X-Rayed Book of Medical Care: Partial Truths, Half Lies

By C. Robert Adams

The X-rayed Book of Medical Care is a carefully selected collection of medical essays. Village rulers (politicians), surreptitious academic researchers, and medical savants know whats best for us. They give us the truth and nothing but the truth, but not necessarily the whole truth. What you dont know can hurt you.

Death panels (rationing of care), hospitalists, inane limitations in cancer screening, and frivolousness in heavily funded medical research are detailed. Issues as regards to use of over-the-counter herbs and supplements, alcohol, cigarettes, and marijuana are discussed. Means are suggested to approach such fuzzy problems as hyperactivity, dizziness, psychiatric misdirection, retired tiredness, childhood insurrection, as well as irresistible or impossible sleep.

Sinister forces and preposterous political proclamations are insidiously trying to dumb down our medical IQ. Elitist leaders are justifying this by touting advances in software and sterile computerized medical decision making. Physicians are being made to fear the consequences of violations of protocols of care (algorithmic sequence).

Common sense, evidence-based medicine, experience, honest data analysis, tradition (custom), and receptive flexible logic need to be blended to make a more perfect union of human and cyber capabilities.

Our medical monolith is becoming a foreboding juggernaut of evolution and revolution. Thomas Jefferson was poignant when he stated, it is safer to have the whole people respectably enlightened than a few in a high state of science and the many in ignorance.

• Language: English
• Publisher: Xlibris US
• Release date: Aug 6, 2012
• ISBN: 9781477120330

C. Robert Adams

C. Robert Adams, M.D. is a board certified neurologist, a graduate of Kansas University Medical School, who has had a private practice in clinical medicine for over twenty-five years.

Book preview

Hole-istic Health Care

Entities regulating or dictating health management profess holistic care. However, the unintentional result is hole-istic health care.

Intellectual honesty is critical for the pursuit, advancement, and positive utilization of medical science. That honesty is not always forthcoming. There may be a lack of integrity. There may be an innocent blind eye to details. The result is a clouding of public and professional perception. There is a shadowy obfuscation of appropriate, beneficial, or best medical care.

It is time for public awareness and insight to rise to a level appropriate for honest and unclouded medical decision making. There is an inherent value or truth in the intelligence of masses (or the public awareness, if you wish). However, convenient lapses of facts or possibly innocent misinformation keep the public awareness (universal health intelligence) from progressing and becoming complete. The observations and fill in information in this book are not annotated, referenced, or otherwise okayed with the so-called medical savants. We did not seek to get permission from professors, politicians, drug companies, or hospital corporations to write this book. The observations contained within are, therefore, provided unabashed and with intellectual impunity.

All of us should be open to honest input. Hopefully, caring, concerned, qualified characters will collaborate to corroborate a more accurate community medical insight. However, our collective and individual health should not be negatively misguided by extreme prejudice of erudite shadowy scholars and corporate executives who know what’s good for us.

The development (generation) of evidence-based practice (EBP) and, more specifically, evidence-based medicine (EBM) is turning in to a misleading juggernaut. Evidence-based medicine (EBM) dictates that health decisions are made by undergoing the best available evidence with professional expertise with the characteristics, conditions, needs, values, and preferences of those affected with any given illness (that is a cognitive mouthful). The definition of EBM sounds noble and lofty on one hand and frightening and disconcerting on the other hand. Regulated dissemination of this scientific and pure information (EBM) is getting to sound like Big Brother is taking care of us. Apparent intent is to ensure they make the best decisions for us. We need, however, a more flexible, insightful, and wise approach from the village rulers (political leaders) who are vapidly espousing the merits of evidence-based medicine.

An example of excessive shallowness in elitist deference to evidence-based medicine includes the use of the substance chondroitin/glucosamine. This combination will help maintain the integrity of or lubricate the joints to maintain their functioning. It has been used for decades in racehorses, essentially crippled by arthritis, to keep them functional. It has been miraculous for dogs with hip dysplasia to maintain the longevity of the family friend for another several years in some circumstances. A meta-analysis of multiple studies done on chondroitin/glucosamine showed a moderate beneficial effect on severe degenerative joint disease in elderly knees. This supplement that decreases aching and stiffness in joints allows people to be more functional and stay active for a longer term in life. However, professors and savants have decried and disdained the value of chondroitin/glucosamine, because there have never been formal evidence-based medicine studies or double-blind, double-whammy, placebo investigations to absolutely establish unequivocal benefit. Sometimes, common sense should just win out over egotistical and elitist condescension.

Inherent truth, camouflaged reality, and (possibly) unintended deception sometimes complicate the use of evidence-based medicine by higher authorities (Big Brother) to dictate our personal and universal wellness. Some elitist individuals can be very adamant in their philopshoic approach to health care. Evidence-based medicine often disdains an approach of common sense, anecdotal experience, rules of thumb, traditions, etc. However, these outlooks and cognitive processes are not mutually exclusive. Following the philosophy of evidence-based medicine may appear scientific. However, it is not the end point of all truth. It does not provide complete data and observations with which to make reality decisions. EBM is unable to make the instantaneous decisions required in emergency or exigently threatening situations where there is constantly changing new data, uncertain projections (future), or variable and shifting patient and doctor preferences.

Erudite professors and politicians are using evidence-based medicine to condescendingly ration health care and dictate the constructs and constraints of health care delivery. In a more perfect world, the truth of evidence-based medicine versus realities of common sense and experience are not mutually exclusive. That is a major point of this discourse.

This dichotomy of philosophic differences in how to make medical decisions is not a moot point. An extreme philosophic stand at one end of the spectrum can be very deleterious. An honest, open attitude is imperative for the most truthful decision making for medical research, public health, governing, and individual sickness strategies.

The Mechanics of Health Care

Health care is basically administered via the following basic scheme with the acronym:

S - Subjective

O - Objective

A - Assessment

P - Plan

The hopeful result of SOAP is alleviation of suffering, facilitation of function, and promotion of happy longevity. The SOAP process starts with subjective complaints, wishes, or desires on the part of the patient. This might include subjective complaints, such as chest pain, which could be a sign of myocardial infarction (heart attack) or pulmonary emboli (blood clots to the lungs). Those conditions could be lethal. Under less deadly circumstances, chest pain could mean heartburn (esophageal acid reflux) or pleurisy (pain from a respiratory infection or bronchitis).

Objective findings in the circumstances of chest pain could include coughing up blood (pulmonary emboli) or an irregular pulse suggesting potentially deadly cardiac rhythm disturbance (imminent sudden death).

Tests such as blood work, X-rays, and tissue biopsy are objective data to put in to the health equation. After the subjective complaints or concerns are so noted, objective findings are identified. Then an assessment is made by the medical professional, hopefully in conjunction with the patient or subject. An accurate or precise diagnosis (assessment) on one side of the coin leads to a better intervention (plan) on the other side of the coin. Never forget there are two sides of the coin. Take headaches, for example. If on the obverse side (heads), a brain tumor is ruled out, then on the reverse side (tails), the headaches discomfort still needs to be palliated. For some medical caretakers, just ruling out a brain tumor is treatment enough for the headache even though the patient is still suffering.

The consequence and plan in treatment of chest pain could include administering strong blood thinners to try to prevent heart damage in the case of myocardial infarction or lung failure in the setting of pulmonary emboli or clots. The plan for pleurisy could be use of an antibiotic in the setting of bronchopneumonia.

The SOAP model of health care is very pragmatic and effective if utilized in the appropriate way. Subjective complaints need to be communicated clearly to medical professionals and should ideally be sorted out in order of priority, with the most pressing problems initially addressed, then moving down to the more minor annoyances. Two concerns arise here. One is a cavalier attitude toward lesser or secondary complaints. The second is a lack of assimilation and integration of multiple complaints or problems.

The egos of primary care doctors, hospitalists, nurses, administrators, and politicians can interfere with diagnoses (assessment) and therapeutic care (plan). Patient obstinance and physician hubris can impede effective communication. Confrontations or contentious attitudes by the patient or professional caregiver do not facilitate a positive and favorable outcome. Succinct, cogent, and polite discussion will be conducive to best interaction between the two parties.

It is scary proposition if your doctor or medical professional feigns honest interchange and cooperation with your other physicians and family when it is not really there. In particular, red flags should be obvious if your care provider has a cavalier or flippant demeanor. The SOAP model should be evident and be more or less explained through the course of the interaction with your health professional. Confrontations or contentious attitudes by the patient or medical professional do not facilitate a positive and favorable outcome.

Why can’t we be friends? Why can’t . . .

In that regard, it can be a conundrum to decide whether to take health advice from:

- Doctor 1: a friendly, sincere, caring, and communicative physician who may have less experience or training

versus

- Doctor 2: a condescending super-specialist that knows what is good for you but has a dreadful bedside manner and inability to effectively interact in delivering recommendations.

Doctor 1 may not be a professor but would willingly and gladly call in whatever expertise is needed in problematic cases. Doctor 2 may be brilliant but too stiff to bend or compromise to find the optimal or acceptable solution to the problem. Doctor 2 may be so confident with his solution to your problem that he is not willing to give you other alternatives or pathways and care. Ulterior motives are suspect in a physician who has difficulty collaborating with other medical professionals or that is not open to options in care. The good doctor can succinctly and cogently lead you to the promised land of plan. A care provider should be open to succinct and cogent discussion with regard to diagnosis and options for treatment.

There are weaknesses of the SOAP model. Subjective complaints do not always point out or highlight all the important health issues. For instance, a conscientious health provider would, in a visit to treat a cold, point out other apparent issues such as a possible skin cancer growing on the forehead or untreated hypertension. A professional that gives attention to important nonsubjective complaints and observations would suggest a caring and conscientious physician.

With regard to the objective or observed features in the SOAP model, tunnel vision on the part of the generalist or the specialist can sometimes leave a number of voids in care. Physicians can sometimes shift responsibility or renege on necessary intervention due to their tunnel vision. For instance, a hospitalist or hospital specialist might admit a person with chest pain and then rule out a heart attack or myocardial infarction. That might be enough for the hospitalist. However, the patient may be left in the dark with persistent, nondescript chest pain without continuity of longer term outpatient care. The patient may be cursorily shuffled out of the hospital after a heart attack has been ruled out but without resolution of the original subjective complaints as far as the patient is concerned.

The wonderment and providence of medical options (or lack of) should not be mesmerizing. Cogent and lifesaving decisions clearly have to be made by the patient, family, and physician. In an ideal health environment, the patient, family, primary care physician, and other specialty consultants involved should all strive to work harmoniously as a team to bring about the best medical outcome.

Twelve Commanders of Urgency

(To Deny Dumb!)

1. Chest pain – This can suggest a heart attack, collapsed lung, pulmonary emboli (clots of the lung), esophagitis, or pneumonia.

2. Abdominal pain – Moderate pain, possibly with nausea, vomiting, or diarrhea, that might appear to be viral gastroenteritis (flu), should not last more than a day or so. Prolonged abdominal pain or crescendo worsening of abdominal pain can suggest penetrating ulcers, gallstones, diverticulitis, ruptured abdominal aortic aneurysm, malignancy, bowel ischemia (gut stroke), etc.

3. Fevers – Temperatures over 101 ºF should be quickly treated empirically with antipyretics, hydration, and vigilance for any deterioration in mental functioning that might suggest serious infection or impending organ decompensation. Fevers over 104 ºF acutely or over 102 ºF for several days should prompt consideration for a visit to your doctor or the emergency room to ensure there is no serious bacterial infection that needs more extenuating treatment.

4. Bleeding – Rectal bleeding can be a sign of ulcers, hemorrhoids, or more bothersome cancer. Bright red blood most commonly suggests hemorrhoids or rectal fissures, while dark blood or black-tarry stools is often more ominous, and suggests higher bleeding such as from colonic cancer or gastritis and peptic ulcers. Bleeding in the urine can suggest an infection or malignancy.

5. Dulled mental functioning – Unresponsiveness or slurred confused speech can suggest stroke, systemic infection (septicemia), diabetic hypo- or hyperglycemia, hypoxia (lung failure), seizure disorder, or poisoning with prescription drugs, illicit substances, or other toxins.

6. Shortness of breath – This can suggest asthma, congestive heart failure, lung infection, or airway obstruction.

7. Blacking out – Loss of consciousness can warn of cardiac rhythm problems, seizures, internal bleeding, etc. Simple fainting (syncope) can be brought on by dehydration, iron deficiency, effects of antihypertensive medications, etc.

8. Difficulty swallowing – This can suggest esophagitis, neurological problems such as stroke or myasthenia gravis (focal facial muscle weakness), or even a malignancy that is blocking the gullet.

9. Headaches – It is worrisome if a new headache is the worst one that someone has ever had, if it is always present upon awakening in the morning, or if the headache has changed its pattern or started to crescendo. Intracranial bleeding, such as from a ruptured cerebral aneurysm, a hypertension-related bleed, or from infections like meningitis, requires acute management.

10. Skin changes – Suspicious lesions, new pigmentations, lumps, or a persistent spreading rash can suggest serious malignancy, infection, allergy, or toxic response to drugs or poison.

11. Inability to urinate – This can occur with prostatism, urinary tract infection, malignancy, and even effects of narcotic and other sedative-type medications. Don’t let it go if you can’t go.

12. Personality changes – This could be a psychotic break or other psychiatric manifestation, adverse effects of medications, strokes, head trauma, or even systemic disease such as infection or blood poisoning (bacteremia).

13. Skeletal trauma – Seek medical attention if ankle sprains, arm injuries, or other post-accident pains that continue to throb or don’t resolve with ice packs and immobilization.

Notice that there are more than Twelve Commanders of Urgency. You have to use your good judgment and common sense. When in doubt, check it out.

Hospitalists, Just Kiss and Say Good-Bye

It has been customary in the past for primary care doctors and specialists to see patients both as an inpatient in the hospital and as an outpatient (office). Historically, this has provided for continuity of care and, of course, a familiarization with patients and their unique problems.

However, over the last several years, there has been a move toward hospitalists. These are doctors who strictly work in the hospital and do not see patients after they leave the hospital. In fact, they do not usually decide to admit patients to the hospital. The emergency room specialist is the gatekeeper who screens who stays and who goes. The emergency room doctor decides who is sick enough to come in and who merits more intensive inpatient treatment. However, these early triage physicians, as a rule, have no continuity with patients after they come in to the hospital. The patients are turned over to the hospitalist. The hospitalist is the primary doctor who directs care and has control, though possibly might have other specialists come to see a sick patient in the hospital. Hopefully, the more specialists the better, as long as they work as a team. However, someone still has to take the bull by the horns to ensure patient management is goal directed and balanced. It is the hospitalist’s responsibility to ensure that any tunnel vision evinced by specialists is focused into a sharp, coherent picture.

People go to the hospital with specific problems and diseases to be addressed. They don’t just go there to have rule outs of diseases the hospitalist thinks are important. The hospitalist should be professional enough to do what’s good for you while still responding to your reasonable personal concerns.

The problem with hospitalists is that they have no vested interest in the patient. In most circumstances, hospitalists will rotate from day to day. If you are admitted to the hospital, say for a heart attack, stroke, or broken hip, you may never see the same hospitalist. They rotate on a daily basis. Although it is always nice to meet a new face, this does not promote continuity of care. It does not promote continuity of thought. It does not promote continuity of communication. It is not the ideal way to develop a therapeutic relationship (medical friendship).

Once the hospitalist is off call for the day, he is exonerated from further responsibilities. Responsibility and culpability is switched to the next hospitalist, transferred on a daily basis. It is not that hospitalists are unprofessional. However, you better grab them when they are around and make sure the SOAP (subjective, objective, assessment, and plan) process is clear. Otherwise, the process can become