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?