Posted by: notdeaddinosaur | January 8, 2015

How to Kill a Doctor

It’s really quite easy to kill a doctor. Here’s a step-by-step process guaranteed to succeed at least 400 times a year:

Start early.

Be sure to denigrate medical students whenever possible. Even if they’ve come to the profession later in life and have accomplished all kinds of amazing things personally and professionally (which don’t count, of course, since those are other professions) they don’t know squat about medicine and you do. Make sure to emphasize their ignorance and inexperience at every turn, because it’s the only way to prove that you know more than they do, which of course means that you’re a better person than they are. The fact that as a group they’re all at the very top of their peer group in motivation and intelligence is irrelevant.

Tell them they’re lazy when they say they’re tired after being up for 36 hours (since they’re not residents, they don’t have work hour restrictions). Tell them they smell of formaldehyde from the anatomy lab and make amusing gagging noises whenever you see them. If all else fails and they are actually able to competently work up a patient, plus answer the most esoteric questions you can think of, impugn their sexuality or tell them they dress weird. Don’t worry about being judgmental; patients are the only ones deserving of your respect. And other doctors, of course; well, the ones ahead of you in training at any rate. But only in your own specialty.

Don’t let up once they graduate from medical school.

The first year of residency training is a great time to kill doctors. They’re foundering around desperately trying to figure out how to function in their new roles. Most of them are also drowning in debt and watching as their non-medical friends (if they still have any) get married, buy houses, and have kids; you know, have lives. Yell at them for everything that goes wrong with their patients, whether it was their fault or not. Tell them it builds character.

Hospital administrators have an important role.

Make sure the physicians you hire understand how important it is that they show up for their shifts, but don’t give them any input into the schedule. Ignore their scheduling requests, but tell them they were lost; better yet, imply that they were never sent. Same with messages, committee meetings, and other administrative responsibilities. Make sure there are enough of these to make it impossible for doctors to take care of the patients. Otherwise the patients may actually think it was the doctors, and not your wonderful hospital (or hospital system) responsible for their recoveries.

If you’re not a particularly affluent institution, make sure that the food, decor, and customer service at your institution is as bare-bones as you can, but lump everything under “Medical care” in your patient satisfaction questionnaires so the doctors get blamed. Then tie their payments to those satisfaction scores. Win-win, for you.

Be sure to switch up your EMR annually at least, but call it “Upgrading” and label any doctors who complain as “disruptive.” It helps if the main hospital, Emergency department, and Radiology departments all run separate systems that don’t interact. Make sure each system requires different passwords, and require that they be changed at different intervals. Forbid physicians to write them down. Security, you know.

Don’t stop once you’re in practice.

Pick on your younger colleagues for their inexperience. Whatever you do, never tell them they’re doing a good job. Stick them with as much holiday and weekend call as you can. After all, you’ve paid your dues; now it’s their turn. (Tell them that.) Don’t listen to your older colleagues either. They’re just old farts whose knowledge is waning. Who cares about their decades of experience? Just tune them out when they start talking to you, then nod condescendingly and walk away.

Practice that condescending look and use it at hospital staff events. Make it a point to ignore newcomers. Concentrate on talking just with your friends and laughing at inside jokes, especially when others are around. Don’t return their calls, and don’t take their calls if you can possibly help it. If you accidentally wind up on the phone with the patient’s primary physician, just tell them you’ve got it all under control, and that he (and the patient) are so lucky you got involved when you did.

Target your efforts.

None of the above actions in and of themselves is likely to drive a doctor to suicide. However if you manage to select individuals with a personal or family history of depression, those with poor social supports or self esteem issues, you can greatly increase your chances of killing a doctor. Concentrating on certain specialties where there may be easier access to more lethal means, like anesthesiology and surgery, may also raise your yield. Don’t despair, though. Intensively applying all the strategies above and more (you know what to do; much of it has been done to you over the years, and may still be occurring as we speak) to doctors in any specialty represent proven ways to kill them.

Now you know how to kill a doctor.

It’s really not that hard. The question is: Why would you want to?

Posted by: notdeaddinosaur | January 7, 2015

Patients Showing Appreciation

Everyone knows doctors are only in it for the money. Not.

The most rewarding thing about the practice of medicine is making a difference in the lives of our patients. Whether it’s saving a life with surgery in the middle of the night, handing over a newly-delivered baby, or just reassurance that it’s only a cold and not bronchitis and everything will be all right; those are the moments we all treasure.

Patients have many ways of showing their gratitude, almost all of which are warmly appreciated. From flowers in the dead of winter:


to homemade holiday cookies (even store-bought), or just the sincere “Thank you” at the end of the visit, patients’ expressions of appreciation always make our day.

But yesterday, a family went above and beyond.

There was only about two inches of it, light and fluffy. No big deal. But after leaving my office reassured that her toe wasn’t going to fall off, this teen and her mom cleaned the snow off my car.

Posted by: notdeaddinosaur | January 6, 2015

Relative Value

How much would you pay a valet to park your car?

Certainly a job consisting of getting into a car not your own, safely navigating it from point A and parking it at point B, then reversing the procedure at your request is a service that deserves compensation. The question is how much?

Does it depend on the car? Or the skill of valet?

I would say, talking to various people, that the appropriate amount lies somewhere between five and twenty dollars, depending on the specific locale.

Now consider how much you would pay someone to draw your blood, a job that consists of the following steps:

  1. Wrapping a tourniquet around your arm
  2. Palpating to locate an appropriate vein
  3. Cleansing your skin to prevent infection
  4. Passing a needle through your skin and into the vein (but not all the way through it)
  5. Attaching one or more vacuum tubes to the needle (without pushing the needle through the vein)
  6. Removing said tubes and needle, dressing the puncture wound, labeling the tubes, completing the paperwork, and processing the specimens.

Here’s a question: who deserves to be paid more? Or in other words, what is the relative value of each task?

Medicare pays $3.00 (less 1% for the sequestration) for the procedure, coded 36415. Other insurers pay from $2.25 to $5.75, if they pay at all.

Because I draw blood in my office, I can legitimately add to the list above:

  1. Reviewing current medications
  2. Inquiring about the need for any refills, and
  3. Refilling meds as needed
  4. Reviewing results when available
  5. Forwarding results to ordering physicians, when someone other than me is the one who wants the tests
  6. Communicating results to the patient by their preferred means (phone call, email, snail mail)

By adding (“bundling”) the things on the second list, I legitimately bill these encounters as Level 1 office visits. Still makes you wonder about the pricing: I guess people care more about their cars than about their arms.


Posted by: notdeaddinosaur | January 5, 2015

Mammograms for 40-Somethings

My New Years *Resolutions* are going well…five days in. The cat box is immaculate, I’m more than halfway through The Lost Gate, I’m on track to post here every single day for at least a week, and I just finished the paper today.

Speaking of today’s paper: What should I espy in the Health section of my Philadelphia Inquirer but a familiar name! My good friend Margaret Polaneczky (I get to call her Peggy), my old blog-buddy from those heady early days of medblogging quoted in an article about helping women in their 40s make informed decisions about mammograms. And here it is: Breast Screening Decisions, Peggy’s interactive online tool that *rocks*. Check it out.

For the record (and just to prove I knew her when), here’s my reaction to the brouhaha instigated by the original USPTF mammogram recommendations: Mammograms for the Masses…complete with a comment from Peggy herself. Even then she was working on the recently launched tool.

Well done, Peggy, and thank you. My 40-something ladies will love it.


Posted by: notdeaddinosaur | January 4, 2015

Beyond First World Problems

First world problems: Problems complained of by those living in a wealthy, industrialized nation that third worlders would probably roll their eyes at. Things like which car to take when going out to dinner, or where to go out to dinner, or what to order when going out to dinner.

The other day I was chatting with a gent who was fretting about getting his tax information together for his accountant. He was bragging complaining that a stock with a large capital gain was forcing him to forage around for capital losses to offset it.

That’s not just a First World Problem; that’s a “1% problem.”

Posted by: notdeaddinosaur | January 3, 2015

Affordability vs. Value

I’ve been enjoying Twitter for a while now (@DinoDocLucy for any wannabe followers). It’s providing me with links to all kinds of fascinating things I never would have found otherwise. It’s also really cool how often I come across things that have nothing to do with medicine but everything to do with my practice.

“Six Mistakes Your Sales Reps are Making”

I thought the title looked interesting, so I clicked through. It turned out that the reps in question were calling on libraries, as the  post was on a blog about scholarly publishing. Still, several points (sort of) applied to pharma and other reps who come a-calling on me.

Then came point #5: Responding to Affordability Statements with Value Arguments

…For the last several years I have been fielding pitches from a particuarly aggressive sales rep who very much wants to sell my library a backfile database at a price of roughly $150,000. When we tell him that we don’t have $150,000 available for such a purchase, the response is always a long explanation of how important and valuable the database is. We couldn’t agree more. But the value proposition doesn’t make $150,000 magically appear in our budget. …Takeaway point: Value and affordability have nothing to do with each other, and price trumps value every time.

Hello! That’s what I’ve been saying about electronic medical records all along. All the “value” they add is completely irrelevant when I can’t afford them in the first place.

That’s the biggest reason I finally adopted a free EMR. When you start by maximizing Affordability (with a price tag of zero), Value approaches infinity.


Posted by: notdeaddinosaur | January 2, 2015

Diets and Denominators

News non-flash: comparison of various diets (low carb/Atkins, low carb + low fat/South Beach, low calorie/Weight Watchers, and whatever-the-hell-the-Zone-diet is/protein-carb ratio) shows no difference in long term outcomes, defined as sustained weight loss, with the attendant presumed decrease in cardiovascular risk factors and events.

Sorry; no great surprise here. But I think it’s because nutrition research has a huge blind spot: not adequately controlling for type 2 diabetes/metabolic syndrome.

Let me explain.

I have a hypothesis that people with the inborn error of metabolism (insulin resistance) that in the setting of dietary carb overload and low levels of physical activity result in overt glucose intolerance and, eventually, diabetes, respond better to low-carb diets than people born with normal carbohydrate metabolism. By not carefully screening them out in the research, negative results are meaningless.

Current definitions of diabetes, “pre-diabetes”, metabolic syndrome, and so on center on blood sugar levels in both the short term (fingerstick glucose measurements) and long term (the 3-month horizon afforded by the hemoglobin A1c). The problem with this is that the increased cardiovascular risks from these conditions appear to manifest independently of actual blood sugar levels. Witness the disappointing results of studies of so-called “tight control”: modest reduction in microvascular disease (kidney failure and retinopathy) but no significant effect on macrovascular disease (heart attacks and strokes.) This says to me that there’s something more than just hyperglycemia going on in these patients.

We also know that lifestyle issues (read: exercise), not smoking, and treatment with lipid-lowering statin medications DO decrease these risks in these patients. But who are they?

Diabetics, of course. Pre-diabetics too, plus anyone with metabolic syndrome (high triglycerides/low HDL/abdominal or “apple” shaped fat). Women with PCOS and/or a history of gestational diabetes. These folks are relatively easy to identify, whether or not they’re excluded (or at least controlled for) in nutritional research. But I think there’s another group of folks who have this inborn metabolic error but who, because they’re already “living right” (exercising, maintaining ideal body weight, not overdoing dietary carbs) have perfectly normal blood sugar levels, and therefore completely normal A1c levels.

How to identify them? A few thoughts: family history. Anyone with any first degree relative with either diabetes or any of the above equivalents (PCOS, gestational diabetes). Or we can check insulin levels. Because the inborn metabolic error is that of resistance to insulin, these folks walk around with higher insulin levels in order to maintain normal blood sugar levels.

Control future dietary studies for diabetes — REALLY control for it — and see what turns up. Better still, select out people who don’t have it. I bet you’ll see better, more robust responses to any version of carb restriction. But until inborn errors of carbohydrate metabolism are adequately controlled for in dietary research, I don’t think there are any valid conclusions to be drawn.

Posted by: notdeaddinosaur | January 1, 2015

New Years “Resolutions”

Happy New Year to all. New month; new year; new calendar. Everything begging to be new and fresh, even while the days are still too short and the air too cold, with the worst of the winter yet to come. What cheer!

Lots of people talk about why New Years resolutions don’t work and they’re right. Hence the quotation marks.

Technically what follows aren’t Resolutions. They’re not goals, or vague aspirations like “get in shape”, “lose weight”, or “Be nicer to your sister.” (Hi, Dr. Kensingon!) They’re more like items I want to add to my daily to-to list. Things you don’t even bother to make a to-do list for because you just do them every day, like taking your pills, brushing your teeth or making your bed (all of which I do.) They’re things I really want to do each day — and often do; just not always.

In order to help myself commit, I figure I should write them down. Even better, write them down publicly. So here goes:

1. Write every day; even just a little.

It doesn’t have to be just a little, and I’m sure once I get started, I’ll often do more. I just have to sit my tush down in front of the damn screen and do it (Nike style.) I’ve reclaimed my writing desk from DDS, and even though it’s in the bedroom instead of my writing room, it turns out to be better than the kitchen table. So no more excuses. At least once a day, sit down and write. It may be a brief blog post (or a longer one), or the next installment in Dr. Lucy’s Ridiculously Simple Guide to Health and Wellness, or who knows what else. But I really would like to get back to writing every day.

2. Read every day, even just one chapter.

Maybe this is the source of a lot of my malaise of the last year, but I somehow got away from regular reading. I had a whole stack of books, but I started having trouble getting into things. Now thanks to the Jock, who gave me two new Orson Scott Card books for Hanukah (the Mither Mages series), I’ve begun reading one chapter before bed. Rather like nibbling at a box of chocolates one at a time instead of pigging out on the whole thing, I’ve decided to savor these slowly instead of “waiting until I have time to read as much as I want” (which only happens on planes anyway). An added advantage is that it keeps me away from backlit screens (cough*Candy Crush*cough) right before bed, which seems to be improving my sleep.

3. Play the piano every day, even just a little while.

A far cry from the distant childhood refrain, “Did you practice yet?” Now that my piano is right out in the open (and tuned! Thanks DDS), my Handel album sitting open and ready, I’m getting great pleasure sitting down and re-establishing that old muscle memory. There has been talk of lessons, but like those who insist on cleaning up for the cleaning lady, I want to get better first. I know how the music is supposed to sound (because I used to make it sound like that) and all it’s going to take is time.

4. Clean the cat boxes every day.

Okay, this one is right up there with pill-taking and teeth-brushing. At the moment, I confess it’s not. But it should be. Which is why I’m including it here.

5. Read the newspaper every day.

I’ve gotten a little lazy on this one. I do eventually read it, often 2-3 days (or more) at one sitting. But if I do it every day, it’s much more efficient.

6. Eat only during an eight hour window every day.

This one’s new-ish. I’ve had good experiences with modified fasting, and bad experiences with eating at night. Following this guideline should be helpful. Whatever time I first eat something in the morning, eight hours later I’ll stop. I’m definitely going to continue writing down everything I eat, which I have done every single day for over five years now. No reason to stop. And I really do have to lose the weight I’ve partially re-gained over the last four years.

7. Walk every day, at least 30 minutes.

Who am I kidding? This one’s not going to happen at least until the weather gets nicer. I’ll give it a shot, but I’m not going to beat myself up if it doesn’t happen.

Posted by: notdeaddinosaur | December 30, 2014

What Doctors are Thinking

Ever wonder what your doctor is thinking while taking your history? If we’re doing it right, we’re looking at you instead of a computer. We’re making appropriate eye contact while displaying welcoming body language. And we’re letting you tell your story with as few interruptions as possible. Clearly we are listening intently, but did you ever wonder what’s going through our minds while you’re speaking?

I’ve been thinking about this lately in the context of teaching medical students about history-taking. They’re being taught all the right questions to ask and how to ask them (body language, open-ended, etc) but it often seems like they don’t know what they’re supposed to be listening for, or how to elicit the kind of information that will let them make a diagnosis (which is, of course, the necessary prerequisite for appropriate treatment.)

So here’s an analogy to try and help both patients and learners better understand what’s going on inside the doctor’s head:

Imagine that someone is telling you a story. There are lots of different stories it could be, but the person has no idea which one it is. In fact, as far as he’s concerned, no one has ever heard the story before, because it’s the first time he’s telling it. But he’s telling it to you because he’s hoping you’ll recognize the story, and tell him how it’s going to end — or, more importantly, intervene to change the ending, if it happens to be a story that ends badly.

What are your prerequisites? First, you need to know a lot of stories. Because you can’t help the storyteller if you’ve never heard of his story. (Even if you’ve never actually heard it, you need to have heard OF it.) Next, you need to know what elements are intrinsic parts of the story, and which ones are minor details that can vary from one telling to another without materially affecting the essence of the story. There are also significant clues you can take from who’s telling you the story. Younger women, older men, little kids each seem to tell their own specific stories. Timing also matters. Some stories are told more often within several months of giving birth, or within a week of major surgery for example.

Say the storyteller begins, “Once upon a time…”

You wouldn’t immediately jump in and start asking a whole bunch of specific questions like:

  • Was there a little girl?
  • Was she in a forest?
  • Was she in a castle?
  • Was she under a spell?

No, you’d let the storyteller go on as long as possible on his own.

“Once upon a time, there was a little girl in a blue riding hood, whose mother sent her off to her grandmother’s house with a basket of goodies.”

If you’re sufficiently familiar with enough stories, you should immediately recognize that the color of the girl’s clothing may not be as important as getting her to turn around and NOT get any deeper into that forest until you’ve had a chance to do a scan and a Wolf-ectomy. Or at least make sure she’s got a hunter escort.

Even though the stories are basically the same, each person tells them differently. Think about how many different ways you’ve heard stories that are basically Romeo and Juliet.

As the storyteller is relating his tale, you start thinking about the various possible stories he could be telling. Once you start to recognize the story (or even what kind of story: is this a short one where nothing much happens of consequence, or one where things don’t end well for the protagonist?) you begin to listen for specific details from one story or another. As you hear them, they lead you down the path towards figuring out the correct story. If they’re not forthcoming, you try and ask open-ended type questions to elicit them. Things like “What kind of place was the princess living in?” as opposed to, “Was she in a forest? Was she in a town? Was there a castle?” (analogous to asking, “What does eating do to the pain?” instead of, “Is the pain relieved by eating or does eating make it worse?” Open-ended instead of yes-no.)

Once you’ve heard a hundred people tell you the story of their gallbladder (“I’ve been getting this pain in my stomach, up high on the right, for a while now, but it’s getting worse after I eat, especially fatty foods. It nauseates me and sometimes I throw up,”) or the story of their appendix, or the story of their hemorrhoids, or the story of the flu, or the story of their ulcer or their pneumonia or their MS or their UTI…you get the idea — you start to recognize it within a few sentences. You want to keep listening, though, because this just might be the person telling you the story of their brain tumor instead of the story of their migraine headaches. The best way to figure it out for sure is to keep listening, which means keep the storyteller talking.

There’s lots of overlap between stories. There are many conditions, like upper and lower respiratory infections, viral syndromes, gastroenteritis, pinkeye, and many other conditions which will all get better with time. Assuming you’re very confident that the story is one of the many short simple ones with lots of overlapping features where nothing really bad happens, recommending things like rest and plenty of fluids will often result in the storyteller living happily ever after. But your patient is counting on you to correctly recognize which story they’re telling, to know how it progresses — including how it ends — and how to intervene to change a bad ending to a better one.

If you decide too soon that you know what story it is, you may stop listening for clues to other stories and miss them altogether. Then, as the story progresses (or as the disease progresses along its natural history) you may be making things worse instead of better, because you’re not getting the right story. Many times, the most important clue is recognizing that there’s a significant detail that just doesn’t fit. The girl in the blue riding hood is being imprisoned in a tower with no doors, and happens to have really long hair. An adult with a sore throat that began with a runny nose two weeks ago is now getting much worse; Rapunzel does not have strep.

There are two basic cognitive strategies to figuring out the story. At first, when you don’t know many stories or what you can do to modify the scary ones, you do something called “hypothesis testing.” You take the first story that pops into your head and start asking all kinds of questions specifically about that story. Once you decide that’s not it, you take the next most likely one and start specifically seeking information to confirm or deny it. And so on. Thinking about it in terms of trying to figure out which fairy tale someone is telling you helps you appreciate the inefficiency of this approach.

The strategy used by experienced clinicians is called “pattern recognition.” That’s what we mean when we tell learners to “listen to the patient,” and “the patient will tell you what’s wrong.” As we listen, we hear familiar riffs: chest pain that worsens with exertion steers us toward the heart; pain with nausea after eating pushes us towards the gall bladder. We have to keep the patient talking, but we have to know how to ferret out key details that will guide our questions when we finally get around to asking them. You just need the confidence that you will recognize the story the patient is telling you.

How do you learn these stories? Aside from hearing them from lots of different patients, of course, you can read them in medical textbooks, where they are called things like “Presentation” and “Natural History”. Except in this case, you know what the story is (because the title is on top of the page), as opposed to learning how to figure out which one the patient’s telling you.

These stories have also been called Illness Scripts. Most of the academic work on them has been done with groups of medical students in small group settings. But I believe there would be value in writing them down in transcript form, just as a hypothetical patient might relay the story, with a sidebar containing the contemporaneous text of what’s going through my head as I listen to the patient. Symptom-based as opposed to diagnosis-based, I think it would be useful to entry-level medical, nursing, and allied health care students to help make the jump to pattern recognition from hypothesis testing.

Any takers for a collaboration?

Posted by: notdeaddinosaur | December 14, 2014

Latest YouTube Parody Star

Okay, not technically the star. But dancing and twisting and writhing around (and decorating a model of DNA like a Christmas tree) in the background is a very stealthy NinjaBaker:

Posted by: notdeaddinosaur | December 4, 2014

Customizing Communication, or Which One I Sent

It’s been a fascinating week or so listening to everyone weigh in on which response they thought I sent to my patient (also here.) The general consensus, unsurprisingly, was that the first was far too cheeky — not to mention insulting — to effectively convey the necessary information.  The second, of course, was the one I send every day, day in and day out. Just this once, circumstances conspired to allow me to send the first.

Let me explain.

I’d like to begin by quoting myself:

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.

The first message was perceived as an expression of my frustration with a patient who wouldn’t comply with recommended treatment while complaining about one of the manifestations of her condition. (There were also some interesting digressions about hypothyroidism and weight loss, none of which actually apply. Remember the first rule of blogging: anonymize! Suffice it to say that her TSH wasn’t 7; it may not have been a woman; the issue may not have been weight loss; etc.)

Here’s the thing, though: in real life, I don’t actually get frustrated with my patients. Really. I’ll admit this wasn’t always the case, however the older I get, the less I care. Not that I don’t care about my patients, but it’s become much easier to actually live the truism embodied by the old Polish proverb, “Not my circus, not my monkeys.” ie, My patients problems are not mine. If patients don’t take their medicine, they’re the ones who live with the consequences. (I take my Synthroid.)

This particular patient was also a health care professional herself. In fact, when I read my first email aloud, my work-spouse said, “That sounds exactly like how she talks to her patients.” Because it was. She’s a cheerful, vivacious, funny, sarcastic person who doesn’t pull punches with her patients, her family, or me. When she said, “Nah, I stopped taking [the synthroid],” it was with a sardonic smile that conveyed recognition of the fact that she was being irrational. Cost wasn’t an issue. Understanding its purpose wasn’t an issue. I don’t think she could articulate precisely why she stopped it. But she had, and here she was, back again, bitching yet again (albeit good-naturedly) about her weight.

So when the repeat blood work confirmed the condition (or at least the distinct possibility that taking the med would help) the first response kind of wrote itself. In a way, I may have been channeling her voice talking to herself. One thing I’ve learned in my own weight loss journey is that no one can be harder on me than I am on myself.

Couple of other things edited out for the sake of the blog:

After the CAPS, I added “(Sorry for shouting)”, and after “Dig?” at the end, I added (“Love you.”) Finally, before hitting the SEND button, I picked up the phone. I didn’t reach her but I left a message, “Just to let you know there’s an email coming, meant to be funny, hope you don’t take offense.” The rest of it, BTW (except for the clinical specifics) was verbatim. ie, “Big girl panties” and all.

Bottom line: She loved it. Message received loud and clear, along with a good laugh. Customized communication at its finest.

Would I ever write such a message again? Perhaps. But only if I were absolutely certain it would be received as intended, as it was this time.

Thanks again to all who responded.


Posted by: notdeaddinosaur | November 22, 2014

Which One Did I Send?

Middle-aged lady, twenty pounds overweight.

Doing everything I can, doctor. Everything imaginable. Diet: I eat practically nothing. Exercise: all the time! Weight Watchers doesn’t work. Jenny Craig, South Beach, the Zone; I’ve tried it all. Nothing works. Have to lose weight. Have to lose weight.

Yadda yadda yadda.

Oh look: a few years back I diagnosed you as hypothyroid and gave you some Synthroid. Are you taking it?

Nah; I stopped that. I just didn’t want to take it.

Hm. Send some blood work. Low and behold: TSH is 7. That’s high, and it means her thyroid is underactive, which is probably a big part of why she’s having so much trouble with her weight.

She’s asked to be notified by email, so I sit myself down at my little keyboard and compose:

Labs are back; report attached. Cholesterol, sugar, blood count all fine. BUT: I don’t want to hear one more word from you complaining about not being able to lose weight IF YOU DON’T TAKE THE DAMN SYNTHROID. Your TSH is 7. That’s hypothyroidism. Until we get you titrated to a dose that gets your TSH below 2, nothing is going to change, including difficulty losing weight. So put your big-girl panties on and let me know where you want me to send a new prescription for synthroid. Then get back here in 6-8 weeks for another TSH. Dig?

But my finger hesitated over the SEND button. Could I really send that?

I hit SAVE DRAFT and started over:

Labs are back; report attached. Cholesterol, sugar, blood count all fine, but the TSH is still a little high. I really think you should try the synthroid again. It’s almost certainly the reason you’re having so much trouble with your weight. Why don’t you let me know what drugstore you use so I can send a new synthroid prescription. Then we can check another TSH in about 6-8 weeks. Okay?

I read both versions over again. Back and forth. Over and over.

Then I hit SEND.

Guess which one?

Posted by: notdeaddinosaur | November 17, 2014

Define “Old”

Chief complaint: “I’m concerned about my balance.”

Further questioning reveals a subjective complaint of “wobbliness.” Has never fallen. No vertigo. Romberg testing is negative (standing with feet together and eyes closed sways only a little). Neurologic exam is normal.

I gently suggest that he try using a cane, mainly for reassurance while walking.

“Oh, Doctor. I don’t want to do that.”

Why not?

“It’ll make me look like an old man.”

Uh, sir: you’re 88. I think that ship has sailed.

Posted by: notdeaddinosaur | November 15, 2014

Assume Nothing

Patient with multiple medical problems (diabetes, COPD, hypertension, hyperlipidemia, headaches, arthritis; you know, your basic Baby Boomer) comes in with a new symptom: food gets stuck going down. It’s been going on for a while now and getting worse. Liquids are becoming problematic as well.

I’m worried. Esophageal cancer is the main concern here, so off he goes to endoscopy.

Good news is that there’s no cancer. Bad news is that brushings show infection with candida. It’s a yeast infection of the esophagus. Treatment begins, but now we have another problem: Why did this happen? Esophageal candidiasis isn’t something that happens to people with normal immune systems. Sure, the diabetes leaves him a little immunocompromised, but not enough for this.

Yes, he’s on an inhaled steroid for his COPD, but he specifically tells me that he’s very careful to rinse out his mouth every single time he uses it. Every single time. Very carefully.

Let’s see; what else? HIV? Nope (I tested.)

I’m puzzled. I run through the possibilities again. Is he sure he rinses out his mouth after using his inhaled steroid?

Yes indeed.

And then what?

He swallows it.

Epic WTF.

The whole point of rinsing after using inhaled steroids is to get rid of whatever medication may still be in your mouth. By swallowing it, it’s going straight down his esophagus instead of down the drain. Instead of being safely flushed away (and contaminating the sewage system, but that’s another issue) those steroid remnants are priming his esophagus for little yeastie-beasties to take hold.

“Should I not be doing that?” he asks.

Um, no. You shouldn’t be doing that.

Posted by: notdeaddinosaur | October 22, 2014

Good News, for a Change; More Followup on Timing

More followup on my post about intentionally not calling a patient with bad news on a Friday afternoon (and my karmic suffering at not receiving timely feedback after the disclosure the following Monday).

It was a 15 cm* primary malignant tumor…that turned out to be completely encapsulated! No evidence of malignancy anywhere else (and there were ten pathological specimens sent, as is customary in cancer surgery)! Stage 1! A little chemo to mop up some leaking fluid (that was still pathologically negative) and the patient will be fine.

Rarely have I experience such elation reading a path report.

The patient stopped by as well. Turns out the spouse’s work requires annual wellness checks (which we’d already done) including cholesterol levels, which I had not done when I sent tumor markers. If the pathology had been anything else (ie if it had been more in line with the radiologist’s opinion), we would have told the employer to shove it. But now that a reasonable life expectancy had been restored, I sent the test. We shared a chuckle over it.

* For any non-medical folks, yeah, that’s f-ing big.

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


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?


Did you try the heating pad we talked about?


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


[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


Puffy Pancake:

photo (2)

Hazardous mainly to the waistline.

Posted by: notdeaddinosaur | August 17, 2014

Muscle Memory


 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.


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.”


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.

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