Many readers know that I co-authored an Annals of Internal Medicine article on retainer medicine.  The article has received (as expected) mixed reviews, because the concept causes angst for some physicians. I believe (and I will not speak in this rant for my co-author) that retainer medicine emerged because of the current payment system.  Retainer medicine is a response to burnout.  Yes, many retainer physicians are making more money.  Is ...

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I am a third world doctor. My patients have first world expectations. Somewhere in the middle, I end up working too hard and then going home feeling cheated. For I too have expectations. I am in a tension between the reality and my aspirations. In Jamaica, health care is free. Day after day, and night after night its freeness is confirmed, tested. But the system is inanimate. It doesn't feel its own failure, ...

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Question: What is the most important thing concerning residents finishing training and looking for a practice in 2011? a. Feeling of insufficient medical knowledge b. Health system reform c. Educational debt d. Availability of free time e. Dealing with patients If you said “d. Availability of free time,” you are either very perceptive and in tune with today’s young doctors or you read an article about this in American Medical News. According to survey ...

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At the University Hospital in Madison Wisconsin in 1938, a patient was dying from a very painful bone cancer which had produced fractures. The young interns knew that more morphine injections were needed but they feared they might be blamed for giving a lethal dose. So a tacit agreement was reached. Every hour or so,one of them would come into the patient's room and give a shot of morphine. This ...

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Let me start by saying that I love my father dearly. We have an excellent relationship, and talk regularly. So there’s no bitterness in this post, nor any desire to engage in armchair psychology. My father, now retired, was a general and thoracic surgeon, who was triple-boarded in critical care, and ran a trauma unit in inner-city Philadelphia. He was in private solo practice for most of his career. He worked ...

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The glittering commercialism and noisy cheer of the holiday season can be stressful for any of us.  But for the parent who’s lost a child during the past year, facing the first Thanksgiving and Christmas with an empty place at the table can make already unbearable grief so much worse. No one in modern America expects a child to die.  Children only die in nineteenth century novels and third-world countries, or ...

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I’ve been involved in clinical medicine for more than 20 years and during this time I’ve come across numerous situations that created stress, or emotional upheaval within myself, and even times of burnout.  At one point, I came close to permanently leaving my chosen profession.  The culture of medicine is not geared towards allowing health care providers to de-stress, acquire emotional support, or discuss in an encouraging environment various conflictive ...

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I recently admitted a patient with a pulmonary embolism. Before heparin drip was started, my attending ordered a hoard of eccentric, non-indicated hypercoagulable workup in the hope of avoiding the effect of heparin on these test results, including phosphatidylserine antibody and methylenetetrahydrofolate reductase DNA. I watched in horror as the nurse drew out approximately 13 tubes of blood, since each test needs its own tube. On rounds, the attending of course ...

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Last year I wrote about a few strategies for decreasing costs in the operating room.  Since being in fellowship operating many days per week, I’ve come up with a new idea, this time a bit more radical. In Freakonomics, Leavitt and Dubner posit that in all things, human beings respond to incentives.  If you want to understand human behavior, all you have to do is identify the incentives that drive ...

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It is almost impossible for me to believe that my views on primary care in the United States have changed so radically in fifty years.  When I graduated from medical school in 1961, I was determined to become a primary care doctor. I completed residencies in both medicine and pediatrics to prepare for a career as a general physician in rural Vermont. That dream was put on hold by an ...

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