Praise to our Intestines
My recent work has taken me to weaving my way in and around people’s bowels, something that is a common task for any general surgeon. However, I’ve had more than my usual share over the last few weeks. While making my way around a particularly difficult colon today those of us in the operating room discussed the relative merits of what has been named the alimentary tract, our intestines, the gastrointestinal tract, bowel , guts or “chitlins”.
If one considers all our various organs one would have to agree that our GI tract is, by far, the most intelligent. Think about it; our brain stands isolated within its protective cage, so snobby and aloof, only allowing certain special materials to enter its domain, always giving orders, but out of touch with its co-organs. The heart is a tireless worker, but mindlessly does the same thing over and over, day in and day out, blood comes in, blood goes out. Ditto for the lungs, a monotonous pastime of breath in, breath out, inhale, exhale, occasionally fending off noxious fumes and fighting invaders.
Kidneys are efficient cleaners and bones are glorified coat racks. Muscle is a little smarter, only working when called upon, but always the same thing, relax, then contract, hold this up, push that down. No wonder they get stiff and sore.
But our bowels do remarkable things. When not needed they rest, blood flow is shut down and our guts essentially go to sleep. Yet, when called upon, they spring into action, sorting out a variety of nutrients, directing them to the liver through the bloodstream or bypassing the liver sending fats through our lymphatic system.
This long tunnel through the middle of our body is constantly fending off invaders, be they micro-organisms, noxious chemicals or a variety of foreign bodies. The GI tract lives in symbiosis with huge numbers of bacteria, using these microscopic invaders for its (and our) own purpose. Yet if one of these foreigners behaves badly they are expelled, one way or another, causing us a brief period of discomfort, but also keeping us well. No other organ has to deal with such insults on so massive a scale, yet our bowels handle them with aplomb. Perhaps, our skin, the body’s largest organ, comes close, but on a much smaller scale.
So, I say, let us praise our bowels. When they are working properly they keep us happy, healthy and whole. But, when they go bad; when they are blocked or punctured or dying nothing can make us so incredibly ill. I say there should be a take your bowel to lunch day. But, come to think of it, everyday is take your bowel to lunch day.
Friday, October 30, 2009
Thursday, October 22, 2009
The Obesity Problem
The Obesity Problem
Today I read an article that tried to shed light on a medical condition endemic to modern society. Obesity plagues our post modern world, particularly in the United States and more particularly in Houston, Texas; my hometown. Houston carries the dubious distinction of having been named the least physically fit, most obese city in the US several years ago. In my general surgery practice I face this reality every day.
There is no question that obesity contributes to the rising costs of health care. Overweight patients can turn straightforward surgical conditions into complex operations that may require significant adjustment or compromise to have a successful outcome.
There is a huge industry catering to the desire of the obese individual to go from size 20 to size 8 or 48 waist to 36. Fad diets, diet pills, lap bands and gastric bypass surgery ads fill our airways, magazines and internet pages promising a svelte and youthful body in thirty (or sixty or ninety) days or your money back.
Today in surgery, while creating a colostomy (always a mind stimulating endeavor), we proposed a powerful solution to this pervasive problem. As background let me say that human beings originally were foragers, searching for their food. Later they became hunters and eventually farmers. The scarcity of food was the driving force in ancient society and wealth was measured in sheep and cattle, rather than dollars.
Of course, times have changed and scarcity of food has become a thing of the past in our developed nations. A casual stroll down the aisle of the neighborhood megasupermarket will result in a cart laden with all the necessities of life. As a matter of fact one need not even make the short drive to the grocery. With a few clicks of your trusty mouse it is possible to select and have delivered to your front door everything you need to keep your pantry and your stomach full.
So, today those of us in surgery decided it is time to return to our ancestral roots. The supermarket should become a place to hunt and forage for food. No longer should the shopper be allowed a leisurely stroll down capacious aisles. No, it is time to work for our food. And, to battle obesity, food that is high in fat and calories should require the greatest work. Fresh fruits and vegetables could require only a short stroll through the “Produce Patch.” However, high fat steaks would need to be hunted, perhaps in a way akin to laser tag, requiring shooting a moving freezer to claim the elusive porterhouse. A craving for donuts would necessitate rock climbing a forty foot wall and Twinkies would oblige the shopper to face a fire breathing mechanical dragon armed only with a sword and a shield.
This very modest plan would fight obesity in several ways. The effort expended to successfully reach the desired food would burn off a considerable number of calories. Those individuals that are unable to put forth the necessary effort would have to forego their fried pork rinds or Ben and Jerry’s and be forced to diet or eat healthy, easily obtainable food.
This plan could solve not only the problem of obesity, but also food shortages in some countries as extra food would probably become available and could be shipped to those in need. A major healthcare issue also would be addressed and in the long term health care costs would go down. Such a modest change could reap benefits for decades.
Today I read an article that tried to shed light on a medical condition endemic to modern society. Obesity plagues our post modern world, particularly in the United States and more particularly in Houston, Texas; my hometown. Houston carries the dubious distinction of having been named the least physically fit, most obese city in the US several years ago. In my general surgery practice I face this reality every day.
There is no question that obesity contributes to the rising costs of health care. Overweight patients can turn straightforward surgical conditions into complex operations that may require significant adjustment or compromise to have a successful outcome.
There is a huge industry catering to the desire of the obese individual to go from size 20 to size 8 or 48 waist to 36. Fad diets, diet pills, lap bands and gastric bypass surgery ads fill our airways, magazines and internet pages promising a svelte and youthful body in thirty (or sixty or ninety) days or your money back.
Today in surgery, while creating a colostomy (always a mind stimulating endeavor), we proposed a powerful solution to this pervasive problem. As background let me say that human beings originally were foragers, searching for their food. Later they became hunters and eventually farmers. The scarcity of food was the driving force in ancient society and wealth was measured in sheep and cattle, rather than dollars.
Of course, times have changed and scarcity of food has become a thing of the past in our developed nations. A casual stroll down the aisle of the neighborhood megasupermarket will result in a cart laden with all the necessities of life. As a matter of fact one need not even make the short drive to the grocery. With a few clicks of your trusty mouse it is possible to select and have delivered to your front door everything you need to keep your pantry and your stomach full.
So, today those of us in surgery decided it is time to return to our ancestral roots. The supermarket should become a place to hunt and forage for food. No longer should the shopper be allowed a leisurely stroll down capacious aisles. No, it is time to work for our food. And, to battle obesity, food that is high in fat and calories should require the greatest work. Fresh fruits and vegetables could require only a short stroll through the “Produce Patch.” However, high fat steaks would need to be hunted, perhaps in a way akin to laser tag, requiring shooting a moving freezer to claim the elusive porterhouse. A craving for donuts would necessitate rock climbing a forty foot wall and Twinkies would oblige the shopper to face a fire breathing mechanical dragon armed only with a sword and a shield.
This very modest plan would fight obesity in several ways. The effort expended to successfully reach the desired food would burn off a considerable number of calories. Those individuals that are unable to put forth the necessary effort would have to forego their fried pork rinds or Ben and Jerry’s and be forced to diet or eat healthy, easily obtainable food.
This plan could solve not only the problem of obesity, but also food shortages in some countries as extra food would probably become available and could be shipped to those in need. A major healthcare issue also would be addressed and in the long term health care costs would go down. Such a modest change could reap benefits for decades.
Friday, October 9, 2009
Global Warming
New Data on Global Warming
An announcement issued today from the Environmental Protection Agency warned of a sudden spike in global warming. This phenomenon has been followed since January of this year. Intense research by the EPA in conjunction with the environmental studies dept at Wassa Matta U. has traced the source of this CO2 spike to Washington DC.
Apparently, increased emissions of carbon dioxide have been measured in the areas around the District of Columbia, southern Maryland and northern Virginia. The economic crisis, coupled with the US Congress’ attempts to reform health care along with cap and trade have led to unprecedented CO2 release from members of Congress and the Executive Branch. The excessive CO2 emissions have also coincided with a three hundred percent increase in hot air emanating from this region of the country.
An executive order was immediately issued from the Obama administration aimed at attacking this environmental hazard at its source. Starting November 1, 2009 there will be strict controls instituted to curb this CO2 release. The order states that Democrats will only be allowed to exhale on Mondays, Wednesdays and Fridays. Republicans will have exhalation rights on Tuesdays, Thursdays and Saturdays. Sundays have been deemed a day of rest and no exhalation will be allowed by members of congress from either party on this day.
An unnamed White House spokesman issued this statement, “The President realizes that this is a drastic step to take. However, the EPA has declared a state of emergency. There estimates are that these new regulations will not only slow the growth of global warming, but actually may allow the planet to cool by several degrees.” When questioned about the Executive Branch reducing its own release of greenhouse gasses the spokesman replied that steps had already been taken in this area. He reported “Although the President firmly believes that CO2 emissions from the Executive Branch have been within appropriate limits he still wants to show that he is doing all that he can. Consequently, he has taken steps to eliminate all carbon dioxide and hot air emissions from the Vice President.”
The newly released order was met with cheers from Wall Street where the Dow Jones immediately rose over 350 points. There was also loud applause heard in northern Alaska where large numbers of polar bears had gathered.
Reaction from Congress was swift. Both Democrats and Republicans condemned the order, calling it an end run around the constitution. A few thoughtful senators, however, stated that it was a wise decision and that they would make every effort to comply. They even went farther, stating that if the newly imposed regulations were effective they would consider drafting legislation that would apply to the many cable news and talk radio sources of excessive CO2 release. FOX News reacted by calling it a violation of the First Amendment. Stay tuned.
An announcement issued today from the Environmental Protection Agency warned of a sudden spike in global warming. This phenomenon has been followed since January of this year. Intense research by the EPA in conjunction with the environmental studies dept at Wassa Matta U. has traced the source of this CO2 spike to Washington DC.
Apparently, increased emissions of carbon dioxide have been measured in the areas around the District of Columbia, southern Maryland and northern Virginia. The economic crisis, coupled with the US Congress’ attempts to reform health care along with cap and trade have led to unprecedented CO2 release from members of Congress and the Executive Branch. The excessive CO2 emissions have also coincided with a three hundred percent increase in hot air emanating from this region of the country.
An executive order was immediately issued from the Obama administration aimed at attacking this environmental hazard at its source. Starting November 1, 2009 there will be strict controls instituted to curb this CO2 release. The order states that Democrats will only be allowed to exhale on Mondays, Wednesdays and Fridays. Republicans will have exhalation rights on Tuesdays, Thursdays and Saturdays. Sundays have been deemed a day of rest and no exhalation will be allowed by members of congress from either party on this day.
An unnamed White House spokesman issued this statement, “The President realizes that this is a drastic step to take. However, the EPA has declared a state of emergency. There estimates are that these new regulations will not only slow the growth of global warming, but actually may allow the planet to cool by several degrees.” When questioned about the Executive Branch reducing its own release of greenhouse gasses the spokesman replied that steps had already been taken in this area. He reported “Although the President firmly believes that CO2 emissions from the Executive Branch have been within appropriate limits he still wants to show that he is doing all that he can. Consequently, he has taken steps to eliminate all carbon dioxide and hot air emissions from the Vice President.”
The newly released order was met with cheers from Wall Street where the Dow Jones immediately rose over 350 points. There was also loud applause heard in northern Alaska where large numbers of polar bears had gathered.
Reaction from Congress was swift. Both Democrats and Republicans condemned the order, calling it an end run around the constitution. A few thoughtful senators, however, stated that it was a wise decision and that they would make every effort to comply. They even went farther, stating that if the newly imposed regulations were effective they would consider drafting legislation that would apply to the many cable news and talk radio sources of excessive CO2 release. FOX News reacted by calling it a violation of the First Amendment. Stay tuned.
Sunday, October 4, 2009
The Health Care Debate Part 2
The Healthcare Debate
The View from the Trenches, part 2
The last article I posted cast light upon the virtues of a single payer system for the delivery of health care to the people of our country. In the time since I wrote that article I’ve had the opportunity to discuss the matter further with many of my colleagues. Responses ranged from enthusiastic agreement to belligerent argument, with several variations in between.
The most commonly voiced objection to a single payer system is that “the government can’t manage anything.” I think there is evidence to the contrary, but the objection raises a very valid point. Reports out of Washington are daily reminders of the incredibly dysfunctional apparatus that is our federal government. An article written by a medical doctor who has been serving in our nation’s capital for the past year casts a bright light on this fact. Our representatives are bogged down in a quagmire of lobbyists, special interests, bloated staffs and insulation from their true employers, namely us.
Politics and perception overshadow careful analysis, scientific study and simple truth. It seems that few congressmen have the time or desire to study this issue from a truly objective vantage point. They glean their information from a bevy of special interests bent on preserving their own slice of the $2.4 trillion healthcare pie and ignore most of the facts that would allow a truly educated decision. In my last article many of these facts were presented.
But, assume for the moment that it is true that the government is not capable of properly administering a Medicare for all system. What is the answer? It seems to me that policy could start at the federal level and then be administered by private insurers. Certain minimum requirements would be mandated, including what and what is not covered, establish appropriate reimbursement for providers and set insurance premiums at a reasonable level. That sounds like a step towards rationing you might say; correctly. But it is no different than what occurs now everyday.
For example, a teenage boy comes to see me with a condition called gynecomastia. This means enlarged breasts in a male. The abnormality may be minor, barely noticeable or it may be a gross abnormality. Either way the unfortunate boy suffers terrible ridicule from his peers. The condition is easily remedied by a surgical procedure, subcutaneous mastectomy. Despite the potential psychological damage the boy may have to endure if the condition remains uncorrected, this procedure is almost never approved by insurance companies; they consider it cosmetic. The patient, his parents and I are left with a dilemma, how do we provide appropriate treatment for this teenager? If the family has resources they can pay out of pocket, probably $4-5000 for the outpatient surgery. I could lie to the insurance company and give them a diagnosis that they will cover, but I really don’t want to commit fraud. What I almost always do is take photos and send them to the insurance company, argue with the medical director at the insurance company, have the parents call the insurance company and after all this, once in a while, the surgery will be approved. In many instances I can find a way to take care of this patient, but sometimes the patient remains untreated.
Denials by health insurers are a daily occurrence and are the current form of rationing health care. It seems to me that any health care reform will have to draw the line somewhere. There certainly is no argument from anyone that a facelift or breast implants (except for reconstruction after cancer surgery) are cosmetic and should not be covered by insurance, just as no one would argue that removal of a cancerous portion of colon should not be covered. There are, however, numerous conditions like the one cited above that are in a gray zone. How they will be dealt with is one of the central issues to any reform proposal.
Having raised these points, what, then, is the answer? The answer lies in spending the healthcare dollar on healthcare. The previous article cited the very high administrative costs for private insurance under the current system. These costs would need to be eliminated and the savings redirected to actually providing care. A government sponsored health plan, one that people could purchase at true cost, should be developed. Health savings accounts coupled with high deductible insurance should be offered. These entities put the power of choice directly in the hands of the consumer and direct the healthcare dollar to patient care, not to administration. A plan such as this is what I have for myself and my family. I have a deductible of $5200, a heath savings account which can be accessed for smaller or uncovered incidents, but catastrophic insurance that pays 100% of costs after the deductible. This allows me to save money each year, but protects me at the same time.
A few other points need to be made. I see the health insurance industry licking their collective chops at the prospect of health care reform as it is currently being proposed. A mandate that 50 million individuals who currently do not have health insurance all of a sudden be covered presents an unexpected bonanza to all the Aetnas and United Healthcares out there in insurance land. Many of the uninsured are that way by choice, foregoing health insurance and playing Russian roulette with their health; many are healthy and rarely use the health care system. Adding these people to the rolls of the insured will put a large amount of money into the insurer’s pockets. I think policy should be that this money be used for health care and not for insurer’s profit. In particular, this windfall should be earmarked to help defray the costs of providing health care to the indigent and those for whom requiring health care coverage would be a great burden.
Health care reform should include relief for providers from frivolous malpractice claims. I am lucky to live in Texas where recently passed reforms have made our state one of the more attractive places to practice medicine. The reforms do not prevent meritorious suits from being filed, but have drastically reduced frivolous claims.
Finally, any reform should be a change in health insurance, not health care. Doctors, nurses, therapists and technicians all receive very thorough training and the overwhelming majority wants only the opportunity to take proper care of our patients and to return them to good health. We all work together towards this goal. Those doctors whose only motivation is earning money soon find themselves in trouble and out of work. There is talk of legislating “clinical, best practice guidelines” with the suggestion that providers that do not adhere to such guidelines face some penalties. However, good medical care cannot be legislated. It is taught in our medical and nursing schools, during internships and residencies and through years of hard work and experience. Every patient is a unique individual and most do not fit into the classic illustrations presented in our textbooks. Despite what one may read, doctors and all allied health professional do a pretty good job of policing themselves and this should be allowed to continue.
In conclusion, I think that any reform of health care insurance should allow the providers to continue to provide high quality care. Money earmarked for healthcare should be spent on the delivery of such care, not on administrative costs or profits. A properly and efficiently administered single payer plan is the most cost effective and efficient system, but any private company that can provide health care coverage within legislated guidelines should be allowed.
Let’s hope that our representatives in Congress can suddenly find the wisdom and fortitude to give us such a system.
The View from the Trenches, part 2
The last article I posted cast light upon the virtues of a single payer system for the delivery of health care to the people of our country. In the time since I wrote that article I’ve had the opportunity to discuss the matter further with many of my colleagues. Responses ranged from enthusiastic agreement to belligerent argument, with several variations in between.
The most commonly voiced objection to a single payer system is that “the government can’t manage anything.” I think there is evidence to the contrary, but the objection raises a very valid point. Reports out of Washington are daily reminders of the incredibly dysfunctional apparatus that is our federal government. An article written by a medical doctor who has been serving in our nation’s capital for the past year casts a bright light on this fact. Our representatives are bogged down in a quagmire of lobbyists, special interests, bloated staffs and insulation from their true employers, namely us.
Politics and perception overshadow careful analysis, scientific study and simple truth. It seems that few congressmen have the time or desire to study this issue from a truly objective vantage point. They glean their information from a bevy of special interests bent on preserving their own slice of the $2.4 trillion healthcare pie and ignore most of the facts that would allow a truly educated decision. In my last article many of these facts were presented.
But, assume for the moment that it is true that the government is not capable of properly administering a Medicare for all system. What is the answer? It seems to me that policy could start at the federal level and then be administered by private insurers. Certain minimum requirements would be mandated, including what and what is not covered, establish appropriate reimbursement for providers and set insurance premiums at a reasonable level. That sounds like a step towards rationing you might say; correctly. But it is no different than what occurs now everyday.
For example, a teenage boy comes to see me with a condition called gynecomastia. This means enlarged breasts in a male. The abnormality may be minor, barely noticeable or it may be a gross abnormality. Either way the unfortunate boy suffers terrible ridicule from his peers. The condition is easily remedied by a surgical procedure, subcutaneous mastectomy. Despite the potential psychological damage the boy may have to endure if the condition remains uncorrected, this procedure is almost never approved by insurance companies; they consider it cosmetic. The patient, his parents and I are left with a dilemma, how do we provide appropriate treatment for this teenager? If the family has resources they can pay out of pocket, probably $4-5000 for the outpatient surgery. I could lie to the insurance company and give them a diagnosis that they will cover, but I really don’t want to commit fraud. What I almost always do is take photos and send them to the insurance company, argue with the medical director at the insurance company, have the parents call the insurance company and after all this, once in a while, the surgery will be approved. In many instances I can find a way to take care of this patient, but sometimes the patient remains untreated.
Denials by health insurers are a daily occurrence and are the current form of rationing health care. It seems to me that any health care reform will have to draw the line somewhere. There certainly is no argument from anyone that a facelift or breast implants (except for reconstruction after cancer surgery) are cosmetic and should not be covered by insurance, just as no one would argue that removal of a cancerous portion of colon should not be covered. There are, however, numerous conditions like the one cited above that are in a gray zone. How they will be dealt with is one of the central issues to any reform proposal.
Having raised these points, what, then, is the answer? The answer lies in spending the healthcare dollar on healthcare. The previous article cited the very high administrative costs for private insurance under the current system. These costs would need to be eliminated and the savings redirected to actually providing care. A government sponsored health plan, one that people could purchase at true cost, should be developed. Health savings accounts coupled with high deductible insurance should be offered. These entities put the power of choice directly in the hands of the consumer and direct the healthcare dollar to patient care, not to administration. A plan such as this is what I have for myself and my family. I have a deductible of $5200, a heath savings account which can be accessed for smaller or uncovered incidents, but catastrophic insurance that pays 100% of costs after the deductible. This allows me to save money each year, but protects me at the same time.
A few other points need to be made. I see the health insurance industry licking their collective chops at the prospect of health care reform as it is currently being proposed. A mandate that 50 million individuals who currently do not have health insurance all of a sudden be covered presents an unexpected bonanza to all the Aetnas and United Healthcares out there in insurance land. Many of the uninsured are that way by choice, foregoing health insurance and playing Russian roulette with their health; many are healthy and rarely use the health care system. Adding these people to the rolls of the insured will put a large amount of money into the insurer’s pockets. I think policy should be that this money be used for health care and not for insurer’s profit. In particular, this windfall should be earmarked to help defray the costs of providing health care to the indigent and those for whom requiring health care coverage would be a great burden.
Health care reform should include relief for providers from frivolous malpractice claims. I am lucky to live in Texas where recently passed reforms have made our state one of the more attractive places to practice medicine. The reforms do not prevent meritorious suits from being filed, but have drastically reduced frivolous claims.
Finally, any reform should be a change in health insurance, not health care. Doctors, nurses, therapists and technicians all receive very thorough training and the overwhelming majority wants only the opportunity to take proper care of our patients and to return them to good health. We all work together towards this goal. Those doctors whose only motivation is earning money soon find themselves in trouble and out of work. There is talk of legislating “clinical, best practice guidelines” with the suggestion that providers that do not adhere to such guidelines face some penalties. However, good medical care cannot be legislated. It is taught in our medical and nursing schools, during internships and residencies and through years of hard work and experience. Every patient is a unique individual and most do not fit into the classic illustrations presented in our textbooks. Despite what one may read, doctors and all allied health professional do a pretty good job of policing themselves and this should be allowed to continue.
In conclusion, I think that any reform of health care insurance should allow the providers to continue to provide high quality care. Money earmarked for healthcare should be spent on the delivery of such care, not on administrative costs or profits. A properly and efficiently administered single payer plan is the most cost effective and efficient system, but any private company that can provide health care coverage within legislated guidelines should be allowed.
Let’s hope that our representatives in Congress can suddenly find the wisdom and fortitude to give us such a system.
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