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Grand Rounds Volume 7, Number 26: The Emotional Edition

Welcome to this week’s edition of Grand Rounds, the Cliff’s Notes of the medical blogosphere. Each week a different medblogger reads through peer submissions and summarizes/organizes them all into one blog post (using their own unique structure or theme). Instructions for participation (and hosting) are here.

When I host Grand Rounds I like to organize the posts into emotion categories – kind of the way that movies are categorized into “drama, action, comedy, etc.” This achieves two goals: first, readers have the option of starting with their favorite emotion – maybe you need a “pick me up” or maybe you’re looking for something to get your blood pumping? Second, I get a general feeling for how my fellow bloggers are feeling these days. Judging from the volume of posts in each category, it seems that the majority of you are either surprised or outraged!

I organized the submissions by emotion category, and then listed them in order of submission (the first one was submitted earliest within each category). I hope you enjoy meandering through the blog posts with this structure!

OUTRAGE

Some people spend years finding the correct diagnosis of their symptoms. Carolyn Thomas (of Heart Sisters blog) relays the exasperating story of a young woman who nearly became bankrupt searching for the cause of her disease. The answer was discovered with a blood test. You’ll have to read the full post to find out what the mystery diagnosis is!

Bob Vineyard of Insure Blog is outraged by the decision of KV Pharmaceuticals to increase the fee for their injectable progesterone medication (Makena) from $20 to $1500 per dose. Apparently they increased the fee once the FDA granted them exclusive manufacturing rights. Read the full horror story here. Dr. Linda Burke-Galloway, an Ob/Gyn specialist, continues the refrain at her eponymous blog, stating that this price hike is tantamount to hijacking pregnant women. Dr. Peggy Polaneczky (at the Blog That Ate Manhattan) explains that reversing the price hike will depend on Big Insurance fighting off Big Pharma. “It’s like Goliath vs Goliath” she quips. Finally, Louise at Colorado Health Insurance Insider suggests that insurance companies have few options and will likely try to decline to pay for the medicine, or increase premiums to cover the cost. Either way, they will be on the receiving end of some very angry patient commentary.

Phil Hickey of Behaviorism and Mental Health blog is exasperated by psychiatry’s inherent monetary incentives to prescribe drugs over talk therapy. He suggests that psychiatrists have been reduced to “drug pushers.”

Jessie Gruman at the Prepared Patient forum takes issue with the New York Times’ recent blanket recommendation for patients to haggle with their physicians. Jessie suggests that the cost of healthcare is driven at a policy/regulatory level (rather than the individual patient) and that patients are often ill-equipped to know where to save on healthcare spending while physicians don’t even know how much tests and procedures cost. Big mess.

Yet more evidence that “platelet-rich plasma” is much ado about nothing has come out. Dr. Glenn Laffel (of the Pizaazz blogexplains that this expensive treatment (used by sports celebrities, and promoted by physicians looking to get rich quickly) isn’t worth the price tag.

Psychiatrist blogger Roy (at the ShrinkRap blog) points out the nuttiness of a proposed Florida Senate bill that would allow physicians to be arrested for asking patients about firearms. You must read this post to get the full dose of crazy regarding the proposed law.

Jacqueline (aka Laika at Laika’s MedLibLog) does an excellent job reviewing the hysteria and misinformation surrounding the recent Japanese earthquake. She argues that social media can be a double-edged sword, both helping and hurting in disaster situations. You should definitely check out her post’s reproduction of a nuclear fallout map, and its fake wave of radiation predicted to waft across the ocean and kill millions of Americans. Outrageous!

SURPRISE

The ACP Hospitalist blog reviews a study suggesting that the most severely injured should not be treated in a nuclear disaster. I guess that “save the savable” is the protocol’s new mantra. Sister blog, the ACP Internist, describes a survey that concludes that most states are not prepared to handle a nuclear disaster. So – whether you’re severely or only mildly harmed by radiation, you won’t get optimal care? Eep.

There’s a lot you can do with Microsoft’s Kinect video console. Gene Ostrovsky at the Medgadget blog reports on a novel use for the Xbox system: helping the visually impaired navigate indoors. Check out the whole story here.

Did you know that the medical treatment you receive may depend upon variables such as where you live and how many hospital beds are in your area? ePatient Dave (at the e-patients.net blog) describes geographical practice variation, and what patients should know about it.

After a breathtaking review of the short history of medical apps, Dr. Felasfa Wodajo (at OrthoOnc blog) explains what he sees as their bright future. Among his predictions is the idea that hospitals and provider institutions will become the prime distributors of medical apps going forward.

Dr. Rich Fogoros (at the Covert Rationing Blog) explains that screening young athletes for heart disease would be cost effective if EKGs could be done at Walmart for $10. He uses the analogy of smoke detectors, which reduce the risk of death by fire:  we have them because they’re affordable, and paid for by the individual (even if they save very few lives on a national scale).

Dr. Michael Kirsch (at MD Whistleblower blog) wonders if hospitals vying for wealthy patrons with hotel-like facilities is much different than pharmaceutical companies offering free samples of their drugs to people. Both are trying to increase their customer base, but no one criticizes hospitals for their activities. Hmmm…

Paul Levy (at his new Not Running A Hospital blog) explores the complex problem of personal bias, inappropriate inferences, and emotional thinking in medical decision-making. It’s a wonder anyone makes a smart decision, ever!

Dr. John Mandrola (at the Dr. John M blog) offers the surprising advice that patient education is the most effective treatment for atrial fibrillation (not drugs, ablation, or procedures of any kind). Check out his 12 tips for people with AFib.

Dr. Tony Chen (of the FDAzilla blog ) points out that the medical device approval process may not be safe. It’s a bit of a catch 22 problem though… If the approval process is too lenient, you end up with too many recalled products.  If the process is too strict, you end up stifling medical innovation and lose all its benefits.

Jeffrey Seguritan (at Nuts For Healthcare blog) explains why high risk health insurance pools have not solved the “pre-existing condition” problem. People can’t afford higher premiums, even if the government helps to subsidize the costs. Plus there’s the issue of not knowing how to get into one of these pools, or wanting to wait 6 months for entry. Surprisingly few people are taking advantage of what we all thought was a great way to help the sick.

GRIEF

Losing your life partner can be emotionally crippling. Barbara Kivowitz explores the process of grieving, including this powerful quote from a widower: “People have told me that I should be nourished by my memory of our relationship. I cry because the despair, the yearning ache I suffer, is just not sated by remembering the way in which she and I loved any more than my hunger is satisfied by remembering a delicious meal I once ate.” Read the whole story at her blog, In Sickness And In Health.

At 33 Charts, Dr. Bryan Vartabedian reflects on the death of a child with mitochondrial depletion syndrome. At the child’s funeral, Dr. V was moved as he recalled how much he learned from the charming 4-year-old.

When it comes time to make end-of-life decisions for loved ones who are unable to do so, it’s very reassuring to know what they want. Dr. Ramona Bates (at Suture For A Livingdescribes the relief she felt in caring for her mother (during her mom’s final days) because they had previously discussed her advanced directives. There’s a lesson here for all of us.

South African surgeon, Bongi Taverner (at Other Things Amanzi blog), relays a tragic story of a missed diagnosis that still haunts him. A young man was shot in the abdomen and died because the surgical team couldn’t tell that the bullet had pierced his small intestine and didn’t operate on him soon enough.

In this touching, dark-humored post, Beth Renzulli (at the Happy Internist blog) writes an ode to a colon cancer patient’s omentum. It’s hard to blend sadness with awe, and Beth does so beautifully.

Dr. Elaine Schattner (of the Medical Lessons blog) explores the role of empathy in the wake of the recent Japanese earthquake. She draws inspiration from Susan Sontag’s book, “Regarding The Pain Of Others” and encourages us to take the time to empathize with those who are suffering.

DEPRESSED

Fisher Qua of the Healthiest State In The Nation Blog gets the sense that most companies believe that employee wellness programs are a waste of time because the companies themselves are unwell. Incentivizing people to make long-term healthy lifestyle choices can be an uphill battle, but before we all give up – check out Fisher’s ideas for turning this around.

David Harlow (of HealthBlawg) explains why it’s cheaper for most companies to ignore some HIPAA rules (like data privacy and protection) and take the risk that they’ll be found in violation by the exceedingly small government enforcement task force. David wonders: “Will HIPAA enforcement become like trading emission credits?” Meanwhile, fellow attorney Bob Coffield (at Health Care Law Blog)  reports that the Office of Civil Rights has requested a 5.6 million dollar increase in the 2012 HIPAA enforcement budget. Is that a drop in the bucket?

FRIGHTENED

Do you know what radiation exposure would actually do to your body? Dr. Paul Auerbach (at the Medicine for the Outdoors blog at Healthline) explains what causes radiation damage, how to decontaminate yourself, and how to reduce or prevent damage with potassium iodide. Dr. Toni Brayer (from Everything Health blog) explains that potassium iodide is no panacea, and that it’s not necessary for Americans to take it prophylactically for protection against possible radiation from Japan. The chance of radiation reaching our shores is basically zero.

The Happy Hospitalist (at the blog of the same name) delves deep into MedPAC  (Medicare Payment Advisory Commission) analysis documents only to discover that most hospitals lose money treating patients with Medicare insurance coverage. Scarier still is the fact that predicted profit margins can be improved by only 3% if perfect execution of care is achieved. These facts may result in a deeper divide between the quality of care for the rich versus poor in America.

JOYFUL

Family physician Ed Pullen (at his eponymous blog) discusses what “carpe diem” might mean to a patient. He suggests that seizing the day may boil down to this: “Make intentional decisions, and take purposeful steps to make today better than it would be if you passively let today slip by without being cherished.”

David Williams (at Health Business Blog ) interviews Jeannie Lindheim (a motivational writer and founder of a hospital clown troupe), about using improvisation to improve communication, physician listening skills and patient empowerment in healthcare.

Mary Pat Whaley (at the Manage My Practice blog) describes a new type of retirement community that combines healthcare, a cap on costs (so the members are not bankrupted), and access to an onsite nursing facility if needed. Her parents are enjoying all this plus hot meals, a swimming pool, games, fitness programs, and entertainment. Sounds like a great solution for aging parents on a fixed income.

Dr. Mike Sevilla, formerly known as Doctor Anonymous, has completely outed himself. He will no longer blog semi-anonymously, but will use his real name in all his future writing. He has a new blog now called “Family Medicine Rocks” – a name suggestive of jubilation and enthusiasm for his chosen specialty.

Kim McAllister (of Emergiblog) describes why she’s so glad that she continued her nursing education. She writes: “Remember the bad old days when it seemed like ADN = BAD! BSN = GOOD! MSN = BETTER! DNP = SAINT! PHD = GOD! LOL!… IF you are looking for a bigger paycheck or a huge pat on the back and a sparkle in the eye of your employer, well, you won’t find it by adding alphabet soup after your name… The immediate external rewards are few. The internal rewards are innumerable…” Check out her post to see why Kim has decided to study for an MSN.

LUSTFUL

Have you ever been physically attracted to a friend? This kind of friendship  - where there is mutual attraction, but romantic entanglement would be damaging or inappropriate – is not uncommon. Will Meek suggests that we give this kind of relationship a name: “fiery friends.” Find out how to navigate fiery friendships successfully at Dr. Meek’s blog.

REPULSED

Tuberculosis is a nasty infection. Dr. Sumer Sethi (at Sumer’s Radiology Sitedescribes a rare case of chronic arachnoiditis caused by a tubercular infection swelling into the foramen magnum, resulting in cervical spine symptoms! Check out the gory MRI images. Ew… Poor patient!

Dr. Allen Roberts (of GruntDoc blog) managed to totally gross out a medical student during a shoulder reduction procedure in the ER. Well done, sir. Well done!

I AM STUMPED

I have no idea how to categorize this post by Dr. Shock (at Dr. Shock MD, PhD blog). He describes the neural basis of cognitive and emotional empathy… in a clinical, unemotional way. How.. er… ironic?

And there you have it! I hope you’ve enjoyed this edition of Grand Rounds, please submit your posts to next week’s host, Dr. Mike Sevilla (the blogger formerly known as Doctor Anonymous), at FamilyMedicineRocks.com. Please go to the website for instructions on submission.

Cheerio!


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6 Responses to “Grand Rounds Volume 7, Number 26: The Emotional Edition”

  1. hgstern says:

    Outstanding job, Dr Val!

    Thanks for doing such a great job hosting, and for including our post.

  2. Wow. Them are a lot of posts! Great job, as always. Happy

  3. Thanks for hosting, Val! The emotional categorization of posts is provocative.

  4. health blog says:

    I can see how you started this venue. Beautifully done. Thanks for keeping this going. A bit sad that the predominant emotions are outrage and surprise.

  5. Val –

    Wow – that’s a fabulously readable and comprehensive compilation.

    Thanks to you and your staff for all your hard work.

    Peggy

  6. Tony says:

    Thanks for hosting! love the categories. (by the way, I’m not a Dr. ;)

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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.

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