It ain’t always pretty – a recollection

2

Category : General, Medical Rants

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.

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WordPress upgrade

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Category : General

I have just upgraded my blogging software to WordPress 2.0 (from 1.5.1). If you notice any bugs, please contact me.

Thanks for reading.

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A medical student blogs about thinking as a physician

6

Category : General, Medical Rants

A Medical Mind (the link takes you to his entries – I am commenting on his Dec. 25th post).

The point is, I am sure that a barrier must be crossed to ‘know’ about patients and medicine and science, I am just a little unsure about when that will happen. I know that I have never really understood the science behind what my physician was saying to me, so I could never fully understand the complexities of each decision that he makes. However, when will that time come for me? I know everyone else thinks that time has already come – I can explain many things that they ask. However, when will I cross the barrier of knowledge?

As Anthony matures as a physician, he will face a major challenge. How do you as a physician explain diagnostic tests, treatments and diagnoses in terms that patients understand?

As physicians, we have an obligation to “break it down” into understandable terminology. I spend much time on rounds developing analogies of disease so that patients will understand what we mean.

A good exercise for medical students is to explain medical concepts to those who do not really know medicine. Practice on your friends (when they ask questions – nothing duller than a medical student talking about medicine when not asked). If you can explain things to them, then you will have an idea of how to explain things to patients.

Now for a quick practice session. Explain these 3 concepts in “laymen’s” terms.

Coronary artery stenting
Beta blockade
Osteoporosis and its treatments

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Another example of the importance of clinical judgement

1

Category : Clinical articles, General, Medical Rants

Medical decision making should never become formulaic. While I use, and have developed, clinical prediction rules, we must always remember that they are merely diagnostic or prognostic tests. Tests provide us some information, but we should always use them in the context of the patient in front of us.

Community acquired pneumonia-Pneumonia severity index falls short

…These AJM authors reviewed 3065 admissions in Edmonton with a diagnosis of CAP over a 2 year period. 586 (19.1%) were classified as “low risk” using the PSI. Was the hospitalization of ” low risk” patients a shameless, thoughtless waste of precious medical resources? Apparently not. Almost half ( 48.4%) were sick enough to be in the hospital for more than five days.19% suffered one or more complications and 31% were still unable to ear or drink to maintain hydration by the fifth hospital day. Clearly the admitting physician’s clinical judgment appropriately overruled the PSI score. Fine’s classification system keys to mortality rate.Those in risk classes I to III have a < 1 % mortality rate.The authors point out that the PSI does not work if the patient has COPD or pulmonary fibrosis or HIV infection or immuno suppression, etc. etc. and there are important prognostic factors not captured by the Fine index including nausea,shortness of breath and diarrhea . Their final sentence is: " It is clear that low-risk patients are a heterogenous group and that a low risk for mortality is not the only factor to be considered in admission decisions".Fortunately for a significant number of patients with CAP, the admitting physicians used what seems to often elude guidelines and algorithms namely clinical judgement...

Retired doc makes a most important point. Physician excellence is manifested by excellent clinical judgement. I know of no quality score which measures clinical judgement.

In taking with some faculty colleagues yesterday, I opined that the biggest difference between 1st and 3rd year residents was in their clinical judgement. That is what we teach during residency. All the faculty agreed enthusiastically.

Clinical judgment cannot be taught quickly. One must see many patients who do well, and many who do less well, to learn the difference. One learns clinical judgement over time.

The wise physician interprets all data in the context of the patient history and examination. This includes lab tests, imaging studies, biopsies and prediction rules.

I will rant more on clinical judgment in the near future. This is the essence of excellence. The mystery is how we might measure it.

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Primum non nocere

2

Category : Clinical articles, General, Medical Rants

Study of Heart Attacks Finds Risk in Use of Blood Thinners

Patients being treated for heart attacks involving narrowed arteries and clots that reduce blood flow to the heart are often given overdoses of powerful blood-thinning drugs in the emergency room, increasing their risk of serious bleeding, a study has found.

Excessive bleeding occurred at catheter sites, from existing stomach ulcers and in the brain, where it was particularly dangerous, said Dr. Karen Alexander, a researcher at Duke University and the lead author of the study, which is to be published Wednesday in The Journal of the American Medical Association.

Of 30,136 heart patients treated last year at 387 hospitals in the United States, 42 percent were given excessive doses of blood thinners. Those given extra amounts of two blood thinners – low molecular weight heparin and glycoprotein IIb/IIIa blockers, which are sometimes called super-aspirin – had about a 30 percent greater chance of major bleeding than those given the recommended dose.

The study suggests that 15 percent of the bleeding episodes were from overdoses and might have been avoidable.

All medications have risks and benefits. We should always strive to pick the right dose for any medication. While the emergency room can become hectic, each ER should have a method for insuring that patients get the right doses of medications.

Obviously anticoagulants epitomize the danger of overdosing. We know that whenever we prescribe an anticoagulant we increase bleeding risk. Physicians always “calculate” the potential benefit from anticoagulation and compare it with the potential risk.

This article should cause ER physicians to reassess their protocols for anticoagulation in heart attack patients. Or, if they have no protocols, then they should develop clear protocols with their cardiology colleagues.

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Might the retainer model have wider applicability?

8

Category : General, Medical Rants

Many physicians immediately recoil when they hear about the retainer model. They attack the physicians and use derogatory code words like boutique, justice, and two-tiered system.

However, one should always look beyond the surface to understand the good and bad in any situation. Perhaps the retainer model provides some solutions.

For those with AMA subscription – West Virginia looks at retainer model

The group is preparing a report for West Virginia Gov. Joe Manchin that offers several recommendations for addressing the health care needs of the uninsured. Among the suggestions is a three-year pilot program that is built on Dr. Wood’s retainer practice-supplemental insurance model.

Many legislators, after hearing Dr. Wood describe the program to them in testimony, compared his model to the way some coal miners received health care years ago. The workers actually would pay a set monthly rate for care from the mining company’s physician.

Dr. Wood’s model, however, was based more on costs than nostalgia. He started by offering the model to his own employees, which he said cut his own practice’s health care costs by more than 50%. He estimated a company could save about 30% in administrative fees by adopting his model.

Dr. Wood said his fees for patients would be $83 per month for an individual or $125 per month for a family. The pilot program, however, could vary depending on the services offered, he said.

“There would be no strict guidelines,” he said. “It’s going to be more wide open. Clinics can charge what they feel is appropriate.”

Questions from the panel about Dr. Wood’s model have centered on whether it’s fair to charge patients for services they might never use. Such issues will be considered while the panel comes up with its recommendations.

As I write consistently, our current system does not work well. Patients do not spend enough time with physicians.

We need a better model. The retainer model has some major advantages. Dr. Wood’s fees are much less than we pay for health insurance. It is conceivable that physicians participating in a retainer model could decrease health care costs by the amount they receive (or even more). Spending time with patients can decrease unnecessary testing. Physicians now default to ordering CT scans and MRIs to save time.

I hope that West Virginia tries this model. We need data to see the impact of such a model. Perhaps this model could change our concept of health care.

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The physician as detective

1

Category : General, Medical Rants

Frequent readers may remember that I love mysteries. I believe that accounts for my love of morning report and CPCs. Many general internists share this love for a genre which closely parallels our field.

For those with access – White coats and fingerprints: diagnostic reasoning in medicine and investigative methods of fictional detectives

Current trends toward routine mass use of sophisticated diagnostic tools is killing off the science and art of clinical reasoning. An ideal clinician would present a harmonic fusion of almost all the investigative methods of fictional detectives and avoid slavish adherence to protocols and procedures

Our underlying premise is that the current trend towards mass use of sophisticated diagnostic tools in routine practice—accompanied by a blind faith in technology and predefined diagnostic algorithms—is threatening to kill off the science and art of clinical reasoning. Besides burning a lot of public and private money to make diagnostic work rather superficial, doctors also risk losing the intellectual pleasure that comes from careful diagnostic reasoning.

Clinical analogies with detective fiction generally revolve around Sherlock Holmes.1 2 However, like medicine, detective fiction has subspecialties and intellectual trends.3 A rapid overview of the analogies between diagnostic reasoning and the investigative strategies found in detective literature may provide us with some clues on how to confront the problems posed by the burgeoning number of available technologies.

I disagree with the initial assessment because the authors leave out an important factor. No diagnostic test helps if we do not know to order the test. The intellectual challenge of internal medicine in 2005 remains active. Patients come in with vague complaints, which we must sort through using history and physical clues. These clues help us develop a differential diagnosis (a list of possibilities) which we can rank as to likelihood. Then, and only then, should we use technology to sort through the possibilities.

We could take everyone who comes in with vague complaints and order a “man scan” (the resident’s slang for total body CT scanning). But this strategy would yield too many red herrings, and still not find the underlying problem very often.

After the somewhat depressing introduction, the authors redeem themselves by discussing in beautiful terms the type of reasoning that various famous detectives use. Their final paragraph is classic!

An ideal clinician could be said to present a harmonic fusion of almost all the investigative models outlined above—a rare event. If one investigative quality marks out the mature clinician it is the ability to spot possible inconsistencies among the clinical, instrumental, and laboratory examinations, considering not only what is present but also what is missing. This requires skills in observation and “deduction,” handling of knowledge, pattern recognition, and the astuteness that comes from years of experience. For well honed clinicians, the clinical part of the diagnostic investigation is not just a question of medical history and physical examination but rather the capacity to establish links among various physical and laboratory or instrumental findings with an eye to both the consistencies and inconsistencies. In this context, simple examinations really do have the same value as the more complex and expensive ones.

Bravo! Bravo!! (here db stands for an ovation)

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Some advances save money

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Category : General, Medical Rants

New Test May Cut Customer Base for Cardiac Implants

Late Wednesday, though, Medicare proposed a plan that could portend new limits on that market. In March, Medicare expects to begin reimbursing doctors for a relatively new type of diagnostic heart test that is currently paid for only in some states in limited situations. Studies show that the test identifies heart patients who are currently eligible for electronic defibrillators made by companies like Guidant but are highly unlikely to ever need them.

Medicare’s plan reflects the desire among many doctors and insurers to narrow the use of the devices to groups that are most likely to benefit from them. As things stand now, most of the heart patients getting such implants go the entire five-to-seven-year life of the device without ever needing to be shocked to restart their hearts.

“I think the payers are going to balk at covering many of the implants,” said Dr. David J. Kessler, an electrophysiologist who implants hundreds of the devices annually at Austin Heart, a cardiology group in Austin, Tex. “It’s not going to be the candy store doctors think it is.”

//////////////////////////////////////////////////////

Perhaps Medicare’s new plan to support the heart diagnostic test will act as a yellow flag.

The test is a modified version of a standard stress test. It costs $350 to $400 depending on where in the country it is administered, and is performed using a $30,000 machine developed by Cambridge Heart, which is based in Bedford, Mass. Shares of Cambridge, which trade on the over-the-counter bulletin board, jumped 50 percent yesterday, to 48 cents.

The machine’s software analyzes a barely measurable electrical wave in the heart known as the T-wave. Heart patients with normal T-wave cycles – at least 30 percent of the defibrillator-eligible population, according to several studies – rarely suffer sudden cardiac arrests.

Cambridge Heart points out that the test also has a track record of identifying patients with abnormal T-wave readings. As a group, such people run higher risks of sudden cardiac arrest than the general population eligible for defibrillators under current federal guidelines. And so, even as the test could eventually be used to limit the overall population of eligible patients, its initial impact might be to make cardiologists more aggressive about recommending implants for those who are deemed at risk.

Interesting and logical!

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The miracle of Hanukkah

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Category : Cartoons, General

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2 new quotes

1

Category : General

Once again I reach to Nietzsche for a quote:

All of life is a dispute over taste and tasting.

and for the first time Thomas Sowell

You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.

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