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.

Wednesday, August 29, 2007

Grand Theft Patient

She started coming to me because she didn't like the impersonal care at the Enormous Group Practice that dominates at the hospital, though she likes the hospital because it's close to home. All she was taking was Synthroid and aspirin.

Until I sent her to the ER with new-onset A-fib.

Two months later -- not a word from anyone in the meantime -- she comes back with a med list that includes two antiarrhythmics, warfarin, a diuretic and FSM knows what else. What happened? Is she in sinus or A-fib with a controlled rate? Who's managing her anticoagulation? What about those new skin lesions on her arm? Drug rash or something else?

It's the oldest story in the world.

When she presented to the ER, they already had her in their computer as an EGP patient. Never mind that she (and her daughter) specifically told them I was her doctor now. Nope; once you're in that computer, you're theirs for life!

That doesn't stop me from calling over there, intending to politely chew them a new one. "The cardiologist isn't here today, and his nurse has Wednesdays off." (Damn; I should become a nurse.)

I do the best I can.

I'm pretty sure the skin lesions are hives, but they're awfully localized and really round, so I do a lyme test to be sure. I do a thyroid test because even though her TSH was fine two months ago, one of her new meds doesn't play well with Synthroid. They've been managing her Coumadin, so I don't mess with that for the moment. Her pulse is 48, but she's as impressively asymptomatic as she was when it was 150.

Finally (2 days later) the cardiologist calls back. He's so sorry, but they already had her in their computer as one of their patients, so he didn't worry about it. Next time I should call and they'll be sure to keep me in the loop. (I did call the ER when I sent her over. How many more times should I call?) He was very sorry, though. By now I have her negative lyme test and have adjusted her Synthroid. Has he seen any strange drug rashes lately? No, not really. He's no help, but he's very sorry about the mixup.

My only real recourse is to "vote with my feet" by not sending patients to this hospital anymore. Unfortunately, medical care has more in common with real estate than anyone like to admit: location, location, location. When patients don't want to travel, I'm stuck. So I just have to suck it up and go calling around to get discharge information.

Ah well. Now I have to go track down what happened to the guy I sent over for a stress test who wound up in the ER.

Tuesday, August 28, 2007

Reminder Calls

We're pretty good about calling patients the day before their appointments to remind them.

Phone call today: "Hi, this is Mrs. Sumdood. What time is my appointment today?"
Look at book. Answer: "That's at 1:30 this afternoon."
Mrs. Sumdood: "Thanks. See you then."

Not-on-vacation staffer walks back in from getting the mail.

Me: "Mrs. Sumdood called to confirm what time her appointment was."
NOV Staffer: "She made that appointment yesterday."

Monday, August 27, 2007

An Inexact Science

Medicine is frequently and correctly described as an inexact science. What this really means isn't just that we aren't always right, but that it is expected -- and fully appropriate -- that "errors" will occur a certain percentage of the time.

This post was originally inspired by a line by Susan Palwick about handouts to the homeless, attributed to her father:
If you aren't getting scammed occasionally, you aren't being generous enough.
That struck me as an accurate restatement of my views about being duped by drug-seeking patients. I would rather be fooled on occasion than run the risk of leaving a genuine sufferer in pain. This stance in no way relieves me of the obligation to exercise caution not to fall for every drug scammer. I use my knowledge and experience to make the best decisions I can based on the information I have, knowing I will not always be right. The art of medicine lies in balancing the risks against the consequences of a given course of action in the event that I am wrong.

This issue comes up quite often in surgery. It's often said that if you don't have a certain percentage of "normal" appendices going to pathology, you are taking dangerous risks by not taking enough people to the OR, presumably increasing the risk of appendiceal rupture. Sid Schwab could tell you better than I what actual numerical level of "false alarms" would be considered -- respectively -- excessive, too conservative and "just right." The fact remains than a "zero" error rate is neither achievable nor desirable.

Similar risk-benefit analyses happen with c-sections, only here the "risk" side of the equation includes the always subjective, always nebulous "risk of litigation." Set that variable high enough and it's a wonder anyone is allowed to deliver vaginally anymore. Although the consensus might be that the present US rate of 29% is too high, surely if it were "too low" there would be some babies being put at unnecessary risk from labor. How are we to calculate what the "just right" rate is?

I bring up this subject now in the context of the recent Medicare rule changes about no longer paying for "preventable complications." Dr. RW does a magnificent job of explaining why these rules have been given this ridiculous doublespeak name. But if the underlying assumption is that complications should have been prevented, caring for them should not have been necessary, and Medicare should only pay for "necessary care." Think for a minute about the logical extension of the policy -- oh so reasonable on its surface -- of not paying for "unnecessary care."

How long before Medicare refuses to pay for an appendectomy if the pathology is negative? If the appendix was normal, then it didn't need to come out, right? What about a negative breast biopsy, or any kind of exploratory surgery that doesn't yield positive pathological findings? Couldn't a cardiac catheterization that showed clean coronaries be considered "unnecessary"?

What about imaging? Billions of dollars spent annually on diagnostic imaging means tremendous opportunities for reigning in costs by refusing to pay for studies that are normal. No brain tumor or other abnormality found on that MRI? Then why should we pay for it?

It's the ultimate Catch-22 and a med-mal lawyer's wet dream; the ultimate damned-if-you-do and damned-if-you-don't for physicians: retroactive denials based on negative results that you needed the test to determine in the first place. I submit that the slope from these new Medicare regulations to this nightmare farce of medical care is as steep as it is slippery.

Sunday, August 26, 2007

Thirty Years: Then and Now

Thirty years ago today I started college.

Today I dropped my son off at the very same campus.

My parents came to my college exactly twice: that first move-in day, and graduation. I don't remember having all that much stuff to move in: a bunch of t-shirts and flannel shirts, a couple of pairs of jeans and cords; a handful of sweaters; a couple of nice outfits; linens and toiletries; and of course the stereo (which includes the record collection) because naturally the first order of business upon arriving in a dorm room is to generate music.

I was a first child, but the kid I just took to college was my last, so he had the benefit of the wisdom of his elders (sibs, that is) as well as the smarts to listen to them, so his stuff fit easily into the van. His necessities included the microwave and TV, as the roommate was bringing the fridge and game system, plus his laptop, printer and calculator -- which of course included the required cables, surge protectors, power strips and other accouterments. He spent the evening in the hotel the night before move-in copying the entire travel case of CDs onto his laptop.

As soon as we got to his dorm room, the first thing he did was whip out that laptop and fire up the music.

My folks helped me carry stuff to my room, but didn't seem all that anxious to watch me unpack. My mother wanted to make my bed, but I didn't want to let her. I loved them very much and was glad that they were there, but I couldn't wait for them to leave so I could go do things like pick up my ID and check out the bookstore.

The roommate arrived, complete with parents to whom you'd be tempted to apply the term "helicopter", except that the connotation of "hovering" implies more space than they seemed to give him. I sat quietly by the window watching as they unpacked and arranged and organized, knowing that both boys were just waiting until we left to re-arrange it all to their liking. The roommate seemed very easy-going; I think the Nestling and he will hit it off very well indeed.

When I began college, there weren't any "family" activities. "Parents' Weekend" didn't even exist yet. I don't think my parents even expressed much interest in wandering around the campus, although it's not like I knew my way around yet either.

We headed off to get his ID. "Where is this building?" he asked me. "Way up at the other end of campus. I'll show you."

As we headed off, he was quickly joined by two girls. They all introduced themselves and headed up the hill much faster than I could go anymore, so I huffed and puffed a growing distance behind them. Only when I yelled after them, "Turn left here" did they turn and acknowledge me. We found our way to the ID office where, after filling out a long, complex form (4 x 6 inches; "Last Name," "First Name") on orange paper under a sign that read "Please fill out the orange form" we proceeded through a fast-moving line where his picture was digitally recorded and his college ID card duly issued, complete with his meal plan stored in the magnetic strip.

At the entrance to what was the main Student Union building in my day was a large white tent covering a collection of tables that housed assorted University services and offices felt to be of interest to Families. It was named, not unreasonably, the "Family Resource Tent." Most of the stations were offering goodies of one sort or another (frisbees, keychains and lots of candy) so we made the rounds. I offered myself as a resource to the Pre-Health Professions Advising department. What better time to infect docs-to-be with the assurance that Primary Care is worth it, despite what they're going to hear in med school and beyond.

Next stop was the bookstore, where we dropped $300 on the rest of his books (the ones he hadn't been able to find on ebay.)

There were orientation events to which families were invited all the way up until 4:30. I still had a six-hour drive home, so I had no intention of staying for them. By about 1:00 I could tell that although he was still enjoying my company, my kid was ready for me to go. He helped my schlep the empty plastic tubs he'd used to pack his stuff back down to the car, where he tossed them in the back to rattle around the huge, empty expanse.

I'll never forget the actual farewell to my folks. My dad hugged me, said goodbye and went to get the car. My mother hugged me too, and then said this:
Be good, and have fun. And if the two don't go together, "have fun" comes first.
Unexpected words, especially from a mother in 1977. I've treasured them for thirty years.

Today I said those same words to my youngest child as I sent him off into the world, from the same launching pad as I, thirty years ago. This time, though, I was headed home and he was the one staying behind, unbearably eager to begin this next phase of his life.

I remember my mother's face dripping with sweat as we said good-bye. Even in New England, August is hot as hell.

I was pretty sweaty myself, and I looked forward to getting in the car and cranking up the A/C. The dorms aren't air conditioned, but at least he has a fan for these last few sweltering August nights.

Soon enough the air will turn salty-crisp, and he'll walk to his classes -- in the same buildings as I did thirty years ago -- under verdant greenery transformed into that magnificent explosion of reds, oranges, yellow, golds and purples that annually grace the Northeastern United States. This fall foliage will peak for him first up in Boston, then roll down the I-95 corridor like a raging tsunami of color down to me in Philadelphia, where I'll be basking in the glow of the end of my children's childhood. It will continue down to Washington, where my father revels in the accomplishments of his descendants; and then a little further, down to the cemetery in northern Virginia, where my mother rests in peace.

Saturday, August 25, 2007

One Year Blogiversary

As of today, this old dinosaur has been blogging for one year. Here are some numbers:

Days: 365

Posts: 339

Comments: 2,130
(Most= 125, Least=0, Average= 6.28)

Total visits: 73,205

Total page views: 114,878

My gratitude to all the new friends I've made and people I've "met" through this electronic endeavor: Infinite.

Friday, August 24, 2007

Night Out With the Boys

Me to the Jock: "When was the last time you had an eye exam?"
Jock: "Those screenings at school?"
Me to the Nestling: Same Question.
Nestling: Same Answer.


So off we went to the eye doctor this afternoon. The appointments were timed so that we could hit Walmart for any last minute things they might still need for college and still get to Cheeburger Cheeburger for an early-ish dinner.

The fun began with signing in at the eye doctor. I was handed two forms to complete, one for each of them, which I promptly handed over to them. Hey; they're college kids; it's not supposed to be asking too much for them to read and write. They came to the line asking them for permission to use dilating drops. They were leery, but I talked them into it. One good dilated exam just to make sure everything was ok wouldn't hurt them. Later the joke was on them when I discovered they didn't actually understand what "dilating their eyes" meant. The Jock's left eye took a bit longer than his right to dilate, cracking up his brother. Trying to show off, I said, "Did you know there is a word for unequal pupils?" Jock's answer, "Freak?"

They both checked out fine, so off we headed to Walmart. I was thrilled when my suggestion for paper bowls and plasticware for eating (instead of microwaveable dishes that would need to be washed, in bathroom sinks, without disposals, that would quickly clog from the little bits of food left on everyone's dishes) was accepted. The Jock revealed that he needed hangers. The Jock also bestowed on the Nestling the wisdom that having some kind of food in the room was a Good Idea. Crackers, soda, goldfish, and ramen noodles (10 cents a package; a case of 24 was still a bargain) found themselves mingling with the paper plates and plastic forks in the cart.

CheeburgerCheeburger was an experience. Think 50's diner with ridiculously sized burgers. (From the menu: "There are no hamburgers on our menu. However our chefs have been known to make a Cheeburger without cheese, if you're sure that's what you really want. No cheese, no extra charge.") The kicker is "The Pounder"; actually 20 oz of beef before cooking. If you finish it by yourself, you get your picture put on the wall. The Jock, who has accomplished this gastronomic feat twice so far this summer, went for a three-peat.

Watching him eat this freakishly oversized burger was like watching an artisan at work. Much of the time it was held upside down, as the bottom bun was thinner, smaller and soggier. The meat threatened to fragment, but he held on to it -- how else -- manfully. Bite by bite, he put away this ridiculous hunk of dead cow interspersed with mouthfuls of really scrumptious fries. The vanilla shake I had was somewhere between awesome and amazing, though the Jock drank only water. When he was down to a chunk about 5 cm in diameter, the waitress came and said, "It looks like you're going to finish it, so I'll go get the camera." Whereupon he stuck the entire rest of the burger into his mouth. Chewed. And swallowed it. Didn't even belch. Although I barely finished a burger about one quarter the size of that monstrosity, I shared vicariously in his accomplishment.

The rest of the evening was filled with a trip to the grocery store, Costco and the storage locker ("Looks like I do need the microwave that's in there after all.") Things are getting pulled together for the Excellent Adventure that is this weekend: the tossing of everyone out of the nest. There is little to no anxiety about their ability to fly. I'm looking forward to watching them soar.

Far away.

And stay there.

At least until I finally get the house cleaned up.

Thursday, August 23, 2007

Smart Blogging

There's been an ongoing discussion in the medical blogosphere about the ethics of blogging. Much of it centers around patient privacy issues, authenticity and authority (l'affair TNT), and commercial transparency. There have been several attempts to formulate honor codes in the name of "ethical blogging", with varying degrees of penetrance and relevance to the general medical blogging public.

I'd like to suggest that conduct not in keeping with these codes -- blogging about identifiable patients without their consent and such -- is more unprofessional than "unethical." Some kinds of blogging -- about court cases in real time, for example -- are just stupid.

Several months ago there was an upheaval of sorts as a few bloggers disappeared, but many more got all bent out of shape and either pulled or curtailed their blogs. In the fullness of time, some of these latter have come back, supposedly "more careful" than they (thought they) had previously been.

Much of the ado is about anonymity. As we all know, there is no such thing as anonymity on the internet. In reality, though, the only way to get in trouble with attempted anonymity is to take it too seriously.

Many anonymous bloggers have an overinflated sense of how much the general public gives a shit about their real identity. In the process of going on and on about how worried they are that they may be outed, they do one of two things to their readers:
  1. They bore them.
  2. They annoy them.
Neither is good.

In the first case, readers will go elsewhere to read blogs where people are actually saying something of interest. In the second case, it's annoyed readers who are sometimes moved to "out" the blogger just because they can. Though bloggers may not realize it, it's almost as if they're daring readers to expose them.

The vast majority of bloggers -- including doctors -- have to realize that as long as they don't say stupid things on their blog, perilously few people actually care about their identity. As a rule of thumb, anyone who really NEEDS to be anonymous probably shouldn't be blogging in the first place.

What of the exceptions? I believe Barbados Butterfly was the victim of an overzealous and/or controlling employer. And Flea (sorry to put it like this, buddy) was just stupid; like a little kid thinking no one can see him because he's got his hands over his eyes.

In the final analysis, whether you choose to amuse yourself with the game of anonymity or not, the issue isn't one of ethical blogging vs. unethical blogging: it's smart blogging vs. stupid blogging. Don't be stupid, and everything will be fine.

(Dedicated to Dr. K.)

(edit: To clarify further on Anonymity:)

Anonymity only has meaning when people care about who you really are, which far fewer people do than most bloggers think. If you think about it, what makes people care who you are: You've said something that can be used against you in the real world (Flea) in which case the people who want to use it against you will move heaven and earth to find you; or you've annoyed the hell out of someone, and they try to out you to get back at you for being so annoying. So the bottom line is don't piss people off, and don't be stupid.

Tuesday, August 21, 2007

Anyone Interested in Trying This?

Dr. Val had this interesting bit about the relationship of taste to eating. Surprise! If you can't taste, apparently you lose interest in food and lose weight.

I immediately thought of this post at OnThePharm about the nastiness of metronidazole. (By the way, the medical term for taste disturbance is "dysgeusia.")

Do you think that a low dose of metronidazole -- just enough to disturb taste sensation without inducing the full, ice-cream-provoking syndrome OTP discusses -- might produce weight loss via essentially the same mechanism?

Hmm...I might just give that a try.

Putting it All Together

It took several separate posts, but a comment from Dr. Val (apologies for not linking to her sooner; oversight rectified) on "What could be wrong with Positive Thinking" finally put it all together:
People desperately want to control their illnesses and will resort to any number of evidenceless therapies for psychological comfort.
That was the essence of what I was trying to say in "The Real Issue with CAM". When we as physicians fail to meet our patients psychological needs -- or more precisely, their expectations -- patients will resort to other means. CAM modalities (and their practitioners) often present themselves to patients as capable of meeting those needs.

Another comment, from MSILF:
We all need to remember that the question most often underlying the patient's words, "Why did this happen to me?"... I've seen answers that range from wonderful, where you see that a great burden of guilt is lifted, to horrible, where the doctor spiels off a list of risk factors.
When we as physicians are able to answer that real question the patient is asking us, we do them a great service. Failure to meet the needs expressed by this question, and others, is what drives them to CAM. Even a treatment without rational evidence can provide comfort, albeit by buying into magical thinking.

Note: This post is not intended to regenerate a discussion on the efficacy of CAM. I'm trying to address the physician who may unintentionally be alienating his patients by simultaneously failing to meet their needs while belittling their attempts to have them met via CAM.

Monday, August 20, 2007

I'm Too Sexy For My Scrubs

Guess what: I'm Dr. August over at Medblog Addict's place.

Many thanks for the honor, MA.

Here's linking with you, kid.

This Sucks

Assuming all the facts are as they are presented, this sucks big time:
A Smithsburg woman is speaking out after she says she was dropped by her obstetrician when she was more than eight months pregnant, all because she refused to have a caesarean section.

"It is major surgery and you do have risks, not only during the birth, but down the road,” says expectant mother Lara Ecker.

Ecker says she knows how risky a c-section can be, after having her first two kids that way. So when she became pregnant with her third child, she told her doctor she wanted to do it naturally, or VBAC (Vaginal Birth After Caesarean).

“I was getting so close to my due date, I thought "certainly they'll help me try to do this',” she says.

But she says she was shocked when at eight months pregnant, her doctor's office, Simmonds and Simmonds in Frederick, gave her a letter telling her they were letting her go. They said it was because she challenged the use of a fetal heart monitor during labor and insisted on having a VBAC, a somewhat controversial procedure that some doctors say carries a higher risk of uterine rupture.

"The tactic I felt she was using was a fear tactic; it was like I was choosing between the life and death of my child, not the type of birth I was choosing,” says Ecker.

Simmonds and Simmonds did not return NBC25’s call for an interview, but officials with Frederick Memorial Hospital, where Ecker planned to have the baby, say the decision to perform a VBAC depends on the situation.

"If the patient comes to the physician with unreasonable demands, and will not allow him to deliver them in a safe manner, then the physician has the right to discharge the patient from his practice,” says Dr. Chet Wyman, vice president of medical affairs at FMH.

According to an opinion issued in July by the Maryland Attorney General's Office, a doctor cannot force a woman to have a c-section against her will unless the baby's health is in jeopardy, and ultimately the decision lies in the hands of the patient. It’s a notion shared by many women who have been down the same road before.

"Even though at that point, she could go into labor at any minute, her doctor only agreed to provide on-going care for the next seven days, we feel that constitutes patient abandonment,” says Barbara Stratton, Baltimore chapter leader of ICAN (International Caesarean Awareness Network).

Ecker says in the letter, her doctor gave her a list of three alternative options for other doctors, one which her insurance did not accept and two others who would not take her in at 38 weeks.
I began with the caveat "if these facts are correct":
  • Did the patient wait until the third trimester to bring up her concerns about delivery? If so, shame on her.
  • Did the physicians (or the allied practitioners) rush her through the regular office visits without allowing her time to discuss her delivery concerns, perhaps telling her, "We can discuss that later." If so, shame on them.
  • Did the docs spend each and every visit patiently trying to explain to her why they felt the hazards of VBAC outweighed the risk of another c-section, failed to convince her and gently warned her that they could not in good conscience abide by her wishes and would have to discharge her as a patient? If so, shame on her for misrepresenting the situation.
That said, assuming the facts are as stated, waiting until 38 weeks and then dismissing a pregnant patient without warning is outrageous. This kind of discussion should begin at the first prenatal visit, and if by the beginning of the third trimester doctor and patient remain at an impasse, the transfer should occur then. Certainly patients deserve the opportunity to discuss things like fetal monitoring and other labor interventions ahead of time. I've known people to change OBs, albeit earlier in the pregnancy, when they felt their wishes weren't going to be respected.

I agree completely that, in effect, by waiting to this point in a pregnancy, this constitutes patient abandonment. The OBs involved knew or certainly should have known that at 38 weeks, the patient would not have any other realistic options for delivery.

I'd love to hear the opinions of my OBG colleague/readers on this issue, but in my humble opinion, this sucks.

Sunday, August 19, 2007

A Tale of Two Rooms

The college freshman-to-be:
  • Neat stacks of folded towels and sheets
  • Folders of orientation info and pamphlets of info on his new bank accounts laid out neatly on the bed
  • Lamps, power strips, printer and other computer gear carefully lined up
  • Plastic tubs, storage boxes and under-bed crates all in a row
Heading off for the third time (granted half his stuff is already out there, stored with friends):
  • Clothes, shoes for every sport, papers, books mingle together, strewn all over the floor
Then again, they are both male: Neither bed is made.

Saturday, August 18, 2007

Home Stretch

One week from today I will be driving my youngest child off to begin his college career, which means I am on the home stretch to being an Empty Nester.

Although classically this is a time of sadness and depression, in many cases (cough*ME*cough) it is a time of celebration. Aside from having a preview every other week for the last ten years (joint custody has its benefits) I see it as a job well done.

My older two, starting their third year, are poised for a wonderful time. One finally gets to indulge in four classes in her major, having finally gotten most of the preliminaries and other requirements out of the way. The other has finally found his way to where I expected he'd end up all along, although the second change in major puts him on the five-year plan.

And the last one is just -- ready to go.

Although not interested in medicine, he's very much following in my footsteps as a scientist. He's already friended* his roommate on Facebook, gotten all his questions answered in the chat rooms, and, having already assembled the essentials (fridge, microwave, TV and game system) is sorting and packing his clothes. But after his hectic senior year in high school, he's going to take to college like a duck to water. I consider that a tribute to his maturity, and I celebrate his heading out into the world.

Still, this week will be special. The emotional countdown will be superimposed on the last minute hustle and bustle (dentist; eye doctor; laundry; clean out the minivan) of things that need to happen. As much as I'm going to miss them, I can't deny that I'm looking forward to being able to clean the nest and actually have it stay clean for more than 24 hours. But I won't begrudge them these last few days of clutter, along with my last week -- in a way -- as a parent of children. Time to morph over to parenting adults, a process that's been going on for the last two years but has accelerated over the summer. However you look at it, it's a special time.

*Attention Grammar Nazis: Yes, "friend" is now also a verb.

Friday, August 17, 2007

The "Oh Yeah!" Moment

From the comments:
I never actually looked at it from this angle before.
I never thought of positive thinking in this light before.
It's interesting how often something like this happens. A patient, family member, student, or even a random stranger on the internet points out something that, in retrospect, seems obvious. Things we say are not so much "misinterpreted" as they are interpreted in a manner consistent with our words, yet in total opposition to our intent. It all comes down to truly "walking in another's shoes," understanding how a patient can hear something very different from what we thought we were saying.

This whole thing is a merely a starting point for the realization that just about anything we support can be viewed as failure to support the opposite. For example, I favor breastfeeding. But once someone has made the decision to wean or bottle feed, they need (and deserve) respect and support too. Being overly enthusiastic about nursing runs the risk of insulting the mother who has chosen to bottle feed, or stigmatizing the mother who has been unsuccessful.

Exactly the same dynamic applies to natural childbirth. As wonderful an experience as it can be, those who do not choose it should not be vilified. Likewise, those who feel strongly that birth should be more than a medical procedure should not be ridiculed. Far too many people fail to see that their support for their way of doing things (the "right" way, in their view) can be insulting and demeaning to those who feel differently.

My original epiphany about this flip side of "thinking positive" occurred in the context of counseling a breast cancer patient once many years ago, though I've had similar experiences over the years. The most recent was just a few weeks ago.

I had a fantastic encounter* with a diabetic patient who took all his meds (including insulin) exactly as prescribed, but did nothing about his diet -- and had an A1C well over 10. Ate whatever he wanted; snacked like crazy on potato chips, pretzels; anything he wanted. I had diagnosed his wife with diabetes as well, and she, frankly, was feeling sabotaged and undermined by him as he encouraged her to join him in his unhealthy habits. When I saw him for a checkup, I set the chart down, leaned forward and got into a real heart-to-heart about why he was in my office. If he really didn't care if he lived or died (his response to my previous admonitions that he was going to wind up on dialysis, or have a stroke or heart attack if he didn't start taking better care of himself) then why bother coming back? To get his meds. But why even bother taking them if he really didn't care? Of course it quickly came out that he did care, wanted to live forever, and so on. From there, I suggested a very simple intervention with which he readily agreed, much to my surprise. We parted, both feeling pretty darn good about the visit.

When I saw his wife the following week, she told me, "You really made an impression on him. But you scared him to death."


"He thought you were going to dismiss him from your practice."

The thought had never crossed my mind! I was thinking more about why he was wasting HIS time coming to me if he wasn't going to take any of my advice. But upon reflection, it was obvious how he might think that's where I was going with the conversation. Another "Oh yeah!" moment, but one that taught me to be more explicit the next time I begin a talk along these lines. ("I'm not talking about dismissing you as a patient or anything, but I wonder why you're wasting your time coming here if you're not going to take any of my advice.")

Educators talk about "teachable moments." I guess those moments never stop happening. It just becomes our own responsibility to notice -- and learn from them.

*What made the rest of the encounter so rewarding was what came later. I suggested that he snack on nuts instead of all the high-carb foods he was consuming. Nothing about portion control; just the snacking issue. My strategy was "baby steps." Later, his wife told me he had come to her with some "menu suggestions" for the two of them. Somehow I'd managed to motivate him to move well beyond my modest suggestions. Totally made my day!

Thursday, August 16, 2007

What Could Be Wrong with "Positive Thinking"?

  • Think happy thoughts.
  • The power of positive thinking.
  • Picture yourself getting better.
  • Mind over matter.
What could possibly be wrong with any of the above statements? Even if they do no good, they can't do any harm, can they?

From the physician's standpoint, there's nothing wrong with them at all. Some docs may even think they're a good idea in terms of "patient empowerment." Anything that gives the patient a sense that they're doing something -- anything -- will make them feel better than if they are just passive recipients of medical care.

Here's the problem: it puts a potentially painful amount of the responsibility for recovery squarely on the patient's shoulders. If they don't get better, it's because they didn't try hard enough; visualize clearly enough; want it badly enough. Because this is so often (if not always) not true, all this "positivity" has the potential to be a cruel two-edged sword.

I'm sure many oncologists and other physicians do their damndest to reassure patients that they are not to blame for their disease. I have news for them (the docs): patients don't believe you. They won't tell you; they'll come tell me. Full of shame and guilt, whispering through their tears, they confide in me. Almost all of them:
  • "If only" they hadn't smoked, they wouldn't have gotten lung cancer.
  • "If only" they hadn't eaten so much red meat, they wouldn't have gotten colon cancer.
  • "If only" they had breastfed longer, they wouldn't have gotten breast cancer.
And those are only the ones for which the popular press might provide etiological support! I would say that almost all patients, deep down inside, feel that they are to blame for their illnesses. They may not always tell us about it, though, so in addition to dealing with their disease, they are also burdened with their guilt.

Now factor in the good, empowering physician -- often one with an open mind to alternative therapies -- who encourages the patient to "think positive." Visualize that chemo killing those nasty cancer cells. The mind-body connection is powerful: harness it for yourself!

Please note that I am NOT talking about hope. Keeping the patient's spirits up by providing hope is not a problem. The issue arises when the patient perceives that hope -- or positivity -- is part of the treatment that is under his control. Now, far from being just "hope", it's another responsibility for the patient.
  • "OMG, I wasn't sure what cancer cells looked like; I must have gotten it wrong in my visualization."
  • "Oops; I was really down this week. I didn't do my part. That's why my white count is down."
I know there are studies that purport to show precisely this phenomenon. My response: how dreadful for those who "just can't keep their spirits up." Now their relapse is all their fault.

Better to say nothing than to inadvertently thrust that kind of responsibility on an unsuspecting patient. Support them in their own expressions of positivity, but don't go actively suggesting that "it might help." What patients are going to hear, if they don't get better, is that it was their fault.

The dear late Sarah said it very well in October of last year, eight months before her death from melanoma:
I'm just so tired of feeling like this is my fault or people implying that I can change it with visualization or positive thinking. Let me see you cure your next cold with positive thinking, and let me see you cure your next bout of food poisoning by visualizing an army of white blood cells attacking the bacteria! That would never occur to these people, but somehow they think that cancer is different? Ya, it's different, it is a hell of a lot more serious, powerful, sneaky and deadly! It is also incurable at late stages....

A lot of the "warriors" and "survivors" that we see on tv... we are led to believe survived because of sheer determination, positivity and strength of character. Nope, I dare say, they survived because they had itty bitty cancers in situ that have less than a 10% chance of spreading! Sure, the treatment sucks and they were scared, and lives changed forever. But the media makes them out to be these rays of hope and living testaments to the power of will and determination, when in fact, they were just damn lucky.

(I just want to make clear that this post has been gestating for months, separate in every respect from recent discussions of alternative medicine. It is not meant as a dig at CAM.)

Wednesday, August 15, 2007

Let Me Make This Perfectly Clear; Yet Another Restatement of the Problem with CAM

Not that I'm under any illusion that the following will convince anyone who "really believes" in CAM:

Orac, via Dr. RW:
Here's the problem. Negative studies don't matter. If a study shows that a particular CAM "remedy" does no better than placebo, CAM practitioners don't believe it. Can anyone point me in the direction of a single "alternative" remedy that, after multiple negative studies, has been abandoned?
Not only that, but the government continues to fund these negative studies that no one pays attention to anyway, to the tune of over $120,000,000 dollars in 2008.

Here's the real difference between me and those who advocate CAM: I am the one who is truly open-minded, and they are the ones who refuse to consider anything other than what they are convinced is right; just the opposite of what they claim.

Show me the science and I will change my actions. Prove to me something doesn't work, and I will stop. (eg: post-menopausal hormone replacement therapy) Hell, show me that CAM works -- with something other than testimonials or anecdotes -- and I'll prescribe it in a heartbeat!

Show them -- over and over -- that their treatments are nothing but elaborate placebos, and all they do is accuse their critics of intolerance and claim that their treatments can't be tested (but still deserve to be called "medicine.")

Where have I seen this before? Oh yeah: it's called "doublethink", from a little tome published in 1949 titled 1984, by George Orwell.

I'm in the Eight

After weeks of biting my tongue and telling myself it doesn't matter to me, I've finally been included with the cool kids of KevinMD's MedBlog Power 8. I confess to being thrilled. Many thanks, Kevin.

Tuesday, August 14, 2007

Grand Rounds 3:47

After a bit of a submissions hiatus (though I rarely skip reading it) I'm back on the Grand Rounds bandwagon. And what a jolly time of it there is to be had over at Med Journal Watch:

Monday, August 13, 2007

Merv Griffin

For anyone who hasn't yet heard, Merv Griffin has died at the age of 82, of prostate cancer.

Best lines overheard so far (on the radio):
  • All eulogy speeches must be in the form of a question.
  • In lieu of flowers, the family is requesting that everyone buy a vowel.

Ethical Dilemma: Doctors as Patients

I got a phone call from a doctor I've covered for from time to time. He had a favor to ask me: would I write a referral for an MRI for him?

Actually, he had his office staff call my staff. I asked to speak to him directly.

It turns out the MRI was a perfectly appropriate follow-up for a questionable CT finding. Usually he writes all his own referrals, but for some reason in this case, the facility was refusing to accept the referral from his office, even though the insurance company had no objections. As it happened, his insurance was a capitated plan. He'd have to switch to my office as a patient; I'd receive capitation payments for him, but then again all his referrals would count towards my utilization figures.

I thought about what I should do.

It's a well-documented fact that many doctors -- especially those in primary care -- do not have a personal physician. They do what this guy does: take care of things themselves. It's also pretty clear that this is not a good idea.

So I offered as tactfully as I could to see him in my office, mainly to have a chart on him so we could document results of tests as well as referrals (in case the HMO came a-calling), but also to serve as his personal physician.

He declined.

He went on for awhile in such a way as to imply that what he was asking wasn't such a big deal and that he thought I was making more of a fuss over it than I should. He'd once needed an MRI of his knee, and a mutual orthopedist friend had written the script without a second thought. He ended the conversation by saying that he'd call around and see if he could find someone else willing to help him out, and would get back to me.

I found myself reflecting on the interaction.

What if the roles were reversed? Certainly I've written myself orders for routine screening tests. I even have a "chart" for myself in my office to keep track of labs and immunizations and other things. I occasionally go see a doctor -- usually a specialist -- for specific acute problems, but I must confess that I do not have a personal physician. However if I found myself in the position of needing a primary physician for administrative purposes, and if that physician were to gently indicate that he (and I, for that matter) wouldn't do what I was asking for a patient without a visit, I would probably sigh, admit to myself that he was right, and go see him as an actual patient.

It bothered me that this guy didn't seem to get it. It's just paperwork for a stupid insurance company. Can't I do a favor for a colleague?

Well let's see. I frequently get calls from neighbors and friends looking for "favors." Sometimes they don't have a doctor; other times they just don't want to bother theirs. (I usually manage to ignore the insult implied by the fact that they're willing to bother me.) I've learned to say no to these requests. Without a doctor-patient relationship -- which includes a visit, an exam and a chart -- I won't sign, order or prescribe anything. It's bad medicine, and -- oh yeah! -- illegal.

So why is it any different when it's a doctor/colleague?

I decided that it wasn't.

Tell me if -- and how -- I'm wrong.

Saturday, August 11, 2007

Be Careful What You Wish For

From the comments:
If insurance ever decides to include [alternative practitioners], the story will be much the same as it is for docs and chiros.
"Alternative Care Preauthorization Center. Please hold for the next available representative. [20 minutes later] Hello, my name is Jane Doe, what plan are you calling for?"
  • United WealthScare.
"HMO or PPO?"
  • HMO.
"What procedure are you calling to precertify?"
  • Acupuncture.
"What is the traditional Chinese diagnosis?"
  • Stagnation of qi.
"What is the pulse quality?"
  • Full.
"What is the appearance of the tongue?"
  • Phlegmatic.
"How many meridians are you requesting preauthorization for?"
  • Ten.
"Electroacupuncture or dry needling?"
  • Electro, please.
"Estimate of needles required? Please round up to the nearest five."
  • Um, say fifty.
"How many treatments are being requested?"
  • Six.
"Thank you. Please hold. [20 more minutes later] I'm sorry. United WealthScare cannot authorize electroacupuncture for the stated diagnosis of stagnation of qi."
  • Well, what will they cover?
"Treatment of Qi Stagnation is limited to no more than four treatments per episode for up to six meridians, with dry needles only, unless there is documentation of pulse diminishment or tongue changes such as fissuring. Thank you for calling the Alternative Care Preauthorization Center. Have a nice day."



I've always prided myself on my sense of balance: work and play; intellectual and emotional; not too yin, not too yang. So imagine my pleasure at discovering:

Your Brain is Green

Of all the brain types, yours has the most balance.
You are able to see all sides to most problems and are a good problem solver.
You need time to work out your thoughts, but you don't get stuck in bad thinking patterns.

You tend to spend a lot of time thinking about the future, philosophy, and relationships (both personal and intellectual).
What Color Is Your Brain?

Hat tip to Runs with Scissors, via Lynn (along with a thousand apologies for omitting the links in the first place.)

Friday, August 10, 2007

More on "CAM"

Not unexpectedly, my previous post generated a measured and considered response from a true believer. [Intended to be read as respectful and not sarcastic.] That's what I get, in part, from having a clear idea of my thesis but rushing to publish its execution. Allow me to clarify, beginning with a quote from Orac*:
I reject the distinction between evidence-based medicine and "alternative medicine" as a false dichotomy. To me, the only dichotomy that matters is between medicine that has high quality scientific evidence showing that it works and medicine that does not, a category that includes plausible treatments that might work but have not yet been shown to work, implausible treatments with little or no evidence of efficacy (a category that includes the vast majority of what is lumped together as "alternative medicine"), and treatments for which the preponderance of evidence shows that they do not work.
Modalities such as homeopathy, Reiki, acupuncture, etc. have not been shown to work. Over and over, mainstream researchers have tried to prove their efficacy. Hey, who wouldn't be excited about new treatments? The problem is that over and over, those experiments -- when well-designed -- have failed. Testimonials, even from initial unbelievers ("I didn't believe it would work, but I tried it and it did") do not constitute evidence.

My problem is when these "alternative" practitioners reject the idea that their modality can be subjected to scientific study. "You have to believe," or it doesn't work. That's what disqualifies it -- right there -- from being considered "medicine" at all. It's trying to claim the rights and privileges of medicine without accepting the responsibility of proving itself objectively, or at least the willingness to try.

Do they make people feel better? No doubt about it.

Many women I know claim that a trip to the beauty parlor is rejuvenating. Getting their hair washed (perhaps with a nice scalp massage), cut, styled and blown dry; maybe get a mani-pedi; it feels great! They can forget their troubles while they're there and allow themselves to be pampered. But no one would dream of calling it medicine, despite its undisputed contribution to well-being.

Perhaps that's where we can forge a compromise: If alternative therapies help, make patients feel better, enhance wellness and well-being, fine. Physicians should feel free to refer away. (In a sense, I do it all the time when I recommend chicken soup.) I'm sure there would be much greater openness from physicians to "other things that may help" as long as they're not misrepresented as "medicine." Practitioners can set themselves up in business all day long, as long as they don't call themselves "doctors." Hell, maybe I should "integrate" a hairdresser into my office. Plenty of women would surely be thrilled with the convenience!

It is by putting on airs, overreaching, and running the risk of steering their customers (not "patients") away from needed medical attention that alternative practitioners alienate doctors.

Let's reserve the term "medicine" for interventions that have either objective evidence of efficacy, scientific plausibility, or the willingness to be studied objectively (which of course runs the risk of not demonstrating efficacy, in which case includes the willingness to be discarded.)

*Actually, this entire post from Respectful Insolence about double standards says some of this more clearly.

Thursday, August 09, 2007


From Indexed:

The Real Issue With CAM

All kidding aside, I've been thinking about CAM (complementary and alternative medicine, also called Integrative medicine by those who feel that makes it more acceptable) a lot lately. Obviously much debate centers on efficacy of unproven treatment modalities, although it can certainly be said that there is no such thing as 'alternative' medicine; there is only medicine that has been proven to work, and medicine that hasn't. While it is important to consider evidence, efficacy, and even plausibility, that's not what I'm talking about.

The real issue with CAM is unmet needs.

When people get hurt or sick, they seek medical attention. Their needs, generally speaking, are for an accurate diagnosis and effective treatment that isn't too unpleasant or expensive, from a friendly-enough doctor with acceptable facilities. When these needs are met, there is no impetus to seek out any kind of alternative care. The system works; everyone is happy

Often enough, though, all of those needs are not met completely. The doctor was brusque (although the diagnosis was right and the treatment worked) or the staff was rude (but the doc was great.) Or they couldn't make a diagnosis (but the symptoms resolved on their own) or the suggested treatment was too expensive (but the diagnosis was right and the nurse was wonderful.)

Different people attach more or less importance to each of these elements; that is, they have different needs. Some people need to understand their diagnosis in greater detail than others. Some people want to know about every single possible treatment option, even those that may not be appropriate for them, because they just want to know. Other folks just say, "Just tell me what to do to get better and I'll do it." Different doctors meet different patients' needs differently in different situations. When one or more of those needs are not met by "conventional medicine" the patient may look elsewhere for relief; to have their needs met.

A patient with vague complaints of fatigue, pain and malaise may go through multiple investigations at the hands of numerous doctors and emerge without a satisfactory diagnosis. Without a diagnosis, treatment options may be limited. Symptomatic care may or may not be tried. Mental health treatment may be recommended; that recommendation may be accepted or rejected. It's easy to see patients' frustration build as their need for diagnosis, relief, validation, whatever, are not met. So they turn elsewhere: the chiropractor; the LLMD; the Reiki master; the acupuncturist.

Each of these practitioners manages to meet patients' needs. They diagnose invented conditions, but they provide a diagnosis. They perform treatments that have no scientific plausibility, but "at least they're doing something." They often spend long periods of time with patients, listening and providing validation that "something's wrong" even if the doctors could never find out what. They meet the patients' emotional need to be heard. They may not provide accurate diagnosis or effective treatment, but they are certainly meeting needs; otherwise they wouldn't exist.

Take another patient diagnosed with cancer. His primary need is for a cure, although sometimes we can't do that. Failing that, we must meet his need for hope; hope that pain will be managed, that he won't be abandoned; all of his emotional needs. If another can be cured, she needs to know that she can tolerate the treatment; that the vomiting can be treated; that she won't be too tired to take care of her kids; again, mainly that her emotional needs will be met. Even when we cannot cure, we can often do a decent job of meeting patient needs.

So when we can't, is it any wonder they turn to laetrile? To diet cures? To all manner of alternative treatments that meet their need for hope, even if not their desire for a physical cure.

Why do doctors turn to providing "alternative" care? What makes them do the mental somersaults required essentially to renounce their scientific training (in the name of "open-mindedness", they tell themselves)? Sometimes, perhaps, it's from disillusionment with patients' poor responses to what they've been taught they have to offer, but I'd wager that far more frequently the underlying motivation is economic.

An alternative (or complementary; or integrative) practice is a cash practice. It's a golden opportunity to ditch the insurance slavemasters, while convincing oneself that one is still helping people; albeit only those who can afford one's services.

Some of us -- those of us who truly understand the science as well as the art of medicine -- couldn't imagine that financial need would ever trump our integrity to the extent required to open an alternative practice, but for many others, when the physician's need to earn a living wage is not met by practicing conventional medicine, turning to CAM is often an economically viable option.

If conventional medicine were able to meet all of our patients' needs all of the time, and if all physicians were able to earn whatever amount of money required to meet their needs, there would be no such thing as CAM.

Researching new medical modalities is important. Who knows which alternative therapies are simply not proven "yet"? It is also important to debunk junk science when it represents a clear danger to patients. However as we go around and around with the debate, perhaps some of our energies would be better spent trying to improve the job we do of meeting our patients' needs. Then there wouldn't be a need for CAM.

Wednesday, August 08, 2007

Here's Smiling at You

Hat tip to Shelley for this one:

Here's a nifty little test to see how good you are at differentiating fake smiles from genuine ones.

I got 17 out of 20, so I have to admit to being pretty impressed with myself.

Complimentary Medicine

Forget the issues about whether or not it works. The real problem is that "Complementary Medicine" is misspelled at least half the time.

So when I saw it once again the other day, I couldn't help thinking about what real "complimentary" medicine might be like:

Acupuncture: You look nice today, Chemo. Is that a new wig?

Homeopathy: Hey, Reiki: nice aura!

Reiki: I can always count on you to cheer me up with a great joke, Chiro; you really crack me up!

LLMD: Your needles are so nice and shiny, Acupuncture. How do you keep them so pretty?

Chiro: This water is delicious, Homeopathy! Where do you get it?

and so on...


In the supermarket checkout line, about a young man known to be quite obese:

Sumdood: I heard he wants to join the Navy.
Anotherdood: As what? A harbor buoy?

Tuesday, August 07, 2007

Folk Concert

Every Sunday night during the summer, there is an open air folk concert near where I live. I get to varying numbers of them through the season, but one performer I never miss is Tom Chapin.

Younger brother of Harry (dead 26 years this summer, if you can believe it), Tom is wonderful. He sings with Michael Mark (on bass and concertina) and Jon Cobert (on keyboard) and always has fun doing a mix of old and new, children's favorites and biting satire (which is what folk music is best at), original tunes and Harry's songs. It's always a great evening, and last night was no exception.

He sang one new song that was so spot on, I had to share: (It's not on any of his CDs yet, so he's got it on his website, downloadable for free)

(Listen here)

Go on to sleep now, third grader of mine.
The test is tomorrow but you'll do just fine.
It's reading and math. Forget all the rest.
You don't need to know what is not on the test.

Each box that you mark on each test that you take,
Remember your teachers. Their jobs are at stake.
Your score is their score, but don't get all stressed.
They'd never teach anything not on the test.

The School Board is faced with No Child Left Behind,
With rules but no funding, they're caught in a bind.
So music and art and the things you love best
Are not in your school 'cause they're not on the test.

Sleep, sleep, and as you progress
You'll learn there's a lot that is not on the test.

Debate is a skill that is useful to know,
Unless you're in Congress or talk radio,
Where shouting and spouting and spewing are blessed
'Cause rational discourse was not on the test.

Thinking's important. It's good to know how.
And someday you'll learn to, but someday's not now.
Go on to sleep, now. You need your rest.
Don't think about thinking. It's not on the test.

Sunday, August 05, 2007

The $500 Pencil Sharpener (or: A Tale of Two Board Exams)

Many years ago I took my first Family Practice Board exam.

Imagine a hotel ballroom filled with tables set up in rows and columns, two people per table. Probably 1000 people all together. I remembered to bring my admission ticket and photo ID, as directed. I remember wondering whether or not to bring my own #2 pencils (this was 1989 and we did in fact record our answers on computerized answer sheets with #2 pencils.) Although I did decide to bring them, I was pleasantly surprised to find that they supplied them.

And what nice #2 pencils they were, too. White, with green lettering spelling out "American Board of Family Practice." Very nice pencils.

I passed the exam, went out and started practicing.

Time passed, as time is wont to do, and six years later it was time for my first re-certification. (The certificate was actually good for seven years, but it was considered a good idea to leave a year's cushion in case of failure, illness, or whatever.) It cost $500 to take the exam, so I sent off the check with my registration and cleared my appointment book for the appointed day.

I remembered the pencils, and didn't bother taking my own this time.

Same hotel ballroom. Same tables. Same 1000 people. But this time the pencils they passed out along with the test booklets and answer sheets were crappy plain yellow ones. Not only that, but they had those little bitty points you see on golf pencils. No way even two of these cruddy pencils were going to suffice for a six hour exam!

But then, plodding along behind the ID-checker lady and the answer-sheet and pencil-hander-outer guy was another lady carrying a large plastic bag, stopping at each board taker and handing over something from the bag. When she stopped in front of me, she dropped a white plastic miniature-pencil-shaped pencil sharpener; the kind you'd see in a kid's birthday party goodie bag. WTF? That's right. That's how they expected us to get through a six hour exam with those crappy little golf-pointed pencils.

When all materials were handed out, another lady mounted the podium set up in the front of the ballroom to give us directions. You know, the "You'll-have-two-hours-for-the-first-book, yadda yadda yadda" and "Don't even try to cheat" talk. The standard verbiage included the following standard warning:
No testing materials are to be taken from the room.
At this point, she stopped reading and looked up at us. In a tone that can only be described as sheepish, she added,
You can keep the pencil sharpeners.
I have it to this day: my $500 pencil sharpener.

Saturday, August 04, 2007

If You Want to Make it a Crime, Why Aren't You Willing to Punish it?

Hat tip to On the Pharm for this one:

It can't be embedded, but check out this YouTube link.

It seems like a perfectly logical question: if you believe abortion ought to be illegal, what do you think the punishment should be?

One little problem is that the makers of this homemade documentary go asking antiabortion protesters what they think should happen to the woman who has an illegal (their desired state of affairs) abortion, instead of what they think should happen to the doctors who do them. Small wonder that folks get downright tongue-tied trying not to answer. They have trouble with the idea of throwing women in jail, which frankly highlights their hypocrisy. If a woman held up a convenience store and shot a clerk in the process, you'd better believe she'd be hauled into court for murder without anyone breaking a sweat.

I have no doubt these same demonstrators wouldn't hesitate to toss docs into jail and throw away the key, though. Still, it's an interesting video.

(Edit: Thanks to Enoreios in the comments for pointing out Anna Quindlen's Newsweek response to this very video.)

Friday, August 03, 2007

Black Toenails

I saw a 14-year-old boy for a checkup.

As I was weighing him, I noticed a strange blackish discoloration around his toenails. Given that it was a 14-year-old boy, I asked him if it was dirt, or was there something going on with his toenails that we perhaps needed to address.

He smiled a little -- just a little -- and muttered, "Sharpie."

I see.

Me: "Were you going for the Goth pedicure look?"
Him: "No. I was REALLY bored."

I'll bet.

More on "Choices": One Patient's Perspective

I saw a new patient many years ago for a chief complaint of low back pain. In the course of my complete history, she added, "I have another problem, but I don't know if I want to tell you about it yet." I didn't push, and of course by the end of the interview she was comfortable enough to tell me:
I've had a "bad breast" [quotes mine] for five years.
One of her breasts was shrunken, hard, red and dry. Not oozing and stinky rotting, but a definite case of "locally advanced breast cancer." ("Partially auto-mastectomized" was the official oncologic terminology.)

My first thought, of course, was that her back pain was from bony metastases to her spine. As it turned out, it wasn't. She had spinal stenosis, for which she was operated on and did fine. But all she wanted for her breast was a simple mastectomy -- it was being irritated by the seat belt in her car -- and no further treatment. Investigation revealed she had some metastases to her ribs ("local invasion") that weren't bothering her, and no distant disease.

This was obviously a very slow-growing tumor to which she would eventually succumb, but her preference was to avoid the whole "cancer thing" of multiple surgeries, radiation, chemo, etc. It sounded like a reasonable option to me, so I found her a surgeon who I thought would be willing to honor her wishes and get her a "toilet mastectomy" ("toilet" in the sense of general cleanliness; another great oncologic neologism.)

I saw her back two years later -- after mastectomy, staged reconstruction including a tissue expander, chest wall radiation and chemotherapy. Here's what she told me:
They kept saying, "We have a lot of choices; a lot of choices. But first we have to do this. But then there are a lot of choices; lots of choices." Then later they say, "This is what we have to do next, but then there are lots of choices; lots of choices." After that they say, "We really should do this now, but after that you'll have a lot of choices; a lot of choices."
Clearly, she felt she wasn't really given much of a choice at all; at least not at any one stage along the way. Frankly, I get the sense that this is the experience of many, if not most, patients with cancer as well as with other conditions.

It's like asking a child what he wants for dinner. Few (smart) parents would simply allow the child an unqualified choice, so we say things like, "Do you want a hot dog or a hamburger for dinner?" Most of the time there are even fewer options, so we learn to say things like, "Do you want meatloaf or hamburgers?" Or even, "Do you want dinner on the red plate or the blue plate?" I don't mean to imply that patients are like children, but the principle is of giving others a sense of control while making the "real" decisions for them. It's still our responsibility to make good decisions, just as it is the parents' responsibility to provide a balanced diet of nutritious food.

In the comments to the previous post on this subject, Sid said this:
Not many of us would actively assist a patient to do that which we knew to be dangerous or ill-advised.
That criterion is a helluva lot more subjective than most docs realize. One person's "standard treatment" could easily be "ill-advised" by someone else, or even "dangerous" to yet another party. We need to admit -- even if only to ourselves -- that we are the ones making the choices.

Thursday, August 02, 2007

The Gift of Schmooze

As regular readers may remember, I try -- hard -- not to pay attention to all the awards floating around the 'sphere, so as not to get myself all bent out of shape, what with my natural competitiveness. Hell, when I was growing up my sibs and I could make a contest out of breathing! However when I first saw this one making the rounds, I confess I craved it.

I admit that in real life I think of myself as the ultimate schmoozer. I can walk into a room with 500 strangers and strike up a conversation in five minutes. I believe I come by this skill honestly; my father can do it in two minutes (competitive? Us? Nah.) To be fair, though, I've noticed this seems to be a trait inherent to family docs. The last ten times I've walked into a room with 500 strangers, they've been FPs; either at a conference or Board re-cert.

So when I saw the Schmooze award passing around, I wondered if anyone would consider me a good schmoozer.

Many thanks to Dr. K, of Frank's Mirror fame, for tagging me with the Power of Schmooze; cool graphic and all:
I know the rules are to tag five more people, adding a paragraph of nice things about them. I'm going to break my rule (about not tagging people) just this once. I checked as best I could to make sure none of the following had already been tagged, which frankly surprised me; they're among the best:

Kim at Emergiblog. Talk about defining "schmooze".

The Blog That Ate Manhattan: medicine and food are two of the most universal schmoozing topics in existence. Besides, she comes around regularly and leaves the greatest comments.

Susan Palwick at Rickety Contrivances of Doing Good: I feel like I know her from her recent pictures of her family visit. Her posts are thought provoking, and eminently schmooze-worthy.

MedBlog Addict: Wracked with insecurity, who else garners half a dozen comments on a post that says, "I'll be posting soon." She's the schmoozer who doesn't even realize it.

Lynn Price of Is it Friday Yet? She may not blog as often as some, but she comments on every post she reads. I'm actually considering asking her -- an actual professional acquiring EDITOR for chrissakes -- to beta-read my novel when it's done. Now *that's* the power of Schmooze.

Wednesday, August 01, 2007

So-Called Choices

Dr. Schwab has once again waxed eloquent, this time on the issue of immediate versus delayed breast reconstruction after mastectomy for breast cancer. One of the things he admits is that he has a bias, in this case a bias against immediate reconstruction, but that he tries not to let it sway him in how he counsels patients. I have no issue with the specifics of breast reconstruction timing, but I'd like to address the issue of physician bias -- and not at all to bash Sid!

I agree that not only do we all have our biases, but I would like to point out that it is the nature of the physician-patient relationship -- as a practical matter -- to use those biases all the time to make choices for our patients.

That is our job.

This is not a bad thing. We make very good choices for our patients almost all the time. Oh, we tell ourselves that we give our patients all the information they need to make their own decisions and that we respect the choices they make. I submit that we are being dishonest with ourselves, and here's why: when patients make choices with which we don't agree, we call them "inappropriate" and do not honor them.

I am not speaking of paternalism, the essence of which is that the patient should blindly agree with whatever we say. Although we are making the decisions, it is still incumbent upon us to explain to our patients -- in sufficient detail, and at a level they can comprehend -- why the course we are recommending is the "choice" they should make.

Many times, as a practical matter, the only way a patient can make a different choice is to consult another physician.

Look at some examples:
  • A patient wants antibiotics for an upper respiratory infection.
I can explain until I'm blue in the face that this is not a good idea, that they don't work and won't make him feel better any quicker, the risks of allergy and resistance and everything else. Although this interaction can be described as explaining appropriate therapy for a URI, the reality is that the patient has made a choice I don't agree with: he has chosen to treat his URI with antibiotics. That's why he's come to my office. My options are to stand my ground and explain my position, or give in and write him the prescription ("honor his choice.") The patient's options are either to come around to my way of thinking (if I'm persuasive enough) or he can go see old Doc Jones up the street who gives out Amoxicillin like candy.

  • A woman wants her breast cancer treated with diet and Reiki.
Similar to the above, but with much higher stakes. Everyone will be all over this lady about what a poor choice this is. The unfortunate truth is that in some tragic cases, these patients will not be convinced. There will always be someone -- Reiki masters and NDs -- willing to do whatever it is she wants; who "honors her choice."

  • A family wants to continue life support for a patient with no hope of recovery.
This is a frequent occurrence in the ICU setting. My guess is that most physicians would gently explain the limitations of futile care, trying to persuade the family to withdraw heroic measures, ie, disagreeing with the choice they've made, and persuading them them that a different choice would be better.

Now how about this one:
  • A family wants to withdraw life support but the physician feels the patient still has a significant chance for recovery.
I know this one is tough to imagine, but imagine a self-limited condition in an otherwise healthy patient; say temporary ventilatory support for pneumonia. The family says, "Dad didn't want to be on a breathing machine," and we rush to say, "That doesn't apply here at all! He's not terminal; the ventilator is only temporary." The family comes around quickly -- and appropriately -- but what really happened is that a family was guided away from making what we felt was a poor choice.

This has been addressed elsewhere:
  • A woman wants an abortion but her doctor is morally opposed to the procedure.
Different doctors respond differently to this scenario, but clearly the physician's bias is the major determinant of whether or not the patient's choice -- legal, and hers to make according to standard medical practice -- is honored.

Patients make bad decisions ("wrong choices") all the time. They decide they're sick enough to need an ER, but medical personnel disagree with them, so they wait until others who are correct in their assessments of how sick they are can be cared for first. Much of the time, we as physicians can agree that one given patient decision is better than another, or even that some are "wrong." On the other hand, that agreement is far from universal; witness the abortion "choice" above.

In addition, there are plenty of other clinical scenarios where we can agree there is no clear cut "best" choice: surgery or radiation for prostate cancer? Beating heart CABG or cardioplegia? Immediate surgical repair or casting for Achilles tendon rupture? In cases where the evidence is not yet complete (or where a doctor is unaware of, or chooses to ignore the evidence) physicians have their biases, often very strong ones. Certain urologists truly believe in their hands, prostatectomy is better than radiation. Some orthopedists will never operate on an Achilles tendon; others insist it's the only way to go, and so on. This is where "physician bias" comes into play. We usually call it "experience" instead of "bias" because we often feel we have a rational basis for the decision (let the patient process the cancer experience before going through major reconstructive surgery, per Sid) but all we've done is legitimize our bias. I'm not saying there's anything wrong with it, but it is still a bias.

I have a friend who needed a valve replaced in her heart. The research she did was exhaustive: hospitals; doctors; complication rates; techniques. As medically sophisticated as she was, how did she -- or anyone, really -- have the expertise to choose between multiple tertiary care centers and different surgeons each telling her his approach was best? Here's what I told her: If there were one clearly superior procedure, it would be the only one. The more different people there are telling you different things, the less it matters; your chances of doing well are good whatever you choose.

How are patients supposed to figure all this stuff out?

They're not. We're the doctors. We're the ones who are supposed to know about these things. We are the ones who should be making the decisions. There's nothing wrong with this. It's our job. As long as we communicate with our patients, get to know them and their preferences with regard to their health (ie some people prefer a cheaper med even if it has to be taken multiple times a day, and have no trouble with adherence; others feel the convenience of once daily dosing is worth paying more) and take those factors into account when we make our recommendations, we are indeed collaborating.

As Sid pointed out and as others are sure to echo, many of our patients will ask us, "What would you do if it were you/your family member?" The only way to fully avoid expressing a bias is to refuse to answer, and I don't know many doctors who can do that. Virtually everyone will eventually answer that question: they will tell the patient which choice they ought to make. If that isn't the same as making the choice, it's too close for comfort.

None of what I've said absolves the physician of the responsibility to make as certain as humanly possible that patients understand their conditions, what the treatment options are, and why the doctor is making this specific recommendation at this time. But at the end of the visit, when the pedal hits the metal and the rubber meets the road, we are the ones making the choices.

What's my point? That instead of foisting off the final decision on the patient by citing "patient autonomy" as the ultimate good, we need to recognize that in the end the responsibility is ours. Making these decisions thoughtfully, transparently, in consultation with the patient -- and with the awareness that we are making them -- is more intellectually honest than telling ourselves that "the final choice is up to the patient."