the test question pictured here. Click on the picture for an enlarged version -- may be easier to read)

A few weeks at the Topakal (our medicine clinic)

The last few weeks at the clinic have been full of fun and surprises.

Volunteers:
We've had an art therapy student hanging out twice a week, bringing lots of color and deep insights to patients in the waiting room. Thanks to Celest for pursuing her dreams in collaboration with us. If providers out there haven't had a chance to work with art therapists, seek it out. it totally transforms your waiting room into a therapy room that can buffer patients waiting time befoer their visits and let them debrief afterwards.

Henry also swung by and added his energy to helping get the word out to the Spanish Speaking immigrant community via Churches and local media. He'll hopefully be volunteering with us as he prepares to enter PA school next year.

Ultrasound fudraising:
We had a generous grant from a small family foundation in New Mexico. This combined with many private donations, adds up to $17,000.00 towards the ultrasound machine. Cost is $22,000.0 so we are close. I'm aiming for mid-may to purchase the macine and get that service started. If anyone knows of a bilingual ultrasound tech interested in part time contract work in albuquerque, nm, let me know!

General Finances:
We are seeing about 5 people per day average now which is meeting all the overhead costs and all new debt for supplies purchased each month. Locums has just about paid down all the credit card debt (about $7,000.00) for getting started and buying initials supplies and equipment. i'm still at over a 90% collection rate on date of service and 95% total collection rate. i suspect some people aren't coming because of the charge ($25), it'll take some time to build the trust with folks so that they know they can come in for care and then pay down the road.

Donations:
A local IM doctor closed his practice and donated the contents of his office to us. This was wonderfully helpful in terms of getting a few sets of oto-ophtho scopes, BP cuffs, exam tables, pulseox machines and other odds/ends. He had an EKG machine too, probably one of the first office based machines made. with some hesitancy I left it behind, I love old medical equipment but i'm trying not to feed that fetish too much. :>

aziwa

Storming the Castle

Two interesting developments in our local efforts to redirect the resources of our public hospital away from privatization back towards its intended mission to serve the uninsured.

1. another community minded public health person, who is also trained as a physician, was appointed to the clinical operations board by the county by a 4-1 vote early this week. This is another dynamic, intelligent, passionate woman, bilingual, who can challenge the CEO on his plans to push out the uninsured to "improve the payer mix." which by the way if you are new to health policy, these are the buzz words of racism and classism in healthcare. "IMPROVE THE PAYOR MIX." If you hear someone saying that, coming from a non-profit or public system, ask them what it means and don't stop asking until it becomes clear to them that these are fighting words, not neutral economic principles.

2. someone from inside the hospital started an email petition to expel the CEO of the hospital. the text of the letter is included below.

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Dear Andru,

From: A Friend

REPLACE MCKERNAN

1. Morale in the University of New Mexico Hospital (UNMH) is at an all time low.
2. Quality of patient care at UNMH has deteriorated.
3. Budgetary shortfalls are attributed to uninsured and indigent patients, while UNMH administration accepts no responsibility.
4. The UNMH CEO, Steve McKernan, is paid over $300,000 and received a 20% raise this year. (Daily Lobo, March 25, 2005). We feel strongly that Steve McKernan must be removed. While his departure will not immediately solve the Hospital's financial and operational crises, it will immediately improve staff morale and will open the door for innovative solutions and positive change.

To demonstrate your support for the removal of Mr. McKernan, proceed as follows:
1. Reply to: replacestevemckernan@yahoo.com.
2. Type your name, title and/or profession, followed by “AGREED”.
3. Click send.

Ultimately, this petition will be presented to the Bernalillo County Commission as well as the University of New Mexico Board of Regents. If you wish, send your own personal perspectives on Mr. McKernan and UNMH to replacestevemckernan@yahoo.com. All perspectives will be compiled and delivered to the Commission and the Regents. Names will be kept confidential.

Please forward this petition to colleagues and friends who share your interest in saving UNMH from disaster.
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We'll see what happens next.
aziwa