Family Medicine Notes

Red Sox Fever

So the series is finally over, and we can get back to our lives.  I was only 4 in 1967 so I don't remember that one .. but I remember 1975 quite well:

October 22, 1975: In game seven, Boston held a 3-0 lead going into the sixth. Pete Rose hit a lead off single; Joe Morgan flew out to right. Johnny Bench grounded to short, but the Red Sox missed a double play opportunity when 2B Denny Doyle threw the ball into the dugout. Bench advanced to second on the mistake. Tony Perez jacked a Bill Lee curve over the Green Monster for his third home run of the Series; Boston's lead was cut to 3-2. 

My favorite player at the time was Doug Griffin - who was always in competition with Doyle for the spot at second base.  So when Doyle blew a double-play that led to a 2 run homer (the Sox eventually lost the game 4-3) .. my dislike for Doyle was enhanced.  The series in 1975 was my first big experience with being a Red Sox fan.  Doyle was my "Bill Buckner."  Nearly 30 years later, I'm happy to have witnessed this historic series .. to wash all of that away.  Congratulations Red Sox Nation. 

Posted by Jacob at 01:08 PM | Comments (0) | TrackBack

When to make a referral?

Referrals are a tough topic in primary care.

Two phone calls today reflect some of these issues:

"JMR .. patient on phone .. wants referral to a back doctor .. ok to make the referral?"

"uhh .. put her through please"

I want to talk with the patient so that I can understand why she wants the referral and why she thinks this is something that requires a specialist.  Clearly I am not a back doctor or a front doctor or a foot doctor ... but I may be able to help people with problems of these parts.  Turns out that the chiropractor hasn't helped much despite thrice-weekly treatments for 3 months.  She has low back pain.  No symptoms of anything bad.

What to do? 

• I can require that she come in to the office .. but then I am being the "gatekeeper."
• I can just refer her to the orthopoaedist .. but then I am making an inappropriate referral.
• I can refer her to physical therapy (which is what would most likely occur as a result of a visit with me or the orthopoaedist).
  
  Hmm ... which is the right answer?

Ok .. number two is harder.

I care for many physicians in my practice.   Caring for other physicians is tough.   Our office got a phone call a few weeks ago from a specialist about a referral that they needed from us so that they could see a patient who was there for an office visit that day.  The patient never called me .. never asked if I thought that a referral was necessary .. and never asked our office for a referral.  By making the appointment directly with the specialist - a message is sent to the primary care physician that our training and opinion is inferior to the patient's own ability to triage the situation.  For this scenario (I won't go into the details) I am certain that I would have been able to provide the service that the patient was looking for myself.    grrr...

Not Enough Generalists?

SoloDoc writes a nice entry on family medicine .. and the problems we're having recruiting students to go into our specialty:

One of the solutions has got to be increasing the reimbursement rate for primary care physicians so that they can make a decent living without working themselves to the bone. If medical students see happy family doctors, they will want to become a happy family doctor, too.

At our local Medical Mecca, we graduate 130 students every year.  Back in the old days - 7 or 8 years ago, we would routinely see 20% of the class go into family medicine.  This year, it may be less than 5%

Of course, this is exacly the opposite of the trend that should be ocurring, if we consider the healthcare needs of the United States (or the world, for that matter).  But the pressures that generalists feel are real, and the solution is unclear.

Hospitalists - a good idea?

When we got the letter from the hospital - offering the new hospitalist service to us .. we told 'em we would give it a try.  So for the past few weeks, if an adult patient of ours comes to the ED, we are supposed to get a call from the ED physician.  S/he will describe the situation, and we will have a choice of whether to admit the patient ourselves, or allow the hospitalist to care for the patient.  They assured us that there would be excellent care and good communication.  So we said we would give it a try.

It makes sense.  We usually have only one or two patients in the hospital.  Just driving there and back takes more time than seeing the patients, so it's a lot of time .. and one could argue that the patients may get better care and/or service from someone who is always in the hospital. 

But ..

Two nights ago, the husband of a patient called because his wife was in the hospital.  She was admitted "with a kidney infection" and now urology said that it wasn't .. and neurosurgery said it wasn't a herniated disc .. but no one had been "in charge" of the visit (from the family's perspective) .. and they were frustrated and angry.

"uhhhh"  says me.  I didn't even know she was in the hospital.  They never called me.  Just admitted her to the hospitalist service. 

So ... like any geek-physician, I logged on to the hospital's computer system and saw that her WBC on admission was 6.5 .. and there were scant RBC (no wbc) on a cath urine specimen from admission.  Renal ultrasound was negative, and an MRI of the l/s spine showed mild herniation at L4/5 .. with no nerve root impingement.

Then I visited her in the hospital yesterday morning.  The admission H & P was dictated and very thorough.  From there, the four day admission read like a team of blind men were treating an elephant.  A different hospitalist saw her every day and ordered new tests and new specialist consultations.  She was confused and angry and the bottom line is that this poor woman had back pain.  Frustrating and painful .. but something that probably should have been managed outside of the hospital from the beginning. 

I nudged the very nice physician's assistant who was seeing her yesterday (for the first time) for the hospitalist service to discharge her asap .. and I would see her in the office in a few days.  I sat with her for five minutes and listened ... something no one had done in four days .. and she felt much better ... eager to go home.

Maybe this hospitalist thing isn't gonna work ...

Posted to Family-L recently:

 NWAHEC - Herbs&Dietary Supplements is a very well done online curriculum on herbs and dietary supplements.

The program includes:

Baseline assessment of participant's knowledge, attitudes and clinical communication practices with regard to herbs and dietary supplements.

Answers on this assessment are for curriculum evaluation only. The answers on this questionnaire do not affect educational credit.

The curriculum. 40 1-page, self-instructional modules on commonly used herbs and supplements (sample module). Access to evidence-based information from reliable Internet sites from academic centers and the US government (links and resources). Access to a moderated Listserv (discussion group) with your colleagues who are interested in herbs and supplements. The Listserv will have a maximum of two postings per week. There will NOT be any advertising in these postings, and participants may choose to un-enroll in the ListServ. Post-course assessment and evaluation. Participants must get 70% correct on 10 knowledge questions to obtain continuing education credit.

Goin to the ER

From "A Chance to Cut is a Chance to Cure"  This note about sending patients to the ER.

In primary care .. it's not so clear as in general surgery.

Yesterday I met a patient at the office (yep -- Saturday afternoon) who called with "doc I feel just rotten." It would not have been appropraite to send him to the ER ... and some may have had him take some tylenol and come to the office Monday AM. ..

when I saw him, I was glad that I did what I did.

Temperature was 103. Exam revealed cellulitis of the right leg ("well, my leg did hurt some") and a blood sugar of 156.

(no known medical problems, by-the-way)

So now you know the diagnosis.

While I doubt anyone would argue that this would have been an abuse of an ER .. I think that most would agree that cellulitis and a new diagnosis of type 2 diabetes is more appropriately managed in the primary physician's office -- where follow-up can be arranged (he's doing much better today) and continuity is maintained.

How to bill?

99215

99050 (rarely paid .. but we'll ask the insurer for it anyway)

90788

J0696

J0696

682.7

250.90

A Primer on Summer Safety

From FDA.GOV: A Primer on Summer Safety.

Is Medical Arrogance Striking Again?

Russ points to this article in the Reno Gazette Journal: "Patients claim fibers sprout from lesions and parasites crawl under their skin. Most doctors tell them it's all in their heads"

The topic brings up a problem in medicine that we (oddly) find hard to acknowledge: we don't know everyting. I do have a few patients similar to the folks descibed in the article .. and I have a hard time knowing WHAT the problem is. Saying "I don't know" is often the best method. My problems escalate when a patient brings to me a hypothesis from another healthcare provider which is as reflexive and condescending as "it's in your head."

Consider Dr Harvey's statement in the Gazette article I link to above: “Without understanding the skin lesions fully, I’m treating patients with antibiotics and having clinical success. Something appears to have happened to their skin immunity.”

He's making a treatment decision in the absence of any rationale. Am I an arrogant physician because I wouldn't treat a problem with antibiotics unless I knew there was a clear rationale for that treatment? Dr Weil's talk at STFM yesterday touched on this a bit. He acknowledged that much of the "alternative medicine" that people are embracing is in fact garbage. We need to be thoughtful and evidence-based as we practice integrative medicine .. just as we do for "traditional" medicine. Yet there will be integrative methods without much evidence, just as there are traditional allopathic methods without much evidence. He suggests that the requirement for evidence of efficacy be dictated by the level of risk in any treatment.

STFM, Medlogs, etc

Like many, I've responded to the change of movabletype from a shareware product to a commercial one. As a colleage suggested to me ... people gotta eat. I will not move to wordpress. Upgraded to MT 3.0 without too much trouble. It does seem more stable - though I lost my HTMLAREA WYSIWYG editing which I liked very much .. so will have to figure out how to reainstall that to MT3. The tempaltes have changed a bit so it may take some work to figure this out.

This morning's keynote speaker at the STFM conference was Andrew Weil. He gave a compelling talk on integrated medicine and I find myself agreeing with much of what he has to say. He appropriately described the obvious links between family medicine and integrative medicine - as we do see patients as the sum of a whole - rather than as a disease or diagnosis. The key is that we need to work the training of integrative medicine into our medical schools and residencies.

He told a compelling tale of Dr Laurence Craven (descibed in this pdf .. and some other places:

In the 1950s, a California physician named Lawrence Craven made a keen observation. For several years, Craven had been prescribing Aspergum, a chewable form of aspirin, as a pain reliever for patients who had undergone tonsillectomies. Craven noticed that these patients experienced an unusually high occurrence of bleeding problems. In a bold leap, Craven theorized that this apparent “side-effect” of Aspergum might have beneficial applications. Within the arteries supplying the heart, Craven reasoned, an increased bleeding tendency might prevent the formation of the clots believed to cause heart attacks. Though his hunch would prove prophetic, Craven’s data were far from conclusive, and he became little more than a footnote in the aspirin story. Craven’s reports on aspirin were uncontrolled clinical observations, which only reached relatively obscure regional medical periodicals. His data were not published in the prestigious journals of the established research community, where they might have sent other scientists scurrying onto the aspirin trail. Craven was a family doctor, not a trained researcher, and his studies did not employ the rigorous scientific methods necessary to test his intriguing hypothesis. For example, he eventually had thousands of patients chronically taking aspirin, but assembled no control group of patients not taking aspirin against which their cardiovascular disease rates could be compared. Craven also betrayed the sort of unbridled enthusiasm for his hypothesis that can sometimes serve to discredit even the most plausible theory. In one report, Craven said that he placed 8,000 patients on regular doses of aspirin and not one suffered a heart attack or stroke. This track record appeared too good to be true. There was a smattering of other reports from scientists who also theorized that aspirin might have beneficial effects on cardiovascular disease, but the exact biochemical basis for such an effect remained unclear.

Weil's point is that one fo our problems in medicine today is that physicians often consider the SOURCE of information before we consider the informationitself. Craven, a General Practitioner, was not considered to be authoritative - so it too the cardiologists another 30 years to "discover" the compelling benefits of aspirin in the prevention of cardiovascular disease.

My session on Medical Weblogs went well on Friday .. I'll post an update about that if I have a few minutes later today .. otherwise we'll get to that tonight .. ;-)

Pneumonia Severity Index Calculator

Physician Fears

Ny Times: Doctors, Too, Have Fears; They Just Go Underground

This is an article about "Medical Student Syndrome" and how it recedes after medical students magically become physicians.

It's an accurate depiction of what happens to students, but the author misses the point in her portrait of physicians. 

AAFP Monograph - Aging

The AAFP sends out mongraphs every few months.  I often glance at them and then pile them up in my study so taht I can r"ead them later"  .. (so that I can throw them away the next time I tidy up).

They're all on line ... so today's copy: Aging and Health Issues: The Family Physician's Role is going right into the recycling.  It looks interesting .... and ther are several useful screening tools:

• Folstein MMSE
• Michigan Alcoholism Screening Test - Geriatric Version (MAST-G)
• ADL self-maintenance scale
• Instrumental Activities of Daily Living Scale (IADLS)

Now I'll never lose it ...  and the office stays clean!

Thyroid Masses

Shared decision-making

The end of Supersize

Lending Library

Starting a lending library at the office ...any other suggestions?  .. I'm light on hypertention, diabetes & smoking cessation. Heavy on parenting.  Leave comments if you have any other suggestions for "must have" lending library books.

Blinking

Salon Reports that Wesley Clark doesn't blink.  Here's the video to prove it.

Hmm.  No blink. 

Why?  maybe ...

• He is under hypnosis
• He has moist eyes
• He's old
• He's thinking:

• Percept Mot Skills. 1975 Oct;41(2):503-6.

  Related Articles, Links

  
  Blinking and thinking.
  
  Holland MK, Tarlow G.
  
  Blinking is related to certain cognitive processes. For example, individuals "punctuate" their speech by blinking between phrases and at the end of sentences. Daydreaming is associated with low rates of blinking. Blinking occurs between fixations and may be timed so as not to interfere with significant visual input. Apparently, blinking occurs at transitions between internal events and is inhibited at other times. In the experiment reported here, blinking was measured while the activity of operational memory was manipulated with mental load kept constant. The rate of blinking was significantly reduced when the cognitive operation of internal counting was being performed. It is inferred that the blink rate is low when information in memory is being operated on. To suspend blinking during certain cognitive activities would be adaptive if blinking disrupts them. Since the blackout period of the blink produces a rapid change in visual level, blinking disrupts those cognitive processes utilizing display areas accessible to visual input. Operational memory and the visual imagination may share components with the visual perceptual system. To protect these vulnerable processes from interference, blinking may be inhibited when they are active.

Fortunately, there is no relation to blink rate and neurocognitive impairments in schizophrenia.

IgA Nephropathy and Mastitis

Tonight I was in the hospital seeing a patient ...and a nehprologist colleague stopped me in the hall and we blabbed for a few minutes.

I asked him about a patient of mine who has IgA nephropathy.  After 10 years without any trouble, she developed mastitis  (btw - this link is a great review of mastitis and its causes and management) and then developed gross hematuria.

His first thought was that this was odd because he usually sees "IgA nephropathy worsening with infections of organs that involve .. IgA .. like the lungs."   Then I reminded him that breasts sure do involve IgA.  

Interestingly, there are only two case reports of mastitis causing exacerbations of IgA nephropathy in the literature.  Perhaps we need a third. 

So then he teaches me about suggesting fish oil to my patients with IgA nephropathy. 

uh .. since the prevalence is about 1:4500, it's not likely I'll have more than 1 patient with IgA nephropathy for a few years.  Ther are about 3000 patients in our practice -- of which about 1,000 call me their primary care physician.

Nonetheless, it's something that I'm interested in.  If fish oil will really alter the progression of this disease ... I'm all for it.  Here's a great review  (pdf) of the state of affairs with fish oil and IgA nephropathy.

Google

My patients google me .. which isn't a surprise (hi folks!) ...  Here's a weblog written by someone who prefers to remain invisibe. 

Invisible Adjunct: Everybody Googles Everybody

Handout for cerumen

Ears / Harvard / Boston

Dave responded to my post below.

I didn't have my facts right.  Dave called his primary care physician first.

I posted a response to the Boston Common weblog   post  (and his response) ... here's what I said:

Dave is sharing some tidbits of his personal life with us, and I shouldn't chastise him for doing so .. I should applaud him. This sort of transparency is educational. Dave is teaching ... and I suppose my goal was/is to teach as well.

Dave - I didn't mean to infer that you were casual about your care. My inference (albeit incorrect!) was that you -- like many -- have been taught -- by a system and culture that values specialty care above primary care -- to seek specialty care before the problem was evaualted by a family physician or general internist.   As point out, I was wrong about how this panned out.  Given your "celebrity" status, and your willingness to share these details of your personal life with us, I used this event as an example of a component of our healthcare system that I believe is dysfunctional.

It turns out that the example was a rotten one, but my sentiment about the dysfunctional system/culture remains the same.

Most patients who reach out to me are seen promptly and are referred to specialists only when necessary. Yes - we see patients on Saturday and Sunday and even at night.  Had you called me, I would have offered to see you in the office.  This is the core of what we do - we are the primary care physicians and we specialize in primary CARE -- not primary referral. We take care of very sick people and very well people. Young, old, pregnant, depressed, sexually active and impotent.

As one who teaches family medicine to medical students, I struggle with the biases against primary care every day. Specialists tell our students that family physicians are "stupid" or that the only role we should have is to "pop the pimples on farmers' butts and refer the rest of the patients to appropriate specialists." No kidding .. this came right out of one of my specialists colleagues' mouths.

My comment speaks to a culture of medicine -- and the role of primary care in how we treat our patients.

Yes .. I have a bit of a chip on my shoulder. (see above re: farmers butts). Primary care physicians are the Rodney Dangerfields of medicine.

We earn respect in an 8 x 10 room with our patients one-by-one-by-one. My post starts with a comment about Dave's encoiunter, but if one reads the whole post, you can see that I discuss much more than that.

Some places - and Harvard is one of them - have developed a culture that remains specialty -focused. I grew up in Boston - where I didn't know what a family physician was until I was 18.   Boston was one of the last of the major cities to host a residency in Family Medicine (There are several in the Boston Metro area now), and there remains NO family medicine education at Harvard. See this note in Harvard Medical School's weekly paper about the dearth of family medicine education at Harvard, and how unhappy the students are about this.  

Finally - since we're all in this to educate ... here's a link explaining why you shouldn't use q-tips in your ears .. and a reminder (I've posted on this one before) that colace (Docusate Sodium) is very good at softening earwax.  I sometimes suggest that people use this once a week to avoid impaction problems alltogether.

Ears

Dave needs a good primary care physician.   His post today reveals his ignorance of the importance of primary care.   This is common in people who are wealthy and/or have "very good" insurance that gives them access to specialty care without referral.

I'm not saying that specialty care is bad -- but I can't even count on my fingers how many times each week I provide services to someone who initially called asking for a referral.  This week's struggle was a dad who called and demanded an emergency referral to a dermatologist for the rash that his daughter had for the past 6 weeks.

"Now .. nothing against you, doctor, but I think that this condition has gotten so bad that we need a specialist."

"I'm happy to refer you to a dermatologist if that turns out to be necessary - but since I have not seen the rash - nor have you even called me about it - it's hard for me to tell the dermatologist why I'm referring the child to him."

"Well you saw her in October for her well-child visit and you said she was fine."

"uuh .. yes .. was she not fine then?"

"Yes she was but now this rash is real bad and we want to make sure it goes away."

"We all want the rash to go away.  I'm happy to see her today and if I can't help you, I will be sure to refer her promptly to the dermatologist."

The child has eczema.  I did a quick google search and found some good handouts to reinforce my counseling and diagnosis.  It's unlikely we'll need to send this kid to derm. 

When I was 15 and living in Cambridge, I scratched my cornea with some sawdust as I was cutting something with a circular saw.  Like Dave, my parents decided that the "experts" would be best to evaluate this and drove me down to the Medical Mecca and I received appropriate treatment for this very common problem. 

So what? 

Like Dave - I could have received appropriate treatment for this problem by any competent primary care physician.   This would have been a better use of the limited healthcare resources that exist in this country.   I treat scratched corneas and impacted cerumen all the time.  So do most primary care physicians.   These propblems are not rocket science - nor do they require the services of specialty care.

The Boston area is hyper-specialized.  There are relatively few primary care physicians and an overabundance of specialists - which is a function of the overabundance of wealthy, educated healthcare consumers, and an abundance of training programs.

While I would agree that the folks at the Mass Eye and Ear Infirmary may be some of the best in the world at what they do - we should only use them when we have conditions that the primary care physicians can't handle.  A good primary care physician would have removed the cerumen from Dave's ears, and would have given him the same lecture about not using q-tips as he received from the specialists.

The disjointed care that people get from a horde of specialists is clearly worse care than the care they get from one primary care physician. 

Yet there remains a perception that the care they provide is better.  We can't combat this work our words - we have to re-educate our patients by providing the comprehensive, care that they deserve. 

IN the context of my patients requesting specialty care - I've been seeing more specialists in MY office.   Caring for another physician is always challening, and initially, this was intimidating to me - yet I've become better at navigating this complex relationship.  Like the otolaryngologist or the ophthalmologist or the CT-surgeon, I am a specialist too - in primary care. 

BMI Calculators

BMI Calculators from the CDC.  Very useful.

Don't treat h.pylori?

From Gut:

... after adjustment for the covariates age, sex, erosive oesophagitis, hiatus hernia, degree of gastritis, and severity of symptoms at baseline, H pylori eradication was the only predictor of treatment failure.

This is quite interesting.  I don't have access to full-text of this article - so let's not jump on this bandwagon just yet - but it's an interesting topic - and a common clinical problem.

Dr Bob on obesity

Dr Bob's entry On obesity provokes response.  Like several of those who comment on his entry - I applaud his honesty - and will come clean like he has:  when we care for patients who have been participants in their illness, it is tempting to blame them, and in our weaker moments, we do. 

Bear with me here ...  

Addiction is a powerful disease - whether to drugs or tobacco or food.   Working with addicts is challenging.   We try so hard to listen, understand, counsel and advocate.

Prescription Medications Online

I started this entry with a link to one of the online pharmacies, but I've now erased the link.

Longtime readers of Docnotes will know that I added Google sponsored advertisements in September or so.  the ads appear only in the archives of the weblog.  So if you're reading this in an RSS reader or you logged in to the home page at www.docnotes.net or www.docnotes.com, you never see them.  But people arriving here from web searches will see them, and while I won't say how much I make on these ads, I will say that they earn me far more than it costs to run host the weblog every month. 

Since google chooses the ads on every page based on the topics that I discuss, theya re hoping that the ads are relevant to what the user is interested in.  The ads can't influence my writing - since the writing happens before the ads do.

But I just looked at an archved page where I discussed a certain medication (and how bad it was) .. and there at the top of the page are three ads for how to buy that medication over the Internet without a prescription.

Hmmm.  I don't like this.  I don't like it that one can buy prescription medications over the Internet.   Yes .. I'm gonna use the same argument you'll hear from most physicians .. I don't think it's safe.   Sure, it may be safe to sell some things (I don't dare name them here!) that have recently become OTC .. or will soo become so. 

But if my role as your physician is to be a resource - to help you make decisions about your health - then I'm hoping that you will let me do my job.  A few months ago I saw a patient in the office who was buying an antidepressant on the Internet.   He had tried another - didn't feel much better in 2 weeks, and tried a second one.  He wasn't dosing either one properly.   It was a  tricky situation, and I was oddly reminded of it a month ago when Ray blogged about how he was over his head trying to replace a wood floor:

Sunday was "Install the Wood Floor" day, which quickly turned into "What in the hell was I thinking" day. So, today I'm on the phone with a few companies to find someone else to come in and finish the job. I have to remember - people pay me to do what I consider to be very easy stuff... so I shouldn't feel bad paying other folks to do things that are probably easy for them. ;)

Ray is a great programmer, but he's never coming over to my house to install my wood floor.   Dosing antidepressants isn't very hard for me to do ... and it may seem so easy that an intelligent person like my patient ccould do it too.  But he can't.  This doesn't mean he's dumb and I'm smart.  Indeed - he's likely much smarter than I am.  I just have a different skill.

In this era of the Internet - with medical information everywhere - I don't doubt that the opportunities to bypass the physician are ample - and sometimes appropriate.  Finding the line between appropriate and inappropriate  medical "self-service" is going to be the hard part.

So .. back to the office ... this was tricky because I don't want to chastise him or be insulting (as I can expect Ray feared when he called the wood floor guys:  "hey bob .. this guy onthe phone wants us to come fix his botched floor.  yuk yuk yuk") ... I want to understand why he did it, and make it safe for him to ask for my help .. now and in the future.

Gabapentin & Headaches

An article in the current issue of Neurology demonstrates that Gabapentin may be useful in the treatment of daily chronic headaches:

 A total of 133 patients were enrolled (41 men, 92 women, mean age 43 years). All were eligible for safety analysis. Ninety-five received sufficient treatment to allow evaluation of efficacy. There was a 9.1% difference in headache-free rates favoring GPT over placebo (p = 0.0005). Benefits for GPT were also demonstrated for headache-free days/month (p = 0.0005), severity (p = 0.03), VAS (p = 0.0006), headache-associated symptoms of nausea (p = 0.03) and photophobia/phonophobia (p = 0.04), disability affecting normal activities (p = 0.02), attacks requiring bed rest (p = 0.001), and QOL related to bodily function (p = 0.01), health/vitality (p = 0.0001), social function (p = 0.006), and health transition (p = 0.0002). Reduction in headache days/month was seen across the spectrum of prerandomization headache frequencies.

This looks like a well designed study.  I've used it a few times for patients in this situation - but I wouldn't say that I have considered it first line.  The treatment of a problem depends on the cause fo that problem -- and chronic headaches can be caused by many many things.  Is the use of gabapentin just masking the symptoms - or treating the problem?  Hard to know.

Rectal Exams

From Trust Me, I'm a Doctor:

I've quit doing screening rectal exams. Unfortunately, it takes more time to tell the patient why we don't need to do it than just getting it over with.

He's right.  The PSA conversation takes 20 minutes, but just ordering it takes about 20 seconds.  No wonder so many physicians just to the rectal and the PSA and .. treat bronchitis with antibiotics. 

My nurse complained to my wife yesterday that I take too much time with my patients.  She's right that I do.  But shouldn't I explain things?  She asks "what in the world are you doing in there for so long?" 

I'm mostly listening - but sometimes I'm explaining.

We physicians do a rotten job in general to explain things to people.  we use this secret language to communicate with eath other.  We learned it in medical school, and some of us forgot how to actually speak English when we graduated.

"Mrs Jones, you have microcytic anemia and your ferretin is decreased.  YOu need to take the feso4 tid.  We'll check a CBC in a month."    No kidding .. I've seen it this bad.  

Of course in my "other job"  (of which I rarely speak here, it seems) I see this even worse.   I work with computers in a hospital.  It's a bit more complicated than that -- but -- you get the idea , right? 

Computer people are worse at the translation from their secret language than physicians.   Interacting with humans was never a required component of their education like it is in medical school (albeit a small component).  So it is rare to find someone in technology who communicates well with "the other side."  Today was no different - and I felt bad reminding them again how speak English instead of TecnoSpeak.   

When I teach medical students how to un-learn the DoctorSpeak - they are appreciative and - yes - a bit ashamed.  I don't mean to make them feel silly - but sometimes when we have a student in the office and we're in a room together with a patient and the student says "do you have any dysuria?" and  I say to the patient "did you understand that?" and the patient says "no" and I ask the student to try again and they say "does it hurt when you pee?"  And we all wonder why the "dysuria" question would EVER be asked.  But it is .. very often.

Maybe the poor student has just finished surgery where some jerk told them that it's important to "be precise with your language."  ugh.

Guidelines, screening

I'm cleaning off my desk today

Items in the pile:

a) Junk mail from Life Line Screening Radiology.  It's targeted to our zip code -- not just physicians.   Like the Bookmibile ... they'll be in the area next week.  It looks like they set up shop in the parking lot of a local church.  I can get a carotid u/s for $45 ... Screen for an AAA for another $45 .. etc .. or  a "complete package" for $99.

I'm not sure what to think about this.  It's certainly not indicated in young people.  I wonder who shows up at such events. 

b) Another version of treatment guidelines for community acquired pneumonia.  As usual, this one suggests that we use:

• A macrolide such as erythromycin, clarothromycin, or azithromycin
  • or
• Doxycyxline
  • or
• An extended spectrum quinolone

When I was in training, I recall wondering what the "right" answer was.  I thought I was stupid because I didn't get it .. that somewhere in the guts of the guideline was the right answer hiding from me.  Instead .. it seemed elusive.  "You CAN do this ...  you could choose one of these .. " It all seemed so ambiguos.

Now that I'm a jaded mid-career 40 year old physician .. I see that these things are vague because no one has the right answer, and they are fearful in such a guideline to dictate what the physician shoudl do.

This is odd.  We need more clarity .. not more ambiguity.   We all end up at an answer when we reach for the prescription pad.   Are some answers better than others?  Yes.  Why?  ... ooh .. we're getting closer.

So the guidelines need to help physicians parse out the distinctions.

Why is azithromycin NOT my first choice for community acquired pneumonia?

• It's expensive
• It's too broad-spectrum
• It causes resistance in all macrolides - likely due to its very long half-life and the verly long time that it remains in tissue at levels below MIC

Smoking kills ...

On Smokefree.net

Randy Daniels Fiddles While Baby Burns

It's been two and a half years since New York passed fire-safe cigarette legislation. To be implemented, however, the law requires Secretary of State Randy Daniels to issue fire-safe standards. While Daniels delays, a series of fatal cigarette-caused fires have occurred. The following story describes the plight of a family whose baby was severely burned in a recent cigarette-caused fire.

This compelling story of how a family is struggling with the consequences of cigarette smoking.  I often counsel parents about the dangers of cigaterette smoking, but this story may provide a different image of some of the health risks

Prevnar shortage

David Pepper MD - Stops Crime

From the fresnobee.com | Local News:

One of the most passionate and persistent of critics to visit City Hall was Dr. David Pepper. In 1997, street racers welcomed him to the Tower District. Two drivers charged down Van Ness Avenue at 90 mph.

One car jumped a curb and crashed into Pepper's new home. He paid $19,000 for repairs. His car was next. It was totaled a year later when two trucks careened down his street. He persuaded neighbors and other doctors to speak to the City Council, "and tell them that speeding is a huge problem in this area."

They asked for more stop signs, crosswalks and traffic officers. Stop signs eventually were added to Pepper's neighborhood, but his crusade against bad drivers continued. Van Ness Avenue is often dotted with homemade signs demanding that drivers slow down to obey the 30 mph speed limit.

 Pepper decided in 1999 that speeding problems extended far beyond his neighborhood. Drivers whizzed throughout the city, he says, because police were not writing tickets. The results were deadly. During a five-year period beginning in 1997, 186 people died in Fresno collisions, more than any other California city with a similar population size. Fresno's fatalities topped those of Long Beach (142 from 1997 through 2001), Sacramento (178) and Oakland (181), according to the California Highway Patrol.

Dave Pepper is a family physician who has clearly had an impact on the health of his community.  Nice going, Dave.

Coenzyme Q10 Decreases Cardiac Events

Specialty Care

Reducing diagnostic tests in primary care

Wearable Communicators

Socks

With holidays around the corner -- Sam's made some revisions to the Sock of The Month Club -- and in doing some "market research"  we learned that there are only 6 days left to purchase these on ebay ... a bargain at any price.

Medicare Prescription Program

The Medicare prescription drug program stinks.  I don't quite understand why AARP supports it.  Many seniors will get LESS benefits under the program.    Here's a report (pdf) that explains some of the reasons that we shouldn't support it.  Our local newspaper published an editorial this week against it, and I am impressed with their insight.

From an article in the Kansas City Star:

Meanwhile, a dozen AARP members gathered outside the organization's Washington headquarters to protest the decision of the large seniors' group to support the Republican Medicare proposal. Some tore up their membership cards.

"I always felt like they were for us," said Queenita Gaskins, 67. "I cannot believe that they want us to go with something that isn't for seniors." Gaskins criticized what she said was the bill's skimpy coverage of drug costs; the package would offer no coverage, for example, for costs between $2,200 and $3,600.

"This bill is terrible, just terrible," added Evelyn James, 85, as she stood outside the AARP building in pouring rain. "This offers nothing for seniors and will diminish our health services."

Anticlue

Beta Blockers and Depression

Faughnan's Notes mentions an article in the economist on beta blockers and memory. 

The mood and memory effects of beta-blockers are subtle, and despite some reviews in the medical literature, I do believe that this is clinically significant.  INdeed, the fatigue associated with carvedilol seems to be greater than that associated with older agents. 

Today I saw a patient who has been on carvedilol for about 10 months - and her ejection fraction has improved from 30% to 55%.  But she's terribly depressed and feeld so fatigued that she can't do anything.   

The SSRI has done rather little  - and today I called her cardiologist and we agreed to stop the cavedilol for a month or so and wee what happens.  

A 45 year old with hypertension felt that the metoprolol was doing fine.  But after a bit of careful discussion and a zung scale - I learned that he had depression.  This is the trouble with much of behavioral medicine.  Since the medication isn't discontinued - the problems are very likely more common than the studies suggest.

John Faughnan

Hey - John's got a weblog -- er -- three.

• Faughnan's Notes.  - Friends and family
• Medical Notes - the medical version
• Quick Notes - quick notes blog

I missed John at AMIA this year.  His weblogs are great.  Hmm .. he's uing blogspot -- so no RSS.

Linux Medical News

Over at LMN: Live from the 2003 Fall AMIA Conference.  This is Ignacio's version of  the EHR session.  He types faster (and has better batteries) than I do.  Neither of us liked what we heard -- but for different reasons, it seems. 

I'm not bothered at all about the code.  Open source of the code that's behind the software is simply unnecessary.  Good software can be "closed source" and still be good.  The key is that our data be accessible.  With many EMR's the data is locked forever.  It's a real problem and dates back to the age of the dinosaurs. 

A key (and laudible) component of the AAFP project is that the data remain accessible.