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. Continue reading “Top 5 Trivial Things No One Taught Me in Training.”
Should we Deny Insulin to Chocoholics?
I’ve always had a tough relationship with cigarettes and the people who love them. As a lung doctor I hate cigarettes, and I hate that patients I see everyday continue to use them. But I also understand that vilifying smokers seems to be in vogue right now. I figure that if someone does something that is not considered socially palatable, and that does them harm, even as they strive to take treatment for it. . . well it must be a pretty powerful addiction.
Recently I was hanging out with a few physician friends, when the topic of conversation came to treating patients who are smokers. Some contemplated whether patients who smoke should even be prescribed inhalers for breathing disorders. Furthermore, we wondered about whether such patients should be followed up for breathing problems unless and until they quit smoking. Continue reading “Should we Deny Insulin to Chocoholics?”
Marriage and Motorcycles.
Being married to a transplant physician tends to give one a different perspective on life, and in particular, risk taking. For example I’m embarrassed to admit I rarely climb ladders anymore unless it is absolutely unavoidable. Between you and me, the last time I had to change a lightbulb in the garage, instead of using a ladder, I stood on the roof of my wife’s S.U.V. (note to self, need to make up story explaining dent on roof of S.U.V.).
But I must admit, I do have a terrible weakness for speed. And while said weakness has been limited to things with four wheels, I’ve always toyed with the notion of someday getting a motorcycle. I never took up motorcycle riding in my younger years, but now as I see older and older people leisurely riding their hogs, and parking their chrome babies in handicapped designated spots, I wonder; could it really be that risky?
The other day, as we were taking a drive on a minimally trafficked two lane road, a couple of kids went flying by us on sportbikes at near triple digit speeds.
My immediate response; “AWESOME! I WANT ONE!”
My wife’s response; “Young . . . healthy. . . perfect candidates for organ harvesting!”
My desire to ride motorcycles has since waned. Continue reading “Marriage and Motorcycles.”
Top 5 Things You Don’t Know About Your Doctor.
1. Your doctors never actually stood up, raised their right hand and took the Hippocratic Oath. If they did, they don’t remember it. The closest thing they’ve taken to a Hippocratic Oath is that time they swore they’re never again staying at that terrible hotel in Athens with lousy views of the Acropolis.
2. Your doctor’s degree of willingness to do something is inversely proportional to how happy they say they are to do it. As in “I’m happy to do that for you” = “I’m very unhappy to do that for you”. And “I’m more than happy to do that for you” = “I’m extremely unhappy to do that for you”
3. Your doctor doesn’t really know whether the respiratory illness you have is viral or bacterial. Chances are that it’s viral and you don’t need an antibiotic. But if you pester enough, you’ll probably get the antibiotic.
4. When you ask for copies of reports to be sent to your other doctors, you should not take their acknowledgment of your request as confirmation that the task will be performed. We may simply be acknowledging that yes, that would be a good idea in theory, or yes we would approve of that kind of bold initiative taking. However, the back and forth motions of our heads may also just be due to migraines brought on by filling out pre-authorizations for nasal sprays.
5. Your doctor lives in deathly, livid, morbid fear that you are going to sue them, put them in prison, infest their home with termites, send their kids to sanitize sweatshop latrines in China, and send them videos of you partying with their significant other on a yacht in the Mediterranean. That is why you are having your 4th stress test in 2 weeks.
Where Medical Reports Go to Die.
It happens thousands of times a day, all across the country. People go to their doctor’s office after some testing has been performed. The physician, unaware that any testing has been ordered by another physician, asks their usual questions. The patient, awaiting an opinion rendered on the recently performed test begins to answer the doctor’s questions with increasing impatience and trepidation, fearing the worst. “Why is he asking so many questions. . . why is he not telling me the results? Did my cholesterol panel show cancer?” And finally the question comes to the fore;
“ Doctor did you get my test results?”
“No, what test did you have”
“But I told them to send it to you!!” Continue reading “Where Medical Reports Go to Die.”
The Squandering of Tobacco Settlement Billions
TO KEEP SMOKING!
Please enjoy this recycled oldie-but-goodie while I spend the next few weeks juggling a high case load with studying for the boards with taking care of two babies, etc. . .
Few things smell worse to me than the stank of a cigarette while trying to trying to load up on cholesterol via awesome blossom. Perhaps one such thing is the beguiling tale of what perverse fate has befallen the gobs of cash money rewarded to state governments from Big Tobacco.
This seemingly righteous pursuit was fought by brave attorneys general of 46 various states to regain money we dished out to pay the costs of Medicaid patients who, due to tobacco use, found themselves in various states of wheeziness and/or infarction. So naturally you’re asking “why then did these same states more recently try to help Big T in getting a recent settlement against it reduced?” Good question. Read on. . .
Continue reading “The Squandering of Tobacco Settlement Billions”
Snow Birds and The Unfulfilled Promise of Electronic Health Records.
Please enjoy this recycled oldie-but-goodie while I spend the next 6 weeks juggling a high case load with studying for the boards with taking care of two babies, etc. . .
The migration has begun. All over Michigan, the annual migration of flocks moving south is in full swing. And behind those flocks, the other annual Michigan migration is starting too. Our office is starting to see our winter ‘checkout’ patients before they migrate south for the winter.
Over the next month, I’ll see a multitude of patients come in to get ‘checked out’ and get paper prescriptions to take with them to Florida in case they find themselves under threat of missing a golf outing due to varying states of cougheyness and/or wheeziness. Many of them have physicians in Florida that they sometimes see, and occasionally they get hospitalized while down there. They usually come back with an impeccable tan, an extra spring in their step, and a story of their various physician visits and /or hospitalizations with more holes in it than your average disability application. They also explain that any tests that I’m about to order have probably already been done by their physicians in Florida, and they’d like me to take a look at those records before I order anything. We then start the dance of trying to get copies of their charts, which goes something like this:
Records Requested: Records Received:
Request for chart. Nothing
Second request. Nurses notes
Third request.. Copy of diet recommendations.
This whole dance has started to make me wonder about my ardent support for the electronification of medical records, which is supposed to do for medical care what the invention of sliced bread did for a fledgling sliced deli meat industry. By now we’re all aware that the Institute of Medicine (which by the way, to me sounds like a made up name) tells us that a gazillion patients are unnecessarily being decapitated every day because physicians’ illegible orders for ‘allow decaf for patient’ are being misinterpreted by hapless nurses as ‘and now decapitation’. Electronic medical records, says the Institute, would successfully ameliorate the silent killer that is physician penmanship.
But how does this impact the care of patients who had treatment from another physician or medical system, whether it was across the country or across the street? Nada. If I want to see those high tech electronic records, it still requires that I talk to a person, those records must then be printed, then faxed. Because of this, many of these tests end up being duplicated, and because of the awesomeness/stupidness of medicare, it has continued to pay for the duplication of these tests even if it has only been days since the original tests were done.
It seems to me then, that adding electronic medical records to the current system is kinda like adding a microchip to an abacus. . . in the end all you get might be nothing more than a fantastically expensive Goldberg machine. To me the only way that electronification of medical records will ever be the revolution that it’s backers claim it will be, is when there is a high degree of compatibility between systems. This would allow patients’ data to be shared among multiple different records systems. It would provide patients greater mobility between medical systems, rather than being tied to whatever system their PCP happens to be in. That greater mobility in turn might place greater pricing pressure on different medical systems as they are forced to compete to a greater degree. So how exactly do we implement this? I don’t know. But I promise I’ll start thinking about it once I’m done faxing all these diet recommendations to Florida.
Money’s “Best Places to Live” is Not the List I Want to See
Money Magazine came out with yet another list of the best places to live. The article describes wondrous places full of affordable housing and low unemployment. What may not be readily apparent is that the cheap houses and easy jobs exist mostly because nobody wants to live in these dark, snowy regions of our nations belly button, housed next to mostly people forced to relocate by various witness protection programs.
If there’s a truth revealed by these lists and their popularity, it’s this; even in today’s hyper-connected society, we really have very little idea of how where we live stacks up with other parts of the country that are not California wine country, or hurricane ravaged areas of N.O. If I thought about relocating from my local municipality to another one in another part of the country, i really would have no clue as to how they compare.
Seeing lists like this is mostly pointless, for most of us anyway, as we relocate based on where the jobs are, and not to end up in a city that ended up on some magazine’s list. So ultimately what I want to know, what all of us really need to know, isn’t a list of places that we need to move to, it’s a list of places that are to be moved away from, to be shunned, avoided like Chernobyl. Yes, what we really need is a list of “The Worst Places to Live”. Money Magazine, are you listening?
Does Oxygen Addiction Exist?
Ok, I know, the joke’s on me. We’re ALL addicted to oxygen, after all it’s in 21% of the air we breathe (if this is not the case, please check your location, you may be on the wrong planet). We all need oxygen physiologically, but I’m talking about psychologically. There are those patients that know, I mean absolutely know, that oxygen seems to make their dyspnea better, even though a check of their pulse oximetry shows an oxygen saturation of one-hundred percent even when exercising. So back to my question, does this mean that they are psychologically addicted to oxygen, or does the supplemental oxygen actually fulfill an as yet unknown physiologic purpose?
Ever since two studies in the early 80’s (one which showed an overall increased survival with oxygen use, and another which showed a benefit with continuous oxygen over nocturnal use), supplemental use of oxygen for people with low oxygen levels has been considered standard of care. The current cutoff for an acceptable level of oxygen in a stable patient is, in general, eighty-nine percent (though there are always exceptions, let’s be clear, that I am talking about ambulatory oxygen in otherwise stable patients, and not about a hospitalized patient who is having a heart attack). For the most part, insurance companies will not pay for ambulatory oxygen therapy unless it is documented that their oxygen hits the magic number of 88, as we know that’s when the hemoglobin saturation curve starts to fall down a steep cliff. Or perhaps it’s because that’s when the Dr. Brown’s Delorean takes off. Either, one, I can’t quite remember.
Anyway, as I was saying, there is no known benefit to using oxygen when the measured levels are normal. And come to think of it, I don’t know of any data showing beneficial effects of its use in those with COPD whose oxygen saturation drops only with exertion (a common scenario where it is prescribed). Yet, many patient often insist on the continuation of oxygen even after it is explained that it is no longer medically necessary. To date I know of no study that shows beneficial effects of adding ambulatory oxygen to people with normal oxygen levels. One study compared forced air with oxygen in people with normal oxygen levels and found no reductions of subjective dysnea. Currently, the LOTT study is underway to see if ambulatory oxygen may be beneficial in patients with COPD and low-normal levels of oxygen. In addition, there are possible negative effects of oxygen, including the possibility of carbon dioxide retention, potential oxygen toxicity, and the hazards of transporting and storing the stuff. Not to mention the dangers of having inflammable substance being used by a smoker.
However, in my experience, patients who really feel that the oxygen is helping them with dyspnea do not care about these ideas, and are resentful about their physician talking about discontinuing it. Given that there is no data to continue the use of supplemental oxygen in those with normal oxygen levels, does their insistence in fact represent a form of addiction? I often see patients who refuse oxygen because of their misconception that their body will ‘get used to it’ and that they will not be able to get off of it. Thus far, I have brushed aside these concerns as there is no known physiologic basis for this. I wonder if perhaps I should consider the possiblity that their bodies might not get used to it, but their brains might.
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One Man’s Enterprising Solution to Beat High Drug Costs.
And that solution is. . . to become a drug rep. A fake drug rep. And get access to all the free free brand name (no generics here) medications your heart desires. The story at Pharmalot states that a well dressed man:
“walked into a physician’s office in East Northport, New York, which is on Long Island, and helped himself to about $300 worth of drugs from a shelf after claiming he was a pharma sales rep.”
The man was apparently later caught. Perhaps he was sent to jail. I say send him to D.C., this may be the kind of creative thinking we need to reduce our health care costs!