He was my first patient — ever. I had seen only a few patients before at my school’s student-run clinics, but never had I conducted a full visit. He was my first patient since starting the second semester of my first year, which meant more independence on my part (theoretically), and that, for the first time, I would be holding the office visit from beginning to end. Without guidance. Of …
My first patient: I felt humbled by his patience
Medical cannabis is a treatment option with a low risk of dependence, minimal side effects, and few detrimental health effects, that has the potential to help hundreds of thousands of people suffering from various debilitating symptoms. Medical cannabis has gotten a bad rap over the past several decades in the United States due to laws put into place in the early-mid …
Medical cannabis: Be informed and challenge the myths
An excerpt from Pharmacy on a Bicycle.
One of the more impressive success stories in health improvement in a low-income country is Rwanda. This small landlocked country of 11.37 million was devastated by genocide in 1994 that left 800,000 people dead, affecting everyone in the country. The tragedy occurred …
Rwanda: The little country that could
An excerpt from Beyond Heroes: A Lean Management System for Healthcare.
Lean was a serious initiative from the beginning. It was energetically championed by our CEO at that time, John Toussaint, MD, who began his own lean investigations in 2002. By this time, I was a vice president with operational responsibilities …
Implementing lean: A hospital case study
Colorado and Washington are the first states to legalize recreational marijuana. In my state of Colorado, Amendment 64 was passed by 55 percent of voters by ballot referendum last year and took effect on January 1 of this year. State government officials are giddy with the prospects of increased revenue from marijuana sales. Marijuana tourism is booming in Colorado, giving new meaning to “Rocky Mountain High.” Now, four months into this new experiment, it may be worth looking …
The unintended consequences of marijuana legalization
The key change in medicine that has caused a escalation of costs, a decline in the quality of care, and an increasing shortage of physicians is the shift toward an exclusively business contract with society at the expense of the social contract.
To differentiate the business contract from the social contract I will use the following example. One afternoon I see my neighbor hard at work changing her tire. If I …
The ongoing battle for the soul of health care
“Nine of 10 doctors discourage others from joining the profession,” writes Daniela Drake on the Daily Beast.
And stats say that by the end of 2014, about 300 physicians will commit suicide.
What is going on?
A few years back, practicing medicine was named the second-most suicidal occupation. Yet, it hasn’t stopped. The level of sheer unhappiness among physicians is on the rise.
Being a doctor has become a humiliating undertaking. There …
Status quo primary care: How did things get this bad?
The last time I was in Israel, I went on some home visits with a palliative care physician in the town of Sfat near the Sea of Galilee. My colleague, a devout Jewish doctor, took me to several homes to offer advice on managing his most serious, terminally ill patients. One older Chassidic Rabbi was dealing with an advanced lung cancer, and having a difficult time accepting any kind of …
Not acknowledging death does not make it go away
I’ve based a huge chunk of my career on the assumption that evidence-based information helps people make better informed health decisions, have better health conversations with their doctors and ultimately leads to better health outcomes.
Evidence is my stock in trade. I have spent many years translating evidence into a form that people can understand. I’ve written thousands of evidence-based articles across many channels. I’ve written position statements, belonged to guideline …
The problem with evidence-based health is not what you think
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 51-year-old woman is evaluated for a 6-month history of diarrhea and bloating. She reports four to six loose stools per day, with occasional nocturnal stools. She has had a few episodes of incontinence secondary to urgency. She has not had melena or hematochezia but notes an occasional oily appearance to the …
MKSAP: 51-year-old woman with diarrhea and bloating
Walking to the 2014 Heart Rhythm Society (HRS) Scientific Sessions recently, I couldn’t help but marvel how beautiful San Francisco was. The weather was perfect, the streets bustling, the quaint shops and eateries doing brisk business in a very hip metropolitan city with a distinctive West Coast vibe. As I walked up to the Moscone Conference Center, I was struck by …
The health care industrial complex is stronger than ever
to live in this world
you must be able
to do three things
to love what is mortal;
to hold it
against your bones knowing
your own life depends on it;
and, when the time comes to let it go,
to let it go
-Mary Oliver, New and Selected Poems, Vol. 1
As a parent, you are not supposed to have a favorite child, and since some of us physicians feel a strange but kindred protectiveness for our patients, likewise we …
My favorite patient died last night
When I graduated from my residency, far from my current professional home, I wanted to write a book called How Not to Get Yelled At in the Operating Room. Or How to Clear the Fear from Your OR.
I had these titles in mind because I struggled so much during my intern year. It was a tough year, full of intense patient care and sleep deprivation, but the challenge that I most wanted help …
Reducing the stress of teaching surgical residents
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Fifteen years ago I got an unexpected invitation to write a column for a dermatology newspaper aimed at practicing clinicians. Because dermatology is a concrete field that lends itself to punning, I called the column “Under My Skin.”
Writing it monthly since then has given me a chance to take a humorous and sometimes cathartic look at the joys and woes of practice. It’s fun to do, and gratifying to hear …
Shared exasperation is cathartic
Patient noncompliance.
I wasn’t very familiar with this term until I started my clinical rotations. But after just the first week, I started noticing that health care providers throw this phrase around all time.
We particularly like using it as an excuse. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? It’s often …
Physicians are noncompliant too
What do we want in the last days of life? We want no pain. We want simple dignity, the physical kind where we clean ourselves, organize our medicine and command our bowels. As important is the complex dignity of choosing where we spend our final days, make tough decisions for ourselves and, as much as possible, live as a person, not a patient. It occurs to me that these critical …
What is quality in end of life care?
I wish I could share the photo of my 4mm boomerang shaped kidney stone. I labored for 2 months, back in early 2009 to pass it, the second stone in 5 years.
During my ordeal with these stones, I had the following health care encounters, tests, medicines, lab and imaging tests.
The high cost of kidney stones
The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.” Often, you’ll hear people advocate that every health care worker should “practice at the top of their license.” What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not …
Preventing doctors from practicing at the top of their license
Health care reform is a reality. The ACA and its associated mandates have forever changed the landscape of medicine in the U.S. today. The Obama administration touts the goals of reform as providing affordable, cost effective, high quality care for all Americans. Certainly these are noble and lofty goals: But have we completely missed the mark?
Today, many remain uninsured and the majority that have signed up for the exchanges are simply …
The salaries of health executives: What can doctors do?
This was the dream: We would use technology to create a seamless health care system, one where people, computers and machines would work together to improve patient care in many different ways. Health care would be more efficient, it would be safer, it would be less expensive, we would be able to transfer health-related information quickly and accurately.
After …
Health technology must improve patient safety
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