Hillary Clinton has asked people on Yahoo Answers what they think about fixing health care. There’s already 34,000 responses! (Via Health Care IT Blog )

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I may possibly be the last person to discover them, but UpToDate has a bunch of really good ECG tutorials broken up into a ton of different sections. Just search for “ECG Tutorial” and you’ll find them.

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RxFacts is a site created by Harvard MDs and PharmDs to provide current, relevant, unbiased information for primary care docs on the latest treatments. It’s the Anti-Drug Rep.

(Speaking of, wouldn’t this be totally evil if a Pharma company actually created a non-profit and claimed to give out unbiased information, all the while peddling their own products?)

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How Doctors Think (Answer: Sometimes Poorly). A New Yorker piece on physicians’ cognitive biases : No way, that healthy-looking 45 year-old without risk factors can’t be having a heart attack! It must be… a muscle strain!

Quote from the piece: “For the most part, patients are not known and their illnesses are seen through only small windows of focus and time.” By calling physicians’ attention to common mistakes in medical judgment, he has helped to promote an emerging field in medicine: the study of how doctors think.” Link to the doc’s paper cited in the article .

Next up is Saving the ER for Real Emergencies in the LA Times. Details frequent fliers at ERs (repeat customers who use ERs as their primary care, which costs taxpayers millions), like Mauricio Hernandez. A new program in place in LA is slated to try to educate and change these patients’ ways: it hires health coaches to attend medical appointments with them, and get them to use clinics and primary care. (And saves money in the process, Hernandez’s care alone in 4 months cost $38,000–that’s $100k a year.) The problems are rooted in the typical things we don’t do a great job with: cultural norms, illiteracy, health education, and health care access. Quoting:

Mauricio Hernandez’s belly was swollen like a pregnant woman’s.

Every month for four years, he’d been going to the emergency room at Los Angeles County-USC Medical Center to have his abdomen drained of fluid, the result of cirrhosis caused by years of heavy drinking.

It wasn’t exactly an emergency, but the ER was his only medical care. An illegal Mexican immigrant, Hernandez had learned that emergency rooms legally cannot turn away patients without examining and stabilizing them. He had stopped drinking, he said. But his job unloading big rigs paid little and offered no health insurance.

At each ER visit, he waited from five to 10 hours, received immediate treatment and left with no long-term plan for follow-up care. So his condition worsened, making more ER visits necessary.

Hospital officials estimate that in the first four months of 2006 alone, Hernandez’s ER visits and hospitalizations cost taxpayers $37,500.

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It’s funny what people can live their lives with thinking it’s just normal–that everyone operates on the same assumptions. If it’s always how it’s been for you, how can you know any better?

Three patients reminded me of this fact.

The first is a teenage Russian mother. Her 4-month old adorable little baby had a terrible case of eczema. She was seen in the ER a week ago, given some medications, and told to get a pediatrician at a local clinic. A week later, she shows up in the ER again. For the eczema. There are mutterings and under-the-breath annoyed words spoken–what the hell is she doing back here with her baby’s eczema? This is not an emergency. We ask her why she didn’t go to the clinic, as instructed, and she says, “I went there and they said I was going to have to wait 3 hours.” We say, “Well, yeah, you’re going to have to wait, it’s a clinic. But if you make an appointment, you’ll be able to get in faster.” She kind of nods, and we kind of stand there for an extra beat, hoping she gets it. We re-iterate to her that we cannot manage the kid–she needs to see a dermatologist, and get a referral from her pediatrician. Once we explained how referrals work, I think she figured it out.

My instincts were to think, “What, is she stupid, does she not understand how doctors work? Does she not realize this isn’t an emergency? Is she just lazy and abusing the system?” But the more I thought about it, I think she just honestly didn’t know how the medical system works. She didn’t know how to get care, or how to get a pediatrician, or get help for her baby, so she went to the one place she knows there will be doctors: the ER.

The next is a 30-something administrative clerk at a law firm, with an exquisitely tender ingrown toenail. Ouch. She tells me she gets these rarely, and I ask, “How rare is rarely?” and she shrugs, “Oh, about once a year or so.” (She usually gets a pedicure, but was too busy with the holidays to get one this year.) She has special clippers to prevent it from happening. She is bewildered when I tell her that I think that’s pretty frequent–that most people don’t get them so regularly. “They don’t?” I tell her there are ways to remove the nail matrix causing the ingrown toenail, and suggest she ask her doctor about it.

Again: she’s had ingrown toenails since she was a kid, and just thought it was your normal, everyday thing. Maybe her family had them too, so the notion was enforced. (This also supports my theory that “All families are weird,” because you’ll hear someone describing what traditions they do for Christmas, or birthdays, or whatever, and you think it’s totally bizarre because it’s not how your family does things.)

The last is a 24 year-old student with a chronic cough. He’s got a pretty good family history of atopy and a brother with asthma. He describes the coughing fits as generally after exercising, like running on a cold day–but sometimes even after weird things like drinking a Slurpee too quickly. They last for a good hour or so–but as far as he can remember, he’s had them his whole life.

Now you may be thinking that these patients are just uneducated about their disease, or don’t have a whole lot of medical knowledge or background. But this last one is nothing of the sort. Turns out he’s a medical student. Turns out his father is a doctor. His mother is a former nurse.

Turns out that it’s me, and my cough-variant asthma.

I had no idea — no freaking clue –that other people didn’t cough and cough and cough like me–I just thought that was normal human behavior, a normal reaction to exercise, or cold air, or… Slurpees. It wasn’t until I was reading about asthma that it finally hit me, Mr. Medical Student.

Don’t make assumptions about what you know, what you think you know, or what you think your patients know. Educate, educate, educate, and if something doesn’t seem “normal” or “right,” there’s probably a good reason (or maybe you’re the weird one, and there’s no good reason at all).

Ahh, medical ambiguity.

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When you haven’t seen kids in awhile, it’s always nice to have a review of the anatomy and pictures of normals and abnormals . Big help.

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Bush is scheduled to announce a health insurance plan for the nation at his State of the Union address this week, but don’t worry–GoozNews (which I just started reading a couple weeks ago, and it’s great) has already summed things up for us . He does the math for the poor and the rich:

You don’t have to be a rocket scientist to figure out that this proposal provides a powerful incentive for healthy, well-off families to abandon their employer plans if their employer gives them that option. And employers will increasingly want to do that since it will save them money: the cash grants will always be less than the cost of insurance. Indeed, as more and more well-off, healthier families opt for the grants, only the sickest and most costly employees will remain in the insurance pool. This will drive the cost of regular insurance higher and further erode employers’ willingness to continue paying for it.

It’s hard not to conclude that this plan was carefully designed to put another nail in the coffin of the employer-based health insurance system, and build upper-middle-class support for individual families purchasing their own plans and care. It has nothing to do with insuring the uninsured, since the benefits are far less than what is needed to effectively move them into the insurance pool.

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In the spirit of belated New Year’s resolutions, and the fact that I’m way past gay fat, and on my way to straight fat, I hit the gym today, and boy did it feel good to exercise again. I go through these cycles q 3-5 months, as I eventually will pull something and need to take a break and then just get out of the habit. But better late than never.

Go do something healthy today!

(I also believe in not being a medical hypocrite: if I’m going to tell my patients they need to find time and energy to do something — eat healthier, exercise, stop smoking, stop drinking — I’ve got to put in my own effort, too.)

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And I’d have to agree ; I always forget to submit, as it’s a weird Monday deadline, but the sites that are restricting posting to a topic of their choosing is the wrong way to go. (It probably started as people–myself included–started putting the posts together with a “style” to make them more fun/interesting–but only listing posts related to a specific field isn’t in the spirit of showing off the Best of the Medblogosphere.

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