Friday, August 31, 2007

Bug, flower, pitty-pat

The alternative names that parents use to refer to their prepubescent daughter's genitals never cease to amaze me.

That said, I'm not sure what to suggest.

With my kids we always called it a vagina. It seemed a bit torturous to try to get my 3 year old daughters to identify the multitude of distinct areas on the female anatomy. "Mommy, my labia majora itch" doesn't roll off the tongue. But calling the entire thing a vagina is less than accurate.

So I get a chuckle out of the dads that come in saying "She's got bumps on her bug."

I knew what he was talking about. She knew what he was talking about. Is calling it a "buh-gina" any better?

Maybe I should have gone with pitty-pat...

Wednesday, August 29, 2007

What are you, an idiot?

I need help.

I'm failing miserably.

I just can't figure out what to say, or how to say it. When presented with woo.

I learned about woo from white coat underground. Of course, I knew about woo, I just didn't know it was called woo. Woo is all that crazy alternative medicine quackery.

I'm not even talking about soft woo. I'll walk with you for a little way, on chiropractry, acupuncture, St. John's Wort. If you ask me point blank I'll tell you what I think (completely bogus), but if it's within reasonable context I leave it alone.

I'm talking about hard woo. Hair analysis, magnet therapy, chelation.

What would I say, if a friend or family member asked me about the above?

What are you, an idiot?

But somehow, that doesn't seem appropriate to say to patients.

I've been waiting for my script to develop, and it's going miserably. I end up mumbling and going on about misrepresentation and lack of controlled trials. I end up sounding like the idiot.

I need help. The Woo is coming out of the Woo-dwork.

I had a patient this week ask me what she should do about the high heavy metal levels that she has in her tissues that don't show up in her blood stream, that cause her fatigue, back pain, sinus pressure, etc. She got tested for it by being hooked up to some electrode type system 6 years ago. And heavy metals can cause blockage of the coronary arteries, didn't I know?

It did not go well.

What am I, an idiot?

Tuesday, August 28, 2007

Professional Courtesy

An uninsured patient of mine recently underwent a colonoscopy. She's not a wealthy woman. She probably makes under $10 per hour.

She's uninsured. Due to some problems she's been having the colonoscopy was necessary. So she's paying out of pocket. Big price tag, shallow pocket.

She had it last week. I got the report, some mild abnormalities but thankfully no sign of what we were hoping not to find.

She called today to ask me for the results. Due to the mild abnormality, I asked her to call the GI office to inquire about results.

She said, "His office told me to call you for results."

You can charge her full price for a colonoscopy, but you can't call her? Classy, very classy...

Monday, August 27, 2007

Monday Monday

Aaahhh...a typical monday:

1. "My puppy ate my Percocet script." Really. How original.

2. The patient I've seen a hundred times before walking unassisted showed up to ask for disability WITH A CANE.

3. I've got a strong stomach, but I'm not touching cottage cheese for a least a month.

4. Topped off with several screaming 4 year olds getting their school shots. School starts tomorrow, of course!

How was your Monday?

Friday, August 24, 2007

Roughin' up patients

I had an elderly patient request to transfer care this week to a nurse practitioner in my practice.

She's got some rather complex medical issues going on right now. I had just seen her 3 days prior in the office, and had no idea what I had done to offend her, so I gave her a call. She refused to tell me why she wanted to transfer. So I did my best to catch up my colleague, and Annie came in to see her instead.

Annie told my colleague that I shook her around and was physically rough with her.

Which I can assure you is not true.

Which does not change the fact that this patient believes it to be true.

I guess my doctor skin is finally thickening. A couple of years ago this would have really bothered me. And while it bothers me that for whatever reason Annie feels that she was mistreated, I recognize that I had no role in her feeling this way.

I've done all I can to assure she gets seamless care from my colleague. That's about all I can offer her now.

Wednesday, August 22, 2007

Fun with Anagrams

Mr. Smak noticed the marquis on a local church recently:

Education without religion makes but clever devils.

He's planning on moving a few letters:

Education without religion makes bevels cut drivel.

And he went to Catholic school for 10 years. Clever devil.

Tuesday, August 21, 2007


There's an infamous scene that plays out in the minds of all budding physicians. It goes like this: It's your first day of medical school. The stern dean approaches your class at the podium, and says, "Look to your left, look to your right. One of the three of you will not graduate."**

Times have changed. Medical schools spend a lot of time and money admitting students now, and don't like to flunk anyone if they can help it. So we didn't get that talk.

On my first day of medical school, we all sat, fresh-faced and nervous, in the auditorium that would hold our tushes for countless hours over the next year. The Dean of Students approached the podium beaming, and said "Some of you can't believe you are here. You're certain that someone is going to come in and tap you on the shoulder and say 'We made a mistake, you don't belong here.' But you all deserve to be here."

I've thought of that moment often through my career. I certainly felt that way, on my first day of medical school. I certainly felt that way again as an intern, as a newly minted second year resident, seeing my "own" patients in clinic during training, and as a young new attending physician. Sometimes for significant reasons, sometimes for just more of the daily grind.

So I've been an attending for almost 4 years now. When will I stop having that thought?

**I can't remember anymore - is that scene from House of God?

Sunday, August 19, 2007

Book Review: A Short History of Nearly Everything

I was recently reminded of this book, and thought I'd share my thoughts. I actually listened to it on an MP3 player during my commute, so I don't know if it would be as delightful to read as to listen to, but I found it very engaging.

Bill Bryson covers the history of the universe, from it's creation right up to our evolution to now. He includes quite a bit on how we figured the above out, and the men and women who did the figuring.

That makes the book sound really dry, but it wasn't.

The next time you need a reminder of exactly how tiny and insignificant you are (a sensation I find oddly comforting), check it out. You are much more miniscule than you thought.

Friday, August 17, 2007

Chatting up the ER...

Ok, another call out to the ER docs. A previous post has me wondering how useful my calls to the ER are when transferring patients. I'd love to hear some opinions.

What are you guys looking for when I send someone in from the office? I know you're busy, and I try to keep it concise. Do you just want "55 year old male for chest pain workup", or is more detail helpful?

C'mon, help me help you.

Thursday, August 16, 2007

Make llamas, not war

Dr. Rob at Musings of a Distractable Mind has written the post that I've been trying to write for three months. Please read it.

Bravo, Dr. Rob. I couldn't have said it any better.

I'll include my reply below.

Powerlessness about sums it up.

So many people struggle with this issue. The occasional patient ‘makes it’ and loses the weight and keeps it off. But they are the exception.

I have begun to progress beyond powerless to feeling disingenuous. When I see a 50 something patient 150 pounds overweight who has tried every diet there is, doing my ‘eat less move more’ speech borders on insulting. They know it’s not going to work. I know it’s not going to work.

I’m not sure where to go with it next. It’s my responsibility as a primary care doctor to point out their health risk factors and advise them on changes.

But research has proven time and time again that my advice is worthless.

So many factors at play: society, genetics, self-control, economic pressures, time pressures, self-esteem, education.


Wednesday, August 15, 2007


50ish hypertensive hypercholesterolemic male smoker.

Seen by another provider 2 weeks ago. Advised to go straight to the ER for shortness of breath, tachycardia, weakness. Told her he'd be driven there by his son, decided not to go, "I felt too sick".

Called a week ago stating he passed out at home. Advised to go to ER. Refused.

Called yesterday stating he still felt weak and dizzy. Advised to come to office immediately for appointment or to go to ER. Said he couldn't come in till today.

Appointment with me today. Hypotensive, tachycardic, normal pulse ox and EKG. Complaining of weakness and dyspnea.

I assumed my "Fear of God" voice (which I pull out on rare occasions only) and told him that he may be suffering from any number of conditions, not limited to a heart attack or blood clot in his lung, which was potentially life-threatening. And as much as I would love to be able to work him up and treat him in the office it was not possible. And that he must go to the ER for appropriate care.

I stepped out so that my nurse could do his EKG.

His comment to her, "Gosh, is she always so grumpy?"

Monday, August 13, 2007

Darwin's nubbin

Saw a 14 year old girl today for a physical. After the full dog and pony show, I was wrapping up. Mom asked me to peek at a spot that they had forgotten to mention, on her abdomen.

Eesh. A supernumerary (extra) nipple.

These are of course commonplace, and of no consequence.

Unless you're a 14 year old girl.

I wasn't sure how she'd take it. I had the forethought to clap my hands over her 11 year old brother's ears before whispering "It's an extra nipple."

She not only thought it was hilarious, I got big points for keeping it from her brother. I'm guessing that kind of info is major currency in the sibling wars at her house.

If supernumerary nipples aren't further evidence of evolution, I don't know what is.

Sunday, August 12, 2007

Dance, dance

There's nothing like going to a rock concert (even an old fart like Dave Matthews) to make you feel old.

Which caused me to remember another recent experience I had that made me feel old and out of touch. Neither of which are necessarily bad things.

We went to see Shrek with the kids. Prior to the movie starting, we noticed one of the big Dance Dance Revolution machines in the lobby. After a few minutes, a few teenage boys, who in my day would be described as "skate rats" began milling about it looking like they were going to play.

I was thinking that if a skinny 14 year old kid played a dance game at the movie theatre, the jocks would be waiting to pound him in the parking lot before his mom came to pick him up. Apparently, times have changed.

One of them started the game. It became immediately obvious that this was a frequent and well-practiced activity. That deaf, dumb, blind kid sure danced a mean revolution. And as a novice dance revolutioner myself (holiday parties at my brother's house), I was quite impressed with his skill level.

We hit the movie. On one of the bathroom trips I made with Son an hour later, they were still going. There began to be a crowd of cute girls watching from afar. By the end of the movie, the cute girls were hanging all over them.

As we left, the dance party was in full swing. Is this a national phenomenon, or just in towns where there's nothing else to do?

Saturday, August 11, 2007

Some Devil

Fabulous fabulous performance by the Dave Matthews Band on Friday night.

I had 7th row center stage tickets.

Without my sister, her college buddy (who scored the amazing seats), and my mother (for babysitting) it would not have been possible.

Hilary was right, it takes a village. To go see a Dave Matthews concert, anyway.


Don't Drink the Water - as always, a great concert jam.

Sister - I sobbed through the song, as I do when listening to it solo in the car. It didn't help to have my own amazing sister sharing the experience.

Some Devil - a Dave solo, and amazing.

He's a great performer, was in a great mood. Very peppy, engaging, and energetic. Will be one of the highlights of the summer for sure.

Monday, August 6, 2007

Dr. Smak, Simpsons style

Doh! I think the sallow complexion becomes me.

What do you suppose the average Simpsons bili level is?

Create your own likeness: the Simpsonizer.

Friday, August 3, 2007


Many bloggers have weighed in on P4P. For the non-medicals out there, P4P stands for Pay for Performance. In a nutshell, Medicare and a number of private insurers want to set some concrete numbers as benchmarks of a "good" physician, and pay them a bit of a bonus.

Sounds like a pretty good idea, huh?

Well, like most completely horrible ideas, on the surface this doesn't sound so bad.

There are SO many reasons why this is a bad idea. I don't have the organizational skills to go through them all today (TGIF), but it's been done elsewhere, and quite well.

There's one reason that's bugging me today.

P4P will make healthcare for the disenfranchised even worse.

We doctors call them "noncompliant". That's the medical buzzword for "lazy, won't listen, doesn't care" and it's fairly accurate. Now, there's a movement (especially in the public health center world) to stop using that word. Apparently it's got a negative connotation, and supports a paternalistic model where doctors TELL patients what to do.

I think that's a steaming load of hooey. You make a well-established evidence-based recommendation. Patient doesn't follow it. Noncompliant.

But that doesn't mean that patient gets thrown out with the trash.

There are lots of reasons for noncompliance. Lack of education. Lack of support. Lack of trust. Lack of role models. Lack of funds. Lack of transportation. Lack of giving a crap. Too many other things to worry about. Too many other family members to care for.

Part of the job of a doctor is to try to identify any modifiable issues and fix them. Another part of the job of a doctor is to continue to take care of people who won't take care of themselves.

Enter P4P.

Every poorly controlled diabetic I have decreases my chances of getting a bonus. Every missed or refused flu shot. Every declined mammogram.

Remember Ross Perot's "giant sucking sound"? I anticipate a deafening thud, as these patients, already doing poorly, are dropped like lead weights off of a sinking ship.

P4P will penalize the doctors who take the extra time and effort it takes to care for the noncompliant patient (not to mention the increased medicolegal risk).

But more importantly, P4P will remove the chance of getting any semblance of adequate health care. No one will want them.

Thursday, August 2, 2007

Book Review, The Tenth Circle

I'm not a huge Jodi Picoult fan. I don't dislike her, she just doesn't light a fire for me. But, my sister lent me her recent book, and I had nothing else to read, so...

Ms. Picoult tends to write about family relationships. Her strength is in presenting points of view of various characters, to allow the reader to identify with many positions.

This particular book is about a teenage girl and the tragedy she, her family, and her community experience after she reports that she was raped.

There are two topics that make me automatically NOT enjoy a book. First is rape, second is death of a child. I am fortunate to never have experienced either of them, but I find both situations so horrific to imagine that it immediately takes the pleasure out of a book for me. I'm a pleasure reader, so this is an issue for me. However, I got past that and was able to finish the book.

The highlights were the comic book drawings that helped to narrate the story. It was an entertaining literary device, and helped pull the story together. I also really enjoyed the portion describing life for the native Alaskans.

Also disturbing was her representation of current teen sexual practices, which in her footnotes she states was based on conversations with real teens. I'm no prude, and don't think of myself as naive, but boy, times have changed, and not for the better.

Overall, I'm lukewarm to this one. It's a quick and easy read, and she puts some interesting twists in throughout. But I preferred My Sister's Keeper to this one, probably because it was about medical ethics. I'd start there.

Wednesday, August 1, 2007

Nausea... what happens when you realize that the a$$hole on the front page arrested for sexual assault of a teenager is a patient of yours for whom you prescribe Viagra.