January 19, 2010 – 11:16 AM
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.
January 9, 2010 – 1:52 AM
jamesloganmd.com has officially become part of the healthcare bloggers' community. Check out the new badge!
December 30, 2009 – 11:23 PM
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?
November 9, 2009 – 2:46 PM
Thomas Nasca, CEO of the accreditation council for GME published, on October 28, 2009, an open letter to the medical community. It details the findings of a 16 member ACGME task force regarding the effect that limiting resident work hours has had on medical professionalism. Thanks to DB for bringing it to my attention.
My problems with this letter are severalfold, but can mainly be distilled down to the following. Dr. Nasca would seem to suggest that it is ACGME's belief that medical professionals, bound as we are by the oath of Hippocrates and motivated as we are by altruism, should not be held to the same standard as other industries when it comes to safety and work hour regulations.
Thus, while residents must not be forced to remain on duty for excessive periods, they must not be precluded from demonstrating the caring and commitment required of them as altruistic professionals. ACGME's standards, and the expectations of the public of the nature of enforcement of those standards, must match this important principle. It is here, as in other places, that the analogy with the airline industry fails. A pilot, running out of hours, can refuse to fly the plane, and the passengers are no worse off for the decision, other than the delay. The Neurosurgeon, faced with a patient requiring an emergency craniotomy, does not see an option to, nor does he or she want to say no. The patient struck by a car, with multiple trauma, acute rhabdomyolysis with hyperkalemia and acute renal failure, needs dialysis now, not after the Nephrologist has slept for five hours. The patient needs and demands no less, as does our vow of Hippocrates.
I vehemently, though respectfully, disagree, Dr. Nasca. It is here that the analogy to the airline industry is more appropriate than ever. No more is it ok for a pilot - who is responsible for over a hundered lives - to violate his work hour restrictions than it is for a neurosurgeon who has been awake for 14 hours to perform an emergency craniotomy despite the fact that it is only one life that is at stake. Taking care of patient needs in violation of duty hour restrictions is not the hallmark of professionalism. Quite the contrary. Lack of adherence to standards that are put into place for the explicit purpose of protecting patient safety is irresponsible and clearly unprofessional
Within the boundaries of reasonableness, and with a goal of patient safety, residents must demonstrate willingness to sacrifice for their patients' needs, being taught and given the opportunity to demonstrate the practical manifestations of altruism, the core virtue undergirding professionalism.
In this case, Dr. Nasca, I will vehemently and disrespectfully disagree by referring the above quoted text as 'BULLSHIT!' As professionals, it is not our job to "sacrifice" for our patients - unless you're referring to the whole enterprise of being a doctor as "sacrifice." On the contrary, it our mandate as professionals to remove ourselves from situations in which our own well being has the potential to come into conflict with that of our patients - just as any professional in any other industry should recognize when his or her interests come into conflict with the interests of those whom he or she is purported to serve. I don't know about you, but I don't want my doctor to be in any situation in which he may have to choose between my well being and his own.
I think the medical profession is going to continue to struggle with this issue until there is some kind of cultural shift toward a more rational conception of the doctor-patient relationship.
November 4, 2009 – 4:50 PM
The 45 year old man who met my gaze as I walked into the exam room smiled and, at least on first glance, appeared to be relatively healthy. When there is a patient on your schedule listed as "routine health maintenance exam," it's hard to know what to expect. Immediately upon entering, however, you can often gauge about how long your visit is going to take. If it's a 22 year old female who's not obese and looks pretty normal, then you can expect to do a pap smear, some contraceptive counseling - done. If it's an 85 year old man in a power chair who's here with his caregiver and sporting a bulge under his shirt suggestive of a nephrostomy tube, you can expect to be running behind for the rest of the day.
"Hello, Mr. Brazil, I'm Dr. Logan," I offered my hand in greeting. "This is one of our medical students who is working with me today."
"Hi!" Jill smiled brightly and waved.
"Um," Mr. Brazil eyed the attractive 24 year old medical student uneasily, "Would it be ok if I just talked to you today?"
"Sure, no problem at all." I shewed Jill out of the room. "What can I do for you today?"
"Well, I've been noticing over the past several months that my penis has been getting more and more crooked."
"Crooked?"
"Yes."
"How do you mean?" I asked.
At that point, the patient lowered his pants to reveal a circumcised penis that was normal in every way except that it made a nearly 90 degree turn midway through and pointed to the patient's right.
After a bit of research and after talking it over with my supervisor, I went back to see the patient.
"I'm going to give you a referral to urology. There may be some treatment options available but, if none of them are helpful, the definitive management for this condition is surgery to release some of the connective tissue surrounding your penis."
"Surgery?" The patient appeared to turn a light shade of green at the thought of his penis being flayed open and I can't say I blamed him. "Is there anything else I can do in the meantime?"
"Well," I mused, "Are you right or left handed?"
"Right handed."
"I thought so. I would say, in the meantime, try masturbating with your left hand. See if things improve. Either way, I'll go ahead and put in the urology referral."
I must confess, I haven't looked at the literature on this - not even sure if there is any. Would any urologists who may read this care to comment on whether there is an association between Peyronie's disease and which hand a patient masturbates with? Could be a good research project.
October 12, 2009 – 10:16 PM
Mr Paul Lewis's elbow had been swollen for the past month when he fell backward and landed on it while walking his dog. Multiple joint aspirations hadn't shown any evidence of infection or any crystals to suggest he had gout. What they did show was blood. He had lots of blood in that joint and a subsequent MRI showing what the radiologist called "extensively destructive arthropathy," which means that he had all kinds of badness going on inside that elbow. As part of the work-up, our attending suggested we get a rheumatoid factor.
Seriously? A rheumatoid factor? In a patient with an acute problem in a single joint following a traumatic event? And if the rheumatoid factor is positive, we're going to do what exactly - start him on some NSAID's and possibly methotrexate and hope he gets better?
The doctor in the example above is double boarded in internal medicine and neurology and was covering our inpatient service for the week. He really is quite knowledgeable. He's the guy that you want taking care of you if you have diabetes concurrent with poorly controlled seizure disorder. Bone and joint issues...not so much his thing.
I struggle on a daily basis to delineate those facts that I should absolutely know in order to consider myself a competent family physician from those facts which I absolutely do not need to know - to figure out during which lectures I need to perk up and during which lectures I can plug my ears and yell, "la la la la la." This is quite a bit more difficult than one would think. Nearly everything written in every medical textbook or journal from any specialty is potentially relevant to family medicine. But, even the very best family docs are only familiar with a small portion of this information. In fact, those in our field who have attained the highest levels of prestige and stature (program directors, department chairs, etc) often are the most actively involved in research and therefore have only mastered a relatively smaller portion of medicine as they've had to devote more time to learning fewer topics, albeit in greater detail.
So, is the guy who thinks you need to get a rheumatoid factor on someone with an obvious hemarthrosis competent? Every physician has gaps in his or her knowledge. If I graduate from residency with as much knowledge of psychiatry as our obstetrically trained faculty and as much knowledge OB as our sports medicine faculty and as much knowledge pediatrics as the guy who only does adult inpatient medicine, will I be competent? I certainly hope so, because there isn't a doctor alive who knows as much OB as an OBGYN and as much psych as a psychiatrist and as much peds as a pediatrician and as much about your teeth as a dentist etc. Yet, in family medicen, we're supposed to know about all of these things. The question is, how much? Where can we stop? Since the very start of my medical career I have been searching for this minimum standard for what it means to be competent. Does passing your boards make you competent? Nah, I think there are plenty of incompetent physicians who've managed to pass their boards. The only standard I've found so far is that you are competent until you start doing too many things that embarrass your colleagues. And that's no kind of standard.
August 28, 2009 – 11:35 PM
Acting on the results of a recent study which suggests that nearly 2/3 of people with gender identity disorder go undiagnosed, the American Psychiatric Association has recommended routine screening for this condition.
Gender identity disorder, or GID, is characterized by strong and persistent cross-gender identification and persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender-role of that sex. These symptoms often cause significant impairment in social functioning and lead to disastrous wardrobe, make-up and hairstyling choices in patients who do not receive proper counseling.
According to Gail Silverman, APA spokesperson and lead author of the study, "We are just now learning that millions of people suffer needlessly due to GID. When there are effective treatments available such as hormone therapy and, ultimately, anatomy-altering surgery, it's simply unconscionable that we allow so many to go undiagnosed." Dr. Silverman also cited lack of reimbursement as a major barrier to individuals with GID getting help. Currently, less than 1 in 10 insurance providers will cover gender identity services and individuals who do receive treatment - which are now believed to represent less than 30% of those affected with the disorder - can incur out-of-pocket expenses reaching tens of thousands of dollars.
The APA will recommend a list of screening questions to identify those who are at risk for GID which can be remembered using the mnemonic "TRANS." It is recommended that all patients screened at routine intervals.
- Thoughts - Have you ever thought about what it would be like to be the opposite gender?
- wRong - Have you ever felt like you were born the wrong gender?
- Anatomy - Are you distressed by your own primary and secondary sexual characteristics?
- Nervous - Does dressing as your assigned gender make you uncomfortable?
- tranS Sexual - Have you ever gone to see Rocky Horror Picture Show?
Opponents of the new guidelines argue that there is not yet enough data to properly evaluate outcomes for individuals receiving treatment. Psychiatrist Harry Seeward today was quoted as saying, "With the enormous technical obstacles we continue face in the phalloplasty procedure, our efforts must first focus on designing a better penis before we can reap the benefits of early diagnosis of GID."
