The Placebo Effect

In his private and personal life, Dr Dork is...a dork. A dweeb, a dolt, a dummkopf.

Yet in his interactions with his patients, he exudes confidence, charm and reassurance.

This is a conscious decision. This is an aspect of the mask.

This is, in essence, utilizing the Placebo Effect to help his patients.

Dr Dork does not think he is being misleading or deceptive. He gives bad news truthfully, but with some dorky aplomb, he hopes. He ensures his patients are aware of potential pitfalls of treatment options. If he thinks a particular medication might help a particular patient, for example, he uses words such as "could" and "might" as opposed to "will". He gives probability outcomes where there is good evidence for such.

But Dr Dork knows that his subtle, subvocal clues, his body's unspoken language, his demeanour and so forth...have themselves a potentially significant contribution to the healing process. Especially in regards to symptoms of pain, depression, nausea and other scenarios where there can sometimes be a large psychological element contributing.

As strange as it may feel in the hands of a Dork...like any tool at his disposal to help his patients, it is sharpened, oiled, and used to best effect.

The Mercy Seat

Dr Dork, as any doctor, has a fundamental difficulty with the concept of 'capital punishment'.
















Is Dr Dork ' a softie '.

Maybe.



The Mercy Seat - Lyrics

Dangers of Dial-A-Diagnosis

Dr Dork was saddened to hear of this tale of unnecessary death in Queensland.

There have been pushes in various Australian states for such "telephone triage" services. At the very best, they are staffed by nurses. Often, by persons with little clinical background in any discipline.

This is very, very dangerous territory.

Any doctor or nurse of reasonable experience knows well that medicine is art, as well as science. That clinical judgement and acumen are acquired through experience. That, sometimes, one can tell that something is just not right at a glance, without being able to put our finger on any objective criterion on which to pinpoint our suspicion...that something is subtly awry.





Dr Dork feels uncomfortable providing telephone advice to a patient he has not seen, and cannot see. He feels this is Bad Medicine.


These "health hotlines" are about bureaucratic cost cutting. A layer of insulation to shield ambulance services and emergency departments. As Dr Crippen and others have discussed in regards to NHS Direct in the UK.


Dr Dork does not know the specifics of what actually occurred in the Queensland case. This is pending on autopsy results.

Dr Dork knows well, however, that an ill wind bodes no good.

Absent poetry

Grand Rounds - 2006 Highlights

Nick Genes, the founder of Grand Rounds, has engendered a summary of the most interesting posts of the year.

Well worth perusing.

Two Tiers (Part the Second of n)

"In a country well governed poverty is something to be ashamed of. In a country badly governed wealth is something to be ashamed of."

Confucius

"And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me."

Matthew 25:40



"The degree of civilization in a society can be judged by entering its prisons."

Feodor Dostoyevsky


"The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped."

Hubert Humphrey

Dr Dork notes a quintessential contrast in what he perceives of the US and UK systems, and of those exponents and critics of their approaches to healthcare.

The NHS is disparaged as “socialised medicine”, as if that is a failing unto itself. Of course, private companies driven by shareholder profits would not exactly be more compassionate, one thinks, in attempting to distribute a limited resource unable to keep pace with demand.

The US provides well, but at great direct financial cost to its users. Dr Crippen, of interest, pointed out the frighteningly high correlation between medical costs and personal bankruptcies in the US. Yet, as far as Dr Dork can infer from his US colleagues, the system is underpinned by a “socialist” Medicaid network.

Australia is a mixture of these two approaches. Here in Oz, we have traditionally operated primarily as a public healthcare system for the most part. In recent years, there has also been increasing growth in a separate private healthcare system. Rather than funding by largely employer sponsored insurance, as in the US, ‘private’ healthcare is funded generally by paying insurance premiums oneself. The exception to this rule is occupational health problems, wherein the cost of treatment (whether via the public or private system) is funded by the employers insurance.

This system is inherently possessed of two tiers of care level – in many areas, but not all. The public system struggles to meet demand in many areas. Emergency departments get overcrowded. Waiting lists for elective surgery are sometimes ridiculously long, and numbers are politically obfuscated. Only in the private system can you choose your doctor, choose your hospital, and not spend several months on firstly a waiting to be seen list, then a waiting to be treated list.

However, for acute, devastating injuries and illnesses, public hospitals are, arguably, much better equipped. Larger and better staffed ICUs, for example. Medium level staff always onsite.

One important annotation to the ‘private’ system is that health insurers in Oz are not-for-profit. There is no CEO earning $30 million in bonuses. There are no shareholders demanding cuts in coverage to boost their stock portfolio.

As mentioned in his previous post, Dr Dork is cogitating out loud on the two-tiered system in which he operates. This is further groundwork.

There is more to the story than this précis. Arguments for and against each approach. Dr Dork would love to hear from others experienced in multiple healthcare systems, as health provider or patient.

To echo the sentiments of Dr Crippen, in large part, Dr Dork is open in his bias: he believes healthcare is a right, and not a privilege, in any civilised society. Tax-based support of the public system in Oz is positively biased to place costs moreso on the wealthy who do not self-insure than the poor (the Medicare Levy).

It becomes, one could say, essentially an argument of efficiency and management, of finite resources confronted with ballooning demand, as our knowledge of the health sciences grows, and our populations age demographically, and live longer lives. Neither approach seems sustainable in the long term.

More on this at a later date. Your opinion is welcomed.

Merry Christmas

Dr Dork likes this picture so much, he has decided to share it again.

Dr Dork would also like to apologise for inflicting his musical tastes upon his audience.

Merry Christmas.

Peace, and goodwill, to all.

Annual Accolades

As far as Dr Dork is aware, there are two ongoing "awards" for health bloggers decided each year by internet voting.

The venerable and highly respected Orac over at Respectful Insolence was voted the best Medical/Health Issues Blog in the Weblog awards.


Orac is particularly known for examining the evidence basis of dubious medical/health claims, and for often drawing the ire of the rabidly vocal anti-vax minority.


The Medical Weblog awards run via Medgadget are currently accepting nominations and voting starts early in the new year.




Voting is limited to one vote per IP address.




Dr Dork is pleasantly surprised to have been nominated for the Literary Medical Weblog category, and extends his thanks to the nominator, wherever you are!

Dr Dork considers himself seriously outclassed but it is nice to appear on the nomination list, especially having only actively blogged for a third of the year.

Well worth perusing the various nominees for both of the above awards in all categories - a great diversity of health blogging is but a click away.

As Shakespeare Said*

Dr Dork is irate.





Livid, even.




This case from the UK is one of the most ridiculous examples of tort law he has ever seen.

The anaesthetist in question is penalised for providing the advice that quitting smoking would prolong this persons lifespan. This is true. This is an attempt to act in the patients best interest. This is trying to do good, when it is easier to say nothing - to the belligerent patient in comfortable denial, regarding the ramifications of their habits upon their health.

Perhaps if the baby in question were premature, it could sue its mother for smoking throughout the pregnancy?




*"The first thing we must do, is kill all the lawyers". Dick the Butcher; King Henry VI, Shakespeare.

Despite popular interpretation as the first derogatory lawyer joke, in the context of Henry VI it is rather complimentary. Perhaps.

Absent poetry

It's Christmas Grand Rounds, Charlie Brown!

Mother Jones from the always interesting Nurse Ratched’s Place is hosting this weeks Grand Rounds - with a Festive theme.

An varied collection of yuletide related ramblings from a menagerie of medical bloggers this week.

Enjoy.

Dr Dorks Holiday Survival Guide

The christmas / holiday season has, to Dr Dorks mind, been so corrupted by commercial interests that any semblance of the true altruism of the season appears lost.

It is also a time of year that is especially hard for many. It is often thought that rates of suicide, for example, peak. However, this is in actuality not the case.

Why ?

There has been some suggestion that the temporary boosting of services at such times is perhaps a reason, at least in part. This makes some sense to Dr Dork.

People do reach out more to others, at this time of year. Which is a good thing. However, come the new year, these good intentions may be often forgotten. Which is sad.

Better transient compassion than none, you might say.

Dr Dork has been of late considering whether he should gift his nom de plume a first name. 'Ebeneezer' had been suggested by Cathy following Dr Dorks reluctant and rather dour response to the "Christmas Meme".

Dr Dork was not being facetious in his responses. Added to the fact that he is wrangling the black dog at present, he understands why many loathe the 'festive season'. For Northern Hemisphere readers, this is also the time when Seasonal Affective Disorder is rampant.

Dr Dork has a simple prescription for making it through this period - watch this movie. And go easy on the eggnog.

The 2006 Medical Weblog Awards

Dr Dork understands there has been a tradition of Medical Weblog awards organised via Medgadget for the last few years.

The nomination process is apparently now open and actual voting begins early next year.

Dr Dork already has his favourites for a few categories and is willing to consider any informal email bets, usually involving some form of public humiliation of the 'loser'.

Or is this just an Oz thing ?

Here are the winners from 2005

Infected with a Christmas Meme

Dr Dork has been tagged with a Christmas meme by Rob over at Musings of a Distractible Mind.

OK then:

1. Hot Chocolate or Egg Nog?

Eggnog. No-one drinks hot chocolate when it's 40 degrees Celcius.

2. Does Santa wrap presents or just sit them under the tree?

Santa places the coal directly into the stockings.

3. Colored lights on tree/house or white?

Coloured on the tree, when I have one. There are motion activated spotlights on the outside to deter small children. Just like Halloween.

4. Do you hang mistletoe?

Nope. Not sure if it grows in Oz even.

5. When do you put your decorations up?

Last-minute if at all.

6. What is your favorite holiday dish?

Meringues.

7. Favorite Holiday memory?

When a toddler, noticing my father jingling some bells behind his back whilst pointing at "Santa flying over the roof'. Dr Dork is a born cynic.

8. When and how did you learn the truth about Santa?

See 7.

9. Do you open a gift on Christmas Eve?

No.

10. How do you decorate your Christmas Tree?

Haphazardly, if at all.

11. Snow! Love it or Dread it?

Love it, but it's not too common in an Australian summer.

12. Can you ice skate?

Very badly but technically yes. I broke my coccyx in an ice-skating mishap as a teenager.

13. Do you remember your favorite gift?

Yes.

14. What’s the most important thing?

Reinforcing the need for compassion, for helping/giving to others. And meringues.

15. What is your favorite Holiday Dessert?

See 6. And 14.

16. What is your favorite holiday tradition?

The backyard post-lunch cricket match with the extended family that has been continuing for decades.

17. What tops your tree?

Is not to be repeated in a PG rated blog.

18. Which do you prefer giving or receiving?

Giving, of course.

19. What is your favorite Christmas Song?

Little Drummer Boy, Charley Pride rendition.

20. Candy canes, Yuck or Yum?

OK....but I tend to re-use them each year. So they get a little stale.

Dr Dork understands that he is now meant to 'tag' several others who may wish to participate. So will tag :
A fellow Antipodean Barbados Butterfly
A fellow anachronism #1 Dinosaur
A fellow traveller Shiny Happy Person
A fellow curmudgeon Dr John Crippen
And DB, for the stimulating debate that has been evolving in his blog on the topic of
"personal responsiblity". Even though our opinions appear irreconcilable.

PS- please don't feel obligated if tagged. Dr Dork is aware that this is almost encroaching on chain mail territory. You will not develop a suppurating pustulence throughout your nether regions by ignoring the meme.

Well, probably not.

Canine Obedience Training

Dr Dork has spoken of the Black Dog in a previous post.

Dr Dork has been acquainted with the Dog for more years than he would care to remember.

This year, the Dog has been rather troublesome.

Rather troublesome indeed.

The reacquaintance, at close range, with this rabid rotty has had more than a little to do with the absence of the Dork in recent months.

The Dog isn’t very nice company. Shiny Happy Person describes it more eloquently than Dr Dork could.

It’s been years since the Dog misbehaved like this..

No tugging on the leash.

No chewing the couch.

No howling at the moon.

No mauling Dr Dork.

Though the Dog is a faithful companion, in his way, and has his own lessons to teach, he is not welcome company.

Breathe. Keep Breathing.
Don't lose your nerve.
Radiohead - Exit Music

Grand Rounds

Grand Rounds are now up,
at Anxiety, Addiction and Depression Treatments.

Dr Dork recommends sauntering on over.

We are what we eat

There has been much brouhaha in Oz and in the US in recent weeks regarding attempts to restrict trans fats.

This gives a nice précis of the problem.

The AMA has been calling recently for either a ban on their use as a surreptitious additive (they currently sneak through a food labelling loophole, it seems), or at the very least for labelling requirements…so that people are at the least aware of the trans-fat content.

In some parts of Europe, stringent restrictions have been in place for many years.

Dr Wes, a cardiologist in Illinois has blogged recently on the topic following a ban on trans fats being enacted in New York, and is one of many voices noting that substitution with saturated fats will often occur, which isn’t really an improvement.

Dr Dork is a bit ambivalent about banning such things outright. He thinks the biggest issue at stake is the lack of disclosure – the situation whereby manufacturers have not had to disclose often inordinate levels of trans-fats until now.

As a doctor, Dr Dork sometimes thinks it would be nice if the ground opened up and swallowed Ronald and cohorts.

Ischaemic heart disease is our biggest killer, after all.

At the very least, we deserve to know what we are eating.

Take the quiz on dietary fats from the ABC Health Matters site.

Responsibility, Choice and Compliance.

Dr Dork has been following with interest some posting earlier in the week by DB over at medrants, here and here...and here. More recently, #1 Dinosaur has thrown in his two cents with a thoughtful post on the topic.

Some interesting discourse has ensued in the comments section of DB's postings.

Essentially this is a discussion on the concept of a "reward" system for demonstrating personal responsibility in healthcare. The debate was sparked by this story.

As far as Dr Dork can tell, there appears to be considerable support in the US for such an approach in terms of health economics.

"Cost effective distribution of finite resources"
"Helping those who help themselves"

And so forth.

Dr Dork finds such a proposal....disturbing. This is not a question of economic principles.

If we reward only those able to comply with recommended treatment and lifestyle regimens, we are in effect punishing those unwilling or unable to comply.

As Dr Dork commented on the original debate on DB's medrants:

"In otherwords…punish those who do not, or are not able to, comply with recommended medical treatment ?

What of the doctor or business executive who develops a stress related cardiovascular problem and refuses to reduce their working hours ? Should they be refused treatment ? What if someone is non-compliant because they are unable to afford the medication ? What of the impoverished who are only able to afford junk food to eat rather than a broad healthy diet ?

In terms of personal responsibility, what if you cause a car accident(eg from fatigue, inattention) and suffer serious injuries - should your insurance be entitled to refuse you treatment?

Where do you draw the line ?

By this line of reasoning, are the homeless and poor in dire straits purely due to laziness ??

Are not mental health disorders, including alcohol and drug addictions, by their very nature characterised by poor insight and hence difficulties with compliance ?

Wolves may cull the weak from the pack…but we are human beings."

Such an approach raises profound philosophical, political and moral questions. It also reeks of countertransference towards "difficult patients".

This was brought to mind by one of Dr Dorks recent patients, Stan. Though seen by Dr Dork for another matter, Stan has been plagued by severe hypertension for years.

Stan is in his late 50s. He works a physical job. Long hours. Work is a bit sporadic, and Stan walks a financial tightrope. He takes several medications, for his blood pressure amongst other things. Some of these are not cheap.

Stan earns just above the low-income pharmaceutical concession threshold. Not by much. With all his health problems...he could probably go on disability if he wanted to. This would greatly lower his medical costs, and he would probably be fiscally better off. His medical costs are, almost entirely, his medication costs.

Stan is bulk-billed by his GP and specialists all. He is not charged anything out of pocket to see Dr Dork.

This week, Stan was waiting for a new job to start. He had to choose between paying his mortgage, and buying his blood pressure medications.

He chose the former.

Whilst not as astronomical as before treatment began, Stan's blood pressure was again high. Quite high, really. Not good. He already has a dodgy ticker.

Should Stan be refused followup and treatment from his cardiologist as he is a 'noncompliant' patient ?

Dr Dork doesn't think so.

Vote Flea

For Dr Dork, Dr Flea is a favourite regular read.

Flea is a US paediatrician with an entertaining, sagacious style of writing, who is clearly driven first and foremost by the needs of his diminutive patients.

Flea has been nominated as a finalist in the 2006 Weblog awards in the Medical/Health category.

Dr Dork is wearing his shortest skirt and waving his pompoms exuberantly.



Sorry about the mental image.


Update: Dr Dork acknowledges that there are many other superlative bloggers in the same category, and intends no disrespect...but Dr Dork definitely has a soft spot for the Flea. Looks like the venerable quackbuster and woo-whomper Orac is lapping the field though.

Two Tiers (Part the First)

In considering the state of the Australian health system, it is probably useful to be able to compare it to those of other countries.

Dr Dork, however, has firsthand experience of only a few different Australian states, and a relatively brief period of working in the UK last century.

Australia, in theory, has a comprehensive public healthcare system. Dr Dork believes this is important. As Dr Crippen puts succinctly in regards to the ideological goal of the NHS in Britain:

“the concept of a decent standard of health care for all, independent of means.”

Dr Dork comes from a similar perspective. He believes access to quality, timely, comprehensive healthcare is a fundamental right of all Australian citizens. Like the right to speak freely, to dress as one chooses (within reason), to hold a protest march, to worship one’s chosen deity, to vote as one pleases to.

Not a privilege for those who can afford it. We’re not talking about caviar. Life, and death, are often at stake.

As far as Dr Dork can tell, the UK and Canada, as other vassals of the Commonwealth, also aim towards the provision of universal healthcare. With limited success, at times. To say the least.

No system attempting to manage such a vast, unpredictable yawning abyss of expenditure can be perfect. Where much of the disdain is directed, it seems, is the gross inefficiency of current systems. The administrative bungling of the NHS and Oz’s public hospitals. The obscene corporate profits of the private US insurers.

Australia has been, at the Federal level, under the sway of the conservative, right-wing Liberal party for a decade. For US readers, we find the name ironic as well. At the State level however, the Labor party runs the show. They are relatively left-wing, and historically Labor draws its power from the unions, the Libs from business and corporate interests. There are also the Greens and the Democrats, but neither has come close to holding the balance of power.

So every single time there is another health crisis - and various aspects of the system are often overloaded, some constantly - the same dance occurs. The States blame the Federal government. The Federal blames the States. Nothing gets done. The media moves on to dead donkeys.

This is not a topic that is lightly broached. Dr Dork is very interested in hearing the perspectives of those who have experienced multiple disparate healthcare systems, as doctor, nurse, allied health staff and, especially, as patient.

Dr Dork is just laying some groundwork today.



To be continued.

The Mask

Dr Dork is not a psychiatrist.

However, one skill he recalls well from his time as a psychiatry registrar is that of the mask. The façade.

This is a necessary thing, at times, in all of medicine. Particularly psychiatry.

A fundamental ethos of medical practice is the necessity to maintain an emotional distance from ones patients. The principal reason is to enable objective judgements to be made, without emotional bias. This protects patients.

Doctors in Oz are discouraged from treating family or close friends, for example. Our emotional attachments result in us usually either undertreating or overtreating. Both of which can be harmful.

Primum non nocere, after all.

A doctor allowing their emotional reaction to a patient to compromise their decision making is perhaps an example of countertransference. A good doctor provides the optimal care to each and every patient, be they saint or sociopath.

But doctors are subject to emotional reactions just like everyone else. Some of us get very desensitised, unfortunately, as a protective defence.

The key, at least to Dr Dorks mind, is not allowing our emotional reactions to affect our decision making. And, obviously, to not express our emotional reactions. Whatever they may be.

To maintain the facade. Protecting the doctor, perhaps, but principally protecting the patient.

Yet we still feel. We feel the lonely, lingering, untimely death that we cannot prevent. We flinch internally at the barrage of expletives. We seethe inside at the dozen old fracture lines on the malnourished childs Xray. Our pulse skips a beat at your drunken threat to our family.

We all learn to wear a mask.

Sometimes it’s hard to take it off.

Grand Rounds

Grand Rounds
are now up at
The Antidote.

My, how this phenomenon is growing. Exponentially, it almost seems.

Dr Dork will need to pack a cut lunch and a thermos of tea to get through all these...but nonetheless anticipates reacquaintance and new discoveries both.

Happy reading.

Notifylist given notice

Dr Dorks posting regimen has always been rather erratic.

Hence the decision to recommend his readers put an email address into the NotifyList thingamajig.

To use the technical parlance.

Unfortunately, notifylist continues to…well…not notify people on the list.

This was a problem prior to Dr Dorks sojourn and is rather irksome.

Thus the decision to terminate NotifyList.

All email addresses registered with the notifylist function have been sold to the Russian spamming mafia, for a tidy sum.

Just kidding. All have been destroyed.

Dr Dork has been noticing many seem to be using RSS and similar notification systems. Seems like a good idea. Any recommendations?

Bearing in mind that Dr Dork is not especially au fait with all these electrickery doohickies and whatnot.

Dr Dork would like to mention the cricket, but is averse to being flamed by his erudite British colleagues. So he won’t.

Back from beyond the back of beyond

Dr Dork is pleased to confirm that the rumours of his demise are greatly exaggerated.

Each and every expression of concern is met with gratitude.

Dr Dork also notes that his unofficial hiatus far exceeded his official hiatus. Typically dorkish behaviour. Or perhaps doltish.

Dr Dork has been recently acclimatizing to the changes in the health blogosphere during his 7 month absence.

The cockles of his heart have been warmed by sentiments sweet, and by virtue of not being forgotten…despite his absence exceeding his presence.

Dr Dork is pleased to see many of his favourites still kicking against the...well, you know what.

Saddened to note the absence of some eminent colleagues.

Enamoured with the many new voices.

Time to update the blogroll.

Let us, then, be up and doing,
With a heart for any fate;
Still achieving, still pursuing,
Learn to labor and to wait.

A Psalm of Life

Henry Wadsworth Longfellow

Absent poetry