The county reported a case of measles in an unvaccinated woman who travelled over seas.

Undoubtedly tax money is being spent on identifying potentially exposed and at risk secondary contacts. These would be most likely infants under a year of age, immune deficient persons with other medical problems or others who tend to believe the "anti-vaccination" propaganda, which, beyond comprehension is given credibility.

WHY? Because it sells product- pure and simple. If the forces of reason are serious about standing up to the forces of greed - the only successful way is to exploit media opportunities as they arise.

Case of measles: Should get front page headline. Depict the individual with measles as a reckless selfish person endangering innocent infants- because she is. Show a photograph of what measles looks like in a third world infant where this disease still kills. Make the point that parents who don't immunize are choosing to assume this risk for their child. Explain the rare disease SSPE ( a fatal neuro-degenerateve disease that is a consequence of measles).

Get people to see that NOT vaccinating caries real risk- That risk has got to be perceived as greater than the risk of side effects from vaccination. In FACT IT IS. The perception depends on the ability to manipulate the media. Right now the forces of capitalistic exploitation have the upper hand . "Alternative Medicine " is a multibillion dollar media and quasi-pharmaceutical industry in it's own right. There is big money to be made exploiting the anti-authoritarian consumer and the alternative medicine industry does so with impunity.

Oddly my thoughts today were very much in line with my last post. If electronic medical records are intended to add value, the program has to be at least as smart as I am, and optimally smarter. Instead of what I call the "trained chimp" approach to health care delivery, programs need to be developed that process input like seasoned clinicians.

Current state of the art is that most EMR's OPTIMIZE how much money can be extracted from the insurers and attempt to minimize liability (arguable since so many of the records look like nothing but drivel)- but do very little to help an experienced clinician evaluate a patient. Actually they get in the way . Most of the time I find myself putting a blank piece of paper on top of the template allowing the patient to talk- following their leads - fleshing out the history, corroborating the story with physical findings. I end up recording the data the computer wants after the day is over. So the whole process creates more work.

It would be a huge error to confine encounters to "that which fits the template". I would have missed a case of extra-pulmonary tuberculosis, if I had used the "back pain" template. Pleuritic inspiratory pain isn't mentioned on the template. Would I have been prompted to examine the patient's lungs? (I would have gotten points off for ordering the chest xray that identified the liter of fluid in the pleural space....)

Today brought a patient with a not so unusual complaint to the office.  As is my usual approach, I let her tell me about it with as little interruption as possible.  The goal is to permit someone to tell their own story and to prompt only for details, nuances...I follow a scheme learned at the bedside 20 years ago from a "master" clinician...1) "Quality"- have the patient flesh out the nature and experience of the symptom,  2) "quantity" - How often, for how long, continuous or not? - 3) Bodily location- (patient defined, and confirm with physical findings) 4) Setting - when are the symptoms noted, when not,  what else is going on? 5)Chronology - How have symptoms progressed/changed  over time  6) Aggravating/alleviating factors? Anything that seems to help? anything that seems to make things worse 7) Associated manifestations? What else seems to be associated are there any other symptoms anywhere else?

Obviously very free form - very unstructured.  That approach still works brilliantly - I would NEVER have been able to definitively diagnose my patients clear endocrinological problem from her presenting neurological complaint had I been constrained to use a template based on the "Chief Complaint"....I'd be doing way too much talking - asking entirely wrong questions, and she'd have likely left the office for a non-needed radiologic procedure that would have failed to yield a diagnosis and been a waste of her time and money.  Instead she left the office with clear knowledge of what was wrong and a treatment plan.

Explain to me why templates are an improvement if they fail to yield a diagnosis?  If I am to use one then someone has to write one that is superior to my current ability to define the nature of the patient's problem.  So far I have been entirely underwhelmed.

Get up at 5:45 am, get to work by 7:30 am...

I try to keep people healthy, or restore their health if something is wrong. First step is always to define what is wrong- or what is going right. Sometimes this is easy, other times it's not obvious and takes a while. Second step is translation- it's my job to make something complex understandable. I try to evoke visual images- usually as you watch people's faces you can see the light of comprehension click on. Third step is to figure out what they can or will commit to- and figure out what the resistance is if they DON'T want to do something that would help them. Sometimes there are tough trade offs and I'd be hard pressed to say which alternative is best. Other times it's a no brainer, but (a usually under educated) zealot has created fear when the odds overwhelmingly favor benefit rather than harm. Other times it involves a life stye change that won't be so easy to achieve...(Like exercise is good - but time to exercise competes with all these other things we have to do everyday)...

At the end of the day I update records, then review results of lab tests, radiology reports, specialist reports, fill prescription refills, call people to explain their reports, track down reports I'm expecting, send reminders to folks when it's time to do check labs or see me again.  Search the literature for clues when the diagnosis is obscure - make a plan for the people seeing me the next day...review their charts to figure out what information might be needed to keep them well or sort out their concerns.  Some of this can be planned in advance - the rest depends on what is going on when they arrive.

Get home - (if early) by 7 pm- sometimes closer to 9 - eat, sleep, repeat...

Reflections on rapidly changing health care landscape:  More and more folks are thrown into the fraying safety net.  More and more budget cuts impact this net. Greedy insurance companies skim the cream, and leave the crumbs for those trying to actually deliver services.  The already wealthy, serving the wealthy can easily afford the expensive EHR records that can artificially produce data indicating quality is available only from the elite private practices. (Appears that no one seems to understand statistics and epidemiology well enough to see through the data manipulation.)

In a nut shell- If the very poor, illiterate, non-English speaking, and homeless population are systematically excluded from the denominator of the data presented, and only the health outcomes of the educated employed insured are presented - Imagine what an effective health care delivery system it will appear that you are a part of!

However when you look past the veneer and scrutinize the drivel that passes for medical history from these EHR's and the differential diagnostic mediocrity hiding under the multi box check lists - and then sit down with the (hand written) medical records of those of us who are still standing in the trenches with the afore mentioned "excluded" population, what you might realize is that better actual medicine is practiced without the dumbed down scripts of EHR.

Presently experiencing round two of clinic management's attempts to institute "open access". Doesn't appear as if any of them have actually read or in any way understand the real concept. Clearly when it works well it's good for everyone - That is, my patients see me today or soon - and all of the reasons for which they have made the appointment are addressed at that visit. Sadly clinic management are clueless about how to actually accomplish this - So what we have instead is "anyone who shows up is seen by anyone with an opening" and if there are no openings then they are just doubled in with anyone - Doesn't matter what the purpose of the visits are or what needs to be accomplished in the (very limited) time frame or who is seeing who. Previously we had paired teams - so patients would always see one or another of us. Now it's kind of a free for all. Patients I've known and cared for for the last 10 years are scheduled with someone else, while I'm seeing patients that are yet another's. Patients aren't even told that they are scheduled with someone else and don't find out until they show up. Sad really. Our community clinic used to provide health care that could go head to head with any private practice and come out the winner in terms of quality of care and continuity. Right now corporate style management is rapidly creating a Medicaid mill - and truth be told - quality of care is rapidly plummeting. You would not know this from the Hollywood slick video clips shown at the annual meeting. The administrators with the smiling facades carefully screen the truth. There is a moment of epiphany when it is perfectly clear that while providing care for poor people is what matters most to you, the institution as a whole has morphed to exploiting the poor for its own fiscal aggrandizement. It's only a few more weeks and I will leave this setting for one more in line with my values.