Department Meeting

Every other month there is a luncheon meeting of the Department of Family Medicine at the hospital where I am on staff. Given that I no longer actively admit patients, the actual meaning of the term "on staff" lends itself to some interesting discussions, but I digress. Actually, there's a meeting every month, but its location alternates between two of the three hospitals in the "Health System" to which they belong. (The third doesn't have an active Family Practice presence; it's a large community version of the "general" hospital, which in this day and age means that it has a large number of highly specialized services.) The staff bylaws require attendance at two such meetings annually. You may ask why, if I no longer admit patients, I continue to maintain staff privileges at all. It is a reasonable question. The answer is that the insurance plans with which I contract require it as a condition of said contracts. Kind of circular, but there it is.

So every other month I leave the office as close to 11:45 as I can manage and make my way to the sprawling suburban hospital "campus", as they like to call the sprawling suburban complex of hospital, attached medical office buildings, the obligatory Cancer Center and the acres of concrete meadow that never -- and I mean never -- have a parking space the first three times you ride around them.

We used to meet in the Board Room, an impressive, mahogony panelled room with an enormous dark wood table surrounded with green cushy swivel chairs. Now, due to assorted construction projects, we are relegated to a tiny room off the Doctors' Cafeteria dominated by four rectangular tables pushed together in the center of the room and surrounded by light blue hard plastic chairs about four inches from the walls.

Lunch is served. It is provided by one of two alternating drug companies, so there has to be a brief "And now a word from our sponsor" moment on the agenda, to which I have no choice but to listen politely, even as I fume. Come on, guys; we all claim not to listen to this bullshit in our offices. Why to we just sit there and take it at Department meetings? I'll have to call the chair and ask to have it added to the agenda next time we meet.

There is a predictable and depressing pattern to these meetings. We complain that the ER isn't letting us know what happens to our patients when they present there. The ER representative says they'll try harder. We complain we aren't getting information from the hospitalists when our patients are discharged. The hospitalist representative says they'll try harder. Then we get to hear from the hospital president.

An older lady fond of perfectly tailored pastel suits, her presentation too is predictable. The hospital is doing fabulously! Admissions are up; surgeries are up; deliveries are up; census is up; they're raking in money hand over fist, up an impressive percentage from the last period measured (month, quarter, fiscal year; whatever.) I struggle not to wince during this part as I reflect on the fact that unlike the hospital, my income has been steadily declining year by year, quarter by quarter, sometimes even month by month. But it's the next part of the talk that always pisses me off.

They need money. They're building a new Patient Care Pavillion, new operating suites, a whole new ER, a new parking garage; all this shit that needs money. They have millions already but they need millions more. Fundraising efforts are detailed, and always inlcude mention of staff participation. That's right: in addition to paying $350 dues annually for the privilege of missing half a day of work every two months, just so the insurance companies will continue to allow me to "participate" by receiving 76 cents on the billed dollar (on average, for office visits), I'm also being hit up for money. Sorry, Madam Hospital President. I have kids to put through college.

Only once in the last eight years I've been at this hospital did this pattern change, and I'm pleased to say it was I who opened my mouth after the first part of the talk. I raised my hand and began ranting (that's really the only word for it) that it was all well and good that the hospital was doing so well, but I wasn't. Not only did I fail to benefit from any of those hospital dollars, but many of them came from my referrals; if not directly, then through my referrals to the hospital's specialists (instead of to the specialists at another hospital much closer to my office, where I was in fact on staff for the first ten years of my practice.) My colleagues joined in, and we basically chewed her a new one.

Neatly coiffed gray (excuse me; silver) hair: $120.00
Perfectly tailored pastel suit: $349.00
That deer-caught-in-the-headlights look: priceless.

Sixth Law of the Dinosaur: Rebuttal or Confirmation?

As is universally known (to anyone who reads my sidebar) the Sixth Law of the Dinosaur reads as follows:

Trauma survival is inversely related to the patient's value to society.

Still occupying a fair amount of column space and air time in the print and broadcast media respectively is the near miraculous survival of New Jersey Governor John Corzine from his recent unscheduled meeting with a guardrail on the Garden State Parkway, which occurred without his seatbelt in attendance. Not only did the 60-year-old governor survive, but to date (knock wood) his recovery has been amazingly rapid and complication-free.

At first blush, this phenomenon would appear to conflict with the Sixth Law.

Then again, he is a politician.

Brief Foray into the "Health Care as a Right vs. Need" Discussion

Panda Bear and Emergiblog [sorry, Kim, but I can't find your specific posts; let me know and I'll edit/link], among others, have eloquently expounded on the topic of Health Care as a Right vs. a Need. This debate often brings up an analogy that I would like to point out is seriously flawed; too much so to be a valid comparison.

It is the analogy of health care to food, a subject near and dear to the hearts of many. The example is given that a commitment to subsistence nutrition does not equate to the right to walk into any restaurant and demand to be fed a five-course gourmet meal. "Basic" medical care available to all is considered the equivalent of not going hungry. This analogy is trotted out a lot, probably because it seems to make sense. Guaranteed health care doesn't have to be "all the bells and whistles;" just the "basics."

The analogy falls apart quickly, though. "Not starving to death" can be accomplished with a huge variety of diets costing anywhere from a few dollars to veritable fortunes per day. One's daily ration of calories (refusing to go into the whole issue of overeating/overnutrition for the purposes of this discussion) can just as easily be obtained by home cooking of thrifty supermarket purchases as it can by patronizing gourmet restaurants seven days a week. The utilization of excess resources to obtain a more exciting variety of food is irrelevant to the issue of starvation.

Medical care is different. Although it is tempting to talk about "routine health care" as things like immunizations and "routine checkups," the whole point of prevention is to detect health problems early and intervene before they become severe. Without including the means to deal with issues identified during routine checkups, "basic health care" is nothing more than a bad joke. What good is it to diagnose an early cancer without providing treatment for it? What good is providing treatment but no follow-up?

Medical care is like the part of the communist ideal that says "to each according to his need." No less, but no more. Advanced testing like MRIs or cardiac catheterizations are either necessary or not. Just because one can pay for it (or, more realistically, is able to purchase insurance that will pay for it) does not mean that unnecessary testing ought to be done. Conversely, patients with life-threatening conditions should not be refused ICU care because of their lack of financial resources.

Just throwing a monkey wrench into the arguments for and against "universal health care," "single payer," and other assorted attempts to solve the current mess that is the US health care "system."

Disappointed New Scottoline Reader

I've just finished reading my first Lisa Scottoline novel, Daddy's Girl. Friends have raved about what a wonderful writer she is and, because she is local and many of said friends have met her, about what a nice person she is. I don't doubt the latter, but my first foray into her oevre was disappointing.

I'm not saying this in a petty, writerly way (though even Darling Spouse acknowledges that her secondary characters are pretty two-dimensional) but because she can't keep her crime scene straight. One must admit that in a mystery, not remembering whose chest the knife was in is pretty sloppy.

I read an excerpt in the Philadelphia Inquirer and thought it looked interesting, so I bought the book. Early on, our heroine encounters a crime scene: a prison inmate has stabbed a guard, or so it appears. The inmate is dead ("A muscle-bound African American inmate lay curled next to the C.O., blood soaking his T-shirt,") and the C.O. has "...the homemade metal knife protruding grotesquely from his chest." Our heroine "...even knew to leave the knife in place."

Later on, another C.O., the victim's best friend, describes the events: "Next thing I know, he pulls a shoe shank.. and he stabs Ron [the dead C.O.] in the chest...Then he tries to stab me, and we fought, and I was able to turn it on him." I'm not even a particularly experienced mystery reader, but I figure at this point the guy is lying, so I wait to see how he gets caught. But later on, our heroine visits the family of the dead inmate and "...relives the gruesome scene. [The inmate] lying on the floor, the metal blade sticking from his chest." Now that's sloppy editing, pure and simple. If it were anything less than one of the, oh, KEY SCENES IN THE BOOK, it wouldn't make much difference. As it is, it was quite a disappointment.

That was the big thing. The little thing was just annoying: It's about a character and a VW Beetle. No mention of whether it was an Old or New Beetle; no problem. But then our heroine "...grabs the strap..." when the driver is going too fast. Aha: Old Beetle. But then they get sideswiped into the guardrail and THE AIRBAGS DEPLOY. No airbags in an Old Beetle, and no side airbags in the New Beetle (ie, the front airbags wouldn't deploy in a side-swipe collision.)

So my question for all you devoted Lisa Scottoline fans out there is this: has she just gotten lazy as the best-sellers pile up, or does she do the same kinds of things in her earlier works? Bottom line: is it worth reading more of her stuff, or just chalk her up as another sorry example of the stuff that manages to get published these days?

Thanks in advance for your input.

Why an Electronic Medical Record is Not Right For Me

Note on terminology: Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) are synonyms. I'll mainly be using the term "EMR," except when quoting from elsewhere.

Family Practice Management recently ran an article on Myths about EHRs; how they don't fix everything, why they won't eliminate errors, and so on. The problem with this article, though, is that it's from the point of view of a practice implementing one, implying that they have at least bought into the idea that there is in fact something to be gained by working their way through the "myths" they proceed to debunk in the article. As I read it, I was struck by the mythology of those underlying assumptions. I'm no Luddite. I've thought long and hard about whether an EMR is a worthwhile investment for me at this stage of my life and the life of my practice. Over and over again, I find that each pro-EMR argument is based on assumptions that do not apply to me. Here are some of them, in no particular order:

• An EMR produces better documentation.

"Better" is one of those nebulous terms that is very much in the eye of the beholder. Certainly an EMR has the capability to spew out voluminous notes that don't actually say very much. "More" is not "better" by a long shot. The FPM article actually discusses this, using the term "signal to noise" ratio. The vast majority of EMR-generated notes I have seen have so much noise that the signal can barely be found.

What are some objective qualities that might constitute "better" documentation?

1. Legibility
2. Organization
3. Completeness

Come with me and peek into my charts for a moment; see how I'm doing now before insisting that an EMR can do it better.

Legibility: I hand write my charts, but I happen to have beautiful handwriting. Something about teaching myself calligraphy in high school, it's the artist in me that finds indented, outline-style notes easier to look back at when I need to review.

Organization: I have templates in my head of what questions need to be asked for a given problem. The trick is to fill in the answers as the patient gives them, then ask only those questions that are left. In many ways I think like a computer, and I have considered "creating my own EMR" by using a database to create the same notes I currently write. It might allow better functionality for searching, but that's about it.

Completeness: Again, those templates in my head serve me well. The inside front cover of my chart serves as Problem List, Med List, Allergies and preventive care flowsheets. I review and update those lists every time I open a chart, including phone calls and prescription refills in addition to patient visits.

The bottom line is that whenever my charts have been reviewed -- as they have by countless insurance flunkies, QA nurses and the lawyers involved in my lawsuit -- they have been uniformly praised on all counts. No one has any complaint with my documentation. I can easily find what I need when I need it. What do I have to gain from an EMR?

• EMRs save time.

Giving this statement the benefit of the doubt by assuming that it does not count the initial learning curve, I still don't buy it. One EMR ad touts the time-saving advantages of its system: "Get out of the office at 5:00 every day." I already do. About half the time I've got the entire note written by the time the patient leaves the office; the rest of the time I slip it in between patients and during other miscellaneous slots of free time through the day. Even if I have an entire stack to write after hours, it rarely takes me more than one minute (by the clock) per chart to finish them. It's the phone calls to patients about lab and test results -- not to mention playing phone tag with other doctors -- that eat up the time. EMRs aren't going to do anything about that.

• EMRs improve reimbursement.

Bullshit. That's just bullshit. How exactly does this happen? Through P4P incentives? Allow me to plagiarize myself for a moment. From the mouth of a recognized "expert" in P4P and performance enhancement who came to give a talk to a regional meeting of my state academy:

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 company -- 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."

A related point:

• EMRs improve performance.

Performance of what, as measured by whom? The usual example trotted out is something like, "How many of your diabetic patients have hemoglobin A1Cs under 7%?" Who cares? I do not take care of populations; I take care of patients, one at a time. Being able to say "87% of my patients are at goal for LDL" is a completely meaningless exercise for me.

• The government is pushing EMRs hard, and are working towards providing incentives to practices that adopt them.

Yeah, right. The government thinks it's a good idea. Don't forget this is the same government that was so sure there were WMDs in Iraq and that still believes, despite the evidence, in the efficacy of abstinence-only education. Sarcasm aside, this point may be true, but I don't see them getting their act together any time soon enough to make a meaningful impact on me or my practice.

• An EMR will add value to the practice when you go to sell it.

Once upon a time, medical practices were actually bought and sold. The assumption was that patients "belonged" to a practice, so the value of a practice was calculated as the sum of the hard assets of the practice (equipment, furniture, etc.), the accounts receivable (money owed to the practice that hadn't come in yet, such as insurance payments) and "goodwill," that indefinable thing that basically meant patients walking in the door. If this were still true today, I suppose this argument would have some merit, in the sense that a practice with nice new modern equipment would be worth more to a buyer than one with all old beaten-up stuff. Still, I'm not looking to sell in the near future, and this advice sounds kind of like selling vs. living in your house. It's not worth putting a bunch of money into home improvements you don't really want or need, but would enhance the sale price, unless/until you're ready to sell.

Here's the line from the Family Practice Management article that inspired this post:

An electronic record is not a paper record on the computer, and you will maximize your efficiency only by making significant changes in your workflow. Expect to work differently to make the most of the EHR system's advantages as well as overcome its disadvantages compared to paper (yes, you will find some.)
(Emphasis mine.)

Why do I have to change my workflow? It works -- very well indeed -- for me. This is not to say that I've never changed anything in my practice. In fact, I'm continually modifiying and adapting my workflow, often in response to evidence-based practices. But so far, no one has been able to credibly show me that the benefits of adopting this new technology outweigh the considerable disadvantages, starting with the initial monetary outlay, when addressed in the specific context of my practice.

That's Right; Blame Me

Yet another "educational" throwaway in today's mail exhorts me once again to encourage, urge and recommend colorectal cancer screening to my eligible patients.

Once more, I am reminded of the criteria for colorectal cancer screening (basically everyone over age 50 and certain individuals under age 50 with risk factors like polyps or a family history of polyps or colorectal cancer), the options for colorectal cancer screening (fecal occult blood testing, flexible sigmoidoscopy, double contrast barium enema, colonoscopy, or some combination of these) and the reasons why colorectal cancer screening is a good idea ("In Pennsylvania, 8,000 residents will be diagnosed with colorectal cancer and 2,970 will die of the disease this year.")

I know this. I do this. I urge, plead, encourage and exhort patients on a daily basis to undergo appropriate screening tests for colorectal cancer, breast cancer, osteoporosis, cervical cancer and prostate cancer, not to mention my urgings, pleadings, encouragement and exhortations for appropriate patients to receive pneumococcal polysaccharide vaccine (Pneumovax for patients over 65), annual flu vaccine, and diphtheria/tetanus booster vaccination (10 year intervals; one dose now to be replaced with a new combination that includes acellular pertussis antigen.) In addition, I regularly urge, plead, encourage and exhort my patients to stop smoking and begin excercising, to get enough sleep and to reduce alcohol intake.

I do my damndest. Really I do.

And yet, in boldface type on the front page of this American Cancer Society sponsored pamphlet provided courtesy of the Pennsylvania Medical Society, it says right there:

...90 percent of the patients who have not had colorectal cancer screening report that they would undergo screening if their doctor recommended it.

Cut me a fucking break!!

Think about how that kind of a survey is done. What do you expect a patient to say in response to a question like, "Would you undergo colorectal cancer screening if your doctor recommended it?"

"Hell no! Shove something up my butt? No way, Jose!"

No, of course not. Isn't it far more likely to hear something along the lines of:

"But of course if my doctor recommended it, I'd do it. I have great respect for my doctors and I would always do whatever they say."

If you're buying that, then you probably also believe that Stephen Colbert is a Republican.

I am sick and tired of having surveys shoved in my face saying that all I have to do is "recommend" something to my patients, as if the only reason screening guidelines fail is that I don't bother mentioning them. (The same thing holds for smoking cessation, by the way. "Surveys show" that -- according to patients -- the most important reason they stopped smoking was that their doctor told them to. Bullshit!! If that were true, none of my patients would smoke; I say something about it every time I see them.) I can recommend, urge, plead, encourage and exhort until I'm blue in the face, and not only will patients refuse to do what I suggest, they'll innocently refuse to remember I even said it when asked by a survey taker from the American Cancer Society.

I know it's my job to be adequately persuasive, and frankly, I'm damn good at it. But don't go telling me -- on the basis of patient reported surveys -- that I'm not trying hard enough.

Road Trip

I have just returned home from a lovely three-day road trip to the New England area. The event was an open house at the college my younger son (previously and hereinafter referred to as The Nestling) will be attending in the fall. What made the occasion extra special for me is that it is also the college I attended; he will graduate thirty years after I did.

The weather was glorious and the traffic was light. The half-way point was a lovely diner with a menu leaning towards Greek but with all the usual greasy-spoon staples done up just right. The Nestling and I share tastes in conversation and music, so the CD case was packed with mutual favorites, paused frequently for assorted commentary. My laryngitis is still trying to hang on so, after singing along with the sound track from Wicked, two of the three discs from The Remains of Tom Lehrer, as well as Don McLean and others, my speaking voice was hoarse again. Worth it, though.

The campus was recognizable, even with some old buildings gone and several new ones in unfamiliar places altering the landscape without ruining it. The official presentations were boring as hell, but one of them (the parents' forum) was held in the actual gymnasium in which I had received my diploma twenty-six years ago. During the buffet luncheon (what my father likes to call "courteous and efficient self-service") I tried to locate the pre-health advising staff, planning to offer myself as a resource to the pre-meds to infect them with the passion of primary care before they get to medical school and have it ridiculed out of them. (No, the Nestling has no interest whatsoever in medicine.) I settled for leaving my card with one of the higher-ups, while the Nestling finished his lunch at a table full of kids he had met on Facebook.

After lunch we made our way to one of the classes that was open to the "pre-frosh" visitors. We chose Introduction to Biochemistry for two reasons: it is the Nestling's intended major, and it was being held in the classroom where I took my very first college class, which happened to be Inorganic Chemistry. We met up with another parent/nestling pair on the way over, so the kids sat together while the other parent and I selected seats a small distance away. Unfortunately the actual professor was out of town, but the class was taught by a perfectly competent grad student. The topic was something the Nestling happened to be having some trouble with in one of his high school classes at the moment, and afterwards he went down to thank the teacher for helping him finally "get it."

Because the rest of the official forums and sessions looked dull, we wandered instead. While the Nestling went to get his bag out of the car and stow it with the luggage of all the other kids planning to spend the night with accommodating students, I perused the bookstore, which had been moved from its old location. Finally we met up on a wide expanse of lawn outside the new student center. The Nestling spotted a group of guys throwing a frisbee around and headed over to join them while I sat and read the irreverent gag newspaper. I later sent the writers a two-line email:

You guys are seriously disturbed.

Keep up the good work.

The final official event of the day was a choice of "Master Classes;" lectures in various disciplines provided specifically for the prospective students. The Nestling and I were torn between two of them, based on their titles alone:

• The Forensics of Human Sacrifice

and

• Channelopathies: When Good Membrane Proteins Go Bad

We went to the second, which was taught in the lecture hall in which I had taken a year and a half of Physics.

What a cool talk! Given by a full Professor of Biochemistry who had apparently been there when I was (though I didn't remember him at all; I was straight Biology) it was as accessible to the bright high school seniors who were there as it was fascinating to me. The computer graphics showing membrane proteins alone were mind-boggling!

The next day we were on our own. This time I led the way up to the area of the campus where I had spent most of my time; the quad where I had lived three of my four years; the campus pub; the student center where the bookstore used to be, and to the mailroom where I quickly found my old mailbox. (Force of habit: walking into that building, my feet were on auto-pilot.) This part of campus hadn't changed as much, and the nostalgia was as warm as the sun that finally deigned to emerge. We settled on a grassy knoll under the statue of the University namesake and chatted with a pair of students who were likewise enjoying the sun. Amazingly, the Nestling wasn't radiating the violent rays of anti-parent embarrassment virtually endemic to adolescence. In fact, he was the one who mentioned my alumni status. He seemed to actually enjoy my company.

After another stop in the bookstore for the obligatory purchases (sweatshirt with the college name for him; t-shirts for Darling Spouse and myself; decals for the cars) we drove north to spend some time with my brother.

My brother is also a doc, but in a specialty that renders most of his clinical experience and essentially all of his administrative issues completely irrelevant to mine. He had recently moved to a new office and had to wait while an alarm system was installed. Fortunately the Nestling had brought along a deck of cards, so we whiled away the time pleasantly enough. By the time he had whupped me at a game of Rummy 500, my brother was ready to go. After a delicious dinner of Tequila-Cilantro-Lime Scallops over rice pilaf followed by homemade ginger ice cream for dessert, we headed back up to his house. His wife and daughters were away so we didn't get to visit with them, but my brother took the Nestling for a ride on the back of his motorcycle that evening and again the next morning when we went out for breakfast at a charming little haunted tavern on the edge of a hand-dug manmade lake. So New England!

The ride home was a repeat of the journey up. We played almost all of the rest of the CDs in the case, and stopped for a meal at the same Greek diner. I even bought an enormous loaf of the sweetest challah I've ever tasted, to share with Darling Spouse.

Although I was only out of the office for two working days, I find myself tremendously refreshed mentally as well as physically. There was a schedule, but not one so rigid as to compromise that wonderful relaxation. The kid had a good time; I had a good time. The Nestling is on track to have a wonderful college experience. For today at least, life is good.

Clinical Case (Part 2)

(Part 1 is here.)

Edited: This post was written immediately after Part 1, and held pending the comment response. ie, these are the things (in roughly this order) that I was thinking of.

To re-cap: healthy, active 67 -year-old with worsening back pain radiating around the right side over several months.

When I first saw her, things that occurred to me were:

• Incipient herpes zoster, though that idea fell by the wayside as time went on without any rash breaking out.
• Kidney stone/renal colic
• Assorted musculoskeletal etiologies; possibly unrecognized acute injury/repetitive motion injury from tennis

As she failed to respond to conservative therapy and I became more impressed with the abdominal/visceral component of the pain, my differential expanded:

• Gall stones/biliary colic
• Pancreatitis (or other pancreatic pathology, including possibly carcinoma)
  
• Abdominal aortic aneurysm (less likely in a female never-smoker)

When she went to the ER, they did a CT which showed a "penetrating" duodenal ulcer. (If you click on that link, you'll see this:)

The most common symptom of a peptic ulcer is pain.

Not perforated (no free air) and no bleeding seen at endoscopy. But her biopsy was positive for H. pylori infection, and she responded magnificently to acid suppression and antibiotic eradication therapy.

When I saw her post-hospitalization, she felt fantastic. She told me, "I didn't realize how much chronic pain I was in. I didn't remember what it was like to be pain-free." (It had been about six months from the time she had first noticed the pain.) Her blood pressure was even back to normal.

Here's the thing: I completely missed the diagnosis. I didn't even think of ulcer disease. I probably should have, but I didn't. Apologies for the red herring in the presentation, but ultrasound wasn't even the right test.

Most of the time in the blogosphere, clinical case presentations like this are meant as a way for the authors to show off their diagnostic acumen, or share stories of bizarre or unusual cases. Stories that show how smart we are, despite our modest demurrals that we're only human, and of course we make mistakes. Somehow, though, those are never the cases that (voluntarily) see the light of day. And so I offer to show rather than just tell of my all-too-human fallibility. For what it's worth, I'll be quicker to think of ulcer disease from now on. That's why it's called "practicing" medicine.

Edited to add this after the comment response:

Kudos to Red Rabbit. Well done!

Honorable mention to RM.

Regarding Sid's surgical "organ-elimination" approach to diagnosis: Sid, remind me not to consult with you about headaches.

I admit I'm surprised at the response. I was certain all you internists with your superior diagnostic acumen would zero right in on it. [No sarcasm intended; sincerity can be tricky to convey in blogging, but that is what I am trying to express.] Although it might seem I should feel less stupid for my failure to consider peptic ulcer disease given everyone else's difficulties coming up with it, it doesn't really change anything. Case presentations in this format are truly a far cry from actually talking with and examining a patient. I continue to feel strongly that many, if not most, of the clinicians who so graciously participated would have in fact asked different questions, elicited different answers, and/or interpreted the patient's presentation differently, coming up with the right answer sooner, and thus sparing the lady a fair amount of pain, had they been in the actual position of caring for this patient.

Clinical Case (Part 1)

There is a principle in writing known as "Show; don't tell." I offer this case as an example of that principle, though the context probably won't be clear until after the discussion in Part 2, in which the answer will be given.

A very active 67-year-old woman came to me several times complaining of mid-right-sided back pain that occasionally radiated around her right side to her abdomen. This had been going on for about one month before she first consulted me. She played a lot of tennis (right-handed) and was under the impression that she had pulled something, although she didn't recall any specific trauma. The pain seemed to be exacerbated by certain motions, though she was unable to be more specific about what kinds of movements. Sometimes it had a "boring" quality. It sometimes woke her at night. Occasionally when it came around to her abdomen it had the quality of "hunger pains" though there seemed to be no relation between the pain and eating (ie, neither exacerbated nor relieved by food, nor consistently recurring before or after eating.) OTC pain relievers taken intermittently provided inconsistent relief.

Other than that she felt fine. The pain didn't radiate anywhere else. There was no nausea, vomiting, anorexia, weight loss, black/tarry stools, melena or bright red rectal bleeding. There were no urinary symptoms. Past history was unrevealing. Her blood pressure was a little elevated, but we were just starting to keep an eye on it. She had never smoked and consumed very little caffeine or alcohol.

Physical exam was basically normal. She had full range of motion of her spine. Perhaps there was some tenderness in the right lower thoracic region, but while in the office she would usually say, "It's not hurting right now." There was no costovertebral angle tenderness. Her abdomen revealed normally active bowel sounds, and was soft. There were no masses or organomegaly, and there was no tenderness or guarding anywhere. There were no skin rashes or lesions. Lab tests were all within normal limits including urinalysis, liver function tests and hemoglobin/hematocrit.

My initial impression (shared by the patient) was musculoskeletal back pain, so she was treated conservatively with heat, massage and OTC acetaminophen. She returned several times, giving a story of increasing pain unresponsive to treatment. She felt very strongly that something was wrong with her back, so when I suggested it was time for some imaging studies, she readily agreed to spinal x-rays. I tried to explain to her my concern that an intra-abdominal process might be causing her pain, so she reluctantly agreed to an ultrasound (although she only went for the x-rays.)

Finally, she called one evening telling me that the pain was now "excruciating," so I sent her to the ER where the diagnosis was made.

Post your thoughts in the Comments.
(Hint/disclaimer: listen to the hoofbeats. No zebras here.)

EMRs: Let's Really Dream

Dr. Bob has posted a Love Letter to the VA. After his quote, he adds this:

So why does the rest of the country not adopt the VA EMR? Interestingly, this is the only EMR designed for patient care, rather than for billing. Hospital administrators want billing systems. The VA system was designed for health care professionals, not accountants.

I wish the entire country had a common EMR.

So why doesn't the federal government make the software available for free to all licensed health care providers? Not access to the VA's database, but the system itself. We've already paid for it with our taxes. Seems to me it would be the fastest, most efficient way to usher in that era of a universally accessible, portable EMR that DB and the Bush administration claim to want.

Nah; too much money to be made keeping it fragmented among dozens of vendors and systems that need periodic updates.

(Coincidentally, post coming soon: Why an EMR is Not Right For Me)

DTC Double Standard

Apologies to David Williams at the Health Business Blog, (Edit: apologies; it was Dr. RW) where I believe I first saw this mentioned:

Does everyone remember what DTC actually stands for? And that the "D" is not for "drugs."

Why is is that "direct to consumer" pharma advertising is universally vilified (except by Pharma itself, of course) whereas the ubiquitous ads on radio, TV and all variety of print media for hospitals, "health systems" and assorted doctor groups are considered legitimate marketing? That is to say, why is medical marketing kosher at all?

At one time, wasn't self-promotion the height of unethical behavior for professionals? Isn't this why billboard lawyers are deemed to have sunk so low? When did the medical profession join in? Aren't doctors supposed to limit their "advertising" to location, hours and perhaps insurance plan participation? Doesn't anyone else find this kind of self-promotion crass and unprofessional? Just because more and more people are doing it -- offering the excuse that one must join in in order to remain competetive -- doesn't make it right. See the Twelfth Law of the Dinosaur:

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

In this case, it's more on the order of everyone else is jumping off a bridge. Going along with the crowd doesn't make it less stupid.

Last week I wanted to write a letter. Not an email; not a phone call; an honest to goodness, pen and paper letter. (Yes, I even wanted to handwrite it. Another post later on the stereotyping of doctors and their handwriting.) I couldn't find any nice stationery anywhere around the house, so I popped out to the mall to find some. Hanging from the magnificent vaulted, stained glass Romanov Egg ceilings were advertising banners. The one outside Nordstrom's flaunted a larger-than-lifesize portrait of a smiling Ryan Howard, the Phillies' slugger. But hanging above the escalator down from the upper level food court was a similar banner touting the Orthopedists at Thomas Jefferson University Hospital. Five Jefferson orthopods stood there, posed and smiling, watching over the shoppers and browsers with the same glint in their eye as Ryan Howard. Each column along the promenade had a smaller poster with one or another of the doctors, all smiling as if they wanted to be your best friend while simultaneously slicing your knee open.

Never mind that if you actually called for an appointment today you'd be told the first one available was in July. Never mind that if your appointment was for 10:00 you'd have to leave your home in the suburbs a good 1-2 hours before that to allow time for rush hour traffic and finding a place to park. Never mind that once you got there (at 10:00) you wouldn't be seen for up to another four hours (true stories from patients of mine braving Jefferson) and then for two minutes by an abrupt ortho resident. Never mind that the exact same "highly specialized and advanced" services are readily available twenty minutes from home at your perfectly good neighborhood hospital, where your perfectly competent orthopedist (who's been doing this for twenty years) sees you within five minutes of your appointment time, and does your surgery himself; no trainees. And never mind that the University of Pennsylvania, Temple University, Lankenau Hospital and any number of other teriary care centers in the same area code all provide essentially identical care.

Medical marketing is bullshit; even more so than direct-to-consumer pharma advertising. Although I am under absolutely no illusions about the extent of my influence, I would like to see it stop.

Places to Go, People to Meet (Well, Places to Go)

(Link thanks to MSG)

States I've visited:



Create your own visited states map.

Rest in Peace, and God Bless

So it looks like A Man Without a Country was indeed his final say.

Kurt Vonnegut, 84, died yesterday after brain injuries from a recent fall at his Manhattan home. He will be missed, though I daresay he will not be missing us. I get the sense he was ready for his next adventure in this existence.

God Bless You, Kurt Vonnegut; rest in peace.

Edited to add this, from Indexed:

Can't Fool a Kid

I saw a 6-year-old for allergies today. As he and his mom were checking in (and chit-chatting with me in the front hallway) a female drug rep came in, left some samples for drugs for which I write frequent prescriptions, and left.

I had a lovely visit with the kid. When we were done, he took the superbill and headed back towards the front desk to redeem it for his sticker. As soon as he caught sight of the desk, he stopped and turned back to his mom (with whom I was still chatting.)

"There's a man up there who looks like the woman who was here before."

Different gender; different color suit; no computer (still in its case, as it turned out.) But there was indeed another drug rep waiting for me at the front desk, recognizable by a 6-year-old from across the room.

A Really Good Freudian Slip

I have a patient who has been seeing me for many years. Even though he has moved out of the area and now lives in Florida working as a big corporate executive, he still flies back here every Spring to spend Passover with his family, and to have his physical, his blood work, and his prescriptions refilled during a lovely visit with me. He's basically healthy, so it's fine with him and fine with me. I consider him a good friend.

At this year's visit we spoke of his work. I asked him what his present job title was.

"Senior Director of Research," he answered, "but as of next week, I shall be the gullible Director of Research." He smiled as he tried to work his way around his tongue. "I mean Global Director, of course."

"No," I said with a smile, "I think you got it right the first time."

Say What?

While catching up on my journal reading, trying to lower the stack of old American Family Physicans in my office, I came across this gem of a sentence in the abstract of Cirrhosis and Chronic Liver Failure:

"Unnecessary medications and surgical procedures should be avoided in patients with cirrhosis."

Got it. Reserve unnecessary medications for hypertensives with good blood pressure control and diabetics with A1Cs under 7%. Unnecessary surgical procedures may be performed between exacerbations of COPD. Both should be avoided in liver disease.

What were they thinking?

BMI Measurements in Schools

An article in yesterday's Philadelphia Inquirer discusses the latest incursion of the schools -- via the legislature -- into my job.

Apparently America is getting fatter. Apparently it is children as well as adults who are packing on the pounds as fast food is supersized and physical activity recedes into the X-box console. And apparently the schools don't have enough to do teaching the basic academic skills of reading, math and science; witness how many people believe the chiropracters who tell them germs are only a theory and immunization is dangerous. Apparently the danger of overweight is so great and its presence so subtle that parents and doctors can no longer be trusted to notice what their children look like.

Fortunately, the government (of Pennsylvania, at any rate) has stepped in and now requires schools to weigh and measure students at school and, using a simple arithmetic formula to arrive at a single number of completely unproven clinical significance in this age group, to enlighten parents about their child's BMI percentile.

Realistically, what are parents supposed to do with this information? I'll tell you what they do: they call me.

"I got a note from Johnny's school saying that he's 'at risk for overweight.' What does that mean?" they ask.

I peruse the child's growth chart and note that he's been tracking beautifully along the 50th percentile ever since he's come under my care at the age of three.

"Nothing," I answer, and proceed to waste ten minutes of my time (and the parent's) discussing the normal growth of children, the hazards of overweight and the greater hazard of trying to predict which child will wind up seriously obese and which is about to begin a growth spurt during which he will stretch out and his BMI recede from the "danger" zone. Granted that discussions about healthy diet, snacking and substantial levels of physical activity are important ones to have, but they take place EVERY YEAR WHEN I SEE THE CHILD FOR HIS CHECKUP.

All I can hope is that mandated BMI measurements in school rapidly go the way of required scoliosis screening which, in the wake of convincing evidence of its uselessness, is disappearing all too gradually. Perhaps they can upgrade the science curriculum to fill all the extra time they will have freed up.

Happy Easter

This is just too cute!

It's a wonderfully tongue-in-cheek scientific exploration of the ubiquitous Easter treat, Marshmallow Peeps. As it happens, I have three packages of them to enjoy once Passover is over. Unfortunately, after perusing this site I may not in good conscience be able to eat them.

My favorite line on the whole site was this, in the section on "Solubility Testing":

Given enough time, the proper resources, and access to some really toxic stuff, one can probably dissolve just about anything except Peep eyes.

Happy Easter, everyone.

Creme Brulee and Medical Jokes When There's No One to Get Them

I've always enjoyed creme brulee, and a few weeks ago Darling Spouse and I invested in a new toy to make it: an adorable little miniature kitchen blowtorch, that came with a set of four cute little white porcelain ramekins with fluted edges. We've made it twice so far, and although it came out great (as in, delicious) I'm discovering that there's some technique involved in burning sugar. Gaining experience has never been so tasty, and fire is always fun. (I suppose the Jock and the Nestling come by their pyromania honestly.)

Last night we went out to dinner with some old friends at a lovely Cajun restaurant. (It was a challenge to avoid bread, flour and other non-pesadech stuff, but we managed well enough.) When the server mentioned that one of their dessert specials was vanilla creme brulee, I stopped listening and ordered it.

Like the rest of the meal, the presentation was lovely: crispy brown burnt sugar crust over yummy custard, served with fruit -- in a heart-shaped ramekin. As I removed the fruit I noticed that there was a blotch of darker brown in the crust localized to the upper left of the dish; though of course to the dish's orientation, it was the upper right.

"Oh look," I wanted to say, "The S-A node." But there was no one else at the table to get the joke. I sighed, and slowly ate my creme brulee. It was awesome.

Cyanide Anyone?

(Sent to me by a friend who works at Evil Pharma. Many thanks, SG.)

A woman walks into a pharmacy and goes straight up to the pharmacist, looking him directly in the eye.

"I need to buy some cyanide," she says.

"Why?" asks the pharmacist.

"I want to poison my husband."

The pharmacist is aghast.

"You can't do that! I can't sell you cyanide! The police will come; you'll go to jail; I'll lose my license! I can't give you any cyanide!"

The woman reaches into her purse and pulls out a photograph of her husband in bed with the pharmacist's wife.

"Ah," says the pharmacist. "You didn't tell me you had a prescription."

An Ultimate Sunday

What a wonderful day!

This past Sunday my Darling Spouse, the Nestling, the Rolling Peke and I all headed out to the rolling green hills of central Pennsylvania where my older son, attending college in the western end of the state, was playing in an Ultimate Frisbee tounament.

This kid has always been a jock. His natural athletic ability led him to all the All Star teams through elementary and middle school. By high school too many of the other kids caught up and surpassed him, but his essential jock-hood was by then so well set in his psyche that it didn't matter. I was the one who went through withdrawal the first year he was away; after 10 years as a soccer parent, I felt a little out of it as a mere Band Booster (the Nestling played in the marching band.) But this year, he managed to find the tryouts in time to make the team, and neither has ever looked back. He made the "A" squad and began travelling with them to tournaments.

Last fall we saw him at Gettysburg (minus the Nestling) as well as at Franklin & Marshall (second day was rained out, so once again the Nestling was bummed, as he had been busy on Saturday.) Finally my kid is on a winning team! Although he and several of his friends were very good soccer players, somehow they never managed to put together much in the "W" column through high school. Now I ask about assorted Ultimate tourneys (they went to one in Ohio) and the usual answer is, "We won."

The usual structure of a weekend tournament is pool play on Saturday (divided into pools of anywhere from 3-5 teams, usually 4, the teams play each of the others round-robin style) with a multi-elimination bracket to determine the winner and placing order on Sunday. (This is done so that each team is guaranteed 3 Sunday games.) This time around, we couldn't come out on Saturday (Nestling's Jazz Festival) but Sunday was open. The Jock made contact late Saturday afternoon: they'd won all four of their games, so their first game would be 10:45 the next morning. (It also turned out they were seeded first in the tournament.)

So we left the house at 7:30, to have enough time to go to Wawa for two meals: coffee, donuts, and breakfast sandwiches, plus hoagies for four for lunch. Poor Jock, stuck out in western Pennsylvania, having to suffer the indignity of Sheetz (rival convenience store chain) and no Wawa, so his Wawa hoagie was a special treat. Rolling Peke sat on my lap for the drive out, and I had yet another interesting conversation in which the Nestling regaled me with his scheme for making music easier to read for various instruments (since the current system that has developed over the last 400 years is so confusing and illogical.)

Although it was cold, misty and miserable, it was fantastic fun watching the Jock and his team play. They're very good, and while they're intense, they don't go overboard; Ultimate is all about spirit. There are no referees, and the fun that everyone has is infectious. The sideline chatter and the cheers the teams offer is incredibly random (in the way the Nestling uses the word.) One team made up of alumni sought to unnerve the college kids they were about to play against, so their opening cheer (the one right before going out to play) was clearly along the lines of, "How can we psych out these youngsters?" Their group shout was, "OLD PEOPLE SEX."

In one game as things were getting very intense (they were coming back from behind) the Jock's captain was shouting, "Who wants it? Who wants it?" (as in, who wants to score the next point.) As a guy on the other team was jogging back to his end zone, he called over, "I want it." Taken aback for only a moment, the answer came, "You can't have it."

The Nestling had a blast hanging out with college kids, getting ready to start his own college career in the fall. He fully intends to play Ultimate as well; he was also very impressed with his brother's team -- and his brother. They have a pretty typical (good) relationship, though the Jock can be an ass. Recently, while at the beach on his Spring Break, he called up the Nestling and told him to go outside and look up, then asked what he saw. When the Nestling asked why (after having done it) the Jock replied, "I just wanted to see if you would." (Later, I asked the Jock if he was drunk when he did that; he was.) Still, it was one of those special days when everyone gets to see everyone in a new light.

Even me. The Nestling offered me the highest possible praise: he said I didn't sound as parental as usual. That, and he found my sideline trash talk/jokes funny. That was worth all the rain and chill.

But hands down the funniest moment came early in their first game.

Apparently it's not unusual for Ultimate players to wear skirts. Mainly the guys; girls by and large are smart enough not to wear skirts to play sports. The Jock and a guy from the other team went up for the disk together ("skying.") The Jock came down with the disk; the other guy came down on the ground. Hard. There was the usual standing around while the guy decided whether or not he was ok (he was, and eventually got up and walked off on his own) as he lay there with his arm over his eyes. One of his teammates -- wearing a skirt -- came and stood at his head, looking down at him; manly body language for, "You ok?" I'm not sure if it was one of our guys on the sidelines or someone on the field or who exactly it was that called out to the guy on the ground, "Dude! Whatever you do, do not open your eyes."

By the way, after a hard fought championship game that saw them down 7-4 at the half, the Jock's team came back to win the tournament.

Marble Dinosaur Egg: Biliary Symptoms

"Clinical Pearl", "Marble Dinosaur Egg"; all the same.

SECOND IN AN OCCASIONAL SERIES

In the wake of Sid Schwab's most recent post about the surgical aspect of the gall bladder, I'd like to toss in something about how you can tell that your patient could benefit from Sid's tender ministrations instead of a few weeks of some wonder drug.

Biliary symptoms are by definition things that are caused by some malfunction of the gallbladder, by stones, bile duct obstruction (stones or tumors) and/or that mysterious entity to which Sid alluded, sphincter of Oddi dysfunction. Those symptoms, though, can include nausea, vomiting, pain in assorted locations and other more unusual kinds of gastrointestinal-type distress. How is one to know that a given patient's queasiness and right shoulder pain is in fact related to the gall bladder and not to the seafood salad and pick-up football game at Sunday's picnic?

When symptoms are "typical" -- nausea, vomiting, right upper quadrant pain 2-3 hours after a fatty meal in a fat, fortyish, fertile, flatulent female -- well, the janitor on Scrubs could make that diagnosis. The problem is that biliary symptoms often present atypically.

(An aside in the context of Zebra diagnoses: as a general rule, common things present uncommonly more than uncommon things present at all. What this means is that weird symptoms are more likely an atypical presentation of something ordinary than a zebra.)

There's an old, probably apochryphal, story of the GP who diagnosed his 45-year-old male patient with left shoulder blade pain with gall stones. How did you know it was gall stones, asks the incredulous housestaff. Simple, replied the old-timer. That's how his father's gallstones presented, and his grandfather's gallstones and his uncle's gallstones.

Here's the key: while symptoms may be atypical (epigastric pain instead of right upper quadrant is common) it's the timing -- post-prandially (after eating) -- that usually indicates the biliary tract as the source of symptoms. Whenever you have a patient with any kind of gastrointestinal symptoms about 2-3 hours after eating (if it's a fatty meal, it's a gimme) think gall bladder early. Ultrasounds are cheap, usually easy to get and generally very reliable for this diagnosis.