Patients are not sheep

I attended the local county fair a couple of weeks ago. Since we have two Shetland Sheepdogs who love to herd things (mostly kids), I wanted to watch the sheepdog trials.

There is nothing like seeing these wonderfully-trained dogs at work. The dogs stare down the sheep and strategically move them in unison from one place to the other. The sheep are visibly intimidated, although many are big enough to kick this dog's butt, if they were so inclined. This demonstration is not unlike some people's experiences at their doctor's office or in the hospital.

The medical provider is the strong-eyed, intimidating sheepdog (of course). The patients are the sheep (sorry). The doctor/sheepdog enters the examination room with regal confidence and determination; chart in hand; stethoscope over the neck.


The patient/sheep is passively sitting (naked/sheared under a paper gown) on the examination table. After a brief introduction to make sure the patient knows this is the doctor, the herding begins. The patient may be herded to the lab, then on to x-ray. They are then herded to the pharmacy, where a different breed of strong-eyed professionals, supply you with various elixirs and nostrums. The patient may then be herded on to specialists, where the dance continues.

At some point, the sheep will either (a) complete their herding journey, or (b) leave the herd and run away in frustration. The sheepdog is not that concerned about runaways. There are plenty of other sheep. The wolves can have a few. (I will let you guess who those wolves might be. Hint: They quack instead of howl.)

When patients (people) are treated like sheep, they tend to ACT like sheep. They relinquish all care and responsibility to their medical providers. They passively sit there, naked, and accept piss-poor treatment instead of working in partnership with their medical provider. As a medical provider and a reluctant patient, I have been on both sides of this equation. Even when my own doctor knows that I am a medical provider, they still treat me like crap sometimes. As soon as my white coat and stethoscope comes off, I am no longer a member of their club.

My most recent heath challenge was a kidney stone, discussed in an archived Blog a few months ago. The ER provided me with surprisingly wonderful care (this time); but my urologist was terrible (I hope he reads this).

During my three visits to his office, he never ONCE examined me! I am still mind-boggled. He also never wrote any notes (I can get in my own chart quite easily). I was curious what he would write about his "examination". He certainly didn't fudge and write a fraudulent examination. He didn't write anything! I spend hours typing charts. I didn't know we could just "not chart". Obviously, that was the last time I would see him as a patient; and of course, the last referral he would ever get from me. There are plenty of other sheep, apparently, since he still has an active practice.

Doctors and other medical providers should have periodic "secret shoppers". Someone needs to challenge some of these arrogant sheepdogs. When I was in family practice, I would often hear my colleagues bitch about a sick patient showing up without an appointment. Those sons-a-bitches! How dare they seek medical care when they are sick! Who do they think they are? I have to go to lunch. When did the word "care" leave "medical care"? I must have missed that announcement.

Yes, some sheepdogs are definitely problematic, but what about the sheep? Don't they have a role in this? You bet they do.


Patients need to stop being sheep. Medical professionals, no matter how intimidating and strong-eyed they are, are really not in charge of your life's journey. Ewe are in charge. Unless people take an active role in their own health care, and the health care of families, this mindless herding will continue. In order to be equal partners with your medical provider, you are going to have to be more strong-eyed and assertive, too.

• Don't accept substandard care for a high-cost visit.
• Do your homework, both before and after your visit.
Don't leave without knowing your diagnosis and the medical provider's rationale for making that diagnosis.
• Then, go home, get on the Internet, and see if you agree.
• Got questions? Call your medical provider. They don't call you back. Call again...and, again.

If they fail at their professional role in providing you with answers and explanations, or at least the courtesy of returning your call in a timely manner, then walk. See a different medical provider. Medicine is much too complex to do it alone. Unless you partner-up with your doctor, and are accepted as a respected member of the care team, then leave the herd.

Maybe I am angry today. I called my mother's nursing home doctor for the third time in the last five days and I am still waiting for a call-back. If she ever calls, she is going to be informed that her services are no longer needed.

On the WebMD Ear Disorders Board, I am sometimes asked to answer a question that should have been addressed by the patient's medical provider. People sometimes post within an hour of their empty medical visit. Sure, medical providers walk in with a hurried demeanor, but that does not mean your visit should be short-changed. If you had an appointment, then you deserve to have a productive visit. Besides, the medical provider is not doing this for free, you know. Someone, either you or your insurance company, is writing them a check.

Try this: "I know you are busy, Doctor, but it is very important that you answer my questions. If you can't do it now, when can I expect a call?" You must be prepared to stare 'em down, in a respectfully assertive manner, of course.

Next time you are sitting in the examination room hearing the bleating of others while waiting for your medical provider to arrive, I want you to repeat this mantra, "I am not a sheep. I am not a sheep."

Related Topics: Language Barrier Affecting Health Care, Healing the Doctor-Patient Relationship (WebMD Video)

Technorati Tags: communication, wellness, health management

Medical Mistakes, Part 3: Failure to Communicate

Mistakes in diagnosis or treatment plans often occur when the parties involved fail to communicate. Sounds like the movie, "Cool Hand Luke".

The Patient's Role: The most critical part of any medical encounter is the history (his-story, or her-story), which is typically provided by the patient. Some patients are more verbose and specific than others, however. It is the responsibility of the medical provider to ask the appropriate, focused questions to fill in the gaps. Many times, patients will not reveal the whole story. They need to tell the whole truth and nothing but the truth, to quote the witness oath.

Recently, a medical provider friend was dealing with a patient with recurrent infections, weight loss, fatigue, and a wide array of vague, but troublesome symptoms. The history did not reveal any sort of risk that would lead the medical provider down the right pathway to a diagnosis. Why? The patient did not reveal critical aspects of his history. He was vague and secretive; a married businessman that traveled. He seemed innocent enough, but had a deep secret that may have cost him his life by delaying his eventual diagnosis.

This family man had a hidden sexual appetite; an appetite that lead him to the disease-ridden brothels of Southeast Asia. He had contracted HIV. While one can understand why he would not want to reveal this information to a medical provider (or his wife), his failure to disclose this information in a timely fashion resulted in a very undesirable outcome. By the way, his wife was HIV positive as well.

Medical providers are trained to be non-judgmental. Over the years, I have been told things that made me scream like a little girl (inside my mind, of course), like those rare (Thank God) people who admit to having sex with animals. On the outside, I am attentively listening and nodding professionally. On the inside, it is AARRGH!

The Provider's Role: Not all people realize that their hidden agendas may be medically significant, so it is the provider's role to eke out those vital facts. Unless the medical provider proper sets the stage as a compassionate, nonjudgmental, and deeply-concerned professional, patients are not going to reveal those secrets.

It can be next to impossible to establish a trusting relationship in one 15 minute encounter. Trust requires TIME. When the medical provider is hurried, or feels that they are hurried, then mistakes in communication are inevitable. Wham! Bam! Here's your prescription. This is bad medicine.

I work with many teenagers; and anyone that has ever tried to communicate with adolescents or been an adolescent themselves (all of us!), then you know how challenging communication, such as a medical interaction can be. The language a medical provider uses is critical.

For several years, my oldest teenager spoke like a Neanderthal. "How was your day?" "Uhhh", he would grunt. Adolescents often do not trust adults, especially adults in power, like parents, teachers, or in my case, medical providers. Before I can help anyone, I have to establish the ground rules of confidentiality. For sexual matters, their confidentiality is protected by law. I can't treat a runny nose in a person under 18 without parental consent, but I can treat them for gonorrhea.

If I ask a teenager (in confidence), "Are you sexually active", I will often get a, shifty-eyed, negative response (I am having sex, but not at the moment. Or, I only have sex twice a week - that is not "active") If I ask the same question, "Have you ever had sex?", I will get a different response. One young girl, perhaps trying to avoid the "sexually-active" question, once asked, "What do you mean? Do I, like, move around a lot?"

I am sure glad that I didn't have Bill Clinton as a patient when he was a teenager.

Another communication problem orchestrated by the medical profession is the failure to communicate test results or to follow up on patients who never show up at the lab. A woman has a pap smear, but somehow in route to the lab, the glass slide breaks or is lost. She never gets her results, so she just assumes the test was normal.

It is the responsibility of the lab to inform the medical provider that the specimen was lost. It is the responsibility of the medical provider to call the woman and inform that they need to have another pap smear (women love this call). And, it is the responsibility to the patient to return for another pap. There is ample opportunity for a breakdown in communication.

I have to say that over my 30-plus years in this business, I have witnessed positive lab reports getting filed in the chart without being reviewed by the provider; or worse, ignored by the provider. No one likes to do those stool tests for blood, but if two out of those three specimens are positive for occult blood, someone needs to act. First, if the patient just doesn't return those samples, we have to get after you. Second, when they do come back from the lab, you need to know those results, even if they are all negative.

Several years ago when I worked in the ER at a local military base (now closed), I heard a story (presumed to be true) of a medical records person who decided that filing lab reports in the charts took too much of his valuable time. So, in order to go home on time, he simply threw the stack of daily lab reports up into the ceiling through a missing ceiling panel. The patients and the medical providers never got those results. Tests had to be repeated, or worse, critical results never were revealed. After a year (yes, a year) of this practice, the ceiling caved in from the sheer weight of these unfiled reports and the perpetrator was eventually court-marshaled. The harm that may have resulted from this act of idiocy is unknown.

Communication requires a minimum of two people. In a medical encounter, those two people are the patient and the provider, and each should equally share the honest responsibility of full-disclosure...including mistakes. Always remember that we are in this TOGETHER.

Related Topics: Are You Too Afraid To Ask Your Doctor?, Be Your Own Health Advocate

Technorati Tags: medical mistakes, communication

HPV Team

When my stepson was a mechanical engineering student at Chico State University, he joined the Human Powered Vehicle project, an on-going engineering project to develop high-tech racing bikes for competition. While attending a party, proudly wearing his "HPV Team" t-shirt, he was approached by a young woman who said that she was pleased to see that there is a campus support group for people with this disease. Obviously, she was not interested in dating him.

On WebMD, there is an HPV support group - a different type of HPV. It is estimated that 20 million people in the U.S. have HPV.

Some types of HPV simply cause non-cancerous flat warts or plantar warts. Like most warts, most will go away without treatment in about 2 years if you can wait that long. Most people elect to take medications and other treatments to help warts disappear more quickly. HPV remains in the body with or without treatment for visible warts, so warts may come back.

The human papillomavirus (HPV) also causes genital warts; spread sexually, of course. Some of the 100 types of HPV cause cancerous changes in the cervix. In women, high-risk types of HPV (such as types 16, 18, 31, and 45) cause changes in the cells of the cervix that can be seen as abnormal changes on a Pap test. Abnormal cervical cell changes may resolve on their own without treatment. However, some untreated cervical cell changes can progress to serious abnormalities and may lead to cervical cancer.

About 3,700 U.S. women will die of cervical cancer in 2006, according to the American Cancer Society. Worldwide, cervical cancer is a leading cause of cancer deaths for women, about 233,000 deaths each year.

Gardasil, a new vaccine developed by Merck and approved in June, targets four virulent strains of HPV known to cause cervical cancer and genital warts. Gardasil has the distinction of the first vaccine designed to prevent a type of cancer.

So far, the vaccine appears to be 100% effective in preventing HPV caused by the strains HPV-16 and HPV-18 in people have not been previously exposed to the virus. At this point, it is known to be protective for at least four years, but it may take another two decades of research to determine if this vaccine offers lifelong immunity. Gardasil is approved by the FDA for girls and women aged 9-26, and eventually, may be approved for women up to age 45.

So, why aren't boys/men getting the vaccine, since they are the ones spreading it around? There is continuing research in this area, and it is likely this vaccine will also approved in males, but right now the focus is on the ones that may get cervical cancer -- prepubertal girls and sexually-involved young women.

A few weeks ago, we received our first shipment of Gardasil. Girls will need to receive a series of three injections over a six month period. In our office, the cost of each injection is about $160, which may or may not be covered by the patient's insurance company. Many parents are asking for it; others are waiting to see if their insurance will cover it (most likely).

Offering a vaccine to prevent a sexually-transmitted disease to a nine or ten year old can be a hard-sale for medical providers. Parents do not even want to think that their little girl holding a doll is going to be sexually active some day. I typically begin to address sexual issues around the onset of puberty, but now I will need to address this vaccine availability at the 9-year well-child examination.

Vaccines have done more to improve the health and longevity of humans on this planet more than any other public health venture, with the possible exception of clean water. Gardasil is a good one. The vaccine is safe, but unfortunately, a bit expensive. But then again, so is everything else. Should you join the HPV team and have your little girls vaccinated? Based on my own research, I would have to say yes, as long as we don't have to wear HPV Team t-shirts.

Related Topics: WebMD Video: Cervical Cancer Vaccine: What Women Need to Know, Cervical Cancer Vaccine Q&A

Technorati Tags: gardasil, HPV, cervical cancer

Medical Mistakes, Pt 2: The Missed Diagnosis

Medical providers are trained to make careful and systematic diagnoses. Sometimes we are right; sometimes we are not. Since we make thousands of diagnoses per year, it is not unusual to miss a few. To be in medical practice is to tolerate ambiguity, because not all diagnoses are straightforward. Neither are patients.

A diagnosis is made by the medical history, the physical examination, and diagnostic tests; none of which are 100% perfect. Clinicians need to ask the right questions; patients need to provide honest and complete answers. It is said that if you listen to a patient's story long enough, they will give you the diagnosis. Sometimes this is true; sometimes the patient's diagnosis is way off base. The medical history is critical to formulating an accurate diagnosis; it should be complete and unbiased.

Patients and providers often have mismatched expectations. Patients expect to be seen on time and be on their way in a timely fashion. Unfortunately, patients are often scheduled for a mere fifteen minutes and sometimes less in a busy practice. In a real world, providers would love to guarantee timely visits; unfortunately we never know what is behind Door #2, or what was behind Door #1 that put you behind in schedule in the first place. Patients expect to be quickly and accurately diagnosed, but this too, is often not possible in just one visit. So, when providers (or patients) are rushed, mistakes are more likely.

Patients often do not give the whole story. Providers often do not listen. When a patient presents with headaches, there are numerous questions that need to be addressed. When did it start? How long do they last? Where are they located...exactly? (The typical response is "in my head")

Are you taking any medications? Do you smoke? And, so on. If you fail to mention that your father died of a brain aneurysm...even if the clinician fails to ask this vital question...an accurate diagnosis may not be made.

I have to say that some providers do not even give the patient a chance to tell their story. They interrupt. They cut you short when they feel they have the answer. I once had a patient tell me that "Dr. Smith is very smart. He diagnosed my sinus infection seconds after he walked in the room. He didn't even need to examine me!" This "treat 'em and street 'em" approach to fast-food medicine can result in terrible outcomes, if that "presumed sinus infection" turns out to be something more ominous.

Patients often have their own agendas. "I have a sinus infection and just need antibiotics." It has been said that a person who diagnoses themself has a fool for a doctor.

If you are paying for the expertise of a medical provider, allow them the opportunity to make their own assessment of your problem. You may be surprised that it differs. If your preconceived diagnosis matches your medical provider's assessment, then everyone will be happy. In clinical practice, it is much easier to just hand a patient the prescription they want, rather than take the time to explain that (a) they do NOT have a sinus infection, and (b) colds do not require antibiotics.

Patients often present with peripheral issues. "Oh, by the way..." When the patient who presents with a particularly troublesome headache, it can quickly become diluted when they whip out a suspicious dark mole, or point out the bunion on their feet.

There is only so much medical care that can be provided in one visit. Although you may feel it is cost-effective to try and get years of medical complaints addressed at one visit, this is a set-up for misdiagnosis.

Good medical care is not cheap. For instance, the Gold Standard for assessing the status of a person's sinuses is a sinus CT scan. Every person who presents with the classic symptoms and signs of a sinus infection will not necessarily need this expensive diagnostic study, but sometimes it is needed.

Many insurance companies put cost constraints on medical providers, so in order to get this needed CT scan; we may have to go through an exhaustive dance with the health plan. Additionally, not all sinus infections can be treated with cheap, generic drugs. Some will require bigger guns, and a bigger bill to the insurance company or the patient. Trying to save a buck can sometimes often result in misdiagnoses and poor outcomes.

Physical examinations miss things. A common question on the WebMD Ear Disorders board concerns vertigo/dizziness. "My doctor looked in my ear and said that every thing looks fine." There are literally HUNDREDS of causes of dizziness, and only a few of the causes can be seen by simply "looking in the ears". When a clinician fails to find an obvious cause for a person's symptoms, it is their continuing responsibility to keep looking, or to send you to someone (like a specialist) that will. The clinical signs of Strep throat are well-known, but even with my 30+ years of clinical experience; I can still miss one that isn't classic or obvious. Taking that one additional step of doing a throat culture will increase the accuracy of a clinical assessment.

Diagnostic tests miss things. A man comes in with recurrent chest pain. The history is suspicious in that he has pain on exertion; his father has heart disease.

The physical examination reveals that his heart sounds "just fine". His electrocardiogram is read as "perfectly normal". He is told that his chest pain is most likely just gas. A few days later, he dies of a coronary infarct -- a heart attack. His wife and three kids are not happy about this misdiagnosis. Their attorney salivates at this story. To err is human; to be sued is not divine.

In retrospect, perhaps a cardiac stress test or an angiogram would have saved this man's life. Retrospection does not bring back a life.

All medical providers practice defensive medicine; some more than others. However, when medical providers fail to order those additional tests, regardless of the reasons, a misdiagnosis may occur -- a deadly mistake.

Your medical provider is your partner in care. When mistakes are made, there are often two parties that are responsible. Effective communication is the key. Medical providers are not perfect, even though some feel that they are. Mistakes will happen. The only thing you can do as a consumer to limit those inevitable mistakes is to take an active, participatory role in your health care. Your doctor is merely a travel agent...you are the one taking the journey.

Related Topics: 7 Key Traits of the Ideal Doctor, Health Simplified: 8 Steps for Healthy Living

Technorati Tags: medical mistakes, misdiagnosis, wellness

Circumcision: An Unkind and Unnecessary Cut

Yesterday, I was asked (again) if I would like to start doing circumcisions in my office. Again, I refused. I do most of the surgical procedures in the office, but there is something about snipping of the tip of a newborn baby's foreskin that has always bothered me (Perhaps not as much as it bothered the baby!) This is just one of the many reasons why I chose not to circumcise my own son.

In the modern world, circumcision is medically unnecessary. The argument that fathers want their sons to "look like them" or the other boys is not a good enough reason. Besides, fathers and sons do not really compare their penises, and school locker room displays and group showering has become less common.

Circumcision became very popular at the turn of the last century when it was believed that it would prevent masturbation. (Yeah, that worked!) As a collector of old medical books and memorabilia, I have read many references on this subject. One reference (Dr. Foote's Home Medical Advisor - 1898) even had a drawing of dehydrated-looking testicles that were "ravaged by masturbation".

More and more parents are coming to this realization and are opting to leave the foreskin intact. They prefer the uncut version. In my pediatric practice, I see about 50-60% of boys being circumcised, and deal with many parents who are still not sure of their decision to Circ or Not to Circ.

Before I go further, let me say this: I suspect that my stance against circumcision is going to generate a lot of comments, both pro and con. Since circumcision is such a personal and often religious, decision, it is not my intention to open those delicate doors. This entry is not a commentary on religious tradition.

Circumcisions, when done correctly, are certainly safe, but complications such as infection can happen. Although extremely rare, infant deaths have been reported as a result of a routine circumcision. In the office and hospital, we routinely anesthetize the foreskin before cutting it off. In the past, anesthesia was not done; the foreskin was just quickly cut.

The people who say babies did not feel the pain of circumcision are total fools, and I am pleased that this most clinicians use local anesthesia.

Circumcision is performed many different ways, from using a bell device to simply cutting off the foreskin with a scalpel. New parents have a lot to deal with, but they are usually unprepared for this procedure (if they are brave enough to watch). New parents are also unprepared for the post-surgical appearance of a recently-circumcised penis.

Even weeks later, parents ask me to look at the circumcision and say; "Does that look right to you?" Some are concerned about the raw appearance; some are worried that there is too much foreskin remaining, or not enough. Either way, the penis becomes a major topic of conversation for those first few weeks.

Religious covenant aside, circumcision is purely a cosmetic procedure. Whether you want the penis to look like it is wearing a helmet or sporting a turtle-neck sweater is really a personal choice; a choice made solely by the parent(s). I hate to say it, but 'ol one eye is really not that attractive anyway.

If you believe in God, then why would the Creator of Life leave some extra foreskin for medical providers and Mohels to lop off? If you believe in Evolution, then why would a seemingly-useless piece of skin remain intact after millions of years of evolutionary change? Most of the men on this planet have their foreskins intact.

Some plastic surgeons are now cosmetically creating new foreskins for those men who lament its demise as an infant. There is strong evidence that men with intact foreskins have greater penile sensitivity and thus have increased sexual pleasure. Maybe that is true, but sexual pleasure is predominantly between your ears, not your legs. Enjoyment of sex is really in the minds of the participants.

Jews have been circumcising little boys as a covenant to God for over 3000 years. According to the Bible, Jesus was circumcised according to Jewish custom and tradition. I often get a kick out of Renaissance paintings depicting Adam, sporting both a circumcised penis and a belly-button! If man was created in the image of God, I want to meet the entity that circumcised God!

In an era before driver's licenses and ID cards, perhaps circumcision was away to definitively identify members of your tribe. In the pre-underwear world of Jews and Gentiles, it was really easy to identify the real Jews. Circumcision is a sacred religious tradition, but it certainly made identification easier for the Romans and tragically, the Nazis.

Some still believe that the main reason for this practice was cleanliness. Granted, in the remote past, men did not have an intimate relationship with soap and water. Even a minor infection of the foreskin could have got out of control and resulted in a life-threatening event. An infection of your toe or finger or lip could have resulted in the same scenario.

No one suggested that we cut off fingers so they won't get infected. Penises are anatomically designed to be relatively trouble-free. Now, don't take the comment wrong. Penises do cause a considerable amount of trouble on this planet, but not usually in the medical sense.

There may be a new argument in favor of circumcision in some populations that is difficult to ignore. In Sub-Sahara Africa, where AIDS is rampant, uncircumcised men seem to contract HIV more often than circumcised men. Why? It is felt that micro-tears under the delicate mucosal surface of the foreskin may provide a route for contracting this deadly infection.

In these countries, it may be best to encourage circumcision, but will we see little boys dying of infections caused by the procedure itself? In fly and vermin-infested areas where sterile conditions are difficult to maintain and antibiotics are few, ANY intentional opening of skin can be problematic.

Muslims also routinely practice circumcision. Shockingly, some African and Middle Eastern Muslim sects even practice FEMALE circumcision -- a barbaric practice that removes the outer labia of little girls (and sometimes, the clitoris); performed without anesthesia, often by a barber. This practice is thought to assure virginity. There are some worldwide efforts aimed at stopping this horrible mutilation practice.

As new parents, you have an obligation to make an informed decision about circumcision for your infant sons. Regardless of your final decision about this cosmetic procedure, you owe it to your sons to choose wisely. Or, pray that you just have daughters.

Other Circumcision Information Resources:

• Male Circumcison Reversal
• The Foreskin Advantage
• National Association for Restoring Men (NORM)

Related Topics: Doctors Now Ease the Pain of Circumcision, Deciding about Circumcision

Technorati Tags: circumcision, infant circumcision

The Dirty Dozen

Think about all the places you visit in a typical week: your office, your favorite restaurant, your child's school. Do you ever look around and worry your surroundings are less than sparkling clean? So does Dr. Moser. Join him on his odyssey through 12 Dirty Places : Dr. Moser's "Dirty Dozen".

1. Public Toilets
2. Airplanes
3. Your Doctor's Office
4. Hotels and Motels
5. Restaurants
6. Movies
7. Daycare and Preschools
8. Pools, Waterparks and Beaches
9. Homes
10. Dirty Jobs
11. Schools
12. Hospitals and Nursing Homes

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Dirty Places, Part 12: Hospitals/Nursing Homes

There are so many more places that deserve recognition as Dirty Places, but I thought I would sum up the Dirty Dozen with the dirtiest and most dangerous places -- hospitals and nursing homes.

This week, my elderly mother was discharged from the hospital and permanently entered a nursing home, and sadly it is going to be a one-way trip. My brothers and I hoped that we would never have to make this decision, but it is no longer safe for her to be in assisted care.

The state of her physical and mental health now requires 24-hour care, not something we can provide. We toured many facilities before making our decision, but my non-medical brothers do not look at those places with the same jaundiced eye. First there are the smells of urine and feces; the sounds of moaning and crying, and the sights of frail elders slumped over in chairs in wheelchairs lining the halls and day-rooms.

Is this really the best we can do for our elderly? Is this what we are getting for $4000 a month? I can assure you that all of us have been losing sleep over this painful decision.

Already, my older brother has experienced problems. He arrived to find that she had soiled herself. She rang her buzzer and they had promised to come and help her to the bathroom, but no one arrived for over twenty minutes. Even in my mother's state of mind, she was clearly mortified.

As poor as we were growing up, cleanliness was paramount in our home. She changed our sheets and pillow cases every day! She even ironed them. We always had clean clothes. Our one bathroom and tiny kitchen was spotless. She was always on her hands and knees scrubbing the floor. My mother grew up in a family of 13 brothers and sisters in a three-bedroom house with a two-hole outhouse and cleanliness was not always on the front burner. I am sure that her childhood experiences set the stage for her being a clean fiend (her words).

For her remaining days, she deserves the right to maintain those high standards of cleanliness. Perhaps, it is my own childhood experience of living with a clean fiend that motivated me to write about the Dirty Places in the first place.

The chance that my mother will get an infection is high. The CDC reports that over two million people contact nosocomial infections when they are hospitalized, resulting in over 80,000 deaths. Unless the nursing home or hospital staff strictly adheres to standard (or enhanced) precautions, people will die. Those precautions are as simple and commonsense as thorough hand-washing, the use of disposable gloves, and the routine environmental disinfection. Those precautions work, but only if people consistently use them. I do not want my mother to become a statistic.

Although this is a bit off the subject, I have been treating an unusual number of patients in the last several months for Staphylococcal skin infections and abscesses. And, not your garden-variety Staph that half of the population carries either, but MRSA -- Methicillin-resistant Staphylococcus Aureus, a type of super-bug that is resistant to certain antibiotics. MRSA infections have been increasing rampant in hospitals and nursing homes since first recognized in 1961, but now they are in my backyard (and yours).

I would like to sum up my Blog series on Dirty Places by emphasizing that all of us are part of the problem and part of the solution. There should be a worldwide "Neighborhood Watch" for hygienic procedures. We must watch out for ourselves as we watch out for the others that share our planet. Viruses and bacteria have thrived on Earth long before the emergence of our species, and they will remain here long after we are extent. In the meantime, we have no choice but to co-exist. Dirty Places (and dirty people) will always exist. We have the continuing responsibility -- no, the obligation -- to make them LESS dirty.

Now, go wash your hands and have a nice, clean day....

Related Topics: Understanding MRSA, Long-Term Care: Choosing the Right Place

Technorati Tags: managed care, assisted care, MRSA, dirty places

Dirty Places, Part 11: Schools

My 6th grade teacher was a real stickler for hygiene. She would rightfully come down on us for openly sneezing, coughing, or nose-picking. There is nothing like being singled out among your peers for having a finger in your nose.

Not wanting to be publicly humiliated, we were very careful about those things. Have you ever experienced one of those sudden, unexpected coughs where a little ball of mucous flies out of your mouth? Well, it happened to me. I was sitting about three seats back from her desk.

Mrs. Sturgeon had her head down writing something. All of a sudden, I coughed. Much to my horror, a loogie went sailing toward my strict teacher. My heart stopped in mid-beat as I watched it land on her desk pad. God must have been watching me that day, because she didn't notice the Mother of All Breaches in Hygiene. I had truly escaped death that day.

Any gathering of children is a place of questionable hygiene. In those days (the 50's) we had full-time janitors that actually cleaned our restrooms and floors. They were respected men with wheeled buckets and mops who always talked to us. Our beloved janitor was Cleat (probably short for Cletus, a common Appalachian name). Our restrooms were clean, or at least I didn't notice they were dirty. I can't say the same for schools today.

I know that I have harped about public restrooms in Dirty Places, Number 1, but I feel that school restrooms deserve special recognition. Parents rarely have the opportunity to randomly visit school restrooms, but you should. Be prepared for a shock. Several years ago while attending one of our kids' school performances, my PA wife used the girls' restroom with some of the other mothers in attendance. Not only was it filthy (I had the mistaken belief that girls restrooms were basically cleaner - certainly cleaner than the boys' restroom), but there were no doors on the stalls.

The mothers were not pleased. There was no soap. No paper towels; newspaper quality toilet tissue. No seat covers. My wife, a self-proclaimed activist from the '60s, decided to do something about it. She wanted to organize a group of appalled parents to reattach those doors, paint the graffiti, and clean that place top to bottom.

No deal. The custodians' labor union would not permit it. When we visited our Japanese exchange students in Tokyo, we were absolutely shocked to find that the children themselves cleaned their own school, including toilets and mopping floors - yet another lesson we can learn from other cultures.

Several times per month, I deal with a little person who has a urinary tract infection. It is not uncommon for me to find a school-related factor for this potentially-serious health disorder. One factor in the development of urinary infections is "holding it", so my first question to the children is the bathroom policy. Can they use the restroom anytime that they want? If the answer is no, then I inquire further. Some teachers have strict policies (and penalties, such as no recess) for kids raising their hands all day, traipsing off to the bathroom. I know random (and "infectious") bathroom trips can be very disruptive to the educational experience, but these are kids!

Recess is the most important part of their day (next to lunch) and to give up recess in order to pee is not a price many kids are willing to pay. Yes, they should use the potty during recess, but maybe the lines were too long, or the intense desire to play with friends too strong, but the reality is "when you gotta go, you gotta go".

There is another factor, too: Dirty restrooms. Children from families that practice cleanliness and hygiene in their homes are not used to the shock of a public school restroom. Girls are taught later in life to "hover" (not sit on the seat), but little legs can't do that.

Many school restrooms do not have seat covers. Some kids fail to flush; so rather than flush it when they see it, the stall is simply abandoned for the rest of day creating a long line at the remaining flushed toilets. The boys' room is worse. Little boys use the stall so no one will see their weenies. Making sure that no one is behind them or sudden open the door, their urinary aim is extra-poor, hitting mostly the unlifted seat. For the rest of the day, there is not one boy who will sit on it. Many would rather have poop build up to their eyeballs than sit on a sticky seat.

So, basically yellow-eyed kids "hold it" when they should be peeing and they don't poop when nature is knocking on that anal verge. The result is that I have to see urinary tract infections and constipation in my clinic. In the immortal lyrics of Lennon and McCartney (with slight personal modification):

"Speaking words of wisdom, let 'em pee. And in my hour of darkness, she is standing right in front of me Speaking words of wisdom. Let me pee."

Now, that song is going to become one of those ear worms and be in your head for the rest of day...

Related Topics: WebMD Video: Surviving Kids' Germs, WebMD Video: Back to School Booster Shots