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.

Friday, October 31, 2008

Why You Should Get a Flu Shot

From the comments:
Tell me, really, if it's worth getting the shot. I've never gotten one and I just hit 60.

I work at home, a telecommuter, but I do get out at least once a day. Previously when I worked out of an office, the others would get a shot and still get the flu. When the flu started its rounds, I worked from home.

Now I have gotten the flu---maybe three times in the last decade, but never [with] the frequency [of] my flu-shot co-workers.

So tell my again, why I should get the shot?
Here's the deal: Influenza is spread:
...from person to person in respiratory droplets of coughs and sneezes. (This is called "droplet spread.") This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and deposited on the mouth or nose of people nearby. Influenza viruses may also be spread when a person touches respiratory droplets on another person or an object and then touches their own mouth or nose (or someone else’s mouth or nose) before washing their hands.
What this means, technically, is that if you have no contact with people during the entire time the influenza virus is in the community then no, you do not need to get a flu shot because you will never get the flu. The problem, of course, is that "little contact" is not the same as "no contact." In general, your chances of getting the flu ("chances" = statistically) are proportionate to the number of people with whom you come in contact. Thus, it makes perfect sense that your office co-workers would be more likely to contract the flu than you, the opportunistic telecommuter, regardless of immunization status.

What the flu shot does is reduce (note: not eliminate) your chances of getting sick with the flu if you are exposed to one of the strains in the vaccine. That's all. Bottom line is that it's a decision you have the right to make for yourself, given the above information, your own personal estimation of your risk for influenza (which most people tend to underestimate) and your tolerance for that risk.

Here's what I tell my patients:
I recommend the flu shot for anyone who doesn't want to get the flu.

Fun with Flu Shots

It's that time of the year again: flu shot season. Thanks to the new and improved expanded official recommendation that all kids get flu shots, my joint has been jumping. In addition to regular office visits, the right-hand column of the appointment book is used for people coming in for just the flu shot. Add to that all the regular patients I am able to spring it on convince it's a good idea, and I'm stabbing away all the live-long day.

Giving out that many flu shots, an old dinosaur has to find a way to remain amused.

Saw a guy today with an elaborate tatoo on his target non-dominant shoulder, and I found myself with a delightful quandary. Where to poke my little needle?
  1. Right in the injun's crotch?
  2. His nose?
  3. Tip of the eagle's beak?
  4. In the center of the "o" in "Mom"?
I settled for the eagle's eye. That way when he gets his little local reaction of redness at the injection site, the bird will look like it's been in a bar fight.

Flu shots are fun. I need a life.

Thursday, October 30, 2008

At Last

What do you say when a long-awaited dream comes true?

How do you express your exhilaration as your adopted city explodes with joy?

What does it feel like to finally shake off the moniker of "chokers"?

Let me count the ways:
  1. Go out at 11:00 pm to buy shirts
  2. Drive around like an idiot honking horn until midnight
  3. Look forward to extra visit home by college-age son who is NOT going to miss the parade
  4. Change Facebook Status to "Celebrating!!"
Yes, it's a very good day to be a Philadelphian; whether by birth or by choice:

Phillies win World Series

So True

Wednesday, October 29, 2008

Color Blindness?

Saw a guy today with chronic back pain; last visit was almost a year ago. Checking the chart, I see that he was given a prescription anti-inflammatory and a pain-killer. I ask if he remembers how they worked. His answer:
The white one helped; the pink one didn't.
Um, ok. They were both generics, so we need to get ahold of the pharmacy where he filled the scripts. I bring the cordless phone into the exam room and make the call. I tell the pharmacist what the two drugs are, and tell him what my patient said. I ask her which drug was which. The answer:
Actually, one was yellow and the other was orange.

(Full disclosure: The "yellow" was a very pale shade, apparently mistaken for white. The other was a deep shade of reddish-orange -- presumably pink; in the morning; with lousy light in the bathroom; without his glasses. But we shared a huge laugh.)

(The other cool thing was that it was the anti-inflammatory that had helped.)

Tuesday, October 28, 2008

Definition of a Specialist

Here is my new definition of a specialist:
One who, when confronted with a horse, insists on continuing to look for the zebra.
This patient, apparently not satisfied with my management (I think it was the family, actually), went to see a neurologist for a problem that dozens of people on the internet were able to correctly diagnose sight unseen.

The neurologist proceeded to order ten thousand dollars worth of studies, including an MRI to rule out a mass lesion, carotid studies and a whole pile of lab work. Eventually I get a letter that says, among other things:
...this could be Ramsay Hunt...
but of course we need to rule out everything else as well.

No wonder our healthcare system is going down in flames!

Monday, October 27, 2008

Memory Issues

Saw a man with heel pain the other day. Treated his plantar fasciitis. Phone message from him the next morning:
I've been having lots of trouble with my memory lately. I meant to say something when I was in for my foot, but I forgot.

Please make an appointment to discuss the memory issues.

Of course:

He forgot to leave a phone number.

Friday, October 24, 2008

Medical Journalism -- "Gotcha" Style

Today's alarming headline:
Doctors Sneaking in Placebos
Turns out that when 1200 American internists and rheumatologists were surveyed, of the 57% who responded, anywhere from 46 to 58% of those "reported prescribing placebo treatments on a regular basis."

Whoa! That sounds bad. Indeed, one of the authors responded:
"Doctors may be under a lot of pressure to help their patients, but this is not an acceptable shortcut," said Irving Kirsch, a professor of psychology at the University of Hull in Britain who has studied the use of placebos.
Oh, the shame!

Turns out when you actually look at the paper in question, THE WORD PLACEBO WAS NEVER USED IN THE SURVEY!!! In fact,
Because the term "placebo" and behaviors surrounding its use can be contentious, we devised a series of non-judgmental questions beginning with broad questions that avoided the term "placebo" and then gradually gained more specificity, culminating in items whose responses used a clear definition of a "placebo treatment."
The way the concept was phrased in the survey instrument: often they recommend a therapy "primarily because you believe it will enhance the patient’s expectation of getting better"
They set their respondents up even more:
When asked if they would recommend a dextrose tablet for a patient with fibromyalgia if trials had shown such treatment to be superior to no treatment, most respondents (58%, 381/654) said they would be very likely or moderately likely to recommend it.
They actually phrased their hypothetical scenarios to include studies showing positive responses to placebos. When put in those terms, wouldn't someone sound like an idiot for refusing to use a "proven treatment"?

I read the entire article very carefully and discovered that the investigators never asked WHY the respondents recommended the "placebo" treatments that they did. That would have been illuminating. I'll bet my annual income (ok; big spender I ain't) that "placebo" prescribing is a response to patient demands to "do something." I know, I know; we're supposed to spend whatever time it takes (never fully compensated) to explain to the patient why there is no effective pharmaceutical intervention for their condition (usually after the patient has refused non-pharmacologic modalities like exercise, diet, physical therapy, etc.) Guess what: the patient then goes next door, to one of the 46% of the 57% of the 1200, who will suggest that they take OTC vitamins or other innocuous compounds, typically describing them not as "placebos" but as "a medicine not typically used for your condition but might benefit you." Adding insult to injury, the patient usually considers that "placebo prescriber" (the one being unacceptably dishonest) to be a better doctor than the first; the one who follows "advice from the American Medical Association, which recommends doctors use treatments with the full knowledge of their patients," by refusing to "prescribe placebos" as described in the journal article.

One last thing: If you use "physician beliefs" instead of scientific evidence to define "placebo", then all the homeopaths naturopaths purveyors of vitamins and other supplements quacks who really believe that the water and sugar pills and vitamins they sell are doing something, then by the standards of this article, they are the virtuous ones who never prescribe placebos. As it happens, the questions about placebos described in this paper were actually part of a survey about complementary and alternative medicine.

So the bottom line is a survey that sets up respondents by specifically avoiding the word "placebo" (although they do state that they re-phrase some of their questions to include it, after carefully defining it); leading respondents on to answer favorably, and then blasting them in headlines over the Associated Press about "sneaking in placebos."


Thursday, October 23, 2008

What Does the Federal Government do to a Highly Successful Local Program?

They shut it down, of course:
A highly regarded Philadelphia schools breakfast-and-lunch program - the only one of its kind in the United States - is being terminated by the U.S. Department of Agriculture.

The 17-year-old program aimed at poor students is unique because it doesn't require students and their families to fill out application forms for free or reduced-price meals. This maximizes student participation.

The USDA said it needed the applications to better monitor the program.


Universal Feeding was based on a concept originated by Philadelphia Community Legal Services and Temple University in 1991.

It eliminated the need for poor children and their parents to fill out applications for free and reduced school meals.

Simple as it sounds, the process of having poor children bring home lunch forms for parents to fill out is a daunting task, said Jonathan Stein, general counsel of Community Legal Services. It was Stein who worked with Temple to get Universal Feeding going.

Children forget, and poor parents already beset by outsized difficulties are unwilling or unable to deal with the forms. And so they languish unsigned. And children miss out on meals, Stein said.

At Stein's suggestion, Temple researchers surveyed Philadelphia schools and learned that about 200 of the district's 280 schools had high enrollments of low-income children - around 75 percent.

"If you have a large majority of poor children in a school, get rid of the paper applications and just provide free lunches and breakfasts for everyone," Stein said.

The lack of paperwork saved the district money, advocates said. And another, more subtle problem was overcome: poor children's stigma over receiving free meals.

Studies show that children who are eligible for free or reduced-cost school meals often do not eat them if other, better-off students pay for their own, said Kathy Fisher, an expert on public benefits for Public Citizens for Children and Youth in Philadelphia.

The program was eliminating paperwork and stigma, advocates said. The participation rate in the Philadelphia Universal Feeding sites has been nearly twice the rate as in non-Universal sites - 80 percent vs. 45 percent.
So you have an important program that's working so well that school districts throughout the country want to emulate it (read the whole article) in part because of the elimination of paperwork, and the Federal Government in its infinite wisdom decides that it prefers the "increased accuracy" of individual paper applications. Un-fucking-believable!

Why would they do this?

Advocates claim that as soon as other cities clamored for the program, the USDA ended Universal Feeding in Philadelphia to save money.

Daniel of the USDA said that wasn't the case.

Of course not.

Look, I don't like paying taxes any more than the next extinct giant lizard, but I'd far rather have my money going to feed poor children than bailing out greedy rich bank executives. Attention USDA: Get with the fucking program already, and restore funding for that program and others like it.

Tuesday, October 21, 2008

Um, Yeah?

Per John McCain: "He [Obama] wants to take your money and write a check to someone else."

Um, isn't that what's been happening for years? I'm pretty sure it's called "Social Security"?

Monday, October 20, 2008

Fifteen Years Then and Now

The last time the Philadelphia Phillies were in the World Series was fifteen years ago. My twins were six years old and just learning to read. My son was a precocious jock even then, and every morning as he came downstairs he would come to the breakfast table and ask, "Can I please see the sports page?" I helped him sound out the words of the articles describing the Phillies game the night before, although more often than not he'd stayed up watching it. Our agreement was that if he stayed up (and remember that there were a LOT of games that went into extra innings that year, including that marathon double-header that didn't end until 4:00 am) he agreed to get up nicely in the morning; no complaining about being tired or cranky about getting ready for camp. He always kept his part of that bargain. I must admit that it was his devotion to the team that made me a baseball fan for the first time since 1971, when the Senators left my hometown of Washington DC.

For the next fifteen years I watched my son grow up, as together we survived the disappointment provided by the Phillies, year after year, as they failed to advance to the World Series.

We joked about how the Phillies always seemed able to snatch defeat from the jaws of victory, as they blew lead after lead.

We twisted their nickname, the "Fightin' Phils" into "the F**kin' Phils" for the seemingly endless permutations of ways they managed to f*** up game after game; season after season.

One by one, the players of 1993 -- the last team to make it to the World Series -- retired and/or moved on. One by one, we tried to fall in love with the new guys, but somehow they never jelled into a winning team.

Year after year, we kept on believin', as my son made his way through elementary school, then middle and high school. He played soccer in the fall and baseball in the spring, living and dying along with the Eagles, Flyers and Sixers all the way. But summers were really our only sports time together, as I still had my Redskins, and didn't really care about professional hockey or basketball.

As he grew, his own sporting skills improved, though he was always amazing. He could hit a pitched ball out of the yard by age 4, so in those early years he was way ahead of his teammates. Yet he never showed off; never boasted or bragged of his abilities. From a very young age, he carried himself almost like a coach; ever willing to lend a hand to his teammates, whether demonstrating a batting or baserunning technique, or anything else he was asked. Always the quintessential team player.

But our beloved Phillies continued to let us down, year after year.

Finally the time came: blue and white vinyl gowns topped with mortarboards and tassels. Graduation came and went; that last summer flew; the car was loaded and he was off to college. We still had summers -- and the Phillies, who continued to lose -- but the rhythm was different. He had his work schedule, his friends and my car, so he pretty much came and went as he pleased. We didn't get to watch all the Philies games together anymore, but there were some. Now I was the one making sure to get to bed at a decent hour, having to get up for work the next morning.

Now he's a senior (first of two senior years; he's on the 5-year plan) in college. He's 21, so he can legally have a beer at the ballpark. Every time he comes home he has a new configuration of facial hair. He's still the ultimate jock; more so than ever, in many ways. And now, just as he's on the cusp of full adulthood, we get to share the sweetness of the Phillies in the World Series again.

Fifteen years ago, my brother got married on October 23rd. During the reception I kept racing back and forth between the party and the hotel room where the children were being entertained -- and where the television was tuned to Game 6 of the World Series, Phillies vs. Toronto Blue Jays. I had just walked in when our aptly nicknamed closer, "the Wild Thing", threw a pitch to a guy named Joe Carter. I watched as it cleared the far wall, not fully realizing at that instant what was happening. But it didn't take long for reality to settle in. The Phillies had lost.

And here we are again after all these years. Oh, sure, we got to the playoffs last year, only to be ignominiously swept away by that upstart team from Denver. Yet because of that, this year feels different. Once again, I can name all the players on the starting roster (and almost all of the backup players too) something I'm not sure I've been able to do since 1993. Once again I'll watch October ball with bated breath. But this time I won't have an earnest, precocious 6-year-old on the couch next to me. I'll have to settle for phone calls between innings.

And he did mention that if...just if...there's a parade down Broad Street, he'd consider coming home from school just for that.

Go Phillies!

Monday, October 13, 2008

The Ultimate Non-Sequitur

So my sister who calls me all the time for medical advice (usually when I'm trying to cook, eat or clean up after dinner) called me for medical advice the other day. This time the topic was a ganglion cyst on her wrist that was becoming increasingly annoying. I gave her my standard spiel on ganglion cysts (reviewed the treatment options) and my standard spiel for her (go consult with a doctor in her own zip code.)

After the advice portion of the call was completed, she segued briefly into family stuff. Apparently, upon complaining to her father* "I have a ganglion cyst" his response was:
Is that good or bad for the Jews?

For what it's worth, the man just turned 80, has all his marbles and even knows what to do with them. He's sharper than many a tack, and yet somehow manages to pull this kind of stuff out of thin air from time to time.

I mean seriously; W.T.F?

*NB: she likes to point out that he's my father too, but when he comes out with stuff like this, I allow myself to wonder.

By the way, her answer was:
For me, it's bad; for all the other Jews, not so much.

Saturday, October 11, 2008

"Just One More Thing"

(Dr. Wes has had some problems of late, to which he appears to have responded by closing comments on his blog. So I'm posting this here instead of as a comment on his blog.)

The blogosphere's favorite electrophysiologist has a great post about the so-called "door-knob question," so-called because it generally comes at the end of an office visit when the doc's hand is already on the door knob, ready to leave. His example of the phenomenon is great; funny, too. Here's mine:

Seventeen-year-old girl with bronchitis:
Can bronchitis make you miss your period?
Um, no.

Dr. Wes is right, though; it added at least another thirty minutes (and a positive urine pregnancy test) to the visit.

Friday, October 03, 2008

Published Again

I'm delighted to announce the publication of yet another article of mine on Medscape (registration required; sorry):

Make Mine Paper

To the surprise of nary a one of the six regular readers of this blog, it is yet another screed against the hordes crying out for the universal adoption of electronic medical records.

Thursday, October 02, 2008

Yet Another Racket

When you go to see a doctor, whatever the specialty, it's generally coded for insurance purposes as an "Evaluation & Management" service. If you need a procedure of some kind, the doctor may want to do it in a hospital or other facility, often the "Short Procedure Unit" as an outpatient. (Oh, did I mention that the facility then bills for the procedure too?) If you're just going for the procedure, then it certainly makes sense to be seen in the facility setting, though as a general rule if you're seeing the doctor for the first time for an evaluation (as opposed to, say, a gastroenterologist for a screening colonoscopy) they're not going to know what kind of procedure you might need until they actually see you.

Several of our HMOs require us to write referrals for patients to see specialists, often including a separate one for the facility if there's a procedure involved. No problem.

Here's the problem: there's a new specialist who works at a satellite facility of the hospital -- presumably the location of his office -- who requires that these HMO patients have referrals for both him and for the facility for every visit, including the initial evaluation.


We did the specialist referral for the patient, but when the guy's office called for the facility referral, I went postal. I spoke with the specialist's staffer (the doctor couldn't be bothered, of course) and here's what I got:

It wasn't the doctor; it was supposedly the hospital's policy (the one that owned the satellite facility.) All patients seen by him were charged both a doctor's fee and a facility fee, so both referrals were needed.

What about self-pay patients? I asked.

"We don't see self-pay," came the answer.

It took awhile for me to pick my jaw up off the floor. Either that, or the girl had no idea what she was talking about. Clearly it was her job to just get that paperwork, and it didn't matter much what she said or who she said it to in order to get it. I pointed out that I didn't think the arrangement was legal. Her answer:

"Oh, it must be! The hospital wouldn't do it if it weren't."

OMG! Um...yeah.

What a sweet deal for the hospital! Instead of just charging a fair market rental for office space, they get to charge a full facility fee for every patient seen in their satellite for every visit by doctors they've gotten to sign on to the arrangement.

I pointed out that my only recourse was to stop sending patients to that particular specialist. His staffer chippy suggested I talk to the hospital, since it was "their" policy. Right. Like anything I might say is going to change the way they do business, especially as long as they're getting away with it.

Excuse me while I go puke.