WHAT DOCS DO

Written by the Happy Hospitalist
http://thehappyhospitalist.blogspot.com/
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Here’s my opinion, most patients have no idea if you are a doctor, a nurse, or the lab tech. Walk in a room. Pretend you know what you are doing. Be nice. Talk to them a little. Let them tell you how Cuddles,their little Chihuahua, likes to lick the enamel off their teeth. When you walk out, I bet just about every patient would tell their spouse, “My what a nice doctor that was.”

I have come to the conclusion that some patients want everything done. They want only sub specialists. They have fallen victim to the more is better mantra. They want all the high tech equipment known to man. Usually, this comes from the highly educated and highly entitled over insured population that demand what they perceive to be the best of everything. They are clueless and are incapable of understanding that more is not always better.

Then you have the chronically old. The chronically sick. The chronically educationally disinclined who have absolutely no clue how anything medical works. These are the folks that get the yearly case of ammonia in their lungs. The folks who get their prostrates checked every so often. The folks with the shugah diabetes. The ones who live and die without a single ounce of interest in learning about their disease process. These folks are also clueless, but for an entirely different reason. They don’t care and they don’t care to know.

This last population of patients are the ones who lack the intellectual capability to question anything medical. If it looks medical, it must be. I could dress up a pig in a lab coat and they would think that a doctor just left the room.

For medicine that involves the diagnosis and management of acute and chronic medical disease, there is only one type of doctor. Someone who has earned a doctorate degree in the study of medicine, not nursing. Someone who has gone on to train under the direction of medical doctors to learn their craft as defined by accredited institutions. Someone who has sat for and passed the requirements for certification as defined by the board of their medical specialty, the competency of which has been determined by other doctors who specialize in that field of training. That’s what a doctor is. That’s what the public expects when they get “a doctor”

And this physician assistant agrees.

My other concern is the use of the title, “Doctor”. It is true that pharmacists, PT’s, and others have moved to a doctoral degree. BUT, none of those professions outside of a psychologist, use the title “Doctor” when treating patients…..why you might ask?

Simple, it is confusing to the layperson, and downright fraudulent, …
A recent article I read in Advance for NP’s suggested that 47% of current NP’s or NP students PLAN ON USING THE TERM DOCTOR UPON completion of their degree. This is a potential legal minefield, and I would urge the NP community to tread lightly with this. Everything will be fine as long as no bad outcomes occur…….unfortunately, BAD OUTCOMES do occur, and they will happen to everyone that practices medicine at some time. It is a simple statistical reality. When that happens, I can already see a case of fraud, or misidentity being brought easily.

I’m not saying DNPs are dumb. I’m not saying they are idiots. I’m not saying they don’t have a role in taking care of patients. What I am saying is that patients, the intellectually disinclined, are incapable of making informed decisions on the differentiation between Dr NP and Dr MD unless it is spelled out for them in clear English. They may not care, because they have not experienced a problem that required a difficult differential diagnosis.

Is there a difference in care? Of course there is. That’s like saying a pilot with 1000 hours is similar in quality to a pilot with 10,000 hours. That’s like saying a pilot who trained on a Cessna can navigate an airplane the same as a pilot trained by the United States Air Force. Are they both granted flying privileges? Yes they are. But their scopes of flying privileges are different. Not so in the MD/NP scope of practice.

You would not certify a Cessna pilot to do combat missions on an F-16. Unfortunately, we have done just that with the creation of independent practitioners who are undifferentiated in scope and practice from the Cessna trained and the Air Force trained.

Can NPs fly with the same quality as an Air Force Pilot? Perhaps they can. And perhaps they can do it often, under certain circumstances. Until one day you have to land the plane in the Hudson. And the training of the Cessna pilot will be woefully inadequate for real life. I live that scenario every day. Every time a patient is crashing. Every time a long tail diagnosis is discovered. Every time an uncommon presentation of a common disease presents itself. Every time a complication arises that is not part of the routine practice of medicine. For me, in the delivery of health care, every day is a plane crash in the Hudson.

You often can’t tell the difference between pilots until the plane is crashing. NPs like to use the argument of “no difference in quality.” The problem is you can define quality anyway you want. And they do. Picking and choosing their parameters that establish quality and equality. I know the truth. That those parameters of quality are irrelevant in the debate.

I get emails all the time asking me what I have against NPs. There are nurses at my place of work who ask me what I have against NPs. Why I think they are stupid. I am here to say, I don’t think they are stupid by any means. Nor do I think they are incapable of taking care of patients, in a defined scope. They have a very important role in delivering health care to the masses. But I don’t believe for a second that the quality they provide is equal or better than the quality that MDs provide within the same undifferentiated scope of practice.

Why? Because I don’t define quality the way a NP or a DNP or a patient or the government will. I define it by characteristics that can’t be measured in a randomized trial or tracked with outcomes data, but is at the same time, the most important aspect of independent patient care.

For me, that greatest determinant of quality care, which you won’t find in any journal or on any government compare website, or in any patient satisfaction survey is the strength and quality of the differential diagnosis generated by that practitioner. Doctors are differential diagnosis generators. This is, by and far, the most important skill set a physician can offer their patient, something that cannot be learned in nursing level training or nursing level graduate school. It is what separates physicians from all other providers of independent care.

The only way you can appreciate the importance of this statement is to complete a physician residency. I don’t expect you to understand because you have not lived it. You can’t possible understand why I am so passionate about my belief in this defining characteristic for patient care because you don’t experience it. You don’t see it. It’s not documented. It’s fully compartmentalized in the mind of the physician providing the care for that patient.

When I sit in front of that computer looking at patient data, absorbing their words, feeling the bumps on their skin, listening to their heart; when I sit there for 5 minutes thinking, I am developing a very large expanded differential diagnosis. I am documenting it in my mind. This process decides my evaluation. It defines my care plan. It is what I do. It is the most important aspect of what I do. Ordering the HgbA1c to meet quality indicators is not what I do. Getting 90% on my patient Happy scale is not what I do. Making sure the patient gets their flu shot is not what I do. What I do is generate differential diagnoses. Not a day goes by where I don’t think to myself, “What else could this patient have?”

Until you do that day after day, night after night. Until you do that 1000s upon 1000s upon 1000s of times. Until you have had the education, direction and mentoring of physicians before you who TEACH you that differential diagnosis and how to apply it to every single patient, every single time, you cannot possibly comprehend the glaring holes in your own differential diagnosis from NP school or DNP school. It is the act of completing a physician residency that develops that process of differential diagnosis. All other training tracks are great imitators in duration and rigor. Of intensity and experience.

If you don’t want to accept this fact, no amount of explanation will help you understand that your training as an NP is nothing compared to the process used to develop physicians into great differential diagnosis machines.

And I’m not just talking about one differential diagnosis. Most patients come in with more than one complaint. As a physician, my job is to create a thorough differential diagnosis for every single complaint, and then try to put the puzzle together. Let me give you an example:

Let’s assume I was an outpatient doctor. A 75 year old patient presents with a complaint of shortness of breath. The history reveals it has been going on for 2 months, progressively worse. Gets worse with lying flat. Gets lightheaded with walking and sitting. One episode of passing out. Feels palpitations. Intermittent diarrhea and difficulty urinating. Sometimes the legs swell and cramp. Also falling, weak fatigued, not eating well. Lost 15 pounds.

I don’t have the inclination to write out my differential diagnosis, but suffice to say at least 50 medical conditions immediately popped into my head when I created this common scenario. They ranged anywhere from hormonal abnormalities , to common and uncommon cancers in this age group, to coronary syndromes, to cardiac syndromes ischemic and otherwise, to acute and chronic pulmonary conditions, both common and not. It included hematological, infectious, allergic and autoimmune processes. The list goes on and on.

Deciding how to evaluate the complaints is determined by the process of cross referencing, in my mind, all the likely probabilities of each of the differential diagnoses for pertinent positives and negatives on history and physical. This is not protocol driven medicine. This is not guideline driven. This is not EMR driven.

This is internal medicine. I wish I could walk you through the process of defining exactly how the differential is developed. But I can’t. That’s what the lay public and those who are trained in non physician level programs can’t accept. The constant bombardment by NPs on my site calling me an ass, demanding data I claim regarding their lack of quality. Here it is. Your differential diagnosis skills are inadequate to practice independently. You want to believe that your training prepares you for it.

It doesn’t. Not even close. Not–Even–Close. It simply comes natural for me. Medical school trained me for it. Residency trained me for it. That’s the only way you can train for it in a manner that provides your patients with the highest quality care that can be delivered.

Here’s a small peak of what I do for every single issue that arises in patient care. It’s automatic. And it’s automatic for every patient I see of every day of every week of every year.

It is the strength of that differential diagnosis that guides ICU evaluation and management. That guides ED evaluations and admissions. That guides questions subspecialists ask of me in consultations. That guides outpatient clinical medicine. It is the strength of that differential diagnosis that deciphers life and death medical conditions. You don’t have time to Google it. You don’t have time to call the critical care specialist. You are it. You are all alone in rural America, and it’s your job to save the patient. It’s your job to save them. Every time. It’s your job. And it must be automatic. There cannot be any doubt.

And your patients deserve the best differential diagnosis, every time, without fail. Not by nursing or NP standards. But that which is developed by physician level training and is verified by testing bodies that credential you as an expert of the differential diagnosis in your field. That’s what your patients deserve.

The only way you get that good is to know your differential diagnosis. And the only way you get to know your differential diagnosis is to learn it in a doctor level training program.

When you call yourself a doctor, you are portraying yourself as a master of the differential diagnosis. Your patients will not know otherwise. But I know that’s what they deserve. And other doctors know that’s what they deserve. Even you know that’s what they deserve. Your job is not to put your signature on a protocol. Your goal is not to achieve 85% compliance with HgbA1c data gathering. Your job is not to get high satisfaction scores. Using these markers to define your quality is a slap in the face to your patients. Your patients deserve an extensive differential diagnosis, every time.

Your job is to diagnose and manage disease in the scope of patient care. To develop an aggressive differential diagnosis. It’s your duty to your patient. Your duty to your profession. Your duty to excellence. You can’t measure it. You can’t study its outcomes. Only you MD, NP and DNP know how good your differential diagnosis is. And if you have any doubts as to your ability to generate one on par with your board certified physicians practicing in your same scope of practice, you owe it to your patients to relieve yourself of your independent duties and practice your scope in a fashion limited by your capabilities.

They may not know it, but when your patients call you doctor, they are expecting the best differential diagnosis of their problems. If you can’t, in good conscious offer them that, you owe them the truth. You owe them the right to know your limitations.

Ghetto Fabulous Med Student

http://themedstudentexperience.blogspot.com/

Sunday, January 25, 2009
Med School Personalities – Ghetto Fabulous Med Student

“Oh no he didn’t!”
You hear her from the study room down the hall.
“He did not just give my group a 4 out of 5 on participation!”
You imagine she’d be wavin’ her finger right about now.
Fiercely.
Fabulously.
Sassy.
Loudly.
Strongly.
In her sweet kicks.
Air Jordans.
Or Reeboks.
Pattin’ her weave.
In her tight-fittin’ aerobic suit.
Accentuatin’ parts of her physique.
You know what I mean.
Lookin’ fine.
With a splash of, “You know it!”
“Uh huh!
“Oh my God!”
“I gots to gets this studyin’ done!”
“I’m fittin’ a’ go do a patient interview!”
Snapping her fingers.
She’s proud of her heritage.
Her strong upbringing.
Her strong personality.
She’s smart.
She’s Ghetto Fabulous Med Student.
Struttin’ her stuff.
Doin’ her thang.
Ain’t no thing but a chicken wang.

First Day On the Job

Progress Notes
A Scared and Sacred Silence

Monica Kidd, BSc, MScMedscape Med Students. 2009; ©2009 Medscape
Posted 01/14/2009

It was just past lunch on my first day in the hospital. I was getting my tour of the facility before getting my passwords for the computers. We were passing through the emergency department when a consulting doctor said to me, “You want to jump in with both feet? There’s an MVA [motor vehicle accident] coming in right now. One victim’s in, another 2 en route.” I had just learned of a patient I had to see in emergency who’d already been waiting nearly 12 hours; there were a couple of histories and physicals to do upstairs; and the surgeon I’d been working with in the morning was expecting me back in clinic, but what was I going to say, “no”?
I saw the mom: 33 years old, the driver of the vehicle, belted. She had 3 kids in her car — her 2 sons and a friend of theirs. She was turning right onto Magee Road, just across from the hospital, when a transport truck T-boned her, setting off the airbags. The examination was difficult because the whole time she kept asking about her son, R, and I had to honestly say that I didn’t know his condition; I didn’t even know which boy he was. One of them, in the first trauma bay, was not doing so well; another in the trauma bay beside him seemed fine.
“Do you know what day it is?” I asked. “Two days before my little boy’s ninth birthday,” she wailed. Besides a bump on the knee and some abrasions from the seat belt, she was physically fine. When I finished with her, I saw the third boy, the one who’d been riding beside her in the front passenger seat. He was okay, too, except for some aches and pains. Word trickled down from the first trauma bay that the boy would need to be medevaced to neurosurgery in St. John’s.
Having settled those two away, I saw my patient with the small-bowel obstruction and talked about him with the surgeon on call. I decided that clinic was a blowout, and went upstairs to do my histories and physicals. I finished the first — a woman in her 70s, admitted for a hemicolectomy for colon cancer in the morning — and was about to begin my second when the charge nurse on surgery took a call.
“You know that MVA?” she asked me. “It looks like he’s not stable enough to fly. Dr. Haggie’s going to take him to the OR [operating room].”
I wanted to go, but having missed out on my tour of the hospital, I didn’t even know where the OR was yet.
I left the second history and physical and went back down to emergency and found the senior resident in the middle of inserting a chest tube in the little boy, whose eyes were partially open but not focused on anything. He was intubated, and a blood transfusion was under way. He looked pale. Several nurses whirled around with flushed faces.
A man in scrubs came through the curtain and said to me, “You must be the intern!” and immediately began a play-by-play of what was happening. The charge nurse said something to the effect of getting the boy’s parents in so they could kiss him good-bye. They were brought in on uncertain feet, the mother still firmly in shock. The dad, rugged and tanned from some kind of outdoor work, kissed his son and stood back to cry.
Into the OR: an emergency laparotomy for a ruptured spleen, diagnosed on computed tomographic (CT) scan. The senior resident was busy speaking to the pediatric surgeon in St. John’s about accepting him in transfer. Looked like it would just be Haggie and me. I scrubbed and came back in to find draping already under way. Surgery would proceed with the boy still on the spinal board and in his cervical collar.
I felt his rigid abdomen. Haggie made a fast midline incision from breastbone to pubis. The blood began pooling in angry eddies, spilling over his sides and onto my shoes, wetting my feet. Haggie reached in and cut the spleen from the mesentery, “delivering” it to where he could identify the vessels. He clamped and cut them, removed the spleen, and showed me the multiple fracture lines. We tied off the vessels, and then he began to explore, moving quadrant by quadrant, sponge in hand, packing and unpacking — petechiae in the mesentery and over the retroperitoneum, signifying either massive trauma or disseminated intravascular coagulation. No perirenal and periaortic hematomas that he could discern. No damage to the bowel — but still the blood kept coming.
The senior resident arrived, mumbling some rather unflattering comments about the surgeon in town. I took my place over by Haggie, who extended the incision to the xiphoid and handed me a retractor to pull up on the breastbone so that they could examine the liver. A laceration to the capsule. First, they tried cornstarch and cellulose, plus holding the liver against the diaphragm to apply pressure. That didn’t work. They tried pressure with a sponge on a stick. That didn’t work. The suture material Haggie wanted wasn’t around, so he ordered up a graft that is normally reserved for vascular surgery. Meantime, we waited. He handed me the sponge on a stick, so I held that in one hand and the chest retractor in the other, and held on until I could feel my pulse throbbing in both hands. The boy’s little heart, fighting against the constant loss of blood, pumped away against my tools, so that our 2 pulses beat out a strange syncopation.
Soon the patient’s blood pressure fell into the 30s and then into the 20s. The anesthetist, constantly frowning, tried more blood, epinephrine. The heart rate rose and fell. The oxygen levels began to slip away. The abdominal bleeding seemed somewhat under control, but somehow he still was losing massive amounts of blood. The chest tube was patent, but no more blood had drained. They tried another chest tube in the left chest, wondering about a tension pneumothorax, but nothing happened to his oxygenation levels.
Finally, Haggie made the call. “Let’s get out. Let’s get him to the ICU [intensive care unit] in time to let his parents say good-bye.” The senior quickly closed as Haggie went out to speak to the family.
I backed off and watched the boy’s vitals. I took off my sterile gown and gloves in anticipation of the walk to the ICU. The nurses debated how best to present the boy to his parents — not on a white sheet, because that would show the blood. A hematoma on the back of his head had grown alarmingly. Blood came from his nose and ears and filled the endotracheal tube. The nurses wiped him down as best they could, removed the blood-soaked tape from his eyes, and the endotracheal tube from his mouth. I looked at his little hands and lips, now turning blue. His pressure metronomed between the 20s and 40s. Things seemed to grow very quiet as the little boy hovered in the infinite space between living and dying.
Out we went to the ICU. The critical care nurses began a dopamine drip and put on chest leads. A nurse in plain clothes said, “What a beautiful little boy,” and walked out to get his parents. I began wiping tears from my eyes. Haggie arranged blood work and admission orders with the staff. The senior resident began to shake his head slowly.
The mom and dad came in, and the mom began to shake. “Don’t leave me yet. You’re momma’s little boy.” And with that, I left to find a quiet room in which to let go my sobs.
In the days to come, an army of teddy bears would be taped and tied to a light pole near the intersection where the accident happened. I would pass it every day on my way to and from work, a constant reminder of that scared and sacred silence into which R slipped under the lights of the operating room.

Monica Kidd, MD, MSc, first-year resident, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, Canada

Disclosure: Monica Kidd, MD, MSc, has disclosed no relevant financial relationships.

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How To Be An Internist In Five Minutes

Taken From
http://thehappyhospitalist.blogspot.com/2008/10/doctors-doctor-how-to-be-internist-in.html

Thursday, October 9, 2008

The Doctor’s Doctor: How To Be An Internist In Five Minutes
Internists are known as the doctor’s doctor. The breadth of knowledge for internists is enormous. I often laugh at the computer science folks who do drivebyes on my blog and claim that one day a computer will neatly categorize all illness into neat algorithms and make me expendable. It is simply not possible. As an internist, I manage the whole body. And the evaluation and management I perform on every patient is multi tiered in its breadth and structure. I do this with every patient encounter. All day, every day. If you have five minutes, I’ll show you how to do what I do. I interpret my data points across four different organizational structures for every patient, every time. Consistency, consistency, consistency.

By Organ System. Looking at things by organ system is the first way to conquer disease evaluation and management. Is the disease in the brain? The heart? They thyroid? The lungs? The gallbladder? The bladder? The blood vessels? The blood? The bone marrow? The skin? The neurons? The spinal chord? The colon? The eyes? The hair? The nails? The liver? Disease can affect any organ and an internist’s job is to figure out which one.
By Category of Disease Process. Looking at things by category of disease process is another way an internist must classify the illness. Is it infectious? Is it autoimmune? Is it hormonal? Is it traumatic? Is it genetic? Is it environmental? Is it medication induced? Is it a toxin? Is it allergic? Is it iatrogenic? Is it cancerous? And within each of these categories of disease processes, the internist must ask himself which organ system the disease process is affecting. Is it allergy induced asthma or is it genetic alpha-one antitrypsin induced emphysema. Is it alcohol related cirrhosis or Wilson’s disease. Is it myelodysplastic syndrome, a disease of the bone marrow, or is it medication induced pancytopenia. What is the process of the disease?
Is It Systemic Or Localized? Once you understand the disease process and which organ it affects, you must also know whether the problem is a localized process or a systemic process, and if it is systemic, how else does it present. So much in medicine is lost when you aren’t keeping your eyes open. When you focus so strongly on one part of the body and fail to understand the rest. Some infections can be localized in an organ, like an abscess in the liver. Some infections can be systemic and involve multiple organs. Like mononucleosis. Some autoimmune diseases can affect just one organ, like multiple sclerosis and its effect on the neurons of the brain and spinal chord. Other autoimmune diseases, like lupus can span multiple organs, from kidneys and brain to heart and lungs. Lets go back to the cirrhosis example. So it wasn’t alcohol related after all. It was hemochromatosis, a genetic disease of iron metabolism that can also affect your skin, joints, pancreas and brain. Is your disease process systemic or localized? Sometimes you find liver disease when your looking for arthritis. It’s amazing disease doesn’t operate in a cubby hole. And if your disease is a systemic process, you must always be on the look out for its systemic complications.

Is It Acute Or Chronic? As an internist you want to know if the problem is new or old. Has the patient had heart disease for 25 years, or was it diagnosed last week? Has the patient had diabetes before or is that blood sugar of 350 a new finding? Is that Hgb of 8.9 new or was it there three years ago? Knowing whether something is new or old means all the difference in the world in how you approach it diagnostically. What are you going to do with the information you have in front of you?

What you have here is how I break down every possible illness known to man. Every possible illness can be categorized by organ system, type of disease process, a systemic or localized process and acute or chronic nature. But we aren’t done yet. This is just the disease. Full of randomized controlled trials with objective data points. What about the patient? Where do they fall into the loop? Patients don’t come to your office complaining of Factor V Leiden. They don’t come to your hospital complaining of systemic inflammatory response syndrome. They don’t come to your office or hospital complaining of grade II esophageal varices. They come to your office complaining of a swollen leg. They come to your office with dizziness and pain when they pee. They come to your hospital vomiting blood. The goal of all physicians is to try and match the subjective complaints of the patient with the object data points. So you must add in the last component of being an internist

What Does The Patient Tell You? Are they pointing to one specific point in their belly and saying it hurts right here in my right lower quadrant? Or do they wave their hand over their belly and say it hurts all over? Are they even able to talk? Do they have one complaint? Or a hundred? Do their complaints make sense anatomically? Do they make sense physiologically? Is that pain that jumps from the right leg and makes a right angle turn across the abdomen into the left pinky finger real? Are their complaints believable? Are there too many complaints to believe any of them, the pan positive review of systems? Does mental illness cloud their reality? What the patient tells you can either be diagnostic of a very specific condition or more likely, a generalized constellation of complaints that could be a multitude of disease processes as described above. Great historians are wonderful. Bad historians are painful to work with.

And after the patient has talked with you, Dr Internist, it’s your job to try and figure it all out, from the top of the their fro to the bottom of their big toe.
It can be very simple

I’m coughing, short of breath and have fever and an infiltrate on chest xray which turns out to be a simple pneumonia.

Or it can be something much more complex.

I’m coughing, short of breath and have fever and an infiltrate on chest xray may in fact be Wegener’s granulomatosis, an autoimmune process associated with acute renal failure. It may in fact be a post obstructive infiltrate caused by large lung mass and complicated by an empyema. It may in fact be acute lung injury caused by amiodarone toxicity. It may in fact be tuberculosis. It may in fact be an infarct from a pulmonary embolism. It may be a lot of things.

It may be a lot of things. That’s what you can expect from your internist. That’s why you should want an internist taking care of you. That’s how an internist thinks. That’s how they were trained. That’s how they manage patients every day of the week. That’s why internists won’t be replaced with computers. That’s why they wont be replaced by extenders. In spite of the folks who say we just need more extenders to manage our health care system. They are not trained to do this type of critical thinking. They do not have the medical foundation or the experience to manage illness through these 4 concurrent stages of evaluation. I know this because I did not fully understand it until the end of my seven year journey to my National Board Exam, which certified my as a physician with expertise in his field of knowledge. A knowledge base you want if you ever get sick.

There you are. That’s what your internist does. Every day. That’s why the world needs us. Because we have the ability to do something nobody else in the world can. And that is to be the doctor’s doctor.
Classification: UNCLASSIFIED
Caveats: NONE

Classification: UNCLASSIFIED
Caveats: NONE

Classification: UNCLASSIFIED
Caveats: NONE

Classification: UNCLASSIFIED
Caveats: NONE

The Transformation of Grand Rounds

December 12, 2006 NYTIMES
The Doctor’s World
Socratic Dialogue Gives Way to PowerPoint By LAWRENCE K. ALTMAN, M.D.
Grand rounds are not so grand anymore.

For at least a century at many teaching and community hospitals, properly dressed doctors in ties and white coats have assembled each week, usually in an auditorium, for a master class in the art and science of medicine from the best clinicians. Before us was often a patient who sat in a chair or rested on a gurney and two doctors, one in training and the other a professor or senior doctor at the hospital. In a Socratic dialogue, they often led the audience in a step-by-step deciphering of the ailment.

But in recent years, grand rounds have become didactic lectures focusing on technical aspects of the newest biomedical research. Patients have disappeared. If a case history is presented, it is usually as a brief synopsis and the discussant rarely makes even a passing reference to it.

Now grand rounds are often led by visiting professors from distant hospitals and medical schools. Sometimes, manufacturers of drugs and devices pay the visitor an honorarium and expenses, a practice that has drawn criticism. And the Socratic dialogue has given way to PowerPoint. These rounds are often useful, but certainly not grand.

Precisely when and where grand rounds began is not known. There are many types of rounds where doctors learn from patients. For example, there are the daily working rounds as doctors walk through a hospital to visit and examine patients. In teaching rounds, more senior doctors supervise the work of residents, or house officers, at a patient’s bedside or in a clinic.

Grand rounds were showcases featuring the best clinicians, and the practice thrived in an era when doctors knew little more than what they observed at the bedside. Professors often demonstrated characteristics of physical findings like an enlarged thyroid, a belly swollen with fluid or another grotesque disfigurement that the audience could see. Those with a flair for showmanship were often the best teachers, adapting the predictable structure to their needs and talents.

Grand rounds usually began with a younger doctor’s reciting the medical history of a patient with an unusual disease, physical finding or symptom. Sometimes the professor knew about the case, other times he did not. The professor would then ask the patient what was wrong. The more compassionate professors gave reassurance by placing their hands on the patients.

The professor would conduct the interview much like a journalist. When did the fever begin? How high was it? Did you notice a rash? Did you have pain? Where did you feel it? What relieved it?

Each major specialty, like internal medicine and surgery, held separate grand rounds. Pediatrics had a different style. A child unable to relate the events involved in his or her medical history often sat on a parent’s lap. The format promoted direct dialogue and emotional reaction between the pediatrician and the family in a way that would not come across if a doctor coldly presented the child’s case.

After arriving at a diagnosis, the professor related the current state of medical knowledge to the patient’s case. The emphasis was on diagnosis, treatment and the management of a patient, not on research.

In those earlier days, the patient stayed for part or all of the session, which usually lasted an hour. Sometimes doctors in the audience asked questions of the patient and professor. Humor trickled into some sessions. So did personal attacks among faculty members.

As a student at the Tufts Medical School in Boston beginning in 1958, I joined the throngs of doctors on grand rounds when Dr. Louis Weinstein spoke about infectious diseases.

Usually, the patient’s pertinent information was on a blackboard. Dr. Weinstein would study the fever chart, seeking clues in the pattern to help identify a particular infection. Then he would regale the crowd with anecdotes from his vast experience in caring for patients with typhoid fever, diphtheria, polio and many other infectious diseases.

Before the Medicare and Medicaid plans were enacted in 1965, many patients treated in teaching hospitals received charity care. In those days, when costs were less of an obstacle, professors sometimes hospitalized patients a few extra days so they could be presented at grand rounds. In other cases, many patients returned after discharge in gratitude for their free care.

Even the smartest experts had to be on their toes, because younger doctors often selected a case intended to tax their brains. Another intention was to have the experts explain their thinking as they matched wits against colleagues and the illness itself.

In San Francisco in 1987, I heard a visiting expert discuss the possible reasons that a woman in her 80s, who complained of weakness and muscle spasms in her back, had a severe loss of potassium.

After the resident gave a detailed account of her illness, the discussant, Dr. Donald W. Seldin, then the chief physician at the University of Texas Southwest Medical Center in Dallas, went to a blackboard to highlight the crucial elements and list possible causes.

As he narrowed the list, Dr. Seldin suggested licorice. But he was told that the patient did not eat it. Next, Dr. Seldin asked whether the patient chewed tobacco. Yes, the resident said. Did she swallow the juice? Again, yes. Dr. Seldin then identified the culprit. The tobacco brand that she chewed contained enough licorice to account for her problem.

Over the years, I have attended grand rounds at a number of hospitals and have even led some. I have also discussed grand rounds with a number of doctors across the country and abroad who recalled some unusual ones.

Dr. Joseph E. Murray, a Nobel Prize-winning transplant surgeon in Boston, recalled a grand rounds session at what is now Brigham and Women’s Hospital. Dr. Francis D. Moore, the renowned chief of surgery at Harvard, talked to a woman who had had recent gall bladder surgery. She sat in a wheelchair with her back to the audience, presumably so she could see the X-rays. Only at the end of the discussion, when Dr. Moore turned her wheelchair around, did he disclose that the patient was his wife.

An occasional grand rounds session became a lesson on decorum.

Dr. Samuel L. Katz, emeritus chairman of pediatrics at Duke, recalled his first grand rounds as a medical student, at Harvard in 1951. The expert was Dr. Oliver Cope, a leading surgeon. As Dr. Cope began talking with a patient on a gurney, he spotted one of Dr. Katz’s fellow students in the audience with an open shirt and no tie.

Dr. Cope ordered the patient wheeled out of the room. He spent the rest of the hour describing the proper attire for young doctors in the presence of patients. “That made an indelible impression,” said Dr. Katz, who has since kept ties handy for students who were not properly dressed.

Other grand rounds have set the stage for ruckuses.

Dr. A. Stone Freedberg, an emeritus professor at Harvard who is 98, recalled a conflict that developed over a patient who died after a lengthy illness and an unexplained fever. The discussant’s list of possible causes did not include histoplasmosis, a fungal infection that occurs in many regions but that is more common in the Midwest.

Dr. Henry A. Christian, chief physician at a Harvard teaching hospital, was in the audience and asked why histoplasmosis was excluded. Because no such case had been seen at their hospital, the discussant replied. Dr. Christian pointed out that theirs was not the only hospital in the area and that the patient might have acquired histoplasmosis elsewhere.

The discussant retorted by asking whether Dr. Christian had ever seen a patient with histoplasmosis. No, Dr. Christian replied, adding that there were many ailments he had never seen but had to think about in examining patients. The discussion grew increasingly heated before another participant told them to continue their argument outside.

Grand rounds remain important in continuing medical education. But in interviews and conversation, many physicians expressed an uneasiness about the lecture format and were disturbed by the lack of a focus on patient-related problems. Many younger doctors did not know that grand rounds were once conducted with patients on stage.

The critics say the switch to lectures is a sign of the time pressures that have contributed to erosions in the patient-doctor relationship and to the dehumanization of medicine. The absence of a patient case history and the impersonality of the lecture format also draw attention from the primary objective of focusing on the patient, they say.

But the classic grand rounds format may no longer be enough to teach doctors what they need to know about proper care. Exercises in solving clinical problems like the licorice case occur in many other conferences in medical schools and hospitals. Since World War II, medicine has become increasingly subspecialized. The size of hospital staffs has soared. Some department staffs list hundreds of faculty members, including some without medical degrees.

Medicine has advanced far beyond learning from bedside observations, though those remain important. Now doctors need to know about the physiological mechanisms and reasons for prescribing a drug or performing a procedure. Understanding a disease depends far more on information from scientifically rigorous trials involving a large number of patients than a professor’s cumulative anecdotal experience.

Nevertheless, experiences with single cases can be important because doctors have to mold treatments for the many patients who do not match the criteria used in studies.

The lecture format may be a more efficient way to learn science, but it is hard to know for sure, because published data documenting the effectiveness of grand rounds as a teaching forum is sparse.

In an era of proliferating subspecialties, a chief aim of grand rounds is to emphasize a core body of knowledge that all physicians need to share and to keep abreast of. And the meetings serve a social function. With coffee cups and bagels or pizza in hand, doctors mingle with colleagues before and after grand rounds. For some, it is the only time they see one another during the week.

Yet attendance at grand rounds has reportedly declined in recent years. Many subspecialists prefer to attend rounds in their narrower field, and doctors who go to national and international meetings can hear much of the same information that may be later presented in lectures at grand rounds.

State licensing boards require doctors to earn a specified number of continuing medical education credits each year. While attending grand rounds qualifies, other accredited conferences often win out in the competition. So some hospitals now require doctors to attend a specified number of grand rounds each year to maintain their staff positions.

As medical educators seek ways to increase the appeal of grand rounds, they might look at being more imaginative and restoring a sense of humor.

In 1961, Dr. Roy Y. Calne, a British surgeon who was working with Dr. Moore at Harvard, achieved a milestone in his search for a drug to prevent the rejection of transplanted organs. He successfully used azathioprine to keep a dog, Lollipop, alive and healthy with normal kidney function for six months after a kidney transplant.

So Dr. Moore asked Dr. Calne, now Sir Roy, to present his findings at a grand rounds session. In his college days, Dr. Moore had been president of The Harvard Lampoon humor magazine. (For full disclosure, years later I was an officer of The Lampoon.) So after Dr. Calne summarized the case, and with Dr. Moore’s approval, he invited the patient to join grand rounds.

As the door opened, Lollipop “pranced into the crowded auditorium, making friends with the distinguished professors in the front row,” Dr. Calne said. After a brief pause, the surprised audience broke out in laughter.

Azathioprine later was licensed as one of a standard antirejection drug for kidney transplants and for severe rheumatoid arthritis that does not respond to standard therapy.

Confronting the Racial Barriers Between Doctors and Patients

——————————————————————————–

November 14, 2008
Doctor and Patient
Confronting the Racial Barriers Between Doctors and Patients
By PAULINE W. CHEN, M.D.
Last Tuesday, like most of the country, I stayed up too late watching the election results come in and then became emotional when it was clear that Barack Obama, an African-American, was going to be our next president. Wednesday morning’s New York Times captured the most salient part of the moment for me in its headlines: “Racial Barrier Falls in Decisive Victory.”

But a few days later, as I thought more about racial barriers, I started to question my election euphoria. In politics, the racial barriers might have fallen, I thought, but what about in health care?

There is no question that racial barriers still exist in many parts of this society. The first time I remember having a frank conversation about racial barriers in medicine was during my residency.

Of all the surgical residents I trained with, “Eric” was easily one of the smartest. He possessed a great bedside manner, brilliant clinical skills and plenty of that Obama cool. Eric was African-American, and one night, when we were both on call together, he told me something I have never forgotten.

“You know, Pauline,” he said, “there are a lot of times when I go to a patient’s room for the first time and they ask me, ‘Are you transport? Are you here to wheel me to radiology?’” I can remember Eric shaking his head as he spoke. “They never assume I’m one of the doctors.”

Most of the research over the last 30 years has focused on the racial inequalities that affect patients; and the findings have been dismal. In 2002, the Institute of Medicine published a report that cited multiple examples of disparities across a wide range of health care and disease settings. African-Americans, for instance, were more likely to undergo less desirable procedures like amputation of all or part of a limb, while minorities with some forms of lung cancer had higher mortality rates because they were less likely to have surgery.

While there are probably multiple factors involved, researchers over the past decade have looked at how patients’ and doctors’ race and ethnicity might contribute to these disparities. One of the leading researchers in this area is Dr. Somnath Saha at the Oregon Health and Science University in Portland. Dr. Saha and his colleagues have shown that minority patients and white patients report better health care experiences when their doctors are of the same race or ethnicity .

But as my residency colleague, Eric, could attest, race and ethnicity can also influence the experiences of minority physicians. A recent study by Dr. Irena Stepanikova from the University of South Carolina notes that white patients who had non-white physicians were more likely to report a medical error than white patients with white doctors.

After reading through these study results, I decided to give Dr. Saha a call. I thought I would initially ask a couple of questions about his research, but I could not help starting with the election.

“On the one hand,” Dr. Saha said, “Obama’s election really provides some hope for people who thought it was impossible. But his election doesn’t automatically change what happens on the ground floor. Part of the downside of this historical event is that we may no longer believe that race can create a disadvantage. We may forget that we still do look at certain racial and ethnic minorities in a different way — not consciously but unconsciously.”

“I think the first step in addressing the disparities,“ Dr. Saha continued, “is really acknowledging that certain things affect the way we deliver care — our own stereotypes, our own cultural upbringing, our own ‘anxiety meters’ when we are interacting with people who aren’t like the people we grew up with.”

I never forgot my conversation with Eric because I, as an Asian-American woman, have had similar experiences. When working on consults with a white medical student or resident, I have watched physicians from other departments in the hospital look past me in order to speak to them. When preparing to operate on organ donor patients in other hospitals, I have had nurses and scrub technicians walk by me to help my assistants first, assuming that they were the lead surgeons.

But my own experiences were not the only reason I remembered Eric this past week. I remembered because our frank discussion was deeply unsettling. In order to empathize with my colleague and friend, I had to do the very thing Dr. Saha was talking about: I had to acknowledge my own biases and stereotypes first. And that was not easy.

I have prided myself on being as fair and as compassionate a doctor as I could be. But I am also very much the daughter of Taiwanese immigrants; and when, for example, I see patients or colleagues who come from a similar background, empathy comes almost automatically.

However, when I meet individuals whose race or ethnicity differs from mine — individuals who, for instance, are black, white, Hispanic or American Indian — there are fewer shared experiences. So I, like others, unconsciously tap into past experiences in order to bolster the connection and bring a greater sense of familiarity to the interaction. And it’s difficult to acknowledge that what I have tapped into may not always be fair.

“I think the key is getting to know each patient’s story and to treat each patient as an individual,” Dr. Saha said. “In doing so, you can really begin to understand where he or she is coming from. Empathy is really walking in their shoes, getting to know them, and putting your own biases aside.”

“It takes time to do that, Pauline,” Dr. Saha reflected. “But when it happens, it can really be a powerful thing.”

Join the discussion on the Well blog, “The Color of Medicine.”

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War– What is it Good For

Medicine on the Battlefield

Calling Dr. G.I. Joe
Today’s soldiers practice high-tech medicine on the battlefield
By DAVID EWING DUNCAN

Early in the Iraq war, when the United States unleashed precision smart bombs, surveillance drones and other high-tech gizmos of destruction, for a moment it seemed as if this war would be automated and for coalition forces largely bloodless. Unfortunately, the gee-whiz weaponry has given way to a daily tally of horrific injuries from crude bombs, snipers and other hazards, injuries that haven’t changed since gunpowder exploded on the scene some five centuries ago.

Jeffrey Decoster

In Iraq, however, the number of those killed from such injuries has dropped to about 9 percent, compared with 24 percent in Vietnam, 30 percent in World War II — and worse in earlier wars. Fatalities are down because of dramatic technological and logistical improvements in preventing and treating the greatest killer in Mesopotamia: bleeding from wounds.

Speed has been a major factor in stanching the bleeding before it kills. If evacuation teams can quickly move a soldier to a hospital in Iraq, the soldier has a 97 percent chance of surviving. Medical teams use advanced communication networks and locators to find the wounded, then dispatch Black Hawk helicopters and ambulances to whisk them to a Combat Support Hospital, a CSH, pronounced “cash.” There surgeons stabilize patients in modern operating theaters before they are loaded onto aircraft (C-17 Air Force cargo planes converted into intensive care units) and flown back to the United States. In Vietnam, it often took several weeks to move a soldier back to the United States; in Iraq, it usually takes about 36 hours.

Soldiers’ kits and training are another factor in a war where G.I. Joes are more than ever becoming Dr. G.I. Joes for certain injuries. For instance, every soldier is equipped with a high-tech tourniquet featuring built-in ratchets that he or she can tighten with one hand. In previous wars, tourniquets were discouraged because delays in getting the wounded to a surgeon to remove a tourniquet often meant the loss of a leg or an arm. In Iraq, surgeons routinely remove them within an hour.

Soldiers are also outfitted with special chemicals to encourage clotting and to stop bleeding. The U.S. Army has issued bandages coated with chitosan, a granular molecule that helps bind the outer shells of shrimp and other crustaceans and that promotes blood clotting. Positively charged chitosan molecules are affixed to bandages that attract negatively charged red blood cells, causing clumping and clotting. Made by HemCon of Portland, Ore., this bandage was named one of the “Top 10 Greatest Inventions this Year” by the Army in 2005. Other bandages used in Iraq are coated with chemicals that occur in humans naturally and help blood clot quickly — fibrinogen and thrombin. And to slow bleeding, Army surgeons use the genetically engineered Factor VII, a clotting treatment developed for hemophiliacs, though some doctors have raised concern that risk of stroke and other complications outweigh the benefits.

HemCon’s bandages are also controversial. The Army has embraced them, but Navy researchers have claimed that they work only slightly better than gauze on bleeding wounds. The Navy, Air Force and Marines prefer a powder applied to wounds to stem bleeding called QuikClot, a hemostatic that seals wounds. Made by Z-Medica of Wallingford, Conn., QuikClot absorbs the moisture in a wound and seals it. The Army is critical of this use because in a few cases Quikclot has caused burns, though the Navy says the risk is minimal, and if burns occur, that’s better than bleeding to death. Cost is a factor. The HemCon costs $120 per bandage; QuikClot is about $20 for a 3.5-ounce bag.

“The hemostatic agents have been great, they are a real advancement,” says Col. Norman Rich, MD, who recently retired as the chair of surgery at the Uniformed Services University of Health Sciences in Bethesda, Md. “It’s still a debate as to what works best, but the end result is that more soldiers are being saved,” says Rich, a Stanford medical alumnus, class of 1960.

HemCon and QuikClot are being used back home, too, by EMTs, police officers and firefighters, though they have been slower to adopt the technology because of the burn problem.

In the pipeline
Battlefield medicine of the future might give soldiers even more doctoring ability. One device the Army is developing to speed up the location and transportation of injured soldiers is a 911-type button that would signal medics their position when wounded. Another more futuristic device is a computerized ultrasound system carried by combat units that could locate and cauterize internal wounds. Colonel Rich is working with a Stanford team headed by Charles Taylor, PhD, associate professor of bioengineering, that’s testing two prototypes developed by competing companies with the support of DARPA, the Pentagon’s Defense Advanced Research Projects Agency.

Engineers are also developing enhanced body armor that would protect a soldier’s entire body. In this war, while Interceptor body armor and Kevlar helmets protect the head and torso (the so-called kill zone), arms and legs are vulnerable. One Army research project is the Future Force Warrior, a system of head-to-toe armor outfitted with a continuous communications net connected to a central command, internal climate-controls to keep fighters cool or warm, external sensors to detect movement and locations, and biomonitors that would keep track of the soldier’s vital systems and report back physiological data and injuries. The armor might also administer basic first aid.

There is talk of outfitting armored suits with a powered exoskeleton that would solve armor’s weight problem: Heavy armor on soldiers’ arms and legs severly curtails mobility. So the Army has funded University of Texas nanotechnologist Ray Baughman, PhD, to develop military-grade nano-fibers charged with electricity that would contract like muscles, but are many times stronger than human tissue. This would reduce the weight-to-strength ratio for tomorrow’s battle armor, which will look more like that of Imperial Storm Troopers on Star Wars than of today’s troops, who look similar to the grunts and G.I.s who have fought in wars since the early 20th century. The armor is years away from being perfected and deployed, putting it in a galaxy far, far away for today’s soldiers.

Back in our galaxy, as the Iraq war rages on, military medicine is making steady progress on the battlefield, hovering somewhere between the bloody wars and injuries of the past and a high-tech future that we can hope never needs to be deployed.

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I Was Wondering Why the Weed Was So Cheap…

nejm-lead-poisoning

Fighting For Life

USU Featured in New Documentary Film

A new documentary that opened in theaters on March 7, “Fighting for Life,” features alumni, students, staff and faculty of the Uniformed Services University of the Health Sciences. The university is a traditional academic health center with a unique focus on military medicine and public health. USU includes a medical school with a graduate program in the biomedical sciences and a graduate school of nursing.

This powerful and emotional documentary focuses on the role USU plays in educating leaders in military medicine and looks at the care they provide to servicemen and women injured in combat. Academy Award-winning filmmaker Terry Sanders produced the documentary, which was the brainchild of Mrs. Tammy Alvarez, president of the “Friends of USU” organization. Alvarez’s son, Navy Lt. Bryan Alvarez, is a 2005 graduate of USU.

“I started out to make a film about the Uniformed Services University of the Health Sciences in Bethesda,” said Sanders. “It was to be an in-depth portrait of this very special institution, the ‘West Point’ of military medicine, which has trained more than 25% of current active duty physicians…and the film grew until it became an odyssey through the world of military medicine in a time of war.”

The university’s story is told through footage, photos and interviews with a number of students, alumni, faculty and staff. The film focuses on some of USU’s unique educational programs, including the first-year Antietam road march, and field training exercises Operation Kerkesner and Operation Bushmaster, as well as several alumni as they care for wounded troops on the battlefield and throughout the patient evacuation system.

Among the many alumni highlighted in the film are:

Dr. Tom Kolkebeck (‘91), an Air Force physician who received casualties as the emergency room director at Balad Air Base in Iraq; Dr. Donald Jenkins (‘88), who was deployed more than three times to Iraq to lend his expertise as trauma systems medical director; Drs. Warren and Gina Dorlac (both ‘89), who cared for critically injured patients at Landstuhl Regional Medical Center; and Dr. Paul Pasquina (‘91), who as Chief of Physical Medicine and Rehabilitation and as the medical director of the Amputee Program at Walter Reed Army Medical Center, works to improve the quality of life for troops returning from Iraq and Afghanistan who have suffered serious injury or lost limbs in service to their country.

The film began with limited engagements in New York; Washington, D.C., Bethesda, Md., Los Angeles, and San Diego throughout the month of March, and in San Antonio in April.

USU Profiles
Field Exercises
GI Film Festival Features Fighting for Life