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

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.

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
Daily Show
Full Episodes
Political HumorHealthcare Protests

The Daily Show With Jon StewartMon - Thurs 11p / 10c
Exclusive - Betsy McCaughey Extended Interview Pt. 2
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

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.