Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, June 28, 2007

This Just About Says It All

Best post *ever* on the subject of "doctors' rights to freedom of religion" here.

(Go read it, then come back.)

Your doctor does indeed own you, but only if he (or she) is too infantile to understand that medical care involves another person -- the patient -- whose comfort and right to appropriate medical care does indeed supersede the right to "freedom of religion."

If you know that your religious views preclude you from providing appropriate, legal medical care to all patients (including women of reproductive age) then GET THE HELL OUT OF MEDICINE! You have no business passing yourself off as an American physician.

If you don't like the law of the land (ie legal abortion) go move someplace where your views are enshrined in law. But please, quit inflicting your views on unsuspecting patients under the guise of "freedom of religion."

Now if you want to post your views in your waiting room, on your website and in health plan physician listings, be my guest. Just make sure all patients know about them before they see you. And for chrissakes DO NOT go into Emergency Medicine.

Edit: Yo, TBTAM (The Blog That Ate Manhattan): as soon as you post this on your own blog, I'll delete it from here. But this comment of yours on The Well-Timed Period deserves wider viewing:

Here's what we do (taking a lesson from the anti-choice playbook) :
  1. Start a website that catalogues practices that don't provide birth control. Make it public, searchable and up to date.
  2. Picket the offices of docs who don't provide BC.
  3. "Rescue" women going into that office and refer them to docs who will provide comprehensive care.
  4. Take out advertisements locally that inform women which docs won't provide them BC. This is not illegal or libelous - it is simply fact
I figure this will have a financial impact on these practices, as well it should.

What's Wrong with This Picture

Picking up a few things in the supermarket last night, Darling Spouse spied this:

Our mutual assessment: "So Wrong."

Wednesday, June 27, 2007

Ratings and Rankings and Grades (Oh My)

(Nick Genes beat me to the crux of this post, but I thought I'd write it anyway.)

What is it about humans that makes us so damned competitive? Why are we so incapable of understanding -- really understanding deep in our guts -- that certain things do not matter.

I'm speaking of the endless ratings of blogs and ranking of blogs; blog awards; top 8/10/100 lists, and so on ad nauseum. I may just be ranting at myself, but NONE OF IT MATTERS!

For example, take a site called the Top 100 Healthcare blogs. As of today, Musings of a Dinosaur ranks #87. When it first appeared it debuted at #40 and has been moving down.

Who cares!

In Truth Laid Bare ecosystem, Musings comes in as a Slithering Reptile, ranked at #7287. Last week it was #7147, with a brief surge to the 6900's in between.

So what!

On the virtual stock market site BlogShares, this old dinosaur is valued at B$22,945 and change.


As of today, SiteMeter tells me I have had over 55,000 visitors since I began blogging last September; 238 of them today so far.

How much does that really matter in the grand -- or even the not-so-grand -- scheme of things?

Last week I had a truly bang-up blogging week. 7 posts in 6 days, covering a diagnosis I missed, a diagnosis I made, a snake bite (with pictures), digs at lawyers and cardiologists, a spiritual linguistic epiphany and a modest endorsement of a routine procedure that brought out an impressive display of the crazies. KevinMD has just begun his MedBlog Power 8, recognizing:
..blogs that have had an exceptional week of blogging, based purely on my subjective measures. Factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency.
Subjective is subjective, of course. So what if I'm not Kevin's cup o'tea? Big whoop.

The more I think about it, I think what it indicates is just how vast this virtual blogging world really is. Each of the various measures above has been criticized for the inaccuracy of the parameters used to judge, to evaluate, to choose. In the end, ranking blogs is as fraught with peril as defining "quality" in medical care. We know "good" when we see it, and that's enough. In essence, I am agreeing with Nick Genes:
The medical blogosphere is a growing community of vital, insightful voices. ... Medical blogs should be surveyed, scrutinized, categorized... but not ranked.

(On the other hand, apparently no one under 17 should be allowed to read this one:)

Online Dating

This rating was determined based on the presence of the following words:

pain (14x); hell (5x); dead (4x); assholes (2x); orifice (1x)

The End of the Rope

So this is what it looks like to finally come to the end of one's rope. To give it all you've got, only to come to the realization that it just isn't enough. Dr. Scott of Just Practicing, who had struggled in post-Katrina Mississippi to maintain his practice and his life, finally made the decision to quit. He is angry, as he expresses with great clarity:
When George W. Bush spoke in New Orleans days after Katrina, he promised to do whatever it took to set things right. He gave us hope. He didn't have to say those words. He could have expressed sympathy, mentioned that "the nation stands with you as you rebuild," et cetera, et cetera, et cetera. But instead he promised action. The terrible tragedy would be met with just as equally awesome a recovery.

Perhaps the only thing worse than no hope is false hope. Hear me out: no hope leads to reasonable expectations. No one is coming; make your plans accordingly. False hope, on the other hand, encourages you to go to the brink, even over it. I may be near the end of my rope, my finances, my energy, but at least the cavalry is coming. Until you finally realize that it isn't. And then it's too late, and the anger comes forth.
This post should be read by anyone who still supports the present administration.

I'm not be on the Gulf coast, but I can understand what it's like to feel pressed from all directions with no end in sight.

Dr. Scott: we wish you well.

Tuesday, June 26, 2007

Another Thought

Darling Spouse has an interesting take on the whole neonatal circumcision debate:

The people arguing against it -- no matter how reasoned or seemingly objective their arguments may be -- are expressing nothing more than subtle anti-Semitism.

Upon first hearing that opinion, I rejected it. I was impressed with SOME of the points made by SOME of the commenters, so I felt that particular statement was overkill.

With the latest turn of events in the comment trail, though, I am ready to concede the point.

Sunday, June 24, 2007

Holy Healing

I went to a Bat Mitzvah yesterday. In parsha Chukat we heard of Moses striking a rock with a staff instead of speaking to it, as commanded, to obtain water for his thirsty, cranky people. As the rabbi spoke of this, he somehow made mention of a snake wrapped around the stick (I confess I missed the precise connection; the Bat Mitzvah girl's tallit was gorgeous and I was busy admiring it.) He then asked, "Does anyone know what the symbol of snakes and a staff represents?" Medicine. "Does anyone know what it's called?"

The Caduceus.*

Darling Spouse turned to me and murmured, "Caduceus. Like Kedusha?"

I felt as if I had been struck by a thunderbolt.

At this point, I have to point out the difference between hearing words spoken and seeing them written. Caduceus is Latin, from the Greek karukeion, for herald or staff, and pronounced "ka-DOO-shus." Kedusha is from the Hebrew root kuf-dalet-shin, which means "holy."

The two words have absolutely nothing in common linguistically. Nothing.

And yet.

There have been plenty of discussion about the spiritual aspects of medicine; everything from medicine as a calling to polls about the role of religion in the exam room. Whatever our individual religious or spiritual backgrounds, I do believe physicians who take their practice seriously would agree that there is a holiness to the art of healing.

Words can be read on a page or spoken aloud. Yet when these two words, from linguistic derivations about as far apart as can be imagined, are spoken and heard, processed by the brain's auditory pathways, they sound alike; related; descriptive; intertwined.


I choose to believe not.

*It turns out that the 2-snake Caduceus was not, in fact, originally the symbol of medicine. It was confused with the 1-snake rod of Aesclepius. However in recent decades, the original "mistake" has become institutionalized enough not to matter. At least not to me, and certainly not in the context of this post.

Saturday, June 23, 2007

Sometimes I Hate Being Good

I saw a little old lady -- 87 pounds soaking wet -- for a gyn exam. We'd done the rest of the physical when I first met her last month, and everything was fine. A little hypertension, well-controlled with minimal meds; nothing else.

It had been about 8 years since her last pap and she was delighted to finally be having it done again. Although usually very conscientious about her health, she had been caring for her husband for the last few years. After his death several months ago, she was ready to take care of herself again.

She felt great. No complaints at all. So today I was just playing gynecologist: weight, BP, thyroid, breast, abdomen and pelvic exam. (She'd had eight kids; no problems there.) Nothing to it.

Silly me. I had to take her blood pressure.

Listening to her pulse between the systolic and diastolic (a nice 132/70) I thought, Man, that's fast. Kind of irregular, too. Felt the pulse at her wrist: surprise! Fast and irregular. I even took a quick listen to her heart. Shock of shocks: fast and irregular.

The gyn exam was perfectly normal for age, but -- silly me -- I just had to go get my EKG machine and grab a quick tracing: rate 150, irregularly irregular; nary a P wave to be found. As I could tell just from taking her blood pressure, she was in atrial fibrillation.

So then I had to go explain to this perfectly healthy, asymptomatic little old lady (and the daughter who brought her) that I wanted her to go over to the ER and be admitted to the hospital for a bunch of tests and drugs and maybe a little cardioversion. (No, I didn't use that word. I said, "They may decide to put you to sleep for a minute and give your heart a little electric shock to see if they can get it back into its normal rhythm again.")

They had a busy day planned, and here I had gone and ruined it for them.

Oh well.

Friday, June 22, 2007

New Definition of Chutzpah

Not making this up:

I saw a patient with palpitations and a rapid heartbeat. She had been treated for Wolf-Parkinson-White syndrome several years ago with a successful ablation, but stated that the present symptoms were very similar. So I sent her back to the very same cardiologist she had seen previously. Here's the opening to the letter I got back:
...Our records on this patient have been purged, and we have requested records that may have been transferred to you from our office concerning her past cardiac history.
That's right. I have to send them copies of THEIR OWN RECORDS. Sort of like:
We can't be bothered to maintain patient information, so please act as a storage and retrieval facility for us.

Thursday, June 21, 2007

Snake Bite Pix

Look in the dictionary under "generous" and you will see a picture of my patient who was bitten by the copperhead snake.

Of course the story was blogged with her permission, but when she saw the reader comments asking about pictures, look what she sent me: (with permission to post them too)

[Reassurance: none nearly as gross as the pictures in the eMedicine Snakebite link from the previous post.]

The two large purple dots are the fang marks. You can see two smaller, fainter dots more distally (to the left in the picture) that are closer together; these are from the snake's bottom teeth.
The level of the swelling was recorded with purple marker on the skin.

From the patient: "These pictures were taken early in the afternoon [the day after the bite.] By that night the swelling had moved above my kneecap." (Just compare her foot and ankle to get an idea.)

Hard to see the redness, but that's what this is showing along with the swelling. Not hard to imagine how much it must have hurt.

This is her calf and popliteal fossa area. By comparing the color to the skin of her arm, you can see how green it is.

Not Something You See Every Day

A lady called to make an appointment for a hospital follow-up. Sure; what had she been in the hospital for?

She had been bitten by a snake.

A copperhead had apparently been lounging on her driveway at night as she walked her dogs. It was pitch black, which was why she hadn't seen it (although notice how incredibly well they blend in with their surroundings:)
In fact, she was grateful that it was she who was bitten and not one of her dogs, for whom the bite would surely have been fatal.

The pain was severe and almost immediate. At the hospital, she told me the ER doc said to her, "I have no idea how to treat you." He got on the phone to Poison Control and they basically talked the medical staff through her care for the entire three days she was in the hospital. (Nothing wrong with that, by the way.)

So as a semi-public service to others (like me) unfamiliar with the treatment of venomous snakebite, the basics of copperhead bite management can be found here.

It turns out that the risks of antivenin (anaphylaxis and serum sickness) are significant enough to render it useful only in "severe" envenomations, ie, edema and erythema reaching the trunk, or systemic symptoms or laboratory abnormalities (consumptive coagulopathy, etc.)

I saw her five days post-bite. Her entire lower leg was green and swollen, but not nearly as swollen as it had been, she told me. She was worried about the green. I explained hemolysis, so she was quick to pick up on the idea of "soft tissue bruising." There was still a fair amount of pain, especially when she let the leg hang down after it had been elevated. She described a "whoosh" of pain, as if the blood rushing to her leg were fire. It did not sound fun.

In addition to continuing elevation of the leg and offering pain medicine, I'd recommend adding outdoor illumination to the driveway. The moral of the story, as always, is "watch where you step." (edit: She told me she's getting a pair of knee-high snake boots just as soon as the swelling goes down enough to try them on. They're hideous, but she doesn't care. And she's not going anywhere near the driveway where she was bitten without them.)

Wednesday, June 20, 2007

Neonatal Circumcision (Controversy? Who, Moi?)

I read an article in yesterday's paper about the decline in neonatal circumcision. Apparently fewer and fewer baby boys undergo the procedure each year, with the overall rate now standing at 57%, down from a high of nearly 90% in the early 1960's. Immigration patterns are felt to play the biggest role in the decline, but a fair number of parents who once would have had their infants circumcised routinely are re-thinking the procedure -- and refusing.

I think this is a bad thing.

For what it's worth, so do many others. Evidence is accumulating that circumcision is protective against HPV and HIV infection (and therefore against cervical dysplasia and the spread of HIV in the partners of circumcised men) in addition to penile cancer, a rare condition estimated to affect fewer than 1300 men in 2007.

Part of the problem is that several medical organizations have officially renounced neonatal circumcision, most notably the American Academy of Pediatrics:
Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided. (emphasis mine)
The American Academy of Family Physicians takes a more generic approach:
The decision to perform neonatal circumcision should be based on the informed consent of the parents, and requires objective, factual counseling of parents by the family physician.
The American College of Obstetricians and Gynecologists is even less definitive:
Newborn circumcision is an elective procedure to be performed at the request of the parents on baby boys who are physiologically and clinical stable.
The problem is that pediatricians don't have to deal with the repercussions of these decisions decades later. Adult circumcision required urgently or emergently for things like phimosis (a "stuck" foreskin that can't be retracted) or a paraphimosis (a foreskin stuck in the retracted position) is a huge undertaking compared to the two minute procedure for a neonate. And yet interestingly, no one seems to have thought of asking the urologists their opinion (except the pediatric ones, and by definition they don't see adults), probably because they aren't the ones doing the procedures. That's a shame, because almost all the urologists I know recognize that the overall benefits of circumcision outweigh the risks, and that the lowest risk time to undergo the procedure is in the neonatal period.

(Another thought: could the increasing incidence of cervical HPV disease in women in recent years be a consequence of the declining circumcision rates?)

Now for those of you who thought the chronic lyme community was, shall we say, passionate, let me just point out that you ain't seen nuttin'. There are multiple, well-organized groups arrayed against this "male mutilation" who are probably going to come out swinging. I've read many of their sites, as well as their criticism of some of the studies linked above, and their own "research" on the subject. They sound like alties, cherry-picking evidence and refusing to acknowledge any findings that contradict their pre-determined conclusions.

They wax eloquent about the joys of the foreskin and the alleged greater sexual pleasure provided by an intact phallus. Then again, the vast majority of circumcised men seem perfectly content with their sex lives, at least vis-a-vis their foreskin status. I am of the firm belief that the vast majority of sexual problems are due to derangements in the large head above the shoulders, not the presence or absence of tissue on the little head between the legs.

I don't have a problem with anyone disagreeing with me. I would just like to see some intellectual honesty brought to the discussion, with a response like, "I understand my little boy (and his sex partners) will be at higher risk for some health problems later in life as a result of this decision we're making for him, but it's a risk we choose to accept for him."

*stepping aside, waiting for the fur to fly*

Tuesday, June 19, 2007

Pity Party

(Via KevinMD)

Oh. My. God.

Please join me in the great handwringing crisis currently gripping the state of California. To be more specific, the crisis gripping the lawyers of California. More specifically still, California lawyers and legal malpractice insurance.

There is a legal malpractice crisis in California. Jury awards are skyrocketing, and and lawyers' rates for malpractice insurance (which they are required to carry) are doubling and tripling almost annually.

The above paragraph is complete bullshit. The only way it comes close to the truth is if you replace the word "legal" with "medical" and "lawyers" with "doctors."
  • Lawyers in California are not required to carry malpractice insurance. (Lawyers in only one state are: Oregon.)
  • Legal malpractice premiums are around $4,000 - $7,000 annually. (That's about what I pay quarterly.)
  • Legal malpractice, especially in the areas of consumer law, personal injuries, immigration, bankruptcy and family law, can cause real harm to clients.
So what are the California lawyers all up in arms about? Is someone proposing that they be required to carry malpractice insurance?


The State Bar is proposing a rule that would require lawyers to disclose their lack of legal malpractice insurance to their clients.

Oh, the horror!

Here's what the rule's critics are saying:
  • ...the proposal would unfairly brand uninsured lawyers with a "scarlet letter."
  • "It sets up a two-tiered bar, those with insurance and those without."
  • "Prospective clients who learn that a lawyer is uninsured will probably be misled into thinking the lawyer is incompetent and go elsewhere."
Two words: Puh. Leeze!

From the article:

Malpractice insurance protects clients who lose money because of a lawyer's negligence -- missing a filing deadline, for example, or providing incompetent representation that affects the outcome of a case.

A lawyer's insurance status is "a highly relevant piece of information that a new client deserves to know," said San Jose attorney James Towery, a former State Bar president and head of a task force that drafted the proposal.


The ultimate irony, of course, is their corresponding stand on medical malpractice insurance. Even as they go merrily picking our pockets with mandated levels of coverage, they bitch and moan about merely disclosing that they themselves can't be bothered to protect their own clients. Can you imagine the uproar that would ensue if doctors not only chose to go bare (if they had the option) but then refused to tell their patients? How dare they! How irresponsible!

I would call these people hypocritical, but that would be offensive to everyday hypocrites. This takes hypocrisy to a whole new level, and mixes in a healthy dollop of chutzpah. I suppose it really is impossible to overestimate the depths to which lawyers will stoop.

Monday, June 18, 2007

Acrodermatitis Chronica Atrophicans

I saw a little old man with a rash on his feet. Actually, his blood pressure was also off the wall (because he'd run out of his meds long ago) and his liver function tests had been way out of whack the last time I'd seen him. He'd never come back for me to work them up, so when he finally showed up again I was really worried that he was riddled with cancer or something.

To my surprise and relief, his LFTs were perfectly normal, and his BP came back down nicely once he re-started his meds. But he kept complaining about this rash on his feet.

He said it was painful, with a burning quality. It had been there for several months and he didn't remember much about how it began. On exam, the tops of his feet revealed a very well-demarcated area of redness, with some skin thinning (increased visibility of blood vessels) but hard to tell because the skin on the dorsum of the foot is very thin anyway.

I struggled to get a history of something he had used topically -- lotion or something -- or sandals he'd worn in the sun. I could have sworn it was some version of contact dermatitis because the rash was so well-defined. (There's a saying I made up: "Dermatology is like real estate: location, location, location.") I tried various forms of topical moisturizers and steroids; nothing helped. Finally he asked for a referral to a dermatologist, a request I did not find unreasonable.

The dermatologist sent him back for a blood test: a Lyme titer. Frankly, I thought the patient had sustained a tick bite between seeing me and the derm, and the derm wanted to rule out ECM. Imagine my surprise when the Western blot came back with every single band positive for both IgM and IgG. I even got a phone call from the derm, letting me know the rash was a "classic case" of acrodermatitis chronica atrophicans, a manifestation of late stage Lyme disease (and he had called in all his students to take a look.)

I had never heard of it.

But I went and looked it up [contrary to the epithets hurled by the latest batch of chronic Lyme disease groupies, I do read and research things for myself] and sure enough, there it was. As it happened, none of the pictures I saw really looked anything like my patient's rash, so I'm not beating myself up over it. Still, it was interesting to learn something new.

The rest of the story is a bit of a downer: we'll treat him with antibiotics for 21-30 days, but chances are at this point that the damage has been caused by B. burgdorferi antibodies and not by the organism. Still, we'll tell ourselves we're killing whatever's there. The other problem is that antibiotic treatment may not help the burning pain, which is apparently considered to be neuropathic in origin. I'm going to try him on some neurontin and hope for the best. The dermatologist concurs.

I don't disagree that Lyme disease can be a nasty condition, with protean manifestations and long range problems if unrecognized and untreated. However it needs to be made very clear that LATE Lyme disease (skin, joint, heart and neurological symptoms) is not the same as CHRONIC Lyme disease (a nonsense label given to syndromes consisting of vague subjective symptoms of pain and fatigue.) I feel bad for folks suffering from the symptoms labeled "chronic Lyme", but the true complications of late Lyme disease will always keep us on our toes.

Sunday, June 17, 2007

Another New Website: A Breath of Fresh Air About Back Pain

Found this one via the comments on my last post:

On checking out his website, this dude Dean Moyer has a refreshing approach to back and neck pain, chiropractors and other woo, book distribution and blogging. Specifically:
  • The ultimate "conservative therapy" for back pain.
  • Chiropractors are full of shit (although his article about them is incredibly respectful; I agree with every word and couldn't have said it better myself.)
  • No advertising on his site (at all.)
  • He's funny and he writes well (which often go together, I have found.)
Other things to love about him:
  • His respect for Family Practice (Hey, Dean: How about adding this link after "If you don't have a family doctor...)
  • His respectful debunking of acupuncture.
  • His very accurate discussions of the anatomy, physiology and neurology of sciatica, pinched nerves and herniated disks.
I'll be downloading his books and offering his site address to my patients. He also has what looks like a nifty forum for assorted discussions. Unfortunately, if I join one more online discussion group, Darling Spouse has threatened me -- in no uncertain terms -- with bodily harm.

Saturday, June 16, 2007

Sitemeter Loves Me

I seem to be blessed in the hit department.

Whenever I have a slow blogging week (the Nestling graduated from high school and even so, I managed to see about the same number of patients in 3 1/2 working days as I usually do in a regular week, leaving exponentially less time for blogging) someone digs up an old post from seven months ago, and the hits, the comments and the fur fly all over again.

I believe I've said all I can on that particular topic, so I don't plan to say anymore. People with fixed false beliefs cannot be argued with.

Sunday, June 10, 2007

Time to Weigh In

This post appeared on KevinMD back on June 4th. Similar items have appeared elsewhere from time to time, with varying opinions. After much thought, I'm ready to weigh in, if you'll pardon the pun.

The issue is that of overweight doctors counseling overweight patients about diet, exercise and other lifestyle issues. The article quoted concludes that overweight and obese physicians are less effective than their slimmer counterparts in providing this kind of counseling and care to their patients.

I disagree.

The article discusses overweight physicians "feeling like hypocrites" advising their patients to exercise and lose weight. The feeling is that "heavy doctors who attempt to counsel their patients to lose weight may find their advice falling on deaf ears." In addition to everything else we are supposed to do and be for our patients, we are now also supposed to be role models.

Interestingly, three of the doctors interviewed for the article "found help at the Obesity Treatment Center, a for-profit operation (emphasis mine) run by internist John Hernried [another physician quoted in the article.]" The article continues:
The program, which in its most intensive phase costs as much as $700 per month, combines a very low-calorie diet and medical monitoring with intensive education around nutrition, exercise and awareness of behaviors that lead to weight gain.
The role model thing may be a valid argument, but this particular article now seems more than a little self-serving.

At any rate, I still disagree with the essence of the argument. At least as important as modeling behaviors for our patients is empathy with them. Frankly, I don't think an overweight patient is going to be particularly attentive to a skinny-minny little doc exhorting her to lose weight with platitudes like, "Just eat less and exercise more." Talk about falling on deaf ears! I can read that patient's mind: "What the hell does that little twerp know about how hard it is to lose weight!"

Disclosure: My BMI is in the range of "obese". My weight has yo-yo'd over the years, most recently ballooning upwards because of painful, treatment-resistant plantar fasciitis curtailing my exercise regime. Despite the article's claim that:
A study published in the journal Preventive Medicine in 2003 found that when doctors watch their own weight, they are more apt to counsel and encourage their patients to lose weight and improve their diets.
I regularly bring up the issue with my patients. I talk about diet and exercise all the time, however I am able to do so with true empathy. "Of course it's hard. Just look at me!" And then on to discussions of Weight Watchers, portion control, thirty minutes of walking daily and all the other lifestyle modifications that I once did and know I have to get back to.

I believe strongly that empathizing with patients counts for a helluva lot more than plain "role-modeling." Having "been there" -- whether it's trying to lose weight, undergoing a procedure (I've had both upper endoscopy and colonoscopy) or suffering the loss of a family member -- and therefore being able to offer genuine empathy is tremendously valuable, and patients appreciate it. In fact, in many cases it's the essence of credibility. I know for a fact my practice of pediatrics underwent a tectonic shift once I had kids. I'm not saying that one can't be a good pediatrician if one isn't a parent; but there's no denying it's a definite boost for credibility.

I know I need to lose weight. I've done it before and I know I can do it again. But I know that shame and fear and humiliation do not work as motivators for me. Just the opposite; depression about inability to lose weight leads to emotional eating. In fact, I'm only able to lose weight once I accept myself at the current weight. (Murphy's Law of Shopping, too: once I buy all new clothes in the bigger size, that's when the diet finally starts working.) So what I offer my patients is loving support: "How can I help?" I've done all the diets; I know all the tricks. Let me help you brainstorm.

But if your BMI is under 21, don't come trying to talk to me about weight loss!

Saturday, June 09, 2007

Two Very Different Days on the Water

Two of my favorite blog reads recently recounted their experiences out on the water:
Hard to find two more different kinds of days.

Thursday, June 07, 2007

Couldn't Put it Better Myself

I don't think anyone could:

Thanks to MonkeyGirl for the link.

She (MonkeyGirl) is right. There's no way anyone could ever say this better than Babs has right there.

Click. Read. Now.

Wednesday, June 06, 2007

Very Nice Round-Up

For all the re-hashing bouncing around the blogosphere, I think the best primary reporting and analysis of the whole Flea affair is by Eric Turkowitz in this set of posts:
  1. Medical Malpractice Trial Starting for Med-Blogger
  2. Dr. Flea Settles Malpractice Suit After Blog Exposed in Court
  3. Deconstructing the Trial of Flea - Part 1
  4. Deconstructing the Trial of Flea - Part 2
  5. Flea, the Boston Globe and Morality in Journalism and Blogging

Having it Both Ways

I cannot stand specialists who pad their patient load by trying to do primary care in addition to their specialty practice.

There's more to specialty training than just a huge collection of esoteric facts and high-tech procedures on a single organ system. (My father likes to joke about the guy who's a specialist in diseases of the left nostril. If there's something wrong with your right nostril, you're out of luck.)

The essence of specialty training is a mindset: the mindset that you are the expert; the go-to guy; the one who will leave no stone unturned to get to the bottom of whatever is wrong with the patient in front of you.

There is nothing wrong with this mindset. It is necessary and useful when faced with difficult or obscure diseases. Keep in mind, though, that the appropriateness of this approach depends upon two important assumptions that are seldom articulated:
  • Whatever is wrong with this patient requires your expertise.
  • The patient's condition actually falls within your area of specialization.
That is to say, the specialty mindset is appropriate for patients who have been referred by another physician who has either been unable to figure out what is wrong, or who has determined that the patient requires a procedure that the first physician is unable (or unwilling) to perform. This implies that the patient has already been evaluated by another competent physician who has decided that the problem is not within the scope of practice of primary care. That first physician has also narrowed down the range of diagnoses to the point of selecting the appropriate specialist.

Patients who self-refer to specialists screw this whole thing up. They're the ones who are more likely to have common conditions that don't really need the specialist's level of expertise, and in whom an extensive (and expensive) workup is unlikely to yield any useful information. In fact, chasing trivial findings discovered in the course of an unnecessary workup is probably one of the biggest sources of wasted money in health care. The other inefficiency of self-referral is going to the wrong specialist. The classic example is the patient with chest pain who goes to the cardiologist, and only after the negative (but lucrative) cardiac workup is found to have pain of gastrointestinal origin, and vice versa.

Primary care training emphasizes keeping an open mind as part of the process of diagnosis, and the recognition that common things really are common along with the constant awareness of when there is something different enough about a given patient to spur the zebra hunt. We develop a tolerance for uncertainty; the kind of uncertainty that drives a specialist crazy. We can do this, in part, because we know that our ongoing patient relationships means we can trust them to come back if/when the clinical picture changes. Very few specialists are willing to use time as a diagnostic tool.

The nature of their training leaves specialists at a huge disadvantage when trying to diagnosis and manage unselected patients. They know a great deal about their specialty, but their knowledge of other specialties is superficial at best. It's the old adage found, among other places, on Dr. Bob's sidebar:
If the only tool you have is a hammer, you tend to see every problem as a nail.
But what if there aren't enough nails around to make a living?

I'll never forget how pissed I was the first time I heard an Internist say that he did "Family Practice" because it was "better marketing." I also once had an orthopedic surgeon say to me, "I can do primary care. I can take a blood pressure, find that it's high and send someone to the cardiologist." I wanted to answer, "Hey, I can be an orthopod: I can tell someone with a sprained ankle to ice it, wrap it and keep it elevated," but I couldn't actually believe my ears at the time. What better way to illustrate either ignorance of or disrespect for what I do!

This ignorance/disrespect leads many specialists to believe that primary care isn't really that difficult. So when a specialist in an overserved metropolitan area finds he can't fill his appointment book with specialty patients, the decision is made to do things like this:
  • Allergy and Primary Care
  • General Pediatrics and Pulmonology (sorry, Flea; that always bugged me.) (Apologies for the pun, too.)
  • Family Practice and Rheumatology
  • Internal Medicine and Infectious Diseases
The problem is that specialist do not do primary care very well at all. They find high blood pressure and refer to the cardiologist. They see an elevated blood sugar and refer to the endocrinologist. They all say "Stop smoking" and think of it as tobacco counseling. Virtually none of them do immunizations, especially gynecologists, who like to think of themselves as providing Primary Care for women. (Obstetricians can't treat ear infections to save their lives, even in a pregnant patient. I've cleaned up more than one of their misadventures, though most of them just refer to ENT.) "Family Practice" rendered by specialists is nothing more than a circular exercise in mutual masturbation.

Don't jump down my throat with the occasional exceptions: sure, the nephrologists take decent primary care of their dialysis patients, though they're not so good about sending the women for mammograms and other screenings. (They probably figure their ESRD will kill them first, which isn't always the case.)

The bottom line is that the primary care mindset and the specialty mindset are mutually exclusive. A true specialist cannot turn it on and off at will. They can't have it both ways.

Tuesday, June 05, 2007

Well, If You Look at it That Way...

So after bragging about my wonderful handwriting, I had to share this:

I saw a patient in the office today, very upset about something-or-other. I did my evaluation and counseling thing, then wrote her a refill prescription for her Ativan.

She took it in her hand, looked at it and said, "I can't even read this."

As my eyebrows flew to my hairline and I prepared to sputter, she added:
"Oh, wait; it's upside down."

Monday, June 04, 2007

Here's What I was Talking About

Via KevinMD:
I have practiced medicine for 40 years. I have never prescribed a pill to lower blood sugar. I still see no reason to do so. If I am disadvantaging my patients, it's to a trivial degree at most. However, I know I am sparing them known and unknown hazards.

And I won't let you measure my blood sugar or the measure of its persistent elevation, the hemoglobin A1c. I don't care, and I won't care till there is compelling science that something meaningful can be done if it is elevated.
(Link to full article here.)

Hm; so Dr. Hadler doesn't bother treating diabetes, hypertension or hyperlipidemia. I'm sure his nephrology colleagues adore him for augmenting their dialysis practices with patients whose kidneys fail years earlier than they otherwise would. Likewise, his cardiologist friends are probably toasting his continued health, as are the vascular surgeons and ophthalmologists.

I don't disagree in principle with being a "late adopter" of new therapies, but to say that "high blood sugar" does no harm marks him as foolishly antiquated; one of those "good 'ole docs" I was talking about here.

(I'd love to hear Amy's take on this.)

Sunday, June 03, 2007

All Minutes Are Not Created Equal

(And now for something completely different:)

Way back in the olden days -- several months ago; before l'affaire de Flea -- we were talking about physician compensation; mostly in the context of Pay for Performance (P4P), but also in more general terms. The irrationality of physician payment for specific procedures and evaluation/management encounters ("cognitive services" or office visits) was contrasted with the fact that attorneys usually bill strictly by the clock.

Bearing in mind that dropping all my insurance contracts and going to a cash-only (well, checks and credit cards too) practice model is my someday-I'd-love-to dream, I began thinking about how I might charge for my services. I think some form of charging by the hour is definitely the way to go, so I tried to work out the nuts and bolts of how I'd manage to do it, what my "hourly rate" should be and so on.

That gave me a headache, so I looked at something else: how I'm getting paid now. For the record, whatever anyone says, we do in fact have price controls on medical fees in this country; it's called the Medicare Physician Fee Schedule, and the vast majority of private plans tie their fees to it in one way or another. I happen to be in an area dominated by 800 pound gorillas, so most of my private plans pay less than Medicare (as opposed to much of the rest of the country, where Medicare rates are bargain-basement.)

It turns out that this information is outrageously easy to access, so I did. If you look up 99201 to 99215 as your range of codes, you come up with each of the five E/M codes for new and established patient office visits in the Philadelphia metropolitan area.

At this point, let me explain again how time enters into the coding calculation. Although there are times associated with each of those 10 codes, you can only use them as the deciding factor in assigning a code when more than 50% of the face-to-face time is spent in counseling or case management. Still, in a sense, those times -- when combined with the fee schedule values -- can be used to show that Medicare values certain minutes more than others.

Here's what I figured out Medicare is paying on a minute-by-minute basis:

New PatientMC Fee$/min
first 10 minutes$38.33$3.83
next 10 minutes$28.20$2.82
next 10 minutes$32.08$3.21
next 15 minutes$50.17$3.34
next 15 minutes$37.54$2.50
Established Patient

first 5 minutes$21.80$4.36
next 5 minutes$17.79$3.56
next 5 minutes$23.68$4.74
next 10 minutes$32.53$3.25
next 15 minutes$33.81$2.25

It turns out that on a minute-by-minute basis, Medicare actually pays less for a new patient. The math works out this way because the time divisions for established patients are much shorter for the first three levels, and although the fee for a "New level 1" visit is higher than an "Established level 1," it isn't "higher enough" to offset the time factor. Isn't it interesting, though, that the longer you spend with a patient, the less you get paid on the margin. I hate to put it this way, but there you have yet another incentive -- numerical -- to limit your time with any given patient.

Just for the hell of it, let's look at how those numbers crunch into hourly rates:

New Patientvisits/hr$/hr
10 minutes6$230
20 minutes3$200
30 minutes2$197
45 minutes3/4$198
60 minutes1$186
Established Patient

5 minutes12$262
10 minutes6$238
15 minutes4$253
25 minutesabout 4/10$230
40 minutes2/3$194

(And realistically, who's going to squeeze twelve level 1 visits into an hour?) Keep in mind these are evaluation and management fees generally paid for primary care, "cognitive skills." That's your Family Practitioner or Internist sitting and talking to you, getting your complete medical history, examining you, deciding what's wrong or what testing needs to be done to figure out what's wrong, explaining it all to you, answering all your questions and making sure you understand it all.

There's also something called a "Consultation," which pays more. Consults are defined as an evaluation requested in writing by another physician. Plenty of specialists go out of their way to run a "Consultative practice only" (although for followups on the same patient they're supposed to use the E/M codes); much more lucrative that way.

Just try finding a lawyer -- highly skilled and in his prime -- willing to work for those prices!

(Anyone have any idea how to get rid of those large empty spaces before the tables?)

Saturday, June 02, 2007

Impulse Control

What's worse than a person (who already has three cats and a dog) who can't say no? (Edit thanks to Sid.)

Answer: the Darling Spouse of said person, who says "Why not?"

So there we were, running our morning errands. We stopped at Home Depot for new leather gardening gloves, because the waist-high weeds laughing at us from the front of the house were finally getting on my nerves. Then to Target (pronounced "Tar-jay" of course) for some shorts and hamburger buns. Finally a stop at the pet store for cat food.

On the way in we noticed a vehicle out front: the SPCA Mobile Adoption Unit. Just inside the front door they had set up shop with their rolling cat cages and literature-stuffed table. As usual, we checked out the denizens to see if anyone struck our fancy. I have no idea why one non-descript brown and gray tabby caught my eye. The nice man opened the cage and let me stroke him. In short order, the cat pressed his head against my hand and began to purr. Game, set, match: cat.

So once again, all I did was go out for cat food, and came home with another cat. So far he's a little timid, but that's understandable. He's had all of, oh, two hours here so far. What I find either fascinating or hilarious (haven't decided) is that the other cats don't even seem to have noticed him yet. Hey; they always seemed pretty mellow to me. Nice to see I was right. (Until after dark; then we'll hear the fur fly.)

(Not to worry. We'll give the new guy a room to himself when we can't supervise, until we're sure everyone's ok.)

Friday, June 01, 2007

Devil's Advocate

Thanks to all for comments on the previous post. FWIW even Darling Spouse has weighed in, saying that I don't know all the facts and so I'm getting all upset over Flea for nothing.

I'll grant that consensus seems to be congealing into a general impression that Flea was foolish for blogging his trial as it was happening, and arrogant/cocky for thinking he could get away with it. Some have even gone so far as to imply that this means that Robert Lindeman, the physician (as opposed to Flea the blogger) was also arrogant and cocky, and therefore "got what was coming to him."

Here's a wild and crazy thought, though: since when does arrogance per se constitute medical malpractice?

Don't get me wrong; I think that, by and large, arrogant doctors are lousy doctors. They tend not to communicate well with their patients, so they tend not to be the best diagnosticians (hit TV series notwithstanding.) But I am forced to admit that there are individuals with specialized technical skills that provide tremendous benefit to patients (cough**CT surgeons**cough.) These folks tend to be arrogant as hell and would probably rub anyone -- including most juries -- the wrong way. But do they -- or anyone else -- deserve to have their medical care judged by their interpersonal skills?

Although a doctor's personality, appearance and demeanor on a witness stand are seen as proxies for behavior with patients, I fail to see how actions (or writings) outside the courtroom or exam room have any relevance to the questions that come up in a malpractice trial. I know that's how the world *does* work. My question is, should it? I say no.

Believe me; no one's more surprised than me to find me, of all people, defending arrogant pricks. I suppose I have an unhealthy attraction to that alien concept known as "Justice."