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Are socks dangerous?

Clothes make the man. Naked people have little or no influence on society.

–Mark Twain

Today I realized that I have spent the majority of my adult daytime hours enduring a continuous, sock-induced lower extremity discomfort. Socks feature a type of tourniquet system that slowly squeezes calf flesh into red indented rings, crowning edematous ankles. Why must socks be so painful? The manufacturers believe that their ability to “stay up” far outweighs the importance of comfort – and so like the sock zombies we are, consumers continue to purchase them under the assumption that painful elastics are simply part of the sock experience.

I decided to search the Internet for sock commiserators, and lo and behold, I found a comment in a diabetes forum about the dangers of tight socks. This person argues that socks can predispose to blood clots, and promote ulcers in those who have preexisting circulatory problems. She goes on to recommend a special type of diabetic sock that is non-binding, manufactured by a company called “sugar free sox.”

I performed a Medline search for articles about “socks” and “stockings” and there were surprisingly few articles. In fact, the majority of articles only mentioned a specific type of medical sock known as “compression stockings” (or T.E.D.s). I didn’t see any studies confirming the potential dangers of the garden variety sock, but it does make intuitive sense that anything that acts as a tourniquet cannot be a good thing for the circulatorily challenged.

Therefore, my recommendation is that if you are diabetic or have any known problems with your circulation, you should do your best to avoid tight socks. I myself am planning to try out these diabetic soft elastic, stretchy socks – and I will wear them proudly about the office in utter contentment and comfort.

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

Do the right thing

Always do right. This will gratify some people and astonish the rest.

–Mark Twain

My favorite writer of all time is Mark Twain. His keen observations and uncanny ability to combine wisdom and wit makes his writing incredibly entertaining, don’t you think? I thought it would be fun to take a few of his quotes and illustrate them with true stories from my mental archives.

Today’s quote is about doing the right thing. I remember a case where a young internal medicine intern was taking care of a 42 year old mother of 3. The mother had HIV/AIDS and had come to the hospital to have her PEG tube repositioned. Somewhere along the way, she required a central line placement, and as a result ended up with a pretty severe line infection. The woman’s condition was rapidly deteriorating on the medicine inpatient service, and the intern taking care of her called the ICU fellow to evaluate her for admission to the intensive care unit.

The fellow examined the patient and explained to the intern that the woman had “end stage AIDS” and that excessive intensive care management would be a futile endeavor, and that the ICU beds must be reserved for other patients.

“But she was fine when she came to us, the line we put in caused her downward spiral – she’s not necessarily ‘end stage,’” protested the intern.

The fellow wouldn’t budge, and so the intern was left to manage the patient – now with a resting heart rate of 170 and dropping blood pressure. The intern stayed up all night, aggressively hydrating the woman and administering IV antibiotics with the nursing staff.

The next day the intern called the ICU fellow again, explaining that the patient was getting worse. The ICU fellow responded that he’d already seen the patient and that his decision still stands. The intern called her senior resident, who told her that there was nothing he could do if the ICU fellow didn’t want to admit the patient.

The intern went back to the patient’s room and held her cold, cachectic hand. “How are you feeling?” she asked nervously.

The frail woman turned her head to the intern and whispered simply, “I am so scared.”

The intern decided to call the hospital’s ethics committee to explain the case and ask if it really was appropriate to prevent a young mother from being admitted to the ICU if she had been in reasonable health until her recent admission. The president of the ethics committee reviewed the case immediately, and called the ICU fellow’s attending and required him to admit the patient. Soon thereafter, the patient was wheeled into the ICU, where she was treated aggressively for sepsis and heart failure.

The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”

The patient survived the infection and spent mother’s day with her children several weeks later.

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

What the heck is a "rehab doc?" Part 2

- continuation of previous post -

What does a PM&R doc do?

The foundational principle upon which rehabilitation medicine is based, is this: physical modalities (exercise, movement, muscle strengthening) are critical components of achieving the highest level of wellness and functionality. The goal of a PM&R specialist is to maximize a person’s functional ability within the constraints of their physical limitations. So that if a person is an amputee, or has had a spinal cord injury, or stroke – the goal is to make them as independent as possible, using prosthetics, orthotics, adaptive equipment, physical training or family assistance.

The rehab physician works tirelessly to enable the disabled. Whether the patient has temporary (such as after a broken bone) or permanent (such as a spinal cord injury) disability, the rehab doctor wants to seamlessly reintegrate the patient into society, into meaningful work, and into a joyful participation in life to the max.

PM&R physicians are the ultimate integrative medicine specialists – they practice a combination of physical and medical healing techniques, while leading a team of specialists to help their patients achieve their goals (nurses, social workers, physical therapists, occupational therapists, cognitive therapists and psychologists, speech & language pathologists, prosthetics & orthotics specialists, and more).

I guess I could sum it up like this: when the proverbial Humpty Dumpty “has a great fall,” the surgeons knit his bones back together, the internists maintain his vital signs, but the rehab doc finds him some crutches, teaches him how to walk again, gets him cognitive therapy and counseling, helps him reintegrate into society, and stimulates his progress towards physical independence and emotional wellness.

Why did I choose this “odd ball specialty?”

Well, truthfully, I didn’t hear much about PM&R during medical school. I happened to meet a group of exceptionally happy residents in the hallway one day, and I asked them why they were smiling. (My only experience with residents was that they were tired, bedraggled, ill-tempered and hen-pecked – and this group defied the stereotype).

They explained to me that they were “rehab residents” and that’s why they were happy. That seemed like a non-sequitur to me, so I investigated the specialty in more detail, and became convinced that there was no higher call than to care for the disabled. I had been a home health aid in college, taking care of young adults with cerebral palsy, and I spent my summers at a camp for disabled adults, sponsored by the March of Dimes, so this was familiar territory and seemed to be a good fit for my nurturing temperament.

As we look at Americans’ current medical needs, we don’t see hundreds of thousands of war amputees (though there is a steady trickle coming from the war in Iraq), or polio victims – but what we do see is a population disabled by obesity and its collateral damage: diabetes (with its amputations), heart disease, stroke, severe arthritis, and various pain syndromes.

I believe that Rehabilitation Medicine, as a specialty, should adapt to serve the needs created by this new obesity epidemic. We have always been the masters of physical exercise for healing – now we should apply those principles to help Americans lose weight and keep it off. I couldn’t agree more with Dr. Jim Hill, who believes that dieting leads to weight loss, but exercise leads to weight loss maintenance (the real key to long term health benefits).

As I have argued in the past, America needs to be rehabilitated. And I hope that my work at Revolution Health will contribute to improving the general wellness of our citizens.

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

What the heck is a "rehab doc?" Part 1

One medical specialty has managed to avoid (nearly completely) the public eye: Physical Medicine & Rehabilitation (or PM&R). Physicians who choose this specialty are referred to as “physiatrists” or “rehabilitation medicine specialists” or “rehab docs.” But the truth is that very few people understand what they do, and unfortunately the rehab docs haven’t made much of an effort to explain themselves to their peers or the world at large.

A dear friend and mentor once asked me, “why did you choose such an odd ball specialty?” This rather direct question forced me to ponder my career decision, and to determine how it came to pass that PM&R was given the unhappy reputation of “odd ball specialty.” I’ll begin with a little background about the specialty and then explain why I chose to devote my life to it.

The history of PM&R

PM&R really traces its roots back to the American Civil War (1861-1865). This gruesome battle resulted in over 620,000 casualties and over 60,000 limb amputations. The modern specialty of general surgery developed through life saving trial and error on the battlefield. Massachusetts General Hospital, for example, was performing an average of 39 surgeries/year before the civil war, and this increased to 2,427 in the late 1800’s.

But physicians and surgeons were not prepared for the aftermath of war – tens of thousands of maimed and partially limbless now trying to live out their careers in a disabled condition. One confederate soldier, James E. Hanger, lost a leg in the war, and subsequently created America’s first prosthetics company, still in operation today. Unfortunately for the disabled, though, there was no guarantee that appropriate accommodations would be made for them to be fully reintegrated into society.

With the rise of surgery came a major realization: patients did not do well after surgery if they remained in bed. Conventional medical wisdom suggested that bed rest and inactivity were the most effective way to recuperate, but now with thousands of post-operative patients in full view, it became painfully clear that the patients who did the best were the ones that got up and returned to regular physical activity as quickly as possible.

Following this realization, the University of Pennsylvania created (in the late 1800’s) an orthopedic gymnasium for “the development of muscular power with apparatus for both mechanical and hot air massage, gymnastics and Swedish movement.”

A young Canadian gymnast trained in Orthopedic Surgery, Dr. Robert Tait McKenzie, was recruited to U. Penn to develop a new field in medicine: “Physical Training.” Dr. McKenzie created a medical specialty called “Physical Therapy” and he was the first self-proclaimed “Physical Therapist.” He wrote a seminal book on the subject called “Reclaiming the Maimed” (1918) and continued to practice orthopedic surgery until his death in 1938.

Other major medical institutions followed U. Penn’s lead, creating “Medicomechanical Departments” at Mass General and the Mayo Clinic. Technicians were trained to assist in helping post-operative patients to become active and reclaim their range of motion – these technicians were known as “physiotherapists” and formed the first physiotherapy training program at the Mayo Clinic in 1918.

World War I (1914-1918) resulted in millions of additional amputations, thus flooding the health system with disabled veterans. In response, the army created two medical divisions: The division of orthopedic surgery and the division of physical reconstruction. By 1919, 45 hospitals had physiotherapy facilities, treating hundreds of thousands of war veterans.

And then there was polio. Suddenly a viral illness created a whole new wave of disabled individuals, further stimulating the need for orthotics (leg braces and such) and rehabilitative programs.

World War II (1940-1945) resulted in yet another influx of disabled veterans. All the while the medical community was developing innovative programs to maximize veterans’ functionality and integration into society and the work place through the burgeoning field of Physical Medicine & Rehabiltiation.

Key players in the development of the specialty:

Dr. Frank Krusen developed the first physical medicine training program at the Mayo Clinic in 1935 and the “Society of Physical Therapy Physicians” (now the American Academy of Physical Medicine & Rehabilitation) in 1938. He coined the term “physiatrist” to describe the physicians who specialized in physical modalities for rehabilitating patients.

Dr. Howard Rusk founded the Institute for Physical Medicine & Rehabilitation in 1950 at NYU.  Excellent research in the field ensued.

Dr. Henry Kessler founded the Kessler Institute for Rehabilitation, in New Jersey, 1949.  More medical research was developed.

Mary E. Switzer successfully lobbied for the enactment of Public Law 565 which mandated that government funds be channeled towards rehabilitation facilities and programs for the disabled.

What’s in a name?

So as you can see, there is some good reason to be confused about the modern specialty of PM&R. It has undergone several name changes, molded by historical circumstance. Today, physiotherapists (they still go by that name in Canada) or physical therapy technicians have become a well known and respected profession: Physical Therapy.

Physicians who specialize in Physical Medicine & Rehabilitation are called rehabilitation medicine specialists or “rehab docs” or “physiatrists.”

-See Next Post for the rest of the story -
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Give your doctor some flowers?

Richard Reece’s recent blog post echoes my sentiments – that it is important, in the midst of a broken healthcare system (and all the frustration that it creates), to stop and ponder the good things that yet exist. There are flowers popping up between the concrete slabs of our system…

Dr. Reece writes,

This is an anti-hero age. We no longer send bouquets or offer praise or optimism, beauty, life, or achievements.

Instead we doubt, dissect, disparage, analyze, impugn, question, and investigate.

Boy, do we investigate. We investigate Presidents, Vice-Presidents, Attorney Generals, Politicians, Army Generals, Priests, Physicians, and Establishment Institutions. The prevailing attitude is: if they or it have succeeded in our society, something must be wrong. Our most prominent heroes, even Mohammad Ali, have feet of Clay. So we send no flowers, only regrets that things are not perfect.

And physicians?

Well, they are the worst. Imagine. They err like other mortals. They occasionally misinterpret signs, symptoms, and results. They cannot guarantee perfect results under all circumstances. They cannot even repeal the Laws of Nature, or the inevitable Limits of Longevity. Physicians are not even omnipotent, omniscient, or omnipresent

Maybe we should praise our doctors and their institutions, considered many to be “the best in the world.” That may be why the U.S. introduces 80% of the world medical innovations and wins 80% of the world’s Nobel Laureates in Medicine even though we only have 5% of the world’s doctors. Maybe we should give our doctors flowers, instead of defoliating them. Maybe they should be our heroes, rather than our villains. American doctors are not miracle workers, but given limited resources and Nature’s limitations, they are damn good.

I encourage you to read Dr. Reece’s whole post. This excerpt doesn’t do it justice.

And if you’d like to give a shout out to a good doctor you know (in lieu of flowers) please comment here!

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

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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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…

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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.

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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…

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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…

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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…

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