James Logan, M.D.

Feedback from between her legs (cont)

2010-07-28T20:33:29Z

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"

2010-06-22T08:46:13Z

The "Rape Axe," 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

2010-06-02T22:04:15Z

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.

Refusal of VBAC

2010-05-18T19:48:20Z

I realize that ton has been written on the subject of whether or when to offer a vaginal birth after cesarean section (VBAC). The NIH recently released a consensus statement on VBAC. For readers who are unfamiliar with the subject, women who have previously delivered a baby via c-section have a roughly 1% risk of their uterus rupturing if they are allowed to labor during subsequent deliveries. As uterine rupture is a potentially catastrophic event, elective c-section is offered to all women who have had a previous c-section. Some hospitals go even farther and refuse to deliver vaginally any woman with a history of a previous c-section. The long and short of the matter is, they can't do this. The International Cesarean Awareness Network has a pretty good Q and A for women with a previous cesarean who find themselves wanting to deliver vaginally at a hospital that "won't let them."

The question of whether or not to "offer VBAC" is one about which there seems to be little clarity. The bottom line is that doctors cannot refuse to offer VBAC because VBAC is not intervention. VBAC is what happens when doctors don't intervene. Doctors are free to recommend strongly against VBAC. Certain patients, particularly those whose c-section was due to arrest of labor and those who have vertical scars on their uterus, are bad candidates for VBAC. But VBAC is simply not in your doctor's toolbox of things to offer. Your doctor can either offer of decline to offer things like medications, tests, minor procedures and surgery. He or she can't "offer" a VBAC. VBAC is what happens when the patient declines her doctor's offer of a repeat c-section. I suppose if a woman presents in active labor and declines a repeat c-section, her doctor could say, "I'm sorry, I'm not comfortable managing this condition." They then have the choice of either kicking their patient to the curb or transfering her to the University Hospital, which does offer VBAC's but which is also 90 miles away. But this, of course, is nonsense as it would clearly expose them to more risk than simply managing a vaginal trial of labor.

Bottom line: there is no such thing as a refusal of VBAC.

First do no harm

2010-05-18T00:09:18Z

I was looking back at an old postand happened to read this comment. In response, I wrote the following:

Thanks for the thoughtful response to my post, Parlancheq. You wrote it almost a year ago and I just happened to read it today :) Although I respectfully disagree with what you have to say, the one thing I will respond to is what you say at the end, "It seems docs should err on the side of screening rather than not screening." If this blog has any mission at all in life, it's to convince people that this is absolutely incorrect thinking. When there is no evidence to direct us one way or the other, doctors should err on the side of NOT screening. First do no harm, right? Do we believe this anymore? Every time we screen for something, we are giving ourselves an opportunity to intervene. And every time we intervene, we are giving ourselves an opportunity to harm our patients. First do no harm.

I thought it deserved to be its own post.

One question depression screen

2010-05-14T20:36:17Z

Hopefully, readers of this blog clearly understand that I do not advocate screening for depression. But if you were going to screen your patient, you don't need a PHQ-9 or any other validated tool to do it. All you need is one question, "Are you depressed?" To be depressed is a completely nonspecific term which people use in a variety of different ways. But it is abolutely necessary for the diagnosis of, not just major depressive disorder, but of any sort of clinical disorder that includes depressed mood. Therefore, a denial of feeling depressed, rules out the disorder. An admission of "feeling depressed," however, does not mean that one has clinical depression, it just means you can't rule it out. In the case that the patient happens to answer, "Yes, I do feel depressed," then you need to ask more questions in order to make your assessment. Not that I advocate asking them in the first place; I don't. But if you insist on it, here's a way to make it easier.

Underground lair (part 2)

2010-05-05T08:13:02Z

BEEP! BEEP! BEEP
My pager had been quite all night. The sinking feeling that happens in the pit of your stomach whenever your pager goes off is typically pretty well ingrained after a week or two of intern year. And it's no wonder. Every time an intern's pager goes off, something bad inevitably happens:

BEEP! BEEP! BEEP -> Dr. Logan, there's a family member at the bedside of the cancer patient in Wonderland. They have questions and need you to come talk to them...(heart palpitations)
BEEP! BEEP! BEEP -> Dr. Logan, there's someone having trouble breathing in Purgatory. You need to talk to them, examine them, figure out what orders you need to write, write those orders and then write a 2-3 page note about them - hopefully finishing all of this before you get paged again. By the way, don't forget to go talk to the family member of that cancer patient when you're done...(heart palpitations)
BEEP! BEEP! BEEP -> Dr. Logan, there's a patient on the 8th floor of the Fog wing having chest pain. You need to go assess what's going on and maybe save her life. And you need to be pretty quick about it because there's still that patient in the ER and that family member waiting for you...(heart palpitations)

BEEP! BEEP! BEEP...(heart palpitations, in the absence of initial stimulus) I pick up the phone and dial a number I don't recognize.
ME: Hi. This is Dr. Logan, returning a page.
VOICE: (snorting and heavy breathing)
ME: Hello? (Dr. Logan wonders if he's just been paged by a wild boar)
VOICE: Hello.
ME: Who is this?
VOICE: (deep throated laughter) I'm surprised that you don't already know.
ME: What's this about?
VOICE: (chains clanking, snorts) We've met once before.
ME: You live under the hospital?
VOICE: (snorts now loader and shorter, more nearly resembling angry barks) I don't live under this hospital, I am this hospital. I am the irate family member in Wonderland; I am the old man who can't breathe in Purgatory; I am the diabetic lady having a heart attack on 8 Fog. It's all ME.

BEEP! BEEP! BEEP
I had set my pager to go off at 6am so I'd be able to get ready for 8am rounds. I recalled the events of the previous night:
1. Calmed a nervous daughter who demanded to know when her father with metastatic esophageal cancer and severe anemia secondary to a bleed at the surgical reanastamosis site was going to have radiation to the lesion in his brain.
2. Admitted a man with a COPD exacerbation.
3. Sent a woman with an ST elevation MI (heart attack) to the cardiac cath lab for emergency revascularization.
After that I had been able to sleep for about 45 minutes and seemed to recall having had the strangest dream. Upon getting home to my own bed in the late morning, I would halfway recall my attending having congratulated me for winning "...The battle."

Underground lair

2010-04-29T04:12:50Z

I just found out about a network of underground tunnels that connects the various buildings on the Medical Center campus to one another.

The pager had been quite all night. In order to break the monotony and do something good for my body, I decided to walk over to the Dark Tower section of the hospital. While most of our hospital is a sprawling mass of mismatched construction projects, each one successively glued to the previous one over the decades, the Dark Tower is the oldest and tallest part of the hospital standing at 17 stories. The seventeenth story of the Tower consists of offices and the two floors below that are filled with ICU and CCU beds. But, the family medicine service does occasionally have a patient on the fourteenth floor - DT 14, we call it. Whenever Dr. Hertz is on service, he insists on making the entire team climb the stairs up to the fourteenth floor. Then we listen to the sweaty intern try and present her patient.

"Mrs. Jameson is 49 year-(gasps for air)-old female who came in with 2 days of (gasps, puts hand on counter to steady herself) fevers, cough and (takes off her white coat panting heavily)..."

So, in the absence of pages, admissions or phone triage calls, I thought I'd get some exercise by taking the stairs up to the seventeenth floor and back down a few times. Our call room is on the 3rd floor of the Enchanted Wing. I walked over to the Dark tower, made the climb from DT 3 to DT 17 and then back down past DT 3 to DT 1 and down 2 more flights to DT Ground. At DT Ground, what I thought was the lowest level of the hospital, I noticed that the stairs continued downward. In order to make my climbing as continuous and uninterrupted as possible, I'd have to start my next run from the lowest level. So, past and unlocked wrought iron gate, I continued my descent. The stairwell had become noticeably cooler and the steps led me to a stone archway flanked by gargoyles holding torches. I couldn't see anything past the 2 gargoyles at the gate, only blackness. But, deep within the blackness I could hear what sounded like the heavy breathing and snorting of an animal. Then, a louder snort and the distinct clanking of chains being dragged along the ground. I listened at the blackness for 60 seconds as the clanking and snorting slowly but perceptibly increased in volume.

I took the stairs back up to DT 3, forgoing the remainder of my workout, and then made the walk back to the call room in the Enchanted Wing. I'm not exactly sure what I discovered down there. If tomorrow night is equally quiet, I may investigate further.

Vaccines

2010-04-28T05:22:09Z

I'm so disappointed in Frontline. I think this episode represents a deviation from their usually excellent reporting. The episode is entitled The Vaccine War. While they do come out on the side of vaccines being safe, it irritates me that they present the issue as if there are 2 sides to it. This is the the danger of reporting on issues where nut jobs like Jenny McCarthy have a substantial voice. Just because a particular group speaks loudly about an issue doesn't mean that their position has any merit. I think Frontline would've done better to have left this one alone.

For christ's sake, people, just vaccinate your kids. There are way more important things to burn calories worrying about than the theoretical risks of vaccines. On the flip side, these parents do have a point. We haven't seen a new case of polio in this country since the 1970's. So, chill out, medical profession. If some parents don't want to vaccinate their kids, we have more important things to worry about as well.

Empiric therapy

2010-04-22T07:19:23Z

In medicine, we have so few tools at our disposal which, just simply, work. More often, any new medical therapy or intervention requires a panel of experts to debate each other and to write long, boring papers about whether the slight improvement in mortality offered by the particular treatment outweighs the risks. This is less true of surgical and procedure-oriented medicine. Suturing, for example, just works. Suturing a wound stops the bleeding and brings the skin together. Done. Draining an abscess gets rid fo the infection. Done.

What about medical treatments? One category of medicines that fall clearly into this category are the inhaled beta-agonists (albuterol). Albuterol works. If someone is having brohchospasm and can't breathe, albuterol makes them better.

So, let's open it up for discussion. For anyone who reads this lonely blog, name one medical (not surgical) therapy which just works. Comments are open!

I'm on a horse

2010-03-11T17:20:25Z

I try to post unoriginal content as infrequently as possible. So, when I do find something that I just can't resist posting, you know it must be good.

Thanks, Shannon.

Stale parts of my brain

2010-03-10T18:49:57Z

Today I visited my blog for the first time in what seems like ages. I half expected my browser window to crack and crumble like stale bread as I scrolled through old entries. If I didn't know better, I would almost believe that much of this stuff was written by somebody else. It wasn't, I assure you. I don't claim any of what you read here to be factually true. But, it is all by a single author and all opinions represented here do represent those of said author.

On a vaguely related note, my brain's limited capacity to keep large amounts of information readily accessible has begun to bother me. It's not so much a matter of total memory storage. I have clear memories of what I ate for breakfast in third grade and the first long road trip our family took during the summer before first grade. Rather, it's a problem of accessing relevant information when I need it. I need more RAM. Take this blog, for example. I created this all myself. I didn't write the actual code or create the HTML doc's. Moveable type, sandbox and various other services were kind enough to do some free legwork for me. But I did put it all together and modify it to my liking. There was a time when I was quite proficient in HTML and web design. Today, I was lucky to remember how to get past the login screen let alone how I set the whole thing up. If something ever breaks, I'll be in trouble because I'm the only one (in theory) who knows how it all works.

Aside these frustrations, the reason this blog has languished is not because I've run out of things to say. Quite the contrary. Nor is it because I haven't had time to devote to writing; residency is actually treating me quite well in that respect. It's mainly just a matter of laziness. And I plan to stop being lazy very soon. Maybe even as soon as tomorrow. Or maybe next month :)

Medical madness: the preparticipation sports physical

2010-01-19T19:16:52Z

For clearance to participate in sports, The American Academy of Family Physicians recommends the following:

Athletes with a murmur that becomes softer with squatting or louder or longer with standing or during a Valsalva maneuver should be evaluated for hypertrophic cardiomyopathy and mitral valve prolapse.

For clearance to participate in sports, The American Academy of Family Physicians recommends against following:

Routine screening with noninvasive tests, such as echocardiography, exercise stress testing, and electrocardiography is not recommended

If this blog has one mission in life - besides to amuse and entertain - it is to prevent those in the medical profession from doing excess harm. Lord knows, there are plenty of people out there who would have been much better off had they never come in contact with the medical profession. As doctors, we can't always help people. But, at the very least, I think it is incumbent upon us to become proficient at not harming our patients. And, one of the best and easiest ways to prevent harm to our patients is to decline to screen them for things that they don't need to be screened for!

Whether or not we should screen for hypertrophic cardiomyopathy in order to prevent sudden death in young athletes is controversial. Currently, there is no evidence to support it, but more studies need to be done. HOWEVER, if there is no evidence to support routine screening with ECG or echo, then you can be damn well positive that there isn't any evidence to support routine screening with cardiac ascultation!

This happens rather frequently in medicine. I'm thinking particularly about the recent controversy over the new age recommendations for routine mammography. Whenever the evidence points us in a direction contrary to what health care professionals believe to be their beneficent duty, we end up with recommendations that simply don't make sense.

I've got to go to the local high school and do some sports physicals this afternoon.

Code of ethics

2010-01-09T09:52:54Z

jamesloganmd.com has officially become part of the healthcare bloggers' community. Check out the new badge!

The squeeze

2009-12-31T07:23:32Z

NBC will be airing a new reality show set in Cook County prison in which investigators probe innmates for information. A brief glimpse of prison life reminded of my former job as in OBGYN resident. There's a very real sense in which OBGYN, and most other surgical, residents are actually less free than prisoners. I think Cook County innmates have at least as much control over their day to day activities as I used to. Of course, they can't quit prison the way I quit my former residency program. Let's put it to a vote: assuming you would be finnancially set by the end without having to work another day in your life, would you rather spend 5 years in prison or 5 years in a surgical residency?