Medical Marginalia

"Just set the wrist. Walk away."

noreply@blogger.com (IcedLatte) — Thu, 08 Sep 2011 01:02:00 +0000

Oh my. "I already told you, I was stamping out disease in my outpatient clinic." Classic from ZDogg.

Long time, no see

noreply@blogger.com (IcedLatte) — Fri, 02 Sep 2011 00:48:00 +0000

Here are a few of the tough questions I have faced in the last few days:

What do you do when you walk in an exam room and a patient hands you a newly removed body part? And then another, from a different part of the body?
What do you do when you run out of pretzels and you're running an hour late, and your coffee gave out several hours ago when you stopped drinking it because if you kept drinking it you'd never sleep and you hardly sleep as it is? And your next patient is on 24 medications?
With what do you follow when you're trying to establish that mythical rapport with a new patient when you ask, "Where are you from?" and the patient answers, "Yes, yes, I work very hard."
When a very large woman says to you during a discussion about her weight "I never eat candy" and you can see the Reese's Cup in her purse AND you're out of pretzels, what do you do?

Extra credit points:

Your answering service informs you that you need to call a radiologist for an abnormal result. The radiologist screams at you for about 3 hours (okay, it was two minutes) because, he says, your answering service hung up on him. You call your answering service to see what happened and they play the recording of the radiologist screaming at the patient and polite operator. His screed ends with "USELESS!" and he hangs up. Now, the service has his direct number and so do you. What do you do? Harass him, or let him enjoy the money he got for reading the CT while you spend the next hour negotiating with the patient to go to the hospital for the serious abnormality said radiologist told you about, all of which you do completely for free?

Spoiler alert: These questions ARE NOT on the Family Medicine board certification exams.

Preniva: You just have to be scared

noreply@blogger.com (IcedLatte) — Thu, 03 Jun 2010 01:11:00 +0000

Very funny.

Ah, Residency

noreply@blogger.com (IcedLatte) — Thu, 03 Jun 2010 01:03:00 +0000

This took me back to late nights in the ER being amused and irritated by le crack addict. (Mostly irritated.) Funny and worth a watch.

What's your name?

noreply@blogger.com (IcedLatte) — Mon, 31 May 2010 14:10:00 +0000

A poignant post over on "A blog inspired by my mom's brain". The author, an old friend of my sister's, has been caring for her mother. Mom has Alzheimer's Disease. If you've cared for somebody with dementia, professionally or personally, it's easy to empathize. Under your nose, the essence of the person ebbs away. The decline is usually gentle. You don't realize that you're losing ground. Occasionally, though, are the jolts, the capricious little insults of nature. They're not on a scale of say, a volcano in Iceland, but on a personal level: ouch. Say, for example, your mother doesn't remember your name. Mom's Brain author grits her teeth and gracefully accepts this. She also explores her own feelings about her mom's new special friend. Not only is mom confused about her own daughter, but mom prefers another's company! Double ouch. Read her lovely post yourself:

What's your name?

In "small world" news, a nod to Mom's Brain's father. Long ago, for a career day in junior high, already a decade into exploring a medical career, "Dr. Brain" graciously let me tag along with him for an hour or two. He was an attending in the old school sense of the word. He had a starched white coat and worked at the huge academic medical center here in town. He radiated smart, calm, and expertise. I don't remember what he said, but I remember he was kind and treated me respectfully and not like the chunky, starry-eyed, clueless 14 year old I was. He seemed like he was eleven feet tall as he took me on a tour of the hospital, including a swing around the emergency room. We might have walked by the door of the OR area. I was on fire! Thirty years later I still remember quivering with excitement, suffused with the light pure emotional clarity you can only have when you are all hormones and feeling, and haven't been beaten down yet by organic chemistry, pharmacology, drug addicts in the ER, not to mention less gracious attendings who whomp your butt just because they can.

I work now about a block from said academic medical center, and often run over because they have the best hospital gift shop. Penny candy, neat gifts, cool cards, and yes, Graeters Ice Cream. There is also a cookie store, and the cafeteria still has the chili which sustained me through many painful 3d and 4th year rotations. They have caffeine-free Diet Coke and hard-boiled eggs.

I had to go there recently to pick up a DVD of MRI films for my dad. It was a typical maddening experience. I walked into the clinic building. It's a mess since it is being torn down to build another, more fantastic and no-doubt labyrinthine facility. I followed the signs for "radiology" and went down not one, but two dead ends. Now, how hard it it to put up good signage? How do people who didn't live in these buildings for medical school or residency find their way? I'll bet if I looked in corners and stairwells I'd find skeletons next to their O2 tanks who got lost trying to find radiology, ran out of oxygen, and gave up.

I followed sign #3 and found myself on the third floor. Trifocals on full power, I find myself in front of the urology clinic. I stand, confused and irritated. I'm looking for radiology. Surely such a popular destination should not be so difficult to find. Blood pressure rising, I spy a tiny little note about two feet above the giant "Urology Clinic" sign which says, "Radiology, 3d desk." At the third desk I say, "I need to pick up a disk...." The employee at the desk holds up her hand to stop me. "Go to the hall. Turn left. Turn left again. Find the hallway marked 'G' then turn right. Keep walking until you find a hall marked 'PACS'. Turn right. Look for the small door." She turns away from me. Really? Is this a Grimm's Fairy Tale? Should I leave a trail of crumbs? As I turn left, left, right, left, and right I can smell the gray institutional green beans for sale today in the cafeteria. I walk by other lost souls who've parked on chairs randomly set up in dark, windowless hallways, trapped in a modern-day Dickens novel.

Finally, I get the disk and make my way back through the more familiar back hallways cursing under my breath. Why is everything so difficult here? Why is everything so unpleasant? Storming through the new cardiac hospital, or "Heart Hyatt" I bump into an old patient whose husband is getting a stress test. I stop and chat. An old medical student walks by me, now a resident. We chat. Next I see an old patient who works in housekeeping, then a medical student, now a patient. We talk about where she'll be for residency. I stop by the cookie shop and by the time I leave, I'm back in the grip of everything I love. I love medicine, even at a hospital full of stinky green beans. I love patients. I love working in my hometown, where I am continually reminded of career days in the hospital when I was 13, of jobs I have had, patients I've known, and late nights watching residents struggle with sick patients. Amusing attendings, maddening assignments, endless bowls of $1 chili and all the saltines I could carry. I'm a junkie for it, even awash in fury over the journey of of a thousand miles to pick up a disk.

At this hospital, it all started with Dr. Brain.

The Vanishing Oath Part II

noreply@blogger.com (IcedLatte) — Wed, 12 May 2010 01:52:00 +0000

Here's another little clip. This physician is working at BLOCKBUSTER for health insurance. Oy.

The Vanishing Oath (excerpt) from Lisa Molomot on Vimeo.

The Vanishing Oath

noreply@blogger.com (IcedLatte) — Wed, 12 May 2010 01:38:00 +0000

If you're a complete medical internet dork like me, you've no doubt heard about The Vanishing Oath, a documentary put together over two years by an ER physician. I just ordered it. I just ordered it after I just watched this short clip

The path to patient care is lined with numerous obstacles

And then I just cried. Sure, our narrator is talking about the ER, but it's the same everywhere. Electronic charts, hospital administrators, forms, insurance companies, prior authorizations, Purell, CLIA-waived nonsense, 90-day prescriptions.....

How does this affect you? Every single doctor in these United States, unless they are cash-only (maybe), had to deal with about three of these before he or she walked into the room to see you, your child, your grandma, your sister, your husband. How distracted do you want your doctor to be? Medicine isn't easy. You're not easy. You want your doctor's full attention, or do you want 20%? The other 30% is going to the chart, 20% to racing mentally through the 50 things you have to do for other patients, 10% to the patient who just left whose electronic chart you didn't have a chance to finish because the computer crashed in the middle of your note, and 20% to just how pissed off you are....

New England Journal had an absorbing piece that resonated with moi about what keeps primary care docs to busy. It's free to read. Just skim it:

What's Keeping Us So Busy: A Snapshot from One Practice

You think your one or two little prescription refills handled over the phone add up to not much, and you're correct. Multiply that by 20 prescription refills, 10 consult letters to review, 5 xray reports, 3 pathology reports, 5 out of 20 appointments that ran over because the patient issues were so complicated, and it ain't nothing. It's the death of primary care.

I really dig your music, man

noreply@blogger.com (IcedLatte) — Sun, 02 May 2010 20:07:00 +0000

First, I'll get a shameful admission out of the way. Yep, I used to make mix-tapes. You know, the kinds that you'd give to friends full of meaningful songs? As I've noted many times, I'm lucky to have time to take a shower now, but I'll bet if I had time I'd still be at it, cruising iTunes for the perfect song for any given occasion.

My husband took the kids to the library this afternoon. I've got a pot of lentil soup on the stove; cauliflower roasting; breakfasts for the week tee'd up; green beans braising; a chicken roasting; and rice for lunches and fried rice this week done. While I've been here in the house alone I've been listening to my mix from my very last month of residency. It's very amusing to visit with mind of then-Iced and now-Iced. Listen along with me, a husband, two kids, two houses, three jobs, and various and sundry other things later:

Learn to Fly, Foo Fighters
Then: Ready for my last big learning experience! My first practice. Ready to tackle the challenge of the business of medicine.
Now: Jesus. How could I POSSIBLY have thought I was on the last leg of a journey?

Tubthumping, Chumbawamba
Then: Okay, Grant Medical Center ED. I'm done with you! You've knocked me down one last time, but I got up, and now I'm leaving.
Now: Come on! Will the pummeling ever stop? Parenting is terrifying. Will Medicare reimbursements ever not suck?

I'm a Bitch, Meredith Brooks
Then: I am indeed a bitch.
Now: I am an older bitchier bitch. And a mother.

You gotta be, Des'ree
Then: Oh, how bad, bold, wiser, hard, tough, stronger I am.
Now: Right. Add clueless to that list. Still, a chick's gotta bring game. My daughter and I have secret handshake: "stronger, tougher, smarter, faster."

Souljacker, Eels.
Then: Ode to my peeps in the Emergency Room and the Butt Hutt.
Now: I miss you and your stinky diabetic feet, chancres, and alcoholic encephalopathy.

Country Grammar, Nelly
Then: I am so bad. I trained at a Knife and Gun club. I still can't dance, though.
Now: I am so tired. And I still can't dance.

Genius of Love, Tom Tom Club
Then: I have a piece of paper saying, "MD", therefore I am smart and uniquely qualified to appreciate brainy, cerebral music
Now: Tired. Tired. Tired.

She Bangs, Ricky Martin
Then: An ode to my dear old friend, Dr. Lizardo, a dancin' fool without whom I would not have survived residency. Also an ode to the many prostitutes whose babies I delivered. They did indeed "bang".
Now: Who has time for sex?

Mr. E's Beautiful Blues, Eels
Then: Thank God! The sun came up. Call will end.
Now: Goddamn right, it's a beautiful day: I'm still alive. Wonder if today will be the day that all changes?

We Can Work It Out, Beatles
Then: Try to see it my way, patient, because I'm right, and I'll expend any amount of energy convincing you 'cause life is very short
Now: I'm often right, but not always, and I'll try to work it out with you patient, but I'll go broke if I spend more than 30 seconds doing it.

Last Stop, This Town, the Eels
Then: This video is hilarious and I am going to watch it over and over because I have all the time in the world.
Now: This song is still on my playlist, only I listen to it running, chasing away middle age.

I Want It That Way, Backstreet Boys (link is to those hilarious Chinese boys)
Then: Sigh. I'm in love with Monsieur.
Now: Sigh. Monsieur is buried on the couch under Little Latte and Mini Macchiato reading books. He and I are lucky bastards.

I'll Fly Away, Alison Kraus & Gillian Welch
Then: End of this Chapter, exciting beginning of another.
Now: How many chapters are left? Should I read ahead?

Eat your greens

noreply@blogger.com (IcedLatte) — Thu, 29 Apr 2010 12:39:00 +0000

Over on Three Squares today, a recipe for creamy Italian dressing, fit for royalty, a painless way to dress your bowl of healthy vegetables:

A bath for your greens

Oh yeah, that's right. I'm on Kevin MD today.

noreply@blogger.com (IcedLatte) — Wed, 28 Apr 2010 20:11:00 +0000

Check it out:

Hospital practice can come with pitfalls for doctors

The Blog that Ate Manhattan was here!

noreply@blogger.com (IcedLatte) — Tue, 27 Apr 2010 13:17:00 +0000

Dr. TBTAM (a NYC OB/GYN) and Mr. TBTAM were here in central Ohio last weekend, visiting The Daughter of TBTAM in Graville. She posted terrific pictures from a bike ride on one of Ohio's many wonderful rail trails. Today she followed her travel post up with a great post about lung cancer in women from a GYN-perspective, but really, works for primary care, too. Read them both:

An Ohio Country Bike Ride
Lung Cancer and Women

Then go ride a bike in Granville.

Not medical, but fantastic

noreply@blogger.com (IcedLatte) — Mon, 26 Apr 2010 13:06:00 +0000

Holy Toledo, Batman. I can't get enough of these pictures. Plenty more over at The Big Picture.

More Ill at Art

noreply@blogger.com (IcedLatte) — Sun, 25 Apr 2010 18:08:00 +0000

Came across this today in buffet, about a self-published book by Finnish photographer Henrik Malmstrom:

On Borrowed Time, limited edition

about the photographer's sister's battle with ovarian cancer. There are pictures at the link, and from there you can link to the photographer's site and download PDF previews for more. Terrific, wrenching stuff.

Today in MedMarg: It's depressing; Ill art, Cash, and Lemon Pudding.

noreply@blogger.com (IcedLatte) — Sun, 25 Apr 2010 13:20:00 +0000

Daniel Carlat, psychiatrist, has one of his quietly subversive NYTimes Sunday Magazine articles again. Remember Dr. Drug Rep? He made shilling for a drug company sound exactly like what it is: shilling for a drug company. What was most amusing to me about that article was confronting drug reps the next day about it. The most amusing thing about that was how many had no idea hucksterism was covered in great detail in the Newspaper of Record. I mean, the medical blogosphere lit up like a Christmas tree exactly five seconds after the Times hit my stoop with posts: Carlat as villian, Carlat as hero, Carlat as clueless. It took a few weeks for the Effexor rep to have an officially well-crafted, Lancome-covered, Anne Klein-clad response. As I recall, she delivered it with a fruit tray, which was difficult to eat as I was laughing so hard. In the end, as always when there is food involved, I persevered.

Today he writes a moving piece, I think, about how he's gotten to know some of his patients. Turns out in pyschiatry that there is some benefit to knowing what makes some of your patients tick, vs. just knowing what pills will make them better. Seriously, hardly seems revelatory stuff, particularly if you've been listening to your patients (while going broke and out of business) in primary care as you sort out why their blood sugars are out of control (gave pills to out of work brother who has worse diabetes); why blood pressure is 180/102 (the medication you prescribed gave patient embarrassing diarrhea); and why the patient is pacing in your exam room sobbing (husband just lost job and health insurance).

I blame insurance companies. I like to vilify and insurers are easy targets. As Carlat says today in Mind over Meds:

Insurance companies typically encourage short medication visits by paying nearly as much for a 20-minute medication visit as for 50 minutes of therapy. And patients themselves vote with their feet by frequently choosing to see psychopharmacologists rather than therapists.

Hear that? You can see three patients in one hour and make more than you would seeing one patient, done right. You do the math, and while you're blaming the doctor for being greedy, remember that you have to fund your staff's 401K this month; make that vexing freakish malpractice payment, plus pay all your office bills; work towards paying off your $200,000 in student loans; and put a little away so that your son or daughter might be able to go to college someday. You'd see three patients, too.

But patients bear some blame, too. Time and time again I listen to stories of overloaded schedules, ailing parents, busy children, ridiculous bosses, and crushing workloads from patients who are so agitated and tense that I have to crane my neck upwards as they are on the ceiling panicking, or who are so overwhelmed that I need a spatula to scrape them off the floor plus a towel to blot the tears. I suggest therapy, some help in sorting through this plate of existential spaghetti. What got you into this mess? How can you avoid it next time? To whom can you say "no"? Why do you assume the blame for this, that, and the other thing? Patients look at me, exasperated. They want a pill. Hell, I want a pill too! To go to therapy, carve out time to get there and get home, to possibly open Pandora's scary box, and to find THE MONEY (Ah-ha! Insurance again.) for a therapist is as possible as building a rocket ship out of strawberries. But so often it's exactly what the patient needs. But the patient leaves with a prescription for Celexa.

Switching gears, I did a blog post for my day job recently entitled "Illness as Art". Spurred on once again by the NYTimes, which called my attention to a series of photographs by a photographer with lymphoma, I pulled together a couple other nuggets which had been rattling around in my brain (including the moving photographs I'd covered earlier in MedMarg of an Afghan boy with tetanus) and wrote a post for the studs at OSU. I begged for comments, links, etc. Got nothing. Ah, social media. Anyhoo, read the post and send me your thoughts, comments, links, etc. Paaaaaaleeeeeaaasse.

Illness as Art

I've been perusing the interweb about alternatives business models to the traditional fee-for-service, insurance-driven primary care providers. Not that I'm thinking of going back into the real world, but I do think about the real world, like all the time, mostly because pretty much every day of the week I hear from former patients who struggle with the procurement of medical services in these United States. The thought, frankly, of fighting again with an insurance company (Damn you, UHC!) for $12.52 makes my hair catch fire. I like being paid for holidays and having time for lunch. I read this oldie but goodie from Family Practice Management,

Breaking Even on Four Visits Per Day

So I started asking the providers at the day job about cash-only practices. Do they know anybody who has one? Everybody claims to have heard of one or more mysterious physicians around town who have started a cash practice and are now driving Jaguars and living in a diamond-encrusted mansion. Nobody could supply a name, though. I can't recall a patient ever telling me they went to a cash practice. I looked in the yellow pages and didn't find any cash-only practices. Why, if this sounds so good and only takes what, like $10-15K to set up, isn't everybody doing it? Ideas?

Last, but not least, I am in receipt of a huge box of Meyer Lemons from California. Let me tell you, opening that box was finding heaven under duct tape and cardboard. Head on over to Three Squares for a protein-filled, somewhat low-fat lemony piece of pudding cake with a little bit of heaven baked right in:

Pass U By Saves the Day. Again. Lemony Goodness.

Okay, off to life. Pancakes are made, but laundry calls and darn it all, we haven't been to the grocery store yet. Good week, good health to all,

Iced

Yeah, I'm lazy. Another repost of an IcedLatte original: Nutrition and the Mona Lisa

noreply@blogger.com (IcedLatte) — Sun, 04 Apr 2010 12:51:00 +0000

Poor Dr. Latte hardly has time to shower anymore, let alone blog on her beloved MedMarg. I do still blog, though. I've had a flurry of posts lately over at my other gig. Not all are of general interest, but a recent post was worthy of a link here. A post at my new favorite medical education site, Life in the Fast Lane, prompted this post:

A little Vitamin B won't hurt me, right?

You can skip my albeit excellent, rather succinct post and go directly to another gorgeous, interactive virtual poster at Information is Beautiful, entitled:

Snake Oil? The scientific evidence for popular health supplements.

Information is beautiful. And power.

My first movie

noreply@blogger.com (IcedLatte) — Sun, 04 Apr 2010 12:45:00 +0000

I apologize in advance....This is silly. I made it for my OTHER blogging gig @ OSU's Student Health Service blog, in honor of testicular cancer awareness month. Without further ado:

The link mentioned in the movie goes to a pretty nifty little poster. Check it out, Joe, check them out if if you find something, go to your doctor, not my apartment.

Take our testicle poll @ iheartguts.com

Potpourri: WSJ, Coffee, and Why I am Still a Doctor

noreply@blogger.com (IcedLatte) — Fri, 18 Dec 2009 01:14:00 +0000

Greetings, ah, Wall Street Journal readers. What a happy Christmas surprise to find in today's Google Alerts:

WSJ links to Med Marg!

To my dear friends and loyal readers, no, that was not Photoshopped.

There was EVEN MORE GOOD NEWS. Dr. Latte might not ever become diabetic. This is important, because Dr. Latte loves cookies and potato chips more than life itself, but slightly less than Jeni's Ice Cream. Why? What important medical break-through has Dr. Latte so juiced? This:

Coffee, Tea may stall diabetes.

A shout out to my peeps at MedPage Today! Every cup of coffee I drink a day lowers my risk of diabetes by 7%. (Okay, yes, I left out the "may". I was too busy adding half and half to my joe.) I think that this week alone I have reduced my diabetes risk by approximately 5,683%, which means I have lowered my risk enough for everybody in the State of Ohio. You're welcome, Buckeyes.

Now, to the meat. The New York Times (where my blog has not yet been extoled on high) doesn't always get health care right. Even when they're not right, they get credit for thoughtful, by which I mean "full" of "thought" which if you watch local news for 4.3 seconds you will see if often in short supply. Today they shot me in the gut.

I have been chatting at length recently with my comrade in arms, Dr. Beardy, about how we've changed. What did medical school, residency, and years of practice do to our brains? Dr. Beardy shrugs and rolls his eyes at my endless fretfulness.

But I wonder. I kept a journal regularly before I went to medical school and for the first year. Entries became more spotty as time went on. I read them now and it's cute, and I mean to be patronizing. Pre-med and -clinical me is so earnest and exciteable. A Richard Selzer essay sends me to the moon. "Oh, noble savage, I am here to lay my healing hands upon you;" I was chomping at the bit to unleash my skills and empathy upon the needy masses.

That was before two years of rote memorization, then many years of a first row seat at some of the finest suffering the body has to offer. Before abscesses exploded at me, on me. Before I got amniotic fluid in my mouth; before I beheld a newborn before anybody else in the world, even its mother. Before stinky diabetic feet met my wrath at 3am in the emergency room. How many times did I cry in the bathroom at how helpless I was to help, really help?

My earnest yearnings were before drug addicts, alcoholics, and prostitutes introduced themselves and their STIs and kept me busy on weekend calls. Before I stuck sharp things in prisoners who promised retaliation and held the hands of felons as they died. Before I pronounced somebody dead on Christmas who had been breathing and warm moments before, then had to turn to the family and think of something not totally stupid to say. I had listened to the slow thump of their hearts. Then I listened to nothing. Silent stillness.

I've held hands, smoothed hair, listened to hearts, thumped livers, ordered blood, checked ears, smiled, cried, worried, fretted, and laughed through thousands of encounters. I've listened. I've catheterized, immunized, yearned, grieved, smiled, giggled, joked, talked, and hoped with thousands of people, most of whom, in fact, I've adored in one way or another. Not all, but most. Listen, listen, I tell myself when I'm starting to dislike somebody; you'll hear the hook. That thing that the patient will say that will reel me into their world, still, to this day, astonished to find myself a tourist in a life and a body quite alike and different from mine.

I remember, like most parents, before my daughter, my beloved, adorable, sparkly, vibrant girl was born, my husband and I worried. We were deeply, completely in love with our quirky, volatile, funny, handsome, curious, brown-haired toddler boy. Could our hearts expand to include another with the intense, physical love we had for our first? Impossible.

But then there was this.

My Lu. In labor and delivery after my semi-emergent section, on mag, exhausted, uncomfortable, worried, a nurse--such a dear woman--brought me a picture of her, so tiny, with oxygen and a giant IV. I had seen my daughter for a few seconds in the operating room before she was whisked to the NICU. Someday maybe I'll take a picture that means as much to me as this picture did, still does. In the wee hours of the night, lonely and a little afraid, I fell hard for a premie in a picture and I haven't gotten up yet. May I never rise. (Look at that face. How could I?)

So. I can't tell you all the ways I've changed because I just don't know. But I can tell you this. I'm bigger. I'm stronger. I'm quieter. My heart grew--like the Grinch's. My brain grew. (May that continue, too.) I know from my kids and from my patients that really, my ability to fret, to absorb, to hope, to love, to grow (my husband would add "to opine" and "to bitch") will go on. And that brings me back to the New York Times.

A picture is worth a thousand words. I should have started with these pictures, because what keeps me coming back, what gets me out of bed in the morning, what flips my switch to "on", what I love about being a physician is to reach out and touch, to help, to listen, to be near. I saw these pictures today of a little boy, with brown hair and eyes like my little boy, with tetanus. (Woe! This dear little fellow didn't need to be sick.) Tomorrow, for some other mother somewhere I will reach out, listen, laugh, hope, and try to help.

Pictures of the day: December 17th

Turns out, despite the agonies of call and the endless needs of the Axis II patient, the earnest little pre-medical journal-girl has survived. (She's much, much older and grayer and wider, now though.)

The gassy winds of change

noreply@blogger.com (IcedLatte) — Sat, 12 Dec 2009 17:09:00 +0000

So. The year is winding up. I am buffeted more by the winds of full-time working mommyhood at the holidays than I am by the winds of change in primary care. I am, though, getting cards and contact from old patients. Oh, how ambivalent I am about this. I am delighted to hear from these beloved folk, but so many tell me tales of woe. No callbacks about tests. Doctor in and out in five minutes. No explanation for an emergency referrals, sometimes no knowledge about the referral until the specialist's office called to find out why the patient missed the appointment. Inexplicable expensive tests based on miniscule probably benign findings. Where are the good primary care providers?

I know what physicians who are reading are thinking. "Iced, you weren't there. You don't know what happened." True, so true. But these aren't nutty patients. They're wonderful patients who never, ever brought anything but joy to my office. I'm only hearing the bad stuff, too. There's selection bias. Nevertheless, the stories make my hair and toes curl. I'm mad. I feel badly, and just a little guilty, not that I can do much about a corporation ramming an office closure down my throat with about 3 minutes notice. Grrrrrrr.....

In this context, I read this:

Primary care physicians spending longer time with patients.

Well, thought I, that's encouraging. Turns out it's only 3 more minutes, which isn't much when you're managing diabetes, hypertension, ordering labs, addressing depression and insomnia, arranging a mammogram, and asking about the kids, but it's something. But wait! During the time visits increased by 3 minutes revenue decreased by 10%. Physicians don't get paid by the hour, but by the patient. Spending 3 more minutes with each patient means I can see less patients in a day--20 patients a day times 3 more minutes=one whole hour lost. Can't make as much bacon. Oh, this burns my breeches. Bend over and receive a special award: Paycut. Yes, yes, but Dr. Latte, you still have a job. Many of your patients aren't having to suffer with paycuts 'cause of course, they don't have pay to cut. Yep. Read above, however, and see how your care is already suffering. The time has to come from somewhere. Didn't get a callback? Doctor had to see three patients rather than explain to you what happens now with your melanoma? Can't get in until three months from now? Have to go to Urgent Care because your doctor is 1. Out of business or 2. Out of appointments?

BUT! Help is on the way; change we can believe in. Two thousand billion pages of health care reform are coming our way sometime in the next hundred years maybe, and it's possible that if you don't have insurance now that you might be able to get insurance maybe in five years possibly and it might not matter than you had a pre-existing condition like fatigue 10 years ago. Here's my predication. Medicare works well for patients; not so well for physicians who are already losing money at it. Particularly if private insurance expands, more primary care docs--if they can without going to jail--will opt out. It's already completely, utterly impossible to know how to code 100% correctly for Medicare, and to not code correctly is to risk going to prison. Add 8000 pages of statutes and physicians rightly will run out of the room screaming.

That is, however, not to say that the present system shouldn't be napalmed, bulldozed, infected with H1N1 and left to die in a ditch full of vomit. To have to see a patient for a cold with 52 million pages of ICD-9 or -10, E&Ms and CPTs, Obama-Care EMR documentation laws attached just isn't going to be feasible for the average physician. Or even the super-human MD. I'm not hopeful. You can't get a straight answer now out of HCFA about some routine matters. How is that going to get better?

But here's something cool: Science. Pure, elegant, lovely, exciting science. From NPR an interview with a researcher who discusses the successful alteration of memory traces after they are accessed, and what that might mean for people with painful, traumatic memories:

Erasing fears by thinking about them.

Hats off! Wow. I'm smiling from ear to ear. Consolidation and reconsolidation. Shining the beautiful hard light of science at a nebulous subject, memory formation. Memory is a fluid, shifting thing, but here is evidence that it can actively be shaped in a more positive light. A little scarey with regard to the corallary--that you'd be able to shape a good memory to be bad--but to help all of us feel safe about traumatic episodes? That's powerful. I think there's some hope that I might be able to get over my medical school Gyn-Onc rotation after all.

One last thing. For now. First, let me be clear about my bias. I will use any excuse to continue to buy books often on Amazon. Here is proof that it is actually good for me and for my brain. I make my living using my brain. Thus, it is not just good, it is necessary for me to continue to shop:

Can neuroscience make you a better writer?

Yes, yes, you might be thinking, there are some caveats at the end about activation maybe not being an always all-good thing, but I'm going to ignore that because I want to continue to shop.

Oops, here's really the last thing. I see patients for a living, and usually twice in every patient encounter--before I lay my healing hands upon the patient and right after I am done--I use hand sanitizer. See twenty patients, that's ah, like 40 Purells a day. In reality, it's more, 'cause I reach for it reflexively after every sneeze or walk in the hall. I do WASH my hands, too, so don't go getting all jiggy on me, but I gotta tell ya. In the days I washed my hands 20-plus times a day the skin was falling off by mid-October and no amount of Vaseline, steroids, and socks would make it better until the following May. Hand sanitizer has made that better, although if you looked at my hands now, mid-December, you might be tempted to think that I am molting. So in my personal study of one, Purell isn't as bad for my skin as washing my hands 50,000 times a day. But how about the nails? The chemists at Beauty Brains have figured it out so you don't have to:

Are hand sanitizers bad for nails?

That's all for now!

USPSTF is mean to 40-49 year old boobies.

noreply@blogger.com (IcedLatte) — Thu, 19 Nov 2009 12:02:00 +0000

Image via Wikipedia

The USPSTF, as you might have heard, recently recommended that women stop getting mammograms and just suck it up, because our lives apparently aren't worth enough to save. Especially women approaching the end of their reproductive lives--as nature casts you aside, so does the USPTF. Don't examine your breasts, and don't get xrays of 'em either. You suck. You probably went back to work and left your children at home to fend for yourself while you saved for a fur coat.

Or did they? If you listened to the news or read almost anything, that's the impression rabid, frothing at the mouth "journalists" gave. Yes, I'm talking to you, Sanjay Gupta. You're about to get your MD taken away by the IcedLatte Medical Excommunication Squad. You're an obnoxious little twerp and spouting nonsense from your bully pulpit about which apparently you know nothing is getting on my last nerve.

Prevention and screening are so lovely and warm to think about. You go in to see your doctor for your (almost always useless for detecting disease) annual physical and leave with a prescription for your mammogram and a referral for a colonscopy, and once those are done, you feel great because you know you're cancer-free. Maybe.

A screen is by definition for detecting a disease in an asymptomatic patient. When I order any screening test, I think about:

What is the prevalence in the population of the disease we're testing for? The less the diseases exists, the less the chance in general that a screen will be positive because most people simply don't have it.
How good is this test? How many people who truly have the disease does it pick up? That is the "sensitivity." How many people with the disease will it miss?
What are this patient's unique risk factors? For example, in a female who is 45 but still have regular periods with no sign of slowing down, is her breast tissue still going to be really dense making a negative mammogram not very helpful? What if her mother had breast cancer? What if her mother didn't have breast cancer, but a maternal aunt did at 35? Not all 45 year old women are created equal.
As noted above, there are technical considerations with a test. Mammograms are better screens for some types of breast tissue. A negative test is less reassuring in others.
What was the exam like? If then exam is negative, and only if it's negative, then I can do a screen. If it is positive, then forget the screen, we're going to do a diagnostic test. Screening guidelines don't have anything to do with that at all.
What will I do if the screen is negative? If I'm suspicious--but only if the exam is negative--will I believe the test? If not, should I skip the screen and consider a diagnostic test?

But wait, there's more. I turn to various screening guidelines--the American Cancer Society, the USPSTF among them--to help me figure this stuff out. They generally make thoughtful, well-reasoned guidelines (not laws) based on evidence. They don't always agree with each other, and I have to plug that into my math.

These groups look at huge numbers of patients over time and tell me things like "How many mammograms does it take in women 41-49 to save one life from cancer?" Turuns out it's about 2000. That alone isn't a value judgement, it's just a number. One of the variables I plug into whether I should screen or not.

To make matters more complicated, they all rate their evidence and level of certainty about the evidence, in sort of a "Great data and lots of it. Go for it." to "One study with one guy who was half asleep and possibly drunk when he did it. Proceed with caution." I paraphrase, but I think you get my drift.

Last, but certainly not least, like every other physician in the world, I'm always plotting my next move. If you have a mammogram, say, and it's a little positive, what am I going to do? If it's a lot positive, what is my next step? A little positive is a problem. There is increasing evidence that some breast cancers spontaneously regress, perhaps 20%. The screening tests we have right now can't differentiate who exactly is in that cohort who won't go on to develop an invasive cancer. FURTHERMORE, will early detection make a difference? If we pick up a cancer early, does it go without saying that it will make you live longer? As it turns out, not necessarily.

Confused? That's for your doctor and you to talk about, sitting in an exam room. The USPSTF isn't trying to get between you and your mammogram. The recommendations are just trying to clarify some of the variables in the giant screening equation. Their recommendations will change. The screening tests will get better. In the meantime, don't go burning your bra at your nearest mammography suite.

For an excellent discussion in exhaustive but terrific details, check out:

The USPSTF recommendations for breast cancer screening: not the final word (written by a breast cancer surgeon and researcher
Truth squad needed on breast screening quotes from Gary Schwitzer
Screen saver from Slate, written FIVE YEARS AGO about the perils of breast cancer screening

One last thought. Screens cost money. I think about that with regard to you (Do you have insurance? If you do, do you have coverage for preventative services?), but not necessarily with regard to populations. This isn't pretend money, though, it's real money. To save a life in a female between 40-49, it costs (assuming the mammogram is about $150) $300,000. Yes, yes, what price life? But you just got a new job at an insurance company. You must decidie what is covered and what isn't. What are you going to deny--vaccines for sweet little babies? Cancer treatments? Knee replacements? Grandma's small bowel obstruction surgery? If you put the money in one pot, which pot do you take it out of?

10 ways to be irritated by your doctor

noreply@blogger.com (IcedLatte) — Wed, 18 Nov 2009 21:28:00 +0000

Hey, I'm a patient too. Here's my list. And by the way, my doctors, this isn't about you AT ALL.

1. Have stupid television playing in your lobby. I hate insipid health t.v. HATE. I don't want to watch Oprah, I don't want anything. Maybe I can listen to unobtrusive music, but nothing loud and nothing Brittny. I know the idea is that white noise or t.v. drown out the sound of actual patient care and decrease the odds of overhearing a dreaded convo involving protected health information, but really. Get a white noise machine and leave me some peace.

2. Have stupid stuff to read. Actually, given recent demonstrations of nasty disease-mongering germ covered magazines, don't have anything to read.

3. Ignore that I'm waiting. Listen, I know from personal experience that the 80 year old patient who scheduled for an upset stomach suddenly turns into a heart attack live and in-person, and suddenly you're six patients an hour behind, and suddenly it's two hours later and you're twelve behind. It sucks. When I check in, please have your staff tell me that you're really running late. Better yet, have them text me or call me to give me the option to reschedule. Leaving me to molder for 2 hours in your waiting room without so much as a "Could I get you a coke?" is rude.

4. Uncomfortable chairs are inexcusable.

5. Sure, I've walked out of a room and left the cap from a needle (not the needle). I've left the odd Bandaid wrapper on the floor. But dirty floors? Bugs? Not cool. Mice droppings?

6. Nasty staff. Your staff should not size me up like I am homeless and stinky, even if I am.

7. When I am back in a room at the OB/GYNs and I am sitting in a paper gown and paper sheet, please do have your staff tell me it's going to be an hour and a half of waiting in paper on an uncomfortable table. I will tell you that I would like to put on my clothes and reschedule.

8. When it's time for my pap smear, don't have your nurse come ahead of you, put me in stirrups so that you can walk in an go, "Spread 'em" and never look at anything but 'da business.

9. Seriously, I know margins are low, but get cloth. Gowns cost $0.25. Paper isn't that much cheaper.

10. GET ME A COOKIE!

11. Most of all, schedule appropriately. I understand if I come once or twice and you've had disasters, but if I come every time with my sick, cranky, twitchy children and I wait, please, please, stop overbooking.

10 ways to irritate your doctor.

noreply@blogger.com (IcedLatte) — Fri, 13 Nov 2009 20:30:00 +0000

From Dr. Rob last week was this post:

Top 10 ways to annoy your doctor

Very amusing. My personal favorite is #8, send your teenage son or elderly parents with dementia to the office alone, without letting anybody know what the appointment is for. Sound crazy? Ha!

To be fair, the next post was:

Top 10 ways doctors can annoy patients

Here's my own personal top 10 historical, real-life ways I have been pissed off by patients. Have I covered this before? If so I do apologize, but it's Friday afternoon and I'm too lazy to look.

Lie about reason for appointment: Never, ever say, "I told the nurse I had a cold, but really, I'm having an affair, I want to kill somebody, and I haven't pooped in a week, and I'm addicted to my sister's Ativan." I'm still angry about that one.

"I don't know why my wife scheduled this damn appointment. Ask her." She's not here and I'm not interested in being in the middle of your marital conflict. Don't come if you don't know why the hell you have an appointment. I'm a doctor, not a psychic.

Give ME some drugs: A mom lied once about getting her daughter an appointment ostensibly for a rash. As I was about to walk into the room, the mom jumped out of the bathroom and demanded that I confront her daughter about her drug use. Screamed at me in the hallway.

Argue with me about dibby dab: I once gave an elderly gentleman Darvocet for some moderate arthritis pain. He came back a week later and told me I needed to refill the medication I gave him, then he handed me a bottle of Percocet. I told him I hadn't prescribed it. He told me I had. I pointed out that the name on the bottle wasn't mine. And wasn't his.

A gaggle of thieves: If you have six kids, DO NOT schedule an appointment for one, then show up with six and ask me (after my receptionist has already told you NO) to look at everybody's ears. Then don't ask me if I can examine your breasts and talk about your anxiety disorder.

Could you babysit? Don't schedule your pap smear and expect to get it if you bring your three small children with you. Don't. Don't tell me it will be fine for them to sit by me on the floor during the exam. No. No. No.

If you're a dude: Don't come to see me for pink eye, then tell me that there's something in your groin you need me to check out, harder, harder. Seriously, now. Do I look like I care, or that I was born yesterday?

Don't ever, ever call my staff a name, any name. Ever. Don't yell at them. First, they get the job done. They call in your refills, they phone you about your test results. They schedule your appointments. Wanna be at the top of the stack or the bottom? Want the office staff at the urologist's office to hate you before they've even met you? My staff tells me everything. I live with these people. They have my back, and yours, too. Here's an example of what not to do, "Listen, I'm coming right over there, BIT$H, whether you have an appointment or not, and if your directions are wrong, you're gonna pay." No, you're not going to be seen, and the police are going to take you to your car.

I can't get out. When you see me knee deep with EMS laboring over a patient who is struggling to breathe, don't yell into the room, jangling your car keys that you're parked in by the squad in the parking lot, and could they move because you have a lunch date. We are going to turn as one and yell, "NO!" at you.

Last, but not least:

But I'm disabled! Your first appointment is not the time or the place to get 50 refills and lay on me your SSDI paperwork done. DO NOT tell me that disability and FMLA forms were due in HR two weeks ago and if I don't do the paperwork today, right now, that you won't get your check. Too badksi for you.

Here's one for bonus points, just for my fellow providers:

"I haven't had good luck with my last few doctors. They just don't understand me. I've had to fire my last five, and I'm suing at least one. I hope you're better than the last. " I don't! This is a true story, uttered from the mouth of a perfectly healthy patient with a little dyspepsia. We're not exactly a Band of Brothers, but few words send chills through my spine faster than, "I have fired your colleague....." and "Malpractice" at your first appointment, particularly when they're the first words uttered from your mouth.

College

noreply@blogger.com (IcedLatte) — Wed, 11 Nov 2009 02:42:00 +0000

So, as many of you know, I have joined the ranks of academia. Ha ha, no I haven't seen all ADD and STIs. You're funny. In fact, I haven't seen an STI in the four-plus months since I started. That makes me a little sad. I miss trich. I haven't seen a lot since residency and for some reason, the sight of that little protozoa swimming happily all over my microscope field always cheered me up. Our protocol for ADD/ADHD doesn't really involve initial diagnosis much. I write for less stimulants now than I did in private practice. Weird. Maybe two ADHDs in 4 month and no trich! No Chlamydia, no syphilis. Maybe some BV, but that's not exactly a world class sexually transmitted disease.

I find myself suddenly in possession of a lunch hour. A real lunch hour. I have oh, maybe 3 or 4 charts a day to do rather than 20-30 (on an easy day) and thus, I have time to kill at lunch. I stroll around campus and

I SEE DEAD PEOPLE.

No.

I SEE OLD PEOPLE.

Specifically, I see myself. I see my husband. I see old friends.

I'm working at the same midwestern university from whence I graduated from both college and medical school. I have gone home again. As I wander around in search of coffee, a sandwich, fritos, Columbian burritos, books, magazines, sushi, and kim chi at lunch, lost in my thoughts, I see myself. There I am, slinking along, 20 years old again, giant backpack at hand, giant sunglasses on, thrift store pants clad, flip flips on my feet (even then), on the way from skipping one class to skipping another class. I see my husband out of the corner of my eye, 20 years younger, NYTimes under his arm, smiling and overjoyed to see me (which, God love him, he still pretends to be). I see the guy I dated before Monsieur, riding his bike, rushing to his micro lab. "Yeah, sure, I can make some tuna noodle casserole on Friday. You wanna meet later at the library?" I see my sister dutifully trudging to class, pleasant smile on her face, cheery greeting at the ready.

It's a little disorienting. I snap out of my thoughts (no doubt mulling over how much I hate the flu) and for a moment, I'm 20 again. I compose my face to wave at my Monsieur, my sister, my friend, my organic lab partner. Then I remember my children. Huh? I have kids? What's the time? Oh, it's noon, 23 years later.

For just one moment, though, I am 20 years old again. It's a rather precious if fleeting interlude. How is it that my 20 year old state of mind is trapped and so easily called forth by my 45 year old brain? I can't remember my phone number half the time, but blam, there I am recalling a physics lab assignment and the nice guy (Michael) who was my lab partner.

I'm not alone. I saw a very depressed young student today who tranferred from the beloved undergraduate institution of her dreams to a college closer to home for financial reasons. She said, "I'm walking down the street and I see my roommate from last year out of the corner of my eye. When I look closer, she's not there of course, and I'm so sad. And I'm alone again."

I'm not so sad, but I do empathize. I see ghosts, too. I call forth younger, sillier, more fact-filled versions of me every day. Then I think of my children, my paycheck, my house, my comfy German blanket, my dear, old friends, and I wave goodbye to my ghosts of students past.

I think my depressed patient will make friends. She's adorable and charming but shy. I managed and I'm neither adorable nor charming. Until she does, my old bones will hold her young hand while we both watch for ghosts.

You might have too much time on your hands if you're doing this

noreply@blogger.com (IcedLatte) — Thu, 05 Nov 2009 15:45:00 +0000

Toilet paper sculptures via Sprayblog

Maybelline for $5 or Latisse for $100?

noreply@blogger.com (IcedLatte) — Thu, 05 Nov 2009 15:44:00 +0000

Grumpiness Rocks

noreply@blogger.com (IcedLatte) — Thu, 05 Nov 2009 13:04:00 +0000

Three cheers to Grumpy Arugula, Esq. who alerted me to this little gem from the BBC News:

Feeling grumpy 'is good for you'

The details:An Australian psychology expert who has been studying emotions has found being grumpy makes us think more clearly.

In contrast to those annoying happy types, miserable people are better at decision-making and less gullible, his experiments showed.

While cheerfulness fosters creativity, gloominess breeds attentiveness and careful thinking, Professor Joe Forgas told Australian Science Magazine.

I'm seriously grumpy today, so I should be in great shape to overhaul pretty much everything. Send me your thorny problems. Your bad memos. Your personal catastrophes. I'm all over it, but I will complain bitterly and scowl about helping you.