2 posts tagged “being a doctor”
Start Rant
OK, now that I caught your attention, I need to explain (before some of the wacky folks who visit Flea start thinking I am in their camp). First off, aside from germ theory, sterile technique, and public sanitation, I think immunizations have saved more lives and improved the quality of more people’s lives than nearly any other scientific discovery. Second off, I do not think there is any merit to the whole thimerosal/MMR/autism “debate.” I think vaccines are safe and should be used whenever possible.
So why say I hate immunizations? It is the business side of being a doctor that hates them, not the medical side. Immunizations:
- Are the largest line-item on our budget apart from staff salaries.
- Have incredibly small margins of profit, so any rejection, failure to pay by either patient or insurance company can turn our small profit into a loss.
- Are constantly changing, so it is never sure which immunizations are covered by whom, making it hard to know if we should bill the patient up-front or bill insurance.
Let me give a few illustrations.
Influenza Vaccine
It used to be that the influenza vaccine was something that we could not get our patients to take. “It just gives me the flu” was the common response when we tried to get patients get them. No matter what the evidence showed, patients just did not want to get that vaccine.
Then something strange happened. There were a few large flu epidemics and subsequent fear of a pandemic made people suddenly want to get the flu vaccine. Patients wanted flu shots, and our office ordered a large quantity of them for the flu season of 2005-2006.
Unfortunately, that was also the season when there was a manufacturing problem with the influenza vaccine and we suddenly could not get them. Now patients, instead of angrily refusing to get the vaccine, were furious that they could not get the vaccine. We actually had patients (who were not at high risk for influenza complications) scream at us because we would not give them a flu shot due to the fact that we were saving it for those who were at high risk.
This past year we again ordered a large quantity of vaccine, being assured that there was no manufacturing problem. We got our first 100 doses in September, but then were told it wouldn’t be until the end of November that we would get our next installation (of the 600 we ordered). Again we had angry patients.
To make matters more frustrating was the fact that Wal-Mart, Walgreens, and other pharmacies had plenty of flu vaccine. Why would we have problems getting them delivered to us while these businesses have plenty? I never got a good answer for that, but I have my suspicions that it regards a word that begins with “dol” and ends in “lar.” In any case, we canceled the remainder of our shipment because we did not want to get stuck with 500 doses and no patients to give them to. We would lose serious money from doing this - besides, we could just tell patients to get them at Wal-Mart.
The other problem we face is the use of influenza vaccines in children. The current recommendations are that children from age 6 months to 5 years of age be vaccinated. Yet, as Flea summarizes in his blog:
Shinga over at Breath Spa for Kids tells us about an analysis and comment article in BMJ on the efficacy and effectiveness of influenza vaccines.
It turns out that the inactive vaccines we fleas give to kids under 6 aren’t all that effective. For patients 6-23 months old the vaccine is no better than placebo, according the Cochrane Database of Systematic Reviews.
Live vaccines perform better, but we can’t give them to kids under 6 years of age.
The author of the BMJ piece, Tom Jefferson (presumably no relation to the founding father, but one never knows) concludes with not a small amount of disappointment that inactivated vaccines have little or no effect on the outcomes studied in the literature. In many cases, Jefferson notes, the methods used in these studies are poor.
At the end of the day, according to Jefferson, we need better study designs. In the meantime, we ought to ask ourselves why we make policy based on such crappy evidence?
Okay, I’ll ask the question: Why do we make policy based on such crappy evidence?
So we have the live vaccine (the nasal spray) that works well but is not covered by many insurances (and runs around $50). You can only use that between ages 5 and 50 - those who are least vulnerable and hardest to access. Then you have the less effective killed vaccine (the flu shot) that is the only one you can give to the high-risk populations. The low-risk people don’t want to pay the high price of the nasal spray (especially if insurance does not pay), so they use up the supply of the high-risk population.
Sigh.
I am not looking forward to flu season next year.
Adolescent Vaccines
“Some insurances don’t pay for adolescent vaccines,” my partner informed me yesterday. I wanted to give a girl the HPV Vaccine and the TDaP (The new vaccine for tetanus, diphtheria, and pertussis for teens and adults). We have to make these patients pay before getting the vaccine because we are not sure they will be covered by certain insurance companies. There have been several new vaccines for adolescents/pre-adolescents recently, including:
- Gardasil - the HPV vaccine. This is recommended by the AAP and CDC to be given to all girls starting at age 11. While there is a big controversy surrounding the vaccine, that is not what I want to address. The real problem for us is that it costs around $120 per dose, requires three doses, and is not covered by all insurances.
- Menactra - this is the meningiococcal vaccine. Meningiococcus is a bacteria that causes a devastating form of meningitis in teens and young adults (occasionally in younger children). It is on every doctor’s “dread” list, as it very rapidly kills previously healthy young people. This new vaccine is quite effective to prevent this disease and is recommended at age 11. It is required for entrance to college, yet many insurance carriers do not pay for it.
- TDAP - This vaccine is the tetanus booster that also treats pertussis, the bacteria that causes whooping cough. Studies have shown that the rate of pertussis in adults has steadily increased over the past number of years and this new vaccine helps prevent that. Yet insurance still does not reliably cover this.
On cue, I got the following communication from the AMA as I was writing this:
The AMA and the American Academy of Pediatrics co-hosted a meeting of key stakeholder organizations last week to address many challenges for patients who need vaccinations and the doctors who provide care for them. One of the outcomes of the Immunization Congress is to establish several task forces to pursue solutions to a specific set of problems surrounding access to vaccination, medical practice costs, public health system shortfalls and how vaccines are financed. Participants included 140 government and public health officials, manufacturers, distributors, private payers, advocacy organizations, pharmacy groups, community immunization providers and medical societies. In related news, physicians who are experiencing problems with inappropriate insurance reimbursements for immunization administration and vaccinations are encouraged to file a compliance dispute under the multi-district litigation (MDL) settlements with six of the nation’s largest health insurers. This process has proved effective in making vaccines more available to patients, particularly in North Carolina, where several outbreaks of meningococcal illness on college campuses created demand for a vaccine that had been prohibitively expensive for students.
Finally, the insurance reimbursement for these vaccines is often at or below the cost it is for us to buy the vaccine. We can (and do) make it up with “administration costs,” but end up having to raise the price for an already expensive vaccine just to make a profit.
So to summarize:
- Immunizations are wonderful things that save lives and should be used more, not less.
- Doctors have to buy the vaccines at very expensive rates and may not be paid by the insurance company, forcing them to charge the patient up-front or risk losing any profit.
- The large number of new vaccines has made this situation far more confusing for patients and physicians.
- Insurance companies capriciously set rates that are often not reasonable. They often continue not to pay for vaccines that are either required (for college entrance, for example) or greatly advantageous for patients.
- Flu season has become a yearly debacle for my and many other physicians’ offices.
Rant completed.
Today I am finally starting to resume most of my normal daily activities after getting my gallbladder removed last Tuesday. I tried to follow the advice of my doctor - given the fact that many doctors “make the worst patients” - I did not want to do stupid things for the sake of being “tough.” Yet I find myself wrestling with the feeling that I am taking it too easy, taking advantage of the fact that I had surgery so I can just sit around and do nothing (something I really like doing from time to time). I don’t want to be too “tough,” but I also don’t want to “be a baby.”
This is not the first time this has come up. Five years ago I was with my family in Puerto Rico. It was the first real big trip we had taken as a whole family (all six of us). I had planned for us spend some time on the east coast, some in the rain forest, some on the west, and then end up near San Juan in a nice hotel.
The first part of the trip was good - although the degree of poverty we saw was unexpected for us. We enjoyed the beach, and the rain forest was especially interesting for us. We traveled to Ricon’, a surfing Mecca on the west coast of the island. Our hotel was reasonably nice, and the beach seemed especially good - with big waves crashing in right at the shore next to the hotel.
On the first full morning in Rincon’ I made a point to play a with the kids. The waves were up to six-feet high and crashing in right at the beach. We would stand and let them knock into us, or we’d run to the shore so the waves wouldn’t get us. The kids were having a good time, but were tiring and wanted to play in the pool.
I decided I would try my had at body-surfing, something I had never had the chance to enjoy. These seemed to be perfect waves to learn on, so I went out to ride. By the second ride in, I was getting the hang of it. I would wait for the wave to crest and start swimming as hard as I could. The wave would push me ahead, and I would end up sliding in on the shore.
The next wave I rode on was my last. I caught one of the bigger waves I had seen and began to ride it in. I had caught it perfectly. The sound of rushing water filled my ears and the thrill of riding the wave was wonderful. My excitement was short-lived, however, as I was suddenly slammed down into the sand of the beach. I put my arm up to protect my head, but my face was ground into the sand and I felt a pain in my neck. I moved my feet to make sure I had not injured my spine; they moved. My right shoulder jolted me with unexpected pain. I stood up and walked in, arm dangling by my side.
“What did you do to yourself? Your face is bleeding!” someone shouted at me.
“My shoulder,” I said, “I think I’ve dislocated it.”
One of the patrons of the bar (which extended nearly on to the beach) told me he had dislocated his shoulder before, and knew how to get it back in. The throbbing pain begged for me to do something to fix it, so I followed him as he guided me to lay face-down on a pool table.
Others got wet cloths to put on my face, which was dripping blood. “Do you want a beer?” Someone asked, hoping it would ease my pain.
I only could moan in response as my shoulder-expert put down his drink and started pulling down on my shoulder. It did not hurt too much, but nothing felt at all better after a few attempts to put my shoulder back in joint. I told him to stop as others ran to call an ambulance and notify my wife.
The hotel manager agreed to watch our kids as Terri rode behind the ambulance as we sped to the nearest big city. The roads were bumpy, and each jolt sent new pain from my shoulder.
The experience at the hospital is a blur to me now. In Puerto Rico you are supposed to bring your own bed linnens to the hospital, so I sat in the cold ER with a paper blanket, caked in blood and sand. They gave me some Demerol, so I faded in and out for the next few hours. I remember sitting in a waiting area watching soap operas in Spanish, laying next to some prisoners in chains. I am not sure why they were there. I remember laying on the x-ray table as the technician tried to coax me to move my arm in positions it refused to assume.
“Dolor! Mucho Dolor!” I cried out in some of the few Spanish words I knew, as she tried to move my arm so she could get a better x-ray.
I had fractured my humerus in the region of the “surgical neck,” which is quite high up on the bone. As I fell and put my arm to protect my head, my arm was jammed into my shoulder, resulting in a compression fracture of the joint. The local orthopedic surgeon was not sure if it would require surgery, but I had already called some friends back in the US and had an appointment waiting for me when I got home. I wore a shoulder-immobilizer for the remainder of the trip, and my wife did her best to hold things together.
I did not need surgery to fix it, as it turned out, but it took nearly four months to recover from the injury. I could not lie down flat for over two months due to the pain. When one of my colleagues told me of his quick recovery from a fractured humerus the year before, I became very self-conscious that I was somehow not handling the pain well. My orthopedist reassured me that my friend’s fracture was not nearly as high on the humerus (it was mid-shaft), and so much easier to recover from.
The big lesson that has stuck with me from this instance (other than the “bring your own sheets” rule in Puerto Rican hospitals) is that it is hard to be a patient. Here I had a severe fracture of my shoulder, and a very good excuse to be in pain. I felt, however, very self-conscious about the degree to which I complained and the time it took me to get better. Why should it matter to me? The problem was: it did.
A good portion of my job is to listen to people’s complaints. They come in and tell me what is wrong, and I do my best to make things better. My experience with my shoulder (and my current experience with my gallbladder) teach me to be sympathetic to the emotions my patients may be feeling. They feel just like I did. They are not sure if they are over-reacting or under-reacting to their pains. This is even worse with people who have psychiatric or less-defined physical conditions (such as fibromyalgia). My patients are looking for me to reassure them that they are OK in their response.
What about the times when I do think that they are over-reacting? My experiences have taught myself that I can’t judge them too harshly. It is hard to know how to react. You want people to know that you do have pain, yet you don’t want to make too much of things.
So now I make a point to say things like: “I’m glad you came in for that,” or “Yes, it seems like you have really had a hard time.” I know how important it was for me - with a clearly painful injury - to hear the reassurance that I was OK to be feeling like I did. I don’t want to make it any harder than it already is to be a patient.
