MKSAP: 67-year-old man with a carotid bruit

Conditions
November 23, 2019

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

A 67-year-old man is evaluated for a carotid bruit detected on routine medical examination. He reports no history of previous focal neurologic symptoms or visual loss. He has type 2 diabetes mellitus and hyperlipidemia treated with metformin, moderate-intensity pravastatin, and aspirin.

On physical examination, blood pressure is 128/64 mm Hg, …

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Stop telling doctors what to do

Physician
November 22, 2019

I enjoy a fairly small private practice and a manageable telepsychiatry side job with good support staff. But even the small scale of my outpatient clinical practice doesn’t fully insulate me from the pain of unnecessary practices that I wish would become obsolete.

1. Preauthorization. The dance of preauthorization starts with the naivety on my part that I decide what medication my patient should be on. I spend precious time crafting …

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Medicine’s not what it used to be

Physician
November 22, 2019

When I was accepted to medical school, I debated — hard — whether or not to attend.

Out of the physicians I shadowed and interviewed, 19 out of 20 advised me not to become a physician.

Their dissatisfaction was rampant.

Over and over, I was told, “Don’t be a doctor. Medicine’s not what it used to be.”

They spoke of concerns ranging from unreasonable work expectations to inhumane conditions. They described insurmountable pressure, decreasing …

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Are Americans really the worst patients?

Physician
November 22, 2019

A recent article was published in the Atlantic about Americans being the worst patients.

Americans are part of a broken and dysfunctional health care system with exorbitant costs, a maelstrom of bureaucratic red tape, and insurance coverage that barely covers what most people need.

But are they contributing to this system by being such bad patients?

The article in the Atlantic seems to imply that this is the case. The …

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What would an optimal libertarian health care system look like?

Policy
November 21, 2019

Next in a series.

In prior posts, I described my Healthcare Incentives Framework. If you haven’t read those, I recommend you check them out first to have the full context for this post. But here’s a refresher of the main points of the framework without re-explaining all the rationale:

The Healthcare Incentives Framework helps show how to fix incentives in health care systems. It starts by enumerating …

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Why choose a woman doctor?

Physician
November 20, 2019

Like all doctors, I’m a lousy patient. My doctor is a lovely man, but going to see him? That’s right there with weighing myself, getting a flu shot and doing my taxes, and behind celebrating Thanksgiving with the in-laws and getting a root canal.

And I’m not the only one. If I had a dollar for every patient who told me they hate doctors (no offense), I’d be long retired.

If you’re …

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A call to increase the availability of the Butrans patch

Conditions
November 20, 2019

Janelle had overdosed 32 times.

Fentanyl coursed through her veins as she was given naloxone (Narcan) for the 32nd time in the ER, from the police, from a bystander. She could never get off of fentanyl. It had made her feel warm and numbed her from the trauma and horrors she had grown accustomed to. When she would wake up in the hospital, sore and discombobulated, she would beg for help. She …

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Choosing family over medicine: Why I decided to leave clinical medicine

Physician
November 19, 2019

When my obstetrician told me I was not going back to my clinic that afternoon due to severe preeclampsia, I was so indoctrinated that my first thought was of the inconvenience to my patients who would need to be rescheduled. Only a few minutes later did it register that I would be giving birth sooner than I had anticipated, and my new life as “working mother” would begin.

I was due …

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The problem with reducing physician salaries

Finance
November 18, 2019

Health care is big business, with medical practices vying for contracts, hospitals undergoing facelifts in order to cater to patient experiences, and insurance companies making deals with pharmacies.  Some of these arrangements are negotiated in the name of reducing health care spending, but there has to be some skepticism when for-profit entities are implicated.  Physician salaries aren’t exactly growing with inflation—some fields have had massive cuts in spending over the …

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3 things every hospital should invest in

Physician
November 18, 2019

In the current health care system, patient outcomes, and patient satisfaction are increasingly important. With the hospital value-based purchasing program, Medicare adjusts payments to hospitals based on the quality of patient care they provide. Hospital consumer assessment of health care providers and systems scores are tied to Medicare reimbursements. Under the hospital-acquired condition reduction program, hospitals in the highest quartile of hospital-acquired conditions are subject to a 1 percent payment …

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Don’t judge patients for researching their health issues

Physician
November 17, 2019

It’s difficult to imagine a world now without Google and the internet. It’s also strange to think that most people alive right now received the bulk of their education in the pre-internet era. I remember in the United Kingdom, where I went to medical school, Google only became a thing perhaps midway through university. Since then, of course, the internet has exploded and penetrated every facet of our lives. And …

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Don’t forget to manage your patients’ dignity

Physician
November 16, 2019

Just before I induced anesthesia, he said, “Doc, I want to apologize beforehand. I am incontinent due to a previous surgery so I might wet the sheets.”

I told him not to worry and that we understood and that “these things do happen.” His response has stuck with me: “Doc, but there is still some shame.”

I nodded, told him not to worry since he was going to get a catheter anyway, …

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Doctor by day, law student by night

Physician
November 16, 2019

I am a middle-aged, full-time emergency physician, and part-time law student. Usually, I practice medicine during the day and attend law classes in the evening. Sometimes I have law classes in the afternoon or early evening then work in the emergency department all night.

So, what’s harder: medical school or law school?

Absolutely the most common question I am asked by physicians, attorneys, and students at all levels of training.

The other most …

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Lawyers have figured out what doctors haven’t

Physician
November 15, 2019

Dear lawyers:

You got it right. Your operations make sense. I know this is wrong for me to say — doctors and lawyers are often at odds with one another — but I have to tip my cap here. I have this unsettling feeling that — from a professional standpoint — your billing practices make sense. And the way you do your documentation also makes sense. Your delegation and hierarchy make …

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From a neurosurgeon: You need a family doctor

Physician
November 14, 2019

One of my favorite scenes in the recent Apollo 11 IMAX film was a dramatic panning shot of mission control moments before lift-off. Row after row of mission specialists, engineers, astronauts, communications technicians — all looking ahead in silent, unbreakable focus. All 100 percent dedicated to the three men about to lift-off into history. It was a truly mesmerizing portrait of teamwork.

While astronaut safety is the focus of every individual …

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It’s time to stop being skeptical of hospital chaplains

Education
November 11, 2019

What is your gut reaction when you hear the words “hospital chaplain?” Maybe it’s an eye roll or confused stare about what you believe to be an incoming attempt at religious conversion. As a family member anxious about a loved one in the hospital, maybe it’s a sigh of relief. As a patient, maybe it’s an overwhelming fear of incoming bad news. Health care chaplaincy is chronically misunderstood, beginning with …

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Debunking the myth that life gets easier once you finish medical training

Physician
November 11, 2019

Residents and fellows around the country have bought into the “medical training myth.” The myth states: “Life will get so much better when I finish residency/fellowship.”

Sadly, too many house staff buy into this false belief and experience tremendous letdown when they graduate.

Residents often see their attending stroll into the team room with a cup of coffee at 8 a.m., ready to round. Meanwhile, they think, “I’ve been …

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How we can help our veterans die in peace

Policy
November 11, 2019

The World War II veteran, now in his 90s and receiving hospice for end-of-life care, was playing military anthems on his harmonica for fellow veterans. But the next minute, reliving the horrors of combat, he grew agitated and started to cry.  “Oh, all those bodies!” he suddenly called out. “Terrible, terrible! Oh, the bodies.” He finally blurted out what he had kept to himself for decades. Two days later, he …

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