End-Of-Life Discussions

Photo: 28misguidedsouls

When I was a resident working in the intensive care unit (the ICU) at the University of Iowa, one of my responsibilities was to communicate with the family members of my patients.  However, an intensive care unit, as its name suggests, is an intensely busy place, and I often observed among my colleagues a tendency to think about communicating with families as the last thing on their list of things to do.  And though I too often found myself making it the last task of my day, I tried to make it a consistent one, knowing, as I did, that not knowing is perhaps even more anxiety producing than knowing that something is bad. Continue reading…

Why We Shouldn’t Decide Ourselves When We Need Medical Attention

Photo: stars alive

Four years ago, I was driving home from work when I began to experience mild chest pain.  It was located slightly to the right of my sternum and felt like a muscle strain.  My chest was slightly tender when I pressed on it, but so slightly that I felt unsure with every other palpation if it actually was.  When I turned in my car seat, it hurt more as well.  I thought it was one of those mysterious minor pains we all get every so often. Continue reading…

Knowing When To Stop

Photo: Nicholas_T

“When do we stop?” my patient’s son asked me.

“That’s really hard to know,” I answered.

We were discussing when to stop making  interventions in hopes of trying to save his father’s life.  He’d been diagnosed with a severe gastrointestinal bleed from a stomach ulcer. Continue reading…

The Whimsy Of Serendipity

Photo: Audin

Years ago, a longtime patient of mine came to see me with an odd complaint:  he’d developed spontaneous bruising on the top of his penis.  “I honestly don’t know how this could have happened,” he said.  “I certainly didn’t bang it on anything,” he added with a nervous chuckle.

He went on to tell me that the previous week he’d been on a bus when he’d been struck with a sudden pain in his left hip so excruciating they had to stop the bus and cart him off in an ambulance to a nearby emergency room.  Continue reading…

The Problem With Being Too Persuasive

Photo: aspearing

When I was a first-year resident, I admitted a 34-year-old HIV-positive man to my inpatient general medicine service for fevers.  On physical exam, I found a large lesion on his right retina near the macula (the retina’s center).  I called up an infectious disease specialist, who confirmed what I’d suspected:  he had CMV retinitis. Continue reading…

Managing Chronic Pain

Photo: RTP

I have a small cohort of patients who suffer chronic pain so intense and unremitting it prevents them from living normally.  They often don’t work, shop, go to restaurants or movies, leave their homes or sometimes even their beds except to visit doctors, or have meaningful relationships outside their immediate family, who often struggle to live with and care for them.

One patient in particular has pain that’s so severe she’s become wheelchair bound, chronically depressed, and regularly experiences times when she contemplates suicide on a daily basis. Continue reading…

The Anatomy Of A Doctor Visit

Photo: Patrick J. Lynch

Working as I do in an academic medical center, I’m frequently called upon to teach medical students.  I do most of my teaching now with the third-year medical students when they rotate through our outpatient clinic.  Usually, I’ll send them into an exam room on their own to see my patients (after requesting my patients’ permission to do so, which they nearly always grant) and then have them present the patient’s history to me in front of the patient.  This model is efficient and accomplishes much: Continue reading…

A Proposal To Contain Health Care Costs

Photo: Thomas Beck Photo

In two previous posts, A Prescription For The Health Care Crisis and Analysis Of The Health Care Law, I attempted to analyze the major cause of America’s skyrocketing health care costs and why I was skeptical that the new health care law would do much to curtail it.  In this post, I’d like to offer some concrete ideas about what I think needs to change to slow the rate of rise of our nation’s health care bill.  While I’m certainly no expert in health care policy or economics, I have had extensive experience as both a health care provider and administrator and would like to get a conversation going in this forum that addresses the most significant cause of our inflated costs. Continue reading…

The Danger Of Early Closure

Photo: gustaffo89

I had a patient once—a fellow physician—who came to see me complaining of mid-back pain.  When I examined him, I found I could reproduce his pain by pressing firmly on the spot he said was hurting him.  He said pressing there also made the pain radiate around to his stomach, a phenomenon known as “referred pain” that meant his pain was almost certainly caused by a trigger point.  I offered to inject it with a mixture of lidocaine and cortisone, a procedure that’s been shown in the medical literature to be helpful, but he declined, preferring instead to use over-the-counter pain relievers. Continue reading…

Criteria For Screening

Photo: zilupe

I had a patient once who wanted an exercise stress test even though he had neither symptoms nor risk factors to suggest the presence of coronary artery disease (such as chest pain with exertion).  I argued vociferously against it.  However, extenuating circumstances (not relevant here) prompted our mutual decision to go ahead with it anyway.  To our surprise and dismay, it came back positive. Continue reading…