October 9th, 2008 by Dr. Val Jones in Expert Interviews
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I’ll admit it – when I was a kid, I admired Dr. Bones (McCoy) of Star Trek. He was a no-nonsense kind of guy who was very clear about his areas of expertise (“Damn it, Jim, I’m a doctor, not a spaceship engineer.”) But best of all, Dr. McCoy had special healing gadgets that he could wave over people for diagnostic and therapeutic purposes. Those “tricorders” fascinated me – and I always wished I could have one myself.
And now my dream could actually come true: advances in focused ultrasound technology (FUS) make non-invasive surgical procedures possible. I attended the very first international symposium about this new technology, and learned some very exciting things.
First of all, Dr. Ferenc Jolesz gave a riveting key note address about the history of focused ultrasound technology, and why modern advances have made this treatment modality feasible. Scientists have been fantasizing about heating tissues with sound waves since 1942 when the first ultrasound experiment was conducted on a liver tumor. Unfortunately back then, imaging studies (beyond X-rays) had not yet been developed – so it was virtually impossible to “see” one’s target.
However, now that magnetic resonance imaging (MRI) machines are capable of displaying our innards in exquisite detail Read more »
April 13th, 2008 by Dr. Val Jones in True Stories
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I received a panicked call from my younger sister today. She is the mother of one-year-old identical twin girls, born slightly prematurely. During her pregnancy she had a problem with twin-twin transfusion syndrome and had to lie on one side for many weeks to ensure that both girls received an adequate blood supply. She delivered by Cesarean section and fortunately both girls have been doing well. That is, until a few hours ago.
My sister described an episode in which her daughter was in the bathtub and suddenly had one of her pupils become very large. It remained dilated for several minutes, which caused her to call her husband in to take a look. He confirmed that the eye was dilated and they decided to call me right away because they’d heard that a dilated pupil might have something to do with concussions or head injuries, though the little girl had not had any recent trauma to her head.
I tried to get a full history from them – they said she was acting “totally normally” – the usual peeing, pooping, eating checks were fine. They said she was sleeping well, not vomiting or lethargic, and that her pupil had now (after several minutes) returned to normal size. They said her fontanel was not bulging, and when I asked them to shine a light in her eyes they both constricted immediately.
My sister asked me, “what could this be?”
Ugh. I’m not a pediatrician, nor an ophthalmologist, but I do know that asymmetric pupils are usually an ominous sign. All I could think of was “space occupying lesion” but I didn’t want to scare my sister unnecessarily. All the other history sounded so reassuring (the child was well, with no apparent behavior changes, the eye had returned to normal, etc.) that I had to say that they should get in touch with the pediatrician on-call.
And here’s where things got confusing. My mother called me by coincidence just after I hung up the phone with my sister. She had been visiting with the babies for a full week, and slept next to their cribs during their vacation. I told my mom about the pupil issue, and she started relaying some potential “symptoms” that she had witnessed over the past week or so. She claimed that the baby had indeed vomited recently, that her behavior was different than her twin (more irritable and emotionally labile) and that her sleep patterns were also disrupted.
Now I was more concerned – was this early hydrocephalus or maybe even brain cancer? Would I be responsible for missing a diagnosis? I was thousands of miles away from the infants and trying to piece together a story from historians with different observations. So I called some pediatrician friends of mine and asked what they made of this. One said – “anisocoria is a concerning symptom in an infant, she needs a CT or MRI to rule out a tumor pressing on her eye nerve. She should go to the ER immediately.” The other said that since there were no other current symptoms, and the eye was back to normal, it should be worked up by an ophthalmologist as an outpatient.
What a bind to be in – I have some witnesses describing very concerning symptoms, others suggesting that everything’s fine except for a fleeting period of pupil size mis-match. I have dear friends suggesting everything from an immediate ER visit with sedation of the child and a head CT or MRI to watchful waiting and distant outpatient follow up. And I have my sister relying on my judgment (as a non-pediatrician) to tell her what to do.
Here’s what I did – I got my sister and her husband on the phone and explained to them that I take their observation of pupillary dilatation very seriously. I explained that this is not a normal event, and should be followed up by an expert to make sure that there’s no underlying cause of the eye symptoms. I also said that the fact that the baby is acting normally and the eye is no longer dilated are reassuring observations. I told them that they should keep a close eye on the infant, and that if they see any hint of recurrence of the pupil problem, or anything out of the ordinary like vomiting, inconsolability, lethargy, swollen fontanel, fever, or strange body movements or seizures, they should go to the ER immediately. In the meantime they should alert the doctor on-call to the situation and discuss everything with their pediatrician during her next available office hours.
I hope that was the right approach. I will not rest easily until the baby has been fully examined by an expert. Being a doctor carries with it a lot of anxiety and personal responsibility – at any time of the day or night your peace of mind can be uprooted by an abnormal finding relayed to you by friend, family, or patient. And if anything goes wrong – or if interventions are not achieved at an optimal speed and accuracy, this question will forever plague you: “Should I have done something differently?”
Who knew that my relaxing Sunday afternoon would be turned upside down by a dilated pupil?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 1st, 2007 by Dr. Val Jones in News
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A recent research study suggests that as many as 7% of adults over 45 have had a stroke without even realizing it. Researchers performed brain MRI scans of 2000 “normal” (asymptomatic) Dutch men and women between the ages of 45 and 96, and found that 7.2% of them (145 people) had evidence of an infarct (stroke), 1.8% (36 people) had small aneurysms, and 1.6% (32 people) had benign tumors (usually a small malformation of the blood supply to the brain).
Interestingly, they also found one person with a primary brain cancer, one person with a previously undiagnosed lung cancer that had metastasized to the brain, one person with a life-threatening subdural hematoma (brain bleed), and one person with an aneurysm large enough to require surgery. So altogether, they found 4 people out of 2000 who needed urgent medical intervention.
Although the authors of the article emphasized the point that many “normal” people have harmless brain abnormalities – I was a bit surprised by the fact that they found 4 asymptomatic people unaware of a ticking time bomb in their brains.
Keep in mind that the study was conducted on middle class Caucasian adults in the Netherlands – so we cannot generalize these findings to more diverse populations. But I do think it’s a bit of an eye-opener.
MRI scans are quite expensive (well over $1000 in most cases) and are therefore not offered to the general population as a screening test. But it does make you think about saving up for one. Your radiologist may find something unimportant, or she may find something that you hadn’t bargained for. Or maybe one day the technology will be inexpensive enough to offer as a screening test in a primary care setting. But that’s not going to happen any time soon.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 20th, 2007 by Dr. Val Jones in Medblogger Shout Outs
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I am opposed to millionaires, but it would be dangerous to offer me the position.
–Mark Twain
As we consider the wastefulness of the healthcare system, I have heard many people complain that physician salaries are one of the main culprits in escalating costs.
Dr. Reece compares the average income of some of the highest paid physician specialists, with that of hospital executives, medical insurance executives, and fortune 500 CEOs. Check this out:
Highest Paid Physicians
1. Orthopedic, spinal surgery, $554,000
2. Neurosurgery, $476,000
3. Heart surgeons, $470,000
4. Diagnostic radiology, Interventional, $424,000
5. Sports Medicine, surgery, $417,000
6. Orthopedic Surgery, $400,000
7. Radiology, non-interventional, $400,000
8. Cardiology, $363,000
9. Vascular surgery, $354,000
10. Urology, $349,000
Executive Pay for Massachusetts Hospital CEOs
1. James Mongan, MD, Partners Healthcare, $2.1 million
2. Elaine Ullian, Boston Medical Center, $1.4 million
3. John O’Brien, UMass Memorial Medical Center, $1.3 million
4. David Barrett, MD, Lahey Clinic, $1.3 million
5. Mark Tolosky, Baystate Health, $1.2 million
6. James Mandell, MD, Children’s Hospital, Boston, $1.1 million
7. Gary Gottlieb, Brigham and Women’s Hospital, $1 million
8. Peter Slavind, MD, Massachusetts General Hospital, $1 million
2005 Total Annual Compensation for Publicly Traded Managed Care CEOs
1. United Health Care $8.3 million
2. Wellpoint, Inc, $5.2 million
3. CIGNA, $4.7 million
4. Sierra Health, $3.4 million
5. Aetna, Inc, $3.3 million
6. Assurant, Inc, $2.3 million
7. Humana, $1.9 million
8. Health Net, $1.7 million
Top Corporate CEO Compensation
1. Capital One Financial, $249 million
2. Yahoo, $231 million
3. Cedant, $140 million
4. KB Home, $135 million
5. Lehman Brothers Holdings, $123 million
6. Occidental Petroleum,, $81 million
7. Oracle, $75 million
8. Symantec, $72 million
9. Caremark Rx, $70 million
10. Countrywide Financial, $69 million
But the real story here is the salary of our primary care physicians – those unsung heroes of the front lines. KevinMD pointed out a recent news article citing $75,000.00/year as the average salary of the family physician in the state of Connecticut, and that their malpractice insurance consumed $15,000.00 of that. Although this is certainly below the national average for pediatricians (they start at about 110,000 to 120,000), I’ve seen many academic positions in the $90,000 to 100,000 range.
Now I ask you, does it seem fair that the vast majority of physicians (the primary care physicians) are making one tenth of the average hospital executive salary? Should doctors really be in the cross hairs of cost containment?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 10th, 2007 by Dr. Val Jones in True Stories
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** This follows from the previous blog post**
A week later a 10 pound package came for me in the mail – it was a copy of the patient’s entire medical record. It took me almost an hour to find the part that had to do with the paralysis event, but as I read through the chart I saw my note and then gasped.
My note was simple: it documented my physical exam findings, the time I first found him paralyzed, the time I called the surgical team, the time it took them to get to the patient’s room. It was all clearly written and nicely documented. But the entry just above mine was from a nurse who had apparently turned the patient earlier that morning to wash his posterior. She noted that the patient was having some neck pain afterwards and that she had given him some Tylenol.
Then came my note.
And then came another note from the nurse, dated 3 months after the incident, and labeled “addendum:”
“Paged Dr. Jones to evaluate patient with complaint of inability to move lower extremities. Dr. Jones responded that she would examine him after rounds. I told Dr. Jones that it was an emergency but she said the patient would need to wait.”
I was horrified. That’s not at all what happened – the nurse was clearly afraid that she would be held responsible since she was the one who had moved the patient earlier that morning, possibly displacing his (recently operated upon) spine and causing a bleed. She obviously wrote the note to make it look as if the irreversible paralysis was due to the slowness of my response.
And so I felt helpless and very afraid – is this what will end my medical career? I thought about all my years of training, how careful I always tried to be, how much I cared for my patients – and would it all end with this insanity?
As it turned out, I had to prepare for a deposition. I studied every angle of the case, read every piece of the chart, sweated it out for many weeks. And then I got another call from the lawyer one day: “They’re settling out of court. You don’t have to come in. Just forget about it.”
I was relieved, but angry. I also felt very sorry for the patient. But most of all I wondered about the legalities of practicing medicine – how vulnerable we docs are, how a complication can be seen as malpractice… and how another healthcare professional can be so damaging. Sometimes practicing medicine scares me – lives are at stake, and even the best intentions can lead to life-altering events.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
