Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, February 27, 2009

Alliteration on Steroids

No matter where you stand on the political spectrum, you have to admire the following sentence:
A parade of pathetic and pallid promoters, proudly producing pitiful and pusillanimous pronouncements and putrid punditry, proclaiming pork in purple prose, plainly projecting their party on a purposefully perplexing path to political poverty.
All I can say, Sid, is "P-you!"

It Takes Two to Tango

I don't usually get ticked off about stuff I pick up from Kevin, because as a fellow Family doc, he usually gets it. This time I'm afraid he missed the boat.

The topic is racial disparity in colon cancer screening. Apparently a study showed that in an all-Medicare population (ie, one in which access was not an issue) whites are still more likely to receive colonoscopy than black or Hispanic patients.

Kevin jumps to the standard conclusion:
...physicians need to be vigilant in offering the same treatment options and screening tests to minority patients.
Two words: Puh. Leeze.

I am hypervigilant about offering appropriate screening recommendations to all my patients regardless of race, gender, age and brand of sneaker. What I find -- and what the quoted article itself explicitly acknowledges -- is a huge variability in the ACCEPTANCE of my recommendations:
The researchers said that a combination of socioeconomic, healthcare access, and cultural factors likely explain the disparity in colorectal cancer screening, with the relative importance of each factor varying by race.
No one wants a colonoscopy. I do my best, equally with everyone, to talk them into it. Many remain reluctant. How is this my fault?

My reaction here is similar to my thoughts upon reading all those studies about how we doctors aren't doing a good enough job telling our patients to quit smoking. Researchers survey smokers and ask them things like,
  • Did your doctor tell you to stop smoking?
  • Would you stop smoking if your doctor told you to?
How many patients are going to answer truthfully:
  • Hell yes, every time I walk in the door he's up my ass about quitting.
  • Don't matter what no one says; I'll quit when I'm good and ready and not until then.
Of course not. You're going to get something more like:
  • Why no; I don't remember him saying anything about it at all.
  • Certainly. I have great respect for my doctor and would take his suggestions very seriously.
Conclusion: Bad doctor. You need to spend more time talking to your patients about smoking cessation.

It takes two to tango. I can "recommend" until I'm blue in the face. My powers of persuasion are pretty darn good, but patients have a responsibility here too. Although I'd love to see more direct studies of patient attitudes and specific ways to address them, I will settle for the acknowledgment that we doctors aren't necessarily to blame for these kinds of observed disparities.

Saturday, February 21, 2009

Oldies but Goodies

The jokes are old. Very old. As are the raconteurs. But there's still a certain panache to old Jews telling jokes.

(Borderline unsafe for work.)

(Speaking of work, SG, do you ever?)

Thursday, February 19, 2009

First Time for Everything

I did something the other day that I had never done before: I sutured a laceration without anesthetizing it first.

It was a 17-year-old boy messing around in the weight room who had been hit in the middle of the forehead, right at the hairline, with a barbell. There was no loss of consciousness, just a tiny little five millimeter laceration that was bleeding freely after being thoroughly cleaned out.

It only needed one stitch to close, and it occurred to me that the injections of lidocaine to numb it up would probably be at least as, if not more, painful than the single stitch with its two needle pokes. I explained this to the patient and his mother and he agreed to try. Of course I told him that if he changed his mind as I was doing it (ie, if it hurt too much) that I would stop and numb it up before continuing.

So I did it. The kid didn't blink; indeed, he said it didn't hurt nearly as much as he thought it would. Nothing to it. It was the first time I've ever documented in a chart,
After informed consent obtained, local anesthesia was deferred.
I know there are tons of you ER types who routinely do this for tiny lacerations, but bear in mind I only sew up about a couple a year instead of dozens a month. For me, it was a first.

Wednesday, February 18, 2009

Worth Repeating

From Margaret and Helen, addressing the Congress of the United States:
To the morons running this country: If you would spend as much time working on the nation’s problems as you spend trying to avoid paying taxes, you’d realize that most of us out here are neither red nor blue. We’re varying shades of purple and we’re fed up with your nonsense. Get together and figure a way out of this mess. Trust me - you don’t want me to come up there and figure it out for you, because if I have to come up there your ass is going to be introduced to my foot. It may not be a gigantic foot like Ms. Coulter’s but it will get the job done.
Helen is reading Ann Coulter's new book (which I am leaving intentionally unlinked) and reviewing it for us as she goes, so none of the rest of us have to waste either our time or our money. Truly, she is performing a great National Service in doing this for us. It's taking its toll on her, though:
...I need to take a nap. This book is boring the hell out of me, but I only have one chapter left. I can’t wait to move on to something more enjoyable than Ann Coulter - like irritable bowel syndrome. I mean it; really.

Tuesday, February 17, 2009

Lancaster Banking

Now that DinoDaughter is no longer all the way across the state, it's much easier to pick up for the day and bop out to Lancaster for a visit. Just in case anyone has forgotten, this is an epicenter of Amish life. Horse-drawn buggies share the roads as nonchalantly as bicycles do in Center City Philadelphia. For those of you whose impressions of the Amish are frozen with their portrayal in the movie Witness, suffice it to say that there's a wide range of acceptance of modern conveniences.

Which is how you wind up seeing things like this in a drive-through banking lane:

(Regarding photographs:
They believe that the taking of photographs where someone is recognizable[emphasis mine] is forbidden by the Biblical prohibition against making any 'graven image'.
Note that there is no way to identify anyone in this image.)

Monday, February 16, 2009

Family Fun

I recently had the opportunity to spend some quality time (defined as a clearly delineated period) with my sister and her family, which consists of a husband and a brilliant 5-year-old daughter with spherocytosis and lifelong eating issues (ie, beyond the usual pre-school reluctance to try new foods and a devotion to ritual that would put an ancient Roman high priestess to shame.)

In the course of the visit, my brother-in-law mentioned that he had recently been diagnosed with lichen planus, an intensely pruritic skin condition. As I considered the diagnosis, I realized that no one should have been surprised, as he and my sister just happen to be in their seventh year of marriage.

This particular visit included a shared meal, during which there were two episodes of note.

The first was when my niece declared, after having eaten three grains of rice, that she was done and wanted a piece of candy for dessert. I did a double take upon hearing her mother say, "Don't you want some real food, like a hot dog or some chicken nuggets?" That time, I was able to limit myself to an appreciatively ironic chuckle.

The next time, though, I was rendered helpless with choking laughter:

I cut off a tiny piece of my tofu and passed it over to my niece, suggesting that she try it. Obviously reluctant, but obeying the clear (though non-verbal) direction of her parents, she warily put it into her mouth. Her face immediately contorted into a crystal clear mask of intense distaste, however she also clearly knew better than to spit it out. Swallowing was an act of supreme will that she accomplished in due course. I saw her preparing to say that she didn't like it, but my sister quickly intervened.

"What do we say [at times like this]?" she prompted.

Face still screwed up from the agony of the experience, the little girl nevertheless managed to correctly display her home training.


Saturday, February 14, 2009

Cuteness Alert

The Rolling Peke is a small dog. She only weighs about 12 pounds. There are also four cats bopping around the DinoAbode. Most of them are bigger than that, but in the grand scheme of things they are all pretty small as domestic animals go.

Some of my DinoFriends are not sane.

One dear friend has a hankering for big dogs. Dogs like 170 pound Great Danes and 150 pound Bernese Mountain dogs. In the past, the Rolling Peke has enjoyed summertime visits to this particular friend. RP made friends easily with the bigger dogs, who tended to sniff her questioningly as if to say, "You smell like a dog, but you're so small!" It was during one of these visits that we also discovered the the RP could swim.

Sadly, my friend lost her 5-year-old Berner back around Thanksgiving.

Two weeks ago, she procured not just another Bernese Mountain dog, but two of them. Puppies, to be exact; 10 weeks old here:

(L: George, R: Tom)

And today the RP had a play date with them:

(Tom on the left; George on the right,
and a very puzzled Peke in the middle.)

The Dane was left at home this time around.

At the moment, each of the puppies also weighs about twelve pounds. My friend expects them to top out between 100 and 150 pounds each. We all went out for a walk together, as the puppies are just learning to walk on leashes. I held onto Tom while DS had RP. I freaked out a bit thinking how this dog will increase his weight by a factor of 10 over the next year or so. I'm sure the Rolling Peke will have just as much fun with them when they tower over her as she -- and we -- did with them today.

Thursday, February 12, 2009

United HealthCare; Still Scum of the Earth

Talk about schizophrenic! United HealthCare, here, is supposedly the good guy for buying into the "medical home concept," a 21st century description of what I and all my fellow FPs have been doing all along but tailored to large group practices. (Don't believe me? How can you have a "team approach" with one doctor and no nurse?) And yet my personal UHC experience, shared extensively on Sermo, is that they routinely find creative and random ways to deny payment for services they are legitimately contracted to cover.

Maybe that's where the money is coming from to fund that pilot project in Arizona. Personally, I'd rather get paid for what I've already done rather than getting into bed with them for more promises. My experience shows UHC to be one of the most unreliable contractual partners I've ever encountered. I would advise any physician to think twice before getting more deeply involved with this ruthless organization.

h/t Kevin

Wednesday, February 11, 2009

The Right Tools

I am frequently struck with waves of nostalgia as the NinjaBaker goes about his college career. He is not technically pre-med, but occasionally sends me palpitating (in fear of the potential tuition bills) by breezily commenting, "I had an opportunity to take a practice MCAT." (He didn't take it, though. Bullet dodged.) However he is taking biology this year, and all you science types should recognize what that means for second semester lab in genetics: fruit flies.

Yes, exactly thirty years after I did it, my kid is doing the fruit fly lab. What makes this so cool is that I know exactly what he's doing and what he's going through. I spoke with him the other day to see how it was going. Fine, he said. They use a different method than I used to knock the flies out before counting them, but they're using the same dissecting microscopes to sort and count them to generate their experimental data. I asked him what they were using to handle the flies under the scope. He said they'd been given a paint brush with a single bristle to push the little buggers around. How was it working, I asked. Meh, came the all-purpose adolescent answer.

Then I came up with a brilliant idea.

One of the things I have at my office are disposable plastic tools with small loops at one end that I use to remove impacted ear wax. Actually, the ones I now prefer are the ones that look like tiny scoops; but that meant that I had a whole box full of the loops that I don't use anymore. It occurred to me that they were the perfect size and shape to manipulate fruit flies under magnification. So the same day I sent a birthday package off to the Jock, I sent another to the NinjaBaker containing a couple dozen earwax loops.

Today I got a call and a very sincere thank-you. They worked perfectly, and his friends were suitably impressed, if somewhat puzzled, by a parental package containing something actually useful.

The whole thing reminded me once again of something I've been saying for years in many different contexts: it is significantly easier to accomplish almost anything when you have the right tools. When I mentioned this to the NinjaBaker, he pointed out that I've told him that several times before, usually in the context of cooking and baking. Other areas I've noticed that it also holds true are woodworking, carpentry and surgery. Also home organization (storage boxes, folders, labels, filing cabinets, etc.); car repair (spark plug wrenches); the list is endless. There have even been times when I've picked up a new hobby just because I've seen a really cool tool.

Today's lesson for life: the importance of the right tools.

Tuesday, February 10, 2009

Cardiac Question

I have a question for all my esteemed cardiology colleagues out there; preferably the ones following evidence-based guidelines instead of the ones who order tests based on their student loan, tuition, house and car payment due dates.

Now that it's been shown that stenting coronary arteries only helps in the setting of acute coronary syndrome or unstable angina (ie, actual symptoms) what is the purpose of "routine" annual stress testing for patients with stable coronary disease?

Assuming that all of them are on statins with an LDL goal of 80 or less, have been convinced to stop smoking and have their blood pressures adequately and have normal LV function by echocardiogram, why do they need repeat stress testing in the absence of symptoms? For that matter, without a murmur or symptoms suggestive of valvular heart disease and a structurally normal heart documented once (you can't call yourself a cardiac patient without having an ehco) what advantage is there from repeating echocardiograms on a regular basis either?

Seems to me like the main thing outpatient cardiologists do -- other than ordering annual stress tests and echoes, along with EKGs at every visit -- is exhort patients to exercise and stop smoking. What really roasts my beef is when patients ignore the same advice from me.

Monday, February 09, 2009

Now *This* is an EHR

First and most important, I'd like to welcome the Tundra PA back to work after her recent surgery. Although she's back in the saddle again, she's working from home for the moment, thanks to one kick-ass system of technology.

In addition to receiving faxed reports from remote villages, her telemedicine program allows her to view EKGs as well as images or brief video clips taken with digital cameras. Furthermore, her patient database gives her immediate access to:
[A] health summary for each patient, with demographic information, chronic diagnoses, prescriptions filled, lab results for the past two years, radiology results for the past five years, surgical histories, and more. It is a thorough thumbnail of the patient...
Wow. Now that would be useful even here in the wild, untamed expanses of suburban Philadelphia.

TPA correctly points out that this is not technically an electronic medical record (EMR) in that individual patient visits are not recorded via computer. However it is an EHR in the best sense of the word. Definitions:
EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.

EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.

If the Obama administration -- or anyone else, for that matter -- wants to go about setting up a similar system down here in the lower 48, sign me up!

In case anyone wonder$ what'$ $topping them, the an$wer is $imple: whoever'$ EHR $y$tem is cho$en to be the official repo$itory of American'$ health information $tand$ to make out, $hall we $ay, quite well financially.

In any event, please join me in welcoming TPA back into the fold. You've been missed.

Friday, February 06, 2009

Happy Birthday

Although I am a passionate fan of the Digital Cuttlefish, I'd like to make it quite clear that my father is a similarly skillful (though perhaps not quite as prolific) doggerelist writer poet. It is him to whom I owe my skill talent cognitive quirks.

The following self-explanatory verse is directed to the Jock:

It shouldn't be so hard
To find a birthday card
To wish my darling son a happy day,
But the ones in stores are stupid
and the ones online are putrid,
So I'm going to have to try another way.

Though you're far across the state
I know your birthday couldn't wait,
As you toil away, so far from Eagles Nation;
It's your birthday -- whoop-dee-doo!
I can't believe you're twenty-two,
As you heft another beer in celebration.

So enjoy this DVD,
Charge your dinner out to me;
Your birthday is a perfectly fine reason.
And don't sweat that Super Bowl
Just 'cause Pittsburgh's on a roll,
For the Eagles, there will always be next season.

And to DinoDaughter, his twin, here's one for you, too:

Roses are red,
Violets are blue,
I'll see you tonight,
So don't complain that I didn't write a special birthday poem just for you too.

Thursday, February 05, 2009

A New Concept for Gun Control

My good buddy AD has a post today about gun control and the Second Amendment in which he references a post by another good buddy of his, Mule Breath. Between the two of them they wax rhapsodic on the Rights of Americans to own guns, and blast any attempts at gun control with slippery slope arguments about "first they ban these guns, then those, etc." The point is also made that laws apply only to the law-abiding -- by definition, in fact -- and will not deter the criminal element in their quest to obtain and use firearms. This is true.

There appears to be an assumption that the essence of "law-abiding" as applied to gun ownership refers to the concept of "time and place." There are safety rules at shooting ranges, are there not? If you're not allowed to shoot in the lobby, doesn't that "limit your rights"? They have posted hours of operation, do they not? I notice that you don't get all hot and bothered at the idea that your "rights" are limited by the hours that the range is open. Time and place, fellas; time and place.

I would like to propose a new approach that should pass muster even with the most die-hard of you 2A supporter-types. Instead of regulating the "who" and "when" (background checks; gun licenses) and the "what" (which guns) how about simply restricting the "where."

How about this: No guns allowed within the city limits of Philadelphia (New York; Los Angeles; whatever municipality you wish.)

The fact of the matter -- frequently overlooked/ignored by gun proponents -- is that firearms are responsible for a truly appalling amount of urban carnage in cities all over the United States. Philadelphia Mayor Michael Nutter has been quoted responding to those protesting gun control by saying, "I have the right not to be shot." Frankly, in the context of urban living, I believe the right not to be shot trumps the rights of every Tom, Dick and Rasheem to own enough firepower to subdue Mogadishu.

Make all guns illegal within city limits. All guns; all gun shops; no guns in the city, period. It may not work right away, but it turns out that perilously few urban shootings are actually the result of law-abiding gun owners using firearms to "protect" themselves against bona fide criminal activity. Over a very short time the carnage would fall dramatically.

Want to shoot? Keep your guns at the range -- outside the city. Don't like it? Move. Simple as that.

There is ample precedent for such local ordinances. Want to contract legally with a prostitute? Only in Nevada. Gambling is similarly regulated. Why the big deal over firearm control on a geographic basis?

It would be inconsistent for 2A whack jobs proponents to object to this idea while accepting other limitations on gun use. AD, wouldn't you be upset if someone left a handgun lying around at KatyBeth's school? (I know that KB knows better than to mishandle it, but can you say the same for every kid in the school? How about the spawn of the idjit that brought it in the first place?) You all seem to accept that gun ownership comes with responsibilities. You even pay lip service to the fact that not every gun owner fulfills those responsibilities. I believe the creation of geographic areas where guns are not allowed would create an acceptable balance between the rights of gun owners and users, and those who prefer not to be exposed to the dangers of the misuse of firearms.

There is absolutely no chance of any slippery slope argument with this approach either. There is no way any of these gun-free zones would ever be expanded one millimeter beyond where the inhabitants want them, because all of the gun nuts law-abiding gun-owning citizens regularly elect like-minded legislators. That's the problem in Pennsylvania at the moment. The pro-gun legislators in the middle of the state have passed laws prohibiting municipalities such as Philadelphia and Pittsburgh from passing any such laws. After all, it's not their children being gunned down on the way to school.

So there you go: a rational attempt to balance the right to own guns with the right not to be shot. After all, what's the difference between a hunting license and prohibiting guns within a certain geographic? Reasonable regulation.

Wednesday, February 04, 2009

EMR Ethics

I find myself on the horns of an ethical dilemma. (Not the ethics of a horny dilemma; get your mind out of the gutter!) The proliferation of electronic medical records (EMRs) has generated a situation that really roasts my beef, and I am seeing it with increasing frequency. It's the flip side of the lawyers' old canard,
If it isn't documented, it didn't happen.
It seems that more and more doctors are taking that to mean that if something IS documented, then whether or not it actually happened is moot, at least as far as payment is concerned.

There are at least two specialist offices who regularly send me letters documenting examinations that I know for a fact did not occur. In one case, the proof is that they document procedures requiring a level of patient cooperation and vocalization incompatible with the patient's age. (ie, How do you get a two-year-old to tell you in which ear the tuning fork sounds louder?) In another, a full body exam is documented at each visit when only the affected limb was examined. Those are the only two where my level of certainty is 100%. There are many others that are highly questionable, but harder to prove because of patient unfamiliarity with examination procedures.

What's the big deal?

What most patients don't understand is that physicians get paid on the basis of what they write down. Of course, the documentation is supposed to accurately reflect what was done, but when the auditor comes along, all that matters is the paper trail. So if a doctor spends a great deal of time with a patient performing a complex evaluation but only writes a few words, he's at risk of not being paid; whereas if he writes pages of stuff that never happened, no one bats an eye. Most of the time, no one will ever know.

Just me.

Here's the dilemma: what, if anything, can I do about this? More to the point, what should I do?

I've spoken to the first office in the past. They claimed they had done all the procedures documented, and then offered to come over to my office to help me implement an EMR myself, given that they had just spent $250,000 on their new one and really liked the way it enhanced their income. The other office only started doing this more recently, and frankly the combination of anger and frustration has resulted in paralysis; I haven't talked to them about it either.

Besides, what would I say?:

Me: You're documenting fraudulently.
Them: So what? You can't prove it.

What else can I do? Is it worth trying to blow the whistle on these guys? I'm certain they'd easily survive any insurance audit, because the only way to prove them wrong is to call each patient and say, "Did the doctor do a complete physical exam each time you went for your broken foot?" Who's going to remember? More importantly, who's going to bother?

So all I can do is sit here fuming while these specialists laugh all the way to the bank. And the Obama administration wants to increase the prevalence of EMRs. Does anyone wonder why health care in this country is so expensive?

Monday, February 02, 2009

Clear That Patient!

Hello Bloggers, and welcome to that fabulous new medical game show, Clear That Patient!


As you know, Clear That Patient! is all about balancing risks. Technically, of course, it is understood that the concept of "Medical Clearance" is flawed. It is sad but true that, taken literally, the statement, "Medically cleared" over your signature could be construed by an unscrupulous attorney as an assurance that all will go well, potentially leaving your hiney on the chopping block in the event of any misadventure. ("But doctor, you said the patient was cleared. Shouldn't you have known he was going to have an MI in the middle of the procedure?")

Your job, contestants, is to examine each of the following scenarios and decide whether or not, in your expert judgment, the benefits of the proposed surgical procedure outweigh the medical, surgical and anesthesia risks given the medical facts presented. Your final answer needs to reflect your opinion as to whether you can, in good conscience, allow the patient -- as presented -- to undergo the proposed operation RIGHT NOW. Possible answers include:
  1. Yes, go ahead.
  2. Needs further workup first, but okay if everything checks out.
  3. No way; not until the patient is better controlled.
It is also understood that the anesthesia, surgical and postoperative care will be the absolute best possible in all cases.

Ready? Okay then; here we go:

38-year-old male with a BP of 240/140 and a creatinine of 4 (refusing ER and hospital evaluation of headaches, melena and hematuria AND has blown off multiple nephrology appointments) presents requesting surgical clearance to fix his umbilical hernia.

65-year-old male requesting repair of a volleyball-sized scrotal hernia presenting at the hospital's surgical clinic, found to be in atrial fibrillation.

35-year-old female, three pack-a-day smoker, diabetic with an A1c of 14, who needs a vaginal hysterectomy after multiple LEEP procedures who now has severe cervical dysplasia.


And now, contestants, for extra credit:

Guess which of these patients have I actually seen, either in training or in my practice.

Sunday, February 01, 2009


A few weeks ago I got a call from a dear friend who was vacationing in Florida. Somehow, she said, the TSA had managed to lose her husband's pill box filled with a week of meds that had been locked into his checked baggage. Could I please please pretty please call them in to a local pharmacy. I did (they were all diabetes, hypertension and basic coronary artery disease meds; not a controlled substance among them) with pleasure.

This week she and her husband brought me a small gift to show their appreciation.

Today as I finally got around to clearing my tabletop, I noticed that the bag from the store they had gone to said "Hoi Paloi Gallery." And my mind went off into a game I sometimes play with myself.

What if the aforementioned gallery also sold large goldfish. Would they be:
  • Hoi Paloi koi
What if they were all male:
  • Hoi Paloi boy koi
What if they weren't Jewish:
  • Hoi Paloi goy boy koi
What if you wanted to play with them:
  • Hoi Paloi goy boy koi toy
What if they couldn't eat wheat? You'd have to feed them:
  • Hoi Paloi goy boy koi toy soy
You get the idea. I suppose the only response is:
  • Oy.