The evolving physician role in end of life decision making

Physician
August 10, 2014

I was taught in medical school (some 50 years ago) that doctors had a special duty to protect the patient.  That seemed self evident and logical.  “Do no harm” was a first principle dating back to Hippocrates. However the teaching I received extended the concept to also protect the patient from bad news, and to make “the right” decision for them — not necessarily including them in the conversation or …

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The evolving physician role in end of life decision making

Bringing the two Americans back home with Ebola: Is it worth it?

Conditions and Diseases
August 10, 2014

Ebola is a hemorrhagic fever that causes death by what seems like a virally induced stigmata. That statement could be even shorter. With a fatality rate that can reach 80 to 90% we could just say that Ebola is death.

The World Health Organization (WHO) says this most recent outbreak is “moving faster than our efforts to control it” and the CDC is calling this “The biggest and most complex …

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Bringing the two Americans back home with Ebola: Is it worth it?

What can medicine admissions learn from Google?

Medical Education
August 10, 2014

In a New York Times column, Thomas Friedman recent wrote about what Google values and seeks in its new employees. Striking to me was the fact that overall intelligence ranks lower on their values totem pole than several traditionally more important attributes.

So, what can medicine learn from Google and how can we apply it to our admissions process? Here are five key points from the article, adapted to our admissions process:

1. …

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What can medicine admissions learn from Google?

A primer on the anesthesia care team model

Physician
August 10, 2014

american society of anesthesiologistsA guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

Daily, and often several times a day, I am asked by patients about my role as a physician anesthesiologist.  Occasionally the answer involves reiterating to patients that an anesthesiologist is a physician.  Once we get into the discussion, patients are also surprised to learn that …

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A primer on the anesthesia care team model

10 potential benefits of robot caregivers

Health Technology
August 10, 2014

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My recent New York Times op-ed on robot caregivers for older adults has elicited curiosity, enthusiasm and controversy.

I have to admit that my own first reaction to the topic was captured in the Times’ letter from Sherry Turkle whom I mention in the piece. I was in a meeting and turned to a colleague, clumsily patted her on the back and said, “It … is …

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10 potential benefits of robot caregivers

Work-life balance begins in residency

Physician
August 10, 2014

A wise friend who had completed residency told me prior to my starting training that the key to having fun was “never sit down when you get home from work.”

Three years out of fellowship and practicing as a psychiatrist in Brooklyn, the words still resonate today.  The residents and medical students that rotate with me marvel at the stories of my full time acting career as a resident performing in …

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Work-life balance begins in residency

MKSAP: 25-year-old man with slowly progressive solid-food dysphagia

Conditions and Diseases
August 10, 2014

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 25-year-old man is evaluated for a 5-year history of slowly progressive solid-food dysphagia that is accompanied by a sensation of food sticking in his lower retrosternal area. He has compensated by modifying his diet and avoiding fibrous meats. He has not lost weight, and he has not had trouble drinking liquids. …

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MKSAP: 25-year-old man with slowly progressive solid-food dysphagia

I am so sorry I didn’t make this different for you

Physician
August 9, 2014

asco-logoThe telephone message arrived in my EMR’s inbox. A patient’s daughter had called and wanted to ask some questions about her mother. Her mother, Louise (name changed), had died about two weeks before.

I hesitated before calling her, recalling her mother’s cancer course.

Louise had been diagnosed with cancer at a relatively young age, in her late 40s. She received curative chemotherapy …

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I am so sorry I didn’t make this different for you

Context is crucial when deciding what to do with abnormal test results

Physician
August 9, 2014

Question: What do you do when presented with abnormal lab results?

Answer: Ask lots of questions.

The nursing home just sent over a urinalysis on a patient of Dr. Carlyle. I am covering his practice for a few days. The test showed that an 82-year-old woman had 3+ white blood cells in her urine. “NKDA” was written in the margin, indicating she had no allergies.

I sighed internally and called the nursing home. …

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Context is crucial when deciding what to do with abnormal test results

Are you a medical liberal or a conservative?

Medications
August 9, 2014

Our nation is highly polarized today, and often bitterly so.  Democrats rail against the GOP.  Pro-lifers face down pro-choicers.  Fox News disses MSNBC.  Isolationists push back against expansionists.  Traditionalists disdain the politically correct.  Free marketers duel against government advocates.  Carnivores deride the gluten-free crowd.  Martin Bashir trashes Sarah Palin, two proxies in a culture war.

There’s a philosophical divide among physicians also.  Would you prefer a liberal physician or a conservative …

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Are you a medical liberal or a conservative?

Learning from the lessons of night float

Medical Education
August 9, 2014

No medical resident looks forward to working night float. The initial glamour of doing chest compressions in the rising light comes up against a litany of administrative tasks. As the glamour wanes, the gulf between the objective curriculum and actual practice widens. On paper, residents learn how to manage acute emergencies and learn deeper clinical reasoning. Actual practice, or the “hidden curriculum” of training, can be a different experience, involving …

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Learning from the lessons of night float

Who is the better radiologist? Hint, it’s not that easy.

Physician
August 9, 2014

There’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes.

In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician?

Let’s consider two fictional radiologists: Dr. Singh and Dr. Jha.

Dr. Singh is a fast reader. Her turnaround time for reports averages 15 minutes. Her reports are brief with a paucity of …

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Who is the better radiologist? Hint, it’s not that easy.

The other vitamin C: Are you prescribing it?

Conditions and Diseases
August 9, 2014

As doctors we prescribe a lot for our patients — pain relievers, medications for specific ailments, exercise, or vitamins. However, too often we forget the power of vitamin C: human connection. As a therapist and medical doctor for children and adults with ADHD, I don’t underestimate the power of employing a variety of treatments that treat the patient as a whole; this may include medication, recommendations about diet, exercise and lifestyle …

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The other vitamin C: Are you prescribing it?

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MKSAP: 72-year-old man with community-acquired pneumonia

Conditions and Diseases
August 9, 2014

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 72-year-old man is hospitalized for treatment of community-acquired pneumonia. Despite 4 days of treatment with intravenous fluids and antibiotics appropriate for the bacteria cultured from sputum and blood, he remains febrile with mild tachycardia. The patient subsequently develops mild hypotension and is transferred to the intensive care unit. Results of two …

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MKSAP: 72-year-old man with community-acquired pneumonia

Progress notes are a poor tool for doctor-patient collaboration

Physician
August 8, 2014

OpenNotes is “a national initiative working to give patients access to the visit notes written by their doctors, nurses, or other clinicians.”  According to their website, three million patients now have such access, generally online.  Participating institutions include the MD Anderson Cancer Center in Texas, Beth Israel Deaconess in Boston, Penn State Hershey Medical Group, Kaiser Permanente Northwest, and several others.

Patients with a premium account in the My HealtheVet program at the VA have access to outpatient primary …

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Progress notes are a poor tool for doctor-patient collaboration

Educate your children about guns

Conditions and Diseases
August 8, 2014

There’s been an ongoing court battle here in the state of Florida over whether physicians have the right to ask families about gun ownership in their home.

The Florida Privacy of Firearm Owners Act was signed into law by Governor Rick Scott in 2011. This law prevents pediatricians from inquiring about gun ownership and discussing relevant safety information regarding how guns are stored and how to protect children from accidental injury. …

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Educate your children about guns

Cutting the wrong test at the wrong time

Conditions and Diseases
August 8, 2014

At the critical time when our nation has made meaningful and measurable progress against colorectal cancer incidence, threats to reimbursement for colonoscopy screening for Medicare beneficiaries are looming, which may jeopardize the effectiveness of public health strategies to increase screening and prevention of colorectal cancer in the U.S.

New data from the American Cancer Society indicate that colorectal cancer has declined by 30% in just the last decade among those aged 50 …

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Cutting the wrong test at the wrong time

One more thing syndrome: 4 tips for doctors to stay on time

Physician
August 8, 2014

“Doc, can I ask you one more thing?”

These words are classic symptoms for those patients suffering from the “one more thing” syndrome. We’ve all been there. The visit has ended, your hand is on the doorknob, and you’re about to leave the room. Precisely at that moment, your patient stops you and says he has one more thing to discuss.

You think to yourself, “No! I almost made it out of …

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One more thing syndrome: 4 tips for doctors to stay on time

Primary care should be paid for directly by the patient

Health Policy
August 8, 2014

Part of a series.

Primary care need not be expensive and until the past few decades it was paid for out of pocket. Heretical perhaps, but it would be very useful to go back again to paying the PCP out of pocket directly by the patient, preferably with a tax-advantaged health savings account (HSA).

A County Doctor wrote on his blog:

I can freeze a couple of warts in less than a …

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Primary care should be paid for directly by the patient

Why bad EMRs are forced on physicians

Health Technology
August 7, 2014

I recently did a tally.  Since starting my locums adventure last year, and going to full-time locums in January, I’ve worked in a grand total of 11 emergency departments.  Let me qualify that for the occasional visitor to my blog.  I decided to do this for purposes of flexibility, finances and a much needed change of scenery.  Not because I’m a problem physician, or unable to do the work in …

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Why bad EMRs are forced on physicians

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