Patients sometimes have good reasons to refuse colonoscopies

Conditions
January 22, 2014

Many times over the years, I have witnessed the following scenario in my exam room.

Here’s the set up of this one act play.

Characters:

Elderly patient
Attentive daughter
The doctor

Scene 1

I’m seated at my desktop computer. The patient is seated before me. The patient’s daughter is seated next to her mother.

A patient comes to see me in the office with medical issues that strongly suggest that a colonoscopy should be performed. As an aside, …

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Reflecting on the history of smoking cessation

Conditions
January 16, 2014

In 1950 Ernst Wynder, MD and colleagues began to produce convincing data that cigarette smoking caused lung cancer. Over the ensuing many years evidence has arisen linking cigarette smoking to many different cancers, chronic lung disease and heart attacks.

In 1964 the surgeon general reported that cigarette smoking was the most important risk factor for development of lung cancer and that quitting smoking reduced that risk. Since that time a concerted …

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When doctors disagree: What should you tell patients?

Physician
January 14, 2014

A recent research article in the Journal of General Internal Medicine, and the gap between its findings and the real world, helps point up the usefulness and limitations of research. The article, by Susan H. McDaniel, PhD, and coauthors, set out to determine how often doctors speak about their colleagues in supportive or critical ways.

Their method is one widely used in the field: simulated patients, actors, were prepared with lifelike …

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Lebron James: The king of junk food

Conditions
January 13, 2014

lebronfood

Lebron James makes over $19 million per year playing basketball for the Miami Heat. Not surprisingly, this salary is peanuts compared his endorsement earnings, which in 2012 topped $42 million. Although perhaps peanuts is the wrong word to use when discussing James outside earnings, which to my knowledge have not involved foods anywhere near as healthy as peanuts. Instead, according to …

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A culture of contempt has led to medicine’s downfall

Physician
January 13, 2014

“Doctors are crooks.”

“They’re getting worse than lawyers.”

“I don’t go anymore. They’re just out for a buck, and they don’t really do anything for you anyway.”

“I stopped getting checkups when my old one retired. He was good, took his time. I haven’t found anyone like him since.”

“They always think they know everything … a bit too much self-importance there, without ever walking in my shoes.”

“They all say the same thing; it’s …

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Increase patient and provider satisfaction by reducing phone messages

Physician
January 12, 2014

Incoming telephone calls should be a good thing in a medical practice, right? Requests for appointments from new patients and established patients are the lifeblood of the practice. But for many practices, the phones are an overwhelming burden for everyone, from the receptionist and nurse to the provider with an inbox full of patient messages to sort through.

In general, approximately 25% of incoming calls to a medical practice are repeat …

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The stigma of becoming a psychiatrist

Physician
January 11, 2014

I’m coming out, but it isn’t what you’re thinking.  I’m writing this to finish answering a question that I was asked 25 years ago by an attending physician.  He was a Scotsman with a ruddy complexion and it was early in my third year of medical school.  I had been up since 4am rounding on patients and then assisting on a general surgery case.

Answering the esoteric questions the Scotsman posed had …

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The cost of peace of mind: A case of unneeded bilateral mastectomy

Conditions
January 10, 2014

I don’t have much in the way of eyebrows.  They were victims of too much plucking back in the 1960’s and when you do that, sometimes they don’t grow back.  There’s a very nice woman in Solana Beach who shapes and darkens what I have left, infrequently, when I bother to think about it which isn’t very often.

I was in there about a year ago when she told me, “I …

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A patient falls off the OR table: Who’s to blame?

Physician
January 9, 2014

An anesthetized patient fell to the floor headfirst from an operating room table during a laparoscopic appendectomy in Scotland. The table had been tilted into an extreme head down position to facilitate the operation. Fortunately, no injury occurred.

The Edinburgh Evening News account says that there were 10 staff members in the room at the time the case started, but no one had placed a safety restraint on the patient.

A follow …

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Why Medicaid patients use the emergency department for primary care

KevinMD
January 3, 2014

A study from Science found that those on Medicaid in Oregon made 40% more visits to the emergency department.

The Oregon Health Insurance Experiment included about 90,000 low-income people and assigned 30,000 of them to Medicaid by lottery. It’s essentially a naturally-occurring randomized controlled trial.

The result seems to have caught the public policy experts by off guard:

“I suspect that the finding will be surprising to many in the policy …

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Holding children back a grade and ADHD: A problem or solution?

Conditions
January 3, 2014

I’ve been skeptical of the trend of “holding back” children with late birthdays. These are kids, usually born in the summer, who are just a few months short of the next grade cut-off. Some parents wonder whether it would be wise to hold them back a few months, so they end up one of the oldest (rather than youngest) kids in their class. This might seem to confer an advantage …

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Our spiritual state can influence how physical ailments feel

Physician
January 1, 2014

The pediatrician Margaret Mohrmann tells the story of caring for a young girl in the ICU who developed a devastating case of meningitis. One day when she came to check on her patient, the girl’s mother asked Mohrmann why her daughter had become sick. As Mohrmann began to explain what meningitis is and how it is transmitted, it quickly became clear to her she was missing the meaning of …

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When does false hope become malpractice?

Physician
January 1, 2014

10:11am Tuesday, June 5, 2006:  This was the moment Marge was told the mammogram showed a mass, which was probably breast cancer.  “But, don’t worry, the tumor is very small and with surgery and radiation, you will be fine.”

1:55pm Wednesday, March 25, 2009: This was the moment Marge was told that the breast cancer had spread to her ribs. “But, don’t worry, the tumors are small, and with hormones, you …

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How many patients can a doctor safely see a day?

Physician
December 31, 2013

Today’s question is a simple one. How many patients can a physician see in one day and still be thorough? Don’t get me wrong; I’m all for efficiency. But we need to recognize when efforts at efficiency become “medical sloppiness” or, frankly, malpractice.

With health care policy and insurance reimbursement what they are today, it’s not uncommon to encounter physicians seeing forty, fifty, and even sixty or more patients a day …

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Why are doctors the worst patients?

Physician
December 31, 2013

We’ve all been there. You’re in medical school, sitting in a lecture hall — maybe the course is pathology — and for the first time since starting your studies, you’re actually learning about real diseases, not just benzene rings and the Krebs cycle. You’re furiously note-taking, and you reach back to work out a kink in your neck. There it is! A palpable, enlarged lymph node. You have lymphoma. You …

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The job of the modern doctor is to convince

Physician
December 29, 2013

The job of a doctor isn’t to diagnose, prescribe, or examine.  It isn’t to be well read, efficient, or punctual.  The job of the modern doctor is to convince.

We now have radiological studies whose theoretical discernment limit is subcellular.  We can not only map clear and obvious genetic errors of metabolism, but also minor variations of the normal.  In a few years, the majority of codes in the procedure manual will probably be laboratory …

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5 universal problems hospitals need to solve

Physician
December 27, 2013

As health reform sets in, hospitals are gearing up for many challenges. While some of these are new to the health industry, several are against the backdrop of old problems that have plagued us for decades. Speaking as a doctor who has worked in a number of different hospitals up and down the east coast, I would like to identify 5 of these that I believe are fairly universal.

1. Medication …

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These are the people who work in a hospital

Physician
December 26, 2013

Who works at a hospital? (Again, just indulge me for now.)

Doctors. If you’re a patient at a teaching hospital, this includes medical students (people in school to become doctors), interns and residents (people who have earned the title of “doctor”, but who are still learning their craft), and attendings (people who have completed their formal training as physicians). If you’re not at a teaching hospital, it’s less likely you’ll see medical …

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When children are abused by foster parents

Physician
December 26, 2013

I click open the x-ray viewer.  After 4 years in emergency pediatrics, I am not really surprised that a tibia fracture underlies the bruised ankle I unexpectedly encountered on physical exam.  Yet I audibly gasp as the chest x-ray loads.  The torso in question belongs to a chubby little cherub of a 3-month-old in room 11, brought in for red eyes.  I begin to count the fractured ribs — 1, …

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