Category Archives: Opinion

Feedback from between her legs (cont)

July 28, 2010 – 1:33 PM

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.

James Logan, M.D. |

No Comments

Refusal of VBAC

May 18, 2010 – 12:48 PM

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.

James Logan, M.D. |

No Comments

First do no harm

May 17, 2010 – 5:09 PM

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.

James Logan, M.D. |

No Comments

One question depression screen

May 14, 2010 – 1:36 PM

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.

James Logan, M.D. |

2 Comments

Medical madness: the preparticipation sports physical

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.

James Logan, M.D. |

No Comments

The squeeze

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?

James Logan, M.D. |

No Comments

ACGME and regulation of resident duty hours

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.

James Logan, M.D. |

No Comments