5 Things No One Taught Me in Residency

Below is a Repost of a previous article, that is appropriate to this time of year.

Since medical school, I’ve gone through an additional 6 years of training, read countless volumes of medical literature, and had the fortune of having some great teachers. Through it all, experience has been the greatest teacher, which I suppose is what training is about. I’ve watched with interest as advice has been hashed out on the web around this time of year to new trainees on all matter of subjects. And much of it is good and useful, to be sure.
Being the helpful person that I am, I naturally want to do my part. What, I thought, could I contribute to this discussion that hasn’t been said already?
To that end I’ve come up with my own list of of trivial and only slightly helpful tidbits of information, based on my own experiences over the last 11 years post graduation. Here I give you my top 5 list of things that no one ever told me in medical training. . .but should have. Enjoy.

1. Before conducting a family meeting, go the restroom. Scan your face for things that might appear distracting or unseemly,  like nasal boogies or lettuce stuck in your teeth, and quickly remove them. If you are one of the few convertible drivers with hair, pay special attention to this area; the “mad scientist” look is generally not one which inspires confidence in these situations.

2. Using hospital Jello-O and graham crackers as the base of your food pyramid makes for a reasonably strong pyramid.  At least as  strong as any other pyramid that has a soft mushy substance at its base.

3. Sometimes an appropriately discharged patient will refuse to leave the hospital. Follow your hospital’s policy in these situations. If it is your hospital’s policy to call security, then do so. However it would be wise to have your patient fill out the house officer rating/feedback form before doing so.

4. If your attending physician gives you an answer that seems wishy-washy, it’s because they don’t know the answer. They still know a heck of a lot more than you, though.

5. When entering a room to declare death on a patient, whose family is in the room, make sure your pager is on vibrate. Particularly remember to silence any cutesy ring tones (such as Cee Lo Green or the Benny Hill theme) that might bring unwanted awkwardness to an otherwise somber moment.

Thank you and Good Luck!

Related Posts: Be Nice to Nurses. . . Of Else!;   Where Medical Report Go to DieTop 5 OTC Meds that would require a prescription if released today;

A Simple Test Can Determine Prognosis in Idiopathic Pulmonary Fibrosis

Sometimes it’s the simplest things that can make all the difference. Unfortunately, when it comes to informing patients with a new diagnosis of pulmonary fibrosis what to expect, things are anything but simple.  For years, pulmonologist, myself included, have dreaded the moment when we inform patients of a diagnosis of pulmonary fibrosis. The discussion invariably involves informing them  that this disease (which they have probably never heard of) may either kill them or have minimal effect on their lives, or have a moderate effect. Alternatively, it may have very little effect at first, but then suddenly become much worse. How can we tell which of these courses the person can expect? Well, we’re not really sure, we’ll just have to wait and see what happens.

To this day, I remain amazed at the stoicism and strength  that the  person who is sitting across from me accepts this information.  For these people there exists neither a good prognostic tool nor an effective treatment. One would think that for such a stark disease there would be 10K runs, gala fundraising dinners, and a powerful Washington lobby.

But there isn’t.

There is no nationwide clamor for research dollars. No push “for the cure” or even for any effective treatment. No distinctive ribbon clad awareness week (ok there is, but I bet you’ve never heard of it).

So it is with a great sense of excitement that we greet any new research which hints at the possibility that we can more accurately  tell our patients with this disease what they might expect in terms of prognosis. Such was the case as I read through a recent issue of Chest.

Researchers at Inova Fairfax Hospital in Falls Church, Virginia looked at the possibility of using the red cell distribution width (RDW) as a prognostic measure in patients with pulmonary fibrosis. The RDW is a blood test which measures variability in sizes of circulating red cells. The test is inexpensive, and usually drawn (and often ignored) as part of a complete blood count. Physicians who order a CBC usually pay attention to the hemoglobin, white blood cell and platelet counts, and hardly ever give the RDW a second glance.

But perhaps we should.

As variability in the size of red blood cells as measured by the RDW can tell us about pathological inflammation. The RDW has already found some use in helping with prognosis in people with Pulmonary Hypertension and Congestive Heart Failure, so why not Pulmonary Fibrosis?

In this study, they found that people who had a RDW of less than 15 had a median survival of 43 months, whereas those who had a RDW of greater than 15 had a median survival  of only 16 months. Survival appeared to be worse in those with even higher levels of RDW, and also appeared better in those with much lower levels. They also found that survival worsened in those individuals in whom the RDW increased by more than 0.01 per month on average.

Truly the idea of using a simple method to help determine the prognosis of patients with pulmonary fibrosis is exciting. Now if only we could find an equally simple method of improving that prognosis.

Flash Mob Medical Research

It was my second day of residency, and something was afoot. As I made my way around my first rotation on the cardiac floor, my medical senses were tingling. There was something strange happening to all of my patients, I saw. As I peaked over my cohort’s shoulders, I secretly saw that it was happening to their patients too, though they hadn’t seemed to  notice. Only I did, and I was going to report it to my senior. Together we were going to report it to the New England Journal of Medicine, and I was going to win the Nobel Prize of Awesome Doctor. Yes, I alone noticed that all of the patients on the floor were somehow inexplicably breathing at the exact same respiratory rate. Not only this, but they were breathing fast, at a rate of 20, clearly something must be causing all of them to do this. Surely this could not have been due to documentation error, since all the of the other vital signs seemed to vary, it was only the respiratory rates which seemed to stay the same among all the patients.

 That day was more than 10 years distant, I still don’t have my nobel prize, and New England Journal isn’t returning my calls. The answer to the question that I posed back then about a phenomenon I now see daily is only too easy to find. It sits in every hospital ward, at the end of the hallway. There a  bank of mobile machines that is wheeled around the ward to check vital signs sits recharging in wall outlets. As nurses and assistants scramble to administer medications, change bedsheets, turn patients, answer call lights, help patients around the halls, answer the phones, answer family questions, speak with clinicians, and pass food trays, they wheel these devices to their patients’ bedside. They quickly first attach a blood pressure cuff and press the cycle button. As the cuff inflates, they attach a finger sat monitor from the same machine  which takes a few seconds to get a reading. As this is taking a reading, they ask the patient to open their mouth and insert a temperature probe to get a temperature. Around this time, the BP cuff says “error”, so they cycle it once more. While this cycles, they now have a reading for temperature, and the finger monitor gives them readings for oxygen saturation and heart rate.

They have a few paper towels left over from feeding the patient in the next bed, so they start jotting down numbers in it, and just as they finish this, they get a reading from the BP cuff, which they write down as well. They would like to put this in the computer right away, but in the hallway call light buzzers are sounding, somebody wants to get up. Another person wants their pain medications, the radiology suite wants the patient in the next bed sent for their ultrasound immediately.  But wait aren’t they supposed to be fasting for that test? And there’s 4 more patients who need to have their vital signs checked.

So several moments later, as the nurse finally sits down to enter all the vital signs into the chart, values will be entered for heart rate, blood pressure, temperature, oxygen saturation. But since no respiratory rate was checked, the default number of 18 or 20 is often entered. Why is the respiratory rate not checked?

Because the Mr. Vital Signs machine does not check respiratory rate. Continue reading “Flash Mob Medical Research”

Motorcycle Accident Medical Claims Increase After Michigan Rescinds Helmet Law.

I wrote last year about the Michigan Legislature’s bold move to help improve the chances of people waiting to receive an organ transplant (see article here). As I discussed in that article, motorcycle riders are among the best organ donors, because they tend to be young and otherwise healthy.  A recent insurance industry study found that after only one year, the push to increase organ donation may be paying off.

A recent study reported by the Detroit News shows that the average motorcycle claim since the motorcycle helmet law was rescinded increased from $5,410 to $7,257. After adjusting for confounders and data from surrounding states, the increase was 22 percent. An increase in claims of course does not translate to an increase in the number of donor organs. Perhaps we need another law asking that motorcycle riders also indicate their organ donor status. . .

Should EMR’s Be Able To Talk to Each Other?

I’ve written several times before about my love/hate status with my EMR. While I enjoy using mine, I long for it’s usefulness to get to the next level. While the EMR is useful at tracking data, it’s greatest handicap right now, is that it can’t talk to other systems. Data is still locked in individual systems and can’t be shared across platforms. This lack of inter-operability has thus far been the EMR’s greatest handicap, and I have longed for the time when EMRs are able to share data.

But as I see more and more systems being employed in my area and talk with other physicians about their experiences, I am becoming increasingly concerned that  the inexorable march forward is going too quickly.

Shouldn’t we get these systems right before introducing interoperability into the equation?

The administration and the public are now clamoring that the information in these systems should be able to be shared among providers. In effect, that the information should not be “held hostage” by each providers respective system. These are fair and reasonable requests that should be expected in the long run. To that end, some EHR vendors have agreed in principle to begin writing standards that would allow inter-operability between systems.

The unfortunate problem here, and one that the public does not understand, is that these systems are not like the  computer operating systems that they accustomed to using. It’s easy to forget that Microsoft, Word, Windows, Powerpoint, and Macs are more than 20 years old.  They’ve gone through several generations and hundreds of billions of dollars in development by the worlds most talented programmers. All to now finally be at a point where the program does not routinely stop working for some unknown reason. Continue reading “Should EMR’s Be Able To Talk to Each Other?”

The Relationship Between Cystic Fibrosis Exacerbations and Environmental Pollution.

If you don’t know this about me by now, I need to confess something, I’m a bit of a geek. I love  Star Trek (all of em), and I regularly check the NASA website  to see how the Voyager pairs are doing. And yes, of course  I follow the Mars rover’s twitter feed, who wouldn’t?.  So as I was perusing my issue of Chest recently, there was a study that really got my attention. It wasn’t only because of the incredibly important  issue of Cystic Fibrosis and identifying what causes exacerbations. It was the novel way that the authors identified air pollution as a factor that contributed to CF exacerbations.

Air pollution has long been thought to play a role in leading to lung disease. Air pollution is also thought to contribute to exacerbations in people with known lung disease such as asthma, COPD, and Cystic Fibrosis. However, these correlations have been difficult to show,  and have primarily depended upon looking at admission rates for people with exacerbations  of lung disease during periods where there is a known environmental anomaly or excess pollution. Unfortunately such conditions are not very predictable.

A study published in this month’s issue of  Chest showed an intriguing relationship between  air pollution and exacerbations of cystic fibrosis. What was intriguing to me about this study was not only that the authors showed a relationship between CF exacerbations and environmental pollution, but also how they set about demonstrating an association between the two.

They first went back and identified  2204 individual CF exacerbations that occurred at their institution in Belgium. Using the patients’ home addresses, they  calculated concentrations of  particulate matter, ozone, and nitrogen dioxide the patients would have been exposed to around the time of their exacerbations. Continue reading “The Relationship Between Cystic Fibrosis Exacerbations and Environmental Pollution.”

Daily Docblock: EHR Style.

Its been a long road to readjusting to my EHR, and for the most part its been worth it. (see previous EHR articles). I’ve fine tuned my typing skills, I’ve become a black belt of check boxes, a jedi of templates, I whip through e-prescriptions and referral letters like Liam Neeson through eastern European bad guys. Yes, I am Neo, the promised one, of the EHR world. But a recent EHR update had me making yet another change to they way I see patients that I’m sad to say, has tripped me up. This relatively minor problem is that, with this recent update, my EHR takes too long to open after I log in.

Huge amounts have been written all over the web about the EHR and  how difficult it is to adapt to. To those EHR haters my response has always been this; The EHR is our new reality, if you just get used to the idea that you need to adapt to the computer and not the other way around, and just get on with the process of adapting your typical routine to this new reality, your life will be much better.
But this newest update has me questioning that philosophy. Yes I have adapted my workflow to the EHR, and made all of the changes I mentioned above. Now I have to make another change after a recent update that made only modest changes to the EHR’s functionality. The update has caused a 15 to 20 sec gap from when I log in to the time that I begin to enter information. I’ve tried to fill this time to prevent an inevitable awkward silence, but 20 seconds is a long time to make small talk. Plus I can only ask “how’s the weather outside” so many times per day.
On the other hand if I delve right into history taking, I’m then 20 seconds behind when I do start typing.
So thus far, my interim solution thus far has been to log in first and then go make physical contact with the patient before entering anything in the EHR. This usually involves  a handshake and maybe a few preliminary questions. In some cases, if I’m already familiar with the patient, I may begin my physical exam right away, before I even start entering data. In any case, if you’re one of my patients and you are reading this, I apologize that I am listening to your lungs before I finish getting your complete history, now you know the reason why. I’ll probably keep going with this interim solution until I find a better one, I’m more than open to ideas if anyone out there has any. Meanwhile I’m hoping all future programming updates don’t force me to change my workflow.
Incidentally, a similar problem has occurred at the hospital’s computer system. When logging onto the hospital’s system for the first time of the day, there is about a 30 to 45 sec wait before the program will open.  I now log in, hang up my coat, maybe get some coffee from the machine or check my mailbox, and then come back to the computer.
Either way, suffice it to say, this is getting kind of ridiculous. I am dearly hoping that all future updates will not similarly dictate a change in how I go about seeing patients. . . are you listening Allscripts?

Why Physicians Should Learn to Pronounce Patient Names Properly

I have it on good authority that it’s not easy being green. But I’m willing to wager that it’s a whole lot easier when you have a lovable name like “Kermit”. Imagine being green (or brown) with a name like “Ramachandran”? Growing up with a name like mine certainly had its disadvantages. While most neighborhoods have a local bully who kicks ass and takes names, in my case, he would typically kick ass, but didn’t bother with the name part because he couldn’t pronounce it. Somehow I found that last part more insulting.

 I’ve long since outgrown the sensitivities about my name (although I still make any telemarketer pronounce it properly before talking with them). For most patients and those with whom I only occasionally associate, I go by “Dr. Ram”, which works fine by me. But perhaps those early experiences left me with an impression about how people can be affected in positive ways by getting the pronunciation of their name right, or at least trying to get it right. As well as the negative ways in which people can be affected by getting the pronunciation wrong, or by not even bothering to try.

So I would like to direct a message to those care providers out there with easy to pronounce names, because this  is something that you probably don’t  know. Getting the pronunciation of somebody’s name correctly (or at least trying to) is important. These people often wave you through that initial awkward part of an encounter, simply because they’ve given up hope that people are going to get it right. They tell you it does not matter only because they have already spent too much time in trying to get the name pronounced properly, only to have it reduced to a few letters. They wave away the mispronunciations because they’ve learned to accept that no one is going to invest the few seconds that it will take to pronounce it correctly. But they do care, and make no mistake, it is very important to them. Not taking the time to learn the pronunciation of someone’s name sends a powerful message. It says “We don’t know you, you’re a stranger here” And doing it repeatedly says “I still don’t know you, and I’m too busy to bother to try”. The subconscious message that the patient takes from these encounters is “these people don’t know who I am”. Conversely, taking the time to try to learn the proper pronunciation of a name  says “I’m listening to you” and “I want to know who you are”. Continue reading “Why Physicians Should Learn to Pronounce Patient Names Properly”

My EHR Tells Me I’m a Bad Doctor.

I’ve written before about our EHR and all the the things that I really like about it. Add to that list the fact that we can now get incentive payments from Medicare (or Medicaid) for buying and using an EHR (we were early adopters of the technology before the current incentives came out). But in order to qualify as an electronic health record in the government’s eyes, the federal government determined that everyone’s systems must meet certain minimum functionality requirements, what they call “meaningful use”. This is where things are getting tricky. . . because my beloved EHR is telling me that my medical records are are not meaningfully useful, and in fact are meaninglessly useful, or meaningfully useless, one or the other, or perhaps both.
As if that was not enough of a slap in the face after all the love and adoration I’ve showered upon the system, there’s this bitter morsel. I’m being told that the manner in which I’ve been deficient is in the department of documentation of smoking. Can you believe that? Smoking! Me! The super-anti-smoking guy! The one who wrote this article. And then the other one. Plus, remember that other one? Seriously?
Could I truly be deficient in my smoking documentation? Refusing to believe such blasphemy, I delved into the medical records. No, see, there it is? Right there.  Under HPI, “patient has no history of smoke exposure”. And there again, in the next chart, more extensive smoking data meticulously typed into the history. I knew that I was documenting this stuff. What could the problem possibly be? Continue reading “My EHR Tells Me I’m a Bad Doctor.”

Should a Medical College Dean Take Money from Pharma?

One of the first posts I wrote here, was a about how pharmaceutical reps provide lunch for physicians while presenting information about a medication that they are promoting.  The post, and others like it, have generated visceral reactions on the part of the public. A similar article to the one that I wrote (also on kevinmd) prompted comments like “Get over yourself and buy your own lunch” and “I’m certainly glad that you are not my doctor”.

The opinions were so strong I was invited to speak on CNN about the topic. In particular, I was asked to speak about all the other extravagant things that physicians get from drug companies. I ultimately did not do the interview on account of me not having any experience with receiving any of the extravagant things they were talking about. It seemed to me that individual physicians receiving lunch was (excuse the pun) small potatoes compared to what happens behind closed doors in the halls of power. While upcoming rules will soon provide the public with a window into the value of goods provided to physicians by drug companies, they will provide little insight about where pharma has its greatest and most effective influence: behind the closed doors of those halls with thought leaders, opinion makers and legislators.

To that point, a story came to my attention recently that reminded me about that fact. The Dean of Weill Cornell Medical College, a prestigious and highly regarded medical school, has apparently kept close financial ties with industry, as reported in the the college’s newspaper.  The college’s Dean, a highly accomplished and awarded physician researcher, has retained positions with a major pharmaceutical company and a laboratory equipment company. In these roles last year she reportedly received about $260,000 from one of the companies and about $277,000 from the other last year. The Cornell Daily Sun also reports that she has apparently received millions of dollars in compensation from both companies over the years as well as more than a million dollars worth of shares and stock options in the companies. Continue reading “Should a Medical College Dean Take Money from Pharma?”