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Sunday, July 25, 2010

An apology

One of the best parts of reading blogs is you are getting honesty. One of the worst parts of reading a blog is you are getting honesty.

The thing about honesty is it allows us to see things as they truly are and not so much how the clique or political world wants us to see them. And, unfortunately, the worst part about honesty is it can hurt.

One of my biggest fears when I started blogging was that I'd get a bunch of comments from people telling me I was an idiot for my opinions. For no other reason than no one with an opinion is an idiot.

On one regional political community I did get quite a few such comments, and I learned it was easier to ignore them than to respond. Yet when I started my blogs, I feared the worst.

Ironically, I have hardly ever received a harsh comment. In fact, I have another blog I write about politics, and I have never had a harsh comment on that site either. So, for the most part, I've been very fortunate.

By harsh comment I don't mean comments where people disagree with me. That I can handle. As in the real world, we know that no two people have the same opinion on anything. While my wife and I are both of the same political affiliation, and vote for basically the same type of people, we can get into some heated discussion about something we both have basically the same opinion. That's just life. It's what makes life fun and even interesting.

By harsh comment I mean those that say, "You're an idiot and a liar."

Yet after nearly three years of blogging, I've learned that evil comments are the least of my concerns. Even greater is myself -- the blogger. As a blogger, I am the sole writer, editor and publisher -- not good. A blog is about writing what's on your mind that you think others might want to learn about or at least read. Yet like any other person, a writers mood often comes across in his writing.

Newspapers and magazines and most websites have separate people writing, editing and publishing, and the reason is to make sure there is a good checks and balance system in place to prevent harmful and wrong material from going to print. As a writer, it's not easy to be your own editor and publisher. It's a chore. It's a lot of work. It's hard. It's a pain.

Do you see what I'm getting at? As a respiratory therapist, there are days when it's so slow at work I have time to write productive posts. Yet, on the rare occasion when it's ridiculously busy,
and I'm running around ragged because our doctors order breathing treatments that aren't needed on every patient, well, of course you know what's going to be on my mind. This causes fatigue, or what we like to refer to as burnout.

So this must have been the mood I was in when I wrote, "A World of Bronchodilator Lies!" The author in me wrote this based on what was on my mind that day, and somehow the editor and the publisher in me didn't nix it. It's the truth, it's how I really felt, yet perhaps the better part of valor would have been to have written the truth with a better tone.

In that post I wrote about a post that was written about pneumonia on another website, where the author wrote that an Albuterol breathing treatment would help thin and remove secretions. I wrote about how that is not true, and that the doctor who approved of that being published was either a liar or ignorant.

Of course he responded with the following comment:
"You should consult the journal Chest as bronchiodilators have, in fact, been shown to remove mucus.

If you wish to be taken seriously by anyone with even a basic knowledge of medicine and pharmocology, I suggest that you change the tone of your writing. Simply stating things are 'lies' makes you look uneducated and uninformed. You repeatedly lambast other websites for failing to accurately reference, yet you do the same thing yourself. You also have a significant tendency to simply ignore the research which doesn't support your position.

I agree that bronchiolators are over-prescribed (HMOs are in large part to blame for this). But the way your site is presented it is the last site I would send anyone to for information."
Now when you write an opinion, your going to have people disagree with you. That's just common wisdom. Yet to have someone so irate they write you a note telling you how stupid you are is never fun to read. However, when I was a journalist, we often celebrated when we received hate mail because that was a sign you were being read.

I'm not writing this post to apologize for writing that bronchodilators do nothing for pneumonia, because they don't. You don't have to do a study to learn that bronchodilators dilate bronchioles, and when a study is done to show bronchodilators help some patients with pneumonia cough up phlegm, it's because that particular patient was having some bronchospasm. That's common logic.

However, I am apologizing here for my tone. I apologize for calling said doctor a liar or ignorant. I have no proof he is a liar. In fact while I think he is wrong, I'm quite confident he's not ignorant. I'm quite certain there are few ignorant doctors, considering it takes a lot of wisdom to pass the doctor exams, and to become a doctor.

The truth is I do understand that the reason most bronchodilators are ordered is because some person sitting in a leather chair in some office in Lansing or D.C. decided, based on what a doctor told that person, that bronchodilators should be ordered on any patient diagnosed with pneumonia.

This is what we refer to as Intensity of Service. For the hospital to be reimbursed, the hospital has to prove the patient needed to be admitted. Thus, Medicare has unfortunately established a system where if a patient with pneumonia didn't need a bronchodilator at least every six hours for the first 24 hours, chances are he didn't need to be admitted.

Yes, there was a study that showed a bronchodilator helps some pneumonia patients. I've seen the first treatment do as much. Yet sometimes a study is telling you more than what we see with the naked eye. We might miss the basics, that a bronchodilator is a bronchodilator and nothing more.

Yet in the medical field, what works for 3% of patients works for every patient. And therefore it has become common place for bronchodilators to be ordered for every patient admitted with pneumonia. That's the way it is in the medical field. And it's easier for doctors to just go along with this flow than to oppose it, or, as I like to say, to make waves.

This particular doctor asked: where is your evidence. I like to send that question back to the doctor: where is your evidence that bronchodilators do anything for pneumonia. There has never been such a study with any conclusive evidence. Yet because of that, because no study is ever conclusive, it's easier in the medical field, safer in fact, to simply err on the side of caution. If it won't kill you, if it's safe, why not just do it. If it helps 3%, maybe it will help everyone.

So now we have hospitals like the one I work for with an order set for pneumonia that requires Albuterol every 4-6 hours based on the theory it might work for the patient. Yes, order sets, and medical studies, and best practice medicine, and preventative medicine, means there will be over kill. There will be tests, and extra breathing treatments, that will cost the hospital a ton of money.

Yet so long as something is deemed safe, it will be ordered. Why not? If a patient wants a breathing treatment, if medicaid and medicare and an HMO wants a breathing treatment for this patient, then just do it. What's it going to hurt?

Well, that's my job as a blogger to see the other side. It won't hurt the patient. It won't hurt the insurance company or Medicare, because they only pay a flat fee to the hospital anyway. Yet the individual without health insurance still has to pay 100% of the hospital cost. It's this private person who will be hurt by all this needless medicine.

The hospital will be hurt too. Because it will have to absorb the cost of all the medicine and therapies that are not reimbursed by the insurance company or the government.

The other individual who will be hurt is the respiratory therapist and the nurse. When you have 80% of what you do not needed, and you have 30 patients, you are going to become burned out. And, when the RTs and the RNs become burned out, not only does the worker suffer, so does the patient who really needs the services of the RT and RN.

So you see, in this way, preventative medicine does not work except to boost the egos of those who write them. And order sets do not work. Treating every patient the same way is not a good idea, it does not save any patient, it does not prevent any patient from dying, and it does not save money as is the intended purpose.

A better approach to patient care is positive outcome based medicine. This is where you might order a bronchodilator to a pneumonia patient if you think it might help, and if it does you order some more. Yet if it doesn't work, you don't do another. It's basically: do what works and don't do what doesn't works.

To me this is the common sense approach that would not only benefit the patient, but benefit the insurance company, Medicare and HMOs. Yet, more important, it would truly benefit the hospital by allowing them to reduce costs, and benefit the nurses, doctors and respiratory therapists by not forcing them to do 20 things at the same time they are trying to take care of the patients who really need their services.

I also would like to note here that when I started this blog I never expected to have an audience, so gaining or losing readers has never been a concern for me.

Yet I truly do take personal attacks personally (can't help it), and I must continue to remind myself that other people have feelings too. Usually we're all pretty good at that, yet sometimes when you're writing in a world of words and no faces, there's always the tendency to lose that sense of personality.

Yet at the same time we bloggers (well, me anyway) want to be honest and truthful, and to do anything other would make this blog boring, bland, common, and not worth reading.

So I went on a rant here, yet I just wanted to explain what was going through my mind as I wrote, "A World of Bronchodilator Liew!" I must have been in a foul mood that day due to needless burnout, and I was irate, and my internal editor and publisher didn't nix the tone. I don't think the post was bad, but the tone was. When he wrote, "You should change the tone of your writing," he was right. I thank him for that comment.

I don't think the doctor who wrote the above comment would have been so upset had I simply disagreed with him. I think he was upset because I basically called him an idiot and a liar, and he is not. I'm sure he's a good doctor, fine person, wise, intelligent, and, most important, he's obviously a fellow lover of the Internet. For implying otherwise I humbly apologize.

1 comment:

Rick Frea said...

For evidence that beta adrenergics do not have a significant enough mucociliary clearance effect, check out this link. The name of the article is "Inhaled Adrenergics and Anticholinergics in Obstructive Lung Disease: Do They Enhance Mucociliary Clearance?" By Ruben D. Restrepo, MD, RRT, of the September, 2007, issue of Respiratory Care (Vol 52, No 9).

Here is the highlight of the article: "The involvement of the cholinergic and adrenergic neural pathways in the pathophysiology of mucus hypersecretion suggests the potential therapeutic role of bronchodilators as mucoactive agents. Although anticholinergics and adrenergic agonist bronchodilators have been routinely used, alone or in combination, to enhance mucociliary clearance in patients with obstructive lung disease (CF, COPD, asthma), the existing evidence does not consistently show clinical effectiveness."