Archive for the 'Life of a Physician' category

It Happens All the Time

Sep 26 2016 Published by under Life of a Physician

I get some test results. They are not yet optimal for whatever the patient has, so I want to make a medication change. We are using a well-established drug with minimal side effects. At the time it was first prescribed, we reviewed alternatives, and the family was in complete agreement with starting this treatment. The drug is also incredibly inexpensive, one of those most pharmacies will provide for $4 per month.

We call to increase the dose, and the family tells us they stopped the drug. Not because it caused side effects or other problems. They have decided to try some supplements for a more natural treatment.

We manage to renegotiate treatment with the original drug. We will now have to test again to assess its effects, at further cost. The insurance covers the cost of the drug, pretty much in full. The supplements the family substituted easily cost five times their out-of-pocket expense for the pharmaceutical agent. So they are more expensive as well as ineffective.

But somehow the family was willing to shoulder those expenses to be "natural," even though there is little "natural" about these supplements. These supplements "support" the systems involved in their child's health issues, so they were worth a try.

Isn't it time to get rid of this costly BS that the supplement industry is allowed to spew?

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The Call to Action, Pain Management Edition

Sep 05 2016 Published by under Life of a Physician

We have now completed two months of the new academic year, and times have been a-changing. We had to rearrange the way our patients get covered by residents in the hospital. We attendings have been taking more direct night call on our inpatients as a result. After taking insistent calls from nurses, I have become even more concerned about how we assess and treat pain.

For example, a kid with a kidney disease or transplant comes in with an infection in the urine or a virus. They are not taking fluids well, and they need some intravenous support and/or antibiotics. The kid looks like they feel sick from whatever the underlying problem may be. We start acetaminophen for fever and pain. Later on, when routine vitals get collected, they get asked if they have pain. They then rate the pain on the infamous 1-10 scale. Then, we start getting called about "unrelieved pain."

Patients with kidney problems, including transplants, must avoid non-steroidal anti-inflammatory drugs (NSAIDs; Advil etc). Filtration in the kidney is often dependent on prostaglandins, and these drugs work by inhibiting prostaglandins. In sick infected patients, generous dosing of NSAIDs can lead to  kidney failure that might even be permanent. That means pain unrelieved by acetaminophen quickly escalates to pain requiring opioids.

If the kid is sick enough to be admitted, I have no objection to the occasional dose of hydrocodone in the evening (even if I would have told my own kid to put on their big kid underwear and deal with it in a similar situation). It often becomes difficult to scale back the medication during an inpatient stay because we have become so focused on "unrelieved pain" assessment. The number of calls for this while covering a handful of relatively well patients was startling. I cannot imagine the pressure to just hand out "the candy" with more problematic patients and a busier service.

Treating pain is important, but we need to have strategies that do not involve medications. Children often respond well to distraction, relaxation, and other behavioral techniques. Unfortunately, these may be difficult to administer, especially in the middle of the night. And why are we waking them up and asking about pain when they should be sleeping anyway?

I am not a pain doctor. I just wish for a more rational strategy that does not create obvious rewards for overtreatment that may lead to addiction.

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Real World Uncertainty

One of the milestones we use to judge pediatricians in training involves uncertainty in the clinical world. We often deal with probability when diagnosing conditions or prescribing treatments. Many times we are convinced that we know what the patent has, but confirming it definitively cannot be easily accomplished, especially in a timely fashion. We make a provisional diagnosis, treat the condition, and, if the patient gets better, congratulate ourselves on our clinical acumen.

At times, the response to treatment remains uncertain, even when the diagnosis is not. A biopsy-proven kidney disease may respond to a certain treatment 90% of the time. If your patient is in the unlucky 10%, then you must develop another plan to try.

We gauge our trainees' abilities to handle this uncertainty that is part of medicine. We discuss odds and statistics with our patients, but how can we help them deal with this uncertainty? This can be especially fraught with potentially fatal illnesses as I am learning on a daily basis. Do we make a long-term goods purchase? How far in advance do we plan things? What will the future hold?

Odds ratios and averages and other statistics give us information, but we cannot know where each patient fits into the disease spectrum until whatever is going to happen happens. It makes having a disease that much  more stressful and frightening.

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A Delicate Balance

Feb 17 2016 Published by under Life of a Physician

As a physician, I often give families bad news. I get to walk in the room and tell them that their child's kidneys will fail or have failed. I then get to tell them about dialysis and transplant, treatments that can give their child a new lease on life. Neither cures their kidneys, but they can provide opportunities for long, fulfilling lives.

I have been on the receiving end of bad news in my life as well, but I have recently become more attuned to its delivery. Some doctors come over waaaaay more optimistic than is warranted. While some families may appreciate a "glass half full" message, in this day you better assume that everyone has been online. The first hit on Google will likely provide a more truthful outcome message that decreases your believability. I understand that no one wants a completely hopeless message, but you have to balance a low possibility of successful treatment with reality. People deserve to have the truth available to them, even if they choose to ultimately deny it.

Bad news generally needs to be balanced with some ray of hope. It's a delicate act, and I am quite grateful for those who do it well.

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Day Job Interferes with Blogging

Apr 27 2015 Published by under Life of a Physician

Last week I found out it was my turn to once again give Grand Rounds.

For you nonmedical folk, Grand Rounds is like a seminar for clinical people. We put everyone in a big auditorium and someone updates the audience on a pediatric topic for an hour. We now have mandatory "interactive components" for our sessions, begging the question of why we still have it in a theater space.

I finally picked my topic which should result in a blog post eventually. In the meantime, it just keeps me from commenting on anything else.

Stay tuned; I will emerge soon.

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Sep 06 2014 Published by under Kidney Function, Life of a Physician

It's been a dry week.

Zer0. Zip. Nada.

Today, the urine output box shows 46 mL overnight.

Less than an ounce, but an important sign of the return of kidney function.

Keep it up, kid.

Urine is golden.

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Trying to Stop a Disruptive Train

Apr 04 2014 Published by under Life of a Physician

My week involved a lot of work with patients as some hemolytic-uremic syndrome came to town. While driving to and fro and using the restroom, I have read some tweets. At one point in a discourse, we talked about "antique" portions of the physical exam.

For example, in medical school they taught us to percuss heart borders. Percussion involves tapping on the chest and listening for the difference between the air-filled lungs and the relatively solid heart as shown in the video:

I cannot remember the last time I percussed a heart. Children do not hold still and quiet for such nonsense, and we get much more information from a chest xray. The latter also provides a lasting objective record of the findings that can be shared with subsequent physicians (or legal professionals). Most of the medical students I queried had no idea what I was talking about.

Many medical schools now incorporate inexpensive portable ultrasound machines into their curriculum. I envy these students who will be able to hear a murmur and figure out what it means on-the-spot. I know several pediatric nephrologists who have trained to perform their own ultrasound exams in the clinic. Unfortunately, its use is not spreading as fast or as far as it should.

Why? Hospital privileges.

When a doctor establishes a practice in a clinical facility, they usually have to be approved by a group at that place to make sure they are competent. I could apply for privileges for many procedures, but then I have to document my proficiency. Generally, they want to know what training you have and how many of the procedure you completed in the past 1-5 years. Imaging studies have fallen under the procedures heading. All those formal ultrasounds in the radiology suite generate lots of income for facilities.

They may not want us doing our own, even when we have the capability to record and store our images for the record.

The nice thing about disruptive technologies is that they are usually hard to stop. Eventually pocket ultrasound may replace even more of those "artisanal" physical exam skills. And that's OK if it makes for better care.

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Weed or Flower?

Aug 07 2013 Published by under Life of a Physician

Lots of students aspire to medical careers. Being a physician seems like a noble calling, you can always find a job, and it will make your parents proud. Over the years, interest in obtaining the coveted MD often exceeded the openings in medical colleges. Pre-med courses often served not only to provide essential knowledge for a medical career, but also to "weed-out" marginal students.

Earlier this week, I saw something that suggested organic chemistry was one of these weed-out classes. What could future doctors learn from the dreaded O-chem? Persistence and fortitude?

How about organic chemistry itself?

I am a graduate of a 6-year BA/MD program. Yes, I entered college and medical school simultaneously from high school. I never took the MCATs. I never took calculus or college physics either. I have managed to succeed as both a clinician and a scientist despite these "gaps" in my education.

I cannot imagine skipping organic chemistry.

All life on  this planet is based on carbon compounds, and those building blocks are the focus of organic chemistry. From understanding the interactions of these molecules, we can then move on to biochemistry and pharmacology and physiology and other more medically-focused disciplines.  Do I use the "raw data" from O-chem on a daily basis? No, but without that background I do not think I could be a good physician.

Over the years, we all learn a lot of stuff that we will never use again. Sometimes this material provides the base to understand the next rung on the ladder of knowledge; other times, this stuff is just crap someone assigned.

O-chem is not crap (although crap is made of organic materials).


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Competing Forces in Medical Care

Dec 01 2011 Published by under Life of a Physician

My November travels took me to the Scientific Sessions for the American Society of Nephrology, a huge gathering of we kidney specialists. As I enjoyed an adult beverage with colleagues from across the country, we began comparing notes about our clinical services. We all hear that we fail to see enough patients!

So how do we determine "enough" for physicians? In private practice you fill your clinics. When the load overwhelms the group, a new doctor can be hired. In academia, where our jobs include teaching, research, and administration, the standard is more difficult to determine. One tactic involves Relative Value Units (RVUs) for physician work.

When you see your doctor, s/he bills a level of service that translates to the amount of reimbursement. That level of service can be translated into the sum of several RVUs for Physician Work, Practice Expense, and Professional Liability. The monetary value of each of these gets adjusted by region, and the final value factor varies over time and by payor. (More on Medicare and RVUs can be found here.) Productivity benchmarks for each specialty are generated annually (Medical Group Management Association, for example, publishes standards). Most academic departments expect a full-time clinician-teacher to generate physician work RVUs at the 75th percentile. Roughly one-quarter of a physician's time will be taken up with trainees. The percentile can be adjusted by job expectations in other ways. Someone with 75% of their time protected for research should only be expected to generate one-quarter of the 75th percentile under this model.

So the bean-counters in our departments look at our numbers and tell us we aren't meeting national standards, but none of us know who they are auditing to determine these numbers! Unlike in adults, pediatric kidney disease has a relatively stable prevalence in the population. Many of us exist in sections that provide the only service in our specialty for a state or multi-state region, so we do not have competition from whom to "steal" patients.

So where do we get these additional patients?

Some centers develop new services. Kidney doctors run blood through filters all the time. Buy a machine with a different filter and we can do plasmapheresis. Of course, that means someone else in our center no longer does those patients; this approach is often a zero-sum game. No, the answer much of the time would be to see patients we might otherwise not see.

For example, asymptomatic microscopic hematuria (blood in the urine not visible to the naked eye) is a common pediatric problem. The typical work-up involves a number of tests. If normal, we just watch blood, urine, and blood pressure over time. Primary care physicians could handle this condition with phone support from us. At this time, our inclination is to see all patients referred to us, rather than doing this level of triage for which we receive no RVUs and no payment.

We have two competing forces here. One involves running our clinics like a business, with carrots and sticks for meeting productivity standards and bringing in the bucks. However, this occurs at a time when there should be even more pressure to avoid unnecessary visits to specialists to keep everyone's costs down - but there is no financial incentive for that.

I do not have an answer. Clearly, current capitalist forces are not going to fix our "system."


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Back to Work

Sep 06 2011 Published by under Life of a Physician

Today I graced the halls of my new employer. A few boxes got unpacked, and I have parking stickers to apply to my vehicle. Tomorrow I should be able to smile for my photo ID. Physicians get a number of other fun tasks, including safety training, standards of conduct, and a whole module on sexual harrassment and other forms of discriminatory behavior.  Tomorrow I get to spend an hour with the billing compliance folks.

Image courtesy of PhotoXpress (Click for source)

I have successfully made it to and from the restroom and my office twice. And I found the other restroom on the floor, as well as the break area!

Not too bad for a first day.

I also downloaded an article to write about. Yes, medical science is coming soon!

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