Sunday, May 27, 2012

God's medicine

  I had a patient recently who suddenly developed an irregular heart beat. There are lots of things that could cause this, including many medications. I asked the patient what medications she was taking and she said none. A few minutes later, looking around her room, I saw a large tub filled with pill bottles. I pointed to them and asked her what they were. She said, "Oh, just my herbals." I told her that herbs are made of chemicals and some of them can interfere with her heart rate (or with the blood thinners and heart rhythm medications we were giving her). She said, "No, they aren't chemicals. They are natural." I explained how many of our modern medicines comes from plants. She smiled, agreed wholeheartedly and said, "Yes, plants are natural medicines." I said that she was right and she should realize that medicines, even natural medicines, can have side effects. She replied, "No, medicines you give me have side effects because they are man made. Natural medicines are made by God and He has made sure that they don't have side effects." I knew I had no chance to convince her why what she was doing was dangerous. I looked through her box of supplements and didn't recognize most of them, but there were some known to be stimulants and others known to interact with blood thinners. I told her not to take those few (5 of the more than 30). She declined saying she trust's God's medicines more than mine. I spent a few minutes explaining why we were so worried, but got no where. When I left she said "God bless you." Mixing quackery with religion makes a dangerous thing deadly.
  I'm not too surprised that quackery and religion go hand in hand. With both you are convinced that you know the truth, that whatever else is out there is a lie and if there is a conflict between the two, you are always right. With both, there is no critical thinking. With both, rather than reasoning with someone trying to convince you otherwise, you get offended. With both, you bend over backwards trying to ignore the obvious deficiencies with what you believe in.

Tuesday, May 22, 2012

The danger of quacks

  A major argument that supporters of alternative medicine use is that it causes no harm, so they might as well try it. Of course, that's pure crap. Alternative treatments cause harm in numerous ways: Untested drugs and techniques have side effects and interactions, they're a huge waste of money, and, most importantly, they keep patients from receiving actual treatment that works.
  Case in point is a former patient that I recently ran into in the emergency department. Nine months ago, she was a perfectly healthy mother of two that was successful in her career. One of the sweetest patients I've had all year. At that time, she was admitted for new muscle pains. We ran many tests, figured out it was an autoimmune condition, gave her steroids and connected her with a rheumatologist to make the final diagnosis and for long-term management. She improved a little and went home with a plan in hand.
  Nine months later, I find her disheveled in the emergency room's psychiatric evaluation room (where you can't hurt yourself) screaming at no one in particular. It turns out that she was eventually found to have polymyositis, an autoimmune condition that affects the muscles and can be hard to treat. She had improved with steroids when I saw her 9 months ago, but a few months afterwards had another flare and went to a holistic "doctor" instead. The quack told her that she has "chronic Lyme disease" and that the her rheumatologist was wrong. He then tricked her into trying various herbs, potions, "magnetized water treatments" and none of it worked (somehow, antibiotics never came to his mind). She went had her primary care physician test her for Lyme disease and it kept on coming back negative. But, she insisted that she had Lyme disease. She became obsessed with having Lyme disease and spent more and more money on hyperbaric oxygen chambers, toxin removers, colon cleansing, etc. She lost tens of thousands of dollars and kept on getting fleeced by the holistic "doctor". Her relationship with her family became strained and she eventually attempted to commit suicide. Hence, her arrival to the emergency room.
  I won't blame the quack for causing her to become psychotically obsessed with her medical condition. Despite having no previous psychiatric illnesses, she must have had some underlying condition. What I do blame him for is playing on these beliefs to make money off of her. I blame him for convincing her that her doctors are wrong, that the tests were wrong and that they are trying to keep the truth of his fake medicine from her. Not all quacks are out to fleece people (some of them actually believe what they're selling), but all of them, whether intentionally or not, keep people from getting the treatments that they need. Luckily, she survived her suicide attempt, but this quack nearly had blood on his hands.

St. Jacobs Oil or Prednisone? (image from here)

Saturday, May 19, 2012

Delta Airlines doesn't want my business

A few days ago, John Stewart had a piece on the "War on Women" and showed a graphic of a nativity scene in between a woman's legs (the "vagina manger"). Bill Donohue, the head of the Catholic League, nearly had a heart attack and demanded from the sponsors of The Daily Show to pull their ads. Delta Airlines decided that one religious person's point of view is more important than that of others and pulled their ads. I, a Delta frequent flyer (even had status with them last year), didn't like the company giving into one religious person's point of view and let them know my feelings. What I got back was less than satisfying:

We’re always reevaluating our advertising opportunities and updating our strategy in an effort to reach our desired audience.  Most importantly I want you to know, Delta culture is one of inclusiveness and we do not discriminate nor do we condone discrimination in regard to age, race, nationality, sexual orientation, religion or gender.  As a global airline, Delta has historically been very committed to diversity and we are proud to embrace diverse people, thinking, and styles. Our commitment to diversity is highlighted on

 Looks like Delta's policies don't exactly match Delta's actions. They just chose to side with a religious nut rather than embrace the inclusiveness that they strive for. They decided that the religion, thinking and style of Bill Donohue is more important than that of John Stewart, The Daily Show and their audience. Sorry, Delta... you've lost my business (and got added to the list).

Monday, May 14, 2012


  This month I'm working on a cardiology consulting team and with it, I've gotten a lot of exposure to the hospitalist side of internal medicine. Hospitalists are internal medicine physicians who only take care of patients in the hospital. They have no clinics and only deal with the short-term problems that the patient is hospitalized for. In effect, they do my internal medicine rotation all the time (except they are the entire team). It sounds terrible. One colleague called it "residency for life." However, it has it's benefits. It is essentially shift-work, so it has a pretty nice schedule. Most people go into it straight out of residency (so only 3 years after finishing medical school). Most hospitalists work a week on followed by a week off. So, a vacation every other week. They also get paid pretty well. 200000+ for working a total of 6 months each year. Because of these benefits, it's quickly becoming a popular choice.
  The problem comes with not having ownership of the patients. Without any continuity of care, hospitalists don't know their patients as well as internists who also have a primary care clinic. With the shift-work schedule, their is a lot of passing patients between hospitalists and resulting poor communication. Also, with 20+ patients a day, there isn't much time spent with each individual patient. Putting all this together, hospitalists tend to not think about each individual case as much. At least that's the trend I've seen when consulting for a hospitalist versus consulting for a resident-run team or a team run by a regular internist. This doesn't mean that patients under the care of a hospitalist are at risk. The more common result is that they are overtested and specialists are overconsulted. If you don't have time to think about why someone is having chest pain, you get a chest X-ray, CT-scan, EKG, an echocardiogram, stress test and lots of blood tests and you consult a pulmonologist and a cardiologist. One of these will figure out what the problem is and your specialists will tell you what to do about it. I've seen this pattern quite a bit recently, including one case in which the hospitalist ordered these tests and consults prior to seeing the patients or even reading their previous notes (the patient was transferred from another hospital and through testing had already shown that his heart was fine).
  Of course, there are great hospitalists who know their patients well, think hard about each of the cases and use hospital resources efficiently. However, there is a disturbing number who are wasting resources and their consultants time as well as running up the cost of healthcare.

Sunday, May 6, 2012

A dangerous doctor

 C = M.D.

  I am doing my internship at a community hospital that mixes graduates from US allopathic schools (MD), US osteopathic schools (DO), American graduates from Caribbean medical schools and international graduates. Having worked with graduates from each of various programs, I knew, going in that a resident's background does not necessarily translate to their performance in the hospital. However, taking all the interns together, there definitely are some that are better than others, and there are a few that really should not be a doctor. For example, I worked with an intern who would like to become a cardiologist. He was asked to draw a heart and he simply did not know how the heart was organized. Not even close. When asked how he would treat someone with a complete heart block, he answered beta-blocker (which would kill the patient). If it was the beginning of the year, I could forgive him. If it was a one-time mistake, I could forgive him. But, this is someone who repeatedly shows that he has no clue how to treat patients. What's worse is that he actually thinks he knows it all. He manages patients without informing anyone of his actions (interns typically have senior residents or attending physicians to report to), because "it's an easy case" (Thank you, nurses, for catching his mistakes over and over again). He has been repeatedly corrected, but continues to make the same mistakes and even once uttering that the person correcting him "has no clue." He plagiarizes notes or writes notes and comes up with treatments without actually seeing the patient. This is a dangerous person. He has been caught and given chance after chance, but continues to make the same mistakes. Unfortunately, there is nothing stopping him and he will be a senior resident in a few short weeks.

  Medicine, though always seen as a rigorous field that only the smartest and strongest make it through, is actually a very formulaic process of which the hardest part is probably getting into medical school. A few often repeated axioms in medical school are: "What do you call someone who graduated last in their med school? Answer: A doctor" and "C = MD". Of all entering US medical students, 96% eventually graduate with a medical degree (in comparison, the same measure for graduate students in 62%). Most who fail to graduate, drop out of medical school for personal reasons, not because they were not qualified. Of those that graduate who want to practice medicine, all eventually find a residency program. With residency, it's a similar pattern. It is rare, but residents can be kicked out of their program. However, most find another residency program that is willing to take them. There are boards exams, but in many fields you don't need to be board certified to take care of patients, the pass rates are high and you can take them repeatedly until you pass. Of course, once you complete residency, even outright fraud or criminal negligence doesn't necessarily get your medical license taken away from you (I'm looking at you doctors who only serve as a prescription mill for narcotics).

  The point here is that once you get into medical school, there is very little stopping you from eventually being a practicing physician. There are several problems. One is that there is a shortage of physicians out there and in many fields, such as family practice and internal medicine, there is a large number of open spots that need to be filled. A second problem is that medical schools and residencies thrive on their reputations. If their graduation rates decrease due to failure of a student or resident, it affects their statistics and makes the program less appealing to future applicants. Finally, there is a culture of avoiding confrontation in medicine. It's easier to pass someone than to deal with the trouble of remediation or removing the person from the program.
Please don't get me wrong. A vast majority of my coworkers and, likely, residents in other hospitals, are fine physicians who will serve their patient's well. However, the culture of passing everyone through the system, even if they are unqualified, has got to go. Patient's lives should be of primary concern.