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.
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.”
(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?
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.
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.
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.
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!
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.
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.