Category Archives: Medical

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!

Grand Rounds for August 2, 2011

This week, I have the honor of hosting my first ever Grand Rounds (http://getbetterhealth NULL.com/grand-rounds).  Let’s make it a good one!  No particular theme this week.  Just submit whatever you think is your best/most relevant work.  I will, however, suggest a few guidelines:

  1. Posts should be no more than 1 week old.
  2. Posts should be the original work of the author and should not appear anywhere else besides the author’s own personal blog or website.
  3. Posts should be medical in nature.
  4. Creative works including fiction and poetry are encouraged.
  5. Posts that make me laugh get the top slots.

Email your posts to james[at]jamesloganmd[dot]com.  I must receive your submission by Sunday, July 31.  Thanks for stopping by!

Don’t treat every patient like your mother

Physicians recommend different treatments for patients than they would choose for themselves.  The preceding statment is true according to a similarly titled article recently published in the Archives of Internal Medicine by Ubel et al and has, I will argue, important implications for how we view the doctor-patient relationship.  In the study, one group of physicians was asked to choose between two hypothetical treatment alternatives for either avian flu or colon cancer as if they themselves were the one with the disease.  The other group was asked to choose between the same hypothetical alternatives as if they were making a recommendation to a patient with the disease (either avian flu or colon cancer).  In the colon cancer scenario, both hypothetical treatment alternatives presented were surgical.  One surgical procedure was 4% less likely to cure the cancer, but did not carry the same 4% complication rate as did the more curative procedure.  The avian flu example involved a hypothetical treatment which decreases the chance of death due to flu from 10% to 5% and hospitalization rate from 30% to 15% but which also carried a 1% risk of a fatal reaction and a 4% risk of lower extremity paralysis.  In this example, physicians were asked to choose between the options of treating versus not treating.

What did they find?  Physicians were significantly more likely to choose the option which carries a higher mortality rate but a lower risk of complications for themselves than they were when making a recommendation to thier patient.  Why was this the case?  The authors point to cognitive bias.  They suggest that the biases of “betrayl aversion” (an exagerated feeling of harm caused by an action designed to prevent harm) and “omission” (the added regret of harm caused by a treatment when compared with the same degree of harm caused by a withholding of treatment) are more at work when doctors are choosing for themselves than they are when choosing for patients. 

The idea that we make better decisions for others than we do for ourselves and our loved one is entirely plausible.  Indeed there is other research to suggest that this is the case.  It is a big part of the reason why doctors shouldn’t operate on friends and loved ones, deliver their babies or, in my view, even prescribe them medications.  This is why I am disturbed by what I believe to be the prevailing view in medicine today – namely that we, as Dr. Wes (http://drwes NULL.blogspot NULL.com/) recommends, “Treat every patient like our mother (http://drwes NULL.blogspot NULL.com/2011/06/for-interns-ten-rules-to-go-by NULL.html).”  I will elaborate.

In the ideal situation, medical decision are based on good evidence, reflect the patient’s beliefs and values and are ethically permissible to the physician.  For this to happen a good doctor needs to a) dispassionately weigh the evidence including all attending risks and benefits of any possible intervention and b) establish a relationship with his or her patient which promotes the expression of autonomy.  Treating patients as we would ourselves or someone who is close to us (i.e. with kindness, respect and empathy) is clearly necessary for the latter of these goals.  But, as the above study demonstrates, it is likely detrimental to the former.

Many commentators worry that the rigorous nature of medical training beats the empathy out of young doctors – that medical students loose their idealism during the third year of medical school, become jaded and cynical.  This may be true, but is the wrong question to ask.  I would argue that being caring and empathic are qualities which are necessary in order to effectively perform one’s function as a physician, but are not goals to be achieved for their own sake.  Just as it helps us develop a rapport with patients and establish an effective therapeutic relationship, empathy impairs our ability to rationally weigh evidence and make decisions free of cognitive bias.  Treating every patient like your mother should not be seen as an ideal to strive for.  Rather, it should be seen as a first step which providers must then overcome in order to provide the best possible care.

Starbucks gift card

Last spring, I took an online learning module developed by the pediatric department designed to test my knowledge of vaccines.  For my participation in this experimental project I received a Starbucks gift card.  Last month, I took a survey designed to evaluate some of our internal clinic procedures.  For my participation I received…a Starbucks gift card.  The thing is, I don’t actually drink coffee!

Most of you reading this won’t understand what it’s like for a non-coffee drinker like myself.  Coffee is so pervasive in our society, soon it will be coming out of our faucets!  I replay the following scene at least a few times every week.

Colleague #1: Hey, I’m going to the cafeteria to get some coffee, anyone want some?”
Colleague #2: Sure, I’ll join you.
Colleague #3,4,5…17: Us too!
(Everyone turns to me)
Colleagues 1-17 (simultaneously): James?
Me:  No, no thanks.  No coffee for me.
Colleague #1: You sure?
Me: Yes, I’m sure.
Colleagues 1-17: (exchange confused looks and murmur to each other)  Really?
Me:  Yes!  Yes, I’m absolutely sure.  Please, read my lips…no coffee for me. Really!

Coffee is everywhere in our society.  Every morning, someone in my vicinity is either brewing it or buying it or grinding it, or french pressing it…and I am constantly having to refuse offers of coffee.  Pretty soon, I’m going to start wearing a sign on my head that reads, “To you generous offer of coffee, I politely decline,” and save everyone the trouble. 

I do actually drink it sometimes.  Just not first thing in the morning.  It makes me nauseous, jittery and have to pee when I start the day with it.  But, back to my original point, couldn’t the ‘thank you’s’ for the various research projects I have so selflessly contributed to be a gift card from some other, non-coffee specializing establishment?  Why not an iTunes gift card, or a coupon for a free lap dance at Club Ecstasy?  (Not that I’ve ever been there…just sayin’)  Or better yet, the gift could simply be a syringe filled with dopamine that I could inject directly into my brain.  That would be cool.

Medicine is my day job

Since it strikes at the very core of what this blog is all about, I couldn’t pass up the opportunity to comment on Dr. Karen Siberts recent op-ed piece (http://www NULL.nytimes NULL.com/2011/06/12/opinion/12sibert NULL.html?pagewanted=1&_r=2&sq=sibert&st=cse&scp=3) in the New York Times.  She argues that, especially given the current shortage of primary care doctors in this country, being part of the medical profession confers one with the moral obligation to serve and, as such, conflicting interests, such as raising a family, should take lower priority.  I worked with a radiology attending once who expressed a similar view of his relationship to his profession this way, “It would be irresponsible of me to have kids because I spend so much time working.  I wouldn’t be able to spend enough time with them.”

The notion that doctors have a moral obligation to serve – to make their profession their top priority, their “life’s work,” as Dr.  puts it, or their otherwise full-time endeavor – comes out of the still prevailing view that doctors have an obligation to the public as well as their patients.  There are, of course, ways in which this is absolutely true.  As licensed professionals, doctors do have certain obligations to the public, among them to maintain patient confidentiality, to practice in accordance with current standards of care and to address any dangerous or unethical behavior in their colleagues.  As Dr. Sibert correctly points out, the practice of medicine is a privilege.  Where I very strongly disagree with Dr. Sibert, is that being afforded the privilege of providing a particular service confers an obligation to do so.  What is the nature of this obligation?  How much medical care are doctors obliged to provide?  How many hours per week is enough?  What kinds of conflicting interests justify taking us away from the practice of medicine?  These are personal considerations which every professional must answer for him or herself, not questions for public to answer. 

There are a subset of physicians who do have a unique service obligation.  The National Health Services Corps (NHSC) as well as many state funded organizations will pay back all or a portion of new physicans’ medical education debt in return for a commitment to practice in an underserved community for a specified time period.  Doctors in these programs enter into a very special contract with the state and therefore have a unique obligation to serve the public which other doctors do not share.  Yes, it’s true that residents’ salaries are paid largely by medicare.  But, far from conferring true financial or symbolic debt upon residents, this payment is in return for valuable services that doctors provide during residency.  If anything, it is the government who is indebted to new doctors for the years of nearly free service they are compelled to provide throughout the course of their training.

It is absolutely true that we have a current shortage of primary care providers in this country.  However, we cannot and should not depend on doctors’ intrinsic motivation to work more simply because it is needed, or to move to rural areas simply because that is where they are needed, anymore than we should any other professional to do so.  As much as we enjoy it when people voluntarily do things which are not in their own self-interest in order to benefit society, change needs to come through rational healthcare policy.  The Affordable Care Act represents a first step in this direction by increasing funding for NHSC scholarships and with new grants to increase the number of primary care residencies.  This is how the problem must be addressed.  A doctor’s relationship to his or her profession and the number of hours per week that he or she decides to practice is a matter of personal, philosophical reflection, not a matter of moral obligation or public debate.

Family medicine boards and compentency

I’m taking ABFM (American Board of Family Medicine) exam on July 19th.  Will passing this exam make me a competent family physician?  Is it possible to be incompetent and still pass the boards? 

The question of what makes any doctor “competent” has plagued me for a long time.  Before starting medical school, I was in awe of doctors.  How can they possibly know and keep at their finger tips all of the facts and skills they need in order to provide good care and avoid mistakes?  I had no idea how doctors obtain this wealth of knowledge and skills.  But I assumed that if I was a good student, passed all my exams and all my rotations and eventually became licensed and board certified, I surely must come out of that process as a competent, error-free physician.  I mean, we trust the various medical boards to only license and certify doctors who are competent, don’t we?

But, in truth, in order to pass any exam or rotation, one only needs to know most of the critically important things, never all of them.  In other words, passing grades are always lower than 100%.  But, presumably, 100% of what we’re being tested on is important.  One could be a doctor who scored 99% on all her exams and inadvertently let a patient die because she ignored a PE (pulmonary embolus).  Maybe she somehow made it through her training without ever learning about PE and so got every other question right but that one.  Is an otherwise knowledgeable doctor who ignores a known PE incompetent?  Most of us would say, ‘yes.’

Althought it doesn’t currently exist and almost certainly never will, I continue to hold onto the idea that each specialty should have a syllabus.  There should be a minimum fund of knowledge which, once you’ve mastered it, you can declare yourself competent.  A family medicine syllabus, for example, would have a section on PE.  It turns out that there is such a thing for ACLS (advanced cardiac life support).  Providers need to score 100% on the practical part of the ACLS exam.  Once they’ve mastered that, they’re done and can be highly confident in their competence as an ACLS provider.  But, as a doctor, you just never know.

Sunflower seed bezoar

I’m an avid listener of the Adam Carolla show (http://www NULL.adamcarolla NULL.com). Yesterday’s guest, Dr. Bruce, describes having a patient with a sunflower seed bezoar (http://www NULL.podtrac NULL.com/pts/redirect NULL.mp3/traffic NULL.libsyn NULL.com/theadamcarollashow/2011 NULL.05 NULL.02ACS NULL.mp3). I actually saw the same thing as a resident a couple of years ago. African-American lady in her 50′s was complaining of constipation. Also complained of feeling something “sharp” in her rectum. She also happened to mention that she’d been pigging out on sunflower seeds! I gave her some stool softeners and sent her home. Next day she was back. A different doctor saw her. He did a rectal exam and successfully removed a clump of black shards. Patient was fine after that. Sunflower seed bezoar!

Feedback from between her legs (cont)

Getting called into the program director’s office is almost never a good thing. I had received a page from Dr. Mann earlier in the day asking if I had time to meet. The answer, of course, was ‘no’ but we had a mutual understanding that I’d find a way to make time. Despite his ebullient charm, outstanding interpersonal skills and overall casual demeanor, Dr. Mann stands 6’4″ and can be an imposing figure.
“You’re probably wondering why I asked you here,” Dr. Mann smiled and gestured toward the chair in which I promptly sat. He was correct in that I did not know the exact reason for my summons. I wondered which of my many transgressions it was over the past month that had come to our program director’s attention. I feared some more than others. “I just wanted to give you some feedback,” he continued. I already didn’t like where this was going. ‘Feedback,’ in this setting, translates to ‘made aware of a situation in which you fucked up.’ I could be assured, at least, that I wasn’t there to be given ‘constructive criticism’ which translates to, ‘made aware of a situation in which you fucked up royally.’ He continued. “Maggie, our psychology intern, came to me the other day after her standardized patient session with you. She shared with me that, during your feedback session with her, she got the impression that you were looking up her skirt.”
This I had absolutely not seen coming. “Looking up her skirt?” I repeated dumbly.
“She felt like you were distracted and not paying attention to the feedback she was giving you. She felt that even when she crossed her legs and shifted to the side, you were still not listening.” This was absolutely true, of course. I didn’t know Maggie well enough to definitively classify her as a ‘bimbo,’ but her “feedback” had certainly been less than enlightening. That glimpse of her underwear had been the only thing that had made the afternoon worthwhile.
“Well, gosh Dr. Mann. I’m sorry she got that impression. I certainly wasn’t aware of looking up her skirt, or seeing anything that I wasn’t supposed to see. Also…I’m sorry, who’s Maggie again?”
We discussed the situation for about 15 minutes, me all the while breathing an internal sigh of relief that this was the reason for the meeting and not something more egregious. I agreed to meet with Maggie and apologize for making her feel uncomfortable. I hoped she would be wearing the same outfit as last time.

For all those sadomasochists who ever wished their partner had “teeth down there”

AntiRapet000.jpg
The “Rape Axe (http://ac360 NULL.blogs NULL.cnn NULL.com/2010/06/21/south-african-doctor-invents-female-condoms-with-teeth-to-fight-rape/),” a toothed female condom developed by Dr. Sonnet Ehlers and designed to deter would-be rapists , is currently being distributed for free in South African cities hosting the World Cup. Thereafter, they will be made available worldwide for $1.50 each. California residents will be able to purchase these at their local boards of health, or at Jade’s Dungeon with various retail locations along the west coast.

Feedback from between her legs

She tapped her pen on a legal pad, briefly stopped and motioned for me to take the seat opposite. Maggie was a psychology intern. She was about 25, tall and wore her blond hair long and straight. She was trim with a nice figure; she almost certainly went to the gym on a regular basis. Today she wore high heels and a black suit jacket underneath which was a sheer white blouse. She sat with her legs crossed. Her matching black skirt came down to about the mid thigh.
At the conclusion of the standardized patient interview, Maggie’s job was to review the video footage with the resident and give him or her feedback on how he or she handled the actor who had been pretending to be a depressed patient. Maggie looked at me through her dark-framed glasses. I wondered whether or not they contained prescription lenses. “So, how do you think you did with this patient encounter?” She sat about 3 feet away, facing me with her legs crossed. Her long, white legs seemed to go on forever. I pondered this while allowing her to induce me to manufacture some feedback on my performance. Feedback on one’s performance within a patient encounter, whether real or simulated, is entirely subjective and largely bullshit. As far as I’m concerned, an encounter with a patient is either successful or unsuccessful. It is successful if a plan of action is developed that everyone is on board with. Sometimes a plan is developed, but only partially implement or sometimes the plan represents a compromise between what the doctor recommends and what the patient is willing to do. In these cases I would call the encounter partially successful. Better doctors are the ones who facilitate the most successful patient encounters. I pondered this as Maggie leaned forward, uncrossed her legs and said something about “eye contact” and “empathy.”
“What do you think you could improve upon for next time?” She leaned back as she asked me this and I took note that there was just enough separation between her knees at this angle to make visible the shiny, white panties she was wearing. She crossed her legs again as I said something about being “patient-focused” and asking open ended questions.
There was nothing noteworthy about the rest of our exchange and I left the interview hoping to get “feedback” from Maggie again sometime.