Not My Second Opinion

Number Needed to Treat

2010-07-20T13:02:00.000-10:00

The Number Needed to Treat (NNT) is a hot concept in Evidence-Based Medicine since it provides a simple statistic that is a simple way for clinicians to objectively determine the effectiveness of a treatment. It is defined by wikipedia as:

... an epidemiological measure used in assessing the effectiveness of a health-care intervention, typically a treatment with medication. The NNT is the number of patients who need to be treated in order to prevent one additional bad outcome (i.e. the number of patients that need to be treated for one to benefit compared with a control in a clinical trial). It is defined as the inverse of the absolute risk reduction. It was described in 1988. The ideal NNT is 1, where everyone improves with treatment and no-one improves with control. The higher the NNT, the less effective is the treatment

That being said, EVERY medication has a number needed to treat that is greater than one. So what are some common NNTs in medicine? The answer may surprise you.

Dr. Shaughnessy from Tufts Family Medicine pulled out a select few that I thought were notable.

Condition Treatment Outcome* NNT
Prevention
Hypertension in patients with type 2 diabetes Hypertension treatment Diabetes-related death over 10 years 15
Hyperlipidemia (secondary prevention) Various versus placebo Heart attack or stroke over five years 16
Hyperlipidemia (primary prevention) Simvastatin versus no treatment Death over one year 163
Treatment
Peptic ulcer Helicobacter pylori eradication therapy versus acid suppression treatment for six to eight weeks Cure at one year 1.8
Migraine Sumatriptan versus placebo Headache relief at two hours 2.6

A more extensive list can be found at Table of NNTs on Bandolier

ACLS Tachycardia

2010-06-28T16:35:00.000-10:00

ACLS Tachycarda Algorithm on Prezi

ACLS Pulseless Arrest

2010-06-27T07:59:00.000-10:00

ACLS Pulseless Arrest Algorithm on Prezi

ACLS Bradycardia

2010-06-26T07:56:00.002-10:00

ACLS Bradycardia Algorithm on Prezi

Prezi is a great presentation maker for algorithms and journal reports because of the free click nature of it (unlike powerpoint, you can navigate anywhere you want by selection or by "slide advancement")

I thought I'd give it a shot with a short set of presentations based on the ACLS 2005 guidelines by AHA and the great mnemonics by ACLS.net!

Enjoy,

The Setting Sun

2010-04-04T23:57:00.003-10:00

His steady hands were folded in his lap and his posture was erect, as if he were called to a silent attention when I walked into his room. As I gathered a medical history from him, I was reminded of someone, but I could not quite place it. He was a stoic, strong Army veteran. He fought in the land of the rising sun. In spite of all that he had seen, he tried to keep a positive attitude about everything. Recently, he told me, he had been taking miscellaneous classes at a community college for fun -- computer science, psychology, ceramics, whatever struck his fancy.

He was an old man. He had been smoking ever since he enlisted, as a way of passing the time. In spite of all the PT he had done to stay healthy, his lungs failed him. He grew acutely short of breath a few months ago, barely able to walk across a street on the once strong legs that used to carry large crates of ammunition. His hair was thin and short, a reminder of times past. It was not because of an enforced crew-cut this time. A cycle of chemotherapy took its toll on his elderly body. In spite of all that he had been through, he tried to keep a positive attitude about everything.

He smiled at me, a steady and determined smile when I leaned forward and touched him on the elbow.

“So, how do you feel?”
“I feel okay, doc. I just want to know… when is it going to happen?”

I paused, not quite sure how to answer this question.

My brain was still reviewing the list of symptoms of chemotherapy: nausea, vomiting, diarrhea, alopecia, oral ulcers, skin rashes, pain, numbness/tingling/weakness, kidney failure, heart failure… I consciously shoved aside the ticker list scrolling across my mind and focused on the man in front of me.

“The condition you have… the type of lung cancer that it is… is incurable. The chemotherapy only staved off the worst of it that was wrapped around your throat and the blood vessels around your heart. People typically live anywhere from a year to … weeks.”

I looked at him and suddenly caught a glance of my Ojii-san, a man who won a purple heart in the Korean War for valor. He was featured on the cover of Time magazine, according to my mother. All I could remember of my scary grandpa was his raspy breath, stained teeth and the smell of tobacco smoke. He seemed to never move from his recliner and refused to see a doctor when he developed breathing problems of his own. He passed away when I was very young.

“I wish I could give you more specifics, but it is hard to say.”

These men grew up in a different time and likely never thought they would survive the war.
In spite of everything, they had lived past their prime.

I looked out the window where the setting sun flared across the grey clouds on the horizon.
“Well, I’ll come and see you tomorrow,” I said, hefting my backpack over my shoulder.
“I’ll do my best to see you too,” he said with a wink.

____________
Picture by conceptjunkie, c/o flickr

Double Vision

2010-03-30T21:20:00.004-10:00

I saw a patient today who incidentally complained of double vision.

"Look straight at me...

To the left...

And now, to the right!"

The misalignment was most evident when I first awoke this patient, but you can still see that the left eye does not track well, especially when looking to the right. (Hint: look at the slight difference in the reflection between the eyes, subtle but present in all photos.)

I was able to diagnose this patient's underlying condition, which is practically pathognomonic for...

Med students: do you know what it is?

----------

Left-sided internuclear ophthalmoplegia, caused by an injury to the medial longitudinal fasciculus...

And the most common source of this lesion is multiple sclerosis. This patient has chronic relapsing, remitting multiple sclerosis (curiously, the patient didn't have any visual problems until a week ago.) We prescribed an eye-patch. I was graciously given permission to photograph the eyes for educational purposes and spread the word.

Sometimes double vision can be "monocular," signifying astigmatism in the affected eye. When it is "binocular," requiring BOTH eyes to be open to create double vision, then you worry about cranial nerve and ocular muscle defects.

How to Feed the World?

2010-03-24T21:02:00.000-10:00

How to feed the world ? from Denis van Waerebeke on Vimeo.

A strikingly simple message that everyone can (and should!) listen to.

Interesting Optho Cases

2010-03-10T23:52:00.002-10:00

Here's some of the cases that I had on my Optho service. Really, that should be "Ophthal" cases, but no one seems to pronounce the "ph" anyhow. I'm not sure if this is of interest to anyone else, but reviewing this list helps me remember what I've seen.

Most interesting/unexpected

Ruptured globe -> repair -> enucleation to prevent sympathetic ophthalmia
Herpes zoster opthalmicus
Narrow angle glaucoma s/p laser peripheral iridotomy (visible via retroillumination!)
Congenital cataracts, amblyopia
Anterior uveitis, HLA B27(+), tx w/ MTX
Anterior uveitis, secondary to psoriatic arthritis (striking case of dactylitis!)
Exposure keratopathy secondary to CN VII palsy s/p parotid tumor resection
Pterygium vs pinguecula
Grave's ophthalmopathy
CN IV palsy secondary to meningioma
Metallic foreign body removal (rust from car) w/ 18 gauge needle, wet Q-tip and Algr brush

Routine but important!

Corneal abrasions vs ulcers
Floaters and flashes: vitreous detachment vs retinal detachment vs ocular migraine
Conjunctival stye vs chalazion
Background vs proliferative diabetic retinopathy
Open angle glaucoma
Age-related Macular Degeneration
YAG laser
Cataract surgery

Glad that Ophthalmologists Know What the Heck they are Looking at

Pseudophakic bullous keratopathy
Choroidal melanoma s/p proton beam radiation
Pigmented basal cell carcinoma
Irvine-Gass cystoid macular edema secondary to atopy and cataract surgery

Shoulder Exam

2010-02-16T23:03:00.003-10:00

Last week I did a presentation at the HOME project on the shoulder exam with a few clinical cases I saw in clinic. It was a smashing success -- everyone seemed to appreciate an introduction/review of some of the maneuvers!

One of the toughest parts of the physical exam is remembering all of the routine shoulder maneuvers.

Here's a few mnemonics I shared that I use to help myself remember things:

Arm Movements

Flexion of the arm = Forward to the Face
Internal Rotation of the arm = In handcuffs
(alternatively, External Rotation = Execution of Ex-Convict)
ADduction of the arm = ADDing to the midline

Scarf sign = toss a scarf around opposite shoulder

Forearm Movements

Supination = Holding a Bowl of "Soup"
Pronation = Putting away Palm

Special Maneuvers

Range of Motion (and Impingement Signs)

Neer = arm "Near" to the ear
Hawkins = flap like a "Hawk"
Apley scratch test = Applying Suntan lotion to back

Rotator Cuff Tears

Supraspinatus

Jobe's Empty Can (duh!)

Hornblower's (ditto!)

Biceps

Speed's = speedin' down the highway

Labral Tear

O'Brian = *Irish accent*
What, so O'Brien gets the thumbs down, but Leno gets a thumbs awp? I'm cryin' heah!!

Subscapularis

Gerber's lift off = wiping baby food off the back (okay, its a stretch, but you can't win 'em all!)

That's not my second opinion! :)

Pre-op "clearance"

2010-02-07T20:53:00.002-10:00

Physicians often receive requests from surgeons for a pre-op physical to "clear the patient for surgery."

What this "clearance" entails is not entirely clear.

Surgeons are worried that an unknown medical problem will rear its ugly head during the surgery and bite them in the butt... or the anesthesiologist will call off the surgery because of blood pressure concerns.

Consults are often made to a cardiologist with the intent of doing a pre-op EKG/Echo + stress test to determine if the patient is fit for surgery at the surgeon's behest. What is important to understand is that another physician is often the one responsible for keeping the patient alive during the surgery and it is this person, who is most interested in the pre-operative assessment.

Unfortunately, the anesthesiologist often just turns out to be the doctor who happens to be in the OR on that particular day and has not established any sort of relationship with the patient beyond their initial bedside assessment in the waiting room.

In the Cleveland Clinic Journal of Medicine, two anasthesiologists tackle this issue and give some general advice for pre-op consults.

Consults that provide pertinent quantitative data about the patient are helpful—eg, the heart rate at which ischemia was exhibited during stress testing and the degree of ischemia.
Anesthesiologists do not need assistance with managing intravenous drugs (with the exception of unusual agents), but they can use specific guidance on managing oral medications pre- and postoperatively to best achieve optimization and steady-state concentrations.
Pertinent recent information (< 5 years old) from the nonanesthesiology literature should be provided.
Medical consultants should arrange for follow-up care for patients with active conditions not addressed by the surgery.
Absolute recommendations should be avoided in a consult: the surgical team may have good reason not to follow them, and legal repercussions could ensue. The words “consider” or “strongly consider” usually suffice, except where there is an absolute standard of care.

Specific questions to answer include such things like assessment of cardiac function (hx of angina, last echo results, exercise tolerance,) successful blood pressure and diabetic regimens, etc.

References

Giving Anaesthesiologists What They Want: How to Write a Useful Preoperative Consult. CCJM 11/2009

Rheum Case 1

2010-02-07T01:19:00.003-10:00

A 55 year old Caucasian male presented to a neighbor island ED with lower extremity skin rash, swelling and severe arthritis following a sore throat.

History of Present Illness: Pt had an itchy and sore throat for which he was treated with azithromycin. He sought out new antibiotics after 5 days without relief. Approximately ten days after the onset of the sore throat, he went to bed complaining of a "sore wrist." Upon awakening the following morning, he felt severe pain in both wrists with progressive immobility of the left wrist. His skin broke out with a rash later on in the day on his hands, wrists and ankles. His legs started swelling and he had difficulty walking.

Denied red eyes or pain with urination.

Past medical history: significant for migratory arthritis, Crohn's disease, HLA-B27(+). Patient has a long history of severe anaphylactic/eczemal allergic reactions as well.

Pertinent physical exam:

Skin exam revealed multiple, progressive, round tender "palpable purpuric" lesions on the hands and ankles.

4+ pitting edema was present in the lower extremities.

Diagnosis: enteropathic arthritis and erythema nodosum most likely secondary to a streptococcal infection of the throat with subsequent reaction *HLA-B27(+)

Differential:
Reiter's/Reactive arthritis triad: conjunctivitis, arthritis, urethritis (Can't see, can't pee, can't climb a tree)

Course: Dermatology, ID, and rheumatology consultations were made. Pt was reluctant to start a course of steroids in the ED, given a past history of steroid-associated insomnia and psychosis. After 5 days of worsening edema and tender arthritis, he agreed to a steroid burst of 40mg daily and tapering regimen with rheumatology to follow.

References

eMedicine: Erythema Nodosum

eMedicine: Enteropathy arthritides

Learning Radiology: An Approach to Arthritis

I love my Kindle!

2010-02-01T01:34:00.001-10:00

I always wanted some "electronic paper" device that I could take notes on and hold all of the files I wanted at my fingertips ...

My parents gave me the Kindle DX as a birthday gift! It has "whispernet" dedicated wireless for simple bookdownloading/wikipedia browsing (battery life 2 days) and a solid read time of 2 weeks with the internet disabled. Since it doesn't have a backlight and it only draws power when the pages turn, it's a great device for travel.

It feels almost blasphemous to admit how I am fond of my iPhone, especially now that the iPad has come out as the sexy attractive alternative to this eReader. Amazon will hopefully step up its game and work harder with the Kindle. In any case, I think that the Kindle was/IS still a good buy.

For my MD preparations, I bought a series of clinical books:

DeGowin's Diagnostic Exam

Good reference, a bit thorough but a fun read nonetheless with great quotables!

The Rational Clinical Examination by JAMA

Great analysis for an evidence-based H&P!

ECG Diagnosis Made Easy

Image quality can be an issue on a grayscale e-Ink pad. Keep that in mind when purchasing eBooks.

First Aid for the Family Medicine Boards

Hopefully this will pay off in spades over the next 3-4 years during my residency!

Then, I uploaded the AFP pdf series on assorted Family Medicine topics (we received a CD with copies of some important articles published in the past 10 years in our third year rotation.)

Additionally, I have been tossing in pdfs along the way, for ICU topics mainly.

There are tons of free e-books to read as well. I've read half of the Sherlock Holmes books and I'm attempting to read the Autobiography of Benjamin Franklin and Physics for Entertainment now.

I put it in a clipboard I bought at Office Depot -- one of those storage clipboard cases -- for protection from damage/theft. I am working on making a USB drive with the PortableApps to create my perfect portable experience now, to use while rounding in the hospital.

I do enjoy the multiple formats that I can use to read my Kindle books -- it is nice to curl up in bed with my Kindle app on the iPhone when I don't want to read with the lights on.

The only thing I dislike about the Kindle is the bookmarking -- there's no way to label the bookmarks so it is a lot of page number memorization! Very frustrating when you're trying to navigate to something specific as a quick reference.

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

Picture by ivyfield via flickr

What does PPD/BCG/TB mean?

2010-01-31T00:59:00.002-10:00

Clinical scenario:
In the Hawaii HOME project, we had a series of patients who were being screened for TB with PPDs. Three of them had a history of (+)PPDs. Two of them claimed to have a history of (+) chest x-ray without follow-up of medications. One of them came in with fever and cough.

Definitions:

TB: Tuberculosis
- Caused by Mycobacterium tuberculosis
- Tubercles are warty, cheesy lesions
- Respiratory infection characterized by:
  - Cough
  - Hemoptysis (bloody sputum)
  - Fever/Chills/Night sweats
  - Weight loss
- DIFFICULT: to catch, to culture, to get rid of
BCG: Bacillus Calmette-Guerin
- Calmette (French bacteriologist) and Guerin (assistant) cultured a cow-version of the TB bacteria and created a TB vaccine
- Similar theory to the smallpox vaccine
  - Jenner made a vaccine from cowpox
- Causes a false-positive PPD skin test
PPD: purified protein derivative aka Mantoux test
- Sterilized tuberculin glycerol extract from the tubercle bacillus
- Injected subcutaneously (right under skin)
- Read 2-3 days later (delayed type IV hypersensitivity reaction)
  - (+) if induration (hardness) forms >5/10/15mm depending on situation
  - (-) if no reaction is present
Chest x-ray
- Test of choice in non-active TB for determining clinical status
- (+) indicates that lesions suspicious for TB are observable
- (-) indicates that the patient is at risk for secondary TB activation in the future, but currently does not have active TB assuming the patient is asymptomatic

Why is this important?

Swaziland has the highest prevalence of TB in Africa (1,198:100,000), shortly followed by South Africa (948:100,000). In the Pacific Islands, Cambodia, Kiribati and the Philippines have high rates as well (495, 365 and 290:100,000 respectively.) In Southeast Asia, DPR Korea, Timor-Leste and Bhutan have high rates; also places of conflict.

Many immigrants pass through Hawaii to the mainland US and the immigrant homeless population has a significantly higher risk of exposure to TB and subsequent infection.

Treatment

Active TB Standard recommended regimen:
2 months of RIPE: rifampicin, isoniazid, pyrazinamide, ethambutol
4 months of RI: rifampicin, isoniazid

Latent TB infection:
6 months of isoniazid, or 3 months of RI
-Advise patients about side effects of isoniazid:
GI upset (loss of appetite, nausea, vomiting, stomach pains)
Weakness, peripheral neuropathy (prevented by vitamin B6 intake)
Liver damage
-Do Cr and LFTs monthly for monitoring

Resolution of clinical scenario:

The two patients with (+)PPDs and (+)chest x-rays were questioned further.

The one with fever and cough was confused and through a translator, thought that the word "positive" meant "good." In the context of the tests, both were negative.

The other patient had a card with a record locator number. The main office for TB screening was contacted for confirmation: the chest x-ray was reportedly normal. This patient had unintentional weight loss of 35 lb over the past year (since becoming homeless.)

The patient was warned about the possibility of "reactivation TB" and was advised to start isoniazid. The patient agreed to prophylactic treatment and routine testing.

Take home lesson:
Always question your patients about what they mean! Positive in terms of disease is may not mean the same thing to a patient as it does to a clinician.

References:

WHO estimates of TB incidence by country, 2007
NICE 2006 guidelines: Clinical diagnosis and management of TB and measures for its prevention and control by the UK's National Institute for Health and Clinical Excellence

Traumatic rhabdomyolysis

2010-01-24T19:27:00.002-10:00

In recent news, a survivor of the 7.0 earthquake in Haiti have been found after 10 days -- including a 22 year old, Jean-Pierre. In the rubble of the collapsed hotel he fed on cola, beer and cookies to stave off dehydration and malnutrition until his timely rescue.

He was lucky enough to dive underneath a desk as the earthquake hit, avoiding major trauma. What if his legs were pinned under tons of rock and timber? What if he were held immobile for the better part of a week?

Jean-Pierre was spared the fate of acute renal failure/acute tubular necrosis by traumatic rhabdomyolysis. It would start as dark red urine, that eventually lessens until there is no urine being produced at all.

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

Myoglobin is a heme-binding molecule present in skeletal and cardiac muscle. It makes our muscles red, especially the slow-twitch (Type I) muscles. It is similar to hemoglobin but greedier -- it's affinity for oxygen is much stronger. Underwater mammals like seals and whales are able to hold their breath much longer than us due to their higher concentration of myoglobin in muscle.

For reasons that are not entirely clear to us, when muscle tissue breaks down from trauma and immobility, myoglobin is released into the bloodstream and subsequently filtered by the kidneys where it can cause major damage -- nephrotoxicity by iron-dependent and -independent mechanisms.
1) Ferrous oxide (Fe2+) is oxidized into Ferric oxide (Fe3+) and leads to free radical damage in the kidneys.
2) Tubule obstruction and direct toxic effects are thought to occur as well.

Aggressive saline infusions with possible addition of sodium bicarbonate to alkalinize the urine (and prevent conversion of myoglobin into its more toxic metabolites) are the sole treatment of this kidney condition. This makes sense, since you're clogging up the filtration system with this muscular gunk, you vigorously flush the whole system out!

We're talking about boluses of 20cc/kg (or ~1.5 L of NS for the typical person) initially, with maintenance IVF of 200-300cc/hr thereafter!

This is expected to go on until the urine output hits 2-3cc/kg/hr (or 150-200cc/hr for the typical person) and the urine clears up.

Hopefully you find this topical and interesting as well.

References

Photo by simminch via flickr

BurnDoc ICU Rounds:
-Traumatic rhabdomyolysis/Crush Syndrome
-Acute Renal Failure

Myoglobinuria - Medscape

"Nonreassuring" Vocabulary

2010-01-23T16:42:00.002-10:00

The word "nonreassuring" is a curious phenomenon of OB/GYN. Nowhere else is this particular word used in a professional context... which is embarrassing that the word is cited in literature when it doesn't exist.

Reassuring is defined thusly:

tr.v. re·as·sured, re·as·sur·ing, re·as·sures
1. To restore confidence to.
2. To assure again.
3. To reinsure.

The implication is that "nonreassuring" means the opposite -- worrisome, vexing. Of course, to a pregnant mother about to deliver, that's some of the scariest news to hear about her unborn child!

In an effort to further obscure the assessment in Fetal Heart Tone monitoring, in April of 2008 the "National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring" issued a new statement to categorize it in a "Three-Tier Fetal Heart Rate System:

Category I
Category I fetal heart rate (FHR) tracings include all of the following:
• Baseline rate: 110–160 beats per minute (bpm)
• Baseline FHR variability: moderate
• Late or variable decelerations: absent
• Early decelerations: present or absent
• Accelerations: present or absent

Category II
Category II FHR tracings include all FHR tracings not categorized as Category I or Category III. Category II
tracings may represent an appreciable fraction of those encountered in clinical care. Examples of Category II
FHR tracings include any of the following:
Baseline rate
• Bradycardia not accompanied by absent baseline variability
• Tachycardia
Baseline FHR variability
• Minimal baseline variability
• Absent baseline variability not accompanied by recurrent decelerations
• Marked baseline variability
Accelerations
• Absence of induced accelerations after fetal stimulation
Periodic or episodic decelerations
• Recurrent variable decelerations accompanied by minimal or moderate baseline variability
• Prolonged deceleration 2 minutes but 10 minutes
• Recurrent late decelerations with moderate baseline variability
• Variable decelerations with other characteristics, such as slow return to baseline, “overshoots,”
or “shoulders”

Category III
Category III FHR tracings include either:
• Absent baseline FHR variability and any of the following:
- Recurrent late decelerations
- Recurrent variable decelerations
- Bradycardia
• Sinusoidal pattern

Basically, Category I is "reassuring", Category III is "Nonreassuring" (ugh) and Category II is somewhere in between.

Personally, I don't like it when the assessment of a patient needs to be translated for the patient's benefit -- why is there a deliberate effort to make something difficult to understand even harder to explain to patients?!? We don't need to tell someone what they already know, but in a completely different language.

It's doubtful, but in the future it could be categorized as "good," "hmm" and "uh oh."

DR C BRaVADO: mnemonic for Fetal Heart Monitoring

Define Risk (low/high)
Contractions (freq)
Baseline Rate (110-160)
Variability (10-15bpm)
Accelerations (2, >20 over 20s)
Decelerations (early/variable/late)
Overall assessment (reassuring vs "nonreassuring" ugh!)

References:

Advanced Life Support in Obstetrics (ALSO)

AAFP website

AAFP Mnemonics brochure

National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring

The Match.

2010-01-17T15:29:00.004-10:00

I submitted my Rank-Order List for Family Medicine programs on Friday. I updated it again today to double-check that my top program numbers were inputted appropriately. Whew!

There's a lot of factors that go into the decision-making process for residency program selection -- geography, work-hours, resident/faculty support, curriculum, monetary factors, etc.

When I looked at Family Medicine programs on the Mainland, I must say, I had NO idea what to look for -- being a medical student from Hawaii, almost all of the faculty in our Family Medicine department trained in the Family Med program here as well! So, I took a shortcut of investigating the P4 programs because I figured that they were excellent programs already, looking for fresh new ideas to integrate into their curriculum. My other choices were based on good things I heard from people, as well as my discussions with them at the Kansas City AAFP National Conference (if you're looking for the perfect family medicine program for YOU, I'd highly recommend visiting in your first month as a fourth year!)

Despite the "4", in the name, not all P4 programs are four year programs, although I found some of the ones that were to be of particular interest. Innovations are a great topic to discuss, but I want to share something else on my mind.

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

Now that the rank-order list is out of my hands, I have nothing to do but wait and see what the final outcome will be, come March 18th. The National Resident Matching Program "matches" me with my #1 choice, putting me in the queue of their program according to their ranking for me -- if I happen to be in their top 10 (or so,) then I get matched there. If someone higher on their list ranks the program highly as well, then I would get bumped down (and possibly off) their list and when all the slots are filled, I would move on to my #2 choice or my #3, until I get placed.

Naturally, I feel a sense of relief.
I've gone through the grueling process of medical school (for the most part.) The countless hours of mind-numbing study in the first two years, culminating in the Step 1 exam. The thrill and terror of third year, suddenly exposed to the organic, living, breathing patient that we've heard so much about. The uncertainty and anxiety of the interviews and the ever-expanding hole of debt traveling across the country far and wide for the perfect place to spend the next three+ years of my life. Now it is time to relax and breathe. It is out of my hands.

I also feel a sense of dread and underlying anxiety.
Questions of self-doubt and second-guessing arise.
Should I have applied to X program?
What if the people at Y didn't like me?
Would I really be happy at Z program?
Can I handle the responsibilities to come?
Will medical school be enough preparation for the next harrowing experience known as INTERN YEAR?

This lack of control is both comforting and anxiety-provoking.
I have no choice but to have faith that my interviews went as well as I felt they did and just keep my brain active in the mean-time. I am tutoring a small group of incredibly fun second year med students and I'm touching on all sorts of issues that I know will be important in the future. More to come on this. :)

*Picture by 96dpi, courtesy of flickr.

Anathem Review

2010-01-14T20:10:00.002-10:00

On my interview trail, I purchased this book for my Kindle DX -- and boy, am I glad that I got it electronically, since it clocks in at 960 pages and nearly 3 pounds in the hardcover edition!

It is a work of Science Fiction in the classic sense, inventing a whole world of "compossibility." A world where concents (monasteries) outlive surrounding civilizations by millenia, watching them rise and fall. The Avout (monks) revere Science, Reason, Logic and Physics instead of religion. Indeed, orders of the avout are called "maths." They strive to preserve the world's knowledge and seek out new discoveries, even though a Saunt (Saint) Lora of the 16th century proposed that all possible ideas had already been thought of, which includes Saunt Lora's own Proposition as well.

Stephenson dreamed up this world after participating in the 10,000 Year Clock of the Long Now project, where he thought of the idea of a church that had a clock with a set of individual gates, each programmed to open only at a set time: everyday, every year, every decade, every century and every millenia. A group of monks tended to the clock and were cloistered until such time that their specific gates opened.

The story follows a young "Tenner" who was collected at age 9 and finds himself released back out into the Saecular world shortly after completing his ten-year term. World-altering events call upon young Fraa Erasmus and his fellow clock-winders to solve a great mystery and save Arbre.

Stephenson definitely does not cut you any slack in the novel as you are introduced to the "Orth" language of the people Arbre on the first page and he never lets up. Slowly, the definitions for all of these words unfold in the novel. The payoff is rich in the form of contemplative prose in classic Plato and Socrates style dialoging that encompasses the physics of geometric coordinate phase space, the philosophy of consciousness, the existence/non-existence of time, the power of observation, and the exciting possibilities of science fiction (yes, there are parts of the book that include classic sci-fi space-opera elements to make geeks and nerds glomph and squeal and huggle and hurr.)

If you enjoy xkcd comics, Snow Crash, His Dark Materials, or anything along this vein where education itself is a form of entertainment for you, then this book is a definite buy.

It is quite a struggle for me to describe how this book has affected me, save to say that I have some upsight into the possible tracings of my own Narrative along multiple Worldtracks as they progress along a Directed Acyclic Graph in a Wick fashion, leaking in from the Hylean Theoric World. Complete nonsense to most, but I could put it best in no other way.

And that's Not My Second Opinion.

Further Blogging Musings

2010-01-13T19:51:00.000-10:00

I started off one of my Family Medicine interviews in a very interesting way.

"I noticed you were a blogger and I must say, I was disappointed." He paused to drink in my reaction and his eyebrows furrowed as he continued in a very somber tone. "You haven't blogged in a few months!"

"Well, I have been busy interviewing," I confessed. "Plus, I would not want to blog about a specific program only to have it come back to me in a bad way."

"Exactly. I thought that I could comment on your thoughts about interviews in the hopes of bringing up a point of awkwardness."

I thought to congratulate him on doing just that, but we moved forward from that point... but he did make me think more about the frequency of my posts as well as the content itself.

One of the things that has made blogging difficult for me has been the way I have spent my free time.
My blogging dropped off precipitously when I started a relationship with a special someone (with a p-value of <0.0001! I like to joke) and when I decided to blog, it quite often turned out to be "catching up on blogs" rather than "writing cool and fun content for my own blog." Sadly, my comments on other blogs dropped off with the exclusive use of Google Reader for my blogging needs. It does a splendid job of offering me text content, but a terrible job in helping me reach out and become a part of a virtual community. I put myself in the position of observer alone, having all of these amazing bloggers teach me about fascinating clinical cases.

I have been afraid to post things of personal interest.
My posts of late have adopted more of a neutral tone and lacked personality. Tossing back the curtain of "pseudoanonymity" by attaching my Real Name to this blog and revealing its presence to ALL of my potential residency programs made me meek. I have been afraid to say anything that may offend, provoke or be of any real interest, to be quite frank. This has made me think of the Happy Hospitalist and his "crap or not, here it comes" attitude to posting. Despite the fact that I often disagree with his philosophy and politics, he does occasionally have an excellent pearl or two to share... the rest are just his opinions.

And I certainly do not live up to my pseudonym if I am afraid to offer up opinions of my own, as ill-informed, naive, idealistic, fluffy bulshytt as they may be.

Writings and Ramblings

2010-01-12T18:55:00.003-10:00

January 1st is a time of reflection on the past year as well as a time to resolve to make changes.

There's a few things that I want to do differently in the year 2010 and beyond.

I want to complete the 100 pushups workout. This is something that I think will be achievable by March.

I want to Blog more. Technically, this is something that I have accomplished with the simple exercise of writing this post! More specifically, I want to blog daily. There are a lot of things that go unwritten that I might find of relevance at a later date.

Recently, during a resident dinner, I found myself making two quite random non-sequitors on the subjects of urushiol and polydactyly -- subjects I fancied enough to blog about in the past. I found it quite striking that these topics bubbled up from my subconscious and became somewhat relevant!

One of my favorite interviews (at my favorite residency program) included a discussion on blogging. Indeed, said interviewer encouraged resident blogging as a way of reflecting on issues that came up!
There was a suggestion to ask yourself three questions:

What?
So what?
Now what?

What: Subject of discussion
So What: WHY is this of importance to you (the writer) and me (the reader?)
Now What: Conclude with something of significance.

So there. I've come up with a new method for generating blogging content that hopefully will me more entertaining and engaging than recent posts (that have been so dry that I bored myself writing them) and hopefully I can find a way to blog more often.

Cheers!

No Such Thing as "Healthy Obese"

2009-12-29T12:05:00.005-10:00

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.

Podcasts

2009-12-21T16:33:00.001-10:00

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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iDistraction

2009-12-20T15:53:00.004-10:00

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!

Family Medicine?

2009-11-19T21:26:00.005-10:00

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.

Adventures in Brain Tumors (Prolactinoma!)

2009-11-16T22:40:00.000-10:00

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.

"Time Lost is Brain Lost"

2009-11-15T21:47:00.004-10:00

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

Hoarseness

2009-11-01T18:06:00.002-10:00

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)

The Mito Mystery

2009-10-30T22:34:00.001-10:00

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...

"The Neuro Exam is not dead"

2009-10-29T21:55:00.002-10:00

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.

ddx

2009-10-21T17:48:00.003-10:00

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.

Differential Diagnosis Generation

View more presentations from Clinton Pong.

diamond in the rough: HI 5!

2009-10-19T13:26:00.000-10:00

"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!

something that I want to be a part of

2009-10-18T13:06:00.000-10:00

diamond in the rough: insurance vs assurance

2009-10-08T11:14:00.002-10:00

(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.

Eye am so confused!

2009-10-05T14:57:00.001-10:00

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.

Eye Am Confused

View more presentations from Clinton Pong.

Psychosocial Medicine

2009-10-01T17:18:00.003-10:00

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.

Cholesterol trends down

2009-09-25T15:29:00.002-10:00

Some good news in the world... people are eating healthier and exercising more. Or they are taking more statin medications.

MMWR Weekly:

QuickStats: Average Total Cholesterol Level Among Men and Women Aged 20--74 Years --- National Health and Nutrition Examination Survey, United States, 1959--1962 to 2007--2008*

Pong's Postulates (II)

2009-09-02T12:29:00.001-10:00

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.

DeGowin Quotable.

2009-08-28T16:48:00.002-10:00

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.

A Picture is worth 1000 words... but

2009-08-25T14:15:00.003-10:00

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?”

PERC up about Well's for PE

2009-08-22T13:42:00.000-10:00

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

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

2009-08-21T12:05:00.004-10:00

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 Stewart

Mon - Thurs 11p / 10c

Exclusive - Betsy McCaughey Extended Interview Pt. 1

www.thedailyshow.com

Daily Show
Full Episodes

Political Humor

Healthcare Protests

The Daily Show With Jon Stewart

Mon - Thurs 11p / 10c

Exclusive - Betsy McCaughey Extended Interview Pt. 2

www.thedailyshow.com

Daily Show
Full Episodes

Political Humor

Healthcare 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

2009-08-21T01:02:00.000-10:00

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.

PubMed searches become easier

2009-08-19T18:46:00.003-10:00

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.

Red pill vs Blue pill

2009-08-11T21:54:00.002-10:00

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.

Pong's Postulates (I)

2009-08-06T16:10:00.004-10:00

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.

Patient Centered Medical Home... say what?

2009-08-02T00:14:00.005-10:00

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.

Doctors are Gamblers

2009-07-15T20:50:00.003-10:00

http://www.flickr.com/photos/robnwatkins/ / CC BY-NC-ND 2.0

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.

Rights vs Expectations

2009-07-10T12:02:00.004-10:00

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."

Atrial Fibrillation Treatments

2009-07-08T22:30:00.002-10:00

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.

ACTIVE-A and W trials

View more documents from Clinton Pong.

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

Metoclopramide for Hyperemesis Gravidarum

2009-06-11T22:59:00.002-10:00

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! :)

Culture of Medicine II

2009-06-09T17:04:00.003-10:00

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.)

When Physics meets Physician.

2009-06-08T20:07:00.000-10:00

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

the image properties for this comic reveals the answer:

413 nanohertz, by the way.

Culture of Medicine

2009-06-07T19:29:00.002-10:00

“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!

Fitness Fun Facts

2009-06-04T23:11:00.008-10:00

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)

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. ;)

Concierge Medicine or Direct Medical Practice?

2009-05-31T11:41:00.006-10:00

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

2009-05-30T00:00:00.004-10:00

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

2009-05-28T23:00:00.001-10:00

Image via Wikipedia

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

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

Patients with threeor more of the seven variables are considered to be at highrisk, whereas those with no more than two of the variables areconsidered 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

2009-05-27T23:26:00.002-10:00

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

2009-05-26T10:26:00.001-10:00

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.

2009-05-25T10:02:00.003-10:00

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..."

2009-05-24T21:36:00.002-10:00

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

2009-05-23T21:25:00.006-10:00

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

2009-05-22T15:08:00.000-10:00

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

2009-05-20T21:11:00.001-10:00

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

2009-05-20T16:47:00.002-10:00

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

2009-05-16T00:26:00.000-10:00

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!

2009-05-15T22:05:00.000-10:00

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

2009-05-14T18:26:00.001-10:00

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?

2009-05-13T00:16:00.004-10:00

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

2009-05-12T07:35:00.000-10:00

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

Dr. Ted Epperly Speaks for FM with Obama

2009-05-11T20:46:00.004-10:00

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

2009-05-10T21:17:00.004-10:00

“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

2009-05-10T10:52:00.003-10:00

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

2009-05-04T00:37:00.001-10:00

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.

Psychiatry in a Page Pocketmod

2009-04-27T23:17:00.002-10:00

Since my Psych shelf is this Wednesday, I thought it would be appropriate to share my PocketMod.

It skims the basic H&P for Psychiatry with a bunch of mnemonics I acquired along the way. It then goes through the diagnostic criteria for the major mood/psychotic/anxiety/personality/substance use/substance abuse/eating disorders. It might seem a bit obscure at first because I abbreviated everything, but the shorthand makes it easier (in my mind) to read it quickly and recite it mentally.

Pocketmod PDF: Psych in a page

Wondering how to fold this document? See my previous post on the subject of PocketMods on the Wards.

National Library of Medicine Feature: Native Hawaiian Health

2009-04-21T10:15:00.003-10:00

Whoa! Dr. Lindberg, the Director of the National Library of Medicine, talks about Native Hawaiian Health and Hansen's Disease (aka Leprosy) in Kalaupapa in his weekly podcast for MedlinePlus. MedlinePlus is an excellent resource for health education funded by the U.S. government with cool things like surgery videos, basic health topics and interactive tutorials.

Here are some excerpts from this week's podcast:

The health status of Native Hawaiians and Pacific Islanders is a major challenge for the physicians and traditional healers who serve the indigenous peoples of Hawaii, Guam, Samoa, and other Pacific Islands. However, the efforts to improve health care are fostering some imaginative, culturally appropriate approaches in Hawaii, including a network of clinics that combine western medicine with native healing, plus an interest in community outreach within the state's medical school and other health care organizations.

...

Kalaupapa is a reminder of ignorance, medical research dissemination and challenges, the ancient stigma attached to Hansen's disease, as well as human courage -- all nestled within one of nature's majestic settings.

Kalaupapa is a remote peninsula on the Hawaiian island of Molokai where from 1866-1969 about 8,000 persons with Hansen's disease (also known as leprosy) were exiled and quarantined. Dr. Lindberg led an NLM team (including me) that recently visited some of the remaining patients and providers.

Hansen's disease is treated today by a multi-drug combination that succeeded sulfone medications, which provided the original breakthrough management of the infectious disease starting in the 1940s. The drugs brought a quick reduction of symptoms, significant improvements in a Hansen's disease patient's quality of life, and removed the possibility that a patient in treatment was contagious.
...

Dr. Lindberg provides a great synopsis of issues in Hawaiian health that I must admit, I've taken for granted having grown up in here. So it's refreshing to hear a distinguished official from the Mainland take an interest in our little corner of the world.

Transcripts and Audio:
Native Hawaiian Health (audio podcast)
Kalaupapa & Hansen's Disease (audio podcast)

Vaccine Schedule Mnemonic

2009-04-20T19:04:00.001-10:00

What is a good way to remember the vaccine schedule for children? This can be a pesky task, but I've come up with a pretty succinct way to help you remember!

Don't Be DR. HIP, who flu in an MVA , the DIMVit! and Hit My Teen

@ birth: Be
HepB

@ months 2,4,6: (DR HHIP)
DTaP, Rota, Hib, HepA, IPV, PCV

@ 12 mo-> flu

@ 12mo (MVA)
MMR, VZV, Hep A (w/ booster at least 6 mo later)

@ 4-6 y/o (DIMVit "dimwit")
DTap, IPV, MMR, VZV boosters

Hit My Teen (for teens)
HPV, MCV, Tdap

For adults, just remember a flu vaccine every year, update Td every 10 years (or 5 w/ dirty wounds), PPV @ 65 (or younger with risk factors... PPV, not PCV), and Zostavax (Herpes Zoster vaccine) @ 60 also.

Clinical Scenarios for Immunizations

2009-04-19T18:32:00.004-10:00

In Pediatrics, I saw a mother who had a 2 year old daughter who was unimmunized.

"Now that she's two and out of the danger zone for autism... I'd like to start some vaccines," she said.

My preceptor and I spent the next ten minutes negotiating with her -- a major worry being "overwhelming" the child with dangerous chemicals. We settled on the DTaP and VZV vaccine after she made a few requests to "split up the components."

I did not understand some of her worries... and I'm not entirely convinced that she understood either. She was just worried. We emphasized that she avoid ALL travel and exposure to anyone who did travel around her child to avoid any avoidable illnesses.

So it's fitting that I found this series of Clinical Scenarios for vaccination at Immunizationed.org, featuring the following topics:

Adolescent Immunization
Chronic Liver Disease
Health Care Workers
Human Papilloma Virus
- Pre-adolescent female vaccination
- 23 year old female with abnormal pap
Pneumococcal Pneumonia
Shingles and Post Herpetic Neuralgia

It's a shame that they do not provide a script for addressing the "anti-vaccine" crowd, with ready statistics and concerns for public health and preserving herd immunity. It will be one of my goals to be capable of solidly addressing this topic in a manner satisfying to my hypervigilant mothers and autism-wary parents in pediatrics.

"For the Life of Me" and "Depression Too is a Type of Fire" by Taylor Mali

2009-04-18T16:47:00.003-10:00

Love and loss.

Taylor Mali is a poet and a teacher and a true inspiration of the Word. He is best known for "What Teachers Make."

I wish that I could speak with the eloquence and gravitas that Mali has at his command. These two poems hit a particular chord in me that continues to hum. There is so much of me that I wish I could share with the world, but my idle thoughts lie unpolished and forgotten in some unexpressed corner of my mind. I find myself wishing that I had more time to compose myself in a manner worthwhile, yet when I do have time, I spend it appreciating only the works of others. I feel a sense of love and loss, but it is more of a manner of withdrawing into my own little safe world of medical facts to protect myself from the real world's imagined(?) horrors and disappointments.

Every once and a while, I find moments. I live moments of love. The smile of a patient at the end of a visit -- "you'll make a great doctor someday." "good luck to you." "it was a pleasure meeting you." "thank you, doctor." "Student doctor," I respond. A warmth creeps into my body, a smile uncurls naturally onto my face. Small moments in which the connections I find myself wondering if I could ever make with another person -- are precisely the things I do every day. I know there is a division between professional and personal life. I wonder if these friendships are worth the lonely nights and weekends spent studying dry facts and memorizing the latest evidence-based guidelines. Am I merely an algorithmic medical computer?

No.

The satisfaction I feel at the end of the day does not stem from the recognition of a particular diagnosis or a particularly clever question I ask. It comes from the bond I forge with my patients. Is it worth the sacrifice of a more social life? For now, yes. However, I don't think it is selfish to want something more.

Critically Appraised Topic Powerpoint Template

2009-04-03T07:58:00.001-10:00

CAT Template

View more presentations from Clinton Pong.

Feel free to disseminate this Powerpoint presentation template for Critically Appraised Topics -- use it to spice up your journal clubs!

My First Practice-Changing CAT

2009-04-02T07:43:00.004-10:00

Here's a presentation I prepared for today's Internal Medicine Journal club. The subject matter: Atenolol "causes" Diabetes. The idea was so preposterous when my IM preceptor brought it up that I HAD to look it up. Now I've found the first journal article I've come across that's so striking I want to change my practice and I'm not even in practice yet!

CAT ASCOT Atenolol and NOD

View more presentations from Clinton Pong.

I enjoyed preparing this. I will continue to post practice-altering CATs as they come up.

Ideals

2009-03-30T16:19:00.000-10:00

Let me tell you a little bit about my ideal job. Maybe that will tell you something about my ideals, my values, my goals, my hopes and dreams.

I would like to be a family medicine primary care physician for a small community. I would be in private practice, but I would have excellent connections with local supportive ancillary services like dieticians, diabetes educators, physical therapy, and sub-specialty care. I would have a broad and diverse patient population that challenges me on a daily basis. Babies, baby-boomers, the extreme health-nut that wants education on alternative medicine, the extremely sick obese/DM/HTN/CAD/COPD/CHF/hypothyroid patient on dialysis and home O2 that needs education on everything, the ethnic-mish-mash, the indulgently elite and the financially-challenged -- I'd like try to juggle it all and coordinate care with other doctors as appropriate.

I would reduce the co-pay for my patients that get started on an exercise program and lose weight, quit smoking, go to support groups, become educated on their disease processes and start taking charge of their health -- with me as their coach. I will brainstorm other incentives for patients to these ends.

I would encourage my patients to have their own health records -- available online through Google Health or similar services to allow for seamless care if they are admitted to the hospital. I would encourage my patients to interview their families to provide an in-depth Family History. I would provide up to date patient handouts. I would create monthly emails/newsletters and update my patients on the specific conditions they have and encourage them to come in and see me if there are any concerns or changes that can be made.

I would make sure that I have adequate time with both new and complicated patients. I would make sure that patients can call and make a same-week or even same-day appointments. I will use services like GrandCentral and Google Voice to screen phone calls and organize my life with a single phone, but multiple numbers for the office, family and friends. I would take care of patients on an urgent care basis too... so they don't have to go to the ER when they don't need to. Sure, this means that I would see less patients every day but if I do my job right, then I don't have to scramble to see them again and again for the potentially-preventable things I may have caught in the first place with an additional 5-10 minutes sitting one-on-one with a patient. If that means that I have less staff to keep overhead costs low, so be it. I would like to be self-sufficient as much as possible.

I would like to take care of a young couple. I would like to counsel them about preparing for pregnancy and then be there for the delivery of their first child. (Maybe even deliver the child?) I would then take care of the kid until he/she is old enough to have children as well, completing the cycle. THAT would make me feel a sense of satisfaction as a true Family Medicine practitioner.

I would like to get to know my patients so intimately that I can provide a narrative about them, like some of my preceptors are able to do seemingly without any effort. If my patients are admitted to the hospital or sent to a specialist, I can glance at their Problem List and their Patient Narrative (two sheets I would update at each and every visit) and provide a clean, concise history that is only 1-2 pages but addresses the relevant biopsychosocial issues.

I would like to be an expert on broad differential diagnoses; ones that encompass the long-tail diagnoses on a cost-efficient yet cognitively appropriate basis. I would strive to avoid becoming a diagnostic robot and instead, really think about each individual patient.

Most of all, I would like to be a part of the SOLUTION for our current health care problems. I would like to come up with new innovative ways to integrate today's technologies with traditional doctor-patient relationships that are built upon the fundamentals of trust, confidence, competence and mutual respect.

I've read a little bit about the "Ideal-Micro-Practice" and it outlines pretty much the sort of thing that I want to do.

Of course, this is a dream job. And I'm a dreamer for thinking that I can do anything close to this in today's economic climate. There's a lot of harsh realities involving paperwork, bureucratic red tape, the BUSINESS of medicine and making enough money to stay afloat. I am only a medical student. I have a few more years to figure that sort of thing out... and I'd like to find a residency program that can prepare me for my ideal job.

These are the things I strive for in my work and think about on a daily basis, even now, to prepare myself for the future. It is exhilarating.

Sweet! (More appropriately, no sweetness at all!)

2009-03-29T15:52:00.003-10:00

Apparently, I have a 0% chance of getting diabetes in the next ten years, according to the QDScore website.

Your 10-year QDScore score is: 0%

In other words, in a crowd of 100 people with the same risk factors as you, 0 are likely to develop Type 2 Diabetes in the next 10 years. This is represented by the smileys below.

The average 10-year risk for someone of your age, sex, and ethnicity is 0%.

Your score has been calculated using estimated data, as some information was left blank.

Your body mass index was calculated as 21.8 kg/m2.

I'll let you in on a little secret -- I've got some bizarre but benign medical conditions -- namely, multiple osteochondromas and hyperhidrosis. I would consider my health a success if I can avoid diabetes and cancer. Those two diseases terrify me.

Hattip to the Happy Hospitalist

Necessary, but not Sufficient

2009-03-28T22:46:00.004-10:00

As an undergrad, I struggled to understand what this phrase meant. In the context of a scientific experiment, it refers to a set of criteria of things that are required, but not enough to fulfill the desired outcome. This needs an appropriate analogy. And I've thought of the best one.

"Nice." As a characteristic, it is a great thing to say about someone. It's much better than "inconsiderate," "cocky" or "self-assured" (minus the self...ured) However, if this is the only thing that comes to mind... you don't think very highly of the person at all. They are lacking of substance!

I was thinking about relationships, residency and beyond and I found this thought most appropriate to both. I haven't received any evals that only say "nice," and I hope I never will. I do hope however, that I can clarify the phrase "necessary but not sufficient" to someone with the word "nice."

Bystander Affect/Effect

2009-03-20T18:58:00.002-10:00

This is another question sent in by a reader.

I was on my way back to the school, after a student's parents had asked me to lunch and something terrible happened. A woman was hit (hard) by a truck about 50 feet from where we were getting into the car. She had a child (about 2 years old) who she had been carrying who landed maybe 15 or so feet away from her. I was appalled, as I have never seen anything like that. A bystander went and picked up the child.

I seriously doubt there is much I could have done to helped, but of course it tortures me that she picked up the child. I feel like maybe if I had gone into the road to help I might have been able to stop her. I kept thinking of what I would have done ("help call 911" and realizing that wouldn't work at all, and I don't even know the number).

I thought... I remember stuff from first aid and the army. I could have checked for a head wound, with my hands first then checked for breathing, then... wait. I realized if I had done anything, and my hands come back with blood on them, that creates a whole new problem. I am not a medical professional, and I'm not even in my own country. I don't have gloves, or one of those safety masks for giving CPR. I've heard lots of horror stories about getting tested, and re-tested for HIV because of touching someone else's blood as a teacher.

How do you (as a soon to be professional, and yet not an EMT yourself) reconcile the two, the safety of the individual, and potentially comprising your own health by doing so.

I've got good friends here who made me immediately snap out of any bad feelings that I had after seeing that, but I am curious about what you think would be an appropriate response by someone like me (with a little relevant medical knowledge)... or what you would do if faced with a similar situation outside of the hospital.

There's a few levels I can address this. The legal one is the most clear, since it has been spelled out in the Good Samaritan law: bystanders are protected from liability in acting to help someone else when it is "in good faith and in accordance with their level of training."

The level of training is important for a health professional like myself... because if I were to rush over and pick up the child, I might be at risk for a lawsuit if the kid had a broken neck and I just paralyzed him or worse. We'll ignore the issues of compensation and volunteerism or I'll just get sidetracked.

So an accident just happened. It's something that's unexpected and you were in shock. That's totally natural! I dread the day when everyone looks to me when a crisis is happening and I don't know what to do. (I'm hoping that I'll be ready and able!) Your situation is complicated by a cultural and language barrier. I imagine knowing the phone number for an emergency "911" call should be the first number you learn when you go to a new country (or at least know where to look, i.e. travel book) to be prepared. Disclosure: I went to Spain and Japan and I even visited a bunch of hospitals in Japan and I don't recall how to call "911" offhand.

Regarding the blood exposure... it's not that bad to get tested for HIV, but turning HIV(+) after helping someone in an accident... that would be a major bummer. Universal precautions are nice, but not everyone has a set of gloves and a bag-mask in the trunk of their car. Don't worry about that. There are other measures you can do like towels and shirts that can limit exposure risks too. There's a lot of prophylactic drugs you can take as long as you request testing of the victim and yourself in a timely manner. If someone is bleeding and you are worried about getting blood on your hands... well, there'll just be more blood the longer you worry about it. There's a few things to do BEFORE rushing over and stopping the bleeding though.

The ABCDE of trauma should be a starting point for figuring out what to do. I've talked about it before in my trauma call post.

I think it's good that you are thinking about what you could have done in this situation. If it ever comes up again, maybe you'll be better prepared to take action.

Soy as an Estrogen Mimic

2009-03-19T18:55:00.001-10:00

Here's a question from a reader:

What do you think about soy as an estrogen mimic. I'm currently in China, and there is a very common drink here called DouJiang, and it's "soymilk" boiled soybeans blended into hot water, with sugar added. I love it, and it cleared up my face. Then I did some reading in an article on Web MD, for effects of estrogen mimics (they were talking about herbal supplements) and they advised for women with a history of different cancers (breast cancer was sited) to avoid estrogen mimics. Other article, perhaps because of other good qualities of soy, say that it can prevent cancer. I was just curious about what you think.

Cuprite, my completely uneducated/uninformed answer on this subject is that... I really don't know.

Deriving what I do know from first principles... our bodies make cholesterol. Then, from cholesterol, we create the hormones known as testosterone, estrogen, progesterone... (and some other ones of other clinical significance like aldosterone and cortisol.) We call it the Steroid Synthesis Pathway and it's a very big deal for board examinations. There's only a few "real world" examples in which to apply it... and unfortunately, I've received no formal training on the subject of soy estrogens. (We're trained as human pathologists, not soy botanists.)

Plants make cholesterols too and they have what are called "phytoestrogens." These plant hormones can mimic the properties of human hormones.

Estrogen can increase the risk of thrombosis (which is why it is contraindicated to take birth control and smoke at the same time) and long term exposure can increase the risk of female cancers -- first and foremost, breast cancer. Hm. Adding to the confusion is that some synthetic hormone look-alikes have been used to treat breast cancer: Tamoxifen being the most famous.

So it is not so simple and we cannot simply say: "ooh, it looks like human estrogen so it must do stuff that it totally natural and safe and healthy!"

I performed a Pubmed search using the term: "phytoestrogen" and imposed the search limits of "Human", "Core Clinical Journal" and "English" and I found the following recent review article: Implications of phytoestrogen intake for breast cancer. CA Cancer J Clin. 2007 Sep-Oct;57(5):260-77. Their conclusions are as follows:

1) Data regarding the role of phytoestrogens in breast cancer prevention is conflicting, but suggest early exposure in childhood or early adolescence may be protective.
2) In several placebo-controlled randomized trials among breast cancer survivors, soy has not been found to decrease menopausal symptoms.
3) There is very little human data on the role of phytoestrogens in preventing breast cancer recurrence, but the few studies conducted do not support a protective role.
4) There is in vivo animal data suggesting the phytoestrogen genistein may interfere with the inhibitive effects of tamoxifen on breast cancer cell growth.

In summary, plants and animals make hormones and their interaction is complex. Eat a healthy diet, but do not take dietary supplements with the expectation that it will do something beneficial. In the US, the FDA has their hands tied for the most part but all products labeled as supplements are supposed to be safe and their claims are truthful. However, the FDA is just a regulatory agency and it is the responsibility of the manufacturers to meet this agreement since "supplements" are not held to the same standard as pharmaceuticals. There are other things beyond eating soybeans that are more likely to cause cancer. Or prevent it, as the case may be.

Thanks for your question, Cuprite! :)

Talking about Small Talk

2009-03-18T18:21:00.003-10:00

Met a patient in psych today who has social phobia. She seemed pretty comfortable talking in my presence. I can only imagine how weird it may feel for a patient visiting their doctor for a psychiatric problem to have an extra person in the office scribbling away on a clipboard. (I do try to be subtle about it, though.)

She talked about how she was challenging herself to perform in public (there are various venues perfect for this, Toastmasters, Choir, etc.) So I was pleased to come across an article in Lifehacker: Use Clever Questions to Ease Into Small Talk

Farley recommends opening any socially-forced conversation with a "wry observation phrased as a question," rather than jamming out your hand for a shake or blurting your name. You could, in certain situations, wonder aloud whether you're at a popular tech conference or a massive iPhone field test. Or wonder aloud what everyone at the office is thinking, with just a hint of rebellious humor.

My take on Small Talk:
I've never been very good at it. When I was a young kid, I hated the big parties with my parents where everyone would stand around and chat about the same stuff that they talked about last year. Plus, everytime we'd run into someone new, they'd want to know the exact same things as the last person! I found it tiring, redundant and wholly uninteresting.

In retrospect, I was quite a precocious kiddo.

The tip that struck me was: "As you listen to the reply, prep your next move. Aim for 15-second bursts that segue into further questions."

There is an art to conversation... and I am not comfortable with the idea of thinking ten moves ahead like a game of chess. You run the risk of not even listening to the person and instead you start thinking to yourself!

My psych preceptor said it best: think of your questions like balloons. Your job at the end of the interview should be to gather up all of the balloons you started with and the ones that they brought up.

That is bound to make for a satisfied small-talker. You engage them, you respond to them and you give them a bunch of their hot air right back. ;)

Religious Belief Linked to Desire for Aggressive Treatment in Terminal Patients

2009-03-17T23:34:00.003-10:00

Religious Belief Linked to Desire for Aggressive Treatment in Terminal Patients

Terminally ill cancer patients who drew comfort from religion were far more likely to seek aggressive, life-prolonging care in the week before they died than were less religious patients and far more likely to want doctors to do everything possible to keep them alive, a study has found.

The patients who were devout were three times as likely as less religious ones to be put on a mechanical ventilator to maintain breathing during the last week of life, and they were less likely to do any advance care planning, like signing a do-not-resuscitate order, preparing a living will or creating a health care proxy, the analysis found.

The NYT article speculates further as to why this is: citing "to religious people, life is sacred and santified and there's a sense that it's their duty and obligation to stay alive as long as possible."

Really? I can think of a confounding factor in this study. Perhaps there's an independent factor that is influencing the choice for terminal patients to meticulously conduct advance care planning... perhaps there's another reason why some patients are more accepting of the limitations of their physicians.

Maybe they know better. They know that Docs aren't Gods. We all come to the end of our ropes at some time or another. Is a hospital bed really the place where you want to die if you had the choice? Hospice is a better option. Home hospice is even better, in my opinion.

I think that this attitude reflects a level of higher intellect and critical thinking (on average) among the less devout patients who use rational thought to guide their everyday lives rather than blind faith and misplaced hope.

I do realize that I'm a bit biased since I consider myself a part of this group. No offense, religious peeps.

Jon Stewart Calls Them Out

2009-03-08T10:05:00.003-10:00

The Daily Show With Jon StewartM - Th 11p / 10c

CNBC Gives Financial Advice

Daily Show Full Episodes
Important Things With Demetri Martin

Political Humor
Joke of the Day

The Huffington Post analyzes the Daily Show piece ranting about the role of CNBC in the current economic depression (yeah, that's right. I'm not going to dance around the word that we should be using.)

The piece wasn't just the laugh-out-loud funniest thing on TV all week (and this was a week in which NBC rebroadcast the SNL "more cowbell" sketch, so that's saying a lot) but it was exquisitely reported, insightful, and it tapped into America's real anger about the financial crisis in a way that mainstream journalism has found so elusive all these months, in a time when we all need to be tearing down myths. As one commenter on the Romenesko blog noted, "it's simply pathetic that one has to watch a comedy show to see things like this."
...
Why be a curmudgeon about kids today getting all their news from a comedy show, when it's not really that hard to join Stewart in his own idol-smashing game?

Here's how:
1) Great research trumps good access to the powerful.
2) The American public is mad as hell right now, so why isn't the mainstream media?
3) Tear down this wall... of pretending that the media itself isn't a major player in American society, and isn't a factor in most big stories.
4) The First Amendment doesn't say anything about not being funny, or not being passionate.

Those are some great points, but I've got something MAJOR to add. A lot of people do not have the time or the inclination to watch three or four 24-hour news channels to learn about the world and to be quite frank, even these major news giants like CNBC, Fox, and CNN have a hard time filling those slots with items that are WORTHWHILE.

The Daily Show and the Colbert Report fill this void by filtering out the most outrageous and nonsensical stories by their media kin for the purpose of amusement and more often than not, a dose of righteous political outrage as well. When these shows are on Comedy Central, they make no bones about it -- their purpose is not to inform, its to entertain -- but they still pull off BOTH in 30 minute blocks better than 24 hours of filler news a day.

That doesn't make the "fake news'" position totally defensible because they feed on the nonsense news. Of course, there's no point in ranting about how they exaggerate the insanity by sharing Fox News clips with a broader audience that wouldn't otherwise care to watch them in context on Fox... because a comedy show would be nothing without absurdity.

Geek Humor on Correlation

2009-03-05T19:51:00.003-10:00

Hehe.

It took me a few seconds. I think the punchline could have been clearer with a response like "Not necessarily!" but only @ xkcd can you enjoy humor like this.

:)

What If God Disappeared?

2009-03-04T00:49:00.002-10:00

This made me chuckle.

hat tip to Pharyngula

I used to read Pharyngula posts religiously (pun intended) but his plethora of atheistic(sp?) and politically charged posts overran his other more science/education related posts. Ranting about Dawkins and Creationism and Christianity made him very popular/renowned/reviled on ScienceBlogs though.

And in many ways, I do agree with a lot of the things that he says as a staunch defender of the Atheistic ways.

However, his contempt and dislike for religious people does rub me the wrong way. My personal feeling is that a lot of people happen to be religious and they happen to be good people as well. In many cases it provides as much guidance (as there is mischief and misguidance,) but that could be said for any other institution.

Atheism is not immune either despite its rational and empirical/experiential roots.

One of my dreams/nightmares is that the world as we know it may get wiped out someday and all that would be left is our books, our information, our knowledge. Rebuilding civilization on these documents would be interesting. Institutions would be created that would worship Rationalism in defiance of common sense things -- despite an ability to blast off into space and take a picture of earth for example, the newbies would assume that the Earth is round.

All of the things that they might be taught would still be founded on assumptions -- and who is to say that these people would not lose their sense of skepticism when so much of what they read turns out to be true anyway? They'd take things at face value. Unquestioning. Unyielding. Yet, still right for the most part.

I guess what I'm getting at (before I get lost in a tangent again) is that it is not about being Right or Wrong. I used to focus on this a lot, when I held some disdain for the truly religious -- especially classmates in science. How could they hold such different concepts in juxtaposition without considering themselves to be hypocrites? I'd wonder.

It's all about the perspectives that we hold and slowly becoming Aware that we only see things from a certain angle. Sometimes we are blessed with new points of view and these glimpses help us to understand others as long as we keep our eyes open. That's the point of religion, in my opinion. Through understanding comes love and acceptance for our fellow man.

"Too much time."

2009-03-01T11:11:00.003-10:00

I've been criticized multiple times by various preceptors that I spend "too much time" with my patients. "FOCUS! LIKE A LASER BEAM!" and "C'mon C'mon C'mon!" are the mantras one of my docs enters before all of my patient visits.

Admittedly, even some of my patients are exhausted by the end of the interview and I've had a few that needed to take a bathroom break before I started the physical examination. (In one case, it led to chuckles and jokes by the nursing staff who assumed that the patient left in a huff because I overextended their patience.)

I laugh along with them and I understand WHY it can be a bad thing to spend too much time with my patients. There's other people in the waiting room and the schedule gets backed up. I get it.

My take? I'm a friggin' MEDICAL STUDENT. I'm still learning! The best way I learn is by spending time with my patients, thinking through their problem in real time under real pressures, deciding what questions to ask, clarifying parts of the story I'm confused about, which pieces of medical advice to dole out, which path of management I would engage in if I were the doctor (so they can see where I'm coming from before the real doc comes in and says something completely different. ;)

One of my more critical preceptors gave me a lecture this past week: "Look... I'm not saying you shouldn't know all of those things you're sharing with me. But we are trusting other docs to do their job before they come and see me. That's the point of this. You need to get some perspective."

I feel that this is the crux of the issue. There's different philosophies in medicine. One of the "Laws of the House of God" is

10) IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.

In other words, if you intentionally don't ask the right questions, you won't need to follow up on them.

Some will gloss over parts of the history that are not pertinent to their particular field or interest at the time. Perhaps they have the data readily available on a computer. Perhaps they've seen the patient in the past and have addressed it already, or maybe they've made a referral to a specialist.

As the ignorant medical student seeing a patient for the first time with nothing more than a blank sheet of paper on a clipboard, I don't have those luxuries or assurances. I only have one tool -- the brute force of the consistently thorough history and physical. In many cases, it can take 30+ minutes. But I find all the fevers. And the headaches. And the chest pains. And the dizziness. And I need to talk about them with the patient to learn more.

The law that follows #10 is:

11) SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.

Even though I feel harried all of the time (and perhaps rightly so in most cases,) I'm glad that these docs have volunteered half a day out of their week to teach me -- because I don't really add much to their practice. I just make their work harder. I'm the one that takes "too much time."

By the fans, for the fans

2009-02-25T18:05:00.005-10:00

My favorite part is batman standing on the roof of a building, looking out at the (C) in the sky.

Hat tip to NPR
Vidders Talk Back to Their Pop-Culture Muses

On another note, I heard this story on NPR and I knew that I had to look it up when I got home. How did I find it? Well, I typed in "british vidding NPR" into Google. That's when I realized that Google Search is just like assembling a differential diagnosis -- coming across exactly the thing you're looking for (an answer) by a unique combination of findings. More on this later.

Top Ten: Study Methods and Habits

2009-02-22T12:45:00.002-10:00

Medical school is one of those interesting fields where obsessive-compulsive behavior is reinforced and rewarded to no end. While I am not an inherently organized and disciplined person, I decided that I needed to change for the better upon entering med school. Here are some of the strategies that I employ:

Buy a lot of different colored highlighters
I use each color for a specific purpose when I read. Colors are a fast way of categorizing items. It helps keep me awake if nothing else. The bonus: having nice colorful notes that are easy to review.

Yellow = important facts

Green = examples, lists, subheadings, lab values/Diagnosis, (+)/increasing

Orange = Key Topics/Vitally Important facts

Pink = In contrast to, (-)/decreasing

Blue = Treatment/medications

Purple = difficult to remember names/eponyms

Tag chapters in textbooks
Dog ear or put in little tags for chapters. When I tag more than the chapters, there's too many slips of paper and it takes a while to find what I want. I also try to use different colored tabs to represent different things: Red = CV, Pink = OB, Blue = Pulm, Purple = ID, Yellow = Renal
Develop concept-maps/case-maps for basic physiology/pathophysiology concepts with integrated management.
Algorithms are boring and thus, terrible ways to learn. A concept map that systematically thinks through a problem is much more engaging. I use C-maps for this purpose.
Use mnemonics. Use them often!
Mnemonics are highly individual and some do not work at all for anyone else but yourself. I've done my best to try and share ones that I thought others might appreciate or those that I've heard but were not readily available online. I made a bank of mnemonics in an excel spreadsheet with the comments as the expanded version -- when I float my cursor over the mnemonic it pops up with the reminder of what it means.
Learn how to think.
Problem-Based Learning helped me develop on the spot differential diagnosis development and consequential workup, diagnosis and management. I like it when experts tell me how they think through a problem... that's why one of the books I'm reading right now is Learning Clinical Reasoning (Excellent resource; unfortunately, it seems like its no longer in print.)
Stay up to date.
Read medical journals, news and blogs. Clinical Cases and Images answers the question: "How do you Eat an Elephant?" by setting up Google Reader. I read feeds on the latest articles in NEJM, JAMA, Annals of Internal Medicine, AFP and The Lancet. Also, I follow some great blogs -- I share the entries that I find of special importance (seen in the sidebar.)
Use a multi-monitor setup.
Buy an extra monitor! The more desktop real-estate you utilize, the more you can read and learn. Typically, I use one monitor for reading something and the other monitor for taking notes on the subject.
Centralize ALL of your notes. When I was studying for Step 1, all of my notes went into First Aid. Now that I'm studying for Step 2 and all of my different shelves, it'll take more than a book to hold my notes. Which takes me to my next point...
Use an online notetaking service.
Evernote is my all-time favorite application now. I can put text notes into it as well as pdf files... perfect for clipping key parts all of those articles I'm reading! It has the benefit of being available on any computer (so I can find my notes on diabetes anywhere I go.)
Use a question-bank to keep things in perspective.
I use USMLE World.
It is easy to lose track of what might be considered "important/high yield" for exams if you don't use a Q-bank on a regular basis. Mark all of the questions you get wrong (be honest!) and review those specific topics and questions again. Repetition is the key to rote memorization... and sometimes that's whats necessary to remember things like drug names. Ugh!
Above all else... Have fun!
Otherwise you'll just end up wasting time . :)

Cheers,

Wondering about Wanderers?

2009-02-17T13:17:00.001-10:00

Suppose your grandmother wanders out of the house in the middle of the night. What can you do for some peace of mind to keep them safe?

One option is a MedicAlert + Safe Return bracelet. Here's some information:

Enroll in program: 1.888.572.8566

Report a wandering incident: Call 911 first. Then call 1.800.625.3780.

MedicAlert + Safe Return enrollment package

For $49.95, with a $25 annual renewal fee, the enrollment kit includes:

* MedicAlert Identification bracelet or pendant
* Wallet card
* "6 Steps to a Safe Return" magnet
* Personal Health Record Summary
* Alzheimer's Association brochure

What are some important considerations for dementia?
Here's a few mnemonics that might be helpful:
Remember the reversible causes of DEMENTIA

Drug intoxication
EtOH
Metabolic (hypothyroidism, order TSH!)
Emotions (screen for depression!)
Nutrition (Vit B1/B12... order B12!)
Tumor/Trauma/"Tension"-Normal Pressure Hydrocephalus
Infection (neurosyphilis, consider RPR!)
Anemia/Atherosclerosis (order CBC!)

I'm very fond of important mnemonics that help me quickly recall things at the bedside, especially if they can be easily detected and treated before it progresses into something much more permanent.

GOMERS go to ground - The Fat Man, House of God. (Elderly people have a tendency to fall.)
There's a ton of mnemonics on falling. IHATEFALLING, CATASTROPHE*... those are too long but you can google them at your leisure.
GMA MOVES is more to my liking.

Gait impairment
Multiple Meds-Polypharmacy
Alcohol and drug use
Medical illness (PNA, MI, anemia, hyponatremia)
Orthostatic/postprandial hypotension
Visual Impairment
Environmental hazards (poor lighting, stairs, rugs, uneven floors)
Syncope, vertigo, presyncope, or disequilibrium

References:
See my post on the Mini Mental Status Exam (ORArL 321 RWD!)
Medical Mnemonics.com
Fall Prevention checklists: Patient Handouts

[edit] * The CATASTROPHE mnemonic is not available on the AAFP article so I've tracked it down for you.
Functional hx after a fall in the elderly
Caregiver/housing
Alcohol (including w/drawal)
Tx (meds & compliance)
Affect (depression, lack of initiative)
Syncope
Teetering (dizziness)
Recent illness/hospitalization
Ocular problems
Pain w/ mobility
Hearing
Environmental hazards

Patient Education

2009-02-14T23:34:00.002-10:00

What are some good sites for patient handouts?
Family Doctor.org
ACP's HEALTH TiPS
JAMA's Patient Page
ACOG (OB/GYN) Pamphlets
Pediatrics: AAP Pamphlets
Postgraduate Medicine: The Practical Peer-Reviewed Journal for Primary Care Physicians (AccessMedicine Login required)
American Heart Association: Diseases and Conditions
National Digestive Diseases Information Clearinghouse (NDDIC): Digestive Diseases

What about online resources for proactive patients?
The Google Approach: Patient Education
Health.gov
Healthfinder.gov: U.S. Dept of Health and Human Services
MedlinePlus: Interactive Tutorials
Health research: NIH
ACC: Cardiology education

This is part of an ongoing process to collect reliable health information on core medical topics for Family Medicine. This post will be updated with new information and comments on a regular basis.

It is my goal to easily provide a handout and education for all of my patients in a cooperative and collegial manner... basically, allowing my patients to take charge of their own health!

See my Patient Education Handouts widget* on the bottom of this page as well for more resources.

*Disclaimer: My Patient Education Widget is a series of clips from other sources. I have provided citations where appropriate.

Finding Common Ground

2009-02-13T00:23:00.001-10:00

When you run up against a patient who is difficult to talk to, how can you come to a meaningful compromise?

Interest-Based Negotiation and Conflict Resolution:
by Roger Fisher and William Ury’s Getting to Yes

1) Separate the people from the problem.
2) Focus on interests, not positions.
3) Generate a variety of possibilities before deciding what to do
4) Use objective criteria to judge the solution, rather than pit one personal opinion against another.

These tips make a lot of sense and I'm thrilled that my Family Medicine rotation had us read an article on this all-too-important subject. It is difficult to learn these sorts of things... a lot of it is intuitive and to be quite frank, I've had to work very hard because it does not come naturally to me.

As a medical student, I lack a lot of the clinical judgment that my preceptors and residents have. About the only good tool I have on hand comes from being systematic, being thorough and hoping that nothing slips through the cracks. I've found this strategy to be especially effective in dealing with long-winded, opinionated patients. Only students have the luxury of time to outlast patients by performing an exhaustive interview. I plan to use this tool for as long as possible, because in the end, my patients walk away happy knowing that someone listened to them -- even though I might not have offered them everything they wanted.

Psych: Biopsychosocial Formulation Pocketmod

2009-02-12T21:34:00.003-10:00

I wish I knew who I could credit for the majority of this information... I got it as a brainstorming handout that's very useful for developing a comprehensive assessment and plan for psychiatry patients.

I made a handwritten version for myself and then I got concerned that I might lose it eventually. What better place to immortalize the these gems than to share it freely with others?

Pocketmod PDF: Biopsychosocial Formulation

Wondering how to fold this document? See my previous post on the subject of PocketMods on the Wards.

Pondering on: Psych diagnosis

2009-02-10T20:16:00.000-10:00

I tweeted the following:

Psych disorders: diagnosis with cause or arbitrary definitions w/o reason?

Here's my follow-up on this question.

What is the reason for coming up with a diagnosis?

Initially, the attraction for coming up with a diagnosis is to determine the CAUSE of the disease. It's nice to have an explanation and for a long time, Freud's psychoanalysis gave us causes. Internal conflict of competing and often unconscious desires manifested themselves as various disorders. It was an attractive hypothesis.

However, psychiatry has come a long way since then. Namely, the discovery of a number of psychoactive drugs that are successful at treating conditions.

Suddenly, the underlying predisposing causes and precipitating factors that were the emphasis of a psychiatric visits took a back seat as a set standardized definitions emerged in the form of the Diagnostic and Statistical Manual of Mental Disorders: the DSM for short.

Initially, it started off as a way for psychiatrists to communicate clearly with each other and for researchers to make sure that treatment modalities were consistent. After all, if one psychiatrist called something "schizophrenia" while another thought it was a clear-cut case of "manic-depression," they would have different approaches. And indeed, British psychiatrists were wondering why the rates of U.S. schizophrenia and bipolar disorder were so different from their own.

However, it has now become an engrained part of oh-so-important BILLING. There are codes attached to all of these diagnoses and in order to ensure that they are properly billed, they must be documented to meet criteria. Before, psychiatrists had an intuitive sense from taking a history with the patient and observing them about what the diagnosis is. Now, it has almost become a requisite to slog through a long list of things to establish criteria.

Here's an example of the criteria for ADHD:

A. Either (1) or (2):
(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Inattention
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively
Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.

That's a long list to try and wade through!

Indeed, the "checkbox" medicine was the sort of approach that I had taken when I was doing in-patient psychiatry. Unfortunately, a list of criteria is much harder to memorize than some elegant "pathoneurology"/psychoanalysis, unless it's in the form of some handy-dandy mnemonics. For example, I'd routinely hit a few things from SIGECAPS and DIGFAST to rule out depression and bipolar disorders during the interview with some very scripted questions.

My psych preceptor has challenged me to think more about the genesis of the DSM criteria and indeed, many of these so called "criteria" are based on professional opinion with very little evidence or scientific basis. So I've become much more accustomed to a more natural interviewing process and I think that this will help my approach to psych diagnoses much more.

Gout

2009-02-09T16:39:00.000-10:00

Gout is one of the few arthritides that is reversible and curable with a few simple dietary/lifestyle changes and drugs.

Current Rheumatology Diagnosis and Treatment elegantly describes it like matches. With flare-ups, the "matches" in the joints light up and cause pain. They can be blown out by NSAIDs, made wet with colchicine and removed entirely with allopurinol. This metaphor is akin to the pathophysiology, with the "matches" representing uric acid crystals precipitating in joint space and lighting up when they get inflamed by the invasion of neutrophils.

On a more clinical note, here's some mnemonics to remember Gout:

A TIC ("thick") red, inflamed joint:
-Trauma, Infection, Crystals

ROPE in your ddx of arthritis:
RA, OA, Pseudogout/Psoriatic, Everything else (some crazy zebras: reactive/Reiter's, Still's, Hemochromatosis, Lupus, Lyme, Whipple's, Behcets, Ochronosis)

When tapping a joint, order 3C's for Synovial Fluid ("CCCnovial")
Cell Count, Culture, Crystals
Synovial glucose is not as sensitive as WBC count (>500-1000) for infection.

The aim for the management of chronic tophaceous gout is <6.0 mg/dL of serum uric acid.
Think: <6 to fix.

If the 24 hour urinary uric acid is >800, probenecid can be an alternative to allopurinol. Probenacid is a weak organic acid so it affects the renal levels of other organic acids (ASA, PCN, etc.)
Think: >800, ProbenAcid instead.

USMLE Step 1 score: a pissing contest

2009-02-08T00:06:00.000-10:00

What Score do I need for my Specialty?

...
There is one highlight pertaining to USMLE Step 1 scores worth mentioning, located on a chart in the document above (page 16 of the pdf, page 11 in print) There appears to be 2-3 tiers of scores with the most competitive specialties falling under the highest tier. A potential breakdown is:

Tier 1 (Median USMLE Step 1 Scores of 233-243):

* Plastic Surgery
* Dermatology
* Otolaryngology
* Diagnostic Radiology
* Radiation Oncology
* Orthopaedic Surgery
* Transitional Year

Tier 2 (Median USMLE Step 1 Scores of 217-222):

* Internal Medicine
* Pathology
* General Surgery
* Emergency Medicine
* IM/Peds
* Anesthesiology
* Neurology
* Pediatrics

Tier 3 (Medan USMLE Step 1 Scores of 208-213):

* Ob/GYN
* Family Medicine
* PM&R
* Psychiatry

I'm all for reporting what score you need to get to be considered for a specialty you're interested in. However, it really irks me that the most challenging specialties (of breadth) are in the bottom "tier."

It's the culture of medicine, working at its best.

Here's the way it works for those of you who haven't been inducted into the secret society of white-coat-dom:
Everyone pisses and whoever can piss the farthest wins.
The guy who pisses for the longest wins also.
Wins what? The easiest and cushiest lifestyle, of course.
Why? Because that's the reason we all applied for medical school, right? Who wants to work long hours for no reward when you can do elective procedures and break the bank?
Why not let everyone win if they aren't pissing red blood or albumin? That's my win-win definition of a pissing contest -- yay, you can pee healthy!

For some reason I keep talking about piss, but I assure you, I'm not pissed.

Even people who don't subscribe to the "lifestyle" theory of natural residency selection agree with its prestige: it is much more difficult to land a derm or radiology residency spot than it is internal medicine or pediatrics. (The unspoken therefore: the people who go into derm or radiology are smarter/better! Too bad supply and demand economics doesn't drive students into the professions we need the most.)

Now, I'm not bashing people who truly love Plastics or Rad Onc. On the contrary, I DO have a great amount of respect for them for having the ambition that I clearly lack to aim for one of those spots. Me, I'm envisioning myself being content to have a small group of patients that I will help give birth to, raise and grow old with (and blog on the side.)

I still want to do my best and that means:
I will counsel the HELL out of people who are determined to lose weight and start exercising!!
I will be an awesome educator for all sorts of common ambulatory complaints!!
I will strive to catch all of the rare zebras in their horse clothing and send them off to the right specialists so I won't be one of the dull-wits in primarycareville.
I will spend that extra time to see the last-minute walk-in or the guy without insurance.

Why? I decided to become a doctor because I want to do the right thing. That's righteous (hopefully without seeming too self-righteous.)

THAT is a first tier goal in my mind. (GOAL being the key word. I doubt I'll live up to any expectations, but I hope to never lose sight of them.) These goals are much more forward looking than a step board score determining what I will do for the rest of my life.