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Showing posts from March, 2012

Studying for the American Board of Internal Medicine Maintenance of Certification Exam

In 1989 after finishing my residency in Internal Medicine at the University of Washington, I sat down and took the Internal Medicine Boards. I didn't study, didn't look at any information about the test at all ahead of time and passed in the top 10%. It made perfect sense that it would go that way: I had been eating, drinking and sleeping (sometimes) internal medicine for 3 solid years in an excellent program, studying all the time and practicing under recognized opinion leaders in the field. Prior to that I had eaten, drunk and slept the entire field of medicine for 4 years at Johns Hopkins School of Medicine where my mind was positively marinated in everything that was then thought to be true about physiology, pathophysiology and care of patients.

When I took the test it was the last time I would ever have to take it. I was forever certified with American Board of Internal Medicine, and the next year all of the doctors who passed the test would have to re-take it every 10 ye…

Do doctors understand statistics? Nope.

That's a bit of an oversimplification, of course, because some physicians really do understand statistics, but an article just published in the Annals of Internal Medicine looked at internal medicine doctors' ability to interpret whether tests to screen for cancer actually helped save lives and found that a majority of us do not understand the numbers that explain why some cancer screening tests may be of no benefit.

Lately scientific organizations have released some pretty controversial recommendations about screening for several common forms of cancer. Initially, in 2009, the US Preventive Services Task Force released a recommendation that mammograms not be performed routinely on women under the age of 50 and that evidence was insufficient to recommend mammograms over the age of 75. This was based on lots of data that showed that in these groups of women, the risks of mammogram screening, including unnecessary treatment, were higher than the benefits, except in specific case…

Why are patients becoming so much more complicated?

When I was in medical school, lo those many years ago, patients used to come in with diagnoses like pyelonephritis or cellulitis or pneumonia or myocardial infarction or cirrhosis of the liver or heart failure. They were very sick, and I was very inexperienced, so it was always a challenge. I drew blood for various blood tests run by a lab, got a urine sample and looked at it under the microscope, got a chest x-ray and sometimes an EKG. I took a history and did a physical exam and wrote this all up on a piece of paper and made my conclusions and wrote orders and started an intravenous line for medications. A nurse would do vital signs, clean up messes, give medications and call me if something bad happened. Rarely had my patients had anything more complicated medically than a hernia operation and rarely did they take more than 6 medications. It was often perfectly adequate to get the entire medical history from the patient, which was good, because finding medical records was difficult…

Local anesthesia with lidocaine, buffered lidocaine, warmed buffered lidocaine, slow injection of lidocaine: publishing the results of perforating my own arm

I have done procedures using local anesthesia with subcutaneous lidocaine for over 20 years, and by the look on peoples' faces, I know that lidocaine stings. About 10 years ago I heard that adding a small amount of bicarbonate to the lidocaine took the sting away, but I never really had a chance to try it since my clinic never had any bicarbonate around. Just recently I went over the literature about reducing pain with injections and read that slowing the injection and warming the lidocaine is also effective in reducing the sting.

The pharmacy of my home hospital is very understanding and cooperative and they treated me to a vial of lidocaine 2%, a vial of 8.4% bicarb and all the insulin syringes I wanted. The insulin syringes have 28 g needles which are only slightly thicker than an eyelash so hardly hurt at all. I buffered the lidocaine with 1 part bicarb to 9 parts lidocaine. (It turns out that despite concerns that lidocaine would not be stable in a buffered solution, it actua…

Simply love them: using lidocaine to anesthetize the skin before arterial punctures or IV insertion

Lately I've been doing hospitalist shifts at a busy medium sized hospital that serves a complicated and pretty sick population. Patients frequently have lots of life threatening medical problems that interact in unpredictable ways, putting them at high risk of dying when they get an acute illness. When they come in they are vulnerable and scared and sometimes angry and difficult. I am sometimes needed in more than one place at a time, which makes it imperative that I figure out some way to make the interaction work so that things will move smoothly in the direction of helping the patient start getting better.

What has been working particularly well has been the approach of deciding ahead of time to love them, and then talking to them and hearing enough of their stories that I can develop a respect for where they are in their lives. When a person is truly vulnerable, there is just nothing like love and respect to buy cooperation. And it is also much more fun for me, because then I …

Yale University Ultrasound Course in Puerto Rico and learning from resource limited settings.

I just got back from Puerto Rico, where I attended Yale University School of Medicine's yearly emergency medicine and critical care ultrasound course. First, Puerto Rico is a tropical island in the Caribbean which has been relatively blessed by the universe, at least as compared to Haiti which is within hailing distance. It uses American currency, has American style roads, mostly deals in English but has rain forests and warm beaches and loud tree frogs and quiet bats that make being outside at night amazing and other worldly. It is not very expensive to fly there, even from the west coast. It is not as cheap as other developing countries, but not as expensive as traveling in the US. It was wonderful to go there in March. I don't usually do this sort of thing, the resort vacation that becomes a tax deduction because of medical education, but this one had fantastic faculty and was everything I could have hoped for.

I have been excited about bedside ultrasound since I took a cou…

Inappropriate medical care, high costs at the end of life, zombies and more (a rant)

It isn't that it was a bad day, because it wasn't really. There was too much work, yes, and I ended up staying late, but it was mostly made of good interactions and I felt generally competent. So, no, it wasn't just a bad day. Still, this evening I feel like the best possible future would be one in which there was no technological medical care, where we just worked on sanitation, vaccinations, good nutrition, maternal health, mutual respect, stuff like that, maybe even penicillin, and called it good.

The stuff that is bothering me is use of really high end technological medicine to prolong life at its very bitter, and I do mean bitter, end. The woman found unconscious at home after not breathing for so long that her brain had died, kidneys had quit, but her heart still had the ability to pump, so she is in the intensive care unit receiving constant dialysis, on a ventilator with intravenous nutrition and scads of tests every day, all for the expected outcome of death, soo…