Test your medicine knowledge: 55-year-old man with elevated liver enzymes

Conditions
October 10, 2015

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

A 55-year-old man is evaluated during a routine examination. He feels well other than mild knee pain. He drinks six to eight cans of beer per night. He has no personal history of liver disease, but his older brother was recently diagnosed with hereditary hemochromatosis.

On physical examination, vital signs are normal; BMI is 24. He …

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The aroma of medicine can be found everyday in hospitals

Physician
October 9, 2015

As a physician, you are required to have keen senses.  Touch, smell, hearing, and sight are absolute necessities for most practicing physicians while we can only hope that taste is reserved for meals and non-professional situations.  I recently returned from a week of vacation in the great outdoors and found myself wishing that I had more olfactory agnosia.  Olfactory is a Latin adjective from olfacere that translates “of or relating …

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A patient turns down hypertension treatment. What happens next is tragic.

Physician
October 8, 2015

I have previously written about a patient on this site: “How elderly patients can be stubborn to their own detriment.” In that post, I discussed how the patient repeatedly turned down appropriate therapy for her hypertension, saying she didn’t need the help.  Now I’m writing an update.

Due to the patient’s refusal to accept treatment for her hypertension, despite counseling on the part of her cardiologist and primary care …

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Terminal dehydration: A gentle way to die?

Physician
October 7, 2015

My father suffered a massive stroke on a September night not long after his 83rd birthday. It left him conscious yet unable to talk and communicate, unable to swallow and almost completely paralyzed.

After numerous scans and other tests, his doctors determined that there was no chance of recovery. My father would never walk, talk, or swallow food again. With nothing more to do for him in the hospital, we — …

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The surprising reason behind an early refill of alprazolam

Physician
October 2, 2015

Theresa arrived in a cloud of noise and commotion.

She had called after four o’clock the day before, but I hadn’t noticed the new message in my electronic inbox before I left the clinic.

Her almost brand new alprazolam bottle and her pain pills were missing, and Theresa was reeling. As she walked down the hall to the exam room, I heard her explain to Autumn how she had been to Walmart …

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Bundled payments means the death of quality medical care

Policy
September 30, 2015

A recent CMS proposal to bundle payments for doctors and hospitals for hip and knee replacements in 800 model centers has hit a roadblock. The five-year program would have begun January 1, 2016, and nearly 300 comments were received by CMS earlier this month. Apparently most of the comments were not, shall we say, favorable. Even the Federation of American Hospitals protested

For those who are unaware, “bundled payments” means that …

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It’s time to remove EHR gag orders. For patient safety’s sake.

Tech
September 29, 2015

I recently read an article in Politico entitled “Doctors barred from discussing safety glitches in U.S.-funded software.”  The article states that, despite massive public funding of electronic health records (EHR), the EHR corporations (including Epic Systems, Cerner, Siemens, Allscripts, eClinicalWorks and Meditech) routinely attach gag clauses to contracts with the hospitals and medical groups who purchase their systems. We are talking about gag clauses that prevent criticism by …

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Medical Jeopardy is a terrible way to learn. Here’s why.

Education
September 28, 2015

Confession time: I despise presentations that involve the use of a PowerPoint Jeopardy! game. To be clear, I get uncomfortable when any game-like activity appears in a medical teaching presentation.

Not that I don’t think games can have an important role in education — far from it. Heck, I once worked on a presentation that turned our residency conference room into a giant Game of Life board with …

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Health inspectors should be trained to do what doctors do

Physician
September 28, 2015

This story is a great one.

It’s about a female dog with only three legs. Her fourth leg was amputated following a traumatic accident as a puppy.

Now, when she walks, she has a hitch in her step. And, when she hitches, she kicks the stump of her injured leg outward.

Step, step, hitch. Step, step, hitch.

One day, the female dog has puppies. And, her puppies do what all puppies do. They nurse. They watch. …

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How call rooms reflect the personality of residency programs

Physician
September 27, 2015

An intern pushed open the call room door so that twelve medical students could crowd their eager faces together to see where we might sleep for the next three years. Only a few months away from medical school herself, the intern acted as if sleeping in such quarters were second nature. She gestured to the fluffy quilts the residents had brought from home to adorn their beds and giggled about …

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Test your medicine knowledge: 27-year-old woman with an intensely pruritic rash

Conditions
September 26, 2015

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

A 27-year-old woman is evaluated for a 1-week history of an intensely pruritic rash on her eyelids. She applied a new brand of eye makeup just prior to the onset of the rash. She immediately discontinued its use and has been applying a moisturizing lotion to both eyelids since then without improvement in her symptoms. …

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Do patients contribute to the God complex in surgeons?

Physician
September 23, 2015

Medical oncologist, Dr. Ranjana Srivastava wrote on the subject on how doctors treat doctors may be medicine’s secret shame in the Guardian back in February 2015.

About a month later, vascular surgeon Dr. Gabrielle McMullin used a book launch speech to expose the problems of sexual harassment in the surgical profession.  She highlighted a story of where a neurosurgical trainee had refused sexual advances and subsequent to launching a formal complaint, …

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It is time for an honest conversation about money and cancer

Physician
September 22, 2015

There are two, old, particularly nasty rumors, about cash and cancer. The first, which seems to be fading, is that scientists cured the disease long ago, but the pharmaceutical industry suppresses the cure so they can get rich selling worthless therapies. This never made sense to me, since the company or person that cures cancer will be rich beyond anyone’s wildest dreams. In addition, I have personally known several thousand …

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When patient-centered care becomes patient-dictated care

Physician
September 21, 2015

“I’d like an MRI for my leg pain. I haven’t had an MRI for many years, and I’m worried.”

These were some of the first words I heard from a patient I was seeing for a new patient visit. Based on this patient’s story and physical exam, her pain was most consistent with a muscle strain. My preferred approach to manage this complaint was to ask the patient to rest her …

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How good of a clinician are you?

Physician
September 21, 2015

In psychology, the Lake Wobegon effect refers to a mythical town where “all the women are strong, all the men are good-looking, and all the children are above average.” In other words, humans have a tendency to overestimate their capabilities, particularly in relation to others.

As a physician, I have yet to meet a fellow doc who didn’t think that their patients loved them or that they weren’t great clinicians. And …

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Pain tolerance: A story of two patients

Physician
September 21, 2015

One thing I learned early on as a doctor is different people have different tolerances for pain.  At one end of the spectrum, for example, I recall a woman who came to the emergency department with a small splinter in her foot.  She arrived wailing in pain, and we had to take her back to a treatment room ahead of other patients because her howling was scaring the people in …

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The story of the pot-smoking neurosurgeon is more complicated than you think

Meds
September 20, 2015

A brief article recently posted the name and picture of a neurosurgery resident accused of smoking marijuana on the job.  Dr. Gunjan Goel, MD is a neurosurgery resident at University of California, San Diego, and the list of her awards and publications alone is almost as long as my entire CV.  The article is brief, and rather uninformative.  The only facts that are known are this: The …

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Caring for the dying patient is a rewarding challenge

Physician
September 17, 2015

I walked silently into the pristinely decorated room of the hospice facility and was greeted by her family.  She lay there, not particularly responsive to her surroundings under the pressure and influences of metastatic stomach cancer.  The warmness and smiles on the faces of her family told me that at some point and somehow, in the midst of actively witnessing the transition of their mother, aunt, sister, and grandmother, they …

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