The Clown Car and Health Care Reform

The recent passage of the House of Representatives version of health care reform has got me thinking about the clown cars at the circus. (And no, the joke is not what you’re thinking. That one is waaaay too easy, and I like to feel like I’ve worked for my laughs. Besides, that’s not really a joke, but merely a statement of fact, just like I’ve heard it said that the mother-in-law joke is not really a joke, but a very serious question.) Thoughts of health care reform brought me to the circus because I always wondered who was driving the car. With so many clowns packed into such a small space, there seemed to be no way that a single clown had enough space to work all the controls. And while it seems to be obvious who’s driving health care reform, and who’s trying to stand in its way, it seems much less plain who actually drives the health care system.

(I think the other, subconscious influence on me might have been that I always seem to have a Schoolhouse Rock song percolating about in my head, and lately its’ been “Three Ring Government.” Schoolhouse Rock is why I also know that interjections show EXCITEMENT or EMOTION and are usually set apart from a sentence by an exclamation point, or by a comma when the feeling’s not as strong. It’s also why I know that legislative bills often wander around the Halls of Congress on their little legs in a state of semi-permanent depression.)

(Incidentally, in the course of writing this blog I also did some research into the history of the Clown Car. It turns out that the gag was first performed at the Cole Brother’s Circus in the 1950’s. Opinions vary on how it’s done. Most references say that the car parks over a trapdoor in the floor of the ring that’s covered with hay or straw, and that the wild actions of the disgorged clowns distract the audience from looking down. Others describe a hollow shell with ledges and grab-ons that allow the clowns to hold on and fit themselves in the car. But what I found more interesting was that the term “clown car” is now used to refer to a particularly fertile woman, such as the “Octo-Mom.” No comment needed, I think.)

Under most circumstances, the question of who’s in charge is actually a pretty easy one. It just depends on who you ask and who’s the villain de jour. The folks driving the car can be the evil insurance companies who charge high premiums for great profit and little return. It might be the government who provides too many benefits, too few benefits, or not enough for me and too many for you. It might be lawyers that force doctors to raise costs and shy away from complicated patients by practicing defensive medicine. (I’m still trying to figure out exactly how terms like 4-3, Zone, and Cover 2 apply to clinical practice.) It might be doctors who shun the care the uninsured to line their own pockets. It might be the administrators whose very existence depends on the proliferation of paperwork that takes time and resources away from medical care. It might be the bean counters for whom patients and medical staff are nothing more than cost centers, and who worship at the Altar of Profit, or at Least Solvency, to the idol of the Third-Party Payer. It might be drug companies and makers of medical devices, who coax doctors to prescribe expensive medications and cajole consumers with slick television ads. It might be unscrupulous health care providers and agents fraudulently milking the system. It might be societal expectations themselves that place an emphasis on the use of technology rather than thought and reason, assumptions that demand immediate satisfaction and flawless performance in an inherently inexact art. (I actually have no problem buying into the latter rationale. At a very basic level, I believe that our attitudes towards health are driven not by a particular individual or institution, but reflect, for better or worse, what we expect of society as a whole.)

But figuring out who’s in charge of the health care system is more than an exercise in blame. Thinking hard about the issue rather than relying on the blame game is key to determining where the most effective interventions within the system might be.

A number of years ago I did some part-time work for hospitals as a physician documentation consultant. In essence, my job was to remind doctors to actually write down on the chart the things they were thinking. Physicians work with a lot of commonly understood but unstated assumptions about patient care. For example, if we say that a patient has come to the ED complaining of pressure-like chest pain and shortness of breath on exertion, virtually every ED doc will have the same three or four things on his mental short list of likely causes. But because these thoughts are a given in daily use, we tend not to write things down so there’s no track record of the thought process nor of the work that goes into the cognitive part of care. Entering these thoughts within the medical record provides a much clearer picture of care for utilization review, quality improvement, physician profiling, and risk management activities.

While I’d like to think these are good and valued goals in their own right, the reason I got paid for doing this is because hospital reimbursement Medicare Part A is based on something called a Diagnosis Related Group (DRG). A DRG is a group of diagnosis within the same organ system that share a similar intensity in the use of hospital resources, and therefore are reimbursed at the same level regardless of actual cost to the hospital. The hospital that provides care at less cost than the DRG will reimburse makes money; the facility whose costs exceed the DRG payment suffers a loss.

DRG assignment is based on review of the medical record for the physician’s documentation of the principal diagnosis (the main reason the patient was admitted) and notation of any accompanying complex medical conditions (comorbidities) or complications of care which can drive up the intensity of the provided hospital services. Successfully maximizing reimbursement requires the physician, and no one else, to fully and completely document the clinical status of the patient in the medical record. For example, clinicians are well aware that pneumonia in nursing home patients (especially those with swallowing difficulties after a stroke or who feeding tubes in place) is often due to aspiration of stomach contents into the lungs. Patients with these kinds of pneumonias often stay in the hospital longer, and have more complex medical issues, than other patients with pneumonia from a different cause. But if all you write down in the medical record is a diagnosis of “pneumonia,” the hospital is reimbursed a set amount regardless of the cause. Of you take a further step and document that the patient has “aspiration pneumonia,” payment increases. And if you also note in the record that the patient has concomitant chronic renal failure or uncontrolled diabetes, reimbursement rises again. The key is that the physician has to write down what’s going on. (Those of you “in the know” will recognize that this is a slightly dated and very simplistic explanation of the system, but please bear with me for the sake of argument.)

But what came to me as I was doing this work is that despite the many outside interlopers nibbling at their heels, it seemed like from a day-to-day, operational view, physicians still actually ran the health care system. In the very narrow sense of the work I did, physician documentation drove reimbursement. But what drove the costs was the process of establishing the diagnosis and providing care, all of which are under the expert control of the physician. And I think this concept of the doctor in charge plays out in a larger sense as well. It’s the physician who provides an entry point into the health care system through the office or clinic. It’s the physician who provides the assessment, orders tests, requests consultations, and order drugs and other treatments for acute or chronic medical conditions. It’s the physician who has to balance clinical realities, resource management, consumer demands, and societal expectations while keeping the patient’s welfare first in mind. It’s the physician’s actions (or lack thereof) which drive the medicolegal system. And while physicians are unquestionably subject to, and necessarily react to, all the outside influences upon their practice, the fact remains that nothing gets done, care is not provided, costs are not incurred, paperwork is not completed, without the doctor starting the chain of events.

(I should note that I believe this not because I happen to have an MD after my name, but because it makes intuitive sense. Nothing gets done in health care without a physician either ordering a test or treatment or passively consenting to the demands of others. And as far as the MD goes, I’m of the belief that outside of the hospital, the abbreviation rarely needs to be unveiled. The only indication I have of my degree in the house…my diplomas are somewhere in the garage, because the Residential Cat isn’t easily impressed and The Child considers my educational achievements as minimal compensation for the fact that I have not memorized the plot of every episode of “Chowder” ever aired…is a framed poem called “My Daddy, MD” whose first verse reads, “Whenever Daddy signs his name he always signs MD; so everyone will know, that he belongs to me.” Okay, it’s syrupy, but I like it. Yet I thought it was well over the top…or under the ground...when I was visiting a cemetery once to find that a head stone was engraved with “Richard Barber, MD.” I would think at that point, it probably doesn’t matter. Does heaven really have special, close-in parking lots for doctors?)

So if physicians are driving the clown car, are they necessarily the cause of this mess we call health care in America? I really don’t think so. Driving the clown car over the trap door is probably the most crucial part of pulling off the gag, and the driver has to be able to do his job to the best of his ability despite all the hangers-on who want in on the show. And while the doctor may drive the car, the car itself is provided by the circus, and once the door is open the success of the act depends on the mercy of the rest of the clowns.

So it seems to me that if we really want to reform health care, we need to concentrate on the role of the physician. Here’s an example. I recently read a study that said that only 20% of physicians in the US will accept Medicaid patient into their practice by choice. Another 20% refuse to do so. The remaining 60% see Medicaid patients not by choice, but when they have to, such as when being on call at a hospital. We already know that it’s difficult for Medicaid patients to get into physician’s offices. While it’s true that expanding Medicaid gets more patients “coverage,” what makes anyone think that simply expanding Medicaid means more patients will actually get to see a physician? Or that physicians will flock to see patients on “public option” programs with undefined reimbursement rates, especially when whatever revenue the physician makes from these is offset by higher taxes and by cuts in Medicare rates?

I recognize that this runs very close to the border of saying that doctors are nothing but mercenaries. But if any of us running a small business had widgets to sell, and one group of customers were willing to pay a higher price for the widgets, wouldn’t you preferentially sell to the higher-paying group? Of course you would, and you’d be entirely within your rights to do so. And until we abandon any vestige of the status quo, put all physicians on salary, and have a single payer system, that is the way it will continue to be. (That being said, I think most physicians recognize that part of their charge is to help those in need. I even once heard a cardiologist I personally dislike as a human being…and referring to him as "human" is pushing it…take another doctor to task for refusing an uninsured consult in the hospital. “Ten percent of everything we do ought to be for free," he said. "It’s not like you don’t have food or your kid’s not going to college.” However, there is a world of difference between giving away 10% of your work…your “societal tithe,” as it were…and greater amounts. There are some studies that show ED physicians often give away over half the care they provide. I’d be quite happy to have that time, and money, back.)

So it seems to me that if we really want to achieve health care reform within the current context…and that includes not only expanding insurance coverage, but also getting patients the care they need…we should focus less on the payment plans and more on the physician. We need to find ways to get patients into the physician offices, and to make sure they get the care they need. Unfortunately the simple solutions are not very helpful. For example, I’ve heard people say that physicians should be required to accept Medicaid or unfunded patients into their practice as a requirement of licensure. But how exactly does that work? The burden will clearly fall more on primary care physicians than specialists, which is inherently unequal. And if we already have an epidemic of medical school graduates opting out of primary care to go into high-technology, high-revenue, stable lifestyle specialties, how will this practice impact care in the long run? And enforcement seems to be a problem as well. Will there be “financial police” to audit doctor’s office and decide if they’ve seen enough Medicaid patients or not? And while we might be able to entice physicians by raising reimbursement rates for patients on public assistance, what does that do to the goal of controling costs?

Crafting real solutions based on the key role of the physician requires more than a knee-jerk reaction. It needs to include a realistic assessment of why, despite the strong tradition of service to all, physicians choose to restrict their practices to certain patient groups. (There is more…a lot more…in play than just money.) It needs to include an evaluation of if there are, in fact, enough physicians in the right places and the right specialties to achieve the overall health care goals for the nation. And it needs to identify a set of operational, clinical, and financial incentives designed to entice physicians into providing care for patients who will now be covered by new expansions of Medicaid and “public option” programs, as well as to provide care to that percentage of the population who will remain uninsured.

Send in the clowns.

Changing Channels

I recently became aware of a physician colleague who claims to have the ability to channel those who have gone on to worlds beyond the grave. As he tells the story, he became aware of these powers somewhat gradually. Ten years ago, he started out with the idea that he would write a book about his conversations with dead celebrities. But he never seemed to make any headway until he realized that the conversations in his head were not imaginary, but real attempts by the spirits of said stars to communicate with our world. Once he let go of his scientific hesitation and accept the voices for what they are, he was able to write freely. To date he has produced five books on the topic, including, “Is There Comedy in the Afterlife?” in which Bob Hope returns for yet another NBC (Netherworld Broadcasting Company) holiday special.

I am truly fascinated by the concept of channeling, but not quite sure I can buy fully into it. While my level of spirituality tends to vary with my desires for immediate divine intervention (as I suspect does everyone’s, whether they admit it or not), I fervently hope there’s something out there beyond that which we see in the world around us and in the ether beyond the grave. But I’m not too sure about spirits channeling through any particular individual, especially when these wise spirits do things that make little sense. For example, if I’m Abraham Lincoln, I might channel through the Leader of the Free World who might actually be able to do something rather than through an auto mechanic in Cuba, Kansas. (No slight on Cuba, which is a lovely place, and only two counties north of the Ottawa County town of Minneapolis, which is the home of Rock City.) And if I’m Johnny Carson I’m going to use the best writers the afterlife can offer.

(This is my theory about the coming of the Messiah as well. When he comes…and I’m purposefully avoiding the argument of who that is or when he’ll show up…I can’t help but think his wisdom would dictate that he shows up in a major media markets on a weekday early in the news cycle. Seems to me there’d be a lot better chance of getting noticed than if he came back in a suburb of the Akron-Canton Standard Metropolitan Statistical Area. Of course, if you’re bringing the Kingdom of the Lord I suppose everyone would know in pretty short order, so maybe it doesn’t matter too much.)

But wanting to give my colleague the benefit of the doubt, I thought I’d try this channeling thing myself. So I took some quiet time and a beer, dressed in loose, comfortable clothing, turned down the lights and lit a Febreeze candle (for mood and to kill the smell of cat litter). I tried to clear my head (actually a remarkably easy task given the very few things that actually live in there) and closed my eyes, hoping for a voice from the afterlife to speak to me about those things I should know, those things that make life worthwhile, those messages I should carry with me to my friends and family so we can all live in warmth and love. And while it was hard to fully submerge my skepticism, I was gratified when I started to hear from the spirits of those who had gone before.

First Charlie Chaplin came to me. He said “

;

.
."

That was heavy, and I resolved to think about this and try to apply it to my own life. But I had no chance for reflection, as Marcel Marceau came by to let me know that, “


?
!"

But clearly there was a problem. Despite my best efforts, it was still hard for me to accept the reality of what was going on. The spirits of those who went before knew they had to talk to me in a language I would understand, in a religious tradition close to my heart. So Harpo Marx came to me and exclaimed, “
HONK
BEEP

HONKBEEP

WAHWAHWAHWAHWAH.”

My life will never be the same.

Status Quo

Heard last night in the hallway:

"I don't know what the big deal is about health care. Everybody's got health care now. They can all go to the ER."

Indeed they can. Which is exactly why we need health care reform.

Personal Responsibility, Policy, and the Pancreas

Let us all raise our glasses to the pancreas,
It has never been an organ of distinction --
Though it functions day by day,
In a most convenient way,
It has never had the glory that the liver gets.

Let us all raise our glasses to the pancreas,
Just secretin’ alkaline digestive juices,
Into the intestine
Just to neutralize the stomach acid
That could be remaining on the food

Hey pancreas, hey pancreas,
You are my favorite organ,
Hey pancreas, hey pancreas,
I can’t think of anything that rhymes with organ…

Pumpin’ out from the lovely Isles of Langerhans
Comes the insulin that regulates the sugar in the blood
And that’s why so high I rank it
And I’ll drop a note to thank it
May you never have a cranky pancreas!

Hey pancreas, hey pancreas, have a nice day!


- Heywood Banks, “The Pancreas Song”


Tuesday night I had two patients with the same diagnosis in adjoining rooms. In G-5 was a man in the mid-forties who had sudden onset of abdominal pain. On talking with him, the pain started suddenly that evening, and he had never had this kind of pain before. His social history noted that he drank 6-12 beers each day and had done so for years. He had never sought help for his problem, and had never been through an alcohol rehabilitation program before.

In the next pod was a slightly older gentleman who had been brought in by ambulance. His abdominal pain had started three days ago, and his use of alcohol had not dulled the pain. He had this many times before, and his old records proved that had been admitted for it on multiple occasions as well. When asked how much alcohol he drank daily, he simply groaned and said it was “too much.” That much did seem clear by the odor in the room. (Incidentally, we stopped saying that the patient has “alcohol on their breath” many years ago when the legal eagles pointed out that other beverages can give the examiner the same sensory experience, and to blame the aroma on alcohol without corroborating evidence was to possibly label the patient in error. So now we say that, “the patient has the odor commonly associated with the use of alcohol about their person,” we get a blood test to confirm it, we are uniformly right in our suspicions, and everyone seems much happier.) He had been to detox multiple times, but had always relapsed almost immediately upon his release from local residential programs.

Their shared diagnosis was pancreatitis. Pancreatitis is an inflammation of the pancreas, and it may occur for a number of reasons. People with very high serum quantities of lipids (such as cholesterol and triglycerides) are at high risk. It can also result from obstruction of pancreatic channels from gallstones or tumors, or from intra-abdominal trauma. But in the ED, chronic alcohol use is far and away the most common cause. Symptoms of pancreatitis most commonly include abdominal pain, nausea, and vomiting. Lab tests show elevations in amylase and lipase, enzymes released by damaged organ tissue. (Interestingly, in patients with chronic recurrent disease, so much pancreatic tissue is dead that there may be no enzymes left to release, and blood tests will look normal.) As the pancreas secretes enzymes responsible for digestion of carbohydrates, proteins, and fats, as well as containing cells that help to regulate blood sugar, long-term issues include malnutrition, diabetes, and severe alterations of blood chemistry. There is also a unique complication of pancreatitis known as pseudocyst formation, in which a fluid-filled cavity collects within the organ tissue. This is extremely prone to rupture and infection, resulting in even further complications. Episodes of pancreatitis are assessed using the Ranson Criteria, which was developed in Glasgow in the early 1970s. The higher the score, the greater degree of metabolic derangement and the higher the risk of complications and death. (Friends of mine from England are careful to note that the system was developed in Scotland due to the high rate of alcoholics. My Scottish friends indicate that any measurable score is simply a sign of weakness.)

The other key shared similarity between them was their financial status. Neither of them had any insurance, and so whatever care was to rendered was going to be on the taxpayer’s dollar.

But the main differences between them were equally key. From a clinical standpoint, one patient was potentially salvageable. By assuming responsibility for his own health, going to rehab and staying with the program, the first patient could halt the progression of pancreatic disease and have no further complications. The second has already demonstrated on multiple occasions his failure to follow through with the need to abstain from alcohol, had already suffered irreversible organ damage requiring intensive medical therapy, and with each admission sees his chances of continued survival fall. And from a policy standpoint, the care of the first patient benefits the entire community in keeping him active, keeping him working, and decreasing health care costs. Caring for the second not only incurs costs that should have been preventable if the patient had assumed responsibility for their own health, but also is likely to continue to place cost and resource strains upon not only the health care system, but also the social assistance sector of society as a whole.

I offer this story not only as an example of how doctors do, on occasion, actually consider their role as unwilling stewards of the taxpayer dollars, but to note that this issue of recidivism and responsibility is one of the significant “downsides” of our current health care system, and one that requires thought as we enter an era of health care reform.

The first question, of course, is why this scenario happens in the first place. Why do we not ask patients to pay a price for their actions? The easiest answer is that they already been held accountable in their loss of the good health. But I think that’s overly simplistic, because while it indicates we should feel sorry for them it doesn’t answer why we keep picking them up over and over again at our own cost.

I’m not a theologian by any means, I would speculate that one of the main reasons we continue to provide unlimited care for people despite their own worst intentions is because the religious traditions of this country hold a great belief in the power of redemption. While we may disagree on exactly how one becomes redeemed, most of us hold in common the idea at any time, one can turn away from our evil ways and resume a life of righteousness. Because this can happen at any time, and because the books are not closed on you until you leave this world for whatever comes next, there are an infinite number of chances to turn the soul back to the ways of good…or, in this case, to turn your behavior from that which jeopardizes health and inflicts costs upon others to actions which better fit our collective sense of justice.

I have no issue with the concept of allowing infinite chances for redemption. I believe that honest repentance and atonement for past evils both cleanses the soul and benefits others, and can do so right up to the moment of death. But if cost containment is a goal of health care reform, we have a hard decision to make. One choice is to accept the status quo and move on, recognizing that this portion of the battle to contain costs is necessarily lost (and will likely worsen as we see more illnesses related to behavioral-based health issues such as obesity). The second, at least in the context of justice within the health care system, is to limit the number of second chances one gets before publically-funded benefits are lost.

Don't get me wrong. I am not advocating for the withholding of care from people who genuinely need it, nor of rules or regulations which discriminate by diagnosis. But I strongly believe that if care is provided on the public purse, beneficiaries of that care must exhibit a certain level of responsibility that go with that privilege. I have no problem in the slightest offering someone free medications, rehabilitation services, educational counseling, and medical care when they are initially diagnosed with illness or injury, even if that problem is of their own making. I have no problem in continuing to provide the highest level of care when the patient has exhausted those reasonable means within their power to maintain their own health. And I recognize that there are those out there who would say this is not an issue of personal responsibility, but of cultural conflict, of prejudice (social, economic, racial, clinical, or educational), and of unclear societal expectations for individual behavior. (I actually would give some credence to the latter thought, because as a society we’ve never made it clear that there's any kind of personal accountability for your behavior as it determines the health care you receive.)

But I do have a problem in providing infinite care on the public purse for those who refuse to act responsibly in their own care. And I believe that if health care reform is to offer any expansion of publically-funded health care benefits or a “public option, that policymakers have an obligation to explore the limits of benefits within these plans and if benefits might ever be withheld through enforcing patient accountability. This is especially true if one of the goals of health care reform is to decrease the cost of care.

Granted, limiting benefits based on patient behavior is a lot easier said than done, and I hope to write more about what ideas have been tried, and the difficulties in implementing them, in a future post. In the end, there may not be a practical way to balance personal responsibility with health care reform. We may also conclude that the moral imperative for second chances outweighs the increasing costs of care. But for now, even to see our policymakers thinking about these concepts would be a start in the right direction.

The Flu Shot Truck

Last week I wrote a piece regarding the controversy regarding vaccines and autism, which seems timely given the recent release of vaccine against the H1N1 "swine flu." But worries about vaccine safety are not the only reasons why people don't get their shots. One is a fear of needles, which is my own personal albatross. While it doesn’t faze me in the slightest to take a finely honed 14 gauge tubular piece of stainless steel and ram it into whichever body cavity seems appropriate at the time, the thought of an infinitely smaller 27 gauge butterfly piercing my own this hide is simply excruciating (I’m getting woozy just thinking abut it).

While this is the kind of thing one in the medical profession hopes to keep to themselves, several years ago my aichmophobia (fear of needles or pointed things) became a very public event. During my tenure as Director of Health at the Kansas Department of Health and Environment, we were having a flu shot clinic for state employees. As the down-to-earth, ground-level leader that I was, I walked among the staff, encouraging the troops and eating the cookies set out for the patients without actually doing any work. (This is called “management.”) One of the public relations folks decided it would be a good idea to take a picture of me, the State Health Guy, getting his shot as well.

Mind you, this totally irrational crazy psychiatric needle thing is not something I share on a regular basis. So I looked for an intellectual, yet remarkably cool, way out. I kept stressing that as of yet, I was not in a high-risk group, so I didn’t want the resource wasted on me when it could be used for someone more deserving. That one was pretty good, I thought. Altruistic, willing to risk his own health for that of others. But they still wanted to get a photo, so we reached a compromise. It would look like I was getting the shot, but the needle would be capped and we would rotate just enough so that nobody could see the needle cap. That way it would look real, but we’d still be saving the dose for someone else. (Still holding that “public service” line, too.)

So I rolled up my sleeve, turned three-quarters to the left, put on my requisite public servant smile, and felt the pressure against my arm. Hard. Really hard. I guess you should push hard to make it look right. The photo over, I turned around to see the nurse put the bare needle into the red sharps box.

I don’t remember a whole lot after that. I remember saying “You gave me a SHOT?”, and my eyes must have opened wide because suddenly my peripheral field of vision extended from Salina to Venus. Then I was in a wheelchair, and I was asked if I wanted to lie down. I refused. Leaders don’t lie down. They do, however, sit quietly, pant loudly, become pale and diaphoretic, and experience a full blown panic attack, the last one of which I experienced when I had to ride a roller coaster in order to impress my soon Bride-to-Be (Note to son: Dad’s not going on Space Mountain this year. Or ever).

The following year, when I went to visit the flu clinic, no shots were offered. Apparently I began hyperventilating simply walking in the door, and was directed immediately to a cot without any prior conversation.

While influenza vaccination is currently on everyone’s mind, it is only a small piece of the overall picture of immunization. Vaccination rates in this nation are not what they should be. We have national targets for immunization rates; The Healthy People 2010 Project of the United States Centers for Disease Control suggests that by the end of the decade, 80% of children should receive the minimum recommended vaccine series prior to school entry, and 90% of those adults and children at risk should receive influenza and pneumonia vaccine. (For the record, the minimum recommended vaccines for children as measured by the CDC’s National Immunization Survey is the “4:3:1:3:3” series consisting of 4 doses of diptheria, tetanus, and pertussis vaccine; 3 doses of polio vaccine; 1 doss of measles, mumps, and rubella vaccine; 3 doses of Haemophilus influenza B vaccine; and 3 doses of hepatitis B immunization.) There are also additional childhood immunizations advised to provide further protection, including those for pneumonia, chickenpox, and hepatitis A. Young women may also benefit from administration of human papilloma virus (HPV) vaccine in an effort to prevent cervical cancer.

While these are goals, they do not necessarily equate to complete protection for the population. To achieve population immunity (also known as “herd immunity,” the phenomena where protection a given segment of the population prevents disease in the group as a whole…and probably why everyone instantly understands why airline cabins are also called ‘cattle cars”), an immunization rate of 95% should be our aim (no “shot” pun intended).

Kansas had been especially concerned with childhood immunization rates, and for some time I was pleased to be part of a project known as Immunize Kansas Kids. It’s an undertaking to find out what factors make an immunization program successful in local communities and the state as a whole. While Kansas had been making solid progress in raising our immunization rates, there was still a long way to go to reach our own goal of 90% coverage for the recommended childhood vaccines.

What we found...much to our chagrin, I think…is that there is no easy answer. Some of us thought that state financing of all childhood vaccines was the key, but there is no good link between the way vaccines are financed on a statewide basis and immunization rates. Another thought was that a high reliance of the local public health department (as opposed to within physician’s offices) for vaccination depressed immunization rates, but some of our counties with the highest rates are those without any local physician. Maybe it was a function of geography and transport, but rural areas generally show higher rates than urban ones. A statewide electronic immunization registry was felt by some to be the solution, but while it makes the immunization process more accurate and consistent it doesn’t bring children in the door for shots. Access to care is likely a factor as well, but it’s hard to tell exactly how that plays out in the context of the other factors described. Of course, one of the problems with any study of this kind is that the people to talk to are those who don’t get their kids immunized on time. But since the children don’t get immunized, those families don’t appear on any record until they have to get the shots just before school, two to three years after the optimal window for care.

One thing that seems to be missing from the discussion is the potential role of prehospital EMS services in immunizing the community. While you could argue that doing preventive primary care is not part of the mission of EMS (and I’d argue back at you that any health care professional should morally be concerned with preventing the very suffering that employs you), logistically EMS is ideally suited for immunization efforts, especially in rural areas where "down time" between calls are often prolonged and where it's not cost-effective to run large-scale vaccination clinics. EMS fixed costs such as the unit, the crew, and the station are constant, and previously non-productive time can now be used as an enhanced community resource, an expanded demonstration of paramedic abilty, and even a potential driver of revenue.

That being said, the idea of EMS services, especially those that are fire-based, giving immunizations is not a new one. Many fire stations dispense flu and pneumonia shots to elders every year during the late fall. It’s a community service, there’s cash and/or Medicare reimbursement involved, you never have to leave the comfort of your work “home,” and immunizing adults plays to the comfort level of EMS staff.

But just think of what impact one could make in children, which is our real target population. The mobility of EMS equipment and expertise means that the vaccines can be taken to where the children are, including disadvantaged parts of the community or labor camps in rural areas. EMS is often not perceived as intrusive or punitive in the same fashion as law enforcement, so access to children of migrants or those here under other circumstances may be enhanced. (While the issue of immigration is beyond this discussion, I do agree with Arkansas Gov. Mike Huckabee who noted, in a debate about immigration reform during the last Presidential campaign, that this nation should be above punishing the children for the sins of the father.)

I would suspect that local health departments would be more than willing to work with EMS staff to expand the outreach of their immunization programs, and may in many cases be able to provide supplies and materials, or even reimbursement for services, using their own federally and state funded resources intended for those in need. Participating in such efforts also gives EMS crews more comfort in assessing and caring for children, which can only benefit the total skill set of the paramedic. Importantly, the increased level of visibility that comes with this level of community involvement reinforces the need for support of EMS services at a time when fiscal considerations are putting the industry at risk.

I hope that EMS services will use the opportunities presented by immunization efforts during this year’s influenza outbreak to expand their reach to the full spectrum of immunizations. Just don’t ask me to come by that day. And if you do, have the cot ready.

Larry Craig Lives Again

Every now and then something you think that has been rightly dead and buried raises its head for a final gasp. Most often this happens in an extremely roundabout way. So it was while watching ESPN discuss the rightful place of Bosie State in the BCS rankings that I remembered that there’s blue turf in Bronco Stadium. The turf is actually Tidy Bowl blue, which made me think of restrooms. This, in turn, brought me to the past escapades of another Idahoan with national exposure, Senator Larry Craig. (“National exposure.” Ha!)

When the story first broke, I tried to maintain a respectful distance from the whole “Do You Know Who I Am?” thing. What a man does in his stall is his own business, and the good one-liners were just waaay to easy to come by (the best jokes are the ones you work for). But as someone who traveled a great deal, an unashamed science nerd, and a true believer that one is innocent until either proven guilty or I think you are, I felt it was my obligation test the “wide stance” hypothesis of the Idaho legislator.

Without going into graphic detail about the scientific method, nor of the very complicated statistical work that went into my research, it turns out that the wide stance hypothesis is fundamentally precluded by the nature of what’s going on in the water closest (I’m going to be working on all kinds of restroom euphemisms throughout the few two paragraphs, so be forewarned). When you enter the Palace of Relief, you presumably do so for a compelling biological reason. The most common response to this need would involve sitting down. Before you do, however, you have to let down the trousers in order to accomplish the task. When you do, it turns out that the waistline of the trousers, falling to ankle level, automatically restricts the lateral motion of the feet and lower legs to the dimensions of the waistband. You cannot, in fact, move your feet apart any wider in a “stance” than the distance from one hipbone to the other. And if the girth of your hips is that wide, you wouldn’t fit in the booth to start.

In fairness to the Senator, there are two ways you can accept the “wide stance” hypothesis and have it make sense. One is to face the porcelain in order to accomplish a different kind of excretory task, as you might do if all the stand-up units were in use. In this context, however, it would take a superhuman, bilateral medical-collateral-rupturing effort of valgus stress to the knee to adopt a wide enough posture to let your foot drift under the edge of the adjoining cubicle, and you can imagine what that would do to your “aim,” as it were. The other is to eliminate the waistband issue entirely and simply sit free of all trousers or undergarments, which I think is a suspicious proposition at best.

(Those of you who had been following the story may also be aware that the Senator had s also been alleged to have had “relations” after making eye contact at the standing metabolic repositories in Washington’s Union Station. I opted not to conduct the same sort of research on this proposition, being a firm believer in the “eyes straight ahead” theory of public deployment of bodily wastes, with the possible exception of when the function is performed in snow in which case it is perfectly acceptable to look around to see if anyone’s watching while you write your name.)

Therefore, I was forced to conclude that the Senator’s indiscretions were non-accidental. I do feel for him…representing a state known for pristine wilderness, wonderful rafting, white supremists, and the world’s most flavorful tubers, what could drive a man to seek romance in the Minneapolis Airport? And yes, the hypocrisy between his public statements and his personal life are disturbing, but we’ve all kind of been there. I would wager we all have habits or desires we know are wrong. So no matter how much comfort it would give me to see certain individuals whacked by the business end of a flaming beer truck…and believe me, the comfort would be great…I still know that it’s wrong and would never act upon it. Moreover, I will vociferously deny ever wishing this upon…well, you know who you are. And soon every one will know, unless the governments of this world give me…hmmm…ONE MILLION DOLLARS (insert official mad scientist laughter here). Isn’t that right, Mini-Me?

Halloween 2009

I was invited to a Halloween party last week and was struggling with what to wear (I thought I might come as a caring and compassionate physician, but was told that someone had already beat me to it). So it was off to the seasonal Halloween Discount Worlds in the Abandoned Big Box Stores for an expedition into holiday spending.

It had been years since I had gone shopping for a Halloween costume, mostly because it had been years since I had been to a Halloween party. It’s not that I have any objection to costumes or parties. In fact, during my tenure as the State Health Officer in Kansas, I dressed up as both an intestinal polyp and as Major Molar. And while I really like going to parties, working an ED schedule and the inevitable fatigue of child rearing and middle age eventually take their toll.

So I was totally unprepared for the wonders of the modern Halloween Discount World. But I was glad to see that despite those who see Halloween as an unholy day, spiritually was alive and well. People were dressing as pastoral leaders like Popes, Rabbis, Priests, Nuns, and Sexy Nuns. All was well in the world.

The divine presence was lost, however, in the next aisle. This could best termed Groins Alive. These are male-oriented costumes whose greatest asset seems to be the ability to repel any vaguely attractive girl it encounters. These costumes feature the gynecology group of Dr. Howie Feltersnatch and Dr. Seymour Bush (names embroidered on the lab coat…their parents must be so proud), the Chief Instructor of the Mike Hunt Diving School, and a Mr. Hunglow who plays for the New York Yankers. (This reminds me of my Vietnamese colleague, who is fond of saying in his singsong accent, “Someday we go to strip club and you find out why girls call me Hung! Hahahahahaaha!”) Slightly more creative, and significantly less offensive, is the Chick Magnet outfit, which consists of a large stuffed magnet-shape pillow worn around the neck a bunch of puffball fowl glued to it.

The Breathalyzer and the Big Top Circus costumes featured a similar theme. The former is essentially a box you wear around your torso, with the “inlet” valve, if you will, strategically located around the groin area. (There is no guidance offered on the package as to who should take the test…apparently, it’s a matter of personal preference.) The latter is a kind of skirt shaped like a circus tent that you wear around the waste. The circus tent opens in the front, according all a view of the performing elephant. (I’m deliberately avoiding all references to the name “Jumbo” because I suspect that for those who would wear this kind of costume, the term need not apply. I am avoiding any references to “peanuts” because while this term may, in fact, be an accurate reflection of the wearer's assets, I can internally gloat while exhibiting public sensitivity.)

There are other outfits as well. There are the adventure-themed costumes like gladiators, pirates, soldiers, knights and cowboys; the animal costumes like pigs, penguins, and cows with squirting udders; and the truly fun costumes like pieces of fruit or the one where there’s a blow-up ostrich around your waist and your legs stick through so it looks like you’re riding the ostrich (riding in the correct form of the word, to be sure). And then there are the ones that are so tasteless as to have no redeeming value (the Blind Referee, complete with cane) or the ones I simply don’t understand (the Tightey Whitey, which seems to be a large pair of white underpants extending from groin to neck). But while there are dramatic costumes, eerie costumes, and funny costumes, at least they bear some resemblance to what they purport to be. Which brings us to the Super Mario costume, which does not look like a little mustached guy in red overalls and a jaunty yellow cap, but instead looks like Aladdin with the baggy pants and open vest topped by a hat which can best be described as a cross between the Hagia Sophia and a hallucinogenic mushroom.

Interestingly, female costumes show nowhere near the same range of styles. All of them…and it’s a bit of a generalization, but not much…are in the “Sexy (or synonym thereof) x” variety, where x = a character. (Like the way we worked some algebra n there? We strive to be both entertaining and educational job.) So we get Sexy Leprechaun, Flirty School Girl, Hot Pirate Wench, Luscious Demon Mistress, Buxom Geisha Girl, and the like. Certainly there are no realistic costumes like Frustrated Housewife, Underpaid Waitress, or Desperate Botox Silicon Cougar. What I found most intriguing is that there is an entire line of “Sexy x” costumes available for the oversized girl as well. I applaud this move as long as we recognize that at a certain point, bigger is not better. My experiences during Bike Week in Daytona have taught me that once you break 300 pounds, neither fishnets nor chaps are attractive. This goes for the guys as well.

To be fair, there are no realistic guy costumes, either. You never get a chance to portray a Dead End Manager or Petty Bureaucrat or Convenience Store Worker or Errant Weatherman. The latter is a shout out to my friend Jeremy, who is a local television weatherman…I’m sorry, that’s meteorologist…in Topeka, Kansas. When I worked an ED shift that got out at 10:30 and his last broadcast ended at the same time, we’d get together at 11 at a bar called Pigskin’s that had half price food after ten (translated as “eat this or we have to throw it out, and we may as well make some bucks on it while we can.”) I think Jeremy felt safe at Pigskin’s. We’d been out places during the day where people would come up to him and accuse him of misreading the entrails of the climate sheep, and he would very patiently explain to them the difference between a forecast and a prediction, and everyone would be thrilled that a TELEVISION PERSONALITY spent time talking to them. At the bar, it was much more likely that someone would come up to me and scream “HEY! I STILL GOT THAT RASH AND MY GIRL WON’T TOUCH IT ANYMORE!”

One costume I didn’t find was the Illegal Alien. You may have heard of this, as it recently was in the news:

A Southern California immigrant rights group has asked Target stores to stop selling an "illegal alien" Halloween costume it says is offensive to immigrants.

The costume…features the mask of an alien with a green card and an orange jumpsuit with "illegal alien" written across the front.

Angelica Salas, executive director of the Coalition for Humane Immigrant Rights of Los Angeles, says she wrote an e-mail to the Minneapolis-based retailer Friday calling the costume "distasteful, mean-spirited, and ignorant of social stigmas and current debate on immigration reform."

(Associated Press, October 16, 2009)

I agree that the costume is clearly inappropriate. In fact, I believe it is our solemn duty, as Good Americans, to welcome any green-faced antennaed aliens into our society with open arms. We must embrace them and share with our national blessings so we all, together, might realize our fondest hopes and dreams. Then, and only then, is it appropriate to send them out to a Secret Government Lab in New Mexico and dissect them to see what makes ‘em tick. And we should do so wearing snappy serapes and sizeable sombreros, all of which are readily available at the Halloween store and apparently cause no one any grief.

Costumes are not limited to the human variety. There is also a large selection of costumes for dogs. I always wondered about people who dressed up their dogs for Halloween until I became the pet of a beautiful young lady Shetland Collie who bit potential human female rivals for my affections and trained me to drop food on the floor at strategic intervals. In exchange, she would occasionally submit to wearing holiday gear. (Actually, getting a costume on a dog was a lot easier than I thought. The first time I saw them, I thought you had to actually get their little legs into the outfits. Turns out you just tie them around their necks.) The Princess apparel was tolerated; the Cheerleader sweater found the pom-poms devoured within moments (“they LOOKED like food”). The best dog costume at the Halloween store this year was the Yoda outfit, with a brown sack-like robe you tie around you dog’s neck and green headgear that I’m still not sure stays on without superglue. (“Good it is that my lips do not you kiss me on. Know not what I have been eating nor know what licking I have been.”) This year’s effort at animal couture has been the application of a jester hat to the Residential Cat. That lasted about three minutes, but the look of utter disgust on the feline face was well worth the five bucks. And I’ll recycle the hat and put it on my six month old nephew.

(Admittedly, in a shameless plug for which I am receiving no reimbursement, the best dog costumes are at Target. They have a lobster suit that’s a killer.)

Of course, it’s not all costumes at the Halloween Store. There are the other accoutrements of the holiday, including all varieties of tombstones, snakes, spiders, rats, assorted bagged vermin (30 bats for $7.99), disembodied organs, hacked-off limbs, severed heads, necrotic fanged infants, axes, swords, scythes, plastic vibrating chainsaws, and other cheery holiday fare. Not a lot of distinction, however, though I was favorably impressed with the motorized rubber rat tugging at the throbbing plasticine heart, as well as the life-sized Hannibal Lector display that kept flipping off its mask and saying things like “I’m having a friend over for dinner.” (The gourmet food industry must have hated the Silence of the Lambs. Pate can be a pretty tough sell to start with, promotion on Top Chef notwithstanding, but now…) And for those who wish to celebrate in a literary fashion, you can get both a glow-in-the-dark skull and a stuffed raven so you can quote both the Bard and the Baltimorean at the same time.

But after all this shopping, I realized I had the perfect costume at home. And at the party, I realized that the best costumes, of course, are the ones you don’t expect. Yes, there was the requisite guy with the Barack Obama mask, but he carried a briefcase full of beer that he called his “stimulus package.” (He could have called something else his “stimulus package,” but he properly acknowledged that you have to respect the office.) And then there was the couple who were dressed in normal clothes, but had a necklace of rope attached to a flat wooden piece of playground equipment. (I’ll let you figure out that one…took me about a half hour myself.) And I learned many other useful things at the party, including that the people you work with actually have bodies when they’re not wearing scrubs, and that it’s weird to see three different people all wearing Brett Favre Green Bay jerseys with foam cheese on their heads in the middle of Florida, and that if the ability to get a whole jello shot out of a medicine cup with your tongue is a measure of intimate prowess I may as well give it up and go home.

Which I did…until next year.