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1209717_19610439The focus of this web site is medicine. In this blog, you’ll read about patient stories. The situations have been changed to be HIPAA compliant. Factual statements may or may not be true. I may change ages, gender or presenting complaints about patients. I may even entirely make up complete patient encounters from my fertile imagination. Trust me, if you think I’m writing about you, I’m not. There are billions of people in this world and readers send me stories about patients all the time. It isn’t you.
You’ll also read a lot about health care policy. I may throw in posts about life lessons, computers, and will even throw in family stories once in a while. If you’re looking for articles about politics, sports, or celebrities, you’re in the wrong place – unless the topics have some relationship to medicine.
If you want to add a guest post or to cross-post something from your blog, or if you have a patient story you want me to write about, e-mail me. See more information in the “About Me” page.

Voices Carry

Wisecracking doc that I work with recently had a little surprise.  He was walking down the hallway and saw a nurse escorting a mother and her overweight young daughter into a room. Daughter was holding her right eye.  When the patient’s registration was completed, he signed up for the patient, took a swig of coffee, and said “OK, looks like it’s time to go see what’s wrong with Honey Boo Boo‘s eye.”  A couple of the nurses chuckled and he had a smirk on his face as he walked into the room and pulled the curtain. Only the patient and her mother could see his face after that, but his smirk probably faded pretty quickly. The first words out of the mother’s mouth were a stern “Honey Boo Boo, huh?” Oops.  Isn’t it just like a bullshitter to be quick on his feet, though? There was a hesitation and then he began laughing. “Awwww. I’m sorry. I didn’t mean anything bad by saying that. I call EVERYONE that.”  There was another uncomfortable silence and then he doubled down on his faux pas.  “OK, Honey, let’s see if we can get your eye feeling better. What happened?” In the ensuing banter back and forth, it seemed as if the mother’s irritation had waned. Then the moron starts in again. He pokes his head out from the curtain and asks the nurse “Ummm Chelsea, Honey, could you pleeeease grab me some tetracaine eye drops?” Chelsea would have none of it. She promptly gave him a stink eye.  He mouthed the word “Pleeeeease” and put his hands together as if he was praying.  The stink eye remained.  He then mouth the word “Starbucks” and expanded his hands to make a “large” gesture. Of course, he knew Chelsea’s weakness. Mocha latte frappucino deluxe.  She raised an eyebrow. And held up two fingers. He scowled. It was then her turn to smirk as she took a big breath acting as if she was about to say something he didn’t want to hear. He quickly re-thought his predicament. He grimaced momentarily and mouthed the words “OK OK.” “Sure thing, doc, right away.”  By the time they were done, everyone was laughing back and forth in the room. A handful of lollipops and an IOU for two Starbucks later and the crisis was averted.  “Jeez. Does my voice carry that much?” he asked. A chorous of responses from across the department responded “Yeeessss.”  “I hope bald Donald Trump from earlier today had a hearing impediment ….”  ———————– 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 DrWhiteCoat.com, please e-mail me.  

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Hurry Home

  First of all, I’m having blog withdrawals. Seriously. I wish I could make a living writing a blog. It would be my dream job to write blog posts and troll the internet. Maybe some day. So a quick story before I go to bed for another long day tomorrow. At one of the hospitals where I moonlight, many nursing homes refer patients to the emergency department for routine medical care. Stuff like “patient has a rash for a week” or “patient is agitated.” Normally, it doesn’t bother me too much, but one specific nursing home not only sends its patients in for routine medical issues, but it refuses to take the patient back unless we do the testing that their nurses want. If a patient with a history of agitation gets sent in for agitation but arrives calm, we can’t just send them back on the same ambulance. We have to do tests … special “agitation” tests … to rule out excess agitation levels, apparently. Rashes have to have skin scrapings sent. Patients found on the floor must have head and neck CTs. Haven’t had a positive one yet, but try sending a patient back without one and the ambulance will be sent back to the ED. I tried fighting it a couple of times. They’d send the patient back. I’d do another exam while the patient was on the ambulance stretcher, take vital signs, then send the patient back again. Then there would be the call from their medical director to our department chair. Bad doctor. How dare we practice proper medical care? Patient returns by ambulance for third time. Just do the friggin tests, OK? So when patients come with orders … er, um … requests … from this nursing home’s staff, regardless of how stupid the orders er, um requests are, we put the orders in to save time and to save administrative hassles. Harry was the unfortunate soul who was drafted one Sunday morning. It seemed that the nursing home staff felt it was odd that Harry hadn’t had a bowel movement in two days. He probably had an obstruction. Needs an acute abdominal series and some labs. I called BS. Harry had normal bowel sounds, no palpable masses, and no impaction on his rectal exam (sorry about having to do that on an early Sunday morning, Harry). Besides, it’s entirely normal for someone not to have a bowel movement for two days. We called the nursing home and told them Harry was coming back. Nope. Need labs and an abdominal series. Bastards. Needless to say, the labs and the abdominal series were [gasp] normal. So I asked Harry “Would you like me to give you something to help you move your bowels?” Harry replied “Sure, doc. Always nice to have a good BM every day.” We called the ambulance and made arrangements for transfer back to the nursing home … after being forced to fax them the lab and x-ray results. So I’m curious. Would it have been mean for us to give Harry lactulose and Milk of Magnesia as the paramedics were loading him onto the stretcher to take him back to the nursing home?

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Eeew-perman

One of many ambulance transfers included a 80-ish year old nursing home patient who was sent by the night staff at the nursing home because they were too busy he had mental status changes. When the patient arrived, he seemed OK to me. Awake, alert, smiling. Held a relatively normal conversation. Watching the news on television. He even grabbed the remote and muted the sound when I came into the room. Unfortunately when a patient gets sent from the nursing home with a complaint like this, you’re forced to prove that a problem doesn’t exist. Woe is the doctor who sends a normal patient back to the nursing home without performing testing to prove that the patient really is normal. Then the nursing home administrator calls the hospital administrator and the patient gets sent back to the emergency department for the desperately needed testing. When – and ONLY when – the testing is normal will a patient be accepted back to the nursing home. It’s a stupid game, but one that we’re forced to play. The sooner the normal testing gets done, the sooner the taxi with the big spinning lights can come back to bring the patient back to the nursing home. So we order the standard nursing home lab panel. CBC, chemistries, urinalysis, and drug levels of any medications the patient may be taking. If the patient has dementia, then add a mandatory CT scan of the brain. You see, we can’t really tell if a demented patient has mental status changes, but if the demented patient DID have mental status changes, those mental status changes COULD be due to an acute stroke affecting only the personality centers in the brain. Hey – it happened once, you can’t be too careful. So the lab tech came in to draw the patient’s blood and the nurse gave the patient a urinal for a urine sample. About an hour goes by and the labs are [gasp] normal, but the lab still hasn’t received a urine sample. So I walk back into the room to see if the patient could give us just a little bit of urine in the urinal. Sur-prise! Anyone have some popcorn? “Ummm. Mr. Clinton … why are you drinking your urine out of the urinal?” [giggles, then whispers] “It gives me secret powers.” At that point, I didn’t know whether to puke or to take a sip. “You haven’t been taking your Zyprexa, have you?” “Oh, no. I take it … some-times.” Then he gave me a sheepish wink. Good enough for me. His urinalysis was normal and he levitated got a ride back to the nursing home. Take that, night nurses. ———————– 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 DrWhiteCoat.com, please e-mail me.

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Medicine Can Be A Taunting, Vicious Profession At Times

By Birdstrike MD   Not too long ago, I was busy at work seeing patients. The secretary yelled, “Dr. Birdstrike, there’s a phone call for you.” “Alright,” I said. “Transfer it over.” I answered the phone. “Hello, Dr. Birdstrike, this is ***** ****** from the ****** State Medical Board,” said a jabbing, deep military sounding voice. “Uh…hello,” I said. I felt a jolt of electricity in my chest. This wasn’t a phone call I expected nor wanted. The state —-ing medical board? What, the…? “I’m calling to notify you, we’ve received a formal complaint about your medical practice and I’ve been assigned as the lead investigator.” At this point, the adrenaline was pumping through my veins, and my heart beating fast enough, that I didn’t hear much of what he said after that. He might as well have told me I had brain cancer and had 6 agonizing weeks to live. Although I have been sued before, though never convicted by a jury, of medical malpractice, I’d come to realize that whole process was more about one group of lawyers fighting with another group of lawyers, to get money from an insurance company, with a doctor and a patient as mere pawns in the game. It’s a game that can feel very personal, but ultimately isn’t, and is mostly about the trophy hoped for by the plaintiff’s attorneys: Award money. But a complaint from the medical board? It’s honestly something I never thought I’d have to face, having been someone that’s always performed at a very high level during my career, at all of it’s stages, not every having faced any significant concerns regarding my performance. Also, in my personal life, I am, for lack of a better word, a rule follower. After, the initial shock dissipated, his words gradually faded back into the ear of my consciousness. He gave me the name of the patient and the stated complaint. I remembered the patient, but I didn’t remember any particularly bad outcome, or any negative interaction or administrative complaint at the time. The accusation appeared out-of-place and baseless. He explained the process: I was responsible for providing a written response to the medical board within 15 days. After that, there would be an investigation. After an undetermined period of time, the complaint would either be dismissed outright, dismissed with a non-disciplinary letter of warning which would go in my medical-license file, or if neither of those, then I’d have to go before the medical board for a hearing. A licensing hearing? The entire thought of any of this was horrifying. News headlines of doctors who had lost their licenses for egregious and horrible misconduct flashed like shocking, intrusive, strobe-light banner-notifications across the home-screen of my brain. I did nothing wrong. Why is this happening to me? This is insane? What the —-? Am I going to lose my license? No way, I’m going to lose my license. I did nothing wrong. Nothing even happened. Wait, what happened? Did anything happen? No, nothing did. But what if I get some rogue medical board or the case is reviewed by someone with an axe to grind or from a totally different specialty? Miscarriages of justice happen all the time. Don’t they? Questions bounced around my brain like a silver pinball. I slowed my breathing down. I logged into the medical record scanning through charts and reports like a DVR player on fast forward. Wait….They have no case. THEY.   HAVE.   NO.   CASE. I started to get angry, very angry. Just like my lawsuit, where I was falsely accused of malpractice, ...

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Texas Lawsuit Damage Caps Must Cause Cancer

Never put it past a plaintiff’s attorney to twist an argument to the benefit of other plaintiff attorneys. The last post I wrote was about (former) neurosurgeon Christopher Duntsch, who was recently convicted of a first degree felony related to his medically negligent treatment of an elderly patient’s back pain. There were extenuating circumstances in this case. Dr. Duntsch had established a pattern of egregious medical mistakes. When patients developed complications after surgery, Dr. Duntsch also had apparently tried to cover up his mistakes instead of seeking help. Then there was an e-mail that Dr. Duntsch purportedly sent to a friend in which Dr. Duntsch referred to himself as a “stone cold killer.” Earlier this week, Dr. Duntsch was sentenced to life in prison for his actions. Dr. Duntsch’s case is an outlier. In general, I have a lot of concerns about charging physicians criminally for the medical care they provide. In the past, I’ve discussed how increasing liability for medical malpractice and “suing our way to better health care” just doesn’t work. Increasing the risk of practicing medicine has a few effects. First of all, it decreases availability of medical care. Physicians who don’t like risk will leave risky specialties or will leave risky states. Here’s an article about how a Florida (which is a high-risk state for medical practice) legislator was whining because there was a physician shortage. Think about it. Suppose that several of the houses in your neighborhood were purchased by families who stay up late at night using drugs, who have shootouts in the streets, and who try to get kids in the neighborhood to join gangs. How would you respond to that increased risk to your family? Second, increasing risk in medicine will increase the practice of defensive medicine. Physicians who are risk adverse will engage in more testing and more referrals, which may minimally improve outcomes but at a tremendous cost to patients and to the medical system. There are other effects of increasing liability for physicians such as eroding the physician-patient relationship, increasing physician burnout, and increasing insurance costs, but I’m getting off on a tangent. If you accept the premise that increasing civil liability for medical mistakes has an adverse effect on availability and cost of medical care, can you imagine what a chilling effect that criminal prosecution for medical mistakes would have on the practice of medicine in this country? Enter attorney Christopher Hamilton, Esq. from Standly Hamilton LLC in Dallas. Mr. Hamilton told reporters for ABC News that Texas’ cap on some lawsuit damages may cause more criminal prosecutions of physicians in Texas in the future. Mr. Hamilton also asserted that if it weren’t for Texas’ malpractice caps, hospitals would have caught on to Dr. Duntsch’s egregious medical practices and would have “kicked out a doctor like this much sooner.” He continues by stating that “A lot of times, hospitals only find out about poor outcomes when a lawsuit is brought.” Finally, Mr. Hamilton goes on record as stating that the Duntsch case is “a circumstance where the civil system was not able to weed out a bad apple because of the damage caps.” Let me see if I get this straight … Caps on pain and suffering may increase criminal prosecution of physicians for malpractice. Caps on pain and suffering prevent lawyers from “weeding out” poor physicians. Filing a lawsuit alerts hospitals to the fact that a physician’s practice may have caused poor outcomes But … even though hospitals may be alerted to a physician’s poor practice patterns by a lawsuit being filed, damage caps render hospitals powerless to take action against the physicians. Makes ...

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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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