In good conscience

I have to admit that my conscience is bothering me a bit after yesterday's OSCEs.  You see, after going through a mockup of a well visit for an adolescent patient, I was told by the observing physician that I should have included counseling about contraception during the "appointment."  I stuttered briefly before explaining that I couldn't really do that in good conscience because of my faith.  "Well, all you really need to be willing to do is refer her to someone..."  I just nodded.  But as I continue to think about it, an old question rears its head: if I refer her to someone else whom I know will provide counseling I believe to be morally wrong, how different is that from simply providing the counseling myself?  I mean, it feels in a lot of ways like it's merely semantics, the same as Pilate washing his hands of the Crucifixion -- something to make me feel better rather than something altering the fundamental moral quality of the choice.  I don't know, maybe I'm overthinking it, but this scenario always leaves me feeling guilty and uncomfortable.  Of course, the flip side is that I'm legally required to provide this referral, and I could probably be barred from practice if I don't offer said referral.  Makes for a bit of a quandary, no?  Maybe peds critical care or neonatology is the way to go after all -- these types of moral questions probably don't pop up quite so often in those populations.  Anyway, if people have thoughts on the subject, I'd really appreciate if you'd be willing to share.

That's all for tonight...Mass tomorrow, then I should probably get some work done.  Till next time, peace and God bless!

Long day = short post

Mostly a good day today. On post-partum rounds this morning got caught briefly in the awkward situation of being in the room while the intern was counseling a patient about contraceptive use. For better or worse, it was short enough that I didn't have time to leave the room. Otherwise, the day was highlighted by two vaginal deliveries (aptly described by one of my classmates as "so gross but SO AWESOME!") and an uncomplicated C-section resulting in three healthy children and three ecstatic families. The residents were also in full teaching mode today for some reason that I'm not going to question, so it was a productive day both in terms of skills and knowledge. No other real issues, blessedly. That will, unfortunately, likely change tomorrow when an attending with whom I've unfortunately crossed paths before delivers a lecture on abortion. Suffice it to say that if it's at all similar to the one he delivered 6 or 7 months ago, I'll have plenty to say about it in this space tomorrow.

Anyhow, I guess so far this hasn't been bad. I hope and pray that lasts, and that the good news delivered by another classmate (maybe we'll get a pro-life Ob-Gyn option after all!) comes to full fruition before next year. That's all from me for tonight; hope everyone's doing well. Peace and God bless!

Things I've Learned...

I guess the best-laid plans end up in about the same place as all those good intentions... Anyway, I'm done with my first clinical rotation (surgery / anesthesia) and a week into my second (infectious disease up at the VA). Some things I've learned from my patients and colleagues during that time (edited to ensure HIPAA compliance):

-It's a terrific idea to play with a loaded firearm. Because it's not like the .357 hollowpoint will blow a sizeable hole in your leg that will require the EMS paramedic and I to take turns holding pressure on the wound for nearly an hour in the trauma bay. You're just lucky that the bullet and all the shards missed the femoral artery.

-It's been said before, but it bears repeating. There is one action that will inevitably land you in serious trouble. So whatever you do, avoid minding your own business. Whether you're standing on a corner or you're hanging out in some park, a bunch of dudes will seek you out and beat you and your buddy to a pulp. When you are telling me your story, I will be hard-pressed not to laugh out loud because, according to you, you were SOCMOB (if you don't recognize the acronym, go to the "Things I Learn from My Patients" link on my blog and read a few entries) when this all went down. The sad part? You're probably telling me the truth.

-If you're an kindly, mild-mannered older gentleman with diabetes and you whack your head on some sharp edge, by all means ignore the laceration and the egg-sized lump on your head and try to tough it out. No reason to trouble the doctors and nurses with something so minor, right? A week later, you'll end up coming in because the wound isn't healing and is purulent and you have a substantial hematoma besides. Bonus: you'll end up with sepsis and round out an evening by coding and being brought to the ICU (first of my patients to code on me...sure he won't be the last).

-As an FYI: if you're going to call an ID consult for a patient to make sure you know what course of meds he/she needs to go home on, you might want to do that BEFORE discontinuing the patient's antibiotics. And if by some chance they do get cancelled / lapse, it's probably not a good idea to wait for a week(!) before checking with ID to see if the meds should have been stopped.

There are more (both ironic and genuinely useful), but that's all I have time for tonight. Till next time, peace and God bless!

A&P + randomosity = this blog post

Spent most of today trying to craft an actual assessment and plan for a patient I saw yesterday, the first of my young medical career. It's, uh...harder than it looks (especially since it was a patient in the hospital with GI problems -- we haven't done the GI block yet). I spent just about 5 hours reading and researching and putting this thing together...a grand total of less than a page. And yet I don't begrudge a single minute of the time I spent on it, especially since it's probably something I'm going to be doing a LOT of over the next several years, so it behooves me to gain some experience and get better (and faster) at doing them. It was also more fun than I should probably publicly admit...but anyone who reads this already knows that I'm a nerd.

Non-medical thoughts for the day:

I'm really looking forward to Monday. That's when all of the Notre Dame alums in my class will go through their weekly ritual of making excuses for their football team. Former Wolverines, go to town.

Really great, Serena. Look, losing a tennis match is excusable. Losing your cool like that is not. Once again, you're just setting such a TERRIFIC example for budding tennis players everywhere. Get over yourself.

The SEC takes a narrow lead in the "second best conference in college football" standings by virtue of not having any of its teams choke on one of their cupcakes. Lemme give you a hint, Oklahoma State...if you want people to take you seriously, losing by 10 at home to a team that barely qualifies as having a pulse is NOT a good way to go about it.

'Bama needs to start playing with more discipline.

I can't wait to see what Florida does to Lane Kiffin's Vols next week. Better hide the kids.

Gotta love Ohio State. They're always good for at least one major gack a year.

Wow. What a round by Tiger. Was he playing the same course as everyone else...?

Still running into the person I mentioned last time. Hopefully that continues. More time and more conversation are the next goals.

You know, if you want to fix the health care system, we're going to have to spend money. Hope and change aren't free.

Of course, where we GET that money is another issue altogether.

In memory of the events of September 11, 2001, please say a prayer for our soldiers abroad and our first responders at home in thanksgiving for their service and in supplication for their protection.

Peace and God bless!

Research and journalism

There's an article in last week's issue of Annals of Internal Medicine that compares retail health clinics to primary care physicians, urgent care centers, and hospital emergency departments. It arrives at the conclusion that these retail care clinics provide care statistically equivalent to that given by PCPs and urgent care centers and superior to that given by emergency departments in cases of otitis media (middle ear infection), pharyngitis (sore throat), and urinary tract infection (UTI). This article was reported on today by MSNBC; you can see that story here. There are, to my mind, enormous problems with both of these pieces, and I want to address some of them here.

I'll start with the MSNBC article. The egregious error lies in the author's assertion that "To track the quality of care, the researchers studied outcomes for three routine illnesses..." This is incorrect. The study does not (and does not claim to) measure outcomes. Rather, it uses quality metrics based on standardized instruments and professional guidelines. Outcome has absolutely nothing to do with it. The reason that this is such a serious lapse is that "outcome" is, essentially, the bottom line for any patient encounter. When all is said and done, how did the patient do? By carelessly using this term, the author effectively creates an illusion that patients "do better" in one setting than another. In this case, yes, one word makes THAT much of a difference.

For the Annals article (written, ironically enough, by an UPSOM professor and his colleagues), I also take issue with a number of things. Most of these issues stem from a single gripe: the emergency department is not a good choice for a comparison group in the study. EDs, unlike retail clinics, PCPs, and urgent care centers, must by law accept all comers. They tend to have higher average acuity (EMERGENCY, people!). They tend to be starting from scratch rather than from an established diagnosis. They don't generally do follow-up visits or chronic care; they have you follow up with your PCP. Many times, in non-emergent situations, after ascertaining the lack of immediate danger the emergency physicians will get in touch with the primary care docs and allow them to manage the course of treatment. And most of all, they are not designed or intended to deal with minor issues. Translation: THE ED IS NOT THE PLACE FOR DIAGNOSING AND TREATING OTITIS, PHARYNGITIS, OR UTIs (or vaccinations, Pap smears, colonoscopies, mammography, or really any preventive health interventions -- all metrics used in this paper). Also, the article does not make it clear what kind(s) of EDs provided data for this research. Were they large academic centers? Children's hospitals? Small community hospitals? It makes a difference. Another point: the study compares the costs of care at the different health care centers, and the ED is by far the most expensive. Why? Because if you have insurance, you're basically paying for all the people who come into the emergency department without it. I wonder how much the numbers would change if they factored in the patients who received full ED services gratis. Anyway, the long and the short of it is that the emergency department was a poor choice for a comparison group.

Of course, the point of the article is that the quality of health care (as defined by the metrics, and in these three particular illnesses -- the latter is a rather severe limitation) is no worse at retail clinics than in other settings and that the retail clinic costs less. Great. Maybe they can start taking all of the patients that don't belong in the ED. But the numbers (and the conclusions) must be taken with a good-sized grain of salt, especially in the comparisons between health care providers. Anyway, read the article (by Mehrotra et al) and tell me what you think.

Peace and God bless!

The joys of simulation

I've said it before (although not in this space) and I'll say it again: medical simulation is one of the most powerful teaching techniques I've ever experienced. And it's not just good for manual skills either. Pharmacology overall has not been a poorly taught class (with one or two exceptions), but I learned more about cholinergic and anticholinergic toxicity in two hours today than in all of the lectures on the subject (some 6 or 7 hours) combined. For example, in explaining why it was a horrible idea to give a patient with myasthenia gravis either succinylcholine (it won't work) or pancuronium (the patient will be paralyzed for an extended period of time), the anesthesiologist presenting the case clarified the entire mechanism of activity of both drugs. He also included a bonus lesson in clinical management of patients so affected; while his advice may be of little help on the test, it was of immense practical value.

So why aren't we doing more to employ this particular modality? Even here at Pittsburgh, where we have a massive simulation center and the medical students make regular use of it, we're only experiencing a small fraction of its full potential. In other places, students aren't even permitted to use the mannequins; they're only used to train MDs. It seems to me that we're wasting valuable opportunities by not making the fullest possible use of this technology -- or at least spending some effort on validating it.

Anyhow, those are my thoughts for the night. Tomorrow's a study day; next entry will probably be after the test on Saturday. Till then, take care.

Peace and God bless!

Health care reform, part I

I've spent some time over the last couple of days looking at the House of Representatives proposal regarding health care reform. Of course, the bill is over 1,000 pages long, so I've only seen a very small part of it. Thus, this will probably be an ongoing (and sporadic) series of posts as I read more. I should say at the outset that I am wary of this plan, but I'm not about to dismiss it out of hand. I plan to frame this as a series of questions, and I will attempt to point out both the good and the bad in the plan. As always, [polite] commentary is appreciated.

One of the overarching questions that I think needs to be addressed: who is eligible for health insurance under this plan? Will, for example, illegal immigrants be able to receive health care under the so-called public option? (I think it's important to note here that I don't think this is necessarily a good or a bad thing; it's all in the context).

Another thing that needs to be addressed: part of the reason that health care reform is necessary in the first place is because of the ballooning costs to which Mr. Obama alluded in his remarks this evening. An enormous part of this cost is derived from the fact that physicians are virtually required to practice defensive medicine rather than being permitted to rely on their best judgment. If you take a blow on the head, unless the doc is 100% certain that there is NO risk whatsoever, you're likely to get a CT, over 99.9% of which will be negative. Why? Because of the threat of lawsuits for enormous amounts of money. Of course, not even doing everything right eliminates the risk. One woman threatened to sue any physician who 'let her father die.' The man was over 80 years old, everything in his body was falling apart, and he was kept alive and coded multiple times (very expensive and horrid quality of life) because the physicians were laboring under the threat of a lawsuit. Of course, they couldn't keep him alive indefinitely, and when at last he died, his daughter did in fact sue. The kicker? The insurance company settled for thousands of dollars rather than undertaking the "nuisance" of defending the physician's reputation and actions in court. We are a litigation-happy society, and that inflates malpractice insurance, requires physicians to order expensive and unnecessary tests and procedures, and drives health care costs through the roof.

A brief interlude here: Mr. Obama is certainly well-intentioned, but in terms of actual health care, he clearly knows not of what he speaks. He's right that we need better communication, but he seems to be laboring under the delusion that there's a single "correct" diagnosis or test for every patient, and that docs should always be able to arrive at the right conclusions. While I appreciate the confidence, that's not the way it works. There's a reason we have different kinds of specialists and different kinds of tests. He's also very deft at playing politics while appearing to take the high road. I know that's ubiquitous in Washington, but it's kind of disappointing in someone who's been portrayed as being above that. I will reiterate, however, that I DO believe that Mr. Obama is genuinely doing his best for the American people, and I agree with his assessment that he was given an absolute mess to begin with.

Another thing I want to comment on is the concept of exclusions for pre-existing conditions. In some ways, these are reasonable protections for insurance companies against fraud. That said, they can easily be abused, and the exclusion periods seem excessive. Certainly they do not appear tenable in their current form; however, is it financially feasible to eliminate the exclusion altogether? It seems like that's the kind of thing that unscrupulous people (and there's no shortage of those in America) could easily take advantage of. How can this be crafted to strike an appropriate balance?

Another interlude: props to Mr. Obama for this one. I completely agree that it should be the physician rather than the insurance company deciding what care is appropriate. Of course, the question of reimbursement becomes a sticky one, but still, the thought is right on the money.

Ok, that's it for now. I'm going to finish listening to this press conference and maybe do some more reading. Any thoughts or commentary would be most welcome!

Peace and God bless!