Family Medicine?

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

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

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

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

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

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

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

Lastly, the vision asserted that family medicine physicians were to provide care for the patient within the context of the patient’s family and social milieu.

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

----------------
The Residency Directors ask this question:

Do we need to expand the definition of the family physician to include alternate types of practice? And, lastly are our values antiquated, are our visions of ourselves valid, or should we change?

I answer with an emphatic No.
I will strive to have a committed relationship with each and every one of my patients. One of the most frustrating thing about being a medical student is the time and effort required to get to know a patient in a 30-45 minute time span only to see them vanish into the Healthcare system never to be seen again. So I look forward to a time when a patient is scheduled for a follow-up appointment in 6 months and I actually get the chance to follow-through.

Adventures in Brain Tumors (Prolactinoma!)

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

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

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

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

"Time Lost is Brain Lost"

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

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

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

After about three minutes, I got up and I said "oh, I'm okay now." I took a shower (there was still some numbness in the arm) and went to work. I figured something was probably going wrong so I called the doctor and he told me to go to the ER.

Lucky thing too... it sounds like you had a mini-stroke or what we call a"transient ischemic attack," (TIA) -- a temporary event. The residual numbness suggests more long term damage though. Since you're right-handed, you are most likely left-brained -- and your language is controlled by that side of your brain too. When you had the brain ATTACK (as threatening as a heart attack!), you wiped out your left brain, paralyzing your right body and knocking out your ability to talk.

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

I went over the ABCD2 scale with him and calculated a moderate risk for stroke:

2-Day Stroke Risk: 4.1%.
7-Day Stroke Risk: 5.9%.
90-Day Stroke Risk: 9.8%.

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

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

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

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

Hoarseness

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



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



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

The Mito Mystery

Brownout: The Mitochondria Detective work Gets a Little Easier

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

I love little pictorial metaphors that just make sense.

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

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

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

"The Neuro Exam is not dead"

Bedside Eye Exam Outperforms MRI in Identifying Stroke

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

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

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

These signs showed a Sensitivity of 100% (n=69) and a specificity of 96%(n=25) which is remarkable... while it makes sense to "wait and see" if future tests show that these results are reproducible, it really does not hurt to spend a few extra minutes in a neuro exam to check for these things:

"I No (know) Strokes!" Impulse/Nystagmus/Skew.

ddx

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

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

one of them is the quote:

if you hear hoofbeats, think horses, not zebras.

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

But db reminds me that premature closure is also a problem.
So I would revise the old saying thusly:

If you hear hoofbeats, think horses, not zebras. unless you're in a savannah and you see stripes.

Differential Diagnosis Generation

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diamond in the rough: HI 5!

"Health Initiative 5!"

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

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

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

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

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

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

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

I'll Hi 5 to that!

something that I want to be a part of

diamond in the rough: insurance vs assurance

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

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

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

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

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

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

so what is the solution?

we need a lot of different fixes.

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

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

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

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

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

Eye am so confused!

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

Eye Am Confused

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Psychosocial Medicine

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

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

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

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

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

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



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

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

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

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

Cholesterol trends down

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)

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.

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

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

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)

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

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

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.