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Author Archives: WhiteCoat

Press Ganey and HealthGrades.com Are Medicine’s Fake News

Whether you agree with the Trump administration assertions about “fake news” or not, the term has gained legs and has at least put the American public on notice that you can’t trust everything that you read in the media or on the internet. Fake News Definition As the term “fake news” has become more commonplace, it remains loosely defined, often being used as a blanket pejorative against information that counters the interests of those using the term. This article from the Daily Caller describing how journalists are declaring war on fake news without knowing how to define it conjures ideas of the old Keystone Cops movies. I’m going define “fake news” as information that is reported as fact but is without foundation, is demonstrably false, or is presented in a manner that is intended to deceive the reader. To differentiate “fake news” from opinion pieces, we sometimes need to look at the actual or apparent intent of the report, since arguments may be intended to sway opinion, but shouldn’t necessarily be considered “fake news” if they are well-reasoned and supported by evidence. In some instances my definition may fall short, but then again, “fake news” may be one of those terms that is difficult to define but that “everyone knows it when they see it.” Compare that “recognition” definition with concepts such as “justice”, “due process,” and “pornography” which even courts have had some difficulty consistently defining. The internet realm of “fake news” includes such things as “clickbait” and sponsored posts. While I would initially fall for links to posts with phrases such as “this will make your jaw drop” or “you wouldn’t believe”, seldom was I incredulous or left with my mouth agape. Yet the clicks that those links created benefited the publisher by improving site stats and advertising revenue. Similarly, sponsored posts may seem like they’re intended solely for the information and benefit of the readers, but may also be created for compensation at the request of another interested party. These types of “fake news” are more difficult to detect, but the federal government was so concerned about the issue that the Federal Trade Commission created rules requiring disclosure of any sponsorship in posts endorsing a product. Applying Fake News to Healthcare Reports The event that prompted this post and bumped others that I was working on was the news story about former prominent Texas neurosurgeon Christopher Duntsch. I wrote about the story several years ago over at EPMonthly.com. My prior post was, in turn, prompted by an excellent article in the Texas Observer by Saul Elbein. The gist of Saul Elbein’s article was that Dr. Duntsch had multiple egregious medical misadventures while operating on patients and that those misadventures caused multiple serious patient injuries and one patient death. Dr. Duntsch would bounce from hospital to hospital after he started feeling heat from his malpractice, so it took some of the hospitals a while to figure out the problems. However, the Texas Medical Board was reportedly notified of these misadventures on multiple occasions by multiple physicians from multiple different hospitals, but Dr. Duntsch reportedly kept maiming patients in surgery while the Board “investigated” for more than a year before suspending his license. See Order of Temporary Suspension from the Texas Medical Board here (.pdf file). The recent articles on Dr. Duntsch provide some closure. He was tried criminally for his botched surgeries – an extremely difficult allegation to prove. However, after only four hours of deliberation, a jury convicted Dr. Duntsch of the first degree felony of “harming an elderly person” with regard to the care of one of his patients. Dr. Duntsch now faces life in prison. See more information on the trial in the ...

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Healthcare Update — 02-10-2017

So I hadn’t planned to continue doing Healthcare Updates, but there are always so many interesting healthcare-related articles that I can’t stay away. To wit … For women, it’s the birth control pill. For men, it may soon be a shot to the nuts. Literally. Researchers showed that an injection of Vasalgel into the vas deferens (the pathway leading out of the testicles) could temporarily block the flow of sperm and effectively sterilize monkeys. Other studies in rabbits showed that the gel eventually “flushed out,” returning flow of sperm. Learn more about Vasalgel here. If you aren’t adventurous enough to inject some slime into your working parts, there’s also an app for that … maybe. A mobile app called Natural Cycles was recently granted approval to be used as a contraceptive in the European Union. It works by tracking temperatures and then predicting when women ovulate. The app will recommend against having sex on days 6 through 16 of a woman’s cycle. That’s all fine and dandy, but to me, there are too many variables involved in fertility. These “fertility awareness” methods of contraception are notoriously unreliable. As in up to 24% of women will end up pregnant at the end of 1 year by using them. Wondering if the app will give refunds for that. If your smartphone can’t keep you from getting pregnant, it may at least be able to tell you if you smell bad. New Japanese gadget called KunKun links to your smart phone and detects multiple different chemicals that are often associated with bad smells. At an estimated price of $300, I don’t know that I’d purchase this for personal use, but it would be an interesting attraction outside of a bar at the end of the evening – as long as no one puked on it. One of my many pet-peeves: Overmedicating our children. There is waaay too much medication for ADHD and ADD being prescribed to young children. The problem is that the diagnosis of ADHD includes activities that are common in most children – doesn’t pay attention, doesn’t listen, fails to finish chores, often loses things, fidgets in seat, often “on the go” …. these activities seem to be the rule, not the exception. This article recommends that we Stop Drugging Our Kids and explores some of the reasons parents may want their kids to take stimulant medications. Helping kids excel in school and perhaps a lack of parenting skills fit in there somewhere maybe? Money quote: “we are putting kids on drugs for behaving in age appropriate ways.” Absolutely true and it needs to stop. The graphic accompanying the article artfully demonstrates one of the issues our society is facing. Fascinating article about how grip strength is a predictor of overall health … and how grip strength is rapidly declining in this country: Raising the American Weakling. One researcher, an occupational therapist, noted that the grip strength in her patients was far from the norms established in the 1980s. The article cites many other studies showing that, for example, that grip strength was a stronger predictor of all-cause and cardiovascular mortality than systolic blood pressure. Another interesting point in the article was that a top NHL scouting prospect wasn’t able to perform a single pull-up during a fitness test. On the other hand (no pun intended), a different researcher noted that womens’ grip strength is worse than men, yet women live longer than men. I’m a fan of exercising, so I tend to agree with the study sentiments – even if grip strength is an imperfect indicator of overall strength/health. Another fascinating article about how some doctors in Wake ...

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Redefining the Pain Scale

The smiley faces just don’t seem to cut it any more. The Wong Baker pain scale was originally created for children. Now it is used by medical providers to precisely gauge pain in adults all over the United States because of the concept pushed on medical providers that “Pain is the Fifth Vital Sign.” Although this phrase was originally created by the Department of Veterans Affairs, The Joint Commission adopted it and ran with it, rolling out Pain Management Standards declaring in 2000 that “the pain management paradigm is about to shift,” that pain control was a “patient rights issue” and that providers would be required to measure pain on a 1-10 scale. See JAMA article here. PDF here. Skeptical Scalpel weighed in on the “Pain as a Fifth Vital Sign” issue in 2013. Of course now that the US is in the throes of an opiate epidemic because of the Joint Commission’s actions, the Joint Commission walked back its demands, stating that it only required providers to measure pain, not to use drugs and that it didn’t require the patient’s pain scale to reach “zero.” Then it put out a propaganda bulletin (.pdf) describing “Myths About The Joint Commission pain standards” … but that’s fodder for another post. So when I get to the whole pain rating thing and someone says his or her pain is a “10” while simultaneously munching on Cheetos and playing Flappy Bird on his or her TracFone, I have cause for concern. Either the patient is dissociated from reality, has some ulterior motive for overestimating his or her pain, or the patient doesn’t understand the pain scale. No matter how many times you shove the smiley faces in front of the patient’s smiley face, the patient just doesn’t get it. So sometimes I call them out. “Consider ’10’ as pain that is so bad that you are rolling around on the floor in agony and asking for someone to put you out of your misery.” [flap flap flap] “Oh, yeah,” [crunch chew chew chew] “it’s definitely a TEN” “Oh, but my unfortunate patient in distress, you’re not rolling around on the floor.” [Looking up from the screen momentarily] “OK, then it’s a 9 and a half” Brilliant. If only everyone could be so mathematically adept. There have been many memorable attempts to describe the pain scale. Brian Regan described his experiences trying to outmoan the patient in the next room, then discusses how he decided to describe his pain scale to the nurse. If you’re at work, don’t drink coffee while watching. If you’re at home, pop a beer and fire up the link. It’s worth 8 minutes of your time. Then there’s xkcd’s take on the pain scale – which piggybacks off of Brian Regan’s stand up routine. How would you rate your pain if 10 is the worst pain you could imagine … ? Allie from Hyperbole and a Half did an admirable job of it when she took her boyfriend to the hospital for vomiting Crasins and needing to be checked for Ebola. You really need to read that post for some good chuckles. So then I happened to come across an Improved Pain Scale picture on Reddit that does a reasonably good job at describing pain. View post on imgur.com Personally, I still like the Hyperbole and a Half scale better, but this Reddit one isn’t bad. And before someone out there tries to call me out for all of the links being in the Reddit post, the only one that I hadn’t seen before was the xkcd scale. I’ve passed around the links ...

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Time To Retire Revisited

Remember the doc from “Time to Retire“? Had a few amusing stories from patients about some of the statements he made while working in the emergency department. Since that post, I became friends with one of the people working in his emergency department. I keep trying to get that person to start a blog … to no avail. Here are a couple of more stories from reported patient encounters. A sick kid comes in. I started an IV. Kid is in and out of consciousness. Doc says “let’s tube him.” The mom is freaking out. I grab the resuscitation bag and hand the doc the Broselow tape. He gives me a blank stare and yells at me. “What the hell is this?” Mom and dad look at him then give me a look of terror. Doc says he’s never heard of a Broselow tape. Fortunately, the rest of the visit went smoothly and the kid was transferred to the peds hospital across town fairly shortly afterwards. I see a patient and then mention to the doc, “Hey just wanted to know that the guy in Room 2 has a glass eye on the left.” Doc says “He isn’t here for a problem with his eye.” I say “I know, I just didn’t want you to look bad by putting ‘PERRLA‘ in your dictation when one eye doesn’t work.” Doc says “What the f*** is the matter with you? I’m not even looking at his eyes. The guy is here for a problem with his leg. Stop worrying about my dictations. ” After the patient was discharged, I look at the dictation. What shows up? You guessed it: PERRLA.

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Antibiotic Apocalypse

The beginning of the antibiotic apocalypse may be nigh. Woman dies from the ultimate superbug – carbapenem-resistant Enterobacteriaceae (CRE) with New Delhi metallo-beta-lactamase (NDM). The bacterium is resistant to 26 different antibiotics. There were no antibiotics left to treat the infection – it was resistant to everything. Word on the street was that she was taking a Z-Pack for her cold before she got sick. Kidding about the Z-Pak thing, but this is no laughing matter. I thought it before and I still think it now – antibiotics should be treated like Norco and other controlled substances. Tracked. Patients who take too many of them should require special paperwork before they can fill prescriptions. All these unnecessary prescriptions for coughs and colds are just making the bugs stronger. We’re doing this to ourselves. Then again, scientists just announced that they have discovered a molecule that reverses antibiotic resistance in multiple strains of bacteria at once. The bad news is that some jerkoff investor will probably purchase the patent, jack the price for the molecule to about $17,000 per dose and will make sure that the molecule won’t be covered under Obamacare or any other insurance plans. The molecule is called a peptide-conjugated phosphorodiamidate morpholino oligomer or PPMO and works to disable the NDM-1 found in the most resistant bacteria. Powerful weapon to beat resistant organisms, but if we don’t change our prescribing habits and demands for antibiotics, it’s only a matter of time before the bugs learn how to beat the PPMO in this high-stakes game of cat and mouse. Is a post-antibiotic world approaching? This NY Times article again notes how the number of effective antibiotics in our arsenals is diminishing and that there isn’t much of an incentive for pharmaceutical companies to produce new antibiotics. The article states that Medicare has moved to require hospitals and nursing homes to adopt plans to prevent the spread of drug-resistant infections and to assure the proper use of antibiotics However, note that under the “Hospital Compare” program – created by the same government that wants to “assure the proper use of antibiotics” – hospitals are deemed substandard if they don’t throw strong antibiotics at every pneumonia within six hours of a patient’s presentation to the emergency department. Have those policies decreased pneumonia deaths since they were initiated? According to CDC data (.pdf file), deaths from influenza and pneumonia decreased from 18.4 per 100,000 population in 2006 to 15.1 per 100,000 population in 2014 – an 18% decrease (see page 37). During that same timeframe, the rate of death from all causes decreased from 791 per 100,000 to 724 per 100,000 – a 9% decrease (see page 35). I picked the cutoff date of 2006 because the Hospital Compare website started comparing hospitals in 2005. There are multiple confounding variables such as inability to separate influenza (viral-related and unaffected by antibiotics) from bacterial pneumonia that would be affected by antibiotics, the fact that pneumonia is a subjective diagnosis in many cases (was it pneumonia, CHF, or chronic interstitial changes?), that many deaths have more than one cause, and that financial incentives may make it more likely that pneumonias are underreported (readmissions for same diseases may not be paid by Medicare). Draw your own conclusions. A somewhat dated article, but one that shows the potential seriousness of a world in which we don’t have readily available effective antibiotics. In Venezuela, the imploding/imploded economy has made antibiotics largely unavailable and turned simple injuries such as a scraped knee into major health threats. One more infection-related article for the day. If you want to be ahead of the curve at medical dinner parties, learn ...

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The Aspirin Technique to Stop Pregnancy

I’m going to preface this post by saying that it isn’t for the faint of heart. You’ve been warned. We’ve all seen them. After a while they become emotionally frustrating. Some patients would rather spend several hours waiting in an emergency department waiting room rather than going to the Dollar Store and buying a test to see if they’re pregnant. No, the hospital tests aren’t more accurate. For all I know the hospitals get them from the same supplier as the Dollar Store. You don’t need to recheck … oh nevermind. Just get five of them. You know that no matter what the test says, if you think you may be pregnant, you’re going to check it over and over again to make sure one way or another. Just buy a handful and be done with it. I’m happy when people are excited about being pregnant, but it gets frustrating when people don’t want to be pregnant and at the same time don’t take any precautions to try to prevent themselves from getting pregnant. Which leads me to my little story… One of said potentially pregnant patients came in for her usual pregnancy test. Her name popping up on the board caused a few people to shake their heads. “C’mon. She was just here like six weeks ago.” “She needs to get a prescription for some birth control.””Or she can just use the aspirin technique.” Suddenly there was a gasp from behind the nurses’ station. One of the older secretaries was coming in for her shift. She was walking behind everyone and had apparently heard the tail end of the conversation. She stood there shocked. This was a four-pack-a-day smoker with a raspy voice who took pride in making others blush with her “colorful” language. Most of the time her breakroom talk could make a truck driver lean back and raise his eyebrows. Yet this time, it was her increasingly reddening face that formed a stark contrast to her white hospital jacket. “What? You know? The aspirin technique? Put an aspirin between your knees and keep it there while you’re having sex to keep from getting pregnant?” She heaved a sigh of relief and smirked. “Oh Hells bells. I thought you said the a**hole technique. Then I’m standing here thinking that you’re all a bunch of sick sons of bitches.” Which made everyone crack up. As she was walking away, she added “Although either way would probably work just as well. Baaaahahaha.” And with that comment the staff decided to skip lunch that afternoon. Got us again. Remember, I *did* warn you … ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me.

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