Embera Puru, Panama -- A Step Back into Paradise

     Our last day in Panama was spent at an Embera Indian village called Embera Puru. Read to learn who the Embera are and how they live just a short distance from modern Panama City.

"Pity the poor doctor!"

     I am guessing that this title struck a cord!  Doctors make lots of money and they certainly don't deserve any sympathy, right?. They all are just trying to rush you through the office, not answer your questions, give you some quick medicine prescription, and then get the bill out for the visit. They really don't care about the patient, right?  I am a retired physician. I don't often write about medical issues in this blog but while reading my recent "throw away journal" called Medical Economics, I ran across 2 articles which point out one of the broken issues in my former career. There are many more but recently several of my own lay (non-medical) experiences have emphasized what these articles and others show as major deficits in the doctor patient relationship and in the general practice of medicine.
    One of the articles talked about this being an era of medicine by the numbers. The editorialist commented that there are at least 50 scales of measurement now being used to generate report cards on physicians. Many of these are percentages: such as what percentage of the doctor's female patient base has had their yearly mammograms; what percentage has their LDL (bad) cholesterol under 100; percentage of smokers counseled on quitting smoking, percentage of people screened for depression, percentage of flu shots given, etc etc. Then sometimes a group of these measures are computed together to come up with a general score rating how good the doctor is. Such report cards that supposedly demonstrate how well a physician is performing his job, are starting to be used to determine a doctor's salary. Without any personal contact with the doctor, and without a complete understanding of his practice, the type of patient he sees, and his style of practice, would such a numerical calculation standing alone really represent the quality of this physician's work?
      Insurance companies are keeping track of cost effective measures, such as how many generic prescriptions are written, which blood pressure medicine is most often prescribed and its cost, what is the average cost of an office visit, and how many times are patients being called back for example for blood pressure follow up. All of these numbers determine whether a physician is "cost-effective" or not and sometimes are used to determine if that doctor is hired or retained on a provider panel. This strong emphasis on saving money while still being sure to meet all of the above performance parameters essentially creates a vice and the practicing physician is right in the middle of that vice.
     As I was readying to retire one of the most frustrating things I that came up every year was the patient satisfaction survey. There were about 5 questions that the patient had to answer -- questions such as Were you satisfied with you last appointment with this doctor?, did this doctor listen and answer your questions satisfactorily,  chances you would return to this professional if needed, and chances you would recommend this physician to one of your relatives or friends? After the questions came 5 check boxes: excellent, very good, good, poor, very poor. Now we as physicians were told that very good doesn't count. Your rating must be excellent. Indeed, my husband and I recently bought a new car and were asked to fill out a very similar survey about our car salesman and the dealership. The salesman told us that if we could not check "excellent" on the survey, then we should not fill it out and we should call him back and tell him why we couldn't check excellent. "Very Good" is not worth anything on these surveys. I recall that when we first had these patient survey questionnaires being handed out about 10 years ago, I gave the survey to one elderly lady whom I had taken care of for many years. I knew that she thought a lot of me as her doctor, so I told her to please fill out the survey and rate me very highly. She filled it out and handed it back to me as she was leaving without putting it in the envelope. I glanced at the ratings and realized that this sweet little lady who loved me as her doctor had  marked "Very Good" for everything. With this knowledge, I wondered how we could possibly increase our ratings. To add to my frustration about 5 years ago, our clinic decided to use only one of these questions as a representative and to use the percentage answers to that single question as the individual doctor's rating score. That question was "What are the chances that you would recommend this doctor to your friends and relatives?" A colleague of mine and I scored quite low on that question and we couldn't understand why? Our scores on the other questions were around 80% excellent, but this question was about 30% excellent. Why? Well both of us were planning to retire within a year or two and our patients knew this. In the other doctor's case, he had already began talking to his patients about what doctor they would choose to replace him. So the patients would be unlikely to answer that question in the positive. They knew we would not be around for their friends or relatives to see us as their doctor. I argued with my clinic that they should not use only this question as the true rating of a doctor, but got nowhere. Their quality consultants had told them this single question was the most likely to be a good measure of the quality of the doctor, and they were not going to change their mind.
     Now patients can log on to the Internet and find their doctor in one of several databases and enter a rating of that doctor. Sometimes these are again a numerical rating scale. But sometimes these entries include a narrative critique of the doctor. A negative critique of a doctor when entered is there to stay and the doctor has no way to counter that narrative. Patients can be dissatisfied with a doctor for many reasons that have nothing to do with the quality of that doctor's care. Perhaps the doctor thought the patient had a viral upper respiratory infection and refused to prescribe antibiotics because he felt they were not indicated even though the patient expected this prescription. The patient can enter a negative report based on this encounter and this rating is forever on the Internet. A doctor is a human being and the patient is a human being and hence there are going to be differences of opinion and there are going to be misunderstandings. But are narratives and ratings that are entered on an Internet survey without understanding the underlying controversies between these two individuals really reflective of this doctor's quality or care? I don't think so.
     The other day at the coffee clutch following my water aerobics class, one of the members of the class said, "A doctor almost killed my husband 4 days ago." She went on to explain that she had taken her husband who had a respiratory infection to see a doctor in the Urgent Care Center. That doctor examined him, didn't order an Xray and gave him some medications. They were told that the husband had a viral infection. The next day the man felt much worse and that evening they went to an emergency room. An Xray showed that he had pneumonia, and he was sick enough to be hospitalized for it. The wife felt that clearly that first doctor had made a huge diagnostic mistake. Clearly if he had pneumonia 36 hours later, he had pneumonia when he went to the Urgent Care Center and that doctor missed the diagnosis. How many of you would agree with this statement? Well, if you agree, you are medically wrong. Pneumonia can develop within 24 hours or less. Many cases of pneumonia start as viral colds or viral bronchitis which does not require hospitalization or maybe not even antibiotic pills. But some of these cases can move on to pneumonia and the individual gets much sicker. Then indeed hospitalization can be required, though sometimes pneumonia can be treated as an outpatient also. This doesn't mean that a misdiagnosis was made; it means that the natural progression of the disease has occurred and the person now needs further care.  The wife and the husband did exactly what was required. He became sicker or did not respond to the first treatment, so he needed to be reevaluated to see what that progression of illness was. But in addition, the lay person often, not understanding medicine, how illnesses present, and how illnesses progress, jumps to the conclusion that the doctor has made a huge mistake either in diagnosis or in treatment. The wife says she called the doctor at the Urgent Care Center and told him what had happened. She said, "The doctor said, "Oh yes, pneumonia can develop quite quickly." The wife said, "Humphs! Well, then they should have told me what to watch for and that he could get pneumonia from this illness."  This is an example of the unmeetable expectations that our society now has of the medical profession. I am sorry to report to society in general, that the doctor does not have a crystal ball. He can not predict what way an illness is going to go. He cannot possibly outline all the possibilities and enumerate them for a patient or his family. In this case the possible list of complications of a  simple viral upper respiratory infection presenting in an Urgent Care Center includes but is not limited to: conjunctivitis, tonsillitis, tonsillar abscess, ear infection, loss of hearing, vertigo, sinus infection, feverish convulsions, epiglotytis, bronchitis, lobar pneumonia, bilateral pneumonia, both viral and or caused by one of several bacteria, empyema, lung absecss, bacterial endocarditis, allergic reaction to antibiotics, shock, sepsis, and the list goes on. How could an urgent care physician possibly prepare a couple for all these possible eventualities? And think about this -- if you were the patient or the family member, if indeed a doctor did give you possible symptoms to look for for all of these eventualities, some just natural progressions of the disease, could you keep track of them all, could you watch for all of these symptoms in the patient, could you even deal with these possibilities? You would likely want the person hospitalized because you wouldn't be able to deal with all of these descriptions. So what is the answer? The answer is that you seek medical attention. If the first treatment doesn't work or the person gets worse, you go back to the doctor or you go to an emergency room, or you at least call your doctor. You don't immediately as a lay person jump to the conclusion that "That awful DOCTOR has made a mistake!"
     Recently I took my mother to see her primary care doctor, a young DO practicing in a small town in northern Illinois. My mother is 94 years old and is on some blood pressure pills and is blind from macular degeneration, and is also very hard of hearing. Most recently she had developed pain in her leg and in her back which to me, her internist daughter, seems to be a pinched nerve probably due to a herniated disc or spinal stenosis from severe arthritis. I took her to her primary doctor, the DO, and went into the exam room with her. This young doctor briefly greeted her, asked two questions about where her pain was, looked down at her leg and felt around the lower thigh where Mom had pointed to. She then turned to her computer and flipped through a screen or two and began asking Mom questions about depressions: "Are you feeling depressed? Do you feel sad when you wake up in the morning? Do you enjoy doing the things you used to enjoy doing? Do you find yourself crying frequently?" She was clicking things on her computer screen. I couldn't see the screen but I think she had gone into some screening questionnaire for depression. One of the performance measurements that I described in the first paragraph above is a screening for depression in all patients that the doctor sees, in order to make the diagnosis more appropriately and to start treatment. Now in this case, you have a 94 year old woman who has only seen this doctor for blood pressure control, who has never been depressed in her life, who is now sitting in a wheelchair in this office in acute back and leg pain and this doctor is screening for depression. She didn't even examine my mother's back, never got her out of the wheelchair. But someone somewhere in the clinic she worked for, or higher up in her medical society somewhere had convinced this young doctor that she needed to run this depression questionnaire on patients. She might have been trying to get her performance score up in this area. I finally spoke up, which I don't usually do, and said, "Mom is not depressed.She is 94 and she has never been depressed in her life.  She is in pain and she is trying to deal with it the best she can. She needs you to pay attention to the cause of the pain and not screen for depression. OK?"  The young DO clicked out of the screen about depression. This is an example of what happens when the government, when administrative and analytic bodies in medicine decide to emphasize performance measurements and thus enter into the relationship between a doctor and her patient. I am afraid that the office visit becomes even more unsatisfying for both the patient and the doctor. Now you might say that this doctor should have realized that this was not the time for a depression questionnaire and indeed that is true. But the pressures being placed on the doctor to accomplish more and more in less and less time in the office visit can skew the ability to decide what is the most important thing to accomplish during those 8 1/2 minutes. ----I believe that is the most recent measurement of time allotted for a routine medium intensity office visit.  Exactly 8 1/2 minutes. That time then allows another 5 minutes or so to document what has taken place, the history, what was examined and found, what tests were ordered, and the working diagnosis, and treatment.
     One quote from a primary care doctor, presented in the April Medical Economics Magazine sums up the major problem. Speaking to physicians, Nancy Falk, MD, internist from Washington, D.C., says "A negative online review can begin in your parking lot, swell up during a bad waiting-room experience, and end with a billing error. You could be left out of the equation altogether, yet the Web ensures that postings that cut like a knife remain long-associated with your practice. The crux of the issue is that physicians today don't have the time to develop personal relationships with patients, which allows small problems to fester and leaves patients feeling as though they have nowhere else to turn to air their complaints. So often, patients are angry because they didn't get what they want, and that's an open-ended question." 
     The issues and the pressures intruding themselves on the relationship between a patient and his doctor have truly reached a point where I think the system is truly broken. More and more performance measurements, more and more documentation, more and more pressure to meet society's expectations which are basically unmeetable, a litigious climate in the background and an ever widening and complex medical knowledge base makes me very glad I am now a retired physician. I now regard my only medical job is to serve as an advocate, liaison, and interpreter of this complex medical world for my friends and relatives. It may be in the future that every patient will need such an interpreter to even begin to navigate their medical care. What do you think? Are my complaints above well founded or am I just a curmudgeon on the issue?
     

Spontaneous Entertaining!

     My husband and I have been married almost 45 years and he still pulls some interesting social blunders in my view. We both enjoy entertaining people in our home so that was not the problem. But I like to plan in advance, make a menu, have a theme of what the gathering is about, and have time to prepare even a few days in advance. We met a young couple who are new neighbors in our area at a Holiday gathering, yes a few months ago. It turns out that her family originates from Moldova where my husband's family comes from. Apparently my husband and this wife agreed that she would like to see our photos from our visit to that  country and he would invite them over sometime to look at them. Various things had happened with my mother's health and our recent long trip so that it is now when we are getting around to ask them to come over. I mentioned something to my husband last Wednesday to see if they could come on the weekend. I didn't set up certain time periods or if this was for snacks, or a meal or what and if their kids would come too. He did nothing about this until this morning, Saturday morning at 9:15 AM.  He originally asked them to come sometime tomorrow, but then when they said they were going to a Brewers' game tomorrow, his last words were: "Or today if you can." The husband had to check with his wife who was gone from the home at the time of the phone call. But 10 minutes later he called back and said, "How about at noon?" My husband looked briefly at me and then said, "OK, that would be fine." That was about 2 1/2 hours away. And nothing was set up: was it for food, were the kids coming also? Lots of questions! None of these were a problem for my man!
     "Just drive to the store and get some pretzels and some lemonade. That's all you have to do,"  he said.
     Of course, he still had the planning folders for our next long trip all over the kitchen table, and the kitchen desk still contained  stacks of mail and all the documents from his recent tax preparation. Our cleaning ladies had just been here on Wednesday so the house was basically clean, but the beds needed to be made and the kitchen counters contained some dirty dishes and left over packaging etc, from the last 2 days of meal preparation. In short, the house needed some quick servicing. Both of us got busy picking up and tidying up, while I went over in my mind what I would need to get from the store. Generally you would not invite someone over at noon if there is not to be any food served. How about a quiche, some fruit, maybe some nuts and pretzels (pure snacks) and some cheese and crackers. I headed off to the grocery store. Thank you for modern grocery stores and delis.
     We have a small buffet counter built into our galleria (hallway) between the dining room and the kitchen. This allows me to put out some food. I wanted to have something that looked attractive, that included something that they could just snack on like the nuts and pretzels, and something more substantial in case they had not eaten any lunch. I wanted something that the kids would like also if they showed up. And I wanted it to be attractive. Here's what I came up with.
     I heated a tomato and basil quiche that was ready made, and two Philly steak and cheese cal zones. I cut them in bite sized pieces and arranged them on a plate, hot. These were the more substantial items. I cut up some apple wedges and placed them in a circle on a colorful plate with whole strawberries in the center. This was the healthy simple item.  I love a local brand of cheese called Carr Valley Creamery. I purchased my favorite cheese, a sheeps' milk called Marissa, and two other Carr Valley cheeses. I had some crackers to serve them with. I always cut the label off the cheese wrapper, tape a toothpick on the back and stick this label in the cheese in order to identify it. In case they just want snacks I filled a bowl with mixed unsalted nuts, and bought some small pretzels. Our local Sendiks grocery store has a wonderful raspberry mustard dip which is sweet and tangy and wonderful. I have a couple sizes of gold toned wire baskets. I put a napkin in the smaller one, placed the jar of mustard in the center and circled it with pretzels. Raspberry lemonade and cold apple cider for cold beverages and I made a French press pot of coffee and set it on the buffet along side a small server for milk and sugar. I used the apples and strawberries because I thought there might be kids coming. But I had another idea: that is to slice a cantaloupe and wrap prosciutto around each slice. I had this for lunch in Sorrento, Italy years ago and have never forgotten that taste combination. That's it. Here's a photo of what the counter looked like before we were ready to have something to eat. I think it met all of my specifications.

     This retired physician may be competing with Martha Stuart , but I am very impressed with myself that we were able to put this spread out in 2 1/2 hours. 

Mystery Photo 17: Central America trip. Panama City.

     We spent much of March traveling in Central America. We had never been there before and decided this area of the world deserved our attention. We chose 3 countries: Guatemala was "culture" -- the pure Mayan culture with its syncretic religion, wonderful and nicely restored ruins, the peoples'  traditional dress and many lovely handicrafts. Our second country, Costa Rica, does not have this degree of traditional culture. The people are of more mixed ancestry -- some Mayan true, but also Spanish, Creole, and also African American and Carib as well. None are as proud of their pure background as are the people of Guatemala. Therefore I would say that Costa Rica is "nature." There are beautiful places to visit there. You will hear more about it in future posts along with many photos of the birds I added to my life list there. Finally we visited Panama which is the location of my mystery photos. Surprise! The city pictured is Panama City. Therefore I would characterize Panama as "modern."
     Hit Read More to learn more about Panama and see some photos of this interesting Central American country.

Mystery Photo 17: A surprisingly modern city!

     Can you identify this mystery modern city? We just came back from a trip here. Both my husband and I were totally amazed at this lovely modern city on the water. We didn't expect this number of skyscrapers. One in particular is shown here for its unique nature.  Here I am just showing you some photos of its modern part. It also has both a colonial and an ancient part as well. Guess where this is?

     Let me see your guesses under comments. Answer in a few days along with other photos of other areas and characteristics of this surprise city.