“We did not come here to fear the future, but to shape it.” –B. Obama(Part 1)

How much does it suck to wake your ass up at 630am, trudge out of the house and race to work in hopes of not having patients waiting? Not as much as getting there and realizing you start 12pm.

            I found my way to a coffee shop. The name of the place was “Coffee Shop.” The diner was so classic diner you would think it was a theme restaurant like Ruby’s or Johnny Rocket’s.

            Putrid pink countertops lined an all white diner decorated with “juke-box rockin” wallpaper. At the end of the counter sat a TV blaring Fox News. The last public place I saw Fox News blaring at was the Acura dealership; it says a lot about a place. Eventually they flipped to CSpan (thank Gods).

            I walked in with full intent of continuing to read “Interpreter of Maladies,” fully aware I would leave in a state of depression, despair and wonderment. But my eyes were so distracted by this alternate reality I only knew in Dublin, CA circa 1982 or from watching folks crazy angry at health care related town hall meetings. Even if I disciplined my eyes back to the page, my ears perked up to the conversation: “Oh it’s just a bunch of Democrats (talking about health care),” a man said waddling into the diner.

            It’s the day after Obama’s address about health care to Congress. Whether he’s right or wrong I praise him for spurring a great debate- from congressmen (and women) to the man in front of me at the coffee shop.

            The man found a pair of willing ears and relentlessly made his opinion known to all of us at the coffee shop, whether we liked it or not: “He’s pushing the insurance companies so tight, he’s not leaving them any room (for profit).”

            The willing ears agreed and chimed in, “Most of us have nothing wrong with our insurance anyway.”

            This came as amazement to a doctor’s ears. As the men I saw were rather tubby and aged. ‘For sure they have a pre-existing condition,’ I thought to myself.

            “What you up to today,” asked the coffee shop owner of one of the men.

            “I’m going to buy a gun set,” he said.

            I had to take a minute to double check that I was in California and then realized that I am not isolated from the images I see on TV….

What's the Difference Between Kaiser and France? (Part 2)

            Starting with the team I know best, the doctors. It is then hard to generalize us as a group, but for greater understanding of the physician it is needed. We went into medicine with the idea of studying science diligently, memorizing a million details about a million diseases. No where in there were we taught about insurance companies, personal finance, business management and legal pitfalls. In a jam packed med school curriculum it seems almost unethical to focus on these things, for it would detract from our greater purpose: to understand medicine in the most thorough, holistic manner. Those who learn about finance and legality of medicine get another degree, an MBA or JD.

As any doctor will agree, the world changes once stepping outside those intense, yet protective gates of medical school.  Hopping onto the professional circuitry of the medicine reveals a disturbing reality of medicine in America: it’s a business. Conferences give lecture options: “billing for sports medicine” or “emerging epidemiology of influenza.” Only one of those is going to keep you in business.

I practice medicine with one eye on diagnosis and treatment and another on signing forms, keeping my patients satisfied, write down enough information to prevent me from getting sued and allow adequate billing from insurance companies and do it all very fast.

            Which brings me to the partner in the co-dependant relationship of the medical profession: the insurance companies. Granted, in the past, the physician’s held the reigns. I can’t back it scientifically, but all you have to do is talk to my parents or any “old-time doc” and you will here: “It’s just not worth it. Medicine isn’t what it used to be.” Reigns were taken from them because of capitalizing on the medical system for their own financial gains.

As we blame the banks for not baring “financial ethics” in mind, we ask doctors to do the same. They should not overbill, do too many procedures or order too many tests just because they can. Without oversight in place, physicians didn’t prove ethically responsible. Putting in some checks and balances was more than appropriate and was attempted by Hillary Clinton in the early 1990’s.

However power transferred laterally instead of redistributing. Insurance companies were granted the power of curbing spending by mandating what labs, procedures, specialist and the like are necessary for the patient. Too many antibiotics prescribed, the physician is dinged. Too many labs ordered, the physician is dropped from that insurance panel. Not seeing enough patients, means not earning the clinic enough money to justify overhead costs, the doctor is dropped from the clinic.

Medicine not deemed necessary per insurance companies is simply not covered. After three days in the hospital insurance companies claim tuberculosis is all-better or that the patient is no longer suicidal, then no more days covered. Patients are a commodity on which to maximize profits and minimize costs.

            And so we find ourselves trapped in an abyss: a space to which the money pours in but very little makes it out. Once again, we find ourselves blaming insurance companies for not having “financial ethics” when dictating a patient’s reimbursement.

            Capitalism, arguably, provides the “healthy competition” needed for advancing health care. At Kaiser there are hypertension clinics run by pharmacists, self-referral to nutritionists and incentives for staying fit. Kaiser knows that keeping its patients healthy keeps them out of the hospital, hence keeps their bills down.

            Kaiser also maximizes its physician’s, nurse’s and ancillary staff’s capacity as to be the most financially efficient as possible. Speed & service with a smile will get you the good pay and a stable job. The focus redirects to meeting the company’s criteria, aiming to get positive survey responses from patients and seeing a lot of patients. Pay is the incentive, not care.

            For a limited time a year Kaiser will have open enrollment for our children without insurance or who are on medical. All of us will try with concerted effort to enlist them. We all recognize that it is a privilege to have all resources available to you in one system. It is for the privileged whom are accepted in.

            Another, often overseen, player is the pharmaceutical company. Medicine abroad will run people 10-50 times cheaper. The price differential extends beyond our extensive research of American companies. Money directed towards marketing and lobbying are often incomprehensible. Pharmaceutical companies spent a reported $40 million lobbying Congress in April, May & June of this year. ( http://www.npr.org/templates/story/story.php?storyId=106899074  ) Does the lay person need to see ads about Plavix, a medication prescribed to patient’s at risk for stroke? Is it appropriate for pharm reps to be constantly present in clinics to promote their product over another? Is it appropriate for physicians to spend time with pharm reps in clinic while patients are waiting?

            After looking at all these groups we see one commonality. Their services and products generate money. We in the United States have decided that the best way to take care of our health is by letting money run it. Unfortunately, it is at the expense of our health. Here lies the crux of how Kaiser differs from France: they diverge at the dollar. Kaiser will decide who is accepted. Once in you will feel the penny pinching from the patient's complaining about copay to the physician's eluding to the "golden handcuffs." 

The bottom line for socialized medicine is the health care, even if moderate, for everyone. Until that goal is redefined the conglomerate of hairy wire mesh chasing the dollar will run rampant, abandoning the citizens it’s to care for, leaving many to fend for themselves on the side line. 

What's the Difference Between Kaiser and France? (Part 1)

Health Care is such a conglomerate of patched together wiring; many people running on different circuits, yet seemingly in conjunction with each other. Looking at the tangled mess can be mind-boggling. I am “in” the system and still get dizzy listening to the news.

I run on the physician network. Though we may seem to be a continuous route on a single wire weaving through the ball of health care, we, in fact, have a fine splays of wiring amongst ourselves.

This is my attempt to understand the conglomerate from sitting within it, looking out. If you look closely you will see a fine red thread running with the thicker black one. That’s me. If you follow it, it will lead you to Pediatric Community Clinics in Los Angeles California.

When I stand back and span out I see, besides us: the physicians, insurance companies, government & policy makers, hospitals and pharmaceutical companies. All play a role in the complicated network that construct the health care system in America today.

First, I think it is important to understand that we are not France, we are not the Netherlands and we are not Canada. We are the good ol’ US of A. No matter what anyone says, we are going to do it our own way. Whether it makes sense or not is yet to be seen. That aside, we are not starting from a blank slate and creating a health care system, rather we are reconstructing some deeply embedded roots of some highly enmeshed wiring, reminiscent of the double VCR, DVD, cable box connections in the back of the Puri family room TV.

This much I get, in the middle of the ever-spiraling matrix sit our patients, with their heads spinning and eyes bugging out of their head. I see looks of despair, anticipation of bankruptcy heaped on top of pending uncertainties of their or their loved one’s health outcomes. If we keep our eyes on the prize, which is ultimately:

1.     1. To provide healthcare to all

2.     2. To provide good quality health care

3.     3. Not to bankrupt the system in the process

then sifting out the meat from the carnage of our current health care system becomes more feasible. 

India Railway Travel: Hours of Awkwardness and Entertainment (part 2)

Alas I made my bed, I must now lie in it. I much rather tuck myself away close to the ceiling than hear the rustling of the midnight passenger making their way to the hole and hoping not to fall in. I would be lying if I said I had a good night’s rest. But I was semi-sleeping until I heard the raucous in the seats behind me: the elder couple had awoken. The rest lay fast asleep.

The seat behind me was, once again, filled with another incoming fleet of passengers, this time it was early early morning, the sun had yet to wake up but you could hear her wrestling.  The elderly gentlemen had made himself comfortable in the incoming passenger’s seats. His old lady, found an empty inch on the bottom berth near me and sat on it as if it was the last remaining piece of seat in the world. Her chin buried deep in her palm and she gazed out in utter despair. Though I monitored the situation with great intrigue. I happily played asleep in my semi-comfortable train bed.

It wasn’t long before the conductor was called to rectify the newly embarked passenger’s frustrations.

“Listen, I need you to return to your assigned seat,” the conductor firmy said.

“What am I supposed to do? Everyone is sleeping, I don’t have anywhere to sit!” the elder gentlemen barked.

Very quickly the distinguished gentlemen who tipped the khooli generously melted into a taunted toddler. Yet the conductor continued to rationalize with him: “These are their seats, not yours.”

“If you remove this old blankets, WE’LL ALL HAVE ROOM! Pick them up.” Said the elderly not-so-gentle man.

The conductor, too, lost his cool and explained in a dauting volume and intonation that these are not his seats. And so a choir of maddened yelping and hawing began: “These are our seats, you belong in the seats down from us!” griped a passenger.

And now we were all up, tucked away in our seat-con-beds, pretending to sleep and ignore the tussling voices invading our space. His wife still balanced her bum on the end of the seat one of the passengers slept on. We really were within arms distance of each other. I cautiously kept my eyes closed catching intermittent glimpses of her head still sorrowfully hung on her hand.

The elderly gentlemen finally left the other seat and returned to where his wife sat, now charged up from not getting his way.  He rustled the two passengers sleeping on the bottom berth awake: “Get up! Get up! There is no space for us to sit!”

The other couple naturally looked at him in disdain. “Why are you causing such a commotion?” You bothered them and now you are bothering us. Just calm down.”

The elderly gentlemen remarked:

“I cannot sit there.

  I cannot sit here.

  I cannot sit anywhere.

 (said the cat in the hat).”

“It is morning time anyhow, this is the time to get up anyway,” he said.

 

I looked at my watch: 5:15am.

 

To my surprise, once again, the couple appeased him. They got up, undid their bed and made room for him to sit.

“Chai, coffee, chai, coffee?” our server chanted. The sun was just opening her eyes and us with her. We all sipped quietly, still feeling the aftershock of the man’s morning tantrum. However next to me sat the elder man and his wife contently sipping their chai. At some point, I believe I saw him literally feed her her biscuit; I mean actually place the biscuit into her mouth. She willingly accepted it.

This equal partnership of a man and wife upholding their roles in marriage and participating as productive members of society dissolved in front of me. I found myself wondering how one lives a life where a man dictates the environment you sit in, the food you eat, when you eat it, when you sleep, when you get up and everything beyond.

As I travel through India from my modern family in Delhi to my conservative family in Punjab to the very traditional villagers of Gujarat I see much of this shared value. Marriage is a position one is assigned in their lifetime. It is a greater part of the intricate workings of the fine machinery that is Indian society. To resist the role is to jam up the turning wheels under which everyone functions. It is not something you do because you want to or because you hope to one day. It is what you do. The power of this is system is demonstrated in the durability of Indian culture and the strong sense of family and social security I feel when I am there.

As I extract myself from my world in America I can look at our system more objectively. We hope to get married because we want to. We hope to find a person that we want to marry. The hope is that from that union rises greater personal happiness. As in America us, as individuals, are always of great priority. Marriage is one other way of attaining happiness. If marriage is not a means of attaining happiness we elect to not marry; if marriage is no longer a means of attaining happiness we may elect to end that marriage. With or without our marriage our family will still survive, our children may still see both their parents, we will continue to work at our job, we may even marry again.

I spent so much of my life trying to justify one system as better than the other. But just like mangos and papayas (I really don’t like apples or oranges that much) Indian and American culture and marriage just remain different.

India Railway Travel: Hours of Awkwardness and Entertainment (part 1)

            “What am I supposed to do? Everyone is sleeping, I don’t have anywhere to sit!” he barks. The bark turns into a tantrum as he yells irrationally waking everyone on the train up: “ This is the time to wake up and they are sleeping in the only place I can sit!”  I glanced at my watch: 5:15 AM.

            I am on route from Valsar, Gujarat to Delhi. The randomness of the overnight train experience is often entertaining at the least and thought provoking at best. In this case, it is the elderly couple sitting across from me that intrigues me. It is the way they handle themselves, handle each other and cope with having to climb up to the upper berths to sleep that is of particular interest.

            The first time I saw them they came with a khooli. In India a khooli comes with a mixed review: partly opportunist waiting to sneak an extra buck off you, partly the extreme poor forced to do extreme tasks in order to survive. I often see two bags on a head, a suitcase in the right hand and a box being dragged by the left. Whatever one’s feeling is, after watching Amitabh rock the movie “Khooli,” I’ll always have a soft spot for them. I have learned to circumvent my guilt vs.“I-won’t-get-ripped-off” internal turmoil by carrying my bags myself. It’s actually not that hard. I pull out the handle and roll the bag behind me.

            It is rather Indian to take a seemingly simple task and make it more complicated for the sake of providing human labor. I’ve had quite a few khooli’s resistant to using the “pulling contraption” on the suitcase, just to pick it up and put it on there head. Munish and I used to remark about the seven person line required to pass a crate of dirt 3 yards down the road.

            The elder couple came in with the khooli. I watched with great interest; waiting for the money haggle to begin. The elderly gentlemen opened his wallet and pulled out some cash. The khooli opened what he was given and quickly began to thank the elderly gentlemen with great gratitude. “I moved your bags okay? Can I shift them anywhere else?”

            I love watching people do surprising good deeds, as the satisfaction is even greater. The truth is that in India the opportunities are abound and the deeds done are many. I couldn’t help but think about what a sophisticated man this is. His wife followed close behind him.

The husband and wife sat down as the train began to pick up steam. Images of the lush greenery of South Gujarat flashed by us. We all peacefully stared out our windows, lost in our own thoughts.

“Chai, coffee, chai, coffee,” the lanky train food server chanted breaking me out of my daze. Soon after he brought our meals: roti, yogurt, lentils, rice, paneer, vegetable curries and dessert. To the airline travel-starved American, this whole service is like riding first class for free. 

I glanced over at the elder couple across the aisle from me. The elder gentlemen not only ate his meal, but watched with great caution that his wife ate in comfort as well. For all the negative hype traditional, pre-arranged couples get, there is a certain beauty in watching two people maintain their assigned roles in support for each other.

Dinner finished and he quickly began to prepare his space for him and her. His wife sat on the lower berth, doubled over, waiting patiently for him to arrange her sheets and blanket.

In the middle of arranging their beds, the train came to a stop. We appeared to be at a small Gujarati town, not unlike the one I got on at. A small fleet of passengers disembarked and an equally small group boarded. The five new passengers hustled in: the women sitting down alas and sighing in great relief, the men pushing and tugging bags under the seat to make space for their own. Now there were seven people crammed into two long rows facing each other made for six. Additionally, the berths had already been lowered by the elderly gentlemen, as he was mid bed making. The new passengers sat with their necks craned and, to my surprise, did not make any fuss about their predicament.

            The train experience is more than thought provoking.  It is a challenge in agility, grace and consideration. We all sit on the first level. Since we all are sleeping on the train at some point the second level berth has to be lowered so the person assigned to that seat can set up their bed and go to sleep. On top of them is a third berth. Each level is separated by about 2.5 foot distance; if you are on the third, you are forced to make your bed while lying in it with your head smashed into the ceiling of the train. God forbid you need to go to the bathroom and you aren’t familiar with the India ways. Your experience will involve a combination of flexing those quadriceps, balancing over a hole and fear of falling in. God forbid you forget toilet paper, you are literally "shit out of luck." Going to the bathroom is always my greatest train challenge.

            The elder lady of the couple was assigned to the middle berth and her task was great: she was forced to climb some bars to hoist herself into the middle berth. With the grace of a baby giraffe she planted one foot in the iron loop provided and the other foot in the iron loop on the other side. I looked up to see the fragile old woman straddling the aisle of our train car in her sari, her thigh and my face intimately shared more space then they could have ever imagined. I was quickly reminded of my college roommate that would always change her clothes two inches from my bed while I was sleeping in the morning. Her bare-naked ass and my face, too, spent more time up-close-and-personal than they could have ever imagined. Weird times.  Her husband, with equal fear and concern, launched her bottom off the palms of his hands on to the second berth. With one big heave she tossed herself on the berth, her bottom half clung on to the top in desperation as it lay hanging in the aisle. Slowly, she waddled her way on to her bed. The elderly man looked exasperated, but relieved. I too breathed a sigh of relief with the passengers with craned necks below her. We thought all had finally settled, but the worse was yet to come…

Protruding Bellys

We've got our sunny days back in southern Cali, at this point I reflect: "were they ever really gone?" That means everyone's out and about sporting latest fashions. LA displays two extremes of sorts: the blonde bombshell about to topple over her newly implanted breasts and the teen popping out of her tshirt layered upon tshirt. My focus is drawn to the latter. 

My work, hence a big part of my life, circulates around obesity. So I can't help but be drawn to it in public. I must say that this low-riding jeans haven't really helped the cause. If someone really wants to succeed through this recession, find a way to make that "full figured teen" look appealing, not appalling. 

But I digress. I was cruising down Melrose Drive, passing Fairfax and see three youthful teens crossing the street. They look happy and chatty, but my eyes are quickly drawn down to the full expansion of their shirts; bright green, bright pink and orange-all stretched to capacity. I shake my head in disapproving shame and once again think, "why can't they control what they eat?" Soda. Gatorade. Firey Hot Cheetos. 

It's not but a second later that I catch myself, thank God. I never look at a malnourished person and think, "why can't they just eat enough, they look horrible!" Why is it okay on the other end? I realized that so much of myself and society carries an element of judgement and shame attached to obesity. Obesity entails failure, lack of discipline, laziness, recklessness and more. Unfortunately, we are passing these labels on to our little ones, to which we are giving the cheetos and chocolates in the first place. 

When there is a problem we always look for someone to blame. Is it Frito Lay, is it the mothers, hotmail which depends on add revenue? A lot of it starts at home in resisting a slue of mixed messages passed to our children on a daily basis. In school they are taught to "be healthy," then offered pizza, hamburger or french fries for lunch. McDonald's sell their food so cheap they almost pay us to eat it and then we plaster images of stick thin women wearing jeans near the mall and school. Lastly we talk about the importance of fitness, then remove the requirement of PE from two of their four years of high school! The "do as I say but not as I do" has yet to prove successful. Today I start with myself. Whether it be upon me or others, I will be mindful about the labels I cast upon the "obese and overweight" in America. 

Father's Day

            Everyday at work I am faced with the consequences of fatherless families. Children are not outright delinquents, however many come into the Pediatric clinic with the life scars of an old veteran: their failing multiple classes, talking in class, fighting with others or take their anger out on their siblings at home. Many of us Pediatricians hang our heads low, accepting this glitch as a reality of our society. I am so accustomed, in fact, that my intake on a well child exam caters to addressing these problems.

            Today in clinic I was taken by surprise. My clinic was the same, my afternoon clinic hours were the typical and my routine of scrambling to keep up with waiting patients persisted as usual. I looked up suddenly and saw a rather husky man wandering the clinic hall. He didn’t quite fit in to our peach pastel walls and circus animal framed pictures, to say the least. I inquired: “Excuse me sir, is your child in one of the rooms?”

"I'll be waiting in the waiting room," he said with a quiver in his voice. I felt like I interrupted a previous conversation, but that was his reply to my question.

“I’m sorry, is your child here?” I asked. This time turning to Sylvia, perhaps this made more sense to her.

“He’s the father of your next patient,” Sylvia explained.

Okay, now we’re getting somewhere. "Is she here for a well child check?" I asked the father.

"Yeah, but I can't be in the room when she gets her shots," he replied. “I just can’t be there when she cries, my wife knows. She’s in the room.”

The tall, husky, Lakers-jersey wearing irony standing in front of me had me chuckling on the inside. However, I kept a stern face and briskly, escorted the man into the patient's room. Inside awaited mom, holding a very petite two-year old that had fallen asleep in her arms. Next to me sat her 4-year old sister and the patient’s Lakers diaper bag. "Have a seat, let's go over a few things," I instructed. 

We started our review of the five million questions I ask during a well child check. “Do you have any concerns today? Is there any cough-cold-fever-vomiting-diarrhea-constipation?" If I could put it all into one word I would. It would sound something like: “any cofevomitediarripation?” I continue: “Do you have any concerns about her behavior?"

The dad explained that she tantrums at times. Tantrums are not atypical for a two year old, but it is the extent of them that gives me a gauge on disciplining and parenting skills. 

"I defer to him. He's home with the girls most of the day," mom explained.

He quickly replied: "Oh, I put her on time-out."

That is music to a pediatrician's ears. If I had a "Dad of the Day" badge, it was going to him. We transitioned into talking about her diet. The girl was petite, though still growing quite fine. I continued with my barrage of five million questions: “Do you have any difficulties around eating?” A quiet silence fell over the room. He didn't say much, his face said it all; it was a face of defeat.

After a while a pediatrician just knows: At lunch there will be one plate of food, four precisely sliced hot dog pieces, two spoons of corn and a ½ slice of bread on the side. The two-year old in malicious defiance will sit there for thirty minutes and only drink her milk. Then 6' 5", 220 pound dad will sit down next to her. At first he will try the method of gentle coercion, followed by bribery. Her mouth will close tightly in protest. Bribery gets tossed out the kitchen window. Empty threats thunder down from burly dad in his Laker's jersey: "Lela, you have to eat this or else..." The protest raises. Dad pushes harder and is… once again defeated by his petite 25-pound daughter. 

At the end of our, likely emotionally draining, discussion I sat in admiration for this father. Nothing else mattered, but the emotional and physical health of his two daughters. All the mothers and fathers that take time out to bring their children in for well child care together always makes me glow. I realized that so much of my attention goes into identifying and helping the fatherless families, of which there are too many. So much of society's attention goes into highlighting the fatherless homes of which so many of our lower economic youth are raised. This Saturday I left wondering why not give more attention and praise to all those men out there doing it right? My hats go off to all the wonderful fathers, especially the ones who come in for their child's well child checks, as you have made a pediatrician's day.