Dr. Malo's Adventures

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I was walking through the emergency room a few days ago and saw a patient sitting on a gurney in the hallway drinking pop and eating a sandwich.

Nothing is more irritating than seeing the emergency department being used for non emergent medicine.

If you can breath, walk, and talk..... It's not an emergency! Call your doctor's office and get an appointment.

Unfortunately, the non-emergent use of emergency departments is more common than you think. It's unclear why people abuse emergency rooms, but it happens a lot.

Sometimes it's because the patient does not have insurance and doesn't have a doctor. And patients know that the ER is not allowed to turn them away. So they just go to the ER and get their primary care there.

Sometimes it's because patients don't know any better. They think that they can just go to the ER for all their problems, and that that is normal. Someone please educate these people.

Sometimes they say that their doctor is "booked and can't see me for 2 weeks". So they stroll into the ER to get their urinary incontinence medication refilled.

ER physicians should not be allowed to prescribe medications for on-going problems. Then patients won't go to them. An ER doctor should not have to deal with refilling Viagra or Flomax for a patient.

How do we fix this problem?

Pay primary care physicians more! What? Why? There really isn't a primary care shortage in this country. There is a shortage of pay for primary care. If primary care physicians were paid appropriately, they would have enough office hours and time to accommodate all their patients.

Instead, more and more primary care physicians are leaving primary care, moonlighting as ER physicians, and sub specializing to try and make more money for their time. They want to be efficient.

If a primary care physician can get paid upfront $130 dollars an hour for working in the ER, why would he bother seeing 4 patients an hour, some of which have no insurance, some have insurance, but he has to hire 3 employees to chase down insurance companies, so that he can maybe make $30 an hour, but get paid 90 days later?

It does not make sense.

So he cuts his office hours down to 10-20 hours a week, and goes and moonlights at an urgent care facility, an ER, or as a hospitalist.

With President Obama touting health care reform, he needs to attack the core of the problem. Fix primary care medicine! Pay the primary care doctors for their time, effort, thought process, and care.

The worst thing that Obama can do is to hire cheaper "providers". Not physicians, but "providers".

A provider can be anyone, a nurse, a physician's assistant, a dentist or even a chiropracter. Sure, hiring nurses and PAs to take over primary care medicine may look cheaper, but the long term consequences are more expensive.

When you have a lesser trained "provider" trying to care for people, you get tons and tons of useless consults. We have seen this in hospitals as well as clinics. Over utilization of consultants costs the system more. While a good primary care physician can work up most problems and only consult for difficult cases, a lesser trained provider will consult more often and cost the patient, as well as the system, more on the aggregate. That is bad medicine.

A patient will not get appropriate care until further down the line from a random consultant. Bad medicine!

My advice to Obama: Pay the primary care physicians what they are worth, and you will not have a primary care shortage. You will save patients lives, ensure better outcomes, as well as have a healthier population in general. Stop short-changing the physicians that are on the front lines.

This will also relieve the emergency departments, to handle "emergencies". The vast majority of ER doctors did not go into ER because they want to see sniffles, fungal toe infections, and a thinning hairline. Nor do they want to refill your Viagra.

It seems like no matter where you go around the country, no matter which hospital, which clinic or which ER, you always have the same type of family members. Here is a humorous look at some exaggerated family types.

The Normal Family:
This is the family we all love. When their loved one is ill in the ICU, they ask questions, try to understand what is going on, and are very appreciative of what everyone is doing to help their loved one. This is the family type we all love and is usually the most common type of family.

The Expert Family:
This is the family that always mentions that they have 5 doctors in their family and wants everyone from the janitor to the CEO of the hospital to know. I'm not sure how they think this will change the course of their loved ones disease, but they think that it may change outcomes.

The False Expert Family:
This family always mentions that they have 5 doctors in the family, and when you finally meet them it turns out one is a podiatrist, one is a chiropractor, one is a dentist, one is a PhD in engineering, and one is a pharmacist. The actual "experts" are all very nice and interact professionally, but that doesn't seem to bother the few family members that aren't "doctors" from mentioning that they have doctors in the family eight hundred times per day. No one is sure why they keep mentioning this, they just think they'd get better care if they did.

The Litigators:
This type of family always talks about suing the hospital and suing the doctors that are taking care of their loved one, even when their loved one is receiving the best care. Of course, this type of behavior may result in worse care for their loved one as all the doctors go into, what I call "cover your ass" mode of practice and start treating the chart not the patient.

We all know what cover your ass means in medicine. Order the extra test, the extra CT scan, the extra lab test, just to make sure it isn't something else that is rare that may be missed. This is not what I am talking about.

This mode of cover your ass care seems to be different. The primary doctor will start adding more and more consultants (experts in various fields of medicine) to help spread the malpractice wealth. If they are going to sue, they sue a whole host of doctors, the less one doctor takes a hit. Can it be that all these experts were wrong? Of course not. It'll probably be thrown out of court or never make it to court. If it does, all these experts can't possibly be wrong. Just look at how good the chart looks!

So what's wrong with that? Lots.
You start seeing every expert offerring an opinion and deferring to another expert. You see, "Restart coumadin if ok with cardiology." Cardiology comes by and writes, "Hold coumadin for now, get head CT and restart coumadin when ok with neuro." Nerology comes by and says, "MRI/MRA head and neck, may restart coumadin if ok with GI." GI comes by and says "May restart coumadin after EGD and if ok with heme/onc." Heme comes by... and you get the picture. You start seeing a lot of charting and not much really being done to fix the patient. And eventually, said patient dies.

Advice.... don't start threatening with lawsuits! Period! This will just prolong and slow down the process of healing. (and they may never heal) This is the surest way to insure that your loved one won't get proper care.

The Loud Family:
This is the family you can hear from a mile away! Before they even make it up to your floor, you know they are coming. They're harmless and funny as hell, but man, they are loud! This family is usually fun to talk to and always have funny stories to share. A lot of times though, suddenly the ICU staff will start enforcing the "2 visitors per room" rule. While everyone else has five or six people visiting, this family suddenly is told that the limit is two.

The Know it All:
This family usually starts off as a normal family; very appreciative of the wonderful care and very happy with everything in the hospital, until the Know it All shows up. The Know it All may have some medical background, just enough to be dangerous, and they start making comments to this seemingly normal family about how everything is being done backwards here.

"Back at my hospital they'd never use that type of IV tubing" or "How come the did the EGP before the colonoscopy?" They don't even realize that's it's an EGD. They just spew medical terms and sound informed to the rest of their family.

The Know it All is usually some distant relative to the family and the family barely knows them, but they seem informed, and the family starts getting fired up. They start asking questions that they think make sense when it really doesn't. The poor doctors and nurses answer their questions without being condescending and they try to be as polite as possible. The family starts thinking that they know more than the nurses and doctors because the Know it All says so. The family will eventually push the Know it All to the forefront and have them start asking questions the next time the doctor shows up,

"Doc, how come she is on 8 different pressors?"

"Mam, there isn't 8 pressors, and she is only on 2."

"Why did you guys give her packed red cells instead of albumin?"

"Her hemoglobin is low and albumin doesn't provide any benefit, let alone fix hemoglobin."

"Why aren't you guys following the latest guidelines?"

"Mam, what guidelines are you talking about?"

"From the IDPRC, for sepsis."

"I am not familiar with that organization and we always follow the sepsis guidelines."

"Why haven't you guys transferred her to a better hospital."

"What is it that you think they will do differently?"

And so on and so forth. The Know it All is toxic to a situation. They are usually stubborn and too misinformed for their own good. Logic and reason doesn't work with the Know it All. It's like having Terrell Owens or Tiki Barber in your locker room. They are cancerous and things start turning bad.

Sometimes you just have to appease the Know it All. Most humans highly value the feeling of feeling important. Everyone wants to feel important. It's the ultimate feeling. If you can find a way to make the Know it All feel important, then you can win these battles. You have to make them feel important and "consult them" (not really consult them, but make them feel a part of the decision making process). You may have to educate them subtly, "As you are well aware, and I am sure they do this at your hospital, albumin in most cases, is useless." Get them on your side somehow. Have them talk to the family and calm things down. Try to get them to be your ambassador.

If all else fails, "You're right, we should transfer her to a better facility." At least you get them out of your hair!

The Religious Zealots:
This family is overly religious. If not overly religious in general, they are overly religious about something. Sometimes it's blood products that they won't accept, sometimes it's heparin, sometimes vaccines, sometimes coffee... who knows. But they always blame God.

Reasoning with the Religious Zealots requires a lot of maneuvering. A lot of times they don't want to withdraw life support on their 120 year old grandmother who has been brain dead and on a ventilator for the past 40 years growing out every resistant bacteria, fungus, and some things we haven't identified yet, because, "God will take her when he wants her."

You have to be careful, and if you aren't the religious type, just levae it alone. You could always try, "Well God tried to take her so many times, but you guys keep insisting that we do our best to resuscitate her and she always makes it." Or, "Is this how God wants his people to live? Let her go to be with Him and enjoy heaven." Just be careful.

There are a few other family types which I will add soon. Stay tuned....

Finally, the American Diabetes Association and a few international diabetes organizations have agreed to allow the use of HgbA1c to diagnose diabetes.

HgbA1c is a better test since, wide swings don't affect it, you don't have to go on an 8 hour hunger strike, acute illness or current administration of steroids doesn't affect it, much more stable and standardized test.

What if you have sickle cell disease and have an abnormally high HgbA1c? You can use the old method of a fasting glucose, or get a fructosamine test (which gives you a two week average).

Before 1997, you had to do an oral glucose tolerance test to be considered "diabetic". In 1997, they changed the guidelines and all you needed was a fasting glucose over 126 (why they chose such a high number I don't know, should be 100).

Of course, after the 1997 change to a fasting glucose of 126, a lot more people who were previously "not diabetic" suddenly became "diabetic". Which is good and bad. On the bright side, you now know you have a serious issue and need to address it. On the bad side, it probably shocked some people.

The committee has already decided that they will allow HgbA1c to be used, the question is where will the number be set? Is it going to be 6.5? Or 5.5?

At 6.5%, you are diabetic. Normal people (who are not diabetic) never have a HgA1c over 6%. In fact, most non-diabetics run in the low 5s.

If you set the number at 5.5%, you have a whole host of people now that will be considered diabetic that previously were told "you are borderline diabetic". This is great, because finally doctors will start treating these people early.

Hopefully, this new standard will spur physicians to start treating diabetics sooner and sooner with metformin (for type 2 diabetics) and delay the complete failure of the pancreas for as long as possible.

The problem in type 2 diabetics (90% of all diabetics) is insulin resistance. Your cells are resistant to insulin, so your pancreas make more of it, to overcome the resistance. Metfromin sensitizes your cells to insulin and allows your cells to use your insulin more appropriately and your pancreas can take a break and not have to make so much. Hence, saving your pancreas!

I am interested in seeing what level they set this at. Of course, smart doctors know that unless your HgA1c is less than 6 (and usually a lot less), you have a problem, and should be on metformin.

The American Diabetic Association already has a calculator on their website that translates fasting sugars to HgA1c values: http://professional.diabetes.org/GlucoseCalculator.aspx

As well as other resources: http://professional.diabetes.org/ResourcesForProfessionals.aspx?cid=60378&typ=17

It's on the news again, a 5 in 1 pill that can cut heart attack and stroke risks by 60-80% (depending on who you read) if taken once a day.

Imagine 5 generic drugs in one pill. Brilliant? The pill will contain asprin, a generic statin (presumably simvistatin), 3 blood pressure medication (my guess is low dose hydrochlorothiazide, a generic ACEI, and probably a low dose beta blocker).

Lots of studies have been done and it sounds like a good idea. Compliance wouldn't be an issue since people take it once a day. They tried coming out with this about 5 years ago, and it lost the PR battle.

Since they are all generic, this pill could cost a small amount. A month supply should be no more than $10-30 dollars at most.

Of course there are always the holier-than-thou "ethicists" that say that creating such a pill would reduce the emphasis on diet and exercise. (Cuz we all know that's working!)

If you eat french fries, butter, heavy cream, and pancakes with loads of syrup everyday and pop a polypill... I'm afraid you will still have heart disease and end up with a stroke or heart attack. A pill isn't a substitute for good habits. It may delay some things or offer some protection, but you are ultimately doing yourself in.

We'll see how this pill goes this time around. Who will combine these drugs first and start marketing it? Will they try to make loads of money off it? Will the government start requiring that all people over 50 should be on it or else lose some tax/insurance benefits?

We'll see!

Nothing is more disturbing than seeing a patient whose cholesterol is elevated, and hearing that their doctor said to them, "It's ok."

Or seeing a hypertensive patient whose doctor said, "We'll keep an eye on it."

Or a diabetic with sugars running in the 160s and hearing them say, "My doctor said I'm doing well."

Or seeing patients in the hospital with some obvious medical problems that are not being treated aggressively enough by their physicians.

Not being aggressive about treating patients is simply irresponsible on the part of the medical community. You can't tell you patient that a cholesterol level of 243 is ok. It's not ok!

Sure, you can try lifestyle modifications for a few months, but how often does that work?

Ok, so they diet, excercise, lose weight... and their cholesterol is now 217. Is that ok? You have to then aggressively manage their cholesterol.

Cholesterol is not a" lifestyle choices" problem. It's a genetic problem. You were born with these genetics. You can slightly improve them by changing your habits, but not by much.

People don't seem to understand that it's not the amount of cholesterol that you eat that matters, it's the saturated fat in the food you eat that tells your liver to make cholesterol. 85% of our cholesterol is made in our liver, not from intake. Saturated fat is fat that is solid at room temperature (butter, cream, fat on steaks, chicken skin, etc).

What about the uncontrolled diabetic. A doctor sends some routine blood work on a patient and their fasting blood sugar comes back at 106. That's not normal! After an 8 hour fast, no one's blood sugar should be over 100. The doctor's just ignore this number and say, "It's ok, we'll keep an eye on it." Instead of treating diabetes early and preserving their pancreas. That's not right.

How about the hypertensive with a blood pressure of 137/89. Is that ok? For every 20/10 that your blood pressure is over 115/75 your risk of having a cardiovascular event (stroke or heart attack) doubles. So is 135 ok? No!

When talking to friends, family, insurance sales people, or others, they always start asking you questions when they find out your a doctor. "Is my cholesterol good?" "Is my blood pressure ok."

You find out that their doctors told them that a cholesterol of 230 is ok, that their fasting glucose of 111 is ok, and that a blood pressure of 140 is ok. It's not ok!

We owe it to our patients to treat them aggressively and get their numbers down. We don't want to see them in the hospital with half their brain not working or half their heart not pumping.

We are highly educated, highly trained. We have to put this to good use and give our patients good advice. We can't let them be with high cholesterol, high sugars,s and high blood pressures. It's not right. We are better than that.

For the longest time, I have been searching for a simple algorithm that will adjust patients blood sugars correctly. Ever since I started working in critical care, I have been longing for a good insulin drip protocol. I finally found one!

For those who are not medically inclined, when a patient is critically ill after surgery or for whatever reason, it is important to maintain tight glucose control. The definition of "tight glucose control" varies based on who you ask and which study you read, but the idea is that their sugars should be under 200 and should be as close to normal as possible, without going too low. Some studies liked sugars between 90-120, others in a slightly higher range.

Critically ill patients, patients with head injuries, patients after surgery, patients who are in a diabetic coma, and even septic patients all need tight glucose control to heal and overcome their injuries and insults. Elevated sugars slow down wound healing, impair brain health in closed head injuries or vascular accidents, and provide for poor infection control in patients with infections.

There are lots of ways to control sugars, but when they are this critical, we usually put them on a continuous insulin infusion through an IV and check their sugars every hour and adjust the insulin infusion (drip) as necessary.

It's this "as necessary" part that gets everyone. How do you know how much to adjust it by? Is it based on how well they respond to the insulin? Or just a guess? Intuition? Experience?

If you had a really good nurse with good intuition and experience you could probably tell her,

"Start the insulin drip at 8 units/hour, check their glucose every hour, and adjust it how you see fit to get their glucose down around 120 or so."

That would be ideal, and at some places, that'd probably work. Hospitals now are becoming more and more strict as to what nurses can and can't do, so they want to come up with algorithms and formulas for nurses to follow when trying to control blood sugars.

I think it's amusing that these same hospitals will let a nurse adjust a norepinephrine drip as she sees fit (which controls your blood pressure and keeps you alive), but won't let her tinker with insulin drips (which doesn't normally kill you).

So the question becomes, can we put that nurses intuition and savvy into an algorithm? Can you legislate common sense? Can the algorithm adapt to variables?

What is the best formula to replicate a nurse or physician's intuition?

You need a formula that not only accounts for the current drip rate, but also accounts for how much the sugar changed. You don't want wide swings in sugars, you want them to slowly, smoothly, and surely, come down to normal and stay normal. You want to adamantly avoid low sugars, and you want to avoid huge swings and drops. Of course, your formula should adjust for increases in sugar as well.

Previous algorithms and formulas I have seen in the past are static. They adjust statically to glucose readings. If a patient's blood sugar is 850, start the drip at 7 units/hour and check sugars hourly. If it doesn't change, increase the drip by some multiplier until it starts coming down.

So if a patient's sugar starts at 850, they start him at 7 units/hour. Nothing changes for a few hours, they keep increasing the insulin drip rate, until say it is 10 units/hour, and finally the sugars start coming down. You keep checking until it gets down to around 120, then you maintain that drip rate. The problem is that the next glucose will be 50 or 60 and is too low. It doesn't dynamically adapt to surroundings.

The insulin drip protocol we have been using at our hospital (the one the residents have been using) seems to follow a static formula. Once the sugars are "normal" the next reading will be way too low, unless the drip rate is cut by 75% or by 50%. I usually have the nurse notify me once we get under 150 or so, so we can dynamically adjust the rate.

If we had a dynamic formula that accounts for the patient's response to the insulin, that would be ideal. Further, it should respond to different values differently. You want slow, smooth control. Not erratic. Your formula should adjust for the change in drip rate and the change in glucose. As well as the rate of change. How quickly or slowly is the glucose changing? Is it going up or down?

In calculus, the rate of change is the derivative. You want an algorithm that adjusts for the rate of change of blood glucose. That would be the ultimate formula.

It seems like the folks at Yale Medical School and hospital found an algorithm that does this quite nicely. Here is a link to their algorithm. It accounts for changes in glucose as well as recommends changes in proportion to the current insulin drip rate. It has some quirks in it, but it works for the average ICU patients that is not a DKA or HHS patient and hasn't had any intracranial accidents.

So we really need an algorithm that works in all situations equally well. You can just tell the nurse follow the "Alo algorithm" and that should be it. regardless of why the sugar is elevated.

Dr. Arcot Dwarakanathan, Endocrinology & Diabetology, who has been involved in every diabetes research study for the past 35 years and who has trained generations of endocrinologists at Chicago's top institutions (the doctor's doctor), and myself decided to come up with an improved algorithm (that is still dynamic, rich, and ubiquitous), and then create a computer program to help nurses follow this algorithm without having to do the math or follow tables or have to look things up.

Of course, there are some programs out there, and their are companies out their that try to market such programs to hospitals for large sums of money. None of the ones I have seen marketed have such a dynamic algorithm. They usually follow a more static formula. Although, they try and make it seem dynamic and self adjusting. None of them works in all situations of hyperglycemia.

Everyone is in a credit and cash crunch, and I have a programming background, so I decided to try and come up with a simple program that will follows our dynamic insulin infusion algorithm.

After spending months with Dr. Arcot Dwarakanathan, we have analyzed various studies, numerous programs, multiple algorithms, and came up with our own algorithm based off the Yale protocol to a certain degree.

The Yale protocol states clearly that it is not intended for someone in diabetic ketoacidosis or other complex medical issues. We wanted an algorithm that will work in nearly all medical conditions, wherein patients require insulin through an IV, including DKA, HHS, steroids, head bleeds, etc.

We spent a lot of time tweaking our algorithm and have come up with what we think is the best dynamic, self-adjusting insulin protocol algorithm, for the following reasons:

1. Slow, smooth insulin control
2. Works in almost all hyperglycemia scenarios (including steroids, DKA, HHS, head bleeds)
3. Self adjusting
4. Dynamic and rich
5. Avoidance of hypoglycemia
6. Quick response to hypoglycemia, if it occurs

Based on this algorithm, I am in the process of developing a computer program for nurses to use to adjust the insulin drip. They input blood sugars and drip rates, the program spits out instructions.

The program is in it's final stages and is ready for testing.

If anyone is interested in testing this program, feel free to contact me by email. Remove the "nojunk" in my address above, and add "com" instead.

Hopefully, this will be the first of many contributions I make to the medical world!

Every year, I am invited back to Midwestern University (my medical school) to talk to the first and second year medical students about medical ethics from a religious point of view.

The try to have as many speakers as possible from various religions speak on their religious viewpoints and how it may affect medical decision making when it comes to end of life care, do not resuscitate orders, abortion, contraception, plastic surgery, in vitro fertilization, and other medical ethical issues.

Once again, I had the wonderful opportunity to discuss the Muslim point of view. This year, I made my talk funnier, and more humorous to try and make it more memorable. The feedback I received was extremely positive. The students said that they enjoyed my talk the most and thought it was extremely relevant to ethics as a physicians, regardless of your faith. In fact, one of the Muslim students came up to me afterwards and said, "Man, I didn't now that was our stance on all of those issues."

So, here it is again, in all of its glory. Download it and follow the slides.

Power Point Presentation

Audio Presentation

Everyone is talking about the economic bailout for the banking industry, and how our country nearly fell apart. We acted swiftly and quickly to fix the situation.

It's time to discuss a healthcare bailout. The healthcare system in place is non-sustainable and the fundamentals are weak (unlike our economy).

What's wrong with the healthcare system? Lots of things, but where to start?

Dr. Alo's Health Care system Bailout:

1. Either fix medicare for good, or fund the heck out of it. Unfortunately, medicare has become a disaster. Over spending and being defrauded in some areas and not paying enough in others. Who suffers? Patients. Especially those that don't have medical insurance. They get stuck with medicare, which works for now, but not well enough.

Some of the problem is that this is a government program and hence, is bogged down by typical governmental red tape. The problem with eliminating medicare, is that tons of people will go uncovered.

Medicare, if it is to remain in place, needs to be funded properly. Real properly! Fund medicare so it can start paying hospitals, clinics, and physicians. Almost every few months, congress has to enact emergency legislation to not slash medicare funding.

Medicare pays so poorly, that many physicians can not take medicare patients, because it costs them more to see these patients than they will ever recoup. For an orthopedic surgeon to grow his practice and start seeing medicare patients, it will cost him more in additional malpractice insurance than it will in additional revenue from medicare. So they don't do it. Try finding an specialist that will see medicare patients? Very rare. These patients end up getting subpar care.

It's extremely complicated, but medicare needs to be fixed or funded properly.

2. Stop the malpractice lawsuit lottery. People should not feel like they can sue the healthcare system, be it hospital, physician, clinic, and win the malpractice lawsuit lottery. Cap lawsuits at a maximum of $10,000 and no lawyer or patient will bring frivilous lawsuits. The amount that physicians and hospitals have to pa in insurance premiums is so much that physicians and hospitals have to rush patients in and out to try and keep up and make any money at all. A hospital should not have to count "empty bed days" and find ways to fill their beds, just to make a buck. Physicians should not have to see 8 patients an hour to make a buck. They should be able to see a few patients, spend extra time with them, and still be profitable. The revolving door and rush makes this crazy and dangerous. Physicians are to blame. They should just stop paying malpractice premiums, until they come down. They should all do it together. It's a never ending cycle. The more we pay in premiums, the more insurance companies get sued for (deeper pockets), the more they raise our premiums, the more they can be sued for. Bad cycle.

3. Pay physicians and hospitals what they are billing. Doctors are just dumb. Why they accept not being paid till 90 days later, I don't understand. They bill $150 per visit and after months of chasing down insurance companies, hiring 4 staffers to call the insurance companies daily, and writing letters to insurance companies, they finally get paid $18 dollars for that visit 6 months ago. This is ridiclous! You spend hundreds of dollars a month chasing eighteen dollars. Wow. Next time your plumber or refridgerator repairman asks for $150 bucks, tell him you'll pay him $18 in 6 months and only after he sends you 4 letters, has five staffers call you daily for three months. That'll work.

4. Physicians are being squeezed and squeezed every day. They are being pushed around and walked all over. As an economist, I know that when you squeeze smart people, they find other places to put themselves to use. If we keep squeezing the brightest people, they will find other ways to use their intelligence and make a living. Many physicians are already retiring early and putting a strain on our healthcare system. They are finding other ways to be productive and earn a living. This leads to healthcare being managed and administered by less qualified individuals (Walmart MiniMarts and Minute Clinics) and people's lives at stake. I have nothing against Walmart clinics, the more competition, the better (I am a free market capitalist), however, our system is now designed to force the intelligent, good physicians into other sectors. This does not bode well for our system. We alread have a diminishing supply of physicians and by 2020 we will see further decline in supply. Physicians need to band together and take healthcare back and stop allowing others to dictate healthcare.

5. Pay primary care physicians and fund preventative medicine. If every American were forced to see their physician yearly, we would have fewer heart attacks, strokes, hypertension, diabetes, and other disease would be caught early. Physicians are trained in prevention. The way medicare and the insurance system is set up, we pay for catastrophic health care, rather than prevention. We will pay for the heart attack, cath, stents, but not seeing the doctor once a year and getting on lipitor. Unfortunately, more and more people are shying away from primary care. After being saddled with $250,000 in debt from medical school, they can't afford to go the primary care route and live a normal life. Pay these people more! And keep physicians in primary care, they know how to keep people healthy. It's unfortunate that these Quick Clinics are being run by nurses and people are using these as a substitute to medical care. No matter how good a nurse may be, they are not physicians. What the nurse thinks is a little nose bleed, could turn out to be some major issue. Don't denigrate health care to such a low level.

6. Healthcare Insurance should not cost that much. Families should not be paying thousands and thousands of dollars for their healthcare insurance. Further, if they show up to their prevantative visits, they should get discounts.

More to come...

At almost every step of the way you are shocked by how very little you actually know about medicine.

When I started medical school, I was in complete awe at how much is known about the human body, our cells, and what can go wrong. It was a serious shock to the system.

When you finish your first two years of medical school and start your clinical rotations, you are shocked once again because you really know very little. You really don't know anything. The cycle just starts over and keep repeating itself.

When you finally finish medical school and are finally considered a real doctor and start residency, again, you are shocked by how little you really know once again. You may have a lot of information and experienced stored, but now you have to put it together and take care of patients.

I remember my very first rotation as a third year medical student, you can read about it on this blog, I was asked by Dr. Luhrwick why I did not examine a patient's abdomen that had abdominal complaints. All that book knowledge and all those classes, but no one really taught us how to put it all together.

When I first began my residency, I had to ask how to order breathing treatments, one of the simplest orders in medicine. This is as a fully graduated doctor with a shiny new long doctor white coat and the new initials behind my name.

"So, Dr. Alo... you don't know how to write for breatihng treatments?"

The education of a physician is long, ardous, and humbling. Every day you are reminded how little you really know. If you think reading helps, it only makes this worse. The more you read, the more you realize that there is that you don't know, and may never know. But you have to keep reading. Read, read, read!

Medicine is an ever changing field. It's so vast, wide, and exhaustive. It's nearly impossible to know even "some" medicine. Now I can fully appreciate why there are so many specialties and sub specialities. And even sub specialists don't know everything about their little niche.

I used to wonder as a student, why is this doctor (ob/gyn or orthopod) sending this guy to another doctor for hypertension? Can't they just fix it. Sounds easy enough?

I always tell my medical students that as a physician you will always be a teacher and always be a student.

One of my favorite sayings is, "If you know something, tell someone. If you don't, ask."