American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, May 30, 2012

I am not a doctor

This morning started off like any other. I parked my car, walked into Starbucks and pulled up my iPhone app while waiting in line. The usual suspects were already there: the elderly fellow that always flirts with the baristas, the business man with his freshly pressed suit and the tired-looking mother. As I approached the counter, I ordered my usual summer morning beverage and went through the motions to pay.

As I meandered toward the pick-up counter, one of the baristas grabbed my attention: "Hey, Amanda! You're in medical school, right?"

I stopped in my tracks and turned my attention toward him. Immediately, I braced myself for the worst; in our Medical Humanities course, the professors warned us that upon entering the profession, family and friends would suddenly start turning to us with their medical questions. We were cautioned that because there would be no escaping the situation, we needed establish an appropriate response to the request. But never did I imagine that as a first year medical student, an acquaintance would turn to me for advice.

"Yes, but ..."

He cut me off. "I have lower back pain that radiates down my leg ..."

The gears in my head started turning. I thought back to my latest clinical experience; one of our patients described a similar chief complaint and during our discussion with the preceptor, we discussed differential diagnoses for that particular symptom. I tried to clear the cobwebs clouding my knowledge of Anatomy and Neuroscience and considered the nerves that could be affected. I wondered if there was an inciting event that precipitated the pain. But in the end, although these thoughts raced through my mind, I never had any intention of sharing them.

"... and I was wondering ..."

As I stood there listening to him, it struck me how entering medicine was almost synonymous with being entrusted with a stranger's thoughts, feelings and ultimately, their life. We are taught how to ask open-ended questions and how to probe for the whole story. We are told to trust our instincts if something just doesn't feel right. But for the most part, patients come prepared to talk about what is bothering them because it is embedded into our culture to have an unspoken confidence in physicians.

As medical students, we reside in a paradoxical limbo. In order to become competent physicians, we need to interview patients and suggest diagnoses. We need to try procedures or practice them to obtain perfection. However, because we have little to no experience, patients tend to shy away from our [supervised] care. Additionally, at this early stage of training, most of us do not feel confident in our knowledge to provide even basic explanations of diseases.

When he continued with, "... what kind of doctor should I go see?" I let out of a sigh of relief and directed him toward his internist. This time, I was posed with a question that I could answer. But the situation gave me an opportunity to consider how I would respond to future questions that I am not qualified to answer. In class, our professors explained that when faced with a medical question outside of the hospital, they defer to the patient's internist because they do not know the details of their medical history. Today, had I been faced with that situation, I would have responded the same way but with the added note that I am just a medical student; I am not a doctor.

Amanda Xi is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Ann Arbor, Mich. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.

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Life at Grady: Why I do this

The following post by Kimberly Manning, MD, FACP, first appeared on the blog Reflections of a Grady Doctor. It is revised and reprinted with permission, and identifying information has been changed to protect privacy.

Last Saturday, one of my student advisees got married here in Atlanta. I have known and advised him since his very first day of medical school, and through our unique curriculum at Emory, have had weekly contact with him since 2007 in a small group with six other students. He invited me to his wedding, and (being my perpetually five-minutes-late self) I managed to slip inside of the church moments before it would begin. Unfortunately, this meant that I was seated away from the rest of our small group, but nonetheless, I was thrilled to have made it just in the nick of time.

 First came the organ music, followed by a soloist that sounded like a professional opera singer. This is nice, I thought. But then something happened. My advisee entered with his groomsmen and the pastor. The minute I saw him walk in to await his bride at the altar, I felt overcome with emotion. I saw the first day of medical school, I saw the first day of clinical medicine, I saw the countless teaching sessions and mentoring sessions. . . .and somewhere in there, I saw my own sons.

I willed myself to keep it together, 1) because I wasn't wearing waterproof mascara, 2) because it would surely lead to the ugly cry, and 3) because I was the absolute only black person there. (I figured that a hysterically crying black woman with raccoon eyes would not be such a good thing at this particular moment. . . .but I digress. . .)

And so, this time I did the "pretty cry"--complete with rapid mascara blotting, upward gazes, and eye fanning. When the ceremony was over, I joined my student group in the vestibule. My advisee walked up, and we congratulated him. It was such a moment, all of us there together supporting him on his big day. Just when I thought this was as good as it could get, he looked at me and said with genuine relief in his eyes, "I thought you weren't here. I looked and didn't see you with them, and I said to (my wife), 'Dr. Manning. She didn't come. She's not here.'" Now his wife touched his arm gently and added, "I told him you were here. I told him Dr. Manning would never miss this." Then she looked at him all new-bride-glowy. "See? I told you."

I couldn't believe what I'd just heard. That, with as much as he had going on, that he would not only think that, but actually take the time to say it to his new wife during his wedding. I chuckled to break up how intensely moved I was feeling. I looked at himand said, "Of course, I'm here. Of course, I made it." He smiled and gave me a tight and genuine hug. "I'm so glad you made it, Dr. Manning. I mean that. I'm so happy you are here."

And before I could even process the emotion I was feeling, he was whisked away to join his wife and family for wedding photography. I walked out of the church and sat in my car for a few moments. I thought about how I had been feeling before. . .how drained. . .how zapped. . .and then I thought about that moment in the foyer with my advisee. It was the most perfect and simple reminder I could have ever been given about why I'm doing all of this.

This is why you do this. This is what happens when you let people plug into you. And then I allowed myself to experience it, really experience it...and then...allowed myself to cry. A tired, happy, and fulfilled cry. I'm learning that the very best downloads I can offer don't involve diagnoses, or science, or complicated concepts. They involve relationships...and most times, just being there. Sometimes it's as simple as rolling over on the couch to face my son...and other times, it's just inconspicuously sitting on a lonely pew in a church full of strangers...quietly patting the corners of your eyes and wondering why you can't stop crying.


Tuesday, May 29, 2012

What do hospitalists take home from medical conferences?

I attended a local conference today sponsored by our Department of Pediatrics and Riley Hospital for Children. Many of our residency graduates, especially those who live and work locally, return for this meeting. It really is great to see our graduates and what they are up to. I enjoy hearing about how they have transitioned to practice, and learning about their own successes and challenges.

This particular year, I was not a presenter, nor did I run any workshops. I went to this conference strictly to learn. It was simply wonderful to do so. The day started off with a dynamic visiting speaker reflecting on the state of well child visits and potential innovations around how to be more effective with these, especially given the changes in medicine that are occurring and will continue to occur.

One might think that this topic is not all that interesting (which the speaker himself even acknowledged). Plain and simple, I was inspired! It brought me back to why I chose to go into medicine in the first place: to make a difference. Other extremely well-presented sessions reminded me of things I should be doing when encountering patients with specific conditions. A lunchtime talk on mentoring solidified a successful day for me (and that was only halfway through the day!). Other great "high-yield" topics in the afternoon piqued my interest as well.

When some people come back from conferences similar to this one, they realize that while the conference was wonderful, there is still a stack of paperwork that needs to be completed, that there is more work to be done, patients need to be seen, and e-mails must be answered. I also have all of those things looming over me. But I also gained a sense of purpose, connectedness, and excitement for the future of medicine from the conference. In addition, I learned some new things, was reminded of things I should already know, and also heard about changes coming in the future.

What do you get out of going to conferences besides the acquisition of information? What other "informal curriculum" things get you jazzed up, and how can conference organizers effectively capture that for other attendees? I am curious if others see this similarly or differently.

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

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Dangerous electrolytes, part 3

The patient, a 40-something year old woman, has a long history of alcohol abuse. Recently she has had minimal oral intake with much vomiting. BP 100/60, pulse 120
120, 67, 32, 99
1.9, 21, 0.7, 8.9


I have several more points to make.

First, the patient has clinical signs of volume contraction. The patient has an appropriate increase in ADH. Volume contracted patients when they drink free water can become hyponatremic. This presentation is classic.

Second, we should address the hypophosphatemia. The patient presents with a dangerously low phosphate. We should worry about all phosphate levels below 1. Around 5 years ago, we had a similar patient present with a low phosphate and die. Severe hypophosphatemia leads to 5 possible organ system dysfunctions:

1) Central nervous system, seizures or altered mental status
2) Cardiac, arrhythmias or depressed cardiac function
3) Respiratory, respiratory failure secondary to muscle weakness
4) Rhabdomyolysis
5) Hematological, hemolysis and/or leukocyte dysfunction

The following is a great review of hypophosphatemia: Hypophosphatemia: an evidence-based approach to its clinical consequences and management. Here is their recommendations for treatment.

Indications for different modes of therapy in hypophosphatemia
--Severe hypophosphatemia (less than 1.0 mg/dl [0.3 mmol/l]) in critically ill, intubated patients or those with clinical sequelae of hypophosphatemia (e.g. hemolysis) should be managed with intravenous replacement therapy (0.08-0.16 mmol/kg) over 2-6 h
--Moderate hypophosphatemia (1.0-2.5 mg/dl [0.3-0.8 mmol/l]) in patients on a ventilator should be managed with intravenous replacement therapy (0.08-0.16 mmol/kg) over 2-6 h
--Moderate hypophosphatemia (1.0-2.5 mg/dl [0.3-0.8 mmol/l]) in nonventilated patients should be managed with oral replacement therapy (1,000 mg/day)
--Mild hypophosphatemia should be managed with oral replacement therapy (1,000 mg/day)

Once you have a dangerous phosphate level (less than 1.0) you should prevent further drop in phosphate. Therefore, we must understand why phosphate levels get dangerously low. This patient had a confluence of two reasons. Alcoholics often eat poorly and have total body phosphate depletion. When you provide glucose to these patients, they develop the refeeding syndrome. In this syndrome, patients with total body phosphate depletion use phosphate and further lower the serum phosphate. Quoting from the article: "The proposed mechanism of hypophosphatemia in these patients is increased insulin release that causes an intracellular shift in distribution of phosphorus. Enhanced synthesis of ATP, 2,3-diphosphoglycerate (DPG) and creatine phosphokinase (CPK) might contribute to the hypophosphatemia associated with refeeding syndrome."

Given this problem, while the phosphate level is dangerous, we should stop refeeding. We must first replete the phosphate prior to giving glucose. In this patient, the team stopped the IV glucose appropriately.

The second factor leading to the initial hypophosphatemia is the respiratory alkalosis. Respiratory alkalosis leads to decreased serum phosphate. Usually alcoholics present with normal phosphate that decreases over the next two days from the refeeding mechanism. This patient presents with severe hypophosphatemia likely secondary to chronic respiratory alkalosis. This presentation put the patient at great risk. Fortunately, my colleagues did a great job and the patient recovered from all disorders.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

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Friday, May 25, 2012

Mentoring in medical education takes its cue from the movies

A big part of medical education is mentoring. The term mentor originates from Homer's the Odyssey and refers to an advisor. The role of mentors vary, but generally serve to guide mentees through work, support them during the process, keep them grounded and focused on the task at hand, and provide general moral support.

Over the weekend, at the Pritzker Revisit session on Scholarship and Discovery, our own students stated the number one thing to consider when finding a project was finding a great mentor.

How does one find a great mentor? Well, our students are encouraged to seek "CAPE" mentors; think superhero mentors. The mentor should be Capable, Available, have a Project that is of interest to the student, and Easy to get along with.

Capable means that the mentor has the skills to not only be a good mentor, but also to carry out the task or project at hand. This may sound like odd, but sometimes faculty are so excited to have a medical student work for them, they may make the false assumption that the medical student will help them with tasks (i.e. statistics) that they themselves don't know.

Availability is especially important as it is the number one reason our students state they had a less than optimal experience in the summer doing scholarly work is that their mentor was not available. While availability of all doctors is an issue, the question is often whether faculty make themselves available when they can (i.e. answer student email, take phone calls, meetings). Setting expectations for when and how to meet can be very important.

Ideally, the mentor has a project that is interesting to the student since if the work is not interesting, it will be even harder to make progress.

Last but not least, the mentor has to be easy to get along with, meaning that their style meshes well with their mentees. Some people simply do not work well together do to different personality types. So, I often tell our students to consider that when meeting potential mentors or deciding between two mentors.

As I was thinking about ways to highlight effective mentors, I recalled some classic movies with mentoring relationship. In relooking at these scenes this weekend, it struck me that there are some interesting reasons why they are good mentors that correlate with our model. Some of them are a stretch but they are still fun to watch!

Yoda in Empire Strike Back encourages Luke Skywalker to not just try, but do. When Luke fails to resurrect the wing fighter, he does not allow Luke to make excuses but instead demonstrates that he can do it, showing that he is CAPABLE.

Mr. Miyagi with the Karate Kid mentors through teaching small movements related to everyday house chores, "wax on, wax off." While he is certainly gruff and challenges Daniel, Mr. Miyagi also makes himself AVAILABLE to Daniel at that moment and in the future by saying at the end "Come back tomorrow" to continue the training.

Remus Lupin goes so far to use a simulated Death Eater to challenge Harry Potter to learn the patronus charm (and making all standardized patient experiences seem like a cake walk). When Harry fails at first, he is patient and nurturing, stating that he did not expect Harry to get it on the first try. He also makes suggestions to the technique which turn out to be the key. Since Harry really needs this charm, this is a PROJECT THAT IS OF INTEREST and Harry ultimately succeeds in casting the spell.

Gandalf in Lord of the Rings provides consolation to Frodo during a moment of despair by highlighting that it his job and also showing that Gandalf is sensitive to Frodo's needs and EASY TO GET ALONG WITH.

In addition to these highly acclaimed superhero and superstar CAPE mentors, let me know if you know of other model mentors from the movies.

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, and directs 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, May 24, 2012

Learning the best way to assess jugular venous pressure

Of all of the physical exam findings that are often taught in medical training, I think one of the most important is the ability to judge volume status from examining neck veins. It's a skill that a lot of medical students and residents strive to become competent in; often many trainees will ask their attendings to verify their findings from their morning rounds.

Finding the level of the jugular venous pressure is hard, but I think it's something that's really worth mastering as it will inform your decision making more so than many other aspects of a daily exam.

To prove my point I ask you, does the quality or quantity of bowel sounds matter in a patient without bowel complaints? Is there any part of the head exam that would change in the course of an inpatient admission? The lung exam may change in a case of pneumonia but isn't the fever curve and the general appearance of the patient better and more important to note? The rales of heart failure may improve in a case of congestive heart failure, but I'd say that when your patient is sleeping flat, no longer dyspneic, and no longer tripoding, the pulmonary finding of rales is irrelevant.

Here is a great website about jugular venous pressure from the University of Washington School of Medicine. Where I got the information at the bottom of this post.

Here is a classic film about the JVP:

I think all of us as internists, hospital and ambulatory, nephrologists and cardiologists should have a good sense of how to find and measure the top of the jugular venous pressure in order to monitor the volume status of our patients on a day-to-day basis. The great challenge in interpreting neck veins, the expert clinician, is to be able to perform wave analysis as Dr. Wood does in this video.

The "a" wave represents the atrial contraction, the x decent represents atrial relaxation, the "v" wave represents ventricular contraction, and the "y" descent represents ventricular diastole.

The most prominent aspects of the neck waves are not the contractions or waves themselves but their troughs: the x and y descent.

Timing of the descents can be done while palpating the carotid or when listening to the heart. The x descent falls into the dub of S2. Lub-clap-dub. The y descent falls during ventricular diastole so it comes after S2. Lub-dub-clap.

Alternatively if you can time the carotid pulse with the x descent by saying C every time you feel the carotid pulse. Then start staying down quickly after every C; C-down, C-down. The x-descent will be occurring as you say down.

Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.

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Wednesday, May 23, 2012

Slow medicine

I can't tell you exactly when it happened, but sometime in the past two decades, the practice of medicine was insidiously morphed into the delivery of health care. If you aren't sure of the difference between the two, then "God's Hotel" is the book for you. It's an engaging book that chronicles this fin-de-siecle phenomenon from the perspective of San Francisco's Laguna Honda Hospital, the last almshouse in the United States.

Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Dr. Sweet discovered, was to the benefit of the patients.

Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, "slow medicine," as Dr. Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.

Sweet realizes that the inefficiencies of this old-fashioned hospital, from the doctors who had time to fully research their patients' complicated histories, to the nurse who knitted a handmade blanket for every charge on her ward, to the chicken that wandered regularly through the AIDS ward, bringing a spark of life to even the most demented patients, were actually its secret weapon. The inefficiencies were actually quite efficient, if your metric was healing patients.

Then arrived the consulting firm of "Dee and Tee, Health-Care Efficiency Experts." Horrified by the rambling open wards and the old-school style of medicine, never mind the chicken, Dee and Tee quickly cut out excessive head nurses, consolidated departments, speeded up discharges and created committees, PowerPoint presentations and forms with 1,100 boxes. The consulting firm never consulted with any staff members who actually took care of patients, but they did stand to earn 10% of any savings engendered.

Thus Laguna Honda was rapidly schooled in the inefficiencies of efficiency, as patients without nurses grew sicker, and enthusiastically discharged patients spiraled downward, had multiple ER visits and were eventually readmitted to the hospital. Dee and Tee, of course, did not have to pony up for any additional costs the consultancy caused.

Over the course of Dr. Sweet's 20 years as a staff physician, Laguna Honda made this painful transition from the practice of medicine to the delivery of health care, and it was the patients who suffered most, followed by their caregivers.

During this period, Dr. Sweet found solace in her doctoral studies of Hildegard of Bingen, the medieval healer, nun, mystic and composer. Hildegard's pragmatic and thoughtful approach to medicine appealed to Dr. Sweet and even informed her own practice of medicine. Stymied by an oddly agitated patient who'd already been given a full diagnostic workup, Dr. Sweet had a What-Would-Hildegard-Do moment, and decided to simply sit with the patient.

She sat with the patient for a good long time, watching her, thinking about her, being in the moment with her. There was something frankly medieval about the patient's twisting and writhing, as though she were trying to expel something, as though she were poisoned.

Reviewing the chart, Dr. Sweet realized the woman was indeed being poisoned, by her own medications. A toxic brew of antidepressants, antipsychotics, pain meds and sedatives had led to serotonin syndrome. Dr. Sweet decreased the patient's medications, and within hours the patient improved. She eventually stopped nearly all the medications, and the patient became well enough to go home.

Untangling the mass of medications that most patients arrived with became Dr. Sweet's hallmark. She found that nearly all her patients could be relieved of a portion of their accrued medications. But this could only work in the setting of "slow medicine," of having time to watch patients carefully over an extended period, of digging deep into the convoluted lives of these patients, of having time to "just sit" with each patient.

This, of course, is highly inefficient, if you are Dee and Tee. But it's remarkably efficient if you are a patient and are interested in being cured, cared for and comforted.

You might not expect a book about San Francisco's most downtrodden patients to be a page-turner, but it is. With its colorful cast of characters battling the tide of history, "God's Hotel" is a remarkable journey into the essence of medicine.

In 1925, Dr. Francis Peabody told a graduating class of medical students that, "the secret of the care of the patient is in caring for the patient." Simple, eh? If Dr. Peabody were practicing medicine today, he'd surely be consolidated with a midlevel provider to deliver health care with maximal quality indicators and operational excellence. Sigh ...

(from The San Francisco Chronicle, April 22, 2012)

Danielle Ofri, MD, PhD, FACP, is the author of three books, including "Medicine in Translation: Journeys with My Patients," which is about learning the individual stories of patients. She is an Associate Professor of Medicine at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review. She is currently writing a book about the emotional life of doctors. This post originally appeared at her blog.

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My love-hate relationship with early clinical exposure

Last semester when I saw an in-patient for the first time, the overall experience was exceedingly positive. I didn't have any confidence in my ability to diagnose anything, but that wasn't the purpose of the encounter. Furthermore, it was still my first semester of medical school; no one expected me to be able to integrate the patient's symptoms with a clinical diagnosis and course of treatment. There was nothing to lose.

My first experience left me wishing for more time with the patient and a sense of purpose when I returned to my textbooks. It reminded me that medical school wasn't only comprised of hours of time with my head spinning; there was a light at the end of the tunnel called third-year clerkships, and with each passing day I came closer and closer to being able to practice medicine.

However, during our most recent clinical experience, I walked away conflicted. The premise of the exercise wasn't too different from the first, but we were responsible for doing a bit more with the physical examination. And with an OSCE looming on the horizon, I was happy to have an excuse to practice.

After we met our preceptor for the day, we headed to a different unit to see our patients. This time, we had two different patients to interview and do a pertinent physical examination on. Prior to walking into the patient's room, the preceptor told us the chief complaint so I felt prepared to solicit more information. We walked into the room and following a brief introduction, I sprang into action.

Our patient's story tumbled out without any resistance; it caught me off-guard how easily pertinent facts could be collected from her responses. After collecting what I needed, I moved on to an abridged physical examination and wrapped up my encounter with that. We thanked the patient and left the room to discuss the encounter.

My preceptor's feedback was mainly positive, but he noted that I was a bit nervous [Well, yeah!]. There were a couple of things that I failed to obtain, but it was a learning experience so these things are to be expected.

We then moved on to our second patient, and my partner conducted the interview and physical examination while I took notes. He finished promptly and we moved outside to wrap up the experience.

It was as I was walking out of the long hallway of the hospital when a wave of dissatisfaction and frustrated rolled in. As one of the patients listed medications, I recognized a couple of them but ended up misclassifying one of the drugs. Even though I am still a first-year student, I am just about halfway done with my preclinical years. Shouldn't I at least be proficient in recognizing and identifying basic information that I already learned? How will I be comfortable with all of this knowledge for the boards and clerkships if I cannot keep simple material I learned a month ago in my head?

I know that I still have time. I know that it's still early. But I am disappointed that the medicine I keep learning seems to slip away so quickly. My knowledge feels transient and fleeting. I just want to be able to feel just slightly confident in my ability in something but it seems that I am far from it.

Amanda Xi is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Ann Arbor, Mich. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.

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How history taking and a Toyota mechanic beat a diagnostic computer

If you give enough time to an experienced clinician working in an ambulatory setting, what percentage of acute complaints would s/he be able to diagnose correctly with just taking a good history? What about with history plus physical examination?

The answer is about 50% with history alone and about 80% with history and exam. Yes, s/he would probably order some confirmatory tests or try some medications as empiric treatment but the above numbers would hold up.

The importance of history taken by an experienced diagnostician was borne out recently. A warning to regular readers of my blog, this is another car story. Don't tell me I did not warn you!

I have a 1999 RX300 which was bought mainly to combat the snowy northeast Ohio winters. It has been a reliable vehicle and I fully intend to keep on driving it until it falls apart. You will probably accuse me of being an emotional fuddy-duddy, but it holds a special sentimental value for the family. So it was particularly upsetting when last year, early in winter it started to have all kinds of problems.

I took it in to the place where I get the oil changed and they are really nice folks, polite and accommodating. The check engine light was on, and they queried the car computer, read the code, looked up the computer and told me that some sensors needed to be changed. We did that but within a day the engine light came on again. This time the mechanic told me that the transmission was gone and it would cost more than the resale value of the car to fix it. I was crushed but appreciated the fact that he did not make me spend a ton of money before telling me this. I began to look for someone who would buy it.

Then a friend of mine recommended that I speak to this guy who works at a Toyota dealership. The Toyota Highlander is almost exactly the same vehicle as the RX300. So he might be able to tell me more. So I gave him a call. I fully expected him to read him the codes from the computer readout. Imagine my surprise when he asked me to describe what the car was doing!

I told him how I had gone abroad (a workshop I did for physicians in Singapore in October) for about 2 weeks. Right after I came back the car started misbehaving. It would work fine for the first 10 minutes or so and then when I tried to accelerate beyond 40 mph it would start revving up like it was stuck in a lower gear. I could not go on a freeway for fear of this. He started laughing and asked me if we had seen any rodents in the garage. I felt like I was talking to Sherlock Holmes! My wife had told me that she had seen a rodent near where we kept the dog food bags.

So he explained. The Highlander and the RX300 have an engine intake area that rodents love to nest in. If the car is not used for a while they start nesting there. This is particularly true of the fall season as they prepare to hibernate. The intake area is close to the wires that run to the knock sensors. The rodents eat the rubber on the wires and this shorts out the sensors (or something like that). The guy to whom I took the car to first read the computer code for the knock sensors being faulty and changed them without realizing that the problem was caused by the wires. Thus he replaced the sensors but did not fix the cause.

Long story short, (well not really but it was a pretty cool story) the Toyota mechanic changed the wires and the sensors and the car now drives like new. The key portion of history was that I did not use the car for a while during the nesting season, that we had rodents, that the problem was same as that caused when a knock sensor is faulty. His experience with having seen this before due to working on similar cars in northeast Ohio for years helped him recognize the problem.

This is a story I will tell all my trainees, that a well-directed history taken by an experienced clinician can beat multiple tests and technology!

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

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Twitter 101 for aspiring SoMe physicians

So you've decided to take the plunge (or at least, dip your toes) into the Twitterverse. Congratulations! Welcome to a vibrant interactive community. You'll find plenty of different personalities here and lots of opinions. But if you are like I was back in January 2011, you currently have no idea how to actually use Twitter, let alone how a physician might want to use it.

There are plenty of places to find information about how to start a Twitter account, (for example here), so I am going to take a leap of faith and say that if you are reading this, you have already set one up. If not, check out some online resources regarding starting your account and come back to this blog so you can figure out what you might want to do after the basic infrastructure is laid down (or, if you are just relatively adventurous, just head to Twitter and start your account without listening to any of the "pundits").

This post is not meant to give you the ins-and-outs about Twitter. I think they do a pretty good job explaining the basics on their help center. There, you'll find the "how's" of Twitter, like how to post a tweet or how to follow others.

Instead, this post contains some of my basic recommendations about how you might first want to get involved in Twitter a professional manner. As .I have said before, getting involved means starting small. I think you will quickly see why many people have stayed involved.

Consider starting with a private account. If you are still treading the water about getting involved for one reason or another, remember that you can have a private account. No one can follow you unless you let them. This means that your posts (or "tweets") will be hidden from view of everyone except those whom you permit. I suggest using this feature really only as a place to test the waters to get the hang of writing in 140 characters and see if Twitter is for you. Be aware that with a private account, your voice will not be heard. You are not really contributing your expertise; you can still listen to and follow anyone with a public account, but you limit your prospective audience. You can always change from private to public once you've established your account, so this is often a good way to test the platform, but I do not recommend maintaining a private account unless you want to remain silent or limited in your interactions.

Start following some accounts. This is the key to finding out the power of Twitter. The majority of the time, you will end up listening (i.e., reading) more than speaking (i.e., posting). Let me spend a few extra moments answering: Who should I follow and how do I find them?

Specialty societies and journals: By now almost all major societies and journals have Twitter accounts. These are generally staffed by communications professionals who often tweet recent articles or news items you might find of interest. You can try doing a search on Twitter for their accounts, or go to the societies'/journals' home pages and find the place on the website where you can "Follow Them". If you are logged in to Twitter, you can usually just click that link or icon, and you will be taken right to their Twitter account where you can choose to follow them. Once you're there, check out who they are following. Chances are, they follow accounts or people with whom you may have some common professional interests.

Let Twitter suggest some accounts: This tool might not give you the most interactive accounts, but at least you can continue to explore accounts that you may be interested in.

Search for accounts with similar interests: Do you have a particular area of interest? Maybe a disease or subspecialty? Do a search on Twitter to find people to see what people are saying about your area of interest.

Listen to what others are saying. Are you surprised I said this before I talked about what to tweet? For everyday folk (and by everyday folk, I mean those of us who aren't "follower millionaires"), Twitter is often more about listening than anything else. By listening, you will get the feel of how people tweet, what people tweet, the format of a tweet, etc. Believe it or not, listening to the voices might lead you to the next step.

Decide what to tweet. This is probably the most common question I get asked about Twitter. There are lots of people on Twitter saying many, many things all the time, but Twitter is not just about tweeting what you are just about to eat at the local diner. Being on Twitter in a professional manner means you are starting to define your own digital footprint and your voice. Did you read a tweet that you liked? Retweet it. That is one easy way to tweet, but that doesn't create any new content of your own. Are you an expert in one particular area? Start tweeting about it. I strongly recommend avoiding tweets relating to patients directly. Use common sense when creating original tweets; remember that patient privacy is paramount. However, you might find it easier though to get started by another common type of tweet. Find an article or a news item about an important health issue or topic in your field and tweet it (or comment on it). Any webpage can easily be tweeted nowadays with one of a number of tools that will shorten the web address to easily fit into the 140 characters of a tweet, like Tiny or bitly. Once you've shortened the link, you can import that into any tweet you'd like. For an example, see the Twitter stream of Dr. Orlowski (@Myeloma_Doc), who tweets virtually exclusively about multiple myeloma.

Find a hashtag. OK, now we're starting to get to "Twitter 102 for Docs". But if you've come this far and you're ready to explore a bit, you might want to head over to's Healthcare Hashtag Project to see what they've created. Let me give you an example. In the tweet below, "#GERD" acts as a tag for the tweet. You can search for tweets by including the hashtag to increase the likelihood you'll find something directly related to your topic of interest.

Well, I hope these hints help you get started navigating your way through Twitter as a medical professional. Please feel free to comment and add your own suggestions or feedback.

In an upcoming post, we'll delve a little bit more into "Twitter 102 for Docs", where I'll discuss some ways to enhance your professional community.

Special thanks to Natasha Burgert (@DoctorNatasha) for helpful hints!

Ryan Madanick, MD, is an ACP Member, 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. This post originally appeared at his blog, Gut Check.

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Life at Grady: People, perspectives and train wrecks

The following post, by Kimberly Manning, MD, FACP, originally appeared on her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect privacy. 

The patient

 This room is suffocating. Like every bit of air in here has already been used up and somehow I was left with the air scraps. But at least I'm in here. I just hope this doctor will understand. Motrin doesn't work. Naproxen doesn't work. That last stupid doctor I saw in that ER had the nerve to part his lips to say "acetaminophen." Like I'm so dumb that I don't even realize that's the same thing as Tylenol. I looked that dude straight in his eye and let him know. This, Mr. Asinine Doctor, is not a "Tylenol" kind of pain. Or an acetaminophen one.

 I need some stuff that will work. Let me sleep and not feel sick. And you know? I just wish I could see just one doctor who listened to that and got that and got up off that high horse long enough to just give me something that works. No, not your BS tramadol or Ultram or "prescription strength ibuprofen" like you like saying. But something real. Real, yes. And no, not half-a**ed real either. Like some Tylenol -- "but with codeine in it" or naproxen and "a few pills of Flexeril." That isn't what wipes this pain out. Or stops me from feeling sick and miserable and like I'm going to hurt somebody. So it all becomes this stupid dog and pony show where I have to say the right words and pray to the heavens for a doctor that isn't a damn know-it -ll detective. You know. Those ones that get all high and mighty and decide that you are an addict simply on a mission to get high.

(Click "more" below to continue reading this post.)  

What the eff? I'm in pain. Real true pain. In my neck. My back. My stomach. All over. And now, on top of that, if I don't get what I need, I feel sick. And like I'm gonna go crazy. For real.

 My old doctor was cool. At least at first he was. He used to give me what I needed for this pain. He didn't make me feel bad or like some kind of addict or nothing and he gave me what would work. Like the hydromorphone or the oxycodone. That dude didn't hold back on this pain. He was the one who gave me this medicine in the first place. I told him about my back and my neck and all that and he said, "Here, take this." And it was some oxycodones and that knocked that pain back. And when my body started getting used to them, he was okay with giving me a higher dose and then even giving me something stronger. Because that doctor? That doctor cared about me. Yeah, he was busy and no, he wasn't too touchy feely or anything but, man, that was cool with me. He wasn't gun-shy with that ink pen when it came to them pain medicines and I appreciated him for that. Matter of fact, that's what he was known for.

 Then one day. . .just like the rest. . . .it turned into something else. That main doctor took that vacation or leave or whatever the hell it was and that partner of his was one of those BS doctor detectives. Asking me about past history of IV drugs and drinking liquor and all this and that, to me, don't have nothing to do with this pain or this sick that I feel when I don't get my medicine. So next thing I know he talking some BS about "weaning" me off the medicine. No more hydromorphone or oxycodone. Just some BS he came up with after speaking with some kind of pharmacist. All with a goal "to help me."

 Help me? Help me!? Man, please. The only way you can help me is to do something about this pain. Period. End of story. So here I am all over again. Seven different emergency departments in six weeks because I really have no choice. No choice but to go there or to do something stupid in the streets to keep myself from feeling sick and in pain. No choice but to do what I have to do,

The intern

 Great.. That man is my patient. That man. I already saw him when I walked through the waiting room writhing all around and rocking back and forth. Eyes all wild and body positioned all funny. I swear he moaned louder when he saw me walking by in this white coat. Can't even lie -- I hoped that he didn't belong to me. But Murphy's law. He did. That man. Great.

 I still have to go back to the wards. And this? It's just too much. I overheard them triaging him and even that was hard. He just wouldn't stop pushing and explaining and moaning -- and that was just his vital signs being taken. Every so often he would let out this yelping sound that sounded like someone stepping on a sleeping dog's tail. I wasn't sure what to make of that, but he did look miserable. Just not that miserable. Not yelping-out-loud-at-the-top-of-your-lungs miserable.

 I looked over his chart and his chief complaint. And the refills he was requesting? Oxycodone? Dilaudid? Dilaudid? Seriously? So I introduced myself and listened to what he had to say. And just like in triage, he had a lot to say. A whole lot. And mostly, it wasn't so bad. He actually seemed to be a pretty nice guy for the most part. But it was weird the way he kept going from very, very miserable to very, very mad to very, very syrupy sweet and cooperative. Something about it made me tired.

 I wonder. Would it be the end of the world to just give him what he's asking for?

The attending
 Ugggh. That poor intern. He looks so exhausted already. And seriously? I don't blame him. These kinds of interactions suck you bone dry. Dry of any traces of the already limited energy you came to clinic with. It sure does. Especially when you're an intern. A lot about this is just like what I've seen many times over. Youngish person comes in. Usually not fitting the more common demographic of our patient population. Why this is? I'm not so sure. What it usually suggests is that a wide net of providers has been cast. At least that's what it seems like. So yeah, the story is usually predictable--some long and convoluted tale about their journey through chronic pain. A journey over rivers and through woods. Some reference usually to college education and a highly successful career that all folded in like origami after the nidus of this pain began. And somehow, some way that journey always seems to end with words like "oxycodone" or "percocet". Or in this gentleman's case, "hydromorphone or dilaudid."

I know it's bad to think these things. I know. So I'd never say it out loud. But it is what I'm thinking. And I know it's bad. Yes, it's bad because I know that every patient is different and that every patient has a story that is uniquely their own. But damn there are some truths or at least semi-truths that always seem to relate to this particular scenario. Always.

 Truth #1: I always feel the same way the moment I walk into the room. Tired. Immediately tired. And like I need to pay attention even closer because the words often feel slippery.
 Truth #2: I always end up scolding myself during the encounter. Telling myself to regroup and individualize this one person in front of me. To acknowledge how this one person is feeling and why they might feel this way. Admonishing myself to let go of the countertransference that I surely have -- and to be "the healer" that I promised I would be with that right hand up in front of Hippocrates and whoever else was listening.
 Truth #3: It usually doesn't end well. Even if, at first, it seems okay. Eventually it isn't. And that sucks because it's like a train wreck that you know is about to happen. At least most train wrecks catch you off guard. These kinds don't. Wouldn't you act funny, too, if you knew the train you were on was about to crash? But I'm the role model so I can't act how I feel. Or even really say it without some sort of extreme filter. Because really, I'm aggravated that some irresponsible person somewhere gave a patient this much narcotic. Or better yet, even more aggravated that they gave it to him repeatedly and then kicked him out of their practice because he kept coming back for more. Duh! Of course he came back for more. You keep putting heavy cream instead of skim milk on the back porch and what do you think is going to happen? Sigh. I know. I can't say that. Or make analogies like that because that's not cool. I know. But I'm human, too. Remember?

 So yeah. Now I'm standing beside my intern and looking at this man with a twisted snarl on his face sitting in front of me. And yes, I do believe that he is in pain-- I do. Pain of one kind or another. That said, I do not believe that his pain warrants the amount of exaggerated behavior I am seeing. And that's what always leads to truth #1. That. Damn. I'm exhausted, too.

 Part of me wants to say, "Sir? Let's say all of this pain medicine is appropriate or at least some version of it is. Let's just say that. Can I just give you some advice? Don't do that. Don't do that thing where you behave as if a machete is stuck between your shoulder blades and as if your back is spurting out pulsatile arterial blood. Or make that blood-curdling sound like someone grabbed a pair of pliers and pulled four molars out of your jaw without a drop of anesthetic. Because that's how you're acting--hysterical--and this doesn't call for that. Besides. Real, true hysteria is something I've seen before. And it damn sure wasn't in a clinic talking about chronic pain." 

That's what I want to say. But I never do. Real hysteria? Oh, I've seen it. Once when this little pre-school aged boy got his foot caught under a riding lawn mower when I was a resident. He and his parents were really and truly hysterical. And you know? It was warranted. His foot was all mangled up and he was wide awake. Staring at it. The other time was when this kid was jumping on a bed in his cousin's bedroom. It was a high-rise and he leaped off that bed and crashed into a screened window. Problem was, that screen was loose so he fell. Six stories. So yeah, his family was hysterical, too. And rightfully so. Okay, and perhaps I did get a wee bit hysterical when I was having that nine pound two ounce baby, but that was before the epidural. Or the dilaudid.

 But this? This is a dude walking around with pain of one kind of another, but not one that calls for all of this. Because real, true hysteria has to be short-lived because it is too exhausting to keep up with. So yeah. These truths (or rather semi-truths) makes it harder to individualize care. Knowing that the train wreck is coming whether I like it or not. Because it is. It always is.

The interaction "Hi, sir. I'm the senior doctor in the clinic today and your doctor and I have put our heads together about your health problems and the plan of care for today." "Thank you, doctors. Thank you so mu--AAAAGGGGGHHHHHHH!!!!" The patient started taking deep, exaggerated breaths. Then he added through panting breaths, "Th-th-thank you." "Mr. Fields? I have spoken to my attending about you. We went over all of the history together and I talked to her about your physical exam. Thank you for bringing in the records from the other hospitals. Do you have anything more recent than four years ago?"

 "Arrrrrrrrgggggghhhhhh. . . .do you mind if I lay down on the examining table? I just can't take this pain. It's so---GRRRRRRRRRRR--I'm sorry. It's awful. Now what were you saying doctor?"
 "I was saying that the records you gave us are from emergency visits but they appear to be pretty outdated. I want to be sure we aren't missing anything. I know you've had this pain in your neck and back since 2000. Did you have a primary doctor caring for you?"

 "Listen, doctors. I had a doctor but eventually he told me I needed to come here to see you guys. He said he couldn't take care of my pain any more. Well, actually, not him. His partner raised some crazy concerns about me like I was some kind of addict. And like I told you, I have a Master's degree. I am not some kind of addict."

 The attending interjected. "We want to be honest with you. Our goal is to have the same conversation with you in this room that we just had outside this room. We are concerned about these medicines and no, we aren't calling you an addict. But we do want you to know that we are concerned that there could be some dependency that you've developed on these medications."

 "That's some fancy BS WAY of just saying the same thing. I'M NOT AN ADDICT. YOU GOT THAT? "
His eyes were wild and agitated. The intern backed up and the attending remained between the door and the patient.
 "Sir, I never said that."
 "The HELL you didn't. I don't know what you expect me to -- AAAAARRRRRGGGGHHHHH!!!!! I'm in PAIN! Don't you see?"

The patient dropped his head into his lap and began crying. Hard, loud and exaggerated. Then it tapered off to a whimper. "You have to help me. . . .please."

 The attending reached out and touched his hand. "We want to help you. We do. We want to do right by you. We think at some point you may have been given more than you needed. We want to be responsible in caring for you. Even if that means it's a little uncomfortable at first."

 "I am happy to cooperate in whatever way you ask, doctor. I just want to not be in pain. I really do."

 "First, I want you to know that we do believe that you have pain. I don't want you to feel like we don't believe you."

The attending looked like she was willing herself to be patient with him. She was still holding his hand. The intern sat on a nearby chair watching.

 "Thank you for helping me. I knew when I saw you that you wouldn't treat me like I was a junkie or something. I went to ivy league schools and have terminal degrees. I'm not the kind of person who would try to just get narcotics just for the sake of getting narcotics. I wish something other than Dilaudid worked for me. But that's what works."

 The attending pressed her lips together instead of instantly responding. After an almost uncomfortable pause, she went on. "Words like 'junkie' and 'addict' are hurtful. I wouldn't call you or any of my patients those words." The patient let out another hysterical yelp in the interim. She pressed her lips together even harder--this time with a deep inhalation.

 "I'm sorry, doctor. I'm just so, so much in . . . aaaagghhh. . .pain." This time his voice was a tiny whisper. Almost cartoon-like in it's quality. "We need to start a process to treating your pain differently. Something that doesn't involve all of these habit forming medications like hyromorphone and oxycodone. I reviewed your records and also saw that you had a CT scan and an MRI here at our hospital. Fortunately, they were mostly normal with the exception of a little bit of degenerative changes from aging."

 "My disks are herniated, though. You knew that right? One doctor wanted to operate. I couldn't afford it. My nerves are pinched from my disks being herniated." He winced again and began audibly gritting his teeth in pain.

 "The images they took of you three months ago were much better. That happens sometimes. This doesn't mean you don't have pain, but it also doesn't sound like you need a surgery, so that's good. I noticed from your urine screen that the medicines aren't in your system. This way we don't have to worry as much about your body withdrawing from not having these medicines. It will take your mind some time to readjust, though."

 The patient yanked his hand away and stood up. "So you're NOT giving me anything for pain? NOTHING for this pain?"

 "We plan to have you go to our cognitive behavioral program for chronic pain. We also want you to see our mental health specialists, too."

 "WHAT MEDICINES THOUGH? WHAT ARE YOU GOING TO GIVE ME?" Now he was up and pacing. His hands were shaky and everyone in that room looked nervous. The attending instinctively cracked the door open.

 "The plan is to give you a combination of naproxen and also something for nerve-related pain called gabapentin."

 "I've TRIED all that and that DOESN'T WORK!!! So you are just going to let me go home in PAIN? Do you even CARE?"

 And that attending started trying to explain the best she could. All while coaching herself to stay calm and like something close to a role model. Something close. The patient turned and looked at the intern. He saw that fear and confusion in his eyes.

"Do YOU even care? I could tell that you did. Follow your OWN heart. Don't let what someone else says make you let someone go home in pain. That's the kind of doctor I KNOW you can be."

And somehow in all of this he forgot to wince. Or yelp. "Sir, I'm sorry you are in pain like this. I truly am. We want to help you," the intern offered. And he meant that. His eyes kept darting back over to his attending. The patient crumbled to the floor and began crying again. On all fours in a way that startled even that attending who had been at this for several years.

 "Then help me with my pain. Even if you just give me a few to help me make it to another doctor. Please. . . .just. . .please." And really and truly he curled up into a fetal position right there in the middle of that floor.

 The attending gently closed the door again. "Sir? We will help you. But it will be a process. Today we cannot prescribe you any narcotics. It's important that you hear me say that because I want to be clear on that part. We don't think this is in your best interest. We will be ---"

 And just like that the patient cut her off. He quickly got to his feet and snatched all of the papers off of the desk. "All of you doctors are FULL OF S**T." He glared over at that doe-eyed intern. "And that includes YOU, TOO." The attending opened the door all the way again and the patient marched past her. "I'm going to somewhere that actually HELPS people."

 Both doctors stood by watching. Their eyes were on him and speaking words like "sorry that you feel that way" but this time only with eyes and expressions. Not mouths and sounds. The patient made a ruckus as he walked away from them. Yelling expletives and saying really unflattering things about the doctors.

At the end of the hall way he looked back at that attending and that intern and said this: "I would have liked it better if you had the guts to just call me a JUNKIE or an ADDICT to my face. Cowards."

 And with that he disappeared between the double doors. You could tell those words stung that attending like the unexpected snap of a rubber band. Interestingly, a senior resident walked by and looked toward her with an amused expression. The kind that comes from being desensitized to such interactions. Unfazed by the sight of a train wreck.

 The intern was not amused. He just stood there in that corridor looking like he'd witnessed a mugging. And the attending leaned against a wall wishing that truth #3 wasn't true. Too bad it was. So again, this was a train wreck. But one that they pretty much saw coming. And just like all train wrecks it didn't end well.

 Sigh. This? This is what complicates medicine and caring and healing so much. The patterns. We all fall into patterns because it's human nature to respond to what we can predict. You avoid Peachtree Road because you know the traffic is heavy. So you take Juniper instead. And you know that because you've seen that over and over again. See, things in medicine have patterns -- but with these patterns there are people involved. And people are not as simple as patterns. They aren't statues just frozen in time and fixed into one position. They aren't traffic patterns or cell phone signals. They aren't. Not the patients or the providers. No, they are not. So the key, I guess, is to fight against becoming a statue.

That's what made me write about this today. I need to flesh out these ideas and the perspectives of those involved. I want to fight myself to make certain that I never get so complacent with the sight of a train wreck that I look at it with amusement. Or freeze like I'm made of stone. So I fight. We fight. Fight to see the perspectives. Try not to take Juniper because of the train wrecks we see coming on Peachtree. But most of all? To still be bothered enough to care when they do.


Tuesday, May 22, 2012

QD: News Every Day--Most state medical boards substandard, watchdog group says

Most states don't protect patients from substandard doctors, in part because of budget cuts, according to an annual ranking of state medical boards by Public Citizen.

The annual rankings are based on the number of serious disciplinary actions taken against doctors in 2009-2011 as reported by the Federation of State Medical Boards. Public Citizen calculated the rate of serious disciplinary actions (revocations, surrenders, suspensions and probation/restrictions) per 1,000 doctors in each state averaged over three years to establish each rank.

Starting with the worst, South Carolina had 1.33 serious actions per 1,000 doctors, compared to the national average of 3.06 per 1,000.

The rest of the bottom 10 are Washington, D.C.; Minnesota; Massachusetts; Connecticut; Wisconsin; Rhode Island; Nevada; New Jersey; and Florida.

South Carolina, Minnesota and Wisconsin have consistently been among the bottom 10 states for each of the past nine Public Citizen rankings. Connecticut has been in the bottom 10 for each of the past six rankings. For the fourth time in a row, Florida is among the 10 states with the lowest rates of serious disciplinary actions even though it is beginning to improve.

Other large states, such as Texas, Pennsylvania and Michigan, have been in the bottom half of state rankings for all nine rankings and California has been in the bottom half for the past six rankings.

Tighter state budgets are the likely cause, the organization said in a press release.

The best states when it comes to doctor discipline are Wyoming (6.79 serious actions per 1,000), followed by Louisiana, Ohio, Delaware, New Mexico, Nebraska, Alaska, Oklahoma, Washington and West Virginia.

Alaska, Ohio and Oklahoma have been in the top 10 for all nine rankings. Only one of the nation's 15 most populous states, Ohio, is represented among those 10 states with the highest disciplinary rates.

Nationally, the rate at which state medical boards take serious action has declined significantly over the past seven years. The average in 2011 was up 3% from 2010 but is still down 18% from the peak rate of discipline in 2004 of 3.72 per 1,000.

The report states, "Absent any evidence that the prevalence of physicians deserving of discipline varies substantially from state to state, this variability must be considered the result of the boards' practices. Indeed, the "ability" of certain states to rapidly increase or rapidly decrease their rankings (even when these are calculated on the basis of three-year averages) can only be due to changes in practices at the board level, often related to the resources available to have adequate staffing; the prevalence of physicians eligible for discipline cannot change so rapidly."

Public Citizen said that boards are likely to do a better job disciplining physicians when they:
--are well-funded, with all license fees going to fund board activities instead of other parts of the state treasury,
--are well-staffed,
--proactively investigate rather than only respond to complaints,
--consider Medicare and Medicaid sanctions, hospital sanctions and malpractice payouts,
--are independent from state medical societies and other parts of the state government, and
--apply preponderance of the evidence rather than beyond reasonable doubt or clear and convincing evidence as the legal standard for discipline.

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Monday, May 21, 2012

Dangerous electrolytes, part 2

Reviewing the patient thus far:
The patient, a 40-something year old woman, has a long history of alcohol abuse. Recently she has had minimal oral intake with much vomiting. BP 100/60, pulse 120
120, 67, 32, 99
1.9, 21, 0.7, 8.9


Your job is to identify all the abnormalities in this panel, and suggest the sequence of events most likely to result in these numbers. What other information do you want?

Three respondents did a great job describing the acid-base disorder.
1) The anion gap equals 32, thereby by definition the patient has an increased anion gap metabolic acidosis.
2) The delta gap equals 21, thereby the revealed bicarbonate is 42, supporting an underlying metabolic alkalosis.
3) These two metabolic problems fit the story perfectly. The patient had both positive ketones and a mildly elevated lactic acid level. We expected a metabolic alkalosis with persistent vomiting. The hypokalemia fits the clinical picture perfectly.
4) Using the Winter's equation, one also finds a respiratory alkalosis. Clinically, we felt that the respiratory alkalosis resulted from the hypotension and alcohol withdrawal.
5) All the acid-base abnormalities resolved over the next few days.

Now the electrolytes are really the point of this presentation. The patient has hyponatremia, likely secondary to volume contraction. Her serum osm = 259 with urine osm = 411.

She had hypokalemia secondary to vomiting. We confirmed that vomiting was the cause with urine electrolytes. Urine Na less than 10, Cl less than 10, K = 45

We also checked Mg, normal at 2.5 and PO4, which was very low at 0.7.

What are the risks of the severe hypophosphatemia, and how would that abnormality impact your treatment plan? Also speculate why her initial PO4 was so low.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

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Over half of drug-related morbidities deemed preventable

Two studies from Norway drug-related morbidity may affect more than half of all patients, much more than observational studies suggest might occur.

Physicians estimated that 51% of all patients outside hospitals and 54% of all hospitalized patients experience drug-related morbidity, while pharmacists estimated this to affect 61% of all patients in health care, researchers reported in two studies.

Of the affected patients, 24 to 45% were estimated to experience preventable drug-related morbidity, and the resulting costs were 730 euros to 1,645 euros per patient with drug-related morbidity.

Drug-related morbidity is defined as new medical problems, such as adverse drug reactions, drug dependence and intoxication, and as therapeutic failures, such as insufficient effects of medicine and morbidity due to untreated indications.

The two expert panels of physicians and pharmacists estimated the proportion of patients experiencing drug-related morbidity, the proportion they perceived as preventable, and the clinical consequences resulting from drug-related morbidity. Costs to the health care system were modeled based on national statistics for costs of health care consumption.

Researchers at the Nordic School of Public Health NHV noted that this method was used to estimate the costs of drug-related morbidity in the U.S.

In the first study, which appeared in the International Journal of Clinical Pharmacy, an expert panel of pharmacists determined the probabilities of therapeutic outcomes of medication therapy. The cost-of-illness analysis included direct costs from the health care perspective.

The expert panel estimated that 61% +/- 14% (mean +/- SD) of all patients attending health care suffered from drug-related morbidity, of which 29% +/- 8% suffered from new medical problems, 18% +/- 6% from therapeutic failures, and 15% +/- 7% from a combination of both.

Drug-related morbidity was considered preventable in 45% +/- 15% of the patients with drug-related morbidity. The estimated cost-of-illness was 997 euros per patient attending health care, corresponding to an annual cost of 6.6 billion euros to the Swedish health care system.

In the second study, which appeared in the European Journal of Clinical Pharmacology, a panel of 19 physicians estimated the probabilities of drug-related morbidity, preventable drug-related morbidity, and clinical outcomes of drug-related morbidity separately for outpatients and inpatients.

Physicians estimated that 51% +/- 22% of outpatients experience drug-related morbidity and 12% +/- 8% preventable drug-related morbidity. Of inpatients, 54% +/- 17% was estimated to experience drug-related morbidity and 16% +/- 7% preventable drug-related morbidity. Of outpatients with drug-related morbidity, 24% +/- 11% was estimated to experience preventable drug-related morbidity, whereas this proportion for inpatients was 31% +/- 15%. The estimated cost-of-illness was 376 euros per outpatient and 838 euros per inpatient.

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Thursday, May 17, 2012

Board exams don't resemble real practice and waste my time

I took the day off today. I'm taking my recertification exam tomorrow, and I like to go into these things well-rested. I got up with PalKid, made her breakfast, had a leisurely cup of coffee and enjoyed a ride to school with a loquacious second-grader. I violated one of my primary rules for before-the-test days and did a little studying at the coffee shop. It's still hard for me to take this exam terribly seriously. I was reminded of this when I dropped by my office to get a little work done, work that bore little resemblance to what I will encounter on the board exams.

Internists trained after the 1980s are required to re-certify every 10 years. It's not a stretch to say that most internists find the process time-consuming, expensive, and largely irrelevant. As medical knowledge has expanded, the practice of medicine has become very subspecialized. There is little need for me to know the current regimen for the treatment of multiple myeloma. It's enough to know how to diagnose it and to know some of the consequences of treatment. I don't manage kidney dialysis, so the ins and outs are, to me, not terribly useful. I'm not a brain surgeon (just ask anyone) so I don't really need to know the best surgical approach for a pituitary macroadenoma.

The recertification process takes at least a year or so. One of the more useful aspects is the requirement that I do "learning modules," sets of questions that help me review important topics (but that are explicitly labeled as being NOT board review questions, wink-wink). Of course, I could do those modules in the course of my yearly continuing medical education. The most onerous bit is the "practice improvement module." I chose diabetes, a condition familiar to my practice.

It required my patients to fill out surveys, for me to enter data from a couple of a dozen charts, go through several other bits, re-review my charts, and at the end of the month or so it took, time was taken away from my life and I learned something I already knew: It's hard to take care of diabetics when they are real people. Not every patient can reach the standards we've set, nor should they, depending on their circumstances.

Tomorrow I show up at a testing facility with two forms of photo ID and must submit to "palm vein biometric analysis." Then I have to leave everything outside the room: my two forms of photo ID, my wristwatch, my wallet, any pens or pencils, and God-knows what else. Probably my belt and shoe laces. No scratch paper for me! (Apparently they provide some sort of small dry-erase board or something to jot ideas on.)

Is this expensive, humiliating, time-consuming effort useful? Who knows? There aren't many useful outcomes measures in the literature. It's not clearly known whether the current process makes better doctors. It is clear, to those of us in daily practice, that the process was not designed by practicing internists, at least not those who work full-time in the busy primary care environment. It also fails to recognize the technology available to modern physicians. We no longer rely exclusively on our memory when evaluating patients. We have quick and easy access to web-based references and to our colleagues. The board exams reflect our ability to recall rote knowledge, something most of us are quite good at, but it encourages behavior that is not good for our patients. Our access to information helps our patients, keeps us from making mistakes based on faulty memory.

I'm not terribly concerned. I do well on standardized exams, but I realize that this little talent has little to do with my daily practice.

It's pretty embarrassing that we allow our colleagues to put us through this. The exam is the least offensive bit. The entire process is a drain on the limited time and resources of a primary care physician. The process could be simplified by having docs do question sets at home, with access to reference sources, the way we actually work in real life. Throw a dozen of those at me and I'll probably learn more medicine in two months than I have in two years of my current recertification process.

(Here's an example of more realistic questions you'll never see.)

Did I mention that we get a TSA-style wanding?

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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Wednesday, May 16, 2012


In the last hour, I suddenly became overwhelmed with just how many choices we make in a day. We choose whether or not to wake up in the morning to drag ourselves to school [some might argue that this isn't a choice ... but let's just go with it].

We choose what to eat when we're hungry. We choose which lane to drive in. We choose how we spend our time [such as right now, I am actively choosing not to study].

In life, we make a lot of choices that we don't think twice about because for the most part, they are trivial.

But if you really think about it, some everyday choices we make affect those around us. Something as simple as smiling at a stranger as you hold the door open could be the highlight of someone's day. Cutting someone off as you merge into another lane could ruin the rest of that person's day. Sometimes, I think we forget just how interconnected we all are; most of the time I think I am just minding my own business and living in my own little world, but there's no such thing. We all end up influencing another human's life at some point in time, whether we acknowledge it or not.

In medicine, our choices hold even more weight. This thought is exciting and chilling all at once; our choices can lead to bringing a new life into this world or ending one prematurely. Our words can tear a family apart or bring tears of joy to a patient. Our actions truly impact the life of our patient, whether we like it or not.

This is the path we chose. We want to help people. We want to heal people. But in the end, there is no escaping the reality that we won't always be right. Most of the time, there is no such thing as black and white; there is just an expanse of gray that will only morph into clarity retrospectively.

Amanda Xi is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Ann Arbor, Mich. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.

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Six in 10 doctors using digital tablets

Six out of 10 doctors are using digital tablets for work, mostly iPads, and half use them at the point of care, according to a survey from health care market research and advisory firm Manhattan Research.

But is it a good thing?

The online study surveyed 3,015 U.S. practicing physicians in more than 25 specialties.

Tablet use for professional purposes almost doubled since 2011, reaching 62% this year.

Physicians using tablets, smartphones and desktops/laptops spend more time online on each device and go online more often during the workday than physicians with one or two screens.

Adoption of physician-only social networks remained flat between 2011 and 2012.

Physicians reach out more frequently to and are more influenced by colleagues they formed relationships with at school or at work than peers who they first connected with online.

More than two-thirds of physicians use video to learn and keep up-to-date with clinical information.

Is this a good thing? How can doctors manage three computing platforms and still connect with patients? ACP Internist addressed this topic in its April cover story.



Life at Grady: Please and Thank You

The following post, by Kimberly Manning, MD, FACP, first appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission. All names and identifying information have been changed to protect privacy.

For the most part, I've always been a "please" and "thank you" kind of girl. I have my mother to thank for that. She has always been the kind of person who is gracious with people---but especially strangers. Got it on a badge in the grocery store? Mom will greet you by your name and thank you by the same. And if she wants something from you or needs you to handle something for her, you can at least count on a nice ice-breaker about how you are before she jumps right into it.

With this upbringing under my belt, I blended perfectly with one of the very first senior residents I had assigned to me during my internship. His name was Antoine and he was probably one of the kindest, most polite people I'd ever met. It astounded me to see him interact with people. Everyone from the head nurse to the man pushing the wastebasket in the hallway had his full attention. I loved that about him. He called each and every one of them by their name and, when he didn't know it, would make a point to learn it. There was something so mindful about the way he treated people in the hospital. They all seemed to have his respect which I quickly learned was a very effective way for him to get theirs.

But of all the things I watched Antoine do, there was one thing that always stuck with me. Every single time he wrote an order in the chart (this was before everything was electronic) he always started it with "please" and then, just before his signature, he would write those two words I've heard my mother say a million times "thank you."

Now, to you, this may not seem so odd. But trust me--in a hospital chart it was quite unusual. No matter how small the order, without fail, he always had those signature words flanking the request.

Please discontinue Foley catheter.
Thank you, 
Antoine R., M.D.


1. Advance to regular low sodium diet.
2. Give patient 2mg Morphine Sulfate now and then q4 hours as needed for pain.
3. Offer pain medication q4 hours. 
4. Arrange for Physical Therapy consult.

Thank you,
Antoine R., M.D.

Since this was my first senior resident, of course he became a very important role model for me. Which reminds me -- always take your role as a supervisor (particularly one that is early in someone's training) very, very seriously. Your good--and bad--habits live on through them.

(Click "more" below to keep reading this post.)
Anyway. Following Antoine's lead, I did the same thing. On every single order I wrote, I added that simple start and closed with that signature gesture of gratitude. And just like it did for my senior resident, it strengthened my relationships with the nursing staff and ancillary teams. Especially when combined with my mother's early example.

Please and thank you. Simple enough, right?

This brings me to a something that happened to me just a few weeks before I moved to Atlanta. I'm not sure what got me reflecting on it, but it remains one of the best things that has ever happened to me so I thought I'd share.

The Please and Thank You Doctor

I still remember one of the first times that I ever called the hospital operators. Announcing myself as "Dr. Draper" still sounded funny. Especially since it wasn't preceded by the word "student." Though I don't remember exactly what the call was for, I do remember how surreal it still felt to be a doctor. Entrenched in habit, I am certain that once I got over being a full-fledged physician, that it went something like this:

"Thank you for calling MetroHealth Medical Center where your health is our primary care! This is Operator Margaret. How may I be of assistance to you this morning?"

"Good morning, Margaret. This is . . .uh. . .Dr. Draper. You doing okay today?"

"Uhhh. . . I'm well, thank you. How may I direct your call, Dr. Draper?"

Very early on I recognized that this follow up question -- "how are you?" or rather "you doing okay?" invariably caught people off guard. Particularly over the phone.

Kind of like Antoine signing his orders with "thank you."

That response -- a pause followed by what I am certain was a smile through the phone -- always warmed my heart. That's when I moved that practice from just "habit" to something more deliberate. I made a decision to add a tiny ray of sunshine to any operator, desk clerk, or lab tech I spoke to over the phone.

So those early nervous exchanges soon evolved to this:

"Thank you for calling MetroHealth Medical Center where your health is our primary care! This is Operator Drema. How may I direct your call this afternoon?"

"Operator Drema! This is Dr. Draper. How are you enjoying the lake effect snow this week?"

"Awww, hey Dr. Draper! What's with this snow? It's April!"

"I know! I left a message for the mayor of Cleveland and told him that Canada called. They want their weather back."

And invariably that operator would chuckle and then professionally move right into the point of the call. Over time, I came to "know" nearly every single operator. So much so that on the very rare instances that I heard an unusual name, voice or accent I would introduce myself. And even welcome them.

It was kind of like Mommy in the grocery store. On steroids.

I was at Metro for five full years. Four as a resident and one more as a chief resident. This meant that I got to know and greet a whole bunch of operators over those years. By the end of my time there, those salutations were easy and familiar. This was very interesting considering in all of that time I never once saw a single one of them face to face.

I used to have thoughts of marching down into the basement to greet them all in person. But after three years or so I had created this entire idea in my head of what they all looked like. The woman with the throaty, deep voice was a snappily dressed transgendered person. The man with the super deep voice looked like Barry White. The operator with the squeaky voice was four foot eleven and had hands tinier than those of a toddler. She even needed her head gear specially fitted since she was so small. I imagined what race they were, what kind of make up they wore and even came up with visions of sparkling gold teeth for one of them. So this stopped me from destroying my imagery by going down there.

Goofy, I know. But residency is hard so you have to amuse yourself however you can.

My final weeks at Metro were spent attending on the wards. Even though I was a chief resident, back then we were credentialed as junior faculty members. This meant that we not only got to do some formal teaching on the wards as attendings, we also "got to" fill in holes for faculty who couldn't fulfill their duties for whatever reason. I was given the great fortune of being the finger in the dyke for a senior faculty member who'd decided on a last minute sabbatical.

Even though he was on wards.

Uh, yeah. This kind of stunk since my last day was June 24 but this time frame I had to step in for was from June 1 - 15.  Yes. I loved working on the wards. But not up to the last week before I was trying to move from one state to another.

June can be a tricky time because it is the last month of the academic calendar. What does that mean? It means that working that month can be either a gift or a curse. On the gift end, your residents and interns are seasoned and independent thinkers and workers. Your teaching focus can be more on patient care and medical knowledge than just logistics of how to get things done or worrying about errors. Kind of like working a shift on a job with a veteran worker versus the guy or gal that's still in trainee mode.

So yeah. June can be totally awesome for that reason, but conversely, it can absolutely suck dish rags for the very same reasons. Sometimes by June the interns know (or think they know) just as much as some of their residents. The dynamic becomes bumpy and uncomfortable. The interns feel micromanaged and the residents feel frustrated. There's also the risk that the resident already has a job and has mentally checked out of residency. They give the interns carte blanche to do whatever they want while then veg out in call rooms on twice fluffed pillows. Even if all hell is breaking loose.

This particular June was mostly a curse. The team didn't fully gel and the service was busy. On top of that, I was no better than they were. My mind was halfway to Atlanta already and my feet were ready to be inside of Grady Hospital. My patience was short with my resident at times and also the petty arguments he constantly got in with the interns. Back then, all interns got the final week of internship off as an unpaid (though super-welcomed) vacation. So even they were out to lunch in that final week with me.

Despite all of this, we slugged it out and took good care of our patients. The days were long and this was before duty hours reform so by long I mean waaaaay more than the current 16 hour maximum. Call days morphed into post call days that lasted 36+ hours. And even though I wasn't the one who had to sleep there all night, I was the one responsible.

And seeing as I was almost getting ready to LEAVE for GOOD, seriously? I just wasn't in the mood for all or any of this.

So I'm not sure of the exact day, but late in the afternoon on what I believe was two days or so before I was to finish my two-week stint I got paged to the floor. What I distinctly remember is that I was all the way down in the Radiology department with one of the medical students. I'd gotten tired of waiting for someone to transport our patient to the CT scanner so, with the help of the student, we had just wheeled our patient down there on our own.

Since I was pushing this ginormous bed through the hall way, it took a moment for me to reply to the page (which back then were only numerical). Subsequently, the person calling paged me two more times in a row.

Ugggh. I got to the nearest phone and call to see what's going on.

"Dr. Draper? I'm sorry to keep paging. This is Mrs. Tift."

"Mrs. Tift? Hey, there, I'm sorry to take so long. We were transporting our patient to CT. Is everything up there okay?"

"Oh yes, Dr. Draper. I was just calling you because we need you to come back up here soon as you finish. Someone left something up here for you."

And since I was in wards-mode, I immediately thought it was something that would add to my work. Or my headaches.

"What is it, Mrs. T? Should I be worried? Should I run up right now?"

"It's not a medical emergency. Just come on up when you finish."

"Can I send one of the interns right now? They're both on the floor."

Mrs. Tift spoke back in her impossible-to-read, stoic voice, "No, Dr. Draper. This requires the attention of the attending physician."

Now. Let me just say that I'm the kind of person who doesn't do well with things like this. Like, when someone says, "Hey, I have something to tell you later" that never works for me. I worry. I fret. And then I press them until they tell me right then and there.

So, of course, I speed up the transport process with my trusty med stud and safely get our patient into the CT suite to wait in queue for an image. You'd think I would have strolled back to the ward after that, but being the nosy and worry-warty person that I am, I pretty much jogged. Which made my unfortunate medical student feel a need to do the same.

We trotted to the elevator and finally got to the ward. I walked briskly to the nurses' station where Mrs. Tift was and approached her. Anyone nearby could see the urgency in my body language and, I'm sure, the tired in my eyes.

"Hey Mrs. Tift. You said there was something that needed my attention?"

And stoic Mrs. Tift looked me square in my eye and smiled so big and wide it almost scared me. She held her right hand out and gestured to something--then she nodded and smiled some more.

I looked around to see what she was talking about. I scanned the area for a stack of papers needing my signature or better yet, a long, lost stethoscope from my internship. Seeing neither, I swung my head back to her and looked puzzled.

"You don't see that, Dr. Draper?"  She let out her signature raspy laugh. "That has your name on it."

And since I still looked confused, Mrs. Tift put her hand on what she was referring to and pushed it toward me on the counter.

It was an absolutely spectacular bouquet of long-stemmed pink roses. Beautifully arranged in a vase with a card peeking out of the top.

"Looks like you have an admirer, Dr. Draper!"  Mrs. Tift winked at me and had no qualms about standing right there to check my reaction as a marker of from whom they came.

"Roses? Who in the world would send me roses?" I asked. And I was serious. My romantic life in Cleveland was non-existent. So I had no idea who they were from. In fact, I felt kind of scared to even open the envelope.

"Not just roses," a senior nurse named Mrs. Vogel chimed in, "TWO DOZEN of them. You go, girl!"  And slowly but surely, the nurses started gathering near me to get the scoop on my suitor.

Problem was, there wasn't one.

So finally I ripped open the envelope and read the card inside. And by the time I got to the end of the very short note, it was as if someone had punched me in the chest and knocked all of the wind out of me. Then, like someone flicking on a sprinkler, I began to weep. A deep, hard, tired weep.

The nurses and staff all looked worried. Mrs. Tift came around the counter and put her arms around me. And I turned my head into her bosom and just wept and wept. She patted my head and back and asked if I was okay. I nodded hard but couldn't stop crying.

Nurse Vogel came to my side and finally asked what everyone was surely wondering. "What was it, Dr. Draper? Is everything okay, honey?"

In response, I looked up from Mrs. Tift's safe embrace and handed Nurse Vogel that card. She read it and immediately covered her mouth. Tears welled in her eyes, too. Nurse Vogel had known me since my very first days as an intern, so I trusted her to see that card. And also to read it out loud which is what she took it upon herself to do.

To the "Please and Thank You" doctor with gratitude. Thank you for always taking the time to be kind. Please don't ever stop. Wishing you the best in your future endeavors.

The MetroHealth Hospital Operators

And that card had the signatures of every single one of them. Drema. Irma. Margaret. Charles. Vera. Amanda. All of them.

It remains one of the proudest and most moving moments of my entire life. In fact, just writing about it has me reliving it and bawling all over again.

Before I went home, I took the elevator to the basement. I asked two people how to get to the operators' suite and finally found that vacuous room where they all worked for all those years. I walked right in with that giant bouquet of flowers and thanked each and every one that was there. I hugged their necks and thanked them right back for taking all of my calls for the past five years and for always making me feel like I wasn't a burden.

And, of course, they said, "You weren't."

And you know? The Barry White man was a tall, thin Caucasian man. The tiny-voice lady was taller than me and quite big-boned. The throaty, deep-voiced person was just a lady with a throaty, deep voice. And no, not a single person had gleaming gold teeth. So that imagery was dead for good. But that's okay because the reality was so much better.

Now. Please . . .pardon me for such a long post. I didn't mean for it to be--I really didn't. And listen. . .thank you. . . seriously, thank you for taking the time to read here. I mean that.


Kimberly M.


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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.

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.

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.

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.

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).

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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