This deserves to go viral:

The browser is my shepherd, I shall not want. He maketh me lie in green desktop backgrounds: he leadeth me beside the still anti-virus programs. He restoreth my GUI: He leadeth me in the paths of kitties for His LOL’ sake.

Yea, though I walk through the valley of the blue screen of death, I will fear no evil: For Norton art with me. Thy mouse, thy keyboard, they comfort me. Thou preparest a popup before me in the presence of my youtube videos. Thou annointest my RAM with files, my hard drive runneth over.

Surely Google and Facebook shall follow me all the days of my life, and I will dwell in the Tubes of the Internet forever.

Original work by the NinjaBaker.

Alternative medicine is big business. Really big. Billions of dollars big. All that money spent on supplements, acupuncture, homeopathy, reiki, and all those other “natural” cures and remedies should make the savvy consumer sit up and take notice. Or at least look into what’s being sold, by whom, and why. I mean, if all that stuff worked, shouldn’t Americans be getting healthier?

First off, does it work? You may have noticed that almost every alternative practitioner starts his spiel with reasons why “the medical establishment” (that would be me) doesn’t want you to know about their new super-secret cure-all that everyone in China has known about for millenia. Look, I want my patients to be healthy. Trust me: we doctors can make a perfectly good living simply caring for the manifestations of genetic misfortune (cancers, birth defects, etc) and random happenstance (trauma, infections, etc). We have absolutely no reason to “keep people sick” just to maintain our incomes, so let’s not even go there. Ditto Big Pharma. If they found a cure for cancer, they’d market the crap out of it, make an obscene amount of money curing everyone in sight, then quit making it once it went off patent and they couldn’t keep raking in the bucks hand over fist, and not care one bit when people started dying again.

So does this stuff work? Turns out it doesn’t. Legitimate medical scientists have studied just about every kind of alternative medicine out there quite extensively. The US government has spent billions supporting this research through something called the National Center for Complementary and Alternative Medicine (NCCAM). What kind of results have they gotten? This: every single truly alternative therapy studied does nothing. Got that? Nothing. Nothing at all. That doesn’t stop the government from spinning their non-results, though.

Consider acupuncture, a pre-scientific theory of energy meridians practiced in China before they had access to real medicine (and which, by the way, isn’t even mentioned in current Chinese health care policy). The more it is studied, the more it is revealed to be nothing more than an elaborate placebo. That didn’t seem to stop the Director of the NCCAM from writing:

A systematic review of randomized controlled clinical trials of acupuncture for postoperative pain, published in the August 2008 issue of the British Journal of Anaesthesia, demonstrated that acupuncture had clear value,[emphasis mine] that it decreased pain intensity and lowered opioid side effects.

That journal article was something called a meta-analysis. It was a study of other studies of acupuncture, which included all kinds of different methodologies, surgeries, acupuncture techniques; everything. Furthermore, all they looked at were subjective symptoms like pain and nausea, two things that are notoriously responsive to placebos (and that tend to get better with time after surgery). Here’s the actual conclusion from the article:

Perioperative acupuncture may [emphasis mine] be a useful adjunct for acute postoperative pain management.

Can you say “marketing”?

Why are otherwise savvy consumers taken in by this crap? Several reasons:

• Persuasively misleading salesmen
• Testimonials
• Plain old greed and laziness

In many ways, alternative medicine and its hucksters resemble the deceptive financial practices of the unbridled, unregulated denizens of Wall Street. Junk bonds are the homeopathy of investment banking; derivatives are the acupuncture of the stock market; Dr. Oz is the Bernie Madoff of alternative medicine. Didn’t your broker sound like he knew what he was talking about while going on and on about those new mortgage-backed securities? Just like all that talk about “like cures like”, colon cleanses, and energy fields sounds so scientific! Alternative medicine hucksters and boiler room salesmen both know how to dazzle you with impressive terminology that doesn’t actually mean anything. By the way, there are plenty of “real” doctors and “legitimate” financial advisers who fall for this stuff, and unwittingly perpetuate the fraud. Just because your chiropractor or banker believes in something still doesn’t make it true.

Testimonials are for advertising, not for advising. Just because something happened to one person (if it actually happened at all to the paid spokesperson) doesn’t mean you’re going to achieve the same result. Hey, Bernie Madoff made lots of money for lots of people for many years. Lots of those people were telling lots of other people about him before it all went to hell. Just because your mother’s hairdresser’s cousin’s boyfriend’s roommate won a gold medal after taking glucosamine for his knee doesn’t change the fact that the stuff does absolutely nothing.

Consumers fall for bad financial deals out of greed. Many patients succumb to alternative medicine out of laziness. There is no way to lose weight except by eating less. Fat burners, colon cleanses, and cookie diets that promise quick, easy weight loss are nothing but scams. Elaborate vegetable diets won’t cure cancer. Back pain generally goes away, though it may take three months. Quick fixes that sound too good to be true pretty much always are.

If consumers looked at alternative medicine as carefully as they scrutinized their investments, they’d have a lot more money available for investing.

Sometimes it’s those perfectly healthy patients who really give us a run for our money.

Good morning, I’m Dr. Dinosaur. What can I do for you today?

Oh, nothing much, Doctor. I’m just here for a physical. I’m perfectly healthy.

Wonderful. So you’re not under medical care for anything?

No, nothing. Unless you count the high blood pressure and the diabetes. Maybe the arthritis. And I suppose the irritable bowel, sciatica, and bursitis are sort of medical conditions.

Sort of. Have you ever been operated on for anything?

No. Wait; does a hip replacement count?

Yes.

Oh, okay. But that’s all. Not including the gall bladder, tonsils, appendix, and c-sections, of course.

Of course. Anything else?

No, nothing. That little thing they took out of my breast last year wasn’t anything.

You had a breast biopsy last year? Was it malignant?

No, nothing malignant. There may have been a little bit of cancer in it, but that’s all.

You didn’t need any further treatment?

Nope. Once they were finished with the chemo and the radiation, I didn’t need any more treatment.

Okay then. Do you take any medications?

No, none. Unless you mean the blood pressure pills and the cholesterol pills, plus the pain pills, the nerve pills, and the pills I take for my stomach. The insulin doesn’t count, does it? I mean, it’s not a pill, right?

You’re right about that. Are you allergic to any medications that you know of?

No, nothing at all. Except that erythro-something makes me vomit, penicillin gives me hives, and I got some guy’s rash from sulphur once.

Whose rash?

Steve someone. Steven Johnson, I think. Something like that. Anyway, once I got out of intensive care from it, I was fine.

I see. Let’s move on; when was the last time you had a period?

Oh my goodness, that was sometime in the 1980s.

Nothing since?

No, not unless you mean the bleeding I’ve had off and on for about a year now. I’d hardly call that a period.

That’s true, though we may have to look into that. Let’s see; we should also address your weight.

Why? I’m only 298.

But you’re only 5′ 2″. 

I’m big boned.

Of course. Is there anything else I should know about you?

Oh no, Doctor. I’m perfectly healthy.

I am so tired of seeing statements like these:

• Nutrition is not taught in medical school.
• Pain management is not taught in medical school.
• Practice management is not taught in medical school.

All three of those statements, and the vast majority of others bemoaning the shortcomings of medical education just because “XYZ isn’t taught in medical school” are right, but oh so wrong.

“Nutrition” is not taught in medical school. What we learn is biochemistry, metabolism, gastrointestinal and endocrine anatomy and physiology. We may not learn “nutrition” per se, but we learn what we need to know to understand nutrition in a more fundamental and comprehensive way than can be gleaned from any course in “nutrition”. This also means we understand nutrition differently — and more completely — than anyone without that same level of medical education can, however much they’ve read about nutrition.

“Pain management” is not taught in medical school. What we learn is neuroanatomy, pharmacology, behavioral psychology, and neurophysiology, so that we have the basic knowledge to understand pain management. Narcotics dosing, epidural steroid injection techniques, rehab protocols and so on are learned in residency. I agree that pain is often not well managed, but not because “it’s not taught in medical school.”

Practice management is not taught in medical school. Why should it? Not every doctor is going to have to manage a practice. Many of them are going to become employees. Should everyone leave medical school knowing how to read an employment contract? Well, yes, but is medical school really the right place to learn that? How about the basics of money management and investing? You should have learned that around the kitchen table from your parents before you started high school. That’s not what medical school is for.

Medical school is where you learn the basics about the human body, its structure and function in health and disease, and the disease processes that afflict it. You learn about the microorganisms that make people ill and the drugs that make them well. And that’s just the first two years. The second two years is when you put those basics to work at the bedside, discovering what all those things you learned the first two years look like in real life. Hopefully by the time you’ve gone through those four years, you’ve decided what kind of physician you want to be, so you can move on to postgraduate (residency) training, where you learn how to do what you need to do. Almost all of the knowledge and skills physicians use in day-to-day practice are learned in residency, not medical school. That’s where a surgeon learns to surge, where OBGs learn to deliver, and where family docs learn everything. Even after training is completed, there’s Continuing Medical Education to help us keep up to date. (There’a also UpToDate.)

Family doctors, internists, pediatricians and all other primary care doctors need training in nutrition. Surgeons, hospitalists, oncologists, and all doctors who take care of sick people need training in pain management. Everyone needs to understand the basics of running a business, including the underlying principle of receiving payment for providing professional services. But medical school is not where these things need to be taught.

Doctors also need to know how to respect others, how to manage their time, even how to wash their hands. Ideally they should know these things long before medical school. If not, they shouldn’t be accepted in the first place.

Most of the hue and cry about alleged med school deficiencies is really a set of straw man arguments made by non-physicians trying to demean medical education because “doctors aren’t taught about this,” whatever it is they’re selling. Don’t but it. By the time you see a doctor, he knows what he needs to know  in order to figure out what’s wrong with you and what to do about it. If not, any deficiencies are not because of things “not taught in medical school”.

Modeled on this post, here is this year’s best (non-duplicated) gift:

Why it wins:

Are you kidding me? Because it rocks! Now I have no choice but to get back to writing.

Much — oh, so much — has been written about how doctors document the medical care we provide. As I sit there furiously scribbling in a chart typing on the keyboard, patients sometimes ask if I have to write all of that in order to get paid.

Well, no; but, yes. The dirty little secret about the relationship between documentation and payment is similar to the concept of the speed limit.

Medicare and other insurance companies do not require that I submit copies of my documentation along with a claim in order to be paid for regular, everyday kinds of services. It’s not hard to see why. They’d quickly become swamped with — and paralyzed by — mountains of paper and/or bytes of data that, for the most part, are completely routine. I’m told that some surgical procedures and perhaps some other specialists do indeed need to routinely include such documentation, but I do not. I’ve gotten requests for documentation for some high-level services (level 5 office visits, which occur rarely), and auto accident claims generally require  office notes to be included. But Medicare generally just processes the claim and sends off the check. Same thing with most of the other insurance companies.

Is it just the honor system that compels me to maintain appropriate documentation? Not exactly. My agreement with Medicare and my contracts with insurance companies do indeed state that I agree to do so, but beyond that I’m pretty much on my own. They do have the right to come in and check up on me after the fact (ie, after they’ve already paid me), so all it really comes down to is the risk of getting caught. All risks can be calculated. In this case, I present the analogy of obeying the speed limit and other traffic laws to medical documentation.

The major variables involved with driving are time and place. I’ve run red lights at three in the morning because I’m exhausted, dying to get home, and just don’t want to wait the two minutes for the damn light to change, and there’s no other car as far as they eye can see. I’ve never gotten caught. On the other hand, I know of a stretch of road not far from my house that’s crawling with police cars and speed traps, especially on Sunday mornings. Zip along at 80 mph and there’s a better than even chance of getting pulled over for a close encounter of the cop kind. Similarly, everyone is familiar with highways where traveling the posted speed limit makes you an actual road hazard as everyone else zips by you five, ten, twenty miles per hour faster.

How do you go about calculating the risks of getting caught fudging medical documentation? Let’s see:

How many people of your acquaintance have ever received a speeding ticket? It’s not rare.

How many doctors do you know who have been audited by Medicare?

Oh, it happens. In fact, President Obama has recently called for intensification of audit attempts to detect theft and fraud. There are all kinds of scary stories out there about bounty-hunting companies incentivized to produce by promises of percentages paid to them. For the most part, though, they’re after the big fish: hospitals, large groups, phantom DME suppliers. Little fish like me, solo docs with less than $20,000 in Medicare billings a year, aren’t worth their trouble.

As a practical matter, while my chances of needing to show those frantic tap-tap-tappings in order to get paid (more likely to keep money I’ve already been paid) are somewhere between slim and none. Don’t get me wrong: my documentation is flawless. Not like certain specialists with their new EMRs who use templates to document out their asses, laughing all the way to the bank. Because if I do get audited and my documentation is lacking, I could potentially end up in jail, though more likely just bankrupt. Either way, I don’t mean to imply that it’s something to fool around with.

The major purpose of medical documentation is medical care. That’s the real reason I keep immaculate records; to reflect the excellence of my care. Protection against litigation is a distant second, with payment issues behind that. I write all my records as if they are going to be pored over by a lawyer, even though it’s very unlikely. Medicare and other payers shouldn’t have any trouble finding what they need, at least according to assorted reviewers who have perused them over the years.

It’s also a little like trying to cheat on your taxes. The chances of getting caught may be small, but the consequences are significant.

So no, I don’t need to write all that to get paid, any more than you follow the speed limit to avoid getting a ticket. You drive safely to be safe. And I write what I need to take care of you.

Antibiotics are wonderful drugs. Penicillin, in fact, was the original “wonder drug”. Eighty years later, though, they’re not quite as wondrous as they used to be, due in large part to the fact that too many patients (and doctors!) don’t understand how to use them correctly.

Here is what antibiotics do: they kill bacteria. (Actually, some of them just stop bacteria from growing, which ends up doing the same thing, since the body will then get rid of the non-growing bacteria on its own. But I digress.) That’s basically all. They have to be absorbed and eliminated, which means some of them can have adverse effects on the GI tract (going in) and the liver and kidneys (going out). Sometimes, like any other foreign substance, they can elicit allergic reactions. Other bad things associated with antibiotics are really the result of them doing what they’re supposed to do, even when we don’t want them to, ie, killing off “good” bacteria normally present in assorted areas of the body. There are a couple of other odd antibiotic toxicities to be aware of (deafness; tooth staining) but killing bacteria is pretty much all they do.

Different antibiotics work differently. Some damage cell walls; some interfere with bacterial protein synthesis; some damage the bacteria’s genetic material. There are many different kinds of bacteria. Some have thick cell walls, which help keep antibiotics out (except for the ones that destroy cell walls); others have different ways of combating antibiotics. The point is that not all antibiotics kill all bacteria. So in order for antibiotics to work properly, you have to:

1. Know what kind of bacteria you’re trying to kill, and
2. Use an antibiotic that will kill that bacteria.

How do we know what bacteria we’re trying to kill? Bacteria are very small. We can identify them, but only if we have a lot of them to work with.  So what we do is take a sample of the infected material and incubate it under whatever conditions it takes for the bacteria to grow, then examine the colonies to figure out what kind of bacteria was in the original sample. This is called a culture. Once we have a lot of the bacteria around, the other thing we can do is divide them up into several little groups and subject each group to a different antibiotic. This way we can actually see in the lab that a certain antibiotic kills the bacteria from the patient. This is known as bacterial sensitivity testing.

Therefore ideally, every infection would be treated by taking a culture, identifying the bacteria, and testing it against different antibiotics so the patient can be treated with exactly the right one. It’s a little more complicated, of course, because different antibiotics penetrated different parts of the body to different degrees. There are also various routes; some antibiotics can’t be given orally; others can be given any which way (intravenously, jabbed into a muscle to be absorbed into the bloodstream, even injected directly into the spinal fluid surrounding the brain). However it goes in, though, it has to be able to get to the bacteria, and then kill it.

What if the patient is too sick to wait until we’ve gone through all that rigamarole to begin treatment? In that case, we look carefully at the likely source of the infection (lung/pneumonia, gut/diverticulitis, brain/meningitis, etc), weigh other patient-specific factors (age; travel; recent hospitalization or institutionalization; is the patient’s immune system intact?) plus other random circumstances (time of year; geography; known bacteria causing other acute infections in the community) and come up with an educated guess about what bacteria is most likely to be causing the problem. We call this empiric therapy. Note that after beginning antibiotics empirically, it’s still important to obtain a culture in order to confirm that the guess was indeed correct, and that the chosen antibiotic is indeed capable of killing the observed bacteria, especially if the patient is very sick.

Empiric therapy is often used without obtaining a culture, at least in primary care. There’s nothing wrong with this in principle, but you still have to know what you’re doing: using antibiotics to kill bacteria.

What about “preventing” infections with antibiotics? No such thing. If there are no bacteria, then there’s nothing (good) for the antibiotic to do. The use of “prophylactic” or “preventive” antibiotics technically applies to situations where there may be some bacteria involved (as in surgery, or  a contaminated wound), and if there’s an appropriate antibiotic around to kill those first few, they won’t grow into a full-fledged infection. This is one of the most misunderstood aspects of antibiotic management. If I had a nickel for every patient who insisted on having an antibiotic “so my cold won’t go into pneumonia”, I’d be rich beyond the dreams of avarice. There are very specific guidelines for prophylactic antibiotics; not that they’re followed as well as they should be. Sometimes it seems like the favorite words of every ER doc and pediatrician are, “Just in case.”

So the correct way to treat bacterial infections when you can get a sample of infected material (urine, in the case of a bladder infection, for example) is to send the culture and begin treatment with an antibiotic known to kill bacteria commonly causing the infection. If the culture shows that the bacteria happens to be resistant to whatever antibiotic you chose, it should be stopped (since it’s not killing the bacteria that are there) and the patient switched to one of the antibiotics that do kill their particular bacteria, according to the sensitivity report. This is why the commonly heard sentiment, “Isn’t it dangerous to stop an antibiotics before finishing the course?” makes no sense at all. It’s important to take an antibiotic long enough to kill all the bacteria causing the infection. After that, it’s useless.

What about when you can’t get a sample of infected material? Or, more likely, when obtaining the sample is far more involved, invasive, or expensive than the condition warrants. That’s when you have to go with your best guess, taking into account as many factors about the patient and the disease (the who, where, what, and when) as you can. References like the Sanford guide are invaluable in these cases.

What if a patient doesn’t get better with antibiotic treatment? There are several possibilities.

Sometimes the doctor has chosen the wrong antibiotic (one that isn’t effective against the patient’s bacteria.) Sometimes the patient’s bacteria is resistant to the antibiotic (even if other versions of the same bacteria are susceptible to it.) Note that these two things are not the same. Sometimes the dose wasn’t high enough. Sometimes the antibiotic can’t get to the bacteria (say, if it’s destroyed in the stomach and should have been given by injection instead of by mouth.) Sometimes the patient never took the antibiotic. It may have been too expensive, or the pills were too big, or they were too scared of the potential side effects.

Most frequently, thought, the patient didn’t have a bacterial infection (often not an infection of any kind at all). Why is it so hard for people to understand that you need an accurate diagnosis if you’re going to expect any kind of treatment to make you better? Viral upper and lower respiratory infections (colds, sinus infections, bronchitis) are almost always caused by viruses, not bacteria. Green mucus is caused by myeloperoxidases in white blood cells, not bacteria. It means nothing! Unnecessary antibiotics represent billions of dollars of wasted healthcare money every year.

Aside from the money, though, what’s the big deal about unnecessary antibiotics? “Isn’t it better to be safe than sorry?” I hear patients say all the time, to my eternal discouragement. “What’s the harm?” they ask.

There’s plenty of harm to be had from antibiotics, even when used correctly. Aside from nausea, vomiting, diarrhea, and other assorted direct adverse effects, the major harms are from allergic reactions, from killing off the body’s normal bacteria, and the emergence of resistant bacteria (that is, bacteria that cannot be killed by antibiotics).

Up until a few years ago, the phrase “resistant bacteria” made the eyes of everyone who wasn’t a doctor glaze right over. Now all you have to say is MRSA. Methicillin (or multiply) resistant staph aureus, also incorrectly called the flesh-eating bacteria is all over the news. I admit it’s gotten a tiny bit easier to talk patients out of unnecessary antibiotics by saying, “This causes MRSA, you know.” Resistant bacteria are a real danger because eventually a bacteria will emerge that cannot be killed by anything. That’s scary.

True allergic reactions to antibiotics are relatively rare. Still, they can be catastrophic. You can die from an allergic reaction to an antibiotic. If you have a life-threatening bacterial infection, that may seem like a reasonable risk to take. When it’s not actually necessary, not so much.

Perceived “allergic reactions” are actually more of a headache than real ones. Hives, throat swelling, and dropping your blood pressure to the point of collapse are signs of potentially dangerous allergic reactions. “I don’t know. Something happened when I was a baby and my mother said I was allergic to penicillin,” is the usual story behind far too many antibiotic “allergies”. According to UpToDate, as many as 85-90% of patients stating they were allergic to penicillin did not show true allergy upon appropriate testing.

Then there’s the problem of “cross-reactivity” between penicillin and another class of antibiotics called cephalosporins. Although the figure thrown around from med school onward is that 10% of people who are allergic to penicillin will also be allergic to cephalosporins, actual research shows it to be significantly less. In fact, only 2% of patients confirmed penicillin allergic by skin testing will actually react to cephalosporins.

What happens in real life, though? Anyone who says they’re allergic to penicillin (90% chance they’re not) is also immediately removed from consideration for treatment with cephalosporins, which just happen to be the drug of choice for most small minor skin infections, even though there’s only about a 2% chance of a problem. Putting those numbers together means that someone who says they’re allergic to penicillin has only a 2 in 1000 chance of reacting to a cephalosporin. So instead of a cheap, effective antibiotic, most of them are given clindamycin, a drug notorious for causing antibiotic-associated colitis (by killing off good bacteria in the lower bowel and letting dangerous bacteria proliferate unchecked), which can be fatal.

To sum up:

• Antibiotics kill bacteria.
• If you don’t have a bacterial infection, you should not be taking antibiotics.
• Appropriate antibiotic therapy consists of the right drug for the right reason at the right dose for the right time/duration, and no more.

First in an occasional series on the differences between public policy healthcare discussions and life in the trenches of primary care:

Why is it easier to talk about quality of life with patients who are dying? Why don’t we factor these considerations into the decision-making for patients with conditions that aren’t fatal?

The presence of a terminal illness serves to focus everyone’s attentions. Widespread cancer metastases? Concerns about tight blood glucose control fade away. End-stage liver disease? Blood pressure control doesn’t matter so much any more. Bony pain from prostate cancer? Narcotic and sleeping pill addiction doesn’t even occur to anyone. I find it far more problematic to deal with patients with debilitating but non-fatal conditions when treatment options are perceived as limited because of co-existing diseases that produce so-called contraindications to certain medications.

I have a patient in his mid-70s with severe pain from osteoarthritis. Several fractures and a couple of unsuccessful joint replacement surgeries haven’t helped matters. Several years ago he found that a little drug called Vioxx worked extremely well for him, reducing his pain considerably and allowing him to do pretty much watever he wanted. As we all know, however, that drug was pulled from the market because of an unacceptable increased risk of heart attacks and other untoward cardiovascular events. Interestingly, one other drug (Celebrex) from the same medication class (COX2 inhibitors) remains on the market. However because of this gentleman’s diabetes, high blood pressure, high cholesterol (all treated to acceptable guidelines, as it happens) and age, all the red flagged warnings about increased cardiovascular risks go off if I were to try prescribing it for him.

Actually, most other doctors would probably make the unilateral determination that the risk from this medication class outweighs any potential benefit, and would therefore not even broach the topic with the patient. I disagree (surprise, surprise!) Here’s why:

“Risk” is an abstract concept. Having a risk factor for a disease or condition is not the same thing as having it, or even a modified or mild version of the condition. Right up until the moment the brain of an un-helmeted motorcyclist splatters across the pavement, he’s feeling just fine. This is also why diabetic hypertensive smokers with cholesterols of 300 walk around obliviously content to continue stuffing their faces with Big Macs. Discomfort with risk is purely emotional, and is a function of one’s perception of the risk. This is why doctors can seem more uncomfortable than patients about certain courses of medical treatment. We know more about what can go wrong, so there are times that we really fear for our patients, for whom ignorance can be quite blissful. It’s like when  little kids barge into a busy street, only to have their mothers freak out as they haul them back. The kid has no idea why Mom’s so upset; he’s just fine.

In this case, though, we have a patient for whom a particular medication holds a real chance for significant improvement in quality of life despite a known, documented increased risk of an adverse cardiovascular event. Why don’t we factor quality of life considerations into the decision-making for patients who aren’t dying? The RISK of a heart attack is not the same as a heart attack. Whose comfort level with risk is more important here, the doctor’s or the patient’s?

I explained all this as best I could to the patient, providing him with various educational materials and information online as well as handouts from my office. I also included prescribing information for Celebrex, complete with all the warnings. Obviously a significant risk issue is medicolegal on my part. But I’ve known this guy long enough, and I plan to explain (and document) out my ass to make sure he understands the trade-offs here. Bottom line is that I offered him a prescription if he wants it. (By the way, he’s currently taking OTC naproxen for his pain, a drug with exactly the same cardiovascular risk profile, but not nearly as much bad press as the COX2 inhibitors.)

What happens if (hopefully when) I try actually writing the prescription, though? First, his pharmacy benefits manager will likely require prior authorization. (Why can’t he use cheaper meds? Because they don’t work well enough.) Second, a pharmacist will probably call and tell me that the drug is contraindicated in the elderly because of increased cardiovascular risk. True. But what we have here is a case where guidelines conspire to keep someone miserable. Shouldn’t the patient be the one to decide if he wants to live ten more years as a crippled invalid, or risk maybe five more while living his life the way he wants?

Take home message: Here in the trenches of primary care, “quality of life” doesn’t apply just at the end of life. It’s something we have to help our patients consider every day.

What could be more terrifying than a college chemistry course about “Weapons of Mass Destruction“?

It has a lab.

Hat tip to LC

 

At last. After a wild and busy week that encompassed travel, cooking, food, family, and fun, not to mention candles, dreidls and chocolate (lots of chocolate), we have come to the final night of Hanukkah. Finally, behold the magnificence that is the latest addition to my menorah collection:

Approximately eight inches high, it feels like it’s made of bronze. Can’t you almost hear them playing, “Maoz tsur*…”

There you have it. Another Hanukkah; another eight nights; another eight menorahs. Until next year everyone. Happy Hanukkah!

* “Rock of Ages” in Hebrew

Edited to add this year’s everyday menorah all lit up for the Eighth Night:

Here’s hoping everyone had a lovely holiday.

This one was for the Jock, purchased a surprisingly long time ago. Yes, it’s been used…lovingly. Now excuse me while I go stick it in the freezer to get the rest of that wax off of it.

(And continuing the sports theme: Happy Boxing day.)

Another whimsical, all-metal entry in the menorah parade.

(And Merry Christmas to all of you who roll that way.)

A gift from DDS a few years back. No, we don’t have this many cats ourselves…yet. We’re working on it. <sigh>

Addendum:

Spotted today on the door of The Old Book Co. of McLean in Virginia:

Simple. Whimsical. All metal. Never used for candles. (I shudder at the thought of scraping wax off every little curlicue.)

(Yes, yes, I know the trick about putting it in the freezer first; I still can’t be bothered.)

This menorah just goes to show that it doesn’t even have to be in one piece. This one is composed of six separate stones; three of them have holes for two candles, two other short ones hold one candle apiece, and a taller one holds the single shamash. The coolest thing about menorahs like this is that you can arrange them any way you want. There are even different designs on the other sides, so there are a nearly infinite number of arrangements.

 

Made entirely of metal, this blue cat was added to the collection last year. The candle holders along the spine are hexagonal nuts, with a double-high one at the tail serving as the shamash. You can’t tell from the (stationary) picture, but the head and tail are on springs, which means the slightest movement sets them wagging. Too cute for words!

My first menorah this year is a ceramic rendition of Noah’s ark. It’s basically just a slab of clay bent into a semi-circular shape, trimmed to shape, and painted. Each of the animal heads along the top has a candle-holding indentation, with Noah himself off to the right supporting the shamash.

Time, she sure does fly. It’s Hanukkah again, and you know what that means: time to add to my menorah collection.

Four years ago for Hanukkah I bought myself an especially magnificent menorah, and decided to celebrate by sharing some of my menorah collection with my blog readership (all 17 of you). Here’s my introduction from then: My Menorahs.

By way of review, here are the selections from 2007:

1. First night
2. Second night
3. Third night
4. Fourth night
5. Fifth night
6. Sixth night
7. Seventh night
8. Eighth night

This year’s addition isn’t quite as colorful as the finale from 2007, but it took my breath away when I saw it, and I am thrilled to have added it to my collection. What does it look like? Sorry; you’re going to have to wait a little while to see it. In the meantime, though, come on back each of the next eight nights and celebrate Hanukkah with me.

Let me see if I have this straight:

There are statutes of limitation for rape, robbery, and child abuse, but not for murder, or for illegal immigration. So a citizen who rapes a child will, if not caught, eventually be forever immune from prosecution. But someone who enters the country illegally is in the same boat as a murderer, to be hunted down across decades and generations, whatever their subsequent contributions to society.

Makes sense to me.

</deep sarcasm>

With the NinjaBaker well and truly launched, his new area of study, Molecular Virology, has yielded some great one-liners.

FIRST:

Because he wants to study HIV, for his birthday last year I went to Giant Microbes.com and sent him his very own HIV virion:

But the best part was pointing out that because it was me sending it to him, technically it counted as maternal transmission.

SECOND:

The first month, he worked in a lab studying a virus that infects certain insects, which allowed me to quip:

“Ah: bug bugs.”

THIRD:

This month he is studying SIV, simian immunodeficiency virus, the monkey version of AIDS. It’s all bench work, studying molecular mechanisms; he’s not working with actual animals at all. My response:

“I see; just Rhesus pieces.”

Cancer. Just the word is scary. Actually, that’s the problem. Once you say that word, the average American will do anything — ANYTHING! — to just get it out of my body!!! Whether or not they have it, whatever the actual numerical chances of their ever developing it, no chance for detecting or treating it should ever be neglected. EVER! Ask any Med-mal lawyer. Better, ask any twelve average people off the street (ie, the ones who are going to wind up on a jury). “The doctor didn’t do every possible test/procedure, and now the patient has CANCER? String him up!”

Hence we have the new guidelines for PSA testing. (Given that many patients with prostate cancer have normal PSAs and lots of patients with high PSAs don’t have prostate cancer, it doesn’t seem semantically correct to call it “prostate cancer screening”.) Surprise! Turns out that not only does PSA testing not save lives, but that urologists don’t really care. Certainly not enough to stop recommending PSAs to just about everyone they can get their hands on.

Nor do breast surgeons have any intention of modifying their recommendations, not only in light of new understandings of the limitations of mammography, but even as their own treatment recommendations contract, becoming ever more targeted and less invasive. I recently heard a local surgeon speak about the progression from radical mastectomies to partial mastectomies to lumpectomies; from axillary node dissections to sentinel node sampling; from whole-breast radiation to intra-cavitary seeds. Listening to him, breast cancer therapy is becoming downright minimalist. Yet at the end of the talk, when asked about the new recommendations for biennial mammography, his response was, “Every woman should have an annual mammogram starting at age 40. I mean, there are no downsides to mammography.” Never mind the psychological stress of extra views, ultrasounds, and false positives, not to mention the bruising and even skin tearing that I see far more often than I’d like. “No downsides”? Not for him, that’s for sure. When will they realize that mammography catches slower-growing cancers that would be treated just as easily if they were found a year later? Women die of aggressive tumors that pop up between annual mammograms, which by definition would not be detected by standard screening.

The gynecologists are no better. They all still insist on annual visits for paps to find cancers that take 10 years to grow (and then only in the presence of HPV) and pelvic exams that detect, well, nothing. Whether driven by legal concerns or patient insistence, scientifically unnecessary medical care is running rampant in this country, playing a pivotal role in bankrupting us in the Orwellian name of “the best medical care in the world”.

What to do, though?

First, stop asking the foxes what they think of the new hen house alarm system. What do you think a urologist is going to say about PSAs? Why would a surgeon ever recommend against a mammogram? And whatever you do, don’t even think about questioning the need for an annual gynecological exam. Goodness. What’s a poor doctor to do without providing all that care? Starve?

Actually, you might be able to get an appointment with a urologist in less than six weeks for a kidney stone if they weren’t so booked up with annual rectal exams and PSAs on every asymptomatic man over 50. Think about getting in to see a gynecologist for heavy bleeding in less than 3 months. Not only would the care be more appropriate, but those same specialists worrying about their empty appointment books would probably be making more money by seeing patients who actually need their specialized skills and procedures.

So if you shouldn’t ask the specialists about screening guidelines, to whom should patients turn? How about me. Why not discuss these complex issues with your family doctor, who doesn’t make any money off your PSA or your pap or your mammogram. Believe me, my schedule is plenty full with sick people and the worried well (defined as those patients I cannot talk out of all those inappropriate interventions. Yes, they’re out there. Yes, I try to explain it to them. Am I always successful? Of course not, though it’s not for lack of trying.)

I’m more interested in seeing that the care you get is medically and scientifically appropriate, especially when deciding which screening interventions to forgo. “Watching and waiting” is often as viable a strategy for cancer as it is for lesser ailments. Let us family physicians educate you, our patients, so that you don’t end up with irreparable harm from treatments intended to cure something that would never have killed you. Sometimes “just getting it out of  my body” leaves you much worse off than leaving well enough alone.

Cancer is a dreadful  disease. Just dreadful.  Make no mistake: I have tremendous respect for the awesome doctors who treat patients afflicted with it day after day. Still, paradoxically, I can’t help but notice that some of them have just as hard a time as do other doctors with caring for patients at the  end of their lives. I believe a large part of their difficulty stems from the ridiculously dysfunctional either/or approach to palliative care and hospice we’re stuck with in this benighted country.

The problem is that in order to qualify for hospice, patients must not only have a certified life expectancy of less than six months, but they must also not be undergoing any active treatment for their malignancy. When you stop to think about it, though, this is actually quite discriminatory. We don’t require people on hospice with other diagnoses to discontinue their life sustaining medications. Patients with COPD are allowed to continue their bronchodilators; CHF patients don’t have to stop their ACE inhibitors and digoxin. But if a cancer patient wants to qualify for hospice, they have to forgo curative treatments like chemotherapy.

So what if the oncologists call it “palliative” chemo instead? That still sounds too much like “giving up”, and that is something that too many oncologists are loath to do. Not only to do, but to even think about. I actually heard one oncology colleague of mine tell a mutual patient, “I’m in the business of hope.”

“Hope” for what? There comes a time, usually after several recurrences of a cancer, when it becomes more rather than less clear that more treatment is not going to help (by which I mean “meaningfully prolong the patient’s life”). This is the key point in the doctor-patient relationship where too many oncologists fall short.

I have a patient with an aggressive, recurrent malignancy who was nevertheless offered more chemotherapy, which was making the patient quite miserable.

“Why are they doing chemo again?” I asked.

“Because the doctor asked me whether I wanted to continue treatment,” answered my patient. “He said it might help, but that it was my choice.”

Yes, it “might” help. Just like you “might” win the lottery, which is the common justification for buying lottery tickets. But the overwhelming likelihood is that you won’t win the lottery, and that the treatment won’t help. All that will happen is that the last few weeks or months of your life will be significantly more uncomfortable than they had to be. I can’t count the number of new widows and widowers whose grief is made sharper by the thought that, in retrospect, their spouse was tortured to death by the very treatments that were supposed to be “helping” them.

What about the fear that stopping treatment, “giving up”, will shorten the patient’s life? It turns out that hospice patients actually live longer. Not to mention that their quality of life is significantly better than that of patients still undergoing active chemotherapy.

Look at it this way: when a given cancer treatment has a good chance of curing you or of significantly impacting your disease, no responsible oncologist is going to present that option as a “choice“. Sure, lots of people get second opinions. Sure, lots of people ask what will happen if they don’t go through with the proposed treatment. But doctors only offer you choices when it doesn’t actually matter.

So when your oncologist says it’s “up to you” whether or not to undergo more treatment for cancer, say no. Just go out and do whatever you want for the rest of your life, however long or short it may be. Sure, you could be the “one in a million” who responds to the drugs (bearing in mind that oncologic “responses” are often measured in weeks or months, generally not in years; we tend to call those “cures”). But the chances of that are far smaller than you think. Statistically, you’re probably better off with hospice.

 

She woke with a start, not quite sure what had roused her. It was still dark, the air crisp and cool in the wee hours of the late October morning. Out of the last few months’ habit, she reached down to feel the swell of her belly, and to her surprise found it taut and hard. It was usually the baby stomping on her full bladder that wakened her these days, but not today. She lay quietly as the muscle contraction reached a peak, more tight than painful, and then receded. Today might be the day, she thought with joy.

She let her mind wander for a few more minutes, loathe to wake her husband still sleeping peacefully at her side. Once he realized what was happening, she knew he would spring into action. Rousing little Shorshie to hustle him off to her mother’s house just on the other side of the garden, then helping her into the car, offering to let her lie down in the back seat if she wanted, though she was fine sitting up; then to the hospital to relinquish her into the care of the professionals. She allowed herself a fleeting daydream of him staying by her side instead, but that just wasn’t how it was done here in Vienna in 1930. Men usually sat in a nearby cafe sipping coffee and nibbling Sachertorte while waiting for word of new offspring.  She toyed with the idea of not saying anything at all until it was too late and having the baby born right here in their bed, but smiled at her own foolishness. There was nothing wrong with the hospital.

She decided to try getting up instead, and was immediately hit with another contraction. Solid; tight; tense; she couldn’t speak; she couldn’t think; it completely monopolized her attention. Yes indeed; this was the day.

“Bert,” she murmured.

Her husband stirred.

“Bert,” she repeated, a little louder. Now his eyes opened, and he regarded her gripping the bedpost.

“Is it time?” he asked.

She just nodded.

“Are you okay?”

Again she nodded. As long as she stood still, she was fine.

“Shall I get Shorshie up?”

A final nod. Carefully she put her clothes on, gripped by two more contractions in turn, as Bert bustled around getting ready. Poor little Shorshie didn’t understand what was happening; he wasn’t even a year and a half old yet, still just a baby himself. She could tell he was smart, though. She could see it in his eyes, even as they twitched abnormally; nystag-something, the doctors called it. It had something to do with his abnormally fair skin and bright blue eyes, so unlike everyone else in the family. She didn’t care, though she did hope the new baby wouldn’t be similarly afflicted.

The ride to the hospital passed in a blur of increasing contractions. The wheelchair, the bed, the twilight sleep; the next thing she knew, she was lying in a white iron bed in a small room, a tiny bassinet at her side, a large woman dressed in white bending over it.

“Oh, good. You’re awake,” said the nurse. “Would you like to hold your daughter?”

Wordlessly, she reached out for the baby, tightly wrapped in flannel.

“I’ll be back in a moment with a bottle,” said the nurse as she swished out of the room.

Carefully, delicately, she unwrapped the tiny bundle. Ten fingers; ten toes; definitely a girl; and best of all, a full head of dark hair, with deep brown eyes that regarded her steadily. Gently she kissed the baby on the forehead, then surreptitiously pulled up her own gown to lay the baby against her chest, skin to skin. The nurse would likely fuss at her for letting the baby get chilled, but she covered them both over with gown, flannel, sheet and blanket. The baby would be fine.

She imagined taking the baby for walks around the magnificent grounds of Shoenbrun not far from where they lived. She smiled as she thought of her children growing up here in beautiful, peaceful Vienna. No reason why they shouldn’t.

She thought about the name they had decided upon, and rolled it around in her head before saying it aloud for the first time. It sounded like an artist’s name, and she imagined magnificent oil canvases, scenes of wild animals, signed with it in red down in the corner.

The baby stirred in her arms as she pulled the infant to her.

“My little Johanna Bettina,” she murmured.

 

I have not worn a white coat since I opened my own practice more than twenty years ago.

Not that I had anything against white coats in principle. I wore my short white one in med school with pride, and the longer one in residency too; their pockets filled to bursting with the 4 x 6 inch six-ring binder emblazoned with my name in gold, courtesy of Burroughs-Wellcome, the long-defunct pharma giant, which had presented one to each medical student in the US for many years, as well as assorted pens, note cards, alcohol wipes, hemoccult cards, and so forth. I even had a tiny teddy bear pinned to my lapel, my own way of personalizing the impersonal.

When I went out on my own, though, I made the conscious decision not to wear one. I confess that all these years later, I don’t completely recall my thought processes on the subject. It seemed pretentious, especially since I was the only doctor in the office and therefore not easily confused with other staffers. Little kids were scared of them, held the common wisdom. I decided that I wanted to project a warmer, less formal tone now that I was out on my own and could do whatever I wanted. Don’t get me wrong: I took pains to remain quite professional. I wore skirts, hose, and heels (sensible low ones, of course) at all times.

Patients noticed, and often commented. My explanations were accepted. It was my style, and I’ve always been comfortable with it. Even when a broken foot 10 years ago led me to begin wearing slacks instead of skirts, I never even considered wearing a white coat.

As a solo practitioner, I rarely see other doctors at work. I interact with them all the time, but mainly via phone and letters. Rare luncheon meetings were usually with other office-based physicians. If they wore white coats in their offices, they certainly didn’t wear them outside their own four walls. White coats seemed okay in hospitals. Wearing them in offices still felt pretentious; almost like a costume.

Then came this past summer. Suffice it to say, I found myself seeing a lot of doctors in a lot of different settings. And every single one of them wore a white coat. Every. Single. One. And all of them with their names beautifully embroidered over the left breast pocket. Gradually, the idea of a white coat in the office began to feel perhaps just a smidge less awkward. That, plus reading more studies documenting the error of “conventional wisdom” about kids. It’s not the white coat that scares them; it’s other stuff associated with doctors and their offices. Hey, all’s fair in love, war, and evidence-based medicine.

So about a month ago, after thinking long and hard about it, I made the momentous decision to begin wearing a white coat in my office.

I happened to have one lying around that I had worn only once. I think I had purchased it as a prop, for something or another. I remember it having been way too tight, but when I tried it on, I realized that had been 50 lb ago. It fit just fine.

Next step was, of course, the embroidery. After agonizing over all the permutations of first name/initial, middle initial or not, “Dr.” in front or “MD” (with or without periods) following, block or script, red or black, I trudged down the street to a friend with an embroidery business, self-consciously clutching the badge of my profession I was so belatedly embracing. It turned out that the all the font/wording/initial/Dr-or-MD choices came down to the space available. “Dr. #1 Dinosaur” on one line, “Family Medicine” below, in block lettering it was.

“I’d like it in red,” I said.

“No one does red anymore,” responded my friend. “They don’t do black either.”

“Oh.”

I looked through her bins of thread, finally spying a spool of lovely turquoise.

“Is that turquoise?” I asked.

“It used to be turquoise,” she answered. “Now it’s ‘California Blue’.”

“Oh.”

Two days later, I was the proud owner of a newly personalized white coat, my name boldly emblazoned in turquoise California Blue.

The next morning, I steeled myself as I drove to the office, rehearsing what I was going to tell my patients. I mean, after all these years, they were bound to be surprised — or even shocked — at this dramatic change in my appearance. I slipped the coat on, glancing at my reflection in the nearest window. Hm; not bad, I supposed. Just very, very different. I draped my stethoscope around my neck and, with great self-consciousness, went out to greet the very first patient I had ever seen while wearing a white coat in private practice after more than twenty years.

She didn’t bat an eye.

Neither did the next patient. Nor the next. In fact, the entire day went by and no one said a word about my brand new white coat; the one I had agonized over whether or not to wear and what color my name should be. Not a single word.

No one.

All week!

Finally, the second week, while finishing up a visit with one of the very first patients who had come to my practice, a lovely woman I had known for more than twenty years, I said, “Can I ask you something?”

“Sure,” she replied.

“Do you notice anything different about me?”

She eyed me carefully up and down.

“New glasses?”

“Well, kind of.” I actually now have eight different pairs; my goal is to never wear the same pair two days in a row. “That’s not it, though. Anything else?”

Again, she gazed carefully.

“New haircut?”

“No.”

“You’ve lost more weight? Different shoes? New sweater?”

“Um, I’m wearing a white coat.”

“Haven’t you always worn that?”

I’m not sure what the take-home lesson is here. Possibly that the white coat is such an ingrained part of a doctors’ identity that patients don’t actually notice whether we’re wearing one or not. More likely it means that I’m just furniture, and that patients don’t notice anything more about me than do my kids (as long as supper’s on the table and the wallet is always open).

In the meantime, I’ve discovered that the left-hand pocket is a handy place for the Rx pad, and the right-hand one is very convenient for carrying the wireless mouse between rooms. And as the weather gets colder, I’m coming to appreciate the extra layer of warmth. Just my luck, though: evidence is beginning to emerge showing that white coats are a source of nosocomial infections, and doctors are now being pressured to stop wearing them.

Shit.

Hallelujah. At last there is an actual, published paper (full text behind subscription firewall, unfortunately) objectively documenting not only a lack of longevity benefit for several commonly consumed dietary supplements, but a numerical association indicating potential harm. Finally!

Investigators looked at nearly 39,000 women (in scientific terms: a lot) over 19 years of follow up (in scientific terms: a long time) and found increased risk of death in women who took supplemental iron (strongest association), copper, zinc, magnesium, Vitamin B6, and multi-vitamins.

Wow.

If nothing else, that should at least give one pause when considering whether or not to take supplements at all, especially in the demographic studied (the “older female”). But are they overstating their case? Scare-mongering? Not at all. In fact, the following caution was explicitly added by the researchers:

“This, of course, is just one study, and other similar studies have not found such a dramatic increase in mortality,” said Mursu, who is also affiliated with the University of Minnesota. “Nevertheless, these studies have provided very little evidence that commonly used dietary supplements would help to prevent chronic diseases.”

They even say in so many words that they have demonstrated merely an association, and not a causal relationship.

Still, I know you’ll be shocked — shocked!! — to hear from a supplement industry whack job apologist spokesman that you should pay no attention to these trifling findings:

These researchers “really do overstate the potential for harm, and understate any benefit,” he said. “The researchers started out with the intention of identifying harm. I caution against making overstated assumptions and conclusions from this data.”

May I respectfully submit (well, as respectfully as possible while snorting hot beverages through my nose at the flagrant hypocrisy) that it is the supplement manufacturers and salesmen who, over the decades, have tended to overstate the benefits without even acknowledging the existence of risk. More:

[The spokesman] noted that “anything, including water, can be harmful if you overdo it.”

Here we go, descending into the old Prohibition-era tactic of watching goldfish immersed in pure alcohol die to illustrate the perils of drink. Of course water is indeed a harmful, harmful substance. (Some) kidding aside, even just drinking way too much over too short a period really is lethal (proving mainly that it is indeed possible to die of stupidity). Finally, though, he resorts to a simple lie:

In the real world, you cannot get all the needed nutrients from diet alone, he said. So supplements are needed when you fall short. People need to analyze their diet and figure out what supplements they need. [emphasis mine]

That statement is wrong, untrue, inaccurate, false, incorrect, and not right. In general terms, this is either a mistake, an error, and/or a lie.

It may be inconvenient, expensive, or difficult to get required micronutrients from the diet (technically, from the environment: the natural biological source of vitamin D is sunlight), but it is indeed possible and, when actually studied with any scientific rigor, better for you (ie, consuming fatty fish is superior to consuming fish oil supplements, partly because the actual fish contains protein and other good nutrients, and partly because the fish oil in supplements often comes from the fish’s liver, where toxic metabolites build up from other things the fish has consumed). Many other nutrients are found in foods that lots of people don’t like to eat, like dark green vegetables, fruits, and whole grains. Fresh food may be more expensive or difficult to obtain, especially given certain geographic or socioeconomic constraints (fresh seafood far inland; paucity of grocery stores in poorer urban areas; etc.)

The realproblem is that precious few people go to the trouble of actually analyzing the nutrients in their diet (their true diet; what they really eat, not what they claim to the guy in the health food store that they eat) before grabbing a bunch of giant bottles off the shelves and popping handfuls of pills instead because they don’t have the time or inclination to prepare or procure an actual diet. Worse are the gullible folks who go to great lengths to consume all the right foods yet are still led to believe that it’s “impossible to get all the needed nutrients from diet alone.” Not only are they paying through the nose for organic and natural foods (formerly known as just “food”), they’re also shelling out more of their hard-earned cash for extraneous supplements that are only giving them very expensive urine.

But just for the hell of it, let’s give that supplement guy the last word (though granted they’re technically the first words of his statement):

Speaking for the supplement industry, Duffy MacKay, vice president for scientific and regulatory affairs at the Council for Responsible Nutrition, said that people who use supplements tend to live healthier lives.

If that’s true, then people who use supplements are also the ones to whom health, wellness, and, presumably, longevity, are most important.  Who then should be all the more attentive to the message of this study that supplements can be dangerous, instead of being lulled into submission by aggressive supplement advertising telling them that all their low-tech efforts at healthy living are for naught.

Wishing a very happy, healthy sweet new year to all my friends and readers. That would be the Jewish new year, for those scratching their heads quizzically at their third quarter statements.

One of the traditional Rosh Hashannah foods is challah, an egg bread usually baked in braided form but often formed into rounds for the holiday. DinoDaughter, an apple not fallen quite as far as she wishes from the tree, recorded her challah-baking adventures thusly:

 

I think it’s just too cool for words!

I get mail, this from a healthy 20-something reader who’s just moved to a new city:

What’s the difference between doctors listed as Family Practice, Internal Medicine, and General Practice?  Also, what are some things I should consider (that I might not already be considering) when finding a primary care physician?

That’s a bit of a loaded question, not because of any bias of mine (perish the thought!) but because each of those terms is used in different ways, by different people, at different times, for different purposes. So here’s the rundown on each of them in turn.

Family Practice

What it’s supposed to mean: Designates a physician who has completed a three-year postgraduate training program in Family Medicine, trained to provide primary care to patients of all ages, presenting with conditions of any organ system, including care of acute conditions and ongoing management of chronic diseases.

What doctors hope people think it means: Some doctors think having themselves listed as “Family Practice” is good marketing. This irks me. (Trust me: an irked dinosaur is not a pretty sight. You wouldn’t like me when I’m irked.)

What it really means: As long as you check for Board certification, pretty much what it’s supposed to. (And remember: no news is NOT good news. No mention at all means no certification. Just like no mention of any marital status on a dating website means “Married”.) Otherwise it means someone trying to horn in on what I do because they think the term is inclusive.

Internal Medicine

What it’s supposed to mean: Indicates that a physician has completed a three-year postgraduate training program in General Internal Medicine. Bear in mind that the vast majority of graduates of those programs goes on to further specialty fellowship training. Precious few of them actually go out at that point and hang up a shingle, opening their doors to a practice specializing in the care of patients with multiple complex diseases

What doctors hope people think it means: In this new day and age of enhanced prestige marketing appeal of primary care, plenty of specialists with sagging revenues and appointment slots to spare believe that a listing under “Internal Medicine” will lure more patients. They have no problem with this double-dipping, but I do.

What it really means: Technically, it could indicate someone who couldn’t get accepted into any fellowship program. Most likely it’s a specialist trying to get listed twice in the directory. As a practical matter for a generally healthy adult, it’s a perfectly acceptable option for a primary care physician.

General Practice

What it’s supposed to mean: In the olden days, physicians hung out a General Practice shingle after one year of internship. Specialists were the only ones who went on for more advanced residency training. After everyone started doing residencies, it was osteopathic physicians who used the term General Practice, while MDs went on to fine-tune the training and certification that became Family Medicine (which now welcomes osteopathic graduates).

What it really means: Either an older MD who only did a one-year internship, or a younger DO who did a three-year residency. By now, though, even this is a little dated, so I’m surprised that there are physicians listed at General Practice. What it really means is that you need to carefully explore training and certification.

What else to look for:

Given that the reader failed to specify what he was already considering in terms of his physician search (presumably such vital indicators as Board certification, convenience of office hours, and courtesy of staff, among other things) the main thing I would do is provide reassurance that it is okay to go with one’s gut. Pick a doctor you like. More importantly, don’t be afraid to STOP going to a doctor you decide you do not like. Trust me; the doctor is not going to care. There are plenty of other patients out there.

Think in terms of finding a doctor who “gets” you. Someone you’d feel comfortable going to when you’re uncomfortable. Someone you can trust. That’s really the bottom line, whatever section of the directory they’re listed in.

Got a letter today from Pain Management about a mutual patient that read, in part:

Patient has responded very well to epidural steroid injections and now reports that he is pain-free.

Great! Wonderful! Success! Gotta love those epidural steroids.

For the record, the patient is not being treated for any other pain syndromes. So I was at a loss to read further in the letter:

I have refilled vicodin 5/500, dispense number 60, 1 or 2 to be taken every 6 hours as needed.

Um, why are you refilling pain meds for a patient you’ve just said is pain-free? No mention of plans to taper (though he wasn’t on huge doses anyway), nor a note about just having the meds for PRN use in case of recurrence? Just a routine refill.

This is the kind of thing that gives pain docs a bad name.

Waiting at a traffic light just before crossing over the city limits between the District of Columbia and Chevy Chase, Maryland, the mother of an 8-year-old decides it is a teachable moment for geography.

Mother: Darling Child of mine, do you know what city we are in right now?

DC: New York?

Mother: [helpless laughter, signalling to child that she may be mistaken]

DC: [trying again] Alabama?

LATER:

Mother: Why did you say New York?

DC: It just looked like it.

NOTE: Child in question has never been to New York (nor to Alabama, for that matter)

fin

Now then: in an uncharacteristic moment of seriousness, what might actually have been going through the child’s mind at that time? Perhaps she was thinking about school, or her upcoming piano recital, or a dance lesson, or a friend she was planning to visit the next day. Maybe she was listening to the music on the radio. Maybe she was in the middle of a rip-roaring good daydream. Maybe she just didn’t feel like being taught at that particular instant.

Teaching is only half of the equation. It doesn’t matter how teachable the moment is if the student isn’t in a “learnable” mood. This comes up in my office every day. I may think patients’ demands for antibiotics for viral infections and CT scanning for bellyaches make for ideal teaching moments about antibiotic resistance and the dangers of ionizing radiation. But no; if they’re more interested in a narcotic prescription and a note for work, all the didactic prowess I can muster will be for naught.

As a rule, young children are up for any kind of learning 24/7. As they get older, though (school age and up) they may have other things on their minds. Which means that sometimes they just don’t feel like learning, no matter how teachable we think the moment may be.

(Either that, or the kid was just having some fun jerking her mother around.)

 

Got a call from a long-time patient over the weekend. Hearing a not overly alarming story but one that was not terribly reassuring either, I suggested she go to the Emergency Department.

Later that morning, sitting at an internet cafe with DSS eating breakfast, each of us surfing on our respective laptops, he says conversationally, “So I see Miss LTP is in the ER.”

My heart stopped and my stomach dropped. Had he managed to access the voicemail program I use for after hours calls? My EMR? Had I left shortcuts up to any patient-related materials on that machine? When had I last used it anyway? My mind was racing. I wasn’t all that concerned specifically about him knowing that a particular person was in the ER, since he understands confidentiality. But if he was able to access confidential patient information, did that mean I had a security breach?

“How do you know that?” I asked him carefully, after a very long pause, during which all of the above ran through my head.

As it happens, I’ve known this person for a very long time. So much so that DSS and I regularly run into her when we’re out and about. So much so that not only has the patient friended me on FaceBook, she’s even friended DSS.

“It’s right here on FaceBook,” he answered. Sure enough, her status read, “Hanging here in the ER.”

As I’ve noted before, HIPAA doesn’t apply when patients “breach” their own confidentiality. Clearly in this case, it’s FaceBook 1, HIPAA 0.