Mexico Medical Student |

I know I haven’ t been good about posting GR updates, but there’s no time like the present with The Blog That Ate Manhattan (TBTAM)’s Seinfeld edition of this week’s best of the medical blogosphere. Check it out!

Happy Birthday America! I wish I could get you a present you’d like, but all I could afford was this stupid card. Besides, what do you get such a refined, stately woman past 230 who pretty much has everything? (rumor has it you are far, far older, but I don’t think you look a day over 150)

Many lament what’s become of you in recent years, abused by caretakers with little conscience. While I, too find your recent treatment deplorable, I trust the situation will get much better soon. Besides, you’ve been through far worse before, and you’re still here.

And God pray, you always will be. Happy Birthday.

Today is Canada Day!  And in honor of a blog friend (to whom I won’t link so there’s no inappropriate association, but s/he knows who s/he is) I post this funny (language NSFW) to celebrate along with:

Obviously, this is from South Park, but this time Canada strikes back!  You hear that, buddy?  Oh, I’m not your buddy, friend?  Well, OK buddy.

Believe it or not, YouTube was full of bum links for this, and obviously the copyright bots are out in full force for something like South Park, so this is my own copy and is being hosted locally.  I’ll keep this post up for a day or so then consider taking it down before the lawyers start sending C&D letters.  Happy Canada Day!

Dr. Val Jones at Revolution Health yesterday wrote a scathing review of freeMD.com, a site that offers to triage a person (for free!) and determine if they need to see a doctor. Our conversation actually started on Twitter where I read that last part to mean, “alerts you to seek medical attention.” I had reviewed a site like freeMD.com about 6 months ago and thought I’d already seen it (I can’t find the URL for the site I thought it was, but it was vastly different, focusing more on disease education than decision-making). I played devil’s advocate for Dr. Val’s test case, a female with abdominal pain (read her post for details), by saying that using a tool like freeMD could very well be a good thing, causing someone to seek medical attention for a condition they’d not thought of (ectopic pregnancy) that could very well warrant medical attention. She has since made some more comments, all extremely critical, and I thought I should finally go and see what the hubbub was about.

The first thing that struck me (apart from the realization that it was a different website than I thought) was the founder of the site, Dr. Schueler, in a video stating, “I’ll help you decide if you need to see a doctor and why.” Already, my alarm bells are blaring. We’re not even talking about a physician encounter via IM, email or other faceless medium–we’re actually talking about a disembodied algorithm given the look and feel of a doctor “there for you.” The whole thing makes every attempt, down to the good doctor reading the text questions in a video (marketed as “Breakthrough technology”) to give you the false security that a real doctor is guiding your care. To make matters more slimy, the footer of the website has the following disclaimer:

freeMD is provided for information purposes only and should not be used as a substitute for evaluation and treatment by a physician. Please review our terms of use.

Why doesn’t Dr. Schueler speak THOSE words just as clearly as “I’ll help you decide…?” Perhaps because the whole incongruous nature of the site, the entire clashing dichotomy is that FreeMD markets itself to be a unique service in healthcare yet disavows itself of the veracity of its own advice.

The Happy Hospitalist did his own mock patient for this site, and it was a doozy. Happy and others are intelligent, experienced physicians who can come up with all sorts of clever zebras to outwit the system. I’m just a med student unable to draw from a well of complicated experiences; nevertheless, I find this approach pointless. Happy’s mock 70-year-old pt in ARF is unlikely to be at home clicking on a website, as would anybody worthy of being in an ICU, volume depleted, electrolyte deranged, in respiratory distress, etc. FreeMD is obviously for 1) a younger, presumably ambulatory crowd, 2) people who would already go to the Internet to research their problem in the first place. I fit that bill, so I put it through its paces. My findings after a few rounds:

• Questions are often “yes” or “no” with no ability to say “I don’t know” when that lack of knowledge is significant. Asking a woman “are you pregnant” or “did you miss your last period” when they are irregular in the first place (and without asking if they are regular) is such an example.
• Questions such as “Do you use cocaine (yes/no)” can be replied “no” when the person uses meth or any other number of stimulant drugs that would elicit similar results.
• As in the above, questions don’t go from general to specific as a normal H&P would proceed but pulled out heuristically from a database of questions at random levels of specificity. Had I been asked if I used illicit drugs first, I could then be asked which ones, or “no” would skip the whole hierarchy.
• Most egregiously, in no example was I ever asked about prescribed, pharmaceutical drugs. How can this thing triage anybody without taking to account the medications they are on? Give me a break. This is a dealbreaker in the first degree.
• A severe headache that’s described as the “worst I’ve experienced” is immediately shortcut to the end of the interview with a possible subarachnoid hemorrhage. Whoah! While I applaud the good doc for not letting a serious one like this fall through the cracks, no question of hypertension, trauma, or other medical history had been made yet. I even said the headache did not come on suddenly (and how “sudden” is that? one day? one hour?). And shockingly, no attempt to quantify pain (”worst experienced”) seems to be a real oversight for an EM physician where pain control is at the forefront of almost any triage.

OK, like I said, I’m just a med student. I’m not trying to outwit the system, yet even I can see how this thing needs serious work. It smacks of a tool that could do some good someday (yes, I see the “beta” in the upper right corner) but is a hammer looking for a nail at best, and irresponsible at worst. While writing this, I saw that Dr. Schueler responded on Dr. Val’s site and said that this tool is not attempting to arrive at a true diagnosis and while far from being perfect, it’s much better than an uncontrolled search of the internet at large. I say that for a large portion of the population, this is probably true. But again, one of the biggest offenses this site makes is an unmistakeable intent to make the patient feel like they were evaluated more thoroughly because a doctor in a white coat is “talking” to them. Take away the touchy-feely schtick and my respect for a tool being transparent about what it offers jumps up several notches. Add to that the glaring holes in logic–clinical and heuristic–that even I can see on first blush, and I’d ratchet back the “breakthrough” rhetoric in a serious way.

I haven’t been as fire-breathing as Dr. Val mostly because I want a site like this to have a place–a proper place–in the ability of patients to have an informed choice. Too many people use the Interwebs and find tripe from the likes of Kevin Trudeau, Reiki shamans, and other snake-oil scammers. At least this is based on some real protocols/algorithms used in medicine. The difference is that those same algorithms in a real clinical setting are never removed from the human element wielding them with clinical judgment. The marketed need of a physician connection is something that needs to be filled by primary care. They should be the ones an unsure patient calls, receiving the expertise of a “live” doctor that knows their history and medications to say, “Come in right away,” “Go to the ER,” or “Come see me about this in the next few days.” I’m sure I’m being naive about this point as a student not able to take into account all the financial issues of this, but Dr. Schueler sure isn’t doing this for complete altruism, so I can’t be completely wrong. Leave a comment telling me what you think.

(P.S. I commented on Happy’s post above wondering if Dr. Schueler would trust his system to triage his wife/mother or other loved ones exclusively. That certainly would cut to the meat of the marketing matter.)

Went out to a park the other day to shoot some wildlife. Uploaded a pic to Flickr, and now I’m seeing how it embeds in the blog. Heeeeere goes:

I could delete this if it works, but I should probably leave it up just ’cause. There aren’t any other pics in my photostream yet, but that will change soon.

Ok, onto the next post…

(Update: Ugh…how do I get the text NOT to float on the right? Small potatoes for now…how do I get the pic to specifically link to the “Large” version on Flickr? Perhaps that’s a blogging software limitation. I’ll try it by hand. And why am I typing “out loud” for testing purposes? Probably to show that even though I may not post every week day, I still think about it. )

Sid Schwab posted an entry the other day about EM blogs (I’m including nurses in what I write here) and their penchant for not only being right-of-center politically, but “vitriolic.” I want to say off the bat that I’m not here to defend his remarks point-by-point, but what he said about his post not being directed at any one blogger in particular and specifically that it was written months ago is absolutely true. In fact, he shared the draft with me in November of last year. The draft then is very close to the post of the other day, down to the same witty ending. In that sense, what is written really is representative of how he feels, not some knee-jerk rant.

But why did he share the draft in the first place? Because I said that I was going to post about that very topic because I had come to many of the same conclusions independently. I’m unapologetically liberal on most issues, but I keep an open mind and try not to let the occasional offhand remark about “lefties” keep me away from an otherwise informative or entertaining blog. Unfortunately, there are some sites that I just can’t read because of in-your-face right-wing screed brought up with no provocation, or commentary that is so ill-informed, it begs the question if the poster has MPD to also be a healthcare provider with [assumedly] a necessary component of humility and compassion. When I took stock of the sites that fit that category as I was trimming my newsreader’s feeds, I came to an inescapable conclusion: almost all of them were EM blogs.

EM has been corrupted by being made into the PCP of the disenfranchised and uneducated, as well as the pressure valve for inpatient floor inefficiency as admitted patients crowd the ED, further straining things. I get it. I was a volunteer at Ben Taub Hospital in Houston for over a year, primarily acting as an unofficial Spanish translator. Ben Taub is a model of your classic, inner-city urban hospital. Analogies would be Parkland in Dallas or King in LA. Houston, being the 4th largest city in the US and given its demographic, the ER population was primarily Black and Latino, both seemingly unable to speak decent English. I’m not going to pretend that my experience means a damn by comparison, but I wanted to make clear that I’m not talking out of my ass here.

I give the benefit of the doubt to any blogger of any kind when ranting that this the blowing off of steam is not representative of the patient care, that the “dumbass welfare mother” did not get treated at 30% of the care as the “private insurance patient.” But when blowing off steam or generalizing various patient populations is a near-daily occurrence (so much so in one example of a nurse blogger that ™ed the phrase “Medicaid Mentality,” as if it took much mental muscle to come up with it), ultimately I see it as a sad state of the person that wrote it. Just as it’s the height of stupidity to tell a cop, “My tax dollars pay your salary…” it’s just as stupid and self-important to say, “My tax dollars paid for that Mexican’s CT scan.” You don’t make enough to make a difference in anybody’s hospital bill as you aren’t that important. Abuses will occur in any system, and to the best of the ability of those responsible, it should be reported and dealt with. But the cost of tracking down every thug who has some drug money stashed away who might just be on Medicaid is ridiculous (watch your tax dollars go away even faster with the new Medicaid Police Enforcement Unit!). The fact that they come into your ER wearing far more jewelry than you’ve deemed appropriate for your label of what their economic/Medicaid status should be is irrelevant at best, pompously arrogant at worst.

On the subject of labels, “liberal” is used as a mild pejorative by those on the right, with “pinko,” “tree hugger,” “moonbat,” “terrorist sympathizer,” and many other colorful words to use for stronger effect. What words are used to describe those on the right? “Conservative” is simply a proper term (except this administration is anything but; real conservatives despise the “neocons” just as much as we do). “Fascist,” perhaps, but there’s a lot in between. You see, therein lies a big difference: there isn’t nearly the same screedy list to choose from because collectively, we try not to be that way. Everyone is guilty of generalizing to a degree as a necessary evil, but profane name-calling and deriding those who are “too stupid to go to their PCP/OBGYN” is not a staple of most any medical blogs outside of the EM ones. For the blogs that are offenders here, the tone of “I’m better than you” (you = patient/family, boss, administration, co-workers) is unmistakeable.

There are very polarizing issues in health care, such as is healthcare seen fundamentally as a right or a privilege? How much should the economics of medicine be market based vs. government regulated? There are no easy answers to these questions, yet too many simply state their simplistic opinion and accept no other. I don’t care if someone’s on the wrong side on an issue from my POV, but a well-stated argument–however ill-informed I think it to be–deserves respect. Too many right-wing bloggers don’t even bother…not they they owe me or anyone else an explanation, but at the same time some of these are the same that jump on others’ sites sniping their tired rhetoric there as well.

When I saw the comments to Sid’s post both on his site and others, it struck me how some didn’t even read it properly; the answer to their question was right in front of them had they simply turned off their prepackaged assumptions. Worse still, some clearly read it by quoting and commenting and STILL overlooked the obvious. It occured to me at that point that Sid’s post acted sort of like a political Rorschach test–in reading it, one would see what one wants, perhaps a reflection of oneself.

Lastly, a modest request to the right-wing EM bloggers that can’t help but make commentary on sociopolitical issues of their less fortunate patients: when there is a positive story (and there are, don’t lie), share it and don’t ruin it with a caustic comment about this or that. Write about a surprisingly positive encounter for what it is. It’s not right to have a situation where your assumptions were turned upside down, proved dead wrong, only to mentally chalk it up as an anomaly. No one here is so naive as to think that there isn’t a definite pattern among certain patient populations, but the exceptions are far more interesting than the rule. Share them.

(Update 6/26/08: The SCOTUS just ruled the DC handgun ban unconstitutional. Believe it or not, I agree with the majority and Scalia’s written opinion that any complete ban that prevents law-abiding citizens from protecting their home is against the spirit of the 2nd amendment. I’m from Texas, after all. Just another example of how none of us are 100% anything politically)