Reflections after 4 years of emergency medicine training

Physician
July 3, 2013

On July 1st, four years ago, I walked through Massachusetts General and Brigham and Women’s Hospitals with an odd mixture of fear, relief, and excitement. Now, as I leave the hospital after my last shift of emergency medicine residency training, I am filled with a similar hodgepodge of emotions and reflections.

1. “You were terrified of being a doctor!” I mentioned this article to the attending who oversaw my first shift as …

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Reflections after 4 years of emergency medicine training

The powerful effects of culture and lifestyle on health

Policy
July 2, 2013

As Americans we spend more money on healthcare per capita than any other nation in the world.  We have the latest medical innovations and for decades have been able to provide cutting edge therapy without regard to cost.  However, as a profession, doctors are not doing nearly enough when it comes to prevention of disease.  Certainly, costs will be reduced if we are able to prevent chronic illness and associated …

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The powerful effects of culture and lifestyle on health

A powerful address to graduating medical students

Education
July 1, 2013

Dear Graduating Class of 2013,

I appreciate the opportunity to address such an impressive pool of medical school attendees.  From the first day of medical school when you were introduced to your cadaver, you have endured countless lectures and lab hours, physical examination and sensitivity training sessions, and ward rotations under the watchful eye of senior residents and attendings.   Today, you will hold something that few people are privileged to …

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A powerful address to graduating medical students

4 complaints of physician employees and 1 solution to fix them

Physician
June 30, 2013

Medscape published an article titled, 4 Top Complaints of Employed Doctors, and it was a very interesting read. Turns out the things employed physicians complain about are basically that they are employees.

Let me lay out these employed physicians gripes for you with a little detail so you will see what I mean. I will finish this article with a solid way to address all of them. These …

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4 complaints of physician employees and 1 solution to fix them

A surgeon deconstructs bowel surgery

Conditions
June 29, 2013

Next in a continuing series.

Let’s make it easy on ourselves. I haven’t yet established why — other than liking the particular operation — we’re removing this nice person’s colon. So since our patient has agreed to remain exposed and to do so for all to see, I declare s/he has diverticulitis. (Were it cancer, the operation would be largely the same, taking a bit more out.) Most likely …

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A surgeon deconstructs bowel surgery

5 benefits of online patient communities

Social media
June 28, 2013

If one searches for “online patient communities” over 19 million Internet sites are found.  Online patient communities (OPCs) may exist as subgroups of social media sites, non-profit organizations, and increasingly as part of websites of healthcare organizations and stand alone sites.

Online communities are now becoming a rich source of information gleaned from their discussions.  This information will be increasingly used for both clinical and commercial purposes. I will touch on themes which …

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5 benefits of online patient communities

Why EMR companies don’t care about usability

Tech
June 26, 2013

I overheard nurses praising the pilot of a new technology with the promise of improving communication, safety, and saving on healthcare spending. The innovation: two-way texting. That’s one of the many indicators that hospitals are stuck the technological stone age.

Imagine how many eyes light up when you offer providers fewer logins, autopopulating forms, and uncluttered menus. There’s an assumption that technology, in the context of healthcare, has to be bad …

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Why EMR companies don’t care about usability

When a child can’t feel his poops

Conditions
June 26, 2013

Kathy wrote about her son: “What can cause a 9-year-old boy to poop in his pants occasionally and not feel it? He was completely potty trained at age three. I have found dirty underwear and poop on the bathroom floor–and it just concerns me that he is unaware of it. It has been suggested at checkups that he may be constipated. My mother suggests he may simply not be paying …

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When a child can’t feel his poops

Should doctors be available to patients around the clock?

Physician
June 25, 2013

Nothing exemplifies more the complete lack of understanding of the issues surrounding our healthcare system than an article that appeared in the New York Times recently.

Author Jane Brody’s piece attempts to address issues with the astronomical costs and misuses of emergency department (ED) visits in the US today.  While I agree that ED visits for routine issues are a waste of resources and money, her suggestion that physicians should …

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Should doctors be available to patients around the clock?

Using Google Docs to manage patients more efficiently

Education
June 25, 2013

During my sophomore year of college as a pre-med, I volunteered at the front desk of a free clinic, where it was typical to see patients waiting sometimes for more than two hours. At first I figured it was just because some patients took longer to examine than others. It wasn’t until I got certified as a nurse’s aide and started working in the medical department at the same clinic …

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Using Google Docs to manage patients more efficiently

A pediatrician’s approach to dehydration in children

Conditions
June 24, 2013

Our bodies are mostly water — about 60% water, in fact. This varies a little with age and sex, but it is a good rough estimate. Of that 60% water, about a third of it is outside the body’s cells, so-called extracellular fluid, and two thirds of it is inside the body’s cells, so-called intracellular fluid. The easiest way to remember this is the “60/40/20″ rule: total body water is …

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A pediatrician’s approach to dehydration in children

How a heart rhythm specialist approaches PVCs

Conditions
June 23, 2013

Here is an edited email I received from an athletic colleague:

John,

A 50 year-old male healthy athlete has the new problem of occasional periods of premature beats. She (or he, doesn’t matter) has visited the doctor and an ECG shows PVCs, or premature ventricular contractions. Otherwise the history, exam, ECG, ECHO and electrolytes are normal.

What’s up with PVCs? Why? Could they be 1) consequence of (chronic) exercise or 2) related in …

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How a heart rhythm specialist approaches PVCs

Every doctor can learn from a medical coder

Education
June 23, 2013

Mrs. B was washing dishes in the kitchen when she heard a thump where her twelve-month-old son was asleep. She ran to him and found her son had fallen from a chair (code: e884.2). He was crying (code: 780.92) and visibly shaken, but did not have overt signs of bleeding, bruising, or trauma. She picked him up and immediately brought him to the emergency room.

There, he was triaged by the …

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Every doctor can learn from a medical coder

A hospital transfer may not always be a good thing

Physician
June 20, 2013

Injury to the brain continues to be a unique thing in medicine. These injuries are scary and unfamiliar to many health care providers. There is a finality to them. Their consequences are hidden a little bit; the asystole is easy to figure in the emergency room but the suppression and brain death isn’t something so easily recognized.

They’re what you might imagine, along with polytrauma, as poster child conditions for tertiarization …

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A hospital transfer may not always be a good thing

The reality of medicine’s inherently unequal power dynamic

Education
June 20, 2013

As part of the first-year curriculum, medical students at the David Geffen School of Medicine at UCLA are required to attend chaplain rounds at local hospitals during which they accompany chaplains to offer spiritual care to patients. This is designed to encourage students to empathize with patients who are enduring difficult end-of-life issues and is part of a ubiquitous and important theme that inundates almost every medical student across the …

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The reality of medicine’s inherently unequal power dynamic

The problem with a negative BRCA test

Conditions
June 19, 2013

There is nothing so horrifying as when your doctor is too nice to you. During my first mammogram at Kaiser Permanente, I knew I had cancer before they even told me because of the hushed voices, the pats on my shoulder, and the way, suddenly, no one cared how much time was being spent on my visit. When that happens to you before the diagnosis is official, there is nothing …

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The problem with a negative BRCA test

Should medical resident training be limited to 40 hours per week?

Education
June 16, 2013

Dr. Sam Ko says resident work hours should be limited to 40 per week. Via Twitter, I warned him that I would rebut his assertion.

Without any data or references except a tangential one, he bases his opinion on four premises.

1. Residents will be happier and nicer to patients because they will be less stressed. There is no proof that this is so. In fact, a recent Read more…

Should medical resident training be limited to 40 hours per week?

When can you override an advance directive?

Physician
June 14, 2013

An 85-year-old woman with moderate Alzheimer’s disease who enjoys walking in her nursing home’s garden with her walker has fallen and broken her hip. An advance directive signed by the patient states a preference for “comfort measures only,” and specifically states that she does not want to be transferred to the hospital. The physician believes that surgery would provide long-term pain relief and the chance to maintain some mobility.

What do …

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When can you override an advance directive?

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