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5 Clinical Resolutions For 2011

Jenni Prokopy (aka Chronicbabe) put us to the challenge for this week’s Grand Rounds by asking for our 2011 clinical resolutions. I have to admit that I’m not one for resolutions because I can never take them seriously. But admittedly there are things that I need to tighten up. So here goes:

1.  Clear my chart rack every afternoon. This is key because my creative mind operates better when my charts are done. Of course this means no more tweeting “47 charts” or “33 charts” when I’m behind. Had I made this resolution for 2009, this blog wouldn’t have a name.

2.  Cultivate innovative communication channels with my referring docs. While I need to be consistent and compulsive with my referral letters, I want to improve mobile, real-time communications between me and my referring docs. For example I’d like to get my local community on Doximity so that I can launch a quick, HIPAA compliant, encrypted SMS messages on my iPhone the second I see a patient. Read more »

*This blog post was originally published at 33 Charts*

Protecting Your Kid’s Brain

Neuropsychologist Kim Gorgens spoke at the last TEDxDU about issues surrounding children’s safety and what parents can do to prevent concussions — and it’s probably not to wrap the little ones in bubble tape. Watch for yourself:

(Hat Tip: Scope)

*This blog post was originally published at Medgadget*

Inner Ear Infections: Still No Need For Antibiotics

Kids get inner ear infections and then they get antibiotics, despite a long-standing knowledge that it’s not always best. Any physician knows this, but who hasn’t faced an irate or anxious parent in the exam room insisting on a prescription, whether the evidence warrants it or not?

Reuters reports that the tally for all those antibiotics is $2.8 billion dollars, or $350 per child annually. And there’s only a slight benefit to them.

While hardly comforting to the parents, physicians can add more heft to their argument that antibiotics are only modestly more effective than nothing, and they can avoid the rashes and diarrhea that antibiotics incur. Read more »

*This blog post was originally published at ACP Internist*

If This Were Your Child, What Would You Do?

Child's doctor visitMany times when faced with a clinical dilemma, a parent will turn to me and ask: “What would you do if this were your child?”

When faced with this question, I never quite know what to say. And each time I feel a little on-the-spot. But why is that? Aren’t I comfortable recommending for someone else exactly what I would do for my own child? After all, what have I got to hide?

Here’s the problem: The decisions we make as parents involve our values, tolerance of risk, level of concern and frustration, prior health experience, and religious belief — to name but a few. There’s no way to fully tease those things from the parent sitting across the room. Read more »

*This blog post was originally published at 33 Charts*

Be Aware Of Heat Dangers In Young Athletes

Young athleteWith back-to-school time around the corner, the Centers for Disease Control and Prevention has issued a warning about the risk for heat-related illness in young athletes, especially football players, the Los Angeles Times reports.

Coaches and parents should be aware of the signs and symptoms of heat stroke, dehydration and other problems, and fluid replacement formulas should be used during practices and workouts, among other precautions, the LA Times said.

*This blog post was originally published at ACP Internist*

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…

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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…

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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.

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Click here for a musical take on over-testing.

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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…

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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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