minors in charge of their healthcare

I recently have had two or three minor patients (under 18 years old) in the office with a fracture of this or that bone, who live in a home for “troubled youth” or ” juvenile offenders”.

They come with a “staff member” from the residential facility, who may or may not know the child. There are no parents. The staff person has no real interest in the health of the child - they function as babysitter and chauffeur.

So, in essence these children are in charge of their medical decisions. None of these kids have had to have surgery - I put them in splints/casts, and tell them not to lift or use their hands, etc. Most come back having cut the cast off at some point.

I guess I could potentially be getting informed consent from an 11 year old child at some point if they ever needed surgery. I wonder if the state would send a health care proxy of some sort to act on the kid’s behalf. The comical thing is that the information I’m giving with regard to cast care and non-operative management of these problems is just as important as information prior to surgery!

all my stress

“I keep all my stress there”

How can I take a patient seriously who handles their pain/symptoms so poorly as to use this phrase to describe their situation? This happened most recently when I was (briefly) examining someone’s neck to rule out radiculopathy as a source of numbness. This happens particularly commonly when someone has neck pain.

As a surgeon, I immediately lose confidence that I can help such a person. There are twelve to twenty other “health care providers” whose office they would benefit more from visiting (chiropractor, acupuncturist, massage therapist, etc.).

warning sign

One warning sign that I’ve learned to pick up on during physical examination of the upper extremity for nerve compression is a Tinel’s sign (percussion over a nerve) over the median nerve which travels proximally instead of distally.

The classic positive Tinel’s in carpal tunnel syndrome should travel antegrade, or toward the fingertips (hopefully in a classic distribution - thumb, index, middle, or radial ring fingers).

I’ve found that most patients who give a bizarre history, have poorly described symptoms (my arm is numb from my fingertips to my neck), or otherwise seem befuddled my simple questions like, “does this hurt?”, usually will demonstrate this positive sign (if they have a Tinel’s at all).

It doesn’t mean they’re crazy or don’t have a classic diagnosis; it just tells me, “slow down, take it easy, assume nothing”, etc. For example, I probably wouldn’t touch that patient surgically with a ten foot pole before getting electrodiagnostic testing.

aarp ad

I saw this ad on the Fox News website today. It ostensibly aims to inform Medicare recipients that Congress is soon to increase their premiums “to cover the cost of paying doctors fairly”. At the core of the linked website and ad is a plea to write your Congressman and voice concern, saying that you want a “permanent fix” to rising Medicare premiums.

The ad involves a flatlining ECG monitor, indicating that as premiums rise, more seasoned citizens will ostensibly die needlessly.

Check it out here: https://secure2.convio.net/aarp/site/Advocacy?cmd=display&page=UserAction&id=111

Most curious to me is that the video ad says, “to cover the cost of paying doctors fairly…”, and the “Do More” section states at the top of the page, “to cover the cost of paying doctors more”. The AARP loves that little word, “fair”.

I always envision some group of web-saavy retirees reading this and what their reaction is. I think the average website reader in the AARP is too thoughtful to be duped by scaremongering. This technique is more effective on TV between soap operas or infomercials.

The pictures at the top of the AARP web pages are also fascinating - three out of four of the pictured retirees appear either angry, or at least worried/concerned, staring directly into the camera.

Why doesn’t the AARP run ads condemning pet pork barrel spending projects that “take money out of the pockets of older Americans to pay for” ridiculous items and programs that are light years removed from members’ lives? At least paying for healthcare yourself makes sense - it’s valuable and relevant to you as a retired person/older person.

I can’t really figure out if the AARP is pro-physician or thinks we are a uniformly greedy group of bastards. Baby boomers don’t strike me as being as helpless as the target AARP ad consumer. I’d bet the AARP membership numbers will decrease as baby boomers retire and “don’t need no stinking AARP to be my voice”, etc.

paid by the widget

DB describes how physicians are paid (including specialists, by the way; at least in the office):

As I write repeatedly, physicians are not paid for their time, they are paid by the widget. The patient visit is our version of the widget. Anything that we do to prepare for that visit, communicate between visits, review the tests induced by that visit or discuss you problem with another physician is gratis. We cannot bill for the proper use of time to improve the patient experience.

In contradistinction to your neighborhood attorney, whose clock is running anytime he’s thinking about, writing about, or preparing for your case.

causation

One of the first things taught in introductory statistics is that correlation is not causation. Unfortunately, it may also be one of the first things forgotten.

- Thomas Sowell

Basic Economics - A Citizen’s Guide to the Economy, 2004

“never events” and public perception

Over on the covertrationing blog, DrRich has succinctly addressed the new “quality measures” that have been vomited forth from our betters at the CMS.

Some excerpts:

There’s also no point in complaining publicly about this expanded list of “never events,” since the public is foresquare behind the notion that no medical complications should ever occur and if they do it is somebody’s fault, and equally behind the notion that the feds can squeeze quality into the system just by demanding it to be so. Therefore, any doctors who complain about these new, tough quality measures will reveal themselves to be both anti-quality and low-quality doctors.

While it is unlikely that doctors will ever refuse to care for high-risk patients who are experiencing genuine medical emergencies, it is quite likely they will stop recommending elective medical therapy for high-risk patients. Patients who seem particularly prone to infection, bed sores, falls, blood sugar abnormalities, blood clots, delirium, or who seem likely to need intravenous antibiotics (which predispose to C. difficile) will be particularly targeted. Roughly speaking, these patients will include diabetics, the elderly, anyone with a clotting abnormality or a history of blood clots, the obese, people with immune disorders, and the chronically ill.

Enjoy!

“I can feel that”

During physical examination, I often try to elicit pain by pressing on anatomic structures.

In the “normal” patient who comes in saying, “my (insert body part) hurts”, the source of pain can usually be reproduced by a physical exam maneuver or by touching the painful area of anatomy.

However, there is a disturbingly large subset of patients that cannot localize pain, despite complaining bitterly about their pain. I see this as a red flag; not so much toward labeling the patient as a nutball or faking symptoms, but as a sign that I can assume nothing nor proceed quickly towards a diagnosis.

For example, in wrist arthritis, or inflammation (-itis) of the wrist joint (arthr-), The wrist joint is palpable and can be found readily by someone who is skilled in wrist examination. It hurts pretty reliably when smashed or smushed by the examiner’s thumb/finger.

Normally, the patient with wrist arthritis says, “ouch” or “yowza”, etc. (accompanied by a wince or jump out of the chair) when I press on their wrist joint. The other, less “classic” patient, might simply continue staring at the wrist and mutter, “I can feel that”. So, does it hurt or not? Amazing. Most people who don’t have anesthetic arms can feel someone touching them. I’m never sure what these patients are seeking to communicate when they say that.

Maybe someone can give me an explanation that I can use to make sense out of that statement and put it to good clinical use.

hospital fallacies debunked

Normally I wouldn’t defend hospitals, as they have shown time and again their progressive functional disdain for physicians, but…

Catron has posted an analysis you’ll find instructive and arming.

the no-show

The no-show patient offends me.

This applies to the OR more than to clinic appointments.  Often, the no-show patient in clinic provides a welcome break.  Coincidentally the type of patient who has better things to do either 1) doesn’t need me or 2) would waste my time anyway.

There are few things more offensive and insulting than someone not showing up for surgery unannounced.  This tells me that they regard others’ time and efforts as worthless.

The OR staff have prepared case material for the operation, rearranged the schedule to accomodate this person, and anticipate their arrival with medicines and supplies drawn up and waiting.

The anesthesiologist looks down the list and sees that he will have work and therefore income ahead of him when he sees the patient’s name on the schedule.

My personal office staff/nurses have gone over instructions and tried to be diligent in explaining directions and making sure all questions are answered, expending valuable time that they could use making the office run more efficiently or helping other patients.

And lastly, little old me.  I read about and prepare for their operation, even “fret” or “worry” about wanting to do the “right thing” and make the correct and ethical decisions for this patient.  They ostensibly trusted me in the office, never showing any signs of disagreement or flinching when I explained that I recommended surgery, etc.  Though I tried to offer ample opportunity for questions, appropriately and painfully going over potential complications and alternative treatments, still the patient agrees and wants to go through with surgery.

All of this has happened; all this time and mental/physical/emotional energy has been churned out.  So instead of a simple phone call - “hey, I had some questions”, or “yo-yo - I don’t want surgery”, or “hey, my granny says you rich doctors think you know everything and she got breast cancer from a trigger finger release”, etc., the patient simply vanishes.

Of course, they could have fallen victim to some unholy accident - just call after the accident/bear mauling/raging inferno and let us know what happened!

People are amazing.  As Elaine from Seinfeld says - “I will NEVER understand people!”, and Jerry responds, “They’re the worst!”.