Posted by: notdeaddinosaur | July 20, 2015

Building a Clavichord – 5

The case has been finished, as have the keys, including gluing on the sharps:

Clavichord - keys finished

If you look carefully, you can see that I’ve already started installing the strings. Just two so far in this picture, but I’ve been working on it. (Obviously, instead of writing.) I’m also putting the tangents in as I go. They’re the little brass wedges that actually strike the strings.

I’ve made the executive decision to omit the “roof carvings.” The keys are supposed to be carved to a sharp point between the two bends, or knuckles. If you look at the two lowest keys, you can see where I tried my best. They looked so terrible, I decided to quit while I was ahead.

Posted by: notdeaddinosaur | July 9, 2015

Building a Clavichord – 4

The lid is on. So is the fallboard, though it wasn’t at the time of the picture:


Don’t worry: the lid is straight. It’s the optical illusion of photographing it against the full scale drawing with so many parallel diagonal lines.

Immediately after this, I was instructed to remove the screw eyes for the lid cord and the lid hinges, and put them all back in their envelopes. I get to put them back on at the very end when everything else is done, but between now and then they’ll just get in the way.

Next up: finishing the case.

Posted by: notdeaddinosaur | July 7, 2015

Mammography Doesn’t Save Lives

Preventive care doesn’t save money and now it turns out mammograms don’t even save lives.

After sitting through a presentation by a general surgeon about treatment of small breast cancers (the vast majority of his patients do great), I was stunned to hear him opine, “Every woman needs a mammogram every year starting at age 40.” Really. That’s what he said.

I’ve had my doubts. I’ve diagnosed women with breast cancers less than a year after their last mammogram because the tumors grew so damn quickly. Mammography didn’t save them.

Now we have new research (linked above) looking at 16 million women (a pretty decent sample size by any reckoning) showing that the more you screen, the more cancers you find WITH NO DIFFERENCE IN HOW MANY WOMEN DIE of their disease.

To put it into the vernacular, overdiagnosis is a thing.

A real thing, with real drawbacks. Time; money; pain; anxiety. I steamed when the surgeon mentioned above responded to my concerns with the definitive statement, “There is no downside to mammography.” Wrong in so many ways.

Ah, but what to do about it? Especially with the juggernaut already running full speed ahead, fueled by millions of pink ribbons and tacky tee shirts. It’s now a performance measure. Women without mammograms are costing me money. So far I’ve been able to take a deep breath and ignore the increasingly strident calls from various insurance companies crying, “Screen! Screen! Screen!”

Why is this drive so powerful?

There’s the default assumption that knowledge is power. Sometimes it is, but sometimes it isn’t. Despite the reality of fast-growing fatal cancers, the normal mammogram (or breast MRI for the “high risk”, a designation surprisingly easy to fudge) provides reassurance. For now. Year after year we irradiate breasts looking for ever tinier lesions, every last one of which must be treated because “cancer!”

Then there’s the cognitive error which blocks women who have been successfully treated for a small cancer from believing this research. The cognitive dissonance created by, “I went through hell getting treated for breast cancer, and you’re telling me it didn’t make any difference!?!” is strong indeed.

I wonder if we are perhaps one step closer to being able to do a truly randomized breast cancer study: enroll a series of women with small (< 1 cm) breast cancers and randomize them to standard treatment (surgery, radiation, adjuvant chemo) or observation only. Maybe we’re ready to look at the biology of breast cancer more closely. Maybe all breast cancer, like most prostate cancer, isn’t fatal after all.

If we really want to lower deaths from breast cancer, how about re-directing the massive time, effort, and funding away from “mammograms for everyone” toward developing better treatments for those wickedly fast-growing tumors that actually kill.

Think about it.

Posted by: notdeaddinosaur | June 27, 2015

Building a Clavichord – 3

Part way through “Finishing the Case”:

Clavichord with soundboard

Sound board now built and installed, surrounded by its tiny cute little moldings. Holes drilled for tuning pins (on the right), marked for the hitchpins (on the left and back.) Next steps include dressing the sound board with two thin coats of shellac, drilling for the hitchpins, and adding moldings to the outside bottom edges. Can’t even think about getting started on the action (the keys) until after the lid and fallboard (the little section that will cover the front of the keys when its closed) are done.

Long way to go. But it is looking pretty.

Posted by: notdeaddinosaur | June 21, 2015

Best License Plate Ever

Pulling out of a parking space, I noticed this license plate behind me and truly LOL’d:


You’ll have to check it out in a mirror to see what I saw.

Posted by: notdeaddinosaur | June 19, 2015

Building a Clavichord – 2

Section 1 in the instruction manual, titled “Building the Case” completed:


Next up is the soundboard. Stay tuned.

Posted by: notdeaddinosaur | June 16, 2015

Emotions and Memories

I couldn’t sleep last night.

I have no idea why. I played tennis for over an hour in the late afternoon’s sweltering heat, but it felt good. I had a good dinner; not too much, not too late. I even remembered to take some naproxen before I went to bed to combat the beginning stiffness.

But then I just couldn’t get to sleep.

My mind wasn’t racing exactly. I wasn’t thinking of anything in particular. I just wasn’t the least bit sleepy. I thought I felt my heart pounding. Tachycardia? Afib? I checked my pulse; 72 and regular. No pain; breathing was fine. I did have a little tremor though. Not really enough to alarm me medically, but definitely not conducive to sleep.

I wondered if I had somehow gotten some caffeine into my system. As a slow metabolizer, caffeine will keep me awake without fail. But dinner had been chicken and rice, and I seriously doubted that DS had snuck some coffee into the barbecue sauce. I even went so far as to consider whether the naproxen had been contaminated or adulterated. It had been a new bottle. But that seemed unlikely. And I really couldn’t attribute any of it to the NSAID itself.

Eventually I took my own advice and got out of bed, turned on a soft light and read for a while. Finally, after another hour, I got back into bed, and eventually managed to get to sleep.

Not for long, though. Before I knew it, it was 5:30. I dragged myself out of bed and forced myself into the shower, then off to work a regular schedule. A heavy-lidded fatigue stuck with me all day. That draggy dullness with its insidious mental fog I recognized from decades ago. We called it PCPC: post-call pseudo catatonia.

I had a meeting beginning at 3:30 that dragged on til 5:00, when all I wanted to do was get home and pass out. Sleep deprivation is cumulative. Extra hours in bed following the night I’d had was just what the doctor ordered.

Then I noticed the date, and a wave of emotional deja vu washed over me.

29 years ago, more than half my life. It was a Monday instead of a Tuesday, and I was post call toward the end of my internship year. Only this day had begun with a 7:00 am phone call both dreaded and expected. Too bull-headed to ask for the day off, I soldiered through. Draggy; exhausted; brittle emotions firmly bottled up until I could get home — my ancestral home a two-and-a-half hour drive away, that is. At 3:30, my residency director insisted that I review the pathophysiology of congestive heart failure with a bunch of medical students. To this day, I don’t know how I got through it. But I did.

Two days later, I don’t know how I got through my mother’s funeral. But I did.

But the draggy, depressed foggy fatigue that clung to me today reminded me of that day far more viscerally than the mere realization of the date, the lighting of the candle, the ritual emails with so few words that say so much.

I can’t help but wonder if that’s why I couldn’t sleep last night.

Funny about that.

Posted by: notdeaddinosaur | June 10, 2015

Building a Clavichord – 1

So it looks like building a house wasn’t good enough. Now I’ve somehow gotten it into my head that I want to build an early keyboard instrument called a clavichord. I have no idea why. Something to go along with this in the Music Room?:

Piano Room

At any rate, I have purchased a kit for building a clavichord modeled after one found in the collection of the King of Sweden — which is why they call it the King of Sweden clavichord — from a lovely outfit in Stonington, Connecticut known as Zuckermann Harpsichords International. The second video down on the first page is of the instrument I’m going to (try and) build.

I have a brand new workshop. So new I don’t even have much in the way of wood scraps. Then again, I do live in the midst of multiple building sites, so I should be okay.

So here we go:

The plan: The Plan

The parts: Clavichord - some assembly required

Updates as it progresses. Don’t hold your breath. I anticipate anywhere from 6 to 12 months for completion.

Posted by: notdeaddinosaur | June 6, 2015

Breaking Up is Hard to Do; Or Not

Question from a reader:

What are your feelings about when a patient breaks up with you? I love love love my doc, but…

Patients “break up” with me all the time. Well, not “all” the time, but it’s not uncommon. There are many reasons, some of which are under the patient’s control, and some which are not. Moving across the country is a good reason to look for a new doctor. (Seriously. When you move several states away, please find a new doctor. I’ll refill your prescriptions long enough for you to get settled, but I have some people still calling me years later “just to keep you in the loop.” I appreciate the love, but come on already.)

Even if you haven’t moved that far, but just far enough that driving to my office is now inconvenient is an understandable reason for a change. It happens.

Some people switch because of their insurance. I’ve done my best to participate with most of the major players in my area, but there are some I don’t take. That said, many people have chosen to continue seeing me, paying out of pocket. I offer a nice cash discount (legal with Medicare and virtually all other insurances), so I’m not break-the-bank expensive if you want to go that route.

There are people I’ve misdiagnosed who make no secret about why they want someone else. Sometimes there are people who think I’ve misdiagnosed them who write me scathing letters when requesting their records. Only once has someone been upset enough to sue. Others decide that for whatever reason, I’m not the right doctor for them.

I’m okay with that.

Then there are the folks like my questioner, who goes on about how she’s been through a lot with her doc, but that things have changed. She’s lost that lovin’ feeling, if you will, and she’s asking about breaking up, but in a way that acknowledges the good care she’s received in the past. She’s also asking specifically about my feelings, so here goes — with the caveat that I’m just one doctor, and that others are certain to feel differently.

Many doctors have forms you can use to transfer records. No problem using any of these (I have them too), but without any further context, I’m left to wonder a little. If the new doctor is in another state, the situation is self-explanatory. Otherwise, it may give me pause. But not for too long. Over the decades, I’ve learned not to take it personally when patients transfer. Unlike other relationships, I still have hundreds of other patients who still like me if you want to break up. So while I may be momentarily bummed, I’m seldom devastated.

All you need to to is send me a simple note telling me where to send your medical records. Like other kinds of breakups, you don’t need to give a reason. As in other relationships, I’ll probably have had at least a hint that you’re not happy. If you want to specifically convey that you’re not angry or upset with me, adding a line like, “Thank you for all your good care over the years” is good enough. Also like in other relationships, there is seldom anything to be added by including a long explicit list of all my shortcomings that led you to the decision. In general, I would like to know if I pissed you off — mainly so I can potentially avoid doing the same to other patients — but it doesn’t need to be an essay. It’s always a good idea in general to avoid burning your bridges, especially if other family members are going to continue seeing me. Also, you never know: you may yet change your mind and want to come back. I just had a family of six move about half an hour away and asked me to transfer all their records. They called last week for an appointment. Seems they just didn’t like the new guy, and they figured half an hour wasn’t that far after all.

Again as in other relationships, the best way to convey your appreciation for good times in the past is to do it in person. A heartfelt “Thank you” in conjunction with a handshake or hug means the world to me.

Posted by: notdeaddinosaur | June 2, 2015

When Turnabout is Effective as Well as Fair

I’ve written before about transforming my own preventive care needs (and failings) into an opportunity to help my patients get things done even when their first instinct is avoidance. It happened again the other day.

I’m not good about going to the dentist. Even though they want me there every six months, they’re lucky when it’s once a year. Every now and then, it stretches out even farther. Now is one of those times.

I’m sure many others share my feelings about the dentist. I also know those feelings extend to other preventive services…like pap tests. I’ve had women in the midst of a pelvic exam tell me they’d rather be at the dentist. Can’t say I blame them.

So when I was seeing a lady for a physical the other day, I noticed it had been a long time since her last pap. More than five years, which is the outer limit of the most liberal of the new guidelines for women over 30 with no history of abnormal paps or evidence of HPV on testing. However I tried to slice it, she was due. But she really didn’t want it. Not today.

As it happens, she’s my dentist’s receptionist. So I came up with the following deal:

I told her that when I called her back with her blood test results, I would go ahead and schedule my dental checkup if she would agree to then schedule her pap. She agreed enthusiastically.

I called with her perfect labs. Then at the same time, I scheduled my checkup. And then she scheduled hers.

I guess I’m not the only one not above using the personal in pursuit of the professional.

Posted by: notdeaddinosaur | May 17, 2015

Circle of Life

Life is all about beginnings and endings. One of the biggest draws of Obstetrics as a medical specialty is the fascination with the birth process as the beginning of life. The other extreme…well, let’s say in this particular place and time in history, it’s still something that catches people unawares. Too often filled with dread and loathing, we approach the death of patients as a foreshadowing of our own. Why else have we as doctors developed the reputation of squaring off with Death? Beating Him off with tubes and drugs and electricity, “No!” we shriek. “You can’t have this one yet!”

Let me share a secret with you: in spite of EMRs, PBMs, PQRSs, insurance companies, malpractice, legislation, and everything else you hear us bitch and moan about, we doctors care for our patients. And I don’t mean just in the sense of providing them with medical services. We care.

Over the decades, we come to know these people who have entrusted us with their lives. Some of them…many of them, for those of us who are especially lucky…we come to think of as friends. Friends who allow us the privilege of joining with them along this journey we call life; friends who trust us to do everything we can to keep them plodding along when its not yet their time, and those who trust us to ease their suffering at the end.

It’s been an interesting few weeks.

Two weeks ago I got one of the most dreaded calls a doctor can get: my patient had come into the ER as a cardiac arrest. He was the same age as me, and he had simply dropped. No pulse; not breathing. No cardiac history; no medications; no chronic illnesses; no risk factors. Nothing. But his gym had an Automatic External Defibrillator (AED), a magical machine that delivered jolts of electricity to get his heart started again on the spot. Once. Twice. Five shocks from the AED. Two more from the paramedics, and another in the ER. Clear coronaries on catheterization; but progressed to cardiogenic shock; hypothermia protocol; aspiration pneumonia; transfer to tertiary center; left ventricular assist device. Suffice it to say, things didn’t look good.

But it worked.

For all the futile aggressive care we mete out to seemingly hopeless cases, this time it worked. After 10 days, I was talking with him on the phone in a regular hospital room. He was still pretty fuzzy on the details, as you can imagine; try freezing and thawing your brain and see how well it works right away. But it was him. And he’s going to be okay.

At the same time, there’s another patient. (There’s always another patient. No sooner do you hang up the phone and breathe a sigh of relief than there’s another patient.) Nearing the century mark, he’d begun the revolving-door process of in-and-out hospitalizations for the last several months. CHF, pneumonia, NSTEMI, high-output cardiac failure from anemia; one thing after another. I’d been trying to broach the idea of hospice all along, but now he was wearying. This time he said yes.

I went to see him last week at home. He was having some pain and a little trouble breathing. He was reluctant to use the morphine on hand. I tried to reassure him.

This morning I took several calls from the hospice nurse as she struggled to keep him comfortable. It worked. Later this afternoon, I got the other call.

I’ve spoken before about the futility of discussing “outcomes” in Primary Care. Yet this should count as a good one. Passing peacefully without pain or suffering, with loved ones present. In its own way, as miraculous as birth. All that begins must end. A life well-lived; what more can any of us ask?

Posted by: notdeaddinosaur | May 6, 2015

Two Little Words

I’m frequently reminded of the power of words. Especially small words added to other small words.

Consider the difference between two states of being reflected in a conversation a while back with this crotchety old guy in his 80s whom I’ve known for years. I was telling him about a mutual friend who happened to be ill. I said that the individual in question was “Not well.”

The crotchety old guy’s response:

Is he “not well,” or “not well at all”?

“At all.” Two little words adding a dire new dimension.

They can also add emphasis. Hear the difference:

  1. If you need me for anything, please call.
  2. If you need me for anything at all, please call.

Nice little quirk of language.

Posted by: notdeaddinosaur | April 27, 2015

Talk About “Manipulation”

I generally enjoy reading my Philadelphia Inquirer’s Health section each Sunday. In fact, for several weeks (beginning in February) I contributed to their Medical Mystery feature. Most of their stuff is generally spot on, providing good, solid information. Other times, not so much. I guess this was a slow week:

Question: How can osteopathic [manipulation] help my cold and sinus symptoms?

The correct answer is, “It can’t.”

But no. That doesn’t stop our friendly neighborhood Osteopath (excuse me: she’s also an assistant professor of osteopathic manipulation at the Philadelphia College of Osteopathic Medicine) from chiming in. After correctly informing us that MDs and DOs get the same general training in school, she segues right into the old (discredited) idea that anything and everything wrong with the human body can be attributed to “blockages” of one variety or another. This is especially seductive when talking about upper respiratory symptoms, when subjectively one’s entire head feels nothing if not completely blocked.

But this:

An osteopath might use [osteopathic manipulative treatment] to gently contact the structures of the upper back, neck, and face and move them so deeper structures are affected, especially if they are blocking drainage paths.Freeing those deeper structures can help thin out mucus, loosen congestion, and ultimately make the patient more comfortable.

This is about as bogus as it comes.

There is no physical manipulation that can “thin out mucus” (pushing fluids does that) or “loosen congestion,” and given the self-limiting nature of cold symptoms, the patient is “ultimately” going to become more comfortable whatever anyone does.

At this point in time, Schools of Medicine and Schools of Osteopathy are parallel tracks providing essentially the same education and training. The reason many DO’s have abandoned osteopathic manipulative therapy (OMT) is because they recognize it as a vestige of philosophical differences from a bygone era predating our current understanding of medical science. Those who continue the practice are no better than MDs who have given up practicing actual medicine for the more superficially satisfying (and eminently more lucrative) practice of “alternative”, or “complementary”, or “integrative” quackery (despite the fact that they still use the M-word. What they practice is not medicine.)

Come on, Philadelphia Inquirer. I expect better from you.

Posted by: notdeaddinosaur | April 12, 2015

Drawing Lines

Who is a Family Physician?

Who is a PCP? (And does that second “P” stand for “physician” or “provider”?)

Who gets to say? Does it matter?

Perhaps we should start with some basic qualifications: the degree of MD or DO, the satisfactory completion of an accredited residency in Family Medicine, and successfully passing the written examination of the American Board of Family Medicine (ABFP, an organization distinct and independent of the AAFP). Hard to argue with those.

How about going by what we do: Primary Care medicine consists of caring for patients as their first contact with the health care system, regardless of age, gender, organ system, or disease process. Also pretty straightforward.

But what about hospitalists? Family physicians trained and board certified who choose to limit their practice to caring for patients in a hospital setting; are they still “real” family doctors? What about those who go into Occupational Health? Academic medicine? Exclusively caring for patients in nursing homes? Do you have to even see patients? What about administration?

Wanda Filer MD, president-elect of the American Academy of Family Physicians (AAFP) and my new BFF, has come out in favor of an inclusive definition, at least regarding AAFP membership. Her position, and it’s a valid one, is that Family Physicians are under attack by enough non-Family Physicians (both inside and outside Medicine) that we should stick together. Her big tent says that we shouldn’t be fighting among ourselves about defining Family Doctor-hood by whether or not we deliver babies, care for children, perform surgery, or do house calls. Meeting the criteria for AAFP membership (completion of accredited residency, state licensure, ongoing Continuing Medical Education, and of course up-to-date dues payments) is what makes us Family Physicians.

Sounds good. But what about Internists who advertise as Family Physicians because it’s “better marketing”? I’ve seen this, and it pisses me off. Do we have any recourse?

Is it self-defined? Can anyone who wants to call themselves a Family Physician? This of course gets into the whole debate over Primary Care. To most in Health Administration, “Family Physicians” and “PCPs” are synonymous. They’re not, of course. NPs who want to practice the full scope of primary care (few and far between, actually; they have the same payment and administrative hurdles as we do), chiropractors and naturopaths; all claim the title for themselves. This is scary. As soon as someone drops dead of hypertrophic cradiomyopathy undiagnosed by a chiropractor who doesn’t even own a stethoscope, watch the fur fly.

What about conventionally trained Family Physician who turn their backs on the scientific basis of medicine and become proponents of “alternative”, “complementary”, and “integrative” modalities? I believe they have effectively repudiated the right to call themselves Physicians at all. They disagree.

Who’s going to draw the lines that say no, you are not qualified, and you may not hold yourself out to the public as a Family Physician, practitioner of primary care? Ultimately I think it needs to be the general public; the patients we care for who use, and ultimately pay for our services. The charlatans (the alties, the chiropractors, the reality-challenged naturopaths) and the wannabes (the PAs and NPs) make their case with wishful thinking and self-serving data.

The bottom line, the one drawn in the sand, is that however difficult it may be to define who is a Family Physician, you know it when you see it.

Posted by: notdeaddinosaur | April 5, 2015

On Shame

Monica Lewinsky has re-emerged, and I say good for her! Please take the 20-something minutes out of your life to watch the video. It’s well worth it. 

I agree completely that “Internet shaming as a blood sport has got to stop,” and I applaud her call for a more compassionate culture, both off and online. Nothing good comes from public shaming of private indiviuduals, usually women, usually over sexual misconduct. Innocent lives have been ruined — even lost — by the vicious words of anonymous haters spewed for no legitimate reasons.

There is another consequence of this cultural coarsening, in which the whole concept of “shame” has been so perverted that its true purpose — yes, shame has a purpose — has been lost. 

Shame is the feeling of distress or humiliation caused by the awareness of having done something wrong or foolish. Note that it requires two separate components: both the action, and the awareness that the action is wrong or foolish. In verb form, it means inflicting the emotion on someone else by making them aware that their actions are shameful. This presumes that the individual is not already aware of it him or herself. 

So how can shame be good? Simple. Fear of shame, and therefore its avoidance, is a powerful motivation to refrain from wrong or foolish behavior, be it words or actions. 

Remember when the expression, “You ought to be ashamed of yourself” actually had an effect on behavior? One of the darkest episodes in twentieth century American history, the reign of reputational terror known as McCarthyism, was finally brought to an end by a courageous lawyer name Joseph Welch who basically told Joseph McCarthy that he ought to be ashamed of himself. (His actual words were, “Have you no sense of decency, sir?”)

There was a time when shame, specifically public shaming of public figures, served to hold those public figures in check. Nowadays, I can’t help but think that the relative explosion of shaming has served to dull the responses to it of those who really should be ashamed. The O’Reillys, Limbaughs, Palins, Cruz’s,  Tea Party folk and their predominantly Republican Congressional ilk who lie, slander, and hypocritize (is that a verb? If not, it should be) their way into our lives trumpeting the evils of “big government” all the while pure and simply ought to be ashamed of themselves. “Ought to” being the operative words. 

Perhaps when the poor choices of young people, troubled gay and questioning teens, and of course women of any age who dare to buck so-called societal “norms” of occupation, appearance, or sexuality cease to be fodder for relentless Internet shaming — what Lewinsky calls the “culture of humiliation” — then those who ought to be ashamed will no longer be able to hide behind the ho-hum numbness of “everyone does it.”

If nothing else, it can’t help but improve our civic discourse.

Posted by: notdeaddinosaur | March 31, 2015

Headline of the Day

Best headline ever:

“Exploding Head Syndrome” May be More Common
Than Previously Believed

It references this article, which is about the frightening perception of loud noises or blasts while dropping off to sleep. But it’s so much more fun to allow the imagination free reign, perhaps pairing it with an ad for special cleaning products to remove splattered brains from walls and furniture.

Posted by: notdeaddinosaur | March 26, 2015

Note to Patients: When it’s Not A “Physical” You Need

We interrupt our regular blogging for a PSA (that would be a Public Service Announcement, not the controversial prostate cancer screening test) directed to our patients.

Dear Patients,

First of all, thank you for calling for an appointment. Seriously. Ever since I’ve gone open access, if the phone doesn’t ring I’m toast. And thank you for your interest in preventive care. The fact that it’s now free (well, no cost to you at time of service; trust me, it’s not “free”) has probably motivated more of you to call. That’s okay. But sometimes it seems that your idea of a “Physical” and mine are worlds apart.

A General Physical examination, often shortened to “a physical,”  is the term used by most people (and most insurance companies, including the ACA/ObamaCare) to refer to a periodic encounter for preventive care. Other synonyms include a “well visit”, or just a “checkup.” Preventive services are, by definition, things done for healthy people. Got that? HEALTHY. As in not sick, no symptoms, feeling well.

There’s actually a lot we need to accomplish at a preventive care visit. In addition to reviewing your medical history (no, I may not have known you had your knee scoped last month), updating your medication and allergy list, addressing your immunization status, and doing a basic examination, this is when we go over your diet, talk about your exercise regimen, and review what kinds of routine screening tests are appropriate for your age, gender, and medical conditions. That takes time; time I’m happy to spend, because preventive care is important (even though it doesn’t save money), but it is a visit with an agenda.

Many of you want “a good physical” when you’ve got multiple vague complaints that might be pretty mild. You may not even be convinced you need to see a doctor, so you figure you’ll just “come for a physical” and I’ll be able to figure out what’s wrong with you (or if there is anything wrong) without you having to answer too many questions like “How long have you been tired?” and “What do you mean by ‘dizzy’?” or “What do you mean by ‘not quite right?'”

It doesn’t work that way!!

If you’re having multiple vague complaints that make you think there may be something wrong, then you need a “new problem” visit so we can sit down together and get it figured out. Maybe there’s nothing really wrong and you are just a worrywart. Or maybe you do have cancer or diabetes or something else that terrifies you to even think about but as long as you don’t say it out loud, it’s not that. Whatever it is, I can help. From putting your mind at ease to getting you started on the road to diagnosis, treatment, and (hopefully) a cure, that’s my job.

But I can’t do it if all you do is schedule a “physical”. And no, we can’t “call it a physical” to save you the co-pay. Doing that fails to fairly compensate me for what’s often a complex visit (vague symptoms are usually much harder to figure out than more defined issues), it cheats you of your actual preventive care visit, and technically it’s insurance fraud.

Thank you for your attention.

-Dr. Dino

Posted by: notdeaddinosaur | March 24, 2015


Really? I mean…REALLY??

From Medscape [behind paywall]:

In a statement to Medscape Medical News, AMA President Robert M. Wah, MD, said, “While immediate access to online information has been of great benefit to patients and health care professionals, the American Medical Association is greatly concerned that a substantial proportion of health information on the Internet might be inaccurate, erroneous, outdated, misleading, or fraudulent, and thereby pose a threat to patients and public health.”

All I can say has already been said here:

Duty Calls

Everything I need to know about romance, sarcasm, math, and language I learned from xkcd.

Posted by: notdeaddinosaur | March 22, 2015

Ignorance, Knowledge, and Bliss; Not Always Obvious

I’ve just finished sitting through a wonderfully aptly named lecture: Probability and Sadistics, in which, among other things, we learned (again) that the utility of various clinical tests depends at least as much and generally more on the patient and condition involved than on the specific test itself. From stress tests to mammograms to PSAs, the relationships of true and false positive and negatives, positive and negative predictive values all hinge on the prevalence of disease; or how likely is it that a given condition is present before you even do the test. Lots of times when you crunch those numbers, the best answer is not to do the test.

Perhaps not unsurprisingly, that tends not to go over real well with patients.

I think we do too many mammograms. Many people agree with me. I spend lots of time talking with my patients about why I don’t think they need a mammogram. Many women understand, but many others don’t. So I order it.

I try not to do routine PSAs. I preface the blood draw with a discussion about how he’s more likely to die with rather than of prostate cancer, and about the risks of incontinence and impotence as complications from its treatment. It’s often enough to talk them out of it, though not always.

I try so hard not to do stress tests unless I’m really worried about heart disease. Note that it has to be ME who’s worried about it. Just because the patient is worried doesn’t impact the decision all that much. Far too often the clinically unnecessary stress test only sets us on the treadmill (sorry about that) of sequential followup testing up to and including cardiac catheterization, with risks for all of those attendant complications (including death.)

Unfortunately, there are still peope who don’t understand what I’m trying to tell them, and sometimes walk away appalled that I “don’t think I need to know if I have cancer.” I know this because I’ve received scathing reviews on several online doctor rating sites saying precisely that.


How can knowledge be bad?

It’s a philosophical question that’s really hard to answer. Why wouldn’t you want to know about every possible little thing in your body that might hurt you? (cue the talk on Incidentalomas) The answer, of course, is the phenomenon of overdiagnosis. Treating things that will never hurt you, like small prostate cancers ini old men and and possibly DCIS (ductal carcinoma in situ, or so-called “Stage 0 breast cancer”) exposes you to all the risks of treatment with none of the benefits, but it doesn’t feel like it. And that’s the problem.

I think the hidden agenda here is not dying. If you find or prevent every possible thing that can kill you, be it a subclinical cancer or atherosclerotic arteries, then you won’t die. Obviously it’s not true. But dying is one of those things to which we pay lip service: “Of course I know I’m going to die, but I really don’t want to.”

It doesn’t work that way, and I’m sorry. I still won’t recommend unnecessary screening tests, even at the cost of my online reputation. As for my patients, knowledge isn’t always more blissful than ignorance.

Posted by: notdeaddinosaur | March 21, 2015

Quote of the Day

Family physicians are the pluripotential stem cells of American health care.
 -Dr. Wanda Filer

Well said.

Dr. Filer (I get to call her Wanda because I’m special; also, she’s really nice) did hands-down one of the best talks I’ve ever heard on the long term effects of childhood trauma, which probably affects more than a third of my patients, and I don’t even know it. (Look for upcoming post on asking established patients — some of them decades-long — new patient questions.) She is also the President-elect of the American Academy of Family Physicians, which means that even though I just went to it last year, and even though I already have more than twice as many CME hours as I need by the end of this year, I just made the decision to attend again this year just to see her installed. She’s that awesome. Also, it’s in Denver, so I get to see DenverDaughter.

I’m spending the weekend at an educational conference sponsored by my state Academy. (Hi, PAFP!) The sessions are fabulous, though it’s like trying to drink from a fire hose as the incredibly useful day-to-day pearls come fast and furiously. It’s also nice to catch up with friends and colleagues I don’t get to see otherwise, professional solitude being part and parcel of solo practice. It’s also inspiring (really the only word) to get a glimpse of the world of organized medicine, which briefly produces a yearning to participate. I call it the “I could do that” phenomenon. But just thinking about the pile of work needing to be caught up on after just one day away from the office quiets that urge rather effectively. 

Things I am going to start doing right away:

  • Stop prescribing low dose aspirin for primary prevention in low risk patients (really no good evidence for it)
  • Add two questions to my domestic violence screen (currently asking, “Are you or have you ever been in a relationship where you’ve been beaten, threatened, or abused?”): “Do you feel safe at home?” and “Have you ever been sexually asaulted?” (as defined by the patient)
  • Feel more comfortable starting insulin sooner
  • Learn more about the newer diabetes medication classes
  • Back off even more on medicating pediatric fever
  • Feel more confident advising just 1-2 days of rest after mild concussions instead of longer periods
  • Look harder for afib after cryptogenic stroke

And that’s just the first day.

Posted by: notdeaddinosaur | March 14, 2015

Happy π Day

Bonus points for recognizing this:

Pi cookie

Not only is today pi day (3/14), it’s uber pi day: 3/14/15. (Also note the time of this post.)

There are many ways of celebrating pi day, many of which include consuming lots of circular foods. This makes sense (as pi is the ratio of the diameter of a circle to its circumference, for the nerd-impaired.)

Many people also like to get together and play games (hence the double entendre of the above cookie design), which doesn’t really make much sense.

It’s irrational.

Like pi.


Posted by: notdeaddinosaur | March 13, 2015

Explaining the Unexpected

Incidentaloma: a cutesy term for an unexpected finding on an imaging or lab study unrelated to the study’s original purpose.

Known more formally as an “incidental finding”, they are a huge source of wasted time, money, effort, anxiety, and medical resources spent tracking down exactly what they are. Because lawsuit!

I found myself trying to explain this concept to a patient the other day, and came up with this:

It’s something completely unrelated that’s photobombing your xray.

Isn’t that exactly it?

Posted by: notdeaddinosaur | March 8, 2015

Shortage of Logic, Not Doctors

In news to absolutely no one with an iota of common sense, the purported physician shortage isn’t actually one of numbers, but rather a problem of distribution. Per this article by Lenny Bernstein in the Washington Post:

[C]ritics of doctor shortage projections have argued for years that the problem is actually poor distribution of physicians, with too many clustered in urban and affluent areas and too few in poor and rural areas.

Doctors prefer to live in affluent urban areas instead of rural poor ones. This is a surprise…why? Doctors are people. There are more people in urban and suburban areas than in rural ones. It’s, you know, part of the DEFINITION. Therefore there are going to be more doctors where there are more people.

Sure, there are doctors who love the rural lifestyle. Hats off to them. However apparently there aren’t enough of them. Then again, rural areas, by DEFINITION, have relatively few people scattered over a wide area. In order for doctors and patients to get together, someone’s gonna have to travel. (Yes yes yes, there’s always telemedicine. Doesn’t help much when you need an actual procedure like surgery, or help delivering a baby. No matter how you cut it, there are times when you and your doctor need to be in physical contact.)

So obviously there are going to be more doctors where there are more people. But why might they cluster in affluent areas? Contrary to popular belief, lots of us feel strongly that everyone deserves medical care. Unfortunately, we are faced with the realities of making a living in a profession that requires a truly obscene up-front investment. I am personally aware of numerous students who would make fabulous primary care physicians who feel they won’t be able to pay off their loans unless they go into more lucrative specialty fields. I’ll bet that distribution problem would sort itself out in a hurry if we overhauled the financing of medical education.

Imagine what public transportation would look like if all the operators had to purchase and maintain their own vehicles, and if they all had total freedom about what routes and vehicles they were going to run? If I’m going to be forced to buy a bus, you’d better believe I’m going to choose the best paying routes in the nicest parts of town. Then again, why bother? How about if I just get a Mercedes limousine, and limit my practice to shuttling rich folk back and forth wherever they wanted, almost like a “concierge”?

And no, Nurse Practitioners and Physician Assistants are not the answer either. In the first place, despite their lofty opinions of themselves, as a group they are not capable of replacing primary care physicians. I think that non-physician providers should care for healthy people and doctors should take care of sick people. Let the NPs do well baby and preventive care til the cows come home. Most of it is education anyway, which is their alleged forte. (Spoiler alert: It’s mainly because they have more time to spend with patients.) And in the second place, it’s just as hard to get NPs and PAs to set up shop in poor, rural areas as it is to attract doctors. Hell, most of them avoid primary care as well, and why? It doesn’t pay well enough. What a surprise.

Here’s a thought: make medical school (college too) affordable to everyone qualified who wants to go. Then see what that physician distribution issue looks like in ten to fifteen years.

Posted by: notdeaddinosaur | February 27, 2015

Crowd Sourced Suckers

“What do you think of this?” writes a friend:

…[A]n untraditional approach to medical diagnosis that is helping solve the country’s most difficult medical mysteries and creating real miracles.

This is the description of something called CrowdMed, the latest version of getting doctors to provide services for free. Thus my short answer about what I think of it: not much.

To be fair, and because I had a few minutes of free time, I went and checked it out. Patients submit questions about their medical condition(s), accompanied by varying levels of supporting detail, and “medical detectives” offer their opinions about possible diagnoses and/or other courses of action.

Are all these “detectives” doctors? Um, no:

Our Medical Detectives include medical students, retired physicians, nurses, physician assistants, chiropractors, scientists, naturopaths, and regular people who enjoy solving medical mysteries. We believe in the wisdom of crowds, not just individual experts, as you never know who will provide the insight that leads to a correct diagnosis or cure. We recruit Medical Detectives from a broad range of medical and non-medical backgrounds to assure cognitive diversity.

Right. Because regular people, presumably with access to Wikipedia and perhaps Up To Date, in large enough numbers, are just as good as doctors; maybe better. Really? “You never know who will provide the insight that leads to a correct diagnosis”?? Even a broken clock is right twice a day.

Ah, but this site actually pays. Well, offers financial compensation. How?:

Point rewards and cash compensation offered by patients are awarded to those Medical Detectives who contributed and/or assigned points to the best diagnostic or solution suggestion as determined by the patient or their physician, divided up according to each Medical Detective’s overall point winnings on that case. Patients may also direct up to 80% of their reward points and cash to named Medical Detectives who they found to be most helpful. Note that CrowdMed collects 20% of cash compensation offers as commission.


Well, where does the money come from?

Where it always does, ultimately: from patients. Anywhere from $99 to $499 depending on how long you want to let the Crowd have at it, whether you want to limit input to just the top tier “detectives,” or have a moderator involved.

There are other sites that try to rope doctors into answering patient questions, like this one. Most of the questions fall into one of these categories:

  1. Just google it.
  2. What the hell are you talking about?
  3. What on earth are you doing at a computer/get your ass to a doctor!

To its credit, CrowdMed tries to offer as complete a clinical picture as they can. But in perusing their cases, I always find myself wondering what the patient is leaving out, even inadvertently. Nothing online can take the place of actually sitting a room with a patient face to face.

So why do doctors go online and answer questions from strangers for free?

At first, you just want to help. Just a few simple words to ease someone’s mind. But then you find yourself carefully crafting those answers, and before you know it, an hour is gone. Points! Ratings! Levels! Increase your score! The competitive urge starts kicking in. Solve the case and level up!

But not for long. It’s as much of a time sink as cats on YouTube, and not nearly as adorable.

“Medical Mystery” is a literary term, not a clinical one. Doctors discuss complex cases, or zebra diagnoses, or “patients with significant psychiatric overlay.” The truly elusive diagnosis is rare. Most of these cases are indictments of a broken medical system in which doctors are not given sufficient resources (mainly time) to both gather the necessary information AND mentally process it, ie time to think. It’s the hectic, workaday world of modern American practice that sends patients shuttling around to specialist after specialist, often repeating expensive tests for no rational reason. It’s almost a wonder that so many complex diagnoses are correctly made .

CrowdMed is just another way for non-physicians to siphon money away from sick people and the doctors who are trying to take care of them. No miracles to see here. Move along.

Posted by: notdeaddinosaur | February 16, 2015

In the News Again

Yesterday’s Philadelphia Inquirer Health section’s Medical Mystery, by yours truly.

I’ve been busy. I think they’re going to print another one of mine next week as well.

Posted by: notdeaddinosaur | February 12, 2015

Aspirin and Altruism

I have a patient in his mid-60s with multiple risk factors for cardiovascular disease. He has hypertension and hyperlipidemia controlled with medication. He’s got mild, diet-controlled diabetes, and his father dropped dead of a heart attack at age 51. At least he doesn’t smoke.

This is a patient who should clearly be taking low dose aspirin daily for cardiovascular prophylaxis. But:

For the last 20 years, ever since his wife was diagnosed with breast cancer, he has been a platelet donor. Every month without fail, he goes to donate. Even after his wife passed away, he’s kept it up. Month in, month out.

Aspirin works by inactivating platelets. It wouldn’t do the recipients of his donations any good to receive defective platelets. So he has made the conscious decision to live with a slightly higher risk of heart attack or stroke so that he can continue to help others as a platelet donor.

Now that is altruism.

Posted by: notdeaddinosaur | February 11, 2015

Told You So

For several years now I have been advising my patients that, based on my admittedly anecdotal but fairly extensive experience, dietary cholesterol is no big deal.

“What?” my patients would cry with incredulity. “What kind of doctor are you, saying that eggs aren’t bad for us?”

My response has generally been that your blood cholesterol levels have far more to do with how you pick your parents than how you pick your food. Cholesterol you eat is metabolized by the liver, which then synthesizes the stuff that winds up in the blood. And that liver metabolism is genetically programmed. Sure, being sedentary and overweight can nudge those levels up a bit, though not nearly as much as you may think. And yes, “diet”, exercise, and weight loss are perfectly good first-line treatments for high cholesterol levels.

I have now been officially proven right. Well, maybe “proven” is a bit strong. Let’s say that the weight of actual evidence (now that they’ve bothered to formally study the issue) is beginning to lean in my general direction.

What else am I probably right about?

ACE inhibitors for diabetes: Regardless of blood pressure. I tell my diabetic patients that it’s good for their kidneys.

Vitamin D: low levels in childhood may be linked to atherosclerosis in midlife. My take: Despite the USPSTF’s “Insufficient evidence” finding for vitamin D deficiency screening, I’ve been doing it — and usually recommending that otherwise healthy adults consume 2000 IU daily. Even though we may not yet understand everything Vitamin D is doing for us, it can’t possibly be good to be low. Technically yes, because it’s a fat-soluble vitamin, you can get toxic on it. But the range is from 30 to 100, and the only person I’ve only seen who was toxic had been taking 10,000 IU daily. By way of comparison, if the level is very low I’ll suggest “topping up the tank” with once weekly prescription doses of 50,000 IU.

Who knows what other new “discoveries” await to support what I’ve been doing for years?

We shall see.

Posted by: notdeaddinosaur | February 5, 2015

New Treatment for Obesity???

There’s some really fascinating research coming down the pike about the role bacteria in our gut (our so-called microbiome) play in our overall health. Rapidly becoming mainstream is the idea of “fecal transplants” to cure resistant gut infections with a particularly nasty germ called clostridium difficile (or C. diff to its friends — er, to those who know it well).

Now there’s a case report of a patient who was cured of her C. diff infection with a fecal transplant from an overweight donor, who is now packing on the pounds. While we need to be cautious about that whole correlation-causation thing, the incident is apparently compelling enough for the authors to avoid overweight fecal donors in the future.

I read this a bit differently.

Analogous to bone marrow transplants (curing bone marrow cancers like leukemia and lymphoma by wiping out the bad marrow with radiation and chemo and then replacing it with marrow from a healthy donor) how about this:

Take overweight patients and wipe out their gut microbiome with powerful antibiotics (preferably ones that aren’t absorbed; vancomycin comes to mind.) Then give them a fecal transplant from a non-overweight donor and see what happens. It seems extraordinarily low risk, despite the ick factor. Frankly, I’d sign up for that in a heartbeat.

Gives a whole new twist to the sentiment “Eat shit.”

Posted by: notdeaddinosaur | January 27, 2015

Down the Rabbit Hole of “Quality” We Go


The Obama administration on Monday announced an ambitious goal to overhaul the way doctors are paid, tying their fees more closely to the quality of care rather than the quantity.

Holy crap: they’re really doing it. Or trying to do it. Who the hell knows what they’re trying to do? Not “them”, that’s for sure.

The United States government via the Department of Health and Human Services is going to start trying to pay for “Quality of Care” without ever defining what that means!

Doctors practice medicine, an art and a skill that sometimes involves procedures and sometimes involves cognitive services. That last one means “thinking.” When you do a procedure, usually when you are done you have something to show for it; generally a wound or a specimen. When all you do is sit and think — which includes listening to and talking with patients — how does anyone else know what you’ve really done?

One way is if you write down what you were thinking about, thus producing what we call the “medical record.” Actually, I’d be okay with this if only they looked at the right part of the record: the assessment. Instead, thanks to EMRs, the medical record has devolved into a useless mass of cut and pasted, bullet-pointed lists of history and exam items that ends up useful only to billing clerks and malpractice attorneys. At this point it’s often more of a hindrance than a help to anyone actually trying to take care of patients.

“Quality” measures are meaningless because “quality” is completely in the eye of the beholder. Actually, that last link is to a damn good post of mine. To quote myself:

Some argue that when you have an operation, the surgeon shouldn’t leave anything inside you that shouldn’t be there. Others would say that everyone taking care of patients should wash their hands before and after every patient contact. Certainly all medical professionals should maintain proper licensure and credentials. I think of those things as basic expectations; more the difference between “acceptable” and “unacceptable”. “Quality” is different from “not unacceptable.”

Enter the idea of looking at “outcomes” (another meaningless word, also previously addressed by me here and here.) To reiterate: only certain kinds of illness and injuries have measurable outcomes. Fractures (should) heal. Surgically treated illnesses (should) resolve after operation. And so on. It’s generally accepted that there is a direct causal relationship between medical treatment provided and resolution of the condition, though this is not always so. Postoperative complications are not always preventable. Some fractures won’t heal. Cancers sometimes recur. So even the measurement of “outcomes” as a proxy for “quality” is fraught with hazard.

What about the relationship between “quality” and “Patient satisfaction”? Two words:Press Ganey. Short version is that there are times (lots of times) when what people think they want from doctors is not only not what they need, but can be dangerous, useless, and expensive. The patient is not the customer (and even so, the customer isnot always right). When you actually look, it seems like the more satisfied people are, the worse their care.

But now Sylvia Mathews Burwell says:

Rather than pay more money to physicians for every procedure they perform, Medicare will also evaluate whether patients are healthier, among other measures.

This is going to sound counterintuitive, but medical care doesn’t make people healthier. Much of the time, it only makes them less sick, or keeps them from dying. I guess according to Medicare’s new paradigm, every death is a failure. What about the outrageous sums of money already being thrown at patients, usually elderly, in the last year of life? And heaven forbid we actually try talking to our patients about stopping treatment. Those conversations are hard. They take time. Time we don’t have and for which we’re not paid.

None of these “quality measures” can possibly capture compassion, dignity, empathy, competence — all the things that together define the true high quality physician. This new announcement heralds nothing but a windfall for those who can wrangle enough doctors gullible enough to fall for the high-minded rhetoric of “innovative health care delivery systems”, “population based care”, “value”, and “quality.” Mark my words: this is the day we will eventually look back on as the beginning of the end of Medicare as we know it.

Which isn’t all bad. Perhaps when this new system of Accountable Care Organizations collapses under the weight of its executive compensation, we’ll finally find our way to a single payer system, which seems to work well enough for pretty much every other country in the world.

Posted by: notdeaddinosaur | January 25, 2015

Bemoaning the Anti-Vaxers; Welcome to my World

Surprise! (NOT) There’s a new measles epidemic centered on California’s Disneyland, primarily because of non-vaccinated children. What is not so much surprising as it is interesting (and gratifying) is the way the mass media has by and large come down against the antivaccine movement responsible for the carnage.

More amusing is listening to long-time med bloggers sound off:

I do not have personal experience with the anti-vaxxers. My colleagues in other states tell me that many of these fools are well-educated. Obviously they are anti-science. I believe that many such vaccine deniers believe that diet and supplements will trump modern medicine.

The striking rise in measles is directly attributable to this ignorant selfishness. I am having difficulty explaining how angry this makes me.

Angry? Hello! Welcome to my world:

and more.

I have been vilified, cursed, accused of “sucking at the teat of big pharma”, and worse. One of the above pieces generated an (outrageously false) accusation of plagiarism. Talk about angry! I’m still reduced to trembling just thinking about it.

And my experiences are nothing compared to those of Dr. Paul Offit. He’s been fighting this fight longer than all of us combined. Only now are the anti-vaxers starting to get the negative press they so richly deserve.

Here’s the thing, though: anger is not a useful emotion to bring to the interaction with these patients/parents. When you stop to think about it, how likely are you to change someone’s mind by telling them they are being a selfish idiot, even when it’s true? Imagine trying to convince a reluctant patient to undergo what you know to be life-saving treatment. Getting angry at them for being stupid is probably not the best approach.

We need to overcome reluctance and resistance to vaccination. The only way that’s going to happen is to approach theses people with respect, hear — really hear! — their concerns, and do our level best to educate them about the logical fallacies underlying those concerns.

Quoting myself:

A few months ago, I saw a new patient in my office. This lovely, intelligent 14-year-old had received no immunizations at all. Having now done the research for himself, this boy was requesting all age-appropriate vaccinations. To his parents’ credit, although they disagreed with his decision, they respected his wishes and brought him to see me. We (he and I) sat down together and set up an appropriate schedule. I administered the first set of vaccinations; he returned as requested, and all went well.

I have another family in my practice who just had their first child. They had “concerns” about the vaccines and came to see me before the birth to discuss these issues. They ended up deciding to forego Hepatitis B, but so far their 2-month-old is otherwise “on schedule.” They don’t want her to get MMR or Chickenpox vaccine, but every time I see them we discuss it some more. I try to provide more information and address their concerns with respect. I’m optimistic that when the time comes, the kid will end up fully vaccinated. And even if she doesn’t, there’s always the possibility that she, like the young man above, will transcend her parents’ limitations and eventually choose vaccine protection for herself.

I understand the anger — and I share it. But it’s not helpful. And we are supposed to help.

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