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.

Late entry secondary to patient care

The patient, whom we will call H.P., delivered a healthy baby something-or-other sometime during the early morning of August 14th. OBGYN intern, Dr. James Logan, was now twenty hours into a thirty hour shift and this was the fifth delivery he’d done. Feeling increasingly queasy at the prospect of rounding on eighteen patients by himself in a few hours – the day intern had called in sick – he opened the 3-ring binder chart, willing himself to knock out a quick a delivery note. He wrote, “On August 16th, patient H.P. delivered a viable –”

He was interrupted by the frantic call of a nurse from down the hall. “Dr. Logan, chi can bree!” Dr. Logan slowly put down his pen, for, while he didn’t understand what the Filipina nurse on the post partum floor was trying to tell him, he had the sense that it was of some urgency. Again came the nurse’s cry, bordering on hysteria this time, “Dr. Logan! Come kweek, chi can bree!” Turning the words over and over, upside down and sideways in his mind, James Logan made his way over to Post-Partum. Slowly at first, then more quickly as meaning began to take shape in these strange syllables. He arrived at the patient’s room to find her awake, sitting up in bed and taking quick, shallow breaths. The look on her face was one he recognized well, as he frequently would see it on his fellow interns – panic.

The next several hours were a blur. James’s chief resident, Jen, came by to help out with the lady who “couldn’t breathe.” It took about twenty minutes for everyone to reassure themselves that the patient was just having an anxiety attack. Shaken but relieved, James got to the business of rounding on his eighteen patients, a task that would have exhausted him on the best of days. Today, crying babies and new moms’ discourteous taking of showers before he’d had a chance to examine them sapped the last few ounces of his strength. There were still notes and orders to write before he would be allowed to leave. While he contemplated these things, Jen popped by the nursing station where James was buried under a pile of charts with a friendly reminder. “Did you ever get to that delivery note?” He hadn’t. The look on his face must have indicated to Jen the need for quick, empathetic intervention.

“Yeah,” she said. “I know it sucks. I was an intern once too.” She smiled encouragingly. “Hey, I’ve got a joke for you! An OBGYN resident walks into a bar.” James waited.

“Where’s the punch line?”

“That is the punch line! When does an OBGYN resident ever have time to go to a bar?” She laughed, slung her purse over her shoulder and made her way to the parking garage.

Fighting back tears, James reopened the 3-ring binder chart, tore out the old, unfinished note and began anew. “Late entry secondary to patient care. On August 16, patient H.P. delivered a viable…” But, he had forgotten the details. The official record of the delivery of H.P.’s baby whatever-it-was would be one of historical fiction.

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.

Docs vs glocks: HB 155 and the doctor-patient relationship

Do doctors have any business asking patients about whether or not they own a handgun?  Like many other paternalistic inquiries with which doctors routinely harass their patients (car seats, bicycle helmets, smoke alarms, etc), my answer to this question is ‘no.’  There is a fairly well delineated sphere of knowledge which is medical in nature and in which I have some expertise and other topics which are purely personal/moral/lifestyle considerations and in which I have no particular expertise.  I was taught that my job as a provider is to give medical advice to my patients and to share in the decision-making process with regard to their medical care.  If a patient were to ask me, “Should I wear a helmet when I ride my bicycle?” I would tell her, “Yes, I think you should.”  I could quote her some statistics, but she knows just as well as I do that she’s much less likely to sustain a serious injury to her brain if she hits her head while wearing the helmet as opposed to without it.  In other words, her opinion on this issue is only minimally less informed than my “expert” opinion.

With regard to gun ownership, my opinion is even less meaningful than for wearing of bicycle helmets.  I’ve never held a gun in my life, let alone fired one.  I haven’t the faintest clue about proper gun safety, nor do I intend to learn.  Just as I wouldn’t presume to ask a pilot whether he follows all proper safety procedures and inspections before take-off, or whether a scuba diver properly checks out his gear before diving, I have no business asking about gun ownership.  Sure, the AAP is fond of quoting the higher incidence of gun-related deaths among gun-owners (hence, my personal decision not to own one).  Similarly, I could quote the higher rate of airplane related deaths among those who fly vs those who don’t.  Or the higher incidence of scuba diving related accidents among those who scuba dive vs those who don’t.  The list goes on.  My point is, that these are personal, life-style decisions.  They’re not medical decisions and, as such, my opinion is really irrelevant.

All that being said, a bill which holds doctors criminally accountable for discussing guns during a patient visit, as Florida law HB 155 does, is simply outrageous.  Mona Mangat argues that this type of legislation places us at the top of a “slippery slope (http://www NULL.kevinmd NULL.com/blog/2011/06/docs-glocks-slippery-slope-hb-155 NULL.html)” at the bottom of which it may become illegal to ask patients about smoking.  I would go even further and say that we’re already well on our way down the slope with this legislation, the issue is no longer slippery.  One can have a rational, academic discussion about which types of behaviors and decisions doctors should and should not be asking their patients about.  But to make a particular line of questioning illegal is an unprecedented step which clearly undermines doctors’ ability to establish trust with their patients.  The issue is not, as some have argued, that this law prevents doctors from their duty to identify a particular risk to patient safety.  Whether or not doctors have a duty to ask about gun ownership as a patient safety concern is a matter of opinion (I’ve expressed mine very strongly above).  The issue here is that making any topic of discussion with your patients illegal, in addition to being a likely 1st amendment violation, represents an attack on the heretofore highly protected and privileged doctor-patient relationship.  As Virginia Hood, president of The American College of Physicians put it,  ”This issue is much bigger than guns, it is about whether the government or any other body should be allowed to tell physicians what they can and can’t discuss with their patients.”

Crimes against humanity

(http://www NULL.jamesloganmd NULL.com/wordpress/wp-content/uploads/2011/06/Muammar_al-Gaddafi NULL.jpg)The International Criminal Court (ICC) issued a warrant for the arrest of Muammar Gadaffi today. What’s the charge, you ask? What is the charge always against these brutal dictators? Crimes against humanity, of course! Always crimes against humanity. In fact, I’m not sure the ICC has ever prosecuted anyone for anything other than a crime against humanity.

I imagine it would be flattering, in a way, to be wanted for crimes against humanity. You have to have really made something of yourself in life to even be in a position to commit a crime against humanity, let alone crimes. I, for example, could certainly committ a crime against a person. Or, perhaps even multiple people. But, I’d basically be committing them one by one and would take ages to count as a crime against humanity. Bernie Madoff’s crimes were committed against thousands of people and yet even he isn’t honored with the distinction of having committed a crime against humanity.

What’s a proper punishment for someone who’s committed crimes against humanity, anyway? Death? I would say they should at least spend the rest of their lives in prison. You really can’t rehabilitate those who commit crimes against humanity. You let these people back out on the street, they’ll j (http://www NULL.jamesloganmd NULL.com/wordpress/wp-content/uploads/2011/06/john_waters NULL.png)ust be committing more crimes against humanity, more genocide, more rape as a weapon of war, more violent crackdowns on innocent protesters.  I hope they catch him before we…wait a second, aren’t we already trying to kill Gaddafi?  We’ve been bombing Libya for over a month.  Don’t we need a warrant for that, or something?

Speaking of crimes against humanity, why hasn’t the ICC ever put John Waters on trial?

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.

Hello world!

Well, the decision-laden, anxiety-provoking, ulcer-causing process of switching over from moveable-type to wordpress is now done.  There’s more work to be done, but the rest is fun.  Check back frequently as jamesloganmd.com will be adding regular content and will be in flux for the next few weeks.

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!