On the other hand, has she been obese
all her life ? A recent study showed that
significantly obese women in this country
averaged one whole hour of aerobic exercise
in one whole year, and I believe it (a solid
hour, no doubt – but jeez! ) Has she been
diabetic, has she smoked, does she drink
to excess, does she abuse drugs? Does she
take the right drugs: does she control her
blood pressure, her blood sugar, and her
cholesterol? Does she use her sleep apnea
treatment? If she does none of these things,
she turns into a diabetic with renal failure,
congestive heart failure, stroke, recurrent
infection, gradual immobilization, and
eventual dementia. It will cost a lot to take
care of her. She will have many specialists,
many procedures, many admissions, many
medications which she may or may not take,
many heartbreaks, and much depression,
frustration, disruption of family life, and
experience of failure. She will not be a happy
camper. By the time she is saddled with
chronic diseases, if she does every single
thing right she might avoid bypass and
dialysis. But she has to do every single thing
right from then on, and sadly, that is all too
uncommon.
In the middle ground is the person
who is aware of her genetic risks, takes
steps to reduce them, and tries her best.
She might carry the medical baggage of
severe childhood illnesses like rheumatic
heart disease, polio, juvenile diabetes or
cancer. She still ends up having to spend
more money all her life on medicines and
doctors and hospitals, but has a much better
shot at living to be old and not demented.
She needs all the help she can get from her
primary care doctor/PA/NP, and from the
specialists who help her primary care doctor
by knowing everything that we don’t.
Who wants to make book on whether
the metric-obsessed will go away and leave
doctors alone? I am not optimistic. I doubt
they are willing to kill their own jobs. By
rights there is no justification for measuring
anything we currently measure. We doctors
have our own standards for leaning on our
patients to do the preventive care that is
meaningful. Our consciences and their
health should be our guide.
Payers spend money on meaningless
“quality metrics” in order to try to control
doctor behavior. They fail to understand
that medicine is not an assembly line.
They would do far better to spend money
on helping patients: covering one-to-one
grocery shopping, one-to-one personal
trainers at the YMCA, one-to-one pharmacy
consultations, and one-to-one “come to
Jesus meetings” with the health insurance
representative who actually holds the power
to reduce the premium for them – if they
are following their plan. If you’ve got to
measure something, measure shrinking
waistlines, home glucose logs, miles walked
and weights lifted.
Patients are the ones who have the final
say on achieving, and measuring, the quality
of their lives and health. Leave me alone.
Maybe I could read a murder mystery, or see
a bird, or cook something that takes longer
than ninety minutes. Maybe there would be
more of me in the office ranks eventually,
if this box checking madness disappeared
from the face of the earth. LM
Note: Dr. Barry practices Internal Medicine
with Norton Community Medical Associates-Barret. She is a clinical associate professor at the University of Louisville School
of Medicine, Department of Medicine.
From the Blogosphere
Editor’s note: Emergency Medicine residents and faculty at the University of Louisville have a private blog called Room9ER.com. With permission,
we share four of their posts with Louisville Medicine readers.
The Wonder of Ultrasound
Hugh Shoff, MD
G
reat case: it combines the excitement
of chest pain, the enigma that is leg
weakness, and a humbling realization
of the life-threatening diagnosis.
Working in the ED one day, and the psychiatry intern went to see a routine sort of patient, who had presented
with right leg tingling and weakness and made it all the way to the
back of the ED. Basic labs were ordered, as well as a Chest X-ray
for a brief episode of chest pain that the patient told triage- so of
course, the sixth vital sign, an EKG too. Intern sees the patient for
about 5 minutes and returns. He tells me that he is concerned that
the patient is sick and wants me to see the patient sooner than later;
he’s concerned for possible stroke due to right leg weakness and pain.
HPI: 58 y/o AAM with hx of seizures, on Dilantin but no other
medications or PMH, presents with chief complaint of right lower
leg pain and tingling. Patient states that while at work today, he was
lifting boxes and felt a sharp chest pain that started in the middle
of his chest and radiated to between his shoulder blades. It then
shot to his pelvis and went away. He went back to work for about
10 minutes then started to have right leg pain. He tried to drive to
the hospital, but had to stop and call an ambulance due to severe
RLE pain. All other symptoms had resolved at this point. No n/v,
diaphoresis, dizziness, loss of bowel or bladder control..
Medications: Dilantin, Allergies: None, Social: Smoker 1 PPD for
30 years, No alcohol, No Drugs
(continued on page 36)
April 2014
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