Archive for: September, 2009

Donors Choose!

Sep 30 2009 Published by under Donors Choose

Here in Michigan, schools are hurting---a lot. Classrooms are crowded, schools are closing, supplies are non-existent. Even in "wealthy" districts, the system is failing. Parents, when they can, supply the bulk of classroom supplies.
This is a good time to think about DonorsChoose, a unique charity that allows teachers to create proposals, and donors to choose what to fund. Many of these have matching funds available. Over on my left sidebar you can click over to check out my page, which is devoted to projects in Michigan. Please consider even small donations.

One response so far

BMI TMI weekly update

Sep 30 2009 Published by under Medicine

I've been putting this off. Today I'm 203.5#. I feel into some bad habits this week.
I've found that routine is my friend. I have a few choices for breakfast at home, a few lunch and dinner choices at the hospital, and a few evening snack choices at home, all of which support my diet.
We had a very stressful week at Casa Pal, mostly due to friends' illnesses, and while I didn't "stress eat" as much as I might have (the donuts don't count, honey), I was thrown off my routine.
But I'm back on track and we'll see how things go.

5 responses so far

Bad idea department: tax doctors to pay for health care for the poor

Sep 30 2009 Published by under Health care reform, Medicine

The state of Michigan is facing massive budget cuts which will further eviscerate the Medicaid program. If the legislature passes it's budget as planned, massive cuts to Medicaid will reduce federal matching funds further limiting access to health care for the state's many uninsured. It's not clear if there is a way out of this, other than a massive overhaul of the nation's health care system.
But lawmakers are looking for termporizing measures. One of these is to levy a tax on doctors. This is insane.
Medicaid pays pennies on the dollar so many physicians (my practice included) cannot afford to participate. This means that our already narrow-margin business would be assessed an additional 4% tax on our gross receipts (in addition to income and small business taxes).
There is already a shortage of primary care physicians, and if health care reform passes, more people will have insurance and seek our care. If we tax doctors to provide care, we are shooting ourselves in the neck.
This is not simply a self-preservation issue for me---the abject stupidity of a narrowly-applied tax for a societal benefit is odd, and to apply it to the people trying to provide the service is even crazier. Providers who already take care of Medicaid patients will still pay the tax, but may see a rise in compensation (although I doubt that it will make it profitable to care for these patients).
If this goes through, may practices are going to be in trouble. In addition to cutting our own pay, we will probably have to implement draconian measures such as dropping health care for our employees and probably laying off at least one worker (out of five).
This is a monumentally stupid idea. If you live in Michigan or in any other state where there are such proposals, make some noise.

14 responses so far

Morning Report

Sep 29 2009 Published by under Medicine, Morning report

Here's how this is going to work. Thanks to a reader, I have a case for you, which I'll present in parts. I will try to make the information accessible to both professionals and lay-people. I'll start with the barest of information and rather than guess what's going on right away, I'd like to see people organize their thoughts into broad categories based on the initial symptoms. One way to think about this is to think about what, anatomically, is in the area of question---in other words, what can go wrong there. Then, think of types of disease---vascular, anatomic, infectious, allergic, etc. I will, of course, help you with this.
A 32 year old woman presents to the emergency department with a chief complaint of abdominal pain. She reports that the pain is in her lower abdomen. It began as a vague, dull ache about one week prior to presentation but now it is sharp, severe, and does not radiate. Nothing seems to make it better or worse.
So think about what structures could be affected and by what mechanism. If you guys can't come up with it, I'll give you an example. After a while, I'll addend this post with a summary of the comments and the next set of findings.
Addendum
I really shouldn't do this without providing an example, so I'll start off a bit for you so you see how to approach this.
Lower abdominal pain can be due to (but not necessarily limited to) some of the following structures:

  • Skin
  • Mesentery/Omentum
  • Large intestine
  • Small intestine
  • Appendix
  • Iliac artery or other large arteries branching off the aorta
  • Female reproductive tract, including ovaries, fallopian tubes, uterus
  • round ligament
  • bladder
  • ureters
  • referred pain from somewhere else, and anything else I might have forgotten

One or more of these structures may be affected by one of these general processes(incomplete list):

  • Infectious
  • Auto-immune
  • vascular
  • neoplastic
  • anatomic/structural

Once we complete this "Templeton Grid" (more on that later) we can fill in some possibilities.

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29 responses so far

Morning Report---what is differential diagnosis?

Sep 28 2009 Published by under Medical education, Medicine, Morning report

Dr. Jerome Groopman, whose writing I generally enjoy, put out a book a couple of years ago called How Doctors Think. It examined, well, how doctors think, how they think they think, and what the future holds for diagnosing disease. It's a good book, but with some faulty assumptions. I'm not the guy to write about how decisions are made---I don't know enough about the field, a field which needs much more research. But most doctors do not, as is sometimes posited, make diagnoses via algorithm. Nor are we slavishly bound to statistical likelihood, as the use of likelihood ratios and, er, the like has some problems. What we do teach formally is the process of differential diagnosis.

Differential diagnosis (DDx) is the fun part of medical thinking, and hopefully the lessons learned about the process endure. When a resident or medical student presents a case to me, they often have an immediate feeling for what is wrong with the patient. This feeling may or may not coincide with reality. Getting a gestalt feeling for a case is important, but it is only a starting point. One of the gestalts I like my residents to get a feel for is whether a patient is really sick---I don't mean whether or not they have a cold or whatever, but do they appear seriously ill. There are parameters which can help determine this, but when someone comes in with a vague picture and you don't have access to sophisticated diagnostic equipment, it's good to be able to make that judgment.

One of the luxuries of being a teaching physician is being able to take the time to break down a case in a more formal manner and to develop a traditional differential diagnosis.

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22 responses so far

Prevention: you keep using that word...

Sep 27 2009 Published by under Absurd medical claims, Medicine, Vaccination inanity

Warning: this post has a long, boring prologue. Proceed at your own risk.

I am an expert in the prevention and treatment of adult diseases. That's what I do from well before the sun rises until well after it sets every day of every week. To become an expert and retain this status is not a simple task. After college I completed four years of medical school, three years of residency in my specialty, and chose to become "board-certified". There are doctors who are not board certified in their specialties, and there's nothing nefarious about that---all that is required to practice medicine is a valid license from the state. But my hospital doesn't allow physicians on staff if they are not board certified, recognizing that this status means something. There is no good reason to eschew board certification. To fail the boards repeatedly betrays a lack of basic competency, given that most doctors are actually good test takers, otherwise they'd never have made it so far.

Historically, once one was board certified in internal medicine, the certification was for life. Several years ago this changed, with older doctors being grandfathered into permanent certification, and all new internists being required to re-certify every decade. Since medicine is an ever-changing field, my license required fifty hours of continuing medical education yearly. In addition to that, I'm now two years away from my re-certification, which requires more continuing education. The American Board of Internal Medicine suggests spreading re-certification over a two year period. I've started doing the required learning modules and they are hard. Depending on the field, each question takes me about twenty minutes of research just to make a reasonable guess at the answer. Most of the modules are knowledge-based, but I'm required to do at least one that helps me review my practices. I could, for example, review a few dozen charts of hypertensive patients to see how well I am managing them, and come up with a plan to improve my practices. After all of this, I may sit for my board exam.

All this is simply to serve as a bit of background---when I talk about medicine, I'm not pulling it out of my ass. Some doctors, though...

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22 responses so far

A new low at HuffPo

Sep 25 2009 Published by under Absurd medical claims, Medicine

The stupid truly burns brightly in this one. Dana Ullman, known to readers of Respectful Insolence, Science-based Medicine, and this blog as Hahnemann's cognitively impaired bulldog, has started blogging at the Huffington Post. It's certainly an appropriate venue for his brand of cult medicine belief, but that doesn't make it any less painful. His inaugural piece, entitled The Wisdom of Symptoms: Respecting the Body's Intelligence betrays a stunning level of ignorance of basic human biology.

I have good and bad news about the human body: it is neither wise nor foolish, good nor evil, nor is it simple in any way.  It is a complex system where few simplistic explanations suffice.  It would be nice to believe in "feed a cold, starve a fever" and other simplistic pablum, but things are rarely so simple.  This is why there is a science to medicine---our instincts and hunches often betray us, and only by studying the body systematically can we form valid conclusions.

Or, if you're lazy or deceitful, you can just make shit up.

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27 responses so far

Doug Bremner: Odd ideas, odder behavior

Sep 24 2009 Published by under Medicine

I'm not a psychiatrist, and I won't guess what motivates someone like Doug Bremner. On his blog, he posted a picture showing the head of a cancer surgeon/researcher/blogger pasted onto a large beast. A little man is doing something to the beast.

An armchair psychiatrist might make silly suppositions based on the image of a little man bent over toward what looks like the genitalia of a large beast, but also like a little man eviscerating the beast with a big tool (which is not part of the little man...he's just holding it). But images probably don't mean anything anyway.

Bremner is a psychiatrist who on his blog takes the real problem of the corrupting influence of drug companies and elevates it to the One True Justification of all of his beliefs. Like many fanatics, he is always right, and anyone who dares to disagree with him is a murderous beast deserving of physical evisceration. I do wonder how someone becomes like Bremner. There is so much real corruption out there, and yet he is so angry, his thinking so muddled, that when someone presents evidence of his being wrong, he reacts as to an existential threat.

I've had plenty of people attack me on and off my blog. They've even been right from time to time. But I haven't been tempted to connect their real name to various projects and accuse them being brainless shills of industry. Nor have I been tempted to post jejune but violent images of them on my blog. But Bremner does eventually use his words:

They start out by saying that I am against the drug industry, that there have been a lot of life saving drugs developed by the pharmaceutical industry, and that I am paranoidly positing a conspiracy amongst drug companies that does not exist. Well first of all as I have said many times before I don't have anything against drug companies per se and I think there are a lot of medications that have benefits for certain people in certain situations. I am just advocating for the right of people to know the true risks and benefits of prescription medications and to be able to educate themselves and not just take the word of some "I am right" doctors. Which is what these guys look like. To me at least.

I would think that a psychiatrist could come up with a better construction than "paranoidly", but anyway...

You see, Doug is just a poor, misunderstood guy trying to get the real scoop out to The People.  He's not "anti-drug company", just pro truth.  He even admits that some medications might be beneficial for some people sometimes (wow...that's a lot of hedging).  He accuses his detractors of being ignorant, with an immovable faith in their own opinions while demonstrating these very flaws.

It's too bad, really.  We need more voices speaking out against corporate abuses, people who can tell the difference between corruption and real science.  Bremner just isn't ready to play with the big kids.

11 responses so far

Fibromyalgia, alternative medicine, and other bad ideas

Sep 24 2009 Published by under Absurd medical claims, Medicine

It's like this: science requires a tolerance of failure. If your shiny, happy hypothesis fails to stand up to rigorous scrutiny, you drop it and move on. If instead of a true, disposable hypothesis, you have a fixed belief that will not change based on the data, you are delusional. Boosters of alternative medicine prefer the term "maverick" to "lunatic" but in the two are often the same.
It is nearly impossible to get someone to abandon a belief in alternative medicine, no matter how strong the evidence against it. Study after study has failed to validate homeopathy as anything other than bullshit, yet it's strongest supports hang on hoping, perhaps, that someone will find out that we were wrong about physics and chemistry all along (you know, regional changes in physical constants and all that). Not all alternative medicine boosters are cynical thieves. Some really do believe that they are doing science, when in fact they are deceiving themselves about the meaning of data. When this type of thinking occurs in medicine, rather than leading to a paper retraction, it leads to quackery and sometimes death. Certain health conditions, because of their special characteristics, are more susceptible to this type of quackery than others.
Fibromyalgia is a poorly-understood and controversial pain syndrome. In brief, it includes patients who have significant chronic pain which is not due to any identifiable pathology. It probably includes a heterogeneous group of problems, but our understanding is limited. There may be changes in the way the nervous system deals with pain signals, but even this is not yet clear. It's a disorder that can be very frustrating to treat, and even more frustrating to have. It is often co-morbid with depression, and the pain can be quite resistant to treatment.

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27 responses so far

BMI TMI update

Sep 24 2009 Published by under Medicine

So the weight loss continues at a slow but steady pace. The exercise has been not so good; I was doing fine until I re-injured my back. Now it's just an excuse.
I've started getting up early to get PalKid to kindergarten. I suppose I could get up just a bit earlier and ride the bike. I'm not looking at exercise as a weight loss tool, but as a way to regain good health.
My morning meal is generally a high fiber cereal, oatmeal, or a bagel. Earlier I was doing eggs, but I got tired of the extra time and effort. The key to the cereal is a small serving size. I do OK until lunch and usually avoid snacking. At lunch I most often have a chicken ceasar salad with oil and vinegar, or sometimes a banana-strawberry smoothie from Starbucks. I may snack a bit during the day with a piece of fruit, and at dinner I'll often have another salad. When I get home in the evening I sometimes have a bit of a carb-fest.
Either way, it's working for me just fine, in that I'm losing weight, and I feel like my habits are sustainable.

5 responses so far

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