Dr. Thompson's Blog

Is Medicare for All a Good Idea?

I believe every person deserves the best possible medical care. As medical care in the U.S. has gradually declined in the last several years, I am not sure Medicare for All  is the answer. The powerful and greedy drug companies, the health insurance industry, and far too many greedy doctors will fight any comprehensive plan. The billionaires who surround Trump and his many supporters will also fight. Why should they worry about others when they can afford the very best health care?

Another problem I see is that Medicare for  All will mostly function the same as the worst HMOs. A patient will have to get permission to see a specialist, and to have any test done. Many of these decisions will be made by nurses or non-medical personnel. Nurse practitioners will have an even more important role, as can be seen in the Kaiser health system. A good nurse is worth his or her weight in gold, but physicians should be the  ones to oversee a patient's care. 

In a recent article in the New York Times by Paul Krugman, he discusses  different plans found in other nations. One is Medicare for America. In this plan patients could keep their own health insurance if they like it, but "they or they employers would also have the option of buying into an enhanced version of Medicare, with substantial subsidies for lower and middle-income families." The U.S. comes last in any survey about healthcare in countries

We need to expand the coverage of the Affordable Healthcare Act and have good regulation of drug and health insurance companies. I don't see  any of this as happening. I am just very glad I practiced pediatrics in the glory days of medicine. It was not about making a lot of money but enjoying our patients, making house calls, meeting patients in the  ER and caring for our patients in the hospital.  The Netherlands and France are still  rated as having the best healthcare. We certainly don't.

How Hospitalists have Changed Patient Hospital Care.

I suspect that few people who have to go into a hospital for medical problems or surgery have no idea about what a hospitalist does. It can change your care greatly. I had my first exposure to a hospitalist when I flew to Las Vegas to see my elderly brother in what was supposed to be the best hospital there. I was appalled at the care I saw from the hospitalist. He wandered in  mid-morning, briefly spoke to my brother and then left soon after that. My brother's private physician said she did not go to the hospital but worked from 9 to 5! I was appallled The hospitalist did not review my brother's past medical records, did not speak to his private physician, or to me. Even the nurses and social workers were appalled at his care. Subsequently, I have had other reports about these physicians. One doctor friend, who had to hospitalize her daughter at our local medical school hospital, finally transferred the young woman to another hospital. She said the hospitalist there was not quite as bad!

I have a friend  who is presently having  surgery by an orthopedist who essentially leaves all  her patient care to the hospitalist. I  have urged my friend not to go back to the surgeon but she liked the results of her first hip surgery, despite the awful care from the hospitalist. I ended up doing a lot of her care with several phone calls a day. The orthopedist is what my favorite medical school professor would call a technician, not a doctor. The orthopedist saw my friend twice and basically stood at the door and said "hello".  She did not examine my friend or really ask her  how things were going. I am afraid we are training more doctors like that. I worry greatly about medical care in the years ahead. It often is all about money. Hospitalists are usually trained in internal medicine and then have some additional training. They make very large salaries and concern about their patients does not seem to be high on the list of the several with whom I have had contact. I am glad I practiced in the "glory days" of medicine.

Health Care for All

I believe every human being deserves the best health care possible. Sadly, in the U.S. with all the lobbyists for the drug and insurance companies, Trump and his group are trying to get rid of much health care as possible. Of course, he and his billionaire pals can pay for the best health care. The members of Congress also get excellent, free health care. 

Many of the Democratic candidates are pushing for Medicare for all. Medicare is a great program, but I don't understand how these candidates plan to fight the insurance and drug companies to get Medicare for all and pay for it. Instead, I think they need too look to other countries to see how they pay for the excellent health care that their citizens get. A single-payer plan, such as Canada has, would be a fight to put in place in the U.S. Another country's health system might be the one to check. This was well put by the journalist, Jamie Daw, in an editorial in the New York Times. The author of the article stated that all German citizens  are required to have health insurance. However, they are given a choice of "More than 100 private, nonprofit insurers. Workers and employers share the cost of insurance through payroll taxes. The government finances coverage for children and the unemployed." The cost of health care in Germany and other European countries is far less than in the U.S. We could make a big start in the U.S. if Congress had the courage to  fight  and place controls on drug and health insurance companies, as well as medical device companies. I read a statistic some place that said there are more health insurance and drug company lobbyists than there are members of Congress. I hope when we  have a Congress, not controlled by billionaires, that some real changes will be made.

Keeping Children Safe

Most parents are aware of things they can do to keep their children safe. By looking for frayed electric cords, having covers for outlets and putting safety gates at the top and bottom of stairs can all make a great difference. A playpen can be life-saving when you are cooking, working at your desk, talking on the phone, or getting your mail. Covering or making a barrier in front of a wall heater, so it is not accessible to a child is important. Keeping medicines up high and not in bedside tables, not having dishwasher soap or chemicals under the sink can  keep children fro getting into them. I've had patients hurt by all of these things.

Having adequate carbon monoxide and smoke detectors is a must.  I had a teenage patient who was having a lot of headaches. For some reason I asked about wall heaters. The parents were great and immediately had them checked when they got home. The heaters were defective and once they were repaired the youth's headaches went away. 

Most garages have lots of dangerous things a child can get into. A backyard can also be a source of problems. If you have a swimming pool, a fence around the pool is essential. Pool covers can be a problem because a small child can slip underneath one and drown. Fences and windows should be secure, particularly if a child is on the autism spectrum and likes to slip away.

One thing I always did before I went to bed was to walk around the house to be sure there was nothing my little children could get into if they got up very early. This is especially important if you have had a party or visitors. I had a small patient who drank from  left-over wine glasses and another  who swallowed cigarette butts. Both had to be hospitalized. As parents you always have to be on the lookout for problems and teach any older  children to watch out for  younger brothers and sisters.

Improving Care of Patients with Disabilities or Chronic Illness

Even though medical care for patients with disabilities or chronic illness is too often sub-standard, there are some technology advances that hopefully will make up for the lack of good medical care.The key to success is coordination of the efforts of the different individuals caring for  a patient. A team of professionals is important, but communication among and between them is important. Doctors, social workers, physical and occupational therapists are essential for most of the patients. I was fortunate to have access to both art and music therapists when I founded and was directing the Center for Handicapped Children in San Francisco. We even had a dance therapist who was amazing. She brought some fun, socialization and even physical exercise to the patients who could benefit from it. 

Computers and other new devices now allow patients to turn on lights and other equipment and this can make a great difference. Most importantly a good quality of life should be the goal to strive for. If a patient sits in a wheelchair or lies in bed with no fun, no intellectual stimulation, and no socialization, the best medical care in the world can not make living bearable. When patients  have a progressive disorder as Duchenne muscular dystrophy and other disorders. I believe the patients, who are able to to make decisions about their lives, should be given a choice about what they want. As patients become more and more incapacitated their ability to fight off unwanted life-prolonging medicine or technology becomes less and less.  When my patients were reaching the stage where some decisions needed to be made, I always asked what  they wanted in the way of life-saving care. Only one young man told me I should use every means to keep him alive. The other patients said "I don't want any breathing or other technology to keep me alive." I   have seen both families and doctors bully patients into  having care they did not want and that would greatly decrease their quality of life. I believe that is morally wrong. 

 

All Muscle Weakness in Children is NOT Muscular Dystrophy

When a child, especially a boy or teenage male, develops muscle weakness, the immediate diagnosis that seems to come to doctors' minds is muscular dystrophy. Because there is little teaching about  muscle diseases in most medical schools and residency training  programs, this is understandable. Even neurologists, unless they train in a neuromuscular center, receive little training in muscle disorders. The U.S. is far behind  several other major countries in this training. China, India, Turkey, Tunisia, France,  Germany, England, Canada, Australia, and Sweden are far ahead of us and have been for countless years. Little money can be made in treating these patients,  which is probably the primary reason, since money seems so important in American medicine today. There is considerable research in the U.S., but good clinical training is lacking. One study showed  that fifty  percent of patients with muscle diseases were misdiagnosed. This is particularly heartbreaking if the muscle disorder is a treatable condition, such as polymyositis or dermatomyositis.

Polymyositis generally develops more rapidly than muscular dystrophy and does not show the typical pattern of progression of muscle contractures. When a muscle biopsy is done and shows no imflammatory cells, these disorders are discounted. Twenty-five percent of polymyositis cases do not have inflammatory  cells, although occasionally changes can be seen on electron microscopy sections. Also the CPK blood test may be normal in 25% of cases which is misleading for many doctors. The sad part of this lack of diagnosis is that if either of these disorders is identified early on and high doses of  prednisone started and then gradually reduced, a patient may be returned to normal or almost normal function.   Polymyositis can occur at any age and should always be considered with rapid developing muscle weakness or in a floppy infant.

Concerns about Teaching in Some Medical Schools

I have been thinking today about the article I read this morning in the New York Times. It  was about how the the new UC Riverside medical students are being taught. The students use dummies for patients, three D instruments to view different parts of the body and other automatic tools. I am wondering how with all these advanced technical instruments, the students are learning to truly interact with patients and particularly children. I have taught in three big medical schools and in several pediatric programs in two big hospitals. 

When I retired to San Diego, I taught pediatrics for two years at U C San Diego with a wonderful child whose grandmother had been one of my first parents when I was in practice there. Emma was and is a delightful child. I had a toy basket for her, books, and gave her a gift at the end of the session. The medical students loved it and I think learned a lot. The third year I was told I could not bring a child and was to use a doll! Showing the students how to check for hip problems, the doll's leg pulled off. That was the final straw and I said I would not teach with a doll. Now I teach second year students about history and physical examinations on adults, all of whom are actors. At the end of each session  I try to  do some real teaching and the students beg me to come more often. They want to learn real medicine, not what is computer based.  

When I was running a program for disabled children at Oakland Children's hospital I  had a child in a wheelchair with a condition where many joints are fused. (arthrogryposis). His hands were badly involved.  An orthopedic resident walked into the examining room, didn't speak to or look at the child, but grabbed his hands. "This interesting", he said. I  asked him to step outside and told him he was never to treat a patient of mine like that. He had no idea what he had done. The child was  just a dummy as far as he was concerned. 

How to get Good Medical Care in an HMO

It is possible to find good physicians and get good care in an HMO,  but only if you demand it. An HMO prefers to have  only healthy, young adults in their care. If you have a medical problem, trouble can be ahead. Each physician gets a report card periodically about how many tests they have ordered and how many referrals to specialists they have made. Their salaries are affected if they order too many. Most HMOs also have a limit on the amount of time to be spent with  each patient. I would last in an HMO about 10 minutes. There is no way I would tolerate these rules. Some patients take a while to really get to the bottom of their problems. Getting to know your patients as a physician is one of the true joys of practicing medicine. You become a very important part of a patient's life and a long term relationship brings many rewards, not financial, but very special. 

Before you enroll in an HMO it is important to answer a lot of questions and also carefully read anything you are given to sign. You want to be sure of which tests are allowed for you and your children. You also want to know if they will pay for emergency care in another hospital if you are traveling. For your children, does the plan pay for immunizations, yearly physicals, lab work and ER care? Also, who will see your children? Will it be a pediatrician or a nurse practitioner? I saw a two- year-old one day with a severe degenerating disorder. The parents said their child was  seen at the local big Kaiser.I asked the name of their pediatrician, so I could send him or her a report of my examination. The  parents said they had never had a pediatrician or M.D. but the child was seen by a nurse practitioner. The  little boy had a progressive, life threatening disorder and I was appalled. I met the CEO of a  large Kaiser on an airplane and told him about the boy. He said not having an M.D.was  impossible. He gave me his card and when the child died a few months later I tried to locate  him, but he had moved. I will never forget  that little boy.  

Breast Cancer and Choices

I am not an expert on breast cancer but I do know about choices. The most important thing is to always get a second opinion. Many people feel that if they go to a well known medical school the treatment will be the best. A good friend, who was an M.D., had a lump and then  a breast biopsy. She was told it showed cancer, so she had a mastectomy. The pathologist could not find any cancer in the breast tissue. They had planned to do chemotherapy and radiation. What a tragedy.

Two friends recently asked me about friends of theirs who had been told they had breast cancer. Neither woman had asked for a second opinion. Plans were being made for one to get radiation in an independent center in a town well known for its terrible medical care. (I know that first hand!) I suggested a second opinion for the woman and asked that she please go elsewhere if she really has to have treatment. First, however  her biopsy needs to be reviewed. All the woman has to do is fill out a form and have the slides sent to the best possible cancer center.  I think patients these days must take charge of their medical problems and always seek second opinions unless the doctor is a true expert in the area of their  medical problem. Many lives would be saved if second and even third opinions  were requested. 

Some pathologists are great about saying they would like a second opinion on biopsy slides. This is not just for breast cancer but any time a biopsy is needed. I  have great respect for  pathologists who admit  they don't have the training to look at a particular kind of tissue. This can be rare but there are some wonderful, concerned pathologists.  You just  have to ask.

Senior Medical Care When Traveling in the U.S.

If you are traveling in the U.S.by yourself or other seniors there are some precautions to take. As an older person, you want to be sure you carry a prescription for your glasses if you need them. Glasses do get broken. You also want to be sure you have refills  for any prescriptions you take. If you become ill on an airplane there may not be a physician on board. The airlines are somewhat better in the past about training their staff about what to do if someone becomes ill. I hope they are better, too, about having more medications available for physicians to use than they did in the past. I have responded to calls for a physician several times when I was flying.  One time it was necessary for me to have the pilots land the airplane mid-way across the country because there was no medication I could use to stop a man from  having seizures. From his luggage, we decided that he was using a stimulant and had been traveling for several days. I was accustomed to treating seizures in children, but there was nothing in the airplane medical chest  I could use. 

Most, and I hope all airlines  have defibrillators on board. I am told the staff are trained to use these. I  have found that some of the flight attendants in the past were quite difficult. One flight attendant insisted I show her my medical license. Would she had done that for a male doctor? Another one asked me if I wanted a glass of wine as I was listening to a person's chest and taking his blood pressure. Amazing!

My other concern, if you are traveling by car or bus, and become ill is about using urgent care facilities. Not all have a physician on-call. I have seen seen some grave mistakes happen when a non-physician tries to treat a patient. One teenager who had muscular dystrophy, was told he had diabetes and the nurse wanted to give him insulin. The parents called me and traveled for several hours so I could see the youth. A chest X-ray showed he had lobar pneumonia! He did well with the right antibiotics.