Sometimes it seems like the emergency room at my hospital is a wormhole between two universes: one where I and the other medical professionals live, and one where the patients live. Some of the differences between these two were unsurprising to me: I already knew that our patient population tends to visit the ER for situations where I’d just pop some Tylenol, for example. (And there are a lot of reasons for that; if you don’t know much about medical issues you might not have any way of knowing whether something’s life-threatening, and if you don’t have access to a primary doctor there’s no one to call when you’re not sure whether to come in, nor is there any way you can just go see your doctor in a week if it doesn’t get better.)
One of the differences I saw this month really struck me, though. I saw quite a few young women with complaints of nausea, vomiting, abdominal pain, tiredness, missed periods, etc. Many of them received a diagnosis of “normal pregnancy.” What got me was that none of these teenagers seemed upset to find out they were pregnant! If I had turned up pregnant at 16, I would have thought my life was over. Apparently (I didn’t see any with their moms there) the mothers are excited to find out that their daughters are pregnant, too. Again, if this had happened to me, I know my mom would have still loved and supported me, but her first word would not have been “Congratulations!” (Of course, my mom did not have me when she was 16, either.)
This is the first thing in med school that has made me feel naive and idealistic. I thought that education was key, and if young people knew about their bodies and their options for preventing pregnancy, and birth control was made available, the teenage birth rate would decline. Now I’m not so sure - if pregnancy is seen as a *happy* thing for high school kids, if they don’t see it as a huge roadblock on their paths in life, what’s the motivation to abstain or use condoms? I guess it’s good that girls who become pregnant aren’t ostracized, but I think this might be a little too far in the other direction!
The other day, I saw another interesting and weird aspect of this. I went in to see a patient whose chief complaint was “nausea/vomiting/need pregnancy test”. She’d been waiting for a few hours in the waiting room, then maybe 20 minutes in the exam room, which really isn’t bad for people who show up with non-urgent complaints. During those 20 minutes she’d been out to the nurses’ station multiple times asking for food (so apparently her nausea wasn’t so bad) and to use the phone. So I went in to see her with the thought that we’d do her pregnancy test, let her know what was going on (at least she wasn’t going to be too surprised if it was positive), and send her out.
ME: [Introduce myself.] So, what’s been going on?
PATIENT: I need a pregnancy test.
ME: OK, we can do that here. When was your last period?
PATIENT: The beginning of August. I’m healthy, I’m 20 years old, I weigh 160 pounds, what else do you need to know, can we just do the pregnancy test and get me out of here?
ME: Well, we can do that, but whenever somebody comes in to the hospital we have to talk to them and examine them to make sure we aren’t missing anything serious.
PATIENT: Fine. Can I have something to eat? I’m hungry.
ME: So your nausea and vomiting is better?
PATIENT: Yeah I just throw up in the mornings. And I’m tired and hungry the rest of the time and my nipples hurt. I’m pregnant, OK? I took a home test.
ME: Oh, you did? What did it say?
PATIENT: It was positive. Three of them.
ME: So… are you expecting this one to be different? [probably not an example of good doctor-patient communication skills, but I was just really confused about why she’d be there if she already knew she was pregnant.]
PATIENT: No, I just need a paper that says I’m pregnant so I can go on WIC.
So I finished examining her, counseled her to stop smoking, told her about getting prenatal care, etc. She ended up being pregnant (surprise!) and very unhappy that she’d had to wait another hour or so to see the doctor to get discharged. I don’t know what the actual WIC requirements are, but it seems like it would be cheaper for them to accept the results of a home pregnancy test with verification in the WIC office, than having the taxpayers pay for emergency room visits for pregnancy tests.
[As always when I post about patients, some details have been changed.]
Every time I meet a patient who’s an organ recipient, I am amazed at the accomplishment of organ transplantation. The way it extends people’s length and quality of life is just spectacular. Sadly, people die every day waiting for organs, while usable ones are buried. There needs to be a national effort to increase donation rates; the payoff is enormous.
I was excited to see today that the Washington Post gets it.
This suffering and waste could be alleviated if more people agreed to give organs posthumously. Currently only a little more than half of the 14,000 people annually who die in circumstances that would make them suitable donors give organs. All state governments and the District have tried to encourage donations by asking people to sign up when they apply for a driver’s license. But not enough people respond to this prompting, so it’s time to consider extra incentives.Three types of incentives merit attention. The decision to pledge organs could be linked to the chance of receiving one: People who check the box on the driver’s-license application when they are healthy would, if they later fell sick, get extra points in the system used to assign their position on the transplant waiting list (other factors include how long you have waited and how well an available organ would match your blood type and immune system). Another sort of incentive is financial: Georgia has experimented with a $9 discount on its driver’s-license fee. A final reform would shift from opt-in organ donations to an opt-out system: Unless you went out of your way to check a box on your driver’s license application to indicate that you did not want to give organs, you would be considered a potential donor.
These reforms don’t raise significant ethical issues. They would not allow people to buy and sell organs, and they would not allow patients to pay their way to the top of the organ-transplant queue. Each reform, or some combination of them, would save money and relieve suffering. The District and state governments shouldn’t wait.
Hear, hear.
Apparently Newt Gingrich thinks WIC is a leading cause of childhood obesity. More on the merits of that claim later, but it did remind me of the following anecdote:
The grocery store closest to my neighborhood serves a wide variety of people, including a fairly large population using WIC. One day I was in line behind a woman who was buying, among other things, Kraft singles and Jif chunky peanut butter. The cashier scanned the peanut butter, the register beeped, and she told the customer “Sorry, WIC only covers the creamy kind. Want to go switch?” The customer went to grab some approved peanut butter, as the cashier scanned and bagged the “processed food product” that was next on the conveyor belt. So apparently on WIC you can’t buy chunky peanut butter, but you can buy nasty “cheese” that can’t even be labeled as such without a disclaimer about processing.
Anyway, I’m pretty sure Gingrich is confusing correlation with causation. Children on WIC probably do have higher obesity rates than average, but that’s because they’re poor, and poor people tend to be obese because of a whole bunch of things like not having access to supermarkets for fresh produce, choosing food with high caloric density, and a culture that doesn’t encourage cooking.
Along those lines, I learned something very interesting in physiology today. Quote from our course book, following a discussion of factors contributing to obesity: “Junk food is cheap because it is made of grains, corn, and/or processed meat and the production of all of these is highly subsidized by the federal government.”
I’m not sure I ever looked at it that way before (though I did know that the prevalence of high fructose corn syrup is due to sugar tariffs and corn subsidies). There’s something the federal government could do about the obesity epidemic!
Via Adrienne, a disturbing bit of news: New York City Starts To Monitor Diabetics
New York City is starting to monitor the blood sugar levels of its diabetic residents, marking the first time any government in the United States has begun tracking people with a chronic disease.Under the program, the city is requiring laboratories to report the results of blood sugar tests directly to the health department, which will use the data to study the disease and to prod doctors and patients when levels run too high.
OK, so New York City decides it wants to figure out how well its diabetic population is controlling their disease, which areas have it worst, and that sort of thing. Seems like a fairly reasonable thing to study. There are procedures for doing studies that involve collection of many people’s information - largely focused on making sure that necessary consent is obtained and confidentiality is respected. If they just wanted to study the disease distribution, and collected test results without any identifying data, I wouldn’t have a problem with it. That’s not an unusual thing to do.
But the city also, apparently, plans to inform patients and their doctors when the patients’ test results aren’t up to snuff. Obviously, this means that the city is collecting personally identifying information; otherwise they’d never be able to find the patients. I sincerely hope that the lack of any information about informed consent to this monitoring was an omission by the newspaper and not the city. But given that the article quotes lawyer Robin Kaigh saying that “they are not even required to tell you this is happening,” I’m skeptical as to whether there is any consent involved. Admittedly, I’m not a lawyer and spend only as much time with HIPAA regulations as I need to so they’ll let me in the hospital, but I can’t see how that isn’t a violation of some sort of privacy regulation. And if it’s not, it should be.
Beyond that, I don’t even see the point of this. Presumably, people who are going to the labs to have their recommended tests done are managing their illnesses. I know medical paperwork is notoriously awful, but it seems to me that most of the time, when people have lab tests done, they’re sent there by their physicians, who get a copy of the results, and they fill out a form with their address, so they get a copy as well. Obviously this doesn’t always work out. But if the city wants to try and improve this process, perhaps it could require that a physician’s address be provided before any test is done, or patients be given a number to call to get their results with no voicemail runaround, or whatever it thinks might streamline the communication of results. Having the city insert itself into the process seems like the worst possible idea - the only thing that could be more difficult than dealing with health-care red tape is dealing with government red tape on top of it.
Besides, I’d imagine that the people who are going to the trouble of visiting the lab and getting poked have some idea of how their disease is progressing, and their doctors probably do too. The people who “don’t take it seriously” or “are not paying good enough attention” are most likely the ones who aren’t visiting the labs.
Hmm. I bet the next step will be to identify people with diabetes (once you start yoinking people’s private health information, it won’t be that hard) and start harassing them to get their tests done. It sounds excessive, but then, once we wouldn’t have thought that public health departments would use intrusive tactics justified by the need to control epidemics for diseases that aren’t even communicable.