Archive for the ‘Medical History’ Category

An MD who acts like an osteopath

January 1, 2017

There once was a doctor named Still

Who wanted to cure more than bill

He went out on his own

For the crunching of bone

But retained the scalpel and pill

 

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

In 1874, Andrew Taylor Still, MD founded osteopathy.

At the time, before the acceptance of the germ theory of disease, philosophical schools divided medicine. Allopaths, the dominant force, felt that illness came from outside the body.  Homeopaths felt that illness came from inside the body.

Still felt that illness resulted from a misalignment of the boney elements of the body, but embraced the scientific method and rejected dogma.

Time has marched on. Homeopathy gave rise to our discipline of immunology and our approach to allergies, but in 1954 Hahnemann University School of Medicine officially stopped being a homeopathic school.  Mainstream US medicine still calls itself allopathic, but recognizes autimmune diseases and medical problems arising from internal disregulation.

Osteopathy continues, distinguished only by teaching and use of osteopathic manipulation.

Michigan State, my medical alma mater, has programs for MDs and DOs. While I have an MD degree, my class was the first to cross the tracks to get instruction in osteopathic manipulation.

In fact, in my first undergrad career I had a roommate who had had a roommate who had been in chiropractic school, and via that long chain of learning, I acquired the skills to manipulate the spinal column. But I got those skills without the rest of medical school, so that I learned to manipulate without learning when or why or why not.  Yet, to the best of my knowledge I never hurt anyone.  I got a lot of practice on the young and the healthy.

(Daniel David Palmer, the founder of chiropractic, probably attended Still’s Osteopathic college in Kirksville, Missouri, for a short time.)

Osteopathy along the way evolved an approach to the patient that I find a good fit. The body, a complex system, functions as a unit.  Ask why the patient got sick before asking what you can do for the symptom.  Maximize the patient’s natural tendency to heal, and do your best not to interfere with it.

I still manipulate, but I recognize those who manipulate better than I do. I like to say that some chiropractors get better results than others, and if I don’t know the local talent pool I say so.

Yesterday I brought my skills into play, got the satisfying crunch so easily as to be humorous, and made the patient better before she left. (And she gave me permission to say more than I have.)

And the same day, I got praise for being thorough, digging through the layers of physiologic dysfunction to figure out the root source of the illness.

Both of those patients benefited from the osteopathic approach, more obvious for one than for the other.

In the 21st century, more and more MDs do manipulation, at a time when more and more DOs leave it behind.   And more and more of the non-subspecialist physicians, regardless of training, take a holistic and humanistic approach to the patient as a whole human being.

I saw profit motive build a bridge between the doctors and the chiropractors, when the docs own an MRI and want the business.

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Strep: to treat or not to treat

November 15, 2016

You might have a pain in your throat

There are a lot of folks in that boat

The very next step

Might be testing for strep

But the score will help with the vote.
Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

The day after Thanksgiving 1997 I hit my personal record for patients seen in a regular clinic day, 63. In other contexts, for example taking call, I’ve attended more, but never in a 9:00AM-Noon, 1:00PM 4:30PM office day.
And not one of those 63 had an appointment when the switchboard opened at 8:30AM.
That November day came in the perfect storm context of coinciding influenza and strep epidemics.
I loved strep epidemics. A simple, curable problem where a minute of history, a minute of physical, a minute of warmth, a minute of education, a simple lab test and a shot of penicillin can relieve great suffering.
We treat strep throat to make the patient feel better, but more importantly, we tell ourselves, to prevent the complications of strep throat: rheumatic heart disease and post-streptococcal glomerulonephritis (kidney failure that follows a strep infection anywhere in the body).
When I started residency, we swabbed every sore throat and sent the culture to a program set up by the family who lost a member to rheumatic heart disease, brought on by strep throat.
In ’85 a widely read article questioned continuing strep treatment in an era of declining rheumatic heart disease.  Much discussion followed, the majority opinion holding that the strains of strep responsible for rheumatic heart disease would start to circulate again. Which, thankfully, has not come to pass.  I heard one doc assert there hadn’t been a single case in the US last year, but couldn’t quote a source.

For decades we’ve had rapid strep tests, which remain in common practice, but in the last year the Centor score, now validated statistically, threatens to make the test obsolete.  The patient gets a point for fever, enlarged nodes in the neck, pus on the tonsils, lack of cough, and/or for age between 3 and 14.  Patients who score 4 or 5 should have antibiotic treatment; under 3 should not.

Those over 44 lose a point; but run a very low risk of rheumatic heart disease.  Treatment in that age group only shortens illness by, on average, 18 hours.

And the post-strep kidney failure?  Treatment does absolutely no good.

But I saw a patient, whose parents gave me permission to write that I’d come up with a perfect score of 5.

I gave penicillin with a clean conscience.

When low scorers come in with sore throats, I discourage testing because a positive result would most likely indicate colonization, where the germs live in the throat without causing problems, rather than infection.

I still do testing if the patient requests penicillin injection, and no injection follows if the test comes up negative.  And I’ll continue the practice till further research demonstrates a reason not to.

Most of the patients with strep throat I saw last week had a sandpaper rash, and very few knew it.

Some things you only find by touching the patient.

 

 

Why I do and I don’t do housecalls

March 6, 2011

The number of docs is deficient

Though the need would appear quite sufficient

    If you ask me why is it?

    I’ll say a home visit

In the end remains inefficient.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  I just got back from a six-week assignment in Barrow, Alaska, the northernmost point in the country.

My father made house calls.

He graduated from medical school sixty years ago, when women were systematically excluded from the profession.  At that time, a physician finished an internship, hung out a shingle, worked solo practice, and took call 24/7/365. He made hospital rounds in the morning, saw patients through the day, and, after supper, made evening rounds and house calls.

Our 1960 Ford Falcon had a spotlight, like the police used, so he could see house numbers at night.

He used to take me with him, to the hospital and to patients’ homes, when I was in elementary school.  I waited in the front lobby of the hospital at a time when it constituted the main ingress, but I got to go into houses with him.  I remember the time spent with him, I don’t remember the time spent waiting.  I can see his stethoscope hanging by the front door, his electrocardiogram machine in the back seat, and his doctor’s bag with the blood pressure cuff and medications like Demerol , penicillin, and digitalis.

But in an era of generalists, my father specialized first in Internal Medicine, and then in Cardiology.  ICUs and CCUs didn’t exist, and before revascularization, statins, and beta blockers, patients with heart attacks frequently received treatment at home.  Looking back, hospital care at the time differed little from a doctor making a home visit.

I have done house calls, but I probably don’t do more than twenty a year. 

When I worked for the Indian Health Service in New Mexico, the government tore down a perfectly functional clinic and paid me to do nothing until the new clinic was built.  After two weeks I realized I had started to be mean to my kids and I hijacked the Community Health Nurse to take me on hogan visits.  I learned a lot about my patients I wouldn’t have otherwise known.

Mostly, when I care for a patient in the home now, I do so more for my convenience than for the patient’s. 

Once, when a heavy, wet snow closed the city and the clinic down in the middle of the day, I got a page from a patient with bad lungs, heart, and balance just as I was about to exit the building.  In the days before common use of cell phones, I turned around, shucked off my parka, and returned the call.  After a brief conversation, I knew I lacked certain key items of information from the physical exam to make a good clinical decision, and I didn’t want to endanger the patient by making him go to the ER in bad weather.  I asked the address, and saw that the patient resided between my clinic and my home. 

I arrived fifteen minutes later on roads I could only negotiate with four-wheel drive.  Fifteen minutes after that I asked for a towel as I washed my hands at the kitchen sink, grateful for the warmth of the water and a ritualized end to the visit.

Today, I talked with a friend and patient who lamented the absence of my house calls.  We talked about how inefficient such delivery of care is, and how we don’t have enough doctors to make the service available on a regular basis.

It’s rare that I do house calls now.  Documentation suffers the longer one waits to make one’s note.  Still, I have a dedicated stethoscope and otoscope in my car.

But I don’t carry a black bag with Demerol, digitalis, or penicillin.

After thirty years, a case of Reiter’s syndrome, and my last Keosauqua patient shatters my complacence.

December 30, 2010

When I stopped to check out the heart,

The rhythm gave me a start.

     It was going too fast,

     And that patient, the last,

Went out on the ambulance cart.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks off, I’m having adventures, working, and visiting friends and relatives.  I’ve been on assignment in Keosauqua, in southeast Iowa.

Today I finished my last clinical day in Keosauqua.  The first patient of the day and the last patient of the day each gave their permission to write the information below.

Reiter’s Syndrome includes the triad of conjunctivitis (inflammation of the eye membranes), urethritis (inflammation of the lower urinary tract), and synovitis (joint inflammation).  Such a constellation signals the body’s abrupt inappropriate reaction to an infection; while attacking germs, the defense mechanisms start to attack the person’s own tissues. 

Separately, each of these three items comes as common as rain, and for the last thirty years I’ve asked each patient with one of them about the other two.  I also ask about fever and rash.  The interview sequence qualified long ago as low-yield, but I persisted for sake of thoroughness, and, later, from habit. 

Over the years, my interview technique has evolved.  In the beginning I listen, later on I ask focused questions.  Today, when I said to the patient, “Tell me more,” three sentences in quick succession revealed knee pain, discharge from the eye, and discharge from the penis.

For the first time, ever, today I made the diagnosis of Reiter’s Syndrome.  I started the proper lab investigation and turned the case over to a colleague.

For those interested in medical history, Christopher Columbus suffered from Reiter’s Syndrome on his last voyage.

The last patient of the day came in with a routine complaint of cough, also a frequent problem in temperate climates in the winter.  Such symptoms have been going around Van Buren County during my short stay here, and I anticipated ending my tenure routinely.

The human condition tends towards complacence.  We tend to “know” we’ll find a normal cardiac exam singing “lub-dub, lub-dub.”  If those sounds don’t come through the stethoscope, the brain tends to want to make the perceived sound fit into the expected sound.

Today it didn’t.  “Breathe normally,” I told the patient, and tried to hear the heart sounds over the abnormal breath sounds.  Unsuccessful, I said, “Hold your breath.”  The first and second heart sounds refused to distinguish themselves; the first kept shifting in timing and character.  And the rate came way too fast.

I took my stethoscope off and checked the pulse, which came through nice and regular.  I listened to the heart again.  The chaotic rhythm pounded irregularly irregular. 

The reassurance I sought from the electrocardiogram fled before my eyes.  Yet the patient had no heart symptoms at all; no chest pain or sensation of his heart racing.

I grabbed one of my colleagues and showed him the strip.  In short order we had sent the patient off in an ambulance.

We agreed that the weird stuff is out there.

Ending obstetrics

May 2, 2010

I sing and I dance like a bunny

I laugh and I think that it’s funny

     I caught my last baby

    I don’t mean maybe

And I’ll take a great trip with my honey.

Thirty years ago, on a fine spring day in Casper, Wyoming, I talked with one of the Family Practitioners in town while making hospital rounds.

“You sure look happy,” I said.

“I stopped obstetrics,” he said.  “They say you retire twice, once when you stop OB and once when you retire for good.  I feel like I retired.”

At the time I thought he was copping out or caving in.

In the ensuing years FP’s presence in the delivery suite has steadily eroded.  Most don’t do OB any more.  In 1987, I said at a partners’ meeting, “If we’re in OB we’re dinosaurs. There’s no way we’re going to be delivering babies in ten years.”  They all agreed with me. 

Time proved me wrong.

In our practice, the doctor who does the prenatal care is the one called for the delivery.  Exceptions include vacations, weekends (sometimes), or the doctor’s day off.  The continuity of care gives a competitive advantage against those practices which do deliveries by rotation.  For the last twenty-three years, I’ve carried a beeper because I’m the only doc in town who delivers babies and speaks Spanish.  The Labor and Delivery units have been under instructions to call me first if the patient doesn’t speak English, even on weekends and my days off.

My patient’s due date was April 24, and we haven’t seen her since March.  When she missed an appointment at 37 weeks, we called her and she scheduled her 38 week appointment but she didn’t show for it.  I’ve had the most capable staffers trying to find her, but the cell phone number we have for her doesn’t work and we kept getting an answering machine at her home phone number.

A normal pregnancy lasts more or less 40 weeks.  First pregnancies go an average of 5 days longer than the other pregnancies.  Women who have sex throughout their pregnancy generally deliver, on average, 5 days before women who don’t.  Smokers have shorter pregnancies on average because they have so many preterm births.  Races vary by one or two days.

The placenta, which nourishes the baby, starts to degrade at 40 weeks.  A few quit working before 40 weeks; after that the decay function has a steep drop off at 41 ½ weeks.  If the placenta wears out before the baby is born the baby dies.

Most babies are ready to be born at 37 weeks, a few aren’t. 

Thus there is a tradeoff; does one wait for one’s patient to go into labor and risk a still birth, or does one induce labor and risk having to put the child in the Neonatal Intensive Care Unit for several days?

National research suggests that induction of labor before 39 weeks causes more problems than it solves, and both hospitals have protocols; we have to arrange for a consultation with a specialist if we want to induce labor.

Most of the patients I’ve delivered in the last six months have had their labors electively induced after 39 weeks.  One patient, who very much enjoyed being pregnant, refused induction till I insisted at 41 weeks (everything came out fine). 

I have been worrying about my last OB patient for the last three weeks, and the worry has grown with every day, borne not only from scientific research but from the first hand emotional trauma of being involved in OB cases that did not go well.  I fretted so much that I stopped delegating the calls to try to reach the patient and I started doing them myself last week.

Friday afternoon I finally reached a live person.  With sick relatives in another state, I was told, the patient left town weeks ago, and has since had the baby.

I set the phone receiver in its cradle and I looked out my office window, saw the fine green grass and the clear blue sky with billowing white cumulus clouds. Waves of endorphins washed over me.  I danced down the hallway even though people were watching and announced the news to a med student and two of my partners, one of whom stopped OB a month ago.

Then I danced down the hallway again.  I didn’t care who saw me.

It was the same kind of feeling that I had when I bicycled into San Diego from Colorado, but more so.  It was an accomplishment twenty three years in the making.  I’ve been riding a roller coaster without a grab bar for more than two decades and I just got off.