Archive for: June, 2011

July is Coming

Jun 29 2011 Published by under Medical education, Medicine

July 1st is the medical new year.  Medical interns begin their journeys into the real world of clinical medicine, journeys that started during medical school but become much more real when they sign their own orders in a chart.  Every year around this time medical bloggers (among others of course) discuss the "July Phenomenon".  Today's post is not about the "July Phenomenon", something that may exist in some contexts but is likely dwarfed by other problems in medical education.

Rather than re-hash the debate on whether July in the most dangerous month to be in a hospital (it probably isn't), I'd like to give a little advice to newly minted doctors.  The rest of you are welcome to read it too.  This applies mainly to internal medicine, but I'm sure much of it crosses over into other specialties.

  1. Embrace your fear.  You have good reason to be scared.   You are directly responsible for the lives of others.  These others are very sick, or they wouldn't be in a hospital.  But remember that you aren't alone.  Your colleagues can and will help you, and you can help them.  Support each other.  And remember that your senior resident and attending physician are there to help you, whether they act like it or not.  Never be afraid to ask for help, but when you call, have your information in hand; anticipate questions.  If you don't know what to do about a cardiac dysrhythmia, make sure you have an EKG and have ordered some labs before you call the cardiac fellow.  It will save you time and embarrassment, and will get the patient help more quickly.
  2. Listen to the nurses and ancillary staff.  They spend much more time with the patient than you do, they've seen many years of interns come and go.  They can help you, but if they sense you don't respect them or that you aren't caring for their patients well, they will hurt you.  They will do whatever they can to help their patients, and they will not care if they make you miserable in the process.  They will often know more than you do.  If you don't trust what they tell you, verify it.  You do posses a different sort of knowledge, one that you can combine with theirs to help your patients.
  3. Read up on your cases.  You may not have a lot of time for formal reading and studying.  Read up on the diseases your own patient has, and soon you will have an impressive breadth and depth of knowledge.  Listen on rounds, especially when your colleagues are presenting their patients and you'll get more bang for your buck.  Teach the medical students if you have them and you'll learn even more.
  4. Sleep when you can.  Sleepiness harms both you and the patient.  I cannot emphasize enough the value of sleep.  Go to bed early, nap if you can.  If you're too tired to drive home, don't.
  5. Don't abuse substances other than caffeine.  Even caffeine isn't that good, but if you are susceptible to substance abuse, the stress of internship can be dangerous.  Be honest with yourself, and if you develop a problem, seek help from your program.  You'd be surprised how much help you can get.
  6. Eat well and exercise.  Even if it's only taking the stairs (three down, two up), exercise will help you.  You'll need it.  Try to avoid all the crappy free food at conferences.  Go for the healthy choices at the cafeteria.
  7. Wash your hands.  If a patient asks you if you did, don't be offended.  Thank them for the reminder and do it again.  If you can, wash them in front of the patient so they can see that you care enough to do it.  Remember that certain pathogens, such as C. difficle, sporulate and will not be killed by topical alcohol solutions but must be physically scrubbed off.
  8. Learn to live with uncertainty.  In the hospital you get used to having information at your fingertips.  You can order stat labs, get X-rays and other studies quickly.  You can't do that in the clinic.  Not every patient will present classically.  It is more common for an common disease to present uncommonly than an uncommon disease to present commonly.  Dig?
  9. Trust no one.  Patients will come up from the ER "pre-packaged", work up done, diagnosis made.  Don't believe it.  Verify it for yourself.  Start from the beginning, because leaning on others' workups simply perpetuates errors.
  10. Corollary: examine every patient yourself, and do it right.  The exam can be focused, but do it.  If your resident or student says that the skin is intact, turn the patient over and search for bed sores.  Listen to the lungs.  Check the mouth for thrush.  Be confident in your skills, skills which will improve every day as you use them.
  11. Senior residents, remember the interns are the interns, not you.  Let them do their work.  Let them answer their own questions.  While they are pre-rounding, do your own pre-rounding, checking labs, checking in on patients.  This way, when you pimp the intern on Mr. Smith's potassium and she doesn't know it, your team will realize that not only are you on top of things, but you're watching them,  both to help and to make sure they stay on task.
  12. Wikipedia is not a valid medical reference. I'm sorry I have to even say this.
  13. Ars longa vita brevis.  Enjoy the art.  Medicine is interesting.  It's fun.  And there are no bad patients.  It's just as important to learn how to manage a drug-seeking sociopath as it is to treat an acute MI.  There is always something to learn, even if that "something" is that you don't want to be a gerontologist.

OK, folks.  Go for it.



13 responses so far

Is Medicare spying on doctors?

Jun 27 2011 Published by under Medicine

The short answer is "yes"; of course they are.  Normally, if Medicare wants to check up on a doctor (rather than doctors) they simply order an audit.  If Medicare (or Blue Cross or whomever) is paying the bill, they are certainly going to check to see if they are getting what they pay for.  If they audit you and don't agree with your charges, then your charges are wrong. As another doctor once told me, "The money Medicare gives you is borrowed; if they disagree with you, they can and will take it back at any time." But what is Medicare paying for?  Are they paying only for the services rendered? Or are they paying for "physician availability"?

The Centers for Medicare and Medicaid Services (CMS) is (sic?) deeply involved in US medical care, which includes subsidizing post-graduate medical training. CMS wants to know if their patients are being seen or turned away, and if the latter, why.  That sounds like due diligence to me.  But...

Primary care medicine is a tough job (a good one, but tough).  If CMS wants to know more about the supply and demand aspect of primary care, this survey seems a weak tool (and for some reason it gives doctors the heebie jeebies).  Doctors have the right to serve or not serve whomever they wish, given they meet any contractual obligations with insurers and ethical obligations to established patients (more or less).  Most internists take Medicare, but less often Medicaid.  We see many elderly people, so closing off to Medicare is usually a bad idea, but Medicaid rarely pays enough to justify the costs of seeing the patient.  Many of us give back in other ways (seeing patients pro bono through charitable institutions, etc.).  If we as a nation decide that service is mandatory for doctors, that's fine, but there must be an incentive that sends people into medicine.  Most primary care docs know that they could have made  a much better living using their talents in the business world but still chose medicine.  If we change our model of primary care to require service (not a bad idea), then we have to pour more subsidies into educating and training docs.  The salary alone is not incentive enough to convince good students to choose primary care (which currently attracts 4% of US medical grads).

But aside from this and the generally hostile feelings engendered in physicians by "being spied on", the sample questions and the approach taken by the research firm is problematic.  Most PCP offices have enough trouble fielding legitimate phone calls.  Adding even a few interferes with the care of real patients.  More important, the questions are, for lack of a better word, stupid:

Mystery shopper: “Hi, my name is Alexis Jackson, and I’m calling to schedule the next available appointment with Dr. Michael Krane. I am a new patient with a P.P.O. from Aetna. I just moved to the area and don’t yet have a primary doctor, but I need to be seen as soon as possible.”

Doctor’s office: “What type of problem are you experiencing?”

Mystery shopper: “I’ve had a cough for the last two weeks, and now I’m running a fever. I’ve been coughing up thick greenish mucus that has some blood in it, and I’m a little short of breath.”

If a Medicare patient (i.e., elderly) I had never seen before gave me this story on the phone (or more likely, gave it to my front office), I would most likely direct them to the nearest urgent care or emergency room:  they sound really sick, and since I've never met them to have any other basis for making a judgment, I'd like them to get seen right away.   It's also a crap shoot as to whether I can crowbar them into my schedule quickly enough to be seen.

I might do it.  But I might not, and I wouldn't fault any doctor who directed them elsewhere.  It's the wrong question.  A better question might be, "My blood pressure has been running high, in the 160's, but I feel OK, how soon can I see the doctor?"

For what it's worth, I don't think doctors should be whining about being "spied" on; CMS can snatch away your money any time they think you've screwed up, and they can stop paying you any time the Congress screws up themselves.  All of this is simply another symptom of a fundamentally broken health care system, and no one in government has the guts to propose real solutions, ones that tear down our current system and rebuild it on a model that recognizes health care as a fundamental right, and finds a just, ethical, and cost-effective way to provide good health care to everyone within our borders.

2 responses so far

Friday thoughts

Jun 24 2011 Published by under Medical Musings, Medicine

I made a really good medical decision the other day. I can't go into details of course, although some day it may end up anonymized and folded into a story, but it felt good (for me and the patient).   It involved using several different layers of knowledge to come up with  a solution, a bit like solving the Friday NYT crossword puzzle: not impossible, but difficult enough to be fun (when I say "difficult" about the crossword, I speak for myself, not my genius brother-in-law who could solve it blindfolded, upside-down, and drunk).

Medicine is full of puzzles, most of which aren't particularly good for the patient.  It's much better to be a boring patient than an interesting one.  There are no truly "boring" patients of course.  When someone relatively healthy comes in, I get to learn about the work they do, often something I've never heard of.  I hear unique family tales, tragedies and triumphs; this is one of the joys of medicine, being allowed to hear other peoples stories.  I never consider the time wasted.

I recently spent twenty minutes with a patient discussing recipes.  Not only did I learn a few tips, but I also learned about how this particular hypertensive patient prepares and eats his meals.  And I made a friend.  Medicine involves a lot of salesmanship.  I have to talk people into doing some fairly unpleasant things, so being on friendly terms with them helps grease the, er, wheels.

In past posts, there have been debates as to whether medicine is "special":  is it a job like any other, or is it more of an identity?  I favor the latter in many situations.  Sure, being someone's  banker involves a level of trust and intimacy, a sharing of private knowledge, but medicine takes it a stop further.   Just a few moments ago (while I was typing paragraph three) a heard screaming form the other end of the cafe.  A barrista had just spilled a pitcher of boiling water on herself.  I invited myself into the back to tend to her.  This was possible only because our gives a special trusted status to physicians (warranted or not).  Once I announced I was a doctor and I was willing to help, there was no argument, no fear, just a look of relief.  I left the office before five today, but I never truly leave the job.

The puzzles, the identity, the stories, the relationships all make medicine unique and enjoyable.  Whatever the instability in the business of medicine, I can never leave the job, because I am the job, and the job is me.

11 responses so far

Today at Science Based Medicine

Jun 22 2011 Published by under Uncategorized

I just wanted to point you toward my piece up today at SBM. Otherwise, Happy Hump Day.

Oh, and be careful about teaching your kid to read. We did that, and she saw "Tornado Watch" for our county on the TV last night. I ended up sharing my bed last night with a child and several dozen stuffed animals.

3 responses so far

Summer veggies

Jun 20 2011 Published by under Uncategorized

My neighbor keeps bees. Really it's her husband who is the apiarist, be she doesn't mind an occasional hive in the backyard during its transformation from nuisance infestation to pollinator of yummy local peaches. She happens to be a fine physician, and as I rode by her house yesterday I saw her out back watering the garden. The weather's been horrible for veggies, but she's growing some sort of heirloom radish that's doing great. She plucked one up for me, rinsed it off, and handed it to me. The leaves were a perfect medium green, tapering to white stems, and bulging into a perfectly round, deep pink bulb. I bit in expecting the usual bland but peppery taste of a grocery store radish. My teeth bit into the crisp flesh, and my mouth was filled with an earthy sweetness, almost like jicama, but with the peppery undertones typical of radishes. This was no garnish: this was real food.

I've been trying very hard to stick to real food, even when I eat crap (e.g. I'll buy real ice cream with only three ingredients). Kids watch everything you do, make note of it, and will use it against you at any opportunity. I'm far from perfect, but I try to let my kid see me eat real, good food rather than crap. She's made me a better eater. Like most kids, her major food groups are chicken nuggets and noodles, but if I sneak a bowl of ripe watermelon in front of her while the pasta is boiling, she'll dig in.

The Midwest is full of good food, if you know where to look, but much of the year we are dependent on imports for fresh fruits and veggies. It's not yet peach season here, but I did find some nice ones from Georgia, the kind that almost taste local and fall apart when you eat them. There are tons of farmers' markets, but for busy people, this just isn't always a feasible option, which is one of the reasons I'm happy to see more and more local produce at my supermarket.

Oh, but the local produce can be just wonderful---corn, apples, peaches, greens, berries. If they keep growing it, and my neighbor keeps sending out his pollinators, I'm a customer-for-life.

3 responses so far

Fathers' Day

Jun 19 2011 Published by under Fatherhood

If you look closely, you can see MrsPal's well-manicured hands

Becoming a father isn't some sort of careful metamorphosis: one moment you aren't, the next you are.  It's insane.  Within a day you can go from overwhelmed former non-parent to head-over-heels in love parent.  When PalKid was born, I couldn't keep my eyes off of her.  I still can't.

These little creatures change daily, and you have to change with them.  And there's no one way to raise a kid.  I hope MrsPal will forgive me this liberty, but at a gathering for a first birthday a group of parents were talking about all the books they were reading to teach them how to raise a child.  We had already been through the "What to Expect" series, meaning they were tossed in anger out into the snow.  When one parent looked at my wife and asked, "So what are you reading?" my exhausted wife answered, "I read the book that says don't read so many fucking books."  I love that woman.

And as all parents know, it's not all hugs and kisses.  It's not just the exhaustion during infancy, or the terror after first blood is drawn (PalKid learned to cruise, pulled off the padding on the coffee table, and immediately slammed her face into it, getting her first stitches remarkably early). For Fathers' Day today, I just wanted a bit of time to myself which most parents know is damned unlikely.  It's doubly unlikely given my wife's illness, but things have a funny way of working out, especially when you have a spouse who loves you.  My niece slept over but had to get up early to go out with her dad, so no sleeping in.  My my folks called and I managed to convince PalKid to come out to breakfast, no her favorite thing to do (but one of mine...MMMM...bacon...).
And I finally picked up my new bike.  I've always loved to ride; not like those serious teams of Spandex-clad road bikers---I just love to get on my bike and ride.  It feels like freedom.  Today I rode with the kiddo very slowly, then took my own Fathers' Day ride to the cafe for espresso and reading.  I came home, hung a bag if IV fluids for the Mrs, and ordered pizza for me and PalKid (a bit cruel given MrsPal's inability to share, but...).

I'm lucky enough to have two living parents.  My dad was born in 1926, one of the few first generation Americans left in my family.  When we had a dog, one that managed to live over twenty years, he would kvetch about the old thing, but he would also sit on the floor hand feeding her until she finally had to be put down.  He's very loving, but I like to think that I had a hand in teaching him how to hug his adult kids.  But when it came to my daughter, he was immediately smitten.

Better than a pet, and talks a lot more

And she is a charmer.  A charmer who hates to go to sleep because it means she would have to stop talking.  When my wife was in the hospital, I had an opportunity to spend more time with her, to both appreciate how much my wife really does raising a child, and how much more time I wish I had with them both.
My father is a physician, one who trained in the 1940's, went off to the Korean War to try to patch up broken minds, and spent decades doing similar but less horrid work in the US.   He is a man who went to college during WW II, and given the absence of young athletes, worked out with the University of Michigan football team---until it interfered too much with practicing the violin.  He rode a train through Nazi Germany as a passenger, riding with his parents to convince our family to leave Europe.  At least, this is how I remember these stories.

As a physician, he has high expectations of himself and of his colleagues.  He taught me very early---before I even considered medicine---the importance of confidentiality, of watching a patient, looking for details, even those that might supposedly be outside your own specialty.  I still call him from time to time to run questions by him, both psychiatric and medical.  My sister, also a violinist, plays the piano, and when I hear her play, I can't believe it's her second instrument. It's the same with my father and internal medicine: it may not be his first instrument, but he sure can play.

The first rule of fatherhood is "there are no rules".  Every child is different, every father is different, and every father-child relationship is different.  I'm still new to this, and I have no advice to offer, but dad's, please adore your children, as much as my dad adores his, as much as I adore mine.  The rest is commentary. Go and learn it.

3 responses so far

Cranberry juice for UTIs?

Jun 15 2011 Published by under Medicine, Uncategorized

I can't seem to stop myself from writing about pee, and I'm not even a nephrologist.  But I deal with pee every day, and many of my younger patients with urinary tract infections will tell me all of the home and herbal remedies they tried before they came to see me.  One of the most common alternative treatments is cranberry juice.  There are several plausible reasons cranberry juice might work against UTIs.

Some studies have shown that cranberry consumption can acidify urine and raise urinary levels of hippuric acid, a compound that can slow bacterial growth. Subsequent studies have found that it is nearly impossible to consume enough cranberry products to significantly change the pH of the urine or to raise concentrations of urine hippuric acid.

Other studies have found that some of the chemicals in cranberry juice can prevent E. coli from adhering to the urinary tract lining.  Since E. coli are the cause of a high percentage of UTIs, this could be significant.  Unfortunately, studies have failed to show significant clinical benefit in several types of UTIs, especially when compared to usual antibiotic therapy.

Adding to our database is a study in the latest issue of Clinical Infectious Diseases. This study looked at preventing recurrent UTIs in young women, a group at significant risk for recurrence.

The results were unimpressive. During the six months of follow up, the cranberry juice group did not have significantly fewer recurrent UTIs than the placebo group.  One caveat to this conclusion is the observation in previous studies that the effect of cranberry is dose-dependent.  In the study, women were given eight ounces of cranberry juice cocktail daily.  It could be argued that this is too little to have an effect.  But to drink, say, 24 oz of low-cal cranberry juice cocktail daily hardly seems like a reasonable trade off.  That's a lot of juice.

For now, I'm not recommending cranberry juice to my patients wishing to prevent UTIs.


Barbosa-Cesnik, C., Brown, M., Buxton, M., Zhang, L., DeBusscher, J., & Foxman, B. (2011). Cranberry Juice Fails to Prevent Recurrent Urinary Tract Infection: Results From a Randomized Placebo-Controlled Trial Clinical Infectious Diseases, 52 (1), 23-30 DOI: 10.1093/cid/ciq073

Raz, R., Chazan, B., & Dan, M. (2004). Cranberry Juice and Urinary Tract Infection Clinical Infectious Diseases, 38 (10), 1413-1419 DOI: 10.1086/386328

15 responses so far

A social media win in medicine?

Jun 14 2011 Published by under Medicine, Uncategorized

I treat a lot of urinary tract infections. UTIs are a common problem, and as we know bacteria and resistance patterns can change.  Keeping up with trends in antibiotic use and resistance isn't easy.  We tend to look to our state and hospital epidemiology departments for resistance patterns, and to professional societies for official position statements.  Data in my area show that E. coli has become more and more resistant to fluoroquinolone antibiotics such as cipro.  We use this information to change our prescribing behavior.

The Infectious Disease Society of America recently released new guidelines that recognize this and other facts.  They evaluated data on antibiotic resistance, potential side effects, and efficacy of different regimens and among the new recommendations was the elevation of an old antibiotic back to a top pick.

Nitrofurantoin (Macrobid) was used for years to treat UTIs but fell out of favor as cipro and TMP/SMX (Bactrim) became more popular.  A major change in antibiotic pricing over the last few years has also favored newer, broader spectrum antibiotics.  Bactrim and cipro are available free at some stores and very cheap at others.

And while the newer antibiotics may be cheap, nitrofurantoin is not.  A typical course can cost $30.  I tweeted this fact and to my surprise, IDSA took note.  Not that they are about to change their guidelines, but the fact that they noted a concern from some blogger in the Midwest is an interesting development.


One response so far

What if the individual mandate fails?

Jun 13 2011 Published by under Medicine

I've always been ambivalent about the Obama health care reform plan.  It's good---no imperative---to cover as many Americans as possible.  But the creation of an individual mandate under the Commerce Clause seems to be causing a bit of a stir.  I have no idea what the legal outcome will or should be, but this might have been avoided.

Mandating that every American be covered by health insurance creates an economically feasible way to take care of sick people.   The law essentially requires insurance companies to take all comers, whatever pre-existing conditions they may have.  Without an individual mandate, there would be no incentive to buy insurance until you get sick, something that could no longer be called "insurance".   By creating a risk pool that includes healthy people, insurance companies are protected from collecting premiums only on people who are spending every cent and more.

But "requiring" people to buy insurance seems to rankle many Americans' sense of "freedom" (yes, I used scare quotes twice in one sentence---sue me).  What people really mean by freedom is freedom to be free riders, to let others pay for their healthcare.  This is what happens in a private system: everyone tries to maximize their profit and minimize their losses, as they should.  But we cannot afford that.

When we lost the single-payer or public option in the health care negotiations, we made the individual mandate, er, mandatory.  Both a single payer system (basically Medicare for all) and a public option (basically a safety valve on the private insurance system) would have made a Commerce Clause mandate irrelevant.  The solution is to simply make everyone pay for medical care, one way or another.   Create a health tax that supports everyone creating the largest risk pool.  How that gets divided up---whether by private or public insurance---can be fought out.

14 responses so far

NYT: Women are ruining medicine

Jun 12 2011 Published by under Medicine, Uncategorized

(I should note that some of this text appeared in a previous piece on an older blog of mine.  The issue just won't die.  --PalMD)

I've written before about many of the challenges faced by women in medicine.  As more and more women enter medicine, there is a cultural shift struggling to be born.  In the early 1960's, about 5% of medical American medical students were women. Now about half are. Women are first authors on more medical papers than ever, yet fill only about 11% of department chairs, and fill about 15% of full professorship positions.

There is literature studying the trends in academic and clinical medicine. But an Op-Ed piece in today's New York Times sums up nicely the barriers facing women in medicine, dragging out the same old tropes.

I frequently hear that women in medicine are likely to take time off for kids, and to work part-time, and that this somehow renders them less valuable. I'm not sure how this reasoning works. After all, doctors treat people of all ages, genders, and ethnicities, and doctors of different backgrounds often have different experiences and skills to bring to the table.

But I can see how some of these ideas are perpetuated. Slots in medical schools, residencies, and fellowships are quite limited, and it costs much more to create a doctor than tuition could ever cover. Some take a false utilitarian view that because it costs so much to create a doctor, only those who can give back the most as measured in time and money should be trained.

Residencies are limited in both the number of residents they can take, and in how many hours these residents can work. When one becomes pregnant, it can burden the entire program.

Well, this is the real world, and in the real world, half of us are women, and women are the ones who bear children. Also, the prime years for physician training are prime child-bearing years. Get used to it. If we think women have at least as much to offer as physicians as men, we better get used to the fact that they have "lady parts" and that this has real effects. Are we to limit the contributions women are allowed to make because a short period of their lives may or may not involve child-bearing?

In clinical medicine (as opposed to academic medicine), there seem to be many more opportunities to work part-time than in the past. The less you work, the less you get paid, but the pay is still pretty good. But academia is still about productivity, and gaps are not acceptable.

As a society and a profession, we have to decide to take the role of women seriously. If we demean women's role in our profession, we may be more likely to demean our female patients and family members.

27 responses so far

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