Refusing the flu shot: Respecting the patient’s right to choose

Conditions
January 29, 2014

I’ve spent the past four weeks learning about primary care on my family medicine rotation. A significant portion of patient care in this setting is focused on health maintenance or disease prevention. Physicians can provide their patients with evidence-based recommendations for various screening tests and vaccinations, but it is ultimately up to the patient to decide what services he or she will receive.

According to the Centers for Disease Control and …

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Mohs surgery is vilified, physicians again fail to respond effectively

Conditions
January 29, 2014

An article published in the New York Times last weekend has been circulating widely on the Internet, and I feel that more than ever, physician voices are needed to reach the public and counter certain misconceptions put forth by the media.

The article, “Patients’ Costs Skyrocket; Specialists’ Incomes Soar,” charts the growth of specialist incomes in the past decade, using the case of a patient from Arkansas who had a …

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The transition from chief resident to attending

Education
January 28, 2014

During my year as a chief resident, I have the privilege to attend on the general medicine service for 8 weeks. I recently completed 4 weeks and, as expected, found myself in an entirely new realm of patient care and accountability. I would be remiss without recalling a few of the pivotal lessons and poignant moments that stand out.

Transitioning from resident to attending inevitably results in greater scrutiny. Despite my best …

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The toxicity of Medicaid

Physician
January 28, 2014

I have noticed over the years that physicians who write about medicine, particularly for the general public, are limited to very specific discussions.  For instance, it is perfectly acceptable to write about the plight of the poor and uninsured.  It is always reasonable to advocate for a single payer system. It is perfectly acceptable to discuss how one downsized in order to make less and “give back” more.  And it …

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Does your joint replacement have a warranty?

Physician
January 26, 2014

shutterstock_36115612

Should joint replacement manufactures provide a warranty for their products?  It seems pretty logical since most consumer products come with some sort of warranty these days.  Basic warranties are almost universally provided and the market for extended warranties is increasingly popular.

Take for instance my recent upgrade to the new iPhone 5s.  At the time of purchase, the AT&T store suggested their extended …

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Why psychiatrists don’t take insurance

Physician
January 25, 2014

In 2007, I wrote a post called “Why Shrinks Don’t Take Insurance.”  The post is a bit dated, the CPT codes have changed since then, and the reasons to not take insurance have increased.  Many other doctors don’t take insurance now, though psychiatry remains the number one specialty where doctors don’t participate in health insurance plans.  This is an updated version of that same post.

Many psychiatrists in private practice don’t …

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When should you use antibiotics in hospice care?

Physician
January 23, 2014

Case 1: You have a 94-year-old woman with multiple medical problems in hospice who develops a fever (subjectively hot to the touch), shortness of breath, and a cough producing yellow sputum.  Her daughter asks if she can be treated with antibiotics “to make her feel better.”  The patient is not well enough to make decisions, but in earlier conversations had stated a goal of remaining comfortable at home, while also …

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Board certification: Valid indefinitely is no longer rings true

Physician
January 23, 2014

I trained in internal medicine and cardiology at the tail end of the era of lifetime board certification by the American Board of Internal Medicine. In fact, my timing was perfect — I was “boarded” in medicine in 1987, and in cardiovascular disease in 1989, which (I am pretty sure) were, respectively, the last years that the ABIM offered certificates without an expiration date in those disciplines.

Late last year, I …

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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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