Today in MedMarg: It's depressing; Ill art, Cash, and Lemon Pudding.

Daniel Carlat, psychiatrist, has one of his quietly subversive NYTimes Sunday Magazine articles again. Remember Dr. Drug Rep? He made shilling for a drug company sound exactly like what it is: shilling for a drug company. What was most amusing to me about that article was confronting drug reps the next day about it. The most amusing thing about that was how many had no idea hucksterism was covered in great detail in the Newspaper of Record. I mean, the medical blogosphere lit up like a Christmas tree exactly five seconds after the Times hit my stoop with posts: Carlat as villian, Carlat as hero, Carlat as clueless. It took a few weeks for the Effexor rep to have an officially well-crafted, Lancome-covered, Anne Klein-clad response. As I recall, she delivered it with a fruit tray, which was difficult to eat as I was laughing so hard. In the end, as always when there is food involved, I persevered.

Today he writes a moving piece, I think, about how he's gotten to know some of his patients. Turns out in pyschiatry that there is some benefit to knowing what makes some of your patients tick, vs. just knowing what pills will make them better. Seriously, hardly seems revelatory stuff, particularly if you've been listening to your patients (while going broke and out of business) in primary care as you sort out why their blood sugars are out of control (gave pills to out of work brother who has worse diabetes); why blood pressure is 180/102 (the medication you prescribed gave patient embarrassing diarrhea); and why the patient is pacing in your exam room sobbing (husband just lost job and health insurance).

I blame insurance companies. I like to vilify and insurers are easy targets. As Carlat says today in Mind over Meds:

Insurance companies typically encourage short medication visits by paying nearly as much for a 20-minute medication visit as for 50 minutes of therapy. And patients themselves vote with their feet by frequently choosing to see psychopharmacologists rather than therapists.

Hear that? You can see three patients in one hour and make more than you would seeing one patient, done right. You do the math, and while you're blaming the doctor for being greedy, remember that you have to fund your staff's 401K this month; make that vexing freakish malpractice payment, plus pay all your office bills; work towards paying off your $200,000 in student loans; and put a little away so that your son or daughter might be able to go to college someday. You'd see three patients, too.

But patients bear some blame, too. Time and time again I listen to stories of overloaded schedules, ailing parents, busy children, ridiculous bosses, and crushing workloads from patients who are so agitated and tense that I have to crane my neck upwards as they are on the ceiling panicking, or who are so overwhelmed that I need a spatula to scrape them off the floor plus a towel to blot the tears. I suggest therapy, some help in sorting through this plate of existential spaghetti. What got you into this mess? How can you avoid it next time? To whom can you say "no"? Why do you assume the blame for this, that, and the other thing? Patients look at me, exasperated. They want a pill. Hell, I want a pill too! To go to therapy, carve out time to get there and get home, to possibly open Pandora's scary box, and to find THE MONEY (Ah-ha! Insurance again.) for a therapist is as possible as building a rocket ship out of strawberries. But so often it's exactly what the patient needs. But the patient leaves with a prescription for Celexa.

Switching gears, I did a blog post for my day job recently entitled "Illness as Art". Spurred on once again by the NYTimes, which called my attention to a series of photographs by a photographer with lymphoma, I pulled together a couple other nuggets which had been rattling around in my brain (including the moving photographs I'd covered earlier in MedMarg of an Afghan boy with tetanus) and wrote a post for the studs at OSU. I begged for comments, links, etc. Got nothing. Ah, social media. Anyhoo, read the post and send me your thoughts, comments, links, etc. Paaaaaaleeeeeaaasse.

Illness as Art

I've been perusing the interweb about alternatives business models to the traditional fee-for-service, insurance-driven primary care providers. Not that I'm thinking of going back into the real world, but I do think about the real world, like all the time, mostly because pretty much every day of the week I hear from former patients who struggle with the procurement of medical services in these United States. The thought, frankly, of fighting again with an insurance company (Damn you, UHC!) for $12.52 makes my hair catch fire. I like being paid for holidays and having time for lunch. I read this oldie but goodie from Family Practice Management,

Breaking Even on Four Visits Per Day

So I started asking the providers at the day job about cash-only practices. Do they know anybody who has one? Everybody claims to have heard of one or more mysterious physicians around town who have started a cash practice and are now driving Jaguars and living in a diamond-encrusted mansion. Nobody could supply a name, though. I can't recall a patient ever telling me they went to a cash practice. I looked in the yellow pages and didn't find any cash-only practices. Why, if this sounds so good and only takes what, like $10-15K to set up, isn't everybody doing it? Ideas?

Last, but not least, I am in receipt of a huge box of Meyer Lemons from California. Let me tell you, opening that box was finding heaven under duct tape and cardboard. Head on over to Three Squares for a protein-filled, somewhat low-fat lemony piece of pudding cake with a little bit of heaven baked right in:

Pass U By Saves the Day. Again. Lemony Goodness.

Okay, off to life. Pancakes are made, but laundry calls and darn it all, we haven't been to the grocery store yet. Good week, good health to all,

Iced