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The referral system to specialists: It’s a nightmare

Physician

April 7, 2018

I need your help.

I’m trying to figure out how to get rid of something that’s terribly broken in our process of taking care of patients, and I can’t do it alone.

It’s time to kill the referrals process, get rid of them altogether.

Every day, a huge proportion of the messages we receive through the electronic health record are requests for us to “put in a referral.”

Patient has low back pain, has …

MKSAP: 41-year-old woman with burning epigastric and chest pain

mksap

Conditions

April 7, 2018

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

A 41-year-old woman is evaluated in follow-up after presenting to the emergency department 1 week ago for burning epigastric and chest pain. In the emergency department, a complete blood count and liver chemistry studies were normal, but a radiograph of the chest and upper abdomen demonstrated calcified gallstones. The pain resolved with administration …

If you go to medical school, you will be stressed: bigly

Skeptical Scalpel, MD

Education

April 6, 2018

Two recent posts highlight the problems facing many medical students today.

The first was by an anonymous rising fourth-year student who has come to the conclusion that going to medical school was “a terrible, terrible decision.” It ended with a comment that medical school “is not fun. It’s jarring, scary, disappointing and absolutely depressing.”

The second was by another anonymous student who described how miserable he (or she) has been …

The unintended meaning behind medical schools’ pass-fail system

Johnathan Yao, MD, MPH

Education

April 6, 2018

In recent years, there has been a push across medical schools to change the grading scale towards that of a pass-fail system. The appeals of a pass-fail system to me were obvious. Instead of worrying about my grades as I had in college to maintain an adequate enough GPA to get into medical school, I believed that merely passing would lessen much of the pressures I faced as an undergrad.

Those …

When you leave primary care, you leave people behind

Anonymous

Physician

April 4, 2018

“The ones you leave behind …”

That phrase often connotes loved ones who have lost a family member, friend or colleague through death.

I have thought of the same phrase often lately in a different context — one of increasing prevalence.

Here, I refer to the patients and colleagues left behind by the loss of a primary physician.

No one would begrudge the retirement of a physician who has served his or her patients …

Physicians must learn to say no

Varun Verma, MD

Physician

April 4, 2018

As a physician, is it acceptable to say no? After working as a hospital medicine physician across five different states and internationally, I’ve realized that saying no is actually imperative. Physicians are stretched thin, abused, demonized and expected to be superhuman when it comes to patient care. We secretly complain in online forums, we commiserate with other physicians in on-call rooms, sometimes we even seek mental health help, but rarely …

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Physicians must learn to say no

Doctors wear white coats. But what do their spouses wear?

Lara McElderry

Physician

April 4, 2018

When we first met and got married, my husband Josh wanted to be a math teacher. Since I was also pursuing a career in teaching, I thought this was a great idea. I envisioned both of us teaching together in the same school district for forty years, becoming local superstars! We would know all the kids in town and spend our summer vacations traveling to exotic locations around the globe. …

Is surgical training stuck in the past?

Justin Barad, MD

Physician

April 4, 2018

When we look back on the last century, the pace and number of advances in our ability to treat disease and injury is truly astonishing. The exponential growth of technology has contributed to this greatly, as we see new advances often come in the form of new technologies. Amazing innovations in the fields of endoscopy, catheterization, robotics, imaging, navigation, 3D printing and more allow us to do things that were …

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Is surgical training stuck in the past?

How to do risk-adjusted diagnosis coding the right way

Betsy Nicoletti, MS

Policy

April 3, 2018

Medical practices with risk-adjusted contracts must sharpen their diagnosis coding. Practices that are part of accountable care organizations (ACOs) or that have risk-adjusted contracts with commercial payers have an economic incentive to accurately report the disease burden of their patients. In fee-for-service medicine, physicians are paid based on the fee schedule associated with a CPT code, and any modifier attached to that code. The diagnosis code establishes the medical necessity …

So you missed the bull market. What can you do now?

Wall Street Physician, MD

Finance

April 2, 2018

We are now nine years into the current bull market, and the S&P 500 has risen over 300% from its March 2009 low.

Unfortunately, there are some investors that have been left behind. They sold their stock in 2007-2008 and never got fully back into the stock market. For example, a reader on the Bogleheads forum recently posted this question:

“I have had about $450k sitting in cash for too …

5 things pathologists want other doctors to know

Collin O'Hara, MD

Physician

April 1, 2018

1. Clinical history is important. What did you see when you took the biopsy? Was there a mass there? Does the patient have a history of malignancy? These are all important questions, and they help pathologists arrive at the most accurate diagnosis possible. Rarely, the best we can give you is a differential, but the more clinical information given to us, the more likely we can narrow things down and pinpoint …

3 ways to better deal with negative interactions

Suneel Dhand, MD

Physician

April 1, 2018

Following a recent article about 3 things we need to be teaching more to our students, I received some good and thoughtful correspondence.

The part which seemed most interesting (for me as well to write) was about being more resilient. I wanted to expand a bit more on this, since I know people may have questions about what I do myself, to be a more resilient person. …

The first time this doctor hated a patient. And what he did next.

Joshua Goldman, MD

Physician

March 31, 2018

“Dr. WHAT?!” she spat.

“Gold … man. Gold, like the precious metal, and, y’know — a man.” This carefully crafted response was curated and vetted by countless returned pages, and it rarely failed to produce a chuckle. The patient was not amused, and she referred to me, instead, with a disdainful, “Rosenberg.” Every day I re-introduced myself, and every day — “Rosenberg.”

This 36-year-old female admitted for road rash and multiple rib …

How silence can help us learn from our patients

Anne Katz, RN, PhD

Conditions

March 29, 2018

As the patient talked, I found myself nodding my head. In so many ways, she was just like me. Highly educated, a professional, a woman who had worked hard and long to get where she was. And then cancer took it all away, or at least that’s the way she described it. She was diagnosed with metastatic cancer one year …

Are there too many female OB/GYNs?

Jennifer Gunter, MD

Physician

March 29, 2018

The Los Angeles Times recently published a piece on the lack of men in OB/GYN. Only 17% of new trainees (residents) in OB/GYN are men and the male OB/GYN physicians who weighed in worried that this “lack of diversity could weaken the field.” Apparently, it sends a “horrible message to men,” and with the lack of men we might “lose the next person who is going to find a cure …

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Are there too many female OB/GYNs?

What should physicians look like? Should it matter?

Maria Yang, MD

Physician

March 28, 2018

I don’t remember her name, but I do remember her light brown hair, the simple nose ring that looped out of her left nostril, and the calm and centered presence she had with patients. She came across as unassuming, professional, and caring. We were both in medical school, though she was two years behind me. I admired how she treated people.

I don’t remember his name, but I do remember that …

An emergency physician delivers a baby, and realizes that it isn’t for him

Edwin Leap, MD

Physician

March 27, 2018

I’m an emergency physician. In common parlance, an ER doc. Which means, like a little kid who will eat dirt on a dare, there’s not much I won’t try in the practice of my profession. Many of my colleagues have had far more challenging careers than me, I assure you. But I have some stories to tell. Cyanide overdose while moonlighting as a resident. Patient nearly dying from bite by …

Clinical plagiarism: the problem of copy and pasting in EMRs

Eric R. Gottlieb, MD

Tech

March 26, 2018

It is all too common for a section in a progress note to look something like this:

# Aspiration pneumonia:

Continue vancomycin 1 g bid

Continue Zosyn 3.325 g q6h

Follow-up blood cultures

Follow-up sputum cultures

MRSA nares screen negative

Blood cultures negative

Discontinue vancomycin

Yesterday, a version of this note (lines 1 to 5 to be precise) had my name on it. Today, it is signed by someone else. Read it …

Learn typical community acquired pneumonia with a Medcomic

Jorge Muniz, PA-C

Conditions

March 26, 2018

Community-acquired pneumonia (CAP) is an acute infection of the lung parenchyma acquired outside of the hospital or less than 48 hours after hospital admission. CAP is classified into typical and atypical subtypes, differentiated by their presentation and causative pathogens. This illustration focuses on the classic features of typical CAP.

The most common cause of typical CAP is Streptococcus pneumoniae. It is an encapsulated, gram-positive, …

The medical student who cries

Orly Farber

Education

March 25, 2018

I’m a default crier. I happy-cry, stress-cry, romantic-comedy-cry, regular-comedy-cry and, apparently, I even doctor-in-training-cry.

Crying is a tough response, especially for someone who wants to take care of sick patients. My default reaction poses challenges for my future career. I had my first taste of this when a patient actor brought me to tears. An actor? That’s ridiculous, you might think. It was all pretend and yet, I broke down. I’m …

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The medical student who cries

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