Docnotes

Ears

Dave needs a good primary care physician.   His post today reveals his ignorance of the importance of primary care.   This is common in people who are wealthy and/or have "very good" insurance that gives them access to specialty care without referral.

I'm not saying that specialty care is bad -- but I can't even count on my fingers how many times each week I provide services to someone who initially called asking for a referral.  This week's struggle was a dad who called and demanded an emergency referral to a dermatologist for the rash that his daughter had for the past 6 weeks.

"Now .. nothing against you, doctor, but I think that this condition has gotten so bad that we need a specialist."

"I'm happy to refer you to a dermatologist if that turns out to be necessary - but since I have not seen the rash - nor have you even called me about it - it's hard for me to tell the dermatologist why I'm referring the child to him."

"Well you saw her in October for her well-child visit and you said she was fine."

"uuh .. yes .. was she not fine then?"

"Yes she was but now this rash is real bad and we want to make sure it goes away."

"We all want the rash to go away.  I'm happy to see her today and if I can't help you, I will be sure to refer her promptly to the dermatologist."

The child has eczema.  I did a quick google search and found some good handouts to reinforce my counseling and diagnosis.  It's unlikely we'll need to send this kid to derm. 

When I was 15 and living in Cambridge, I scratched my cornea with some sawdust as I was cutting something with a circular saw.  Like Dave, my parents decided that the "experts" would be best to evaluate this and drove me down to the Medical Mecca and I received appropriate treatment for this very common problem. 

So what? 

Like Dave - I could have received appropriate treatment for this problem by any competent primary care physician.   This would have been a better use of the limited healthcare resources that exist in this country.   I treat scratched corneas and impacted cerumen all the time.  So do most primary care physicians.   These propblems are not rocket science - nor do they require the services of specialty care.

The Boston area is hyper-specialized.  There are relatively few primary care physicians and an overabundance of specialists - which is a function of the overabundance of wealthy, educated healthcare consumers, and an abundance of training programs.

While I would agree that the folks at the Mass Eye and Ear Infirmary may be some of the best in the world at what they do - we should only use them when we have conditions that the primary care physicians can't handle.  A good primary care physician would have removed the cerumen from Dave's ears, and would have given him the same lecture about not using q-tips as he received from the specialists.

The disjointed care that people get from a horde of specialists is clearly worse care than the care they get from one primary care physician. 

Yet there remains a perception that the care they provide is better.  We can't combat this work our words - we have to re-educate our patients by providing the comprehensive, care that they deserve. 

IN the context of my patients requesting specialty care - I've been seeing more specialists in MY office.   Caring for another physician is always challening, and initially, this was intimidating to me - yet I've become better at navigating this complex relationship.  Like the otolaryngologist or the ophthalmologist or the CT-surgeon, I am a specialist too - in primary care. 

Chronicle of Acute PVR Disorder

isography is my brother's website.  Yesterday he posted a wonderful review of his efforts to record TV shows at home without buying a Tivo.

Very well done.

BMJ

This week in BMJ : how frequently should we have patients follow-up for management of hypertension?

• Every Month
• Every 3 months
• Every 6 months

?

BMI Calculators

BMI Calculators from the CDC.  Very useful.

Don't treat h.pylori?

From Gut:

... after adjustment for the covariates age, sex, erosive oesophagitis, hiatus hernia, degree of gastritis, and severity of symptoms at baseline, H pylori eradication was the only predictor of treatment failure.

This is quite interesting.  I don't have access to full-text of this article - so let's not jump on this bandwagon just yet - but it's an interesting topic - and a common clinical problem.

Speling

The title is a joke.  I can spell pretty well.  I just can't type - especially on this little keyboard on my Tablet. 

Microspell looks like it may work for me.  I used to use IEspell, but it's slow and hard to access from mt's edit-entries windows.  Microspell copies over the whole text of an entry, helps me to edit out the typos and plops it back. 

We'll see. 

Dr Bob on obesity

Dr Bob's entry On obesity provokes response.  Like several of those who comment on his entry - I applaud his honesty - and will come clean like he has:  when we care for patients who have been participants in their illness, it is tempting to blame them, and in our weaker moments, we do. 

Bear with me here ...  

Addiction is a powerful disease - whether to drugs or tobacco or food.   Working with addicts is challenging.   We try so hard to listen, understand, counsel and advocate.

I often suggest that patients read James Prochaska's book:  .. and it's helped several of my patients change self-destructuve behaviors. It's also a  good read for physicians.  A core concept of the book is that we don't change our patients -- they change themselves.

 

How we act at the bedside

Dr. Bob rants about how we interact with patients and how we interact with each other.  He says that we need to model professionalsm, and I would concur.

How we act at the bedside is an entirely different discussion which we may have another time.

Now seems like a good time, eh? 

Last summer, I made note of Carl Gandola's weblog.   Like Dr Bob, Carl is an attending physician in a residency program.  Carl describes sitting down at the bedside and listening to his patients.   While the quote on Dr Bob's post today may be accurate ("some doctors put on a better show than others") ... listening can't be faked.  We say much more with our actions than with our words:

We know that physicians interrupt their patients:

Patients spoke, uninterrupted, an average of 12 seconds after the resident entered the room. One fourth of the time, residents interrupted patients before they finished speaking. Residents averaged interrupting patients twice during a visit. The time with patients averaged 11 minutes, with the patient speaking for about 4 minutes. Computer use during the office visit accounted for more interruptions than beepers.

I find that I sometimes bite my tongue (literally!) to remind myself to keep quiet.   I've posted on this in the past as well  .. so follow the link and take a look if you like ...  it's a real-life example of how listening just a little can save a lot more time and money than you think.

Thalassemia - diagnosis in 5 seconds or less

We family physicians don't know everything ... and if we knew it once .. we may have forgotten.  Clincial problems that we don't see often will cause us to make referrals to specialists - and this teamwork is often a good model for patient care.  Yesterday's call to a local pediatric hematologist reminded me of a simple formula I learned in medical school, but hadn't used in 10 years. 

Mentzer Index = MCV/RBC
Ratio < 13 then the patient most likely has Thalassemia
Ratio >13 then the patient most likely has iron deficiency anemia

Though we often look at a low h/h and low MCV and think iron deficiency right away ... recall that ferretin is a better measure of iron deficiency ... and the Mentzer Index can always help us to identify Thalassemia.  Remind me of this in 2014 ...

Granfalloons

Humans (and other species) prefer to be together.  Even those of us who actually like being by ourselves will admit that we prefer to be on a team.  Kurt Vonnegut called this a "Granfalloon."   The "Bush in 30 seconds" ads remind some of us that we are not alone in our distaste for the current administration .. and in some way - weblogs help us to accomplish this sort of connection as well.  In a sense, welbogs are more like parallel play than true interaction.  Like the toddlers who play near each other (but now WITH each other) - we wouldn't enjoy writing in isolation - yet the writing is much more often a monologue than a dialogue.   Back when there were only two medical weblogs (Docnotes and MedEdNews), I'll admit that it was hard to stay motivated to keep writing.  There were days that David and I were the only ones reading each others' weblogs (and of course they weren't called weblogs back then either).  Now we're a broader community, and I've had a few discussions with Enoch about moving our medical weblog community forward one more step.  Stay tuned ... ;-)