"Irony" Lung

This is the definition of irony as much as the man who murdered his parents asking for mercy because he was an orphan:

A woman who defied medical odds and spent nearly 60 years in an iron lung after being diagnosed with polio as a child died Wednesday after a power failure shut down the machine that kept her breathing, her family said.

Holy shit! She survives polio and then six decades in an iron lung (she couldn't use more modern technology because of a spinal deformity) -- including, I'm quite certain, multiple bouts of pneumonia and other life-threatening illnesses related to her disability -- only to perish because the POWER FAILED (and they couldn't get the backup generator online.)

Now that's "ironic."

What Else are We Born With?

This week's Time Magazine has a fairly balanced article about vaccines. One of the pictures, though, shows a mother with her two baseball-uniformed, unvaccinated sons, with this in the caption:

My husband and I believe that we are born with an immune system, and we need to trust that.

Fine. We are also born with two legs and two feet that can get us anywhere we need to go. So why do we use bikes and cars and trains and planes for travel? Because we were also given the brain power to enhance the things we were born with. Just because your sons are fortunate enough to have been born into a time and place where the specter of vaccine-preventable diseases no longer hovers over the four out of ten newborns who never used to make it to their first birthday doesn't mean we don't trust their immune systems.

Playing Doctor, 21st Century Style

True story:

A pair of 4-year-old little girls (both born by C-section to older parents) playing doctor.

One is lying in the bed with a doll stuffed up under her shirt; the other stands next to the bed holding a (toy) saw.

Before proceeding, the standing child hands a clipboard to the one in the bed, indicating that she should sign her name; which she does, after which the "doctor" proceeds to "deliver" the "baby."

Oy.

What is this world coming to when pre-schoolers obtain informed consent?

Warning: Another Pharmacy Rant

I hate:

1. Idiot, moronic, too-stupid-to-live patients who don't bring all their meds in, even though they say that all their meds are in the bag.
2. Fucking asshole gastroenterologists who can't be bothered to drop me a line after scoping said patient, giving them Protonix and then changing it to some other PPI; again, without ever letting me know.
3. Cum-burbling trout-fucking (thanks again, CrankyProf) chain-store pharmacists who send me requests to preauthorize Prilosec WITHOUT EVEN FUCKING NOTICING THAT THE PATIENT ALREADY HAD A SCRIPT FOR ANOTHER PPI-- complete with refills -- ON FILE!!!

So what ends up happening is that I spend forty-five minutes of my life that I'll never get back on the phone with a West Virginian who tells me that:

1. Prilosec will never be covered because it's available OTC (even though he needs 40 mg. BID) but that,
2. Another PPI will go right through.

So I call the patient -- who doesn't answer, of course, so I leave a message -- to let him know I've changed the Prilosec to something that's covered for him; only then, upon calling the pharmacy to call in the other PPI, TO DISCOVER THE SCRIPT ALREADY ON FILE!!!

Jaysus H. Kee-reist! Any independent pharmacist -- excuse me, I mean any pharmacist with more than 2.5 functioning neurons; oh, wait; that's the same thing -- would have noticed the therapeutic duplication and would have called me on the spot to help clarify the situation. I know; they do it all the time. But no; not this IDIOT working for a pharmacy chain that will remain nameless (though its initials could stand for CardioVascular System) just looks at the new prescription (that the patient waited almost a month to fill; that's why he's #1 on the above list) and FAXES ME A FUCKING REQUEST FOR A GODDAMN MOTHER-FUCKING PRE-CERT!! Angry Pharmacist would never do that. Then again, AP probably already fired your idiot ass and the only place that would hire you without a brain was that stupid chain.

So not only have I lost an hour of my life -- did I mention that it's an hour I'll never get back? -- but I'm also shaking with fury, wasting perfectly good catecholamines that could be used ranting about something I haven't already beaten to death.

Owning Up

The comment thread in a previous post of mine has been hijacked by a discussion about lying; doctors and pharmacists and patients all castigating each other over lying about whether or not med refills had been called in, left on voicemail, faxed over; whatever. Aside from the fact that this is a non-issue in my office, as we always do our best to respond promptly to all such requests, the discussion got me thinking.

We're not talking about big lies here; just little, face-saving ones, like when you forget to call in the script but tell the patient you did -- and then hang up and call it in right then. Or telling a patient that you tried to call them back and couldn't get through when in fact you just forgot. Or telling a patient that the nurse forgot to draw the blood when you only decided to do a test after the patient had left. Or that the file room lost the results when you just never got around to calling the patient back with them promptly.

Why do people do this? If they think they're doing it to avoid looking bad to their patients, then all I can say is that they are dead wrong!

Not only is lying wrong -- little ones as much as big ones -- but it makes you look like a jerk, completely defeating the purpose of saving face. Frankly, I'm shocked at how often I hear these kinds of transparent little lies from doctors (and their staffs, though as far as I'm concerned, it's the same thing) and I disapprove. Heartily.

And I never do it. I just don't. I don't mean that my staffers and I never make mistakes, but that we don't lie about it when we do. We own up to it; we apologize.

An apology has three parts:

1. Acknowledgment that one has made a mistake,
2. Expression of regret that the mistake was made, and
3. Correcting the mistake as quickly as possible.

All three part are necessary. Here's why:

This is an "apology" without the acknowledgment:

I don't know what I did wrong, but whatever it is, I'm sorry.

What the hell does that mean?

Here's what it looks like without the regret:

Yeah, I know I forgot your birthday. I'll pick up a card on the way home.

That's not going to cut it.

Then there's this:

We forgot to call back with your results. Sorry about that.

So tell me about the freaking results already!

Offering a sincere apology, complete with all three parts, may seem complicated and time consuming, but it's not:

Patient: You never called in my refill.

Answer:

You're right, we didn't. [acknowledgment]
I'm so sorry about the oversight. [regret]
We'll call it in right now. (Then do it!) [correction]

The first thing, of course, is to see that mistakes don't happen very often. If they do then you have far more of a problem on your hands than can be solved by mastering the form of the apology. There are other kinds of situations, though, for example when you research a patient's condition and change your mind about what you want to do (order a different test; prescribe a different med, etc.) that I see many physicians treating like "mistakes;" at least in terms of telling those little face-saving lies.

Once more, I claim that any approach that includes lying will backfire.

I once heard a doctor try to convince a patient that they had discussed performing an MRI during an office visit, when in fact the doctor had decided it wasn't necessary at the time, but had later changed his mind. I found myself squirming, listening to him try to get the patient to believe she was mistaken about what had transpired during the visit. Although he probably thought he was saving face by making the patient think he couldn't possibly have made a mistake, I know if I were that patient I would have hung up the phone and said, "What an asshole."

Here's what I do when this happens to me: I call the patient and I say, "I looked this up," or "I called another doctor about your case and he suggested I do something different," or "I thought about it some more," or even "I changed my mind," and then explain what I want to do differently from what we'd discussed in the office. Guess what: no one has ever thought less of me as a result of receiving that call. Here's why: admitting when you're wrong (or when you change your mind) enhances your credibility for when you're right; hopefully the vast majority of the rest of the time.

There's a lot to be said for owning up.

Best Comment Ever

Probably thanks to the fine print, my post against breastfeeding is eliciting nothing but hilarity in the comments. This one deserves wider dissemination:

In the tribe of the Wuktuks, in the jungle of East Quatanagungtao, the chieftain is sustained entirely by breastmilk. As a result, he is nearly 250 years old, and discovered relativity before the invention of the steam engine. He thought it so patently obvious, however, that it needed no documentation.

Wackyvorlon, you rock!

Ethics and the Lazy: the FP Version

The Angry Pharmacist has another awesome post, this time about pharmacists absorbing the cost of medications for lazy medicaid patients, because the kids need the medicine; it's the right thing to do. I applaud his altruism. Granted he's only talking about $18. I wonder what he would have done in my position:

A teen mom who had moved away from home called me because she was worried about blood coming from her baby's ear. I told her there was nothing I could do over the phone; she said she didn't have a ride; I said to call me back if she found one.

She didn't call; she just walked in -- an hour after closing time. The staff had left; I saw her anyway. She said she had noticed the bleeding the day before and that it had stopped by now. There was a tiny bit of dried blood from a scratch in the ear canal; the tympanic membrane was intact. The baby was fine.

Here's the thing, though: the kid was five months old and the only immunizations she'd received were the first two hepatitis B shots; the first in the hospital and the second from me at one month of age. And I still hadn't been paid for that visit or for the shot. She didn't have insurance and didn't seem to realize there was such a thing as Medicaid, or even that her baby needed shots despite the fact that I had told her multiple times during the pregnancy and during the month she'd brought the baby to me (while living with her mother.) Her own mother had washed her hands of them; apparently the baby's father was in jail for murder; I'm pretty sure there were some issues of diminished intellect, possibly borderline MR. Whatever; I was faced with a hypoimmunized infant, a fridge that held the four shots she needed, and the near certainty that I'd never see a dime if I administered them.

It would have cost me $200. The right thing to do was to give the shots.

God help me: I didn't do it.

I told her about the Well Baby Clinic at the Health Department; I gave her their phone number and tried to explain how important it was. I have no idea if she followed through or not.

So what do you think?

Why Breastfeeding is a Bad Idea

The medical literature abounds with evidence of the beneficial effects of breastfeeding: maternal-infant bonding, enhanced response to immunizations and higher intelligence in breastfed infants, to name just a few. I don't dispute any of this, but I would like to point out an unintended consequence that I have not seen addressed previously.

Breastfeeding is too damn expensive.

Using my family as an N of 3, we observe that the first two children, each breastfed for about a week, ended up graduating from high school in the middle of the class and went on to in-state public colleges; a highly economical way to obtain a higher education. The third child on the other hand, breastfed for two years, wound up fourth in his high school class and now attends an outrageously expensive out-of-state private university, where expenses run five times higher than those of his siblings.

Clearly the effect of enhanced intelligence from prolonged breastfeeding led directly to these ridiculous tuition bills. Even if you banked all the money saved on formula via breastfeeding, there's no way to accumulate $40,000 per year; no baby eats that much!

So to all those new moms out there planning to breastfeed, think twice about the inevitable sticker shock down the road. Formula may seem expensive, but it's a bargain compared to a top tier college. Better to go with bottles and end up at state schools. After all, it's never too soon to start planning.



(Note: I have actual money riding on how many commenters don't get this.)

Many Thanks

Thanks to all for the kind words about Grand Rounds.

I just wanted to offer more prominent exposure to the comment by Dr. Emer of Parallel Universes regarding next week's Grand Rounds:

The deadline for submissions is on Sunday, May 25th at 11pm (EDT). Please send all submissions to doc.emer[at]gmail.com, and put MGR-4.36 at the subject line.

Again, many thanks.

Grand Rounds Volume 4, No. 35

IN THE BEGINNING, Nick Genes created Grand Rounds. And the Rounds were unformed and void; and Nick Genes said, "Let there be Hosts!" And there were Hosts; and Nick Genes saw that it was good, so he did pre-Grand Rounds interviews with the Hosts on Medscape. And it came to pass that on May 20, 2008 Grand Rounds did come to be hosted by #1 Dinosaur, who was pleased as punch to be hosting for the second time.

Then Susan Palwick of Rickety Contrivances of Doing Good was greatly blessed by the discovery that she was Neither Ill nor Nuts.
The first submission.

And Dr. Shock MD, PhD did ask if there is such a thing as Vascular Depression, or if it is just "treatments seeking new markets."
The second submission.

And David Williams of the Health Business Blog did interview Rich Noffsinger, CEO of SafeMed, a clinical decision support company based in San Diego.
The third submission.

And RLBates of Suture for a Living did present a wonderful review of Von Willebrand disease, wherein the blood flows freely; too freely.
The fourth submission.

And there was working and there was sleeping; the first day.

Then someone who's not really a cowboy arose from the void and did summon his courage to submit to Grand Rounds for the first time, and was welcomed by #1 Dinosaur and the minions of the medical blogosphere; and he waxed eloquent on the topic of obesity, and its measurement, and the pitfalls of the BMI, and the wonders of skin fold measurements. And it was very good.
The fifth submission.

And How to Cope with Pain did describe different kinds of pain occurring in Multiple Sclerosis.
The sixth submission.

And there was working and there was sleeping; the second day.

Then Peter Zavislak of Medical Pastiche did wax eloquent on the topic of Adverse Selection in health insurance.
The seventh submission.

And Clinical Cases did explain how to use your cell phone to listen to medical podcasts.
The eighth submission.

And Fat Doctor did see to it that a certain patient did get what was coming to her. And it was very good.
The ninth submission.

Then Bob Coffield of the Health Care Law Blog did present the latest enforcement statistics of the legislative leviathan called HIPAA, showing -- surprise -- increases.
The tenth submission.

And Walter of Highlight Health did share the results of a fascinating experiment: apparently just remembering what you ate at lunch can actually decrease the urge to snack later in the day.
The eleventh submission.

And Doc Gurley, upon discovering that she would be expected to exercise God-like powers in the event of a disaster, spent a day pondering what that might be like.
The twelfth submission.

And there was working and there was sleeping; the third day.

Then Jolie Bookspan of The Fitness Fixer did share an exercise designed to strengthen the ankle, complete with video.
The thirteenth submission.

And Ian Furst of Wait Time & Delayed Care did expound on the alleged wonders of the almighty Web 2.0; and he saw that it was not good. (The claims for Web 2.0, that is; actually, his exact words were, "It's bullshit.) And it was very good. (The post, that is.)
The fourteenth submission.

And The Blog that Ate Manhattan did celebrate the 125th birthday of the inventor of the Pap test with a moving and appropriate post. Bet you didn't know who died of cervical cancer!
The fifteenth submission.

And Insureblog did condemn a foolhardy publicity stunt.
The sixteenth submission.

And Laurie Edwards of A Chronic Dose did point out some interesting relationships between socioeconomic class and the experience of chronic pain.
The seventeenth submission.

And Nancy Brown of Teen Health 411 did share an amazing new internet resource for locating nutritional data for more than 400 chain and fast-food restaurant choices.
The eighteenth submission.

And Sam Solomon of Canadian Medicine did vent his mighty wrath upon a recent BMJ article that said in part, "[P]eople don’t become doctors because they were destined to do so but because they weren’t good enough at anything else." And it was very good. (The blog post, that is; certainly NOT the BMJ article, which was deplorable.)
The nineteenth submission.

And there was working and there was sleeping; the fourth day.

Then Martina Scholtens of FreshMD did suggest a simple and straightforward way to obtain a sexual history.
The twentieth submission.

And Paul Auerbach of Medicine for the Outdoors did pontificate on the dangers of hyponatremia, without watering anything down.
The twenty-first submission.

And Dr. Penna did point out that NHS professionals in the UK are eligible to get Microsoft Office really cheap.
The twenty-second submission.

And Dr. Trofatter of Fruit of the Womb did expound on the causes of polyhydramnios.
The twenty-third submission.

And Dr. Rich of The Covert Rationing Blog did offer proof that Warren Buffet reads his blog. And it was very good.
The twenty-fourth submission.

And Sandy Szwarc of Junkfood Science did skillfully deconstruct a study purporting to show frightening results about the effect of electromagnetic fields on premature infants. And it was very good.
The twenty-fifth submission.

And Dr. Val, the Voice of Reason, did share distasteful memories of post-operative travel, and fifth-floor walkups, and heartlessness incarnate.
The twenty-sixth submission.

And the good Dr. Crippen did heap disdain upon Iain Dale.
The twenty-seventh submission.

And there was no working, because it was an absolutely glorious weekend day, with bright skies, mild temperatures, and an Ultimate Frisbee tournament to attend; and there was eating and there was sleeping; the fifth day.

Then Nurse Ratched did weep and cry and was greatly distressed at the sorry selection of garments available to cover her nakedness (without making her look fat or stupid or inappropriate.)
The twenty-eighth submission.

And Mind, Soul and Body did ask if medicine was losing its credibility.
The twenty-ninth submission.

And David Harlow of HealthBlawg did discuss a study that claimed Massachusetts medical malpractice insurance premiums aren't as bad as we think.
The thirtieth submission.

And Joshua Schwimmer, a man of many links, did announce his creation of a medical wiki and present a slideshow of Life Hacks for Doctors.
The thirty-first and thirty-second submissions.

And there was no working -- unless you include the laundering of clothes and the shopping for food and the vacuuming of rugs; but there was much sleeping; the sixth day.

Then Jonathan Foulds of Freedom from Smoking did discuss comprehensive tobacco control.
The thirty-third submission.

And Louise of Colorado Health Insurance Insider did wax indignant over the limitations of recent pending legislation about disclosures of gifts made to doctors.
The thirty-fourth submission.

And the great and powerful Orac did expound at Respectfully Insolent length and with great dismay about a more "fluid" concept of evidence -- at Yale, of all places. And it was very good. (The posting, that is; not the sad decline of the Ivy League.)
The thirty-fifth submission.

And David Gorski of Science-Based Medicine did explain in great detail why early detection of cancer and improved survival is more complicated than it appears.
The thirty-sixth submission.

And Christine's mother, guest-blogging on But You Don't Look Sick, did share 10 lessons her daughter has taught her. And it was very good indeed.
The thirty-seventh submission.

And there was working and there was sleeping; seven days; seven days of emails and editing and drafting and posting; seven days of great amusement; seven long days.

And Grand Rounds 4:35 came to an end; but Grand Rounds is eternal, and will be hosted next week at Parallel Universes (of all places.) Thanks be to Nick Genes and all who submitted. And let us say: Ra-men.

Don't Forget the "P"

If you haven't heard fourteen million times that 99% of diagnosis comes from the medical history you are either:

1. Not a doctor,
2. Not in medical school, or
3. Deaf.

I agree wholeheartedly that the history is the usually the key to making the diagnosis. Although many people think it's probably one word, "H&P" stands for History and Physical examination. Even when you find something unexpected on the exam, you can almost always go back to the history and find out something else that makes the physical finding less unexpected. Still, there are times when it is the physical examination that is more impressive than the history (and I'm NOT talking about those all-too-frequent occasions when there is no real history obtainable, as when dementia patients are transferred from nursing homes, or when the patient is too out of it -- or just too stupid -- to tell you what you need to know.)

I saw a woman last week who specifically refused to use the word "pain" to describe her "discomfort." It had begun in her upper abdomen the day before, and then moved to the upper right part of her abdomen (where she pointed, while sitting up) later in the day. It seemed worse when she moved around but was still present (and very annoying) when lying still. She didn't have any nausea and she hadn't vomited, though she did say she wasn't overly hungry and had to force herself to eat (and then kept it down.) She couldn't recall when her last bowel movement had been, but thought it might have been that morning. She did state that she was passing gas. Her last menstrual period was "now"; there were no UTI symptoms of dysuria, urgency or frequency; overall, she didn't feel terribly sick except for this "discomfort" on her right side.

On exam, she had no fever; her skin and eyes were anicteric; her lungs were clear and her heart exam was unremarkable. Her abdomen was non-distended and I could hear bowel sounds. When I went to palpate it, I began at the upper left quadrant, where she was fine. I moved down to the lower left quadrant and asked her if it hurt. It didn't, but as I began to move rightwards she began to wince by the time I got to the suprapubic region. She got squirmier as I moved to the right lower quadrant, screwing up her face as she informed me in no uncertain terms that it hurt quite a bit, even though I wasn't pushing very hard at all. The right upper quadrant also didn't hurt; there was no Murphy's sign. But whenever I moved back down to the lower right, I got the same reaction; her hands even started to come up as if to push mine away.

Finally, I tried to see if I could elicit rebound tenderness. Rather than the classic "push hard then let go" technique (since she wouldn't let me push any harder than I was, which was fairly lightly) I use something more subtle but just as effective: I jammed my hip against the exam table, jarring it -- and her potentially inflamed abdominal contents -- slightly. In my experience, this maneuver is just as sensitive (in the statistical sense of the term) at eliciting rebound, and much more kind to the patient. It still hurts, which gives you the information you need, but not nearly as much as pushing as hard as you can and releasing quickly.

The test was negative. She didn't have any rebound.

The concern, of course, was appendicitis. The problem was that the history was far from classic: no fever; no nausea or vomiting though her appetite was decreased; still passing gas and possibly moving her bowels normally. Granted there was epigastric pain that moved to the right lower quadrant, but it had been going on a little longer than usual for an acute appendicitis (more than twenty-four hours.)

Overall, though, I was impressed by how uncomfortable she was during the physical exam -- and I told her so. Under "Impression" in the chart, I wrote "?Appy; equivocal history but worrisome exam." What she needed was a CT scan, and since she would need surgery if it showed appendicitis, the best thing to do was send her to the ER; which I did.

Today I got a phone call from her: she had indeed had appendicitis. Her appendix was tucked behind the cecum and had not ruptured. She'd been operated on laparascopically that night and had gone home the next day, feeling much better.

The take-home lesson is that even though the history is indeed all-important, don't ever forget to pay attention to the physical exam.

Seasonal Verbiage

In the process of getting rid of a telemarketer at the office one day, one of my staffers told them I was away. After she hung up, we discussed how long she should have said I'd be gone; she smiled as she came up with the old expression: "summering" at the Cape.

Ah yes: summering at the Cape; or in the Poconos; or at the Shore. Similar to wintering in Florida, Arizona or the Riviera. Then I got to wondering why those were the only two seasons used in that sense. But as I tried out the others, I realized I was creating some unfortunate turns of phrase:

• Springing in the city (sounds like surprising someone during an urban pogo stick contest)
• Falling in the Caribbean (especially unfortunate if one doesn't swim)

Ah well; best to just tell the telemarketers that I am unavailable.

Dear Angry Pharmacist

I really like your blog. In fact, I rarely comment because I almost always agree with you. Unfortunately, this means I can't remember which form of my Username I used to create an account to allow me to comment; either that, or my new computer has cookie issues. In any event, although your recent post about your hellacious Friday was heartrending -- and didn't actually say anything about me at all -- someone was kind enough (no sarcasm; traffic has been through the roof) to link to me in your comments. Many (many!) others have since come here and commented as well, so I'd like to address those folks directly.

I'd just like to point out that obviously many doctors are idiots. Uneducated front office staff calling in prescriptions must be maddening; illegible handwriting, nonexistent dosage forms and ridiculous quantities are certainly infuriating; waiting on hold over and over to clarify these things -- while saving the necks of ungrateful patients -- surely earns you millions of karma points towards your halo. That's why I like your blog; you put those doctors squarely in their place with great anger (obviously) but also with humor and panache.

I'm also certain you agree that patients are morons; many so stupid you wonder how they manage to breathe and blink at the same time. Of course they hear what they want to hear; often the exact opposite of what was actually said, whether by you or me.

It just so happens that there was this one particular patient who really really really needed a cholesterol medicine, and with whom I spent an inordinate amount of time carefully explaining exactly why he really really really needed it. So when this particular patient reported that a pharmacist (actually not one but two) told him he should stop taking it...I did not in fact go ballistic in front of him, but rather spent another extended visit explaining why he didn't have to take it if he didn't mind being at increased risk for another heart attack; and succeeded in persuading him to go back onto a different statin, as it happened. Still, there was exasperation, and the blog provided a fun way to let it out.

So for the record, I'd like to specify some things to those who so graciously commented on my humble rant:

1. I don't see drug reps, nor do I accept anything -- including food -- from them.
   
2. My handwriting is quite legible.
3. My office phone is answered promptly -- by a person.
   
4. I prescribe narcotics and other controlled substances with great caution, but
5. I try always to be acutely aware of patients in true pain who are not abusing their drugs.
6. I do not rush patients through my office, and in fact probably see only about half as many patients a day (usually the same day they call) as some other docs; of course I'm only making half as much money, but I believe it's worth it.
   
7. Some of my best friends are pharmacists; by which I mean that in person I have wonderful, respectful working relationships with my local pharmacists (which actually means I should call the one (or two) this patient spoke with and get their side of the story.)

Finally, to all those who called me things like "idiot", "tard", "moron", "lazy", "know-it-all" and "spoiled": please, I beg you, go peruse Cranky Epistles for a little while and come up with some original insults. Heaven knows Cranky Professor has elevated the epithet to an art form! The least you can do is exercise some creativity.

Miscellaneous

Miscellaneous #1:

Friend talking about his daughter's last law school exam (not CrankyProf; congrats to Mr. Cranky too, though):

It must be such a relief; I told her it must feel like taking a really good shit.

Miscellaneous #2:

Phone call at 4:00 am:

Patient's husband: "My wife just fell down the stairs. Should I take her to the hospital, or just put ice on it?"

Me: "How badly is she hurt?"

Him: (muffled) "How badly are you hurt?"

Later: sharing the exchange with my staff; one of them asked me, "What was she doing up at 4:00 am?"

The only answer I could come up with:

"Going downstairs."

Miscellaneous #3:

Darling Spouse got an obscure answer correct on Jeopardy.

Me: "How did you know that?"

DS: "I'm smart."

Me: "No, really; how did you know that?"

Grand Rounds; Present and Future

This week's edition of Grand Rounds is up at Health Business Blog, and a fascinating compendium it is of the finest in medical blogging.

Next week, May 20th, Grand Rounds will be -- of all places -- here, for only the second time. Looking forward to all submissions, emailed to notdeaddinosaur-at-msn-dot-com. All submissions will be included, in the order in which they are received, so hurry up and get those posts into the queue.

Reputation

I'm not sure why, but my traffic seems to have picked up lately. What that also means is that people are reading and commenting on old posts. (Thanks, folks.) Here's a recent comment by Dr. Sissy (no blog link; start one and I'd be happy to send you some linky-love) on my post about identifying drug seekers in the primary care setting:

Any advice for a new FP? The narkies are coming out of the woodwork. I offer referral for counseling, hospitalization, pain management and physical therapy, along with NSAIDs, tramadol and other lower risk meds and watch them leave in a huff.

Yes, I do have some advice: keep it up; you're doing exactly the right thing. Here's why:

After I'd been in practice for only a few years, I saw a patient for a non-drug-related problem (bronchitis or something like that) who mentioned as part of her medical history that she was an active heroin addict. I looked up at her and told her point-blank I wouldn't prescribe any narcotics for her. Here's what she said:

Oh, I know. The word is out on the street: don't call Dr. Dino. No drugs to be had there.

My honest reaction was to swell with pride! That's obviously why the narkies were leaving me alone. Stick to your guns; once you establish your reputation, you're home free. By the way, I told the patient it was the nicest thing anyone had ever said about me. She didn't leave in a huff, either. Maybe someday, when she's ready, I'll be the one she comes back to. In the meantime, I treasure the reputation I worked so hard to achieve.

A Political Wish

Would it be too much to ask that sometime during the upcoming general election we can be treated to a debate -- between whichever two candidates end up running -- moderated by Jon Stewart?

John McCain has been a guest on The Daily Show numerous times. Barack Obama has been on at least twice. Hillary hasn't yet, and if she turns out to be the Democratic nominee, her handlers will probably try to dissuade her from appearing. But if the contest ends up being between Obama and McCain, I think there's an excellent chance they would actually agree.

And it would be fabulous! Stewart is funny but he's also brutally honest and incredibly straightforward. He regularly discusses issues of great substance, even as he cracks everyone up with his stealthy one-liners. After all, where is it written that a Presidential debate can't be fun? Heck, I wouldn't put it past him to stage an informal one on the Daily Show by inviting both of the candidates at the same time. Seriously, though; that's something I'd really love to see.

(And PS: Happy Mother's Day to all the mothers out there!)

Edit: Thanks to Blogger's new "scheduled" feature, I wrote this before I saw this, posted by Movin' Meat. Based on his comments, I would guess he'd agree with me, and would eagerly lobby for such a debate.

Rant Alert: Attention, Pharmacists

To the friendly, trusted neighborhood pharmacist who told my 74-year-old diabetic patient with coronary artery disease and arthritis to stop his Zocor because maybe that's what was making his knees and hips hurt:

You fucking moron! Do you have any idea how hard I worked to get this guy to take this stuff in the first place? Do you know how long it took, how many visits over how many months of teaching, explaining, describing, convincing, persuading, cajoling and begging to get him to agree to even try this medication in the first place? Are you even aware of evidence-based guidelines that recommend statins for patients with diabetes and CAD? I assume you're aware he has these conditions BECAUSE YOU FILL HIS FUCKING Avandaryl, Diovan and Procardia!

And guess what, asshole: his knees and hips still hurt. Think it might be osteoarthritis? You think you'd never seen that in a septuagenarian before.

So thanks for nothing, fucktard. No matter how hard I work my ass off trying to educate my patients about the need for their various medications, you go and undo it all -- why? Because you can? Just to prove to yourself that patients hold you in higher regard than they do me? Think I can get you named as a co-defendant when he has a stroke and the wife sues because I wasn't following the guidelines? No, of course not. You'll just keep smirking there behind your counter, saving poor patients like him from us arrogant docs whom you claim don't know one tenth as much about drugs as you do. Well guess what, you cum-burbling trout-fucker [thanks, CrankyProf!]: you may think you know all about drugs, but you don't know the first motherfucking thing about using them in people.

So why don't you go down a bottle or two of tylenol and chase it with a quart of vodka for good measure. Your basal metabolism is contributing to global warming, and there are slime molds who'd make better use of the oxygen you consume.

End Rant.

Managing Risk

Response to Just (Don't) Do It from the ER/Hospitalist camp (paraphrased):

I can't [fail to provide futile care]! I might get sued!

Yes. You might. So what? Heresy alert: being sued is not the end of the world.

In the first place, you almost certainly won't be. Despite its bad rap, the legal system really does work more often than it doesn't (excluding the John Edwardsian bad baby cases and such.) Besides, there's far more to a "lawsuit" than just "being sued." The chances of a case being filed, having it go all the way to trial, actually losing at trial AND having the verdict upheld on appeal are vanishingly small. As I mentioned previously, you seem to have no problem ignoring identical threats from patients requesting narcotics when you feel they're inappropriate. Why? Because you know damn well that their chances of finding a lawyer stupid enough (even given the median lawyer IQ) to take such a case is somewhere between slim and none. Guess what: failure to provide extraordinary, futile care to a patient who is clearly in the terminal phase of life (again, I'm not talking about borderline cases) is also NOT breaching the standard of care anywhere in this country. That irate family is going to have just as hard a time as the druggie finding a lawyer to file it. Grow some gonads and stand up to those families who use empty threats of lawsuits to demand inappropriate care.

You could be sued -- as could anyone; anytime; for anything -- but there is no way such a suit could prevail. In fact, the more you/we stand up to them, the more firmly we establish that the "standard of care" for terminally ill patients is indeed NOT providing futile care -- which will further lessen the chance of a successful lawsuit.

I know, I know:

Getting hit with a lawsuit is so traumatic, even if I'm in the right, that there's no way I'm going to risk it. Besides, people are wrongly convicted of things all the time.

Think about this: there is a small but finite chance that a healthy patient undergoing a routine screening colonoscopy will suffer a perforation of the colon as a direct result of the procedure. It is also possible that he will then require surgery for the perforation, during which complications could arise; he may even die. So how are you going to address the patient with the lower GI bleed who needs a colonoscopy but refuses because, "I could die from it!" You explain to her that the risk of death is remote, and the adverse consequences of not having the study are much greater. Believe me, your chances of being successfully sued for not torturing granny to death are lower than having a colonoscopy complication.

In this case, though, there's the other side of the equation: however much suffering you endure as the result of a lawsuit, I can guarantee it pales before what you've inflicted on each patient whose death you prolong so painfully. How much torture -- actual physical and psychological pain -- are you willing to inflict just to avoid possibly enduring an unpleasant but incredibly unlikely event?

Just for the record, I have indeed been sued, and no, it wasn't the great psychic rape/trauma everyone reads (and shudders) about all the time, because I knew I hadn't done anything wrong. Granted, one needs to take some common-sense precautions: make sure your policy specifies that the insurance company can't settle without your consent, and then refuse to settle frivolous and nuisance claims. Treat your patients well; keep good records (and NEVER alter them); cooperate with your defense team; (don't blog about your trial while it's going on); all the usual advice.

As it was, hearing that jury foreman say "Not Liable" was an empowering, vindicating experience. Sure, I had better things I could have done that week, but running and hiding and doing things that weren't medically appropriate just to avoid the possibility of a lawsuit would have left me much worse off emotionally in the long run.

If a bully threatens to beat you up, acceding to his demands is understandable. But if you never stand up for yourself -- even when you're in the right -- eventually everyone makes the threat, even those who have neither the intention nor the ability to carry it out.

Isn't there a case to be made for standing up for what's right?

The DNR Code

You get what you pay for.

Medicare pays for procedures, so by FSM, procedures are what you're going to get. If the American people decide that futile care is indeed futile -- and that something needs to be done about it -- I have a proposal:

Medicare should pay for DNR orders.

Recognizing the sensitive, difficult and time-consuming nature of the effort required by a physician to discuss end-of-life issues with patients and families, Medicare (and by extension, all other insurers) should create and pay for a procedure code for obtaining a DNR order. This payment should be significant; I'd suggest on the order of at least a Level 4 office visit ("25 minutes face to face time") given the time usually needed for these conversations. Not bundled into a hospital or office visit for other problems or discussions, but a separate, identifiable service that culminates in a DNR order being entered into the patient's medical record. To the extent that a DNR limits futile care, this code should easily pay for itself many times over.

This code should not be limited to use by the primary care provider. If Fat Doctor is the one who takes the time to talk about these issues with the family, she should be paid for it -- above and beyond the DRG hospital payment. (I'm ok with limiting it to once per hospitalization, but not once per patient; people do change their minds.) Same for the ER docs. Would the financial incentives be worth it for the surgeons and subspecialists to take time away from their lucrative procedures? Probably not, though I have no doubt they'd try to claim the payment one way or another. Systems are meant to be gamed, after all. Still, I think it's worth considering.

In a way, it's the ultimate pay-for-performance. You walk into a room and come out with tangible evidence of your ability to help someone understand a difficult inevitability.

So who's with me? Our train leaves for DC in the morning.

A Proposal: NHP = DNR

Think for a moment what the world would look like if everyone admitted to a nursing home was immediately considered a DNR (or, perhaps more acceptably, "AND" as in "Allow Natural Death.") What if the whole concept of Hospice was applied to the nursing home setting? Comfort care only; living life to its fullest, each day. No invasive medical interventions except to relieve suffering.

It would solve a lot of problems.

No more fishing through mounds of paperwork from the nursing home in the ER trying to determine a patient's code status; hell, if they're all DNR, why send them over in the first place? How much of a dent might be made in ER overcrowding by eliminating the nursing home traffic altogether?

Sure, families may balk at the idea of "nursing home as a death sentence," but it might also provide that extra incentive to keep caring for the elderly at home until it's clear that they are in the last stages of life. Certainly with the rise of assisted living facilities, there shouldn't be any problem applying Hospice principles to the final stage of care in the nursing home portion of the facility.

There's no down side here. All I'm talking about is an injection of honesty and realism into our national discourse about the end of life. People die eventually; nursing homes are frequently their last "home." Why not admit it and let death come with peace and dignity, instead of the medicalized nightmare that all too frequently ensues from our refusal to address the issue.

Just (Don't) Do It

A previous post of mine discussing the fact that the "last year of life" is a retrospective designation was not, as some have misinterpreted, meant to be about futile care. This one is.

Futile care can be defined as medical intervention with no hope of prolonging life or easing suffering. Although there seems to be substantial agreement that determining the futility of a specific intervention for a specific patient can be difficult at times, many practitioners (or at least several bloggers) feel quite confident of their ability to do so. The Happy Hospitalist has said (in my comments) that he is 100% certain he can predict on admission who will not leave the hospital alive. If so, then why does he proceed to hook these patients up to nine IV pumps? Panda relates similar stories of demented grannies (his term) sent over from nursing homes to be tortured to death scheduled for surgeries and other endless treatments that are clearly futile.

So why do it?

Why do you go ahead and admit someone to the ICU if you know they won't live? [Note: I'm not talking about borderline cases; I mean those patients you really do *know* won't make it. You claim to know who they are, and I believe you.] Why do you consult the surgeon when nothing he does will make a difference? Why don't you stop? Why don't you say NO?

I know what you're going to say: "We don't know the patient. The families are strangers to us. We don't have the right to say no; to initiate these kinds of discussions. That's your job; the Family Doc. It's your long-term relationship with the patients and families that makes you the person to have those difficult talks, helping the families come to grips with the idea that medicine can't do anything more. It's not my place."

Bullshit.

You're the treating physician. You seem to have no difficulty forming relationships quickly enough to tell someone they need emergency surgery, and heaven knows you have far more experience than I conveying tragic news in the case of horrific trauma. You're the one standing there in the room with the patient, certain that nothing you do matters [a determination I'm agreeing with, mind you.] Whether or not there's a formal DNR order in front of you, all 50 states have legal protections for physicians who refuse to provide futile care. Yet you go ahead and intubate; start the pressors; call the ICU. Somehow you manage to grow a backbone and refuse inappropriate narcotics to blatant drug seekers. This is no different, no matter how you protest.

If managing the problem if futile care is important (and given the demographics of aging Baby Boomers, I would say it is rapidly becoming critical) then we all have to step up to the plate and do something about it, by not doing what shouldn't be done in the first place. I have two concrete suggestions (to be discussed in future posts) but first and foremost, you -- the ER docs and the hospitalists -- must stop passing the buck back to us, the primary care docs, to help patients and families make end-of-life decisions.

Don't tube that demented old granny. Explain to the family why it's not appropriate to put dad in the ICU. For heaven's sake, stop thinking "Hospice" is a synonym for "we give up"! When faced with a terminal patient (and yes, we all know dementia is terminal; why can't we face that?) just don't do it.

It is your job.

Mourning a True Dinosaur

Truth be told, I'm stretching the Dinosaur image; I'm not really that old. But on perusing the newspaper this morning I came across this obituary of a true Dinosaur:

June Klinghoffer, 87, a physician and educator who inspired thousands of students during the half-century she taught at the former Woman's Medical College of Pennsylvania, died Saturday of cardiovascular disease at home in Merion.

As it happens, Dr. Klinghoffer was in charge of coordinating third year clinical rotations when I was in medical school; a distinction that poses little risk to my anonymity, as it applies to multiple thousands of students. She was a pistol; our first contact with the clinical world who made the intimidating seem manageable. My favorite line of hers from orientation to the third year of medical school was this:

Junior year is like going through a car wash, with the windows open.

Somehow it doesn't matter that I didn't keep in touch, or that I can't even honestly say I had much of a personal relationship with her even in school. Just the idea that she's gone gives me pause. I shall miss her.

Deserving

I was having a conversation with a patient the other day, chit-chatting after the visit. She asked how my writing was going and I shared a (potentially) very exciting development with her. She expressed her joy and congratulations, and then said,

"You deserve it!"

I smiled and thanked her, but grimaced a little inside. People have said that to me a lot, and I've learned to be polite at what is essentially an expression of good wishes; but in my heart of hearts I remain acutely aware of how much in my life is nothing more than good fortune; being in the right place at the right time; in other words, blind luck.

The writing development certainly fits in that category, as was being born into an affluent, intelligent family. The issue of "deserving" something comes under the rubric of Karma; or you get what's coming to you. The problem is that way too many times in my life I've seen things that defy the concept of cosmic justice. During my dating days I met lots of wonderful people who "deserved" to find someone equally wonderful, but never did. All kinds of dreadful crap gets published while fantastic authors remain undiscovered. The more you look around, just being "deserving" doesn't seem to count for much.

As I said, I've been lucky in my life. Sure, I've worked hard to make the most of the advantages I've been lucky enough to enjoy, but I still can't discount the role of pure, blind, deaf, dumb luck.

Why post on this topic today? Because a little more than seven years ago, I happened to be in just the right place at just the right time for what turned out to be the most amazing, wonderful lucky moment I could ever imagine. And today, I celebrate six of the best years of my life. Thank you so much, for everything, my Darling Spouse. Happy Anniversary. I love you.

You Want PACS?

Several people have commented on my previous Rad Rage posts that introducing an electronic Picture Archiving and Communication System will solve all the problems arising from image storage and retrieval, specifically in the context of comparing current radiology studies to previous ones.

Ha!

Real life example: Patient had a "routine chest x-ray" (ordered through his workplace; NOT me.) Report comes back:

Possible nodule left lower lobe. If comparison to previous films cannot be made [emphasis mine] then chest CT should be performed.

In my chart I have two previous chest x-ray reports (normal) from 2006 and 2004, performed at the same hospital -- NOT one with PACS. So once more, with great trepidation, I call and ask them to go ahead and compare the current study. Once more, at least with an apologetic tone this time, I'm asked to fax the request (and at least this time they don't lose it.) The next day I get an even more apologetic phone call: they found the patient's film jacket, but there were no films in it. (Reaction: somewhere between *WTF* and *sigh*) So he needs a CT of his chest.

As it happens, the patient's insurance requires him to go to a different facility for the CT than the hospital where his workplace-ordered (and paid for) "routine" chest x-rays were done. Although that hospital does not appear to have a full-fledged PACS up and running, they do provide the patient with an electronic copy of his film on a CD. He opened it on his computer at home, so he knows there's an image on the disk. Off he goes to the second facility -- the now proud purveyors of a brand-spanking new PACS system (meaning they presumably have computers and know how to use them) --for his CT and hands them the CD with his original chest x-ray image. The CT report:

Normal CT of the chest. No previous chest x-ray image available on our system.

Slow. Deep. Breaths.

Cut me a fucking break!! Lessons one, two, three and four in Radiology are about comparisons to previous studies. The whole idea of "portability" is central to the concept of continuity of care, and is something the fans of EHRs everywhere are claiming is their strongest point. Here's a guy with his film on a CD in his hand and no one can be bothered to point and click -- as he was able to do with commonly available software on his home computer -- and compare the goddamn images!

Until everyone gets their act together and agrees on some version of electronic formatting for both images and medical records (and then USES them) abso-fuckin-lutely NOTHING is going to change.

Thank you for your attention. We now return you to your regularly scheduled blogging.

UPDATE: I had the opportunity to go to the hospital recently and review some films in the department of Diagnostic Imaging. While there, I mentioned this case. The radiologist with whom I was speaking pulled it up and in fact found the chest x-ray from the other hospital. Apparently, the tech had copied it from the patient's CD into the system. He scrolled down and saw the name of the doc who had read it and commented, "She must not know how to pull it up. I'll have to go show her how to do it." So it turned out -- as it so often does -- to be a matter of people not using the technology to its fullest.

Doing Things the Hard Way

Forwarded by Dear Old Dad, who doesn't usually forward things. He's right, though; this is pretty cool:



Even though it turns out it's just CG and not really the "engineering marvel" DOD forwarded it as, I like it.

Philadelphia Hockey: Best Overheard Lines

Written (Philadelphia Inquirer 4/30/08):

There was no need of the scoreboard announcer welcoming "the most intimidating fans in hockey"...They know who they are -- a crowd that would have made the lions wet themselves in Nero's Rome.

Spoken (by Martin Biron, Flyers' goalie, locker room interview after the Flyers' 4-2 win of game 4, putting them up 3-1 for the series):

When you're doing well, they send you flowers. When you blow it, they start throwing the vases at you.