Healthy Policy

Conquering the crutches

I'm ready to author a mini round up. I'm not finished yet -- the doctor says it will still be two or three months until I'm completely back to normal.  From here I get tortured by physical therapy and try to erase my limp, but it's all uphill as far as I'm concerned.

It started with this procedure. (look here to see my post-surgery x-ray)  The total cost of my surgery was $21,113, and that doesn't include any of the follow up appointments. 

I stayed in the hospital for two nights, an experience I had managed to avoid since the age of thirteen, but quite valuable as I've continued my foray into health policy.  I wrote a lengthy post describing my experiences, but I'd make these main points: you will see dozens of people, most of whom you don't know, and they will poke and prod you and bug you regardless of whether you're sleeping, going to the bathroom, or bright eyed and bushy tailed.  Also, don't expect to get any rest.  Or have anyone know anything about you besides your procedure.

Once I was released from the hospital, I had a leg brace comprised of straps and hinges at the knee.  It wasn't bad really, and made me feel more like a basketball star or skier who tore a number of ligaments than a girl whose childhood bone disease left her leg requiring some tweaking. 

And then there were the crutches.  Three months of hopping around on two, unable to carry anything for myself (although I did devise some creative hopping patterns to carry small things a few feet).  Three months of fearing steps, refusing escalators, and avoiding wet pavement.  Three months of sore armpits, rambo-esque biceps, and dwindling leg muscles.

Following my foray into two crutchdom, I was introduced to the single crutch.  For the first time in three months I fetched my own coffee.  My single crutch became more of an appendage, or a presentation I took with me everywhere.  Whenever I sat down, I searched out a place to lean it where it wouldn't tumble over.  It fell repeatedly; I learned the only way a crutch doesn't fall over is if you lean it against a brick wall or similarly rough surface, or lay it on the ground.  I flung it into my passenger seat when driving, it fell over with a clang constantly when shopping, and sat as a constant reminder of an annoying friend to be carried everywhere.  But I don't want to complain too much-- it also afforded me the ability to walk semi-normal, my armpit mostly calmed, and it represented progress.

The next step after the single crutch is either more of the same or total freedom.  My appointment, scheduled for six weeks after the move to one crutch, was a source of stress and anxiety -- will I be making enough progress to move on?  Or will I have to endure this awkward way of moving for any number of additional weeks? 

And after 18 weeks, I've finally done it.  My x-ray showed enough improvement to let me walk without assistance.  There was concern early on that my bone wasn't healing and additional efforts might be needed to make it do so (i.e. a bone graft).  So after four and a half months of slow progress, my doctor was as happy to let me go as I was to leave.  I felt like Steve Martin pretending to walk in Dirty Rotten Scoundrels -- ridiculous grin on my face and all. 

I know it's all uphill from here, and that I don't have to fear going back to the doctor and taking a bad x-ray.  My leg feels heavy and unwieldy; I have a small limp and it takes a lot of concentration to try to move as normal as possible. 

But as summer rapidly approaches, I know I'm lucky enough to be released from my body's shortcomings, and I will be able to do whatever I want, barring training for a marathon. 

Now that's progress.

Mumps and the Midwest

My initial reaction to the Midwest Mumps outbreak story was "Hooray for being vaccinated!"  Then I read this:

Mumps, a viral infection, is usually not serious, and there have been no reports of deaths. The most troubling aspect of the epidemic is that many of the patients had been vaccinated. Does this mean that millions of people who thought they were safe actually are not?

So, uh, considering I live in Kansas, I'm feeling a bit worried...

And then the article goes on to suggest that there might be significance that many of the afflicted are young adults (read: college age), rather than children.  Crap.

Trust, doctors, and race

A new study unearthed evidence that blacks trust physicians less than whites.  The study, from the University of Pennsylvania, found nearly 45% of blacks have low trust levels, compared with 33.5% of whites.

The finding that there is a racial disparity in terms of practitioner trust doesn't surprise me at all.  That's due, in part, to a recent discussion with my long-term pediatrician (who works at an acute care children's hospital) about treatment issues he sees.  We talked about defensive medicine and lawsuits, but the part I found most intriguing was our discussion of racial disparities at the hospital.  He told me that low-income black patients in the metro area just don't trust the doctors, particularly at the ER, and often give false phone numbers and addresses, which makes follow up impossible.

The UPenn study attributed much of the lack of trust to the fact that many blacks are uninsured and seek care in the ER, where the staff changes often.  This makes perfect sense to me -- the experience of medical treatment chiefly through an ER setting, where you wait hours to see anyone, see a different doctor every time, and have an invasive, thorough medical history taken each visit, is quite different than visiting a consistent primary care doc.

What's interesting about the study as well is that the race of the physician didn't impact trust level, as one might expect it would.  And that speaks to grave, structural trust problems between the African American population and medical practitioners.

Latino trust levels were not examined in this study.  My pediatrician didn't believe that Latinos had as many issues with trust, but I wouldn't just take his word for it.  Language barriers and fears of deportation create further hurdles for these families. 

Many low-income patients continue to use the ER for care even when they have insurance (whether it's Medicaid or otherwise).  The question for public health experts and medical practitioners, then, is to figure out how to decrease this utilization, which will lower health costs while building trust and more consistent care. 

The various intracacies of medical devices

This post by Chronic Babe is a great round of up trying to engage in sexual activity while being affixed to medical devices.  Well written, straight forward, and non-apologetic (as it should be)!  Well done, babe.

Calling Bill and Melinda Gates!

Please donate some money to this:

Researchers are closing in on a breakthrough microbicide gel to help prevent HIV infection in women, scientists said on Monday, but a lack of funding by major pharmaceutical companies is hampering research.

For those of you who won't know, microbicides are gels or creams, usually inserted vaginally, that help prevent sexually transmitted infections.  The chief target of current microbicide research is to prevent HIV infections. 

Microbicides are the ugly stepchild of already poor funding for HIV medications.  That's because the people they'll help the most are women in third world countries who have extremely patriarchal marriage arrangements (read: most of Africa and India).  Many men in these cultures make regular visits to the local prostitute, where they contract HIV and bring it home to their wives, who pass it on to their children.  Because condom use is taboo (especially women requesting that condom use), women have little ability to protect themselves from infection.

The development of a microbicide for HIV would give these women power to protect themselves and their children.  But a successful anti-microbial agent hasn't been developed yet, although a few are in the final stages of clinical trials.

Microbicides would also be significantly cheaper than treatment with HIV medications, which people in third world countries have essentially zero access to. 

Good Read

This WSJ article on how doctors are seeking to improve their primary care practices is an interesting read. 

Get your tests people

From WaPo:

Despite strong evidence that tests like a blood pressure check every two years are worthwhile, barely 50 percent of U.S. adults receive the diagnostic and preventive screenings that many medical experts recommend. Several factors explain why many Americans remain unaware that they have hypertension, colorectal cancer, high cholesterol and other lethal conditions: the proliferation of recommended tests, doubts about the value of some once-standard exams and time demands that keep many doctors from performing systematic screening.

Explain to me how the value of blood pressure cuffs has been questioned? (those drug store things don't count)  If people aren't getting their blood pressure checked every two years, it's because they're not getting/going to check-ups. 

In a study published last year, Duke University physicians suggested why compliance with screening standards is so spotty: "Taken together, the time needed to meet preventive, chronic and acute care requirements vastly exceeds the total time physicians have available for patient care," they said

If the patients don't show up for their physicals, that's one thing, but is it really that tough to screen for the basics -- blood pressure, high cholesterol, and diabetes?  Colorectal cancer is a different story, you have to get an oh-so-pleasant colonoscopy, but surely the others aren't such a problem that primary care docs aren't doing their purported aim -- verifying the general health of their patients. 

Physical therapy and me

So I've been doing physical therapy the last few weeks.  There's lots of different types of PT offices.  There's the ones that serve mostly athletes or people injured in sports, and the therapists tend to be very fit, A-type personalities, who wear tight shirts (that goes for the men and women) and it's all a glorified in-shape machine.

Then there's my PT office, which is in a medical plaza building that, as far as I can tell, serves mostly old people.  It's probably the smallest PT office I've ever seen; the staff consists of a calm, harmless middle aged man and an intensely religious assistant in her mid twenties.  The other patients are all over fifty, with the exception of one high school age girl who tore her ACL.  The other patients seem to have shoulder/neck injuries, so they spend their appointments stretching their arms or getting massages or anti-inflammation massages with some little microphone thing. 

And what are my exercises?  The newest additions consist of walking around the room sideways and backwards.

But they fooled me at my small old people physical therapy office!  The first day I went they gave me 8 exercises -- mostly 80's exercise video-style leg lifts and a theraband.  But every time I go I get more and more and more.  Now I have like 25 exercises, including the silly walking sideways and backwards, and a variety of other weird things.

The real kicker is I'm not even bearing full weight on my leg yet -- what will they come up with when that happens???

Hospital Story Time!

It's Friday, and that means fun story time.

Today's story is not about yours truly, who has managed to stay out of the hospital since surgery, thankyouverymuch.  It's about my mom, who went under for surgery yesterday.

And may I just take a second to remark that it's so much more fun to collect hospital stories as a visitor/friend/advocate than as a patient.  (Here's my impression of my hospital stay back in December)

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They wheeled my mom into her spacious private hospital room.  She was fairly woozy, but happy to be out of the recovery room, where she told me the other patient had been moaning (a low, growling moan) f0r about an hour.   Within a minute an attractive nurse in bright pink scrubs enters.  She surveys the room, my mom, me and my dad, and picks up the chart. 

She begins to ask my mom the usual "Welcome to the hospital, are you in pain/are you nauseous/do you want ice chips" questions.  Her speech is fairly clear, except for the harder consonants, which are muddled, and I immediately realize: she's deaf.

In my non-patient humble opinion, I think it's fantastic that a deaf person is a nurse.  She reads lips incredibly well.  But for my mom, this isn't the best situation.

Because my mom is also deaf, and she left her hearing aids at home.

My mom has a degenerative disease that affects her hearing.  Because she's been losing it slowly over the last thirty years, she hasn't learned sign language.  She can understand people for the most part, when she has her hearing aids on, but the nurse's muddled consonants confuse her. 

At one point a woman comes in with cleaning supplies and starts disinfecting all the counter tops in the room.  Immediately my mom freaks out and asks for a cloth to put over her nose and mouth (apparently cleaning solvents are very bothersome when you've just left surgery) (Also, I'm quite sure the room should have been cleaned before my mom was actually in it, but I digress).

So my mom is laying there holding the blanket over her mouth, trying to talk to the nurse, who now can't read her lips, and they're both looking at me to interpret.  It's the deaf leading the deaf, except they can't communicate.  This strikes me as a pretty amusing irony.

Aside from the deaf nurse, they had a nifty e-prescribing system, where the tech scans both the patient's hospital bracelet and the medication before administering.  The tech wheels around a little cart with a laptop attached.  It's quite mobile, and I was very impressed. 

And can I just say that ever since I got in to health policy, I'm a total nerd at doctors/hospitals.  I'm like a detective taking note of everything I see, and I get excited by e-prescribing systems.  My family must think I'm crazy...

Are you obese?

A new study from UNC-Chapel Hills found that only 15% of obese people correctly identified their weight class:

About 90 percent of normal weight adults and 85 percent of overweight and obese adults accurately self-reported their weight and height such that the BMI calculated using those self reports fell in the same category as actual BMI.

That accuracy changed, however, when researchers asked participants about their perceived weight status, that is, if they would consider themselves NOW to be underweight, normal weight, overweight, or obese. Seventy-one percent of normal weight and seventy-three percent of overweight adults classified themselves correctly, compared to only 15 percent of obese adults who correctly considered themselves to be obese.

If you read this Washington Post article, however, it's perfectly understandable where the confusion comes from:

A 5-foot-10-inch adult _ both male and female _ is overweight at 174 pounds and obese at 209, according to the U.S. Centers for Disease Control and Prevention.

Did you know that? (Doctors, you're not allowed to answer).  I definitely didn't, and this is where the disconnect is coming from: messages have been unclear about the point at which we are considered obese.  Sure, there's the BMI calculator, but how many of us actually use it?  Or trust the result?

The sample size of this study was very small (~100), so more research is certainly called for.  But better education efforts need to get going, ASAP.

Also, do most PCP's take your BMI at annual physicals?  If doctors aren't telling their patients that they're obese when they are, that will certainly impact patients' self-image.  It would be an uncomfortable conversation, but if your doctor won't tell you you've reached that dangerous weight point, who will?