The art of taking an excellent medical history

Physician
July 21, 2016

The art of eliciting the medical history requires medical knowledge, cultural knowledge, and many “people skills.”  History taking is not science, but rather, art, because it requires interpretation and clarification.  Patients with the same symptoms express them differently.  A major feature of the art of medicine involves learning how to interpret different descriptions of the same phenomenon.

A few examples might clarify these concepts.

The patient tells you that they have chest …

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I have seen both worlds, and the naturopathic one is terrifying

Physician
July 20, 2016

I find it amusing to be accused of being an unsuccessful practitioner of naturopathic medicine. I graduated with high grades from Bastyr University. I landed a highly competitive naturopathic residency. Had I remained in practice, I would currently be eligible to take the naturopathic pediatrics “board-certification” exam offered by the Pediatric Association of Naturopathic Physicians.

I was making decent money at my practices in Seattle and Tucson. By all accounts, I was …

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The cost of taking the USMLE exams is staggering

Education
July 18, 2016

Based on recent data, medical students pay approximately $136 million dollars each year in registration fees for the U.S. Medical Licensing Examination (USMLE) Step 1, Step 2 CK, Step 2 CS and Step 3 exams.

Current registration fees to take the four USMLE exams are $3,320 per U.S. medical student and $4,125 per international medical graduate (IMG).  Estimated annual registration fees for the USMLE exams …

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Saving billions of dollars in health care: The story of Avastin and Lucentis

Meds
July 17, 2016

I sometimes worry that my wife Paula won’t be able to see me grow old. Not that I expect to outlive her. She is four years my junior and has the blood pressure of a 17-year-old track star. It’s her eyesight I’m worried about, because she is at risk for a form of blindness called macular degeneration. Paula is the youngest in a long line of redheads, several of whom …

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Blood pressure in the elderly: How low is too low?

Conditions
July 15, 2016

A recent publication in a fine peer-reviewed medical journal of the SPRINT study proved that lowering our blood pressure to the old target of 120/80 or less led to fewer heart attacks, strokes, and kidney failure.  There was no question on what to do with younger people but to lower their blood pressure more aggressively to these levels. Debates arose in the medical community about the ability to lower it …

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There are limits to what a careful physician can do

Physician
July 15, 2016

Sometimes, I think that that guiding principal of the medical profession, “first, do no harm,” is hopelessly out-of-date. Clearly, a physician should understand her limits, and never should she give care, which hurts, more than helps. Nonetheless, this axiom implies that the doctor is in control, and decides the treatment. Some of the time, a modern motto, which recognizes the true position and limits of the modern doc, might be, …

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Why obstetric anesthesiology is the next frontier in medicine

Physician
July 12, 2016

There’s a lot of fear and anxiety about the job market with recent medical school graduates. The 2008 crisis almost collapsed the housing market and many of our large banks, prized institutions, and beacons of financial stability, dissolved overnight.  If you combine these events with the financial burden of student loans that many graduates have, it’s easy to see why many medical students are somewhat skeptical of the job market.

In …

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Poised at the abyss: A wife faces her neurologist husband’s brain cancer

Conditions
July 11, 2016

My husband, Mark, called me at my practice. “I’ve been working on something; I need you to come home now.” He spoke definitively, urgently. “Is it the kids?” I was instinctively anxious. “No, not the kids, just come home now.”

6 p.m., a cool evening, an ordinary day. The life before the fact. And then life afterward, irrevocably and catastrophically changed.

A tense ride home, then the revelation. “I’ve been having difficulty …

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What a medical student learned during his psychiatry rotation

Education
July 10, 2016

Psychiatry was my first clinical rotation, and I did not know what to expect when I began. When I initially got assigned to the dialectal behavioral therapy (DBT) team, I had no clue what that would entail beyond working with some borderline patients and that the preconception of borderline patients is that they can be “the most difficult” patients to help due to their intense emotional instability, chronic feelings of …

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The case for teaching medical students about religion

Education
July 9, 2016

Health care providers are often uncomfortable discussing issues of religion with patients, despite studies that indicate nearly 9 in 10 Americans believe in some sort of spiritual power. As a medical student, I have noticed that religion plays an important role in many patients’ lives, and that conversations about spirituality can build rapport between doctors and patients.

As the United States becomes increasingly diverse across religious lines, it is imperative for …

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MKSAP: 52-year-old man is evaluated for low back pain

Conditions
July 9, 2016

A 52-year-old man is evaluated for low back pain of 3 months’ duration that is nonradiating, progressive, and worse with ambulation. He reports no preceding injury. Medical history is notable for smoldering multiple myeloma diagnosed 1 year ago; he has been stable since that time. His only medication is as-needed acetaminophen.

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 132/82 mm Hg, pulse rate is 70/min, and …

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Obesity changes the way our endocrine system functions

Conditions
July 8, 2016

A patient of mine brought donuts in yesterday for the staff, and I confess! I had the one with sprinkles.

But with the study published in JAMA reporting that 35 percent of U.S. men and 40 percent of U.S. women are obese, I felt the need to talk a little about obesity and reproduction.

The endocrine system is tightly regulated by hormones which provide feedback to the brain to control their …

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A case of abdominal pain in the ER. And a surprising cause.

Conditions
July 6, 2016

(Triage note: 45-year-old male, vomiting for two days. Abdominal pain.)

Dr. Stephen Cluff is like Yoda. Judging by body hair, he’s more like Chewbacca. But he’s short, wise, and with his white hair and arthritic limp, he may as well have green skin, poor sentence structure, and a Muppet’s voice. If I’m stumped on a case, I’ll ask him. If I’m pissed off about department politics, I’ll call him for advice. If I want …

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The end of residency means difficult goodbyes

Physician
July 6, 2016

“It is easy to see the beginnings of things, and harder to see the ends. I can remember now, with a clarity that makes the nerves in the back of my neck constrict, when New York began for me, but I cannot lay my finger upon the moment it ended.”
– Joan Didion, Goodbye To All That

So it feels at the end of residency. Of course, there is a graduation date. …

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It’s time to end the medical hierarchy

Education
July 6, 2016

I was a few weeks into my surgery clerkship and was on the tail end of a student call shift. I had been at the hospital for almost 24 hours, and the last thing left to do before I embraced the comfort of my own bed was to round with the faculty surgeon on call that weekend. The night had been busy, but I was prepared to update my attending …

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Your daughter is going to medical school. Please don’t worry.

Education
July 3, 2016

Dear parents,

Congratulations on your daughter’s acceptance into medical school.  Like the first day of kindergarten, this launch is notable for parents as well as children.

You may have some concerns about the stresses she will face. Having been there, I can tell you there will be many.  Not to worry, though. Times are changing.  You daughter is free to learn among the brightest of the bright while avoiding problems women before …

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Don’t remove your own IUD. Please.

Conditions
July 2, 2016

Removing one’s own IUD is apparently “a thing.” There are even YouTube videos of women sharing their experiences. If you can get a medical degree from Google then why not get your OB/GYN residency from YouTube?

All kidding aside, I’m a gynecologist and I’m going to explain why you shouldn’t.

It’s not that people can’t technically pull out their own IUDs. It does happen accidentally, albeit rarely. An occasional …

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Open access endoscopy raises potential ethical issues

Conditions
July 2, 2016

Like nearly every gastroenterologist, we have an open access endoscopy system. This means that patients can be referred, or refer themselves, directly to our office for a a procedure without an office visit in advance.

Why do we do this? We offer it as a convenience, so patients do not need to make two visits to see us when it is clear that a procedure is necessary. For example, a referring …

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New doctors may be more unprepared than ever

Education
July 1, 2016

July is back, and clinical faculty at teaching hospitals have again braced for the annual deluge of new residents just beginning their specialty training. Unfortunately, our new doctors may be more unprepared than ever.

The gap between medical school (the four years leading to the MD degree) and residency (advanced training in a particular field) has widened over the past several years. Changes in the health care system, shifting patient expectations, …

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It’s time for physicians to demand a national medical license

Physician
June 30, 2016

The practice of medicine in the United States is almost entirely based on national guidelines and regulations. Minor, inconsequential differences may exist from state to state, but nothing significant enough to justify the current requirement of comprehensive, redundant licensing of physicians in each individual state in which they practice.

Notably, in an uncommon example of federal common sense, physicians can work at any Veterans Administration facility, in any state, with any …

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CME Spotlights