Dr. Iliff’s 2012 Practice Newsletter/Rant

What’s New for 2012: It’s going to take an election in November before anyone has any idea what’s going to happen with ObamaCare. Insurance companies haven’t had the luxury of waiting until then-- they need a couple of years to change their contracts and computers. Therefore, like it or not, ObamaCare has become the de facto law of the land. If you read the Capital-Journal, Dr. Bill Roy has been telling you over and over that it won’t control costs, and he’s right. Nevertheless, we all have to adapt to its demands, and not all of them are bad. For instance: all preventive services recognized by the government must be provided with no copays or out-of-pocket expenses. Therefore, I got a notice that I can have a free screening colonoscopy despite the fact that my deductible is $5000. How cool is that! Other People’s Money gets to certify that my colon is free of disease! For 40 years I’ve been paying for health insurance without getting a dime of benefit (the curse of stoicism, otherwise known as eating right and exercising); finally, the payoff!

And for You, as Patients: An annual physical is now free! As some of you know, I’ve always maintained that an “annual physical” is a waste of money. Nevertheless, you can’t fight City Hall, and I’m not going to penalize you for my eccentric ideas about cost-saving. Therefore, we have been experimenting this year with an “Abbreviated Physical,” which will get you an annual visit without a copay. It will take a little more time in the office, but it won’t involve the two-stage visit of the Database Physical, where you meet with Jackie for an interview and bloodletting, then see me later. We’ll still do one of those every five years or so, just to make sure we’re caught up on everything, and new patients will have to start with a Database. Nevertheless, this will save you some money, and cost will be shifted to everybody else, which will be reflected in increased premiums (mine went up $60 per month), so maybe it won’t save you money after all, but-- oh, never mind.

Use It or Lose It: We’re approaching something like a fundamental law of the universe, documented scientifically. For years we’ve known that the brain is more “plastic” than we realized: not just a blob of fat, it changes, it morphs, in response to stimulation. New research shows that “gray matter”, the stuff we think through (not think with, but through-- we think with the soul, which, as Aquinas demonstrated, is not a physical body) expands and contracts as it is exercised. That’s right-- just like a muscle does. So all you aging crossword puzzlers, bridge players, and musicians: keep up the good work. Just don’t forget that your body benefits from the same thing. So keep walking, swimming, and gardening, too.

Do I Take New Patients? Every year I ask myself this question, and for a quarter-century the answer has always been Yes. The reason is that I don’t take Medicare, Medicaid, or TriCare, and so every year I lose patients to those transitions as well as moves out of town. This has been our busiest year ever, and at times the staff has started to feel the strain. If I had to start restricting the inflow, what I would do is take only referrals from existing patients. You already know the kind of character you’re dealing with, and you’re in a better position than the Yellow Pages or a newspaper ad to recommend people who would like what we have to offer: unlimited harassment, with a smile. So if, at some time in the future, a friend or colleague asks if you would recommend them, that’s why.

As for Straining the Staff: Some of you still aren’t getting the picture, but we’re not giving up on you. If I want to see you in 6 months, I’ll give you six months of medicine. That’s not too hard to understand, is it? So if you’re down to your last 10 pills, what do you do? This is a test:

[ ] a. Wait until the bottle is empty, then call the office and ask what the hell is going on? Why aren’t those pills waiting for me at the pharmacy?
[ ] b. Call for an appointment, get your labs done, and see me without wasting the nurse’s time calling in a ten-day supply of medicine.

Note that option (a) involves two phone calls for the nurse, instead of one. It also involves an extra refill for the pharmacist, and an extra trip to the drug store for you. And you’ll be paying more per pill than with a 90 day prescription. Does that seem smart, in the age of Ecology? And will you then be angry when you can’t get through on the phone because some other procrastinator is tying up the lines? Other offices simply refuse to fill your medicine until you make an appointment. It seems to me as though that adds doctor malpractice to patient absentmindedness. There has to be a better way. There is. Your choice.

Watch Out for That Teeter-Totter! Remember that staple of our childhood, fellow Boomers? I’ve seen two in the past six years: one was in Italy, the other in New Zealand. While our kids grow fatter exercising their thumbs, a vigorous recess is becoming an endangered species. Climbing is dangerous; a child might fall. Running is dangerous; a child might trip. Swings are still to be found, though much lower than I remember. And yet some things I did as a kid really should be forbidden. I used to sit on the trunk of our ‘57 Chevy convertible as my dad rode around Prairie Village with the top down. The hardest thing to find these days is an example of Aristotle’s Golden Mean. Moderation in all things is no vice.

Whooping Cough Makes a Comeback: In 2009, the last year we have confirmed case counts, there were 16,858 cases of whooping cough reported in America. A few of these were in children whose parents avoid immunization, (wrongly) fearing that the risks of autism or whatever outweigh the risks of polio, diphtheria, tetanus, pneumonia, meningitis, whooping cough, measles, mumps, or rubella. (They’re right about chicken pox). However, most of the cases are in adults whose immunity has worn off. For the last few years we have been using a “tetanus” vaccine which has whooping cough back in the mix (Tdap). I’m trying to catch adults for this vaccine as you come in for physicals, but you can get the shot without an appointment just by asking.

How Long Will I Be at the Office? This is an era of busyness and multitasking, although evidence indicates that multitaskers often don’t do anything very well. But never mind. When you are scheduled for an appointment, you need to plan realistically. Let’s start with the basics. At our office, we ask you to show up on time for your appointment, not 15 minutes early. That means that your appointment time is NOT the time I will walk into the room. You’ll meet with the nurse first, and that is going to take 10 to 20 minutes, depending upon the number of issues we are addressing. Add to that the time that I’m running behind, because rare is the day that no patient arrives late, or no visits take longer than they are budgeted. Finally, add the time I spend with you. So how much should you plan for? A good estimate is an hour for a routine appointment, 1½ hours for a database physical, and 2 hours for a database and a treadmill. We usually do better than that, but remember-- I’m not a dentist or an optometrist. I let people talk to me, they’ve got the whole body for subject matter, and I can’t control the breadth and length of those conversations. Anyway, try to be realistic about plugging these times into your smartphone, and we’ll all experience less frustration.

Advice on Parenting, based on 37 years of experience and 5 children, the last of whom is just about through college:
I’m no cheerleader for the “good old days.” I like central air-conditioning, reliable automobiles, and TIVO as much as anybody. Still, in every generation we forget some things we ought to remember; maybe the explosion of attention deficit disorder and autism are a result of something in this list-- it’s not the immunization schedule, which is one of the really good things in modern life. You don’t have to give your kids separate bedrooms, because living with siblings promotes the ability to tune out distractions. You don’t have to respond every time your kid cries, because they may be slow to learn “self-regulation”, meaning the ability to work through their own problems rather than relying on other people; that which doesn‘t kill you makes you stronger. You don’t have to be obsessive about dirt and hand sanitizers, because they may do more harm than good; kids need to develop their immune systems, and that’s the function of germs. You’ve got to restrict video games and cell phone use to an hour a day, lest their brains turn to oatmeal. You’ve got to teach them that other adults, including neighborhood parents and especially teachers, should be respected and obeyed, except for dirty old men offering candy and rides in their car. Finally, you’ve got to know the difference between “tiger moms” and “helicopter parents.” Tiger moms have high expectations for performance, but believe in progressive emancipation and responsibility-- once their kids go off to college, they’re on their own. Helicopter parents hover and overprotect, and often side with their children against peers and adults without evidence that it is warranted. My parents spent a lot of time ignoring me. It was good.

Am I Obese? I heard a remarkable story on NPR while driving to the office a couple of months ago. They were interviewing a 300 pound woman, who was blaming her doctor for being so fat. Her reasoning? She said he never told her she was obese. Then the interviewer grilled the poor physician, who was embarrassed to find that he could not document the fact that he had ever told her specifically that she needed to lose weight. When I brought this up at the dinner table as a ridiculous example of blame-shifting in the Nanny State, my wife grilled me on the same subject. OK-- I admit it. Maybe I haven’t ever told you that you were obese. Maybe it’s because I’m a nice guy, and maybe it’s because I weigh you every visit, and at least once a year give you a sheet with your body fat percentage, which, if you read it, will tell you that you are too fat and you need to lose weight. If that isn’t good enough, please tell me, and I will tell you about your obesity personally and directly, looking you straight in the eye. Geeesh!

And Speaking of the Nanny State: The anti-libertarian collectivist committee-lovers who rise to the top of every professional organization are taking over medicine-- and they’re devising ways to put the responsibility for your health on your doctor. For instance, if my nurse sets you up with a CT scan, they want me to assure that you showed up for the test. I respectfully decline the invitation. I respect all of my patients too much to treat them like children. If you don’t want to follow my recommendations, that’s OK with me, and I’m not going to harass you later. The word “doctor” means “teacher”, not “mommy”. Who knows? You may be right-- the test might be a waste of time and money.

Jack LaLanne, RIP “Dying is easy,” the fitness guru of my childhood once said. “Living is a pain in the butt.” This year, at age 96, the old man finally took the easy road that awaits all of us, still fit as a fiddle. He died of pneumonia, having been sick for a week but refusing to see a doctor. He did his usual two hour workout the day before he died. What a way to go!

Closing the Barn Door After the Horse Has Fled: Exercise wise, there is no such thing. There is no age, and no disease, which does not benefit from daily activity. If you can’t run or walk, bike. If you can’t bike, swim. If you can’t swim, crawl. If you can’t crawl, roll. You don’t have to be a helpless, whiney, dependent old crank. What offspring wants to be around someone like that? And if you’re going to retire, find some way to earn your social security check. Being useless is a good way to die young.

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