random thoughts for today...

As the title suggests, this post will include some random things I have had rattling in my head for a while.

Since I turned 26 this year and pretty much have only a receding hairline and expanding waistline to look forward to, I've been contemplating thoughts of getting old. Here are some tell-tale signs you're not a kid anymore:
1. You listen to National Public Radio while driving to and from work and you LOVE it!
2. You hate when it snows because all you can think about is how much it is going to suck driving to work and those lazy kids who get the day off.
3. You're all about going out for a beer with the guys, but instead of heading out at 10pm like in college, you'd rather have your butt in bed by 10:30pm.
4. You know what a 401(K) is and you spend Saturday mornings (when you're not in the hospital of course), "checking your portfolio."
5. Getting up at 8am on your day off is sleeping in.
6. You notice how curtains actually DO make your windows look better.


If you've ever had the misfortune to see me get riled up about the utter debacle that is our health system, then you have undoubtedly heard me rail on the cozy relationship between physicians and the pharmaceutical industry. Recently there was an article in The New York Times about a doctor who, for 1 year, spoke on behalf of Wyeth Pharmaceuticals to promote Effexor - a medicine for depression. The catharsis provided to the author is evident in the pages. Read it HERE.
There is also a great article in the medicine section of the Public Library of Science by a former drug rep detailing the tactics he and other drug reps use to 'befriend' docs. It was quite revealing and I already was a huge skeptic! I was surprised to learn that the American Medical Association - an organization I belong to - sells information from their database that allows 3rd party corporations to match physicians to the exact number and type of medications prescribed. Sounds innocent enough, but this information is then bought by drug companies to track the prescribing habits of doctors. The article makes the assertion that the AMA made $44 million in 2005 from selling this data. Absolutely deplorable. I will be canceling my membership. That article is HERE.

I magically morphed back to highschool... seriously

I'm finally on an outpatient month, a local GYN clinic, which is awesome enough (if you didn't catch it, that was sarcasm in my writing). I don't want to complain TOO much because working 8am-5pm with no call and no weekends is just slightly more than amazing. After working 80 hours/week for a couple months, 50 hours is like a walk in the park. Ya'll have it easy thats all I'm going to say.

Back to the point. This clinic has an EMR (electronic medical record), which if you didn't know, is the direction all of medicine is heading. This particular EMR is bulky, cumbersome, and VERY time consuming. It takes me around 30-40 minutes to type a note for a routine annual exam, and I type pretty darn fast. Thats on top of the 45 minutes to do the annual exam! So after all the time I put into writing the note, what happens to it? The 'consultant,' ie nurse, reviews a printed version and suggests changes in a standard issue red pen. Then, of course, I have to go back the next day and put in those suggestions, which takes at least 20 minutes. Absurd! I'm back in highschool again! It feels like when you get your term paper back and it's covered in red ink. The only thing missing is the A- in the top right corner... ok ok, maybe B+.

Here are some stellar corrections:

My entry: "pt is sexually active with only men, 1 current partner."
Suggestion: "pt is sexually active with 1 male partner."

My entry: "pt denies F/S/C/dysuria"
Suggestion: "pt denies fevers, sweats, chills, dysuria"

I never knew my poor use of the english language was being graded on a medical document.

"The absolute worst thing is seeing a woman come in pregnant..."

Yeah, that just happened. The above title is from a conversation I had today with one of the staff at the GYN clinic I'm stationed at for the next month. Taken out of context? How can you take that comment out of context?! But for completeness sakes, no its not out of context.

To their defense, this person, and the clinic as a whole, is openly pro-choice. I, or you, might disagree with this (or agree), but nonetheless I believe it important to respect the decision that has been come to.... however wrong. For on the flip-side, I want my beliefs to be respected, even if they are disagreed with. Please tell me though, when did having a kid become such an unbearable burden?! Truly they are a large responsibility, but what an awesome responsibility it is - your shaping the future! I can't help but being reminded of a movie I saw recently, Children of Men. If you haven't seen this movie, rent it. Regardless of your thoughts on the fiery subject of reproductive rights it paints a scary picture of a future where man has essentially extincted himself. Not that we are there or heading in that direction, but it makes you think that maybe we should be respecting human life just a little more than we do.

It is going to be an interesting month to say the least.

Who Me?!

In my opinion, its very easy to become jaded in medicine through the long hours, reality of death, ungrateful patients, and the revolving hospital door of non-compliant patients. I am probably listing only a few of the myriad mechanisms, and likely only those that I have myself experienced. Recently I cared for a young patient, 30's, who had received a heart transplant a number of years ago. She came into the hospital because she was acutely having chest pain, was admitted to the Cards service and stabilized on the floor. Promptly, the next morning, she coded. Since I was a resident in the Cardiac ICU and she was a cardiac floor patient, myself and my resident ran to the code.

We arrived to find her in PEA (pulseless electrical activity), which isn't important except for two things: 1) that type of code has notoriously bad outcomes and 2) there are certain things (7-8) that cause PEA. The residents and nurses at the code, including myself, immediately and hurriedly began CPR, tubed her (intubated), and reasoned our way through the etiologies of PEA to determine how to correct this situation. After about 10 minutes, the patient had a pulse and became arousable. She was transferred to the CCU and within 5 minutes of arrival, coded again. This particular code lingered on for approximately 20-25 minutes and were within seconds of 'calling it,' but noted she amazingly had a pulse... albeit on 4 pressors and 1 inotrope.

Fast forward a week. Extubated, off all pressors, fully awake, aware, and neurologically intact, and the most difficult patient I have ever cared for. Nothing was right for her, she complained about everything. This hurt, that hurt, she didn't want her blood drawn, she wanted to check her email, she wanted ice cream, on and on and on. Nevermind the fact that she was still alive, nope that wasn't good enough.

Why the story? A simple contrast. Weeks before I had cared for a very nice older gentleman. He honestly didn't need to come into the hospital, but nevertheless was admitted. There was delay after delay and he stayed for 3 days, when it needed only be 1. I could tell he was frustrated, but he never voiced it and a few days after his discharge I received this email:

---

Dear Dr. ********,

Thank you for taking the time to work me into your busy schedule. I know
what a busy person you are and I am very appreciative for the time you took
to see me.

After I checked into the hospital I was seen by Dr. ********** and Dr.
Mandichak on your staff and they did an excellent job of reviewing my case
and providing a constructive course of action. I was very impressed by the
skill of these two Drs., by attention to detail and by their interpersonal
manner. I am feeling much better and I feel I am finally on the road to a
full recovery. I could not have been more pleased with my treatment by you
and the aforementioned Drs.

With best wishes,

****
---
I have taken out the other names so I don't get sued for violating HIPPA. The contrast between these two patients is striking. It has also struck me, how quickly I forget about all the pleasant and cooperative patients I care for and often immediately focus on the more troubling ones. I'm trying not to become jaded, but at times I think that is only a dream.

Ethics was never my strongpoint....

Well, folks, it finally happened! And it only took 4 months! Let me explain... Many of you probably know my aversion to the historically intimate relationship between big pharm and the medical profession. Let me not be misunderstood, I - as much as anyone - love free stuff such as expensive dinners, CME credits in Hawaii, front row seats, and the ever ubiquitous pen. But as much we doctors deluded ourselves to thinking such freebies do not change our prescribing patterns, we're wrong. It does and multiple studies confirm it.

Sooooo, that being said, I stand before you the new recipient of the Mayo Clinic Internal Medicine Review - free of course. Obviously my bark is then much stronger than my bite. I make the excuse that fundamentally my acceptance of such a gift is purely educational. By taking the book, reading it, and employing that which I've read, I will make medical decisions based upon evidenced based outcomes.... right?! Surely, I am not ethically challenged enough to prescribe Plavix in situations where it's efficacy isn't proven. Well, honestly, that is a question we'll never know the answer to.

I fear I have engaged a slippery slope.

"Sweep the leg..."

I recently watched The Karate Kid, Part 1, for the first time in easily 15 years. If you asked, "Why Mark did you watch THAT movie?," I truthfully would have no acceptable response. I do, however, have many conjectures. Maybe I was feeling a tad 80's that night, maybe I thought Rocky was too barbaric of a comeback story, or maybe, just maybe, I needed to brush up on my sweet ninja skills... whatever it was, I partook and here are a few thoughts:

1. Daniel-son has an attitude problem.
Who in their right mind moves to a new state and proceeds to a) act like a flippin karate master after two YMCA classes and a How-To Guide b) pick fights with dudes older and at least 100lbs heavier (for goodness sakes they had totally rad dirt bikes compared to his I-couldn't-afford-a-real-BMX-bike, bike) and finally c) proceed to hit on the most attractive girl in the school. I looked up to this kid the first time I watched the movie, but now all I can think is how much I WANT him to get his butt beat... I'm actually rooting for the Cobra Kai!

2. Daniel-son is more of a dweeb than I remember.
I vaguely remember watching KK, Pt1 back in the day, but I don't remember Daniel-son being such a loser. His legs remind me of a giraffe and I'm pretty sure a watermelon weighs more than he does.

3. The 'Crane Kick' is pathetic.
The Crane Kick was the move to end all moves after this movie debuted. Mr. Miyagi even said, "There is no defense," when speaking of the move in the movie. The mere preparatory fanning of one's arms to perform said move would send chills up every middle-school bully's spine. But c'mon, lets be honest about the utility of the Crane Kick... you're standing on one foot for goodness sakes!!! Hmmm, lets see... how about I NOT run right at you and instead take 3 steps to the right and tiger-claw your skinny butt!

4. You are lead to believe wearing 'karate' bandannas at all times is not only commonplace, but a requirement to be cool.
To quote another movie, "You ain't cool, until you...." The shear amount of screen time that both Daniel-son and Johnny (the bad dude) wear their respective bandannas is ludicrous. Honestly, who wears it to school? You would be laughed out of first-period history. Side by side though, Daniel-son wins the bandanna war easily. C'mon Johnny, if you're going to wear it all the time at least get one that doesn't look like a piece of twine.... maybe a skull or something equally as awesome.

5. The role of John Kreese (the Cobras evil sensei) was originally offered to Chuck Norris.
Chuck Norris turned down the role because he didn't want his sweet ninja skills portrayed in a negative light. How about punching a guy already caught in a bear trap... how do you explain that Norris?! http://www.youtube.com/watch?v=DImbCzcSif4

Oh the Things I've Learned

So it has been a while, I know, but its time to get back in the groove. Currently I sit in the Neurology call room desperately trying to avoid any and all patients... joking (or am I?!) It dawned on me the vast length of time that has passed since I last wrote and thus wanted to scribble a few notes before I am whisked away to save a life (ha!).


A few things I've learned whilst being here:

1. The amount of bow-ties worn in this area is staggering. By my unscientific calculation 1 out of 4 residents/attendings sport one daily! And as a side note, if one wears the 'pre-tied' variety you are promptly heckled and poked repeatedly with a really pointy stick.
2. Tobacco is not a drug, its a way of life. Being the stellar Jefferson grad that I am, I routinely ask about three cardinal sins - Alcohol/Tobacco/IV drugs - during my 'social' history-taking. What seems to be a reoccurring theme is the patient's vehement denial of all things alcohol (to the point you know their lying). But on the subsequent question of tobacco use, they respond, "Oh yeah, well of course doc," while looking incredulously at me that I asked such a ridiculous question.
3. There is no sport but NASCAR and invariably my patient "knows a guy."



I'll end with a recent 3am nursing call that had me chuckling (well actually I was quite peeved when it happened)... and I must mention, no disrespect meant.
Nurse: Dr. Mandichak, your patient in 42....
Me: ...yeah...
Nurse: ...her hand is cold.
---- silence ----
Me: umm... her hand is cold? Does she have a pulse?
Nurse: oh, she has a good radial pulse. Its just that her left hand is colder than her right hand... just thought you should know.
Me: well is she in pain?
Nurse: oh no, she's fine, she's sleeping actually, I just noticed her hand was cold.
Me: *click*


For the non-medical people out there, an acute cold extremity can be a scary thing and one would be concerned with an arterial clot, something that can progress to amputation in very little time, HOWEVER, a good pulse in that extremity definitively excludes such a diagnosis (btw you'd also note pain and parathesias).

How Do I Fix My Head?

I've recently learned that my reading base extends well beyond what I anticipated and probably even wanted (if you feel guilty now.... good :)). In all seriousness though, I cannot reiterate enough that I write for me. Its one of only a few ways I have found to adequately and fully express my jumbled and, at times, incoherent thoughts (as an aside, the other ways once included punching walls, which thankfully God has pacified such aggression). I share what I write - and hence think - because I believe often it can have implications for others, allowing them to ponder a subject they might not have previously - or possibly from a difference perspective. This is not to say I hold in such high esteem what I think and say, but rather I mean to emphasize the value of dialogue sprung forth from differing perspectives - and I truly doubt that you and I hold the same opinions regardless of whether our core values coincide.

One subject that has been on my mind recently is the difference between "comfort care" and "withdrawal of care." First lets be clear, I do not intend to entertain the topic of euthanasia - see Dr. Kavorkian, - which could be construed as similar to the above, but for these purposes will be left for another time. So what has me thinking of death? Obviously it stems from my time in the hospital, but more directly from of a patient I recently cared for. I will be as blunt to say, I think there to be a very distinct difference between these two realms of care. Furthermore, I believe, this difference becomes clouded in the hospital. Is this due to sadism of doctors and nurses? Certainly not. The more likely reason is because such terms are used with great frequence yet not given adequate contextual definitions.

Thus, I will begin by defining exactly what I believe each of the above terms to mean, hoping to stave off any unintentional confusion. First, "comfort care." In my eyes, it is care that aims to provide peace and, as much as possible, pain-free medical management in the setting of a terminal diagnosis. A bulky definition to be sure, but a definition nonetheless. So how then do I define "withdrawal of care?" Most simply, an intentional action of taking away some pharmaceutical or nutritional substance, or device, which thereby the end result is death.

So the difference? Both require actions, on one side for the provision of care - to make one 'comfortable' an action must certainly be taken - and on the other to stop the giving of care. Both have the same end point, death. But the difference, I would contend, is the intention - and therefore mindset - of the action. Having had two patients in the recent past placed on 'comfort care,' I have felt, in both circumstances, the care being provided was less than ideal.

The natural continuation of these thoughts has led me to ponder (not for the first time) how often one medical advancement to prolong our lives leads us to discover another limiting factor. Examples abound, such as better acute heart attack treatment that helped lead to the burgeoning population of heart failure patients. We weren't meant to live forever, this I know. Yet sometimes I feel trapped in an occupation that demands my commitment to ensuring the exact opposite.

Pronouncements, and the like....

I walked into the hospital Monday morning after a much-needed Sunday off, not anticipating - as no one would - that my patient had a stroke hours before leaving him unresponsive. But that is exactly what happened. Discouraged enough, I drudged on to see my next patient, a sweet elderly woman, expecting to be discharged that morning since her recent cardiac procedure was without complication. My heart sank again after I learned she spiked a fever overnight, was short of breath, and had some increased cough. I hoped it was simply a charting error, a poor use of terms, and her history of chronic bronchitis all coalescing to present as some perfect storm, rather than the more plausible explanation of hospital-acquired pneumonia.

That was Monday.

Tuesday brought overnight call - the myth-like 30hr workday that becomes my reality every four days. Tuesday also brought my first pronouncement. Late into the night - about the time you wonder if your supposed to say morning rather than night - I got a text page informing me that my patient had died and I needed to come pronounce him. I don't know how long I stood motionless in the hallway, but I suspect it was pretty close to the eternity it felt like.

I feel a certain level of comfortability with death. I have had a few deaths in the family. I have seen numerous dead bodies in my profession. As a student I accompanied my resident when he pronounced a patient of his. I even spent two months cutting through a dead body four years ago in the name of education. Yet, at the same time, when encountered with death I notice this wave of emotion that perpetually surges through my mind - as if it was something so completely novel to me. I felt those very same emotions once again Tuesday night. I proceeded to my patient's room, walked in, and found him as one would - supine and motionless. I snapped out of my haze quickly enough to perform the necessary steps in a pronouncement, then stood there for another few minutes staring. I don't know what I was looking at, or for, or whatever. I found myself curious of his last thoughts. Was he happy? Was he in pain? Did he know Jesus? Did he even know what was going on?

Surreal doesn't even begin to describe it. This was someone who entrusted his medical care - nay, himself - to me. I couldn't help but feel I had failed him in some way. Was there something I forgot? Could I have done something different? Of course those reading think, "you did what you could, it was his time," "you can't save everyone," or some other trite derivation. But you have no idea what its like. You have never stood next to the bed of a person who used to be your patient.

I was only gone for one day.

Stories From The Other Side

I would hate for this to become little more than a dumpster for my humorous (to me) medical stories, but sometimes seeing an industry from the other side can be quite revealing. Additionally, with my horrible memory for memories themselves, I have to write things down. So that means either handwriting or typing... and for those who have seen my penmanship, you understand there was no decision needing to be made.

I had an elderly gentleman for a patient recently that presented to our ER for syncope (passing out due to decreased blood flow to the brain). Syncope is a rather broad work-up - encompassing neurologic, cardiac, vascular, psychiatric, and metabolic systems as possible etiologies. That, however, is not the point of the story. My patient was 'slightly' demented, by which I mean he didn't really know what was going on around him, but was really nice. Before I met the patient, I was reading through his chart prepping to write my H&P and I came across the ER resident's patient encounter note. Hoping to glean important information from their history and physical (if you know ER docs thats pretty funny) I furiously read through the scribbles. Under the 'HEENT' (Head, Eyes, Ears, Nose, Throat) exam was written, "wobbly jaw." Curious... never heard of that before. So I go and see the patient, finding him hiding under his covers. I call out, "Mr. _____," I'm Dr. Mandichak, one of the residents that will be taking care of you. He promptly answers me - from beneath his covers. The funny part of the story, the guys actually has a wobbly jaw. For whatever reason (probably partly age and dementia) he constantly moves his jaw like he is chewing something, despite the fact he has neither teeth nor food in his mouth. He was henceforth referred to as "Wobby Jaw" on rounds. My hope is to get him and Salty Beans together so the three of us can hang out.

Most recently, I was caring for another elderly patient (why did I do Internal Medicine again?) who had heart failure. She wasn't a particularly nice lady, refusing to speak to me on many many occasions. After she had been in the hospital for about a week getting diuresed - aka peeing a lot - and had a cardiac cath, to assess the ability of her heart to pump, she decided she wanted to go home that minute (essentially a day before we were going to discharge her anyway). After explaining that she was guaranteed to be back in the hospital within a week if she left at that time due to her medical condition, she still refused to stay. Long story short, I did all the paperwork and her ride arrived that evening. As she being wheeled out of her room by transport, she tells the nurse she has cherries and strawberries in the floor refrigerator. Below is the following conversation:
Nurse: Here you are Ms. ______
Patient: Thats just my cherries, where are my strawberries?
Nurse: I didn't see any strawberries in the refrigerator. Are you sure you had some?
Patient: Of course I had some. I brought cherries and strawberries with me.
----Not in earshot of the above conversation and sitting down at a nearby computer, I interject---
Me: Ms. ____, you all ready to go?
Patient: No I'm not ready to go. Somebody stole my strawberries! I want my strawberries!
Me: Hmm, I don't know what happened to them.
Patient: Whose going to pay for my strawberries?! I paid $8 for them!
Nurse: I'm sorry I can't find them them. You may call the hospital comment number to report any concerns you have.
Me: Take care Ms. _____, have a good day.
Patient: I ain't takin care nothin.... you stole my strawberries! I'm gonna get my strawberries!


Ahhhhh hilarity ensues......


My second call turned out to be more dramatic than my first. A patient of mine admitted for Peri-Partum Heart Failure was to be discharged the next day. Well don't you know, that night she had a tonic-clonic seizure. I of course was in the cafeteria at the time finally getting food around 11pm. It was my first experience running through the hospital to a crashing patient as a doc. The only other time I did that, I was still a student and things were flying out of my pockets as I was running. My pager fell off and literally slid 20ft down the hall.... quite embarrassing.

From The Pen of Dr. Mandichak

It has been quite some time since I last wrote and would probably be much much longer if I didn't take a second to scribble a few words now. Last night was my very first overnight call as an internal medicine intern and it certainly didn't disappoint. Before I divulge the memorable happenings, a quick thought regarding being a 3-day old intern. One of the most frustrating aspects of medical school for me was the repeated marginalization. I'll explain. As a medical student you are the lowest person on the totem pole. Heck, even the techs are higher than you because they generally know where the bathrooms are. Even if you are a stellar med student everything you do, and I do mean everything, is checked and re-checked. Every physical exam you perform must be "confirmed" by a superior - the funny thing being residents and attendings generally do more cursory exams - before your clinical findings are believable. By the end of 3rd and beginning of 4th year, I was beyond irritated by this. I know I'm still learning, but don't treat me like I am incompetent.

Somehow, after one receives an oversized, and borderline pretentious, medical degree you can be trusted. Somehow, there is no longer any need for people to question your decision... for you are a doctor and of course you know what your doing. Riiight. Despite the fact that I HATE the being marginalized in med school, I am terrified at the idea that people actually think I know what I'm doing. I find myself craving the marginalization I once despised.

So the highlights of my first overnight call on Acute Cardiology:
1. A well-known congestive heart failure patient at the hospital is admitted for an exacerbation of his CHF yet again. He is affectionately known as "Salty Beans" by the staff because during each of his multiple admissions he cries out, "Dang them salty beans I ate!"

2. Nurse: "Could you come look at Mr. _____ in room 18."
Me and the other intern: "Why whats going on?"
Nurse: "I just need you to look at him."
Us: "Well is it important? We're busy at the moment."
Nurse: "He's got a bloody penis! Just come look, ok?"

He did in fact have a blood coming from his penis. I know those in the medical profession are thinking, "ok a little hematuria, no biggie." Yeah, no. We're talking frank blood oozing out of his penis.

3. I'm called to the bedside to assess a patient with a bloody nose. I find a 75 year old lady with 7 or 8 soaked gaze pads in her lap and another equally as soaked held against her nose. Its been like this for 30 minutes and by the way, she's on a heparin (blood thinner) drip. I order a STAT PTT and its 155, which is 54 over the therapeutic range. The outgoing team forgot to order the PTT to check the level before they left.

Fun times.

The Greatest Compliment

Those who know me, know that I have recently (within the last year) been bitten with the photography bug. I purchased my first digital camera last summer in preparation for a trip to Mexico and was instantly addicted. To me, there is little else that can evoke such powerful emotions as much as pictures. They make us laugh and cry. They captivate and envelope us. They strip away the external world so in that very moment our perceived reality consists only of ourselves and that into which we are staring.

This past fall, with one or two decent photos 'in hand', I joined the amateur photography website, Caedes.net. My intention was - and still is - to garner critiques from fellow photographers with the hope of improving my composition, technique, style, etc. Thus far it has been a somewhat rewarding experience and I have learned quite a few things. Much to my amazement, when I signed on today I had a personal message waiting for me. Below is the full text of the message, with names removed.

Mr. Taylor,

Upon recently reading the copyright information for all Caedes images, I realize that I owe you an apology. In "Copyright and Image Use," it is clearly indicated that, without written permission from you, I cannot use your images as any part of a webpage.

As you will clearly see, I have used one of your images in this banner and background for webpage usage: http://i96.photobucket.com/albums/l170/naomi_onthetundra/SendTheLight.png and http://i96.photobucket.com/albums/l170/naomi_onthetundra/SendTheLightbackground.png. I edited the image on Photoshop and created a banner and background. I have them displayed on my website, http://www.xanga.com/naomi_onthetundra; it is near the bottom of the page. Although I give you sole credit for the original image through the address to your gallery on the banner (and also below the image preview and other features, in a type of “box“), I know that does not suffice for my actions.

However delayed, I now ask for your permission to you your image for this banner. Please give me a Yes or No; I will gladly accept a No answer and remove the image from the Internet, if that is your wish. If you grant permission to use the image, I would be grateful.

Again, you have my sincerest apology.

In Christ alone,

XXXX

First of all, I have no idea why the person addressed me as 'Mr. Taylor,' for this is nowhere in my profile, but that is a minor point. In the few short months of my 'photographic career', I have received a number compliments from friends and family (as well as those on Caedes) for my pictures, but by far the greatest compliment is the realization that someone, unbeknownst to me, thought highly enough of my picture to reproduce it on their webpage.

By copying and pasting the above urls you can see the altered image.

Tying up Loose Ends + Bonus Feature

A friend of mine, in response to my last two posts, emailed me a recent article in the Wall Street Journal entitled "The Case Against Stents: New Studies Hint at Overuse" The title is rather self-explanatory, but it is about the burgeoning trend in medicine of cardiac catheterization and stent placement. Honestly, at this point, calling it a burgeoning trend is probably not the best description - since the procedure has been around for at least 10 years - however, every year more and more people are having it done. The article very accurately identifies one of the problems in medicine my last two posts have hinted towards, hence the reason I bring it up. The fundamental argument of the article, as one might guess from the title, is that new studies are finding that the long-term outcomes of cardiac catheterization is probably not as good as we originally thought and likely have a mortality benefit only in a select population - much like Coronary Artery Bypass Grafting (CABG).

I would love to post the entire article, however, it is quite lengthy. If you have a subscription to WSJ - which is never a bad thing to have - then you can search for the article title above. But, I would like to share with you one 'pithy' remark from the article.
"It's a medicine-for-dollars scenario," says Kevin Graham, director of preventive cardiology at the Minneapolis Heart Institute. "The doctor who practices disciplined medicine makes significantly less money than the doctor who is trying to find some justification for stenting a patient. That's the system. People get paid for doing things."

It is a deplorable idea to think of healthcare in such a way, but unfortunately, seeing it everyday, I would have to agree with Dr. Graham. My friend had this to say "So I guess my basic thought is that medicine, like law and all other supposedly high-minded professions, is really just a business." Again, sadly this is true.

Bonus Feature
I had to share this. I saw a bumper sticker the other day, which I can honestly say was the funniest I've seen in a long time. It was stuck to the back of a Scion xB - a picture of which is shown below...

The bumper sticker read: "Sadly, you've just been passed by a toaster"







thanks to EVN for the article and remarks....

My Frustrations with Medicine 2 - Making the Patient Happy

For some inexplicable reason, the last two days have been extremely light, thus I write again much sooner than I anticipated. I want follow up my last post with a secondary frustration from a recent rotation.

I'd like share with you a story of an encounter I had with a patient, then explore its foundations. Of course with HIPAA being what it is I'll try to be as vague as possible, without blurring the fundamental point of the story. I stepped into the occupied patients room, introduced myself and started the interview portion of the encounter. To make a long story less long, the patient (who I will refer to as 'X') explains, tearfully, that she has gained so much weight recently she doesn't recognize herself and can't walk because her legs are so big and has never looked like this and doesn't eat breakfast or lunch and exercises 20 minutes every day and her daughter's wedding is in 4 months and she doesn't fit in her dress anymore and so on.... At this point, I am trully feeling sorry for her and empathizing as much as possible, but also slightly confused. Anyone who eats one meal a day and exercises everyday does not gain weight, unless there's a metabolic problem. Thus, I go down the hypothyroidism route. In conjunction with the weight gain she's constipated, cold all the time, and fatigued. In the setting of a 'normal' exam, I feel like I have a pretty strong case for hypothyroidism as a diagnosis - at the very least a reason to check a TSH. I mention this to her and say if her thyroid levels are low we can replace it. Then the interview turns sour. She says to me "there's nothing wrong with me, I just need a diet pill... give me a diet pill." I hedged. "If Dr. _____ won't give me a diet pill, I'll just go find another doctor. That's what you are here for, to help me, to give me what I need. How can you say your a doctor and not give someone what they need." I'm a little perturbed at this point. I assured her I (we) wanted to help, but also wanted to do what was best for her. Again she scolded me. So I challenged her a little (my frustration surfacing) about the exercise and find out she sits on her stationary bike and watches T.V. every morning, sometimes actually moving the pedals, but never sweating. Tiring of the tension between us and the energy to persistantly respond kindly, I exited to find the doc and report my findings.

After the doc and I are both in the room, X continues to insist she needs a diet pill today. "When I broke my foot years ago I couldn't do anything for 4-weeks and gained so much weight. I went to my doctor and he gave me a pill and all the weight came off." After going back and forth for a while there is no happy conclusion to be had. X insists on a diet pill she doesn't need and refuses to let us take blood to run basic labs.

So what would I do at this point? Peace out, cheerio, ciao! As a future doc, if my patient is not willing to work with me in their care and is simply using me to get a medication, I don't feel there is any reason to continue our relationship. I'm young, inexperienced, and jaded - heck, I'm not even a real doc yet - but I'm not going to prescribe a medication with a risk-benefit ratio far schewed to the former. That being said, what did happen? The doc prescribes Lasix, which is a diuretic! Are you kidding me?! Her exam was completely unremarkable - no fluid in the lungs, ascites, or edema in the extremities! No indication for a diurectic whatsover, but the patient left happy.

Here is an abridged list of the possible adverse effects of Lasix:
COMMON
Dermatologic: Photosensitivity, Pruritus, Rash, Urticaria
Endocrine metabolic: Electrolyte imbalance (14-60%), Hyperglycemia, Hyperuricemia (40%)
Gastrointestinal: Constipation, Diarrhea, Loss of appetite, Nausea and vomiting
Neurologic: Asthenia, Dizziness, Headache, Vertigo
Renal: Glycosuria
SERIOUS
Cardiovascular: Hypotension
Gastrointestinal: Pancreatitis
Hematologic: Hemolytic anemia, Thrombocytopenia

So I ask the question, how far should we go as docs to make the patient happy?


Two interesting articles from today's news:
http://www.healthday.com/Article.asp?AID=601105

http://news.aol.com/topnews/articles/_a/nicotine-increasing-in-cigarettes-study/20070118122009990001?cid=2194

My Frustrations with Medicine

Currently, I am doing a 4-week rotation in outpatient adult medicine. For those not comfortable with med school lingo, this essentially means I working at a doctor's office where one would go if they were feeling ill. Those who know me realize I do not particularly enjoy functioning as a doctor in this outpatient setting - mainly because the repetition of titrating a patient's hypertension/hyperlipidemia/diabetes/[insert any other chronic disease] medication bores me - there's no learning new presentations or seeing interesting pathology. Those that choose primary care as a career (whether that be Internal Medicine or Family Medicine) have my respect, because its something I couldn't do. And frankly, to be an excellent primary care doctor is much more difficult than being any kind of specialist in my mind (conversely to be mediocre is tremendously easy). I say all this to share some of my experiences the last few weeks - or rather my frustrations - with the understanding that they come not from my distaste of the outpatient setting, but rather practicing bad medicine.

The practice in which I am working is very busy. It is composed of many docs and subsequently a whole host of patients. Besides the patients, doctors, and office staff there is another group of people that can be seen milling the halls filling cabinets with samples.... that's right, drug reps! Honestly, a day has not gone by when I haven't seen 5 different drug reps in this particular office. They're dropping off samples, bringing lunch, handing out pens, quoting the latest study that supports their medication (often forgetting to quote those that show no benefit), etc. Now, I have nothing personal against drug reps - 75% of them are female and very attractive - but it does bother me the intimate relationship doctors have reciprocated with big pharm. Fundamentally, how can two groups with such different inherent objectives operate together? Axiomatically, doctors are (or should be) concerned first and foremost with the interests of their patient(s) (it's spelled out in the Hippocratic oath we all take). Compare this, to a multi-million dollar company (multi-billion dollar industry) that, bare-bones, consists of investors. You can believe all the sugar-coated PR bull pharmaceuticals exude, but at their heart, their responsibility is to make money for their investors.

Being on the outside, maybe patients don't see a problem with this. Maybe they walk by, notice the hot blond in the tailored business suit talking to the doc and think nothing of it. I think our patients are smarter than that. Maybe they realize physicians are in bed with big pharm and don't think it affects them. I believe it does. Accepting gifts - whether it be pens, lunches, dinners, vacations - does indeed affect prescribing patterns and is certainly a breach of patient-centered ethics. For you are no longer thinking of the best option - physically, emotionally, monetarily - for that patient or for other patients inhabiting this society. That is essentially what we as physicians (I speak from a soapbox 5 months from now) have done in allowing big pharm our ears. Obviously, there are times when only the latest and greatest medication will do, but that is far, far from the norm. Moreover, newer drugs (the only ones pushed by pharmaceutical companies) cost 10x - or more - as much as an alternatives.

As an aside, a study published in the Journal of the American Medical Association last year reported "third-year medical students get one gift or attend one event per week sponsored by the pharmaceutical industry, which spends $12 billion to $18 billion annually on marketing to doctors and medical residents."

That is the ethical side of the argument. Where do samples fit in? Pharm companies are marketing geniuses (not to mention scientific wizards with some of the drugs they make). By ensuring a plentiful supply of free samples in offices, they know, once a patient is started on a medication, likes it, and has negligible side effects they have effectively guaranteed repetitive use. This is not a bad thing if indicated for the best care of a patient, unless of course there was a cheaper alternative that would have done the same thing. Just the other day, the doc I was working with gave a patient a 1 month supply of the newest Type 2 Diabetes medication, Januvia, worth over $300. Now tell me there isn't any repercussions for society when this patient goes on that med long term and lifestyle changes would have achieved similar results.

As with most of the 'problems' I point out, do I have a solution? Not really. I would like to see drug reps no longer roaming the halls of any hospital or practice, along with their free pens and food. I would like to see samples done away with. I would like to see drug prices reduced. But, truthfully, it's a multifaceted problem and one also has to realize that it takes a RIDICULOUS amount of money to make a successful drug. Less than 10% of all compounds patented actually make it to market. And it takes millions and millions of dollars to bring a drug from discovery to FDA-approved. No one is going to spend the money to make a medication if they then can't recoup their investment. Thus is the way a capitalistic society functions. Stories like this are not singular instances. Despite all the fancy drugs our national health-care is mediocre at best - compared to other developed countries - and we spend twice as much. So what do we do? When I figure it out, I'll let you know.

next up: Making The Patient Happy

Change is Good?

I have recently found myself enamored with books - reading them, browsing them, and just touching them. I wasn't always like this. Much to the contrary, my mother was at her wits end trying to get me to read when I was younger. I remember this went all the way through high school, with my mom finally giving up on me. I hated reading, I mean what was the point? Back then, I couldn't understand why anyone would read; T.V. provided much more entertainment and, well, best of all you didn't have to READ IT! The worst part was summer vacation. How can you call it vacation when you have to read 5 books in 3 months?! But now, I walk into any bookstore and buy at least one book regardless of whether I need it or not.

I'm sure your reading this, pointing out the fact that a lot of kids hate to read... hold on, I'm getting to the point. So in high school and college what was I obsessed with? Clothes (thus my outward appearance to the world). It sounds really stupid, but man I loved clothes and I spent all my money on them. So in order to be financially responsible I did what any respectable high school student does... I got a job in retail. First it was The Gap. I worked there for over a year, simply for the discounts. Then I moved up the retail ladder and worked a few years at J.Crew. Man it was awesome, I was getting clothes for real cheap. I graduated college, moved on to medical school and left my retail days behind me. Again your wondering, SO WHAT!

It wasn't until after I left retail that I realized how pathetic I was being. The only reason I worked in those stores was to accumulate more stuff - specifically clothes - which I thought by owning would make me more and more admired. It's amazing how immature I can be when I pause to analyze my actions. So what about now? Honestly, I could give a crap about clothes. I haven't bought myself a single article of clothing in over 3 years. That might seem a little extreme, but when one has over 40 button down shirts, its really not. Can I thus say I am cured? Have I finally hurdled over my immature and self-indulging insecurities?

Back to the books. Over the the holidays, during a time of reflecting, I realized that I have not so much 'matured' as I have replaced one stumbling block for another. Namely, books for clothes. While in college, I yearned to be accepted by the 'cool' kids and much to my detriment was indeed accepted. This acceptance was based heavily on superficiality. Indeed, at many "institutes of higher learning," physical appearances are heavily relied upon - essentially mirroring society at large. In medical school, however, a different attribute is praised, that being one's intellect. Thus - and you can see where I'm going with this - books are held at a higher value. Have I not then simply conformed my insecurities to the environment in which I am placed? To a degree I would say yes. For a long time, an area of weakness for myself has been the pathologic emphasis I place on the external. I doubt I am the only one to flounder in this way. God has transformed my life with His grace and without this continual and renewing grace I would truly be doomed.

Do I write all this to say clothes or books are bad?! Of course not! Books are great! And clothes are... well... good too. Nonetheless, it is quite revealing to analyze why I (we) do and emphasize certain things. For it is these exact things that reflect what is important in our lives. Thats enough for now, I need to finish this next chapter.... ;)