tag:blogger.com,1999:blog-11304982738633902202024-03-13T07:43:36.785-07:00Hal Dall, MD --Outlier PhysicianMedical Commentary and anecdotes; some serious, some satireHal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.comBlogger45125tag:blogger.com,1999:blog-1130498273863390220.post-44754494595705127452013-01-24T14:03:00.000-08:002013-01-24T14:03:44.177-08:00Post-Residency ClerkshipsAs the EHR/EMR Borg assimilates the medical world, the level of documentation required by E&M coding, EMR "Meaningful Use" and other administrative toys turns doctors back into "clerks".<br />
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<img alt="Funny Somewhat Topical Ecard: I have 5 pages of Documentation for<br />her visit,<br /><br />But I can't remember<br />why she came to see<br />me." src="http://static.someecards.com/someecards/usercards/MjAxMy0zYTNhNTc0OTQ4ODU5MTQy.png" />Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-73754710599146150382012-12-31T12:09:00.001-08:002012-12-31T12:13:42.844-08:00Lies, Damnable Lies, and Statistics<img src="http://www.thelookingspoon.com/images/general/funny/the_new_study_msm_lie.jpg" /><br />
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<a href="http://www.thelookingspoon.com/images/general/funny/the_new_study_msm_lie.jpg">http://www.thelookingspoon.com/images/general/funny/the_new_study_msm_lie.jpg</a><br />
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<img alt="Significant" src="http://imgs.xkcd.com/comics/significant.png" /><br />
<a href="http://xkcd.com/882/">http://xkcd.com/882/</a><br />
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<br />Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-46392469924374620442012-12-27T17:19:00.000-08:002012-12-27T17:20:32.276-08:00SNAP Off Food Stamp ObesityJAMA has a viewpoint this week "<a href="http://jama.jamanetwork.com/article.aspx?articleid=1487507">Opportunities to Reduce Childhood Hunger And Obesity</a>" (behind paywall) about the paradox of obesity in Food Stamp Program (SNAP) recipients.<br />
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The authors point out the program sucks up about $4,000,000,000 yearly for taxpayer funded soft drinks. I also observe our local Starbucks doing well with my state's program.<br />
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Although the article had tidbits pointing to improvements, in the end the bureaucratic solution of more study ("more systematic approach to data collection") was recommended.<br />
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Why not use the <a href="http://www.fns.usda.gov/wic/">WIC</a> rules to define eligible items for food stamps?Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-91577410511111752612012-08-07T16:44:00.000-07:002012-08-07T16:44:20.729-07:00No Wonder Some Of My Patients Feel SickAccording to a crossover type <a href="http://www.usatoday.com/news/health/story/2012-08-04/honesty-beneficial-to-health/56782648/1">study</a> reported in USA Today, subjects had fewer physical and mental heath symptoms when telling fewer lies, and felt worse when lying more. Read the report <a href="http://www.usatoday.com/news/health/story/2012-08-04/honesty-beneficial-to-health/56782648/1">here</a>.Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-49300056752146072652012-06-12T16:01:00.002-07:002012-06-12T16:02:56.120-07:00Weighing The Fa(c)tsNurse Dall: "Many of the overweight patients assert: 'Your scale is wrong. My home scale never reads that high!' (often claiming a 10 pound discrepancy)."<br />
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"The normal weight people tell me the office scale is correct."Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-20510423600332070572012-05-10T13:51:00.003-07:002012-05-10T13:51:55.904-07:00Stinky FeetAs I gloved to perfom a rectal exam on the 45yo man with rectal bleeding, he said:<br />
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"I must apologize for my stinky<i> feet</i> "!Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-14743632061168649242012-04-01T19:14:00.003-07:002012-04-02T07:28:42.511-07:00Oregon Medical Methamphetamine ProgramATTENDING PHYSICIAN’S STATEMENT<br /><br />Oregon Medical Methamphetamine Card Program<br /><br />Instructions: Please complete all sections of this form in order to comply with the registration requirements of the Oregon Medical Methamphetamine Act OR provide relevant portions of the patient’s medical record containing all information required on this form. This does not constitute a prescription for methamphetamine.<br /><br />PLEASE TYPE OR PRINT LEGIBLY.<br /><br />PATIENT INFORMATION<br /><br /><span style="font-size:85%;">PATIENT NAMES (LAST, ALIAS LAST, FIRST, ALIAS FIRST, M.I.) DATES OF BIRTH:</span><br /><br />____________________________________________________<br /><br /><span style="font-size:85%;">MAILING ADDRESSES: MESSAGE TELEPHONE #: </span><br /><br />________________________________________<br /><br /><span style="font-size:85%;">CITY, STATE AND ZIP CODE</span><br /><br />_______________________<br /><br />PHYSICIAN INFORMATION<br /><br /><span style="font-size:85%;">PHYSICIAN NAME: TELEPHONE #:</span><br /><br />__________________________________<br /><br /><span style="font-size:85%;">MAILING ADDRESS: CITY, STATE AND ZIP CODE:</span><br /><br />__________________________________<br /><br />PHYSICIAN STATEMENT<br /><br />Patient’s Debilitating Medical Condition: Check appropriate boxes.<br /><br /> [ ] 1. Malignant unproductive disorder<br /><br /> [ ] 2. Excess Teeth<br /><br /> [ ] 3. Pre-ulcerated Skin<br /><br /> [ ] 4. Positive status for White Trash Virus (WTV) or Acquired Life Deficiency Syndrome<br /><br /> [ ] 5. Agitation due to narcotic refusal<br /><br />5. A patient with a medical condition or treatment for a medical condition who causes the attending physician any of the following: (check all that apply)<br /><br /> [ ] a. Persistent ED/office visits, including but not limited to visits seeking narcotics<br /><br /> [ ] b. Severe Tenesmus<br /><br /> [ ] c. Believable Threats<br /><br /> [ ] d. Severe agitation<br /><br /> [ ] e. Chronic or Acute Suicidal Ideation<br /><br />Comments:<br /><br /><br />I hereby certify that I am a physician duly licensed to practice medicine in Oregon under ORS Chapter 677. I am stuck with the primary responsibility for the care and treatment of the above-named patient. The above-named patient has caused a debilitating medical condition in me, as listed above. Methamphetamine used medically may mitigate the symptoms or effects on me of this patient’s condition.This is not a prescription for the use of medical methamphetamine.<br /><br /><br /><br />PHYSICIAN’S SIGNATURE: DATE:<br /><br />MAIL ATTENDING PHYSICIAN’S STATEMENT TO: DHS/OMMP PO Box 14450 APS 2008 Portland, OR 97293-0450Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-47696312734635987962012-04-01T18:25:00.002-07:002012-04-01T18:50:24.443-07:00April Fool 2012The best I've seen:<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://britishlibrary.typepad.co.uk/.a/6a00d8341c464853ef01630319898d970d-800wi"><img style="cursor: pointer; width: 800px; height: 364px;" src="http://britishlibrary.typepad.co.uk/.a/6a00d8341c464853ef01630319898d970d-800wi" alt="" border="0" /></a><br /><br /><br />Medieval Unicorn Cookbook found<br /><br />http://britishlibrary.typepad.co.uk/digitisedmanuscripts/2012/04/unicorn-cookbook-found-at-the-british-library.html<br /><br /><br />Adblock was taken over iz now Catblock<br /><br />http://adblockforchrome.blogspot.co.uk/2012/03/inturdusing-catblock.html<br /><br /><br />Google Street Roo<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://1.bp.blogspot.com/-kvarqmfYzBY/T3dzXsaV2LI/AAAAAAAAAFU/Du7xYx5ccsw/s400/Kangaroo%2Bwith%2Bhead%2Bcamera.jpg"><img style="cursor: pointer; width: 400px; height: 266px;" src="http://1.bp.blogspot.com/-kvarqmfYzBY/T3dzXsaV2LI/AAAAAAAAAFU/Du7xYx5ccsw/s400/Kangaroo%2Bwith%2Bhead%2Bcamera.jpg" alt="" border="0" /></a><br />http://google-au.blogspot.com.au/2012/04/google-street-roo-exploring-outback-one.html#!/2012/04/google-street-roo-exploring-outback-one.html<br /><br />Many links to more at http://www.pocket-lint.com/news/45109/april-fools-day-2012-highlights and http://www.telegraph.co.uk/news/9178949/April-Fools-Day-todays-best-stories.html#disqus_threadHal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-54316923659463331122012-02-13T13:13:00.000-08:002012-02-13T13:34:50.416-08:00STAT RefillPhone call of the morning:<br /><br />"Can you refill my Viagra? I need it before Noon".Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-15238780466678654112012-01-12T16:56:00.000-08:002012-01-12T17:05:18.014-08:00Let Me Rephrase ThatPhone call.<br />Neurosurgeon declines to perform procedure on my alcoholic elderly patient.<br />I hang up and turn to my staff and say:<br /><br />Hal Dall, MD: "Dr. X won't operate on Mr. Y because he's a drunk".<br />Dr. Dall's staffer: "Dr. X is a drunk"?Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-62489969382409055062011-10-21T11:30:00.000-07:002011-10-21T13:56:26.463-07:00The Critical Value of Lab TestsMany months ago our hospital "improved" the laboratory critical value list.<br /><br />In the resulting tsunami of early AM phone calls for critically chronically low albumin levels in the malnourished, high bicarbs in lungers and multiple 3.4 meq/dl potassiums, one test stood out: <a href="http://en.wikipedia.org/wiki/Prothrombin_time#International_normalised_ratio">INR/protimes</a>.<br /><br />I was called for <span style="font-style: italic;">every</span> therapeutic(and many subtherapeutic 1.6+) INR on my warfarin patients.<br /><br />I "improved" my results by ordering fewer tests, especially those I expected to trigger a call, until our medstaff successfully pushed back the expanded rules (see <a href="http://www.medscape.com/viewarticle/751974">here</a> for a study of the problem elsewhere). The INR standard was altered to accommodate anticoagulated patients, so the calls abated. Until today.<br /><br />This morning I was called for a "critical" normal INR of 0.9 in a (non-anticoagulated) liver patient.Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-41772830641600273432011-09-29T13:27:00.000-07:002011-10-06T16:07:58.398-07:00"hCG" ReduxI've seen much more of the "hCG" nonsense since my <a href="http://haldallmd.blogspot.com/2011/02/expensive-ingredients.html">previous post</a>.<br /><br />I had a (very tall and obese) 11 year-old boy brought in by his father's female friend to receive my stamp of approval for "hCG" drops and the 500 calorie diet. She hoped to recruit me in her war against his mother (who refused the scheme, thinking it crazy).<br /><br />Hal Dall, MD: "It's not appropriate, 500 calories are too few for a growing child".<br /><br />Ms. Fireworks: (at 100 db) "Why do you want him fat?!? Do you want him dead? His mother is killing him"! etc. [rant]<br /><br />HDMD: "He needs a balanced, moderately low calorie diet. 500 calories is too low".<br /><br />Ms.F: "You want him fat? Why do you want him to get fatter?" etc. [rants more]<br /><br />HDMD: "He'd lose weight on a balanced low calorie diet, and I'd be happy to refer him to a dietician for it".<br /><br />Ms.F:(at 110 db) "That won't work!! He needs the "hCG"! He can't lose without it! His mother feeds him toasted cheese sandwiches! Is THAT the diet you want for him? Toasted cheese sandwiches? ...[rants longer and louder]<br /><br />After a sharp exchange she accused me of child abuse for not giving approval to her scheme and she stamped out of the office.<br /><br />I've not encountered the lady again, but the boy has since dropped from BMI 34 to 30.1 in the 8 months since his mom instituted a 1800 kcal diet with consistent exercise.Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-19352053534337200682011-04-01T13:52:00.000-07:002011-04-01T16:21:24.286-07:00The Vast Medical Wing Conspiracy!<p><span style="font-size:180%;"></span><span style="font-size:180%;"><br /></span></p><p><span style="font-size:180%;">Doctors Conspire to Create Epidemics </span><br /></p><span style="font-size:130%;">Widespread Corruption Revealed By Informants</span><br /><br /><br />April 1, 2011<br />By Justin Kidding and April Fuel<br />Internet News Service<br /><br />ALERT!! Your Doctor may be making you and your whole community sick!!<br /><br />Our multi-hour investigation has exposed a massive conspiracy to spread illness organized by Chicago medical mobsters with corrupt doctors and pharmaceutical companies. Allegations of deliberate infections, kickbacks, and drug company trinkets have been raised by multiple personality insiders.<br /><br />This elaborate scheme’s structure was revealed by our whistleblowers; “Dr. A”, “Dr.MD” and “Dr.HD” spoke to us on condition of strict anonymity. Each doctor tells an aspect of this many-faceted tale of conspiracy, greed and fear. Due to the sensitivity of the information and danger to our informants and ourselves, we will refer to the nefarious coordinating organization by the pseudonym “the American Mobster Doctor Association” aka the “AMDA”. We have confirmed and expanded on these allegations by consulting Google, Art Bell and Charlie Sheen.<br /><br />We will start with the testimony of “Dr. A”, who gives the overview. “In spring we get the ‘wishbook’ from the “AMDA” which lists available pathogens. Our association reviews it and we make orders specifying germs and optimal timing of epidemics. It is required that a minimum 25% of the pathogens must be bacteria sensitive to antibiotics. In July we receive the (regionally) adjusted schedule, and the first enteroviruses appear. We order our influenza vaccine which is made to counter the 3 strains “AMDA” is using this year. In the fall, the first epidemics arrive, perhaps via jet contrails or ‘mosquito control’ spray trucks. Often a large daycare is contaminated to start things up or in smoke bombs at football games. Each month we promptly kickback part of our fees from office visits to the “AMDA” to ensure the next germ deliveries”.<br /><br />How is Big Pharma involved? “The drug companies profit from the antibiotics, flu vaccines and cold medicines sold. They also help breed new flu strains to, ah, influence people to get another shot next year or else”. “Dr. A” adds, “I kept silent for years, but my loyalty ran out with the last ink from my final surviving free drug company pen”.<br /><br />“Dr.HD” filled in some details. “Outbreaks are staggered around a region to decrease suspicion, the timing consistent with historical patterns. For example I might tell a parent, ‘It’s strep. We always get it this time of year’. Of course we do! As we ordered! Ha, ha, I have too much fun with it. I diagnose ‘what’s going around town’ the very day it started! And people whisper government conspiracy theories about black helicopters and I can smile, knowing it’s really the ‘AMDA’!”<br /><br />“Dr. A” added, “The government is a party to it, though. Remember the saying, ‘Never let a virus go to waste’? The support of the ‘AMDA’ and Big Pharma was needed for the health care bill, so provisions hidden in the bill will continue the lucrative scheme. Of course there will be return payoffs to politicians from the profits through 'meaningful use' of EHRs. It’s the Chicago Way”.<br /><br />We asked “Dr.MD”, With so many individuals in the know, how have doctors have kept this secret? She replied, “Fear. Naked fear. We know what they have, and they will not hesitate to use it on stool pigeons. C difficile. Vibrio. Entamoeba. Botulism. Even undercover sources are in danger from Treponema, Chlamydia, HIV, HPV and GC”.<br /><br />It is as yet unclear whether hospitals are part of the syndicate, having no defections surviving from that quarter. Our questions of the “AMDA”were initially ignored, but after revealing our location were politely denied.<br /><br /><p>What can an individual do in the face of these threats? Unfortunately very little except wearing a little Japanese-style face mask and keeping your tinfoil hat in place. </p><p>There is no refuge from the contrails.<br /></p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-13607801588007731492011-02-25T14:05:00.000-08:002011-03-01T19:04:04.708-08:00Expensive Ingredients<p>Recently a long-time patient asked my opinion of the 'new' weight-loss method becoming popular in our town. She has lost and regained hundreds of pounds over the years, trying various diets without long-term success. She did best with Weight Watchers, but a successful friend convinced her to try the "HCG" diet.</p><p>I scanned the pages of propagandvertising (the usual pseudoscientific rationale) and instructions she had been given. The diet was primarily very-low calorie (500 kcal/day) with periods of low calorie (1800 kcal) and had a long list of forbidden foods. No surprises there (as I told her, who <em>won't</em> lose weight on 500 Kcal/day?). In addition "HCG" drops are the magic ingredient- to be taken sublingually in 23 day cycles. HCG drops??</p><p>"Can I see the bottle they sold you"?</p><p>"Here it is. I paid $40 for it".</p><p>I look at the front of the label. " hCG". "homeopathic". I turn the bottle and see this on its side:</p><p><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://4.bp.blogspot.com/-jPEApWnbFVE/TW1iiYzjxnI/AAAAAAAAAAk/1m2TgpAHrp4/s1600/Ingredients.jpg"><img style="cursor: pointer; width: 200px; height: 95px;" src="http://4.bp.blogspot.com/-jPEApWnbFVE/TW1iiYzjxnI/AAAAAAAAAAk/1m2TgpAHrp4/s200/Ingredients.jpg" alt="" id="BLOGGER_PHOTO_ID_5579223856295691890" border="0" /></a><br /></p><p><br /></p><p>I turned the label toward her and she read aloud "Ingredients: Water."<br /></p><p>"What! I paid $40 for <em>WATER</em>?!? How dumb was THAT"?</p><p><br /></p><p><br /></p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-84017948412407770152011-01-18T10:02:00.000-08:002011-02-25T17:19:05.852-08:00I Want The Drug Of Choice<p>A retired teacher recently presented with nontender quarter sized minimally red blotch on her leg. She told of recent treatment for a skin infection at an ED. She had no drainage to culture so was treated empirically with a cephalosporin, the infection rapidly diminishing but she soon stopped the med due to GI side effects leaving this minimal lesion. A few days later she came to my office, seeking further treatment.</p><p>Mrs. Surfer:I want linezolid for this. The Internet says it is The Drug Of Choice for skin infections.<br /></p><p>Dr. Dall: It's used for severe, dangerous infections with possibly resistant staph. We try to hold it in reserve so we don't breed resistance.<br /></p><p>Mrs. Surfer: I want the best medicine, it is what is recommended.</p><p>Dr. Dall: I'm not going to give it to you. Your infection is minor, non-threatening, and responded to an ordinary antibiotic and is essentially gone. You don't need a horrendously expensive IV medicine. </p><p>Mrs. Surfer:I want the best medicine, I don't care about the cost. I can pay for it if my insurance does not. </p><p>Dr. Dall: I'm not going to give it to you, I reserve it for specific circumstances.</p><p>Mrs. Surfer:Could you give me IV penicillin then? I won't take anything oral.<br /></p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com1tag:blogger.com,1999:blog-1130498273863390220.post-8375194111621683392011-01-06T12:35:00.000-08:002011-01-06T14:09:11.712-08:00MMR Derangement Syndrome<p><a href="http://www.bmj.com/content/342/bmj.c5347.full">BMJ</a> published the first article in a series documenting how Andrew Wakefield falsified data to publish a purported link between the MMR vaccine and autism. Please read the <a href="http://www.bmj.com/content/342/bmj.c5347.full">article</a> and <a href="http://www.bmj.com/content/342/bmj.c7452.full">commentary</a> in full (and future installments as they are published).</p><p>A summary from the <a href="http://www.bmj.com/content/342/bmj.c5347.full">BMJ article</a>:</p><p><span style="font-size:78%;">How the link was fixed<br /><br />The Lancet paper was a case series of 12 child patients; it reported a proposed “new syndrome” of enterocolitis and regressive autism and associated this with MMR as an “apparent precipitating event.” But in fact:<br /><br />Three of nine children reported with regressive autism did not have autism diagnosed at all. Only one child clearly had regressive autism<br /><br />Despite the paper claiming that all 12 children were “previously normal,” five had documented pre-existing developmental concerns<br /><br />Some children were reported to have experienced first behavioural symptoms within days of MMR, but the records documented these as starting some months after vaccination<br /><br />In nine cases, unremarkable colonic histopathology results—noting no or minimal fluctuations in inflammatory cell populations—were changed after a medical school “research review” to “non-specific colitis”<br /><br />The parents of eight children were reported as blaming MMR, but 11 families made this allegation at the hospital. The exclusion of three allegations—all giving times to onset of problems in months—helped to create the appearance of a 14 day temporal link<br /><br />Patients were recruited through anti-MMR campaigners, and the study was commissioned and funded for planned litigation</span><br /></p><p>The original paper fueled anti-immunization sentiment, and contributed to decreasing immunization rates and increasing infection rates across the Western world. Although the original paper was retracted last year by the Lancet, and Wakefield was stripped of clinical privileges in Britain, he remains a star of anti-immunization groups.</p><p>For his fraud, Wakefield gained fame and filthy lucre (including over $600000 from the legal firm). He remains unindicted, free to peddle his ideas here in the US. </p><p>The rest of us have paid a heavy price for these lies, in distrust and alienation between parents and doctors. In millions spent trying to disprove a fantasy. In children with preventable illness and untimely death. <br /></p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-37058853391396464592010-11-19T13:03:00.000-08:002010-11-19T16:41:19.953-08:00Handled By the Medical Safety Administration<p>Rejoice America! Help is on the way to rescue you from those ham-fisted unprofessional exams at airport screenings!</p><p>Soon, the Medical Safety Administration (MSA) will emerge from the Obama Health Insurance law to deliver you from unneeded medical screening exams, and will then (certainly) move on to non-medical ports of entry.</p><p>The <a href="http://www.uspreventiveservicestaskforce.org/recommendations.htm">US Preventative Screening Task Force (USPSTF)</a> is the sole arbiter of medical screening in ObamaCare, so here are some highlights of <a href="http://www.uspreventiveservicestaskforce.org/recommendations.htm">USPSTF recommendations</a> for the bashful:</p><p><strong>NO</strong> recommended <a href="http://www.uspreventiveservicestaskforce.org/uspstf/uspsskca.htm">skin checks</a> (visual or using scanner)</p><p><strong>NO</strong> recommended <a href="http://www.uspreventiveservicestaskforce.org/uspstf/uspsovar.htm">ovary</a> checks!</p><p><strong>NO</strong> <a href="http://www.uspreventiveservicestaskforce.org/uspstf/uspstest.htm">testicular</a> exam!</p><p><strong>NO</strong> <a href="http://www.uspreventiveservicestaskforce.org/uspstf/uspsprca.htm">rectal</a> exams!</p><p><strong>NO</strong> <a href="http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm">breast exams</a>! Not even <a href="http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm">self breast exams</a>!</p><p>SO, at your local MSA outpost(aka doctor's office)----<strong>no one</strong> will <em>"TOUCH [YOUR] JUNK"</em>.</p><p>When the U.S. puts the MSA in charge of both medical and airport screening, all you hassled travelers can rest easy, at least until we <a href="http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm">get out the colonoscopes</a>.<br /></p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-631568423104194562010-10-04T10:58:00.000-07:002010-10-08T22:22:35.523-07:00Risk ManagementToday a cardiologist's office called. My referred 49 y/o patient refused her scheduled radionuclide cardiac imaging fearing danger from radiation exposure. Perhaps I can convince her that her cigarettes, liquor and methamphetamine are radioactive.Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-64985897983949754502010-08-14T13:34:00.000-07:002010-08-14T14:48:57.127-07:00Peculiarities of ClassNearly 20 years ago I had a young man present with a fractured a rib from a fall. I noted aloud the codeine allergy "documented" in his chart when I had first seen him 3+ years prior. I've never forgotten his response.<br /><br />"Doc, I'm not allergic to codeine. I used to say that when I was still doing drugs so I could get Vicoden instead. We'd take 6 or 8 Vicoden at a time to get high, when I tried that with codeine, I'd just throw it up".<br /><br />Drugs within the same class may (or may not) have significant differences in side effects (as above), intended pharmacologic effects(ditto) and cost. These differences are exploited by every player in the medical care bazaar.<br /><br />My patient exploited differing intended and unintended side effects of two narcotics.<br /><br />Drug reps exploit the most miniscule distinction to try to sell me on a product while talking down price disparity.<br /><br />Insurance companies force choices due to cost while ignoring other considerations, regarding <span style="font-style: italic; font-weight: bold;">generic </span><span>(same chemical)</span><span style="font-style: italic; font-weight: bold;"> </span>and <span style="font-style: italic; font-weight: bold;">same class</span> (similar chemicals) as synonyms.<br /><br />Recently I had a patient's spouse who explicitly adopted the latter view and was angry when I tried to explain the distinctions between one of his meds and her proposed substitute. "They're the same, there's no difference, they're in the same class". <br /><br />The medicrats are smiling.Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-32209836281158774222010-05-25T13:20:00.000-07:002010-05-25T13:55:13.306-07:00Dr. Rob's 10 Rules for Good Medicine<p>This superb <a href="http://distractible.org/2010/05/23/10-rules-for-good-medicine/">post from Dr. Rob</a> comes via <a href="http://medrants.com/">DB</a>'s excellent blog. Please go read <a href="http://distractible.org/2010/05/23/10-rules-for-good-medicine/">it all</a>.</p><p>A taste:</p><p><span style="font-size:85%;"><span style="font-family:times new roman;">Rule 2: Minimize<br /><br />Many doctors and patients have a “more is better” mentality. This not only costs more money to the system, but it can cause harm to the patient. Here’s what I think should be done:<br />1. Patients should only be seen when a visit is appropriate.<br />2. Use as few medications as possible, and when necessary, use the cheapest one that will do the job.<br />3. Order as few tests as possible. No test should be ordered for informational purposes only; the question, “What will I do with these results?” should always be answerable. If it is not, the test should not be done.<br />4. When changes are made, make only a few at a time. Many simultaneous changes make it hard to tell what helps and what hurts.</span></span></p><p>If Dr. Rob's rules were followed, we'd waste less money to achieve better outcomes with less hassle and heartache. Contrast these precepts of of professionalism to modern mandates by medicrats. <span style="font-size:85%;"><span style="font-family:times new roman;"><br /></span></span></p><p><br /></p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-91096674998623011082010-03-23T14:16:00.000-07:002010-03-23T15:50:40.271-07:00The "Missing Targets Sign"<p>Several years ago I had an elderly patient who was an excellent competitive trap-shooter. He came to my office one day with this specific complaint: "Last weekend I was <em>missing target</em>s and losing to guys who have no business beating me". </p><p>He had no other symptoms and had a normal neurological exam, but related that he had fallen a few weeks earlier and sustained a small scalp laceration which was sutured at an ER. His CT scan subsequently showed a subdural hematoma so I referred him to a neurosurgeon for treatment.</p><p>When he returned four weeks later for followup he reported, "I'm fixed Doc, I'm beating those guys again".</p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-35215193844736109452010-03-14T12:10:00.000-07:002010-03-14T22:11:55.256-07:00The Health Commission (THC) Bans "Daily" Orders<p>A new standard for Health Care Organizations was announced today by The Health Commission (THC) [formerly known as the Joint]. </p><p>As of today, March 14, 2010, in medication orders, use of daily, weekly and monthly are now considered a Type 1 violation of patient safety. Medication orders must be written in this format: </p><p>x(quantity) every y(time period in hours, minutes, or seconds); e.g. 10mg every 24 hours, or 5ml every 12 hours.</p><p>This new rule is necessary due to <strong><em>thousands of overdoses</em></strong> which <a style="font-weight: bold;" href="http://americanaffairs.suite101.com/article.cfm/us_daylight_savings_time_information_for_2010">began earlier today</a> in hospitals across most of North America. Patients receiving medications scheduled for "daily" or "twice daily" administration were <strong><em>dosed one hour early</em></strong>, exposing them to possible drug toxicity. There will be a ripple effect with further inappropriate dosing of "weekly" and monthly" in the next doses. This phenomenon is thought to comprise a large portion of the hundreds of thousands who die each year of medical errors. This can be seen in that there were no cases in Hawaii or Arizona which have <a href="http://www.statehealthfacts.org/comparemaptable.jsp?typ=3&ind=58&cat=2&sub=17&sortc=1&o=a">2 of the 4 lowest mortality rates in the USA</a>.</p><p>THC has enforced previous crucial safety standards to protect patients from harm such as banning "qd" in typed as well as handwritten records, requiring writing out "magnesium sulfate" instead of its chemical formula, and enforcing the <a href="http://thehappyhospitalist.blogspot.com/2009/09/today-is-day-your-joint-commission.html">24 hour rule for signing physician verbal orders.</a></p><p>Note: an equivalent rule will soon cover other orders such as vital signs, therapy, and weighing the patient.</p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-30565759580517266402009-12-21T16:08:00.000-08:002009-12-21T16:21:19.549-08:00Homeopathic ER<object width="425" height="344"><p><embed src="http://www.youtube.com/v/HMGIbOGu8q0&rel=0&color1=0xb1b1b1&color2=0xcfcfcf&hl=en_US&feature=player_embedded&fs=1" type="application/x-shockwave-flash" allowfullscreen="true" allowscriptaccess="always" width="425" height="344"></embed></p></object><p>H/T to <a href="http://www.getbetterhealth.com">Dr. Val</a> and <a href="http://gruntdoc.com">GruntDo</a>c.</p><p><br /></p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-55205721228212776142009-11-19T22:52:00.000-08:002010-03-23T15:51:25.625-07:00Doctish-English Phrase Book: Dialogue 1<p>This lesson illustrates a conversation using two dialects of Doctish. The physician, Dr. Lucre uses the standard form, while his patient, Mr. Slippery speaks Evadian. (Translation is provided in italics)</p><p>Dr. Lucre: Good morning, how are you today? <span style="font-style: italic;">You're here?</span><br /></p><p>Mr. Solvent: I'm fine <span style="font-style: italic;">I'm here</span><br /></p><p>Dr. L: What can I do for you? <span style="font-style: italic;">Can I make this a 99214? I have a Porsche payment due</span><br /></p><p>Mr. S: You told me to come in for a recheck. <span style="font-style: italic;">You have a Porsche payment due</span><br /></p><p>Dr. L: How has your blood pressure been doing? I see your pressure is high today. <em>It's always high</em></p><p>Mr. S: It's always high when I'm in your office. <em>It's always high</em></p><p>Dr. L: Do you check it elsewhere, is it any different? <em>You don't check it</em></p><p>Mr. S: Once in a while. <em> </em><em>No </em>Here's my list of numbers<em>. I made them up </em></p><p>Dr. L: We talked before about lifestyle modification. I see you've gained weight, have you been exercising? How about salt intake? <span style="font-style: italic;">You'll blow me off again and I don't get paid for talking </span><br /></p><p>Mr. S: Your scales are off, at home I weigh less than last time. I try to watch the salt. <span style="font-style: italic;">I have this script memorized</span></p><p>Dr. L: Any side effects from your medicine? <em>Can I get moderate risk?</em><br /></p><p>Mr. S: Only the price. <span style="font-style: italic;">Didn't buy it</span></p><p>Dr. L: Any new symptoms in any way? <span style="font-style: italic;">Nope, not even limited risk. I need more HPI elements. Mx/Dx options?</span></p><p>Dr. L: Have you had any chest pain, trouble breathing, edema, etc... <span style="font-style: italic;">ROS x2, check</span><br /></p><p>Mr. S: Nope <span style="font-style: italic;">Nope</span><br /></p><p>Dr. L: Any Family Medical History of hypertension? <em>need 1 pfsh, Check</em></p><p>Mr. S: Not yet. <em>Check your notes, idiot! You ask every visit.</em></p><p>Dr. L: Let me check you over [does brief physical exam]. <em>I need 12 bullets, Check</em></p><p>Mr. S: Why'd you hafta check my ears? <em>He's padding the bill</em></p><p>Dr. L: It's a valuable thing to check. <em>I'll get to charge more</em></p><p>Mr. S: Anything else Doc? <span style="font-style: italic;">Anything else?</span><br /></p><p>Dr. L: I want to double your Hypotensin pill. <span style="font-style: italic;">Take your Hypotensin pill</span></p><p>Mr. S: OK, I'll need a new prescription. <span style="font-style: italic;">I tossed the old prescription</span></p><p>Dr. L: Ok, here you go. I want to recheck you in 3 months. <span style="font-style: italic;">Same same in 3 months</span>.</p><p>Mr. S: Ok, 3 months. <span style="font-style: italic;">Same same in 3 months</span>. </p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0tag:blogger.com,1999:blog-1130498273863390220.post-49086454631844040582009-10-06T12:19:00.000-07:002009-10-06T14:11:40.576-07:00Volitional Dementia<p>I recently saw an elderly gentleman whose wife thought he might be developing dementia. </p><p>To introduce the subject I stated "Your wife is concerned that you forget things. Do you have any trouble with your memory?"</p><p>"Not unless I want to."</p><p></p>Hal Dall, MDhttp://www.blogger.com/profile/03853309002983404637noreply@blogger.com0