I follow single-payer news by following an RSS feed of a Google News search for single-payer , and I think it’s a pretty decent way to track how popular a term is over time. And I’ve noticed, over the past 6-8 months, there’s been a quantitative rise in the number of news articles that include the word single-payer–from a low of 4s when the program started out, to now about 25 a day. Keep it up, single-payer!

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I honestly wonder how much the American Health Insurance Plans association paid United Press International for this total fluff piece supporting Medicare Part D .

“I’m hearing shock from (state) Medicaid directors that we’re getting better prices than they are,” she told UPI. “I don’t know of any other government program where the real costs are less than the estimates,” she said, arguing that the plans are offering “affordable products” with low premiums and low deductibles. -Karen Ignagni, president of the health insurance association

Actually, Karen (can I call you Karen?), the administration has been charged with trying to supress the real cost of the plan, getting the program passed with a much lower estimate . The administration told Congress the plan would cost $534B over 10 years, when it’ll probably actually cost more than double that. Whoops.

And, uh, by the way, UPI, your headline is absolutely wrong. The “Fed”–that’s the VA, right?– actually gets better prices than Medicare Part D .

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Call me crazy (“Hi, Crazy!”), but I think we need to start changing the medical school curriculum a bit.

One of the main focuses of the pre-clinical and clinical curricula is teaching the medical student the art of the differential diagnosis. You basically take someone’s symptoms, and try to figure out what’s causing their disease–any number of body systems can cause similar systems. And as the saying goes, “You can’t treat what’s not on your differential.” That is, you’ve got to consider everything, so if it’s not what you think it is, you’ve got a fallback 2nd or 3rd idea for what the problem could be. Obviously important to reinforce this concept into our heads. Over, and over, and over again. And then over some more.

But one area where I think we’re lacking–because medicine has changed so much–is the treatment of the chronic disease. We focus so much on the acute still in medicine, when our patients have primarily shifted to the chronic. Sure, as residents we have clinic time where we see patients as outpatients in a chronic disease setting–but most of our residency (and much of our medical school) training is still focused on the acutely ill patient. While this definitely hammers home important concepts in many diseases, which can then be translated to the outpatient basis, I wonder if there’s more we should be learning. If you look at physicians as a whole, they’re not working in hospitals, taking care of acute patients. They’re working in private practices, seeing outpatients.

What should change? A couple ideas:

1. Focusing on trends, not on specifics
2. Focusing more on prevention if the disease will be life-long
3. Time management with patients
4. Changing the culture so that patients expect to come in when they’re well and when they’re sick
5. How to stay energized and avoid burnout
6. How to maintain relationships with patients over years
7. How to work efficiently and effectively with other specialists/generalists
8. The differences between acute care and chronic care
9. Explaining chronic versus acute care to patients

A lot of this you can pick up on your own with trial and error, tips and tricks from attendings, and good social skills–but it seems like it’s this gaping hole that medical training is de-emphasizing, even though it’s the bulk of “practicing medicine” as professional physicians.

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So I got pimped mercilously by my attending two days ago, while I was sick, feeling like crap, and had only seen my patient for like 20 minutes. So it never happens to you, I present the quick’n’dirty acid-base disorder step-by-step guide:

1. Get a blood gas. Put it in ice, send it to the lab.
2. Look at pH: Less than 7.4? Acidosis. Greater than 7.4? Alkalosis.
3. Look at pCO ₂ and bicarb. Do they move in the same direction as the pH, or the opposite direction? (Nl pCO ₂ = 40, nl bicarb = 24.) If they move in the sa ME direction, it’s primary ME tabolic. If they move in a diffe RE nt direction, it’s primary RE spiratory.
4. Is the non-primary system compenstating appropriately? (Calculate that with those annoying equations I can never remember.)
5. Is there an anion gap? (Na – Cl – bicarb > 12) If no, you’re done.
6. If yes, take the anion gap – 12. Add that to the bicarb level. If it’s greater than 26, you’ve got a metabolic alkalosis as well. If it’s less than 22, you’ve got a non-anion gap metabolic acidosis, too. Classic pimping: You can have 3 disorders co-existing, but not 4. (Your lungs can either be making respiratory acidosis or alkalosis, not both.)

And on to the mnemonics for the causes:

Anion Gap Metabolic Acidosis: MUDPILERS

• Methanol
• Uremia
• DKA/Alcoholic KA
• Paraldehyde
• Isoniazid
• Lactic Acidosis
• Etoh/Ethylene Glycol
• Rhabdo/Renal Failure
• Salicylates

Non-Anion Gap Acidosis: HARDUPS

• Hyperalimentation
• Acetazolamide
• Renal Tubular Acidosis
• Diarrhea
• Uretero-Pelvic Shunt
• Post-Hypocapnia
• Spironolactone

Acute Respiratory Acidosis (Chronic Respiratory Acidosis = COPD/restrictive lung dz): any hypoventilation state

• CNS Depression (drugs/CVA)
• Airway Obstruction
• Pneumonia
• Pulmonary Edema
• Hemo/Pneumothorax
• Myopathy

Metabolic Alkalosis: CLEVER PD

• Contraction
• Licorice*
• Endo: Conn’s/Cushing’s/Bartter’s)*
• Vomiting
• Excess Alkali*
• Refeeding Alkalosis*
• Post-hypercapnia
• Diuretics

* = Associated with High Urine Cl levels

Respiratory Alkalosis: CHAMPS (think speed up breathing)

• CNS disease
• Hypoxia
• Anxiety
• Mech Ventilators
• Progesterone
• Salicylates/Sepsis

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