Everything I ever needed to know about medicine, I taught myself

This week’s post comes in the form of a commentary on a recent N.Y. Times article, The Real World is Not an Exam (http://well NULL.blogs NULL.nytimes NULL.com/2014/02/10/the-real-world-is-not-an-exam/).  As someone who has generally performed better on tests than he has in real life myself, my bias has always been in favor of allowing medical students and residents to first learn the material before being asked to perform.  I agree that doing well on the hundreds of multiple choice tests that one is required to pass before graduating from medical school only gets one so far.  But, wouldn’t it be grand if we had some way of teaching the material to students ahead of time (you know, the way they do in school)  rather than simply expect them to absorb it on their own in the clinical setting?  As an undergrad, I was required to get A’s in a bunch of classes which were really not necessary in order to be prepared for medical school.  As a medical student, I had to pass a bunch of classes during my first 2 years which only minimally relate to what I need to know for practice.  Therefore, going into my clinical clerkships, I was only marginally more prepared than a really good high school graduate would have been.  And, by the time you get to this point in your medical training, true teaching experiences are few and far between.  They tend to happen on the go – i.e. a quick discussion of how to manage hyponatremia before seeing the next sick patient.  And any “knowledge” transmitted in this way is inherently suspect.  Prior to becoming a 3rd year medical student, I considered myself to be a rigorous skeptic with regard to medical or other scientific knowledge, obsessively combing through primary sources in order to sort out a contradiction between 2 equally reputable textbooks.  I quickly realized that is impossible to function this way in medicine.  The students who do well and get ahead are those who have strong opinions and present them with confidence, not those who fail to reach an opinion in the absence of a scientifically compelling reason.  In many ways, the difference between doctor an patient is pretty minimal.  Patients can google all the same information we can.  The major difference is that people believe doctors because we wear the white coat and express our opinions more forcefully.

On farting and yawning

It requires that you have a certain closeness of relationship in order to comment on the fact that someone else farted.  It’s not something one does in polite company or in a professional setting.  In such settings, the onus is on the farter to either a) excuse him or herself or b) ignore it and hope nobody notices.  So why is it considered socially acceptable to comment when someone else yawns?

I’ve spent the past decade teaching myself to suppress my yawns for this very reason.  (I was already pretty good at suppressing farts and, per discussion above, nobody ever comments on this anyway).  Suppressing yawns became immeasurably easier when I finished residency, but one does slip out on rare occasion.  I was up watching the late coverage of the Olympics last night.  I hadn’t gotten  that much sleep, so  I decided to let out a quick yawn – no sound, hand over mouth, jaw only half way open - after placing my sandwich order for lunch.  “Oh, don’t do that,” the middle-aged woman behind the counter scolded.  “I’ve still got hours to go.”

You’ve got hours to go?  What does that have to do with anything?  Yes, I yawned.  Yes, it’s a signal that I’m more tired than usual.  And no, it’s really none of your business!  Farting, in a way, is much more everyone’s business because of the sound and the smell it can create.  But a yawn?  How about if we make a deal, Von’s deli worker:  you don’t comment on the fact that I yawned and I won’t comment on the fact that you have bags under your eyes, need to loose about 20 lbs and, truth be told, really didn’t even do such a great job on my sandwich?

Family medicine 2.0

Twelve years ago, the seven national family medicine organizations launched The Future of Family Medicine Project (http://www NULL.aafp NULL.org/about/initiatives/future-family-medicine/ffm NULL.html).  The goal of this project, was to define the core values of family medicine and establish our specialty’s role in a modern medical world.  Some good ideas came out of this including the development of a new practice model known as the Patient Centered Medical Home.  In fact, the clinic where I practice is currently involved in what seems like a Sisyphean task of becoming PCMH certified.  Now, twelve years later, the same organizations are again working to a) define the role of the 21st century family physician and b) ensure that the specialty can deliver the workforce to perform this role.  As I happen to be board certified only in family medicine, my future income depends upon family doctors continuing to play a robust role in delivering primary care medicine and, as such, I am grateful to the Future of Family Medicine Working Party for their endeavor.  And, if I were smarter than I am, this blog post would stop right here.  But it won’t.

My argument, one which I try not to state too loudly as it goes against my own self interest, is that anyone who takes an objective and critical look at how we deliver healthcare in the 21st century will realize that the specialty of family medicine does not need to exist.  No single person or entity invented the medical specialties.   They grew up organically.  And, as such, there is substantial overlap between them.  I spent 3 the standard 3 years completing my family medicine residency.  During those 3 years I learned how to care for adults (internal medicine resident take care of only adults for 3 years), I learned to take care of children (pediatric residents take care of only children for 3 years), and I learned to do prenatal care and deliveries (obgyn residents spend 4 years doing this).  I continue to do all these things as part of my practice.  How is it possible that I became competent in these areas in 3 years when it would take me a total of 10 years to complete an internal medicine residency + a pediatrics residency + and obgyn residency?

I think the main answer to this question is that we simply can’t/don’t do as much for the patients we see as doctors of other specialties.  We’re more likely to referer an adult patient to a specialist than our internal medicine colleagues; we are much more likely to refer our pediatric patients to a specialist than our pediatric colleagues and the vast majority of family medicine trained physicians never deliver another baby upon completion of their residency training.  While I’m glad that the Future of Family Medicine Working Group is fighting the good fight on my behalf, I’m not sure I see a bright future for family medicine.  As medical knowledge continues to exponentially increase, it will be impossible for a single person to become competent in all the areas which our training covers.  Sure, we can continue to cover all areas of medicine in minimal depth, becoming ever more reliant on specialists and subspecialists to provide the sharp end of medicine while we coach our patients on quitting smoking, losing weight and getting a flu shot.  But a PA or a nurse practitioner can do this just as well as we can.  In fact, in many places, they already do.  We have reached the point where the service that family physicians perform can be effectively taken over by mid level providers. 

With the continuing shortage of primary care providers in the country, there’s no doubt that family medicine physicians practicing today will have useful work to do until they retire.  But, I seriously question the wisdom of continuing to train new ones.

 

Some stories only have villians

I avoided Trayvon Martin’s fate.

On Wednesday evening, I left my department meeting at 6:55pm.  Our church holds choir practice on Wednesday evenings at 7pm.  Fortunately, my church is right across the street from our department office and so the third Wednesday of the month affords me the opportunity to enjoy a pleasant walk from the medical campus to the church campus.  However, this means that, instead of entering our church campus from the parking lot (as most people do), I walk across the lawn – approaching from he opposite direction.  Perhaps this is what made me appear suspicious.  It’s true, I was wearing my motorcycle jacket.  On the flip side, I am white and was professionally dressed.  I also believe that I tend to walk in a purposeful and decidedly nonsuspicion arousing manner.  Despite these things, I was approached by a man in some sort of uniform.  Not a police uniform.  Perhaps he was a security guard, perhaps he was a fire marshall.  Perhaps he was just a creepy guy carrying a concealed weapon.

“Where are you going?” asked the tall creepy man as he stepped into my path, blocking my way to the welcome center.

“Choir practice,” I said, sporting the winningest smile I could muster.

“Oh, ok,” tall creepy man said, stepping aside.  It’s right in there.

“Thanks,” I replied.  “Have a nice evening!”

Now, this conversation could have gone a very different way.  Rather than replying to his man’s inquiry with an explanation and a smile, I could have responded by punching him in the face and slamming his head on the pavement.  Had I done that, he may have shot me…and he would have been perfectly justified in doing so.  I don’t belive that there are any self defense laws in the country which require you to wait until you’ve actually been killed, or raped or suffered grave bodily injury before using deadly force.  That you feel threatened is enough.  And, based on the only account of the Trayvon Martin shooting that we have (George Zimmerman’s account), he had pretty good reason to feel threatened.  Does that mean his account is exactly the way it really went down?  No, of course not.  But, it’s the only account we have and, in the absence of any contradictory evidence, it’s the one we should believe.  Or, even for those who choose not to believe Zimmerman’s story, there is still a troubling lack of evidence to support a murder conviction.

I simply don’t understand the logical contortions everyone seems to be going through in order to defend Trayvon Martin.  Is it that people are so afraid of being labeled a racist they are more willing to believe made up, hypothetical accounts of an event than they are willing to believe the entirely plausible account given by someone who was there?  I’ve heard Mr. Zimmerman interviewed.  He appears to be of borderline intelligence.  Does anyone this he is sophisticated enough to make this story up?  Like he thought to himself, “Hmmm…I’m going to go kill this black kid.  But I have to make it look like self defense…maybe I can go provoke him into throwing a couple of good punches.”  And even if this were what was going on in his mind, Travyon Martin still threw those punches!  He was not forced to do this.

My point is that either party could have walked away from this conflict.  But neither one did and, predictably, the fight was won by the person with the gun.  Similar situations play out in this country thousands of time each year.  I’m not defending George Zimmerman here.  Both parties were in the wrong.  But either one had the opportunity to prevent a violent confrontation, neither one took advantage of that opportunity and now we have one more victim of senseless gun violence.  But, please people, defending the verdict doesn’t mean you have to defend Zimmerman.  And expressing your justifiable moral outrage at the actions of George Zimmerman, doesn’t mean you have to defend Trayvon Martin.  Some stories have only villains and no heroes.

Nexplanon

I have the privilege of working in a really nice community office.  I’m a family physician working for Big University Hospital.  As you would expect, our practice location has a modern emr, we have clean floors and fresh paint.  We are always well stocked with supplies, etc. , etc.  You can imagine my chagrin when I was forced to tell a patient this morning that we could not place her Nexplanon (implantable birth control) because I didn’t have the ability to run a pregnancy test.  Our clinic has a fancy new ultrasound machine, we do all manner of in office procedures; if there is one test that is absolutely vital to running a functioning clinic, it’s the ability to run a pregnancy test!  Oy vey!  We sent a blood sample to the lab and had her come back in the afternoon.

New motorcycle

I am not longer between motorcycles! A couple of weeks ago I purchased a 2004 BMW R1150R. So far, the riding has been superb. I’ve been using it for the work commute while my car jealously sits on the street. I may never go back to driving on a daily basis. Like a woman who’s gotten used to the feel of thong underwear and just can’t go back to wearing full-bottomed panties, motorcycle riding is part of who I am.

Spirituality and health: the doctor as clergyman

Tomorrow, I have the unenviable task of teaching the first year medical students at our institution how to do a spiritual assessment. To answer the reader’s next question, no, I did not recently switch professions. I did not have an early-mid life crisis and leave medicine in order to pursue a life of poverty and a degree in divinity. Apparently, taking a spiritual assessment is part of medicine! Who knew? In fact, the Association of American Medical Colleges – the body in charge of accrediting American medical schools – actually requires that this be part of the medical school curriculum! Somehow I managed to graduate without learning this incredibly important medical skill!

Here’s one tool for taking a spiritual assessment, developed by doctor named, Puchalski:

F – faith, belief, meaning: Do you consider yourself spiritual or religious? Do you have beliefs that help you cope with stress? What gives your life meaning?
I – importance, influence: What importance does faith have in your life? Do you have specific beliefs that might influence your healthcare decisions?
C – community: Are you part of a religious community? Is this a source of support?
A – address/action in care: How should the healthcare provider address these issues?

I have never done a spiritual assessment in a clinical situation, nor do I ever plan to. In general, whenever I make bold or controversial statements, I try to provide some argument. The position, however, that discussions of religion/spirituality have no place within the context of the doctor-patient relationship, I consider to be neither bold nor controversial. Doctors get paid the big bucks to provide treatment and to help patients make medical decisions. Could someone’s faith influence their medical decision making? Sure. So what? Is there ever a situation in which I would counsel a patient differently, treat them differently or recommend different treatment based on their spiritual religious beliefs? Absolutely not. Never. In no situation is it ever necessary or even preferable to know what a patient’s religion is, indeed whether or not they have religion/spirituality in their lives at all, in order to provide effective medical care.
Eliciting a patients preference with regard their medical treatment, on the other hand, is often of critical importance. But there’s no need for your doctor to know what’s influencing those preferences. Your preferences are your preferences and where they come from is between you and you and, perhaps, God.

Oh, well…so much for not providing an argument.

Stay tuned

Sorry for the sparse posting lately. If you’re curious about the reason for this, see my previous post (http://www NULL.jamesloganmd NULL.com/?p=361). However, if all goes according to plan, I will have high speed internet again by Tuesday. Expect my next post and regular posting thereafter beginning August 10th. Thanks for stopping by!

Grand Rounds Vol. 7 No. 45

(http://www NULL.jamesloganmd NULL.com/wordpressp-content/uploads/2011/08/Web1 NULL.0-21 NULL.png)<tt>Remember the days when one accessed the internet by using a telephone line to dial up an isp? For that matter, remember when one made telephone calls using an actual telephone line? Well, for this blogger, that day has returned. I very foolishly agreed to host grand rounds during the week after a move to a new apartment (still no agreement on a new dining room table (http://www NULL.jamesloganmd NULL.com/?p=352), by the way) not realizing that our high speed internet would not yet be set up during the time I would be preparing this post. No matter. I temporarily have free dial-up access! Hence, this grand rounds is going to be a tribute to Web 1.0 and the various deprecated tags of HTML 4. Comments, of course, are still enabled.</tt>

<ul>

  • <DM>Guest post by Sysy Morales at Diabetes Mine (http://www NULL.diabetesmine NULL.com/) on the top 10 things women want their partners to know about their diabetes (http://www NULL.diabetesmine NULL.com/2011/07/10-things-we-women-with-diabetes-want-you-to-know NULL.html).</DM>
  • <!>Henry Stern from InsureBlog (http://insureblog NULL.blogspot NULL.com/) gives us the story of man who takes the idea of patient empowerment (http://insureblog NULL.blogspot NULL.com/2011/07/emtala-vs-diy NULL.html) a bit too far.</!>
  • <ouch>Ryan Dubosar, who blogs at ACP Internist (http://blog NULL.acpinternist NULL.org/) runs with this theme, mentioning the same case in his post about self surgery (http://blog NULL.acpinternist NULL.org/2011/07/qd-news-every-day-self-surgery-seems NULL.html).</ouch>
  • <chest pain>Ryan also blogs at ACP Hospitalist (http://blog NULL.acphospitalist NULL.org/) and, in this post (http://blog NULL.acphospitalist NULL.org/2011/07/chest-pain-unrelated-to-heart-attack NULL.html), examines the connection between chest pain and the liklihood of acute MI.</chest pain>
  • <ALCL>Can breast implants cause cancer? Ramona Bates from Suture for a Living (http://rlbatesmd NULL.blogspot NULL.com/) gives us more information on a clinical entity known as anaplastic large cell lymphoma (http://rlbatesmd NULL.blogspot NULL.com/2011/07/more-on-implant-related-alcl-of-breast NULL.html).</ALCL>
  • <med news>Jessie Gruman gives us a post on how the revenue model for online news undermines our ability to make good choices about our health care (http://blog NULL.preparedpatientforum NULL.org/blog/2011/07/our-preference-in-health-news-uncertainty-or-naked-ladies/). She posts regularly on the What It Takes (http://blog NULL.preparedpatientforum NULL.org/blog/) blog at the Prepared Patient Forum (http://www NULL.preparedpatientforum NULL.org/) website</med news>
  • <brca 1>Amy Berman, who blogs at The John A Hartford Foundation Blog (http://www NULL.jhartfound NULL.org/blog/), gives us the fifth post (http://www NULL.jhartfound NULL.org/blog/?p=3973) in her series on living with stage IV breast cancer.</brca 1>
  • <brca 2>Breast cancer survivor Beth Gainer gives us a post this week on the psychological burden of her illness (http://bethlgainer NULL.blogspot NULL.com/2011/07/psychological-burden-of-cancer NULL.html) Her blog is called Calling the Shots (http://www NULL.bethlgainer NULL.blogspot NULL.com/).</brca 2>
  • <htn>Dr. Charles (http://www NULL.theexaminingroom NULL.com/) looks at the pitfalls of evaluating blood pressure in an office setting (http://www NULL.theexaminingroom NULL.com/2011/07/how-to-improve-your-blood-pressure-check/).</htn>
  • <heat>Dr. Paul S. Auerbach has a post on this past week’s unprecedented heat wave (http://www NULL.healthline NULL.com/health-experts/outdoor-medicine/midwest-heat-wave-2011) over at Healthline (http://www NULL.healthline NULL.com/).</heat>
  • <portal>Steve Wilkins of Mind the Gap (http://healthecommunications NULL.wordpress NULL.com/) gives us his take on patient portals (http://healthecommunications NULL.wordpress NULL.com/2011/07/31/patient-portals-%E2%80%93-what-do-patients-really-think-about-them/).</portal>
  • <psych>Finally, Will Meek gives us a very interesting post on the clinical issue of believing that something is fundamentally wrong with oneself (http://willmeekphd NULL.com/item/defective-self-complex). He blogs at www.willmeekphd.com (http://www NULL.willmeekphd NULL.com/).</psych>

</ul>


<i>Next week’s Grand Rounds will be hosted by Dr. Deb (http://drdeborahserani NULL.blogspot NULL.com).</i>

Thanks for visiting!

Political deadlock with August 2 deadline

In recent days, the Logan household has found itself in the middle of a fierce political standoff.  Dr. Logan and his wife are moving into their new apartment on August 1st.  They have already rid themselves of all their old furniture and will need to furnish the new place upon arrival.  So far, Dr. Logan and his wife have agreed on a bed, a dresser and a living room set for the new apartment.  But they have been unable to reach an agreement on a dining room table.  In the past, the purchase of a dining room table would have been a routine, even perfunctory process in the Logan household.  However, Mrs. Logan – whose parents are Marshall and Lacey Claremont – has taken this opportunity to demand that any new dining room table have seating for at least 10 people and must be rectangular in shape.  Dr. Logan, on the other hand, believes that, in the interest of fairness, efficient utilization of space and given the constraints of the Logan household budget, the new table should be square and need not seat more than four people.

Analysts agree that a failure of both parties to reach an agreement by the August 2 deadline, the date that Dr. Logan is scheduled to host Marshall and Lacey Claremont for dinner, would be disastrous.  Lacey Claremont, who has been following the standoff closely, had this to say, “I just don’t know what they’re thinking!  Do they expect us to eat off the kitchen floor?”  While it has been proposed that Dr. Logan simply take his wife and his in-laws out to dinner on August 2, it is widely believed that an inability to provide a home cooked meal would seriously damage his credibility with the Claremont family requiring him to buy more expensive Christmas and birthday gifts for the next 5 to 10 years and also to visit the Claremont’s in Alburqurque, NM more frequently than the previously stipulated once every 8 months.  “It would amount to a giant tax hike on the Logan household,” Dr. Logan was heard saying the other day, “And neither Mrs. Logan nor I are willing to going to accept that.

But, unfortunately, Dr. Logan and his wife are no closer to a compromise than they were 3 weeks ago.  At press time, Dr. Logan is believed to be out shopping for a round table which would expand to seat 6 people.  Mrs. Logan dismissed this as political posturing saying, “If he thinks that particle board s@&! from Ikea is what we’re going to seat our guests around for the next 20 years, he can forget it!”