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) (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

An online course for provider education is available on

November 01, 2009


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)