MrPBH

Hey ZDogg, love your work. Keep fighting the good fight.

I'd love to hear your thoughts on Suboxone prescribing by primary care doctors in the community. I'm an Emergency Physician with an interested in addiction treatment and right know I'm trying to create a pathway to get our opioid dependent patients into rehab from the ED. The program revolves around the idea of ED suboxone initiation with immediate referral to a treatment center.

Have you worked in a primary clinic that provided Suboxone or have you put thought into doing it? It seems like the uptake in the primary care community has not been as robust as anticipated and Suboxone prescribing is remaining in drug rehab centers or addiction medicine practices (despite the original intention of the DATA 2000 waiver to provide primary care physicians and family doctors the opportunity to treat opioid dependent patients in their community clinics).

No we're all nerds of the medical field. The nerdiest doctors are nephrologists (kidney doctors) and infectious disease specialists (aka, "gotta catch 'em all"). If anyone had a real Pokedex, it would be an ID doc (oxacillin wasn't very effective against MRSA... Vancomycin was supereffective!).

Except for orthopedic surgeons. They're more like cabinet makers.

(Just kidding, orthopods are among the smartest surgeons. They just really like bones. Like a lot.)

Medicare pays for home hemodialysis (EDIT: and all other forms of dialysis) for all American citizens (with few exceptions). No one is dying of ESRD for lack of hemodialysis in the US.

I still agree that the US healthcare system is fundamentally broken and deeply unjust, but thanks to Richard Nixon (yes that Nixon), no citizen goes without dialysis.

(Please note that I said "citizen"; if you don't qualify for Medicare/Medicaid, you will not receive dialysis without paying out of pocket. This means that undocumented immigrants with ESRD don't receive dialysis benefits. In practical terms, they get dialyzed when they have an emergent, life threatening condition such as hyperkalemia [high potassium] or fluid overload because at that point, the hospital must treat them under the mandate of EMTALA. Such patients typically present to their local emergency department every 2-5 days, have their potassium level checked, and then get admitted for hemodialysis if they meet criteria. It costs a lot more to do it this way compared to just paying for scheduled, outpatient hemodialysis and these patients suffer emotionally and physically but that's one more flaw of our broken health system.)

I understand. Would be great to hear your thoughts on the subject, given your enterprising mindset.

Sigmoidoscopy does not investigate the entire colon but rather just the rectum and sigmoid. It will discover rectal tumors and tumors in the last portion of the colon but it will miss tumors that are located more proximal.

If a patient opts for sigmoidoscopy instead of colonoscopy, they also need more frequent screening, which is more expensive and wastes more of their time (a physician would make more doing two sigs on each patient compared to a single colonoscopy in a decade, which counters your implication that colonoscopy is done for the money it generates alone). I would also challenge your claim that sigmoidoscopy can be performed without sedation; most folks are not very comfortable with a large camera up their rectum and therefore many undergoing sigmoidoscopy will receive sedation as well.

As sigmoidoscopy requires almost as much effort as a full colonoscopy, why not just evaluate the entire colon while you are there?