Posted by: notdeaddinosaur | October 19, 2014

Guidelines be Damned

The urologists have done it again:

Patient’s [non-prostate-related urological issue] is resolved. Annual prostate cancer screening with PSA and DRE emphasized. [sic] Re-check in one year.

Prostate cancer screening guidelines; FOUR of them: from the American Cancer Society, the American Urological Association, the American College of Physicians, and the United States Preventive Services Task Force. Go ahead; click through; read them.

Central to EACH AND EVERY ONE is the concept of “shared decision making,” recognizing that “[t]he benefits of screening with the prostate-specific antigen (PSA) test are outweighed by the harms for most men.” (American College of Physicians)

Here it is again:

The American Cancer Society (ACS) recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information. [emphasis mine]

Oh, but that’s just from a bunch of people who don’t actually take care of patients with prostate cancer.

Okay. Here you go. Guideline statements from the American Urological Association (that would be the folks who do actually take care of patients with prostate cancer):

Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years.

Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk.

Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences.

Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives.

Guideline Statement 5: The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy.

[all emphasis mine]

Nowhere in 2014 does anyone responsibly “emphasize” annual prostate cancer screening with PSA and DRE. Nowhere. Nowhere, apparently, except in the offices of stubborn specialists refusing to relinquish their old ways. They literally have their patients by the balls (well, close enough.)

I’ve addressed this before. Twice, in fact. To say I was dismayed to receive the letter above is like saying T Rex can be a bit excitable when he smells food. To keep to the subject at hand, let’s just say I’m really really pissed.

When I started practicing, it was standard procedure to treat upper respiratory infections with antibiotics. Knowledge grew. Recommendations changed, and I stopped; even when patients didn’t understand and I had to take time and make the effort to explain it to them.

What good is it to do research and make new discoveries when no one pays any attention to the findings?

Posted by: notdeaddinosaur | October 2, 2014

Silver Practice

Twenty-five years ago today, I hung out my shingle.

That’s a long time. Not quite half my life ago, but getting closer to that benchmark every day.

Twenty-five years. Wow. Every time I think about it, that’s all I can say.

In many ways, my practice today is more like it was in the beginning than ever before. I’m back down to just one staffer, two exam rooms, same number of phone lines, even some of the same patients.

In many other ways, my life has morphed into one that, twenty-five years ago, I could barely have fathomed in my wildest of dreams. My kids are all grown, all employed, all homeowners…and all pet owners; but all still healthy, happy, beautiful, competent, and utterly wonderful. I’m still married, albeit to a very different spouse. I’m thirty pounds thinner (yeah, I lost fifty, but twenty have found their way back), I’m growing my hair out, and I have over a dozen pairs of glasses to switch up my look every day. The most stunning change (for me) has been the new house.

Yet through all the personal changes, metamorphoses, and evolutions there has always been the practice. Office hours have shifted over the years to accommodate school schedules, but now that the kids are gone, the office schedule has settled in some. Yet the practice remains my joy, my job; my life’s work. Ongoing and ever changing, yet steady as the tides. August is busy with physicals; October we’re crushed with flu shots; flu season usually peaks around February; allergies blossom in the spring with the flowers. The cycle goes on.

There are changes there too, of course. Two moves and two remodelings; the shift to electronics and away from paper. Still, the things that remain continue to outweigh the changes.

The blog is still here as well Not nearly as active as in the past, but what is? Looking back, there’s lots of good stuff there. Not the least of which is this, written five years ago on the occasion of my practice’s twentieth anniversary:

But now as then, what I look forward to most is the people. They’re usually called patients, but what they really are is people who have done me the tremendous honor of allowing me into their lives at their most vulnerable; the best and worst moments of their lives; the beginnings, the endings, and everything in between. When I think of twenty years in practice, I don’t think about the three locations, the comings and goings of assorted staffers, or even the hospital staff and committee meetings. I remember the patients; my patients; my friends. Now as then, they are the reason I do what I do, and why I love what I do. Now as then, I thank you all.

Nailed it.

Twenty-five years.

Twenty-five more? Who knows?

I’d sure like to try.

Posted by: notdeaddinosaur | September 30, 2014

Timing; Following Up

Many thanks to all who responded to my conundrum about conveying bad news on a Friday. Lots of different answers confirmed my initial impression: there really wasn’t any “right” answer. I just did my best based on what I know about my patients. Just thought I’d let y’all know how it played out.

Monday came.

I picked up the phone the moment I got into the office (pretty FSM-damned early) and caught the patient before leaving for work. Conveyed the fact that I had news and that it wasn’t good. Arranged for patient (and spouse) to come for an appointment within the hour.

They reacted about as expected. It actually hit the spouse significantly harder than the patient. Tissues were proffered and accepted. They had spent the weekend reading up on some of the various diagnoses we’d discussed earlier, though not the one that it turned out to be.

But it was a good weekend for them. Mission accomplished.

Phone numbers were provided to the required specialists. More hugs offered and again accepted. After they left, I picked up the phone again and spoke with the surgeon myself, giving him the specifics and to expect the call. He reassured me that the patient would be taken care of promptly. In my experience with this practice, it usually means surgery will ensue within the week.

And yet…

It’s now more than a week later, and I haven’t heard anything from either patient or specialist. Chances are that surgery has already occurred, a definitive diagnosis has been obtained, and further treatment is being planned.

But I know nothing. Out of the loop. Radio silence.

I’m confident that my patient is being well cared-for. But what about me? I’m still worried.

I know how whiny that sounds. I know I’m not the one facing major surgery and potential further treatment for a life-threatening illness. But still; I care. I don’t want to bother the busy surgeon by calling and bugging him. I’ll probably get a letter from him eventually. And I certainly don’t want to bother my patient or the spouse. It’s not their responsibility to keep me informed.

But still; not knowing is difficult. Karma for having waited until Monday? Perhaps.

Oh well.

 

 

Posted by: notdeaddinosaur | September 20, 2014

Timing

The history was concerning. The exam was alarming. Labs were sent; imaging ordered; possible diagnoses, including dire ones, were discussed at length. A hug was offered and accepted, and the patient left with assurances that I would call just as soon as I knew anything.

The next day the radiologist called, which is never good. It wasn’t. Then the labs popped into my inbox. All the information was back. It was time to call the patient.

But I didn’t.

Why not?

It was late Friday afternoon, and I made the conscious decision to not make the call right then.

Here’s how I looked at it: either the patient got to spend the weekend not knowing, or knowing the worst but not being able to do anything about it for three long days. I elected not to ruin the weekend.

Was I right? Was I wrong? I don’t know.  I asked myself how I would feel getting that kind of call late on a Friday, and that’s how I decided. It was my call, for better or worse.

First thing Monday morning I’ll pick up the phone and make the calls to the patient, the surgical oncologist, and do whatever else it’ll take to get the ball rolling. Surgery will likely ensue within days; the surgical oncology group is really good about not making people wait.

But for the moment, I’ll carry the burden of knowledge alone, letting my patient enjoy a beautiful weekend. Well, as much as possible waiting for this kind of news.

What would you have done?

Posted by: notdeaddinosaur | September 11, 2014

Hypochondriasis (Part 2)

Even paranoids have enemies [citation needed]* and even hypochondriacs get sick.

I have a patient who is a full blown hypochondriac sufferer of health anxiety. He firmly believes he has full-blown AIDS after a single extramarital sexual contact (non-genital) one month prior with a woman not known to have HIV. (Reality check: the other person didn’t have HIV, the specific contact as described was ridiculously unlikely to have transmitted the virus had it been present, and AIDS takes months to years to develop after actual HIV infection.) He once believed his kitchen counters were radioactive because of a news reports of toxic spillage into a creek next to his housing development. He was also concerned about having inhaled particles of styrofoam doing a project with his kid, which then made their way through through his body and were coming out in his saliva. In short, he has it bad.

But he called a few weeks ago with a new concern: his blood pressure was high at another doctor’s.

So I brought him into the office and checked his blood pressure. Sure enough, it was 160/110. Last year at his physical it had been 120/80.

He wasn’t having any symptoms (surprisingly); no headaches, no chest pain, no visual disturbances. He was just very worried about his blood pressure, which wasn’t even inappropriate.

Of course, we don’t make a diagnosis of Hypertension on a single reading. By definition, the blood pressure has to be elevated on three separate occasions before the diagnosis can be appropriately made (in the absence of symptoms and/or evidence of end organ damage). Could have been too much coffee, not enough sleep the night before, energy drinks. Any number of things can cause transient blood pressure elevations.

I sat him down and explained all this. Somewhat to my surprise, he took it fairly well. I suggested that he begin a program of regular exercise (walking 30 minutes a day, every day) and limit sodium in his diet, then come back in a few weeks and we’ll check it again.

Chances are that he does indeed have essential hypertension (he has a positive family history, as do a great many people; it’s a very common condition) and that he’ll wind up on medication for it. But I was impressed that he finally came in worried about something worth worrying about.

So how do you know when that hypochondriac is really sick?

Generally because they present with something completely different, or with objective findings (like abnormal vital signs) instead of merely subjective complaints. But the only way you’re going to know that is to keep open the lines of communication with them, even as frustrating and time-consuming as it can be.

Even though I know this guy generally isn’t going to have something serious, whenever he calls I go ahead and see him, listen to his concerns, perform an appropriate examination and testing when necessary, before blithely reassuring him nothing is wrong. There usually isn’t. Except when there is.

 

*Mixed attributions, to both Henry Kissinger and Golda Meir.

Posted by: notdeaddinosaur | September 10, 2014

Hypochondriasis (Part 1)

HYPOCHONDRIAC: a person who is abnormally anxious about his or her health.

“Am I a hypochondriac?”

It’s a question I hear with quite some regularity, almost never from people who suffer from bona fide anxiety disorders related to their health.

No, the fact that all you have is a simple upper respiratory infection — the common cold — instead of a potentially lethal strain of H1N1 avian flu does not qualify. Not when your response to my reassurance is relief. That’s completely appropriate, and I have no problem providing all the reassurance you need. Whether it’s explaining why your headache that goes down the back of your neck that worsens when you fight with your spouse is definitely not a brain tumor, or that the itchy rash on both arms and one leg can’t possibly be shingles, I’m good. Confirming that what you have isn’t serious is right in my wheelhouse.

I never actually use the term “hypochondriasis,” mainly because it’s not particularly useful. These individuals have a real disorder; it’s just not physical. It’s also known as “Health Anxiety”, a term I swear I came up with on my own, completely independently from Wikipedia. Because that’s what it is: an anxiety disorder.

Have you ever been worried about something? Really worried about something potentially serious? My working assumption is that everyone has. If you think about it, you’ll realize these patients are miserable. Their hearts race, they can’t stop their mind from working overtime — forget about sleep. Whether it’s cancer or AIDS or Ebola or Lyme — whatever happens to have been making the media rounds most recently, these people can’t get their minds off their bodies.

Ordinary sensations become magnified and over-interpreted until they are convinced there’s something dreadfully wrong with them. Sometimes these symptoms cross over into delusions — fixed false beliefs — at which point nothing, by definition, can convince them otherwise.

So what do we do with these patients?

Two answers: first, there’s what we ought to do; second, there’s what’s usually done.

In the usual course of events in a busy medical office, patients presenting with statements of physical symptoms are generally taken at face value. Those symptoms are worked up, usually with testing and imaging (“But how can you know for sure if you don’t do any tests, Doctor?”) Everything comes back negative. The feared diagnosis is ruled out. The patient is told nothing is wrong, but they don’t really believe it. So they come back again the next week or the next month or the next year, and the whole thing starts anew, wasting untold amounts of time and money, not to mention exhausting resources that could be put to better use for other patients; the ones with actual physical conditions.

What ought to be done is to address the anxiety part of the condition. Yes, it’s a mental illness. And however great the stigma, however reluctant the patient may be to bear the label of mentally, as opposed to physically ill, we do them a great disservice by repeating workup after workup after workup, inadvertently validating their perception of a physical condition.

It’s tough, I know. It’s time-consuming; boy, do I know! But how many CT scans, how many MRIs, how many scopes and specialist will it take to say enough.

We need to do a thoughtful, thorough history and a careful focused physical exam, followed by specific testing and imaging indicated by our findings. Then we need to help the patient deal with the real problem: anxiety. Believe it or not, they’ll be glad we did.

Note: please don’t flood the comments with stories of missed conditions by patients indignantly waving their incorrect anxiety diagnosis at me in anger. I’m not talking about difficult-to-diagnose conditions. I’m talking about people who over the course of many years present repeatedly with non-physiologic or changing complaints with repeatedly negative workups. For every indignant e-patient whose symptoms were dismissed causing prolonged suffering with genuine disease, there are at least ten others (probably many more) whose accurate diagnosis really is anxiety-based.

Posted by: notdeaddinosaur | September 9, 2014

Why Isn’t it Better?

Doc, my shoulder is killing me. I can’t sleep, I can’t work; you’ve got to help me.

I saw you in the office two weeks ago for this, right?

Yeah, that’s right.

Did you get the x-ray I asked you to get?

No.

Did you try the heating pad we talked about?

No.

How about the over-the-counter pain relievers I mentioned.

No.

[Deep breath]

How can I help you.

I think I need a MRI.

[Another deep breath]

They won’t let you get an MRI without an x-ray [see Third Law]

But why isn’t it better?

[Pause for several deep breaths]

Why indeed.

Posted by: notdeaddinosaur | September 1, 2014

Those to Whom the Rules Do Not Apply (In Their Opinion)

There’s a patient I don’t like very much. I’ll call her Mrs. X.

Mrs. X has definite medical problems, though she doesn’t seem to think so. Her lipids and blood pressure really are much higher than they should be. She could stand to lose a couple of pounds, and she really should be more active. She does not concur.

Every time she makes an appointment, she calls and changes it three, four, five times. After all that, she often doesn’t show up.

The first time I saw her, I identified several health issues. I told her that her blood pressure was too high, as was her cholesterol.

Her response: “I disagree.”

Say what?

“I don’t really think I have much of a problem. I’ll see if I can do something about the way I eat, but I’m not really worried.”

That made one of us. The BP was 190/114, with fasting triglycerides over 700. Her liver function tests were also abnormal (no surprise with TGs that high), so I asked her to get an ultrasound of her liver.

“I don’t think that’s necessary.”

Okay then.

She agreed to begin a medication, for which I asked her to return in three months for a blood test. She took the prescription, and vanished for a year and a half. After a while, I got a notice from the pharmacy that she was requesting a refill. I refused, telling them to ask her to call for an appointment. Six months later, she did. Then she re-scheduled it three times, no-showed once, called again, and finally came in…late.

Without exaggeration, I can say this patient has repeated this cycle at least three times since I’ve known her.

Make no mistake: I have plenty of patients who are reluctant to take my advice about their health. I’m not even quite sure what it is about this person that rubs me the wrong way.

Why does she expect me to continue calling in prescriptions without seeing her to monitor them? It’s as if she doesn’t seem to feel that the rules for everyone else (coming to appointments on time, for example) should apply to her.

As I say, I don’t quite understand why this particular patient has this effect on me. Suffice it to say that I cringe a little whenever I see her name on the schedule. Then I reassure myself that she probably won’t show up, and two out of three times I’m right. But when she does, I know it’s going to be a frustrating encounter.

Is there anything I can do? Firing her is an option, though a bit of an over-reaction as I don’t really have grounds for something that extreme. Stop prescribing without visits? I have, though I fear for her health.

I guess I’ll just keep on muddling through.

Posted by: notdeaddinosaur | August 24, 2014

Breakfast

Puffy Pancake:

photo (2)

Hazardous mainly to the waistline.

Posted by: notdeaddinosaur | August 17, 2014

Muscle Memory

Piano

 Muscle memory is a marvelous mechanism. Now that I’ve gotten that alliteration out of my system, let me explain.

The piano pictured above is a family heirloom Bluthner grand piano built in 1909. We know this because we found the serial number inside, then looked it up on the Bluthner age table. It was brought over from Europe by my mother’s family in the late 1930s. My uncle had it for a number of years, then my parents took it when he died. I’ve had it since about 1985. When we recently downsized, we made sure there would be a dedicated space for it — and what a space it is! Suffice to say the picture barely does it justice. After several months in storage, we finally got it to its new home. Then last week we got it tuned.

Many have asked me if I play. My response is, “I used to.” I took lessons all the way through high school, and apparently became good enough that my piano teacher sat me down and said, “I want you to think seriously about Julliard.” It was a mark of how much I loved her that I didn’t let the first words that sprung to my mind pop out of my mouth: “But Libba, their pre-med sucks.”

I kept my hand in pretty well for the next few decades. Through my 20s and 30s I would sit down and teach myself pieces from this old Schirmer Handel album that contained a Passacaglia from high school. I got to the point where I could play more than a few of them entirely from memory. Then kids came along and started demanding more of my time and attention, as did the medical practice with its hundreds of patients. Gradually I stopped going into the living room and futzing around with the Handel. Finally, I got to the point where I could only play the first few notes of a few pieces before my fingers fell apart.

But now…

The freshly tuned piano sits out in the open. The guy has left the lid open, allowing all of the sound to escape the confines of its old black hardwood case. I sit.

And can barely play more than a few notes.

But I fish out my old music book and leaf through the pages.

Here; let me try this one. Slowly, I begin to play. Studying the music after those first few notes, I continue, gratified as the familiar tunes emerge. Plenty of sour notes, of course. My fingers have to re-learn what an octave feels like, the shape of different chords in my hands. It may be called “muscle memory” but there’s a good bit of proprioception as well. Gradually, I make my way through the pieces. Even though the notes aren’t all there, I find the intonations still are. Legato here, I remember; these notes accented; forte the first time this figure appears, then piano for its echo.

I have to admit I’m surprised at how quickly it starts to come back.

I’m reminded of a Beethoven quote my sister told me about:

To play a wrong note is insignificant.

To play without passion is inexcusable.

Plenty of passion left in these old fingers, even as I fumble for the notes.

Maybe someday soon I’ll be able to say “Yes” when asked, “Do you play?”

 

Note to this crotchety old guy in his 80s whom I’ve known for years: It’s ready for you whenever you come to visit.

Posted by: notdeaddinosaur | August 3, 2014

Marble Dinosaur Egg: “What’s Your Concern?”

Another in a continuing series of the Dinosaur version of “clinical pearls”. Okay, so the series consists of three other posts, all in 2007:

  1. Medication adherence
  2. Biliary symptoms
  3. Extending your scale

But hey. Here’s another.

One of the most important things we teach medical students is to elicit any specific concerns patients may have about their conditions. Many of them get pretty good at it, though by the time they get through the rest of their training, perilously few of them — now that they’re called “attendings” — are still doing it. Yet I maintain it’s still one of, if not THE most important thing you need to elicit from the patient. Here’s why: if you don’t address whatever the patient is really worried about, that patient is not going to be completely satisfied with the encounter.

The major reason doctors stop trying to elicit this critical information is their perception that it takes too much time. They believe broaching the topic will open up a can of worms, as the patient drones on and on about all kinds of intangibles.

Wrong.

Actually, it’s as quick and easy as it is important. And here’s the kicker: it’s your chance to look outrageously smart, since the vast majority of the time, the patient is worried about something so far-fetched and different from everything in your differential that addressing it — and easing the patient’s real concern — is quick and straightforward.

Here’s how to do it: last question of the interview (phrasing options, depending on the presenting complaint, the seriousness of the differential, and the sophistication of the patient):

  • What’s your concern?
  • Is there anything specific you’re worried about?
  • What did you find when you googled this?

Some examples:

A patient rattling off symptoms of MS as if he’d read the textbook:

  • “What did you find when you googled this?”
  • “I didn’t.”
  • “Well, is there something specific you’re worried about?”
  • “Yes, a brain tumor.”

Piece of cake to reassure him that’s not what it was. Interestingly, once he’d heard that, he took the possibility of an MS diagnosis totally in stride.

Next: an older woman presenting with a complaint of her arm shaking, with a story very worrisome for partial seizures.

  • “What is it you’re worried about?”
  • “Parkinson’s disease.”

Last thing anyone would think of, given the specifics of the history. But very easy to explain why. Of note, the (young) neurologist she saw never asked if she had any specific concern, and was floored when I told him she was worried about Parkinsons. Never occurred to him.

Easy ones:

Sore throat, stuffy nose, cough in an adult. No fever.

  • “What’s your concern?”
  • “I want to make sure it’s not strep.”

Thirty second explanation and everyone’s happy. You could go on for half an hour about upper respiratory infections and viral pharyngitis, but if you never said, “Strep” (preceded by “not”) that patient would leave unsatisfied.

Tough ones: (mainly when there’s the potential for something serious, and the patient knows it)

Bloating, weight gain, early satiety, urinary symptoms for two to three months in a 50-something woman:

  • “What are you afraid it is?”
  • “Some kind of cancer.”

My answer: “That’s definitely a possibility. Let’s do everything we can to find out as soon as possible.”

By and large, though, when you take the time to ask something simple along the lines of “What’s your concern?” patients will come up with things that are so ridiculous from a medical standpoint that it would never occur to you to specify that that’s NOT what they have. The only way you’ll find out is to ask.

Do so.

It takes hardly any time at all, and the benefits in terms of both patient satisfaction and looking really smart are significant.

 

Posted by: notdeaddinosaur | July 30, 2014

Good Guys and Guns

Just in case there’s anyone left who hasn’t heard, there was a shooting in a hospital last Friday. A mentally ill patient brought his legally-owned gun into his psychiatrist’s office, where he proceeded to shoot and kill his case worker. He then pointed the gun at the doctor, who ducked behind a chair, drew his own legally-owned, concealed-carry pistol, and proceeded to shoot the patient in the arm and torso, disabling him and preventing him from utilizing the rest of his ammo (approximately 40 bullets total).

Official comment was swift and relatively unanimous:

Yeadon Police Chief Donald Molineux said that “without a doubt, I believe the doctor saved lives.”

“Without that firearm, this guy [the patient] could have went [sic] out in the hallway and just walked down the offices until he ran out of ammunition,” the chief said.

Wow. There it is. Can’t argue that at that specific time, in that specific place, in those specific circumstances, a guy with a gun he wasn’t supposed to have (per hospital policy) shot an armed individual who had already killed, preventing him from killing more people.

No, the first guy should never have had the gun. No argument there. And as it turns out, at this particular time and place, the doctor’s actions were appropriate. (The word “heroic” has been used; I do not disagree.) I can hear it now; all the 2A fundamentalists gleefully preparing to jump me:

“See! How can you possibly doubt the wisdom of our position now? A good guy with a gun stopped a bad guy with a gun.”

Yes. Yes he did.

How does this change my stance on responsible gun control? Not much. Why not? From the Harvard Injury Control Research center:

  1. Guns are not used millions of times each year in self-defense.
  2. Most purported self-defense gun uses are gun uses in escalating arguments and are both socially undesirable and illegal.
  3. Firearms are used far more often to intimidate than in self-defense.

References and more here. Rare events are rare. The fact that people win the lottery every day doesn’t make the purchase of a ticket a sound financial investment.

So in what way, if at all, has my thinking changed? This: Successful, legitimate use of concealed firearms is so rare that, to be honest, I doubted that it ever really happened at all. I now admit that, clearly, it does. At least it did. This once.

Do I intend to seek training in order to procure and carry a weapon of my own? No.

Do I continue to believe there are too many guns in this country without enough adequately enforced regulation, producing orders of magnitude more suffering and death from firearm violence than in any other developed country in the world? Yes.

Extending deepest condolences to the family and friends of the slain caseworker, Theresa Hunt, and wishes for a speedy recovery to Dr. Lee Silverman.

Posted by: notdeaddinosaur | July 21, 2014

Personae Public and Private

The house is done; we’re all moved in, mostly unpacked, and just starting to get organized. The guest room is my temporary writing room. No more excuses. Back to blogging.

My post analogizing car seats to vaccines has taken on second life thanks to a cool Australian site (Thanks, Mamamia of Oz.) This in turn has generated more comments (thanks, all!) including a long, thoughtful one from Patrick, who begins thusly:

I honestly believe there is fault on both sides of this debate. Vilifying and ridiculing each other doesn’t bring about good health results.

I feel the need to clarify something here:

I am not the same in person as I am on my blog.

In person, dealing with patients one by one, I neither vilify nor ridicule. I take my time, explaining in however much detail a given patient or parent wants to know, about anything and everything. How does this blood pressure medicine work? Where to kidney stones come from? Why won’t you give me an antibiotic for my cold? Is there any substance to these scary things I’ve heard about vaccines?

Even when people clearly do not believe what I am telling them (not “do not understand”, but “do not believe”) I remain polite, as I try to persuade by explaining. Analogies; stories; diagrams; articles; whatever it takes. I strive at all costs to educate.

So what happens when, after explaining AND ascertaining that the patient understands, she says in essence, “I don’t believe you.”

Nothing.

I don’t tie the kids down and vaccinate the m against the parents’ will. I don’t yell, I don’t wag my finger, I don’t shake my head sadly as I leave the room. Nothing.

Above all, I remain professional.

After a while, though, all those encounters begin to take their toll. Being called a liar tends to get me down. News flash: I’m human. So what do I do?

I take to the blog and hammer away at the idiocy of the antivaccine leaders and the sheeple who follow them. I flay the alt-med charlatans with words (though not nearly as eloquently as these guys.) Yes, I ridicule. Yes, I vilify. Yes, I shout from the hilltops, spreading far and wide the truth of science: vaccination works. But only online.

I find it amusing to intentionally adopt a far more curmudgeonly attitude here than I would ever dream of displaying in meatspace. It’s part of the fun of blogging, which is why I’ve been doing it now for almost eight years.

All I ask is recognition that my public blog persona is different from my personal, real self.

 

Posted by: notdeaddinosaur | July 12, 2014

Built a House (27): Final

House final

It’s done. We’re all moved in. So is our stuff; well, most of it. The piano arrives in a few more days. Then all we have to do is unpack, hang art, paint; you know, make it ours.

Once that’s all accomplished — or at least once I’ve cleared away a spot to sit down with a computer — real blogging will return. For all of you who followed along (three or four, I think) thanks so much for hanging in there with me.

 

Posted by: notdeaddinosaur | June 29, 2014

Not Just Tacky…

Wandering around Lowes picking up stuff for the new house, I came across this:

Tiki tacky

How tacky is this? Not just tacky. It’s….

 

 

 

…Wait for it…

 

 

 

Tiki tacky.

Posted by: notdeaddinosaur | June 25, 2014

Building a House (26)

House 26 (2)

Landscaping is in. Sod will be placed either the day before or the day of settlement, still on target for next week.

We had our walk through yesterday and everything looks great. Well, except for the dozens of sticky dots indicating painting and spackling imperfections to be addressed by yet another once-over by the painters and trim guys.

Moving day tentatively set for week after next. The journey is coming to an end…with a brand new one about to begin.

 

Posted by: notdeaddinosaur | June 16, 2014

Yahrzeit

Carousel 6-0057 (2)

28 years. Gone from our lives, never from our hearts.

candle

Posted by: notdeaddinosaur | June 15, 2014

“Energy” Does Not Mean What You Think it Does

Every time I think I’ve seen it all, something new blows me away:

Energy wataah

For those with trouble reading the fine print, this is “Energy Wataah”, on the shelves along with regular “Wataah”. As soon as I saw that word “Energy”, I thought “caffeine”. But no. Here’s what that green fine print on the label says:

Forget about caffeine and sugar. Ultra pure water with just enough oxygen is all the clean fuel your body craves.

WTF?

Water and oxygen are both critical for proper bodily functioning, but “energy”? “Energy” or “fuel” for the body comes from calories, found in carbohydrates (like sugar), fat, protein, and alcohol. Nothing else contains calories. Water and oxygen are necessary for burning them properly, but no matter how you twist the semantics, they’re not “energy”.

Here’s the thing, though: anyone know what you get when you add oxygen to water? Anyone?

Hydrogen peroxide. ( 2 H2O + 02 –> 2 H2O2)

Not really. That equation is thermodynamically backward. Bubbling oxygen through water will just give you water with bubbles of oxygen, which will probably come out of solution, collect at the top of the bottle, and escape into the atmosphere the moment you open it.

Besides, drinking oxygen isn’t going to do a thing. Oxygen is transported through the body attached to hemoglobin, a protein found in red blood cells. Red blood cells pick up oxygen when blood flows through the lungs, not through the stomach or the intestines.

This product makes no sense physiologically, chemically, or thermodynamically. Yet somehow this company figures it can get unsuspecting scientific illiterates to fork over six bucks for twelve little bottles of this stuff.

Unbelievable.

Edit: Clearly this is a New England based company. If it were in Philadelphia, they’d call it “Wooder”.

Posted by: notdeaddinosaur | June 14, 2014

Building a House (25)

photo (3)

The front door has been painted black, and the final trim/flashing/whatever-it’s-called has been added across the bottom parts of the roof line over the garage. Now the outside just needs some sealing and painting (mainly the half columns on the front porch), landscaping, and sodding.

Inside is practically done. They’re working hard on the final painting and trim; then it needs a really thorough cleaning. Everything still on schedule though.

 

Posted by: notdeaddinosaur | June 11, 2014

Driving While Hypertensive

The Second Law of the Dinosaur states:

It is impossible to make an asymptomatic patient feel better.

So true.

Chapter 2 of my book, Declarations of a Dinosaur, discusses how I handle a patient who may be asymptomatic at present but who will not remain so for long without taking my advice. Essentially, I explain in as much detail as necessary to create just enough anxiety, which can be relieved by doing what I say, be it taking pills, quitting smoking; whatever.

Another way of looking at it is that although the patient may not feel there’s anything wrong with him, my anxiety spikes when I see things like a hemoglobin A1c of 14 %*. All I have to do is find a way to get my patient to feel the same level of alarm as I feel.

This is what I did a few months back when I saw an African American gentleman with a blood pressure of 210/130. He hadn’t been to see me in quite a while (I think his BP had been a little elevated then and he was afraid of what it was going to be now). It also turned out that his LDL was 180, and his A1c was 12%. I felt like I was on the verge of a cardiovascular event just sitting there in the room with him! With that collection of risk factors, he was literally a heart attack waiting to happen. And that’s what I told him.

He felt fine. No chest pain; no headache; no retinal changes. No symptoms at all (which was why he didn’t meet the criteria for a diagnosis of Hypertensive Urgency with its attendant trip to the ER). Still, as I explained to him, if I were to get a phone call the next day that he had dropped dead of a stroke, I wouldn’t be surprised.

He hated pills. That was another reason he hadn’t returned earlier. Carefully prioritizing the situations, I prescribed two antihypertensives (in a single combination pill) and a statin. Hardly optimal therapy, but I wanted to start him as slow as I felt was safe, explaining at length exactly how scared I was, and how important the pills were.

He said he understood, taught it all back to me to show he got it, and thanked me, setting up an appointment the following month to see how he was doing.

Job well done! Or so I thought.

Next month he comes back.

“How are you doing with the new medicines?” I ask.

“Well, I didn’t start them.”

Aack!

“Why?”

“I don’t know.”

Double aack!!

Blood pressure was still over 200. Another month closer to that stroke. How could I have failed so utterly to get through to him? No idea. I had to try something else; some other way to communicate to him the emotions these encounters had produced in me.

I had an idea:

“Listen,” I began, “Have you had the conversation with your sons about ‘driving while black’?”

“Oh yes,” he replied. “Of course I have.”

“Okay,” I continued. “Do me a favor. Think for a minute about how you would feel if, after you had this conversation with your son, knowing what you know about the world we live in, he came home one night and told you that a police car tried to pull him over, but he managed to ‘get away’? Or that he was stopped, and boy did he give that cop a piece of his mind. Somehow, he lucked out, and got off without serious consequences. But wouldn’t your heart be in your throat, aware of the risk he had taken? Even worse, that he didn’t even seem to recognize it?”

My patient was nodding.

“Well, that’s how I felt hearing that you’re not taking any of the meds I asked you to. Seeing how high your blood pressure still is gives me palpitations. Please, please, please…please start taking the pills.”

This time I got through to him, and I’m pleased to report that three months down the road, we’re on the right track at last.

 

 

*(corresponding to an average blood sugar of 355; poorly controlled diabetes, with increased risk for heart attack, stroke, blindness, kidney failure, impotence, etcetcetc.)

Posted by: notdeaddinosaur | June 9, 2014

Building a House (24)

House 24
We now have trim over the garage and windows, a lamppost, and downspouts. The deck — really just a landing and a few stairs — out back is also done:

20140609-213137-77497056.jpg
Just a few more weeks to go.

Posted by: notdeaddinosaur | June 4, 2014

Building a House (23)

House w-shutters

Brick is completed and cleared from the front yard. Shutters are up. The deck is going on the back (really just an oversized landing with a small flight of stairs.)

Inside: tile is complete. Finishing is in progress.

Closing 4 weeks from today; on schedule.

 

Posted by: notdeaddinosaur | May 31, 2014

Building a House (22)

House (22)

Finally the brick is done. Actually, there’s still one small row of it to go under the front door, but clearly the vast majority is completed. The “holes” over the garage doors and window are where the trim will go. The front door will be painted and shutters will be added to the single first floor window.

Indoors; well, indoors is magnificent! Hardwood flooring is down (and protected with cardboard and duct tape), the kitchen cabinets are in, as are the counters (covered with protective plastic that makes them look weirdly blue.)

Still a lot to do: bedroom carpets, installing appliances, finishing up the tile, trim, painting, and fixtures. Outside there’s a lamp post that still has to go in (whenever the brick is finally moved out of the way), a light between the garage doors, and a tiny deck out back. Plus grading, landscaping, and sodding.

However we cut it, though, it’s definitely closer to the end than the beginning.

 

 

Posted by: notdeaddinosaur | May 31, 2014

American Rights

Americans have rights. Most of these rights have limits, though. For example, even though the First Amendment to the Constitution guarantees the right to free speech, Americans do not have the right to yell “Fire!” in a crowded theater.

There is one right, however, that would appear limitless. I’m referring of course to the right to be stupid. I suppose this means that someone can walk into a gun show and yell, “Bad guy!”

Posted by: notdeaddinosaur | May 24, 2014

Urgent Hypocrisy

I received a solicitation in the mail to apply for a position at a new company moving into my area, forthwith to be known as the “Facility for Urgent Care, Killer-Docs, that’s going to be opening a new office nearby:

FUC, K-Docs is looking for physicians who enjoy the practice of medicine, and the chance to focus exclusively on patient care. If you are looking for freedom and autonomy without the heavy financial and administrative burden associated with establishing and maintaining a practice, FUC, K-Docs may be right for you.

Cool. Unlike too many other primary care docs these days, I still very much enjoy the practice of medicine. It just so happens that I have found the greatest freedom and autonomy comes from having my own practice instead of being an employee. But hey; maybe this is something I should think about.

I read on:

Responsibilities include, but are not limited to:

  • Providing the highest quality* patient care while on shift.
  • Managing all patient care at the center while on shift.
  • Supervising all medical staff while on shift.
  • Ordering and reading all diagnostic x-rays and labs.
  • Ensuring medical staff follows proper protocols and conducts patient callbacks.
  • Ensuring pharmacy and CLIA approved laboratory compliance with regulations.
  • Ensuring center has all the necessary urgent care equipment, supplies, and medications.
  • Ensuring accuracy of ICD-10 coding.
  • Participating in the hiring and training of medical staff on shift.
  • Compiling quality data and addressing with medical staff as needed.
  • Participating in monthly conference calls with Chief Medical Officer
  • Ensuring all charts and medical records are accurately completed in a timely manner.
  • Ensuring patients are discharged with detailed instructions.
  • Collecting biological specimens and process them in the lab when needed.
  • Adhering to all center policies and procedures.

Excuse me? Only four out of the fifteen items on that list address actual patient care (bolded by me). Sounds to me like all of the hassles of running a practice — a pretty good-sized one at that — without any of the actual authority of ownership.

How could that introduction, followed by that list, be written without the author’s head exploding from sheer irony? It’s downright Orwellian.

It even turns out the guy opening the place isn’t even a physician. Figures. More money to be made getting doctors to manage, supervise, compile, ensure, participate, and adhere than by actually practicing medicine.

Sorry, dude. Not buying it.

* Defined as…?

Posted by: notdeaddinosaur | May 23, 2014

Building a House (21)

20140524-222326-80606026.jpg

Approximately one half of the brick done. It took three days, which means that the unofficial estimate of another three days sounds about right. Unfortunately, nothing is going to happen until after the holiday weekend, though we’ll probably still go out there and keep poking around.

Posted by: notdeaddinosaur | May 22, 2014

What if Car Seats Were Like Vaccines

What if a big TV station, say WTOP in Washington DC, came out with a blockbuster story claiming that infant car seats were implicated in cerebral palsy? After all, something like 99.7% of babies diagnosed with cerebral palsy had been brought home from the hospital in a car seat. In fact, every single time they went anywhere in a car, they were strapped into them. That’s an impressive number. There has to be some connection!

Imagine video of kids crying piteously as they’re buckled into the wretched contraptions. After all, car seats are restraining and uncomfortable. Kids hate them! But parents have been duped into using the damn things claiming it makes their children safer. Pshaw! How could a baby be safer anywhere other than in its mother’s arms?

Suppose this idea gained traction. Cerebral palsy is a dreadful thing! Why take the risk? Don’t use those nasty old car seats. Besides, don’t you know that the doctors who recommend them are all getting kickbacks from the manufacturers? [Less preposterous than kickbacks from vaccine manufacturers. Far more money in car seats.] Some Playboy celebrity reality centerfold comes out as the spokesperson against car seats. Suddenly there’s pushback from new parents who want to decide for themselves what the safest way is to transport their precious bundle. Never mind decades of car seat research. They may not be automotive engineers, but their parental gut feelings are good enough. Besides, no automotive engineer ever had to listen to their baby cry whenever she gets strapped in.

Facebook communities emerge where car seat refusal is supported and celebrated as the newest way to keep babies safe. Parents are carefully steered to “research” that hypes the dangers of CP. “Why take unnecessary risks?” becomes their mantra. Because the hype is scary. Parents of kids with CP conspire to sue the car seat manufacturers, because “Someone’s got to pay!” Why did this happen to their child? No one has any good answers [hint: It's not birth trauma] and vague discussions about prenatal injury to the brain like “Sometimes these things happen” is just not good enough.

Of course there’s no plausible connection between car seats and cerebral palsy. But that doesn’t matter. Studies are done to try and prove car seats don’t cause CP, which is technically impossible, since you can’t prove a negative. The anti-carseaters deny that they’re against car seats. They just want “safe” ones — defined as ones that don’t cause cerebral palsy. Do a large double-blind trial: randomly assign some babies to car seats and some to be held in mom’s arms and see how many in each group develop CP, they cry. It will take nothing less to convince them.

What happens? By and large, nothing much. Most kids don’t develop CP, however they travel in cars. And the vast majority of babies who ride in mom’s arms arrive safely at their destinations. There is a small uptick in infant fatalities that steadily grows as more and more people refuse to use car seats, but not many people take notice. The occasional family is devastated by the loss of a baby in a crash, and vow to tell their story high and wide. They do, but the only minds it changes are the ones that weren’t already made up.

Far-fetched? Sadly, not so much.

 

Edit: NOT plagiarized from this, which in turn is probably not plagiarized from this or this.

h/t TBTAM for the second 2 links.

 

 

Posted by: notdeaddinosaur | May 20, 2014

Building a House (20)

House 20

New mailbox.

Inside: Painting has occurred. Final electrical has begun. Most light fixtures are in, though not all. On track to close in about 6 weeks.

Posted by: notdeaddinosaur | May 20, 2014

To Refill, or Not to Refill?

I have an ethical dilemma, and would appreciate the opinion of the Collective.

Patient with controlled hypertension who hasn’t been in for a visit for over 2 years keeps requesting refills on her medications, despite multiple requests and decreasing quantities first of refills, then of medication quantities. We are finally down to my Note to Self in the Refill field, “No more refills without visit.”

Pharmacy request comes in for refill. No call from patient; no appointment on the schedule. Ideally, I like to see my hypertensive patients twice a year, but I’ll settle for annually. This patient hasn’t been in for over three years.

What to do?

First round of analysis: What are the harms of going off BP meds? Answer: potentially significant, in that patient is on several meds which are controlling BP well, and has other cardiovascular risk factors. 

Next, anticipating the patient’s objections to a visit: Why exactly to I need to see her? We call it “monitoring”; making sure her BP is still controlled, and that there are no side effects or other related (or unrelated) problems emerging. “But you never do anything,” I hear her responding, and it’s hard to argue. It certainly seems that the greater benefit comes from continuing to authorize the refills.

What’s the down side? This: What if something changes, and either the BP is no longer controlled, or something else happens as a result of the meds (kidney failure comes to mind)? I can just hear the lawyer bellowing, “Why were you continuing to prescribe these dangerous medications without monitoring them?” causing the jury to come back and strip me of all my worldly goods. 

So what to do? Refuse the refill and risk having her stroke out from uncontrolled blood pressure? Or keep on prescribing without seeing her? If so, how long? Four years? Five? Ten? 

Another option, of course, is discharging the patient from my care. But that’s not going to help her in the long run, nor me in the short run. (Discharging a patient is at least a 30-day process, and involves certified mail, which costs money and involves a post office run.) I would prefer not to go that route.

Thoughts?

 

Posted by: notdeaddinosaur | May 16, 2014

Building a House (19)

House 19

And garage doors.

Not sure why the brick hasn’t gone up yet.

We have reason to believe that painting will begin inside today.

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