When doctors treat their patients, they are essentially performing one of two basic functions. They are either a) addressing a complaint that a patient has come in with or b) identifying screening tests that are appropriate for the patient and performing those tests. The management of chronic disease kind of encompasses both categories. There's also a third function doctors tend to feel obligated to perform which is to motivate health behavior change. I myself feel no such obligation but I often do this anyway (time permitting) because it's fun and because patients are often looking for motivation. It's good customer service.
Accepting for the sake of argument this view of medicine, what does a good doctor do when a 17 year old girl who is 20 weeks pregnant and has had no prenatal care comes into the emergency room with abdominal pain? The good doctor will identify a complaint that needs to be addressed, namely abdominal pain and he will also identify a litany of screening test that should be performed because the patient has had no prenatal care and needs things like an HIV test, gestational diabetes screen, rubella, Hepatitis B, etc. The good doctor will further recognize that her complaint is of vastly greater urgency than any of the above named screening tests. This patient is in the emergency room and screening tests never need to be done on an emergent basis. Let me repeat that for all you OB chiefs and attendings out there who like to make your junior residents do 1 hour glucose tolerance tests on patients in triage: screening tests never need to be done on an emergent basis. They can always wait until the patient has a clinic visit.
I think that in general, when it comes to screening doctors tend, not to forget but rather, to misinterpret their Hippocratic oath - above all, do no harm! There are very good reasons to do certain screening tests, marginally good reasons to do other screening tests and there some screening tests which we have very good reason not to offer. Every test one performs has the potential to come back abnormal. And for every abnormal test, there is some intervention we can perform. And for every intervention we perform, we subject the patient to some increased risk of harm. The only way to determine whether the benefit of screening outweighs the risk is to study the test on a large scale and to determine who does better - the screened group or the unscreened group.
Bottom line is when you're addressing a patient's complaint, by all means, test them for whatever might be causing their symptoms. But be very cautious about testing asymptomatic people for stuff. Something as simple as a cervical exam on a patient who is not complaining of any symptoms consistent with labor is screening. For every patient you help based on your exam findings, you may hurt two or three. We take an oath to do no harm and refraining from unnecessary screening tests is one really easy way to decrease the amount of harm you do as a physician.
Rounding on post-partum patients can get pretty monotonous. You ask the same littany of questions about bleeding, breast feeding and birth control to everybody. Once in awhile someone has a hemorrhage or fever, but the vast majority would do just fine without our monitoring or assistance. As a result, your post-partum notes all tend to look very similar. My physical exam section usually looks like this on pretty much every patient:
Gen - A and O x 3
CV - rrr, no murmurs
Abd - soft, nt/nd; fundus firm below umbilicus
Ext - no c/c/e
For those of you unfamiliar with medical abbreviations and terminology, allow me to draw your attention to the last line, "Ext - no c/c/e." It stands for, "Extremities - no cyanosis, clubbing or edema." Translation = her legs and hands are not blue, not swollen and her fingernails do not look like those of a person who suffers from chronic low blood oxygen levels. I wrote one such note on a patient this week, seeing her on post-partum day #1. Someone else saw her on post-partum day #2. I returned to see her on post-partum day #3. Upon reviewing the note from day #2 I find the following in the other resident's physical exam section:
Gen - A and O x 3
CV - rrr, no murmurs
Abd - soft, nt/nd; fundus firm below umbilicus
Ext - no clubbing or cyanosis. previously patient was noted to have no lower extremity edema but on this resident's exam, trace lower extremity is present
What? Are you serious? You thougt it was worth using valuable ink and using up the valuable pen-stroke time to write that piece of baloney! Please, unless you're worried about DVT or some other pathology and plan to use your physical exam findings to justify a change in the management of this patient, keep your editorial comments to yourself. Am I out of line here?
Sometimes it's fun to go to your stat counter and look at the links referring to your blog. I think it's particularly enlightening to see which google search items have brought people to your site. Since I once wrote a post with the title Please, look at my vagina, you can imagine some of the search items that bring people here. I also get a lot of people looking for information about traumatic foley's for some reason. But, what I find to be the most hilarious is the occasional search item that reads like, "what are the ingredients that make up blood?" or "why is this thing broken?" Yes technology is amazing, but your MacBook has not yet reached the sophistication of the on board computer of the Starship Enterprise (special bonus points to anyone who can name the Star Trek movie in which Scotty picks up a mouse and says hello computer, not realizing that computers of the 1980's don't accept voice commands).
Let me just preface this post by saying that I can't express how thrilled I am to have Barack Obama as our next president. Everything about his campaign has been unprecedented. He is a very special politician who, I believe, will help us heal the deep political divide in this country. But is he the first black president?
Fast-forward to the 2007-2008 democratic primaries. Some said Obama couldn't win because he's black. Others said he couldn't win because he's "not black enough" and therefore wouldn't be able to mobilize African-American voters effectively. Apparently, Obama had whatever margin of blackness he needed to achieve a victory. But is he black enough to count as the first black president? Can the child of a white woman and African (non-American) man who grew up in a white family, was Harvard educated and who is not himself associated with the civil rights movement really represent a significant milestone? I believe that Obama's victory - while special, historic and all around awesome - does not have the same meaning for this country in terms of establishing racial equality as would the election of a Jesse Jackson Jr., an Al Sharpton or (god forbid) an Alan Keyes. Obama's personal family history has never known slavery. He's not a man who has always been 100% sure exactly which box to check but he is a man who has known a lifelong struggle with racial identity. Consequently, his beliefs, ideas, values and even his looks have been shaped in ways that are very different from what we think of as traditionally African-American.
In conclusion: does Obama count as our first African-American president? I don't think so. Does he count as the first black president? Insamuch as this represents something different, sure. My hope as that his election ushers in a era where it doesn't matter.
I love it whenever I get the opportunity to wear a tux because I just look so damn awesome in it! I had one such opportunity last weekend.
Let me explain by first saying that, on a given Friday night, I am far from the best looking guy in the club. I'm 28 years old, 5'9". I have a somewhat dark complexion which Greeks and Italians will equally claim as a reflection of their selfsame heritage. I have brown hair and eyes and, after having been a resident for over a year, I carry around about 20 pounds more than I need to. And, I think it's precisely because I am neither your handsome stud nor your ugly slob in ordinary life that the tuxedo does so much for me. Put a tux on my buff, 19 year-old, 5'11" cousin with his carelessly tousled hair and winning smile and it almost detracts from his appearance. I'd almost rather see him in a sleeveless tank top and tight-fitting jeans. My 53 year-old uncle suffers from a similar failure of appearance enhancement secondary to tuxedo wearing, but for different reasons. My 53 year-old uncle weighs 270 pounds has 3 chins and what hair he does have left falls in thin, greasy threads on the sides of his head. Sadly, the penguin outfit does no more to disguise his slovenly appearance than the application of lipstick does to disguise a pig.
But for me, the tuxedo is utterly transformative. I have enough imperfections that I can benefit substantially from the outfit's shaping power, but the imperfections are not so severe as to make me a lost cause. I wish I could wear one every day :)
