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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.

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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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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