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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.

Happy Marriages, Rainbows, Yin and Yang

“She’s a peach,” the nurse quipped as I clicked the link assigning the new patient to my list. “A positive review of systems … if you know what I mean,” she winked. I like getting a head’s up about patients before I go to see them, but sometimes advance notice of a difficult patient gives me anxiety. I took a deep breath and put on a big smile as I pulled back the curtain. “Hi, I’m Dr. WhiteCoat. What brings you here today.” “Didn’t you read the chart? I’m not explaining it again.” “I did read your chart, but it looks like you have a lot of things going on, so I’m going to have to get some more information from you about all of them.” She rolled her eyes, sighed loudly, and gave me a brief end-expiratory “You’ve got to be kidding me.” I listened and took notes as the patient described her chest pain, her chronic dyspnea, the dry socket she had when her wisdom tooth was pulled 6 months ago, and how a tingling sensation sometimes begins in the fingers of one hand, runs up her neck, down her back and into her leg like someone is “ripping the nerves out of her body one at a time.” My “kill them with kindness” tactic seemed to be working … at first. But the more I asked questions about her eight different complaints, the more that the patient became impatient. Finally, she snapped. “You ask too many questions. THIS is why people hate coming to the emergency department.” “Well, I need to find out more about what is bothering you so I can try to figure out how to fix the problems.” “YOU’RE the problem and YOU’RE bothering me. Why don’t you just run some tests?” “But learning more about your problems helps me figure out what test need to be run, though.” “You don’t listen very well, do you?” By this time, I was getting frustrated. “Ma’am …,” I started, but she cut me off. “I bet your wife LOVES it when you leave for work in the morning.” Ooooh. Eeee. Oww. Oww. Poke me with those pointed barbs. I was going to be a smart ass and tell her that I work nights, too, but my inner peace took over and I bit my tongue. “Tell you what. Why don’t I … order some tests … to see if we can get to the bottom of all of these problems you’re having.” Then I left the room. About 15 minutes later, the nurse hunted me down and told me that the patient had pulled off her EKG leads and walked out of the emergency department while yelling at someone on her cell phone. One of the other doctors at the nursing station smiled and shook his head. I briefly explained what had happened. “That’s nothing. Yesterday, I had a lady tell me that men like me were the reason she became a lesbian.” We both got a good laugh out of that one. Later that day, though, I had a patient and her family ask me if I had an office where they could see me as patients outside of the emergency department. Ahhhh. That’s better. The yin and yang of my day has now been re-equilibrated.

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Helloooo … ooo … ooo [echo]

Lots of cobwebs in here. Heck. I don’t even recognize the new WordPress control panel. So I made a New Year’s resolution that I’ve already broken. I resolved to post once a week on this blog of mine. Here we are at Week 2 and … nothing. I counted. I have 24 pieces of paper sitting in a file on my desk with posts just waiting to be written. People have sent me stories to post and I’ve not been very good at checking e-mails, either. I’ve got another dozen or so half-written posts in an Evernote account. That’s enough for almost a year if I do one post a week. So what’s the holdup? I thought long and hard about why I stopped writing. The root cause of the problem was that I like writing about policy. What I think we should do in medicine and why. But writing a compelling post about a single topic sometimes takes all day. Time isn’t on my side in that regard. Family. Work. Disaster after disaster. But I miss writing. So I decided that instead of taking all day to write about a specific topic, I’d treat the blog kind of like an extended Twitter account. Twitter gets on my nerves any more. Yes, I agree that Donald Trump is a jerk. I don’t need a running account of his alleged inherently evil actions from every person who was upset that Hillary Clinton lost the election. Spend your energy on things more productive than the “Tweet” button. Give the guy a chance and see what he can do for the country. So I’ll just post short thoughts about things that cross my mind. Progress on health goals. Throw in some patient stories. Policy issues if I get motivated and have the time. Bring back the Open Mic days to see what’s on everyone else’s minds. I’m dictating things into voice recognition on my phone while driving. I tried it a couple of times and it works OK. Need to do quite a bit of spell checking, but it works. If nothing else, you’ll get some new #Dragonisms. I’m going to clean up the site a little too. When I get more time. There are a lot of old blogs to get off the “Links” page and a lot of new ones to add. What pushed me over the edge to get back to the keyboard was someone who just wrote me an e-mail thanking me for what I do for doctors. Here I am thinking I don’t do much of anything. But people apparently enjoy reading stories and they like someone who will write about what many people are afraid to write about. As in … how’s that Press Ganey bullshit going lately? We’ll see how this New Year’s resolution pans out. Don’t expect a lot … all three of you who still check this blog once in a while. At least I took the first step. Second step: My first patient post already written up. Check back tomorrow.

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Healthcare Update — 03-07-2016

“VA suicide hotline. Your call is very important to us. Please leave a message after the beep.”  Data provided to USA Today shows that up to 1 in 5 calls to a VA suicide crisis hotline was dropped or sent to voice mail. One veteran from Illinois allegedly killed himself by laying on train tracks after being unable to reach someone on the hotline. Want to get the munchies? Pull an all-nighter. Study shows that those with “restricted sleep” (4.5 hours per night) have higher levels of hormones that stimulate hunger and were less able to resist eating “palatable snacks.” Study in Annals of Emergency Medicine shows that elderly patients are more likely to die after discharge when they met any of four criteria: the doctor planned to admit them and then changed the disposition to “discharge” (showing that doctor should follow their instincts), the patient had cognitive impairment, the patient’s blood pressure was less than 120 systolic, or the patient’s pulse was greater than 90. Seems odd that patients with abnormally high blood pressure are at less risk for discharge while those with potentially normal pulse rates are at higher risk for discharge. And how many nursing home patients don’t have some type of cognitive impairment? Another study in Annals of Emergency Medicine shows that patients who overuse the emergency department one year are highly likely to overuse the emergency department in subsequent years. Younger age, Medicaid status, and mental illness were all predictors of frequent emergency department use. I’m betting that Iraq doesn’t have patient satisfaction scores. Video shows Iraqi doctor slapping patient (twice) who yells out in pain when getting stitches. Dr. Toughguy isn’t using gloves, either. Here’s a study showing that patient satisfaction scores are dependent upon location of care. Same doctors treated patients in both an emergency department and an urgent care center. The exact same doctors had courtesy scores that were 0.35 points lower on their Press Ganey ratings in the emergency department when compared to scores from the urgent care center. Those 0.35 points on a 1-5 scale can mean the difference between having a score in the 90th percentile and the 20th (or lower) percentile. When is the hospital C-suite going to learn to understand grade school statistics and bias? There’s an app for that … but it doesn’t work. Study shows that in 77% of cases, blood pressure measuring app from mHealth gave artificially low readings and hypertensive patients were falsely reassured that their blood pressure was normal. Then again, I’m sure that if you asked Press Ganey statisticians, they’d say that the app is an absolutely valid measure of blood pressure. Because they say so. Fighting incurable MRSA infections with … viruses. Man had “raging infection” in leg after dozens of surgeries to repair damage from a car accident and antibiotics weren’t working. Doctors wanted to amputate at the hip. Patient took a trip to Georgia (the Eastern Europe country, not the US State) and underwent phage therapy. Came back cured. Why aren’t we doing more of this in the US?

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Dear Diary #21

So, diary, it’s been almost a month since my last post. I keep writing things down to post about, then when I make time to actually sit down and write the posts, something comes up – almost without fail. I’ve had five days off of work and today – the night before a string of shifts – I finally have a little time while the family is out doing errands. This whole 2016 year has been quite trying. I already went through some of the stuff that’s gone on in my last diary entry. The hits keep coming. Daughter WhiteCoat’s car needed almost $1000 in repairs. Then, within 2 weeks, it broke down again. Estimates were another $1500 to repair it this time. With 200,000 miles on the vehicle, we opted not to throw good money after bad. Instead, we financed a used Toyota with low miles. We surprised her with it and watching her dance around the yard yelling still makes me smile. We parked it in the driveway and parked her old car behind it. The following morning, she gets in to drive to school, forgets that her old car was behind her, and backs into the old car, gouging her rear bumper. She didn’t want to tell me about it, so she went to Sherman Williams and they tried to match the paint based on a picture she took on her cell phone. Now it looks worse than it did with the scratches. I am NOT replacing the bumper. I’ve got a used BMW that I got for a good price off of CraigsList. That is the first and last time I’m ever buying a BMW. I used to like to work on cars. Now you can’t do it unless you have a degree in advanced computer programming. Battery went bad about 6 months ago. Can’t just purchase a battery and replace it. Have to purchase a special battery and register it to the car. Cost: $500. Driving to work and suddenly get this message that pops up on the navigation screen. “Turbo output failure. Car is safe to drive. See dealer immediately.” Take it back to dealer. Nothing is wrong with the turbo. A total of four sensors went bad. Sensors, mind you. The cheapest one was $189. Most expensive sensor was $629. Total cost to replace bad sensors was more than $1500. Looks like I’m working a few more shifts in the emergency department next month. My trusty color laser printer took a crap on me as well. Purchased new toner and now it has banding on all the prints and the color looks like everything has been mixed with mud. So I take apart the printer, vacuum out the insides, clean the corona wires and the drum, put it back together, no change. Reinstall the printer drivers. No change. Fortunately, I have a second printer in the basement. Same brand and model. Had it at Mrs. WhiteCoat’s office for a while and then she went to a straight black and white printer. Lug that printer upstairs and switch it out with the first printer. Plug it in. Error message. Look error message up on internet. “Laser malfunction. Take printer to nearest service center.” In other words, throw both of the printers in the garbage. But wait! When you leave the printers on the curb, the garbagemen won’t take them. Even the shifty-eyed guys in the pickup truck that drive around the neighborhood before the garbage trucks get there and dump over garbage cans looking for loot won’t take them. No. We have to take the printers to the recycling ...

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That Hesitation When …

… a patient’s family member comes up to you and asks “Hey. You’re Dr. WhiteCoat, aren’t you? Didn’t you work at University Medical Center like 6 or 7 years ago?” You casually look to see if there are any weapons in his hand and, seeing none, you cautiously say “Yeah.” Then the family member says “I thought that was you. Yeah. You’re a good doctor. You saved my father’s life. He talked about you up until he died a couple of years ago. Always told everyone what a good doctor you were and how if you ever had an emergency you should go to University Medical Center and ask for Dr. WhiteCoat.” Then you get a little grin on the inside and have to hold it back while you tell the family member you’re sorry about his father passing but you appreciate his comment. Then you go into the lounge with a dumb smirk on your face and think about how an offhand comment like this can make your whole day. Then the nurse sees you smirking and asks “What warped thoughts are running through your mind THIS time?” “Oh nothing.” Then you can’t decide whether the nurse’s suggestion that you have a warped mind is making you happier or is worrying you. Who cares. It’s still a better day hearing that you’ve had that much of a positive impact on someone’s life.

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Healthcare Update — 02-01-2016

Another example of why Dr. Google and the links Dr. Google produces may lead you into poor choices for your health care. Some sites scrape the Web for keywords about drugs and side effects, then use a program to combine the pages in a manner that may cause patients to stop taking the medications. Very informative article! Dermatologist accused of rubbing his genitals against female patient’s thighs during examinations uses unique defense – his huge gut covered over his penis, making it impossible for him to rub his genitals against the womens’ legs. That defense backfired. The doctor had to go to a urologist for a formal examination and the size of his penis – a whopping 2.5 cm (a little more than an inch) was published in a Toronto newspaper. Even worse, he was then given a chemically-induced erection and forced to “assume various positions” to see if his penis was visible. I just shake my head in disbelief when I read some of these stories. Your tax money hard at work. NASA spent $80,000 to see what effect space flight has on herpes virus. I was going to ask how they cleared a certain TV commentator for rocket travel, but then thought better of it. Wouldn’t want to be unprofessional, now, would I? More of your tax money at work. NIH spending more than $400,000 using “state of the art technology” to send texts to Latino men telling them to exercise more. What’s the risk of letting algorithms judge us? Once people know the algorithm, they game the system. But algorithms also cause a chilling effect on behavior. Stifle dissent. Make the people judging you happy so your score goes up. That doesn’t work so well in certain arenas, though … including medicine (hack hack Press Ganey cough). An older article, but interesting nonetheless. Nine things you didn’t know about cursing. I saw an experiment about one of them – how swearing helps alleviate pain. About 0.7% of the words we use during the course of a day are swear words. That seems like a f*cking lot to me. Larry the Cable Guy contributing to the kidney disease and fractures of elderly patients? All of those proton pump inhibitors (such as Prilosec, Protonix, Nexium) may help with your reflux symptoms, but they also increase your risk of developing infections like Clostridium difficile (“C. diff”), increase the risk of chronic kidney disease by 20-50%, cause decreased magnesium levels in your system, and contribute to osteoporosis and fractures.

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