Ignorance Is Bliss

From the comments section comes this juicy tidbit:

 AAA said...

I agree with the notion that MDs are no longer needed in primary care settings. Physician Assistants or Nurse Practitioners could do this job as well or in many cases better than MDs. Increase the number of Nurse Practitioner Programs and PA programs and decrease medical schools to a handfull number. That would solve our escalating cost in health care, and provide patients with a higher quality of clinical and caring care.

When taken to AAA's blog,  Botanical Medicine Posts...

It's an interesting theory.  A theory filled with holes.

1. Physicians are focused more on how to handle filling for insurance, avoiding law suits for malpractice, and how to see as many patients in a 10-hour shift than really caring for their patients.---The assertion here is that somehow nurse practitioners would be immune to these forces.  AAA, how would a nurse practitioners run their office without filing for insurance.  How would they avoid lawsuits.  And how would they pay their bills without seeing as many  patients as possible?  If there is a magic NP business model that somehow is able to evade all these problematic issues of outpatient comprehensive care, I would certainly love to see it.   
2. A new breed of clinicians is being surfaced in USA where Nurse Practitioners and Physician Assistants are as competent in disease management as any physician.--Do you believe that the medical trained boards of internal medicine, family medicine and pediatrics are therefore unnecessary?  
3. They are willing to spend more time with patients without worrying about managing a business.-How is it that nurse practitioners don't have to worry about managing their business.  Is there a nurse practitioner fund that will bail them out when their business bankrupts from not seeing enough patients.  How is that many comprehensive care doctors need to see 30 patients a day to earn the same amount as many salaried nurse practitioners these days.  Is there some magic money tree that will pay the NPs bills?
   
4. Perhaps the model for health care in the immediate future is clinics staffed with NPs and PAs and one physician who is just hired to manage the clinic, but not to see patients.-What?  Did the really expensive physician just become the business manager?  That seems like the worst business model ever.
   
5. This will save cost and gradually eliminate the health insurance system. Patients want more caring clinicians and less business like providers-Saving cost?  Perhaps.  Unfortunately, the cost of the comprehensive care physician in the grand scheme of the 2.3 trillion dollar health care business is minuscule.  If you think trading out NPs for MDs will 'save cost', you fail to understand the grand scheme of expenditures.  What about the other 2.25 trillion dollars in expenditures not related to the fees of comprehensive care doctors.  It's easy to write about the front end cost savings.  It's easier to ignore the back door expenses of this model.  You can't be a caring provider if your office goes bankrupt.

I am amazed, really amazed at the lack of knowledge displayed by those in the lay public when it comes to the realities of providing care to patients.  This  botanical medicine person appears to live in some sort of economic black hole where the rules of revenue and overhead expenses only apply to some populations but not others.  To believe that a NP could operate a clinic independent of the financial and legal concerns that is currently crushing outpatient comprehensive care physicians, is to show a total lack of understanding or desire to education oneself on the process.

Let The Cards Fall Where They May

There seems to be a growing prevalent attitude that out patient comprehensive care is a scope of practice that is capable of being managed independently by those with out MD degrees. There appears to be a growing belief that nurse practitioners, those who have completed a nursing degree and have gone on to do masters level training in as little as a year, are capable of taking on the reigns of independent practice across the same scope of practice as internists and family medicine physicians.

So I say, great.  Let's let the cards fall where they may.  With less than 2% of medical students entering a comprehensive care field, I say it's time to disband the teaching and training of outpatient internal medicine (and family medicine and pediatrics) to focus on the inpatient aspects.  If we as a nation believe that NPs are capable of practicing their scope as equals in terms of diagnosis and management of acute or chronic or acute on chronic medical illness, with no decrease in quality or increase in cost, then it's time that us MDs bow to the will of the nation.

For a peak on where we are heading, continue reading here.

Darvocet Ban Government Recommendation

Sounds like the government is contemplating a Darvocet ban.   Darvocet has been around for 50 years. What are all the chronically addicted pain folks who swear up and down that "the only medicine that works is Darvocet" going to do?  Banning Darvocet?  Really?

It kind of reminds me of my inpatient smokers who ask to go out and smoke. I tell them this hospital including the outside grounds is a smoke free zone. If you want to go out and smoke you will have to leave AMA. Would you like a patch instead?  

My opinion is that Darvocet is a very weak pain medicine, but apparently loved by millions for its addictive nature.  Perhaps they will no longer get their fix.  But, if they are going to ban Darvocet because of it's limited effectiveness and high abuse potential, I can't imagine Demerol is far behind.

Where's The Beef?

A Hospitalist goes out of his way to find family.  Doc, I would have quit long before you did. 

There was no family at bedside. I figured I ought to call the family. So, I check the face sheet (has all the patient info, including emergency contact info) and call the phone number. It was Arby's... Yes, the fast food roast beef place (with wonderful curly Q seasoned fries)...

Be Careful When Renovating Your Home

You could give your child lead poisoning. From the weekly MMWR comes this tidbit about exposure to lead in New York homes under going renovations, repair or painting (RPR).  Keep the little ones in mind if you decide to get a new kitchen or bathroom.

Happycon And Puppycon

From Shepard Fairey's iconic poster, now you can create your own Obamicon.

Italian Greyhounds Scared By Talking Santa (Funny Video!)

That's Marty and Cooper, our two little Italian greyhounds being scared by a talking santa.  Good times!

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their three beautiful slide show presentations, a full color slideshow, another  full color slide show and the all black and white slide show, all available for viewing in my side bar as well.

I Found A Bone

Marty And Cooper Find a Bone



See other funny and cute Marty and Cooper Videos

Unprepared For The Unexpected

I created a four box theory of medical care here:  

	Expected	Unexpected
Prepared	Prepared/Expected	Prepared/Unexpected
Unprepared	Unprepared/Expected	Unprepared/Unexpected

In the original post I describe the left column, the expected course of disease.  The  rows indicated how prepared or unprepared your provider is in caring for you.  In general you as the general public don't have to worry about getting unprepared providers of care for expected course of disease.  Unless the provider is practicing outside their scope of training.  This process can happen if you are a NP a comprehensive care doc or a surgeon.  Your scope of practice will guide you. I went on to discuss my thoughts with having two different providers practicing in the same scope with a large variation in experience and education.  That's how you become unprepared for the expected.

But what about the unexpected column?  How does one become prepared or unprepared for the unexpected?  There is only one way.  Education and Experience.  At some point or another, most, if not all patients, will follow the unexpected course of illness.  They may limber on for years with controlled type one diabetes.  Then they may show up in your office with a blood sugar of 800 in florid DKA because of a diverticular abscess. 

The only way to be prepared for the unexpected is to prepare for it.  And the only way to do that is to experience it.  To study it.  To recognize it.  When we start talking about truncating residency hours to accommodate work restrictions we risk creating a whole population of physicians who are unprepared for the unexpected.  When we plan on NPs with their residencies and educational training that is thousands upon thousands of hours less than a board certified physician practicing in the same scope, we risk over and over again being that patient for the unprepared for the unexpected.  When we send surgeons home earlier and they miss the rare anatomical variation or that life threatening complication, we risk creating thousands of surgeons who freeze in the operating room.  Who have no one to turn to when they don't know what to do.

What's the risk of harm?  That's hard to measure.  It could be nothing.  It could be delay in diagnosis.  It could be unnecessary morbidity.  It could be death.  Given enough time, most patients will have an unexpected course of illness.  

How can we expect to minimize the unprepared for the unexpected when all of our current policies are pushing us here?   

As a patient, you want to live in the prepared for the expected quadrant.  But as a country, we are moving more and more into the unprepared for the unexpected.  One more reason to take care of yourself, exercise, eat right, and don't smoke.  Because those taking care will be unprepared for your unexpected.

How To Make Meth or Methamphetamine From Cold Packs

Cold Packs?  Yes folks.  You heard it right.  You can make meth or  methamphetamine from cold packs.  Now comes word of the latest greatest way to get your fix.  You need a subscription to read the whole thing, so I'll summarize for you.

1. Extract ammonium nitrate from instant cold pack
2. Take the lithium from household batteries
3. Get your pseudo ephedrine from the local pharmacy
4. Mix up in a plastic container, such as a soda bottle
5. Shake and Bake for 30 minutes to get your high
6. Hope you don't blow yourself up.

And there you have it.  Meth.

So America, if you go to your neighbors home and you open the freezer to find 50 instant cold packs tucked away, be suspicious.  Be very suspicious about meth or methamphetamine.

I see lots of patients addicted to meth or methamphetamine.  They never have any teeth.  I've never seen one blow themselves up from making homemade meth or methamphetamine.  But I'm sure it's only a matter of time.  You want to know how to make meth or methamphetamine?  I suggest you find another hobby.

Neither Ran Nor Sleet Nor Heat Nor Gloom Of Night

A reader sent me this story.

I thought you would find this interesting in regards to your blogs about government workers, etc.  .  I haven’t received any ground mail for TWO days.  I couldn’t figure out why.  I didn’t get my mail two weeks ago for one day too.  The mail man left a standard note saying the 15 feet before and after the mailbox needed to be cleared to the curb, not snowed in.  So I shoveled and the mail resumed.  Then, all of the sudden, no mail the last two days.  I figured it was because “up to the curb” was not cleared.

You would think that this mail man had a point.  That he couldn't deliver the mail if he couldn't get to the box.  Right?  Of course, you would think that was reasonable.  But it couldn't be that easy.  Continuing on...

But this is an ice block 4 inches thick from the recent snow and clearing snow.  I would need a chisel to get rid of it.  I suppose when the government pays you, there’s not incentive to go “out of your way.”  Hide behind the regulations.  The answer is simply not to deliver the mail.  I attached two pictures of the mailbox.   Do you think I’m being unreasonable to expect my mail be delivered, especially when I’m trying to get my taxes done and need my W2 form?

?

You want federalized health care?  A system where all your docs and nurses are federalized?  I have worked in that environment.  You do not want to be a patient in that system.  Be prepared for this level of arrogance and stupidity.  Try and fire that mailman because he isn't doing his job?  Good luck.  Be careful what you wish for America.  This is just pathetic. I would be embarrassed to show up to work with this attitude.  This is the government mentality, pure and simple.

If You Are Looking For Auto Insurance

Look no further.  CompareTheMeerkat.com

Hilarious viral advertising.

It works.  You're reading it.

"Micro Managing Morons" Says The Dinosaur

That's what Dr Dinosaur called us folk after she rants about guidelines and  the reality of real life medicine.  The gist of the post is well taken.  It's difficult to manage all patients with guideline driven medicine all the time.  In fact, I would say its very difficult to manage most patients with guideline driven medicine all of the time.  Obviously this fictional patient she speaks of in exquisite detail doesn't exists.  Perhaps he never had diabetes.  Perhaps he never had cancer.  Maybe he never had a problem swallowing pills.  Perhaps the whole thing is made up.

Your make believe patient was managed in a way that other doctors, me included, would not have.  I suppose there is more than one way to skin a cat.  And that's all fine and dandy.  That goes along well with the point of the post.  That guidelines aren't always appropriate.  At least I presented my rational for my thought process.

I suppose you can consider those that question the rational of your fake management decisions "micro managing morons".  I wouldn't.  I would consider it communication.  If you are going to present a fake patient, be prepared for others to present their opinions on your fake management skills.   Or better yet, disable the comments far sooner that you did in this case so your management skills stand without discussion.

The Day Lucky Seven Turned Into Eight

The bedside exam is often maligned in favor of technology.  It is often easier to order an echo and get a chest xray than it is to listen with a stethoscope.  Sometimes technology isn't better.  Take this case reported in the NYT.  Seven babies turned into eight, by the act of diligent bed side exam.  And no ultrasound in the world was able to find this little two pounder.

Great.  Now they're going to have to buy extra diapers.  I wonder what would happen if nobody had found that baby and mom was sewed back up. Assuming it had its own placenta, would it continue to grow up to the due date?  Can you imagine.  Going home to start your family, then coming back nine (they were born at 31 weeks) weeks later to deliver your last.  Wouldn't that be something.  You probably wouldn't even know you were still pregnant.  And your belly size probably wouldn't give you any clues.

(Thanks to a reader for this link)

Everything You Need To Know About The Lost Tampon

And more over at Grand Rounds.

Prilosec Plavix Interaction Together May Kill You (And or Cause Other Serious Side Effects Or Bad Outcomes)

Prilosec Plavix Interaction:   FDA UPDATE NOVEMBER 2009.  Concerns confirmed.  Read on...

Taking Plavix and Prilosec together may kill you.  Or so I read today on the LA Times Health Blog about this damning evidence.  Folks, this is bad news.  Really bad news.  A safety review is on regarding a potentially deadly interaction of Plavix (generic name clopidogrel) with proton pump inhibitors (PPIs) prilosec (omeprazole) and others.  PPIs are acid suppression medications such as Prilosec, Nexium, Protonix among others.  Plavix is a permanent platelet aggregation inhibitor.  That is, it prevents platelets from clumping together, which is one of the requirements of clot formation.  It is indicated for the prevention of arterial type thrombosis events.  Most notably, it is used extensively to try and prevent thrombosis of arterial stents.

 Proton pump inhibitors  are used universally for heart burn suppression and the treatment of ulcers, gastritis, esophagitis and GERD.  You name it.  Any irritation in the esophageal-gastric tract gets a PPI.  We use it extensively in the ICU for gastric suppression.  It's also used fairly often in other hospitalized patients as well for protection of gastric mucosa from acute hospitalized illness (but shouldn't be).

I suspect it won't be anymore.

This news is not looking good.  The study out of  Circulation says that those taking Plavix and a PPI  such as (Prilosec) had a higher incidence of adverse outcomes after one year.

Here's what the FDA says to do:

Until further information is available FDA recommends the following:

• Healthcare providers should continue to prescribe and patients should continue to take clopidogrel as directed, because clopidogrel has demonstrated benefits in preventing blood clots that could lead to a heart attack or stroke.
• Healthcare providers should re-evaluate the need for starting or continuing treatment with a PPI, including Prilosec OTC, in patients taking clopidogrel. 
• Patients taking clopidogrel should consult with their health care provider if they are currently taking or considering taking a PPI, including Prilosec OTC.

This is not good. Many patients have symptomatic relief of severe heart burn with the use of these PPIs.  These folks are often smokers and often obese, two of the main risk factors for GERD related symptoms.  It just so happens that these are the same people who develop CAD and require cardiac stents, which then require Plavix to keep from clotting off.  How do you treat a patient with a bleeding ulcer who requires a PPI who also happens to be on Plavix for their cardiac stents (or renal stents or peripheral arterial stents)?.  How do you treat severe GERD  in a patient with stents?

Which would you rather have, painful GERD symptoms all the time or an MI that could potentially kill you or leave you with significant cardiac morbidity?

It's one more reason to get out and exercise, stop smoking and eat healthy.  Drugs won't fix you (but if you need your Prilosec, check out Amazon's prices)  In fact, a false sense of comfort in their efficacy can be destroyed instantly when you read about stuff like this.

Banning Smoking In Your House

The battle to smoke in your own home federally subsidized apartment that infests non smokers with your toxic filth.

What a great thing this is. Smoking is the only activity, when used as directed kills 1/2 the people who do it and takes out innocent bystanders in the process.  Make it socially unacceptable. Make it horribly expensive. Shrink the boundaries. And the problem will fix itself.

Wash Your Hands

Any questions?

via Wired Science

A Coconut Sized Kidney Stone

I've never seen a kidney stone that big.  That's just crazy.  

You Are Killing Yourself

Source: Schroeder SA (2007) "We Can Do Better — Improving the Health of the American People" NEJM v357:1221-1228.

We also know that behaviors can directly affect genes. Exercise and eating healthy can turn on good genes and turn off bad genes. I would venture to guess that over 1/2 of early mortality is attributed to behaviors.


Why are we spending 2.2 trillion dollars a year on 10% of the problem?  Because we don't like to be told no.  We have a right to treat our temple like a pile of trash.  As long as someone else foots the bill when the walls come crumbling down.

Hug Me Pillow For Those Lonely Nights.

Is it me or did that arm grab her boob?  And if you're babie's hungry, try the Brest Friend Pillow for successful feeding, every time.  

Medicare Is Intellectually Bankrupt

A have to say,  I agree with him.  Does Obama have the political will to save America from its own entitled ways?  Something tells me pushing a doomed to fail 850 billion dollar spending disaster on to the backs of future tax payers is a resounding no. 

Government Does Not Know Better

Exactly.

Obama: George Bush On Steroids

"If government spending was the key to growth, North Korea would be an economic Nirvana."

The definition of dumb ass is one who does the same thing over and over again expecting a different result.

Stimulus #1: $150 billion dollar Fail

Stimulus #2: $700 billion dollar bigger Fail

Stimulus #3: $850 billion dollar monumental Fail.

Two trillion dollars taken out of the efficiency of the public sector placed into the bloated vice grips of politicians who determine who gets the money by how much campaign contributions they get. If you believe the government can spend your money better than you, perhaps you should double your contribution to their cause. Kind of like a volunteer tax system. How many people do you think would give up more of their money than they currently owe? None you say? I thought so.

Watch the video.  

Hospirestaurant

You've heard of the hospitel phenomenon sweeping America. Hospitals being turned into hotels. But I bet you've never heard of the Hospirestaurant. Restaurants being turned into hospitals. That's what they're doing in Latvia.

If I'm ever in Latvia, I'll have to check this place out. Click on the link above to check out the other pics.

Stereo Speakers Like You've Never Seen Before

As one commenter said,
I don't think Mrs Happy would let me put one of those in our living room.

Wall*E

Americans are getting heavier, with the largest increases seen in the heaviest weight group.  Where do you weigh in?  And what are you going to do about?  There is no money left to take care of you

How Long Is Enough?

 A reader brings up a great question. How long is enough to be trained to take care of patients?

albatross said...
I'm curious how anyone knows the right amount of training needed for treating patients. I mean, it sure *seems* intuitive that someone who went to medical school and did a residency is going to do a better job than someone who has had less training. But is there evidence about this, in terms of better outcomes for comparable patients?

This question kind-of hangs over all these discussions of shorter hours in residencies and the use of PAs/NPs, right? How much difference does it make in patient outcomes if you get the MD with 15,000 hours of residency, or the one with 10,000 hours due to work-hour restrictions, in terms of outcomes when they're practicing? How much difference does it make if it's a PA instead of an MD? Is there good data about this?

It would be pretty remarkable if the historical number of hours of training happened to be optimal, right? That number is pretty clearly a trade off between economics and the advantages of training.

January 26, 2009 10:32 AM

I speak from personal experience.  As an intern,I had the confidence of a rock.  Just when I thought I was ready, along comes a situation where I froze.  Where I looked to a supervisor for help.  A situation that put me in my place.  I was not a complete provider of primary care.  In fact, I would say my care was so incomplete, I would fear for the patients I was taking care of.   These situations were common.  I was in the process of learning more about what information to gather and how to separate important information from noise.  I see this in first year family medicine residents I work with now.  Many are still in the medical student mode.  Acting as data gatherers.  Collecting information from the history and physical.  Then looking to me to formulate the plan.  Many don't have the confidence to formulate a plan, because the basis of their foundation is not yet built.

By year two, supervisor roles are introduced.  At the academia mecca I trained at, our team consisted of two interns, a supervisory resident the attending and a gaggle of medical students.  As a supervisor, my role was to make sure the interns didn't f**k up.  My job was to guide them.  By now, after a year of intense internship and exposure to thousands of patient experiences, the ability to filter the information into an appropriate plan starts to take shape.

Being able to determine who needs a CT scan and who doesn't.  Who needs an urgent ICU transfer and who doesn't.  Along with the daily educational lectures and morning reports and conferences, the patient experiences were constant.  Repetition, repetition, repetition.  Seeing 500 cases of COPD.  Seeing 100 cases of Sepsis.  Seeing acute shortness of breath a 1000 times.  The work up is enforced and ingrained.  The subtle nuances of knowing what data to gather and what to do with it once you have it.  That is learned by 1000's of hours of repetition.   There are no shortcuts.  It can't be learned in a 2000 hour residency.  The shear volume of information and permutations simple doesn't allow it.

I can say that with pure confidence.  Because I wouldn't trust myself to take care of ANY patient independently at the end of my intern year.  I was just then learning how to evaluate the patient, let alone formulating an adequate plan.

By year three, the experience as a supervisor, the countless hours of repetition finally sinks in.  Being able to weed out worthless information.  Being able to connect the dots.  Being able to create dispositions.  Communicating with families.  Educating patients.  It takes 1000's of hours to learn.  Do I have data to back that up?  Yes.  Ask any physician if they felt comfortable evaluating and managing after their intern year and I'm sure more than 100% would say that assertion is laughable.

Now go out and ask any NP if they feel comfortable being a complete provider of primary care after they graduate and I'm sure you will find many that do.  There in lies the difference between MDs and NPs who wish to practice independently.  Once you experience  a physician level residency training program, you gain a deep appreciation for what it takes to be a true independent provider of primary care.  Those that haven't undergone the process simply do not understand.  They choose rather to denigrate the physician process and question its necessity while pushing an agenda  of minimal academic rigor in an effort to legitimize their own educational process.

There are no shortcuts to the process of providing independent care.

Why those with less intense training and education feel they could is why I always say you don't know what you don't know.  Walk in the shoes of a residency.  You will understand after just a month, Heck even a week, why there are no shortcuts to independent practice of medicine.  You cannot learn what you need to learn to be a complete provider of care in 1/10 the time.

This is not irrational thought.  And if others out there think I'm being irrational or degrading, so be it.  I speak the truth.

Hospitals Are In Trouble Too

From the AMA News comes the revelation that hospitals are tanking with the rest of the economy and laying off jobs by the thousands.

I can't wait to see what happens when the Hospital Insurance Trust Fund (Medicare Part A), is bankrupt.  From the 2008 Trustee's report to Congress:

That 2019 figure has been accelerated to 2016 do to declining revenues in this deep recession.  Seven years folks.  What you want to do now is take care of your body.  Stop smoking, eat healthy and lose weight.  America can't afford to take care of you.  It's up to you.  

This Guy Thinks Medicaid Is The Answer

From the January 22nd, NEJM titled Medicaid and the US Path To National Health Insurance

All I can say is, he doesn't have clue. If this country's hospitals and physicians were to try and operate economically on the payment scale of Medicaid, you would have to travel hundreds of miles to find anyone to take care of you. For many states, Medicaid payment wont even cover the cost of doing business. Running a doctors office takes money. With overhead expenses often 50%, 60%, 70%, Medicaid payment won't even cover the cost of rent.

In my community, no comprehensive care physician takes Medicaid, except the federally subsidized sliding scale clinics, and then EVEN THEY receive a higher payment scale for Medicaid. It's amazing to me. The federal government subsidizes a higher pay rate for Medicaid to their own subsidized clinics.

What does that say about the current payment scales of a program this guy wants to expand.  I think this guy needs to live one year with Medicaid to understand what his proposals mean in reality.  Insurance without access will only lead to more emergency medicine and higher costs. Expanding Medicaid is NOT the answer. You will witness the FREE=MORE phenomenon on an expanded grand scale.

Addendum:  Here's a great Op-Ed from the WSJ about its failures.

$850 Billion Dollars

The goal is to create 3 million jobs. Let's see, a stimulus plan of $850 billion dollars to create 3 million jobs?  That works out to $283,333.333 for every job.

Anyone here tell me how I can  sign up for one of Obama's jobs?

Dr Val Talks Acid

But I can safely say that as a rehab doctor I no longer think about acid/base equations--Dr Val

Dr Val. I can safely say as a hospitalist, I don't have time to think about acid/base equations either.

Trust Your Doctor And Don't Get Caught Up In All The Logic

Alec Baldwin talks herpes and doctors.

Are Family Medicine Physicians Specialists?

I pose that question for an honest discussion.  The Philadelphia Business Journal labeled nurse practitioners as a primary care specialty.  I disagreed and discussed my thoughts here.

One nurse practitioner responded with the belief that family medicine is not a specialty.  Perhaps with the belief that NPs can practice medicine with equal educational and clinical  ability as MDs, of course, just not "specialty" medicine.

America, do you believe that family medicine is not a specialty?  I can only assume that this NP feels the same about internists and pediatricians, since all three fields encompass "many different facets of medicine".  

The way I look at it, that is exactly what makes family medicine, internists and pediatricians  specialists.  Because the knowledge base must be broad, the training must be intense.  The ability to understand all organ systems and how they interact must be learned.  I don't believe that four years of nursing school and a couple years of NP level residency is capable of providing NPs with the foundation educationally, nor clinically for independent practice across the vast scopes of adult or pediatric medicine.   And because the intensity is not equal, the education is not equal.  And because the education is not equal,  the ability to practice independently in the same scope isn't either.  

It's like me saying I can be an independently practicing gastroenterologist or cardiologist because I have internal medicine training in many diseases that they manage.  For me to make that statement would be as foolish as a NP saying they could do my job (my WHOLE job)  with equal capability.  It's utter foolishness.  But that's what I'm hearing when you say NPs will become complete primary care providers.  Perhaps they will.  But I don't see it as being complete.  The scope may be the same.  The practice won't.  The reason is education, or lack there of.  I am no more a cardiologist as you are a complete independent provider of primary care.  Unless you believe I can be a competent independent cardiologist because I manage cardiac issues.  Then I fear for us all.

If in fact the training tracks of internal medicine and family medicine and pediatrics were all able to be learned with NP level residency training, we should be abandoning MD  programs forever, in favor of NP level education.   

I disagree that that kind of action is wise.  These are some of the hardest specialties to learn.  The argument that they don't focus on one organ system so there for they aren't specialties is flawed.  They focus on all organ systems, all the time.  That's what makes them difficult.

I've heard many specialists tell me over and over again, call the hospitalist, that is out of my training.  Well, guess what, just about everything you can imagine is in my training.  In many ways, being a subspecialist is far easier than being an internist, clinically speaking.  Tis far easier to focus on one medical problem for a patient with ten active issues.  

Most physicians, of all specialties, practice 80% or more of their practice in a hand full of common conditions in their practice.   You get really good at diagnosing and managing those 20 medical conditions.  Could I manage many conditions as good as a cardiologist or a gastroenterologist?  Yes.   Does that make my scope the same as theirs.  Hardly.  Would I call myself a cardiologist because I can  manage heart failure or atrial fibrillation?  Of course not.  Would I call myself a gastroenterologist because I can manage acute hepatitis or ischemic colitis by myself?  Of course not.  My scope is not their scope, even though my scope overlaps their scope.  

The extra three years of training they receive accounts for the 20% of the long tail diagnosis, and the long tail management of the common conditions.  I would never in a million years consider myself competent to practice gastroenterology or cardiology independently.  That requires the ability to manage more than just the 80% of common diagnoses.  

Unfortunately, you are asserting that you can do the same to primary care.  By asserting your ability to be a complete provider of primary care.  I'm here to tell you you can't.  You don't know what you don't know.  I am not a cardiologist because I am not trained to be a cardiologist.  My scope of practice in cardiology is different than a cardiologists.  Just as you are not an internist, nor a family medicine specialist, nor a pediatric specialist for the same rational.  However, you wish to practice independently with the same scope as a family medicine specialist or an internist or a pediatrician.  And that is my beef.  

Being a specialist in all medical fields requires the intensity of medical residency level training to practice independently.  If your scope of practice is undifferentiated from mine, then our credential process and education should be equal.  Otherwise, the process is deeply flawed.

Just the other day I had a woman with an acute change in vital signs.  The subspecialist was on the floor bedside.  I got paged to come up pronto.  As soon as I walked in the door, the doc says "Thank God you're here.  I only manage XXX(take your pic of organ system)."  I hear this rational day after day after day.  It's easy to ignore the rest of the body when you focus on just one.  I don't get that luxury, or patients would die.  That's what makes me a specialist and thats what makes a family medicine doc a specialist and that's what makes a pediatrician a specialist.  

They are specialists of the entire body.  When I get consulted by a cardiologist for nausea.  When I get consulted by plastic surgeon for hypertension.  When I get consulted by general surgeon for electrolyte disturbances, I am a specialist of everything at any time.  Day or night.  I don't get to pick my organ system.  They are all in my scope of practice.

With that said, I will have to strongly disagree with this  NP that family medicine is not a specialty. 

The other part of your rational is that because there is a shortage, NPs will evolve into complete primary care providers.  Why does this rational not work for a cardiologist?  Or gastroenterologists? Could not a NP do one additional year of fellowship training in cardiology (truncated just as it is for family medicine NP training), attend to the minimum number of required procedures and become certified in independent cardiac management?  To practice cardiology independently?

Perhaps you could go on and do a four month (again truncated) subfellowship in EP cardiology and attend to the minimum number of required procedures to become an EP cardiologist?  Perhaps your truncated training affords you the ability to put shock boxes in without assistance after just three years and four months of post undergraduate nursing training.  This is the type of logic that is employed when you assert that your training affords you independent practice capabilities on par with my scope of practice.

Doesn't it sound foolish?  Do you believe you could be an EP cardiologist with just one year and four months of NP cardiology level fellowship training?  If you don't believe you could, you cannot also believe you are equal in scope and practice as board certified specialists in family medicine, internal medicine and pediatrics.

This is the same kind of logic that you use when you truncate MD level primary care into a truncated NP educational experience and call yourself equal in scope and practice.

Do you believe that family medicine, internal medicine and pediatric tracts of training, four years of medical school, 12,000 hours of residency, should be abandoned in favor of the NP model?

Do you believe your skills are equal to a board certified family medicine doctor, internist or pediatrician in terms of diagnostic capability and management.

If you believe that, then you have to believe that medical school and residency in these fields are unnecessary.  That your training is adequate to practice a full scope of medicine across all organ systems, all the time.  Unless of course you feel you are not qualified to handle many aspects of primary care.  If that is the case, do you feel your duty as a NP provider is more of a triage artist?  To refer cases of management that can be handled by an MD level family medicine doc but not you?  If that is in fact the case, than you must believe that your scope of practice is also limited?  That you have less diagnostic capabilities and fewer management skills that are played out  in your mind on a case by case basis, but not on paper as a defined scope of practice.  

I really am open to discussion on this matter.  But you have to be able to explain to me what I as an internist, or Dr Dinosaur as a family medicine physician bring to the table that you don't for me to understand how you consider yourself equal in scope and practice as us.  Because being a complete provider of primary care indicates to me that you believe your scope of practice is the same.  Unless of course  your definition of complete primary care is different than mine.  In which case this whole discussion is moot.  Perhaps complete is however you want to define it, on a case by case basis.  

Perhaps it's only complete for some patients, and not others.  Perhaps the decision on complete care will be decided every day for every patient based on your skills and knowledge base at that moment.   Perhaps the deficits in your knowledge base, compared to mine, will create an equal scope, in theory, but far different in reality.  Perhaps that what this is all about.  Equal scope, different reality.  

That I can understand.  

Richard Simmons Is Da Man.

What's the problem with US Health care. We alway talk about inefficiency. But what does that mean? Here we are walked through the differences in productive and allocative inefficiency. An excellent read.

Lowest pH Ever Survived

Add another record to my book for the lowest pH ever survived by a patient.  They had diabetic ketoacidosis and they weren't on a ventilator.

pH 6.83

Damn. Noncompliance can kill you, but it didn't this time.

see my other records

44 Years Later And Nothing Has Changed

Read this excellent review on how teaching hospitals are paid extra for the cost incurred by medical education training, and the proposals to slash payments. I found this comment particularly interesting:


It's been 44 years and the government continues to foot the bill. That's what happens when government entitlements become the norm.

The Beer Hoodie

Why didn't I think of that?

A Coke Addict Like No Other

Yes folks, In Sweden you can now admit yourself to inpatient treatment for a Coca Cola addiction. I wonder how bad the withdrawals will be. Perhaps she'll need an IV and titrating doses of D5NS. I can only imagine how hard this will be.

Fox News reported:

The Transurethral Lithotripter

19th Century style. It looks like a putter for a midget.




via Morbid Anatomy

How Does Your Cigarette Taste?

Dry Cracking Hands

The enemy of every health care worker in the dry winter months. Besides moving to Hawaii, what is your cure America?

Chest XRay With Morbid Obesity

When you look at a thousand chest x-rays, your mind trains you to see automatic outliers. I like to call this asymmetric lines of demarcation. Massive obesity affects the ability of your doctor to diagnose and treat you. When the xray doesn't penetrate. When the ultrasound doesn't penetrate. When the echo doesn't penetrate. When you can't get on the cath table or fit in the MRI or safely survive surgery. The ability of your doctor to evaluate and manage your illness is severely limited.

Sadly, often times the patient nor their insurance has the motivation nor the desire to intervene. Generally speaking, the morbidly obese, I'm talking hundreds of pounds overweight have limited medical resources available to them. In spite of most being on full disability with guaranteed life long government care, most have difficulty at some point or another in undergoing appropriate diagnosis and evaluation. They have all the health care taxes can buy. Yet, they have almost nothing. A lot of the evaluation process and accurate diagnosis becomes a guessing game who's outcome is based on the skill of the physicians.

I take care of many incredibly obese patients in a years time. 500 pounds. 600 pounds. The story is always the same. Skin infections. Heart failure. Life threatening obesity related respiratory failure. We can't scan them. We can't xray them. They are too heavy for the procedural tables. The cardiac echo machines can't find a decent picture of the heart. The x-ray machines can't bounce enough x-rays to get a good image. Medication doses are generally inappropriate. Their physical exam is generally very limited due to massive layers of tissue that hide blood vessels and auscultated sounds.

You treat them to the best of your ability. But you know, they will be back. Soon. Or perhaps they will die in their sleep. When they are on my service, all I can do is give them a band aid and hope they survive until the next admission.

It's quite sad. How do you help them? I mean REALLY help them? The hospital care is a band aid for their life threatening obesity. The resources for help are often limited. The home life is often self fulfilling. The ability to rehabilitate the mind is often limited. The motivation is often lacking.

Perhaps life threatening obesity is a chronic form of physical and mental suicide. Where I practice folks who are suicidal get admitted to psychiatric floors. Should life threatening obesity be treated any differently? Is there a difference between saying "I want to kill myself" and "I am killing myself?"

Whatever the answer, I know I am not the doctor for them. I am their band aide. Their needs are far greater than any one doctor or field of specialty. Or medical care for that matter.

Happy's Proposal To Fix The Economy

The bleeding hasn't stopped."

What's wrong with letting bad businesses fail? I don't buy all the talk about too big to fail. I say you fail because you are poorly managed. You have to fail. You lose your house because you had no economic business buying it in the first place. You have to lose it. Those that played by the rules will thrive in due time.

We blew through $150 billion dollars when all the non tax paying Americans got rebates that promised to fix the economy. Didn't work. Then we blew through 1/2 of the 700 billion dollars trying to save banks. And the banks are worse off now than they were before.

Now we want to throw $850 billion dollars at a problem that money can't fix. The assets are worthless because no one can force anyone to buy a house for $500,000 when it's only worth $250,000.

I have a different proposal. Instead of throwing hard earned tax payer dollars at businesses and Americans that are proven failures at risk and money management, why don't we give $850 billion dollars to all the people and businesses that didn't mess things up. That played by the rules. They are the ones that have proven their ability to succeed.
Now. Where do I go to pick up my check?

Banning Bottled Water

banning the sale of bottled water

Why anyone buys bottle water is beyond me. You complain about the price of gasoline. What you pay a dollar for is worth maybe a tenth of a penny or less. Buy a reusable screw top bottle and fill it with tap water. By purchasing bottled water you are consuming the oil required for that plastic, you are taking up space in the dump for that never degrading plastic and you are depriving yourself of the fluoride in city water systems used to to protect your teeth.

Buying bottled water is about the dumbest thing you can do on a daily basis.

Ambulance Fail

Ambulance Fail video

Unprepared For The Expected

It is quite possible to split all of medical care into another four box theory of life (see below).

I have so many angles I could take on this analysis that it may bore you to death. But hear me out. The above is one possible four box representation of your illness and your providers of care. It is an important one. Perhaps one of the most important. With talk of reform in the air, you should ask yourself which boxes are most important to you. For this blog post I'm going to talk about the left column. the expected course of disease. I will save the rest for later.

I can assume most people would not want to have an unprepared provider taking care of an expected course of illness. Perhaps that would constitute malpractice. Perhaps even negligence. As to the credentials of physicians, nurse practitioners, physician assistants, pharmacists and nurses, I would expect the vast majority of any of these health care workers to provide appropriate care based on the expected course of disease. That is what board certification in a field of study affords you. And it should give the lay public a sense of confidence in those providing the care.

In general, one need not worry that you will get unprepared providers of care for expected disease management, unless of course the scope of practice by the provider is beyond their level of training. So how does that happen? It happens when the scope of practice is not clearly defined. Most doctors will live most of their life in the prepared and expected quadrant. Their scope is defined. Their training defines their scope. They are trained well for expected courses of disease. I would say most NPs, PAs, PharmD, and RNs also practice most of their life in the prepared and expected quadrant. Is my preparation for the expected the same as a NP's or PA's preparation for the expected? Is the breadth of their prepared knowledge base of expected disease course the same as mine? No it's not.

	Expected	Unexpected
Prepared	Prepared/Expected	Prepared/Unexpected
Unprepared	Unprepared/Expected	Unprepared/Unexpected

The question becomes, should all front line independent providers of primary comprehensive care be equally certified by the same standards. Should they all be capable of managing the same scope of practice? If we do not define limitations of scope between MDs, NPs and PAs then we should expect all of them to pass the same certification standards.

If we don't have the same standards of certification, we risk having a large population of patients being cared for in the unprepared but expected quadrant. The quadrant where people die. Where bad things happen because you not only don't know what you are doing, but you also don't know what you aren't doing. I know exactly when I don't know what I'm doing. My scope of practice defines my care. If you don't define your scope, you don't know your limitations.

The unprepared but expected is a dangerous quadrant to practice in. Dangerous for patients. Risky for providers. Expensive for a system of care with frequent referral to other specialty societies.

I maintain that all providers of primary comprehensive care should be required to pass the same certification standards. If the scope of practice is the same, the standard certification process should be as well. If the scope is not the same, than than those limitations of practice scope should be defined. Right now they are not. To the best of my knowledge, states are allowing nurse practitioners equal scope of practice as many internists and other family medicine specialists. They should be required to meet the same certification standards as their MD counterparts.
Perhaps I am wrong. Is the scope the same? This is sometimes hard to define. What is the scope of practice for a NP? What is the scope of practice for a PA? For many, the boundaries are blurred. I would say most RNs and most PharmDs have defined scopes of practice. But where are the boundaries for NPs and PAs? For many who practice independently, how does the state know when they have moved from the prepared and expected quadrant to the unprepared for the expected quadrant? I think the vast majority of physicians will inherently limit their scope to the extent of their training in their defined scope. I don't do heart caths because I am not trained to do them.

How do NPs limit something that isn't defined? I think one of the inherent flaws of NP and PA training and their certification process is that the their scope is not well defined. They fill the role of internist provider, family medicine provider, cardiology provider, oncology provider. What is their defined scope? Should they be allowed the independent practice of cardiology? And if so, should they be required to pass cardiology boards? Should they be allowed the independent practice of internal medicine? And if so, should they be required to pass internal medicine boards? That's my biggest beef with the independent practice nature of providers who are certified to practice independently in my field, without having to certify in my field.

If you want to define the scope as something more focused than internal medicine, that's fine, define the scope and certify that scope. If you want to define the scope as internal medicine, then all practitioners of internal medicine should be required to pass internal medicine boards. If you want to defined the scope as family medicine, then all practitioners practicing family medicine should be required to pass family medicine boards. Only then do certification standards hold weight. Why should I be required to certify in internal medicine when nurse practitioners are given the right to do the same, without the benefit of internal medicine board certification. It's a fair and honest question. And one that should be answered.
If my scope is the same as theirs, then my unprepared for the expected box should be the same size as an independently practicing NP or PA. And I know, there ain't know way in Hell that that will ever be the case.
Just speaking the truth.

FREE=MORE

Eloquently stated.  I couldn't have said it better myself.

Grand Rounds Is Up

Presidential Style.  Courtesy of Dr Val.

How Often Do Patients Lie To Their Doctor?

How often do patients lie to their doctor?  Well, I'm sure it's a lot and recent research suggests that patient lie often to their doctor. 40% lied about following their doctor's treatment plan. Why am I not surprised?

Try practicing your educational training in a field where 40% of the input data is potentially false. Now try measuring your quality in a field where 40% of the data is potentially false. Impossible. Since we treat dishonest people, expect dishonest data to track outcomes.

Bootie Benefits Covered By Medicare?

Sounds too crazy not to be true.

Here Comes Bundled Payments

 focus on bundling

I am a strong believer in bundling payments.  Done well, bundling is a WIN-WIN for all.  The current Medicare payment system treats physicians like criminals.  Every potential claim is fraud.  Any formula that buries E&M coding is a system worth evaluating.  I could easily double the number of patients I see everyday if I wasn't forced to document worthless information every single time I open a patient chart. Bundling forces physicians to reevaluate, at every step of the evaluation, what is necessary and what isn't.  There is a lot of unnecessary productivity in medical care.  Fee for service has a way of creating business that need not be created.  Will less be done under bundled care?  Yes, I think so.  Is that a bad thing?  I don't think so at all.

Primary Care Is Screwed

Time to go do a specialty fellowship.

pleasure women get

Nurse Practioners, A Primary Care Specialty

That's how the Philadelphia Business Journal refers to them.

Hmm. That's interesting. It sounds like they are being referenced as equals to physicians. Now they carry their own classification as a specialty. When I think of specialties, I usually think of internists. I think of pediatrics. I think of family medicine. I think of perhaps cardiology, gastroenterology, even general surgery. Maybe orthopaedics. Perhaps neurosurgery.

I'm not sure I would call a nurse practitioner a specialty. I suppose if you get right down to semantics, being a nurse is a specialty. A lab tech is a specialty. An ultra sound technologist is a specialty.

As far as I am aware, there is no board certification for nurse practitioners to specialize in primary care. Just as I am unaware of any board certification for nurse practitioners to specialize in cardiology. The reference to specialty should be limited to those professions that have specialized in their field of practice. I would be more apt to call a nurse a specialist in nursing than I would be to call a nurse practitioner a specialist in primary care.

Perhaps, instead of using the words specialist in primary care, we should limit it to specialist in Minute Clinics.

You see primary care is not Minute Clinics. And Minute Clinics are not primary care. The two are completely in congruent with patient populations, disease states, time constraints and management issues.

The moment Minutes Clinics run by nurse practitioners have, as their normal population 70 year olds with CHF, DMII, CAD, OA, Obesity, HTN, CKD, AF, Coumadin dosing and PVD who show up with vague complaints like dizziness or shortness of breath  (COPD dyspnea)is the day that minute clinics become primary care.

Until then, calling them a primary care specialty does a disservice to the seven years of post graduate training and board certification exams required for medical doctors to achieve that title. Just another reason I hate the classification of family medicine and internists and pediatrics as primary care. It has the connotation of simple medicine. A medicine of triage. That is not what it is.

Perhaps bits and pieces, like Minute Clinic care, can be siphoned off at the expense of subsidizing the complicated time consuming medical care of chronic medical conditions. But the fact remains, primary care is difficult. It requires physician level training to practice in whole, to accommodate for vast differences in patient populations and presentations of disease. It requires physician level training for quick and accurate differential diagnosis. It requires physician level training for that long tail diagnosis to be made. The correct terminology for primary care should in fact be specialists in comprehensive care.

By the way, most nurse practitioners I know work in sub specialty medical groups as data gatherers, pager deflectors and efficiency stimulators. They are not primary care specialists as the Philadelphia Business Journal implies. Yet they have the same educational requirements as those that do practice in primary care. Why aren't we calling these nurse practitioners cardiologists? Why aren't we calling them gastroenterologists? Why aren't we calling them Oncologists? They have the same training as their "primary care specialty" trained classmates, classmates who have apparently achieved a rank of specialist in primary care.

If you want to call nurse practitioners who practice in primary care a primary care specialty, then you must also call nurse practitioners who practice in cardiology or gastroenterology cardiologists and gastroenterologists. An assertion that would be struck down without regard for debate.

That's my beef.

Ask An Ex Con

Investigators are looking into allegations that Kaiser Permanente allowed unlicensed staffers to make medical decisions.

On the surface I gotta say, that's what happens when someone else pays your bills. Get used to it America. However, I have to wonder, if people are calling into these call centers and the people answering them aren't nurses, what exactly do they call this service? Ask a high school student? Ask a pizza delivery driver? Ask an ex con? Why is a nurse not answering the call?

We Have Thousands of Beta Players and No VHS

Remember when VHS vs Beta was all the rage.  Eventually the winner became the standard.  You could rent any VHS from an video store and play it across a thousand different brands of the same dang VCR.

The Bailout #3 has in it $20 billion dollars for health care IT.  Great.  $20 billion dollars to generate electronic medical records.  All trying to talk to each other.  Each built on a different platform.  Each secure in their own private hospital or office.

Here's what I request.  One platform.  ONE platform.  Let the local IT departments modify it to their needs.  But use this same platform everywhere, in all offices, in all hospitals.  In every place in this country.  That's what I'm asking for.  Not thousands of beta machines in a land with no VHS.  Right now, I can't retrieve records from anywhere other than my hospital, or by talking with a body at another facility to fax things.  Even if there is a body, if I try and get records from a VA on a holiday, I am laughed at.

Let VHS win and be done with it.  So I can do my job efficiently and safely.

over 160 electronic health record (EHR) products

Balloon Animal Sex Video. Safe For Work?

This is hilarious, but may not be suitable for work, depending on your balloon animal sex policy.

Fat Bastard Big Government

All bloated and gassy

When You Tax Something

You get less of it.   This concept is hardly limited to alcohol.

Suing Your Doctor For Sarcasm

  Did I mention that she is also suing for a handicap parking tag?

via Overlawyered

Dispelling the Myth

Once again that doctors make too much money.

Can You Spend $1.5 Billion Responsibly?

Just brilliant from Cafe Hayek

I hope your hope and faith is really strong.

Going After Patients

Instead of going after doctors and hospitals, it's time to go after patients. Full speed ahead. If the government is going to pay for your care, then be prepared to sacrifice and change.

Hope and Faith

Yes We Did.    I hope the devastating disappointment of reality doesn't crush the hope and faith of this population when they realize that governments don't create hope and faith.  They misspend other peoples money.  And they do it well. And that's all they do well.

Hope and faith is achieved by personal introspection.  By family.  By faith.  By your circle of friends.  Why on earth would you want a multimillionaire stranger controlling your vision of hope and faith?  That basis of irrational thought will devastate you.  If you base your vision of hope and faith for yourself on the actions strangers, you will always be disappointed.  And you will always look to the government to fix you.  The more you rely on government for your hope and faith, the more disappointed you will be when they let you down.

I'm just telling you now so you can prepare yourself.  Feel free to bookmark this entry for future reference.

Senator Kennedy Collapses

With a seizure.  What are the possibilities?  Here is my differential diagnosis:

1. Progressive Tumor
2. Subtherapeutic levels on his seizure medication
3. Seizure despite therapeutic seizure medication; may need second or third medication
4. Electrolyte disturbance, usually in relation to hyponatremia
5. Stroke
6. Random chance
7. Alcohol intoxication or withdrawal
8. Other medications that can lower the seizure threshold, notably antibiotics like Levaquin
9. Infection in the brain such as encephalitis or meningitis or infection elsewhere such as a UTI, although much less likely to instigate a seizure
10. Traumatic injury or subacute fall that could cause an undiagnosed subdural hematoma.
11. Street drug use such as cocaine or methamphetamines.

That's my starting differential, in that order.  If I was Mr Kennedy's doctor tonight I would order an accu check, basic laboratories, blood counts, electrolytes, perhaps a TSH if he has known thyroid disease, drug screen, alcohol level.  A stat head CT in the ED as well to rule out acute bleed.  I would order an MRI if he has not had a recent one to better clarify his anatomy in the absence of bleed.  I would obtain all old records from his primary doc and neurologist and oncologist as well as prior operative reports.  I would check seizure medication levels, whatever they may be.  A detailed history to tweak out any changes in his life.  Sleep.  Caffeine.  Stress.  I would order prn ativan for further seizures.   I would examine him for any neurological deficits.  I would like to know his vital signs.  Atrial fibrilation?  Murmur?  Fever?  Rash? Jaundice? Hypoxemia?  Hypotension causes?   I would like to know a lot about his current clinical exam.

Once I had all my information, I would develop a plan.  Perhaps recurrent tumor required reevaluation with a surgeon and oncologist or radiation oncologist.  Perhaps consultation with a neurologist should additional medications be required.  If electrolyte disturbances are found, additional tests and fluid management would be indicated.  If he is found to be using cocaine, evaluation with a drug and alcohol intervention team would be initiated.  If he has other organ system failure, then further workups would be warranted.

Every differential requires a level of thought and evaluation.  Every abnormality on physical exam may add a level of complexity to the decision making.  When I walk into a patients room the chief complaint by itself will have a broad differential diagnosis without any further information.  As the history and physical examination progresses that differential is either narrowed down or expanded.  Sometimes the differential diagnosis is one condition.  Sometimes the differential diagnosis could be 100.  It is different for everyone.

The physicians differential will guide what the likelihood of the cause is and ultimately what tests to order.  Not all tests for all differentials are run immediately.  Common things to start.  Rare and esoteric conditions are evaluated if no answer is achieved.

If somebody asked Dr Happy what I would do if Mr Kennedy walked into the ER for admission, that's the answer they would get.  Now, where is that cook book I should be using...