After getting off a 15 hour call day, all I want to do is write.
These past 2 weeks death has been on my mind a lot, more than it ever has been. I have always known that physicians counsel patients and families on dying, but actually being the one to do it is entirely different.
How do you tell someone that their best medical option, the best thing you can offer …
The price for improvement sometimes outweighs the benefits
Is there a patient who goes through a hospitalization who does not have stories to tell about the obstacles, errors and indignities that they endured? I just wonder sometimes.
A family relative was hospitalized this week with a stroke at a hospital a few hours from me — and his experience left me demoralized about medicine.
Joe (not his real name) is an 82-year-old grandfather, father, husband and one of a kind. …
Improve health care by seeing through the patient’s eyes
Ms. A was a sweet older lady with a bad heart who was transferred all the way from Montana in order to get expedited workup for cardiac (heart-related) surgery.
Her story of her symptoms and disease course was the story told by hundreds of patients seen at any given hospital every year. It started with a few weeks of chest discomfort while walking, followed by a day of chest pain, nausea, …
What to do after you make a medical error
We all try to do our very best for our patients. Often the decisions we make have profound impacts on outcomes. Medicine is not always cut and dry, and many times gut instinct and judgement calls must play a role in choosing therapies for patients (especially when made in the setting of best available data). As it is in most professions, Monday morning quarterbacking frequently occurs in medicine as well. It is …
Doctors shouldn’t criticize other physicians in front of patients
Recently, I awoke to a picture of myself in the Wall Street Journal. I was asked to comment on the effects of the coming Sunshine Act. Respected health care journalist Peter Loftus found me through social media channels.
What follows are some thoughts about how the Sunshine Act might play out.
Every Thursday during my cardiac fellowship training, at noontime, the entire department gathered for an hour-long conference on echocardiography. Unknown …
The Sunshine Act: A chilling effect on medical education?
If Hattie had but one flaw, it was that she held her doctors in too high esteem. It was not unusual for an eighty-year-old woman of her culture to want to please her cardiologist. So when her blood pressure came up a little high, she was too embarrassed to admit that she had forgotten to pick up the Toprol and hadn’t taken it in over a week.
The cardiologist hemmed and …
Dissection of a needless hospitalization
You probably already know that what you do know about your medicine could kill you. You may not know that what you don’t know could do so as well. Hold that somber thought — we’ll get back to it.
You, and I, and everyone else has seen those direct-to-patient drug ads that Big Pharma runs on primetime television. Invariably, they feature a person skipping through butterflies and wildflowers, demonstrating the …
Remember the side effects of needed drugs that go untaken
We all know that physician-patient communication is important. Poor communication, not deficient clinical skill, is the primary driver of malpractice suits; conversely, good clinical communication alone can improve patient outcomes. For example, patients of physicians with superior communication skills have been shown to have superior blood pressure control. Fortunately, physicians generally recognize the significance of good communication, and often take the time to ensure that it happens. Yet there …
Use visual aids to teach patients and improve decision making
I smelled the patient, unfortunately, even before walking into his room to introduce myself. From the hallway, his odor of lingering stale smoke flared my nostrils, instigating childhood recollections of the wood-burning furnace at my grandmother’s home. From a distance, the scent of smoke was just that — charred-burnt air, its weight clinging to my nostrils. As I approached the patient, however, the scent of smoke smoldered my wishful memories …
The knowledge that one wasn’t alone in an uphill fight
I used to think medicine would get easier over time. It makes sense, right? You see patterns, you learn how treatments work, and you just get to know stuff. Experience should make it easier to diagnose and treat.
That’s not been the case for me. In fact, it’s closer to the opposite. In the exam room, as I look up to the patient from my stool, and before I stand at …
The hubris of medicine has to end
With its expansion of Medicaid eligibility, the Affordable Care Act (a.k.a. Obamacare) was supposed to go a long way towards providing healthcare coverage to millions of uninsured Americans. That accomplishment was dealt a large blow by the Supreme Court, when it forbade the federal government from requiring states to expand Medicaid coverage. Nevertheless, many states plan to offer Medicaid to anyone with incomes at or below 138% of the Federal …
What good is Medicaid expansion if no doctor sees Medicaid patients?
Folks must think than all doctors know all things medical. I know this is true by the questions that I have been asked over the years. While my expertise spans hemorrhoids to heartburn, I am routinely queried on medical issues well beyond the specialty of gastroenterology. When I can’t answer questions about a new medicine for hypertension or if an MRI of …
Does your doctor know ACLS? Does it matter?
In case you missed it, former President George W. Bush had a stent placed in one of the arteries that feeds his heart.
The 67-year-old came through the procedure with flying colors, we are told. Stents are tiny metal mesh tubes that get inserted into clogged arteries, essentially to prop them open.
Bush, heretofore thought to be in excellent shape, seems an unlikely candidate for the procedure. We hear tale of him riding his …
Doing more than necessary in medicine is the opposite of safe
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Ten years ago, my tennis partner suffered a stroke. He was a sixty-year-old at the time, working to move up into the top ten players in his age group. In the country! You could not have found a healthier sixty-year-old. He played tennis three-plus hours a day, scampering across the court like a hyperactive adolescent. In other words, he was not …
We offer patients too many unproven treatments at too much expense
Edward arrived at the hospital following a stroke; a standard work-up failed to reveal an obvious cause. His physician explained that a previously diagnosed patent foramen ovale (PFO), a hole in between the chambers of his heart, may have led to his stroke. He presented three possible treatment options to Edward: (1) medical management with drugs; (2) open surgery to correct the defect; or (3) interventional catheterization to correct the …
Teaching medical students to provide high value care
Technology in medicine advances at a rapid pace. In the US today most patients have access to mobile phones, smartphones and tablets. Medical device makers continue to innovate and create ways in which these technologies can be used by patients and physicians to monitor complex biologic machinery such as implantable cardiac defibrillators (ICDs) and pacemakers at home — without the need for …
Does home monitoring make a difference in cost and outcomes?
Patients often come to me seeking advice about what they can do to live longer. The number of things that have been proven to extend life, however, remains shockingly small. What follows are things that have enough support in the scientific literature that I generally recommend them (though the strength of the evidence varies even with these):
How do I live longer? Here are 10 ways backed by evidence
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 76-year-old woman is evaluated in the emergency department for dizziness, shortness of breath, and palpitations that began acutely 1 hour ago. She has a history of hypertension and heart failure with preserved ejection fraction. Medications are hydrochlorothiazide, lisinopril, and aspirin.
On physical examination, she is afebrile, blood pressure is 80/60 mm Hg, pulse rate …
MKSAP: 76-year-old woman with dizziness and palpitations
I am a 47-year-old female. In December of 2010, I had surgery to remove a 2 inch atrial myxoma (a heart tumor) in my left atrium. The costs for that were astronomical. That is not what I am writing about. I am writing about what happened in the months after my surgery and a cure that cost $9.19 if you don’t count all of the unnecessary doctor visits and …
Why patients have to be their own advocates
As the director of a health education program at a public university, my work is predicated upon the belief that greater knowledge is the key to improving health outcomes. If patients and healthcare professionals simply had better access to the latest information on a particular medical topic—if they simply knew more about a diagnosis, treatment, or prevention strategy—then we’d surely see improved health outcomes.
I have come to realize this assumption is wrong. …
Why more medical information does not lead to better health
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