Peculiarities of Class

Nearly 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.

"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".

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.

My patient exploited differing intended and unintended side effects of two narcotics.

Drug reps exploit the most miniscule distinction to try to sell me on a product while talking down price disparity.

Insurance companies force choices due to cost while ignoring other considerations, regarding generic (same chemical) and same class (similar chemicals) as synonyms.

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".

The medicrats are smiling.

Dr. Rob's 10 Rules for Good Medicine

This superb post from Dr. Rob comes via DB's excellent blog.  Please go read it all.

A taste:

Rule 2: Minimize

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:
1.  Patients should only be seen when a visit is appropriate.
2. Use as few medications as possible, and when necessary, use the cheapest one that will do the job.
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.
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.

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. 

The "Missing Targets Sign"

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 missing targets and losing to guys who have no business beating me". 

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.

When he returned four weeks later for followup he reported,  "I'm fixed Doc, I'm beating those guys again".

The Health Commission (THC) Bans "Daily" Orders

A new standard for Health Care Organizations was announced today by The Health Commission (THC) [formerly known as the Joint].

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:

x(quantity) every y(time period in hours, minutes, or seconds); e.g. 10mg every 24 hours, or 5ml every 12 hours.

This new rule is necessary due to thousands of overdoses which began earlier today in hospitals across most of North America. Patients receiving medications scheduled for "daily" or "twice daily" administration were dosed one hour early, 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 2 of the 4 lowest mortality rates in the USA.

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 24 hour rule for signing physician verbal orders.

Note: an equivalent rule will soon cover other orders such as vital signs, therapy, and weighing the patient.

Homeopathic ER

H/T to Dr. Val and GruntDoc.

Doctish-English Phrase Book: Dialogue 1

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)

Dr. Lucre: Good morning, how are you today? You're here?

Mr. Solvent: I'm fine I'm here

Dr. L: What can I do for you? Can I make this a 99214? I have a Porsche payment due

Mr. S: You told me to come in for a recheck. You have a Porsche payment due

Dr. L: How has your blood pressure been doing? I see your pressure is high today. It's always high

Mr. S: It's always high when I'm in your office. It's always high

Dr. L: Do you check it elsewhere, is it any different? You don't check it

Mr. S: Once in a while. No Here's my list of numbers. I made them up

Dr. L: We talked before about lifestyle modification. I see you've gained weight, have you been exercising? How about salt intake? You'll blow me off again and I don't get paid for talking

Mr. S: Your scales are off, at home I weigh less than last time. I try to watch the salt. I have this script memorized

Dr. L: Any side effects from your medicine? Can I get moderate risk?

Mr. S: Only the price. Didn't buy it

Dr. L: Any new symptoms in any way? Nope, not even limited risk. I need more HPI elements. Mx/Dx options?

Dr. L: Have you had any chest pain, trouble breathing, edema, etc... ROS x2, check

Mr. S: Nope Nope

Dr. L: Any Family Medical History of hypertension? need 1 pfsh, Check

Mr. S: Not yet. Check your notes, idiot! You ask every visit.

Dr. L: Let me check you over [does brief physical exam]. I need 12 bullets, Check

Mr. S: Why'd you hafta check my ears? He's padding the bill

Dr. L: It's a valuable thing to check. I'll get to charge more

Mr. S: Anything else Doc? Anything else?

Dr. L: I want to double your Hypotensin pill. Take your Hypotensin pill

Mr. S: OK, I'll need a new prescription. I tossed the old prescription

Dr. L: Ok, here you go. I want to recheck you in 3 months. Same same in 3 months.

Mr. S: Ok, 3 months. Same same in 3 months.

Volitional Dementia

I recently saw an elderly gentleman whose wife thought he might be developing dementia.

To introduce the subject I stated "Your wife is concerned that you forget things.  Do you have any trouble with your memory?"

"Not unless I want to."

Ezekiel Emanuel and Medical Rationing- Link

Ezekiel Emanuel (Rahm Emanuel's brother) is an influential player in health care reform and rationing. I began to write posts descibing his writings, but I didn't complete the pieces, yearning for someone more erudite to do so.

DrRich (the must-read writer on medical rationing) has now published a must-read article on Emanuel here.

BaucusCare: Keep your Doctor?

Here is a portion of a simple flowchart which allows you to determine if you can keep your doctor if the Senate health plan becomes law. Click this link to see the whole chart. Alles klar?



Update: The chart doesn't seem to appear on the post at times. The original is here.

Background Music for the O.R.

Here is some excellent stuff!



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