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Wednesday, August 31, 2011

Life at Grady: Potty meat

The following post, by Kimberly Manning, FACP, was adapted with permission from her blog Reflections of a Grady Doctor. All personal, identifying information has been changed to protect privacy.

"What questions do you have for us?" my intern asked his patient diligently one morning on rounds. Mr. P immediately craned his neck over to his wife who sat next to his bed.

"You gon' ask about what you was sayin' earlier? About my legs?" he asked her.

Mrs. P did all the talking. No matter how many times we tried to get him to ask his own questions, he preferred to have his wife take care of such formalities. So Mrs. P, who had just sat down to the bedside tray table with a full meal/snack she'd brought in, looked over in our direction with her mouth a-watering and her eyes half-mast. She then looked back at her husband. "You talkin' 'bout the water pills?" She shifted back to us. "His legs was swelling sometimes. Tha's why we was wondering does he need more Lasix pills in case they swell again."

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I looked down and inspected his legs once more. He had very trace amounts of swelling, and he had no signs of volume overload. Before I could say anything, my intern chimed in. "Your legs look fantastic, Mr. P. We've had you on a low-salt diet, and I think that's helped a lot."

"See, I told him don't be eatin' all that salt!" Mrs. Purifoy announced with a curl of her lips. She picked her teeth with her thumb nail and nodded. "Ummm hmmmm. I told him. See me? I don't use no salt. I mean, I know it can hide up in stuff but I don't eat that stuff."

I looked at the tray table and surveyed her bounty. The entire meal was from the hospital gift shop--which couldn't possibly be low on salt since everything needed to have a decent shelf life.

Here is an inventory of what she had:

•A jumbo bag of potato chips.
•A big dill pickle.
•Some kind of sandwich wrapped up in foil
•And. Wait for it. . . . wait for it. . . .
•Yes. A can of Vienna Sausages.

Vienna Sausages? Seriously?

My husband Harry's voice began furiously swirling around my head. "Watch your own lane!" he hissed. "Don't even START with this lady! She is NOT your patient!"

"But how is she just gonna bust on his salt intake when she has VIENNA-freakin'-SAUSAGES at the bedside? That's, like being a TOTAL hypocrite, man!" I subconsciously replied.

"STILL!" the little imaginary drill sergeant hollered. "It AIN'T your lane, nosy girl! Drive in YOUR lane!"

And for two seconds I did drive in my lane. But then she started situating herself to eat what might as well have been a salt lick, and I could. not. take. it.
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"So. . . .uhhhh. . . .do y'all know how much salt you should stay under for the day?"

I directed this right at Mrs. P since she seemed to be the speaker of the house. And she lit right back at me, calm as could be. "Oh yeaaaaahhh. I check all the labels for saturated fat and all that."

"Okay. . .let's just go over it again to make sure it's fresh on your mind, okay?"

She nodded--while still getting her food ready.

"Mind if I use this for an example?"

Harry's voice was in my ear again. "You KNOW you are wrong if you pick up those Vienna Sausages. You are TOTALLY being a jerk if you do because you know how salty they are."

"Go right on ahead," she said. "Baby? Make sure you pay attention 'cause you be the one eatin' all that salt. See me? I got sugar diabetes and I don't eat no salt. Tha's him." She bit the pickle.

Could. Not. Take. It.

"Okay, so here is where the sodium is," I said. "You know this already, but the sodium is the salt. You both want to keep it under 2000 milligrams of sodium. So you have to count it up. . . ." I looked at the label of the can. "If you eat this can. . .it has 2.5 servings total. . . . . and if you eat the whole can. . .that's like a third of what you can have for the day in terms of salt. And let's check the chips. . . . okay. . .so 590 milligrams in this bag. . . . and you're already well over half of what you can have for the day. See? Watching salt is really, really hard to do."

"He eats potty-meat. Tha's waaaay worse than Vi-ennas. Tell him, doctor."

Huh?

"Potty-meat?"

"POTTED meat!" the voice of another patient clarified from the neighboring bed.

"Aaaaahhhh," I said. "Is potted meat pretty salty?"

"Horrible!" exclaimed Mrs. P. "Just HORRIBLE!"

I stood there for a few beats watching Mrs. P as she popped the airseal on the bag of chips and peeled open her can of Viennas.

"Mrs. P? You both really need to watch the salt. If you have diabetes you probably should avoid this stuff, too."

"I told you. I don't be eatin' salt like he do." Again she bites the pickle.

Killing me.

I glanced up at the clock and then at my interns. They were shifting on their feet and obviously wondering how long I would let this go on. Much to my disappointment, I knew I would be forced to do the unthinkable--get in my own lane.

"Do you think we can get you both to come see us at the primary care center?"

"Oh yeaaaaah. He definitely need to see y'all."

"Okay. But. . .what about you, Mrs. P? Will you see us, too?"

"I could probably see y'all, too."

"And can you do me one more favor, Mrs. P?"

She raised her eyebrows.

"Can you make this your last can of Vienna Sausages after today?"

She looked down at the can and back up at me. "It's that bad?"

I nodded slowly (knowing that if Harry were there he'd be shaking his head and giving me the hairiest eyeball ever.)

"Okay then," she conceded. "But Dr. Manning?"

"Yes, ma'am?"

"Make sure you tell HIM about that potty-meat, okay? 'Cause I just know tha's waaay worse than Vi-ennas."

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Monday, August 29, 2011

Half of hospitals buy gray market drugs

Severe shortages for life-saving medications have driven a "gray market" in the wholesale drug supply industry, a watchdog group reports.

And the mark-up on gray market drugs is a budget-buster, reports the Institute for Safe Medication Practices, a Philadelphia-based nonprofit organization devoted entirely to medication error prevention and safe medication use. Purchasing agents and pharmacists at 549 hospitals responded to a survey on gray market activities associated with drug shortages.

The report includes chilling anecdotes from the respondents about pressure from physicians and administrators to ensure drugs are available, and drastic price gouging from the gray market suppliers. Price mark-ups of 10 times or more than the contract price were reported by about a third of respondents from critical access hospitals and community hospitals, and more than half of university hospitals. Examples include a box of calcium gluconate that cost $750 instead of the contract price of $50 (1,400% mark-up), and a supply of propofol that cost $25,000 instead of $1,500 (1,567% mark-up). Oh, and there's exorbitant shipping and handling fees, too.

More than half (52%) of respondents reported buying one or more drugs from gray market vendors during the past two years. Most (80%) of these respondents said gray market purchases increased as drug shortages grew. While most respondents (54%) reported buying products from only one or two gray market vendors, a quarter (25%) of university hospitals reported purchases from more than five.

Even in states that require documentation of authenticity for pharmaceuticals, 50% of respondents bought medications from the gray market during the past two years. Of these, only 35% reported always receiving the required documentation of authenticity. Approximately two-thirds of all respondents never checked the manufacturer's website to see if the secondary distributor was authorized by the manufacturer. Most were unaware that this information is available.

And, 56% respondents get daily solicitations to buy medications no longer available through the manufacturer or usual wholesaler. They often contain high-pressure pitches more suitable to QVC than to health care, such as, "We only have 20 of this drug left and quantities are going fast." And 13% of respondents also are solicited to sell their stocks of drugs into the gray market.

In general, the most common reasons respondents did not buy gray market drugs were concerns about authenticity (74%), ethics (66%), cost (69%), and storage conditions (58%).

Up to 12% of respondents reported awareness of a product authenticity issue, medication error, or adverse drug reactions associated with the use of gray market products in the past two years. Most cited errors include a different product strength, improper storage, recalled or stolen products, illegally imported drugs, questionable chain of custody, and sale of counterfeit products and placebos.

The Institute for Safe Medication Practices suggests a four-pronged strategy:
--The Food and Drug Administration (FDA) needs greatly enhanced authority to manage drug shortages.
--Stronger regulations are needed for pharmaceutical distribution, such as a national law to limit distribution of pharmaceutical products to authorized distributors of record, and to limit price gouging during shortages.
--Minimize the need for buying gray market drugs by planning ahead, forming local coalitions to cooperatively borrow from each other, back-ordering or direct ordering from the manufacturer, and seek out alternatives for drugs in short supply.
--Take stronger regulatory and law enforcement action against illegal activities, such as counterfeiting and theft. Five drug makers are seeking stronger penalties for stealing chemotherapy drugs, for example.

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Wednesday, August 24, 2011

Life at Grady: The difficult patient

The following post, by Kimberly Manning, FACP, was adapted with permission from her blog, Reflections of a Grady Doctor. Names and identifying information were changed as needed to protect privacy.

"Oh man, I heard you guys got him on your team last night. Oooo weee."

"I think this is my first time taking care of him," I replied.

"Really? Man, how could that even be possible? Dude. Everyone has had him before."

This was the exchange I had with a colleague the day after my team admitted a frequently admitted man to our service. Yes, him. He was well known to nearly every physician in our hospital because of his constant revolving-door hospitalizations for his underlying--and yes, complicated--medical problems.

But mostly, he was also known for being difficult. Real, real difficult.

"He will cuss you out and then throw you out." This was what one of the senior nurses had to say about him. She went on to say, "Chile please. . . . I've taken care of him so many times that I don't even take it personally anymore. He's just a miserable, miserable little soul." She shook her head and punched in a code into the Pyxis system.

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Him. That difficult guy of legendary status. Challenging enough to grate on the nerves of even the most seasoned Grady nurses--which is pretty difficult to do. Him. Guaranteed to either demand that I get out of his room or yell expletives in my direction until I turned red in the face and was rendered completely useless as a clinician. This was the word on the street about him. Demanding and difficult. Demanding his pain medications. Demanding someone to "cave" in the face of his unruly behavior. And just downright demanding a whole bunch of things.

Even one of the nicest people in the entire hospital had this to say: "Look, there's just no other way to spin it. He's just an a-hole."

Look. We're all grown folks here and sure, I'd like to pretend like every single health care professional is SO professional that he or she would never, ever even go so far as to THINK of a patient as "an a-hole"--let alone actually say it. But the reality is. . . .members of health care teams are human. They have feelings and nerves that, despite their altruistic origins, can be stepped on. And deep down inside of every single one of them is that "OH HEEELLLL NAW!" button that some patients just push. If they can find it.

And this guy? He seemed to know exactly where to find it in every person he encountered.

My team had seen him first and I knew they would tell me all about him on rounds. A palpable heaviness came over the entire team as we got closer to his room.

Everyone who had already met him looked so tired. The intern. The resident. Even the bright-eyed bushy-tailed medical student. This man had found their buttons and pushed them hard. They looked so tired. Which immediately made me feel tired. And I hadn't even met the dude.

Before I could even get down the corridor in the ward, another person saw us approaching and chimed in another jovial two cents. With a thumb pointing in the direction of his room, the passerby laughed and said to me sarcastically:

"Wow. . . . Good times, Dr. M."

This was getting nuts. I offered a half-hearted smile and nodded as I watched the passerby disappear into the neighboring room.

We paused in front of the door and focused our attention on the intern. The same tired-looking intern who'd been given the distinct pleasure of admitting him to the hospital. Not tired-looking as in I-was-up-all-night-and-might-be-an-assassin. More tired-looking as in this-dude-is-working-my-nerves-so-bad-that-I-am-dangerously-close-to-catching-a-case.

The intern's face was twisted and emotionally exhausted as he reached into his pocket for his notes... He shifted his feet and did his best to channel the most empathic part of his psyche. Next, he launched into this patient's story. The same story that seemed to be playing like a broken record all over Grady Hospital.

Suddenly I heard someone hollering from the other side of the door.

"Jest get the f--k out of my room! I ain't doin' none of that! Get the f--k out!"

My intern looked over his shoulder at the door and then down at his shoe laces. Kind of like a child that was being forced to do something he really, really, really didn't want to do.

"Wow," I said wincing as one of the patient techs passed through the door after being kicked out.
"It's bad," my resident said.

"It's awful," the intern cosigned.

I felt like a person who was waiting for a fight after the school bell. All this buildup was just too much for me to stand any more.

"Alright, y'all." I finally interrupted my own thoughts and the intern's presentation that he'd just resumed. "Let's think about this for a minute." The whole team paused, almost like they were all being operated by a DVR remote controller. I sighed hard and was honest with my intern. "I'm feeling completely drained by this patient and I haven't even met him yet."

"Dr. M. . .he's difficult. Like. . .so manipulative. . .it's just. . .I don't know. I'm sorry."

"No, I hear you." I stared at the card with my notes scrawled all over it and looked over at his door again. "Okay. Let's make a pact. Regardless of how he treats us, we will treat him with kindness and respect. And we won't fight with him. No passive aggressive stuff from us, either." That statement seemed to make my team bristle a bit, so I quickly tried to clean it up. "I mean. . .there is no way that this guy is getting the warm and fuzzy treatment here. No way. I haven't even been in there yet and nearly five people have already made it very clear that being tazed by the Atlanta Police would be far more pleasant than being the person caring for him."

"Tazed?" one of the medical students asked.

"Yeah, tazed," I repeated. I reached in my pocket for my phone and pretended to jolt him in the arm with it. The team released a bit of much-needed nervous laughter. "I'm just saying, guys. How about we just decide right here and right now to throw everyone a curve ball?" I had their attention so kept going. "Look, y'all. Every body was once somebody's baby. This man could not have aspired to be in and out of Grady Hospital infuriating ER staff and ward teams when he was five years old. Like, do you really think he drew himself like this with his crayons when he was in kindergarten? I don't think so." No one said anything. "I know it probably sounds corny but. . . .I say we just try to see that five year old."

So in we went. We talked to him as a team and examined him, too. And you know? It wasn't so bad.

I'd be lying if I told you some lovely story of a cosmically heartfelt interaction shared between us. Okay. . .yeah. . . wouldn't it have been nice if I told you that the heavens opened up and that he'd become wonderfully angelic? Wouldn't a perfect ending have been for us to sing kumbayah and all cry together? Yeah. He was still 100% difficult, 200% unreasonable, and 300% annoying and manipulative.

But you know what? Sometimes my kids can be annoying and manipulative. And, depending upon what's going on with me and my husband, I can be the same way--especially when I'm dealt a hand that I don't like.

Shortly after we saw him that day, someone walked up to our team and made another negative comment about this patient. In unison, we all just sort of looked at each other and didn't really respond. For the rest of his hospitalization, we spoke of him with compassion, paid no attention to references about his prior behavior, and . . .dare I say it? Simply showed him some love.

And you know what happened next?

By the end of his hospitalization, nearly everyone else did, too.


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Tuesday, August 23, 2011

Door-to-balloon times decrease, but does mortality?

Heart attack patients are now being treated on average 32 minutes faster than they were five years ago, and medical societies are touting it as evidence of the success of national campaigns to treat heart attacks more quickly.

The study, "Improvements in Door-to-Balloon Time in the United States: 2005-2010," found that the average time from hospital arrival to treatment declined from 96 minutes in 2005 to just 64 minutes in 2010. In addition, more than 90% of heart attack patients who required emergency angioplasty in 2010 received treatment within the recommended 90 minutes, up from 44% in 2005.

Also, the study reported that 70% were treated in less than 75 minutes in 2010, compared with 27% five years earlier. And, the median time from hospital admission to emergency angioplasty declined from 96 to 64 minutes during the years studied. The study appears in Circulation: Journal of the American Heart Association.

The analysis includes all patients reported by hospitals to the Centers for Medicare & Medicaid Services for inclusion in the time to percutaneous coronary intervention acute myocardial infarction-8 inpatient measure for more than 300,000 patients from January 1, 2005, through September 30, 2010.

Declines in median times were greatest among groups that had the highest median times to begin with, those more than 75 years old, (median decline, 38 minutes), women (35 minutes), and blacks (42 minutes).

In 2002, only a third of patients received primary PCI within 90 minutes, and a third underwent the procedure more than two hours after arriving at the hospital. Three efforts were launched, Hospital Compare in 2005 by the Centers for Medicare & Medicaid Services, D2B Alliance in 2006 by the American College of Cardiology, and Mission: Lifeline in 2007 by the American Heart Association.

Now, researchers will have to examine how improved D2B times will affect the mortality rates. ACP Hospitalist discussed how they don't necessarily do that its March issue.

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Friday, August 19, 2011

Congratulations on the pay raise you may have missed

Although nearly 70% of medical specialties saw increases in compensation in 2010, increases were marginal, reports the American Medical Group Association's 2011 Medical Group Compensation and Financial Survey.

Primary care specialties saw about a 2.6% increase in 2010, while other medical specialties averaged an increase of 2.4% and surgical specialties averaged around 3.8%. Specialties with the largest increases in compensation were allergy (6.38%), emergency medicine (6.37%), and hospitalist-internal medicine (6.29%).

In comparison, in 2009, primary care and surgical specialties saw about a 3.8% increase, while other medical specialties saw 2.4%.

Operating margins for medical groups are increasingly thin, the group reported in a press release. Only organizations in the Western region were nearing break-even at a loss of $27 per physician. All other regions operated at a loss per physician; Eastern, nealy $1,600 per physician; Southern, nearly $1,900; and Northern, nearly $10,700.

Many of the losses were supplemented by other non-clinical revenue sources and/or funding from health systems.

The AMGA 2011 Medical Group Compensation and Financial Survey represents responses from 239 medical groups employing 51,700 providers (55.6% of groups report more than 100 physicians). The survey was done by a national accounting firm.

In case you missed it ...
A new blog is offering near-daily posts on retractions from the peer review literature. The blog, Retraction Watch, is a watchdog service offered by two journalists with a long history in scientific reporting. The pair offer reactions ranging from withdrawals ranging from simple errors to outright plagiarism.

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Thursday, August 18, 2011

History and physical the best way to diagnose patients

Four out of five doctors agree that they don't need scans to make the right diagnosis.

It's an old-fashioned concept frequently discussed among ACP members, but the history and physical combined with basic tests is way more important to diagnosis than ordering scans and advanced tests. A recent research letter in the Archives of Internal Medicine makes the case.

In the letter, Israeli researchers described a prospective study of 442 consecutive patients admitted from the emergency department in 53 days.

A senior resident examined all patients within 24 hours of admission (mean=14), including a history, physical, and review of ancillary test findings done at the emergency department, such as blood and urine tests, electrocardiography, and chest radiography. The resident also reviewed additional tests such as troponin, C-reactive protein, and international normalized ratio, as well as computed tomography or ultrasonography. Finally, medical charts from previous admissions and all medications and vital signs were reviewed.

The senior resident then determined a main diagnosis and indentified what helped her reach it. Her diagnosis was sealed. Hospital physicians, either hospitalists or medical educators with more than 20 years of experience, repeated the process (mean exam time was less than 25 minutes), and they also sealed their diagnoses. At least one month after discharge, the senior resident verified the patient's final diagnosis and called the patient's primary physician.

The senior resident was correct in 354 of 442 diagnoses (80.1%), while the hospital physicians were correct in 373 patients (84.4%). They made identical correct diagnoses in 327 cases (73.9%). Both were wrong in 42 patients (9.5%) (P=.04).

For the resident and the hospital physicians, patient history was the key element in making the diagnosis. The physicians could make the correct diagnosis on history alone in about 20% of all diagnoses, or in combination with the physical in another 40%. Basic tests with or without the physical examination were key to the correct diagnosis in one-third of cases.

While the exam or basic tests alone were very seldom helpful, the physical examination doubled the diagnostic power of the history (19.5% to 39.0%). Imaging, mainly head computed tomographies, were infrequently used in the emergency department and added little to making the correct diagnoses.

"We found that more than 80% of newly admitted internal medicine patients could be correctly diagnosed on admission and that basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases," the researchers wrote. 90% of all correct diagnoses were accomplished on presentation through a combination of the history, physical and basic tests. This combination correctly diagnosed three out of four admitted patients.

"Our results do not mean that sophisticated studies need not be used after admission, but they do suggest that their choice should be guided by the clinical data on presentation," the researchers concluded.

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Wednesday, August 17, 2011

Life at Grady: You make a grown man cry

The following post, by Kimberly Manning, FACP, is adapted with permission from her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect privacy.

That first day you went off on me and everyone else.

"I'm in pain!" you yelled in no particular direction.

"I will work on your pain," I said back to you, my voice decidedly softer than yours.

"Yeah, right." That's what you retorted. Phtooo. Take that.

The next day I asked you, "How do you feel?"

Again you lit me up, this time threatening to kick me out altogether. "Worse! Worse! I'm in pain! Y'all got my medicines all confused and I'm still in pain!"

And see, you had a reason to be in pain. This was not some "soft call" where you had a little ache in your back or a visit from "Arthur-itis". No, this pain was legit. And this analgesia you were calling out for was warranted.

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I took your venom and withstood your anger because I knew it was really at the pain and not me. And, seeing as you were a born-at-Grady elder who happens to be old enough to remember the segregated "Gradys", then that gave you license to go off whenever you felt ready.

"Okay, let me compare your home medications to what we are doing here," I replied. "Were your home medications helping at all?"

"They were working better than what y'all doing! This don't even seem like it's as much as what I was getting at home and I thought I was s'posed to be getting my pain medicines worked out. This is some bulls***."

"Sir. . .I'm sorry. Please. . .let me look at--"

"Get out, please. Just get out. I need some rest. I'm tired and my body is hurting. Just go."

"Okay. I'm going to put you back on your home medicines and then move up from there. Okay, I'll leave now."

"And turn my television that YOU shut off back on 'fore you go."

"Yes, sir."

"And get that bright-a** light, too."

I clicked it off on the way out and left with my tail between my legs.

As a team we carefully reconciled your home medicines with your hospital medicines. Looked like we were a few milligrams under what you'd been getting, and we brought it all to speed by changing the orders.

The third day I came in to see you and your back was to me.

"Hey there, sir. I'm making my rounds and I'm here to see about you."

No answer.

"How are you feeling?"

"Terrible."

"Terrible?"

"Terrible."

"The medicines aren't taking the edge off?"

"It helped a little bit, but now I feel sick to my stomach. My bowels are loose, too." Your voice was quiet and defeated. This was different. . . and it scared me.

"We put you back on what you were getting at home and--"

"I know that. Soon as you said that yesterday I started. But now all I feel is sick."

"I'm sorry. . . what do you mean by 'as soon as I said that?' Do you mean the nurses told you it was a new dose?"

"What?"

"The medicines. You said you started as soon as I said something? That part confused me. Just wanted to get clear."

You reached under the bed and pulled out a plastic Kroger bag full of pills. "No, I'm talking about my home medicines that you said to get back on. These here."

Wait, huh?

"Sir. . .wait. You're taking. . .hold up. . . you're taking these . . . and the ones we're prescribing in the hospital?"

"I did what you said." You pointed straight at me. You were talking about ME. Not my intern. Not my resident.

"What I said? You mean you were opening these bottles and taking these pills in the hospital?"

"Just the pain pills. Just those like you was talking about." You pulled out a bottle and showed me. "I took two of these here."

I looked and then read the bottle. You had just shown me some Reglan to help with digestion. This was not a pain medicine at all. "This is what you took, sir?"

"Yes, I took my pain pills from home. That's what you said!" Your voice was rising higher and cracking a bit. Your repeated yourself. "You said to get back on my pills from home!"

Briefly, I was relieved that you didn't take double the amount of narcotic pain medicine, but that was only fleeting. I squeezed my eyes and rubbed my forehead with the heel of my hand and sighed. "Sirrrr. . ."

My voice sounded scolding, even though I didn't mean for it to sound that way. "Noooo. . .noooo. . . .you're never supposed to take your pills from home when you're in the hospital. This could really--"

That was it. That was the straw that broke the camel's back.

Your face melted into frustration and tears began shooting out of your crinkled eyes. You shrieked out, "I DON'T KNOW!!! I DON'T KNOW!!! I DON'T UNDERSTAND THIS! I DON'T UNDERSTAND THESE MEDICINES!!!" Your body was limp and your shoulders slumped. And you wept. An exhausted, exasperated, tired weep. "I'm tired of the pain. I just want to stop my body from hurting. This illness going all through my body. . . I know it ain't a cure but they said. . . you said you would help my pain. Please, please. . . .help me."

Your hands were shaking and your lips were quivering. Each word was punctuated by your throaty cry. That cry sounded like it had been bottled up for all seven of your decades and I had just rubbed it out just like some kind of genie. It rose out into the hallway, first slithering around my head and strangling my neck.

I stood there dumbfounded. My face felt like it was on fire and my eyes blinked like some kind of involuntary tick to fight back the rapidly forming tears. I dared not talk. I had done enough.

I reached down and patted the bed, looking at you for permission to sit beside you. You noded, still crying. . . now trickling off into restrained manly crying instead.

And so I sat next to you in silence. I held your hand and wiped your cheek with a paper towel since it was the only thing sitting on your tray table. Then, when you were ready, we started over. Going through each medicine one by one. . . opening the bottles, pouring out each pill, and making it more concrete.

You told me that sometimes it's hard to see the words on the pill bottles and that even when you can, sometimes it's hard to read them depending on the words involved. I told you I should have asked that and I apologized for what feels like the one hundred-trillionth time.

Then, eventually we got somewhere. I excused myself with your permission and shared this with the other members of our team. The intern, the resident, the pharmacist, the students. I let them see how ashamed I felt and how much it hurt my heart to see you cry. Yes, you. A grown man. Their faces looked sorry, too, and I said nothing to blow it over or shrug it off because your being confused and in pain and frustrated just wasn't acceptable. So together, we vowed to do better.

And so we did.

On the fourth day you were smiling. A big beautiful, nearly toothless smile. . . lighting up the room and even the hallway.

"How do you feel today?"

"Spectacular."

"Spectacular?"

"Spectacular."

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Saturday, August 13, 2011

Interesting neuro case for doctors who hate neurology

Yesterday, I presented the case of a woman with double vision and ptosis and challenged you all to a game of "spot the lesion." To be honest, I found this stuff impenetrable as a medical student and it was only by sheer force of will that I was able to commit it to memory for exactly long enough to pass a test on it before immediately purging it from my memory. I did this several times for various board exams and such, but it never really "stuck." Hated neuro beyond words, I did.

As mind-numbing as I found it all in the abstract, I get excited about these cases in application. I may not remember where exactly the internal capsule is or what it does, but when I see someone with an interesting neuro deficit due to a lesion there, all of a sudden it makes so much more sense, and is, dare I say it, cool. I know, kinda sad.

This case is as classic (and cool) as you will ever see. It's a complete palsy of the Oculomotor Nerve (CN 3 for those keeping score at home).

So how do you approach figuring that out?

First of all, it's unilateral. Note the movements of the left eye are all normal. Some other things, systemic diseases, can cause ptosis (the droopy eyelid) or diplopia (double vision), so think neuromuscular stuff like myasthenia gravis, botulism, etc. But those are usually bilateral. As an isolated right-sided finding, however, that should prompt you to think about either a central cause or a direct neuropathy. But central causes of this sort of thing are not likely, because the oculomotor nuclei are located deep in the midbrain, and are crossed, so a stroke or something bad there is not likely to give unilateral or isolated neurological findings. Therefore, we know it's a peripheral neuropathy. Yay! But which one?

The ptosis, especially a complete paralysis of the levator palpebrae, should be a huge red flag that the third nerve is involved. Even I remember this mnemonic from medical school: The III is the pillar that holds the eye open; the 7 is the hook that closes it.

Then you look at the pattern of movements that the eye has lost and note that it matches the oculomotor muscles which are innervated by the third nerve.

She can abduct it, so CN6 is intact, but up, down and adduction are shot, which are all CN3. The fact that with straight gaze and lateral gaze the right eye is a bit down compared to the left is due to the preserved function of CN4. Thus, the classic pattern of CN3 palsy, "down and out."

Then you look at the pupil. It's big, so you know this isn't a Horner's syndrome, though that wouldn't cause ophthalmoparesis either. And it's not reactive, either. The most common cause of acquired CN3 palsies is diabetic microvascular ischemia, one of the many peripheral neuropathies that the sugar causes. But those are usually pupil-sparing. This involves the pupil, so something is compressing or otherwise pissing off the nerve directly.

The solution (as for just about everything in neurology, it seems) is to order your MRI, but in this case, you definitely want an MRA as well. Because the next most common cause of CN3 palsy is compression by an aneurysm (notoriously the PCA, posterior communicating artery). The deficit can apparently be intermittent with an aneurysm. But all sorts of things can do it, and the treatment will depend on the cause. It could be direct compression from a pituitary tumor, or a cavernous sinus thrombosis. If the patient presents with stiff neck and meningismus, either subarachnoid hemorrhage or meningitis should be considered, as they can do this. Demyelinating diseases can also do this, so if all else fails and if the demographic makes sense, consider MS. In older patients, consider arteritis, too. Herpes zoster can also rarely do this, though it's more classically the seventh nerve. These can occur post-traumatic, but be sure that the pattern of the deficit matches the nerve and that you're not going to miss an orbital wall fracture! I recently saw a patient with a post-traumatic transient internuclear ophthalmoplegia, which was also pretty cool. Sadly, I didn't have the presence of mind to get pics of that one.

In the incident case, the MR showed a suprasellar mass invading the cavernous sinus, most likely a pituitary macroadenoma:

Not something you can see commonly, but very classic, and a nice opportunity to review and relearn all the neuroanatomy we learned in medical school, but in the context of a real case.

This post by Liam Yore, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Friday, August 12, 2011

The 5 F's for futuredocs and new interns

The other day a tweet caught my attention from @JasonYoungMD who stated "My Five Foundations of Felling Fine: Food, Fitness, Friends & Family, Falling Asleep, Fulfillment." This seemed like the best advice I had heard for the newbie interns taking teaching hospitals by storm as well as the rising third year medical students who are about to be unleashed on the wards (if they haven't already). It also is a great starting point for program directors who are wondering how to ensure that their residents are "Fit for duty" according to the new ACGME rules.

F by docksidepress via Flickr and a Creative Commons licenseFood While this is basic part of sustenance, finding food sometimes in the hospital can be challenging, especially at odd hours. Fortunately, this has gotten better, but the choices may not be healthier. In my own hospital, I've seen the front lobby transform from a small coffee kiosk (Java Coast which was celebrated when it arrived) to a full-fledged Au Bon Pain (ABP as we affectionately refer to it). While ABP was a welcome addition, it is easy to consume a lot of empty calories eating muffins or breakfast sandwiches! To make matters worse, research from one of our very own sleep research gurus has shown that the more sleep deprived you are, the worse food choices you make! Therefore, the thing you will reach for after a night shift is going to be the carbohydrate loaded Danish. Residency programs must know this and usually have morning reports full of this type of food. So, consider how you will make healthy food choices, whether that be bringing your own food, or finding out where the healthy options are. Lastly, don't forget about the empty calories that come with beverages, especially coffee-related drinks. For you Starbucks fans, there is an app for that, and I guarantee you may change your choices.

Fitness Like food, fitness can be hard to come by. Interestingly, working in the hospital can actually be a way to get exercise. For example, some studies demonstrate that residents walk as much as 6 miles on call! However, it's also just as easy to sit behind a computer and take a "mission control" approach to your call night where you are monitoring all your iPatients. So, think about this and consider wearing a pedometer and most importantly getting into a routine. When time is of the essence, find a way to work fitness into your day like taking the stairs in lieu of the elevator, or parking farther away. If you join a gym, you have to make sure you go, and one easy way of doing this is to make sure your gym is on your way home from work and that is your first stop. During residency, I actually switched to a gym that was directly on my route home that had a parking lot so I literally had no excuse and actually felt guilty while I drove by and did not stop there. Others opted for 24-hour gym craze that that could work for anyone's schedule. Lastly, exercising with a friend will likely lead to greater results than the solo work out.

Friends & Family Speaking of friends and family, this is the support system that gets interns through residency. Fortunately, another omnipresent F can be helpful here: Facebook. Busy interns or students can at least get reminders to electronically wish your friends happy birthday or log in on that random Monday off to reconnect with friends. It's also important to set appropriate expectations with your friends and family, for example when you are starting on a time intensive rotation that can be demanding. Because of the intense nature of working in the hospital, some of you will form fast friendships with your co-interns and residents, which can be helpful to get you through. However, even your closest friends (including those at work) will ask you to choose between them and sleep, which can be very tough when you are running low on sleep.

Falling asleep So, speaking of sleep, my first question was where do I sleep? Sounds silly I know, but I actually did not know where the call rooms were or did not have the call room key for my first call night ( I actually can't remember which) so I ended up going to sleep for an hour in an unoccupied hospital bed. So, this may not be possible today for two reasons: (1) interns are not likely sleeping when working the jam packed 16-hour shifts; and (2) hospital beds are nearly always filled! Still the challenge for today's interns is getting sleep when working odd hours, especially if starting night shifts on night float or night medicine as programs are evolving to include more night rotations. If this means you have to invest in window treatments or wear an eyeshade at night, just do it. There is nothing better than sleep for a resident and the more the better. While your sleep at home may be limited regardless due to your other family obligations, it's important to know your limits and set aside nights where you will recover.

Fulfillment Last but not least, it's important to figure out how to keep yourself happy and fulfilled during your residency. In some cases, that is a particular hobby or loved one that you need to stay in touch with. In other cases, fulfillment is more complex. It is not uncommon to have doubts about your future career as you stand by the fax waiting for outside hospital records, wait on the phone to schedule a follow up appointment for a discharged patient, or even transport a sick patient to get a needed test. While many are working on ways to reduce the burden of this largely administrative work, interns and medical students are still straddled with a large amount of scut which can be demoralizing. So, where do you find the fulfillment in your work? Well, you will find it when you least expect it, in the words of a patient who is eternally grateful. In other cases, you will meet a mentor or role model who shares your passion and interest in medicine, whatever that may be, and can inspire you to keep you going. Whatever it is, find it and hang on to it for dear life during your darkest hours and it will pull you through.

I do need to add one more F to this fine list. Provided that you are keeping up with the first 5 F's, the best thing is that being in the hospital, learning medicine, and caring for patients is actually FUN! So, don't forget to pause and enjoy it. These tips will also serve you will in the FUTURE!

Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, I also direct the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

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Thursday, August 11, 2011

'Your ER doctor will see you now'

For those in-between health problems that are urgent but not an emergency, hospitals are now scheduling them and offering the reservation fee back to patients not seen within 15 minutes of your appointment. This policy is already in place in outpatient care, but now it's arrived to the ER.

East Cooper Medical Center in Mt. Pleasant, S.C., is one hospital offering the service to its "consumers," according to a press release.

For $10, patients can reserve a time online and then wait in their own homes for an appointment. If other emergencies cause a delay, the patient gets a text message or e-mail and the patient can set an alternate time or get a full refund. The service claims to not affect the wait times of other emergency room patients (so no cutting in line).

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Better angiography standards needed at low-volume facilities

Hospitals need to be more selective about when to use diagnostic coronary angiography, researchers say, after finding that some hospitals found obstructive coronary artery disease (CAD) in less than less than one-quarter of patients who underwent the procedure and others found it in every patient who underwent the procedure.

Because angiography is an invasive procedure with all the risks inherent to that, angiography should be limited to patients with moderate to high pre-test probability for obstructive coronary artery disease. Nationally, less than half who undergo the procedure do.

Researchers conducted a retrospective analysis of 565,504 patients without prior myocardial infarction or revascularization who underwent elective angiography at 691 hospitals from 2005 to 2008. Results appear at the Journal of the American College of Cardiology.

The rate of obstructive coronary disease, defined as being present in patients with more than 50% stenosis in any major epicardial vessel or branch vessel greater than 2 mm in diameter, varied from 23% to 100% among hospitals (median 45%; interquartile range: 39% to 52%). Ninety-one hospitals (13%) had diagnostic yields less than 35%, whereas 82 had diagnostic yields greater than 75%. Results were consistent from year-to-year and when alternative definitions of coronary stenosis were applied, including that included any lesion greater than 70% stenosis (greater than 50% left main) and greater than 20% stenosis.

Sites that were more indiscriminate in conducting angiography were more likely to perform procedures on younger patients, those with low Framingham risk scores (33% in lowest yield quartile vs. 21% in highest yield quartile, P less than 0.0001); those with no or atypical symptoms (73% vs. 58%, P less than 0.0001); and with a negative, equivocal, or unperformed functional status assessment. Hospitals with lower rates of finding obstructive CAD also less frequently prescribed aspirin, beta-blockers, platelet inhibitors and statins (all P less than 0.0001).

Modeling suggests that up to one-third of elective, diagnostic cardiac angiograms might not be required if small-volume centers adopted similar patient selection patterns used by facilities with the highest rates of finding CAD.

"Indeed, the parameters most powerfully associated with finding CAD are those well known to be predictive of CAD, including advancing age, male sex, risk factors, and typical symptoms," the authors wrote. "Although our data cannot indicate what the ideal or 'optimal' CAD rate is for elective coronary angiography, these associations suggest that improved patient selection could increase the rate of finding CAD in these institutions. Consistent use of clinical risk stratification algorithms and improvement in the use, accuracy, and quality of pre-procedural noninvasive testing, and perhaps future coronary angiography appropriate-use criteria, may help raise the rate of finding obstructive CAD."

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Wednesday, August 10, 2011

Life at Grady: Rise

The following post, by Kimberly Manning, FACP, was adapted with permission from her blog Reflections of a Grady Doctor. All names and identifying information have been changed to protect privacy.

On the first day of medical school, they had us all sitting in a lecture hall perched on the edges of our chairs. Okay, maybe not everyone was "perched on the edges" but I can at least say we were engaged.

Because this was the start of the show. The lights were down and the curtain was up and finally the spotlight was on us. This was it. That point where you officially get to transition from saying, "Yeah, I think I'm going to go to medical school someday" to a bona fide declaration-- "I am a medical student." And it's kind of a big deal.

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I remember that first day in an unusual amount of high def and detail. A sage senior physician paced back and forth in front of the room. His heavily starched and blindingly white coat had pristine cloth balls for button closures and his name was embroidered in an elaborate cursive above the left chest. His pockets were flat and empty with the exception of the one that held a fancy ink pen; it was as if everything he needed to know was stored perfectly in his brain. Finally, he stopped, freezing us all to stone statues like Medusa with his steely gaze. You could hear a pin drop.

"Your lives will never be the same." He spoke in this strong and deliberate tone, confident and with intention. Every syllable was enunciated as if a person in the front row needed to read his lips to get the message. He pointed at all of us with his long index finger. "YOU are the result of what was, for many, a dream deferred. You. You are the result of hard work, you are the promise of what can be, and yes, you are the very definition of what will be. So, you see, young people…you owe it to more than yourselves to be excellent. You owe it to all of us….and all of them."

Dang.

"Them." You know. . ."them." The "them" that couldn't go to medical school even if they wanted to or who were told that they'd never succeed if they did. Or even the "them" that did go to medical school, perhaps, but were treated unfairly by colleagues. Yep, "them." The same "them" that had to eat in the kitchen or back on the porch when company came, and the very "them" that only counted as only 2/3 of a person for an embarrassingly long time in history. "Them." This was a lot of pressure to put on a twenty-one year old sorority girl. It's the first day of medical school and I already have to worry about not letting "them" down?

I guess I should share that I attended Meharry Medical College--one of the oldest historically African-American medical education institutions in the country. What this means is that, with very few exceptions, that message was being delivered to a group of promising young medical students of African descent. For this reason, I think that senior physician with his perfectly pronounced words and with his espresso-colored complexion spoke so passionately because he'd been to the mountain top already and probably felt like he was looking into a back-to-the-future mirror. And you know what? I remembered his speech from that day. It resonated with me because he was right. For many, this was the result of countless dreams deferred. And I did owe it to myself and "them."

It's funny. For the last ten years, I have worked with medical students of every imaginable ethnicity. One thing I have learned for sure is that even though that message was being directed at a roomful of black future doctors, the lessons are both timeless and applicable to anyone of any race. Getting to the point of medical school, no matter who you are, is a dream come true for someone somewhere. And just like he said--yes, it is the result of some elbow grease and is swirling with promises for a future that someone somewhere only wishes they could know.

And so. This is how I approach all of the medical students with whom I work. Whether they are black, white, blue, green, short, tall, straight, gay, born here, born there, really young, really seasoned, outgoing, introverted, amazingly tri-lingual, or hopelessly uni-lingual. . . . I tell them words quite similar to the ones I heard on my opening day. . . .because we all have a "them." I remind them that yes, this is a big deal, you being in medical school and yes, you do owe it to more than just you to make the most of it.

Oh yeah, I also say that even if your mama and your daddy are doctors, this medical education is yours, not theirs. You need to be the one handling it with care and you are only entitled to what you do from here forward. Not what they did. (But that doesn't mean you shouldn't let their expectation motivate you.)

Yesterday was the first day of school for our Class of 2015 (!) medical students. There they sat. . . in a similar setting to me on my first day, with the brightest of eyes and the bushiest of tails. And sure, a few things were slightly different than ours back in June of 1992. . . . but those same truths were still self-evident nearly twenty years later.
"You are the result of what was for many a dream deferred. You are the result of hard work, the promise of what can be, and the definition of what will be. So, you see, young people. . . you owe it to more than yourselves to be excellent. You owe it to all of us and all of them."

In other words, rise.

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Friday, August 5, 2011

Overwhelmed ERs continue to rise to the challenge

Last night I was contacted by a physician in the local urgent-care. I like him, and we made polite, but brief, conversation. "So, are you guys busy?"

safety net by skuds via Flickr and a Creative Commons licenseI gave him the status report. "Well, yeah. We have about 25 people waiting to be seen the waiting room is full and every patient room is full. Also, we just received a gun-shot wound to the head by EMS."

"Wow, sounds terrible! So, here's what I need to send you ... "

What he sent was, in fact, reasonable: a young woman with signs and symptoms of meningitis who was treated earlier in the day for and upper respiratory virus ... (with Amoxicillin, of course).

She needed a lumbar puncture, which I performed and which was negative.

But I had this thought. I could probably have said, "An airplane crashed through the roof and half the staff are dead," and he might well have still said, "Bummer, here's what I need to send over."

Emergency medicine has risen to such a level of importance, has become so indispensible, that no one pauses to use EDs no matter how overwhelmed they may be. Another patient went to the local orthopedic office, and was told to come to the ER since he couldn't afford to pay for his surgical follow-up and pain prescription refill. So in the midst of our chaos, we were treating surgical follow-up for free.

I'm glad we're useful, and that our specialty is capable of great things. I'm happy that my department rises to any challenge and that my partners and I can sort through almost any crisis. I consider it a blessing that I can help those who need care but can't afford it. (And by the way, I do not work for the hospital, but am paid for what I see.)

I worry, though, that due to Emergency Medical Treatment and Active Labor Act and nationwide financial pressures, due to the ability of others to shield themselves from EMTALA and engage in "moral diversion," our EDs will continue to be crushed.

It doesn't really matter how busy we are, how overwhelmed we are, how understaffed or underfunded, someone else will always be able to send patients our direction.

And as it stands, we'll always have to deal with it. But something has to change, because the safety net is ripping, slowly but surely.

This post by Edwin Leap, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Wednesday, August 3, 2011

Life at Grady: Short fuse

The following post, by Kimberly Manning, FACP, was adapted with permission from her blog Reflections of a Grady Doctor. All personal, identifying information has been changed to protect privacy.

I was talking to a 70-something-year-old man with an 80 pack/year smoking history. By this point, all that tobacco use had led to:

1. Oxygen-dependent COPD
2. Peripheral Arterial Disease
3. Hypertension
4. Congestive Heart Failure

Just to name a few.

Now check it. The real problem was that, despite all this, the patient was still smoking. In his defense, he had cut back to one pack, but still. I felt myself getting irritated with the thought of it all. I looked at the rubber tubing nestled inside his nostrils feeding him supplemental oxygen, while taking in the tell-tale scent of cigarettes emanating from his skin. It was like the entire room had been fumigated with it. I released a sigh, and felt all of my empathy seeping out of me into a pool on the floor.

Even after annihilating his lungs, withering away his blood vessels, and pooping out his heart, he was still smoking? Oh come on.

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Now, before you hate me…let me first confess something…


On this day, I wasn't in the best of moods. Anytime my day starts out with a crash and a bang, it ain't good, and that's exactly what had happened. First of all, I had overslept (and so had my human-alarm-clock kids) that morning. This made my house complete mayhem and it made me rush so much that my already short fuse had become undetectable.

To make matters worse, everyone with a Y chromosome in my house was ridiculously whiny--including my 40 year-old husband who virtually stalked me from the moment I woke up about ME making coffee. Yes. Despite the obvious fact that I had just woken up two minutes before I was physically supposed to be at Grady. (Insert deep breath with fist balled here.)

Which reminds me: Ladies. Gentleman. When and if you get married or otherwise boo-ed up--please. Heed my advice--start the game the way you want to finish it. In other words, if you start the game being the one who makes the coffee every morning while whistling like Andy Griffith. . . and just if, by doing that, you somehow get your spouse/partner/boo/fill-in-the-blank to believe that when you make it that you somehow put "love" in it which is why it always tastes better when YOU make it. . . . then guess what? Even if you are late as hell you can guarantee that you will still be stalked for your love-coffee.

But I digress. So, Mr. Gill, his oxygen and my short fuse. All I'm saying is that I wasn't in the mood to try to convince a grown man with a flammable gas strapped to his face that lighting up anything nearby was a great idea.

The good news is that I wasn't so off that I didn't realize acting on these feelings was inappropriate. So right then and there I started coaching myself to get over my craptacular morning full of whining and java-stalking. I swallowed hard and began shadow-boxing in the corner of my head to deal with Mr. Gill and his love affair with cigarettes.

After examining him and reviewing the changes in his medications, I knew it was time to go there. "Okay…so let's talk about the cigarettes, Mr. Gill."

He shut that down real quick.

"Nawww. It ain't nothin' to talk about there." His voice was crunchy like velcro and his will was as strong as steel. This wasn't going to be easy.

I tried to think carefully before speaking, still coaching myself to be professional. "I wish you didn't feel that way."

Mr. Gill launched right back again with another zinger. "Oh yeah? Well, I wish y'all would stop trying to talk about me and smoking! But y'all keep on askin' so I guess everybody got a wish that don't come true, don't they?" He let out a raspy and sarcastic laugh punctuated by a prolonged wheezy-sounding hack.

Man. He was too quick for me and was requiring me to think faster than expected. I bit my cheek and tried to think of something insightful but came up with nothing. Instead I just told him what I was thinking.

"Mr. Gill, sir? The thing is the oxygen. That's the issue I mostly have because--"

"Do you thank I'm stupid a' somethin'? I ain't stupid, hear? Baby, I know damn well the oxygen don't mix with matches and cigarettes! I don't never smoke near the oxygen. I take it off every time."

Wait, huh?

"But sir. . . .you're supposed to be on oxygen all day. Smoking that much time every day with your oxygen off of you is dangerous, you know?" He cocked his head and looked at me like I'd just said the dumbest thing he'd ever heard. It was intimidating. This man was older than my father and firm in his resolve. "Look, Mr. Gill…I mean…I realize that you've been smoking a long time…"

"Yeah. Longer than you been alive."

This time I did have a comeback, albeit a lame one. "Long as I have been alive actually."
Finally he shook his head and said, "Miss Manning? Look here . . .regardless of all that. . . . I ain't ready to not smoke at all. I'm just not."

I swiped my hand over my face. Mostly because I didn't know what to say just then. He was too fast and I was too irritable.

"Mr. Gill, sir. . . have you ever quit at any point in these forty years?"

"Nawww, not really. I went up and down and done cut back here and there. But nawww. . . .I ain't never really quit altogether. See, I drove trucks for years and even after that I just always was a smoker. It's just parta who I am."

I stared at his leathery fingers with their yellowing tips and clubbed fingernails. His face had deep grooves throughout with the exception of the fine wrinkles framing his mouth filled with tobacco-stained teeth. The portable oxygen tank provided to him that day hummed beside him; he would periodically ball his fist and let out a gelatinous cough. The khaki pants he wore had been cut at the knees into shorts, revealing shiny, hairless legs that were textbook for circulatory impairment. And in his shirt pocket was a pack of Newports. Mr. Gill was as unapologetic about that rectangular box as he was about his refusal to quit smoking.

Yes. This was part of who he was. I could feel my icicles melting. I wanted to "get" what he was feeling and suddenly felt much more intrigued than annoyed.

"Sir?"

He raised his eyebrows but didn't speak.

"What do you think it would take to get you to quit altogether? Like…have you ever just been tired of it? Like…sick of all the nagging…the cost…all of it?"

Mr. Gill narrowed his eyes and thought about my question. I appreciated the fact that he at least was giving it some thought.

"You know,I do get sick of the nagging. But the rest? Honestly, not really. No, matter of fact. Not at all."

I'm not sure what I expected him to say, but for some reason I felt disappointed when he said that. It must have shown all over my face.

Mr. Gill gave me an endearing smile. He seemed a little amused by my earnest efforts to understand him and move him toward smoking cessation. Even if neither were working.

This patient was in what we call a "pre-contemplative" phase--the point where you aren't anywhere close to even thinking about changing a behavior. When people are in this place, the main order of business is patient education and not much more.

But with Mr. Gill, we had been there and done that. He'd been given information out the wazoo and had been told all the risks of continuing and benefits of quitting ad nauseum. At this point he just needed to quit already.

"Miss Manning, you ever smoked in your life?" he finally asked.

"Smoked what?" I answered. We shared a quick chuckle at my comic timing, but after that I quickly got serious. "No, sir. I haven't smoked."

He pressed his lips together and nodded. "Then you don't know. I mean. . . no offense, Miss Manning." He paused and coughed into a clenched fist again. "See, smoking is part'a who I am. And I like who I am."

I tried to understand his perspective. I really did. But this was killing him. He had to acknowledge that this part of his life was killing him. And so I told him that.

"But see. . . that's not how I see it. See, I see it like enjoying a piece of sweet potato pie when you know you got sugar. Sometimes when you get older you just got to enjoy your life. You can't be worried about every single thing you do that ain't perfect. See, I'm almost eighty years old. At this point I jest might die with a cigarette lit in my hand." He let out that sandpaper laugh again and shrugged. "And I'll be happy 'cawse I enjoy it. I sure do."

Huh. How do you compete with that?

"I want to say 'it's okay,' Mr. Gill but I just can't, you know?"

"I know, baby. This is your job to do this. You 'sposed to give it all you got to get me on the straight and narrow so I could put them thangs down." Again that laugh. "But you got to understand-- smoking is part of my life. I get up, have me some coffee and a cigarette. Then I make me some breakfast and eat it. Have me one after that."

"I know what's next," I chimed in remembering the countless patients at Grady who've shared with me the common practice of blazing up on the commode. "The toilet, right?"

Mr. Gill threw his head back and laughed hearty and loud at that. "You sure you ain't smoked?"

"Naaah. Just been working here for a minute, that's all."

He softened his eyes and continued. "Yeah. I guess it's just such a part of my day, my people that I hang out with and play cards with…my whole daily routine--all of it. You know…me and my wife used to smoke together 'fore she passed on and I just…I don't know. I just don't have no desire to quit. I don't. I know it's bad but there's a parta me that love smoking."

I listened to his side and felt the sincerity in every word. Finally, I got it.

He was right. I had never been a smoker and no, I had never tried to quit. Hearing his perspective made me think about someone plucking part of my daily routine away from me and how it would make me feel. Like if I was told I couldn't have coffee in the morning or that I couldn't put my hand on Harry's back at night when I sleep? What if a doctor marched into an office, wagged a finger in my face and insisted that I altogether quit…writing? How would I feel? What would I do?

"I hear you."

That's what I finally said. And I said that because it was true. I did hear him…and every other long time smoker…for the very first time.

I can't say that this encounter swayed me to think smoking is a good idea. But one thing for sure that can say is that on that day, I saw a little of myself in my patient…which is technically what empathy is all about, right?

"Mr. Gill, sir?"

"Ma'am?"

"Will you think about the stuff I told you about quitting and your health problems? Like the reasons it could be good for you?"

He flashed his large beige teeth. "I will, baby."

"That's all I ask." I smiled back and signed one of the encounter forms to wrap up our visit. When I put down the pen, I noticed his eyes resting on me. The right side of his mouth turned upward in a coy smile. It was a little embarrassing.

"Miss Manning?"

"Sir?"

"I want you to think about what I told you, too, hear?"

I stuck out my hand toward him and smiled as my fingers were lost in the grasp of his coarse palm and bulbous fingertips…and in that moment, I was okay…okay with my day….okay with all of it.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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