The emergency room

I went to the emergency room recently. The head of a tick was embedded in my arm, and I couldn’t get it out. My arm was swollen, red and sore. My GP’s practice—taken over by a conglomerate—doesn’t take “walk-ins.” Heading for the ER, I was aware that this wasn’t an emergency, but what was I to do?

In 2022 there were 155 million visits to emergency rooms, up from 130 million in 2018. With Trump’s cuts to Medicaid, that number is expected to increase. A third of Americans have no primary care physician, up from a quarter ten years ago. In the past, the ER was used for last-resort care. Now it’s become the doctor’s office for millions of people (like me!). Some patients sit in the ER for days—a situation called “boarding”—while they wait for hospital admission.

I read an article about a Columbia University student who fell ill with headaches and chills and went to the ER. The best diagnosis they could come up with was “acute viral syndrome.” They sent him home. He returned to the ER the next day, and after careful examination, they stuck with that diagnosis and sent him home again. Two days later he died in his dorm room. (The cause of his death, according to the autopsy, was “pulmonary hemorrhage of unknown etiology.”) The father sued Mount Sinai Morningside hospital for medical malpractice.

I’ve read lots of books by ER physicians. They work hard. They’re conscientious. They do their best. As one ER doc said, “The spectrum of disease is just unbelievable.” The first job of an ER physician is to treat patients in need of resuscitation. More difficult is determining which patients are in imminent danger, neither obviously dying nor obviously well.

In their high-volume, fast turnover environments, should doctors be expected to follow mysterious blood results over days or phone patients after discharge to check up on them? As one doc said, “Our job is kind of perilous…bad things can happen. It’s on you to be extremely vigilant, and to some extent, lucky.”

Maybe I should buy some lidocaine and instruments and take care of future tick heads myself.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Doctor-patient relationships

I got to thinking about the different ways people interact with their doctors. My own style is to diagnose myself, then tell the doctor what I want. (One physician’s assistant told me, “I love it when patients tell me what they want!”) I wondered about the nature of the doctor-patient relationship in cases where the patients themselves were doctors, so I asked a couple of friends who are doctors (both are long retired).

Dick, a psychiatrist, was raised in an environment in which “the doctor was revered and the patient was dutifully respectful and deferential.” After becoming a doctor himself, he struggled with such roles, mostly because he “did not feel as omniscient” as patients may have perceived him to be. Because he still has a “life-long deference to ‘authority figures,’” it makes it difficult for him to settle into a peer-to-peer relationship with a doctor. At the same time, Dick says, “I feel comfortable saying that I don’t understand something (common issue, actually) and asking for a more detailed explanation.”

Before making an appointment, Dick does an internet search of the provider, looking for “level of training, where trained, awards given, research papers published, etc.,” as well as common experiences that may “form the basis for rapport.” To ensure there’s no problematic bias, Dick holds off on letting the doctor know his profession. Once in a relationship, Dick reports that about 25 percent of his MD/MD relationships become collegial, and the remainder are “various shades of cordial professional interactions.” At the same time, he reports that he doesn’t “stay with an MD who makes me uncomfortable, even if he/she seems quite competent.”

Bob, an internist, tells me that for the most part he has “an excellent relationship” with his doctors and that he probably gets more time and attention than the average patient." For his appointments, he brings a list of any history and symptoms that may have developed since his last visit. Because Bob's medical practice ended many years ago, his doctors "know that how I practiced was how they would ideally like to practice.” He finds that “all of my doctors want to complain about the difficulty of practicing medicine nowadays.” Particularly maddening for them are today’s requirements for “checking the right boxes,” meaning filling out forms and using the right key words needed to get paid by Medicare and insurance companies—documentation that “may be more important than accurately documenting the patient’s health.”

Bob considers his doctors to be friends, but not socially. He has each of their home and personal cell numbers in case of emergencies, and that “they would be more likely to come to see me in the hospital, although that is not even allowed in today’s world.” When he was a practicing physician, he was “honored to have a doctor choose me as their physician” as it showed they valued his judgment and his standing in the medical community.  

It occurs to me that the dynamics at play in the doctor’s office may accurately reflect a core component of your psychological makeup (also the doctor’s). Think about it and analyze yourself!

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Rising breast cancer in young women

The incidence of early-onset breast cancer has been steadily rising. The reason for this appears to be an increase in menstrual cycles: girls now get their periods around age 11 or 12—slightly earlier than those born in the 1950s; the average age of first pregnancy, when menstruation ceases, is now 27 ½, up from the early 20s in the 1950s. This longer time between first period and first pregnancy—allowing for more menstrual cycles—may be one reason that breast cancer rates are rising in young women.

With every menstrual cycle, breast cells expand, proliferate and contract. The more menstrual cycles, the more opportunities for mutations to arise. During the interval between first period and first pregnancy, cells are more susceptible to harmful exposures such as radiation or alcohol. When women are in their 20s, damage to their DNA is particularly dangerous because they have a lifetime to accumulate mutations.

During pregnancy and breastfeeding, the number of immune cells increases in the breast, offering protection against potentially cancerous cells. After a baby weans, the mother’s milk cells die and get cleared by the immune system, leaving fewer mutated cells behind. The cells that remain spend more time repairing DNA.

With societal shifts to later first pregnancies and fewer babies, women are subject to the potential harms of these natural processes for longer—and get fewer of the protective benefits.

While I’m not concerned about breast cancer for myself, I thought this information was interesting, partly from a societal standpoint, but also because it demonstrates the complexity of the body’s natural healing processes and how they can be disrupted.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Using a chatbot for your health care

According to a 2016 Johns Hopkins study, medical mistakes kill 250,000 Americans a year—behind only heart disease and cancer. Even if that number turns out to be too high, a recent article in The Wall Street Journal advises using a chatbot to help you “spot errors, understand lab reports and stick to care plans.”

In one experiment, a diagnostic chatbot solved medical cases reported in the New England Journal of Medicine with an 85 percent accuracy, roughly four times as well as primary-care doctors using the same data. Because the chatbots “ingest” research from every specialty, they can connect dots that doctors may miss.  

Here's how the Journal article tells you to use a chatbot:

Keep a health diary: Open your AI chat, such as Claude, ChatGPT, Gemini, or other top model and insert your health information, such as diagnoses, surgeries, lab results, current medicines and doses, and even “mystery” symptoms. Ask the bot: “What patterns jump out? What’s overdue, and which gaps should I address first?” If the answer is confusing, say, “Explain that in simpler terms and give an example.”

Enlist AI’s analysis: Tell the chatbot about your health concerns, such as a pain you’re experiencing. For example: “Find the triggers to my pain flare-ups, rank likely culprits, and offer standard and unconventional fixes.” AI might find a hidden side-effect from medication or a disorder that doctors missed.

Clarify communications: If your doctor has recommended a course of treatment or prescription that isn’t clear, you can ask the chatbot for clarification. For example, if you don’t understand why an anti-anxiety drug was prescribed for your stomach pain, the chatbot will explain: “The drug calms overactive nerves.”

Ask your chatbot for second opinions: Seek counter-evidence to any significant AI suggestion by asking: “Show peer-reviewed studies—especially clinical trials—that argue against this recommendation.” Assuming the studies will be dense, ask the chatbot to summarize key points.

I've never done this, but it sounds sensible to me.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.