The Hardest Conversation - Part 2 (The "C" Bomb)

Dr. Blog has a discussion about this New York Times article. He advises us Primary Care types:

...to wait until they are 150% sure of the diagnosis before breaking out the ‘C’ word. One can find onself neck-deep in fear, tears, wadded-up tissues and hard questions in a very short period of time after saying it. The ‘C’ word tends to turn off rational thought and turn on the “white noise of emotion” machine at 110 decibels. You can’t take back the ‘C’ word very easily.

I understand that this is a pediatric oncologist talking, so the situations he is addressing are very different from what I encounter in practice. Nevertheless, I understand the principle behind this statement and, in general, I agree with it. On the other hand, I have "broken" this rule on occasion, fully aware of what I was doing, because of a carefully thought out rationale that effectively accomplished what I wanted to do: provide the best possible care -- psychological and emotional, in this case -- for the patient.

A patient in her late 50's came into my office complaining of upper back pain, and two small lumps "on" her right breast. I had last seen her three years earlier for a checkup, at which time I suggested she have a routine mammogram. She hadn't.

The entire right breast was replaced with a locally advanced, stony hard, obvious carcinoma. The two "lumps" the patient was referring to were areas where the tumor had broken through the skin. She had large nodal masses in both axillae, as well as the right supraclavicular area. My strong suspicion (which turned out to be correct) was that her back pain was from bony metastases.

Now technically speaking, because I didn't have a tissue diagnosis, I couldn't be "150% certain" that it was cancer. Except that it was. It was like coming across a guy from a motorcycle accident with his leg bent mid-femur and telling myself that I couldn't tell for sure his leg was broken if I didn't have an x-ray.

I stepped out of the room while she dressed and collected my thoughts. I went back in, pulled my stool up next to her chair and took both her hands in mine. I held them tightly for the remainder of the visit, and began by saying, "This is cancer." She didn't freak out, because obviously she had had a pretty strong suspicion from the start. I went on to tell her that we needed to find out just what kind it was, what cell types and receptor status we were working with, because that would determine treatment. We also needed to find out exactly how much it had spread.

I told her that it was very possible that this is what she would die of eventually, but that I had no idea how far in the future that might be; she might live 10 or even 20 years more with treatment. (I did not say she might live as little as six months, partly because I really didn't have enough information to come up with a meaningful prognosis at that point, but also because even though I was telling her she had cancer I was specifically trying to give her hope.) I also told her -- several times -- that whatever happened, I would be there for her and for her family, whatever happened. I wasn't going anywhere; I wasn't going to be afraid to talk about dying, if that's what was going to happen. She was not going to be abandoned.

Here was my thinking: There was no doubt clinically that this was a malignancy. By coming out and saying so directly, I was removing the uncertainty of "maybe it isn't cancer" and letting her get through the 110 decibel "white noise of emotion" machine now; here; with me, instead of a surgeon she'd meet once before the biopsy and once afterwards, perhaps as much as a week later, "once the pathology report is back" (in order to be 150% sure it was cancer.)

I believe that my approach put her in a much better position to hear what was being said when it counted: when those vital reports came back. Having had the several week lag time it was going to take to complete the diagnostic work up to adjust to the idea that she had cancer, when talk began of chemo and surgery and radiation options, she wouldn't also be dealing with the shock of the "C" bomb.

It worked. At least, she told me that it worked. I got her hooked up with surgery for the biopsy and oncology for the metastatic work up (which showed tumor in her upper thoracic spine; right where her pain was.) Her wonderful oncologist (the same one who so thoughtfully sent me this) told her that chemo first was the best option, with further treatment dependent on her response.

It's been well over a year. (Perhaps even two; I'd have to check her office chart.) She's responded amazingly to her chemo. All her tumor masses have shrunk drastically, and she hasn't even had any surgery yet (except the initial tiny punch biopsies the surgeon did in the office.) She feels great. Her back doesn't even hurt anymore. She looks wonderful (she has a great wig.) Her son had twins; she just helped them celebrate their first birthday, and she is looking forward to the birth of her daughter's second child. This lady has metastatic cancer, and although "cure" is not an option, she is certainly not "dying" at this time.

There is such a thing as compassionate honesty. It can even include the "C" word.

The Hardest Conversation - Part 1

This article in the New York Times has spawned some discussion in the blogosphere, and I would like to chime in.

Many years ago I remember seeing a woman in my office with an acute abdomen. She was in her mid-60's, and as I recall, I was very suspicious of a bowel obstruction. Although colon cancer was foremost in my mind, it turned out to be ovarian cancer.

Through the next year or so of surgery and chemo, remission and relapse, she came to me for acute care for non-cancer related problems as well as her blood draws, because her insurance was such that all blood had to be sent from my office. I never minded this, as I've become quite adept at phlebotomy and we had some wonderful visits.

I've read that what people with terminal diagnoses fear is abandonment. They also fear pain, but they feel they can talk to their doctors about their pain, and hopefully it can be controlled. But they're afraid of people being too afraid to talk to them or be with them because they are dying that they're going to be alone. Even if they aren't literally abandoned, if everyone around them (including the doctor) is too uncomfortable to talk about it, then they have in fact been abandoned emotionally.

It turned out that I was the only one who ever talked to her about dying.

Late in her disease, she told me that the oncologist never spoke of it. Only about what treatment they could try next, and so on. She and I always talked about it very openly. I always made it a point to tell her explicitly that I would always be there for her; I'd see to it that her pain was controlled; and that I'd take care of her family after she was gone. She understood what was happening, and told me how much she appreciated my willingness to address it directly.

A few weeks before her death, she obstructed again. Miraculously, other than that she never had any pain. She had exploratory surgery, but her entire abdomen and pelvis was socked in with tumor. There was nothing to do but close her up and send her home with hospice.

I went to her home, which she shared with her daughter and her family, to visit her on a Thursday morning to say good bye. She still had no pain. Her body looked like a concentration camp victim's, but the brightness of her eyes was striking. Peaceful; almost angelic. We talked. We laughed together when she told me about the surgeon telling her to "Come back in two weeks so we can take the staples out." She wasn't going to be here in two weeks, and everyone knew it.

We talked of her children and grandchildren. Her son and his family were coming up from Virginia that weekend for what everyone understood was a final visit. She spoke of a dream she had had the night before: her father was calling to her, telling her it was time to come in. She didn't, of course. She woke up instead. But she joked with us that when her mother called, then it would be time to go. Dad could be ignored for awhile, but not Mom!

When we had said all that needed to be said, I leaned over and hugged her gently. I thanked her for letting me be part of her life, and told her again I would take care of her family. She thanked me too. And I said good-bye.

She died on Monday.

I don't know why I've never shied away from discussing a terminal illness, nor why I do not find it awkward to talk with patients who are dying. They are intense, important conversations, but they are issues I feel competent addressing.

Perhaps it was the death of my mother, which occurred right at the end of my internship. I was devastated at the time; it felt like the worst thing in the world. What happened, of course, was that life went on. I had children; they grew. I started my practice; it flourished. I was blindsided by a divorce (which was even worse) which I also survived. Somehow, the idea took hold in my soul that death was not the enemy. It is a part of life, and a very important part of my job is dealing with patients who are going to die. (Technically, all of them.)

I applaud the efforts described by DB to incorporate training in these discussions into educational curricula. Hopefully, the next generation of caregivers won't find them quite so hard.

I Looked as Hard as I Could, But I Couldn't See Them

Another task usually performed by my Wonderful Staff is posting the checks and preparing the deposit, which I then take to the bank. Today, after patients were seen and Darling Spouse had gone home (I insisted we come in two cars today so I wouldn't feel guilty staying later to finish things up) I was the one posting the checks. This also included stamping them with the little stamper that says "For Deposit Only." (I love playing with little stampers.)

As everyone knows, checks are no longer printed on plain paper. There are now all kinds of nifty new security devices like water marks and tiny printing and colors. One check had a little pink bar and bore the message, "Bar will disappear when rubbed with finger and reappear if check is genuine." I did, and it did, so it obviously was.

But one that had me stumped said this:

DO NOT ACCEPT IF SECURITY MARK OR INVISIBLE FIBERS ARE ABSENT.

Only one question: how can you tell?

Dino Laws Keep Coming

I gave my staff the week off between Christmas and New Years, but I'm still seeing patients. Darling spouse is answering the phone, taking messages and making appointments for me (getting pretty darned good at it too) but even so, I find myself subjected to a lot of the crap that my Wonderful Staff usually takes care of entirely behind my back.

I'm talking about "Referrals"; those dreaded things referred to by a former patient who went to Hollywood to write comedy as a "secret handshake to allow you to get medical care." My office policy is to require one week's notice for elective referrals. So of course the call comes, "We're in the dermatologist's office and my daughter needs a referral." Can they wait until next week? No, of course not; the daughter is home from college and going back next week. Even as I stumble through the referral maze (and get it done; I'm too good to my patients) I find myself muttering:

Poor planning on your part is not an emergency on my part.

Presto! Although I've been saying it for years, only at this instant do I think, "Dino Law!" While I'm at it, I realize that another thing I've been saying for years -- and have tried to immortalize on my blog footer, waaaaaaay down below -- is this:

A bad idea held by many people for a long time is still a bad idea.

It has now become the Twelfth Law of the Dinosaur (and has been removed from the footer.)

Studio Audience

I have only had cable television for about five years. I never watched enough TV to justify the cost, but when my new spouse came into the picture, cable came too. Within a year I was addicted to Law & Order, even as I gained a passing familiarity with other staples of cable, including my spouse's favorite: Food Network. Rachel, Bobby, Alton, Giada, Ina, Paula (not quite as much; sometimes I find her kind of cloying) and the Iron Chefs (both American and Japanese; our favorite pastime is making up and lip-synching our own X-rated commentary on the latter) are now familiar personages to me, as is the format of watching professional cookery in progress.

I am the only Jew left in a large, happily intermarried family, so when I decided to join them for Christmas, of course the high point of the holiday was Christmas dinner. This year it was at my step-sister's new house, which I had never seen. What a treat we were in for!

The house, originally built in 1937, was magnificent! (I've also learned to enjoy A&E's Sell This House. Watching Roger Hazard and Tanya Mammary clean up houses for sale has gotten me used to seeing what a house really looks like, even when cluttered with the detritus of teenagers and Christmas.) My step-sister -- did I mention she's an architect? -- had designed an addition that melded flawlessly with the original in terms of style and decor. The dining room -- easily larger than the largest room in my house, the family room -- held the two tables for 16 total with plenty of room to move around. The kids' table in the living room was a nice touch. The only child at the main table was my sister's 3-year-old, who was almost as good a conversationalist as anyone else. (Making sense is optional in my family.)

The family room sported the Christmas tree and a colorful undulating sea of gifts, which the kids passed around to assorted relatives, eliciting appreciative oohs and ahs. My sister's father-in-law served as a "reverse Santa," following around with his trash bag to help scoop up paper and ribbons as they disgorged their loot. But of course the centerpiece of the house was the kitchen.

At this point I should mention that my brother-in-law is a professional chef. And the kitchen they designed for him is the equal of any seen on the Food Network. Enormous eight-burner industrial gas range with double ovens; butcher block island; granite counters; separate bar sink. Just a truly magnificent space.

Once all the gifts were opened, we gathered at the breakfast bar (under the stunning glass lighting fixtures) as we watched him finish preparing the meal. Cooked sirloin of beef was carefully sliced (how does he do that so evenly?) and arranged on a platter, then spritzed with jus and piled high at one end -- just so -- with wild rice. Green beans; rolls to die for; honey roasted ham; and an enormous earthenware pot filled with macaroni and cheese (a perennial kid favorite; merely attaining the age of 18 does not negate one's status as a "kid" for the purposes of mac-and-cheese) with the most scrumptious, thickest layer of breadcrumb topping I've ever seen, so much so that I didn't even realize that's what it was until I got a whiff of it; that completed the buffet.

I felt as if I were sitting in the studio audience of a Food Network production.

Watching a professional chef live and up close is truly amazing. Somehow they make everything, inlcuding the most awkward kitchen tasks, look not only easy but elegant. All the while laughing and chatting with family, cracking us up while nonchalantly reducing some spiced apple wine (our gift to him; we were thrilled that he used it right away) in a pan and dashing it over the salad as part of his vinaigrette. Tossing salt crystals over the sliced meat; garnishing the ham; he made it all special.

He told us that many years ago when Food Network was just starting out, he went up to New York with some tapes of a local cooking show he used to do.

"They just laughed at me and said, 'Go away'," he told us.

They don't know what they missed. Eat your heart out, Food Network!

Intellectual Dishonesty

Dear Katie;

You know what bothers me most reading your responses in the comment trails of medical blogs? It's the hypocrisy of your own words.

In Flea's post about the Hemophilus Influenza type b vaccine, you posted a list of meaningless "questions" in the comment-trail-that-will-not-die that you later "answered" yourself, including this:

Is it possible Hib disappeared, rather "almost disappeared," for other reasons?

Yes, anything is possible. [emphasis added]

and yet you then go on to assert in my comment trail:

Hib is pretty much impossible for breastfed children

But Katie; as you yourself have pointed out:

"Anything is possible."

The sad thing is you can't even see how ridiculous you look when you say these things. But congratulations on starting your own blog. You may be an intellectually lazy idiot, but I never said you were a coward.

Yours,
#1 Dinosaur

Seasons' Greetings

Best wishes for an environmentally conscious, socially responsible, low stress, non-addictive, gender neutral winter solstice holiday, practiced within the most joyous traditions of the religious persuasion of your choice, but with respect for the religious persuasion of others who choose to practice their own religion as well as those who choose not to practice a religion at all;

Additionally, a fiscally successful, personally fulfilling, and medically uncomplicated recognition of the generally accepted calendar year 2007, but not without due respect for the calendars of choice of other cultures whose contributions have helped make our society great, without regard to the race, creed, color, religious or sexual preferences of the wishers.

(Disclaimer: This greeting is subject to clarification or withdrawal. It implies no promise by the wisher to actually implement any of the wishes for her/himself or others and no responsibility for any unintended emotional stress these greetings may bring to those not caught up in the holiday spirit.)

Credit: John Eakin of Airsafety.com (email: reports@airsafety.com) and my father, who found this on the internet and printed it out for me, because I don't think he knows what the "forward" button on the email screen means.

(That's probably not true; I think he thought it would be easier for him to just hand me the piece of paper when I saw him over the holiday. Thanks, Dad.)

(And Dad: If you ever doubted me, please note the full attribution/credit duly given. Happy?)

HIPAA vs. Community

I have always been a stickler for patient confidentiality. From the moment I hung out my shingle I refused to use a sign-in sheet. (The tenth patient of the day had no business knowing who else had been in.) I trained my staff not to holler out patient names if there were other patients standing around. I also practice what I preach; I'll bring a chart to them and point to the name while saying "This lady is on line 1 and needs an appointment." Even the fact that someone is my patient at all is potentially sensitive. Although I do my best to jump through all the HIPAA hoops, I tell my patients, "Here are my 'privacy policies': I won't tell anyone anything about you unless you say I can in writing."

On the other hand, when patients discover how wonderful you are, one of the good things they do is rush out and tell all their friends, neighbors and family members all about you. And in the fullness of time, many of these friends, neighbors and family members come in and comfirm for themselves that you are, in fact, wonderful. So what happens is that you get to caring for clusters of people: family groups, neighbors, office mates and entire aerobics classes all become patients. I've lost track of how often I hear the exclamation from the waiting room, "I didn't know you come here!" While there are certainly busybodies and gossips out there, many of these community groupings are people who care deeply about each other and are entwined in each others' lives. It is my opinion that blindly following the letter of the HIPAA laws is not only unnecessary and unreasonable, but is detrimental to the care of our patients in the context of their communities.

Example 1: First Monday morning patient is standing in front of me signing in for her visit. (Her diabetes is under great control with her 55 lb weight loss, but she always bring us cookies or doughnuts when she comes to visit. Not the crappy ones that are easy to pass up either; the rich butter cookies with the sprinkles, or the chocolate covered miniature doughnuts -- the ones that are impossible to resist.) The phone rings; Mrs. A has a cold and wants an appointment. We set one for later today. Then she says, "Did you hear that Mr. B passed away Saturday night?" Mr. B is a hospice patient of mine who happens to attend the same church as Mrs. A, who has frequently made remarks on previous visits about him. It seemed rude -- not to mention pointless -- to be coy about knowing Mr. B, so I felt comfortable enough with polite responses acknowledging the relationship. (Also, as it happens, the hospice had somehow screwed up so that the last doctor to discharge him from the hospital had somehow become the physician of record, so that was who'd been called.) So I got to say to Mrs. A, "No, I hadn't. But thanks for letting me know." (It also came in handy later in the day when we got a call from the funeral home to sign the death certificate. I punted it over to the other guy.) I jotted Mr. B's name down on a post-it, planning to pull the chart and call his wife later.

Wonderful Staffer #1 walked in about then, saw the post-it and exclaimed (yes, in spite of her training; WS1 isn't quite as tuned into the subtleties as WS2) "Mr. B passed away?" Whereupon Cookie-or-doughnut lady said, "Mr. John B?" Whereupon I recalled her having previously told me about her friendship with Mrs. A. She too knew Mr. B, but had not heard of his passing. A group of caring people moving in the same social circle; I refuse to view this "HIPAA violation" as a bad thing.

Example #2: A lovely gentleman in his early 80s with six children, of whom four are my patients and two of whom bring their entire families to me. Although sharp as a tack, he had hearing problems for decades, and sometimes had difficulties recalling what I said at visits and questions he had intended to ask. His two daughters (the ones whose families I see; one of whom works for a local orthopod) were very close to him, and he frequently asked me to call them to schedule his appointments. When he was diagnosed with a colon cancer recurrence (to which he eventually succumbed) information was often given at "family conference" visits. Even on those occasions where I essentially informed one of the daughters of a test result before telling the patient, I knew it was ok with him. Not only did he never express any dismay at my having done so, he told me several times that he wanted them to know first so they could help explain things to him. It was truly "Family Practice" in the most rewarding sense of the term.

Then again, this community thing can be hard to get away from. I went to my local big box hardware store to look at some doors for my living room at home. The above referenced gentleman's oldest son (also my patient) was in charge of the doors department. He wrote up our order for unstained pine French doors with lovely bevel cut glass windows and arranged for the installation. No problem.

A week later his sister -- the one who works for the orthopod -- came into the office for a BP check and said, "What kind of doors did you get?" We discussed the various color options of urethane stain under consideration.

The following week their mother came in for blood work to monitor her lipid medication, whereupon I was treated to a very informative discourse on the relative merits of rag vs. brush for applying urethane stain to unfinished pine. (Rag: much easier to apply the stain evenly, for a nice uniform finish.)

Darwin and Vaccines

(Note: this post is written partly to avoid exacerbating Flea's burgeoning comment trail, and partly to address an issue that got buried in it; but mainly to offer my support to the noble Flea.)

Flea is in the process of writing a wonderful series of posts about vaccine-preventable diseases, and of course in the process has been subjected to the attack of the wingnuts. Now at 121 comments and counting, there were a few along the lines of "Just let them die" (ie, let natural selection kill off the anti-vaxers by allowing them to contract the diseases in lieu of receiving the vaccines to which they so object.) Although I know (or sincerely hope) that these comments were tongue-in-cheek, I would like to address the question -- perhaps unasked in precisely this form -- "Why bother fighting them if it's only their children they're putting at risk?"

First of all, I am not agreeing with the second part of that statement. Herd immunity is real but fragile. Nevertheless, it must be agreed that unvaccinated children are at much more immediate risk from their status than are their innoculated peers.

So what's the harm? They may be whack jobs, but it's a free country. And in America, the most treasured right is the right to be stupid. Why should we waste our time and effort trying to convince delusional science-illiterates?

The answer is similar to that given by the senior OB resident during my third year med school rotation during the particularly hectic treatment of a drug addict in labor. I forget who raised the issue, but the question was asked, essentially, "Why are we bothering?" If the mother didn't care enough to take even the slightest care of herself all through the pregnancy (as I recall, she kept getting herself pregnant so she could shoot up in the dilated veins of her breasts) why should we be putting in all this effort to care for her now? The answer -- which I know comes as no surprise to any pediatrician or ethical OB reading this -- was that it wasn't the baby's fault its mother was a drug addict. Whatever your belief in "original sin" from a theological standpoint, it is never medically appropriate to punish one patient -- the baby -- for the sins of another.

The same issue holds in pediatrics. By and large, the ideal of the "best interests of the child" is seen similarly by loving parents, who want to do everything that can be done to keep their children as healthy as possible, and physicians with our armamentarium of vaccines.

Conflict arises when parents object to standard medical treatment -- whether they be paranoid, anti-vax wingnuts, or thoughtful, religious Christian Scientists. We may question the intellectual stands they take, but I don't think it's fair to impugn their feelings for their children. Still, we are left with the conundrum that has led to court orders overriding parental wishes in life-threatening medical matters. Although we cannot draw the line directly enough from "refusing to vaccinate" to "immediate threat of death" to justify that degree of intervention, it is still the innocent children whose interests we must keep striving to represent, even if it means dealing with irrational people.

That is why these discussions -- futile as they may seem -- deserve to continue.

There's also another side to this.

A few months ago, I saw a new patient in my office. This lovely, intelligent 14-year-old had received no immunizations at all. Having now done the research for himself, this boy was requesting all age-appropriate vaccinations. To his parents' credit, although they disagreed with his decision, they respected his wishes and brought him to see me. We (he and I) sat down together and set up an appropriate schedule. I administered the first set of vaccinations; he returned as requested, and all went well.

I have another family in my practice who just had their first child. They had "concerns" about the vaccines and came to see me before the birth to discuss these issues. They ended up deciding to forego Hepatitis B, but so far their 2-month-old is otherwise "on schedule." They don't want her to get MMR or Chickenpox vaccine, but every time I see them we discuss it some more. I try to provide more information and address their concerns with respect. I'm optimistic that when the time comes, the kid will end up fully vaccinated. And even if she doesn't, there's always the possiblity that she, like the young man above, will transcend her parents' limitations and eventually choose vaccine protection for herself.

So hang in there, Flea. Even though the crazies may come out of the woodwork, you never know who else is listening.

Think About This

Topic: insurance companies whose preauthorization (or "prior authorization) process for approving medications requires a "trial" of one or more "equally effective alternatives" before the drug in question will be approved.

Example: I have a patient whose depression has been successfully controlled with name brand Prozac for several years now. (Yes, back when I was young and stupid -- about two years ago -- I offered her a trial of the generic; didn't work.) Now her insurance is again looking for a trial of cheaper meds.

Never mind that this patient is being asked to potentially suffer a relapse of debillitating depression symptomatology (or, as the esteemed Dr. Dork puts it: hosting the black dog.) What they are asking is for me to prove that their formulary medication choices are inferior to my selections based on clinical experience and the patient's proven response.

Not only are they practicing medicine; they are doing it badly.

Why Do We Really Do It

I just finished reading Sid Schwab's book, and -- among lots of other things in it -- I find that he brings up an interesting point. How do patients really know how good he is, when all his amazing work (which includes the "cognitive" aspects of what to do, what to do it to, and when and how to do it along with the purely technical aspects of "doing it") is hidden away behind neatly tied sutures? (He also addresses this in his blog from time to time.)

Sid is right. As he has said, the body is very forgiving, and even if a surgeon isn't quite as elegant as he is, the patients heal up fine and no one is the wiser. Lest he think he's all alone in his sense that no one really knows how good he is, allow me to assure him that he is not.

A deft turn of phrase in a patient interview that elicits the nuanced response that suggests what turns out to be the correct diagnosis is just as much a thing of beauty as an elegant dissection. Coming up with just the right words of comfort at just the right time; breaking bad news without breaking the spirit; the plain talk that cuts through the dense jargon to explain the everyday esoterica of medicine; these too must be appreciated for their own sakes, because no one else will ever know.

Ah, but the patient knows, you say. Your patients don't watch you operate (though there are nurses, sometimes assistants and anesthesiologists as occasional audiences.) While that may be true, I have to believe that the "better" surgery -- the one that causes the least necessary damage to the body -- is going to be easier to recover from. Although any given patient may not recognize that his recovery was marginally easier than his roommate's, I know that in the aggregate that kind of quality gets noticed. (Also, by definition, a given patient does not have the opportunity to compare how he feels recovering after the same surgery performed by two different surgeons.) Other physicians come to know that Dr. Schwab's patients get out of the hospital sooner, have fewer complications, and just seem to bounce back quicker that Dr. Schlub's. With the reputation comes the respect.

Then again, is that really the point? Certainly the respect and admiration of one's colleagues is an important reward; validation of ones' skills always feels good. But is that really why you do it?

I don't think it is. I think doing the right thing in the right way for its own sake is its own reward. (We sure as hell aren't in it for the money; right?)

We can brag to our staffs, to our families, to our colleagues. We can blog. We can even write books. We can enjoy our listings as Top Doctors in magazines; our nominations as Best New Blogs; perhaps even Doctor of the Year someday.

But ultimately, the only true satisfaction we are going to get is that which comes from knowing in our heart of hearts that we did a damn good job. If that's not good enough, we're in the wrong business.

(Postscript: I actually drafted this post before writing about my personal blogging rules. I just noticed that taking them together, they seem to be saying much the same thing.)

Just Saying "No" to Drug Reps

Stop the presses! DB and I agree on something.

The good Dr. Bob has not one but two posts about the perniciousness of drug reps pushing their wares. Frankly I have been saying the same thing for years; to their faces, though not on a blog.

Here's my take on it -- freely shared with reps who call on me:

1. Everything they say is propaganda.
2. They are better at it than I am (that is, even if I listen "criticallly" and "skeptically" they will compensate accordingly and therefore something will get through, whether I want it to or not.)

Here are my rules for reps (and only between 12:00 and 2:00 pm):

• I only take samples for drugs I already write for (comes in handy to hold folks over when their mail order is delayed)
• I will not accept *any* gifts. No pens/pads/kleenex/candy (even though it kills me to pass up chocolate) nor will I participate in any dinners or programs, no matter how "educational" you try to spin it. (See #1 above)
  
• If I have time, I will happily listen to stories of (or check out pictures of) your kids/pets/weddings/etc.
• I will not listen to any of your drug spiel (to the point of putting my hands over my ears and chanting "na-na-na I'm not LIStening".)
• If you keep on trying (or slip studies onto my desk while I'm in with patients) I won't let you back into my office.

Over the years I've made actual friendships with some of the reps. They've learned to "leave the rep in the car" and just enjoy their visit. (No, they tend not to bring their managers. Unless said managers are a real PITA and they want them taken down a peg. Then I'm happy to oblige.)

One rep's twins are growing *so* fast it's unbelievable. Another rep never fails to get down on the floor with my doggie and rub her tummy (the dog's, that is.) One guy's son is in my son's scout troop; we're planning to get together for dinner one Sunday night. Another rep with kids the same age as mine kept crossing paths with me at school sports events. Despite the fact that I haven't written his drug for years, he's a real friend. And another's black lab puppy is *too* cute. One of my best rep friends left to become a nurse; she's going to be an awesome one. Another married her med student fiance and moved to DC for his surgical residency; I went to her baby shower a few months ago, and just sent a baby present to her new daughter.

While I don't resent the reps as people, I don't feel their profession should exist. When you stop to think about it, I neither buy nor use their product. Nevertheless, I'm the one they must "sell" on it. I can't think of a worse reason to prescribe a given drug than, "The rep is a nice guy." Five of the six "weapons of influence" quoted by DB are routine for them. Drugs should not be *sold*.

DB's commenters disagree.

One points out our "responsiblity to listen [to drug reps] critically." See #2 above. We do not have the information readily at hand to counteract the spin they have been carefully trained to deliver. Studies have shown that even when we think we are listening critically, our behavior (ie, prescribing patterns) are still affected.

Another laments that he is "not as virtuous" as DB (or me, for that matter) for not finding out about new drugs and pharmaceutical developments on our own; independently of reps. I don't think it's a question of virtue, but of responsibility. I agree that listening to drug reps as a primary source of new drug information is risky at best and foolhardy at worst. In addition to Vioxx and Celebrex, they were pushing Ketek like there was no tomorrow. I admit to being quite proud of my status as a "late adopter" when it comes to most drugs.

Now, as soon as DB recognizes the absurdity of his arguments for so-called "patient responsibility," we'll all be just ducky.

Update: DB's commenters continue to elaborate on all the above points.

A Cure for Diabetes?

Why hasn't this gotten more play in the blogosphere? I just happened to see a link to it on Instapundit, when I went there checking out a link on hyperthyroidism on GruntDoc:

In a discovery that has stunned even those behind it, scientists at a Toronto hospital say they have proof the body's nervous system helps trigger diabetes, opening the door to a potential near-cure of the disease that affects millions of Canadians.

Diabetic mice became healthy virtually overnight after researchers injected a substance to counteract the effect of malfunctioning pain neurons in the pancreas.

"I couldn't believe it," said Dr. Michael Salter, a pain expert at the Hospital for Sick Children and one of the scientists. "Mice with diabetes suddenly didn't have diabetes any more."

The researchers caution they have yet to confirm their findings in people, but say they expect results from human studies within a year or so. Any treatment that may emerge to help at least some patients would likely be years away from hitting the market.

This isn't just woo-based hype from some altie group; it appears to be the real thing, research-wise. Here's a summary of the article in the journal Cell, and here's the full text. Will diabetes go the way of ulcers (with the recognition of the role of the H. Pylori bacterium) in our lifetime? Exciting stuff.

What Jews Do on Christmas

While I am well aware that a sizable proportion of those reading this know perfectly well what the answer is, I love this dude's take on it:



Happy Holidays, everyone.

With Friends Like These...

Here is a fascinating take on how things got this bad despite the alleged advocacy of the AMA and American Academy of Family Physicians (from the AAFP Practice Management bulletin board; with permission from Dr. KS):

I know [organized medicine is] well intentioned ... but I am afraid that in the final analysis they have hurt us far more than helped us.

The reason is because they fostered the illusion that we can work with the Government and Insurance Companies for the benefit of all. They have encouraged us to be patient and just learn how to work with this new small inconvenience because it could have been much worse. The result is the free market has been totally removed from health care and we are now fully controlled by entities who will slowly squeeze us until we have nothing more to give up.

I believe that if the AMA/AAFP had not been there encouraging us to be good little boys and girls and just be patient, physicians would have risen up long ago and rejected what they have done to us.

This message was in response to an invitation to next year's AMA meeting in Chicago to "voice your concerns." For many years now I have felt that the emperor's wardrobe was getting a little ragged, but of course who listens to one little old dinosaur off in a solo office somewhere. Other posts in response to the message above pointed out that all the dues we've paid over all these years has supported the mailings and publications and lobbying, plus keeping all of the administrators and employees in the style to which they have become accustomed, without demonstrably affecting the day-to-day problems with government intrusion, ever-changing insurance company demands and constantly declining reimbursements.

No wonder it feels like my pockets are being picked on all sides.

Change of Shift 1:13

I am a doctor because I couldn't do the work of a nurse.

I am honored to have a post of mine included in this week's Change of Shift at Protect the Airway.

Holiday Meme

Having been tagged not just once but twice with the Meme of the Season, I must thank dear Flea for the wonderful response.

So here are my answers:

1. Latkes or Sufganiyot ?

• Latkes -- for dinner. Can't make a meal out of jelly doughnuts.

2. Multi-colored candles or blue-and-white?

• Multi-colored. Whoever's turn it is to do the candles picks the colors.

3. Do you place the Hanukiah by the window or away from the window?

• Leave it on the kitchen table. The window ledge is a tad too narrow for my fire safety-consciousness.

4. Favorite Holiday Dish?

• Hanukah brisket: a two-day recipe made with onions, apple cider, molasses and fresh rosemary. Cooked on day one, then cooled overnight; sliced and reheated in the juice. A new addition (just a few years now) but an instant favorite.

5. Favorite Holiday Memory? (two part answer)

• Childhood: Because there were four of us growing up, Mom sometimes didn't get around to wrapping all the gifts. So she she took an orange bedsheet and decorated it with appliques of hanukiot, dreidls and Jewish stars. She'd arrange the gifts under the "Hanukkah Cloth" and then usher us into the dining room, situating each of us in front of the appropriate -- tantalizing -- bump in the cloth. Then, depending on her mood, she'd either whip the cloth off all at once (to collected sqeals of delight) or slowly expose one child's gift at a time, stretching out the anticipation deliciously.
• Adult: One year I gave each of my three children identical mini-scooters. As the heir to the Hanukkah Cloth, I set up the three boxes on the dining room table under the cloth and then ushered them in. Then, for as long as I could drag it out, I pretended not to remember whose gift was whose; moving the kids around, sending them out of the room so I could "check" which was which; moving them again and again. It was awesome.

6. One Hanukiah or more than one?

• Now that the kids are bigger and back and forth between divorced parents for the holiday, it depends. Generally just one, but at least once during the holiday we break out the usable ones from the collection (ie, not the impossible to clean, gorgeous artsy ceramic ones) and each person gets to light one. It's best when we have guests. The best part is the competition for who has the last candle going.

7. Do you remember your favorite gift?

• No, but what I do remember with great clarity is the first year I was more excited about the night when it was my turn to give my gifts, rather than anything I was going to receive.

8. Favorite Holiday Dessert?

• Gelt (gold foil-covered chocolate coins)

9. Favorite Holiday Song?

• A doo-wop version of "I Have a Little Dreidl" that we first sang in the synagogue choir about five years ago.

Regarding tagging: I'm not much into this part of the game, so anyone who wants to may consider themselves officially *tagged*.

Happy Holidays, everyone!

Is This Woo?

I love Orac. He is funny, insightful and brilliant -- not necessarily in that order. Respectful Insolence is one of the most wonderful things I have found in my brief (3 months to date) sojourn in the medical blogosphere. I just love him.

In response to this discussion of his about the woo/non-woo interface in medicine, I submit the following:

Many years ago, I first heard about the use of potatoes for the treatment of warts. I figured it was cheap and harmless, and the worst it could do was nothing; so I began recommending it to patients -- with the full understanding that it was a folk remedy with no known medical proof of its efficacy.

As it happened, over the years two of my three children came down with plantar warts. The first time, it was my daughter when she was about 5. After her bath (when the skin was still moist) I took an old, sprouting potato and cut it in half. I rubbed the cut potato edges on the wart, then covered it with a bandaid overnight. The next morning I forgot about it (she and her twin brother and the baby had to get off to daycare.) I also forgot about it that night. The night after, I remembered again and we repeated the procedure with a freshly cut, old sprouting potato. Covered it with a bandaid. Forgot about it. A few days later, I remembered and called my daughter over.

Me: Let me see your foot. (No wart. Wrong foot?) Let me see your other foot.

Success.

As it happened, a few years later her little brother developed a strange plantar lesion. I even ended up taking him to my friendly neighborhood dermatologist, who wasn't sure it was a wart (I'm good enough at derm so when I send something, it's either very rare or really atypical-looking) but when he shaved it a bit, he revealed those little black spots that bled. Wart it was. Potato again for a couple of nights (this time I sliced the old sprouting potato into about 1 inch slices and used all the cut edges, to get the most potato juice on it) and voila! Wart gone.

Because I love Orac, I know that "evidence" is not the plural of "anecdote." (I love that line.) But still, I was batting 2 for 2 at home, and about 50% over the years at the office.

My full potato treatment consists of debriding the wart by shaving it down in the office as much as I can, then instructing the patient in the key points, which are:

1. Moist skin (bedtime, after bath/shower)
2. Old potato; must be sprouting
3. Saturate the lesion with juice from fresh slices
4. Cover overnight
5. Pick or emery board away dead tissue
6. Repeat nightly as necessary

Orac requires a scientifically plausible hypothesis for the mechanism of action. Here's mine:

Perhaps by the time a potato has begun to sprout, the flesh has produced enzymes (to allow the sprout to break through the potato skin) that also have keratolytic and/or virucidal properties. I know I should try to perform an RCT (or persuade someone else to) but I just haven't gotten around to it. I would love to see an organic chemist with some time on his or her hands do an analysis of sprouty potatoes and, if possible, isolate the active compound. We'd make a fortune. I already have a name: VerucaSpud.

And so I put it to the medical blogosphere: is this woo?

More on "Patient Responsibility"

DB has rejected my counter arguments, and re-asserts what he is after with regard to patient responsibility:

If we just charged more for those who continue to smoke cigarettes, then our system would immediately have increased fairness.

Smoking cessation and weight loss are clear benefits. We really cannot debate the desirability of patients stopping smoking. We have no debate that obesity puts patients at risk for many problems.

Patients who continue to smoke and eat excessively spend more health care dollars. Now I understand that this is only on average, but I am happy to assert that the expenditure difference is great.

The esteeemed Dr. Dork -- of whose demise the rumors were, thankfully, greatly exaggerated -- also asks the good DB for clarification, and DB responds (in part):

Some commenters have argued that nicotine is addicting and smoking cessation is too hard. I do not consider that my problem. My problem is that your smoking causes my health care premiums to increase. Your smoking infringes on my financial health.

Whoa!

Smoking cessation is "not my problem?" You claim smoking increases your costs, and that increased costs are your problem. You can't have it both ways.

"Your smoking causes my health care premiums to increase." Where did that come from? Can you back up that statement? I don't think so. If that is the main support of your argument (which none of the rest of us can seem to grasp well enough for you to deem our concerns relevant) then I confess I am rendered speechless.

But let's set that aside. As it happens, I have no problem with setting health insurance premiums on criteria other than membership in a group (ie, sharing a certain employer) but, as one of the commenters to your response to the good Dr. Dork put it, you're trashing the concept of shared risk, which is the essence of "Insurance." I'm cool with that, though. Then again, remember that one of my proposals is to dispense with the present system -- which is basically health care payment brokerage -- in exchange for actual "health insurance," just like auto and life insurance (ie, that pays for catastrophes but not maintainence.)

Still, I would suggest being careful what you wish for.

Do you really think that the premium structure for auto and life insurance is based on "fairness?" Sure, that's how they sell it; but don't forget for a minute that all insurance companies are in it strictly for the money. Actuaries are only looking at the bottom line. Sometimes the outcomes are "fair" (smokers pay more for life insurance) but often they are not. Folks with family histories of cancer also pay higher premiums than those born into less risky families. They may not think it "fair" but they have no choice.

Auto insurance is no better in terms of "fairness," despite your blithe comments about higher rates for lousy drivers. My two sons, age 17 and 19, have never had a ticket or an accident, yet are charged the highest rates for auto insurance. Why? Because of the statistically bad behavior of their age- and sex-matched peers.

So by all means, let's get rid of group health insurance and let the actuaries set "fair" rates based on voluntary health habits. I think you'll find that because they're part of the insurance industry, they're going to be looking more at the bottom line than primarily at the health benefits. So in addition to surcharges for smokers and sliding scale premiums based on diabetics' A1Cs, don't be surprised to find runners being charged more than those who walk for exercise -- based on their actuarial higher risk of injury and greater use of (expensive) orthopedic interventions.

However this old saurian heart was also warmed by the following:

Thanks for reading oh dinosaur. Your blog is entertaining, and intellectually honest.

I thank you sincerely for the compliment. I enjoy your blog as well, and am trying to do my part to get you up over that 1 million mark.

"Patient Responsibility"

Prompted by West Virginia's plan to incentivize Medicaid patients, DB has a great discussion going on here and here about some of the philosophical, ethical and economic aspects of "Patient Responsibility." At first I was going to join in the fray, but then I found that his commenters were all making my points -- many of them far more eloquently than I could.

Nevertheless, DB appears unswayed by their arguments. He accuses his commenters of avoiding his question, and then rephrases it. Before I address it directly (since it's a terrible mish-mash of a non-question) let me begin with my take on "Patient Responsibility" and why, with regret, I cannot support the concept. (Philosophically, DB. No Fisking here.)

Essentially, we are talking about "P4P for Patients", and every single argument that we legitimately make against P4P for physicians also applies to this.

Several conditions would have to be met for a Patient Responsibility/P4P program to be fair:

1. Patient choices would have to be the direct and only cause of whatever poor outcome you are trying to prevent.
2. "Good choices" made by patients would have to reliably lead to health improvement.
3. "Choices", which imply free will, need to be behaviors or actions that a patient has the opportunity and resources to undertake.

Unfortunately, none of those conditions apply; either in West Virginia, or anywhere in the world, because of the nature of the complex interaction between health and human behavior. Taken one at at time:

It's oh so easy to talk about diet and exercise in the context of things like diabetes and body weight. Unfortunately, the ability of diet to influence serum cholesterol levels, body weight and glucose levels -- among dozens of other parameters -- is tremendously dependent upon individual genetics. We all know 300 pound carnivores with LDLs of 90 and 120 pound vegetarians with triglycerides of 400. Insulin resistance is a necessary precondition for the development of diabetes in the presence of carbohydrate overload and a sedentary lifestyle. Despite all the hype about the "diabetes epidemic", it is clearly not true that everyone who overeats and gains weight will become diabetic. "Ideal body weight" is variable enough across the population so as to make the Metropolitan Life Insurance Tables meaningless from an actual health standpoint. And as long as non-smokers continue to be diagnosed with lung cancer, no one is ever going to be able to make a cause-and-effect argument effectively enough to make "Patient Responsibility" morally feasible.

So-called "good choices" must show reliable and postive results. If we're including medication complaince under the heading of "good choices", are we looking merely for compliance, or for outcome? I don't know about you, DB, but I have plenty of patients who are very compliant with all the antihypertensives I can throw at them whose blood pressures are still not optimally controlled. Just as I would object to having such a patient "count against me" in a Physician P4P program, I would imagine the patient would object to being penalized for "not getting his blood pressure under control." Weight loss is an even stickier subject, especially for the perimenopausal female population for whom maintenance caloric needs drop precipitously. They can truly follow an 1500 calorie diet without meaningful weight loss, even with vigorous, regular exercise. And of course, before leaving the subject of compliance it must be pointed out that the only interventions you plan to reward or penalize patients for must be thoroughly evidence-based. As Diora put it, 5 years ago a woman who refused HRT would have been considered non-compliant. Who knows what interventions we insist upon today might be shown to be either meaningless or even harmful sometime in the future?

Finally, are those things you designate as "choices" really things patients have a choice about? You may be rightly proud of yourself for your regular exercise program, but what about the arthritis patient? The plantar fasciitis sufferer? The busy mom who has to get three kids up and out to school before work, then has to supervise homework, dinner and baths before collapsing herself? You may "choose" not to smoke, but plenty of smokers struggle with addiction, depression, anxiety and other mood disorders. The argument, "I can do it; so can you" can be seen as analogous to telling a person with major depression to "just snap out of it." ("I have bad days, too; why can't they 'choose' to cheer up and look at the bright side.") Perhaps the best way of formulating this is the principle of walking a mile in another man's shoes before judging him.

Believe me, I'd love to lose this debate! I'm just as frustrated by what appear to be willfully self-destructive patient behaviors as you are. Sure, it would feel good to see them forced to "take responsiblity for their actions," which of course boils down to punishing them under the guise of "rewarding good choices." I agree that it sounds like a good idea intuitively, but examining the implementation requirements reveals the weaknesses of its philosophical underpinnings. (And that's not Fisking, DB.) Just as it makes intuitive sense that chest CTs are better than CXR at finding early lung cancers, I believe it was DB himself who correctly called upon us to wait for the evidence. Banal as it sounds, good health must remain its own reward for good health habits; just as the only appropriate measures of physician quality must ultimately remain patient opinion.

Now, let's see how DB rephrases his original question:

Should we reward those who work to improve their health? If we do not then those who ignore their health (by continuing to smoke, show poor adherence, avoiding exercise and not avoiding high calorie diets) are subsidized by those who do the “right things”.

We have a challenging philosophical question. Treating all patients financially the same means that we penalize (financially) those who take care of their own health. That is hardly fair in my mind. Why should my insurance rates go up because obesity is increasing, and therefore diabetes is increasing?

Our current system is financially disadvantaging the normal weight, non-smoking exercisers. Is that fair?

What are you talking about, DB? What the hell does "treating all patients financially the same" mean? Charging everyone the same amount for health insurance? Do you really think your insurance rates are going up just because there are too many other fat slobs (who happen to be unfortunate enough to carry the insulin resistance trait that renders them susceptible to diabetes) who can't get their asses in gear and never met a Big Mac they didn't eat? Don't you think the William McGuires of this world, who never met a legislator or insurance commissioner they couldn't buy, have something more to do with it?

As it happens, there are already plenty of rewards available for good health behaviors. BC/BS programs to reimburse gym membership costs exist. There are partnerships between Weight Watchers and other insurance plans for similar financial incentives. What you want to add now is the stick: punish those smokers who "refuse" to quit. It's a lot easier to do that than to sit down with them time and again over years and years and years as you patiently persuade and cajole and encourage. I fully understand the urge for the former, but the latter; well, that's our job.

(Read more of DB's comments here. They continue to expand on my points with great eloquence.)

The Passing Parade

The above title was the "Subject" line in an email from my father this morning. He was forwarding the obituary of our old pediatrician (age 82) who made housecalls and who retired to South Carolina at the ripe old age of 61.

Here is my response in its entirety:

I make housecalls. Does that mean I can retire at 61?

On with the parade...of life, that is. Think of it this way: *We* are the ones in the parade, and as we go marching along, eventually others will step out of the line. We may stop for a moment at the roadside to bid them adieu; perhaps linger a short (or longer) while as we ponder the distance we've come together, the things we've seen together, how we'll miss them as we navigate the road ahead, and how much they would have enjoyed the sights yet to come. But we always keep marching right along.

Some people spend a lot of time complaining, "When is this parade ever going to end?" I think the luckiest among us come to realize that the parade is the adventure; that there is no destination, and those who are always rushing to get ahead in it are like little kids complaining "Are we there yet?" It never ends. Some day, those we love will stop for a moment at the side of the road and remember us too. If we really love them, we'll want them to get right back into that glorious parade. They'll miss us, but they'll go marching off down the road without us.

And once the parade is out of sight, we don't really know what else might come along.

Sometimes the creative juices just flow early in the morning; right along with the coffee.

Grand Rounds 3:11

It's Tuesday again, which means it's time for Grand Rounds. Even though I don't have a post in it this week, Emily at The Antidote has done a wonderful job with it; well worth checking out.

A Very Good Rule

In another online forum for FP's, discussion often rages about how far to go for our patients, at what point they are taking advantage of us, and how to set the line between the two. Dr. G says it best:

A colonel I respected more than many other leaders I've served under made his expectations known in a clear, succinct manner. The members of his squadron were given the following instructions more than once:

"Though I expect you all to bend over backward to help a patient, I do not expect you to bend forward for them."

There's a fine line between delivering good customer service and being taken advantage of. My rule of thumb is the minute I feel that I'm doing more forward flexion than lumbar extension, I've gone too far the wrong way and it's time to redefine my expectations with the patient.

When I asked for permission to quote his wonderful writing, Dr. G did point out, "I'm glad you appreciate my writing; I think the colonel did the bulk of the work creating a catchy, memorable rule."

True, Dr. G. But thank you for sharing it.

Rad Rage

Flea is to Emergency Department as #1 Dinosaur is to Radiology.

It should be so simple. A patient with fever, productive cough, chest pain and rales on exam. I order a chest x-ray. I write a note that says, "CXR; r/o pneumonia." The patient goes to the hospital and gets the chest x-ray. So far, so good.

As it happens, this patient has been through a lot in his life (including throat cancer and asbestos exposure) that has left its mark -- lots of marks -- on his chest x-ray. The report comes back:

We do not have any previous studies for comparison. It is very important that we compare the current study with the previous study to determine any changes. This patient has extensive asbestos-related pleural changes and calcifications in both lower pleural surfaces. There is also nodularity in the left mid lung fields which needs to be compared with previous chest x-ray to ensure stability. If this is new, then a CT of the chest would be indicated. There does appear to be subtle infiltrate in the right lower lobe, which may represent an early right lower lobe pneumonia.

As it happens, I have reports on this patient's chest x-rays going back to the early 1990s at the same hospital. Therefore the films described in those reports are all -- say it with me -- at the hospital. With a choice of a CT of the chest or comparison with old films, guess which one has no radiation or contrast exposure, is completely independent of patient compliance and doesn't cost nearly as much? I'll just get them to do a comparison with the old films.

I call the film room. I give the patient's name, date of birth and medical record number. I tell the clerk that I would like the radiologists to please compare the current chest x-ray to the old films that they (should) have in their files. The clerk asks for the patient's date of birth (again.) I give it (again.) I am told that I need to put my request for comparison with old films in writing. I am given a fax number to fax it to. I write the following (after writing the patient's name, date of birth and medical record number):

Please compare CXR of 10/6 to previous films. I include dates of 3 most recent previous films going back to 2001. Previous reports attached.

I fax not just this note but the report from the most recent previous CXR. Hey, I'm trying to be helpful. Maybe there's some secret code number somewhere on the report that will help them find the film more easily.

I wait.

A week later I call the file room back. They never got the fax. I send it again. This time I call to confirm that they got it. They did. I ask when I can expect to see the comparison. They tell me they have to find the patient's old film envelope; then the radiologist can dictate an addendum to the report.

I wait.

Another week later I call back. Monica, the film room clerk, and I are now on a first name basis. She lets me know that the films are in the radiologist's pile and I should see the addendum in 2-3 days.

I wait.

The following week I call my friend Monica, who promises it will be faxed to my office by the end of the day.

The next day, the addendum reads (essentially) "No change from previous films." Time elapsed: 1 month to determine that my patient has all kinds of nasty-looking pleural shit that is stable, and a new superimposed RLL pneumonia (for which I treated him) and from which he is now clinically recovered.

Just in time for the followup chest x-ray to make sure that infiltrate cleared. Keep in mind this is a guy with asbestos damaged lungs who stopped smoking for about 5 minutes after he was diagnosed with his throat cancer (ok, it was maybe about 2 years) so there's always the possiblity that the new infiltrate dscribed last month wasn't actually pneumonia but something bad like a lung cancer.

(Deep sigh.) Ah, but this time I have learned my lesson. My note for the CXR reads:

CXR; please compare to study of 10/6 to determine resolution of RLL infiltrate in patient with known abnormalities on CXR.

Six days ago he had the film done. Three days ago it was read. Yesterday it was dictated. Today I saw the report:

PA and lateral views of the chest were performed and compared to a previous study done on 10/6. Again noted is extensive asbestos related pleural changes with calcified pleural plaques as well as increased density in both lower lung fields especially in the left perihilar region. While this has not significantly changed since October, I would like to compare these findings with older chest x-rays which we will attempt to obtain. Once the previous chest x-rays are available, additional recommendations will be made.

AS YOU CAN SEE, NOT ONE WORD ABOUT THE RIGHT FUCKING LOWER LOBE!

Fay Wray is to King Kong as Monica the film room clerk is to #1 Dinosaur.

I call the film room. I tell Monica what the problem is. She is so good at her job that I actually keep a civil tongue in my head. She is also a fucking miracle worker: about two hours later, the radiologist -- the VERY SAME RADIOLOGIST THAT ACTUALLY READ THE FILM even (after supposedly having read my note) -- calls me back! I surprise myself at the civility of my tone (after listening to her tell me why they can't find the older films anymore and these two are so abnormal she really wants to compare them to the older ones) as I ask, "What about the RLL infiltrate? Is it still there?"

Finally finally finally it turns out that the two films are identical. The likelihood is that it wasn't really an infiltrate from 10/6 at all but rather all pleural based stuff, as he has very extensive bibasilar changes. But the bottom line is that now what he needs is a CT of his chest. (Very. Deep. Sigh.)