I am so sorry I didn’t make this different for youThe telephone message arrived in my EMR’s inbox. A patient’s daughter had called and wanted to ask some questions about her mother. Her mother, Louise (name changed), had died about two weeks before. I hesitated before calling her, recalling her mother’s cancer course. Louise had been diagnosed with cancer at a relatively young age, in her late 40s. She received curative chemotherapy ...

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Question: What do you do when presented with abnormal lab results? Answer: Ask lots of questions. The nursing home just sent over a urinalysis on a patient of Dr. Carlyle. I am covering his practice for a few days. The test showed that an 82-year-old woman had 3+ white blood cells in her urine. “NKDA” was written in the margin, indicating she had no allergies. I sighed internally and called the nursing home. ...

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Our nation is highly polarized today, and often bitterly so.  Democrats rail against the GOP.  Pro-lifers face down pro-choicers.  Fox News disses MSNBC.  Isolationists push back against expansionists.  Traditionalists disdain the politically correct.  Free marketers duel against government advocates.  Carnivores deride the gluten-free crowd.  Martin Bashir trashes Sarah Palin, two proxies in a culture war. There's a philosophical divide among physicians also.  Would you prefer a liberal physician or a conservative ...

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No medical resident looks forward to working night float. The initial glamour of doing chest compressions in the rising light comes up against a litany of administrative tasks. As the glamour wanes, the gulf between the objective curriculum and actual practice widens. On paper, residents learn how to manage acute emergencies and learn deeper clinical reasoning. Actual practice, or the “hidden curriculum” of training, can be a different experience, involving ...

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There’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes. In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician? Let’s consider two fictional radiologists: Dr. Singh and Dr. Jha. Dr. Singh is a fast reader. Her turnaround time for reports averages 15 minutes. Her reports are brief with a paucity of ...

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As doctors we prescribe a lot for our patients -- pain relievers, medications for specific ailments, exercise, or vitamins. However, too often we forget the power of vitamin C: human connection. As a therapist and medical doctor for children and adults with ADHD, I don’t underestimate the power of employing a variety of treatments that treat the patient as a whole; this may include medication, recommendations about diet, exercise and lifestyle ...

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 72-year-old man is hospitalized for treatment of community-acquired pneumonia. Despite 4 days of treatment with intravenous fluids and antibiotics appropriate for the bacteria cultured from sputum and blood, he remains febrile with mild tachycardia. The patient subsequently develops mild hypotension and is transferred to the intensive care unit. Results of two ...

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OpenNotes is “a national initiative working to give patients access to the visit notes written by their doctors, nurses, or other clinicians.”  According to their website, three million patients now have such access, generally online.  Participating institutions include the MD Anderson Cancer Center in Texas, Beth Israel Deaconess in Boston, Penn State Hershey Medical Group, Kaiser Permanente Northwest, and several others. Patients with a premium account in the My HealtheVet program at the VA have access to outpatient primary ...

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There’s been an ongoing court battle here in the state of Florida over whether physicians have the right to ask families about gun ownership in their home. The Florida Privacy of Firearm Owners Act was signed into law by Governor Rick Scott in 2011. This law prevents pediatricians from inquiring about gun ownership and discussing relevant safety information regarding how guns are stored and how to protect children from accidental injury. ...

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At the critical time when our nation has made meaningful and measurable progress against colorectal cancer incidence, threats to reimbursement for colonoscopy screening for Medicare beneficiaries are looming, which may jeopardize the effectiveness of public health strategies to increase screening and prevention of colorectal cancer in the U.S. New data from the American Cancer Society indicate that colorectal cancer has declined by 30% in just the last decade among those aged 50 ...

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“Doc, can I ask you one more thing?” These words are classic symptoms for those patients suffering from the “one more thing” syndrome. We’ve all been there. The visit has ended, your hand is on the doorknob, and you’re about to leave the room. Precisely at that moment, your patient stops you and says he has one more thing to discuss. You think to yourself, "No! I almost made it out of ...

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Part of a series. Primary care need not be expensive and until the past few decades it was paid for out of pocket. Heretical perhaps, but it would be very useful to go back again to paying the PCP out of pocket directly by the patient, preferably with a tax-advantaged health savings account (HSA). A County Doctor wrote on his blog:

I can freeze a couple of warts in less than a ...

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Top stories in health and medicine, August 8, 2014From MedPage Today:

  1. Ain't No Sunshine in This Act. Robert Harbaugh, MD, just wanted to do the right thing.
  2. Gut Bacteria May Aid Testing for Colon Cancer. Analysis of gut bacteria in stool samples improved detection of colon cancer or precancerous polyps by fives times compared with a standard fecal occult blood ...

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I love old people, but I will not accept Medicare I love caring for patients -- young and old. And though I may not accept your insurance, I will always accept you. I’m still happy to care for Medicare patients even though I opted out of Medicare in 2006. Why don’t I accept Medicare? Let me fill you in. I do not accept Medicare because: Medicare treats physicians as criminals -- guilty ...

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I recently did a tally.  Since starting my locums adventure last year, and going to full-time locums in January, I’ve worked in a grand total of 11 emergency departments.  Let me qualify that for the occasional visitor to my blog.  I decided to do this for purposes of flexibility, finances and a much needed change of scenery.  Not because I’m a problem physician, or unable to do the work in ...

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Not long ago, Tracy Hume, a freelance writer who lives in Greeley, Colorado, sent me an email posing this question: "Do ER-affiliated urgent care providers ever try to escalate patients to the ER when it is not medically necessary?" It seems that over the July 4th weekend, Tracy’s teenage son was complaining of a headache, nausea and abdominal pain, and was vomiting. He doesn't complain much, she said, so thinking that ...

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My grandmother recently went into hospice care. At 94, she has lived a longer, richer life than probably most of us will ever hope to. Given the nature of the work I do, end of life care is not a topic I’m unfamiliar with. Initially, I spent a lot of time asking my mother probing questions about the care my grandmother was receiving. I imagine I did this partly out ...

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Somewhere late morning, after rounding on my first day of internship, I received a call from my sister. “She wants to kill herself. What do I do?” We had been through this before with our mother, fifteen years ago, the week I moved out of her house. She ended up in the psychiatric unit as we packed our bags to move in with our grandmother. This time, fifteen years later, things were ...

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Dear new medical student: Congratulations! You are about to embark upon an exciting, life-altering experience, one you will never forget. You are about to join an elite group of people who will now be your peers going forward. You will be continually fascinated, and not a single day will go by from now until you retire that you aren’t challenged by something you have never encountered before. You will be solving problems ...

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Top stories in health and medicine, August 7, 2014From MedPage Today:

  1. Return to Warfarin Okay After TBI? Restarting warfarin (Coumadin) after a traumatic brain injury (TBI) improved overall outcomes despite the bleeding risk.
  2. Dietitians Take Aim at Food Industry Sponsorships. Andy Bellatti has been troubled by some of the continuing education programs he's seen at the Academy of Nutrition and ...

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