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We Are All Patients

We are all patients, damnit.Two weeks ago, I attended my third year at Kru Research’s ePatient Connections conference, and every year, I’m amazed at how many different industry people show up and showcase their impressive efforts … but how few patients.  But this year, there were a lot of patients.  Lots as in “more than five.”

For a conference with “ePatient” in the title, it was good to finally see more than just a handful of ePatients in the audience.  (And this is thanks, largely in part, to the ePatient Bill of Rights project that took place on September 19th, across the hall from the SXSH event).  And it wasn’t just a handful of diabetes patients – there were many health conditions well-represented at these events.  For me, it was nice to talk about the universal issues that people with chronic illnesses face, instead of drifting around in the bubble of diabetes.  I like stepping outside of our comfortable space and learning about what others are living with.  I need that exposure to other types of patients … keeps me thinking globally.

Part of the panel discussion Read more »

*This blog post was originally published at Six Until Me.*

Following The Rules: Is The Patient Really Yours?

I had a patient with non-valvular atrial flutter denied dabigatran (Pradaxa®) by their insurer recently. The patient had diabetes, hypertension and has had a heck of a time maintaining therapeutic blood thinning levels (prothrombin times).

But those are the rules, you see. Only patients with non-rheumatic atrial fibrillation can get dabigatran, I was told. Dabigatran was never approved for atrial flutter, only atrial fibrillation. Never mind the stroke risk in non-rheumatic atrial flutter, like atrial fibrillation, has been found to be significant.

For my patient, dabigatran would have been the perfect solution.

But increasingly I’m finding the patient is not mine, they’re Read more »

*This blog post was originally published at Dr. Wes*

BBC America Introduces New TV Show About Real Life In The ER

You know me.

I’m all over anything that is from the BBC.

But this is different.

There is no TARDIS. And there are nurses along with the doctor. Lots of nurses.

And the only people flying through time and space are the trauma patients before they hit the bus or the ground.

24 Hours in the ER premiered last night on BBC America. I received a copy of the first two episodes from BBC America unedited for American television. Of course in Great Britian, this was called “24 Hours in A&E”.

On a personal level, I like it. It reminds me of the old “Trauma in the ER”.

On a professional level, Read more »

*This blog post was originally published at Emergiblog*

Interaction With A Patient Shows Physician A Major Transition In Medicine

Sometime around 1998 in the Texas Medical Center:

DrV: (enters exam room) Hey, How are you? I’m Bryan Vartabedian (extends hand).

Father: (arms crossed, smiling, leaning against wall) Oh I know who you are, Doc.  And I know where you went to school, where you’ve lived, if you’ve been sued and a few other things. And I’m fine, by the way.

DrV: Um, Okay. (Shakes hands with father. Looking to child, scruffing his hair).  And this must be Caleb.

An odd moment, for sure. When it happened I didn’t know what it was about. After similar encounters I understood.  It was about where patients found themselves in the early days of the information revolution.  And there was the father who wheeled into the exam room two large boxes of printouts perched on a dolly.  Inkjet validation of his role in the decision about his son’s surgery.

These situations illustrate Read more »

*This blog post was originally published at 33 Charts*

Should Doctors Want Their Patients To Use The Web To Stay Informed?

Recently, I’ve had an interview with a national newspaper and the woman who performed the interview told me she was surprised that I seemed to be the first doctor in her life who was happy about patients using the internet. Well, she surprised me with this statement as I’ve never thought about that before. But she must be right. There are many doctors who get upset when they find out the patient tried to find information online. They are frustrated as they don’t even know how to use these online tools and have no idea how to help the patients in this perspective.

Myself, I’m pretty much happy about it. I love to hear patients Read more »

*This blog post was originally published at ScienceRoll*

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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