healthcare

CHASING DEPRESSION

Editor’s Note: One of my favorite shows right now is CBS Sunday Morning with Jane Pauley. They do such a great job at presenting interesting topics in a meaningful way. When I saw the spot about the promising treatments for depression, I thought of dad (eshrink) and knew it would be a great topic for eshrink’s blog. This post is a wealth of information on depression and Eshrink FINALLY weighs in on the TV program that prompted me to have him write it (that’s a little sarcasm that you’ll get when you read his blog) That’s just how we roll 🙂 Here is link to the spot that aired. SAINT: Hope for new treatment of depression – CBS

CHASING DEPRESSION
My slave driving editor who sometimes masquerades as a loving daughter has directed me to write a critique of a Jane Pauley TV show that featured information about a newly discovered treatment for depression. Maggie’s interest comes naturally since she had worked in my office as a receptionist when she was in high school, and her interest was undoubtedly enhanced by the presence of depression in our own family. There is no doubt that what we call Clinical Depression is a very common disabling and often fatal disease. Unfortunately, the word depression is also used for less serious mood deviations which often leads to a lot of misunderstanding. It is estimated that over 1 million people worldwide commit suicide each year and no ethnic group or race is immune from its paralyzing grip. Nearly all these victims are suffering from depression.

In 2017 there were 9.6 million people receiving treatment for depression, never mind the millions who were not treated. According to data from the 2017 National Survey on Drug Use and Health, 17.3 million adults in the United States—equaling 7.1% of all adults in the country—had experienced a major depressive episode in the past year.

There is said to be an alarming increase in suicide rates in the United States over the past decade however; such stats must be viewed with caution for in the past, coroners, who in order to spare family members the stigma of mental illness, would often rule suicides as accidental or from natural causes. Unfortunately, the stigma persists although there has been considerable progress towards classifying depression, the major cause of suicide, as a medical illness.

DEPRESSION of the AGES

It seems as if depression has always been endemic in human populations. There are multiple Biblical references offering solace to the despondent, and fables from even older times suggestive of unwarranted sadness. Perhaps the high level of consciousness afforded us by our massively complex brains has in some way contributed to our vulnerability. Throughout history, there have been endless speculation and theories put forth as to the cause of depression including: moral failure, demon possession, witchcraft, sinfulness, masturbation, or sexual deviancy to name a few. Most of these theories blame the victim, which further contributes to the self-loathing that typically accompanies the disease. To this day there are those well-meaning souls who unwittingly aggravate the depression of the one they are trying to help. In my practice, I had some patients with a strong spiritual orientation who become depressed,  sought help from their pastor who diagnosed the problem as lack of faith, and suggested they pray harder.

The COMPLEXITY of DEPRESSION

In medicine, as with most things, transparency minimizes speculation. There is little doubt in my mind that an understanding of the causes of mental illnesses would go a long way towards eliminating the stigma associated with psychiatric illnesses. There is also the maxim in medicine that prevention is preferable to treatment of a disease. It is my belief that since it comes in many different shapes and sizes, depression is not a single entity, but more likely a cluster of illnesses producing similar symptoms, much as we see the symptom of fever in many different types of infections. Depression also takes different forms as for example, some patients suffer from severe insomnia while others find escape from the horrible feelings of hopelessness by sleeping for days.

Although depression often occurs spontaneously, it can also be precipitated by extreme stress or loss. For example, grief presents with symptoms indistinguishable from depression. Seasonal affective disorder with its recurrent depressive episodes appears to be related to disturbance of circadian rhythms, and one could make a case for it having resulted from the migration of humans to temperate zones a few hundred thousand years ago. As a matter of fact, depression frequently accompanies a variety of mental health syndromes, not the least of which is bipolar illness in which a manic episode is frequently followed by extreme depression. There is even a separate category of bipolar illness where those afflicted only cycle to depression and don’t experience manic episodes.


A Little Shrink History

It has been my good fortune to have been involved in the shrink business during a time in which there has been more discoveries leading toward an unraveling of the mysteries of the mind than have happened since the beginning of time. For centuries a cure for what was called “the black dog” by the Roman poet Horace and later repeated by Churchill occupied the greatest minds to no avail. Hippocrates was the first to identify the brain as the major control center of the body. The pseudo-science of phrenology became popular in the 19th century, which was the idea that one could diagnose problems, estimate intelligence and diagnose personality types by measuring the size of the bumps on their skull. Although it was soon discredited, its proponent, Franz Gall, is credited for advancing the idea that there is localization of brain function. He identified 27 different areas of the skull which he said controlled different functions.

Franz Gall diagram that identified different areas of the skull that he said controlled different functions.


In the early 1900’s along comes a Viennese neurologist who would influence thinking about the entire field of psychiatry and psychology for a half century. Freud’s focus on sexuality, in a Victorian society in which even uttering the word sex itself was considered in bad taste, gained him much world-wide attention. He developed a form of treatment both lengthy and intensive which he called psychoanalysis. Even now that many of his theories have been discredited, many terms which he introduced have become part of our every-day lexicon.

The Pharma Era

Fast forward a half century and I was in medical school witnessing miraculous advances in medicine almost daily. Following Fleming’s accidental discovery of penicillin there had been a rush to develop antibiotics that might be effective in treating organisms refractory to penicillin. Among those was isoniazid which had proven to be effective in the treatment of tuberculosis. In those days total bed rest was required as essentially the only treatment for TB consequently; patients who were confined to continuously stay in bed for months at a time often became depressed. However, following the use of isoniazid, moods of patients in TB wards often brightened, they became more verbal, less angry, and even happy. This led to investigation of similar compounds and the first group of antidepressant compounds called Monamine oxidase inhibitors (MAOs) were developed. These drugs were effective for some, but not for all patients. They also required great care in their administration as they interacted with many other drugs and there were severe dietary restrictions.

Depression and Pharma

1956 was my junior year in medical school and it was a banner year for the pharmaceutical industry. It marked the development of broad-spectrum antibiotics, i.e., those effective against penicillin resistant organisms. Thorazine, the first drug to ever prove effective in the treatment of schizophrenia was introduced. Within a year more than 70% of patients in psychiatric hospitals in the US were discharged, and there would be no more barbaric lobotomies performed. A group of antidepressants called Tricyclics whose side effects were less onerous than with MAOs came on the market at the same time. The response to these antidepressants, even though understanding of their mode of action was largely theoretical, led to the development of what came to be called the catecholamine hypothesis of depression. It theorized that the symptoms of depression were due to defects in the transmission of chemicals called neurotransmitters which were necessary to transmit electrical impulses between nerve fibers.


No Silver Bullet

Despite all these treatment, relief from depression was still elusive for many patients. Electroencephalography had been around for nearly 20 years, and it had become more sophisticated and especially valuable in the treatment of seizure disorders. Before Freud, there was a guy named Bleuler who wrote a widely quoted book on schizophrenia. As a matter of fact, he is credited with coining the term. He noted that he had never seen schizophrenia and epilepsy coexist therefore concluded that seizures must protect against schizophrenia. With that in mind several people set out to induce seizures as a treatment for schizophrenia by giving drugs known to cause grand mal seizures. The problem was that response to the drugs was unpredictable and the mortality rate was too high even in a non-litigious time. They also noted that although seizures did not have any effect on schizophrenia except for those in a catatonic state, it did seem to be remarkably effective for those who were depressed.

In the 1930s Italians Cerletti and Bini found they could induce seizures by passing an electric current through the brain. This method allowed for better control, and proved to be remarkably effective in cases of severe depression. Electroconvulsive Therapy or ECT as it is called, was widely used throughout the world and I saw firsthand how effective it could be to treating depression that was resistant to drug therapy. It got a bad rap due to the type of complications that could accompany it, such as broken bones, and the movie ONE FLEW OVER THE CUCKOO’S NEST. Additionally, ECT was sometimes used in cases where it was not indicated, yet were we in the shoes of those guys would we not be willing to try it if it were our only tool? Recent developments of anesthetics and muscle relaxants have made it much safer and better tolerated, but it is still mostly reserved for antidepressant resistant cases, yet there are some cases of depression that don’t even respond to ECT, which has been designated the last line of defense.


My Experience with the NEXT SILVER BULLET to TREAT DEPRESSION

After years of research, primarily investigating the neurotransmitters, norepinephrine and dopamine, researchers had become interested in another neurotransmitter, serotonin, which eventually led to the breakthrough development of Prozac in 1987. I vividly recall the first person for whom I prescribed Prozac. He was a very depressed young man in his mid-20s who had been an outstanding athlete and valedictorian of his high school. Unfortunately, he had become severely depressed, and developed a disabling social phobia. He rarely left the home where he lived with his parents, except to keep his appointments, and requested to be allowed to come in via the back door of my office in order to avoid occupants of the waiting room. I had been seeing him for some time, but my efforts were to no avail. On this particular day, a drug rep had left a sample of this new drug called Prozac which had just been approved for general use, and I thought “What the hell, I ‘ll give it a shot!” Two weeks later, David (not his real name) bounced into the waiting room and with a broad smile announced to the receptionist that he had arrived. Indeed, he had. He was proud to inform me that he had just come from a theatre where he had enjoyed the first movie he had seen in several years. My first thought was, “Could I have misdiagnosed this problem, and this guy is actually bipolar?” but he continued to improve and said: “I have finally got my life back”. The last time I saw him he was a sophomore studying engineering at Ohio State University.


Needless to say, David sold me on Prozac. It proved to have a remarkably good side effect profile other than for occasional sexual dysfunction which most people thought was a small price to pay for relief from the horrors of clinical depression. There would follow, as always is the case, a number of other “me too” drugs all of which came under the heading of SSRI’s (selective serotonin reuptake inhibitors), and after prolonged usage would sometimes lose their effectiveness a phenomenon called Prozac poop out, but in my opinion they have remained heads above other treatments. Unfortunately, the SSRIs as with other antidepressants are only effective about 70% of the time, and psychiatrists are often forced to make use of the trial and error method of finding an effective medication.


Seeing is Believing

Other than the unraveling of the human genome, nothing has impressed me more that the development of scans. They always remind me of the STAR TREK physician Bones who could diagnose and simultaneously treat any problem by putting people in his scanner. I am in awe of those engineering types who figure out all this stuff. The Curie’s invention of the x-ray was monumental, but the enhancement of that technology with computers to produce a cross section view was over the top. It was called Computerized Axial Tomography (CAT or CT scan) and provided a much more detailed look at the brain. In addition to hundreds of other medical uses, it was a valuable tool for brain research and a straight forward way to eliminate brain tumors and other brain diseases which often mimic psychiatric syndromes, a problem that had bedeviled psychiatrists forever. It was not long (the late 70s) when along came the PET scan with which one could actually visualize brain function. Even more fascinating and incredulous to me was the MRI which use a powerful magnet to actually turn protons on end to produce an image from the energy given off when they return to their normal position. They produced amazingly detailed pictures especially useful to orthopedists.


MAGNETISM

There has long been interest dating back 200 years or so on the effects of magnetism on the human body. In 1989, after studies suggested that magnetic energy could be effective in the treatment of depression, the FDA approved TMS (trans-magnetic stimulation) as a treatment. It was a very benign procedure that involved placing a 2-pronged electrical coil which produced a weak magnetic field on the patient’s head. The procedure was simple, painless and without side effects, and could easily be performed in a doctor’s office. Analysis of effectiveness of treatments for depression are difficult due to the placebo effect, but double-blind studies (clinical trials in which some administrations are real, others shams, and neither the patient or the physician is aware of which treatment is real) demonstrated effectiveness in some patients, but not all. In general, responses were not seen as very robust, and it was used mostly as an adjunctive therapy along with antidepressants.


This paper is in no way meant to provide comprehensive review of past and presently available treatments of depression, but believe me they are numerous and sometimes bizarre. In the November 13, 2021 issue of PSYCHIATRIC NEWS, Charles Nemeroff MD, PH.D in his review of treatments for depression, notes there are currently 26 medications approved by the FDA for the treatment of depression and another 12 in the pipeline. There is one study published in the May 2020 American Journal of Psychiatry regarding the use of psychedelics like LSD and psilocybin in the treatment of depression. Who’d a thunk it? In addition to the many types of psychotherapy, there also are always a plethora of non-medical procedures touted to be effective. Lest I get carried away and in deference to my editor who is by now tearing out fists full of that beautiful red hair as she screams “When in the hell is he going to talk about the spot on the TV show?” I will proceed to offer my humble thoughts.

SAINT

After watching the Jane Pauley show about the Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT (thank God for acronyms), I found the original publication that described their novel treatment of depression to be in the August 2020 issue of The American Journal of Psychiatry which I had discarded long ago. Since I am a lifetime member of the American Psychiatric association, I continue to be automatically subscribed, but I must confess that since my retirement eight years ago, I tend to scan rather than peruse journals in much detail. Frankly, because the rapid changes in the field with its increasingly complex technologies have left me often wondering what they are talking about. Nevertheless, the Stanford U website reported an astonishing 87% recovery rate in the treatment with this new procedure named SAINT. Even more impressive, was the fact that these patients had all failed on other conventional treatments. Dr. Nemeroff mentioned in his review that the effectiveness of SAINT had recently been confirmed by a double-blind study which lent even more credibility to the reports of its effectiveness.


SAINT: What it is

The procedure involved is a much more complex, powerful and targeted version of the TMS mentioned previously. The researchers (Dr. Cole et al) were able to direct a burst of very powerful magnetic energy to the dorso-lateral prefrontal cortex (you must look that up in an anatomy book if you plan to do this at home) of the brain for 5 minutes per hour for 10 hours daily times 5. They are convinced that their success is dependent on their ability to target that particular area of the brain which has long been suspected of playing a prominent role in mood regulation. The patients and their families who were interviewed on TV were absolutely euphoric in their endorsement of the treatments. They used the phrase “game changer” and one was convinced this procedure would change the world, and I guess it has changed her world. I agree that this treatment holds promise, but think changing the world may be a bit over the top.


CAUTION: With Experience Comes Pragmatic Skepticism

Members of my illustrious family have accused me of being pessimistic by nature, while I insist that I am simply a realist, and much too naĂŻve to be a bona fide pessimist. In spite of this alleged cynicism, Maggie has asked me to share my opinion of this SAINT thing, and I do find it promising however; all those years practicing medicine have taught me that although all people are the same, they are also all different, or as Grandma used to say: “One size doesn’t fit everybody.” Time after time I have found the initial exhilaration associated with ground breaking discoveries in medicine are later tempered by experience. I do feel this may well be a large step towards conquering this dreadful disease.


Nothing that I have written here should be construed to mean that I believe pills or procedures alone are the answer to the problems of mankind. At best I feel that medications or other somatic treatments enhance the therapeutic benefit of human intervention. Pills are important, but so is the hand that dispenses them. I have been heartened by a trend towards more balance in the nature versus nurture debate which has persisted for generations, for in recent years neurochemistry has dominated the psychiatric literature. Those of you who have read some of my other blogs probably know that I have strong feelings about that subject. Again, one size doesn’t fit everybody, but the more tools (based on scientific research) that psychiatrists have to treat the black dog of depression, the better off the world will be. The brain is a wondrously complex organ and the acceleration of knowledge is promising indeed.

Uncomfortable Hospital Bed

BED REST? ARE YOU SERIOUS?

 

For a lot of years, I routinely admitted patients to hospitals. Due to a recent brief sojourn in one, I now feel compelled to seek atonement for those sins.

As I am sure you are all aware, to be hospitalized means that during your stay, you will spend almost all of your time in a contraption the medical staff will refer to as a bed. My recent experience has enlightened me, for I naively thought that the word bed when used in medical parlance had the same meaning as it did in ordinary conversation, i.e., a place where one could rest or even sleep. In truth, it turns out that a hospital “bed” has little to do with such a concept, but is simply a workbench designed primarily for the comfort and convenience of the worker.

As such, today’s hospital beds are of course designed to perform all kinds of tasks with minimal effort on the part of the worker. The hand cranked mechanisms of past generations are now powered by electric motors, and with a push of a button, will raise or lower all or parts of the bed. They come equipped with a variety of connecting mechanisms that allow all kinds of accessories to be attached. All in all, as tools, they are marvelously engineered and do amazing things none of which have anything to do with patient comfort.

If you have the misfortune to find yourself in a hospital bed, you will find yourself lying on a thin, usually lumpy, mattress atop a metal slab. Such discomfort does not come cheap however for Modern Healthcare says the average cost for a hospital bed in 1998 was $15,627 while specialized Intensive care beds can cost $25,000 to $35,000.

Since these so-called beds are narrow enough that to roll over could land a patient on the floor resulting in a wrongful death lawsuit, they come equipped with side rails as standard equipment. The practices of shackling patients to their beds, euphemistically referred to as the use of soft restraints, has received a lot of bad press in recent years consequently; our always innovative design engineers have located the side rail lowering mechanisms in a place where they are inaccessible to the patient. The result is that one is virtually immobilized.

Such a strategy does have its limitations however. I recall a conversation from years ago with a patient of mine who sustained some rather serious injuries when he fell while attempting to climb over his bed rails. Following the time-honored tradition of blaming the victim, I asked him why he had done such a thing. He replied that he needed to use the bathroom. When I responded with the equally inane question as to why he didn’t wait for help, his answer was prophetic: “If you ever have a prostate like mine you will understand and not ask such a dumb-ass question.” Now, a few decades later I do understand.

When trapped in one of those cages, the patient’s lifeline is the “call light,” presumably so named from the days when the push of a button turned on a light in the nurse’s station. This would summon a nurse to the patient’s room. Now due to the miracles of modern science, that gadget has morphed into a 2-way radio, and your voice will probably be answered by the ward secretary in a businesslike fashion, but in a tone that suggests “what the hell do you want now?”. In the event you happen to reach a nurse who has been forced to work overtime after completing a 12-hour shift, prayer will be your best option.

Most of you are undoubtedly familiar with the aforementioned gadget which also has buttons to operate the TV and room lights. It is attached to a cable which is the umbilical cord to the outside world. This presents a hazard to a klutzy guy like me who tends to drop everything he touches. Consequently, panic set in when I dropped the thing on the floor in the middle of the night. There was urgent business which needed immediate attention and no way for me to escape containment. The feelings of helplessness engendered, rapidly progressed to an exacerbation of my latent claustrophobia.

Fortunately, I was saved from psychotic decompensation when someone who in other circumstances I would have cursed for awakening me at such an ungodly hour came in the room to check my vital signs. She turned out to be very helpful and I felt like kissing her for saving me. I have no idea who she was for it is difficult to distinguish the nursing staff from the cleaning crew these days for they are all dressed in scrubs. Gone are the days of starched white nurses uniforms with dainty white caps perched on their coiffured heads, which announced the school from which they trained. White oxfords and stockings have been traded in for sneakers. Dress codes long gone demanded that hair must never reach the collar.

It is not that I have ever been intrigued by formality, and I confess that I have not worn a necktie in the past couple of years. Nevertheless, I believe that some uniformity conveys a sense of pride in one’s profession and in medicine inspires confidence in the caregiver, which has been proven to be therapeutic, but that has been given up in the name of casual comfort for the caregiver.

 

Now that we have hospital beds doing most of the heavy lifting, could not engineers now engage all that superior intellect in an all out effort to design a bed with the comfort of the patient in mind?  Back in the dark ages when I was in medical school we were taught that rest was a powerful tool to aid in the healing process, a principle undoubtedly discovered by grandmothers thousands of years ago. Who knows? To be in a real bed might even allow us to catch a few winks in between assaults on our body.

HEALTHCARE GOES DIGITAL

HEALTHCARE GOES DIGITAL
In my last blog, I promised to delight you with my observations about the Electronic Medical Record (EMR). In accordance with the current custom of using anachronisms rather than words in the medical literature, I will henceforth use the term EMR in my discussion of the topic. Since early on in its development the computer has contributed much to medicine. Without it the various scanners routinely used to make instant diagnoses could not have been developed. It has become an essential tool in medical research. Without computers what many believe was the most important medical discovery of the century, namely the unraveling of the complexities of the human genome could not have happened. One can hardly imagine any area of medicine that has not been influenced by the so called digital age.

Considering all this, it is little wonder that the computer would eventually be touted as the answer to all the problems said to exist in the delivery of healthcare in the United States. The promise was that it would: 1) save money, 2) reduce errors, and 3) improve outcomes. The stick that The Department of Health and Human Services used to encourage adoption of EMRs was to penalize those non-compliant by reducing their reimbursement rates.
1) SAVE MONEY (?)
It is a bit difficult to imagine there could be significant savings when one considers the cost of the initiation and ongoing support for these systems. One study estimates the initial cost of a five physician group to set up a system to be $233,000, not taking into account an average of 600 hours needed for training in its use. Following the initial investment it is estimated maintenance costs would average $17,000 per year. Since the costs for a solo practitioner would obviously be higher, it is not surprising that many such individualists are either retiring, joining a group, or taking a salaried position.

1) SAVE MONEY (continued) / Too many zeros…
But physicians’ costs are chickenfeed compared to the costs of hospital computer systems. Perhaps the most outlandish was the $4 billion spent by Kaiser Permanente. They report however that this will result in a cost of only $444.00 per each of their insured. This came after an admitted $300,000 dollars was spent on a previous plan which was abandoned. The interviewee, CIO Philip Fasano, insists that the $4 billion expended for the current plan is well spent as he believes it will save 15 to 17 percent of costs by eliminating duplicate testing. It will be interesting to see if such savings will result in a reduction of premiums. In addition to the price paid by hospitals and physicians to set up and maintain EMRs, there is the $30 billion spent by the feds on these projects. In my research on this subject I did come upon more numbers, but by then I was so busy counting zeros that I became too dizzy to record them.

2) REDUCE MEDICAL ERRORS ?
As for the reduction in medical errors, the most obvious benefit accrues from the virtual elimination of handwritten orders, reports, prescriptions etc. From personal experience I can attest these are often illegible, and consequently subject to interpretation. Some may insist that poor handwriting is a prerequisite for graduation from medical school. If that is true, then I have been imminently qualified as penmanship was not my strong suite in first grade and it has gone downhill from there. In spite of the problems associated with writing, verbal orders and reports carry an even greater risk of miscommunication. It has been demonstrated time and again that the more steps through which information passes, the greater the likelihood of error.

2) REDUCE MEDICAL ERRORS / The disconnect between theory and application
When information is communicated digitally, it follows there should be fewer errors. If such information can be delivered automatically the risk should be even less. For example, hospital laboratories are largely automated these days, and it follows that if a machine delivers its report seamlessly i.e. without touching human hands it should be less likely to be misread, misplaced, or ascribed to the wrong patient. Unfortunately, Erin McCann of Healthcare IT reports that in a nationwide study 74% of nurses reported feeling burdened by the need to do data entry, which took time away from patient care. The impression left is that much data must be entered manually; consequently most systems are anything but seamless, and therefore still subject to error.

It is easy to imagine the scenario in which a patient’s electronic medical record could be lifesaving. For example, when an unconscious patient is brought to an emergency room his medical record may be critical in making a diagnosis in situations where time may be literally a matter of life and death. As a matter of fact there are many situations when the instantaneous availability of a patient’s record may save time, unnecessary tests, and even lives. It should no longer be necessary to spend time in hospital record rooms or doctor’s offices copying records, x-rays, scans and such. Not only written reports, but actual copies of films, EKGs and such could be called up in order to see if changes have occurred. Come to think of it, there would be no need for record rooms or the floor to ceiling racks stuffed with file folders we see in our doctor’s offices. Yes, in a perfect digital world Joe Patient would carry his entire medical record with him wherever he went and it would be accessible whenever needed, but anyone who owns a computer knows that we are some distance from perfection when it comes to this computer stuff (more about that later).

3) BETTER OUTCOMES ?
The third premise that EMR would create “better outcomes” is still up for grabs. It is noteworthy that, according to a report in FiercehealthIT, 17% of physicians surveyed thought EMRs actually worsened patient care. One might be led to think this group would consist mostly of old digitally challenged physicians like myself, but the disturbing fact is that the number of negative comments has increased since 2012.

According to a Patrick Caldwell piece in Mother Jones5, 75.5% of hospitals were using EMR programs by 2014, but I am not aware of any indications that quality of medical care has improved. Indeed, I don’t know if it would be possible to do such an assessment of an issue that complex. He goes on to issue a scathing report on the business practices of competing providers of EMR software. He contends that the various programs do not share information with each other in order to protect company secrets. This would prevent the seamless passage of information unless all his healthcare providers subscribe to the same system thus defeating a major purpose of the program. Thus Joe’s record would only be available to a consulting doctor or hospital ER if they subscribed to the same version as did Joe’s regular physician. Peter Pronovost MD, director for patient safety and quality at Johns Hopkins, was likewise critical with his statement that: “Medicine invests heavily in medical technology, yet the promised improvement in patient safety and productivity has not been realized.”
EMRs and Me
My own brief experience with an EMR tends to validate the premise that interoperability is a problem. When a facility where I was working adopted a program, I was able to sufficiently overcome my age related aversiveness to change and make a half-hearted attempt at compliance. I tried to hone my deficient typing skills (we had no typing classes in medical school), and dutifully began typing check marks in the boxes provided, which often resulted in a great deal of useless information. There were some advantages, such as the ability to send prescriptions on line rather than writing them on paper or calling the pharmacy. In addition to the convenience for both myself and my patients, it solved my penmanship problem, reduced errors, and prevented forged or altered prescriptions.

Maybe this EMR thing will work after all
With that in mind, I was heartened by the news that our local hospital was going digital. We were dependent upon the hospital’s psychiatric department as a place to send our patients who needed intensive treatment, and for the psychiatric department’s extensive outpatient diagnostic capabilities. I had visions of entering my patients’ identifying numbers in the computer and instantly being privy to every bit of medical information about him. No longer would nurses spend time on the phone calling about lab work, or waiting for the record room to respond to requests for discharge summaries, or reports from consults. The fax machine would no longer go through a ream of paper every couple of days. I would no longer be accused of nurse abuse because of questions like: “Where in the hell did you put that lab work?” As some of my younger, more verbal patients would say: “Dream on baby!” For as computer geeks would say their system was incompatible with ours (in plain speak, their system would not talk to ours) and we were forced to continue to rely on that older, but more reliable invention called the telephone.

Is our healthcare system broken?
The statistics available seem to confirm the premise that the U.S. healthcare system is broken. In an interview by PBS, Mark Pearson the head of the health policy division of the Organization for Economic Co-operation and Development (OECD) provided some discouraging statistics. Politicians have long trumpeted the fact that we spend over 17% of the gross national product (GNP) on healthcare, which is second only to defense spending.
Healthcare by the numbers
Pearson reported that we spent $8,233 dollars per person in 2010, which was two and a half times more than the average per person cost in 33 other developed countries. The average cost for a hospital stay in the U.S. is $18,000 which is three times that of the other countries, in spite of the fact that hospital stays were shorter in the U.S. The Commonwealth fund  reports that 25% of that cost is for administration. Drug prices in other countries are sometimes less than half the price we pay, in spite of the fact that the majority of new medications are developed in the U.S., often with financial support from the National Institute of Health. Of course the drug companies also get some help from their friends in congress who have without apology passed a law forbidding Medicare from negotiating prices. Oh yes, just another example of the perverse golden rule of the corridors of power, namely: “those with the gold make the rules.”

What are we getting for all this money?
After digesting all this information, you may be asking, what am I getting for all this money? The answer: not much. There is no doubt that we lead the world in medical research, and people come from all over the world to study in our institutions. We have been the absolute leader in the development of medical technology.  Then, why is my life expectancy over one year less than it is in 33 other countries? We might blame it on lifestyle, obesity and such, or could it be that our shortened hospital stays could have a deleterious effect?

Words matter, but true listening requires vision
Patients have complained to me that they are often told their doctor cannot see them in between appointments and they are told to go to the emergency room sometimes with even minor complaints. But the most frequently heard grievance was “my doctor doesn’t listen to me.” Not surprisingly, this was more commonly heard as the digital age invaded the consultation room and some physicians pecked away at their computers while the patient talked. Of course, there is much more to effective communication than the use of words, and no matter how attentive the listener, without visual cues much of the message is lost.
In my humble opinion, it is incredibly naïve to think that computerization could have a major effect in closing the gap between us and the OECD nations. After all we are undoubtedly ahead of them in implementing EMRs and management systems; consequently, any advantage gained would be countered as they would inevitably follow suit with similar technology. You may be asking what is the answer, if EMRs are not. I have long held the position that there is a shortage of medical doctors in this country, and OECD study tends to bear this out. They report the U.S. has 2.4 physicians per 1,000 people while the average for the countries scrutinized was 3.1 per 1,000. Thus we have fewer physicians, fewer hospitals, and shorter hospital stays at 2 ½ times the cost.

What we do have are more CT and MRI scanners along with lots of other expensive gadgets, and they are utilized much more frequently than in other countries. One disturbing bit of research by the Dartmouth Institute for Health Policy concludes there are very large differences in the rates of utilization of such diagnostic machines in different areas of the country.
Even more upsetting is their conclusions that the number of elective surgeries, cardiac interventions, and even open heart surgeries are all performed at vastly different rates in different areas of the country. Should we conclude from this that some areas of the country are over treated or that others are undertreated? Information obtained from the OECD study would suggest the former is likely true. Hospitals are required to have a utilization committee composed of physicians who look for outliers among their peers; however, in my experience they are not very effective in rooting out excesses.  Indeed, if they were one would not expect to see such disparities in diagnostic procedures and treatments.

Enter Managed Care
In recent years insurance companies’ managed care programs have gotten into the act. They exercise control by simply not paying for services they feel are excessive. I believe it is safe to say that they are universally hated by physicians. I share that feeling with more intensity than most of my colleagues because I blame them for the too early discharge of one of my patients which led to his death. It is interesting that the courts have ruled in such cases that the managed care company suffers no liability with the rationale that they are not denying treatment, only refusing to pay for it.

No doubt, many of the problems I have enumerated with The EMRs will be fixed eventually, and the concept can be of marvelous benefit, but it is also clear to me that computers will not fix everything that is wrong with our medical system.

So, what is the answer?
At this point, if you are still awake, you may be thinking: “OK wise guy, if you are so smart, what would you do about it?” And I would reply, “Thanks for asking for of course I have all the answers.” After all, I have been a participant and observer as medicine evolved into the current mess, besides I now have learned how to use Google.

The Age of Assembly Line Medicine
It may seem counterintuitive, but I am convinced that a significant part of the problem is due to a shortage of physicians. No, it is not merely a matter of competition although that is not necessarily a bad thing, rather it has to do with the pressure to be productive. Dealing with lives merits deliberation, and impulsive decision making is apt to lead to errors. The production processes of assembly line manufacturing Henry Ford developed may be advantageous for manufacturing cars, but completely inappropriate for treating human beings, especially those who are sick, in pain and in distress.

The lost art of LISTENING
One of my professors from medical school once said: “if you listen carefully to your patients they will make the diagnosis for you 80% of the time.” As I mentioned previously many of my patients complained that their doctor was not attentive, and always seemed in a hurry. Since there is a shortage of physicians, there will be a need to see more patients; consequently less time is made available to talk, and the doctor seems remote and uncaring. The patient may leave with unanswered questions and harboring a great deal of anger. When called upon to consult with hospitalized patients as a psychiatrist, I often found the problem to be the result of a doctor patient relationship gone bad. To the physician, the patient seemed unruly and uncooperative when they just didn’t feel they were being heard.

Litigation
Another downside of failed communication between a physician and patient is litigation. As a matter of fact, insurers report this scenario is a major cause of malpractice suits, and that the best protection from malpractice suits is a good doctor patient relationship. Of course the cost of these suits, which are less prevalent in other countries is also said to be a major cost factor. Some states have initiated procedures to help reduce the number of suits and to limit the amounts which could be paid; meanwhile refusing to search for reasons for why there are so many suits filed.

The Conundrum
A few years ago, after retiring from private practice, I began working part time at a public facility that had a very long waiting list of people needing to be seen. I was asked if I would be able see a patient every 10 minutes. I replied haughtily that I was not a prescription technician, yet afterward wondered how many of the people on that waiting list might be suicidal. These are the kinds of dilemmas facing doctors, especially those in primary care settings (i.e., if you spend adequate time with each patient, how many won’t be seen at all). In my small town, there are very few primary care physicians who are currently accepting new patients leaving many people to seek care at our ER which of course is much more expensive. The solution, which is currently underway, is to license those with lessor training to diagnose and treat. I am sure there is also the thought that these nurse practitioners, physician’s assistants and such will demand lower fees, although that may not have work out as expected. I also question the wisdom of solving the doctor shortage in this manner, especially during a time when the increasing complexities in medicine demand more knowledge than ever before.
Fee-based vs. appointment-based physicians
There is also, in my opinion, a maldistribution of physicians, with the shortage most acute among primary care doctors. Family doctors have always been the grunts in the healthcare domain, with the specialists commanding the most respect especially the surgical specialties. Those who do procedures are reimbursed based on a fee schedule while primary care docs are essentially paid based on time spent with the patient. This can lead to serious inequities in incomes. The days of the solo general practitioner are past, for most find they cannot generate enough income to pay their overhead. It requires a considerable staff to do billing, get authorizations from insurance companies, fill out forms, deal with managed care, medicare, medicaid, pharmacies etc. He is forced to accept insurance company fee schedules if he wants to be “on their panel”. Add his malpractice insurance to the mix and soon he will be looking for a salaried job or a group to join. Young doctors may be saddled with hundreds of thousands of dollars of student loan debt which can be a powerful motivator in choosing a career choice as he may look toward the more lucrative specialties.
Living History
In 1965, I had been doing general practice for a very few years and when medicare came in to being that year I was convinced that this was the beginning of the end, and Joe McCarthy was right when he said we were well on our way to being taken over by the communists. The precedent of connecting healthcare to employment had already become entrenched by corporations who used that fringe benefit to attract workers during the labor shortages of world war II, but in the 60s Blue Cross and Blue Shield were the only significant players and all that was necessary was to send a bill and receive payment. Of course it made no sense for health insurance to be tied to employment, but the labor unions were not about to give up that goody, and it remains in ObamaCare, which is one of the reasons why although better than nothing it is not by much.

Eating crow
Now, 50 years later, I have eaten so much crow that I regurgitate black feathers as I have become an unabashed promoter of a single payer system, that is medicare for everyone. Such an idea is certainly not new as it was first proposed by Teddy Roosevelt in 1912. I have dealt with a system that has become increasingly complex each year, and have done battle with giant corporations whose major function appears to be to find ways to deny treatment to those whom I feel are in need. I have this perhaps naïve view that with the insurance companies out of business and their lobbyists gone maybe our do nothing congress might do something beneficial for their constituents.

One frequently hears that socialized medicine would bankrupt the country due to the inevitable inefficiencies that would result. The reality is that medicare may be the only efficiently run federal program in existence with an administrative overhead of less than 3%. The affordable care act only allows health insurance companies 20% in administrative costs, whoopee. Of course this does not take into account the millions of dollars spent by hospitals and doctors which would be greatly simplified if they only had one entity with whom to deal. Even without taking this into account, we would reduce total health care costs by at least 15% if not more.

More savings could also accrue were congress to repeal that ridiculous law prohibiting medicare from negotiating drug prices. In addition to the effect on total costs, I find it repugnant that populations all over the world pay less than I do for my medications. This seems unlikely to change since Pharma seems to be especially adroit with their lobbying efforts. I would be very interested to hear from Congress their rationale for this law. It must be a dandy.
There is also the economic effect on businesses to be considered. Many industries report that providing health care for their employees is a rapidly rising expense that makes it difficult for them to compete internationally. One would think they would be busy lobbying for a single payer system. The digital movement in healthcare has spawned new departments in most institutions. In the mental health center where I had recently worked one person managed to keep all the computer stuff running, until the introduction of an EMR. It soon became necessary to hire 2 more people, and an IT department was born.

Longevity has its advantages, and in my case it has allowed me to witness and in a small way be part of the profession of medicine during a period of momentous discoveries. The 60 years of my involvement saw the virtual elimination of many illnesses which had been responsible for millions of deaths and untold suffering. When I began practicing medicine, if someone told me that it would one day be possible to transplant a human heart I would have laughed in their face. To confirm the suspicion of a brain tumor would require two or three days of tests some of which were dangerous, now an in depth picture of the brain is available in a matter of minutes. Even in my own field of psychiatry the study of the mechanisms underlying brain functions has revolutionized the field, and the complexities described often leave me wondering what the hell they are talking about. This paper is in no way meant to denigrate these accomplishments; rather it is an attempt to expose some of the factors which have resulted in an inefficient and costly system of providing them to the masses.

At the outset, I listed three goals that were hoped to be accomplished by the digitization of our medical records. The first was to decrease cost. From what I was able to glean from my research and personal experience I have concluded that the attainment of such a goal is unlikely. As for the other two, I am convinced that an all-encompassing computerized system has the potential to improve treatment outcomes and reduce errors. Unfortunately, the systems in play are too fragmented for that potential to be realized. It would appear that fixes are readily available. It remains to be seen if they will be applied.

Reminisces
As with most old guys I like to end my conversations with reminiscences of the good old days even though the current ones may be better. In spite of a lifetime in which I have witnessed the most exciting time ever in medicine, a time of more discoveries and progress made in the alleviation of suffering than had occurred in thousands of years, I sometimes feel nostalgic for the way things used to be even though without the miracles of modern medicine I would probably not be here today. I recall a time when the doctor patient relationship seemed much more personal than it does today, when doctors saw themselves as healers rather than fixers or technicians. I remember a time when one could even talk to one’s doctor on the phone. Now if I have a question for my doctor I must answer to the receptionist regarding my reason for calling, and if she considers it worthy of note, she will post a message to the doctor’s nurse or direct the call to the nurse’s voice mail, and if the nurse considers the question worth consideration she may consult with the doctor, but if not will devise her own answer. If she is not too busy, I may be fortunate enough to receive a call back with either the doctor’s or her answer to my question. In any event the doctor will be insulated from the stupid patient with his stupid questions. You might think that since I am a physician I would be more readily granted access, but you would be wrong for the fellowship of physicians is no longer a strong tradition.
How it used to work
I remember a time when most people had a personal physician, and usually their relationship was indeed personal. If admitted to the hospital your personal physician would see you daily even if he had referred you to a specialist, now you are apt to be followed by a hospitalist whom you are meeting for the first time. Were you to have surgery, your doctor would assist if possible. A visit to the emergency room would prompt a call to your doctor. If you were unable to come to his office, he would come to you. In short your doctor was in charge and responsible for your treatment. He would likely know your strengths, your weaknesses and usually knew most of the members of your family. In short the doctor patient relationship was very personal.

There have always been those dedicated to healing their fellow man even in prehistoric times and in the most primitive of cultures. Much of the science has been off track; however, there has been much learned about the art of medicine. It would be a great loss if that knowledge were abandoned in favor of purely digital solutions.
1. Health Affairs: Study puts a price on EMR implementation in small practices
2. Info World: tech’s bottom line May 2, 2013.
3. Healthcare IT News: Nurses blame interoperability woes for medical errors. March 15, 2015
4. FierceHealthIT: The cost benefit calculation of electronic health records systems.
5. Mother Jones: Epic Fail, November/December 2015.
6. PBS Newshour: Health Costs, How the U.S. compares with other countries October22,2012.
7. The Dartmouth Atlas of Healthcare: Reflections on Geographic Variations in Healthcare, May 12, 2010.

MY LEFT FOOT

My left foot is under assault by some nasty little microscopic creatures. I like both my feet, but my left one is my favorite. Since I am left handed, it naturally follows that I should be left footed; consequently, I find that such activities as kicking something or someone, stepping on an insect, climbing a stair, or putting on my pants are always led by my left foot. If I am dancing or tapping my foot to music, my left foot leads the way, and the right one follows. When I feel the need to show my anger at having been bested in an argument with Barb, it is my left foot which will be loudest as I stomp out of the room. Of course these are minor functions when compared with its utility along with its companion on the right in providing a convenient means of getting from point A to point B. For these and many other reasons, I would very much like to keep my foot as I do need it.

The problem first appeared two weeks ago when I noticed redness and swelling on the dorsum (that’s doctor talk for top) of my left foot. I thought it looked like a cellulitis, a condition which can progress rapidly with very serious consequences. With that in mind, I talked my way into a next day appointment with my doctor’s colleague (my doctor was on vacation). He agreed with my diagnosis, and started me on an antibiotic with instructions to return “ASAP” if there were any signs the infection was spreading. There was no change after two weeks so he changed antibiotics and informed me that he would admit me to the hospital for IV antibiotics if there was no improvement after a week on the new bug killer. I was a bit shaken by this new game plan.
You may be thinking: what is the big deal about going to the hospital for a relatively benign treatment? Surely I would submit to the harshest of treatments if I thought there was the slightest risk of losing that left foot of which I had become so fond. Although I had spent thousands of hours working in that hospital, I felt some trepidation about becoming a patient there, simply because a hospital is a dangerous place.

One study reports 440,000 preventable hospital deaths annually, making such errors the third leading cause of death in the U.S. I believe these numbers are inflated somewhat, as preventable does not necessarily mean they could have been foreseen in time to intervene. Even so, if these numbers are even half accurate, one must consider hospitals as dangerous. They are further contaminated by including hospital infection rates. We are currently experiencing an epidemic of infections in hospitals. The CDC reports 724,800 such cases in 2015. 4% of all patients admitted will contract an infection while in the hospital. This in itself is scary enough, especially when one considers that hospital infections are apt to be treatment resistant.

The problem of hospital infections continues to bedevil the medical community, and most experts believe that it has evolved due to the inappropriate use of antibiotics which results in the development of bacteria which have become smart enough to develop immunity to the effects of antibiotics. The most common of these organisms are: MRSA (methicillin resistant staphylococcus aureus) and clostridium difficile which is usually referred to as C. diff. The elimination of these bacteria from hospitals has been a daunting task on which most hospitals expend a lot of resources. Such infections do present a significant danger to those whose immune systems are impaired or patients who are weak and infirm. They appear to be spread throughout the hospital by caregivers who are at risk of carrying an infectious agent from one patient to the next.

The VA reported they were able to reduce hospital induced infections by 40 percent by the simple expedient of requiring all staff members to use an antibacterial lotion on their hands when leaving or entering a patient’s room. Compliance was carefully monitored in the study. It is now common practice to have antibacterial dispensers near the entrance of every room; however, there are always those who will not follow protocol. It is also true that lotions are ineffective against most viruses.

Sometimes the mode of transmission is less obvious, for example in one case a number of patients all belonging to a particular surgeon contracted a MRSA infection. Eventually the source was traced to the surgeon’s necktie after it was noted by a nurse that when bending over to examine his post op patients his tie came in contact. A culture confirmed that the tip of his tie was contaminated. Some post-surgical wound infections have been traced to closed circuit ventilation systems commonly used in surgical suites with a mechanism of spread similar to that seen in Legionnaire’s disease. The increase in the use of medical devices, and other invasive procedures, both in diagnosis and treatment, also undoubtedly increases the risk of infection. Although it seems probable that lack of caution is responsible for many of these infections, I submit that if an event is not predictable it is not likely to be preventable, and I don’t believe the statistics I have quoted take this into account. However; whatever the cause, the numbers are frightening.
A few years ago (I dare not say how many), my wife Barb’s first job after nurse’s training was what was then called private duty. As such, she was employed by her patient to provide nursing care exclusively for him, and therefore, except for very brief periods, was in constant attendance during her shift. I suppose such care is still enjoyed by the super-rich but is beyond reach for most of us. Besides, if one arranged for such a nurse, it is unlikely said nurse would be welcomed by the hospital.

Now, many wisely suggest that if hospitalized, one should arrange for an advocate. The wisdom of such an arrangement was brought home to me when I was hospitalized a few years ago. When I did not get an adequate response after pushing the nurse call button to get help for what I believed to be a serious problem, Barb channeled the tigress within her and attention was immediately forthcoming. It appears to me that the most highly trained of the caregivers, the RNs, spend much of their time with administrative functions, while the hands on care is delivered by others, yet the RN is in charge and is expected to know all about the patients under her care. As Barb says “I learned more about my patients while giving a back rub than from taking a formal history.” But alas, back rubs are mostly a thing of the past.

None of this is meant to disparage hospital nursing staffs, for I believe nearly all are fully dedicated to the most noble of all professions; however, many to whom I have talked complain they are not able to spend enough time with their patients, and consequently worry that they might miss something important.

There are several factors that may contribute to the problems of medical errors.

Due to cost cutting efforts by third party payers (a code word for insurance companies), the criteria for admission to hospitals are more stringent than they have been in the past, and there is intense pressure to discharge patients. The result is that the typical hospitalized patient is sicker and therefore more vulnerable to even minor mistakes.

Modern miracles in medicine require many people to get in on the act. Diagnostic and treatment procedures are much more complex and require the involvement of those with specialized skill sets and knowledge. In addition to consulting doctors there are therapists of many disciplines, and others trained in specific diagnostic procedures who are likely added to the mix. It is generally accepted that the more people involved in an activity the greater is the chance of a screw up.

The latest statistics on hospital errors suggest that those involving medication top the list. The most common as you might expect is due to misidentification of the patient, although errors in the pharmacy are certainly possible. Any who have been hospitalized in the past year or so probably noted that whatever was done to them was preceded by a question as to their name and birthdate, which was then verified by reading the hospital wrist band. The fact that mistakes still occur in spite of all these precautions confirm the impression that as humans we are all fallible.

Mistakes in the operating room can be especially disastrous. One of my closest friends, who also happens to be a retired orthopedic surgeon was forced to have back surgery twice because his surgeon picked the wrong vertebral level on the first try. This confirmed my impression that whatever status I thought was conferred on me as a doctor would do little to make me immune from an unwanted assault on my body.

Other mistakes can be even more serious. I recall hearing of an instance in which a person had the wrong kidney removed, necessitating her being put on chronic renal dialysis. There have been similar rare reports of people who have returned from surgery to find their good leg has been amputated, and the bad one remains. I once had a patient who was scheduled for X-rays, but realized she was taken to the wrong place when she found herself surrounded by people with caps, masks and long gowns. The transportation person insisted he was told to take the patient in bed two to surgery, and the charge nurse was equally adamant that she had instructed him that surgery was waiting for the patient in bed one. Fortunately, the surgery staff discovered the error at about the same time as did the patient, but the incident raises the issue of how important those repeated questions about name and confirming birth date can be. I also remember having three patients by the name of Smith in one room back in the days when most hospitals had a few four-bed wards. You can imagine the problems that situation could cause.

Now that modern medicine has contributed to an average longevity greater than nature intended, we have a much older population and since the prevalence of many illnesses is directly proportional to the amount of aging, hospital populations have become older, weaker, and susceptible to many problems which may interfere with their equilibrium. They are also more likely to be on medications that may affect their balance. Put these factors together and it is easy to see why falls are more common amongst the elderly. Since old folks are more susceptible to injury, falls are a serious problem and nowhere more so than in the hospital.

Recently, I visited an old friend who has had unsuccessful back surgery. He was in a rehab facility to get physical therapy, and has been unable to walk. It was a nice day so I got help and placed him in a wheelchair and took him out for some air and sunshine. As I got ready to leave, I noted that he was slumped over a bit in the chair and I was concerned about leaving him there without something to prevent him from falling out of it. I was especially concerned as he has had a couple of falls since his surgery, one time by falling out of bed. When I asked for something to keep him from falling out of the chair, I was told that I couldn’t do that as it would be considered a physical restraint which could not be used in their facility. I thought that was the dumbest thing I had heard since the last presidential debate, and decided to do a little research on the subject. What I have learned is that there has been a great deal of debate about the use of physical restraints, and that some courts have issued rulings about their legality. Some researchers insist that restraints cause more injuries than they prevent. They insist that even bedrails designed to keep people from falling out of bed are dangerous as patients will often try to climb over them and sustain serious injuries. They point to cases of strangulation by so called “soft” restraints often used to prevent confused patients from pulling out catheters, endotracheal tubes, chest tubes, etc. sometimes causing serious damage. I am always bothered by such research, for although it documents carefully the injuries caused by such restraints, there is no way to know what injuries if any they may have prevented. Of course the best solution would be for the patients to have someone in attendance constantly, which is unlikely to happen.
In the interest of full disclosure, I must confess that I have been guilty of using “full leather” restraints on a few occasions when dealing with severely agitated violent patients who are determined to do harm to themselves or others. It was never for very long and I was usually surprised at how well they tolerated it. It may have been because there was someone assigned to be with them, that they realized they had needed to be subdued, or simply that it gave the medication time to work.

Ordering such treatment always made me shudder for I am quite claustrophobic for which I blame my older brother, rest his soul. When we were kids he delighted in putting a blanket over my head and pinning my arms until I panicked. I have dealt with homicidal patients in the past without totally losing my cool, but find that anything which prevents free movement of my arms takes me all the way to the edge of a panic attack. The thought of being handcuffed with my hands behind my back fills me with dread. The only fear I have of surgery is that I will wake up restrained as is often the case when complications result in a patient being attached to a respirator. A couple of years ago l was forced to have my left arm pinned against my chest and to lie flat for 24 hours following a procedure. I, the one who feels nerve pills are for everyone else, begged for Xanax. And you thought psychiatrists didn’t have hang-ups.
No treatise on hospital errors would be complete without mentioning the current fad of electronic medical records, and as you can imagine I have a lot to say about that subject. In addition to reducing costs, and increasing the quality of care, these systems are touted to dramatically reduce hospital errors, but for now I will spare you my ruminations about that subject as Maggie has chastened me about making these things too long. As for my favorite foot the current medication seems to be working and hospitalization seems unlikely.