Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

Speed & quality: are they inversely proportional in medicine?

In my last post I described a form of short hand that we docs use to communicate. One of my readers sent me a personal note via email. I thought she made some excellent points, so I’m going to post them here (with the silent conversation going on in my head when I read it typed conveniently in ALL CAPS).

The modern day pace is so incredibly stepped-up nowadays that it makes me nervous about human error. YOU SHOULD BE AFRAID. When doctors don’t have time to write complete words on paper, do they have time to give your case enough thought?  PROBABLY NOT. Will some important detail slip past them?  SURE. Will they make a mistake because they misread one of those code letters? NO, I DON’T THINK SO, THERE ARE PLENTY OF BETTER WAYS TO MAKE MISTAKES, LIKE GRABBING THE WRONG CHART.  I should think that would be easy to do when doctors have terrible handwriting due mainly to haste. DON’T KID YOURSELF, THEIR HANDWRITING LOOKS EXACTLY THE SAME WHEN THEY HAVE ALL THE TIME IN THE WORLD.

All jest aside, we are in a serious quandary here… the poor primary care physicians in this country are totally swamped, they are under extreme pressure to see more patients in a day than should be legal, and in the end the patients suffer. At a certain tipping point (let’s say 12 patients/day) speed really does become inversely proportional to quality.

Instead of developing complex pay for performance measures, why not find ways to incentivize docs to see fewer patients? Truly, quality would automatically improve, patients would learn more about how to manage their chronic diseases, and docs would be happier and more productive. The quality police fail to recognize that time is the key to improving care. Can we really afford to keep up this frantic pace?

This post originally appeared on Dr. Val’s blog at

Medicine’s "secret" code

To you Internet savvy folks out there, LOL means “laugh out loud” but to us doctors, “LOL” usually means “little old lady.” We have shorthand for everything, and our notes can look like stock tickers to the uninitiated.
For example, “NAD” means “no acute distress” (which, when translated into consumer speech, basically means that the person looks well). We shorten common words with an “x” after the first letter. So “diagnosis” becomes Dx, “treatment” becomes Tx, and “past medical history” becomes “PMHx.” Of course, there are some exceptions – “significant for” becomes s/f and “chief complaint” (or the reason why the patient believes he or she is there to see you) becomes CC. The events leading up to the chief complaint are called the “history of present illness” or HPI.
We also abbreviate the most common diseases, so that hypertension becomes HTN, diabetes mellitus is DM, heart attack is MI, and coronary artery disease is CAD. We like to use “status post” to indicate “after” something happened. And many symptoms have shorthand: DOE means “dyspnea on exertion” which is basically that you get short of breath when you walk. Or chest pain, CP. We sometimes use “?” when the patient is a poor historian (this usually indicates psychosis, dementia or severe language barrier). The pain scale is always listed as a fraction of 10. We can summarize a person’s mental status with how alert and oriented (meaning they know their name, where they are, and what the date is – they get 1 point for each of 3) they are. Vital signs (VS), such as temperature, heart rate, blood pressure, and respiratory rate, are considered “stable” or VSS if the values are all normal. Now let’s see if you can decode these short medical notes on 2 theoretical patients in the ER:
HPI: s/p long walk
PE: LOL in NAD, A&Ox2,VSS, 0/10
Dx: r/o MI
Patient #2
CC: CPx1 hr, 10/10
HPI: s/p walk
Dx: r/o MI
Now, both of these patients have the same diagnosis listed, but I can tell you that the first patient is going to wait around for many hours before she’s treated, but the second case is going to marshal the cavalry immediately.
Can you picture in your mind’s eye what patient #1 is like? A little old lady who appears physically well but is complaining of shortness of breath (we think – we’re not really sure what her main problem is as indicated by the question mark) and is a little bit disoriented. She has no major medical problems.
Now the second lady has severe chest pain that has been going on for an hour. She has all kinds of risk factors for a heart attack and appears unwell. This is worrisome, indeed.
So that’s your crash course in medical short hand. Do you think you can crack the code on your next chart review?
My next post will discuss one consumer’s fear of medical shorthand… So stay tuned!

This post originally appeared on Dr. Val’s blog at

Your mom will always be your mom, part 2

I’m afraid you’re going to need a box of tissues for this next post. My good friend Carolyn (she is the Cancer Center Manager at Revolution Health – and has a great blog) sent me a link to a story she wrote about a school program developed to raise awareness of the dangers of drunk driving. It’s called: “Fatal Choices – Shattered Dreams.”

Basically, the entire school goes through a detailed reenactment of a fatal car crash where several classmates are killed. Part of the program requires that all the kids (and their parents) imagine the goodbye letters they’d write if they knew they would be killed in a drunk driving crash. Carolyn and her daughter wrote these letters to one another, as they imagined this horrific scenario:

Dear Mom & Dad. I really don’t know what you are supposed to say in a good bye letter. I couldn’t even imagine waking up one morning and not coming back to see you later that same day. Today, that unimaginable thing became a reality. Dad – if I could go back to this morning knowing what the day would bring I wish more than anything that I just would have said I love you instead of griping about stupid things. I truly do love you and hope and wish that after my death, you can move on, heal and live an amazing life full of happiness. Mom – my only regret with you is that I did not even get to see or speak to you this morning. I would give a lot just to be able to see you this morning. You are the one person that I would not mind being completely like when I grow up, if I would have grown up. You are more than just my mom, you are the one I can talk to and count on. I love you so much! Both of you mean the world to me and I would give anything just to be able to say good bye. I love you with all my heart and I hope that after my death, everything will be OK. I wish you both the best life you could possibly have and please live it the way you would with me there – with happiness, excitement and adventure. Thank you for everything you have given me. You are the absolute best parents I could have asked for. I love you forever, wherever. Erica

Here’s what Erica’s mom, Carolyn, wrote:

We thought we had a lifetime to talk to you, call you on the telephone or e-mail you, but this will be the final time we will write:

Dear Erica, This is not the proper order of things – parents bury parents and grandparents. We are not supposed to bury our children, but yet, here we are saying good-bye for the last time. We hope you left this world knowing that we loved you more than life itself. If either of us could trade places with you, we would do so without hesitation. Our lives will never be the same. They say time heals all wounds, but not this one. We have holes in our hearts since you are gone, and we will be this way until the end of our days. We will never see you graduate from high school. We can imagine the smile on your face as you are with your friends when you leave high school for the last time as a graduate. We will miss seeing you swim in college, something we know you were looking forward to. We’ll never see you graduate from college – beginning what for most is the start of a lifetime of rich and fulfilling experiences. We will not see the love you show for others as you proceed with your career as a neo-natal nurse. How many babies will never know your soft and caring touch? We will never see you walk down the aisle with the love of your life. We will never hold your children. But the most tragic thing of all Erica, we will never hold you again – something we cannot bear, but must now deal with. Puffy, Puppy and Kissy are with you in your final resting place. We hope that whatever journey you take from here on – that they bring you comfort throughout eternity. Remember us as two people who loved you so much that even in death, we want you to be comfortable and at peace. Good-bye for the last time, Erica. This is not the proper order of things, but we will love you forever.

This sort of program and reflection may truly save lives… Do what you can to support this initiative.

This post originally appeared on Dr. Val’s blog at

Your mom will always be your mom, part 1

Alright, I confess – my mother is probably the number one fan of this blog. Ever since I told her I’d be writing one, she has been reading it faithfully. I asked her not to post comments (only because it’s a tad embarrassing to have your parents interacting with you in front of an audience, and frankly, I haven’t noticed a single other blogger doing this!) but alas, she couldn’t resist on that last one. And that’s ok, because I know you readers don’t mind.

My mom does have rare occasions of impulse control failure. One of the more memorable ones was during “Parents Day” at my medical school. The Alumni Association had planned a reception for the parents of the incoming class of 2000 at Columbia U. College of Physicians & Surgeons. There was a full agenda, and my mom quickly noticed that the surgeon who’d saved my life was slotted to speak. The auditorium was full of hundreds of proud parents and their kids, all excited about embarking on a noble career in medicine.

Well, just as my former surgeon was introduced and was walking to the podium my mother jumped up and ran in front of him and asked if she could please have the mike. The MC was visibly nervous (not as much as I was), but after quickly sizing my mom up, she decided that it would be ok to let her have the podium briefly.

In one of the most moving speeches in recent memory, my mother proceeded to explain the story of how Dr. Schullinger had promised not to give up on me (a baby with little chance of survival) and how he had kept his promise to this day. She described the miraculous abdominal surgery (where he had to remove most of my colon), and how he had faithfully responded to every Christmas card she sent him, reporting on my progress for 26 consecutive years. She thanked him for what he did, and pledged that her daughter would devote her life to “doing likewise.”

Well, that brought down the house. Everyone cheered for Dr. Schullinger, who turned beet red (he’s a very shy and humble person) and stumbled through the beginning of his speech. It was a great moment in medicine.

Of course, I was teased mercilessly for the rest of the year – my classmates called me Valerie “semi-colon” Jones, and they would ask if my mother was going to help me with my homework… But kids will be kids.

What I learned from my mom that day is that this old Hebrew proverb is important to follow:

“Never withhold good from those to whom it is due, when it is in the power of thy hand to do it.”

So if someone has done something good for you, or you notice an act of kindness – why not shout it from the hill tops? May goodness rise above the low level grumbling that we live in day to day.

Let’s revel in the sunny parts of life.

This post originally appeared on Dr. Val’s blog at

Patient advocacy: a baby’s life is saved

Ok, so now that I’ve given you a really good example of the dangers of VIPs bullying doctors, I will present the flip side of the coin: a good kind of patient aggressiveness.

A 10 month old baby was vomiting and febrile, and her new mom brought her in to the hospital for an evaluation. She was told that it was gastroenteritis (my favorite diagnosis of late) and that the baby would get over it soon enough. The young mother insisted that she knew her baby, and that the infant had never been this fussy and that there really did seem to be something more serious at play. Again, she received eye rolls from everyone from technicians to nursing staff to physicians. “New mothers are so histrionic,” everyone thought.

But as the evening wore on, the baby became fussier and fussier, and began scratching herself all over. The nurses came in and tied her chubby arms and legs down so that she wouldn’t tear her skin. The mom wrung her hands all night. The doctor went home, yawning and sure that the baby would be fine in the morning.

Several episodes of violent, projectile vomiting ensued, and the mother pleaded for someone to take another look. No one would listen, as the doctor had written in the chart that the baby had gastroenteritis, so that was what it was.

In the middle of the night, after the physician had gone home, the mom insisted that the nurses page him to come back to the hospital. The nurses initially refused, but the mother told them that she would personally make their night miserable if they didn’t comply. The annoyed physician came back to the hospital against his better judgment, and found the mother and baby looking far worse than when he’d left. In fact, the baby’s vitals were becoming unstable and her abdomen was quite distended.

The physician ordered an abdominal x-ray series. It showed an advanced intussusception and the belly was distended with gangrene. He knew that she was likely to die. He asked the mother if she wanted him to call the general surgeon (who had no experience with operating on babies) or if she’d like to take a chance and get the infant to an academic center in New York City that had a team of pediatric surgeons on call. Time was of the essence, but surgical expertise varied greatly between the two options. The mom could tell that the physician was terrified, and her instincts told her that she should get the most experienced doctor to operate on her baby.

A few hours later, the baby was rushed into the O.R. at Columbia Presbyterian Hospital. The pediatric surgeon on the case told the mother that it was unlikely that the child would live, but that he promised not to give up on the baby. At that point, the baby was septic and seizing.

In a truly miraculous turn of events, the surgeon was able to resect the dead bowel and save the baby’s life. If the baby had arrived even a few minutes later, she probably wouldn’t have made it.

So in this case, I applaud the mother for being persistent and forcing the medical staff to take a closer look at this “gastroenteritis.” In our imperfect medical system, patients and families must sometimes advocate for themselves in order to get the attention they require. This story, in particular, means a lot to me, because I still bear the abdominal scar from the surgery.

This post originally appeared on Dr. Val’s blog at

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

Read more »

See all interviews »

Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


Click here for a musical take on over-testing.

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »