Grand Rounds

When has this feat ever been done like this before?

Only one answer: NEVERMORE!!

Hiatus (Sort of)

I won't be blogging much in the month of November because I'm going to be writing a novel.

A whole novel? In the month of November?

That's right. Actually it's only 50,000 words (most modern commercial fiction runs about 80-120,000 words, for comparison) but yes, it must be completed by November 30th.

Why?

Why not? November is National Novel Writing Month (NaNoWriMo for short.) If you've never heard of it before, check out the website; it's a hoot, especially the FAQ page (be sure to read all the sections; they've broken it up so it doesn't go on for three years, but some of the funniest bits are in the Rules, Community and Technology sections.) If you are familiar with it, go check it out again anyway; it's still funny as hell.

I did this last year, had a blast, and completed a very funny murder mystery that I self-published and sell out of my office. I still have to get around to marketing it to my community (it's got lots of local references) but it's selling even without being on Amazon.

One woman who read it sent me a note telling me she was looking forward to reading more about my hero's adventures. That's when I got the idea to take the same hero (he's sort of a buffoonish caricature, as were all my other "characters") through all the different genres of fiction. So this year I'm trying my hand at a thriller: an intentional spoof of The DaVinci Code. I'm a little worried about what they call the "Sophomore Smack-Down"; apparently the second year is the hardest. But starting tomorrow, 1667 words a day minimum is my goal. Blogging will have to come second.

I'll keep you posted, if anyone gives a shit. Otherwise, see you in December.

Stupid People and the Pain They Cause

(Thanks to all the encouraging commenters on my previous post. Yes, I was having a bad day, and, as always, things were much better in the morning. Because of that last post, though, I feel compelled to point out that this one is intended as humor and not pathos.)

There are times when I finish seeing someone, watch as the patient leaves, gets in their car and drives away, then go up to my two front office staffers (I don't have a nurse) and shake my head.

"There are times," I hear myself saying to them, "when I cannot imagine," (I speak slowly, for emphasis) "that being *that* stupid," (another dramatic pause; they've heard me say this before and are getting ready to laugh) "wouldn't hurt."

What now?

Oh, let's see:

• "I had a rash a few months ago. It was right there...or maybe it was on this side; anyway, what was it?
• [Pointing to spot on abdomen]
  • "Is that skin cancer?"
  • "No, it's a stretch mark."
  • "Can I get rid of it?"
  • (No.)
• [Holding out hand with perfectly normal fingernails]
  • "My manicurist says there's something wrong with this nail."
  • "What did she think was wrong with it?"
  • "She didn't say."
• "My son had a cold last week. He's fine now, but I just want you to check him out."

When I'm in a room with one of these people, I feel pressure building in my head. It builds slowly, pounding, and I feel it moving to my ears. It's my brain struggling to force its way out of my skull, trying to fill the intelligence vacuum created by the person sitting in front of me.

It hurts.

There are some people you want to smack over the head with a 2 x 4, trying to beat some sense into them. And then there are these; the ones that make you think, "Why ruin a perfectly good 2 x 4?"

It is for these patients I have coined the term "pneumocephalic." (Yes, I know such a thing actually exists, seen rarely on head CTs and the like; but I really did make it up without realizing that.) It's doctor-type jargon for "AIRHEAD". One day, I even realized there's a code for it.

[Digression for explanation: There is a document known as the International Classification of Diseases (we're on version 9; ie: ICD-9) which contains codes for every conceivable diagnosis, symptom and/or ailment known to humankind. In fact there is a code for every conceivable reason for walking into a doctor's office. The "administrative" codes -- checkups, driver's physicals, routine gyn exams -- are preceded by the letter V, and so are known (of all things) as "V-codes."]

Here's the code for pneumocephaly: V02.
(Oxygen; get it?)

The moment I came up with that, I realized that there's even a code for a bad hair day: V05.

Mediocrity

What the hell am I doing with my life?

Here I am, babysitting anxious suburbanites afraid they're having heart attacks or dying of Lyme disease when all they have is muscle pains and achy joints from overdoing their version of "exercise." Trying to talk overweight forty- and fifty-somethings into taking statins to lower their LDL cholesterol of 165 after three years of "trying" diet and exercise, because there are guidelines that say it lowers their risks of MI and stroke. Explaining to diabetics why a blood pressure of 120/80 isn't good enough, again, according to all the latest that evidence-based medicine has to offer. Feeling pretty good when I diagnose a basal cell carcinoma instead of the ringworm the patient has been treating for two months. I spend an entire day doing nothing but giving flu shots.

And so on...and so on...and so on.

Then I come home and log on to my computer, where I read things like this:

People who hunt because they have to. (My version of stocking up on meat is going to Costco.) Villages who gather for funerals. Places where life and death seem more real than the Philadelphia burbs, where folks folks carry on about Flyers and Eagles as if putting a small piece of rubber into a net or getting a leather balloon over a line really means a damn thing at all.

People who tend caringly to a woman who has just lost her baby -- not because it's actually their job, but because there's no one else to do it. People to whom HIV "post-test counseling" is the emotional equivalent of a diagnosis of cancer -- not quite a death sentence, but just about. (Do you know how often I've seen a positive HIV test? Never. The only HIV patients I have came to me already diagnosed.) And these are medical students breaking this kind of news.

People who work 19 days straight; twice, with only a weekend in between. After surviving two strokes; who also have children and families and friends and all the other things I struggle with (never having had even one stroke; nor arthritis; nor anything worse than a fractured metatarsal that took a year to heal.)

I've never really saved anyone's life. The closest I've come to that was picking up ITP from a purpuric rash on a little girl and finding that her platelet count was 3. I sent her down to Children's for IVIG, where she did great. It's now 10 years later and I just signed her driver's permit. But to this day, her mother swears I saved her life.

I bitch and moan about how hard it is to make a living doing...what is it I do?

• I called a lady back today to tell her she doesn't have mono.
  
• I saw a man yesterday who was worried because the left side of his face felt hot -- as he was undergoing a work-up for transient blindness in his right eye several weeks before. His MRI was scheduled next week back home in the UK, and he wanted to know if it was ok to wait. I did a careful history and exam, found nothing, and told him it was.
• A lady was worried because a mole on her leg was changing; it wasn't even an actual nevus.

I make people feel better.

What a crock.

And yet...

When I counsel and console people in pain who insist that they're not so bad off -- so many other people are suffering so much more than they are -- I validate their pain for them. I point out that pain is absolute; not relative. If you have a broken leg, it doesn't hurt any less just because the guy down the hall has two broken legs.

I suppose nervous suburbanites have as much right to reassurance and health maintenance as Yupik villagers have to basic (and not so basic) health care from amazing paramedics who also hunt, mush and mourn with them. I guess encouraging women to go for mammograms is a form of caring, even if it doesn't seem as profound as being the one to tell them it wasn't their fault their baby died.

So yeah, I'm a wonderful doctor. But oh, what a mediocre person I feel like today.

Thank You, Cathy

Cathy has done it again. Thanks for bringing some wonderful blogs (now blogrolled to the right) to my attention:

That Mirror Belongs to Frank by Dr. K, a medical school educator; and, through him:
Try Not to Kill Yourself This Year by a South African med student whose self-appellation -- "Garbage" -- I refuse to use.

Cathy is so right about this: "If you can read this story and not shed a tear, then you are much stronger than what I am."

This Patient Does NOT Get It (with apologies to Kevin)

This doctor went bankrupt.

This is what one of his patients has to say:

I am disappointed with whoever is responsible for allowing a shortage on primary-care physicians. Our Dr. Matthew Masewic is closing his practice due to finances and high insurance costs, which are ridiculous.

It's sad and a shame to lose such a wonderful, kind doctor who is much needed and wanted. We pay high premiums every week and expect our doctors to be paid when due. They work long, hard hours and deserve every cent they get.

Dr. Masewic had a dream - helping everyone - and I believe everyone should help him. He kept us on the right track to staying healthy, and he will be greatly missed.

It would be nice if legislators would do there job and stop allowing insurance companies to do what they want, and hospitals from charging a fortune. It costs more for an aspirin than a doctor visit. Hello, what's up with that? It's time we helped keep our doctors, because soon we won't have any.

Did this patient pay her co-pay when she saw the doctor? If he had tried to stay in business by cancelling his contracts with all the insurance companies and insisting on payment at time of service, would she have continued to see him, cheerfully paying the full fee for receiving care from "such a wonderful, kind doctor who is much needed and wanted"? Or would this letter to the newspaper have been in the same mail as a heartfelt letter to the wonderful doctor thanking him for all his kindness while regretfully requesting the transfer of her records to the big practice up the street who will take her insurance so she can see another wonderful, kind doctor for only $15?

We can go around and around and around about what a shame it is that docs like this guy, me and all of the rest of us primary care dinosaurs can't make a living without ever pointing a finger squarely where the blame belongs:

1. The enormously lucrative, parasitic industry called "Health Insurance" (instead of what it really is: "Health Care Brokerage") that sucks out billions of dollars a year from the interactions between doctors and patients, because it can.
2. American citizens who have come to believe that health care doesn't (and shouldn't) cost them anything. Deep down (not even so deep in some cases) everyone thinks the "ideal" health insurance plan is one that is completely paid for by one's employer and pays for everything. Payroll deductions, deductibles and co-pays are admitted to be necessary evils, but the smaller the better -- hence, the ideal.
   

Capitalism is a good way to do a lot of things, but what it has done to health care in this country -- unfettered -- is to bring it to the brink of destruction. Despite all the calls for doctors and legislators to "do something" about it, I believe Matthew Holt is right: "We'll eventually end up with a health care system like Brazil's where you can have anything you want if you're rich, and most of the rest of you can die in the slums." (quoted from 6 Dirty Little Health Care Secrets)

America is already polarizing itself into oblivion; why should health care be any different?

Grand Rounds is Up

At the Health Care Law Blog; check it out for the gorgeous pictures if fascinating reading isn't your thing.

Laughing My Ass Off

Caution: contains more personal disclosures (as if anyone cares.)

Although I am in the Philadelphia sports sphere, I am not originally from here. And whatever happens through the years, no one and nothing can ever stop me from holding the Washington Redskins first in my heart. Not even a son born within the city limits of Philadelphia -- just barely -- who now bleeds Eagles green. Although the poor dear is stuck at college in Steelers' country, he's home for Fall break and got to watch the Eagles play in Tampa this afternoon.

He was very quiet for the first half, watching Ronde Barber run two interceptions back for Tampa TDs. Silence reigned from the other end of the couch for a Matt Bryant field goal (30 yards; his longest for the season so far had been 28 yards.) Not a peep from him at the half (17-0 Tampa.)

The second half was better for him. Two Eagle touchdowns evoked loud cheering. A long fourth quarter Tampa drive ended in a field goal (44 yards.) With less than 3 minutes to go, the Eagles went back to work; marching the ball down the field. Finally Brian Westbrook broke five tackles and stepped daintily into the end zone.

"I love that guy!" shreiked my kid.

David Akers' extra point gave the Eagles the first lead of the game with 33 seconds to go, and the boy was going nuts. The kickoff return took six seconds. Five plays and twenty yards later, there were 4 seconds left and the Bucs were going for a 62 yard field goal.

"The NFL record for the longest field goal is 62 yards," proclaimed the TV announcer.

"63, genius!" he shreiked. "Jason Elam for the Broncos and Tom Dempsey for the Saints." How does he keep track of this shit? "They're basically conceding the game," he chortled with glee.

The snap. The kick.

Good.

Two weeks in a row Donovan McNabb and my son have to watch the Eagles lose the game on a last second field goal. The only sound in the room was my hysterical laughter.

(Now I get to watch my Redskins play the Colts. I suppose we'll get to see who laughs last.)
(Monday morning edit: he is.)

More P4P (or: DB, You Ignorant Slut)

Somehow over the last two months since I began blogging (hard to believe that's all it's been) I had gotten the impression that DB, that Wild and Crazy Guy, was in favor of Pay for Performance. Where might I have gotten this idea?

There's this paragraph from his post titled What is Quality?:

Last week, SGIM sponsored a Quality Summit. During this 1 day meeting we focused our discussions on performance measurement and how should adjust for multiple co-morbidities. As the President of SGIM, I organized this conference and greatly enjoyed the intellectual stimulation during the presentations and the discussions that followed.

and a few weeks later, in Measurement: blessing and curse:

I consider myself partially responsible (emphasis mine) for the P4P crisis. I have participated in studies which examined “quality” as measured by adherence to performance indicators. While I am a minor player here, I have published literature on this “problem”.

I loved that post, especially the Albert Einstein quote:

"Not everything that can be counted counts, and not everything that counts can be counted."

and I commented enthusiastically on his blog. An email exchange ensued, in which Dr. Bob thanked me for my comments. I said "You're welcome" and commented that I thought -- perhaps because of his research interests -- that he was in favor of P4P. This was his answer:

[I'm] not proP4P. I am in favor of research which examines how we can help physicians improve their care delivery - 2 different concepts.

I realize he was probably just throwing together a quick response, but his exact words began eating away at me: "Research that examines how we can help physicians improve their care delivery."

I understand the concept of improving care. That kind of research usually uses terms like "evidence based medicine" and "best practices", and looks at the relationship between care given by physicians and outcomes experienced by patients.

Where does the care "delivery" come in? If I get 90% of my diabetic patients to an A1C below 7%, presumably I'm doing "better" than a doc who only gets 65% of his patients to that level. Why does it matter how I do it? What difference does it make if it takes me an hour of counseling twice a week for six months to get the patient into a healthy routine of diet and exercise, or three drugs plus insulin? I submit that the only possible distinction is (get ready for it) -- costs. Those drugs are costly; those visits take time, and time is my stock in trade, for which DB agrees I should be fairly compensated. Assume two potential clinical management strategies achieve the same outcome at different costs; anyone want to bet which one will be considered "better"?

I'm a solo family doc in full time practice, and while I welcome input on medical outcomes, evidence based medicine, and so on, I have to tell you that I don't grab JAMA the moment it drops on my doorstep and pore through it trying to figure out how to "improve my care delivery." Not many of my colleagues are either. When we get together for CME dinners, the casual conversation doesn't go, "Rats; I really need to ratchet up my care delivery." Reimbursement gets talked about, but only because we are being hassled to death instead of being fairly compensated. So why is this such a hot research topic?

Let's agree that DB is referring to "quality of care." Here's his definition of that, by the way:

• Diagnostic acumen
• Patient interactions (Careful explanations; Motivating patients (behavior change or adherence); Understanding the patient’s motivation)
• Management
• Interactions (Understanding how drugs interact; Understanding how diseases interact)

I don't see the word "cost" anywhere in there.

I submit that "quality" in this context is the unit of P4P (the unit of performance "4" which they are proposing to pay.) There is no other reason to discuss, define, or research "quality of care" (not the same as "best practices" "optimizing patient outcomes", or "evidence-based medicine.") Why study something that has no use except in constructing a P4P scheme, if you're not in favor of P4P in principle?

What seems to have happened is that insurance companies (and the government) have taken the lead in this, effectively saying to us, "We're going to do this. Either we'll define things like "quality" and "performance" ourselves (and then pay you for them -- or not -- as we see fit) or you can sit down at the table with us and have some input into how these programs are going to work." Forgive the outlandish analogy, but how different is it in principle from the Gestapo telling the Jewish Council in the Warsaw Ghetto to put together lists for deportation or they'd do it themselves? Because in the end it made no difference anyway, as they did what they wanted. As they will again, I predict.

There's my rant, DB. I guess I'm just on a mission from God.

New Old Law

An observation dating back many years, from the chief of medicine at med school, now reincarnated as the Eighth Law of the Dinosaur:

The better the surgeon, the more reluctant s/he is to operate.

Sigh; Just...Sigh

You know those people who make you sigh when you see their name on your schedule?

I have one (or two) of them.

I saw a lady last week with a pain -- no, it was not a pain; it was a DISCOMFORT -- in her left side; sort of in the middle, but lower down, and around to her back. She had a fullness in her lower abdomen and a sense of having to urinate (but not really urgently; or frequently; no burning with urination.)

Me: How long has this been going on?
She: I've always had this.

I finally managed to ascertain that it had been a few weeks. No nausea, vomiting, anorexia, or change in bowel habits. Her past history was significant for IBS, a TAH-BSO, no kidney stones or family history of them. Her exam was completely negative; so was her urinalysis and blood work. GYN evaluation was completely normal; a urine culture was negative. I'd ordered an ultrasound of her abdomen months ago when she came with right upper quadrant pain and nausea -- sort of -- that she still hadn't gotten around to having done. Then she called and said what she wanted was a CT scan of the lower half of her body.

This is not a clinical puzzle. This is something between somatization and hypochondriasis. That, and she calls. Often. Every day. Several times. And talks. A lot. Every time.

Somewhere in there we also had to pre-authorize Avapro for her hypertension, because according to the chart, lisinopril had made her cough. (Actually, the cough had gone away while she was still on it, because even though I gave her the Avapro and told her to stop the lisinopril when she told me about the cough, she had wanted to "finish up what she had." In fact, she'd been fine on Avapro before, but had asked for "something cheaper." Then her insurance had changed. In any event, it was easier to fill out the form for the pre-auth and fax it off.)

Today we got notice from the insurance company: they approved the Avapro. Even though they approve it all the time, this notice included a message I'd never seen before (caps theirs):

"A DECISION HAS BEEN MADE TO AUTHORIZE THIS DRUG BY ADMINISTRATIVE EXCEPTION. THIS ACTION WAS TAKEN DUE TO INTERNAL ADMINISTRATIVE/PROCEDURAL ISSUES AND IS NOT A DETERMINATION BASED ON THE SUBSTANTIVE ISSUES PRESENTED IN THIS REQUEST."

I showed it to my staff and chuckled. I joked that they probably got sick of listening to her and just said, "What the hell; just let her have it! Anything to get rid of her."

Then I called the patient to let her know about her normal CA125. I also told her the insurance company had approved her Avapro. I swear this is what she said, and I'm proud to report that I managed not to crack up until I got off the phone:

"I know. I was on the phone with them for an hour and a half yesterday."

TV and Autism

I usually enjoy reading the blog over at Freakonomics, as they often come up with fascinating stuff. Then again, this post about TV and autism seems way off base to me. In fairness, though, they don't seem enamored with it themselves.

Grand Rounds

Grand Rounds 3:4 is up. Thanks a zillion for a fantastic hosting job, Kim.

Pretty Pictures

Check out this site.

This picture of Tylenol is enough to give anyone a headache.

Clinical Dilemma

This is a true story; names and some identifying details have been changed to protect privacy, but I'm having a tough time with this one.

A lady (call her Abigail) came to see me a few weeks ago, very upset: her father had just died. Apparently he had known he had cancer for a year and a half but had told no one. Not his children; not his wife; had not seen a doctor. By the time he came to medical attention it was far too late, and he had died the week before.

She described her family as "not very supportive," including a brother and a sister, as well as her husband. In fact she said she had been talking to a lawyer, mainly to prevent her husband from hiding money if she decided to leave. I tried to get a sense of what the issues were, but she was pretty vague. The patient had taken care of the father in his last days and had been with him when he died. She had not gone to the funeral because, as she said, she and her family just didn't agree on certain things. Besides, she said she didn't want to remember him in a box.

I proffered my usual comfort, offered a small prescription of tranquilizers (there was no history of prescription drug abuse; just scrips for half a dozen Xanax for flying once or twice a year) which she accepted, and a gave her a handout from Family Practice Management called "Mourner's Rights", which I've found quite helpful. She thanked me and, at my request, made another appointment in about two weeks to see how she was doing.

Later that week I saw another patient I'll call Bob. He apologized for being late, as he explained that his father had died a week ago. His mother was having a tough time, so he had just taken her out to lunch. He went on to tell me that his father had known he had cancer for a year and a half but hadn't told anyone. By the time they finally got him to the doctor, it was too late.

That was too odd to be coincidence, so I asked him, "Do you have a sister named Abigail?" It turns out he did. Then he said, "Oh yes; I'd forgotten she comes to you too. We're at the end of our rope with her. She does drugs. Cocaine. She stole our father's hospice meds. She didn't even come to the funeral."

This happens more often than you'd expect. No, not skipping a funeral or stealing hospice meds; but a family member telling me about another's drug use, or drinking, or infidelity, or noncompliance with medical care; all kinds of information that, while potentially useful, is also filled with pitfalls. Is the family member telling me the truth, for starters. I've found myself in the middle of all kinds of family conflicts.

"Bob, are you sure?" Having just seen her, I hadn't detected any signs or warning flags that there might be a drug issue.

"100%. I've seen her with drug dealers. This has been going on so long, we're all just fed up. The problem is that my mother is a nervous wreck, and my sister is really doing a number on her."

"Bob; I'm not very good at keeping secrets." I am, but this is how I broach the topic of sharing uninvited information. "Can I tell your sister that you told me about this?"

"Absolutely not. She's mad at the rest of us anyway, and I'm afraid it would just make things worse." I tried to persuade him. No luck. There was nothing I could do but confront her directly with general questions about drug use and hope she admitted it to me.

I saw Abigail again. I noticed her smiling in the waiting room. When I asked how she was doing, she said, "Fine", but still had this wide grin on her face the whole time she was talking. She said she had another bombshell: "We're getting divorced."

I've been divorced. I never smiled like that.

"Tell me more," I said.

"We just decided. It's been coming for a long time. I've been talking to a lawyer." She went on for a while.

Finally I got a chance to ask some more questions. In the guise of updating her history I asked about any surgeries, new allergies or immunizations in the last year. When I got to the social history I asked about smoking (no), exercise (walking) and drug use: "No."

"Ever?"

"Not since high school, and that was just some experimentation."

"With what?"

"Pot."

"Cocaine ever?"

"No."

She had mentioned she was getting a little cold, so I had a pretext for a brief physical. Nothing abnormal I could detect about her nasal mucosa, pupils or anything else, so I was stuck. There was nothing I could say.

I had the chance to talk with Bob again when I called with his blood tests. He asked if I had seen Abigail and I avoided answering directly. But I said to him, "What can I do if she flat out denies the drug use?" He suggested lying about physical findings, telling her something like "I can tell from your nose you've been doing coke" but those kinds of lies often backfire. I don't do things like that. What if she wasn't snorting it?

I asked again how certain he was.

"Positive. I've seen her with known drug dealers, right up the street from your office." (Oh, great!) "I've seen where the money comes from. I'm certain."

"Have you said anything to her?"

"Like I said; it's been going on so long now, we're all fed up. She won't listen to us."

"Any idea who she would listen to?"

"You, I hope." (Great.)

What if her brother is lying? I don't think so. The balance of credibilty is very much with him (even if I haven't done a very good job in this post of conveying that.)

And that's where it's been left. So what should I do:

1. Confront the patient with the information, along with the name of the informant (against the informant's wishes?)
2. Confront the patient with the information but refuse to tell her how I found out? (This often becomes problematic as the visit devolves into a guessing game about the informant's identity.)
3. Not say anything to the patient unless or until she comes clean on her own? (This becomes more difficult for me as time goes on, as I see things in the context of her drug use but can't address them directly.)

#3 is the obvious ethical default, but it's hard to just stand by and watch when you know someone is doing this to themselves.

Thoughts?

Adventures of The Mighty Hunter

Another personal tidbit: I am a cat person. At the moment there are three felines of various sizes, intelligences and proclivities vying for the patch of sunlight on my kitchen floor:

• A fat but fluffy gray tabby who doesn't go out (because when he does he reverts to a feral state)
• A gray short-hair with more than a little Russian Blue in him, who goes out once in a while to check things out, and who has no facial expression whatsoever; so much so that he appears to have received incompetent Botox injections (therefore hereinafter referred to as "Botox Cat" or BC)
• An orange tabby -- spittin' image of 9-Lives' Morris -- who rules the neighborhood, to whom I refer as The Mighty Hunter (TMH.)

As I was going out to get the mail yesterday, TMH and BC dashed out ahead of me (well, BC dashed out; TMH slipped out with dignity.) I noticed a squirrel hanging on the trunk of a tree perhaps four feet above the ground, surveying the scene. I didn't think anything of it; the squirrels are usually smart and fast enough to get above where the cats can climb to quickly enough to escape from any danger they usually present.

Imagine my surprise -- mingled with dismay (I like squirrels) and pride (atta boy!) -- a bit later when my son pointed out what was happening on the front porch: BC was just sitting there watching as TMH grabbed a dead squirrel in his mouth, threw it upward, then batted at it with his front paws, playing with it. My son was laughing as he commented, "It looks like TMH is teaching BC how to kill a squirrel!" Indeed it did. TMH had killed a squirrel! Impressive, even for one who regularly comes bearing gifts of small former rodents. The thought later occurred to me that perhaps the squirrel had been preoccupied keeping BC in view, so TMH ambushed it while it wasn't looking. I don't give BC credit for enough intelligence to call it "teamwork", but it seemed like a great strategy for TMH.

I picked it up gingerly by the tail and tossed it a few feet onto the lawn, just to get if off the front walkway, intending to come back later and dispose of it.

Oops!

This morning my son and I went out for breakfast. We arrived home to find the lawn service finishing up (blowing away rubbish; the lawn was already mowed.) My heart sank as I rolled down the window and asked the guy, "You wouldn't happen to have picked up the dead squirrel in the middle of the lawn before you mowed, did you?" His blank expression conveyed ignorance of either the presence of a dead squirrel in the middle of the lawn, or of English.

My son got out of the car and walked over to the last known position of the squirrel carcass. I called out, "Is it still in one piece?" or was the lawn covered with tiny shreds of squirrel, I refrained from adding aloud. He laughed (always a bad sign from a teenager in this context) and replied, "Sort of." I went over to check it out for myself, and was greeted with a sight that I shall refrain from describing, for the sake of those who may be eating or drinking, have recently done so, or plan to in the near future. Suffice it to say that garden utensils will now be required to effect removal.

All hail The Mighty Hunter.

Update: my step-daughter has correctly pointed out that BC more closely resembles the British Blue Shorthair rather than the Russian variety. In fact, this could be his brother. Also, TMH presented us with a tiny former mouse the next morning. (Dessert?)

Surgery and Rape

Sid Schwab is a semi-retired surgeon, a medical blogger and an amazing writer. He recently wrote a powerful piece called Taking Trust, about his experience of the intimacy (his word) of surgery.

Why then did I find myself profoundly disturbed as I came upon this part:

I will reach in gently and caress the liver, the stomach and spleen. Slide over the top, into the recesses, curl the fingers enough to sense the texture, the fullness. The bowels move away and under, and over the top as I direct my hand. I can describe your kidneys now, I've circled the top of your rectum, held your uterus, measured your ovaries between my fingers. Part of you is gone at the moment, but I'm here, I know you now. You trusted and let me in, you opened your belly to me, and I entered with force. I'll stay until it's right. It's what I must do. You think you'll never touch me so intimately as I've touched you. But you have. You have.

The word-image he had drawn so skillfully -- a female (as this patient happened to be) immobilized, unable to respond, carefully positioned, and then invaded -- reminded me of another powerful blog entry I had read. Although this other post described a very different situation, I was stunned by the similarity of my visceral response to each:

He ran his hands all over me, inside and out … gently at first, and then rougher and rougher. After what seemed like an eternity of having his hands prying, pinching, pressing … he positioned me the way he wanted me … and did what I knew he was going to do. I remember thinking that it was never going to end. Rough doesn’t even begin to describe it. I hurt for a long time afterward in places I didn’t even know I had.

For anyone who may not recognize this, it is part a description of a rape. I almost got the feeling that I was reading about the same incident, but from the other side (since no one knows what the rapist was thinking.)

Surgery is not rape. I do not mean to imply in any way, shape or form that it is. I am well aware that these are two paragraphs taken out of context, and juxtaposed. (Please read the two posts again in their entirety. The links are here and here.) But what am I supposed to do when two skilled wordsmiths describe such different things and evoke the same disturbing picture in my head?

There is no getting around the subliminal ways in which surgery resembles rape. There is bodily violation by one person of another; and there is pain. Obviously all resemblences end there. Every effort is made to minimize the violation (laparoscopy) and the pain. The intentions are polar opposites: service, not subjugation. But I submit it is that visceral resemblance which engenders the trepidation, the unease, the fear with which surgery is approached by the patient. And I confess it bothered me to sense the surgeon's enjoyment of it.

I have exchanged emails with Dr. Sid, and I understand that he was trying to convey surgery's mystique, the reverence with which he undertakes it, and the respect he has for the patients who allow him to do this to them. I don't believe he feels any differently from generations of surgeons, but I do think he has a gift for words and more courage than most as he tries to share his feelings with us.

Perhaps more explicit acknowledgement of these superficial similarities -- even if just in our own hearts -- will allow us to better assure our patients that our caring and concern sometimes requires actions with roots of brutality.

Punched in the Gut (Again)

I am about to reveal two pieces of information about myself that I have been withholding -- for the sake of "anonymity" -- until now.

1. I love baseball, and
2. I live in Philadelphia (for baseball purposes.)

My brother is about to celebrate his 13th wedding anniversary. I remember his wedding well; I found myself constantly checking on my small children off in a hotel room with a babysitter. Why yes -- there was a television there, to which my jock-precocious 6-year-old was glued. I was actually in the room for that wrenching (and wretched) Joe Williams' homer that defeated the Phillies in the World Series back in 1993.

It's been a long 13 years.

My brother and his wife have two beautiful daughters. My son has grown from a baby jock to a full-fledged one, always pulling for the "Fightin' Phils" -- though we used a different adjective that began with "f" to describe them; always snatching defeat from the jaws of victory. This season was one of the best so far. I really got into it. I also confess to growing attached to the players, forgetting they're just "playing pieces" traded regularly. I always feel a special attachment to anyone who used to be a Phillie. So when they announced that major trade a few months ago with the Yankees (Bobby Abreu and Cory Lidle) I was crushed. Bobby had always been a fan fave here, and Lidle had thrown some gems.

Yesterday afternoon I followed this blog in real time, stunned when I learned the name of the pilot. Although the national news refers to him as "New York Yankee Cory Lidle", the radio here this morning said, "Former Phillies pitcher Cory Lidle." Bottom line is that he was only 34. Sad however you cut it.

Another discolsure: my father has been a pilot since he was 16 years old, and has owned a small plane much of his life. Many of my treasured childhood memories are of "punching holes in the sky" with him on weekend afternoons. Actually, though, the headlines also display one of his greatest fears: that of dying in a plane crash with someone famous, so that the papers trumpet something like "Paris Hilton and 79 others killed in plane crash." How ignominious to be the "another man" killed "with Cory Lidle." I'm sure we'll find out more very soon; I haven't yet read the paper this morning. (I should stop blogging already and go read it.)

More P4P (Sigh)

There's an interesting discussion taking place in the comments trail of my opening salvo on the topic of P4P. Rob and Diora are going at it hard and heavy, but they're not actually discussing P4P anymore. They're locking horns over the value of screening tests in particular and preventive care in general, trading figures and citations. As it happens, I agree with both of them, at least on that particular topic: preventive care is a good thing, but patients should have the final say about all testing and treatments -- including screening -- in consultation with their physicians.

Why does P4P always seem to devolve into a discussion of preventive care? It's because P4P needs a way to measure what "performance" is being "paid" for (or "4"). Preventive care, screeening tests, immunization rates, concrete numbers like blood pressures and A1Cs are measureable, so that's what's measured. It's hard to argue that higher rates of evidence-based interventions aren't better than lower rates, so those are the numbers that become a proxy for "quality" as we all get sucked into meaningless discussions about the value of preventive care.

This whole thing is starting to sound more and more like the move in the early '90s towards physician practice sales to large hospital systems to create so-called "vertical integration." Remember what they said then:

• It's coming; you'd better get ready for it; it's inevitable, so you're going to have to deal with it.

Didn't make sense to me then and guess what: it never happened. We heard plenty of this, though:

• I/we/my practice did great/made a heap of money; glad we did it; couldn't be happier.

The first docs to sell their practices were happy at first. It was only when their initial four-year contracts came up for renewal (and the "system" was losing money because things weren't working out as advertised) that they found themselves behind the eight-ball, stuck with a tiny fraction of the negotiating power they had when the hospital was so desperate to buy the practice in the first place. Down the road, when the shortcomings of the model (foreseen by me and others from the beginning) became apparent, they were screwed.

Have you noticed that the biggest proponents of P4P are those who have found a way to benefit mightily from it? (And yes, I recognize the corollary argument: those who holler loudest are the ones who haven't made any money from it. So how much is legitimate criticism and how much is mere sour grapes?)

But Rob again makes the statement "Fee for service is broken," and again I say, bullshit. If that's the premise for all this P4P discussion, then we're just not starting from the same place.

Here's the bottom line:

The following statement makes no sense: "Pay for performance will improve quality of care," without defining "quality", "performance", and even "pay" and "improve." It is a bad idea to embark on a course of action without understanding the reasons for that action. Therefore unless/until someone can why P4P makes sense, I am not going to do anything (ie, go out and bankrupt myself by purchasing an EMR just for P4P.) Nor am I going to lose any more sleep over it.

P4P: My Point Exactly

From the comments, regarding the issue of "loyal patients who adore you but still haven't had mammograms and colonoscopies":

Isn't screening a patient's choice? Yes, colonoscopies can prevent cancer. Yes, mammograms might diagnose one of those cancers that are destined to spread before they become palpable, at just the right time. But the probability of an individual benefitting is small - less than 1/1000 after 10 years of mammograms, for example, and this is a pretty optimistic estimate. And screening has risks. Like overdiagnosis, for example, in case of mammograms. Like longer period of "being sick" if the cancer is so aggressive that early detection doesn't make a difference in the course of the desease. Like biopsies for false positives.

So if a rare patient feels that for her personally a higher chance of becoming a cancer patient, for example, is too high a price to pay for less than 1/1000 chance of having her life saved 10 years from now (forgetting that we are talking about desease-specific mortality and not all-cause mortality), how are you going to convince her? Assuming she is really informed, should you waste the precious time of the visit to try to get her to change her mind?

And what is quality? Openly discussing both benefits and risks of screening or just using scare tactic to get more patients screened? If you are not mentioning the risks, if you using relative mortality reduction and not mentioning the real chance of your patient benefitting, are you not misleading the patient?

My point exactly. You have to have something to measure in order to call it "Performance." It's easy enough to count up how many of your patients have submitted to assorted screening tests and other procedures, so that's what is being done in the name of "quality," and that is what I disagree with.

In addition to criticizing my choice of wine, Dr. Sid points out this:

There are some doctors who have better outcomes at lower costs than others. Were it possible -- and I'm not at all sure it is -- it would be nice to see an effort to figure out the differences and encourage them.

This was actually one point the speaker addressed that I felt was valid. He described data showing the number of tests a cardiac patient had from first presentation to cath lab. In cardiologists' offices with diagnostic equipment (echos, treadmill stress tests, etc.) the average was 4.5; in offices without such equipment, it was 1.5 (average number of tests between presentation and cath lab.) This information was made public, and the results were gratifyingly predictable: the overutilizing offices were promptly contacted by referring physicians who said, "We're not sending any more of our patients to you." Surprise: the number of tests from presentation to cath lab decreased. But this valid and useful intervention is a far cry from "pay for performance" in general, and specifically in defining "quality" in the office interaction between patient and primary care physician.

Further down in the comments, in a spirited exchange between Rob and Diora, comes this nugget:

As a patient I have a right to decide for myself whether certain small risk reductions are worth the risks or side effects for me or not. I don't want an incentive for a doctor that would depend on the choices I have a right to make.[emphasis mine]

followed by Fat Doctor's observation which, as always, is right on target:

I am not a salesperson. I am not a factory worker. I am a physician. Who will judge my performance best? I hope it remains the patient.

Amen, sister.

Creating Confident Parents

Comment from the esteemed Dr. Flea:

Another proposed Dino Law, Flea version:

"Nervous first-time parents tend to become nervous second-time parents".

At least that's been my experience.

With all due respect, Dr. Flea, my experience has been somewhat different. One of the coolest things in my 17 years of practice has been watching families come into existence, expand, grow and develop. Not just the kids but also their parents, as both parents and people. I feel an important part of my job is not just teaching the parents about caring for their child, but supporting them -- explicitly and enthusiastically -- in their child-rearing abilities. And guess what: it works.

I can't even begin to count the number of families I've known (often both parents became my patients before they were married) who were hopeless nervous nellies when the first baby arrived. By holding their hands and being their number-one cheerleader through those early days, I know I accomplished my goal of building their confidence when -- lo and behold -- they were nowhere near as nervous when that second baby came along.

I also have a lot of fun telling parents of toddlers -- who may be contemplating another child -- that second children are the complete opposite of first children. (And third children are the complete opposite of the first two.) I can't tell you what I kick I get when the mother of a five-year-old and a ten-year-old tells me, "She's so different from him," and I get to say, "I told you that before she was even conceived!" and the mom gets to say, "Yes, you did."

If I remember correctly, Dr. Flea has been in practice about four years. Perhaps as the years begin to pile up a little more and as relationships with patients' parents are honed to succor them with confidence in their own skills, nervous first-time parents can become confident subsequent ones.

P4P and Other Nonsense

I just got back from a meeting tonight; a meeting of my state specialty society, not something sponsored by Evil Pharma (a term invented by one of their employees, to whom I happen to be married.) The main reason I went was because the restaurant was

1. awesome (very tough to get into, especially on a weeknight; no reservations) and
   
2. five minutes from my house.

I figured the dues I've been paying all these years was enough to cover the cost, ("free") to assuage my hypertrophic sense of integrity.

The topic was "Pay for Performance", often abbreviated P4P. Somehow the idea is that doctors will take better care of patients if they're paid more. The State chapter had reserved us a gorgeous, cozy upstairs room with four tables each set for ten. There was a cash bar, where I bought myself a glass of merlot, and then helped myself to a scrumptious slab of mozzarella on a slice of tomato from the appetizer bar. I found a seat as my Academy Representative began her Update.

They're having conversations with the big insurers in our state; the ones who have us all over a barrel as they ratchet down reimbursements and pile on the denial hassles. Our Academy is making sure that our concerns are heard. They're talking to the insurance companies, and our legislators, and we should rest assured that our pain is being communicated to the appropriate parties. I helped myself to a plateful of delectable antipasto salad from the bowls placed on the table ("family style service") and savored the mixture of crispy lettuce, salty proscuitto, cheese and spicy vinaigrette dressing as I pictured the offices of whoever they're talking to at the insurance companies after the door has closed behind my Academy rep: soft chuckles, a gentle shake of the head, and on to the next order of "real" business. My concerns may be heard, but they ain't about to do squat about them. The Italian bread on the table was delicious; soft and freshly baked. As I spread it with a pat of butter and chewed the crunchy crust with pleasure, I realized that both the Insurance Exec and my Academy Rep were taking home regular paychecks; unlike me for the last three months.

The waiters filled the tables with platters of Chicken with Farfalle in Parmesan Broth, Salmon with Herbs and Lemon, Three-Cheese Ravioli (giant; al dente; in a scrumptious butter-cheese sauce) and Eggplant Parmesan. We passed the platters around and filled our plates as the main speaker began.

He was nice enough. Well spoken; confident; engaging; funny. He used to be a doctor, but is now working for some kind of healthcare company that doesn't actually provide health care. His power point slides had a nice sky blue/cloudy white background design, and he put forth bullet points that you couldn't really argue with. Well, you could, but he was such a smooth speaker it didn't seem polite to interrupt. A woman up front tried a couple of times, but he smiled knowingly and politely told her she was wrong. He began with:

• Capitation is broken

It's not really "broken." Capitation is/was a way to shift the risk of having to pay for a doctor's visit away from the insurance company and onto the doctor. Somehow or another back in the early '80s enough people were fooled, but have since wised up. If no one's willing to take it on, capitation won't work. That's why it's fading away. It's evil gatekeeper step-sister, referrals, are alive and well, though it's quite clear by now that they've devolved into merely a way for insurance companies to deny payment if all the hoops haven't been jumped through properly.

I noticed a lady at my table sopping up the ravioli sauce on her plate with a piece of bread. I reached for another piece myself and did the same, as another bullet point came up:

• Fee for service is broken

Bullshit. Pay me a reasonable rate for what I do and I'll be happy as a clam. Again, though, no one could say anything because the speaker was on a roll; examples, studies; none of which sounded quite right, but I didn't have an internet connection in front of me to google up data with which to confront him. Then he moved on to the meat of his talk:

• Fee for service has no incentive for quality
  
• Fee for service + bonus/incentive
• We need to reward quality

WTF? At no point in this talk -- or in any other P4P talk or discussion I've ever heard -- was the word "Quality" ever effectively defined in the context of medical care. I actually had a theorem in the early days of managed care and their black box bonus calculations: The more times the word "Quality" appears in a document, the more bullshit it is.

You can talk about "outcomes" until the cows come home: what percentage of your diabetic patients have A1C's under 7%; how many of your hypertensives' blood pressures are controlled; all kinds of things. And the guy did have a valid point about having loyal patients who adore you but still haven't had mammograms and colonoscopies, so obviously "quality" doesn't always track with "customer satisfaction." But I still say that the central element of "quality" will forever remain fundamentally unmeasureable; and here's why:

In the primary care context, the essence of a given encounter for medical care consists of an interaction between two people: me and the patient. There are certain things I'm expected to do: ask appropriate question to elicit sufficient information to come to an accurate diagnosis; decide upon and discuss various treatment options with the patient; make sure that the patient has enough information, education and emotional support to understand and implement the treatment (or work up) plan; and so on. But the key element is that the encounter is an interaction. There are two of us. The quality of that interaction is not 100% dependent on me. Any attempt to "measure" it implies that it is. And I don't buy it.

I managed to calm down as the plates were removed and platters with Tiramisu and Apple Crisp a la Mode appeared. The ice cream had ribbons of caramel swirled over it, so I had a plateful of ice cream, caramel, apple and sweet pastry alone, so as not to risk contaminating it with the chocolate coffee flavor of the tiramisu. I took a clean plate for a slice of that afterwards.

The talk turned -- inevitably -- to EMRs (electronic medical records) as an integral part of P4P. Everyone has to have them; that's how they're going to get the performance data they're going to pay you for. The lady up front pointed out that all the favorable data about the wonders of EMRs are from large organizations like Kaiser and the VA. The speaker again politely told her she was wrong, but neither she nor I had a laptop in front of us to Google him right or wrong. A man in the back spoke of the new EMR he had just purchased for $30,000. Once all the numbers were crunched, though, it turned out he was only going to see about $3,000 in P4P bonuses. The response, delivered somewhat more softly than the stentorian tones of the main presentation, was that his return was more likely to be in the areas of quality and lifestyle. I imagined presenting a proposal to an insurance comany -- actually to any kind of business -- and saying, "Now, you'll only make back about 10% of your initial investment, but you're likely to see improvement the areas of quality and lifestyle."

I sighed, finished my merlot and headed home.

In the early '90s the buzzword was "vertical integration." Hospitals and health systems were buying up medical practices like crazy. The idea was that by consolidating the referral base, the "system" would rake in the profits, which would then trickle down to the now employed physicians. The private office, especially solo, was considered an unworkable business model. It didn't sound right to me then, so I did not sell my practice. Sure enough over the next ten years, it didn't work out quite the way the hospitals and health systems said it would. So docs were stuck either buying back their own practices, or being subjected to more and more outrageous working conditions (required to see 56 patients in 8 hours, etc.)

This whole "pay for performance" thing doesn't sound quite right to me, for many reasons. I've been around long enough to be very wary in situations like this. When everyone seems to think something is so, but can't explain it in a way that it makes sense to me, either I'm stupid or there's something wrong with what they're saying. I have learned that I am not stupid.

But the dinner was delicious.

(More here and here.)

Long Range Planning

Comment from Still More About Money:

Everyone is replaceable when they are not making a whole lot. Once you are paid what you think you are worth that's when you move more towards the irreplaceable realm. Those 2000 people will find someone else to treat them and you are more likely to have more satisfaction by working less and making more in another market.

I actually find this comforting. Given that I can see my balance of happiness (personal/professional) tipping sometime in the next five years and that my goal is to re-invent myself into a cash-only practice, this commenter implies that those who truly value me will be willing to pay me. I'll stay where I am, but create my own market. Sounds like a good deal.

Funeral Song Meme

Thanks again (for nothing) DP (and RN Wannabe). I actually followed this meme from its inception:

BlogMD started it; one of those he passed it to was Frectis (new to me), who tagged At Your Cervix, thence to Ripple (and RNW), and finally to me. And all in one day (even though I'm taking an extra day before posting.) Hey, guys...we need a life.

The question is: What five songs would you like played at your funeral.

Let me begin by saying that I don't really care what happens at my funeral. I ain't gonna be there. It's the ultimate expression of the sentiment that funerals are for the living. I come by this sentiment honestly, by the way. My father's answer to the question, "Dad, do you want to be buried or cremated after you die?" has always been, "Surprise me."

Also, the traditional Jewish funeral -- which I assume will be the context of the festivities -- is usually short and frankly, five songs would be just too much; the service would run way too long. So I choose to read the meme as requesting a list of five acceptable options, as opposed to a playlist. With that as a preface:

1. Changes in Latitude (Changes in Attitude) by Jimmy Buffett (explanation: this is our family "vacation" song; the first song to get blasted out of the player as we head off to wherever we're going, to get us into the mood. In the setting of my funeral, it would be a way to let my kids send me off on my final journey.)
2. Pachelbel's Canon; just about my favorite piece of music, and appropriately "funereal".
3. Judy Collins singing the Beatles' In My Life; she does it as a ballad that is, well, heavenly.
4. The last movement of Beethoven's 9th Symphony; also one of my favorite pieces of music. I like the idea of a Joy-ful funeral (as long as the double bass players don't go out to a bar and get drunk, after fastening the last pages of the conductor's music with string so he can't get to it until they get back.*)
5. The Impossible Dream from Man of LaMancha (suggested by my spouse, because "It fits you," and I couldn't come up with five.)

Finally, since I'm not really into internet tag, I'll do the same thing I did before: anyone who wishes to, consider yourself tagged. Count off in the comments, up to five.


* The last movement of Beethoven's 9th symphony features the melody played by the double bass, which is so soft they need like 12 of them to play it loud enough to be heard. They only play at the beginning and very end of the last movement, so there's a huge stretch in the middle with nothing for them to do. The story goes that once, all the bass players snuck out to a local watering hole and proceeded to get smashed. Suddenly realizing they were going to be late getting back, the section leader reassured them: he had tied the last few pages of the conductor's musical score (before their entrance) with twine. When they finally made it back on stage, though, the conductor was furious; and with good reason:

It was the end of the 9th, the score was tied, and the basses were loaded.

And the Puns Just Won't Stop*

Unfortunately retitled "Viagra keeps you up at night" by Blog Around the Clock, Sleepdoctor has this:

Each year, millions of men in American seek treatment for erectile dysfunction (ED), a condition that is often associated with obstructive sleep apnea (OSA). Since its introduction in 1998, Viagra has become the most common form of treatment for ED. It works by enhancing the effects of nitric oxide, a compound that relaxes muscles in the penis and allows for increased blood flow, triggering an erection. Now a new study by a team of Brazilian and American researchers suggests that a single 50-mg dose of Viagra may actually worsen symptoms of obstructive sleep apnea (OSA). The study involved 14 middle-aged men with severe OSA in a double-blind crossover study. Using polysomnography, the researchers analyzed the severity of symptoms and found a significant increase following a dose of Viagra compared to placebo.

There is a full abstract of the study at his post here.

I don't know for sure, but I suspect lots of other primary physicians have a *hard* time talking people into going for a sleep study. They don't like the idea of spending the night away from home, in a strange place, with all kinds of wires attached to their heads and other gadgets stuck to their fingers and faces and bodies. The study is expensive, time-consuming and -- just to rub salt in the wound -- often a hassle to get precertified, and even then often denied by insurance companies. Still, sleep apnea remains a very important condition to diagnose and treat. It can even be fatal (Philadelphia's Reggie White.)

It can also contribute to erectile dysfunction. For which men are flocking to me and my colleagues for Viagra and its friends. And now it turns out to make ED worse; what a vicious cycle.

On the other hand, it also gives me more *leverage* to get my patients into the sleep lab. No Vitamin V without treating your sleep apnea first. Cool.

*Originally titled: "And the puns won't stop *coming*"

Ouch

This one is so dead on, it just hurts.

Good Enough

MedStudentGod over at Creating the God Complex is having a little crisis of confidence:

In some ways I think I’m inferior to other medical students around the country simply because I attend a “humbler” medical school. I’m not trying to sound arrogant here, but a sizeable portion of my class wouldn’t have been accepted anywhere else and were only allowed in after completing some after undergrad program...I don’t know. Right now I consider myself lucky to be in medical school at all, but wonder how it would have been in another school – a top 50 medical school.

Here's my answer to him (edited, because I've had more time to think about it):

NEWS FLASH: There really is such a thing as "good enough". All US medical schools that teach you enough to pass parts I and II of the Boards are "good enough". Beyond that (residency) your education is truly up to you: you will get out of it what you put into it.

Despite your dim view of some of your classmates, the fact remains that they did get into medical school, which means that someone, at some point in time, thought they could become good physicians. In many ways medical education is as screwed up as the rest of the health care system in this country, beginning with the fact that too many people who will make lousy doctors are admitted in the first place. On the other hand, the real issue is that it's impossible to tell. Plenty of jerks in school get their heads handed to them one way or another later on, which turns them into pretty nice people and decent docs after all.

I know this sounds difficult (if not impossible) to believe, but there really will come a time when you will no longer be tested, graded, ranked, compared and evaluated continually. (No; specialty board re-cert doesn't count. It's too sporadic and too easy.) Not only that, but despite the fact that you are finally in a group of equals, the system still insists on ranking you. If 1000 valedictorians get into Harvard, 10% of them will wind up at the "bottom of the class" -- by definition -- 4 years later. Whether or not you are a "good doc" or a "bad doc", or even a "mediocre doc" is entirely up to you, and has NOTHING (I need to repeat that: NOTHING) to do with the name of the school on your dipoloma.

There are docs from Harvard and Yale who suck, and alums from your school (note: I don't even know what school you're at, and it doesn't matter) who are amazing. Coming from what you and others may consider a "mediocre" school just means you may have to work harder. It's not fair, and I applaud your surgery professor for wanting to change things, and I agree, med students deserve better, but don't go getting yourself into an inferiority complex.

The whole "prestige" thing of paying attention to (or even noticing) what residency or med school you attended is really only an issue in the academic setting. Guess what: there's a very big, wide world out there composed of sick and hurting people who need your help, and who don't give a shit about that stuff.

You sound like you need a bolus of confidence. Infuse it over twenty minutes, preferably through a central line (straight into your heart) and re-check your anxiety level in the morning.

Be the best doctor you can be by concentrating on your patients, especially when you get to residency. I know you can do it.

Love Those Old-Time Peds Guys

From the Right Time comments:

When my son swallowed a penny, the doctor asked if we knew the year. Yes, we did (it was from my older son's collection.) We told him.

The doctor said "That's a worthless penny. I've already got it in my collection. Just let it pass."

I'm reminded of a story a patient told me of her old pediatrician: she called him frantically one day upon finding her daughter eating kibble from the dog's bowl.

His response: "Is she barking?"

*****

Something is bothering me. Back in the day -- my med school day, that is -- the Blades vs. the Fleas (with an awesome West Side Story take-off for Skit Night) was the way we described the eternal divide between Surgery ("to cut is to cure") and Medicine ("last to leave a dying dog".) How and when was the term "flea" was co-opted by pediatrics?

*****

Also from a long ago Skit Night:

Surgical Attending: Dr. Resident: what procedure do you suggest for this patient?
Dr Resident: Uh...uh...I think we should do a lap chole*.
S.A.: Lap chole? Lap chole? This is a seventeen-year-old girl with a broken elbow. Why should we do a lap chole?
Dr. R: I'm a surgeon. Surgeons are supposed to do what they do best. Lap chole is what I do best.


*Short for laparoscopic cholecystectomy; removal of the gallbladder through a series of tiny little incisions instead of one huge right upper quadrant one. In the original joke, the operation quoted was a "feeding gastrostomy", an ancient procedure frequently performed before someone figured out how to stick an endoscope up against the abdominal wall and get a trained monkey -- er, assistant -- to numb up the spot, poke a hole and push in the feeding tube. (The so-called PEG -- Percutaneous Endoscopic Gastrostomy -- tube.) It's so easy the surgical interns are doing them on each other these days so they don't have to stop working just to eat.

Skeptic's Alert: Another Community of Crazies (Old News)

I ran across this post at Freakonomics the other day:

[My dentist] told me that tooth decay in general, even among wealthy patients, is getting worse and worse, particularly for people in middle age and above. The reason? An increased reliance on medications for heart disease, high cholesterol, depression, etc. Many of these medications, Dr. Reiss explained, produce drymouth, which is caused by a constricted salivary flow; because saliva kills bacteria in the mouth, a lack of it means increased bacteria, which leads to increased tooth decay. Given the choice of taking these medicines versus having some tooth decay, I’m sure most people would still choose the medicines—but I am guessing that most people haven’t thought about the link between the two.

followed by this in the comments:

The dentist's comments are a classic example of anecdotal beliefs espoused by many healthcare professionals to their patients without the backing of evidence-based medicine; i.e. clinical trials. If Dr. Reiss could back up his assertions with some evidence I would be more prone to believe them. And in case you are wondering, my skepticism arises from his broad claim that most medications used to treat modern chronic medical conditions cause dry mouth. Many medications do cause dry mouth, but of the ones I know that are used for today’s most common conditions, none of them stand out as particulary drying to the oral cavity. Furthermore, there is an alternative explanation that seems to me to more closely follow Occam's Razor, an explanation I might add that is popular among many other dentists. The increase in tooth decay seen in modern times can be linked to the increased popularity and pursuant consumption of bottled water, the nonfluorinated cousin of regular tap water. And of course we know that one of the greatest things you can do for your teeth is consume adequate amounts of fluoride. Go figure.

A little further along there was this:

I thought if a child ate enough toothpaste, he’d die of fluorosis – is this urban myth?

Dino to the rescue! (Someone else beat me to it, though.) I was researching an answer to the effect that no, fluorosis was a cosmetic discoloration of the tooth enamel (but the author may have been thinking, correctly, of the danger to children from mouthwash with high alcohol content) but in the process of finding links to document my comments, found this:

The Fluoride Action Network: A group vehemently opposed to the poor little halide.

Minimal googling on my part, though, came up with these reassurances that while I've been off nibbling the tops of the trees and losing the name Brontosaurus, nothing has changed. Just the tip of what I found:

CDC Fluoridation Home Page
Surgeon General 2004
Why Fluoridation is Important (QuackWatch)
American Dental Association
World Health Organization

In fact, Quackwatch has that very same Fluoride Action Network on their NOT RECOMMENDED list of information sources. I suppose I'm only just stumbling across this nonsense now because I'm the new kid on the block. Have people like Dr. Bartram, Flea and the Woo-Meister already demolished these pretenders before I got here, and/or is it time for more exposure?

Law Number Seven

Why is there such a steady supply of anti-vaccination nuts, anti-fluoride extemists, and all the other craziness? Stupid people reproduce. I feel a dinosaur law coming on:

Fertility is inversely proportional to intelligence.