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Latest Posts

A Surprising Discovery And The Value Of The Physical Exam

I’ve remarked in the past how rarely I ever learn anything useful from physical exam. It’s one of those irritating things about medicine — we spent all that time in school learning arcane details of the exam, esoteric maneuvers like pulsus paradoxus, comparing pulses, Rovsing’s sign and the like. But in the modern era, it seems like about half the diagnoses are made by history and the other half are made by ancillary testing. Some people interpreted my comments to mean I don’t do an exam, or endorse a half-assed exam, which I do not. I always do an exam, as indicated by the presenting condition. I just don’t often learn much from it. But I always do it.

The other day, for example, I saw this elderly lady who was sent in for altered mental status. There wasn’t much (or indeed, any) history available. She was from some sort of nursing home, and they sent in essentially no information beyond a med list. The patient was non-verbal, but it wasn’t clear if she was chronically demented and non-verbal or whether this was a drastic change in baseline. So I went in to see her. I stopped at the doorway. “Uh-oh. She don’t look so good,” I commented to a nurse. As an aside, this “she don’t look so good” is maybe 90% of my job — the reflexive assessment of sick/not sick, which I suppose is itself a component of physical exam. But I digress. Her vitals were OK, other than some tachycardia*. Her color, flaccidity and apathy, however, really all screamed “sick” to me. Of course, the exam was otherwise nonfocal. Groans to pain, withdraws but does not localize or follow instructions. Seems symmetric on motor exam, from what I can elicit. Belly soft, lungs clear. Looks dry. No rash. Read more »

*This blog post was originally published at Movin' Meat*

Medicare’s Deficit Effect On The Economy

Medicare poses a deficit problem, note some very influential analysts. A former Congressional Budget Office head and a former Medicare chief chime in on the scope of the program’s impact on the economy, and the difficulties of trying to scale it back.

Yet, a presidential commission is considering just that among other measures. The 18-member, bipartisan commission released its report weeks ago and was scheduled to have voted today on a shocking scope of deficit-trimming measures that included changes to military spending, Social Security and Medicare, among other areas. But they deferred the vote until Friday to try to garner more votes from members who are also currently elected officials. The panel needs 14 votes and substantive approval from its roster of Congress members to gain serious attention.

In related news for Medicare recipients, the Employee Benefit Research Institute reports that seniors will need hundreds of thousands of dollars in savings to cover health insurance and other out-of-pocket health needs. (NPR, The New York Times, ACP Internist, The Washington Post, Reuters)

*This blog post was originally published at ACP Internist*

Should “Old Age” Be A Cause Of Death?

The Washington Post asks whether “old age” should be reconsidered as a legitimate cause of death for the elderly. Because more people are dying at very advanced ages with multiple system failure, it’s often harder for physicians to pinpoint the specific underlying cause, but using “old age” as a catch-all term could make mortality data less meaningful, the article said.

An upcoming revision of the International Classification of Diseases might provide some guidance: “Each revision of the ICD is the right moment to reconsider this question,” the co-head of the ICD’s mortality statistics committee told the Post. (Washington Post)

*This blog post was originally published at ACP Internist*

Feeding Tubes In The Elderly Demented?

An article in [last] week’s New York Times entitled Feeding Demented Patients with Dignity suggests that hand feeding dementia patients may be a better option than tube feeding them.

My God, are we really putting feeding tubes in the elderly demented? When did this happen?

During college, I worked as a nurses aide in a nursing home outside Philadelphia. For 20 hours a week (40 hours in the summer) for two years, I cared for patients in all stages of dementia, from the walking confused through to the end stage, stiffened victims confined to wheelchairs or beds. But in all that time, I never, ever saw anyone with a feeding tube. Read more »

*This blog post was originally published at The Blog that Ate Manhattan*

New Medical Drama “21″ And The Evil SGR Conspiracy To Cut Medicare

Name: “21″ (% to be cut from Medicare)

Protagonist: Dr. Rob and a cast of thousands of physicians (Kiefer Sutherland wouldn’t work for such small payment.)

Villain: Evil SGR (Sustainable Growth Rate) conspiracy to cut Medicare by 21% across the board.

Victim: The elderly population depending on Medicare for payment of their medical care.

Plot:  A follow-up to the popular drama “Lost” where members of congress were stranded in Washington D.C. with the task of reforming healthcare without any contact or communication from doctors and patients. This new drama “21″ tells the tragic tale of an industry under siege and a population facing possible disaster.

Already stretched to the limit by the paltry reimbursement from Medicare for primary care office visits, Dr. Rob and his band of physicians is hit by the evil conspiracy of SGR, a secret society whose goal is to harm the elderly people in the country by driving away all people willing to give them care. The congress, tired out from haggling over the healthcare reform bill, allows evil SGR to exert its power in the name of “fiscal responsibility.” Read more »

*This blog post was originally published at Musings of a Distractible Mind*

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.

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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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