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Latest Posts

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*

Medicine Won’t Fix Life

The man who twirled with rose in teeth
Has his tongue tied up in thorns
His once expanded sense of time and
Space all shot and torn
See him wander hat in hand -
“Look at me, I’m so forlorn -
Ask anyone who can recall
It’s horrible to be born!

- Bruce Cockburn, from song “Shipwrecked at the Stable Door”

I found the discussion around my recent post about treating colds very interesting. Sick people come to the office to find out how sick they are. Most people don’t want to be sick, and when they are sick they want doctors to make them better.

Most people.

Some people want to be sick, and some doctors want to make people sick. I am not talking about hypochondriacs — people who worry that they may have disease and become fixated on being sick. I am not talking about malingerers — people who pretend to be sick so they can get medications. I am talking about the slippery slope of defining disease. Read more »

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

The Humanistic Side Of Medicine

An excellent opinion piece by Sally Satel, M.D., a psychiatrist, appeared in the Wall Street Journal this morning about white coat ceremonies as ways to reinforce the humanistic qualities of medicine. The best part, however, was this perspective:

But the question of whether empathy can be taught—and, in particular, whether a white-coat ceremony is a good means for promoting that virtue—is a matter of some debate.

Judah Goldberg, a young doctor at Chilton Memorial Hospital in New Jersey raises an intriguing paradox. He asks how the white coat can bring doctors closer to the subjective experience of patients when, as an icon of the profession, it is meant to isolate and distinguish them from the lay community.

“To the extent that empathy can be taught through a ritual,” Dr. Goldberg told me, “a hospital gown, the common garb of human frailty, would be more fitting than a distancing white coat.”

I must say, the thought of everyone seeing each others’ posterior sides as they paraded across the stage at such a ceremony did make me smile. Read more »

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

Sports On “Doctor Time”

We all know about “doctor time.” No matter how hard I try, the clock seems to out sprint me. Morning rounds in the hospital go longer than expected, a colleague stops you with a question, a son forgot his lunch, or something else. The list is long.

In fact, as a very well-educated patient, it seems that the doctors I choose for myself and family are even later than I. It seems that most good doctors have long waits. A coincidence?

However accepted ”doctor time” is in the office or hospital, it doesn’t work the same in the bike racing world. In the land of genetically endowed androids, the clock waits for no one in particular. It turns out that our pizza-sponsored team has a few doctors who run on “doctor time” in real life. Read more »

*This blog post was originally published at Dr John M*

Stress Is Like A Tsunami

StressedSo I’ve been thinking a lot about stress lately.

Obviously, it’s because I’m in one of those work/personal periods where the word comes in all capital letters and my dreams seem to be caught on a continual loop of taking-an-exam-in-a-class-I-forgot-to-attend-all-semester (and yes, I’ve been out of school for 26 years now)/realizing-I-just-bought-a-new-house-and-have-to-move/or, finding-that-I-have-10-stories-due-tomorrow (for the newspaper at which I haven’t worked in years).

This latter dream comes closest to my own situation at the moment given that I find myself with just a wee bit too much work for the time allotted (ok, maybe a lot too much work). I’m coping — going to bed later, getting up earlier, reaching out to a couple of writer friends for help) but it nonetheless has my cortisol and norepinephrine hormone production on overtime.

Which brings me to the point of this blog. Your health on stress. Read more »

*This blog post was originally published at A Medical Writer's Musings on Medicine, Health Care, and the Writing Life*

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.

***

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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