DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

Search

Q&A 8

Sitting here, back at the Q&A desk. Today I will share both questions and comments. Receiving these comments provides a great reward – it tells me that some readers really care about my rants. And that is a wonderful feeling!

Reframe the discussion how ever you feel is convenient. The bottom line is state medical boards do a pretty lousy job of patrolling the profession for substandard care, based in large part on failure of professionals and health service organizations to self-report problem physicians, and budget and staffing support received from state legislatures. And responsibility for budget and staffing support limits, as well as limited grounds upon which to trigger an investigation or disciplinary action, can be placed at the feet of the provider interest groups.

This represents one of my excellent comments from the Bloviator (you should read his page regularly – just look over to the Medical Blog list). He forwards an interesting viewpoint on self-policing. I hope he is reading this rant – do lawyers do a good job of self-policing?

He points out that State Medical Boards do not receive adequate funding. Thus, they have difficulty becoming proactive in searching for “problem physicians”. He has served as counsel to a State Board – so I would not dare challenge him on that point.

However, I believe this issue is indeed a side issue. Our problem stems from how our society defines and pays for malpractice. The entire concept of punitive damages is quite problematic. How can anyone adequately define those?

As I (and many readers) have said repeatedly, the problem with malpractice settlements should concern everyone. If malpractice premiums and rewards continue to rise, then no rationalization for the high rewards will matter. If physicians cannot afford to practice, then patients will really suffer. In some ways we are considering the penalties for errors of commission, and as a society ignoring the costs of paying those penalities.

I empathize with true malpractice victims. However, our current system works more like a lottery than a true check and balance.

Trial lawyers are the problem here. We need an alternate system for judging and paying for real malpractice. Our health care system really does an excellent job of caring for most patients. But we never get extra rewards for great care. When we make an important diagnosis or help a patient through a crisis, we receive the same fees as when we care for a more straightforward, simple diagnosis. If the patient has a bad outcome (even if we really did everything right), we just might get sued. That cannot make sense to anyone. Our system of judging malpractice is broken. The penalties for malpractice are broken. As a result, medical care actually suffers. The current malpractice system discourages improvements in health care.

I am a second year general surgery resident at a busy metropolitan academic center. I enjoy reading your medrants whenever I can find the time. Major kudos is due to you and your site.

You have written often about the 80-hour workweek issue. I agree with most of what you have written. I can tell you though, from my own experience and from talking to friends that I have in other surgical residencies around the country, that compliance by surgery programs will be very poor. My program director has hatched a plan of pseudocompliance. “You can go home 6 hours after you finish call if you want to, but everyone else is staying. By the way, if you stay to work extra, its on your own time and you can’t count it on your timesheets.”

This comment does not surprise me. I suspect many surgery programs will try such tactics, and some will get caught. Such programs will probably penalize residents who do not play their game. But if they fire those residents, the residents will likely sing.

Surgery programs have attitude (yes I know this is a generalization – but many colleagues around the country confirm that generalization). They truly believe they understand training better than any outside group. Some programs will comply; some programs will have the above attitude. We will have to follow the changes in July to see which specialities adapt well and which struggle.

An endoscopy the other day revealed “very mild” gastritis (probably from taking Advil on an empty stomach), also “very mild” esophogial irritation from a bout with heartburn that I had during a particularly stressful period several months ago. The doc, who is does a great job with the endoscopy, does not do such a good job with followup and simply gave my husband on the way out a script for Nexium, with little direction. I have so many questions! First of all, I have lowish platelets, around 100,000. Does Nexium, like Tagamet, interfere with platelet counts. Secondly, is this drug really necessary??? If both problems are “mild,” and if I really don’t even feel heartburn anymore, can’t I a)change my behaviors and cure the gastritis and b)assume that the esophagial damage is from an old problem and that the esophagus will heal itself, given time? By the way, I am a 47-year-old woman who takes no scripts, who hates taking pharmaceuticals and likes to believe she can heal herself holistically — until something life-threatening comes along, at which point I will be grateful for life-saving drugs. I don’t see this situation as a life-threatening one. Thanks for listening and for whatever advice you can offer.

Thanks for the question. Giving advice on medical issues without actually talking with a patient and examining them and their medical record is a bad idea. Thus, I will couch my answer in generalities.

I am not aware of proton pump inhibitors (the class which includes Nexium) causing problems with thrombocytopenia. A quick search did not find any such problems. Tagamet is a histamine-2 blocker – a different drug class.

Not knowing your history of gastritis and esophagitis, I can make no comments on treatment. If you truly have endoscopic evidence of esophagitis, then I doubt holistic treatments will work. In general weight loss does help esophagitis.

If your gastroenterologist does not discuss your diagnosis well, you might try going back to your internist or family physicians. They should be able to sit down and discuss your management strategy. If you do not have a generalist, you need one (as I rant about regularly).

“We teach residents to consider a complete differential, but to concentrate on the four most common diagnoses – undiagnosed asthma, ACE inhibitor cough, post-nasal drainage, and gastroesophageal reflux disease (GERD).”

How about chronic bronchitis?

This comment came from a rant about cryptic cough. I did not make clear that I was talking about cryptic cough. Chronic bronchitis, in my experience, is rarely (if ever) cryptic). These patients have a productive cough and fit into a classic syndrome. If we take all cough presenstation, then chronic bronchitis is an important consideration.

I knew one attending whose favorite retort to the “natural” argument was to snap, “Well, poison ivy’s natural
too!”

Well stated.

and what about the “natural course of an illness?” We all know that over 90% of common maladies like Otitis Media, Sinusitis, and Pharyngitis will resolve with NO intervention. Try saying THAT to the next patient with a runny nose who asks for a “natural cure.”

While I do think we should prescribe antibiotics for bacterial otitis, sinusitis and pharyngitis, I agree that we are too quick to give patients antibiotics for viral infections. Why do we do this? It saves time and the patient expects it. I have always tried to avoid this behavior. Unfortunately, I see too many colleagues, residents and even students who start “a Z-pak” whenever they get a cold. We need to do a better job here!

A pre=emptive apology for this rant.

This is old news to the average otolaryngologist. OVERHWELMINGLY, patients who I see for chronic cough have underlying GERD. I’d guess that 80% have GERD, 10% have chronic sinusistis, and then there are about 10% “other.” Most are not difficult to diagnose on history alone (not to sound facetious- most are easy to diagnose my simply LOOKING at them). Chronic sinusitis is easy to rule out- order a CT scan. The only problem you’ll run into in that regard is that our radiology colleagues have a penchant for overreading these scans. (I would LOVE to see a blinded study of sinus CT scan interpretations by radiologists. I would wager that you’ll get a substantially different interpretation by 5 out of 10 readers.)

I have a pet peeve: I IMPLORE my generalist colleagues (and others) to stop using the term “post-nasal drainage” so flippantly. I peer into pharynges every day of my working life (X 20 years) and I can tell you that it is RARE to actually spot any kind of discharge trailing down the posterior oropharyngeal wall. The only other time one sees this is as a subtle finding on endoscopic exam- a modality that is not available to the average generalist. I’m constantly astounded at how many patients come in telling me that their Primary care doctor “spotted drainage down my throat.” Don’t you find it odd that everyone and his cousin talks about “post-nasal” drainage” and yet this is not a term that is loosely used by the one specialist in human medicine who ought to know the most about it?

Sadly, most of my day is spent UNDIAGNOSING “sinusitis.” These patients are almost always complaining of facial pain (shockingly, predominantly female, often depressed; usually with a background history of headache and other pain syndromes) i.e. “another sinus infection” and/or “post-nasal drainage” i.e. almost always symptoms of GERD. Is it any surprise that they don’t get better with antibiotics? And the ones that do are often responding to a placebo effect.

There has been, and continues to be, a lot of gold to be minded treating “chronic sinusitis” surgically. Please spare your patients needless antibiotics and surgery. Concentrate on SYMPTOMS, not preconceived diagnoses. If you do, you’ll almost always come upon the right assessment the first time.

Sometimes readers have better rants than DB. This is a great example. Thanks to Dr. Kranky for this post!

Do you know of a medical study on use of Singulair for people with chronic sinusitis? I do not have asthma but have had injections for years, had 2 sinus surgeries and suffered 10 years of infections every 3 months (average). I’ve slightly improved via acupuncture, but still need help. (It does not help living in the humid Washington, DC area)

First, read the comment about. Second, do you have chronic sinusitis or allergic rhinitis, or both. If you have allergic rhinitis, then Singulair can help (but is not better than nasal steroids). You might benefit from a fresh look at your symptoms and treatment. Again, not talking with you and having access to all your records, I cannot completely answer your question.

One way to calculate the benefit is to measure the number of specialty referrals generated in a “shared” practice vs. the model that most of us feel is more beneficial- per given condition (or tentative diagnosis). AND factor in the number of visits to each primary care model BEFORE the referral was made.

It’s been my experience as a consultant that too many conditions were turned into “chronic” or “complicated” this or that, simply because there were 3, 4 different primary care physicians (sometimes PA’s of NP’s) on the given patient’s care.

Another excellent comment which complements (in my opinion) the point I tried to make. Continuity certainly has important benefits on satisfaction (for both patients and physicians). It also often leads to better care. I agree with the comment, although I do not know of a good study to confirm this observation.

Once again, thanks for the comments and questions.
When there is no continuity in the thought process on a given patient’s situation, is it any surprise that delay
and anxiety result?

Categories
Meta
Blogroll
Newer Blogs