prescriptions

Al Franken, the humorist-turned-senator once published a book that was titled something like “Oh, the Things I Know!”.   Indeed, by the time we reach parenthood, it is truly amazing what we keep up there in that attic of a brain.  Here is a brief selection of things about the practice of medicine that I have had to discover for myself or never quite figured out, including clinical pearls, aphorisms, dictums, platitudes,  mysteries and conundrums that have somehow found their way into my own cranium and are constantly trying to escape.

If you are called for a consult, don’t accept the ostensible reason as it comes from the student, nurse or P.A.  I have learned that rarely when I arrive is the problem what it was purported to be. As in everything else in life, “Nothing is as easy as it seems or as simple as it sounds.”

Once you are out of your training, you no longer find yourself an object in the chain of blame. You have reached the pinnacle. But if you are not at a teaching hospital, you must devise a new paradigm. My own goes as follows:  ”If anything goes wrong, first blame the patient. Then blame the equipment. If that doesn’t work, blame the anesthetist,  and if that doesn’t fly, blame the nurse.  And only if all else fails, yourself.

I have observed that “All patients, even if moribund,   look improved sitting up in a chair if the last time you saw them they were in bed.”

How come they never teach you how to pronounce someone dead? My first day on the job as an intern, when I was called at 1 AM to do so, I had to improvise. After entering the vacated room (aside from the dead body) and certifying for myself that the patient had no pulse or respiration, I proceeded to pronounce: “By the authority vested in me by the Johns Hopkins School of Medicine and the New York State Board of Medical Examiners, I hereby pronounce you dead.” I immediately heard raucous laughter from the nurses in the hallway, who informed me that pronouncement only required my filling out a form.

If you become a consultant, always remember what is expected of you: “Consults are requested for two reasons only: ‘Please make this patient’s problem go away”‘or ‘Please make this patient go away’.

Why did they never teach you how to open one of those Johnson & Johnson band-aids with the red string? I always end up pulling it out.

Regarding the standard recitation of the physical exam, some things they teach you are just plain useless. If you ever see an adult patient in your office for a scheduled visit who isn’t “normocephalic and atraumatic”, go immediately and buy a lottery ticket.”  Such occasions are unprecedented and augur momentous events.

What in the world is “walking pneumonia”? I can’t find it in my Principles and Practice of Medicine text and it doesn’t seem to have an ICD-9 code. Maybe they’ll put it in ICD-10. For that matter, I have never made a diagnosis of a “nervous breakdown” or “exhaustion)”either.

“Never ask a patient if he is feeling better before finding out if he has actually obtained and taken the medicine you prescribed.” Otherwise you might say “I’m glad to hear the medicine is working” and receive the reply “Oh, I never filled the prescription.” or “I filled it but I was afraid to take it until I saw you again after I read the warnings.”

The topic of how to charm a patient could occupy an entire post in and of itself.  Here’s one dictum I have developed. “Humor always breaks the ice. If you are a male physician seeing a married man, make jokes at the expense of your wife. If the patient is a woman, make yourself the object of the joke, especially if you can quote your wife. If both husband and wife are present in the exam room, make fun of husbands if you know what is good for you.”  Female physicians have to write their own rules, but Borsht-belt style humor is not generally required of them. As a matter of fact, I haven’t any idea what women patients talk about with their female doctors, but I suspect the topic of husbands doesn’t come up unless they are  a problem.

If you are a specialist, when providing all hospital consults, visit radiology before you see the patient, not afterwards. You’ll look smarter, do a better note, and you’re going to have to go there anyway.  I have  learned over the years through great inconvenience not to follow the usual sequence of history, physical and laboratory data in gathering evidence that I was taught in school. As I tell my students, “Always visit the radiology department before seeing the patient in consultation. There is much that doesn’t get into radiology reports. That way you won’t have to change your opinion to accord with the facts after rendering it.”

Not a hard and fast rule, but patients over 60 can be addressed as Bob and those under 50 as Rob. Unless they go by their nickname, which is usually their middle name. If so, enter that in your chart. It impresses patients if you know their nickname.

For further wit and wisdom, a great compendium of advice and humor that I wish to credit for inspiration, although I don’t agree with all its advice, is entitled “Kill as Few Patients as Possible (and fifty-six other essays on how to be the World’s Best Doctor by Oscar London, MD, WBD” , published in 1987 by Ten Speed Press and excerpted in Medical Economics Magazine. Perhaps you can find a copy on Amazon or eBay.

Part of the well-known oath we swear upon receiving the degree of Doctor of Medicine is that we will honor those who taught us this art. It occurred to me last month as I was preparing for Thanksgiving how many thanks I owe to those who have taught me to be the doctor I am. Some of them were physicians and some were patients. Some meant to teach and others did so without realizing it. I meant to post this on Thanksgiving Day, but as usually happens, I was on call and things got busy, but I still think the topic is a propos. So today I want to thank some of the people I have learned from in so many different ways.

First there were my schoolteachers going as far back as elementary school . I owe my early interest in anatomy to my fourth grade teacher Mrs. Raynor who undertook to  dissect a cow’ s heart in front of the gathered class, demonstrating the valves and chordae that tethered down the mitral valve leaflets.  Mrs. Veigel, my sixth grade teacher, whereever you are, thank you for inspiring confidence in my ability to help others and supplying me with the first contributions to my collection of adages, aphorisms, and old saws, which have served me well in speaking with my patients colloquially and to which I have added an abundance and even made up a few of my own.

My first medical experience other than as a patient was when I volunteered to be a phlebotomist at a community hospital in Rockaway, Queens in order to polish my extra-curricular credentials as I pursued my pre-med studies. In that small, squat and squalid hospital I was welcomed eagerly by the phlebotomy team without any qualifications, to help the overtaxed LPN’s and technicians, if only for a couple of months.The woman who taught me was head of the team and I believe she was an LPN. Somehow she was able to get me past my initial reaction to the sight of blood and my flinching from inflicting pain on anyone. She patiently taught me the skill of drawing blood with the newly invented vacutainers and then with “butterfly” needles, first from slam-dunk antecubital veins to smaller ones on the back of the hand.  In those days the oral anticoagulant Coumadin was in wide use for conditions we now treat with injected Heparain, and it required daily monitoring of blood clotting, so there were many people who needed their blood drawn.  She herself was tough, caring, always full of good cheer, and constantly on the lookout for ways to instruct. She even sneaked me into the pathology department to stand behind the residents, all foreign medical graduates, to observe an autopsy. I must also thank the many patients who gladly suffered my early practice on them just because it even gave them some pleasure to have a young, handsome man (in their eyes), be their “vampire” as so many of them called us. I search my memory but I cannot summon up her name. What I do recall is learning at the end of my stay that she was very ill and had been hospitalized at Kings County Hospital in Brooklyn. One of the other phlebotomists took me along to visit. To my questions during our ride about the nature of her illness, my companion would only divulge that it was due to a habit she was unable to break. I wish I could say my final words with my teacher were an unforgettable valedictory, but all I can remember was her telling me I would be a great doctor some day. A week later she was dead.

As a third-year medical student on the wards at Hopkins, my best teachers were for the most part the patients. We were charged with “following” the patients, which I didn’t at first understand, because I couldn’t see how I could learn to treat people if no one would teach me how to do things to them and how to order others to do so. So follow them I did, to the radiology department and back to their rooms, doing histories and physicals that occasionally someone took the time to critique. EveAt that early stage in my career, my efforts at constructing a narrative at the expense of hitting every element cost me points. Perhaps our system of bullet points for billing codes was already in its infancy.  I got to follow the interns and residents on rounds, mostly to be ignored. But I learned a great deal from the patients in spite of what seemed to me to be abysmal clinical teaching. One man with small cell carcinoma of the lung liked to call me his doctor, though he well knew my role, because I was the one who stopped to explain things to him. Another young woman said, “Dr. Sack, you had best keep that stethescope of yours in your pocket if you want to put it on me, because that thing is COLD!”.  I carried my stethescope in my pants pocket for the remainder of medical school, internship and residency.

There was one resident at Hopkins who did make a big impression. His name is Lou Frees (sp?), and he probably doesn’t even remember me. He sat in the day room of Osler 4 with the interns, smoking his pipe, an affectation that at the time  looked to me as natural as if he had been born with it in his mouth, and made pronouncements and gave orders. He must have been all of 29 years old , but he looked to be the eyes of age. Uncounsciously, I think I pereceived him as a Mark Twain – like figure. He spoke in a colloquial manner that I quickly came to admire and then adopt. I could see how he immediately put patients at ease with how he spoke to them regardless of what he had to say. To this day, I remember him saying things like, “I’m going to look you over” as he picked up his stethescope, or “Let’s take a gander at you.” This began my study of how to use words to put people at ease in the exam room. I have since learned to adopt whatever the patois might be of those I see as patients, whether it be a machinist from Maine or a PhD from Philly.

I owe a debt to the interns and residents on the wards at Baltimore City Hospital for teaching by example, but this was much more literal example. It was the first time, and not the last, that I heard the words, “see one, do one, teach one.” I’m still not quite sure what gave them the trust in me to allow me to do  thoracentesis, paracenteses , pleural biopsies and lumbar punctures with only the most brief and casual of instruction , but I assume that it was simply a matter of too many patients and too little time. I can only thank God that these procedures all came off at least apparently without mishap.

I remain indebted to Dr. Ira Morris, who was then leading up one of the first HMOs in the nation in the slums of East Baltimore . I was at a low ebb in my clinical confidence and one of my advisors suggested doing a rotation with him. That  experience gave me the assurance I  needed to look after people without another physician in the room.  But perhaps the greatest debt that I owe in medical school is to one of my teachers who never actually taught me anything directly other than to have that confidence in myself . My student advisor, Dr. Philip Tumulty,  was a revered member of the faculty and was known for being a consummate clinician. He wrote a textbook on how to be an effective clinician, which I have read and reread when I was in school and many times since. He repeatedly assured me that I would make a great doctor, although I felt at the time he hardly knew me and that he was only saying so out of kindness. In retrospect, I can be sure that he would have been kind, regardless of whether I merited such praise.

The doctor who most of all deserves my thanks and gratitude was Dr. Ezjel Lederman, worked for 40 years in southern Brooklyn as a family doctor and who became my father-in-law.    He was nothing short of a giant of a man in every respect.  He was trained in post-war Germany in an era when clinical diagnosis relied upon physical examination and he finished his career in the era of genetic engineering and  magnetic resonance imaging.  Every week he read the New England Journal of Medicine religiously and studied the CPC as if it were the Sunday crossword puzzle. There were many dinners at the Lederman household when the conversation was one of spirited dispute between him , his two physician sons and myself about the difficult cases that he had seen that week and how they should be treated.  What I learned from him as a physician cannot be summarized in the remainder of this post, so my thanks to him here are merely a promissory note for  a fuller account that I hope to render. sometime soon.

In an age when electronic charts and ever more burdensome regulations threaten to remove all meaning from our profession, let us remember what a privilege it is to be entrusted with the lives of others. Even when we know there is little we can really do to alter the course of events, we must remember that our patients don’t always know that, and we are all they’ve got.

Well, here I go again. I’m about to install an electronic medical record for the second time. I installed the first exactly 10 years ago this week. And boy am I nervous! (And boy is my right index finger tired!)

I am nervous about what I know is to come, from prior experience, and about what I don’t know is to come, because every electronic record is different, and because I now have not one but two partners looking to me to have configured it perfectly. (Remember the known unknowns and unknown unknowns our old friend Donald Rumsfeld spoke of? I have to grant he was right about that, if not much else.) After having put in about 50 hours, I can tell the new system won’t be even close to perfection. The last one cost me 200 man-hours. But the vendor tells me it is unrealistic to expect to get it right the first time; every practice they work with spends the first 6 months polishing and refining. I know that better than anyone.

But this will not be a rant about electronic medical record software in general or about its influence on medical care. I already did that one a year ago.  Instead, I want to share a response I gave at another website to the blogger whose commentary I found interesting, valid and provocative, as well as to the substantial commentary that followed ranging from cynical to outraged. That part I disagreed with. So here is my take on the original topic.

I wrote:  “I’m sympathetic with all tht has been said by the commentors but I think there is a level of hyperbole and hysteria in their reactions to EMRs. I have used one for our 3-man practice for 10 years, and because it does not qualify for ‘meaningful use’, we have had to replace it. After a few months of searching and 3 site visits we selected one that is set to go live in 4 days. Naturally, I am quite apprehensive. The first time around we were slowed substantially for several weeks. I put in over 200 hours configuring it, and I don’t see that the new one will cost me fewer than that. The old one had no order-tracking – i.e., the ability to follow-up on orders to see if they were done and what the results were.  The new one does that, and  I have worried for 10 years about the lost blood test, or more likely, the one the patient failed to go for.

“The new EMR still generates a note that looks robotic in authorship, just like the old one, but it does look a bit neater and “prettier”, if such can be said about a medical report. And although the interface is seemingly more complex,  it is more powerful and customizable.  The old system and its replacement both force us to think about the list of possible diagnoses and lab tests that might not have otherwise entered my mind. They both allow me to edit my note at the end of the day, unlike ones that I simply dictated before 2002. They both allow me to use Dragon Speech, and I have been using this voice-to-text  application fairly happily these 10 years(although I have to watch it diligently as it does commit grievous mis-transcriptions every few lines). One of my partners, who prizes speed over completeness, is worried greatly he will have to slow down, and he will for a while. But he has been clicking on ‘non-contributory’ or  ‘ROS essentially negative for 14 systems’ for the past 10 years and I doubt he will change.

“I am not worrying about the questions I have to ask my patient for my new system to qualify for  meaningful use as specified by the new healthcare law, the way everyone among the commentors who are  already using one of the new EMR’s seemed to be.  Maybe I have not yet experienced it for myself, but I am planning to have staff enter most of the past history, review of systems, and other important data.

“Of course the use of an EHR will not offer the kind of efficiencies we are hoping for yet. We will need new generations that allow me to view the blood count that is in my referring doctor’s EMR so I don’t have to order redundant studies or have my staff nag his staff to fax the reports. We need better prescribing abilities that don’t set of alarms about drug interactions for every pair of medications prescribe, to the point that frustrated physicians disable that feature.  We need computer-aided diagnostics.  Of course we have a long way to go. And I know I will want to throw the tablet through the window at least once next week, as I did for the first 6 months the last time around. But overall, I am still hopeful.

“And stop blaming ‘the government’ for everything that’s wrong in medicine. Without “government”, we would have no Medicare  – and no clean air and water, for that matter. So to all the incensed commentors, stop all the grousing and make some constructive suggestions! The problem is not that we have the wrong incentives, but that we need new and better incentives for my colleagues to remain in primary care and for new trainees to enter it. Forgive me, but as someone who can hope to see his internist retiring before I expire, I would prefer not to see a physician “extender” when he goes. But that’s a whole ‘nother rant.

And thus endeth this one.

I read a few months ago that the number of available iPhone apps had exceeded a million, with new apps now appearing that are intended to help sort through the mountain of other apps. We have reached the age of meta-apps.  Parenthetically, I have always loved that “meta”concept. In college, when people asked why I majored in philosophy despite the fact that I was pre-med, I explained that my intention was to become a metaphysician.

In any case, there are now many thousands of medical apps, and the number seems to be growing arithmetically! (Perhaps it was exponential at first, but I suspect the viral replication phase for apps has peaked, so anyone who uses the term exponentially at this point probably needs to review their 8th grade algebra.) In spite of this seeming  plethora of handy apps, there are still a few I have yet to encounter and would like to see created, although I will probably receive some comments on this post alerting me to the fact that some of what I am looking for has already been produced.

So here are, in no particular order, 7 apps I would like to see:

1. Hold-It for Docs. Do  you play the “hold for the doctor” one-upsmanship game of who waits for whom when you try to reach a colleague on the phone? How often has your secretary buzzed you in the exam room to say “Dr. So-and-So is on the phone for you”, you pick up with “Hi, Tony, how are you?” and Tony’s secretary says, “Just a moment, Dr. Sack,  I’ll put him on”?  Then you wait for your colleague to come on the line. You want to sound welcoming to your referring physicians but by that time you feel like an idiot repeating your greeting with an enthusiasm made stale by the wait. Why not call back at your convenience? But then you’ll still face a long wait on hold, assuming you call yourself. Instead, have your receptionist make a policy of saying you are on another line, promise a call back in a minute, and have her let you know of the call. Then, with this app on your iPhone, you tell Siri to place the call.  After you have had a couple of chats with that doctor, this handy add-in learns to recognize your colleague’s voice, monitors the line, and switches to speakerphone only when Siri recognizes him or her.

2. Visit-Minder 1.0 This deceptively simple timer can save valuable minutes with each encounter and your patient will be none the wiser. Taking a thorough history can be distracting if, like many physicians,  you are somewhat compulsive. That wall clock is fine for reminding you that you are running late, but what if you had a way of really budgeting your time within the visit? With this attachment, your a bluetooth device (hardware is extra) senses by signal strength when you enter the exam room and starts a timer that you can set to vibrate after specified interval of your choosing. Keep your phone on vibrate and you will be discreetly reminded that the family history need not include second cousins once-removed and it is time to move on to the exam…or the formulation and plan…or whatever. Multiple intervals can be set.

3. Drug-Buster Pro  I haven’t yet decided what this one does but I really like the name. Can I copyright it? Don’t you dare steal this idea, because I already e-mailed it to myself in a postmarked sealed virtual envelope.

4. iNterrogator.  This one requires a small external attachment. Analogous to the Square (TM) card readear attachment, this device can interrogate a pacemaker and email a printout to your cardiologist. Actually, this might be a serious good idea. Might even be on the market. Medtronics, are you listening?

5. Global Risk for Google.  No, this is not your father’s game of world-wide domination. This pocket prognosticator shouldn’t be too difficult for Google to produce with their army of saavy statisticians. You’ve seen risk calculators for cardiac events, breast cancer, prostate cancer, life expectancy, and numerous other gizmos. But none of them are really adequately individualized or global in nature. We need something that will pull together all the relevant data for your patient and then, in the same way that mathematical models test whether their conclusions are influenced by altering assumptions, inform you and your patient of how much impact any given measure will have. The app would need to be able to pull in not only their medical data and lifestyle parameters, but shopping habits off Amazon, your facebook visits, the patient’s motor vehicle registrations, and where they spent money on their credit cards. Given the nature of the snooping that Google is up to already, it really doesn’t seem as though it would be that difficult! Heck, if Google can predict what products you will buy, why not have them predict when you will buy the farm?

Here’s how it would work: You have your pateint punch in a few passwords that will be safely stored by Google, enter a few items off the history, physical and labs, and poof! Their own individualized Kaplan-Meier curve.  I know we are supposed to ask about seat belt use, but does that really matter if your patient is 68, has COPD, still smokes and drinks, and rides a Harley to your office? Will quitting smoking make a difference? Will having a colonoscopy matter? Why not have the means to provide him with an honest answer!

6. ePocrates Translate (apologies to ePocrates).  Everyone knows what a great utility ePocrates has become. I can’t live without it. But suppose you want to tell your patient the 10 most common side effects of the drug you are recommending? Why waste time reading it to them or having them fiddle with their reading glasses as you scroll? And if there is a language barrier?  This little add-on matches ePocrates with a text-to-voice translate tool that allows you to read the list in Spanish, Chinese or Cambodian, and you can set the speed anywhere from deliberate and thoughtful up to Viagra commercial voice-over.

7. PhonyPage 1.0.  Most docs have had the experience at one time or another  of being trapped in the exam room with a patient who won’t stop talking and can’t be distracted, interrupted, or in some cases, even conversed with on a rational basis. Some of us have kind clairvoyant medical assistants who detect the problem and interrupt us for some “urgent matter” to get us out of the exam room. For the rest of us, there’s PhonyPage. On your iPhone, pressing the home button twice calls up Siri. But how about an app that emits a beeper-like tone when the button is pressed 3 times in rapid succession? Make an excuse that you have been paged for an urgent matter and dash.  Our slogan: Three strikes and you’re out of here.

These suggestions are meant to be at least partly tongue-in-cheek. But maybe some enterprising app-maven will run with one of them. I’ll let you know in my next few posts  if I hear of anything.