One of my attendings this month is a big history buff, and I get the sense that he enjoys discussing it, as he discusses it with me all the time. He even gave me his copy of Truman to read in my “spare” time. Of note was a particular conversation we had where he quizzed me on the cause of FDR’s death–hypertension, as it turns out. (Stroke, to be exact, but it might not have happened had his hypertension been controlled.)

I just thought it interesting that things we take so for granted now were still so poorly treated 60-some years ago. There’s a great history on the treatment of hypertension , and our favorite agent, a diuretic (water pill) called hydrochlorothiazide, made its basic debut back in 1958. (Note: we still don’t exactly know why hydrochlorothiazide is so good for hypertension.) Prior to that, we tried terrible diets that were bland and intolerable.

There are a couple really great President Medicine sites, including a summary of the causes of the deaths of all the US Presidents , and a Medical History of all the US Presidents . As we move from acute to chronic care in the US, there’s far fewer deaths from pneumonia, and more from heart failure.

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I’m really enjoying clerkships so far. Besides the long hours, I can’t really complain. I have, however, been a little annoyed with the off-handed homophobic remarks made by certain people. In all other aspects, they seem like really great people, but I don’t think they realize how much respect I lose for them when they make some little snide gay joke to a colleague.

It’s never anything blatantly offensive, always just little things. Asking a straight male colleague if he’s dating anyone, and then saying, “Oh, did he break your heart?” for example. It reeks of the old boys club mentality, and hell, we’re 30 minutes outside of San Francisco. I can’t imagine what it’s like anywhere else. I’m always curious why this is socially acceptable, but if any person were to make a similarly snide racial or gender comment, they’d get disgusted looks from their team.

It’s really easy for me to type out here that I should challenge these remarks. I should try to change people’s thinking. That if I’m not part of the solution, I’m part of the problem, and that if no one ever stood up against this kind of thing, we’d be much more regressive in our thinking and behavior than we are now. But man, even if I was the most confident guy in the world (which I’m not, I just fake it), it’s hard to decide when to say something and how to say it, especially when it’s your superior, and they probably have some part in your evaluation.

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I thought I’d start compiling my knowledge about Medicare Part D here. If you have something to add, just leave it in the comments. (See also Medicare: D Is For Disaster and Medicare Prescription Drug Calculator Tutorial for the very basics.)

1. When do I have to decide by?
   You have until December 31, 2005 to enroll in a plan that starts January 1, 2006. But May 15, 2006 at the latest, if you’re a current Medicare beneficiary. If you become Medicare-eligible in the mean time, or after these dates, you have 7 months from your 65th birthday to enroll.
2. What happens if I enroll after that?
   Unless you’re already in a drug coverage plan (from a pension benefit, for example) that is certied as good or better than Medicare Part D, your monthly premium can increase by at least 1 percent per month of delay.
3. What if I start a new drug that isn’t covered under the plan I signed up for?
   Your doctor can petition for an exception. The plan has 72 hours to determine if it will grant an exception. Denials can be appealed, but it could take awhile.
4. Can I change my plan?
   Once a year, from November 15 to December 31, you can change to a new plan. You can also change if you enter a nursing home or move to an area that your current plan doesn’t cover.
5. Will co-pays go up?
   The plans can increase co-pays or drop coverage, but they have to give a notification 60 days in advance. Unfortunately there’s no choice but to pay this increase, although a vice president of Humana claimed this “would be unlikely,” unless a drug manufacturer started increasing the drug cost.

Sources:
Millions Face a Deadline for Choosing a New Medicare Plan

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Health Care Renewal has the scoop on why New York wasted so much money on me-too drugs . A not-for-profit run by the corporate execs that run big Pharma? What a surprise!

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I’ve now seen two really excellent physicians really stumble when it comes to using an electronic medical record, and it puts them at a severe disadvantage. While they could easily perform a better and faster physical than me, take a better history, and come up with a better list of possible diagnoses, I’ve got them beat hands-down when it comes to entering orders, medications, consults, or clinic notes. They hunt and peck with two fingers, staring at the keyboard, and click everywhere very cautiously. They’ve learned one way to get the system to do what they want it to do, and while it works, it makes a lot of wasted time. One of the physicians even told me he has to come in on weekends to get all his notes written, because it takes him so long.

We’re moving toward a medical record; if you’re not comfortable with computers, and don’t know how to use them effectively, hire the neighborhood whiz to come give you a few lessons. You’ll save immense amounts of time in the future.

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Part of the difficulty of medicine is turning the qualitative into the quantitative, so various physicians have come up with rating or scoring scales to try to make one able to compare one patient’s state to another. I’ve been reviewing a number of these recently, so I thought I’d start a collection. Feel free to add your favorites.

Pulse Scoring

Pulses are rated on a scale ranging from 0 (not palpable) to 2+ (normal). In the event that the pulse is not palpable, the doppler signal generated is also rated, ranging again from 0 to 2+.

Edema Scoring

1+ Mild pitting, slight indentation, no perceptable swelling of the leg
2+ Moderate pitting, indentation subsides rapidly
3+ Deep pitting, indentation remains for a short time, leg looks swollen
4+ Very deep pitting, indentation lasts a long time, leg is very swollen

Strength Scoring

5/5 Normal strength: movement against gravity with full resistance
4/5 Movement against gravity and some resistance
3/5 Movement against gravity only
2/5 Movement with gravity eliminated
1/5 Visible/palpable muscle contraction, but no movement
0/5 No contraction

Glasgow Coma Scale

I. Motor Response
6 – Obeys commands fully
5 – Localizes to noxious stimuli
4 – Withdraws from noxious stimuli
3 – Abnormal flexion, i.e. decorticate posturing
2 – Extensor response, i.e. decerebrate posturing
1 – No response
II. Verbal Response
5 – Alert and Oriented
4 – Confused, yet coherent, speech
3 – Inappropriate words, and jarbled phrases consisting of words
2 – Incomprehensible sounds
1 – No sounds
III. Eye Opening
4 – Spontaneous eye opening
3 – Eyes open to speech
2 – Eyes open to pain
1 – No eye opening
Glascow Coma Scale = I + II + III.
A lower score indicates a deeper coma and a poorer prognosis.

Deep Tendon Reflexes

0: absent reflex
1+: trace, or seen only with reinforcement
2+: normal
3+: brisk
4+: nonsustained clonus (i.e., repetitive vibratory movements)
5+: sustained clonus

Heart Murmur Grading

Grade 1 = very faint
Grade 2 = quiet but heard immediately
Grade 3 = moderately loud
Grade 4 = loud
Grade 5 = heard with stethoscope partly off the chest
Grade 6 = no stethoscope needed

Apgar Score for Newborns

Color
All pink (2 points)
Blue extremities/pink body (1 points)
Blue/pale (0 points)
Heart rate
over 100 (2 points)
less than 100 (1 points)
Absent (0 points)
Respirations
Good/crying (2 points)
Irregular/slow (1 points)
Absent (0 points)
Response to nose catheter
Sneeze/cough (2 points)
Grimace (1 points)
None (0 points)
Muscle tone
Active (2 points)
Some extremity flexion (1 points)
Limp (0 points)

Mallampati Airway Score

Class 1: Can see PUSH Pillars Uvula Soft Palate Hard Palate
Class 2: Can see USH Uvula Soft Palate Hard Palate
Class 3: Can see SH Soft Palate Hard Palate
Class 4: Can see H Hard Palate

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Quote of the Day, to an 84 year-old Asian woman with Hepatitis C from an attending:

Doc: So we’d like to figure out what the subtype of your viral genotype is…
Patient nods.

This woman had no, I mean no idea what a genotype is, let alone a subtype of it. Please don’t forget, when you’re talking to a patient, speak to his or her level, not MEDICAL. I would look just as dumbfounded as my patient today, and probably nod as well if a lawyer spoke law to me, or if a mechanic spoke car to me. I’m sure I’m at fault myself sometimes, but I think I’m pretty good at catching myself, and pretty good at detecting the dumbfounded “what the hell are you talking about” look, too.

There’s evidence to suggest that patients will be more adherent if you speak their language, too. Everyone wins.

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