Those who follow me on Twitter know that I went to the beach to give a talk this week. On the trip down (4.5 hours) and back I listened to my trusty IPod Nano. While at the beach I took a first listen to Wilco (The Album).

These were the key observations from all that listening.

Wilco (The Album) – for sale this coming Tuesday – if you are a Wilco fan you have probably found the First Listen stream on NPR All Songs Considered. If you are like me, you are smiling. Jeff Tweedy is a genius. This might not be their best CD, but I think it will be highly ranked.

Veckatimest – Grizzly Bear – I had heard of this group, but had not really listened to them. My son, he of great musical taste, told me that I had to check it out. Wow! The songs grab you with their beauty and complexity. They are inventive, musical and have gorgeous voices. Read this review – Veckatimest. I will warn you that this music is complex and not related to top 40 pop.

The Seldom Seen Kid – Elbow – I had this CD on heavy rotation about 6 months ago but had forgotten it. On Wednesday night I was watching a music station and saw them perform One Day Like This. I really enjoyed the performance, and while driving remembered to listen to the CD again. I found myself singing along on at least 4 of the songs. Here is a good review – The Seldom Seen Kid

That Lonesome Song – Jamey Johnson – I rarely listen to Country – and this is country. Jamey Johnson has a classic country voice and tells stories that you know – but you still smile the way he tells the story. Only a country singer could write:

I tell you
The high cost of livin’
Ain’t nothing like the cost of livin’ high

These were the top 4. I am also listening to Merriweather Post Pavilion by Animal Collective – have not listened enough to be certain – but certainly beautiful thus far. I listened to Sophie Milman – Take Love Easy – great young female jazz singer.

Listening to Wilco while writing this post – they are really good.

My son has joined the world of blogging.  He blogs about urban planning and the economy.  I highly recommend this thought-provoking piece he wrote this week – Where is the pie?  It has nothing to do with medicine directly, but health care is part of the pie.

No, you have not stumbled onto the wrong blog.  Last night we had dinner with 2 other couples.  On the drive to the restaurant we were discussing the financial collapse.  One friend, a successful businessman, recommended this article.  I had heard of Liar’s Poker, and actually had heard of this article.  Having just read it, I highly recommend it for anyone who wants to understand.

The End of Wall Street

Then came Meredith Whitney with news. Whitney was an obscure analyst of financial firms for Oppenheimer Securities who, on October 31, 2007, ceased to be obscure. On that day, she predicted that Citigroup had so mismanaged its affairs that it would need to slash its dividend or go bust. It’s never entirely clear on any given day what causes what in the stock market, but it was pretty obvious that on October 31, Meredith Whitney caused the market in financial stocks to crash. By the end of the trading day, a woman whom basically no one had ever heard of had shaved $369 billion off the value of financial firms in the market. Four days later, Citigroup’s C.E.O., Chuck Prince, resigned. In January, Citigroup slashed its dividend.

From that moment, Whitney became E.F. Hutton: When she spoke, people listened. Her message was clear. If you want to know what these Wall Street firms are really worth, take a hard look at the crappy assets they bought with huge sums of ­borrowed money, and imagine what they’d fetch in a fire sale. The vast assemblages of highly paid people inside the firms were essentially worth nothing. For better than a year now, Whitney has responded to the claims by bankers and brokers that they had put their problems behind them with this write-down or that capital raise with a claim of her own: You’re wrong. You’re still not facing up to how badly you have mismanaged your business.

Fascinating and scary reading. 

I am going way outside my comfort zone in this rant.  If I make a fool of myself, please tell me.

Like many Americans I am fascinated with the Obama/Clinton competition.  I have temporarily switched from Mike and Mike in the morning to Morning Joe.  In watching this ongoing contest, I have my own theory.  I suspect that my theory is just as accurate as all the talking heads on TV and radio.  Afterall, I have no qualification for understanding politics, which makes my opinion so worthless.

When I see the Barack Obama campaign I see a campaign which primarily focuses on leadership.  He sells himself as an inspirational leader.  He displays charisma, and captivates with oratory.  Many voters want to follow him, because they trust that he will lead them.

When I watch Hillary Clinton I see a technocrat.  She proclaims that she has solutions.  She can fix our problems.  She implies that she knows what is best for us, even if we disagree.

Watch their body language.  He stands tall, and has an easy smile.  He displays passion but always with grace.

Warning – I know that this may read as sexist!

When I watch Hillary (without the sound) she reminds me of a middle school teacher who is trying to intimidate the class into behaving properly.  She points at us.  She shakes her head, suggesting that we really do not understand as much as she does.

The Clinton campaign wants to feature her legislative achievements.  She apparently knows how to get things done.

She and her campaign are missing the point.  I suspect they will never understand, because they are micromanagers.  They want to manage health care, the economy, education, …

Men have a negative reaction to her campaign.  She has a serious gender gap problem, because she stimulates adolescent memories of female teachers (I am really stretching here, but my gut suggests that I am in the right ballpark.)

As I consider academic medicine and especially ward attending rounds, which candidate would likely run better rounds.  We know (from our own research) that residents resent micromanagement.  They want leadership; they value management; but they resent being told what to do.  They work best when the leader helps them find the right path, not when they are made to follow a path.

I do know a lot about attending rounds, and I know little about politics.  My observations have coalesced over the past week.  I find this struggle fascinating, so like most observers I strive to understand.

My experience with learners is that they do not want solutions, they want direction.  They prefer to work towards their solutions.  Maybe this observation fits the primary race.

I live in a suburb of Birmingham. When I moved to Alabama, I remember the looks that I received from friends and colleagues. I often joke (but as most jokes understand the underlying truth) that prejudice against Alabama is the only politically correct prejudice in the US.

This article makes me very happy. My experience in Alabama over the past 14 years has been very positive. This article should make everyone smile.

‘Mockingbird’ School Drama Bridges Gaps

A high school play based on Harper Lee’s classic ”To Kill a Mockingbird” brought together black and white high school students to tell the classic story of racial injustice — and even drew out the novel’s reclusive author.

Wednesday night’s invitation-only performance was organized to celebrate diversity and arts education in Alabama, the home state of the novel’s author, whose book and the movie made from it won immediate acclaim at a time when Alabama was still rigidly segregated.

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The two public schools near Birmingham are only about 16 miles apart. But Mountain Brook is one of the state’s wealthiest communities, with a median home price of about $300,000, while the same figure in Fairfield is about $68,000.

Mountain Brook High draws from an overwhelmingly white suburb, while Fairfield students are from a mostly black district.

The performance has helped the students transcend not only the 30-minute distance between their communities, but a cultural divide as well. Teens who were strangers this time last year are spending hours on the phone, sending each other multiple text messages per day and chatting on the Internet networking site Facebook.

Just a very happy story – no medicine – just good feelings.

While this is generally a medical blog, today I veer. During a recent visit to my parents house, my mother gave me a copy of a program from a concert celebrating my greatgrandfather’s 70th birthday.

Mostly for myself and my family, I publish the text of that program.

Mordechai Golinkin’s life has been bound with one dominating idea; the vision of an opera in Palestine. It is no exaggeration to state that the story of his life in the past quarter-century is the history of opera in Palestine. He was a pioneer in the full sense of the word, having created something dynamic from a void.

His struggle for an opera in Palestine commenced in fact more than two score years ago, when he first began to dream of establishing a Citadel of Art in the Holy Land. But July 26, 1923, the date of the initial opera premiere in Palestine, marks the first milestone in the history of Palestine opera. The way from there was no path of roses. It was punctuated with moments of sweet satisfaction and bitter disappointment. But through the vicissitudes, Golinkin bore the torch steadfastly toward the goal.
Golinkin’s career from his boyhood in the Russian hamlet of Izlotschistaya in the Province of Cherson was that of a restless Jewish artist. As a cherubic choir boy at the age of ten, synagogue hymns evoked in him a yearning for broader and more comprehensive art. Later, as a mature artist, music showed him the way back to his people. His arrival in Palestine bolstered his faith in the ultimate establishment of his projected Citadel of Art, and he dedicated himself to that idea with steadfast devotion.

His rise in the Russian musical orbit was rapid. After completing his studies in Warsaw under Roguski, the theorist, and Nosokowski, the composer, Golinkin returned to Russia and devoted his talents to opera. Advancement from assistant choir leader in Razan to &e conductorship of the “Marinskaya Opera” in Petrograd was obviously fraught with pitfalls, but Golinkin took it all in his stride. Opportunity knocked at his door one night in Rostov when an adventure-loving conductor went out on a spree a few minutes before curtain time. The distressed managers appealed to the deputy director to fill the breach, and Golinkin stepped to the podium. His success was immediate and sensational, and from then on he marched from achievement to achievement.

Nevertheless; the crowning recognition was withheld from him. He was not granted an invitation to appear in the Czar’s Royal Marinskaya Opera in Petrograd. The obstruction was Golinkin’s faith. In vain, friends of the conductor including the great Chaliapin interceded on his behalf for six years.

After the revolution, however, Golinkin was promptly invited to mount the podium which was the ultimate goal not only for Russian musicians but that of artists from all Europe.

Golinkin’s success confronted him with a dilemma. The bond between the musician and the Zionist movement had already been forged. In 1917, he wrote an essay on “Citadel of Art in Palestine’ and organized a benelt soiree in Petrograd where Schaliapin rendered his unforgettable recital of “Hatikva” in Hebrew. While he won fame and laurels as a brilliant conductor, his soul continued to be stirred by the vision of a great opera company in Palestine. He had under his baton the Petro grad Opera with 120 musicians, the greatest vocalists in the world, thousands of ballerinas and choral singers, while all Palestine had to offer was a dozen pupils of Mr. Hopenko’s “Shulamith” Conservatoire, a few experienced singers working in the fields and roads, but no hall, no facilities, no tradition.

But Golinkin made his choice. In May 1923, he came to Palestine. In September he conducted “I1 Traviate”. His opera developed and he was acclaimed as a pioneer who had come to lay the foundation or art and culture in Palestine. He produced “Aida”, “Hugenots”, “Othello”, “Troubador”, “Romeo and Juliet”, “Rusalka”, “Rigoletto”, “Carmen”, “La Juive”, “Samson and Delilah”, “The Barber of Seville” etc.

Golinkin regarded his production of European operas in Palestine as a mere phase. His aim was to introduce an atmosphere and to evolve a tradition in order to conceive an original Hebrew opera. He proceeded with his plans for a great Citadel of Art which would meet not only the requirements for the development of culture, but would also create the answer to artists’ social problems.

Another matter which concerned Golinkin was the social status of artists. IN his Citadel of Art scheme, he provided for social betterment for artists no less than for the advancement of culture. To collect funds for his venture, he toured the United States between 1927 and 1929. Difficult times in Palestine and economic depression hindered the Maestro. There is still no home for opera or symphonic music in Palestine. But Golinkin still believes that the day will come when his dreams are realized.

At seventy, Golinkin is still vigorous and is fired with the same zeal, enthusiasm, and faith which marked his pioneering work in the past two score years. Now that the star of music and art in Palestine has risen, the country’s culture lovers will join in celebrating the occasion, which is indeed not a personal one but of national significance.

My greatgrandfather’s dream lives on – The history of the New Israeli Opera

Thanks for indulging a greatgrandson kvelling

Yesterday I cited a NY Times essay on the messiness of patient care – It ain’t always pretty

At the time, I knew that I wanted to comment, but struggled, so I delayed.

Later that day I wrote the piece on clinical judgment. Last night as I pondered these two posts, I realized how interrelated they are.

One way to think of the diagnostic process comes from mystery novels. Excellent mystery novels confuse you because the clues are there but buried amongst many “red herrings”. Thinking clearly about which clues are relevant and which clues can be ignored is the challenge for the detective.

The same is true in medicine. As Dr. Zuger describes brilliantly, patient stories are not linear, laboratory data come back in confusing fashion, and imaging studies do not always occur in a timely fashion.

Our documentation rarely reflects the true messiness of patient care. We document to meet financial imperative and to communicate important information.

Messiness defines the challenge of medicine. Performance indicators do not account for messiness.

Our challenge is to live in a world of messiness and yet provide reasonable order. This challenge we relish.

I have decided to revamp the look of my blog. I guess this is a bit like changing ties.

Please note that you have control over the colors used with this new theme. I have switched to a 2 column theme to make the look a bit cleaner.

I hope you like these changes, but please let me know if you see any problems.

As always thanks for reading.

Over the past year, I have thought extensively about the concept of quality health care. I have participated in research designed to measure one aspect of quality, i.e., adherence to known quality indicators.

Examples of this version of quality include:
• Foot exam in diabetes mellitus
• Aspirin for patients with known CAD
• Colon cancer screening in patients above age 50
• ACE inhibitor (or ARB) in diabetes patients with proteinuria

To use a philosophical term, the above examples are necessary but not sufficient. Checking the boxes of the quality scorecard is useful, but does not define a high quality physician.

The competency that I worry about the most is clinical judgment. I fear that clinical judgment remains (and will remain) difficult to define and therefore even more difficult to measure.

Some commentors have suggested that competency measures are easy – just measure outcomes. Now this might work in subspecialties where one sees the same diagnosis repeatedly. This certainly would work for a cardiovascular surgeon who only does CABG procedures. This certainly would work for an interventional cardiologist.

But I am not concerned about subspecialists. I worry about specialists – general internists and family physicians. We live in a different world. We see undifferentiated patients, with undifferentiated complaints, and our job is to achieve differentiation. We live in a world of vague or common symptoms. We live in a world of causal comments that we must recognize as clues to follow.

At this risk of seeming self serving I will briefly present 3 patients in whom clinical judgment made a major difference. Now clearly I have picked patients for whom I made the right diagnosis. The point here is not the diagnosis, but rather the clinical judgment involved in getting to the answer – and the answer matters in all three cases.

#1

A 52 woman came to my office for investigation of abdominal pain. Her internist (my resident when I was an intern) asked me for a second opinion.

The patient had had severe (8/10) LUQ pain for 2 months. Extensive investigations including UGI, CT of the abdomen and colonoscopy had shown no abnormalities. Multiple laboratory tests had normal results.

She had a history of Type II Diabetes Mellitus for 15 years. On questioning, she said that she had a similar pain in the RUQ 3 years ago. At that time, testing showed no abnormalities, her doctor blamed depression and treated her with tricyclic antidepressants – with a slow resolution.

On examination, I noted that she had surface pain in a dermatomal pattern over the LUQ. She had no deep pain.

As I considered her problem, I considered the possibility of herpes zoster (shingles) with a rash. Then I wondered if diabetic neuropathy could present like this. I ordered nerve conduction tests and proved a diagnosis that I not previously known – Diabetic truncal radiculoneuropathy. For a good review of diabetic neuropathies – THE DIABETIC NEUROPATHIES: TYPES, DIAGNOSIS AND MANAGEMENT

The point! By carefully considering the patient’s complaint and physical exam – I avoided more expensive imaging studies. I made a correct (albeit rather unusual) diagnosis. This diagnosis led to appropriate treatment and the patient recovered over the next 3 months.

#2

A 57 yo executive secretary came to my office for spells. She described 7 episodes over the past 6 months – one a month until the previous month during which she had 2.

The spells caused great physical and emotional distress. She stated that she would feel ill and her pulse would go up to 150 (she recounted measuring her pulse precisely). The spells lasted approximately 15 minutes, after which she felt drained. She had had spells during the day, at work, at home and in the evening – no obvious inciting events.

After the 3rd episode she saw a cardiologist who ordered an echocardiogram and a stress test – both of which were normal – and told her that the spells were “in her head”. As she recounted the story, I could feel her frustration.

I ordered a loop monitor, which the patient wore for the next 2 months without any further spells (perhaps a therapeutic loop monitor). I was convinced that she had PSVT (paroxysmal supraventricular tachycardia), but I could not prove it.

So I told her that when her next episode occurred to immediately get to the ER and get an EKG. She lived in a very small town and was always within 5 minutes of the ER.

2 months later I received a faxed EKG confirming my suspicions. I referred her to an electrophysiologist who performed a radiofrequency ablation. Two years later she had no recurrences.

The point! The patient gave a clear history – virtually pathognomic for her eventual diagnosis. My job was to persist until we could confirm the diagnosis. However, many such patients have their symptoms dismissed as psychological.

#3

A 64 yo veteran was admitted to my service for chest pain. The housestaff presented his story on rounds, and reported that he was scheduled for a sestamibi stress test later that morning. They reported on his risk factors, and had prescribed all the correct medications.

However, when I went to the bedside, I asked the patient what was bothering him, and he immediately complained of RUQ pain. He related a 2 month history of progressive RUQ abdominal pain. He denied a relation to eating. He admitted to a brief episode of chest pain the previous day, but minimized that pain compared to the RUQ pain. On exam he had a positive Murphy’s sign.

I ordered a RUQ ultrasound for that day, and assumed that he had gallbladder disease causing his abdominal pain (and probably his “chest pain”).

Later that day, radiology called to let me know that he had a liver mass – suggesting that he needed an abdominal CT. We had that test the next day – and they again called to tell me that he had a liver abscess. Now most clinicians joke that the national plant of radiology is the hedge, and yet these radiologists did not equivocate – they called it an abscess.

Liver abscesses are rare in the US. Over the next few days the patient developed a fever and an elevated white count. As this occured around Christmas (several years ago), we struggled to get the abscess drained. Surgery wanted interventional radiology (IR) to drain the abscess, and IR said that they could not drain the abscess because of location. We persisted and eventually got surgery to do an open drainage of a large staph abscess. The patient had a successful recovery.

The point! Rather than focusing on the initial complaint and reason for admission, I listened to the patient and proceeded in a linear fashion towards the correct diagnosis. Making that diagnosis may well have saved that patient’s life.

Now I have told you my successes. Like all physicians I have failures. My clinical judgment is good, but even the best make mistakes, because clinical judgment is difficult.

I submit that clinical judgment – making the correct diagnosis, ordering the correct tests or the correct antibiotics – is the key competency for generalist physicians We must note the clues, sorting through the false alarms to find those complaints which need evaluation.

Yet how does one measure this. Perhaps clinical judgment is like pornography. As Justice Potter Stewart once said “I shall not today attempt further to define the kinds of material [pornography] . . . but I know it when I see it.” And yet this seems unsatisfactory.

I do not believe that we assess clincial judgment well, because it requires so many skills and situations to truly demonstrated. Clinical judgment is nuanced. The best physicians note subtle details or inconsistencies to reach a good judgment. I believe this is a difficult process to evaluate.

And yet, I reassert that it is the most important process for physicians. As physicians we must make judgments daily, hourly and multiple times with each patient. These judgments matter, and thus we should emphasize clinical judgment in our training and our assessment.

As the quality movement grows, I fear that it could minimize our focus on judgment. If that is true, then we may harm health care rather than improve health care. Our quest for quality should not ignore other concerns in health care.

HL Mencken (although perhaps a despicable human being) has that wonderful quote –

For every complex problem, there is a solution that is simple, neat, and wrong.

Perhaps this applies to the quality movement.

Cleaning Up the Mess of Medicine in the Pages of Posterity

As I headed up to the laboratory to deliver our hard-won tubes, it occurred to me that in the event our patient proved to have some unusual infection and we wrote up his case for a medical journal, the last surreal 30 minutes would be immortalized in print as follows: “Cultures were obtained.”

Medicine has two faces: the iodine-stained, glass-splintered messy reality we all work in, and the clean, quiet, dignified prose we use to record it for posterity. No absence of order penetrates our documents of record. The journals’ glossy pages – or, now, neat online screens – are serene and pristine, rational and assured. Every study has a conclusion. Every case has a diagnosis. Every necessary test is performed, without fuss or muss.

If there has been any drama finding a vein, or cajoling a claustrophobic patient into the M.R.I. scanner, or debating a practicing pagan who is refusing his blood tests because the moon is waxing gibbous, you certainly aren’t going to read about it in the literature. Yet, it all happens, all of that and more.

Back in my days of predawn shivering, I figured that once training was over, life would become as orderly as it was in the journals. It was a delusion born of sleeplessness: medical reality always diverges wildly from the printed record. Drugs often don’t behave the way they do in studies, and patients almost never do. Labs make mistakes. There is an unending parade of problems for which the received wisdom holds no answers.

Sometimes I think the oasis of the medical library should be maintained as a pleasant and essential refuge, mirage though it may be. Loose ends are all neatly tied there, and every chart flows nicely down the page. Like the mythic Jerusalem, city on the hill, it inspires us all.

Sometimes I think it’s a disgrace and a lie. Why not tell it the way it is, for a change? Let journals immortalize all the messes and foul-ups in print, the spurious lab results, the problems that never get solved or the ones that seem to solve themselves despite us.