Why Do Incompetent Doctors Flourish?

Last week Doctor D answered this question in a way that made him sound like a frickin' hero:

How do doctors deal with colleagues that they know are incompetent?

Now that you all think I'm awesome, I have to make a confession: I have looked the other way a lot more often than I have saved the day.

Doctor D has known some bad doctors over the years. I don't mean doctors that make errors—we all do that sometimes—but doctors that flagrantly disregard patient safety and don't give a damn about right practice. And Doctor D usually kept his mouth shut.

The code of silence started early...

Doctor D's first run-in with reckless care was as a first year med student. D was working with Dr. Subethical who happened to teach the medical ethics class. Dr. Subethical who seemed so cool in class spent most of his clinic time screaming at patients and dictating physical exams he didn't perform. Lowly Medical Student D thought that this didn't seem right, but he never confronted Dr. Subethical or filed any complaint. Young D figured he must have just misunderstood the situation. Also Dr. Subethical was an honored professor while D was just some lowly student who didn't want a target on his back.

MD's usually have more power and more knowledge than their patients and other healthcare providers. This often keeps patients, med students, and nurses from confronting doctors. So it falls on other doctors to keep an eye out for bad care among our colleagues.

Unfortunately, we doctors do a terrible job policing each other.

Young D always kept his mouth shut in medical school, but he told himself that when he got that MD with some power and knowledge he would set the world right. He would stamp out crappy care and save the world from low-life doctards! Yeah, well old habits stuck around. D's been out of medical school for a long time now, and has seen quite a few doctards, and his number of confrontations thus far is a grand total of... one! To be honest, Doctor D only whooped some doctard ass at Crayzee Clinic after having incompetent care shoved in his face month after month till he couldn't ignore it anymore.

So in this anonymous blog Doctor D confesses:

"Hi I'm D, and I have turn a blind eye to bad medical care."

Doctor D's readers all gasp and shake their heads.

"But wait, I can explain!"

There are lots of reasons good doctors are always letting the bad ones off the hook:

• Nobody Likes Tattletales: You might assume that Doctor D's heroic battle with Crayzee Colleague looks good on his resume. Nope! D has a big FAIL stamped right across his forehead. Nobody wants to work with a goody two-shoes who rats out his buddies when they break the rules. Even the excellent docs got kinda distant while I was fighting Crayzee Colleague. If I called out bad doctors wherever I worked before long I wouldn't have a job.

• Nobody's Perfect: Our culture expects perfection from doctors. Of course, we all make mistakes, and many of us live in dread of errors. We want people to forgive our mistakes so we are willing to accept that other docs make errors too. Now there's a big difference between understandable human error and the doctard who makes a habit of flagrantly and willfully doing stupid shit. Unfortunately, this unspoken "culture of forgiveness" in medicine protects the guilty as well as the innocent

• Everybody Hates Lawyers: Every MD lives in constant fear of a malpractice case, which is a professional and personal catastrophe. We usually keep our mouths shut about bad care because discussing possible malpractice is taboo. If you accuse a colleague of malpractice you might as well send the poor schmuck in front of a firing squad. There just isn't any safe environment where we can confront other physicians. It's ether shut your mouth or throw your colleague to the dogs.

• There's More Than One Way To Skin A Cat: Every doc remembers that abusive attending in medical school that yelled that there was only one right way do do medicine, which happened to be his way. Later we learned there are a lot of different right answers in medicine. Every doc has a different treatment style. Nobody wants to grow up to be that jerk that attacked others' legitimate care because it wasn't the way he did it. So sometimes when we see obviously bad care we shrug and say, "Well that's not what I would do, but maybe it's just a different approach?"

• Second Hand Information: Most of the bad care I know about is hearsay. I usually don't have time to sit around and watch my colleagues practice. I hear things from patients or read charts that sound concerning, but I wasn't there. I tend to give other doctors the benefit of the doubt: "Maybe there's a good explanation for this?"

• We Expect Lawyers To Do Our Dirty Work: Every good doctor can probably think of an incompetent doctard who they secretly hope will get destroyed in a malpractice lawsuit. (Yep, Doctor D is thinking of one right now.) Malpractice is horrible, but some doctors deserve it. Why should we waste our time confronting bad care when lawyers will take out the garbage for us? Unfortunately, this is a total cop out. Malpractice does a terrible job policing medicine. First of all, the lawyers and juries don't understand medical care very well. Second, lawyers don't bring malpractice cases to improve medical care. Lawyers bring malpractice cases to hit the jackpot. The malpractice system creates a mad scramble where big money gets awarded or denied based on the lawyer's cleverness or the jury's mood, rather than the doctor's competence. Good doctors are often screwed while bad doctors get off on legal technicalities. Malpractice doesn't really improve medical care—it just makes doctors afraid to discuss bad care.

Of course, all these are just lame excuses. Doctors should step up and call out the bad ones who are endangering patients. Doctor D can think of a couple that need to be set straight, but after his adventure at Crayzee Clinic he isn't too eager to try any more heroics. He's keeping his mouth shut and venting anonymously on his blog.

So Doctor D has taken the first step: he admitted he has a problem. Any ideas for 11 more steps that could motivate D and the other good doctors out there to remove the incompetent doctors from their midst? I've got no answers on this one.

This is an intervention!
Your favorite blogging doctor has a serious apathy problem, but he is totally unmotivated to change. Use the comments section below to convince Doctor D why he try to be a hero again when the first time was a big fail!

Merry Christmas (A Friday Without Links)

Today is Friday, but it is also Christmas—so no Friday Links shall be served today.

I hope today is a day that you link to your family and friends and to the Great Physician whose birth we celebrate today. He can heal what no doctor ever will.

God bless you all and merry Christmas!

The Battle Against Incompetence

A while back Nurse K asked a really good question:

How do doctors deal with colleagues that they know are incompetent? Keep your mouth shut? Frank discussion with the medical director? Anonymous letter?

Doctor D has two ways of answering this question. One makes him look really awesome, and the other exposes him a part of the problem. Doctor D will start out all the heroic stuff and then tell you more in the next week:

Doctor D once worked at a place called Crayzee Clinic, because he really wanted to practice primary care in an underserved community. (What a saint! Let's give Doctor D a Nobel Prize or something!) Unfortunately the clinic came with a partner we shall call "Crayzee Colleague."

Now Crayzee Colleague was pleasant enough, but the medicine she practiced didn't even remotely resemble proper standards of care. Doctor D, being the totally nice dude that he was, thought maybe Crayzee Colleague was just behind the times and hadn't heard of the cool new stuff doctors have been doing for these last fifty years. D mentioned his concern in the gentlest possible way, but would you believe it, Crayzee went nuts! She called D a "young doctor who doesn't know shit."

So Doctor D printed out some info for Crayzee Colleague on how medical care is done in this century to prove that he isn't the only one who believes in things like vaccines, mammograms, and such. Unfortunately nothing changed about Crayzee Colleague's incompetent care.

Doctor D was worried because he shared patients with Crayzee Colleague and the stuff she did wasn't exactly safe. From time to time he sent her pleasant little notes reminding her about sensible medical care as he was cleaning up her disastrous work. After a few months of this our hero realized Crayzee Colleague had no interest in changing anything.

Since Crayzee Clinic was federally funded, Doctor D figured he should go up the ladder and speak to "The Man." The Man isn't a doctor, but he has a fancy title, sits behind a big desk, and supervises a whole lot of doctors. D figured his colleague would surely listen to The Man. So D informed The Man that he was very worried about Crayzee Colleague's care. The Man said "Doctor D you are right. Crayzee should step up her game."

And then nothing happened.

Crayzee Colleague kept providing downright dangerous care, ignoring D's still friendly but increasingly firm reminders to at least try to practice something resembling primary care.

Finally, Doctor D had enough of Crayzee Colleague doing dangerous shit to his patients. He blew the whistle as loud as he could. He warned every healthcare bureaucrat he could find, "Look, if Crayzee Colleague keeps doing this stuff that endangers patients I will resign from Crayzee Clinic and tell every patient I see on my way out that I'm leaving because the care here is a treat to public safety!" And still nothing happened.

So Doctor D did exactly as he had threatened he would.

At the end of our story The Man's bureaucracy remained intact, Crayzee Colleague was still at the clinic, and Doctor D had all his principles but no job in the middle of the Great Recession.

...but Doctor D is still proud he opened that can o' whoopass on medical incompetence as well as The Man and his Crayzee Clinic.

Please feel free to praise the fearless Doctor D in the comments section! Get his ego good and inflated because next week he has to make some confessions that will disappoint you.

Shuffling Links! (Friday Links)

Doctor D wishes you all came to his nifty site for his brilliant answers to your questions, but let's face it, it's Friday and you're here for the links. That's okay. D forgives you! Since this site is where a lot of you come to connect to the medical blogsphere Doctor D is going to be sure the linkage is up to snuff...

So if you will direct your attention to the right of the blog just below the "followers" section you will see the new, improved link lists:

• First of all, Doctor D realized that putting doctor-blogs at the top is probably likely to exacerbate these bloggers god-complexes. Henceforth, the links shall shuffle! Currently Patient Blogs have risen to the top. Nurses and medical students are also above the docs! The shifting lists should always bring something new to the top.

The lists themselves are also evolving:

• Patient Bloggers: I took out a few links that honestly I'm not reading anymore. Six Until Me is a popular diabetes blog, but if you aren't a diabetic it doesn't really have much to say. Ditto with Reality of Anxiety. It's a good blog for what it is, but right now I'm more interested in blogs that explore the experience of being a patient than blogs about a particular disease. You don't need to know anything about bladder diversion to enjoy Neo-Conduit's blog or the diagnosis of unusual illnesses to enjoy Queen of Optimism. Their writings are essentially human not medical stories. I also added a very interesting blog: Coming Out Of The Trees, about a patient overcoming a history of severe abuse—heavy but fascinating.

• Nurse Bloggers: Well with Nurse K's blog gone again I had to cut the link, but she's still there on twitter. So for D's top Nurse Blogger the award goes to MAHA! She is a new nurse fresh out of nursing school who is an very funny articulate blogger. Heck, she deserves the top slot just for this post. Unfortunately Lonely Midwife appears to have gone into unannounced hiatus, so her link is gone, but if she comes back D will return her to her rightful place.

• Medical Student Bloggers: Ella is still D's favorite med student blogger, but a new contender is Indifferential Diagnosis. It seems to be the work of a group of medical students just teetering on the edge of sanity. God bless, those poor suckers sludging through the misery of med school! Doctor D can reasure them it gets better, but while they are somewhat delusional you can enjoy their brilliant posts like this one.

• Doctor Bloggers: D is thinning out this category right now. Doctor Rob is wonderful despite his strange fascination with lamas, but with his blog on a semi-hiatus his link is being retired for the time being. Buckeye Surgeon is a great storyteller, but recently his blog has gotten a bit overly political for D's tastes. The Happy Hospitalist's link is also gone. Doctor D was just tired of reading so very much about so very little, and without Nurse K around to antagonized Happy what is the point? This opens up space for you to discover some of the other great doc bloggers over there.

• Resident Bloggers: This category is getting lonely! Agraphia appears to have shut down his blog which is too bad, but understandable. Residency is a trial by fire. Only Doctor Ottematic is left. Anybody know any good resident bloggers D can link to?

• And as an extra bonus Doctor D is adding an Other Fun Stuff section. What's in there? You guessed it: other fun medically-related stuff! Enjoy.

Thanks for coming to this week's Friday Links! I promise fewer links next week.

What do you think? Did D miss a great blog that should be in the lists or delete a blog that should have stayed? Tell him all about it in the comments!

Of Course, It's All In Your Head!

A patient asks me:

"Doc, are you saying this is all in my head?"

The assumption behind the question: things in the mind are not real. Doctors also display this unfounded assumption. We just obscure our prejudices by using medical jargon like "supratentorial." (First reader to define Supratentorial and use it in a sentence wins Doctor D's prize of the week!)

Every illness you ever had was "all in your head." Seriously, where else could it have been? You have never felt a symptom, whether it was a broken ankle or a broken heart, that wasn't felt in your mind. Your mind is your consciousness. Every pain, cramp, anxiety, or ache is felt exclusively in the mind. Your mind is not a part of your body. Your body—as you know it—is a part of your mind.

Doctor D, has had a couple brain-dead (literally not figuratively) patients. Trust me, they never complained of anything! They never had any symptoms. They never felt bad. And their bodies didn't survive long without minds.

Many doctors hold to this absurd theory that your body is a separate entity from your mind and physicians should focus solely on the body. But the human mind keeps getting in the way and annoying these stupid doctors. Of course it does! The mind and body are completely interwoven and inseparable.

This crazy idea that the mind shouldn't interfere with the body has spread from stupid doctors and now created a stupid culture. It is tricky to actually figure out what is going on with a person because everybody now denies their mind has anything to do with their symptoms. Lots of patients refuse to answer when Doctor D asks about their feelings about their symptoms or illness. I can understand why. They're worried that Doctor D thinks they are nuts. Having a mind doesn't make you crazy, it's loosing your mind that is crazy!

So Doctor D has some ideas for how MDs and patients can overcome our anti-mind biases and improve doctor-patient relationships:

• First, doctors and patients both need to acknowledge that all symptoms are real. If you feel it in your mind then it is real—period. We don't say that happiness is "imaginary" because it is a mental state. We shouldn't say that any discomfort is imaginary. Fibromyalgia and panic attacks are just as real as pneumonia and broken bones.

• Second, doctors and patients both need to acknowledge that the mind is real and it matters. I know this sound obvious, but some doctors still think only Psychiatrists should pay any attention to patients' minds. No matter what the disease, ignoring the person to focus solely on the body will lead to disaster after disaster in medicine. Patients also need to be willing to discuss their mental attitudes and recognize that the mind plays a role in illness and healing.

• Finally, we need to understand that different symptoms need different treatments. Not every symptom needs a big work-up or a strong medicine. It is my job to help people distinguish dangerous symptoms from ones that are not. Shortness of breath that starts when your girlfriend breaks up with you merits a different work-up than shortness of breath with unilateral leg swelling and a low pulse ox. Both are real problems, but not the same problem. Understanding your mental and emotional experience of your symptoms helps me better diagnose you and avoid giving you treatments or work-ups that could cause you harm. In order to successfully negotiate these interactions a patient must trust that the doctor has taken the first and second step and isn't assuming they are crazy.

What do you think? Does it bother you when your doctor asks about your mental state when you report physical symptoms? Or does your doctor seem to be biased against the mind and imply you are crazy if you bring up your feelings? Do you think that these 3 steps can improve doctor-patient communication? Doctor D would love to hear your thoughts!

Friday Unlinking

It is a sad day in the medblogging world! Nurse K has pulled the plug on her blog again!

We can only assume that the illustrious Nurse K had renounced blogging out of shame! She had been promising to do a guest post for Doctor D for like a month now and never got around to doing it. Poor K! Her guilt at letting down Doctor D must have driven her to despair. And now she has closed her blog and assumed a life of quiet contemplation in order to do penance for her transgressions.

Nurse K, all is forgiven! I never really thought you'd do that guest post anyway. I knew the topic was too dull for your tastes! I forgive you the guest post you owe me. You are free to return from your seclusion. Your readers need you in these dark times!

Actually Nurse K is still cool, but her blog is down for the near future. She is missed, but Doctor D will keep her link on the sidebar, ready for her triumphant return. Until then you can get your dose of ER Crayzees at this site.

Is The Patient Crazy—Or The Doctor? (Friday Links)

Doctor D found a great blog by a patient with lots of physical maladies who used to be reporter for the Associated Press. Now she is "Sick Momma" and blogs on her life as a chronically ill mother and wife. As D was enjoying her blog and came across this post about some conditions he'd never heard of.

Apparently Sick Momma believes that many doctors suffer from a mental disorder which causes us to attribute symptoms we don't understand to a patient's mental state. Whatever!

Patients expressing unfamiliar complaints to their physicians often induce the "It's All In Your Head" (AIYH) or the "That's Impossible" response in doctors suffering from these behavioral problems and personality disorders.

Physicians fixated upon the metaphysical belief system of "If we don't know about it, then it doesn't exist" are suffering from a mental defect or psychological condition known as "Doctors with Unexplained Medical Beliefs": D.U.M.B.

Excuse me? I'm the doctor, so I'll decide what is a disorder and what isn't!

And I've never heard of these "behavioral disorders," which leads me to suspect they don't exist! Since I have no idea what put these crazy ideas in Sick Momma's mind, I shall diagnose her as depressed and put her on Prozac. I shall continue to add psychoactive medications until she learns not to challenge my god-complex!

***

Actually this is an interesting problem: What should be done about symptoms that make no sense? Lots of patients and doctors end up these situations.

The doc is thinking, "This doesn't sound like any disease I know about. All these symptoms are subjective sensations. Maybe it all is in this patient's head?"

The patient is thinking, "This doctor doesn't know what is causing my symptoms! What an ignorant doctor! If my doctor has never heard about this it must be something rare and horrible!"

It is a tricky impasse. Each can't help but have these impressions sometimes. We all want to prove we aren't ignorant or crazy, but then again we all want to be agreeable. Often these situations end up with either unnecessary antidepressants, unnecessary testing, or both.

We need better ways of discussing strange symptoms. Hence, in next week's reader question Doctor D shall provide some answers! (or perhaps some humble suggestions)

Until then, what do you think? Has a doctor ever told you your symptoms were all in your head? Have any of you healthcare providers ever had a patient who had nutty symptoms? Doctor D would love to hear your stories!

The Bad News Room

A reader asks:

On rare occasions, a doctor won't say anything while I'm on the tissue-covered table and silently escorts me to a small room with ugly upholstered furniture for a conversation. I think the idea is that this is a more "comforting" environment, but to me, it's just another strange medical space. Perhaps you could explain how your compatriots decide where to speak to patients?

Yes, some doctors have this weird idea that bad news is only tolerable when given in a sitting room with upholstered chairs and fake plants.

The trouble, of course, is that patients suspect this and therefore getting moved to the little room with comfy chairs significantly worsens your already nerve-racking visit. You know the bad news is coming, so the comfy room feels like a cell where you await your sentence.

As I've mentioned before, giving bad news is always a rough part of this job. We want to be as gentle as possible, but I think the little room is more for our comfort than yours.

Doctor D believes the most important thing about news is to give it straightforwardly and in a private place. Last thing your doc needs to do is to give it in crowded ER when your neighbor is listening on the other side of the curtain. Of course, the small, busy ER where Doctor D works has lots of curtains and no cute little room. D has even been known to take people in the medicine closet for a talk when it's the only safe place to protect their privacy.

But when privacy isn't a concern, the last thing I want to do is move you somewhere where you know you are waiting for bad news. I'll tell you straight up what I'm thinking. Doctor D believes people care more about hearing news directly, honestly, and kindly than they do about the location where they are told. I have used offices or these little sitting rooms in the past, but only because the patient wanted me to tell a lot of family members that wouldn't fit anywhere else.

I start directly and tell you straight up wherever we are. I know their will be lots of further discussion and questions. I'm always glad to finish the conversation wherever you would prefer to talk.

What do you think? Would you be upset by being told in an exam room sitting on that tissue-covered table? Would you prefer to be moved to the room with the comfy chairs? Let Doctor D know if he should change his strategy!

Blogging Fatigue (Friday Links)

Blogging can be an exhausting thing~ Doctor D is pretty familiar with exhaustion these days between doctoring, husbanding, fathering, and blogging.

Don't worry, this isn't one of those hiatus posts. AskAnMD is still going strong, but one of the web's favorite medbloggers Dr. Rob decided to throw in the towel this week. He was always an interesting read and will be much missed. Also D will now never be able to figure out that dudes odd obsession with lamas.

Blogs don't last forever, although there is always the hope Rob's blog will have a resurrection like Nurse K's and Ella the Med Student's have.

Fortunately amazing new bloggers are always appearing:

The new link this week is Medical Moments in 55 words! Word Doc is an internist who tells medical stories in short 55 word posts. The stories are both funny and poignant, and best of all they take less than a minute to read. So go check out Word Doc. Doctor D guarantees you won't be disappointed!

I'm really impressed with the brevity of Word Doc's posts. The shortness doesn't take any power at all from her stories. Should Doctor D try to answer your questions in 55 words for a while?

What Are My Chances, Doc?

As you may recall from the last post, if Doctor D suspects you might be facing a lethal illness he'll let you know straight up. He brings it up gently, pointing out that any doctor's guess has a lot of uncertainty.

You do, of course, have the right to ask, "How certain are you, doc?"

But here's the secret: MDs hate answering this because we often don't know how certain we are. I'm usually pretty good at predicting what will kill a patient. How good? Results may vary...

In a few diseases there is solid data: 80% of people diagnosed with pancreatic cancer will be dead one year later. Usually, however, the situation is too complex and there isn't any research data to answer the question. Then Doctor D whips out a gut guess.

I once had patient with curable but advanced colon cancer develop urosepsis and then have a heart attack from the septic shock. His family wanted a percentage for his chances. I made one up, "Maybe a 40% chance of surviving the next 24 hours." He survived and went home.

As I said, I'm not perfect.

Percentage numbers don't really mean that much when I'm guessing, but people just like something that sounds mathematical rather than “almost certainly dying” “could die” or “maybe dying but probably not.”

Predicting death is a risky business. Doctor D once had to dodge a fist when D told a dude his dad probably wouldn't make it. (Fortunately crying people can't pull off a good sucker punch!) Doctors also don't like mentioning death because most people don't like to discuss about their own mortality. We vaguely acknowledge we all die sometime, but you don't expect "sometime" anytime soon. Then Doctor D sits you down and says, “Now might be your time.” It's never an easy talk, and it's almost always based on an educated guess.

Doctor D still thinks it is worth letting you know, even if his estimations aren't perfect. Most patients want to prepare themselves and their families if death is a real possibility. I only withhold such information if a patient told me ahead of time they don't want hear any discussion of death.

What do you think? Do you want your doctor to tell you your chances? Even if it is only an educated guess?

Some old MDs never mention the word “death” because “they don't want to take away hope.” Obviously, Doctor D takes the opposite approach. Which would you prefer? For yourself? For your family?

Recognizing Death

A reader with a bad illness writes:

I would prefer that my doctors give me any bad news straight up. I'm not confident they will. No one is saying anything definitive. I've asked two of them about my prognosis. One said, "I can't tell you that." I don't really think anyone knows, but I wonder if they just don't want to tell me bad news?

Predicting the end of life is very difficult even for the most knowledgeable doctor. People with certain conditions are obviously closer to their death, but estimating how and when a person will die is extraordinarily difficult. With some illnesses (like common cancers) we can say what percentage of people will be dead in a year, but a percentage from a study doesn't tell you with certainty how long one individual will live. And most life-ending situations don't have good percentage studies. Still, experienced doctors become pretty good at recognizing when a person's body is declining and fighting a war that it won't win.

One thing that frustrates Doctor D is that MDs often talk amongst themselves about a person's prognosis without frankly mentioning it to the patient. They discuss the disease process in such techno-medical jargon that you don't recognize they are saying you will probably die. The confusion is intentional. They don't want you to hear the word "die" because they are often afraid to discuss with you it themselves.

Death is hard to discuss. No one likes to give bad news. You are telling a person about the end of their life. It is a heavy conversation. Since all they have to offer are educated guesses, doctors often busy themselves and the patient with the technicalities of treatments and tests—until the end is obvious and undeniable. Only then do we frankly discus dying. By then, death is sometimes so close patients have almost no time to prepare themselves and their families.

Your doctor is technically correct. A doctor cannot tell you exactly how and when you will die. But your doc may have a good guess as to where things are headed.

Give your doctor permission to guess. Let the doc know you won't be angry if they cannot win against the disease. Only then are you likely to get a straightforward estimate.

Doctor D has a policy of not hiding his guesses from patients. If I think a person may have a life-ending illness I won't keep it a secret. I point out that I am not certain, but I need to let them know my suspicions. It is hard to discuss someone's mortality, but I believe it is one of the most important duties of a physician with a patient facing a potentially fatal illness.

Of course the next question everyone asks is "What are my chances?" and "How long do I have?" These are also difficult questions to answer, so I will save them for a later post.

All of us will eventually die, but today you have your life and the lives of those around you to be thankful for. So today forget about shopping and tell someone that you love them. See you next week!

No Friday Links Today

Sorry! Doctor D spent the holiday with family and friends and didn't read any blogs. No Friday links today, but I have an answer to a reader's question I'll be posting later today.

Mammogram Madness

The U.S. Preventive Services Task Force recently advised that most women don't need mammograms as early or often as previously believed. Now you can't turn on a TV without some reporter telling us how angry Americans are about this.

What is Doctor D's take on the new guidelines?

As a working clinician I trust the USPSTF. They have no agenda-axe to grind and spend a lot of time studying mountains of data. These experts meticulously examine the thousands of studies that I just don't have time to read. They crunch numbers and come up with carefully considered recommendations.

While I can understand all the public concern, I am irritated that many doctors seem eager to jump on the irrational bandwagon.

What no one seems to comprehend is that even relatively safe tests and treatments can still be deadly. Doctor D has hurt some very nice people with the "right" treatment because all medical interventions have risks.

Men can also get Breast Cancer, just less often. Men die of this disease. Would screening every male "save lives" by catching some early cases? Probably. Would there be lots of false positives? Absolutely. Would the number of men we maim or kill with work-ups and treatments outnumber the lives saved? Almost certainly. Hence the need for evidence-based guidelines.

Breast Cancer is a horrible disease, so it was worth a try to screen women in their 40's. But now we have years of data indicating that we hurt more low-risk women than we helped. Uh-oh! It's one thing to hurt people with what we hope will be the right intervention, but when we hurt people by doing something we know doesn't work it's shameful. The same thing happened with prostate screening for men. We don't need to keep doing things that don't work.

We have a natural bias towards doing something rather than doing nothing. People expect doctors to "do something!" Doctors like to do things for patients. Hence over-testing and over-treatment run rampant in all fields of healthcare. Sometimes we make educated guesses at interventions and hope they work, but when we have evidence showing we aren't helping people, it's time to acknowledge that doing nothing is safer and wiser.

The trouble is that the guidelines are based on mountains of studies that the public, politicians, and many doctors are unequipped to evaluate for themselves. So we go for next best thing: anecdotal evidence. We base our opinions on heart-wrenching stories of women in their 40's that died of Breast Cancer. All the evidence in the world is no competition for a really moving story.

What the USPSTF needs to do is come up with a convincing narrative. Stop referring to data that nobody understands and give your arguments a human face! Parade the widowers of and orphan kids of women that died as the result of a workups for false-positive mammograms in front of every TV camera you can find. Get doctors up on stage and have us apologize, "Sorry, we did what we thought was best, but now we know we were wrong. We'll do better in the future."

Doctor D realizes he'll probably loose some readers over this post, but somebody had to defend the USPSTF against this crayzee smear campaign.

Feel free to post your thoughts, but please don't accuse me of "not caring about women's lives." I follow the recommendations because I care about women, and I've been saying the same thing about PSA in men for a while.

Psycho-Analysis (Friday Links)

It's Friday and Doctor D has a fun semi-medical blog for your reading pleasure:

The Last Psychiatrist

This very enjoyable blog is the product of an academic psychiatrist. Unlike most MD bloggers he doesn't discuss his patients or his practice much at all. Instead he caustically analyzes cultural phenomena from parenting to medical bullshit, teenagers to television (for all you Don Draper fans).

Despite the long posts and the obtrusive presence of Happiesque ads, Doctor D has been reading Last Psychiatrist most of the night, and this guy never gets dull! He diagnoses nearly everyone with Narcissism and warns about the danger, but never has a self-righteous Jeremiad against selfishness been so much fun! Seriously, this dude ranks 8 of 10 on a blog funscale (with Dr. Grumpy as a 9 and Nurse K as perfect 10)!

A taste of Last Psychiatrist:

Pop culture controls you even if you think you're separate from it. It is everywhere, from the clothes you wear to the language you use to the way you think. It is a viral pandemic that masks infection by pretending to be part of you. There's no cure.

"No way, I'm not getting infected, I'm not exposing myself to all that trash. I'm going to think for myself."

That's the virus talking.

Is the Last Psychiatrist a brilliant modern prophet or perhaps a closet narcissist himself who gets off on critiquing his readers? Doctor D isn't sure yet and isn't sure if he cares. Right now I'm just enjoying the ride.

Take a look at Last Psychiatrist and let me know what you think: Is this blogger a genius or a mad psychiatrist?

Why Not Call? (Exhaustion and Economics of Phone Calls)

A reader writes:

Why do I have to take time off of work and make an appointment for my doctor to explain test results? Wouldn't it be much easier to do over the telephone?

It would be easier to discuss this over the phone, and cheaper. Your doctor isn't paid for talking to you over the phone. Getting info over the phone is always a win for patients and a loss for doctors.

Primary Care Doctors (like Doctor D) for whom much of the job is educating you about your health are making a less and less every year (we're the green line) and we started out as the lowest paid physicians. Primary Care clinics are just barely scraping by, so when it comes to discussing your labs they can either do it over the phone for free, taking time away from seeing patients, or bring you in and get paid by your insurance to have the same discussion. The economic solution usually beats the common sense solution.

Now, I don't want this to sound like one of those Happy Hospitalist I-don't-get-reimbursed-for-all-I-do posts. Primary Care is still a good job and Doctor D doesn't have to worry about keeping food on the table.

But when Doctor D worked at Crayzee Clinic he spent many hours every day getting patients results, refills, and forms without pay. He did his best to call patients when he could, but if he knew it was going to be a long talk he usually had you come to the office. Doctor D had to keep some work during office hours—as it was he barely saw his wife or son while working primary care. Of course, some docs avoid phone calls because of greed, but most in primary care are just exhausted having to see more patients faster and faster while doing more paperwork in the evenings. An appointment to follow up tests was usually pleasant and easy, and didn't keep Doctor D in the office later at night after office hours.

But for the patient, it sucks! You have to get off work and drive to the doctor's office, just to get information you could have gotten over the phone. You can and should ask if your doc can call you the results without an appointment. Your heathcare is already too costly without extra visits. But please realize that this is harder on you doc, so don't abuse it. If you are the sort that needs to ask lots of follow up questions please schedule a visit instead of tying up your doc on the phone for 20 minutes!

Okay, after a long blog post about money and reimbursement Doctor D feels dirty and must go bathe the Happyishness off of himself.

This is one of those annoying situations that forces either you or your doc into a financially frustrating situation. The solution proposed on most doctor blogs is billing for phone calls.

What do you think? Would you be comfortable being billed for phone calls? It would save you costlier office visits. Or do you want to keep phone contact free?

Should I Get A Medical Alert Bracelet? (Upselling Healthcare)

A question from WarmSocks:

When should someone wear a medical alert bracelet? Nobody has ever recommended that I should consider it, but my med list seems awfully long so I'm wondering if it would be appropriate?

The purpose of the alert bracelet is two-fold:

1. To provide vital information in an anticipated emergency.
2. To make money off of people with illnesses.

Should I wear a bracelet? Do you have a condition likely to cause you to be found unconscious, and have something about you that would make your care different than the average unconscious person? You should probably carry a brief list of your medical conditions and medicines, but most of those things don't require a bracelet.

These bracelets are marketed to people with things like insulin-dependent diabetes or heart rhythm problems. The bracelet basically says, "This is likely the reason I'm unconscious and this is what to do!" I've seen a lot of diabetics and heart patients with such bracelets, but I've never seen these bracelets make much difference. Paramedics always check blood sugar and heart rhythm as soon as they find you in such situations, so in my experience people with and without these bracelets get about the same care.

The best reason I can see for a bracelet is a rare condition that rescuers aren't going to be thinking about. Diabetics need not worry—we check a sugar on everybody that's unconscious, bracelet or not. (Other reasonable situations to have a bracelet would include: severe anaphylactic reactions to medicines or if you don't want to be resuscitated if your heart stops. )

The second reason for bracelets is to stimulate the economy. The healthcare industry is massive and you—the patient—are the cash cow. If you stop consuming all the medical accessories and extras then the Healthcare economy might shrink! Proven, effective care can be a narrow margin business, but all the physical and pharmaceutical accessories that you see marketed keep the Healthcare Business healthy even in lean times.

If you call a bracelet company they will say that your daily aspirin or history of ankle sprains should definitely qualify you for a bracelet. "Let's bill your insurance, and for a bit more you can get a stylish 14 K gold band for it!"

Your doc should be able to tell you if your condition really needs a bracelet or not.

But be careful if you doc is offering bracelets or any other "value added" products in their office for your convenience! With Primary Care profit margins razor thin, a lot of doctors are going over to the darkside and letting corporations talk them into adding "secondary income streams" to their practice. If your doctor is selling something (bracelets, supplements, skin rejuvenation, etc.) other than medical care you should run the other direction. Your doctor should be an advocate for you, not the spokesperson for some product line.

Is Doctor D may be alone in his righteous anger about MDs who sell extras in their practices? D was highly offended when Little D's doctor was selling vitamin products at the clinic. Mrs. D told Doc D to quit being a pinko Commie and accept that capitalism works this way. Do you mind if your doctor makes extra by selling products?

The Best of D (Friday Links)

This blog has grown so much recently that Doctor D's big doctor ego deemed we should link to all the fun and informative older posts buried in the archives. So if you will direct your attention to the right side of the screen you will notice AskAnMD's new feature:

Doctor D's Best Answers

Of course, if you've been visiting Doctor D's virtual clinic as long as WarmSocks you've already read it all, but if you are new here you can go check it out for loads of doctor-patient enjoyment.

Yes I realize that it is sort of cheating to count a "best of" page as this week's Friday Links, but D is suffering from an acute case of laziness today. Sorry. I will be back on my game next week.

Pregnancy Quiz

So Doctor D normally isn't one to tell stories about his patients' wackiness, but some things are just so odd they demand a teaching moment in the form of a Grumpy-style multiple choice quiz:

You are 39 weeks pregnant and you start feeling the "really bad pain" that keeps coming every 5 minutes. You should:

A. Call your OB

B. Get to the big hospital where your OB delivers babies

C. Wait about 14 hours till you just can't stand it anymore, then drive yourself in the other direction to the tiny hospital ER with no delivery rooms, no neonatal resuscitation equipment, no surgical backup, and ask Doctor D if he can do anything to make the pain stop.

If you answered C it was an honor to be a part of the miracle of your child's birth this morning, and yes, that is what labor feels like so please choose A or B next time.

Thank God women have been having babies without doctors since time began, because all Doctor D had to resuscitate this slippery kiddo was an oxygen mask and his own two hands!

Any readers have fun stories about babies joining our big bright world?

Primary Care: The Best and Worst Job in Medicine

Shawn the medical student asked Doctor D:

As a medical student, I am constantly wondering what type of physician I will become. So my question is, what kind of doctor are you, and how did you decide that field?

Doctor D is a Family Medicine doctor. He chose this career because he is a glutton for punishment! Actually, D chose Family Med because he likes people much more than he likes the technical aspects of medicine. As a jack-of-all-trades doctor I can usually help anyone no matter their age, gender, or medical history, but my knowledge on any specific subject is limited. I can sew up lacerations, give end of life care, deliver babies, prevent future illness, and educate people on how to handle most common medical problems. I did this because I enjoy working with human beings and want to help people with their physical needs.

Should you choose Family Medicine as your specialty you will be constantly looked down upon by other physicians. Even though you probably store more knowledge in your brain than any other doctor, specialists assume you are slow-witted because you don't know as much about their particular disease of choice as they do. You will make much less money than other doctors because insurance doesn't think keeping someone healthy is nearly as worthwhile as doing big tests and procedures. You will constantly be pressed to see more patients in less time because the reimbursement for your work is continually dropping.

After his training Doctor D chose to work in a community health clinic to provide primary care for underserved patients. He absolutely loved his job and the amazing people he cared for. He also learned to hate the medical system and the bean counters that were constantly pushing him to cut corners on patient care. In the end the bureaucrats won and Doctor D quit that clinic rather than choose to hurt the patients he cared about. He is currently working odd shifts as an ER doctor in a tiny hospital in the middle of nowhere to pay the bills till he returns to Primary Care. He blogs about patient-doctor relationships because he misses having patients of his own and still has those crazy ideas about "helping people" with his medical knowledge.

Of Course there are days Doctor D wishes he would have never signed on to be a general doctor (or a doctor at all for that matter). But when I realize I can help nearly every person that walks through my door I am certain that I chose the right career. Family Medicine is one of the most frustrating and rewarding paths in all of medicine. I advise med students to seriously consider general primary care—it is the fullest embodiment of the ideal of doctoring—but only select it as your specialty if you are certain you will love it, because it will probably get harder for primary care doctors before it gets better.

Wow, that was a touchy-feely post! I'm afraid Nurse K is failing to make a good hard-ass ER doc out of me. Quick, someone ask a question that will awaken my god-complex angry doctor side!

Patient Eduction (Friday Links)

Doctor D's recent Friday Links have focused on healthcare providers. It is good for patients to hear what doctors and nurses are saying. Conversely it is useful for those of us in medicine to listen to the voices of patients. So today I bring you two patient blogs that Doctor D never misses.

These are patients who write only about one illness: their own.

• ∞ itis: WarmSocks blogs about living with Rheumatoid Arthritis. She was the first blogger who found AskAnMD and sent encouraging emails and a link from her site. I was hesitant to feature her on Friday Links because most readers don't have RA and therefore might not be interested, but the more I read of WarmSocks' practical advice, insight, and humor the more I realize that she is useful for just about anyone who is interested in medical care.

• Neo-Conduit: Even some medical people (like Doctor D) don't know much about a Urinary Diversion, but this blogger's courage after years of difficulty in the medical system is to be admired. She has some understandable frustration with medical folks, but her perspective is worth listening to. Her observations about patient suffering and frustrations are a insightful and never angry. She is on Doctor D's "must read" list every day.

For some other great patient blogs check out the "patient bloggers" section on the sidebar. And if you follow Doctor D's Friday Links for the physician perspectives you should definitely go over to Dr. Rob's site and read Top Ten Ways To Annoy Your Doctor.

Doctor D will be back soon to answer your questions and with a special post with Nurse K! Stay Tuned!

On Asking Doctor D

Sorry about this dull info post.

A lot of the emails Doctor D gets are anonymous. People with sensitive questions about doctor-patient relations often want to keep their identity private. Doctor D understands completely (since he blogs incognito too).

I often get questions from people with excellent blogs. I don't want to write, "Question from a reader..." if you would prefer a link back to your site.

So if you send Doctor D a question in the future please let me know if you want it answered with or without a link to you.

If you have a question in Doctor D's "to be answered" pile, I will assume you want it answered anonymously unless you write me and ask that I link to you when I answer.

Email Doctor D at AskDoctorD@gmail.com

The Purpose of Pain (Why the Painscale Doesn't Work)

Last week I answered a question by explaining the trouble with how doctors interpret your painscale. Doctor D confessed that he doesn't like the painscale at all. Today I will tell you why even if used perfectly the painscale still just won't work:

The 1 to 10 painscale ignores the way the human body uses pain in the first place. The scale assumes that we can observe the sensation of pain and then compare and contrast it to other pains we know or imagine. Your analysis of pain is supposed to produce a number that doctors and researchers can use to make calculations. There are a lot of things the human mind does a great job analyzing, but pain isn't one of them.

The purpose of pain is to get your attention. Pain is your body screaming, “Something is wrong!” It doesn't take much pain to completely capture your mind's focus. Pain functions as a useful warning system. It tells you to pull your hand out of the fire or not to walk on that broken ankle. Your brain pays close attention to pain and obeys its commands. So what if being burned at the stake is a 10 and your broken leg is only a 7? Trust me the broken leg will get and keep your attention till the bone is set.

Asking the mind to quantify pain is like asking it to assign a number to love or fear. It simply doesn't work that way. This is the reason that so many patient's say their pain is 10 of 10. No they aren't feeling the worst imaginable pain, but the pain does have their full attention.

Doctors want hard facts from painscales. We scoff at patients who say things like, “My pain is still a 10, but it's better than the 10 I felt before,” or “It's a 10, but not as bad as when I delivered my baby!” We demand hard facts and we get irritated when patients give us flawed and subjective data.

The worst pain Doctor D ever felt was probably about a 6, but subjectively it was miserable enough to get my attention and keep me from hitting my finger with the hammer ever again. We should listen to patients' descriptions of pain and seek to relieve it, but we shouldn't demand they to turn their pain into a number. The human experience of pain just doesn't work that way!

Doctor D is always talking about the natural purpose of things like hunger, laziness, anxiety, and pain. His theory is that understanding the natural functions of the feelings helps us respond when these feelings give us trouble. What do you think? Would understanding the useful warning function of pain help those of you that suffer from pain problems?

The Triumphant Return of Nurse K!

Yes, it is 3 a.m. and Doctor D should be sleeping since he is still getting over his viral infection, but some news just can't wait:

The world's greatest medblogger has returned! Nurse K is blogging again and as brilliant as ever. Who knows how long the cynical goodness will last? So head on over there and laugh till you wet your undergarments!

By the way, this is by no means lessens my endorsement of Tex and Nurse Lee yesterday, but heck, Doctor D would recommend Nurse K over even his own blog.

ER Nursing Blogs (Friday Linkages)

Doctor D actually works in an Emergency Room, but he only rarely tells fun ER stories. He prefers leaving the wild and crayzee emergency stories to the professionals. Nurses always have the best emergency room stories.

With Nurse K still on blogging hiatus the world is a little less fun, but fortunately Doctor D as a little ER joy to share. He has found two ER nurse blogs that never cease to make him smile:

• Nurse Lee is a newcomer to medblogging who blogs at Life in the ER. Doctor D found her when he came across this post and has been enjoying her ever since. She can be a bit silly, and Doctor D has no idea whats up with the glamor shot with a gasmask profile picture. Perhaps her way of preventing airborne illnesses? You should go check Nurse Lee out.

• Another great ER nurseblogger is Tex over at Weird Nursing Tales. He has been serving up wildness from the ER since 2007.
  

Of course, neither Tex or Lee could ever replace good old Nurse K, but reading them will definitely help scratch that ER story itch until K makes her triumphant return.

You can also hang around here with Doctor D (who isn't nearly as funny) to hear more next week about how silly the 1 to 10 painscale is, and to get your doctoring questions answered.

Never Say 10! (How Doctors Interpret the Painscale)

A question from a reader:

My doctors all use that 1 to 10 pain scale. Could you explain why? It seems so crude. Is a doctor equating my "6" to someone else's "6"? I always figure that "10" should be left for when a wolverine is gnawing off my face while my lower extremities are on fire, but other people may use "10" more casually.

The painscale is one of Doctor D's biggest pet peeves! The “powers that be” in medicine prefer looking at data rather than real people. And by data I mean numbers. Academics, researchers, and bureaucrats love numbers! They add them up to make treatment or policy recommendations. I often appreciate these bean counters that help clinical doctors, but it gets problematic when we try to pull hard numbers out of subjective human experience.

Medical people are now all commanded to record a numerical pain level on each patient. 0 means no pain at all and 10 means the greatest pain humanly possible (such as fiery wolverines.) They tell us to record this number like a vital sign, but while a fever of 102° F is the same temperature in every person, 8/10 pain may be a very different experience for different people. And lots of hospitals are making policies like "No one can be sent home from the ER until their pain is less than a 5."

Doctor D sees lots of people every day who claim they feel level 10 pain—the most excruciating agony a human being can experience. 10 is by far the most commonly chosen number on the scale. Doctor D suspects that some people might be exaggerating a bit when they answer “Ten” while texting and complaining about the lack of pretzels in the waiting room vending machine. I've seen a few people I was certain had 10 of 10 pain and it seems like disrespect to those people to classify bruises and upset stomachs in the same category. But pain is subjective, so who is to say a mildly sprained ankle isn't more horrific to this individual than the fires of Hell?

Obviously there are some addicts who lie about pain to get drugs, but I think more commonly people say 10 because they lack the imagination to conceptualize greater pains or they hope that a 10 will cause doctors and nurses to take their discomfort more seriously.

While the painscale is supposed to empower patients to define their own pain, it ends up tricking people into an answer that gets them nowhere. Anyone who says 10, who doctors don't think looks like a 10, is immediately assumed to be full of shit. And anyone who answers 11 or greater must a histrionic drama queen who is both lying and saying something impossible. If pain is a vital sign, then saying your pain is an 11 is like saying your temperature was 200° F.

If you want your pain to be taken seriously never say 10! (Unless you're pushing out a baby without an epidural or you have several broken bones sticking out of you.) If you want a doctor to respect your pain say. “It hurts like hell, but I would give it a 7 or 8.” Your doctor will recognize that if you understand how bad 10 is then your 7 is really horrible, so your doctor will work hard to alleviate your misery.

But trust me, never say 10! Even if it you had to set your self on fire to get the wolverines to stop eating you say 9. Ten on the painscale is a Catch-22; answer “10” and the doctor immediately thinks you are about a level 4.

What is the worst pain you every felt? Doctor D's worst pain of his life was about a 6. Did a doctor believe you went you complained of the pain? Do you think the painscale was helpful for getting your pain treated?

Follow-up post: The Purpose Of Pain: Why the painscale doesn't work

Work Excuse

Doctor D's blogging excuse note:

Sorry to readers for the lack of posts this week. Between weening myself off of coffee and catching a virus from my son, Little D, my free-time productivity has drastically dropped. I'll get a post up answering one of your questions soon. Right now I'm taking another Tylenol.