Wednesday, March 28, 2012

Dirty jobs

Every doctor has some area of medicine that they flat out don't like.  I am no exception.  In fact a lot of physicians choose their specialty not based on what they like, but rather by avoiding what they don't like.
As a medical student, I was dead set on going into family medicine.  All that changed, however, one dreadful day after witnessing an unpleasant delivery.  We had a very petite 16 year old female with gestational diabetes who was set to deliver her son.  All was going well - her contractions were regular, baby was doing well, and she was comfortable after getting an epidural.  Little did we know that she had a 9 lb baby squeezing through a birth canal that would have been too small even for a 6 pounder.  This kid's head was enormous.  I didn't have much experience at all in obstetrics, but even I could tell this was not going to fit.  As the head descended slowly down, I was told to glove up and 'stretch out the vagina a little bit.'  Ummm, what?  Ok, here goes nothing.  I gown and glove up, get the boots and mask on, and do as I'm told.  As I'm stretching things out gently, I feel the tissue start to tear under my fingers.  Oh geez.  That didn't feel good.  Blood starts oozing out, then it drips, then is really starts coming out.  Then she gives a big push and poop flies everywhere.  Miracle of birth my ass - this is disgusting!  About this time the baby's heart rate starts to drop and I really don't remember things too clearly from that point.  I got shoved out of the way by someone above me in rank and somehow they got this massive child out of the mother, but not without tearing the posterior part of her vagina all the way down through her rectum.  I stood there horrified.  This poor girl's pelvis was now opened from top to bottom like a book.  I'm not sure how her legs didn't just detach from her pelvis and fall off.  

Next thing I know my hands are getting extremely warm.  Recall that I'm in a gown, gloves, mask, and hat.  Wow, now my head is sweating, and my mouth is getting extremely dry.  For the love of Moses, why is my vision narrowing so fast?  Then it occurred to me that I might just faint if I don't get out of there.  And heaven forbid I faint and fall forward on the bloody battlefield in front of me!  Damn it all - I'm going down!  I rip off my mask, pull off my gown and gloves, and bolt right for the door as fast as I can.  I stumble out to the nursing station and fall into the first chair I see and put my head between my legs.  I wondered if this is what it feels like to die.  Seemed like a good option at that point - that's how bad I was feeling.  It was just then that I heard a nurse yell across the pod, "Oh my God!  The nursing student is about to faint!  Get him some juice!  He's pale as a ghost!"  I sat there for a good 5 minutes with wounded pride, sipping on my juice and contemplating my future as a family practitioner and having to deliver babies as part of my training.  No way, screw this.  I never want anything to do with that again!  Later that afternoon I walked over to the internal medicine department, set up a rotation, and the rest is history.

So I suppose it's good to get exposed to all sorts of nasty things so that you understand what you really like or don't like.  Looking back, I'm glad I had that experience. 

That's not the only thing that has grossed me out.  As a matter of fact, there's no shortage of things to be grossed out by in medicine.  The grossness is limited only by your imagination!  If I were to make a list of things that gross me out, it would look something like this:

6. Nonhealing wounds

Have you ever seen a stage 4 pressure ulcer?  How about an infected one?  Omg I can't handle the sight/smell/feel of these.  There are nurses/physicians who only deal with chronic wounds, which is just unfathomable to me.  I could never do it.  

5. Poop

Do I even need to explain this?  Believe it or not there are doctors out there who specialize in poop (gastroenterologists).  Wonder why they do it?  Because they get paid handsomely for it.  Cut their salaries down to primary care level and the specialty wouldn't even exist.  Think regular poop smells bad?  Take a whiff of bloody poop (especially an upper gastrointestinal bleed) or c. diff poop and you'll be gagging for a week.

4. Childbirth

Not so bad when it goes well, but it just isn't my thing.  As if making me physically ill wasn't enough, I also had a good pair of dress shoes ruined during medical school when a baby came too fast and I didn't have time to get my boots on.  I can still remember the feeling of warm, meconium-filled amniotic fluid bathing my lower extremities.  Yuck.

3. Unkempt obese people

There's nothing like examining between the rolls of a super obese patient and finding some strange, smelly, disgusting goo of uncertain etiology.  The closer you get to the groin, the nastier it gets.  Sometimes is so old that it's crusted over and stuck to the skin.  I think I just barfed a little bit in my mouth.

2. Mouths

Speaking of mouths, do you know what the dirtiest orifice on the human body is?  Actually it's the anus.  But the mouth is a close second!  For some reason I'm just disgusted by the oral cavity.  I'd rather be a gastroenterologist than a dentist.  Even mouths with good hygiene are repulsive.  One look inside a meth mouth can ruin my day.

1.  Vaginal discharge 

As gross as all the others are, this one takes the cake.  Hands down winner.  Not even close.  Can't think of anything that ruins my day more than this.  Thankfully this isn't common in the hospital, and if it's even an issue, it's usually something more serious than I feel comfortable dealing with and I usually punt to gynecology.  If you like emergency medicine, get used to it.  But thankfully not many people are admitted with vaginal complaints.   Clinic, however, is a different story.  When I see this chief complaint on the clinic schedule, I secretly hope that the patient doesn't show up.  If they do, then how I handle it depends on what kind of mood I'm in.  If I really don't feel like dealing with it, I refer them to gynecology.  I send cardiac patients to cardiology and surgical patients to surgeons, so why wouldn't I send a vaginal problem to a gynecologist?  I'm an equal opportunity referrer.  If there are people out there who like treating diseased reproductive organs (you know who you are, gynos and uros!), who am I to keep them from fulfilling their dreams?

One of the nice things about internal medicine is that you can always refer someone to a specialist if you don't feel comfortable handling something.  Is it cost-effective to refer problems to a specialist that in theory I should be able to handle?  Probably not.  Would the old-school physicians scoff at me for doing this?  Probably.  But I do it anyway.  I don't abuse it, and in fact I don't like to refer most things out unless I feel it needs to be addressed by a specialist.  But there are just some aspects of medicine that I'm not good at or don't like doing (usually they go together), and so I refer them out. 

I'm glad there are specialists out there.  I think I would get bored seeing the same things over and over and over again.  Each of us shoulders a bit of the unpleasant load and collectively we do a pretty good job of taking care of the 'dirty work' in medicine.

Lest I not give credit where credit is due, I should point out that the majority of the dirty work in medicine is not actually done by doctors.  We all deal with it and are involved to some extent, but by and large nurses handle most of the dirty work themselves.  I have tremendous respect for the work they do.  Day in and day out they clean, bathe, groom, change, wipe, and feed their patients.  And they are expected to do it all with a smile and treat them with the utmost respect.  So props to all the nurses out there for doing what you do, because I would be terrible at it.

Now that I've let you in on another secret of the inner workings of internal medicine, I hope you aren't displeased.  Remember, we too are human beings.  We have likes and dislikes, just like you.  And like it or not, it's part of our job, so we get it done.  Perhaps next time you see your internist and he has a referral printed out and signed before the word discharge even leaves your mouth, you'll know why.

Stay tuned.

Saturday, March 24, 2012

Death cookies

One aspect of medicine that I really enjoy is that no two days are alike.

Every day I see new patients with new problems and old patients with old problems.  And don't forget the old patients with new problems of the new patients with old problems.  You get the picture - nothing is ever the same.

This is especially true in internal medicine, where the spectrum of disease we treat is quite broad.  In one day, I can treat anything from a pesky wart to a life-threatening pneumonia in the intensive care unit.  I can help with your chronic back pain (ooooh how I loathe treating chronic pain) or treat your heart attack on the medical ward.  

Specialists may disagree, saying that there is a large spectrum of disease within their respective disciplines, which to an extent is true.   But get them out of their specialty, and they are pretty much useless.  Next time you see your cardiologist, casually mention the rectal bleeding that you've been having and watch him squirm - something akin to 'you should talk to your internist about that one' will flow naturally from his lips.  Or if you really want to see someone get uncomfortable, tell your neurologist about the vaginal discharge you are having.  Whoa!  No thanks!  They'll punt that one back to me in a hurry as well.  Point being that we have to know something about everything, which makes each and every day new and exciting because, like Forrest Gump said, you never know that you're gonna get.

For better or worse, administrative policies and procedures seem to change daily as well.  Some of them are for the better, and some of them are clearly for the worse.  This is not unique to medicine - you all know what I'm talking about.  It seems we can't go more than a month without some big change to our EMR that throws us all for a loop (I love you and hate you at the same time, technology).  And then there are the changes that are, well, neither good nor bad, but are just more changes.  I don't mind these so long as they don't move my cheese too much.  But there was one particular change that I noticed last week that really made me stop and think.  I'm still not quite sure what I think about it.  You decide for yourself what you think and let me know.

I had a patient that I was caring for die in the hospital this week.  She was in her 40's and had all of the sequelae of many years of poorly controlled diabetes - retinopathy, nephropathy and now on hemodialysis, vascular disease with below the knee amputation of a lower extremity, coronary artery disease, and so on.  If that wasn't enough, she was diagnosed with colon cancer 5 years ago and had 2 recurrences that were successfully treated with surgery and chemotherapy.  Just last week, however, she found out that the cancer had recurred for the third time.  Some people just have no freaking luck in this world.  As an old professor once told me, "Sometimes I think the Good Lord goofed."  You all know someone like this - it seems that all of the bad stuff happens to them.  Anyway, she started on chemo 10 days ago (third time's never a charm for chemo) and ended up terribly dehydrated from the nausea and vomiting.  On top of that, her immune system was so devastated by the chemo that she had almost no white blood cells circulating in her system and developed a terrible abscess and cellulitis of her arm.  She ended up in the hospital on my service with sepsis.  

This hospitalization was the last emotional straw for this poor woman.  She was tired of living.  She wanted to be treated for the infection, but didn't want any aggressive treatment.  On her second day of hospitalization, her already broken body succumbed to the overwhelming infection and she passed away peacefully.  None of us were surprised at the outcome and even expected it.  Her loving family was thankful for the care that she received.  They were understandably sad - yet relieved at the same time that her suffering was finally over.

Now here's where it gets a bit interesting.  I got to the hospital at 7am and learned that she had passed away sometime in the night when I wasn't there (on-call physician handled everything overnight).  The family was already gone by that time, so I didn't go to the pod where here room had been.  If I would have known that there were fresh cookies there, maybe I would have stopped by.

What? Fresh cookies?  You mean one of the nurses happened to coincidentally bring in a batch of cookies for everyone on the pod to share?  Ummm, no.  

A few hours later, I was chatting with colleague about this patient and she told me that she happened to be on that very pod earlier in the morning when she came in to work.  She noted that many of the nurses were eating cookies and asked who made them.  "Oh," she was told, "these are from the cafeteria.  They're the death cookies.  Do you want one?"

The what?  Death cookies?  Did I miss something?  Is this a joke?  Well apparently it isn't a joke, but I did miss something.  The hospital (recall the concept of constant change) has now decided to provide a batch of warm cafeteria cookies to family members any time a patient passes away in the hospital.  Yes, you heard that right.  Maybe it's been around for a while and I just never new it, but this was the first I have heard of it.

They've been around now long enough to be known by the nurses as death cookies.  I cringe a bit every time I even write that now.    

Have you even been present when someone passes away?  It's a very unique circumstance - one that I can't even really compare to any other that I've had.  For me, it's almost a sacred moment.  It's so much emotion wrapped into a brief moment.  If you've been through it, you understand.  It's hard to describe accurately.  But what I can tell you after seeing a lot of people die is that I don't ever recall craving sweets after witnessing a death.  In fact eating is about the last thing you want to do.  Maybe I'm abnormal in that sense, but I haven't ever seen anyone bust out the picnic basked after seeing someone die, so I must not be that abnormal.  

But cookies?  That just seems so weird!  We don't give them out on admission.  I've never seen anyone get them after a successful surgery.  I don't even think that my wife got any after the birth of our children!  So what's so special about dying in the hospital that warrants fresh cookies?  

The cynic in me instantly wondered if it wasn't some crafty policy drafted up by the risk management department.  Maybe studies have shown that lawsuits were significantly decreased by offering warm cafeteria cookies to families within one hour of death (p value < 0.0000001).  Perhaps I need to stay up to date with current literature better!  

Then I rebounded to the opposite end of the spectrum, thinking that maybe it was the idea of some sweet, well-intended nun who made it her life's mission to help loved ones in their grief.  Maybe she's well known for her homemade cookies.  Maybe they are symbolic to some particular faith. 

Then I remembered patient satisfaction scores.  If you aren't aware of these then you might be surprised to find out that hospitals, starting this year, will receive financial incentives from Medicare if they outperform their peers with better patient satisfaction scores.  

Am I jaded and cynical for even thinking that this could be the impetus behind the death cookies?  Surely money has never enticed anyone to do anything strange in this world!  But could they really be so shallow to think that no one would notice if this wasn't done in a genuine manner?  Then again, if that was the real purpose behind it, why don't they give unhealthy, yet satisfying treats to all patients when they are discharged home?  Omg I can't stand it anymore - will someone just tell me the truth and let me lay this to rest?  

It really doesn't bother me that much -  I tease simply for dramatic effect.  But at some superficial level I'm still curious as to the etiology of the death cookies.  I'm glad that the nurses enjoyed them.  I'm not sure that I even would have eaten one so early in the morning - especially after my usual morning breakfast of oatmeal and a big frosted donut (I love you whoever created donuts).  But I'll never look at those cafeteria cookies the same anymore, that's for sure.  And maybe with enough persistence and investigative fervor I'll find out the real story behind them.  And maybe it will be enough to restore my faith in hospital administrators - or even mankind - or maybe even in myself.  

Sunday, March 18, 2012

Not so foreign object

I like almonds.

Thankfully I've never had one get stuck in my mainstem bronchus.  An unfortunate patient this week wasn't so lucky.  

A 67 yo mentally challenged male was admitted to the ICU this week for respiratory failure.  He couldn't provide much history, and the caregivers only reported a fever and that he wasn't feeling well.  Chest xray showed a dense left lung consolidation consistent with pneumonia.  He was intubated, started on antibiotics, and transferred to the ICU.

Bronchscopy (small scope to look into the lungs) was done and revealed an unexpected surprise - a almond wedged in the left mainstem bronchus!

Here's a look at what normal vocal cords look like.  In order to get to the mainstem bronchus, the almond had be swallowed whole and then push right through the vocal cords.  Not an easy task!   The opening is about the size of an almond - imagine what that would feel like!

Fortunately the almond was able to be easily removed with the bronchoscope and the patient is doing much better.

Now here's where it gets good.  The physician sent the almond down to pathology for review.  This is standard procedure any time you suck gunk out of the lung, but I've never seen a foreign object sent down when it's identity was already known.

Nonetheless it made the trip down to the basement in its very own little sterile cup.

I have to explain a bit about pathologists before I go on.  They are an interesting breed of people.  Imagine the type of personality that finds joy in handling dead bodies and microscopic tissue samples.  Yum.  They are represented by both males and females alike.  Then men tend to have beards and thick bifocals at a higher rate than the general population and are generally soft spoken, serious, and deliberate with their words.  The women, on the contrary, don't stick out as much and tend to fit in with the general population quite well.  

One of my good friends in medical school trained to be a pathologist.  While all of us in anatomy lab were generally disgusted by the smell of formaldehyde and dissecting through dead tissue, he couldn't get enough.  I remember vividly the time that he got a little too aggressive with the forceps during dissection of the lower back and unintentionally flung a piece of subcutaneous fat across the table into the hair of a future psychiatrist.  He kindly apologized, reached up and grabbed the fat out of her hair, and then continued right along with the dissection as if nothing had happened!  

Even though I can't understand how they find joy in their work, I am incredibly grateful that they do what they do.  They are doctors' doctors.  Without them, a majority of diagnoses would never be made.  They are essential to good healthcare.  And they are incredibly intelligent folks - they have a robust knowledge base and understand pathophysiology of the human body perhaps as good as - if not better - than any physician.

So imagine the scenario this week when the pathologist, sitting at his workbench in the basement of the hospital (why are they always relegated to the basement?), receives the specimen container with the almond in it.  

If I were in his shoes, I might think it was a practical joke.  I may even think that someone was kind enough to share their trail mix and just pop that crunchy little thing in my mouth and move on to the next specimen.  But not the pathologist - to him this is a curiosity that deserves the utmost respect and attention.  This is not simply an almond, but perhaps something sinister that only superficially mimics an almond and thus must be examined with all the same scrutiny as a liver biopsy.  Here's the official report he rendered:

          Gross Description:
The specimen consists of a foreign body (almond). It tapered at one end and rounded at the opposite end. The almond measures 1.8 cm length and is up to 1.2 cm in diameter. The almond is light brown but some of the surface is peeled-off and the surface underneath is cream-colored. The specimen is retained in pathology. No sections are submitted.

You would think that a one word description would have sufficed, right?  Who doesn't know what an almond is or looks like?  I laughed out loud when I read this - it truly made my day.

And why was the specimen retained in pathology?  Perhaps we can send it for a DNA PCR test of some sort just to make sure that it's not some macrovirus particle that cleverly morphed itself into the exact shape of an almond in order to evade routine detection by the body's immune system!  Or perhaps it will come out later that a serial almond murderer is on the loose, stalking and killing victims one at a time by inconspicuously forcing an almond into his helpless victim's windpipe!  This could be the evidence that finally cracks the case (lol my sides are hurting)!  I don't even need to watch TV, because we have our own little CSI - Hospital going on each and every day!  

It's little things like this that happen every day that keep me entertained.  You have to have a sense of humor in medicine to keep you from getting down - especially in internal medicine.  We deal with chronic illness - which by definition means that our patients never really get better.  How's that for being a doctor and wanting to help people?  We manage symptoms and try to prevent further deterioration of your chronic illness, but rarely do we cure anything.  So you have to find things to laugh at - whether it be flying back fat or a pathologist's description of an almond - but you have to laugh.  And I'll even bet that pathologists giggle once in a while, although I'm pretty sure I don't want to know why because I just ate dinner.

Stay tuned.

Tuesday, March 13, 2012


A colleague recently related the following story.

Two friends were flying over the Pacific Ocean when their plane crash landed at night on a remote island.  They were captured by the local natives, who took them back to their village and brought them before the chief. 

Standing in front of the fire, the chief walks to the first and says, "Death or chi-chi?"  The captive has no idea what on earth chi-chi is, but certainly it must be better than death.  He boldly chooses chi-chi.  The chief then takes out his knife and proceeds to poke out his eyes, chop off his ears, cut out his tongue, and lop off his balls - but he lives.

He then turns to the other prisoner and poses the same question, "Death, or chi-chi?"  Seeing the state of his friend, he quickly responds, "Death!" to which the chief replies, "Ok - but first a little chi-chi!"

As a doctor, I decided how much chi-chi to administer every day. 

Have you ever been a patient in or visited an intensive care unit?  If so, you've seen the chi-chi.  It's well intended chi-chi and usually necessary for survival.  Other times, however, it's futile - yet we still do it.  Take the following example of a patient that I'm currently caring for in the ICU.

55 yo M with end-stage alcoholic cirrhosis was admitted a week ago for e. coli sepsis from peritonitis (abdominal infection common in cirrhotics).  His liver disease is as advanced as I've ever seen in a patient that is alive.  He is cachectic (weighs about 120 lbs - much of which is ascites - or fluid buildup - in his protuberant abdomen).  His arms are thin as pencils, yet his legs are the size of tree-trunks from all of the swelling.  His hemoglobin is 7, platelets of 12, INR 5.6. 

Most importantly, because of his alcohol use he is not a candidate for the only procedure that can save his life - liver transplantation.  Life expectancy for someone with this severe of liver disease is less than 3 months at most - realistically probably closer to a few weeks to a month at best.

He's brought to the ER by concerned family members because he is lethargic and having difficulty breathing.  He's in septic shock from the overwhelming infection.  Here's a brief synopsis of everything he's had done to him thus far (pictures hyperlinked).

Poked my times for IV's, blood draws
Restrained in 4 point restraints
Large central venous catheter inserted (Cordis)
Hemodyalisis catheter inserted
Femoral arterial line
Chest tube
Foley catheter
Rectal tube
Another paracentesis
NG tube

These are all done at bedside - sometimes with sedation and sometimes without.  He looked similar to this.

Remember the final scene in Braveheart when William Wallace gets tortured to death?  Some of those instruments look eerily similar!

Now take a step back and look at what we've done.  We've taken a poor patient with a terminal illness (remember - lifespan probably in weeks-months range) and subjected him to all sorts of chi-chi.  And for what?  In the best case scenario we keep him here for 1-2 weeks, he gets well enough to leave the hospital but is so weak and sick that he lives out the rest of his life in a nursing home, and then he dies.  The other possibility is that we do all of that stuff and he still dies in the hospital.  Either way, he dies.  And up to this point we've done a lot of chi-chi. 

How about the cost?  He may rack up a few hundred thousand dollars in medical costs (or more) just to be tortured before he dies.  See my first post for the cumulative economic burden this type of care imposes. 

Chi-chi isn't cheap.  Medicare spends 55 BILLION dollars on doctors and hospital bills in the last 2 months of a patients' lives.  It is estimated that 1/3 of the entire Medicare budget is spent in the last year of life.

I believe that the cultural mindset of end-of-life care in America is completely backwards.  Have you ever thought about how you would like to die?  Do you want to die in an ICU restrained, naked, and with tubes coming out of every orifice?  Or would you like to die peacefully at home in the presence of loved ones? 

If I am still relatively young, healthy, have a good quality of life and for whatever reason wind up in an ICU, I'll take the chi-chi as long as there's a reasonable chance that I get to return to my previous state of health.  But if I am 75 years old, have 5 chronic health conditions and can't walk from my couch to the toilet without getting short of breath, I'll pass on the chi-chi.  No thanks.  Not worth it.  I've seen how awful it is, and I don't want it.  I'd rather die.

Instead, when I get to the point that I have no quality of life, I'm hoping I qualify for hospice.  Studies have shown that people fear pain more than death, and I'm no exception.  Keep me comfortable, that's all I ask.  And no tubes or needles!  Keep your damn chi-chi to yourself!

Most patients find themselves on the receiving end of the chi-chi because we, as physicians, are lousy at communicating our real thoughts to patients and their families.  We assume you want aggressive care because you came to the hospital.  It's what we know how to do, and we're good at it.  Somewhere along the line we have been taught a 'life at all costs' mentality.  But sometimes, when we take a step back and look at the big picture, it's the wrong decision. 

I am very pro-hospice/palliative care because I've learned it's what many patients actually want.  When patients such as those described above come in to the hospital, I really try to have a good discussion with them about what my honest thoughts are.  Does it take more time to do this?  Yes.  Do I get paid to have these conversations (more on this in a bit)?  No.  But I feel it is part of my duty.  Sometimes they aren't receptive to this kind of frank discussion, but that rarely is the case.  Most times they are glad to finally talk openly about death.

Patients occasionally bring me gifts in appreciation for the care I have rendered.  And guess what?  The most gifts/praise/appreciation that I have been given are not from patients that I 'save,' but rather those whom I've referred to hospice.  Some of the most touching conversations have been when I've taken the time to sit down with the patient and their loved ones and ask them what they really want.  I've been surprised at how many people choose the hospice/palliative approach when given the choice.  It's like a huge weight is lifted off their shoulders.  I really think most people in that situation would choose hospice - they are just waiting for someone to bring it up.

Earlier this year I even had a terminal patient who was a retired hospice nurse (which she didn't disclose to me at first) who never even mentioned hospice until I brought it up with her and her husband!  They were so relieved to have a frank end-of-life discussion and that someone was very honest with them.  The patient's husband even sent me a hand-crafted gift as a token of appreciation.  I can recall a number of similar circumstances.  Many times by the end of the discussion we're all in tears.  Sure it's difficult, but it's necessary.

So why don't we have this conversation more often?  Recently there was a proposed amendment to Medicare that would include funding for end-of-life care discussions between Medicare recipients and their PCP's.  Physicians would be reimbursed for an outpatient visit every 5 years to address this very issue and come up with a long term plan.  This would be the ideal setting - it's important to discuss these issues before you are acutely ill and unable to speak for yourself.  Great idea, right?  All was well until Sarah Palin got word of this and criticized it as being a "death panel."  Nationwide outrage ensued, and that portion of the bill was removed. 

Thank you, Sarah Palin.  Thanks for offering your opinion on something you know nothing about.  Come spend a week with me in the hospital and let's see if you change your mind.  Once you see the chi-chi, you'll never look at healthcare the same.  Until you have been through it yourself or seen someone go through this, you will never understand.

Does this make me a part of a death panel?  I guess by definition it does.  It's funny that patients are so appreciative of my evil tactics.  Heaven forbid they should want to die in a humane, dignified manner rather than lying naked in a cold ICU bed, restrained and defecating on themselves.  If you want chi-chi, I can give you chi-chi.  But if you don't want it, I would be more than happy to send you home with what you really want - a roomful of loved ones and plenty of pain medication. 

Friday, March 9, 2012

The Z-pak

Sexy names sell products. 

Ipod, Spanx, and Twinkle Toes are sexy names.  Their products sell. 

Prescription drugs are no different.

I don't know who comes up with the brand names for new drugs, but they must have a high-stress job.  The profitability of a drug seems to be directly proportional to the sexiness of its name.  Imagine your job depends on picking the right name for a new drug.  If you pick a good one, profit soars into the billion dollar per year range.  If you choose a dud, millions of dollars in research and development are flushed straight down the toilet.

I've noticed a trend in the brand names for new drugs.  Apparently the letters x,y, and z are finally getting the attention they deserve.  And apparently Americans think there is something sexy about them.  Take the following examples from recent years:


Ah yes, but I've intentionally left out the most popular of them all for dramatic effect.   Not only does it have an incredibly sexy name, but it comes in its very own package!  You guessed it - in fact you may have gotten one from your PCP recently.  It's the Z-pak.  

The generic name for the Z-pak is azithromycin.  Zithomax is the brand name, and it's packaged in a neat little box and marketed under the name Z-pak.  Azithromycin isn't too bad in and of itself, but nowhere near as sexy as Z-pak.  The popularity of the Z-pak is tied to nothing other than its name.  Whoever thought of that one is now probably living comfortably on a Carribean island.  They scored big time - hit the ball out of the park.  Would it have achieved the same level of popularity if was called a P-Pak?  Or how about an A-Pak?  No way!  The Z was genious. 

There aren't many prescription drugs that people ask for by name.  Z-pak is at the top of the list (with oxycontin following close behind).   Why don't people ask for clarithromycin or erythromycin?  These are both very similar drugs in the same class - for all intents they are chemically the same compound.  They would likely work equally effectively as well.  But Z-pak is just sooooo much cooler.

Now let me tell you a dirty little secret.  Ready?  This might sting a little - I hate the Z-pak.   

What?  You're kidding, right?  How can you say such a thing?  They work so well! 

No, I'm not kidding.  I really don't like the Z-pak at all.  I love azithromycin, but I despise the Z-pak.  Azithromycin - the generic name of the drug - is actually a wonderful drug.  I commonly use it for pneumonia and it works wonderfully for certain bacteria.  Regrettably, I also prescribe it commonly for sinus infections, which is why I hate the Z-pak.

Confused?  Let me explain.

Somewhere along the line, the Z-pak became the main go-to for treating patients complaining of acute sinusitis.  I'm not sure if this was excellent marketing or what, but somehow all of us just started using it years ago for upper respiratory symptoms.  And why not?  It is easy to take, has relatively few side effects, and is covered by insurance.  There are only 6 pills - two the first day, then 1 per day for the next 4 days.  Patients liked it.  In fact they liked it a little too much.

Let me tell you another dirty little secret.  Acute sinusitis, the condition that all of you have taken a Z-pak for at some point, is caused by a virus approximately 98-99.5% of the time.  And guess what?  The Z-pak is and anti-bacterial drug.  That means it has NO effect on viruses whatsoever.   So 98-99.5% of the time you've used one, you didn't even need it.

But what do you do when you get sinus pressure, greenish-yellow snot, and a fever?  You go to the doctor and secretly hope he recommends a Z-pak.  It's so innate to your thought process that it's like wanting water when you're thirsty of food when you're hungry.  And if the doctor doesn't give you one, you'll politely remind him that the amazing Z-pak has cleared up your symptoms every time you've taken one in the past.  And if he still doesn't give you one, you may even be so bold as to demand one.  After all, you paid money to see him and you feel like you have to get something out of this deal.  Chances are, he is so far behind in his schedule and tired of having the same conversation that he rolls his eyes and just gives you one.  That is why I hate the Z-pak.

The very name itself has empowered my patients to demand it by name.  It has imbued them with striking confidence - almost as if their medical knowledge is somehow better than mine.  No longer am I the physician who has spent my entire adult life learning when and how to use this drug - now I'm nothing more than a Z-pak dealer. 

Truth is, 98-99.5% of acute sinusitis will go away within a week without any treatment at all.  The official recommendation is to not even consider treating for bacterial sinusitis until you've had symptoms that are 1) persisting greater than 10 days; or 2) symptoms worsen after day 7.  And guess what the recommended drug for treating bacterial sinusitis is?  Not the Z-pak!  Good old fashioned amoxicillin is the recommendation.  Why?  Because bacteria, thanks to gross Z-pak overuse in the past 20 years, are becoming more and more resistant to azithromycin.  Don't believe me?  Look at this article and read the studies for yourself.  Resistance is as high as 30%!!!  Anecdotally, I was told recently that the rate is approaching 40% now - but I don't have a source for that (omg doctor you are soooo not evidenced-based).

But doctor, I swear the Z-pak helps! 

There's an old saying in medicine - you'll get better in 1 week if I prescribe medication, 7 days if I don't.  Fact is that you're getting better because you would have gotten better even without the Z-pak.  It's coincidence.  Still don't believe me?  This has been demonstrated over and over and over again in randomized, controlled trials.  Still don't believe me?  Then go get your Z-pak from someone else, because I'm done being your dealer.

So enjoy your life in the Caribbean, Mr. whoever created the Z-pak, because you've done your job and you've done it well. 

Next time you go to the doctor for sinusitis and he prescribes a Z-pak, surprise him and ask him if you really need it, or if you can just wait it out and see if it clears on its own.  I know you don't like taking all the other medications I prescribe for you, so why should the Z-pak be any different? 

Thursday, March 8, 2012

The two great fallacies of healthcare

I will now attempt my first root cause analysis.  

Actually I'm not even sure I'm using that word in the correct context - I heard it at a "Morbidity and Mortality" conference a while back and now I'm using in a rather cavalier manner.  As long as I'm pretending to be an analyst, I might as well try to use their words.

In true minimalist fashion, let's just cut to the chase.

I will now attempt to explain the root of a host of misconceptions in healthcare.  They are espoused by both patients and physicians alike.

Behold the two great fallacies in healthcare:



I so wish that I was smart enough to come up with those on my own, but I'm not.  They were mentioned almost in passing by a statistics professor that I had in medical school, and for whatever stupid reason those were two of the bits of information that were seared in my memory.  Why couldn't more insightful, useful memories like these have implanted themselves in my brain during my medical school education?  Instead, I paid $245,000 and all I can recall with any sort of detail are the traumatic times like my first rectal exam (thank you to Mr. fake patient guy who offered his rectum to a host of medical students that dreadful October evening).                                            

The truth is that very few - if any - tests in medicine are 100% accurate.  In the medical community we talk in terms of sensitivity and specificity of tests.  This tells us how good a test really is.  A perfect test will have a sensitivity and specificity of 100% and 100%, respectively.  That means it would detect 100% of whatever your test is looking for (sensitivity) and it that test would be 100% accurate for the disease it is looking for (specificity).  Likewise, a terrible test would have be 0% and 0%.

Stick with me - this will all make sense in just a minute.  Consider the following case.
 45 year old female who comes to clinic because of a sore throat (maybe this was you this week).  She wants to know if she has strep throat.  Fair enough.

Capitalism has provided us with a quick, in-office kit to help test for group A streptococcus, the bacteria that causes strep throat.  At first glance it sounds like a great idea, right?  Swab the throat, make a quick diagnosis right there in the room, and be on your way with your prescription in hand.

Not so fast lest you succumb to fallacy #1!  Remember - not all tests are accurate!

As a matter of fact, what would you say if I told you that the commercially available kit only picks up around 75% of strep cases (depends on kit and clinical setting, but values from 65-90% have been reported in the literature).  In other words, if you rely on the test alone, there is a 25% chance that you could actually have strep throat but that the test missed it.  Your doctor tells you that you don't have strep, you go home and develop rheumatic fever, your heart valves are destroyed, and before you know it you've purchased an open-heart surgery complete with have two shiny new mechanical valves.  

I repeat, tests in medicine are not 100% perfect. 

Thus, mammograms miss breast cancers every day.  Colonoscopies miss colon cancer.   CT scans miss intracranial bleeds.  Blood tests miss cirrhosis.  Biopsies miss cancer.  Every test can miss things.  Feeling a little uneasy yet?  

Likewise, all tests can give false positive results.  How many times have your routine blood tests come back "abnormal", only to be repeated and turn out normal?  Now you understand why - all tests are not perfect.  

A major portion of the art of medicine is to understand the limitations of all of the tests that you order.  A well-educated physician will understand the value of a test before he/she orders it and know what a positive or negative test really means - and what to do about it.  That's what we, as internists, do.  We use our brains (theoretically) to determine the pre-test probability of a certain diagnosis, order appropriate tests to pinpoint a diagnosis, and then decide what, if any treatments are appropriate - all the while keeping in mind the two great fallacies of medicine.  This can become incredibly difficult as I will demonstrate later on.

Speaking of treatments, let's move on to the second great fallacy - all treatments are beneficial.

This rule is better understood by physicians than by patients, although we too fall victim.

Here's a scene that plays out every day in America.  Again, you may have been this person.

50 yo M presents to his primary care physician requesting a cardiology consultation to be screened for heart disease after his 50-year old neighbor had a heart attack last week.  He has no cardiac history, no risk factors, and is in very good health.  He runs ultra-marathons, chops timber on his acreage in the woods on the weekends, and has only 2% body fat.  Cardiology consult is ordered and patient sees a cardiologist (the best in town of course!), who in turn orders an exercise stress test (brisk walk on a treadmill with EKG leads on).  The test comes back as slightly abnormal (recall fallacy number one - this particular test is only 75% sensitive and 90% specific).  He is very nervous and fears his life is in danger - after all his neighbor just had 'the big one' last week!  Not to worry, the cardiologist says, let's just do a coronary angiogram to make sure you don't have any significant blockages in your heart vessels.  Besides, he reassures, it's near 100% accurate and is the 'gold standard' test for detecting blockages.  And if we need to, we can stent a blockage while we're in there.  I have a new, state of the art drug-eluting stent that I can deploy if I need to (thank you, and damn you at the same time, capitalism)!  Angiogram is scheduled and he undergoes the procedure.  

During the procedure, however, the cardiologist accidentally tears the patient's main coronary artery and he dies on the table (not an infrequent occurrence).   At autopsy your coronary arteries fail to show any plaque buildup.  In other words, the angiogram was negative.  Oops.  Turns out he stress test was a false positive.  So you've taken a completely healthy 50 year old with no cardiac risk factors, put him through an invasive test that wasn't really indicated, and now he's dead.

Think this is far fetched?  I see it more often than I'd like to admit - not just with angiograms, but with all treatments (surgical as well as medical).  There are risks to EVERYTHING that we do in medicine.  

So what the hell happened?  Both patient (usually ignorantly) and physician (either ignorantly or arrogantly) fell victim to BOTH fallacies.  They trusted that the test was accurate and that the treatment was beneficial.

At this point you should be feeling very vulnerable.  If tests aren't perfect and treatments can be harmful, what the are you supposed to do? 

The answer is quite simple, actually.  You need to find a good doctor.  And you need to trust him/her.

Educated, well-intended physicians understand the limitations of tests and treatments.  That is, after all, the essence of what it means to be a doctor.  Hence the term the art of medicine.  

Crappy physicians (there are plenty to go around) either don't understand this, or even worse, they don't care.  It's much easier to just shotgun off a slew of tests and then react to every abnormality than it is to consider the consequences of how you will handle any abnormality you find.  After all, it's easier not to think!  Insurance doesn't reimburse us nearly as well to think as it does to treat.  Why do you think specialists make 2-5 times what a PCP makes?  We are paid handsomely to do procedures, but little to use our brains.  Is it any surprise then, why we test and treat so much here in America?  We (physicians) are rewarded for that kind of behavior.  

I don't really have a good way to help you know if your doctor is good or not.  But some general observations that I have seen may be able to help you.

First, be wary of doctors who want to test a lot.  Labs, xrays, consultations, medications, etc should not be done routinely for the majority of healthy patients.  Some do it out of ignorance, and others do it because patients generally liked to be tested for things.  Why?  Because they like to be reassured that nothing is 'wrong'.   Now you understand the shortcoming of this logic.  You are assuming that all tests are accurate!  Sooner or later, if you continue to be tested, something will come up abnormal.  Next thing you know, you'll be on the table getting an angiogram and next thing you get the picture.

I'll talk more about screening tests in a future post, because this deserves more attention than I have given it here.  But safe to say, a physician who seems to be 'screening' you for a lot of things when you have no symptoms should make you think twice.

Second, be wary of physicians who don't explain anything to you.  Much of my time is spent telling patients why I am ordering certain tests or offering certain treatments.  Does it take more time out of my schedule?  Yes.  Do I get paid for it?  No.  But it's part of my job, and in good conscience I can't forego this.  Many physicians - perhaps yours - tell you what to do and then don't offer any explaination.  This technique sets the stage for major communication problems and potential bad outcomes.

People innately sense these qualities when dealing with physicians.  Trust your instinct.

Let me conclude with you one more example of how I apply these rules on a daily basis.  Hopefully it will give you an idea of what I do all day, every day.

I recently had an 80 year old M who was admitted to the hospital for abdominal pain and blood per rectum (we find ourselves at the ass once again).  He had longstading pulmonary fibrosis, a condition that slowly scars the lungs until it eventually kills you.  There is no good treatment for it.  He was on oxygen at home.  Despite this, he was very functional, lived alone, and walked a few miles a day.  CT scan showed a large mass in his colon.  Colonoscopy was done, showing a large, fungating mass in the transverese colon that was very suspicious for malignancy.  Biopsies were done, but shockingly came back negative for cancer! 

Further workup revealed a cavitary lung lesion of significant size that could be caused by a number of things - one of which being metastatic cancer. 

So I have a patient that I'm fairly certain has colon cancer, but with a negative biopsy.  What am I supposed to do now?

Recall the two fallacies of healthcare.

First, this gentleman is 80 years old, has never had a colonoscopy, and now has a large fungating mass that is bleeding.  Already my pre-test probability for cancer is somewhere in the 95% region.  The biopsy, however, is negative.  If I stop there and send him home, what happens if it really is cancer and he dies 2 months later?  Oops.  So I ask for a re-biopsy.  Gastroenterologist says thanks but no thanks, that mass is cancer and I'm not going to put him through the risk of another colonoscopy.  Hmm.  Ok.  Next step for a near obstructing colon lesion is surgical removal of the mass.  I consult general surgery.  General surgeon comes by and says there's no way she's operating on him until we prove that this is not metastatic disease (remember he has a lung lesion too) because he is a high-risk surgical candidate given his poor lung function.  She understands (as most surgeons do) that surgery is fraught with risk (see, we're not all ignorant of the great fallacies) and doesn't want to operate if he has widely metastatic disease as it likely won't change the patient's overall outcome.  

So I turn my attention to the lung lesion.  I check a Valley Fever titer via a blood test as he was new to Arizona and Valley Fever is notorious for causing solitary, cavitating lung lesions.    Test comes back positive.  But how good is the test for Valley Fever?  Turns out the screening blood test is not that great, and the number of false positive tests is actually quite high.  Damn.  That's no help. 

Next I order a PET scan.  This is a test that looks for areas of malignancy.  It comes back abnormal - but only mildly so in the colon mass.  Lung lesion does not light up, making cancer less likely (but never ruling it out completely!). 

Now I'm reasonably satisfied (but not totally, of course) that this is a solitary colon tumor without metastasis.  I take this information back to the surgeon.  Sorry she says, after more thought, I'm not convinced this colon mass is a tumor.  She wants another colonoscopy and biopsy.  Gastroenterology balks at it again.  Eventually they agree to take the patient to the operating room, do the colonoscopy in the OR, send it to pathology, and then operate if the repeat biopsy comes back positive.

This whole process to make this decision took about 10 days.

Meanwhile, the poor patient is sitting in his room, eating only liquids because he's scared he'll get an intestinal obstruction if he eats regular food.  He loses 12 pounds.  He's starving.  And he's mad as hell because I can't give him an answer as to what is going on. 

When I finally tell him the plan about the repeat colonoscopy and possible surgery, he gets even more upset.  "Just take the damn thing out," he tells me. "I won't do another colonoscopy.  Just do the surgery and get it out.  I won't do the colonoscopy."  The surgeon did not agree to this (remember - he is high risk for surgery and may have a poor outcome), and she was absolutely right to consider this.  If it turns out its just a benign problem and he dies in surgery, that's not good.

The next morning the patient left the hospital against medical advice.  Just up and left.  Either we did a very poor job of communicating out thought process, or he was being unreasonable.  Probably a bit of both.

I have no idea what happened to him, but there are a few possibilities.

1) He went home, it turned out to be cancer, and he'll now die from it (if he hasn't already).
2) He went to another hospital, found someone willing to operate, and had one of a few outcomes:
            a) this was cancer and he survived the operation;
            b) this was cancer but he died on the OR table (oops);
            c) this wasn't cancer and he survived the operation; or
            d) this wasn't cancer and he died on the table (double oops).

Option B and D are the worst case scenario - 1) because the patient is now dead, and 2) there are scum lawyers out there who make a living off of stuff like this (especially off of D).

Talk about paralysis by analysis.  I'm exhausted just replaying this again in my mind.  And that was just one patient.  Try doing this for 20+ patients every day and now you have a better understanding of what we do. 

At any point along this continuum of care exists a potential for error, malpractice, and bad outcomes.  Why did I sign up for this again?

Now that I've made you feel so insecure about your health, your doctor, and medicine in general, let me offer some reassurance.  These represent a minority of cases.  By and large, doctors are well educated, want to do the right thing, and really do care about our patients. 

But at the end of the day, remember that doctors are imperfect people working with imperfect science.  We miss things.  We make mistakes.  And when we do, we feel terrible about it.  But if nothing else, hopefully we can say we did the absolute best we could with the information that we had.  And we hope that you understand that.

Stay tuned.

Monday, March 5, 2012


The US healthcare system is crappy, and I can prove it.

There, I said it.  I feel much better already.

And trust me, I know poop.  I deal with it on a daily basis.  I'm an internist in a major metropolitan area and there is no shortage of poop here.  And the fun doesn't end when I'm done with work - home is where the real action is.  I have two small children, one of whom is still in diapers.  Fortunately at work I don't have to actually handle the poop.  I paid enough in tuition to absolve myself of that duty.  My degree, however, doesn't command the same amount of respect at home as it does at work.  In fact just last month I bare-handed a turd out of the bathtub.

I know poop when I see it, smell it, or sadly, when I touch it.  And for better or worse, that is my everyday life.  Fortunately I'm not a gastroenterologist - if it weren't for their incredible salaries I don't know that such a specialty would even exist.

I also know some medicine.  I trained at a very good institution and did well on all my exams. 

So it's no exaggeration when I say that the US healthcare system is crappy.  I see it, smell it, and handle it every day, and it has all of the same consistency of poop. 

I don't mean it in a disparaging, "I hate your face" kind of way, but rather in a "yes, your face IS ugly but let's see what we can do about it" kind of way. 

But doctor, this is America!  We have the best healthcare in the world here!  How can you say such a thing!  My great-grandma had a 5mm tumor removed from her pineal gland by a uber smart sub-sub-subspecialized surgeon using a Davinci robot with a state of the art harmonic scalpel! 

Well, it's really a relative crappy when viewed on a macroeconomic scale.  Certainly it's better than nothing.  But for the amount of money we spend on healthcare, our overall outcomes suck.  Yes, they suck.  Take a look at the following data of life expectancy (in years) by country (1):

Country 2008 2009 2010
Czech Republic77.377.3..
New Zealand80.480.8..
Slovak Republic74.875..
United Kingdom79.880.4..
United States7878.2..

And look how much money it takes us to buy this sub-standard outcome (1):

Total expenditure on health, % gross domestic product
Czech Republic8.2
New Zealand10.3
Slovak Republic9.1
United Kingdom9.8
United States17.4

I should point out that I'm no economist.  I have no formal business or finance training.  I'm pretty sure I took an economics class at some point in high school.  But I understand enough to know what I don't know, and so I don't make any claims in complete ignorance (partial, at most). 

But look at the freaking data!  We (America) spend a bazillion dollars each year on healthcare and have a life expectancy similar to that of Slovenia and the Czech Republic!  (Don't take offense at that my Eastern European friends - the joke is really on us!)  In essence we're spending $100,000 to buy an average Chevy truck!   Don't get me wrong - I enjoy Chevy trucks as much as any American male.  But at that price?  No thanks.  That's a horrible deal.  And for that much, it's a relatively crappy piece of machinery.

Furthermore, the money that we spend is money that we soon won't have.  Medicare spends much more than it brings in.  In 2010 47.5 million people were provided some sort of care at a staggering cost of $516 billion (2).  At the current pace, the Medicare fund is expected to run out in 2024.

And it gets worse!  Not only do we grossly overpay for healthcare, but we're under the impression that we're getting something great for it.  We're buying the perception of good healthcare.  We're spending so much, we tell ourselves, that we must be getting our money's worth.  But we're not.  We're taking it in the shorts is what we're doing.  Those of you who purchase your own insurance know this already.  Premiums are rising at an incredible rate.  And for what?  So we can live a shorter life than most of the industrialized nations of the world?

Look at the following data on perception of healthcare.  This is the percentage of population (all ages) who considers his/her health to be "greater than or equal to good" (1).

Country 2008 2009 2010
Czech Republic68.2....
Slovak Republic31.1....
United Kingdom7676..
United States8890..

But doctor, there got to be some logical explanation for this! 

Translation:  but doctor, my shit don't stink!

Yes, as a matter of fact it does.  It looks, smells, and even tastes like poop!  OK, I can't prove that last part because I have not, to my knowledge, ever ingested enough fecal material at one time to actually know what it tastes like.  (If you're disgusted at that thought, recall that most gastrointestinal illnesses are transmitted person-to-person via the fecal-oral route.  Yep, you've all tasted that yummy goodness!)

What we have done is manage to fool ourselves into thinking we have the greatest healthcare system in the world.  We have all the greatest medical gadgets (thank you, capitalism), the most MRI and CT scanners per capita (thank you, whoever makes these things) (1), and the best of the best of the best drugs that money can buy (thank you, big pharma).  It makes us feel healthier, and the data prove this. 

Chew on this - given our staggering rates of obesity (more on this is a future post), it is anticipated that life expectancy may, in our lifetimeactually decrease for the first time in the recorded history of mankind (excluding the influenza pandemic of 1918).  We'll be spending more and more money and getting less and less for it.  What a great freaking deal.  But I digress.

Until I recently discovered this data, I too was of the myopic American view that we have the best healthcare system in the world.  Damn the internet for moving my cheese!   And now I have just returned the favor and moved your cheese.  You cannot live in pleasant ignorance any longer.

Spending a number of hours on the OECD website has caused me to change my mind.  It has influenced my perception of healthcare in a very real and powerful way.  It has changed the way that I practice medicine.  

It was because of this that I decided to give birth this blog (without opioids or an epidural - omg those are toxic!).  Economics can provide a top-down view complete with data analysis sliced in an infinite permutation of ways, and there are plenty of economists out there doing that for a living.  Not to mention the politicians (I mean lobbyists) that pretend to understand what is going on here.  My intent, however, is to supply a view of healthcare from the bottom up - from a physician's perspective, that is.  It can be dirty down here, and damn does it smell at times, but sometimes you have to spend time in unpleasant places to get an answer.  It's a unique vantage point that neither economists nor politicians seem particularly interested in seeing first hand, which really is a shame considering all that you can learn from poop.

As a whole, us doctors don't do a very good job of communication - both with our patients as well as with the public.  We are masters of critique and criticism, yet we can't seem to offer any tangible solutions.  Our heads are teeming with good ideas, but heaven forbid we share them with anyone!  This is, after all, the House of God, and people should come to us for answers!  And so I am making a bold move to reach out to anyone interested in reading a doctor's opinion on random topics related to healthcare.

I don't have any real purpose other than to write my thoughts, experiences, and impressions on the state of healthcare in the US.  I am not using this as a platform to spew any ideological political nonsense.  For the record I am a fiscally conservative independent that tries to avoid politics at all costs. 

I am a minimalist.  I try to use common sense.  I want a better America and a better world.  And I certainly don't want the United States of Amercia to mortgage itself to China as a result of our egregious healthcare spending (a real possibility).  Then again, I enjoy spicy Chinese food and so maybe that wouldn't be as oppressive as I am imagining it.

And so I will ramble on this blog in a very stream-of-consciousness type manner and hope someone finds some worth in my partially evidence-based opinions.  And if you don't, then I don't particularly care.

Stay tuned.