February 26, 2009 – 7:10 PM
I've written more than once about my belief in not creating more problems for than they have already. To that end, one of the easiest way to avoid labeling patients with additional problems is to refrain from screening them for things that they don't need to be screened for. To review some basic principles, we screen patients for conditions that are:
a) asymptomatic
AND
b) conditions for which intervention at an earlier stage of the disease improves morbidity and/or mortality
Therefore, we should not be in the habit of screening for things like drug abuse because drug abuse is a condition that fails to meet our first criterion. Drug abuse is not asymptomatic. Calling up your dealer, paying him for drugs and then using those drugs to get high are all symptoms of drug abuse.
Even though to the common wisdom is that we should screen, in practice I don't think anyone really does. We may ask more in depth questions regarding drug and alcohol use of patients whom we have a reason to suspect of having a drug/alcohol problem or in patients who come in with a different problem which we suspect might be caused or exaccerbated by drug or alcohol use. And this is perfectly appropriate. But, sweet lord, there is no need to screen every patient.
On an unrelated note, I'm reading Watchmen in anticipation of the movie. This is my first graphic novel experience and so far Watchmen has not disappointed. I'll give a final review when I'm done.
February 20, 2009 – 2:34 PM
In the hospital setting, we have some rather elaborate and expensive systems in place the sole purpose of which is to increase efficiency. For example, we have a transcription service, thus allowing us to dictate our notes rather than having to type them. This is simple economics. Allowing us to dictate rather than having to type saves time for us doctors, thereby freeing up time to see more patients during the workday resulting in more income for the hospital. The extra revenue this generates more than justifies the added cost of hiring transcriptionists to type out everything for us. Why then do we continue to insist upon deliberately decreasing the efficiency with which we do things? The most prevalent and striking example of this phenomenon in the modern age is using our cell phones to communicate via text rather than voice. Many very smart people were paid very well to labor on the problem of how we might talk to someone who is a great distance away without being dependent on pesky wires which limit our mobility. After much perseverance, they found a solution - the cell phone! So why in God's name do we continue to insult these hard working innovators by taking something which they designed specifically to enable us to communicate very efficiently and deliberately perverting its in such a way as to enable us to communicate less efficiently? Consider, if I get a text from a friend asking WHAT I'M UP 2 DOG? (which took longer for my friend to enter into his phone than it would have for him to simply say) and I reply with NOT MUCH, U?, we've both spent valuable time and money on these messages and we are no closer to having plans for the evening than we were before.
Our textual habits seem to have carried over into the hospital setting. Quite often I'll get a text-page inquiring about whether a particular lab value has come back yet. I will then have to page this person and wait for a call back so we can have a discussion about an abnormal bilirubin value, whereas if they had simply paged me with their callback number, instead of a text message, I could have initiated the bilirubin conversation straight away. Alternatively, I could reply with a text page of my own. I might reply with: YES, IT DID COME BACK. Then perhaps I would receive a later page: WHAT WAS IT? I could respond with 4.5 etc. I could also use a pair of scissors to mow my lawn and Q-tip to paint my kitchen but these things don't make much sense either.
February 14, 2009 – 12:16 AM
The purpose of this entry is twofold: first, to help any medical students who may read this blog in their transition from preclinical to clinical years and second, to fulfill my need to rant.
In medical school, we are taught the myth of The Complete History and Physical. Myths are fun and good to know about. The problem is that we are taught to believe this myth. Like Theseus and the Minotaur or The Abominable Snowman, the Complete H and P does not exist. There is no such thing. It is a fictional construct used by medical educators to teach those without very much medical knowledge how to approach a patient. It serves the same purpose as the story about Apollo pulling the sun across the sky in a chariot every day. The truth is that the type of questions you ask a patient and the type of physical exam maneuvers you perform completely dependent on a) the patient's chief complaint and b) the context in which you are seeing them (i.e. inpatient already seen and evaluated by ER doc vs ER not yet evaluated by any doc vs outpatient vs OB vs pediatrics vs nursing home vs hospice etc.) There is no such thing as a "complete" set of elements that must be present. To be complete, you need only whatever elements are relevant to whatever objective you are trying to achieve.
Of course, this presents at least one huge problem for medical students and physicians in training. Since your knowledge is less complete than that of the person who will be making the final clinical decisions, you may not always know which information is relevant and which is not. Not only that, but you as a learner may not even be sure exactly what objective you are trying to achieve since this is based on a) your medical knowledge, b) the patient's wishes, c) whatever overarching principles guide you in your beliefs about how medicine should be practiced. Therefore, with all of these unknowns, the diligent learner is obliged to gather more data that what he believes to be strictly relevant in the event that his supervisor wants to know some detail that the learner had no reason to think important.
Which brings me to what I now perceive to be the point of this post: rather than subjecting medical students to this highly inefficient process of gathering mountains of data and only later helping them to understand which data they needed to gather, why not first teach them which data are important before throwing them in a data-gathering situation? Seems only reasonable, doesn't it? Yet, we continue to teach medicine by putting students in situations in which they are expected to perform without first giving them the opportunity to learn how best to proceed. Do not misunderstand me, the current process does work...eventually. Spend long enough in France and you will eventually speak French pretty well. But it seems to me that we could make the path from learner to skilled clinician many times more efficient.
February 11, 2009 – 7:30 PM
Just ran across Dr. Phil and a panel of "experts" all giving their opinions about the woman who gave birth to octuplets, the fertility doctor who helped her get pregnant and the hospital where she gave birth - among other things. Note: I do not routinely watch Dr. Phil. We don't get very good reception where I live. I have two channels worth watching and then a bunch of crappy channels. It was on one of these crappy channels that I found Dr. Phil. He won out over celebrity news and black history documentary.
In any case, I think it's time for the medical community and the press to leave the octuplets alone. We don't know all the details. We've said our peace about the limits of what kind of medical procedures consenting adults should be permitted to agree to. Good night, good luck and we wish them all the best.
February 6, 2009 – 11:27 AM
In his op-ed piece in the Philadelphia Inquirer, Art Caplan argues that the fertility doctors involved engaged in "grossly unethical" conduct by failing to set limits on who may take advantage of reproductive technology (article here). The idea that patients are not entitled to whatever elective procedure they ask for and that doctors may ethically refrain from providing certain procedures based on their own perception of the potential risks involved is widely accepted and I have no disagreement with Prof. Caplan on this point. But, to claim that it is simply obvious that inserting 8 embryos puts the woman and her potential offspring at grave risk and should not be done is entirely unhelpful and unsatisfactory. There is a rather long list of elective procedures which doctors routinely perform - procedures which are not "medically necessary" in the strictest sense, procedures which subject the patient to unnecessary risk and procedures which at the same time are NOT considered to be unethical - or at least not obviously so. Among these: any type of fertility treatment, gender reassignment, any type of cosmetic procedure, gastric bypass surgery, vision correction procedures, etc. Shall we have the government weigh in on ALL such procedures in order to make sure that rogue doctors aren't practicing unethically, or shall we keep such decisions between the doctor and the patient as has been our tradition? I believe the government does have a role to play in keeping us safe which is why I believe the limit of 3 embryos per in vitro cycle imposed by most European countries is not unreasonable. But we must tread with great caution when allowing the government to have a say in decisions once made exclusively by a patient in consultation with his or her doctor. Other medical procedures our government has legislated upon include female circumcision, electroconvulsive therapy (banned in Berkeley, CA) and, of course, abortion. We should be careful about adding in vitro fertilization to what should and must remain a very short list.
February 5, 2009 – 6:12 PM
Honorable chairman Max Baucus, with regard to the $900 billion economic stimulus plan on which the senate will begin debate on Monday, February 9, jamesloganmd.com would like to request your assistance in the form of inclusion in this bill. Our reports show that last quarter's profits fell $200 million below expected. In fact, the sum total of revenue generated by our company since it's inception in 2006 is $0. We are in serious danger having to lay off our entire staff and shut down production in all but one state in effort to cut costs. In order to stay viable, our company esitmates that we will need $2 billion over the next five years. Our CEO has agreed to stay on with a salary of $1/year in order to keep our company from going bankrupt - an event which would almost certainly result in the total collapse of our economy and unemployment rates higher than those of the Great Depression.
I thank you for your serious consideration in this matter and would be happy to testify before the committee should I be asked.
February 2, 2009 – 7:00 PM
Time has ceased to have meaning as I sit staring at my monitor while the tool I downloaded disinfects my computer of Trogan.Brisv.A. All I wanted to do was download Fall Out Boy's Let It Rock so I could listen while I work out at the gym. What a debacle that turned out to be!
