December 29, 2009

No Such Thing as "Healthy Obese"

I've been doing a lot of thinking about Science Writing.

Here is an example of great Scientific Journalism from Forbes.com (via Dr. Ves)
Study Debunks Notion of 'Healthy Obese' Man

The report concisely analyzes a new study in the journal Circulation, including the patient size and population (1800 Swedish men) and most importantly, context: ("starting at age 50 for an unusually long time, 30 years, recording those who have died of a heart attack or stroke.") Problems with previous studies did not track patients over an adequate period of time (in which patients were only followed for 15 years or less.)

The results:
the study found that over the 30-year period, the risk of cardiovascular disease was 63 percent higher in men of normal weight who had metabolic syndrome, compared to normal-weight men who did not have metabolic syndrome. It was 52 percent higher in overweight men without metabolic syndrome, 74 percent higher in overweight men with metabolic syndrome, 95 percent higher in obese men without metabolic syndrome and 155 percent higher in obese men with metabolic syndrome.


The only thing that this report fails to do is cite the original article, which I will do (along with an older one that is readily available on PubMed.)

Circulation. 2008 Jun 17;117(24):3057-9.
Healthy lifestyle: even if you are doing everything right, extra weight carries an excess risk of acute coronary events
.
Johan Ärnlöv, Erik Ingelsson, Johan Sundström, and Lars Lind
Impact of Body Mass Index and the Metabolic Syndrome on the Risk of Cardiovascular Disease and Death in Middle-Aged Men
Circulation, Dec 2009
Poirier P.

-----------------


It's topical and relevant, especially in this holiday season :)

So what will I tell my patients?
If you are a middle-aged Swedish male with a pot-belly, high cholesterol, elevated blood sugars, and high blood pressure, you are doubling your risk for a cardiovascular event (1.74x for overweight, 2.55x for obese.) If you only have a pot-belly you ALSO increase your risk (1.52x for overweight, 1.95x for obese.)

This is likely even higher for other more at-risk populations.

December 21, 2009

Podcasts

This part was a real struggle for me, since I have never used podcasts before. I didn't even use iTunes before. After a lot of searching, I came across some fun podcasts.

My new podcast stream:






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December 20, 2009

iDistraction

My blogging has dropped off, due to some new distractions.
I thought I'd share one of them, since it bears medical/educational relevance, in the same vein as Joshua Schwimmer of Efficient MD.com:

Other apps recommended: "8 Medical iPhone Apps You Should Prescribe to your Health-Care Professional."

Medscape loads faster than Epocrates, but Epocrates is the go-to for medicine info.
Medcalc is a classic that I used a lot on my PDA, just like Eponyms.
Heme Calc also has formulas for nephrology, cardiology, gastroenterology and obstetrics -- I couldn't tell the difference between the other apps offered (so I went with the one with the prettiest color.)
Reach MD radio has streaming radio for medical professionals. Really good for a smattering of general medical topics.
PubMed on Tap: Joel Topf found this very helpful when he needed a citation to back up the statement he made that "the data doesn't support the common sense notion that contrast accelerates the loss of residual renal function."
Shots online and NEJM Image Challenge are two weblinks that I found worthwhile storing on my homepage.


Evernote is ever AWESOME. Especially when I found out that I could *Favorite* my handout on Acid-Base and EKG reading for quick access (local file, no repeat downloading necessary)
Google Reader and Twitter provide me with round-the-clock streaming data on the latest and greatest, by subscribing to some of the best, web-savvy, provocative and brilliant physicians!

November 19, 2009

Family Medicine?

A question I get asked a lot is "Family Medicine, huh? Is that like a GP?"

It is strange but a lot of people do not know what a Internist does, much less a Family doc.

I was pleased when I came across this article in the Annals of Family Medicine: FAMILY MEDICINE: WHAT ARE WE GRADUATING?
From the Association of Family Medicine Residency Directors


The original guidelines from family medicine covered a mere 3 pages laying out the length of training, and general content, as well as proposed categories of programs that reflected and embraced the wide variation of locations where family medicine physicians lived and worked. Our founding document also defined the family medicine physician in 4 domains

First, the family medicine physician was to serve as the physician of first contact with the patient who provided an entry for the patient into the health care system.

Second, the family physician was tasked to evaluate the patient’s total health care needs and to provide personal medical care and referral management.

Third, our graduates were to provide continuous and comprehensive care as well as the coordination of care.

Lastly, the vision asserted that family medicine physicians were to provide care for the patient within the context of the patient’s family and social milieu.
Primary care. Primary as in First contact. Total care as in from beginning to end. Family medicine -- with a focus on the context of interrelationships, family, and society. I love it! It's all in the name but the IDEA is somehow so foreign to the sort of fragmented, disjointed care that we have now that we've lost sight of these sorts of basic principles.

----------------
The Residency Directors ask this question:
Do we need to expand the definition of the family physician to include alternate types of practice? And, lastly are our values antiquated, are our visions of ourselves valid, or should we change?
I answer with an emphatic No.
I will strive to have a committed relationship with each and every one of my patients. One of the most frustrating thing about being a medical student is the time and effort required to get to know a patient in a 30-45 minute time span only to see them vanish into the Healthcare system never to be seen again. So I look forward to a time when a patient is scheduled for a follow-up appointment in 6 months and I actually get the chance to follow-through.

November 16, 2009

Adventures in Brain Tumors (Prolactinoma!)

notmy2ndopinion: Adventures in Brain Tumors, (by @mathowie) http://bit.ly/37DMa4 (via @JoshuaSchwimmer)

My favorite part comes in the conclusion and it is very revealing about how AWFUL the patient experience can be. All too often, health care professionals feel pressured by their own time schedule and do not take the time to move at the pace more comfortable for the patient. Even small, simple things can make a big impact, like pulling up a chair to sit while talking, tuck the blanket in after pulling it down to examine their abdomen, etc...

The days in the hospital didn't go by so much as a blur as they did a smear. I was either asleep, passed out and seizing, lethargic, and very briefly completely awake each day as an army of medical professionals grilled me with a couple dozen identical questions and eventually life altering decisions were presented to me when I had been awake for all of 30 seconds.

I came away from this experience feeling the OHSU hospital in Portland continues to impress me with its amazing staff, but that the process of dealing with patients could be done in a more efficient manner. I know they all sort of kept an internal log of my story but to constantly be asked the same things by different groups of people and then not know who is your main decision maker was a challenge. Given my state of sickness and exhaustion, I felt like what an elderly man might feel like in the medical system. I had trouble understanding what people were saying as they woke me from sleep, I was constantly poked and prodded without descriptions of what results entailed, I literally wanted to "phone a friend" when those surgeons asked me in the early morning hours what I wanted to do.

November 15, 2009

"Time Lost is Brain Lost"

I woke up at 0430 and I couldn't get out of bed. Oh, that's weird, I thought. My right arm was completely numb from the shoulder all the way down to the fingertips. After about two minutes I jumped out of bed but I fell straight down onto the floor with a crash. My legs were weak -- it was like the right side of my body didn't exist!

My wife awoke in the commotion and asked me what was wrong.

I opened my mouth to talk to her, but nothing came out! I could understand her but my words weren't there.

After about three minutes, I got up and I said "oh, I'm okay now." I took a shower (there was still some numbness in the arm) and went to work. I figured something was probably going wrong so I called the doctor and he told me to go to the ER.
Lucky thing too... it sounds like you had a mini-stroke or what we call a"transient ischemic attack," (TIA) -- a temporary event. The residual numbness suggests more long term damage though. Since you're right-handed, you are most likely left-brained -- and your language is controlled by that side of your brain too. When you had the brain ATTACK (as threatening as a heart attack!), you wiped out your left brain, paralyzing your right body and knocking out your ability to talk.

We call this right-sided Hemiparesis (weakness) or hemiplegia (no movement), right hemineglect (inability to register things on the right side of the world) and Broca's aphasia (inability to verbalize thoughts; staccato, halting speech.)

I went over the ABCD2 scale with him and calculated a moderate risk for stroke:
2-Day Stroke Risk: 4.1%.
7-Day Stroke Risk: 5.9%.
90-Day Stroke Risk: 9.8%.


We started him on clopidogrel (Plavix) and he is undergoing a cardiac workup to rule out an embolic cause for his TIA/stroke.

In stroke patients, further assessment is done with the NIH Stroke Scale.

An pdf of the NIH Stroke Scale is available at http://www.ninds.nih.gov/doctors/stroke_scale_training.htm

An online course for provider education is available on
http://www.strokeassociation.org/presenter.jhtml?identifier=3023009

November 01, 2009

Hoarseness

In my Neurology rotation, I saw a lot of patients with "spasmodic dysphonia," which makes people sound like they are choked up with emotion or they are sick. It is described as "breathy," or "halting, strangled" voice that trips up on diphthongs, two vowel sounds. It can be precipitated by a stressful event, leading many physicians to think that it is psychogenic.



Surprisingly, Botox (Botulinum toxin A) is a definitive treatment! With EMG guidance, a needle is advanced into the vocalis muscle and injected with a small amount of Botox to paralyze the spastic muscle for 3-4 months.



Other causes for hoarseness include:
Inflammation-> allergies, trauma, URI
GERD-> laryngopharyngeal reflux (treated with a PPI)
Vocal cord lesions (granuloma, papilloma, edema, squamous cell carcinoma,)
Recurrent Laryngeal Nerve injury or Vagus nerve injury (aortic aneurysm, mass effect)
Neurological problems like Parkinson disease, multiple sclerosis, myasthenia gravis
Systemic disease (acromegaly, amyloidosis, hypothyroidism, inflammatory arthritis, sarcoidosis)

October 30, 2009

The Mito Mystery

Brownout: The Mitochondria Detective work Gets a Little Easier

“The mitochondria are like engines,” he says. “When a car engine doesn’t work right, it smokes.” Similarly, malfunctioning mitochondria produce nasty gunk Enns refers to as “biochemical smoke.”


I love little pictorial metaphors that just make sense.

The article delves into the medical mystery of a young girl who is "anorexic" despite a healthy appetite who had two siblings who passes away with some sort of muscular dystrophy. They get referred to a mitochondrial specialist.

But sometimes, for a single patient, a glimmer of hope breaks through the fog. Veronica Segura recently learned what’s at the root of her disease: a mutation in the cellular instructions for building the enzyme thymidine kinase 2, which plays a key role in synthesizing new mitochondrial DNA. Most important for Segura, a child must receive a bad copy of the gene from each parent to manifest disease. Segura’s husband, Aurelio, doesn’t carry the disease gene, which means their little daughter will never suffer her mother’s mitochondrial illness.


The article ends on this happy note, but I am doubtful of its veracity.
It is my understanding that mitochondrial DNA are EXCLUSIVELY inherited by the mother, who provides ALL of the baby mitochondria as the egg donor -- the sperm mitochondria do not become a part of a zygote->baby...

October 29, 2009

"The Neuro Exam is not dead"

Bedside Eye Exam Outperforms MRI in Identifying Stroke

"We only misclassified 1 out of 25 patients who had a vestibular disease that was a benign condition of the inner ear,"

"This study demonstrates the critical importance of function-linked tests over purely time-static anatomic tests in discerning the localization of vestibular dysfunction early in its course," session cochair Nina Schor, MD, PhD, from the University of Rochester Medical Center, New York, told Medscape Neurology. "It's so much the better that the tests described by Dr. Newman-Toker can be performed at the bedside in these often critically ill patients."


There are three signs to look for:
Head Impulse test
Beating Nystagmus in lateral gaze
Test of Skew with the Cover/Alternating Cover

These signs showed a Sensitivity of 100% (n=69) and a specificity of 96%(n=25) which is remarkable... while it makes sense to "wait and see" if future tests show that these results are reproducible, it really does not hurt to spend a few extra minutes in a neuro exam to check for these things:
"I No (know) Strokes!" Impulse/Nystagmus/Skew.

October 21, 2009

ddx

I have a project that I am putting together about differential diagnosis.

it is by no means a topic that I have "mastered" by any means... but there are a few things that i try to keep in mind.

one of them is the quote:
if you hear hoofbeats, think horses, not zebras.

this quote is supposed to remind people that common things are common.

But db reminds me that premature closure is also a problem.
So I would revise the old saying thusly:
If you hear hoofbeats, think horses, not zebras. unless you're in a savannah and you see stripes.


October 19, 2009

diamond in the rough: HI 5!

"Health Initiative 5!"

I want to give my patients high-fives when they doing something to benefit their health. In this day and age, a lot of costs of healthcare are occult -- they are hidden behind the corporate/government behemoth that are the main payors of our current system.

Even doctors and nurses scratch their heads when the question is raised -- "how much will this X-ray cost?" Medications are usually more straightforward -- you find out when you go to the pharmacist that you lack drug coverage from your student insurance and the Augmentin antibiotics (that you're not even sure if you really need) will cost you $90 while the Keflex alternative would be around $20. (True story for me!)

People see so much money dumped into the system. They feel that some services are "free" when in fact, they are just patches hiding the real costs. Take Former President George W. Bush's assertion that "we have access to healthcare -- just go to the Emergency Room." To prevent the free=more wastefulnees, we need to feel like we get something back every once and a while.

One of the things I have thought a lot about is the question "How can I get my patients to feel invested in their health? How can I get them to take initiative?"

A recent lecture I attended about IBM's health plan includes "Healthy Living Rebate Programs." People get paid $150 to eat right and exercise. YESSS!!! That's exciting.

One of my plans that has come out of this consideration is the "Health Initiatives 5."
1) this is a physical hi-5.
-- Contacting palms in mid air is a show for positive reinforcement and enacting good changes.
2) this is a financial hi-5.
-- I will give my patients MONEY (as in five dollars off their co-pay) for performing certain small tasks that I outline in their health binder (another diamond in the rough to come)
-- this includes things like filling out an online form about family history. going through an extensive medication reconciliation form and review of systems at the visit. successfully quitting smoking or meeting "TLC: therapeutic lifestyle changes" goals and thus, not requiring medications for high cholesterol or high blood pressure.
--this checklist will be a series of small personal challenges for my patients; a way of defining their management plan and turning it into something tangible.

Lower co-pays with increased patient compliance and excitement to save money by working hard with me on a lot of challenging issues = happier patients, more appointments and better health.

I'll Hi 5 to that!

October 08, 2009

diamond in the rough: insurance vs assurance

(let the uncapitalized and flow of thought format convince you that this is just a ""thinking out loud" post rather than a heavily researched topic... although it is something I think about all the time and plan to turn into a formal proposal at some point.)

a lot of the healthcare debate rages over the issue of what "health insurance should cover."

what should it cover?
whatever the consumer is willing to pay to have it cover, of course.
the whole point of insurance is to stack the odds and cover for those emergencies -- you know, when you go to the hospital for an emergency surgery or you get in a car accident.

what the REAL issue that everyone is arguing about is health ASSURANCE.
we want to be able to have affordable care from our doctors to keep us healthy! as more and more medications hit the market (or have been gathering dust on the back shelves despite comparable proven efficacy and safety records) and more screening tests are shown to be helpful to prevent X Y and Z, we expect more from our healthcare providers.

Think about it.
Fifty years ago, people thought that smoking was not hazardous to your health -- now we know it causes irreversible lung damage that may require expensive home oxygen, frequent life threatening lung infections that require hospitalization and lung cancer that may convince people to make a last ditch effort to go for some surgery or chemotherapy.

we expect healthcare for our buck rather than someone who sits back and tells us what will happen if we dont do x y and z. (as i highly doubt my 10 second description of possible complications of smoking would EVER convince someone to quit.)

so what is the solution?

we need a lot of different fixes.

we need to keep health insurance -- it may benefit insurance companies if they are no longer the sole cash provider of ALL health services since many things are fought against tooth and nail from a financial perspective like pre-existing conditions as ways of cutting costs. (and thus better deferred to the government)

we need to maintain health assurance -- and that's where the government can step in. obviously, we have the knowledge and the means to keep our populace healthy. this starts with the simple concepts of public health. it worked with public sanitation, why not extend it to public nutrition and public exercise? those are the largest lifestyle changes that impact health to the public (and thus falls under public health domain.) this means that there would need to be a HUGE shift in public imagining of the way things work -- public gyms with trained physical therapists competing with private gyms with trainers. growing garden programs, subsidies for local produce, taxes on unhealthy snacks and cooking classes for those with hypertension, diabetes and high cholesterol.

we need to have this health assurance on the provider level. doctors and their staff need to be assured that they can have the tools they need to provide the best care that they can. this means no hoops to jump through to approve medications or procedures (no retarded justifications for complex medical decisions to people who may only have training in insurance policy instead of medical necessity.) No unjustified denial of payment based on deadlines that are not medically relevant. this means we need an integrated system for health sharing -- a network where a patients labs, imaging, and ideally records and procedures can be accessed by all who need this information without filling out endless requisition forms.

most importantly, we need this health assurance on the patient level. they need to feel that they have the time to talk with their doctor and understand what is going on and how they can be a team member in their game of life. docs are only coaches in this, occasionally directing the plays, but the patients make the ultimate decisions and live with the consequences. Patients need to feel free to find someone that they feel they can work with instead of being locked in a room with one grouchy overworked doc who may disagree with what they want.

i dont know where we are with the healthcare reform.
but i want to be assured as well.

October 05, 2009

Eye am so confused!

I remember when I had my one and only ophthalmology lecture in medical school (in a Problem-Based Learning curriculum, few formal lectures exist if at all.) We spent just 30 minutes on this topic and I still stumble on it, so I thought I'd clarify it and review it using a simple image (see slide three.) The rest of the presentation is just gravy, but that's notmysecondopinion.

October 01, 2009

Psychosocial Medicine

I do not believe in fate, just the idea that we can be receptive and perceptive to the patterns of the world around us.

With that said, I have been feeling touched in a special way these past few days. I traveled across the US for a rotation in Family Medicine in what might be arguably the birthplace of Psychosocial medicine... it is really nice to see a program that openly and seamlessly integrates aspects of this into daily practice.

Yesterday's Grand Rounds covered a health care model that incorporates mental health as a key component of medical health. Behavioral Health Professionals are considered to be Primary Care Providers at the clinics (in this model) and indeed, many patients actually view the BHPs as their PCP instead of the doctor!

It goes to show that a lot of the pain and suffering people have can be alleviated by having someone open and willing to listen.

One of my favorite rotations on Maui when I did my third year longitudinal outpatient experience was psychiatry for precisely this reason. We had the opportunity to have longer, uninterrupted routine visits with people who had complex psychosocial issues in addition to a number of medical problems... and such a simple process led to so much healing.

Due to privacy and confidentiality concerns, I hesitate to speak in specifics about the cases I have been involved in. Luckily, I watched the season premiere of House which illustrates many of these principles.



House is committed to Mayfield Psychiatric ward and goes through an incredible process on the road to recovery... from nearly everything that makes House a Vicodin-popping, biting caustic sarcastic jerk.

The psychiatrist he is "pitted against" exhibits a lot of great traits for a physician. He listens, he reflects, he foils almost every antic that House can throw against him in the crusade to get his medical license back. How does he prevail? He speaks openly and honestly. He has impeccable timing, anticipating, confronting and deflecting to just the right degree that he makes conflict seem like a meaningless endeavor. Most importantly, he identifies what is important to House and uses THAT as House's path to rehabilitation.

Of course, for House it is the practice of medicine. In a psych ward, he is immediately able to identify and disable all of the different characters with the right combination of words and actions. He can diagnose and antagonize... but as he discovers in the course of this episode, he finds that he cannot FIX everything. He cannot fix anything really, since these are the fragile minds of people rather than diseased organs to be removed and discarded. In the process of helping others (as tragic as it may be on occasion) he helps himself.

I am hoping to see this process recur throughout the season, with him returning to the psychosocial aspects of medicine -- it is a daring move on the part of the writers since they have freed House to be redefined.

September 25, 2009

September 02, 2009

Pong's Postulates (II)

Pong's Postulates
1) Health is something we have until we notice we do not.
* Preventive services help people notice their health.
2) There are two types of disease: those we live with and those we do not.
3) "Docere" in latin means "to teach." Doctors primarily help people know their illnesses.

* It does not matter what doctors say; what matters is what patients hear.
4) Comprehensive Generalists see the big picture.
* Interventions happen all they way along the natural history of health to disease to complications.
5) I want to be a part of my patients' long lives through sickness AND health acting as their advocate and guide.
Therefore, I want to be a Primary Care Family Physician.


Elucidating Pong's Postulates

Health and illness:

One of my early experiences with disease is unusual. It was nothing more than a nuisance at worst but it affected me greatly. I have a condition called hyperhidrosis, characterized by excessive sweating. As a child, my palms would literally drip with sweat, sometimes for hours. I went to a dermatologist and after failed trials of topical antiperspirant and uncomfortable iontophoresis, I considered Botox or surgery. So in the midst of applying for medical school, I had a bilateral thoracic sympathectomy performed. Now I can take notes, read books and put on gloves without a struggle. I reflect upon it every time I greet a patient, now that I can shake their hands without hesitation. I am thankful for the help of my dermatologist and the skills of my cardiothoracic surgeon who have boosted my confidence as a physician.

Disease and dealing with it:

In the summer following my first year of medical school, I shadowed a few doctors at a clinic for the underserved. One patient in particular stands out in my mind. She was an obese Micronesian woman who came in with her teenage daughter complaining of fatigue, thirst and frequent urination. The resident made the diagnosis of diabetes. The plan seemed simple enough: diet, exercise and metformin. I was impressed with the way that the resident delivered the information but I noticed that she stopped listening. She broke down and started to cry. Her sobbing grew even louder as the resident started to raise his voice -- as if it would help her hear what he had to say!

"I'm sorry," I said as I handed her a tissue. "I know this is all coming as a shock to you..." I struggled with what to say next. "Are you afraid you'll be like your father and need an amputation?" Suddenly being diagnosed with the same disease that almost killed her diabetic father was too much for her. The resident apologized; "I'm sorry. Sometimes I forget that this is not as routine for you as it is for me." I have never forgotten those words -- it does not matter what doctors say; what matters is what patients hear. What can be a straightforward routine for physicians is often a life-altering alien experience for patients.

We comforted her. Diabetes was something that she could learn to live with instead of dying from it. "You need to lose weight. I do not want to say 'go on a diet.'" I said at the end of the visit. "That is temporary. We really ought to work on lifestyle changes for you AND your family... you do not want your daughter to follow in your footsteps, do you?" Both of their eyes welled with tears at that and they silently shook their heads. I was gratified to see that her daughter's half-full soda was swiftly discarded as they left the exam room.

The Big Picture and Interventions:


In my first elective as a fourth year clerk, I rounded with a cardiologist covering his partners' patients in the hospital. One of the patients we met was an elderly Hawaiian man with forty grandchildren who clotted off his stent. Three weeks ago, he was told very emphatically to gather up his family and say goodbye. Three weeks later, we found ourselves face to face with a restless grandfather. "I don't want to die here in the hospital." It was a sentiment I could understand except he had a surprising recovery. The cardiologist tried to negotiate with him to stay to make sure he was stable on the correct medications. "You may die if you leave the hospital. Do you understand?" The patient frowned and replied "Do you have grandchildren? Do YOU understand?" "No. But I understand. Do YOU?" It went back and forth until the cardiologist left abruptly.

I could see them slicing past each other trying to press their points. No doctor had given him the simple courtesy of three minutes of time in the past three weeks. He was frustrated and confused. At first, he was told that he was going to die in the hospital, then he could go home for hospice and now he was supposed to stay. I do not have any grandchildren, so I could not understand how he felt. This man cared more about his family than his own health. Perhaps it was a pervasive trend; there were many interventions that could have guided him down a different path. Yet here we were with only one thing to do: I just listened to him.

I want to be a Primary Care Family Physician:

I often wonder how the story ends for these patients. I wish I could be a guide for the mother and her daughter through health and an advocate to fight for the grandfather. I know that this is precisely what I will get to do as a family physician.

My doctors helped me prepare my HANDS for medicine. My teachers in medical school helped me prepare my HEAD as well, but it is my patients that have prepared my HEART for a lifelong commitment to medicine.

August 28, 2009

DeGowin Quotable.

DeGowin's Diagnostic Examination seemed like a silly book to have, but I inherited it from one of my previous upper medical student benefactors. I had already read through Bates... what more could it offer?!?

Boy, was I wrong.

I bought the book for my Kindle and I have enjoyed reading it from time to time. It goes beyond talking about history taking and physical exam maneuvers to philosophy.

Here's my favorite quote:
DeGowin's Diagnostic Exam (Richard F. LeBlond, Donald D. Brown and Richard L. DeGowin)
- Highlight Loc. 898-901 | Added on Saturday, July 25, 2009, 11:17 PM

Disease is a four-dimensional story, which follows the biologic imperatives of its particular pathophysiology in specific anatomic sites as influenced by the unique characteristics of this patient. Your task is not verbal, but cinematic; construct a pathophysiologic and anatomic movie of the onset and progression of the illness: the words are generated from the images, not the images from the words. After all, a picture is worth a thousand words.
Indeed, I remember my patient's problems better and I learn better when I visualize things instead of simply trying to MEMORIZE. It is tough to stay on task with it, but it is very effective during presentations -- when I've got things straight, the story comes out the right way.

August 25, 2009

A Picture is worth 1000 words... but


It's been said that a picture is worth a thousand words.

And sometimes two words aren't worth telling based on a picture.

Thanks a bunch, Palin.

Dr. Rich fights back in the Covert Rationing Blog.
When Sarah Palin uttered the fateful words, “Death Panels,” she unleashed the holy wrath of the great unwashed masses, and as a result caused many of our more complacent legislators to abruptly bestir themselves into a higher state of arousal, if not outright agitation. Palin’s accusation caught more than a few of them utterly unawares, and embarassingly flatfooted.

They felt, no doubt, like they were in that dream where you unaccountably find yourself naked in a crowd. But this time, rather than reaching to hide their sadly exposed nether parts, they reached instead for their pristine copies of HR 3200. One could almost pity them, desperately rifling through the 1100 virgin pages, wondering whether perhaps they should have tried to read that monstrosity earlier after all, and muttering to themselves, “Death panels? This damned thing has death panels?”

August 22, 2009

PERC up about Well's for PE

PERC up about Well's for PE
mnemonic for workup of Pulmonary Embolism
Items in italics and bold refer to unique features of the PERC score and Well's Criteria.

PERC Score: (PERCx2)
PaO2 <92%
Pulse >100
Extremity swollen now (DVT)
Elderly >50
Recent surgery
Recent DVT -- unilateral extremity swelling in past
Contraceptive use
Coughing up blood


Medscape: Differentiating Low-Risk and No-Risk PE Patients: The PERC Score
http://www.medscape.com/viewarticle/702755

Well's criteria: S.S. PERCC
Suspicious for PE (3)
Signs of DVT now (3)
Pulse >100 (1.5)
Extremity: Past DVT/PE (1.5)
Recent surgery/immob (<4wk/>3d respectively) (1.5)
Coughing up blood (1)
Cancer (1)

High >6.0 pt
Moderate 2.0 to 6.0 pt
Low <2.0 pt


Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998;129:997-1005. Study used a "minimally invasive" approach to managing patients with suspected PE, emphasizing use of serial dopplers rather than PA grams in patients with a non-diagnostic initial work-up. Approach is comparable to the 1999 ATS guidelines; it does not include CT angiography. A particular strength of the study was the use of set criteria to establish clinical suspicion. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9867786

August 21, 2009

Healthcare Reform 3200 Bill: 425-430 (Section 1233)

At a wedding recently, my aunty came up to me and asked "so what do you think of the healthcare bill?" I jokingly said "well, I read all thousand pages and... hehe. I don't know." I rely on the news like everyone else and I hear about "death panels" and "physician reimbursement for needed services." The Daily Show had a great interview elucidating some of the key parts of the controversy.

The Daily Show With Jon StewartMon - Thurs 11p / 10c
Exclusive - Betsy McCaughey Extended Interview Pt. 1
www.thedailyshow.com
Daily Show
Full Episodes
Political HumorHealthcare Protests

The Daily Show With Jon StewartMon - Thurs 11p / 10c
Exclusive - Betsy McCaughey Extended Interview Pt. 2
www.thedailyshow.com
Daily Show
Full Episodes
Political HumorHealthcare Protests

Betsy McCaughey is the writer of the controversial article: Ruin Your Health With the Obama Stimulus Plan on Bloomberg.com.

I do not know how I feel about this. The text of the bill says that it will provide payment for engaging in a discussion about end-of-life care every five years, otherwise the physician will be penalized.

That sounds good to me... carrot on one end (you get paid for something you should be doing) and stick for the other end (you get punished for neglecting to do it often enough.) That does not make it mandatory, nor does it force patients to choose DNR. I find those words despicable when I step away from the mantle of medicine... it strikes me as WRONG to label someone as "not worthy of resuscitation" when we mean to "allow their natural death" which is why I have posted previously on my thoughts in DNR does not = Do Nothing.

At the same time, it sounds really bad the way that some phrase it. McCaughey thinks the worst of the government as it quests for heartless objective quality improvement at monetary gain, which will drive elderly off the cliff to their doom! The fact that there are people who even perceive/misconceive/misinterpret this measure says something about the wording.

It should be revised and it will probably end up being dropped altogether.

That's sad because it is a great idea to give an incentive to initiate this tough discussion between people and their doctors.

Rob at Musings of a Distractible Mind puts it best in his post: Dying Patients and Ugly Politics. He talks about a discussion he has had with one of his patients with advanced dementia.
Politicians have labelled this merciful conversation as an act of rationing. That is not only ignorant, it is shameful. Talking to people about end-of-life issues will certainly save money. But it’s a contemptible step to imply that this money is saved by killing the elderly. It’s more wrong to make money off of keeping them alive unnecessarily than it is to save money by letting them die when they choose.

This is politics at its ugliest – taking a provision that will reduce suffering and help people and pervert it to be used as a tool to scare the people it will help. The discussion about healthcare has been subverted by those who want poll numbers.

Shame on you.

Psych Drugs as Venn Diagram


source: Information is Beautiful

David McCandless, a "visual and data journalist" should team up with Hans Rosling to get the public excited about Statistics that Matter.

Some of their displays about the influenza outbreak and country wealth are truly inspiring to see... it really shows how a good presentation makes all the difference in conveying understanding about an issue of numbers.

August 19, 2009

PubMed searches become easier



PubMed, I'm still waiting for the day when I can copy and paste a reference into the search field and get a single citation match! I find it absolutely frustrating that when I already KNOW the author, journal article and even the title of the article... the search bar is often unreliable and refuses to post the link when I type in NEJM instead of New England Journal of Medicine.

August 11, 2009

Red pill vs Blue pill


One of my friends sent me this article from the Economist: Friends for Life - Big Drug Firms Embrace Generics
"If there’s a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half the price for the thing that’s going to make you well?" Thus Barack Obama captured one of two powerful global trends forcing pharmaceutical giants to look for a new business model.
The new model that they refer to incorporates smaller generic-drug producers into larger drug-name companies. Basically, providing "responsible" oversight in exchange for name-brand recognition with the original patent holder/drug producers.

My personal opinion is that drug companies should not be "for-profit" entities. Otherwise they put the company ahead of patient interests and defy responsible and ethical regulations. That's my Hippocratic bias and I guess stockholders should get some benefit of the doubt and perhaps they invest in drug companies for nobler reasons than "oooh, they've got a new great drug on the market for the next ten years that will rake in profits and give me a 7% return on my investment!" :-\

Pharm company takeovers of smaller generic producers is a good trend in my opinion! The thought of my local drug store buying generic drugs that turn out to be contaminated with lead or nephrotoxic chemicals terrifies me. It's been done with toys and dog food in China which has shown itself to be notoriously unreliable in its oversight relative to its ability to provide cheap labor and products.

It's funny that the drug companies are going to be providing oversight for these small generics companies (basically providing them with a reliable name) so they can continue making money. The next inevitable step will be in aggressive, large-multicenter, multinational studies in comparative-effectivness research that demonstrates benefits of certain drugs WITHIN a drug class that will provide them with future guaranteed profits if they happen to be the reliable producer of the best-name drug.

As a future physician, I will always choose "Obama's Blue Pill option." It is the obvious choice in his scenario... it's cheaper and just as good! Of course, Neo is seen reaching for the Red pill, so he's off to a harsher reality. So too with us, most likely.

August 06, 2009

Pong's Postulates (I)

In the movie Pi, by Darren Aronofsky, a paranoid mathematic genius recites a near daily mantra:
Restate my assumptions:
One: Mathematics is the language of nature.
Two: Everything around us can be represented and understood through numbers.
Three: If you graph the numbers of any system, patterns emerge.
Therefore, there are patterns everywhere in nature.
Evidence: The cycling of disease epidemics;the wax and wane of caribou populations; sun spot cycles; the rise and fall of the Nile.

So, what about the stock market? The universe of numbers that represents the global economy. Millions of hands at work, billions of minds. A vast network, screaming with life. An organism. A natural organism. My hypothesis: Within the stock market, there is a pattern as well... Right in front of me... hiding behind the numbers. Always has been.
I found it to be an excellent, albeit strangely rigid way of honing in on a mission statement so to speak for this character. He proceeds from an axiom: math = nature, follows a logical set of basic principles and subsequently derives a set of values and his motivation for his current project. A way to predict the numbers in the stock market.

--------------------------

I would like to derive my own set of postulates.
A mantra that I can repeat to myself on a daily basis to remind myself of what keeps me going. My personal mission statement, if you will. The abstract version at least. If all goes well as I review my entire medically related personal history in preparation for the all-encompassing personal statement... I'll discuss each section in turn over the next week.

Pong's Postulates.
1) Health
Health is something we have until we notice that we don't. (or is it "aren't"?)
2) Illness
There's two types of illness: those we live with and those we don't.
3) Physicians
Doctors help people notice their diseases.
4) Primary Care/Prevention, Family Physicians
Primary Care helps people notice their health. Some doctors value long-lasting relationships with all sorts of patients, treating them as a part of a family-unit striving for health.
5) My Role. My Choice. My Calling.
My observational and problem-solving skills qualify me to be a great clinician, since you only see what you notice and what you notice is what you know.
My passion for science, my love of learning and my joy for sharing knowledge qualifies me to be an excellent educator in disease and prevention.
My strong sense of duty to help those in need, my commitment and my desire to make a difference in the lives of those I work with qualifies me to do hard work for the underserved and push for changes where they are needed most.

Therefore, I want to be a Family Physician -- an advocate, a coach, a guide, a mentor, a healer. It's almost like being married -- I want to be a part of my patients' long lives, through sickness and health.

August 02, 2009

Patient Centered Medical Home... say what?

One of the key components driving our healthcare debate centers on something called the "Patient Centered Medical Home." In a simplified, beautiful poetic statement it is:
"A continuous relationship with a personal physician coordinating care for both wellness and illness."



At the recent AAFP FM NC (American Academy of Family Physician's National Conference) for Residents and Students that I attended... the speaker Dr. McGeeney said:
People get the concept. People like the idea. It's the NAME that they hate.


I will freely admit, it sounded like just another silly buzzword that's thrown around to me. I do readily subscribe to the concept of a medical home -- and I do want to put my patients first in all respects. These are things that I got excited about planning for my future practice without even realizing what a PCMH is!

One of the commenters at the end of Dr. McGeeney's talk summed up my own sentiments quite nicely. He raised his hand and said "it sounds great and all, but you REALLY have to change the name. No one knows what that means. I get that it's an old concept from 1967, but it needs to change. It sounds like a nursing home to me."

So, I found myself thinking about the CONCEPT.

What does it mean to have a PCMH?
To me, it means having a doctor for life. Someone you can trust. Someone who has known you through thick and thin.
It means having a group of people who work with you. Dietician, exercise trainer, medication manager, physical therapy, diabetes educator, etc... "ancillary services" that deserve a central role in care.

Why don't people get it?
I think Home is a solid object in a lot of people's minds. When you tell them "we are going to give you a medical home" they think of a location, rather than a group of awesome people who are trying to keep them healthy! A funny story is that one of the family medicine residency programs got a phone call from a reporter, asking to see their new medical home. "So, this home. Is it a house? A clinic? What sort of structure is it?" After some forehead slapping in trying to explain that it was just a concept, the director ended up just telling him their address. UGH. PCMH really doesn't lend itself well to a clear definition.

So what's your brilliant solution?!?
I am very biased on this point. I'll say it up front because it is a shameless plug for my specialty of choice.
I propose that we call it Patient-Centered Medical Family.

Think about it.

July 15, 2009

Doctors are Gamblers


Doctors are Gamblers.

One of the questions in surveys that determine what sort of career in medicine you want asks:
How much ambiguity can you tolerate?
read: How much are you willing NOT to know? The answer is surprisingly telling.

I thought that as a physician in training, I would learn how to become more confident in my diagnosis when in practice, this is a very difficult thing to achieve. Especially in a brief visit where there are no clear labs or studies to elucidate the answer. Take a simple cold. A patient comes in with a sniffly nose, fatigue and a sore throat and asks: do I have strep? You can do a throat culture, but that will take time. You can do a rapid strep antigen test, but the test is not sensitive and you may get a false negative. Even for the most common conditions, there is a great deal about which we DO NOT know, nor can we ever know. We don't even have the tools to test for a lot of the different viruses that may cause a common cold... and why bother? It'll go away on its own with some fluids and rest.

Take another common concern: Doc, what are my chances of getting a heart attack?
We gamble on answers like this when we prescribe medications to reduce risk factors for coronary artery disease like high cholesterol (diet, exercise and statins,) and diabetes (diet, exercise, and metformin.) We risk stratify patients based on a collection of factors that have been shown to lead to increased risk of a heart attack in the future. The biggest study of this is the Framingham Heart Study. From a collection of statistics gathered from anamnesis (patient history) and labs, we can determine the 10 year risk of a patient for having a heart attack!

That's pretty powerful. But it is still just a Chance.
And how often do you really have a discussion like THIS with your doctor?!?
You're a 57 year old male. Your total cholesterol is 275. That's high because it's bigger than 200. Your HDL(good) cholesterol is only 35. That's low because it's less than 40. On top of that, you're still smoking and your systolic blood pressure(big number) is 150 despite being on medications!

You know, that means you have a greater than 30% chance of getting a heart attack or something similar in the next ten years. Think about that.

If you quit smoking and exercised to bring your blood pressure down to normal (120,) you could pull your risk down to 18%. That's still high but if we put you on a medication to lower your cholesterol and it was brought down to a normal level, we'd bring it down to 12%!

We can cut your risk in half with some simple changes. What do you think about that?


We gamble with people's lives. Some people live gluttonous self-indulged lifestyles and never have any health problems. Other people are health nuts but suffer from multiple ailments.

We don't know what hand people are dealt... but we can help stack the deck in their favor.

July 10, 2009

Rights vs Expectations

Even though I disagree with a lot of what Happy Hospitalist writes when he waxes political, I find myself drawn to his blog. Perhaps it gives me something to react against. In any case, he wrote the following short bit yesterday:
Does America Have A Right To BASIC Health Care?

I hear it everyday. Affordable access to basic health care should be a right.

Could someone please define to me what constitutes basic in the basic health care arguement? I want to hear examples of what is basic health care and what would not be considered basic and why you have a right to one and not the other.

Why should we have a right to health care but not health? Should we not have a right to stay healthy? Should we not have a right to free gym memberships? How about a right to free vegetables. If you have a right to basic health care, we should also have a right to services that prevent the break down of health as well.

Right?

My response in the comments section:
There are a lot of things we take for granted -- clean water, sewage treatment, uncontaminated needles for IVs and sterilization procedures before surgery.

These are PUBLIC HEALTH measures that have greatly affected our quality of life. So much so that their effects are practically invisible.

When we say "basic," I think of something along the lines of "do or die." There are a lot of things that factor into this... obviously someone with untreated hypercholesterolemia and diabetes for 40 years who comes in with a heart attack could have received appropriate intervention before this life threatening event.

The question is this: What OUGHT to be covered?
Primary prevention: healthy living (free gym memberships, shelter, access to fruits and veggies)
Secondary prevention: screening for CAD risk factors (checking lipid panel per ATPIII recommendations or just total cholesterol per USPSTF.)
Tertiary prevention: intervening after disease is detected to prevent complications (starting off treatment with statins and metformin.)

A lot of people would argue that it is fully within the scope of medicine to intervene with Secondary and Tertiary preventive measures (which SHOULD be covered as basic health care to some degree.)

Primary prevention... like the rest of PUBLIC HEALTH falls more under the scope of the government in my opinion, not accounting for the occasional harassment by a PCP to "eat right and exercise." As needed, I'm sure there are a number of excellent docs who can go more in depth into personalized primary preventive measures but when this is not reimbursed... not many will opt to do it with all their patients!
This made me realize that the Rights argument is very progressive (in more ways than one.) We all expect some certain unalienable rights to Life, Liberty and the Pursuit of Happiness.

What does it mean to have a "right to Life"? This draws an issue like abortion (ugh! let's keep that at least 10 feet away for now) to the forefront when really, there is a much more fundamental right that this draws upon... one that I have not seen clearly defined or reflected upon. Is it a right to a healthy life? A right to live?

I think it is a Right to Live as others live. There is an element of Expectation to this as well. We expect that we can all live equally in a democratic society.

Access to healthcare is becoming more of an issue than our forefathers expected because our medical knowledge and power to intervene has increased dramatically. This has created new power relationships and health deficits in socioeconomic status that cross generations! It goes beyond doctors and hospitals. That's why the government must play a role "to Secure these Rights," "deriving their just Powers from the Consent of the Governed."

I expect this from my government. A lot of people are afraid that the government will mess this up and want it to stay out of the Healthcare debate as much as possible. This is not a dig, but merely an innocent question: Republicans/conservatives in congress, if you distrust government so much and are afraid of its collective incompetence, why are you in office? I would much prefer it if you created some solutions rather than saying "the best thing we can do is to stay out of it."

July 08, 2009

Atrial Fibrillation Treatments

Atrial fibrillation involves the two top small chambers of the heart. They quiver instead of coordinating a strong beat which makes patients with a fib often feel palpitations with an irregularly irregular heart beat.

Last year I had a patient with atrial fibrillation. She was hospitalized for a splenic infarct after discontinuing her warfarin because she found out she was pregnant. Luckily for her, it was only her spleen that got hit and she agreed to go back on the warfarin after an elective ITOP -- things did not work out as planned with her ex-boyfriend apparently. My chief resident had me read about the ground-breaking AFFIRM study, which showed that rate control was equivalent to rhythm control, with less drug side effects since antiarrhythmics can induce arrhythmias (go figure.)

This week I started my cardiology rotation with a day FULL of patients with atrial fibrillation -- some newly diagnosed, some medication induced, some status post valvular repair! It was as if the medical gods convened to help me learn something new.

My cardiologist encouraged me to read further on this subject so I found two other trials: ACTIVE-A and ACTIVE-W. I performed a Critically Appraised Topic (CAT) review on these different treatment options for anticoagulation in a-fib.


After presenting the results to my preceptor, he asked me about mortality data. Unfortunately, I didn't look into that as closely as it was a small part of the primary end points (stroke, MI, non-cerebrovascular embolic events and vascular death.)

Enough about medical interventions.
Here's an excellent video on one of the surgical procedures for removing the ectopic foci in the pulmonary sleeves. I didn't know it was so involved with the computerized models using US and CT to create a digital image of the heart!
Atrial Fibrillation Ablation (Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, 2/11/2009) - MedlinePlus: Videos of Surgical Procedures

June 11, 2009

Metoclopramide for Hyperemesis Gravidarum

Hyperemesis gravidarum is a fancy way of saying really really bad "morning sickness," severe nausea and vomiting associated with pregnancy.

There have not a lot of drug options here in the U.S., ever since thalidomide was shown to cause severe birth defects - phocomelia, where the children have shortened "flipper" like limbs. As you might imagine, pregnant women are very hesitant to participate in drug trials. It is just as hard to get children enrolled in studies. Unfortunately, the fundamental goal of trying to protect infants and children gets warped from lack of knowledge... and we know very little about how to medicate lil kiddos!

NYT Health says that Metoclopramide is safe for pregnancy. Reglan, as it is more commonly known, is a common anti-nausea medication has been shown to be safe in over 80,000 births in southern Israel.
Our study [The Safety of Metoclopramide Use in the First Trimester of Pregnancy] is about 10 times larger than all of the other studies of this drug put together,” said Dr. Rafael Gorodischer, one of the study’s authors and a professor emeritus of pediatrics at Ben-Gurion University in Israel. “We studied exposure in the first trimester because that is the most critical period for the development of the fetus, when most malformations would be caused by an external cause.”

“We can now say with a high degree of confidence that it’s a safe medication,” he said.

On the heels of this announcement, the British Medical Journal published their ClinicalEvidence on Nausea and Vomiting in Early Pregnancy (updated June 3rd 2009.)
Metoclopramide for treating hyperemesis gravidarum: One RCT found that metoclopramide was less effective at reducing vomiting episodes and readmission to the intensive care unit compared with corticosteroids. Other drugs and interventions may be more useful. Categorised as Unlikely to be beneficial.
Hm... so what does this mean? There is proven safety, but no clinical efficacy in severe cases. Clinical trials will need to be performed to look at this further. And thanks to this new study, we can! :)

June 09, 2009

Culture of Medicine II

The saga continues.

President Obama made some comments in the news regarding McAllen, Texas, suggesting that he read Dr. Atul Gawande's article on "the Cost Conundrum." Indeed, a recent New York Times article "Health Care Disparities Stirs a Fight" confirms this:
The [Gawande] article became required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators.

“He came into the meeting with that article having affected his thinking dramatically,” said Senator Ron Wyden, Democrat of Oregon. “He, in effect, took that article and put it in front of a big group of senators and said, ‘This is what we’ve got to fix.’ ”
There's a fundamental difference in approaches between politicians and doctors. Docs are taught to care for every patient as if they were a member of our own family. Perhaps healthcare spending reflects this attitude. Politicians often abuse their constituents as if they are unwanted members of family. Perhaps they are willing to sacrifice X number of lives to save Y number of dollars in an annual budget. I say this only half-jokingly; it is a political necessity to be separated from the issues since there will always be a passionate dissenting group that protests any sort of stand they make. The difficulty, in politics as well as medicine, lies in controlling our emotions so they do not rule our intellect.


But how do you resolve the most personal and emotional issue of all?
I agree with Obama's eloquent response to the question: "Is healthcare a privilege, right or responsibility?":
I think it should be a right for every American. … for my mother to die of cancer at the age of 53 and have to spend the last months of her life in the hospital room arguing with insurance companies because they’re saying that this may be a pre-existing condition and they don’t have to pay her treatment, there’s something fundamentally wrong about that.

What price do you put on the health and welfare of your family? The New York article mentions data that provides EXACTLY what sort of numbers the government has been willing to spend on each person in 2006:
Nationally, according to the Dartmouth Atlas of Health Care, Medicare spent an average of $8,304 per beneficiary in 2006. Among states, New York was tops, at $9,564, and Hawaii was lowest, at $5,311.

Researchers at Dartmouth Medical School have also found wide variations within states and among cities. Medicare spent $16,351 per beneficiary in Miami in 2006, almost twice the average of $8,331 in San Francisco, they said.
Wow! Hawaii? I wonder if the fact that we also have mandatory healthcare (Pre-Paid Health Care Act of 1974) for full-time workers (>20 hours per week) in the nation has anything to do with these statistics. Massachussetts has a cool system too. Unfortunately, I don't know how well it is working out for them with the confluence of crises.

While it might sound appealing to adapt practices Aloha-style... that really would be doing things just for the love of it. A lot of doctors in Hawaii (regardless if they were Hawaiian doctors or not) are retiring, leaving the state or cutting back on their practice because of low reimbursements for Medicaid/QUEST and Medicare patients. So on the surface, it sounds appealing from a political point of view to slash wasteful spending but this can run antithetical to the goal of improving primary care by chasing doctors away.

Another thing that clogs up the gears of the glimmer of hope for Hawaii's healthcare... recently, the Medicaid/QUEST contract has gone out by two Mainland firms: UnitedHealth Group Inc. and WellCare Health Plans Inc. These companies were under investigation in billing fraud and improper claims scandals. Also, there is concern that the 37,000 enrolled aged, blind and disabled patients may have to change providers and lose continuity of care. Waianae and Waimanalo, the two regions on Oahu with the most Native-Hawaiians ironically are the two areas where the Community Health centers have opted out. (citation DENIED, see below)

I hope that the nation does not look at Hawaii for all the answers. It's much more likely that our docs have just gone uncompensated for a lot longer.

(Disclaimer: My commentary comes from the point of view of a medical student trying to stay informed on health-related news while studying to become a doctor in these changing times. As such, notmysecondopinions are not the best source around on health policy! I wish I could provide better local references... unfortunately the archives for the Honolulu Advertiser are on a pay-per-article access of $2-3! That model is detrimental to quick online Google News Searches for proper content.... gr.)

June 08, 2009

When Physics meets Physician.

With our powers combined...
I am Captain GEEKITUDE!


the image properties for this comic reveals the answer:
413 nanohertz, by the way.
:)

June 07, 2009

Culture of Medicine

“So, what brings you in today?”

The young Filipino lady before me wrung her thin hands together. Her eyes betrayed a sense of fatigue as the corners of her eyes crinkled with anxiety. “Doctor, I am still feeling dizzy.”

Dizziness is a common complaint, but a difficult one to get a handle on. So many different things manifest themselves as dizziness… an unsteadiness with walking, the presyncopal feeling like you are going to pass out or just the sensation of violent spinning (the same as how you felt as a child after twirling in circles in the park or on an office chair). “What do you mean?”

“Well, it started almost two months ago. I had two episodes of dizziness that went on throughout the day that lasted for a few seconds. It felt like I was spinning in a circle. I was worried so I went online to see what could cause it. And I tried to make an appointment with my family physician but that would be in a few weeks so I saw an audiologist, a neurologist and a psychiatrist too. The audiologist tested me for nystagmus and had me perform the Dix-Hallpike maneuvers and asked me if I was dizzy. I told her no, but she noted some eye movements with the electronystagmogram so she diagnosed me with bilateral benign paroxysmal positional vertigo anyway. She prescribed some modified Epley maneuvers. The neurologist thought I might have migraine-related vertigo and put me on Amitryptyline. And this whole time I was doing research online I would read about these different symptoms and I would start to get them! My parents were very worried and suggested that I see a psychiatrist for my anxiety. He put me on Sertraline and Clonazepam.

Wow… I thought to myself. That’s quite a few specialists! This was a highly educated woman… she understood what nystagmus and Epley maneuvers were, and she could pronounce BPPV which put her pretty much at my level as far as I was concerned. Yet after seeing all of these different doctors, she was still here in the FM clinic even though her last visit was *flips through the chart* two weeks ago… when she was given meclizine for nausea.

“Uhm, I’m sorry…” I apologized. “I don’t understand. You’ve been diagnosed with BPPV and anxiety with the possibility of migraine-related vertigo… what can I do for you today?”

“I just want help. I am not feeling the spinning dizziness anymore. That was a long time ago. Now it is more of a… it’s hard to describe. It’s a rocking sensation.” “Like you’re on a boat?” I offered. “Sort of.”

It took me a while to piece the whole story together, but it seemed like her main complaint of dizziness had resolved but she was having residual anxiety and a number of other unusual symptoms -- getting visually overwhelmed by venetian blinds and patterns on carpets and being unable to go into a store without feeling anxious. However, she persisted on calling it dizziness with her subsequent physicians, although perhaps “uneasiness” would be a better way to put it. She told me that when she saw the audiologist and the neurologist, she was feeling very anxious about what was going on… but aside from performing tests like an ENG and an MRI of her head, they offered little comfort or support except to say “Go see your family physician.” She saw the psychiatrist about a week ago and after some persistent questioning about functioning, she said that she felt much better with the SSRI and benzodiazepine.

While I do not doubt the technical ability of the audiologist to interpret an ENG or a neurologist’s ability to identify and treat a migraine headache, these skills have their time and place. Her underlying problem was the anxiety she was having about the dizziness which took over and became a general sense of worry and unease. These specialists were ill-equipped to deal with that aspect -- and it was not until the Family Medicine doctor intervened that the whole picture could be assembled for the patient.


“You’ve seen a number of specialists and they have helped us rule out dangerous things like a brain tumor. You are still able to work and you have not had any difficulty walking, so functionally you’re doing really well. I understand that you’re feeling dizzy. The good news is that it is nothing serious as far as we can tell so far!” She left feeling reassured and I saw her with the psychiatrist as well to keep up the continuity of care.



The culture of medicine has changed and I feel that this is the crux of it! This patient had fallen through the cracks of the system. She tried to get an appointment with her PCP and when she couldn’t see her immediately, she resorted to a series of more expensive but ultimately unfulfilling specialists before her family helped her find someone address the underlying problem. She needed someone to put the pieces of the puzzle together. All too often, patients think that specialists are better than primary care for everything and this fragmentation of care leaves the patients with the pieces. Even worse, they assume that their primary care physician is automatically receiving all of these specialist reports! It is hard to piece all of these things together from a confused patient. I think that family medicine physicians are more than care coordinators or a bouncer at the specialty doorway. Similarly, specialists are more than just procedural technicians who punt back even small things like reassurance and education back to a family physician. All doctors go to medical school instead of OR or ER or psych ward school for a reason. We all know the basics of patient care.

A recent New Yorker article by Atul Gawande, entitled the “Cost Conundrum” also addresses this “Culture of Medicine.” Gawande outlines the problem of controlling health care costs by comparing the habits of physicians living in McAllen, Texas to nearby El Paso, Texas. He also went to Mayo clinic in Rochester, Minnesota, where he expected that their world-wide renown, high-tech and high quality of care would equate to more money.
McAllen’s Medicare expenditures per enrollee in 2006 were $15,000.
El Paso’s were $7,500.
Mayo clinic's were $6,688, less than either McAllen or El Paso!
What accounted for this difference?

McAllen physicians were highly enterprising and saw more patients each day, ordered more tests, and performed more aggressive interventions earlier. This padded their pockets a little bit more and thus rewarded, they continued onwards. This cycle of greed and profit is perfectly legitimate in our system of Relative Value Units (RVUs) where procedures are valued above cognition and doctors are compensated not be the quality of their patients’ health or their ability to make a diagnosis in a cost-effective manner… they are paid based on how many patients they see each day. This drives them to maximize their patient numbers and minimize their time with each of them! It becomes much easier to check a box and order an MRI of the brain than it is to spend an extra TEN minutes with a patient to sort out the true history and duration of dizziness -- but which one is more ideal?

I think that healthcare will be the next bubble to burst, now that dot.coms, real-estate markets, Wall Street and Auto makers collapsed under similarly empty value-for-cost pressures. Our healthcare dollars are being poured down a hole with little regard about whether they are spent on the RIGHT things. Gawande made a comment that I found Twitter-worthy:
“the most expensive equipment is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.”
The culture of medicine needs to change if we are going to fix our “broken system." Doctors cannot sit idly by and complain that it is insurance reimbursement or Medicare that is causing the problem. We need to admit that we are a part of the problem -- and seeing patients as a revenue stream and maximizing “business” by turning up the speed on the conveyor belt is not the solution! There is a sense of entitlement that because we have worked so hard and studied for so long to get to the position that we are in today (or in my case, soon will be,) we deserve the highest compensation for our services as possible. We measure our success based on how our income and lifestyle compares to our peers -- and so, in medical school, ironically fields like anesthesiology and radiology are highly valued despite the minimal patient contact. (It's a a pissing contest, if you pardon my French.) Our value to society and our true measure of success should be based on how healthy we keep our patients and how comfortable we make them feel when we cannot. That's our value to keep healthcare costs down!

We do not gain the sympathy of the general public by complaining -- “I don’t get paid enough to see patients!” Many patients who go to the doctors only to find a nurse practitioner or a physician assistant may just reply -- “You never saw me anyway.” We need to ground ourselves again and remember that our duty is to Care for patients before ourselves. That’s my interpretation of the words “Primary Care.” And that’s Not My Second Opinion!

June 04, 2009

Fitness Fun Facts

I was born in 1983 and will be 26 years old very soon! I weigh 145 lb. I am 5'7".

This information is very basic and very static (except for the ten pound weight gain since I started med school.) It is a part of who I am -- it's on my driver's license after all. It is a part of the Vital Signs, measurements that doctors utilize to determine your health!

Using myself as an example, I will go through a few calculations quickly that you might find interesting.

Body Mass Index (BMI):
Everyone and his mother knows what BMI is. It basically categorizes people as ok (BMI 18.5-25), overweight (>25), underweight(<18.5), obese (>30) or morbidly obese (>35).
You calculate it by taking your weight(in kg) and divide your height(in m) to the second power. Or use can use an online calculator or chart. Be warned though, that it just measures weight - it makes no distinction between fat and muscle (a confounding factor that tells us Arnold Schwartznegger is obese.)

Example: I am 5'7"->170cm->1.7m and 145lb -> 65.8kg.
Wt(kg) / Ht(m)^2 = BMI
65.8kg/1.70^2 = 22.77
My BMI is in between 18.5-25, so I am of normal weight for my height.

Ideal body weight (IBW):
This is something that differs for men and women.
in men, the IBW is 106 lb, plus 6 lb for every inch above 5'.
in women, the IBW is 100lb, plus 5 bl for every inch above 5'. Tough break!
Example: I am 5'7", therefore 7" above 5'.
106(lb) + 6(lb)*(7) = 148 lb
I notice that this does not correlate with other results I've found online... but this is the most straight-forward formula I've found (in an NMS Family Medicine text)

Measuring the pulse at the neck and wrist.Image via Wikipedia

Heart Rate target with exercise
Now for some of the fun stuff!
Your maximum heart rate is 220-age in beats/second. For moderate exercise, it should be 70% of that, or 0.7(220-age.)
Example: my age is 26.
0.7(220-26) = 135.8
You can find your pulse on your wrist (radial pulse) by making a fist and curling your hand to find the pit formed by your flexor tendons. Place your index and middle finger in that pit at the base of your thumb after relaxing your hand. To find your pulse in your neck (carotid pulse), poke the back corner of your jaw and slip your two fingers underneath the mandibular angle up against your neck. (The guy in the wikipedia picture has his fingers slightly malaligned for a perfect pulse... if he slid them down further he'd get it right on the pads of his fingers..) Count the beats for a minute (or alternatively, for 15 seconds and multiply by 4.)

Caloric expenditure for walking one mile:
How many calories (technically it is kilocal) do you burn walking one mile?
Take two thirds of your weight(in lb)! Simple... but scary too.
Example: I weigh 145#.
2/3(145) = 96.67 kcal
That means if I eat one of those little 100cal snack packs, I need to walk a mile to burn it off! If I drink an extra can of coke, I need to walk a mile and a half! No wonder I've gained weight. It also can be put into the context of cutting out one cookie every day. Over the course of a year, you would prevent an average of a ten pound weight gain assuming everything else was equal. (per personal communication with a physician who co-authored the DASH diet.)

Energy requirements for a typical day:
The kilocalories we need is about 10*IBW per day.
Example: my IBW(see above is 148).
10*148 = 1480
Assuming the average American male is ~5'9"...
10* (106+6*9) = 1600
That must be where the generic 1600 kcal ADA diet recommendation comes from.

Weight loss:
Mathematically, this requires a caloric deficit. That means more calories out (burned) than calories in (eaten.) There's a lot of different diet plans floating out there online on how to lose weight. I'm not going to go into that in this post. A very aggressive weight loss plan to lose a pound per week would be a 3500 cal/wk or 500 cal/day deficit.

That's walking five miles a day! A word of caution though... the goal is to lose fat, not water and muscle! Any faster and you risk dehydration, lactic acidosis buildup and muscle breakdown from starvation.

A more reasonable goal is perhaps simply walking a mile or two three to five days out of the week. A pound of weight loss every month may be seen with this. Coupled with diet changes... you'd be set to start living healthier and wiser! I know I'll try to keep these things in mind for myself as I strive to rebuild some of my lost muscle in lieu of brain power over the past three years of med school. ;)

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