I was a junior medical student, wearing a short white coat, pockets stuffed with reflex hammer and spiral bound Washington Manual of Therapeutics, rubber tourniquet and pens and pads. I was on a rotation out at the Dwight David Eisenhower Army Medical Center in Augusta, Georgia. DDEAMC was not too far from my home away from home, the Medical College of …
How to sign your name: A decades-old lesson that still resonates
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 …
Why Medicaid patients use the emergency department for primary care
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 …
Holding children back a grade and ADHD: A problem or solution?
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 …
Our spiritual state can influence how physical ailments feel
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 …
When does false hope become malpractice?
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 …
How many patients can a doctor safely see a day?
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 …
Why are doctors the worst patients?
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 …
The job of the modern doctor is to convince
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 …
5 universal problems hospitals need to solve
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 …
These are the people who work in a hospital
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, …
When children are abused by foster parents
The holiday season means most of us will be socializing with colleagues and neighbors, friends and family. Chances are good this circle of friendly acquaintances and loved ones will include a child with autism.
Why? An estimated 1 in 88 children are now diagnosed with the neurological disorder, with a four times prevalence for boys. Among other challenges, those with autism often have difficulties with social communication (be it verbally or …
How to talk to a child with autism
It’s the beginning of cold and flu season. That means a lot of kiddos, big and small, are coming to the office with fever.
As docs, we know that fevers can freak moms and dads out. Kids look pretty awful when their temperature climbs, and it is understandable that parents want to bring them to the office for an evaluation.
In the exam room, I often hear worried parents …
Treat your child’s fever before the doctor’s appointment
I nearly died a month ago on a treadmill halfway through a stress test.
The short story is this: I had just gone to bed and was about to go to sleep when I started to have some chest pain that I told myself was just my usual heartburn, only worse. As a gastroenterologist, I knew better. It was bad enough that I couldn’t go to sleep. After two sleepless hours …
When you get frustrated with my interpreting a chest x-ray as “atelectasis at the right lung base, pneumonia can’t be excluded,” trust me, I don’t enjoy it. But when you ask me to rule out pneumonia you leave me no choice but to tell you that pneumonia can’t be ruled out.
To rule out a disease a test must have a sensitivity of 100%, meaning there should be no false negatives. …
Stop asking radiologists to rule out disease
A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
When you need anesthesia for surgery or a diagnostic procedure, of course you want to know who’ll be giving you anesthesia. If you live in Texas, Florida, the District of Columbia, or 14 other states, you may be lucky enough to have an anesthesia team taking …
Anesthesiologist assistants should be able to practice in every state
If you learn nothing else today, I would ask you to learn that moral hazard is the cause of medical price hyperinflation.
Moral hazard is not just two words that don’t seem to go together. Moral hazard is when the person who bears the economic burden of a decision is not the decision maker. In the health care setting, moral hazard is when the third party payer (insurance/government) bears the …
The cheapest form of health care is to let sick people die
We can now add vitamin B12 deficiency to the growing list of risks of long term use of the proton pump inhibitors (PPIs).
The New York Times had an article outlining the evidence that prolonged use of both proton pump inhibitors (PPIs) like Prilosec, Protonix, Prevacid and others, as well as the less potent H2 blockers like Zantac and Pepcid, can lead to vitamin B12 deficiency. This is in addition …
Proton pump inhibitors and B12 deficiency: What to do now
Over the years that I’ve worked in acute inpatient rehab centers, I have been truly vexed by a particular type of patient. Namely, the stubborn patient (usually an elderly gentleman with a military or armed forces background). I know that it’s not completely fair to generalize about personality types, but it seems that the very nature of their work has either developed in them a steely resolve, or they were …
The downward spiral of the stubborn patient
To err is human. To really screw things up, you need government.
One half of my patient population and one fourth of my receipts are from Medicaid patients. My state has a mandatory balanced budget, which means in this age of perpetual recession Medicaid runs out of money every year.
Last year, my state capped the monthly brand name prescriptions to 1 for the summer. Apparently the information that asthma inhalers and …
There is only one reason why I still accept Medicaid
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