In the wake of the recent flood of allegations of sexual harassment against so many men in so many different positions of power, the refrain has begun, “The rules have changed.” Frivolous concerns about office holiday parties threaten to trivialize the remarkable transformation of women finally being believed, and men finally beginning to be held accountable for their actions. The rules have not changed. What has changed is that, at long ...

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I had an upsetting encounter the other day with a 22-year-old woman, who mentioned (secondary to the purpose of the visit) that she was pretty sure she had breast cancer. Why did she think that? She’d found a lump in her breast. (Somewhat unusually for the specific setting, she let me do a breast exam. All I felt was a small area of lumpy breast tissue, possibly a fibroadenoma at worst. Of course, ...

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Everyone has their abscess story. Tales of pressurized pockets of pus abound. Trust me: However far-fetched they may seem, they’re not. I had one such experience last week in which a man came to me with a painful red swollen lump on his back. It was about 2 inches in diameter, angry and fluctuant (softened) and ready to be drained, which he pleaded with me to do. So I did. Although ...

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It’s that time again. As the year draws to a close, various insurance plans try to finish collecting data to calculate bonus payments as “incentives” for “Quality” care. The only problem is that, as I’ve written before, all of their “Quality” measures are in fact nothing but proxies for cost, most of which I have no control over. Back in the 1990s ...

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Apologies to Mark Twain, but reports of the death of private practice are somewhat exaggerated. There are still plenty of us around, and most of us are making out quite well. Not all, though. I’m quite sure the murmurs of discontent have reached many ears by now. So much so that many doctors unhappy with the status quo have taken action. One such action is to “go concierge.” Concierge practice, also known ...

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Closing a medical practice to new patients is like cutting off the very top of a tree. It’s the beginning of the end. The top of the tree, the crown, is where the newest leaves are. It’s also the part that continues growing ever upward, at least until it reaches it’s maximal genetic height, depending on environmental factors like the availability of water and sunlight (both of which also depend on ...

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Dr. Robert Centor has an important post about hubris. It’s not a long post, if you want to click through and quickly read it. It’s about the danger of overweening pride and overconfidence that can come from blindly believing the praise that is often heaped upon us by those in our care. Essentially Dr. Bob is saying that we must avoid believing all the wonderful things our patients ...

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"How many patients do you have?" I’m not sure what you mean. How many patients do I see on average each day? About twelve. "No. How many patients do you have?" Let’s see: Last week I saw about sixty patients altogether. Five of them were new patients. "No, no. How many patients do you have on your panel?" My panel? I don’t know what you mean by that. I don’t work as an employer in ...

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Poor bored government. So much time on their hands; so little real work that needs to get done, all they can do is micromanage poor physicians like me to death. Well, they can try. For its first forty-five years, Medicare was (in)famous for the very narrow limits on things it covered. It would pay for medical care when you were sick or injured, and that was basically it. No preventive care. ...

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For the moment, I still take almost all insurances in my practice. And as long as I see enough patients (i.e., as long as the phone rings) I’m doing OK. I’ve been billing electronically with a free clearinghouse for about five years now, and things are pretty good. Over all these years, I’ve only dropped one insurance company. It covered a fair number of patients, including many of my ...

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shutterstock_216140242 Question from a reader: "What are your feelings about when a patient breaks up with you? I love love my doc, but ..." Patients “break up” with me all the time. Well, not all the time, but it’s not uncommon. There are many reasons, some of which are under the patient’s control, and some which are not. Moving across the country is ...

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Life is all about beginnings and endings. One of the biggest draws of obstetrics as a medical specialty is the fascination with the birth process as the beginning of life. The other extreme ... well, let’s say in this particular place and time in history, it’s still something that catches people unaware. Too often filled with dread and loathing, we approach the death of patients as a foreshadowing of our ...

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Who is a PCP? (And does that second “P” stand for “physician” or “provider”?) Who gets to say? Does it matter? Perhaps we should start with some basic qualifications: The degree of MD or DO, the satisfactory completion of an accredited residency in family medicine, and successfully passing the written examination of the American Board of Family Medicine (ABFP, an organization distinct and independent of the AAFP). Hard to argue with those. How ...

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Dear patients, First of all, thank you for calling for an appointment. Seriously. Ever since I’ve gone open access, if the phone doesn’t ring I’m toast. And thank you for your interest in preventive care. The fact that it’s now free (well, no cost to you at time of service: trust me, it’s not “free”) has probably motivated more of you to call. That’s OK. But sometimes it seems that your ...

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I’ve just finished sitting through a wonderfully aptly named lecture: Probability and Statistics, in which, among other things, we learned (again) that the utility of various clinical tests depends at least as much and generally more on the patient and condition involved than on the specific test itself. From stress tests to mammograms to PSAs, the relationships of true and false positive and negatives, positive and negative predictive values all ...

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In news to absolutely no one with an iota of common sense, the purported physician shortage isn’t actually one of numbers, but rather a problem of distribution. Per this article by in the Washington Post:

Critics of doctor shortage projections have argued for years that the problem is actually poor distribution of physicians, with too many clustered in urban and affluent areas and too few in poor and rural areas.
Doctors prefer to ...

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shutterstock_115761625 Yikes:

The Obama administration on Monday announced an ambitious goal to overhaul the way doctors are paid, tying their fees more closely to the quality of care rather than the quantity.
Holy crap: They’re really doing it. Or trying to do it. Who the hell knows what they’re trying to do? Not “them,” that’s for sure. The United States government via the Department ...

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Ever wonder what your doctor is thinking while taking your history? If we’re doing it right, we’re looking at you instead of a computer. We’re making appropriate eye contact while displaying welcoming body language. And we’re letting you tell your story with as few interruptions as possible. Clearly we are listening intently, but did you ever wonder what’s going through our minds while you’re speaking? I’ve been thinking about this lately ...

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shutterstock_156241253 It’s really quite easy to kill a doctor. Here’s a step-by-step process guaranteed to succeed at least 400 times a year: Start early. Be sure to denigrate medical students whenever possible. Even if they’ve come to the profession later in life and have accomplished all kinds of amazing things personally and professionally (which don’t count, of course, since those are other professions) they don’t know squat ...

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News non-flash: A comparison of various diets (low-carb/Atkins, low-carb + low fat/South Beach, low calorie/Weight Watchers, and whatever-the-hell-the-Zone-diet is/protein-carb ratio) shows no difference in long-term outcomes, defined as sustained weight loss, with the attendant presumed decrease in cardiovascular risk factors and events. Sorry, no great surprise here. But I think it’s because nutrition research has a huge blind spot: not adequately controlling for type 2 diabetes/metabolic syndrome. Let me explain. I have a hypothesis that ...

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