Concierge Medicine or Direct Medical Practice?

First it was Hello Health, now it is Personal Pediatrics.

Dr. Natalie Hodge is the "first iPhone doctor" for pediatrics.
She is going back to the basics of primary care by doing what a lot of doctors no longer can afford by reducing her overhead, moving out of the office and into your home.

“We intend to be an entirely mobile platform –there is no need for an office, at least for pediatricians,” Hodge said. “I have found that everything I need for my practice could fit in the trunk of my car,” Hodge told mobihealthnews in a recent interview.

“Some would call Personal Pediatrics a ‘concierge medical practice,’ but I prefer to call it a direct medical practice,” Hodge explained,”because we’re connecting patients who want house calls to physicians who want to make them.”

I love this idea. It is the Ideal Micro-Practice... just you and your doctor. There are many situations where such a model will breakdown, but it does reduce the barriers to care that so many people complain about. No more long wait times at the office. No more late appointments, made months after a phone call. No more problems calling up the doctor in the middle of the night when there's a problem. Best of all, no more 15 minute visits!

This is a small business model that ADAPTS to new technology. It UTILIZES resources so much more effectively to care for patients without any clunky outdated systems. (Disclaimer: I am a huge fan of paper charts over electronic medical records in terms of access and organization. However, EMRs as they stand today are terrible because they are designed with ancillary personnel in mind instead of physicians. As a result, hospital "chart review" becomes an exercise in "Where's Waldo" searching for the single line on a page of text that has been altered from the "Copy Note" function by nurses and docs alike.)

I am not sure where I fit into this picture, but I know I would like to practice in a similarly independent and free manner.

However, I also would like to care for a population of the lower socioeconomic status... and that is where the Concierge model fails. How can patients on medicare afford a subscription with a retainer fee for a personal physician? Especially (from their perspective) when it is "cheaper" to go to the Emergency Room for care?

Hmm. Questions that need answers. Someday, I hope to provide a solution that makes me happy.

For now, Drs. Jay Parkinson in NY and Natalie Hodge in CA(?) have their solutions that they hope to spread. Good luck to you both!

Jay Parkinson at Pop!Tech from Jay Parkinson on Vimeo.

Jay Parkinson at Pop!Tech talking about Hello Health.

He created a new kind of medical practice on September 24, 2007 summarized by:
1. Patients would visit his website.
2. See his Google Calendar.
3. Schedule an appointment online and provide a chief complaint.
4. His iPhone would tell him.
5. He’d do a house call.
6. and get paid via PayPal!

An Ode to Mastication

Pure poetic silliness.

Oh, the simple glee
of Freudian immaturity!
forgive my pontification
on joys of oral exploration

my language turns quite evocative
on no other subject so provocative
i speak of meals, you see
not some other form in gratuity

Cranial nerve Five!
Masseter, medial pterygoid: writhe!
Cranial nerve Twelve!
Hypoglossus: dart and delve!

"Are you done yet?"
My friends all whine and moan.
"My food and I just met!"
They get up and go,
I chew and swallow alone.

TIMI Score Mnemonic: 1234567

Image via Wikipedia

Thrombolysis in Myocardial/Infarction (TIMI) UA/NSTEMI: 1234567
1/2, 2+, >3+, (4), .05, >65, 7d

1. CAD hx (>1/2 stenosis)
2. Angina (2+ episodes in past 24hr)
3. Atherosclerosis RF (>3+)
   FHx
   CAD
   HTN
   HLD
   DM
   Smoker
4. Hi cardiac markers (of which there are 4): TnI, TnT, CKMB, LDH
5. ST-segment deviation of 0.05 mV or more
6. Age >65
7. ASA use (in past 7d)

Patients with three or more of the seven variables are considered to be at high risk, whereas those with no more than two of the variables are considered to be at low risk.

 

References:

Optimal Management of Acute Coronary Syndromes. L. D. Hillis and R. A. Lange - 21 May, 2009

TIMI scores :
TIMI Risk Score for UA/NSTEMI
TIMI Risk Score for STEMI

Global Registry of ACS Events (GRACE)
www.outcomes-umassmed.org/grace

Bleeding Risk with www.crusadebleedingscore.org

Trauma Scenarios

Image via Wikipedia

In a previous post, I talk about my first night on Trauma call (and the preceding training that was... traumatic for me. In which I receive a lecture from our clerkship director about how I need to be serious and more prepared before coming to class.)

My my, how far I've come since I've bumbled through my confusion on how to deal with tension pneumothoraces, flail chests and hemoperitoneums. At least, on paper.

In my current review for my upcoming surgery exam, I wanted some case scenarios on different aspects of trauma.

Simply googling "trauma scenarios" brings up the most excellent site: Trauma.org with "Moulage" scenarios in the following categories:

Initial Assessment - ABCDE of Primary Survey
Prehospital Care - Hop in a chopper and stabilize a pt en route to the trauma center
Cervical Spine Clearance - the supplemental info links are broken, so i figured out the right answers by trial and error.
Paediatric Moulage - this one was hard -- my volume resusc was always inadequate -- until i realized that the pt's age kept changing (and I needed to recalculate my pt's wt to compensate!) they use an older formula, BTW: ~age*3=est kg... the newer formula is age*3+7.
Neurotrauma Moulage - this was by far the hardest scenario. granted, i haven't done neuro (or Neuro ICU!) but after an hour of tweaking levophed, mannitol and RR, i think i've got the physiology figured out.
Trauma Team Leader Decision Scenarios - a nice summary.

Hope you find them as enjoyable and as useful as I did!

Cheers,

Caution when steaming foods in the microwave

Image via Wikipedia

I am a big fan of the microwave. Now that I am cracking down for my finals, I am cooking less and just "nuking" more.

The microwave is an amazing device for quick meals... healthy or otherwise. I opt to microwave my veggies with a wet paper towel over them for ~90 seconds rather than wait 5 minutes to steam them on a stovetop.

What is the downside of the microwave?
Researchers found that microwaving foods decreases the amount of vitamin B12 present.

Appreciable loss (approximately 30-40%) of vitamin B12 occurred in the foods during microwave heating due to the degradation of vitamin B12 molecule by microwave heating.

You also need to be careful of flash boiling your cup of hot water. You can actually superheat the water above 100deg celcius and it will bubble over and scald you with a tiny nudge, a spoon or a bag of tea!

What are some of the myths of microwave cooking?
One of my favorites is the "dioxin" theory. Dioxins are chemicals, labelled as potential carcinogens by the FDA. KHON-2 news (I'm somewhat ashamed that misinformation was spread via a station my dad used to work at) in Hawaii had a health alert that it was bad to microwave plastic. Dioxins have not been shown to be present in plastics, nor is there any evidence that it leaches out from microwave-safe plastic containers. The reason why some containers (like styrofoam take-out containers and margarine tubs) are not microwave-safe is because they melt and warp in a microwave.

Uhm... well, that's about the only myth I can think of.

I read something else on the nets (i.e. from a .com website rather than a .gov or .edu site) about anemia -- but vitamin B12 deficiency does give you anemia. It also can cause peripheral neuropathy (numbness and tingling in extremities, loss of vibration sensations and clumsiness) and dementia.

---

Reference:
Effects of Microwave Heating on the Loss of Vitamin B12 in Foods. Fumio Watanabe. Journal of Agricultural and Food Chemistry 1998 46 (1), 206-210

Snopes.com: Microwaving Plastic Releases Cancer Causing Agents: False! last updated 3 April 2007

Food Safety.gov: FDA Consumer - Plastics and the Microwave

USDA: Cooking Safely in the Microwave Oven - Fact Sheet Nov-Dec 2002

We Do what is Needed.

New York Times: Where Life's Start is a Deadly Risk

BEREGA, Tanzania — The young woman had already been in labor for two days by the time she reached the hospital here. Now two lives were at risk, and there was no choice but to operate and take the baby right away.

It was just before dawn, and the operating room, powered by a rumbling generator, was the only spot of light in this village of mud huts and maize fields. A mask with a frayed cord was fastened over the woman’s face. Moments later the cloying smell of ether filled the room, and then Emmanuel Makanza picked up his instruments and made the first cut for a Caesarean section.

Mr. Makanza is not a doctor, a fact that illustrates both the desperation and the creativity of Tanzanians fighting to reduce the number of deaths and injuries among pregnant women and infants.

Pregnancy and childbirth kill more than 536,000 women a year, more than half of them in Africa, according to the World Health Organization.

One of my early dreams in medicine was to volunteer for Doctors Without Borders (aka Medicins san Frontieres) after the completion of medical school and residency. I was a pre-med at the time and a part of the Medical Student Mentorship Program at UH. I told my mentor what I wanted to do and he said "That's charity work. Your debts will accrue and you'll fall behind." He went on for a few more minutes and I got the distinct impression that A) it would not advance my career if I wanted to pursue a fellowship and B) it would bring about financial devastation.

If I cared about those things, I would have taken his words to heart. Part of the reason why I did some research (a sideline to medical school) on Malaria was to get in contact with some of people with similar interests. I worked with a lab that has extensive connections in Cameroon and participated in research with involving the risks of malaria infection in pregnant women. (more on that to come.)

"Am I ready for something as big as this? Can I handle it? This would be a huge change in lifestyle." These sorts of anxious questions give me pause in pursuing such ambitious dreams wholeheartedly. The NY Times article has a real sense of urgency and fatigue to it. These undertrained, underappreciated doctors and nurses are working so hard and with such little help. What could I do? I would be but a drop in a bucket.

I found the words of Paul Farmer to be very inspirational.

For me, an area of moral clarity is: you're in front of someone who's suffering and you have the tools at your disposal to alleviate that suffering or even eradicate it, and you act.

My future plans to have a private practice with greatly motivated patients is tempered by my equal desires to become a teaching faculty member for a medical school and train young physicians, as well as travel to rural areas. Why do I want to do all of these things? I am reminded of something I said at a homeless clinic to my preceptor -- "We Do what is Needed." As a physician, I feel a sense of strong duty to the world to ensure that I make the biggest difference possible... and that means tackling the problem from as many angles as possible. That's my dream at least. We'll see how it all plays out.

"Change Your Heart..."

The song lyrics in the montage at the end of Omega sounded very familiar and when I realized it was from "Eternal Sunshine of the Spotless Mind," I got goosebumps. The core of the stories are the same (wiping the brain, but retaining the soul.)


[MOVIE SPOILER FOR ONE OF MY MOST FAVORITE MOVIES EVER!!]

The song gets looped over and over at the end when Joel and Clementine are at the beach throwing snow at each other... hinting that they are going in an endless loop too.


[END SPOILER]

Just like Echo! We fight to find meaning in our existence and we struggle just like Echo to hold onto one lesson each day (or each episode) that will make us stronger and better. "I try to be my best" is the motto of the dolls. Naive, but even more misguided is Alpha -- his flaw is that he thinks he IS his best.

I love this episode sooo much! At first, I thought that this show was going to nothing but a flashy lovefest for Eliza but I've had a change of heart. It really does a great job at addressing a lot of issues of free will, identity, and righteousness not to mention aesthetics as well. (btw... I LOVE YOU ELIZA!!! lol)

[The preceding post is a re-entry that I wrote on the Hulu discussion boards after watching the season finale for Joss Whedon's show Dollhouse. If you like to ponder the ephemerality of memory, you admire the ease of programmability of Matrix i.e. "I know Kung Fu", and/or you think that Eliza Dushku is a hottie... you should watch too! :)]

Chemistries, Part III

This is a follow-up post of the series on Chemistries, Part I and Part II.

I get overwhelmed looking at something like this... so I always take a few deep breaths and approach it sequentially.

Starting with the admission data.
First, I scan it for anything that might KILL the patient. Check the Sodium, Potassium and Glucose levels.

Most alarming is the hyponatremia of 120! Is this something acute or chronic? A sudden drop of sodium may cause seizures and we may be observing a post-ictal state. However, as my astute classmate points out, by circling the blood glucose, we see that the low sodium may in fact be artifactual. When approaching a hyponatremia, we first look to see if the serum osmolality is altered -- Glucose, Alcohol, and Mannitol can cause HYPERtonic hypoNa. For every 100 above 100 of glucose (in this case, 879 or ~900) will draw out water into the intravascular space and dilute the present sodium down by 2.4 (in this case, 9*2.4 = 21.6) So the corrected sodium is actually 120+21.6 or 142. Whew, ok so that was not as scary as I first thought.

Even though we've got a high glucose, I try to stay on task so I don't miss anything. A low potassium. Combined with a low chloride and HCO3, I'd say that this is a volume depleted state with a metabolic acidosis. Normally, we would expect a high potassium with an acidosis as it drives a transcellular shift leaking out potassium. Also, a HYPERglycemic state will also lead to HYPERkalemia. The "paradoxical" hypoK so this is a very significant finding even though it may only be 0.2 below the lower limit of normal. It's not really a paradox, nor is it unexpected. Hang on for further exploration of this.

Let's address the acid-base disorder here.

On the surface, we've got someone with a HCO3 of 18 (which is <24), therefore there is a metabolic acidosis. However, we also note that the anion gap is 32 (which is significantly >>>12!) This is where the "delta-delta" comes into play.

There's all sorts of fancy equations of "it should be greater than this ratio" (d:d>2 = coexisting metabolic acidosis/alkalosis) or "the difference should be less than that" but let's keep things simple, the way my preceptor did.

AG of 32 -> 32-12 = 20. This means that there are 20mEq of unmeasured ions (presumably acid) floating around.
HCO3 of 18 <- for the HCO3 to drop by 20mEq (consumed by the acid in the anion gap, we would need to have an initial HCO3 of 20+18... 38 (>>24!) This markedly high HCO3 is a metabolic alkalosis.

There it is, folks, right there in the numbers: a metabolic alkalosis (likely from vomiting) and a metabolic acidosis (likely from ketone body production.) If you prefer, the d:d is 20:6 or 3.3.

---

Let's take a deviation in our chemistry analysis for a second....
If we note the time of admission labs as 0930, we can see that the ABG was drawn at 1353. The metabolic acidosis is GONE! It is quite a head-scratcher if this seemingly normal ABG (or only slightly metabolic alkalotic) is the first thing that you see.

Keep in mind though, that the underlying metabolic alkalosis cannot clear as quickly as the metabolic acidosis. We are seeing a cross-sectional sample of a resolving problem:

The tides of acidosis are pulling back, revealing the rocks of alkalosis that were already there, hiding under the surface.

The lesson: BE AWARE OF A WIDE ANION-GAP, even in a non-alkalemic/non-acidemic patient! ESPECIALLY in this seemingly benign situation, because the acid-base see-saw is balanced, but it won't stay there for long!

It's a shame that the ABG was not drawn at the same time as the Chem20.

Now, back to the chemistry analysis...

---

The differential for an anion-gap metabolic acidosis is classically remembered as MUDPILES: Methanol, Uremia, Diabetic ketoacidosis, Paraldehyde, Isoniazid, Lactic acid, Ethylene glycol, Salicylates. However, Paraldehyde is no longer used. GOLDMARK: Glycols, Oxoproline, L-/D-lactic acid, Methanol, ASA, Renal failure, Ketoacidosis is another mnemonic recommended by Dr. Topf.

Shifting further down the list of labs, we've got an increased creatinine. Sometimes ketones can artificially increase this. It may also reflect a 19:1.31... or ~15:1 prerenal azotemia at work. Decreased renal blood flow from a low volume state like dehydration accounts for this.

Now, the big money. A high glucose and a (+) "large" acetone clinches the diagnosis. As we suspected, from our systematic approach, a patient with hyperglycemia and very little endogenous insulin began to produce other sources of energy for the brain. Namely, proteins like beta-hydroxybutryate and acetoacetate which are acidic. These products are degraded spontaneously into acetone (the same stuff as nail polish remover, giving the patient a nice fruity breath.)

Whew. That's only the initial diagnosis.

We haven't even delved into the treatment and resolution of this common problem.

More to come.

Chemistries, Part II

The following is a real case presented to me as a "wrap up" of some stellar weekly sessions with a local nephrologist.




This is my first time attempting to post something like this up, so please bear with me with the formatting.

Answers to come tomorrow.

Chemistries, Part I

Precious Bodily Fluids (love the name and title image, by the way, nice punny homage!) offers a quick way to view acid-base problems in an excel sheet in a post entitled "Introducing the Acid-Base Machine."

Acid-Base problems are awful awful MENSA problems for docs:
It sounds most excellent and fun in principle, but in practice they are bewildering and difficult and I just want to give up on them. Unlike the dusty MENSA book that has sat on my bookshelf since 10th grade, I cannot afford to ignore Acid-Base problems.
Aptly named, they burn like acids and bases and seem to exist just to torture medical students! Meanwhile, the attending recites Winter's formula, calculates it in 2 seconds flat and proceeds to lecture about the ventilator settings for their patient, leaving bewildered faces in their oh-so-glorious wake.

Thankfully, I haven't found myself quite in those shoes (on either side yet!) So I've still got a shot to get this sort of thing right without looking like some pretentious IM buffoon. (Nor have I met any such IM buffoons. I imagine it's a common occurrence though.)

I am by no means advanced in my understanding of Acid-Base problems.
For the teaching of this challenging subject, I defer to some experts:
Acid Base Online Tutorial by University of Connecticut
Clinical Cases and Images: Acid-Base Cases and Calculators
Resident and Staff Physician: Top Ten Clinical Pearls in Acid-Base Disorders



Acid Base Handout (Student)

Publish at Scribd or explore others: Study Guides, Notes, School Work osmolar gap delta gap

Finally, my meager acid base step-by-step handout scrounged from a lecture.
Stay tuned for the continuation on this series, in which I review my hardest paper case yet!

Open Water

A couple goes out to the Gulf of Mexico and they get caught in the current, pulling them away from their anchored boat... leaving them stranded for more than 24 hours.



Wow! They are so lucky to have survived, considering that no one even knew they were gone!

SCUBA diving is a very zen activity. I haven't done very many dives yet (can still count the total on my hands) but I've noticed that staying calm is key to good diving. It is all about breath control and peace to conserve your energy and thus, your air.

Unfortunately, the fact that you try to have this sense of tranquility under water does not make it a safe activity. Just like hiking (or almost any outdoor activity,) you should always tell someone where you are going and how long you will be out there, just in case something bad happens.

Resonating Quotes

A series of quotes have dropped into my lap during my daily blogwanderings that I found striking for one reason or another. They reflect parts of my own philosophy and I am pleased to find kindred spirits. U.S. President John Adams:

"Children should be taught ambition, not for fame but for excellence."

I couldn't find the quote directly attributed to Adams, so it might be more of a summary.

The sentiment that exists is certainly applicable to my approach to life. The only person I really care to measure myself up against is the person I want to be.

hat tip to the Honolulu Star-Bulletin for the great "Family First" article in which I discovered the quote.

Picasso: All children are born artists. The trouble is, remaining an artist when you grow up.

Ken Robinson says something to this effect... in essence, school stamps out creativity. I feel like that from time to time in the fact-munching, patient-crunching churning Combine of an education I currently endure. Lately, I've discovered my refuge in the patients I see everyday. They spur me to be my best at every (precious) moment I have to spare with them.

I am a small piece of the universe observing itself.

I stumbled across the blog "Existence is Wonderful" after hearing the TED talk on creativity and the importance of diversity. Neurological diversity in all of its wonderful pathology is celebrated in the stand alone novel "This Alien Shore," by C.S. Friedman. The blog writer is autistic which only adds to the poetry of her review on the book.

Tales of EMTALA: I'm not the patient!

Emergency Medical Treatment and Labor Act (EMTALA)

In 1986, Congress enacted EMTALA to ensure public access to emergency services regardless of the ability to pay. All Medicare-participating hospitals with emergency services must provide an appropriate screening examination for any pregnant woman experiencing contractions who comes to the emergency department for evaluation. (Emphasis mine.)

The definition of an emergency condition makes specific reference to a pregnant woman who is having contractions. Labor is defined as "... the process of childbirth beginning with the latent phase of labor continuing through delivery of the placenta. A woman experiencing contractions is in true labor unless a physician certifies that after a reasonable time of observation the woman is in false labor." A woman in true labor is considered "unstable" for interhospital transfer purposes until the newborn and placenta are delivered. An unstable woman may, however, be transferred at the direction of the patient or when a physician certifies that the benefits of treatment at another facility outweigh the risks of transfer. Physicians and hospitals violating these federal requirements are subject to civil penalties of up to $50,000 and termination from the Medicare program.

Amusingly, I had a patient tell me that she accompanied her husband (she was 7 months pregnant at the time) to the ED for recurrent bowel obstruction. He'd gone in multiple times and he'd get better right before the surgeon decided to operate. This time, things felt different.

On at least three separate occasions, someone came up to her in a hurry to put her in a wheelchair and whisk her off to the Labor and Delivery unit. "I'm not the patient!" she'd exclaim amusedly.

"Too bad you couldn't harness that desperation to get them to see your husband sooner..." I remarked.

Reference:
Williams Obstetrics > Section IV. Labor and Delivery > Chapter 17. Normal Labor and Delivery

How to talk to your doctor

Google's Knol winner for Dummies.com is on "How to talk to your Doctor" by Dr. Jennifer Frank, a FM physician at the University of Wisconsin. She offers the following "top ten" list in greater detail here.

1. Identify your Agenda
2. Make a List
3. Ask for the Time you Need
4. Be Honest
5. Be Patient
6. Be Nice to the Office Staff
7. Make Sure You Understand: use AskMe3
- 1. What is my main problem?
- 2. What do I need to do?
- 3. Why is it important for me to do this?
8. Tell the Doctor about Barriers
9. Follow Up as Directed
10. Be the Coach

It is a very straightforward and common sense list. I like her additional bits of advice like "bring all of your medications." Discuss ALL of your meds with your doctor. This includes OTCs and herbal supplements. Just because it is over the counter doesn't mean it is safe for you!

I am surprised that she doesn't mention any of the more controversial issues I've run across like "describe symptoms and presentations, not diagnoses." Some patients have the tendency to say "I have cholecystitis," in an initial interview when they should really say "I have stomach bloating and gas pains about 30 min after eating fatty meals, with loose stools. I saw Dr. X who did an ultrasound that found gallstones." Dr. Engel's book, "The Clinical Approach to the Patient" (out of print,) highlights the importance of this. Reporting patient data is a subjective activity and including tentative diagnoses, even if it is by other physicians, may interrupt the diagnostic process. In the appendix of his book he gives a woman an exhaustive interview that includes everything for a woman who minimizes her symptoms, but in the retelling of her own story from the beginning, she begins to realize how progressive her condition was and how early she began to have symptoms.

"Be the Coach" is not the way I would have phrased #10. "Get in the Game" is what I would have said. The doctor's role is the coach and the patient is the player in the game of healthy living.

Reference:
The Official Google Blog: We have a Knol for Dummies.com winner!

Swine flu hype?

via Gapminder.org

This prompts the question? What happened to SARS? What happened to the Avian flu H5N1? Part of the silence on these diseases can be attributed to the success of our infectious disease agencies like the World Health Organization and the Center for Infectious Disease and Control. Another part could be hype.

It's easy to be dismissive in hindsight, though... and it's too early to tell which world-wide pandemic will result in economic disruption and chaos.


Other fun links:
Hans Rosling: TED talk on Stats. It is very amusing to hear him make it sound like a sports broadcast!

Obama at the White House Correspondents Dinner

Great orator, great comedian and dare I say it? Great President. From Hawaii. :)

Dr. Ted Epperly Speaks for FM with Obama

Dr. Epperly, the president of the American Academy of Family Physicians, blogged about his meeting with President Obama on Healthcare.

OUR INCREDIBLE MOMENT
And then the most amazing thing happened. The AAFP hadn’t been assigned a speaking role at the summit, but suddenly, to my complete surprise, our country’s president said he wanted to hear from the nation’s physicians—and he called on me for comments. I was shocked to have this opportunity drop into my lap. What should I say? I hadn’t prepared anything! So I stood up about 10 feet from the president, looked him in the eye, and said the words that flowed from my heart.

I thanked him for his leadership in assembling the group and said I was honored to be there. Speaking for family physicians, I told him that we believe health care coverage should be expanded to everyone in the United States, but I also warned him of the need to fix the primary care workforce so patients actually have access to that care. I told him that the nation’s FPs are ready to roll up their shirtsleeves and do everything possible to make reform work, because it’s the right thing to do.

And then I sat down, elated that the president had called on the AAFP to speak for the nation’s physicians. He could have called on one of the other medical groups at the summit, including the AMA, but he didn’t. He chose us. He chose family physicians!

I think this speaks volumes about the respect the Academy has gained in Washington and the respect the people on Capitol Hill have for family doctors in the trenches. They know family physicians and the patient-centered medical home will play a key role in the reform that’s coming. They know we are part of the solution.

I know that things have looked dire for primary care for a long time now so it is reassuring to hear Dr. Epperly's enthusiasm and passion for the future of Family Medicine.

Quite frankly, I feel very lucky to be poised on this new front of change for health care. People will be looking at my generation (and at me!) for new ideas, conviction and dedication to primary care. That's the main reason why I am excited to go to the Family Medicine National Conference in Kansas City, Missouri this summer. I'd like to get involved somehow.

An encounter makes a lasting impression

“Good morning, Mrs. K, I’m Clinton Pong, a third-year medical student,” I said warmly as I swept into the small exam room, shook her hand and pulled up a seat. “I’m here with the doctor today and before she comes in, I’d like to get a chance to hear a little bit about what’s been going on.”

She proceeded to tell me about how often she checks her blood pressure, her struggle with cutting down on shoyu and how she’s been golfing more. I responded in kind with encouragement on her lifestyle changes and reviewed her medications. It was a routine follow-up visit but it was my first time with her, so I spent some time finding out more about her. To my surprise, I realized that I saw her husband earlier in the day (they must have patiently swapped places in the waiting room) and she was the grandmother of one of my classmates! “He just got married, you know,” she said conspiratorially. “WHAT?!?” I exclaimed, “I had no idea!”

Indeed, I would not have known any of these things if I resigned this patient encounter as something mundanely routine and checked off some boxes. One of the things that I love most about Family Medicine is actually stepping away from the medicine from time to time and treating patients like family. I think that’s what Primary Care is all about -- care first and the rest will follow.

---

I told my friend Brad recently that "one of the hardest things to do with patients is to forget all the medicine." He looked at me strangely and I clarified: "because you really have to put yourself in the place of your patient to understand whats going on for them."

It struck me that this was a kernel of wisdom.

Since I have been following various preceptors over the course of the past 5 months in outpatient clinics, there is a lot of the common things like the cold, the flu, the stomach flu, high blood pressure and high blood sugar check ups that have become entirely routine for me. However, every time I walk into the room, I am impressed by how different each of the cases are. Every patient has a different set of challenges that do not do my patient logs justice when they are reduced to an age bracket, a diagnosis and treatment.

This is especially true in the hospital. Patients are isolated in their rooms, shaken awake at all hours of the night to take their medications, get their blood pressure checked and who knows what fluids or solids need to be put into them or flushed out. When the finally start drifting off, they have a brief encounter with a medical student at 5-6am who rattles off a series of rapid-fire questions: "do you have any complaints/concerns? hows the wound/infection/blood pressure/reason why you are in the hospital doing? are you in any pain? can you walk ok? hows the urine? are you passing gas/having bowel movements/eating ok? any nausea or vomiting? diarrhea or constipation?" And then before they can shake themselves fully awake to ask the questions that matter, like "when can I go home? what's wrong with me?" the doctors are gone. After the flurry of midnight-midmorning activity, the patients are left to twiddle their thumbs.

Too often, this hospital routine forgets that it is NOT A ROUTINE for (these individual) patients to be in the hospital. Healthcare workers take this sort of thing for granted. The rub is that it comes off as cold and uncaring.

Even though I often feel rushed or out of time after going through all of my (mostly irrelevant) questions and pausing for all of my patients (mostly very important) concerns, I always feel a sense of immense gratitude from them. Sometimes, this simple pause with an invitation for questions at the end of an encounter turns it into a lasting impression. It's funny how such a small thing makes such a big difference.

Mouth Exercises Significantly Reduce OSAS

Tongue and throat exercises have been found to reduce neck circumference and improve the symptoms of obstructive sleep apnea, according to an article in the May 15 2009 Am J Respir Crit Care Med entitled "Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome."

BMI and ABD circumference did not change significantly, but neck circumference did in the tongue exercise group (n=16, 39.6 +/- 3.6cm) vs the null group (n=15, 38.5 +/- 4.0 cm) with a p value <0.05. Sleep apnea measures like snoring frequency/intensity, daytime sleepiness/sleep quality score and apnea-hyponea index were also decreased.

This is an exciting alternative to CPAP, which many patients dislike because they have to wear a mask that blasts air down their throats to sleep. If they are willing to be compliant with exercises that strengthen their throat muscles and reduce their neck size, then I would certainly refer them to the following video below for some example exercises:

Exercises include: brushing the tongue with a toothbrush, putting the tip of the tongue on the soft palate and sliding the tongue backward, pronouncing vowels quickly or continuously, and keeping the tongue in a certain position when eating.

Download the Video of Oropharyngeal exercises

References:
Am J Respir Crit Care Med. 2009 May 15;179(10):962-6. Epub 2009 Feb 20.
WebMD: Tongue Exercises May Ease Sleep Apnea

hat tip to Clinical Cases and Images

Author's Note:
I am not trying to infringe on copyright by posting the video to my blog... I am just trying to eliminate one extra step for the viewing of something that I find very interesting and want to share with others. If it proves to be a legal problem in spite of the fact that I posted the public links to the article as well as the link to download the video for personal use, then I will remove the video from my site.

My Fourth Year Elective Schedule

Here's what my tentative fourth year elective schedule looks like.

 

Block	Dates	Subject	Location
A	7/6-7/31/09	Cardiology	Queens Med
	7/30-8/1	FM National Conf	Kansas City, MO
B	8/3-8/28/09	Emergency	Castle Med
C	8/31-9/25/09	Family	Wahiawa
D	9/28-10/23/09	Family	? Mainland?
	10/26	Step 2 Clinical Skills	Los Angeles, CA
E	10/26-11/20/09	Neurology	? Queens?
F	11/23-12/18/09	Endocrinology	Honolulu
Winter break!	12/21-1/03/10	---Chillin'---	Hawaii
G	1/4-1/29/10	Rehab	Straub
H	2/1-2/26/10	Dermatology
I	3/1-3/26/10	Infectious dz	Tripler
Match day!	3rd Th in March	FAMILY MED!	?????OMG?????
J	3/29-4/23/10	Geriatrics	?
K	4/26-5/14/10	Senior seminars	JABSOM

 

Looks intense.  I'm very interested in being prepared for my field of choice (Family Medicine) and I've taken a lot of the electives that I know I won't get as much in depth in (namely Cards, Neuro, Endo Derm and ID.)  If I had more time, I would have done an elective in each organ system.  I know that screams out INTERNAL MEDICINE!!! but to be honest, I love kids and OB/GYN too much to give up those aspects of medicine.  My FM advisor talked me out of doing a Peds and OB/GYN outpatient elective ("You'll get that in your residency! Do something else!)

I'll also be tutoring the Life cycle unit in the second semester (blocks GHI) for the MS-2s.  I'm super excited about getting the opportunity to teach and mentor.  I've been tossing around an idea for a differential diagnosis research project that I want to run concurrent with the unit.