Archive for: March, 2011

Dusting off the keyboard

Mar 31 2011 Published by under Medicine

I itch---a lot.  Mrs. Pal swears it's scabies, impetigo, or some other horrible and embarrassing contagion.  I suggested body lice, to which she replied, "There's such a thing as body lice? Ech! Sleep in the guest room!"

It's not any of those things (thank Asclepius), but I'm gaining a new level of empathy for patients with rashes.  Luckily I was able to carve a chunk of time out of my schedule tomorrow to head over to the dermatologist, a specialty for which I suddenly have a renewed respect.  (I'm betting on guttae psoriasis, which means it cannot be guttae psoriasis).

Rashes are a fascinating area of medicine.  The skin is incredibly complex, forming a physical barrier between our important bits and the environment, but also a living shield patrolled by immune cells who mark and attack invaders and create a cellular memory to defend against future attacks.   Diseases that injure this barrier open us up to horrible infections.  Burn patients often die of fluid loss and overwhelming infections, but any significant injury to the skin can have similarly bad results.

Being so immunologically active, the skin is susceptible to "friendly fire", where our own immune system either attacks the skin or causes uncomfortable reactions (among these are common diseases such as psoriasis, hives, and eczema).  Skin contains many different kinds of cells, and something can go wrong with all of them.  Skin cancers are very common, especially the "benign" sorts like basal and squamous cell cancers.  Cancers of skin pigment cells, called malignant melanomas, are often deadly.

The complexity of skin and all the things that can go wrong with it are endlessly fascinating, and endlessly frustrating for internists.  To non-dermatologists, just about all rashes can look "red and bumpy", a completely un-helpful assessment.  But most people with rashes come to see me before they get to a dermatologist, so I constantly work on refining my ability to describe and diagnose skin conditions.

This time of year, I start to see my first cases of rhus phytodermatitis (that's poison ivy---I think dermatologists keep the competition down by giving every thing Greek and Latin names).  People are starting to do a little spring cleaning and the classic "leaves of three, let them be" aren't out yet, just vines and stems covered in nasty urushiol.   It should be at least another month or two before I start seeing mosquito bites (yes, people come to the doctor for them) and sun burns.

I'm pretty good at spotting psoriasis, seborrheic dermatitis, eczema, and other common rashes, but when it comes to skin, it's not that hard to stump me. I might not always know what a rash is caused by, but I usually know when I need to refer to an expert, and right now I'm counting on benadryl to keep me going until tomorrow.


11 responses so far

Yet more medical ramblings

Mar 23 2011 Published by under Medical Musings, Medicine

The Midwest is home to some pretty crazy weather.  Thirty-five years ago this month a tornado tore apart the new, rapidly-growing Detroit suburb of West Bloomfield.  MrsPal was looking through pictures of the aftermath saying, "That was so-and-so's house.  And that one was across from..." etc.  Everyone knew someone whose body or property was damaged.  I knew a kid who had scars all over his body from a house collapsing around him.  He had the same name as another local kid, so we always would say things like, "No, not that Steve, tornado Steve."

Tonight, it's not stormy, but something is falling from the sky that isn't hail, isn't sleet, isn't snow, isn't rain.  Whatever it is, it hurts, and I have to chip away at my car door to get in.  We just got back from dinner.  A local Lebanese place has great fish during Lent (the rest of the year, feh).  It's a whole Great Lakes whitefish, fried, and covered in lemon juice, garlic, and other yummy things.  Before that we were at a shiva, the reason for braving the weather in the first place.  The decedent had been a patient of mine, but I also knew him socially.  I met him many years ago when he and his wife, neither of them terribly young, were sitting in my office holding hands and making eyes at each other like drunken teenagers.

He was concerned about his memory.  He was a brilliant medical professional, and he and his wife visited all the local experts and had been unable to avoid the conclusion that he was becoming demented.  Oh, but they were so in love, and while they were frightened and sad, they had each other.

That was ten years ago, and his life went on as these things often do, with those around him trying to lead normal lives while a man they deeply loved slowly but surely disappeared.   It is one of the privileges and one of the sorrows of medicine to develop uniquely intimate relationships with strangers only to preside over their decline.

I've been in practice about ten years now.  The recent move to a new practice, which has kept me away from the keyboard, took a bit of work.  One of the most unsettling tasks was going through a list of thousands of patients to contact and weeding out the dead---it's bad form to send letters to dead people.  Each time I would come upon a name, I would halt and see an image of them, remembering their voice, the way they lived, the way they died.  Sometimes, I wasn't sure if they were dead---maybe they just hadn't been by in a while, but they sure were old.  I would cross-check various databases and then delete their name from the mailing list, wondering how they had left.

While I may see a lot more of my older, sicker patients, I know that the younger ones will eventually spend more time with me, around the same time I start seeing my own doctor more than once a year.  It reminds me that every night that my daughter pesters her mother at bedtime whining for Daddy, I should be there.  Every second with my family, even the "bad" seconds, are precious.  It seems that it would be easy to accumulate regrets in life, many of which are seen best in retrospect.  Perhaps I can learn this sooner rather than later, that despite being carded at a restaurant last week, time isn't infinite, childhood cannot be taken for granted, and no one has ever said at the end of their life, "I wish I'd spent more time at work and less with my family."

6 responses so far

Muslim Terrorism in the US: A Public Health Threat?

Mar 14 2011 Published by under Medicine, Politics

Representative Peter King (Bigot-NY) is chairing Congressional hearings on "homegrown Islamic terrorism." Terrorism is usually seen as a national security issue, but as a physician, I also wonder how terrorism might impact health.  If we are going to devote time, resources, and cause irreparable harm to our morals and to our image in the Islamic world, we should at least know the extent of the problem.

Public health problems, such as emerging infectious diseases, accidental deaths, and homicide can be tracked, and interventions can be designed to mitigate these problems.  The largest mitigation effort for terrorism has been law enforcement/national security, as it probably should be, but at the pointy end of each terrorist act is a dead or injured person.   What is the public health impact of terrorism?  Leaving aside anxiety, post-traumatic stress, and other psychological factors, how many Americans are injured or killed by terrorists?  What proportion of these terrorists are "homegrown Muslims"?

According to once source, terrorism injures and kills very few Americans each year.  In fact, since 9/11, thirty-three Americans in the US have died as a result of terrorism perpetrated by Muslims.  Eleven Muslims were responsible for these deaths.   In that same time, there have been about 150,000 murders in the US.  Most terrorist plots in the US involving Muslim American perpetrators are disrupted early in the planning stage, often from sources within the Muslim American community.

In other words, national security and law enforcement, along with significant help from American Muslims, prevent most attacks, attacks that would constitute a small percentage of yearly homicides in the US.  Rather than being a major threat, the Muslim American community seems to be a major ally to law enforcement and national security.  Either way, there are so few acts of terrorism perpetrated by American Muslims that it is a theoretical threat to public health rather than an actual threat.

What about terrorist acts not perpetrated by Muslim Americans? According to the FBI (as reported by the Council on Foreign Relations) 95% of terrorist acts in the US are committed by non-Muslims.  Now, one could argue about "percentages", that is what percent of the Muslim community vs. the non-Muslim community is involved in domestic terrorism, but there are so few total terrorist acts that this statistic is probably meaningless.

Any rational human being can see that King's hearings are bigoted political grandstanding.  But from the point of prevention of terrorism in the US, they are also useless.


11 responses so far

Saturday Evening Rant, Iodine Edition

Mar 12 2011 Published by under Medicine

Hey, folks.  Thanks for sticking around despite my relative blogopenia.  Real life pulls at me relentlessly, and needs must when the Devil drives.   But for a few moments, at least, I have some time to myself.  PalKid's having a sleepover and is playing some sort of "tsunami magic pony land" game with her friend, and MrsPal is out having coffee with a friend.  I figure I have about a half an hour before some sort of fight erupts downstairs, likely having to due with said magic pony land and the oncoming tsunami.

Speaking of tsunamis, I'm pretty much glued to the set, watching the news from the nuclear plants in Japan.  There's a lot of talk about "iodine" in this context.  Nuclear fission has many toxic products, one of which is iodine-135.  It isn't the most dangerous fission product, but it has specific dangers that can be prevented (that is, prevented in ways other than preventing a nuclear disaster in the first place).

The thyroid gland is responsible for the production of thyroid hormone, a chemical that modulates many critical physiologic functions.  A key component of this hormone is iodine, an element naturally present in the diet to a greater or lesser extent.  Like many hormones, thyroid hormone production is regulated by a feedback loop.  When the brain senses a drop in thyroid levels, it sends a chemical signal to the gland to ramp up production.  When thyroid levels rise, the brain sends a signal to turn things down.

Iodine is not evenly distributed in the world, and in regions with less iodine in the environment, the thyroid cannot produce enough hormone.  The brain senses this, and sends the signal to the gland to ramp up production.  The gland responds by growing.  And growing.


The results can be quite dramatic, and so can treatment.  When iodine is consumed, it collects in the thyroid, so taking in iodine can both prevent and treat goiters.  This avidity for iodine is also exploited in the diagnosis and treatment of other thyroid diseases.  Radioactive isotopes of iodine can be used, for instance, to image the thyroid gland.  A patient can be given a small amount of a radioisotope of iodine and a gamma camera can look for thyroid tissue that "lights up".  It can also be used to treat thyroid cancers.

Radioactive iodine is toxic to cells, and since iodine-135 is taken up mainly in the thyroid, and has a relatively short half-life, a patient can be given a dose high enough to kill off a diseased or cancerous thyroid gland.  If a thyroid cancer has spread, the iodine will "seek out" metastases and kill them.

Radioactive iodine is used very, very carefully.  When I was a medical resident, we would round on I-135 patients from the doorway, and the nutrition service would leave food at the door.  I-135 from, say, a nuclear accident can be taken up by the thyroid, causing genetic damage to thyroid cells which lead to cancer.  This continues to happen in the areas affected by the Chernobyl disaster.

(Speaking of disaster, someone just yelled, "Pillow fight!"  Ten bucks this ends poorly.)

Unlike many other types of radiation poisoning, I-135 poisoning is preventable.  People in danger of exposure, especially kids, can be given iodine tablets or liquid.  The non-radioactive iodine is taken up quickly by the thyroid, blocking the entrance of radioactive iodine, preventing future cancers.  The thyroid can only take so much iodine, and the rest is excreted, radioactive or otherwise.

I imagine that many Japanese children will get unneeded doses of iodine in the next several days.  But needs must when the Devil drives.

6 responses so far

Real medicine

Mar 09 2011 Published by under Medicine

A number of years ago I wrote a post about why your doctor always runs late.  I have no idea where the link is, but the general idea is this: you only have so many hours in a day, and lots and lots of patients want to be seen.  There are only so many primary care docs, and so many spaces on a schedule.  So you schedule people as tight as you think you can get away with, and toss in some add-ons who call to be seen the same day, and generally hope that the couple of people who no-show will leave some gaps for catching up.  My own schedule has a 45 minute lunch built in, but that never really happens, and all it takes is one person with pneumonia or chest pain or depression to throw the schedule out of whack.  This is cold comfort to those who sit around waiting forever, the only consolation being once I'm in the room with you, I'm yours for as long as is needed.

My post on this phenomenon garnered the expected griping about the patient's time being just as important as the doctor's, etc., an idea that I appreciate but that is short-sighted.  Doctors are, for better or worse, a limited resource, and patients are stuck competing for that resource.  When someone demands to be seen immediately, it is another patient whose time they are taking.   Of course, with our inefficient, non-science-based health care system, I can probably get you an MRI of your entire body done in a few hours, but I still can't get into your room on time.

All that aside, real medicine---the good kind---takes time.  It may only take me a few minutes to diagnose a cold, but it may take me several more to explain why antibiotics aren't needed.  In a more paternalistic system, the patient would be told, "You have a cold, go home and have soup" and shuttle out the door.  In a harried, "bad medicine" office, you would probably be given some Miraculocillin for $10 a pill and sent home.  But to practice good medicine, you have to sit and explain what your are recommending and why, and then sell it, because even though patients are competing for your time, you still want to keep them coming back, both for business reasons, and  for medical humanitarian reasons.  Practicing good, humanistic medicine is a lot harder than practicing bad medicine.

All sorts of things can toss a monkey wrench into the daily schedule, not just someone who is severely ill and needs extra attention.  A patient may come in after a hospitalization, and after getting the story from the patient, I'll have to log in or call the hospital to dig up records.  I don't expect someone to give me an accurate accounting of their prolonged hospitalization, so I'm left to do the detective work (which is usually interesting).  I may have to fill out new insurance physical forms since patients often change insurance companies frequently.  Each of these forms has slightly different requirements, and if I screw it up, the patient will pay higher premiums.

I may find a patient who seems to have a simple infection didn't do well on an antibiotic, and have to look up local resistance rates to see what new data from the community can help me make a better choice.  I may need to look up the latest recommendations for screening for one disease or another, or I may have to figure out if a patient's insurance covers preventative care or not.  I may need to set up a consultation with an expert, calling them to explain the situation and asking them to make room in their own over-crowded schedule.

The day-to-day practice of medicine, when done well, is complex because it deals with human beings.    But it gets even more complicated.

Under our current system, I get paid for what I do, that is, I get paid based on the complexity of an office visit, and for any procedures that I may provide.  Most doctors are not salaried, and the rates charged are essentially non-negotiable, based largely on the way big insurers such as Medicare and Blue Cross do things.  I recently moved my practice 2.5 miles down the street.  I can nearly see my old office from the window of my current office.  Despite this, I have to re-credential (which is apparently a word, according to insurance companies) with Medicare, Blue Cross, and all of the other insurance companies that we work with.  Even if they have current copies of my license, etc, they need them all again, and will take months to get me into their system at my new practice.  I moved in December, and I was finally re-approved for a bunch of the smaller insurance companies. Medicare is still working on me. This means that my practice has not been paid for my work for the last three months.

Some would argue that this shows how dangerous a single-payer system would be: imagine if Medicare were in charge of everything!  The converse is that dealing with a single entity would be a helluva lot easier than a dozen.  The paperwork is astounding and expensive, and cuts into patient care.  So while insurance companies push at doctors to adopt the latest model for reimbursement (with phrases such as "meaningful use", "patient-centered medical home", and "accountable care organization") doctors are busy trying to see patients, and trying to not lose money by doing so.

I'm cynical enough to know that there are problems with a single-payer model, but from the standpoint of a patient and of a busy practitioner, the paperwork couldn't get any worse.  And from a social justice perspective, it's a no-brainer.

10 responses so far

We have no idea what we're missing

Mar 05 2011 Published by under Medicine

The ongoing health care crisis in the US is so pervasive and yet so invisible.  It is a smog you and I breathe in every day, everywhere.  It is manifest on so many levels, so overwhelming that it is nearly invisible.

In primary care offices, doctors struggle to see more and more patients, many of them medically and psychologically complex.  We order all manner of complex studies, and if we've taken advantage of a current subsidy, we record this all in electronic health records (EHRs).  This subsidy, which helps pay for EHRs, is slated to turn into a penalty over the next few years, as practices that hold off on the risk of such a large purchase look to which will be worse: spending a few hundred thousand now with the promise of a rebate, or having payments withheld for failing to buy a system which may very well be obsolete in five years.

Information technology in medicine is stuck in the 1980s.  Individual hospitals and practices purchase their own systems, customize them, curse, bless them and operate them as if they were simply electronic versions of paper charts.  The technology has existed for decades to give every person their own comprehensive and portable health record, one that could be accessed by any health facility.  Whether held in the cloud, in a USB stick, or a magnetic card, a personal health record, or even a unified national medical informatics system could save millions, perhaps billions, in unnecessary testing, treatment, waiting.  It could streamline preventative care.  It could help us track the real results of interventions on a population-wide level, as is commonly done in Scandinavia, England, and other industrialized nations, nations that spend less and get more for their health care Euro, Pound, or whatever.

Privacy concerns are real, outside of the paranoid rantings of various libertarians, but these problems can be minimized, and the price we are paying simply isn't worth it.

17 responses so far