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In oncology, hoofbeats are nearly always from zebras

Physician

January 29, 2013

It happened again today. A youngish man, age 59 (youth being relative these days) comes in for a consultation. His history began eighteen months ago when he started to notice hoarseness. Thinking he had laryngitis, he saw his primary care doctor. He was indeed diagnosed with laryngitis despite the fact that he had not been shouting for his grandson at the local soccer playoffs, nor had he had upper respiratory …

Countertransference is a reality that must be grappled with

Ilana Yurkiewicz

Medical Education

January 29, 2013

“Sometimes, how you feel at the end of an interview can be clinically revealing,” my preceptor says. “How does this patient make you feel?”

***

“Mr. M?” I ask gently, knocking on the hospital room door. “May I come in?”

“Hello? Hello?”

I enter at what I think is an invitation to me, but see that 79-year-old Mr. M is speaking into the phone instead.

“I’m sorry, I can come back…” I start to say. …

Is consolidation the answer to healthcare’s fragmentation problem?

Margalit Gur-Arie

Health Policy

January 29, 2013

Adam Smith would disagree, Karl Marx would be appalled, and heck even Milton Friedman and Ayn Rand would be raising objections. But for some peculiar reason, there are enough contemporary lesser economic minds scattered throughout the entire philosophical spectrum, that are advocating for, and enabling the execution of, a government induced transition of our health care system to an oligopoly model …

Seemingly small connections with patients refresh and revitalize me

Loreen Herwaldt, MD

Physician

January 29, 2013

As far back as I can remember, I’ve deliberately spent my life on the high road. I was the seventh-grader who was told by adults that she was very serious. I was the college student who majored in chemistry because it was the strongest premed major. I became a doctor.

Before becoming a doctor, I imagined that I would be the epitome of compassion. I envisioned pausing for a moment before …

Vaccines: Those who forget history are doomed to repeat it

Davis Liu, MD

Medications

January 29, 2013

Those who forget history are doomed to repeat it. Most of us have not had personal experience with illnesses like measles, mumps, German measles, or polio. Thank goodness for that. It is because a generation ago individuals, families, and doctors choose a different path. They witnessed loved ones stricken with these diseases. When the opportunity arose to protect themselves from these …

Who really won when Accutane was pulled off the market?

Michael Kirsch, MD

Medications

January 28, 2013

I was engaged in one of my pleasures, sitting in a coffee shop leafing through medical journals. Usually, I am perusing newspapers. I spend many hours each week combing through various newspapers and routinely forward items of interest to folks of interest. No newspapers today. I have a few gastroenterology journals to look through. My professional reading habits have evolved over my career. I am more interested in reading about …

Taking care of other physicians and their families

James C. Salwitz, MD

Physician

January 28, 2013

Terry is a particularly difficult patient. She is not hard because of her cancer, which is in remission, nor is there a problem with pain, of which she has little, and Terry is not particularly demanding for the nursing staff. No there real problem, the challenge, the thing that makes her so difficult is that Terry is married. Terry is married to Dr. P and he is a particularly difficult …

Why I’m saying goodbye to football

Jeffrey Parks, MD

Conditions and Diseases

January 28, 2013

Junior Seau had CTE, chronic traumatic encephalopathy, the degenerative brain disease known to afflict individuals who have sustained repeated head injuries over time.

Junior Seau played football his whole life and was never officially diagnosed with a concussion. Last May he sat down one day and shot himself in the heart. Dave Duerson, the former Bears safety, did this too, as a way to …

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Why I’m saying goodbye to football

A hospice visit: We will sing together again some day

Rick Boulay, MD

Physician

January 28, 2013

I mustered up the courage to visit Mary today.

Pulling into her driveway, I was greeted with the majesty of autumnal brilliance—golds, rusts, and crimsons set against a brilliant azure sky. A bold display of nature’s defiance against the upcoming long winter’s sleep. Not to be ignored, those leaves that had flamed out early chattered against my every step as I slowly ambled toward the doorway.

I took a deep breath and …

The only way to accomplish big things is to do the little things

Rob Lamberts, MD

Physician

January 27, 2013

Sorry for not posting for a while. It’s not that things have been quiet; they definitely haven’t been.

Here’s the update:

The construction has been delayed, so the office will open on the 28th of this month at the earliest. Inspectors are a pain in the buttocks.
This delay has kept me from hiring staff, as I need to have a solid start date for them.
The extra time has allowed me to do …
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The only way to accomplish big things is to do the little things

One day of a psychiatrist at a geriatric adult home

Maria Yang, MD

Physician

January 27, 2013

A sample agenda as the consulting psychiatrist at a geriatric adult home:

8:20am. Arrive at the concrete building. Wave through the locked glass door at the woman sitting behind the desk. She pushes a button and the door buzzes. Pull the door open. Say good morning. She never sounds cheerful when she replies, “Good morning.”

Because there is no open stair access, take the elevator up one floor. It travels slowly. The …

Why should I try to find compassion for Adam Lanza?

Alex Lickerman, MD

Physician

January 27, 2013

Like most Americans, when I learned that twenty children and six adults had been massacred in Newtown, Connecticut, I recoiled. Like most parents, my next thought was for my own son, the image I retain of his happy, smiling self for one moment replaced by an image of his tiny body lying twisted on the ground. Even as I write these words, an emotion I rarely feel—one I often can’t …

MKSAP: 71-year-old man with new dyspnea on exertion

mksap

Medications

January 27, 2013

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

A 71-year-old man is evaluated in the emergency department for new dyspnea on exertion. He has a 15-year history of type 2 diabetes mellitus and has had a number of changes in his medications over the past 12 weeks to improve glycemic control. His dosage of metformin has been increased to 1000 mg/d, glyburide …

The closing of a mental health facility in Newtown

Deep Ramachandran, MD

Physician

January 26, 2013

I wrote in a previous post about what life was like growing up in Newtown, Connecticut. It truly is a picturesque New England town. But what might be surprising is that within that town sat a gem. A hundred acres of wooded rolling hills within which sat an inner campus of professionally landscaped and meticulously manicured grounds crowned with stately and handsome brick buildings in a colonial architectural style. These …

Patients need to be involved in quality metrics

Kyle Bradford Jones, MD

Physician

January 26, 2013

I recently heard from an aging and respected physician the old adage that “what is good for the doctor is good for the patient.” The room full of physicians of all ages and specialties nodded their heads in agreement. This saddened me, as it represents a physician-centric system that oftentimes leaves the patient’s needs and desires completely out of the equation.

An area of emerging importance in medicine, whose impact should …

When should physicians hire an IT consultant?

Rosemarie Nelson

Health Technology

January 26, 2013

Should physicians use a consultant to help choose a practice management system or EHR for their practice? According to recent Medical Group Management Association surveys more than 50% of physicians used the services of a healthcare consultant or firm at least once in the previous 3 years.

But did they have to? Was it a smart move?

The answer: It depends

Not every practice needs a consultant’s assistance when replacing and choosing …

MKSAP: 38-year-old man with ulcerative colitis

mksap

Conditions and Diseases

January 26, 2013

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

A 38-year-old man is evaluated during a routine examination. He was diagnosed with ulcerative colitis 10 years ago and is currently asymptomatic. His last colonoscopy, performed at the time of diagnosis, showed mildly active extensive colitis extending to the hepatic flexure. There is no family history of colon cancer or colon polyps. His only …

Why I’m not sure that psychiatric medications work

Steve Balt, MD

Medications

January 25, 2013

I have a confession to make. I don’t think what I do each day makes any sense.

Perhaps I should explain myself. Six months ago, I started my own private psychiatry practice. I made this decision after working for several years in various community clinics, county mental health systems, and three academic institutions. I figured that an independent practice would permit me …

The culture of ruling out leads to misdiagnosis

Leana Wen, MD

Physician

January 25, 2013

May is a recent divorcee in her early sixties. She was working out at the gym when she began to feel queasy and lightheaded. She awoke in the back of an ambulance, and soon, she was in an ER getting blood drawn. “We need to make sure you don’t have a heart attack,” she was told.

As the day went on, May underwent test after test to “rule …

How will pay for performance ultimately impact the quality of care?

Thomas Santo, MD

Health Policy

January 25, 2013

“Pay for performance” made headlines again this week, when Health and Hospitals Corporation (HHC), the multi-billion dollar corporation which operates New York City’s public hospitals, announced that they will be linking physician reimbursement to pre-determined “quality” metrics and patient satisfaction scores.

This announcement comes quickly on the heels of details recently released by the Centers for Medicare and Medicaid Services (CMS) regarding its first Medicare payment adjustment to hospitals under the …

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