Attention Cardiologists:

I'd like to have a few words with my cardiological colleagues: stick to inpatient medicine and acute care and forget about trying to take care of outpatients. You're not very good at it.

I don't deny that when someone's having an acute MI you are the knight in shining armor! All hail the cardiologist as he comes dashing in, rumpled green scrubs flashing beneath the crisp white coat, name embroidered in red over the breast pocket (that he reads as "Dr. God"), hustling the infarcting patient off to the cath lab to save the day, along with all the salvageable myocardium he can. You definitely earn your white horse image on those occasions. My hat is off and I bow low with gratitude. I am not worthy.

On the other hand, don't let all that adulation go to your head. Once you've worked your magic, stented your arteries, prescribed your cocktail* and gotten the patient out of the hospital, take a page from the surgeon's book: follow them for 3 months or 6 months or whatever interval you're comfortable with to assure that their heart attack has "healed," then discharge them back to primary care; ie, me.

I'm perfectly capable of ordering stress tests and echocardiograms at whatever intervals you advise, just as I continue to do annual mammograms after the surgeon has removed a benign lump. I can also manage their blood pressure, cholesterol and diabetes and monitor their medications; probably better than you can. I diagnose and manage hypertension every day. I write a shit-load of statins and monitor them regularly. Despite what you might think, I really do talk to them about quitting smoking every time I see them. Part of your God-like delusion is your belief that somehow when you say, "You really need to quit smoking," it somehow makes more of an impact than when I say it. Of course, I do more than say it. I also do more than just write a script for Chantix (or, in previous times, Zyban or the patch or the gum) and throw it at them. I actually discuss strategies for quitting along with wielding my Rx pad. Why do I think you do this? Because the patients come back to me with your unfilled script to ask me about it.

If you put a pacemaker in, I have no problem with your interrogating it at will. For patients with arrhythmias, the electrophysiologist is the hero. Ablate to your heart's content. But do you really need to see that patient every year for the rest of his life? I'm more than happy to do an annual EKG and whatever else you think you need.

If I think a patient needs surgery, I send him to the surgeon. If the surgeon agrees, he operates, follows up and discharges the patient back to me. If the surgeon disagrees, he tells me (and the patient) why, suggests an alternate course of action, and sends the patient back. Cardiology should work the same way. If I think a patient needs a cardiac cath or an EP test or procedure, I'd like to be able to send them over and get your input. If you agree, cath him (or whatever.) If not, tell me why and suggest medical management (which I'm perfectly capable of implementing, thank you very much!) Certainly it's within your purview to mention to the patient that he ought to quit smoking and be more compliant with the diet, exercise and medication regimen I've tried to get him on. But don't go ordering lipids (which I just did a month ago) and prescribing Chantix (which I've already given him twice) and basically trying to do Primary Care. You don't know what you're doing, and you don't even realize it.

And for crying out loud, when I talk to you about a patient with godawful coronary artery disease (at least two perioperative MIs during diverticulosis surgery) with extensive myocardial scar and segmental wall motion abnormalities AND evidence of continuing anterior ischemia on stress testing -- who you agree needs to be seen and cathed promptly, DON'T:

• Wait three weeks to get him in, then
• Have your office call the morning of the appointment asking why he's coming, and THEN
• Write me a letter saying you're going to cath him, but also that you told him he's killing himself with obesity and smoking, gave him Chantix and recommended bariatric surgery! Think about that for a second: you can't even clear him for anesthesia! Geez.
  

*I'd love to market a beta blocker, ACEI, statin and aspirin in a single pill. I'd call it the "Cardiac Vitamin" and make a fortune.

Oops

Vaguely modeled on the ridiculous but ubiquitous 1-10 Pain Scale, I would like to introduce the Dinosaur's

OopsMeter

Starting with the extremes:

Forgetting to bring lunch: 1 on the OopsMeter (OM)
Sending warheads instead of batteries: Burying the needle on the OopsMeter


Here are some other examples, from the medical and other worlds:

Saying "Oops" during surgery: 4 OM (h/t Dr. Sid)

Doing the wrong operation: 7 OM
On the wrong side: 8 OM
On the wrong organ: 9 OM
On the wrong patient: 10 OM

Calling your child by the wrong name: 2 OM
Calling your spouse by the wrong name: 5 OM
Calling your spouse by the wrong name during sex: 8 OM

Breaking wind:
Alone in the bathroom: 0 OM
In bed (not alone): 2 OM
During sex: 4 OM
In a crowded elevator: 6 OM
In an elevator with no one but your boss: 8 OM

Driving a 12'6" truck under a 10'8" bridge (well, trying to): 9 OM (actually happened to a certain Dinosaur who shall remain numberless)

Forgetting to put the cup in the one-cup coffee maker before turning it on: 5 OM



(To be added to; I'm too tired right now, but wanted to get this posted. Feel free to add your own in the comments.)

In Which I am Evil

Chatting with a (long time) patient (ie, good friend) who had suddenly forgotten what she wanted to say.

Patient: Oh, dear. I suppose you ought to test me for Alzheimer's.

Me: I already did. Don't you remember?

Doctors, Patients and Fools

I like the Happy Hospitalist a lot. Most of his economic analyses of medical care are quite accurate, although, like Panda, he sometimes resorts to hyperbole to make his points. Still, his essential observations that patients need to assume more financial responsibility for their care and that medical liability needs to be seriously re-worked are spot on.

And I'm not mad at him.

However, his disclosure a few posts back of his diagnosis with primary hypothyroidism and his intention to manage it himself raise another issue I believe worthy of discussion: the doctor as patient. HH himself quoted Sir William Osler:

The doctor who treats himself has a fool for a patient.

yet he didn't seem to feel it applied to him in this case. Frankly, I agree with him.

Primary hypothyroidism is not difficult to treat; certainly less so than diabetes, which patients are often taught to manage, and self-monitoring of anticoagulation, a procedure that also has its proponents. Yet it occurs to me that it might be the beginning of a slippery slope; a shallow one, perhaps, but with the potential for some problems along the way.

At the other extreme, for example if he needed surgery, a cardiac cath or other invasive procedure, I don't think HH would hesitate to place himself in the care of a trusted colleague. Even for certain conditions he can and does easily manage every day -- pneumonia, kidney stones, COPD (though I agree he's probably at the same ridiculously low risk of that particular ailment as I and other non-smokers) -- I believe he and most other physicians would agree that self-management is not appropriate.

The problem is the middle ground. What about acute, self-limiting conditions: bronchitis; Bell's Palsy; UTIs? How about chronic conditions like asthma, diabetes or migraine? I think answers to the question, "Should a physician treat himself for these ailments?" would be all over the map. Some would agree that a doc could safely and effectively manage the illness himself, where others would feel strongly that he should not. Specialty matters here. I think neurologists are probably quicker to treat their own migraines and pulmonologists likely to self-prescribe for their asthma. Doesn't anyone else have a problem with this? I think Dr. Osler did.

How about this twist: should a rural oncologist manage his own chemotherapy? He's perfectly competent; he does it every day; it would be so much more convenient not just for him and his family, but also for patients he could continue to treat. I think it would be a bad idea, but it wouldn't be up to me.

What about self-limited but painful conditions like shingles or sciatica? No need for MRIs or other extensive testing. Everyone knows it will get better on its own, but how do you feel about doctors self-prescribing narcotics? Suppose HH knows he has no personal or family history of addiction issues; he's perfectly capable of managing narcotics. What's the big deal? The problem, of course, is that although plenty of doctors have done it safely, some have gotten themselves into big trouble; even some who thought they knew better.

As things stand now, these decisions are made by individual physicians on a case by case basis. I don't deny that everything works out fine the vast majority of the time, but I believe there are suboptimal outcomes frequently enough to prove Sir William correct. So without denying HH's ability to successfully manage his own thyroid replacement, I respectfully suggest that he consider the wisdom of taking this opportunity to forge a relationship with a primary care physician of his own. He may not really *need* one for this, but the benefits of consulting with someone else -- who may, perhaps, some day, who knows?? know certain things he might not -- are real, even if he can't see them right now. If nothing else, it is the opportunity to avoid becoming a fool at some point in the future.

Clarke's Law and the CAM Corollary

Back in the day I read as much science fiction as anyone else. Asimov, Heinlein and Clarke were the holy trinity. Now, in the wake of Sir Arthur's death, there are appreciations blooming like tulips, many of which reference "Clarke's Laws," the most famous of which is the third:

Any sufficiently advanced technology is indistinguishable from magic.

The appalling rise of science illiteracy, though, actually renders more and more of our everyday technology "magical" in the eyes of the general public. How many among us can explain specifically and accurately how a telephone works? How about a cell phone? Copier? Computer? There's a lot of stuff that we accept as not magic, even as we don't personally understand how it works. This leaves us vulnerable to the following argument perpetrated by the proponents of non-scientific medicine (Reiki, homeopathy and their ilk):

Anything that looks like magic (ie, cannot be explained by contemporary science) must be too advanced for us to understand.*

"I'm not sure how it works, but I know it does," could be the response of either a non-techie trying to explain a cell phone to an African bushman or a Reiki practitioner discussing energy fields.

The difference, of course, is that in the case of technology there ought to be someone, somewhere, able to explain it adequately, even if the equivalent of years of science education has to be provided to clarify the answer. Although Reiki and Homeopathy have done their level best to field such explanations, they have consistently failed. Still, the ultimate retreat to fully magical thinking can be justified by appealing to this CAM corollary of Clarke's Law.

The difference is the existence of people who do understand the technology, rather than the wishful thinking of "someday, someone will figure it out" of non-science based phenomena.

Clarke's Law is not transitive.

*Although I believe I am the first to apply this specifically to CAM, it turns out many others have already dealt with this. From Wikipedia: Larry Niven, referring to fantasy: "Any sufficiently advanced magic is indistinguishable from technology." Dean Coontz: "In an age when faith in science is ascendant, supernatural phenomena may be mistaken for advanced technology," among others.

Thoughts on Appointment Deposits

Following up on my previous post, I'd like to review some of the thoughts other folks had about charging a deposit to make an appointment with a specialist, and my final formulation for myself.

I completely understand the point about the value of a physician's time and patient responsibilities. I feel your pain; I lose money when patients don't show too. But although the concept seems valid, I have some real problems with it; at least with its execution in this particular case.

First of all, the comparison to placing a deposit for a hotel room doesn't quite hold up. Although deposits are accepted practice in certain industries, they are hardly universal. You don't need a deposit to make a restaurant reservation (last I checked, although precisely the same arguments hold.) Hairstylists don't routinely require payment at the time the appointment is scheduled; neither do car repair shops that accept appointments. Does your lawyer charge you if you don't show for an appointment? (I know, I know; he doesn't have to; he can still charge for phone calls.) At this point in time, I believe it is still generally accepted that the risk of no-shows is considered a business expense for professionals in service industries.

Certain patients will fail to keep appointments, and certain other patients wouldn't dream of it. Reminder calls are an accepted strategy to minimize no-shows. So is charging fees (albeit nearly impossible to collect) after the fact for missed appointments. The problem with charging everyone upfront is that you're assuming the worst; guilty until proven innocent, if you will. Even if you give the check back, what I find insulting is the implication that you don't trust the patient to show up.

What about patients who don't have checking accounts? I suppose it wouldn't rub the wrong way quite so much if it were a credit card number requested instead of a check, but I have some patients who don't have credit cards either. In this case, the free-market argument is that those patients "can't afford" to see those specialists; they're just out of luck, even if they have insurance that would otherwise cover the visit.

Here's the other piece of this that I think slipped past most of my commenters, some of whom said they'd be happy to pay if it guaranteed them face-to-face time with the doctor: the issue of choice. It's one thing if a self-referred patient wants a second (or third, or fourth, or however many it takes to find one that says what they want to hear) opinion. In this case, my patient didn't feel like she had any other option but to comply: I was the one who referred her, therefore she "needed" to see him. In a strange way, I felt guilty. If I were a better doctor -- smarter, better read, more on top of her condition -- then she wouldn't have to see the specialist or pony up the $75 check. Somehow this felt like my fault.

I had actually spoken to the doc about this patient, and we had agreed on a trial of treatment for a month, after which he would see her. At no point in that conversation did he mention anything about this new office policy of his. If nothing else, I could have warned the patient. It sounds weird, but I felt betrayed. Perhaps the policy should be modified for patients when I speak directly to the specialist; perhaps they should have requested a credit card; actually, what they should have done was be more polite about it. My patient felt the appointment scheduler was rude; but again, she didn't feel she had the option not to go.

After much introspection (and appreciation for all the thoughtful comments) here is what I have decided:

I completely support this physician's right to run his practice however he pleases. However as long as this is his office policy, I shall no longer refer patients to him. I just can't do it in good conscience. I haven't decided if I'll call and tell him so (I don't really refer to him all that much as is, so it's not like he'll miss much) but that's how I've decided to handle the situation.

A Glimpse Into the Future

Recently relayed by my dear, departed father (he isn't dead; he came up to visit last weekend and then departed -- for home):

Apparently there is more money spent in this country on Viagra, other ED drugs and breast augmentation combined than there is on Alzheimer's research. I suppose that means eventually everyone will be walking around ready for sex, but won't remember how to do it. (Or if they do remember how, they won't have any idea when they last did it.)

Yet Another Racket (or, Damn! I'm in the Wrong Specialty)

I sent a patient with a hard-to-figure-out autoimmune issue to a local rheumatologist a few weeks back. She came in today for (more) blood work and told me the following:

The specialist's first available appointment was April 22 (six weeks out.) That's par for the course around here, but what floored me was the demand to send a $75 check along with the required pre-visit paperwork, along with a deadline after which the appointment would be canceled if not received. The check would be returned to the patient at the time of the visit, and would only be cashed if she failed to keep the appointment.

(Patiently waiting until you pick your jaw up off the floor. I know it took me a while.)

I'm stunned.

I'm speechless.

Frankly I'm amazed they can get away with it. Hell, $75 is more than I get for a Level 3 Established patient visit!

I'm still shaking my head.

Do as I Say, Not as I Do

Yesterday I received a special envelope, hand-delivered by Federal Express. Inside this special envelope was a survey from the National Institutes of Health. They wanted to assess my knowledge, attitudes and opinions about obesity, diet, exercise and lifestyle issues. Also enclosed within the special hand-delivered envelope was a check for $30 as a token of their appreciation.

The survey was a booklet of questions with large blocks in which I was to record my answers with either X's or check marks. As promised in each of the three separate cover letters, it took no more than fifteen minutes of my time. I inserted the completed survey in the postage-paid envelope, sealed it and put it into the outgoing mailbox.

I slipped the $30 check into the envelope of deposits I needed to take to the bank, locked up the office and left for the day. I went to the bank and put the various deposits into their assorted accounts, and cashed the $30 check from the National Institutes of Health; a token of their appreciation for my completion of a survey on obesity, diet, exercise and lifestyle issues.

After dinner, Darling Spouse and I went over to the mall to replace our dishwasher. (The thing was over twenty years old; it didn't owe us anything.) After completing that chore we strolled out into the mall, where I made a beeline for the Lindt store; where I spent the $30 -- from the National Institutes of Health survey on knowledge, attitudes and opinions about obesity, diet, exercise and lifestyle issues -- on chocolate.

Answering the Real Question

I recently received an extremely moving email on the topic of suicide from a lurker. It turns out that my words, wrung from the pain of the deaths of two children, brought solace; truly a miracle of our times and the internet. Fat Doctor also had a post several weeks ago about how to answer the question, "Give me one good reason not to kill myself." (Back off, Grammar Nazis; the actual sentiment in the form of a question would be, "Why shouldn't I kill myself?")

My answer to that is to address the real question.

First of all, let me point out that it can take some skill NOT to answer what appears to be a question. It's not really hard to do, though it can take some practice. Here are some questions that are routinely not answered:

• How yoo doin'?
• Is the doctor there?
• Why do I have to go to bed?

The first statement, of course, isn't meant as a question at all. It's Philly-speak for "Hello." The second is answered, Jewish-style, with another question: "Can I help you with something?" The third, usually asked by a pre-schooler, also isn't a question. What the kid is really saying is, "I don't want to go to bed." The wise parent learns this -- sometimes the hard way -- and responds with a non-answer like, "Because." But a mark of skillful parenting is learning to address "the real question," which is that the child wants to stay up because he doesn't want to miss interesting things (he perceives) going on without him. Of course he needs to sleep in order to be alert for much more interesting things the next day, and the wise parent learns to address this lovingly and explicitly.

"Why shouldn't I kill myself?" is, in my opinion, not really a question at all. It is an expression of despair so deep that the questioner cannot believe it will ever get better. In the case of a terminal illness with physical suffering, it is a statement that symptoms are not adequately controlled, and should prompt efforts to better manage them. This is also the case in the psychiatric version, but because the suffering is the belief itself, it is by definition resistant to intellectual logic.

The problem is that trying to answer these non-questions enters into a tacit agreement that an issue is open to debate. If you start trying to explain to a kid why he needs to go to bed, what happens if he makes a better argument than you can? Are you going to let him stay up? (Perhaps; but stay with me here.) Similarly, if you can't manage to come up with "one good reason" not to commit suicide, are you going to agree that the patient ought to kill himself? The flaw in the logic is that a suicidal person is unable to comprehend such a reason, just as a non-suicidal person doesn't need one.

Anyone who has contemplated suicide but not gone through with it eventually comes to realize that it was not a good idea, and that they were not thinking clearly at the time. What sense does it make to enter into a highly intellectual debate about life and death with someone unable to think rationally? I believe a better approach to the question, "Why shouldn't I kill myself?" is to recognize that what has really been said is, "I am in pain, and I am desperate." Expressions of empathy for the pain and reassurances that things will get better -- even (especially) if the patient doesn't understand or believe it -- strike me as a more honest approach than trying to come up with an "answer" to the wrong question.

And to my lurker: You cannot begin to imagine how deeply your words moved me. I can't even fathom the courage it took to write them, much less the courage it took to step back from that abyss. Please be assured that whatever my words did for you, you have returned the favor hundred-fold. Peace.

Amazing

The Philadelphia Phillies' So Taguchi is the only Japanese major league baseball player who does not use an interpreter. How come?

Taguchi used an interpreter when he first signed with St. Louis in 2002. However, he was sent to the minors that season and with the demotion came this message: You want an interpreter, you pay for it.

"I decided I don't need it," Taguchi said with a laugh the other day.

Isn't it amazing what you decide you no longer need when you have to pay for it yourself? I wonder how that would play out in health care.

Decisions

One of the down sides of solo practice is not having anyone readily available to act as a sounding board for difficult decisions. On the other hand, one of the up sides of blogging is having the whole world available to help with that function. I have recently worked through a dilemma, and although I believe I am comfortable with my conclusions (as I have reason to believe the patient is, too) I still have this nagging voice in the back of my mind. Preceptors from long ago? Hypothetical partners in a non-existent group practice? Who knows? I'm far beyond actually caring what anyone thinks of me, so it's not pure ego; rather I want to feel more confident that my approach to this situation -- while perhaps different from many others' -- is rational. In fact, what I really feel is that my approach ought to be the norm and not the exception.

I have a lovely 87-year-old lady who has been -- for lack of a better word -- failing, for about ten months. Although she claims to eat well, she has been steadily losing weight. Her memory is slipping as well, qualifying at this point as mild dementia. She complains of an overwhelming fatigue; all she wants to do is sleep. She's always been very active, especially in her garden, so she finds this lassitude quite distressing.

I don't really know what's wrong with her. Chest x-ray and mammogram are negative. Routine blood work is within normal limits. Brain MRI shows chronic ischemic small vessel disease and age-appropriate cortical atrophy; nothing to explain her condition. Upper and lower GI endoscopy were both negative. She hasn't "lost her will to live," a phenomenon I've seen in the past. She doesn't want to die. She's just failing.

I was trying to decide what -- if anything -- to do next. I could send her for a CT of her chest, abdomen and pelvis, looking for an occult malignancy. I thought long and hard about what those scans might show, given that from a cancer standpoint I've already ruled out brain, lung, breast, stomach and colon. Just about any finding I could imagine would require another procedure to confirm a diagnosis (ie, to obtain tissue.) At that point, any diagnosis I could think of (widespread malignancy being the most likely) would either not be amenable to treatment, or would subject her to surgery with or without chemo and/or radiation. She wasn't crazy about any of those options.

Then I considered the risk of kidney shutdown from the IV contrast plus the discomfort of consuming a large volume of oral contrast just to have the scans. Given the truism about what a large percentage of medical expenditures occur at the end of life, would I not also be doing the right thing for society by not even giving her a chance to get stuck in the endless cycle of tests and specialists and more tests? The more I thought about it, the less I was able to justify sending her for a total body CT.

But I don't know what's wrong with her! Isn't it my job to figure that out? Am I being aggressively compassionate...or just lazy?

I know what you're all saying: What does the patient want?

I'll give you her exact words: "I'll do whatever you say."

News flash, all you patients and patient-advocate types: when push comes to shove, most people ask me to make these decisions. In a very real sense, "patient choice" comes down to finding a doctor whose recommendations you can live with. We're the ones with the training and experience, and by and large it is our opinions patients want and deserve. I happen to already have an Advance Directive for this patient in my chart (dated 1993; the standard DNR in case of vegetative state, or -- her words -- "ability to live normally") and in all our discussions during her decline, she's never indicated that she's changed her mind. She is willing to concede this decision to me at this time. Frankly, that means she'd have the scans even though she didn't really want to -- if I thought it was important.

She took a turn for the worse over the weekend. I went out to see her (yes, a house call; on a Saturday night) and after a very long discussion with her and her family, I referred her to hospice. As it happens, she perked up considerably over the next 48 hours. Still, I'm not going to scan her.

So what's the consensus? Am I being prudent and compassionate, or am I just a lazy clinician?

Precision

When I was very young, my father once tried to impress upon me how very old a certain relative had been:

"Do you realize Uncle Shlomo was almost 80 when he died?"

My response:

"You mean he was 79."

Time passed -- as it is wont to do -- and last June, when my father turned 79, I vowed to spend the entire year calling him "almost 80."

Just to show I can take it as well as I can dish it out, I would like to share that today I am officially "almost 50."

Expectations

I got a call yesterday from a 40-something guy with a bad cold, asking if I could "call something in." I asked about his symptoms and, hearing nothing alarming, explained that his best plan of action would be to rest and drink plenty of fluids, allowing the illness to run its course. "But can't you call something in?" "Not without a visit," which is my standard rejoinder. I explain that I wouldn't know what to prescribe without an examination. I offered an appointment; he said he'd call back.

About twenty minutes later I got a call from his irate father (not my patient.) The man is sick! He needs medicine! Why won't I call something in for him? Once again I begin to explain the natural history of viral infections ("colds", however bad) and the necessity for an exam before issuing any prescriptions. "Well, my doctor doesn't have any trouble calling things in. You tell them your symptoms and they call something in. Why can't you do that?"

I'd love to say, "Because I'm practicing medicine the right way and your doctor is either too lazy or doesn't care," but remember, we're not supposed to bad-mouth each other. I have no doubt that other offices have come to the conclusion that it's too much effort to spend the time explaining things the way I've just tried to (twice) so they just "call something in;" most likely a prescription version of an OTC medication -- that's recently been shown not to work better than a placebo anyway!

What's the harm, you may be tempted to ask. The harm is to me and my reputation! Now that you've led my patient's family to believe that "calling something in" is acceptable and accepted medical practice, I'm the one stuck with the brunt of their anger just because I'm doing things right. I have no problem standing my ground, but now there's a dissatisfied, angry family bad-mouthing ME everywhere they turn. I resent the way your laziness drags down MY reputation!

I have similar problems when ER docs routinely prescribe antibiotics for bronchitis and otitis media. Hello! Don't you guys read the same evidence we do? Antibiotics in lower respiratory infections don't lessen symptom severity or duration in the absence of pneumonia, and most OMs have been shown to be viral and are most appropriately treated with analgesia for 24-48 hours, reserving antibiotics for persistent fever (hint: persistent > 1 day), vomiting and refractory pain (hint: refractory > 1day.) Or could it be that although you're aces with trauma and really sick people, you suck at dealing with the not-as-sick and just follow the path of least resistance to get them discharged? So what, you say. You're too busy to be bothered trying to explain all that. The problem is that the next time they get bronchitis, they expect antibiotics because "that's what they gave me in the ER." Again, I'm the one who looks stupid for doing it right.

So the next time you're faced with a patient's unreasonable demands and figure there's "no harm" in just "calling something in," recognize that you're managing the patient's expectations as well as their medical condition. And you're doing a shitty job of it.