Shadowfax finds a kidney stone in a “known drug seeker” and treats her with toradol. Success. I had a somewhat similar case with a “known homeless drunk” who had pretty severe electrolyte derangements after I bothered to check, despite nurse balking. Only re-iterates the point: trust no one.
In two common infections of the vagina, bacterial vaginosis (and sometimes in trichomonas vaginalis) your doctor may do a “whiff” test, where he or she takes some discharge, drops some potassium hydroxide on it (a base, KOH) and smells it for a fishy, foul odor. The base causes some foul-smelling amines to be released: cadaverine and putrescine . What great names.
Interestingly, some women will complain of foul odor after intercourse, and the reaction is the same: semen is basic, and when it mixes with the discharge, you get the same release of cadaverine and putrescine. Cool.
Flea (RIP) used to talk about the medicalization of childhood –that kids don’t just run the spectrum of normal variation, that everything nowadays has to be a diagnosis or a pathology that requires treatment. I’ve started to come across the same thing in pregnancy.
There’s this strange phenomenon that several of the docs, nurses, and assistants have commented on–that women will come in, having missed their periods, taken several at-home pregnancy tests, all positive, and still want or need the doctor to “deem them” pregnant. (Plus often a number of the pregnancy changes: nausea, vomitting, breast tenderness, bleeding gums, etc.) Just seems strange that in some ways we’re so out of touch with our bodies–or at least the “natural” changes of them–that we need some “authority on bodies” (doctors) to concur with our own diagnosis.
I guess you can take this a step further and apply it to a lot of common complaints: a weird twitch somewhere, a strange sensation. In some ways it makes sense–you see plenty of patients who wait too long before they see a doctor for what turns out to be a heart attack, or cancer, or stroke, or out of control diabetes–and you wonder how they could possibly have waited so long. And on the other hand, you have people coming in for weird aches and feelings that are just typical, natural weirdness of our bodies.
Sometimes I wonder if a lot of the extremes are due to the break up of the extended family, and the more migratory lives of people. Had a newly-pregnant woman been living with her parents or grandparents, the mothers would just immediately recognize, “Duh, you’re pregnant.” Likewise, the guy who looks green and is clutching is chest might be convinced to seek medical care if his family members urge him to.
I volunteered this past Sunday at one of our free student-run clinics and was working with mostly pre-clinical students. We talked a bit about applying to residency, and we practiced blood pressures on each other. One student remarked, “I can never hear the sounds!” and I told him to turn his stethoscope around. It was adorable. And reminded me of when I had to have that pointed out to me, and that I had to remember “earpieces point TOWARD the patient!”
Another student practiced presenting to me about a guy with GERD, and I asked a couple follow-up questions and the student said he hadn’t asked my follow-ups. I told him that was totally normal, fine, and not a big deal. I guess anyone can probably learn most things if they’ve been at it long enough (4.5 years and counting for me), but it was still amazing to me that I’ve become fairly good at making diagnoses on my feet, multi-tasking differentials while still talking to patients, asking pertinent follow-up questions. It’s pretty cool. A similar feeling to mastering a foreign language, I think.
Great piece by a psychiatrist who used to give lunchtime talks to other docs to promote Effexor . $750 a pop for an hour’s talk. And you wonder why it’s easy for doctors to get mixed up in it all. (Answer: we’re human.)
Started Family Medicine this week (my last clerkship!) and very much agree with the philosophy, probably more than the Internal Medicine approach: that you must take the patient in context. That much of what we consider “health” doesn’t fit within the conventional boundaries of medicine, and that a person’s environment greatly affects his or her health. A couple of thoughts from the introductory lectures, one by a patient advocate on Advance (not Advanced!) Directives:
And finally, via the wonderful
Gooznews
:
KevinMD loves loves loves to talk about how universal health care will stifle innovation , and while theoretically I see where he’s coming from, I just don’t see the overwhelming data to support the hypothesis. His most recent link is to a Happy Hospitalist post about purchasing pens and limits to innovation, but I don’t really see the connection. I’ve seen plenty of surgeons get to choose which devices they’d like to use being paid by Medicare, the VA, or private insurance.
And because timing is everything, The New Republic’s Jonathan Cohn has a really fantastic piece on innovation in universal health care: Creative Destruction: The best case against universal health care . Just like he says in the article, I’ve yet to see an innovator in the academic sector (where much of innovation begins) be driven by profit. It’s driven by wanting to alleviate suffering, to find answers to questions, to let curiosity and discovery flourish. If you didn’t know, the invention of the CT scanner is shared between the US and UK. France was the first to discover the HIV virus.
The article’s a good 5-10 minute read, but well worth it. Key bits:
But it’s one thing to say that universal coverage could lead to less innovation or reduce the availability of high-tech care. It is quite another to say that it will do those things, which is the claim that opponents frequently make. That argument requires several leaps of logic, many of them highly suspect. The forces that produce innovation in medicine turn out to be a great deal more complicated than critics of universal coverage seem to grasp. Ultimately, whether innovation would continue to thrive under universal health care depends entirely on what kind of system we create and how well we run it. In fact, it’s quite possible that universal coverage could lead to better innovation.
Of course, the idea of involving the government in these decisions is anathema to many conservatives–since, they argue, the private sector is bound to make better decisions than a bunch of bureaucrats in Washington. But, while that’s frequently true in economics, health care may be an exception. One feature of the U.S. insurance system is its relentless focus on short-term good. Private insurers have little incentive to pay for interventions that don’t yield immediate benefits, because they are gaining and losing members all the time. As a result, money invested on patient health may very well help a competitor’s bottom line. What’s more, the for-profit insurance industry–like the pharmaceutical and device industries–responds to Wall Street, which cares more about quarterly filings than long-term financial health. So there’s relatively little incentive to spend money on the kinds of innovations that yield long-term, diffuse benefits–such as the creation of a better information infrastructure that would help both doctors and consumers judge what treatments are necessary when.
The government, by contrast, has plenty of incentive to prioritize these sorts of investments. And, in more centralized systems, it can do just that. Several European countries are way ahead of us when it comes to establishing electronic medical records. When fully implemented, these systems will allow any doctor, nurse, or hospital seeing a patient for the first time to discover instantly what drugs that person has taken. It’s the single easiest way to prevent medication errors–a true innovation. Thousands of Americans die because of such errors every year, yet the private sector has neither the will nor, really, the way to fix this problem.
Another nice short vignette from Lisa Sanders, MD in tomorrow’s NY Times magazine . Quotes from the article, showing how technology has changed us:
The medical record, from flipping through it, to scrolling through it;
Abend, a 61-year-old neurologist, scrolled through the patient’s electronic medical record as the resident described the case.
The initial presentation of the patient, via instant messenger:
“When is our wedding date?” she quizzed. “Can you tell me that?”
“No :(”
I see it now, 20 years in the future:
“This is a 27 year-old male who presents using inappropriate emoticons while chatting and cannot remember how to attach a document in Gmail. Sounds pretty serious, probably should get admitted.”