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Tag: Physicians

Morning Distort

By MARTIN A. SAMUELS

A 35-year-old woman complains of weakness of the right side of her face and pain behind the right ear.  She lives in an urban environment and denies any recent illnesses.  She is not vaccinated against COVID-19 but is COVID negative. 

What do you think, I was asked at our Morning Report?  Well, I said, it sounds like a straightforward Bell palsy.  The pain around the ear suggests swelling of the VIIth cranial nerve in the facial canal and the stylomastoid foramen, a very common historical point, I opined; so much so that its absence would make me doubt the diagnosis and make me consider other causes of facial palsy such as sarcoidosis or Borreliosis, though the urban environment argues against that tick born disease.  Then we went around the room, expanding the differential diagnosis (as this exercise is often called) to include tumors of the parotid gland, leptomeningeal metastases and many more.  At one minute before the end of the thirty- minute conference, a photo of the patient was shown.  There was only one problem.  There was no facial weakness, but rather she had a definite Horner syndrome on the right with a smaller pupil and subtle ptosis due to weakness of the Muller muscle, a small circular sympathetically innervated muscle that acts as a minor controller of the palpebral fissure.  The patient’s pupils were not tested in bright and then dim light, nor was sweating tested because why would one do those things in someone with facial weakness and pain around the ear.  In fact, this patient had nothing like a Bell palsy but rather Raeder syndrome, a painful oculosympathetic (Horner) syndrome, which implicates a disease of the carotid artery.  Once this was discovered it was learned that the patient had hyperextensibility of the joints and hadn’t suffered any neck trauma.  Now a spontaneous dissection of the right carotid artery becomes the focus of thought with a very different implication for therapy and prognosis.

This experience vividly emphasizes two traps in the diagnostic process:  thinking fast and framing.  As Daniel Kahneman and the late Amos Tversky have articulated and summarized in their book, Thinking Fast and Slow, there are two subsystems within the nervous system that they dubbed system one and system two.  System one is a very rapidly acting, involuntary system which estimates the likelihood of a given circumstance and reacts to it.  System two is a voluntary, tedious, slow system that weighs evidence, considers the frequency of a likelihood in the environment according to The Reverend Bayes’s prior probability.   In neurology, system one is the autonomic nervous system (or the reptilian brain as it was called by the late Paul MacLean in his triune brain).  System two is the cerebral cortex with its complex networks that facilitate various aspects of awareness, an aspect of consciousness.   Neither system is good nor bad, as both have their place.  The first presumably survived the rigors of evolution because it allowed our ancestors to react to potential threats rapidly (i.e. a movement in peripheral vision is not analyzed; it is rather escaped as if it were a snake, even though Bayesian reasoning would predict that it was probably a stick).  System two allows for more accurate conclusions in less time sensitive circumstances.  What happened to me in the conference was that my system one rapidly generated a theory, but this was based on incorrect data (it was a snake; not a stick).  If a mistake is made early in the diagnostic process, the processes thereafter are all distorted and there is virtually no way to reach the correct answer.  Recall Conrad Waddington’s epigenetic landscape, wherein he used a metaphor (marbles rolling down a hill) to describe how mistakes early in a developmental process have enormous effects on the ultimate outcome, whereas errors later in the process are less destructive.   In addition to my system one error, I was also taken in by the framing shortcut (heuristic).  The person who presented the case had a theory of his own, which was promulgated in the headline:  a woman with a painful facial palsy.  In fact, it was a woman with a painful Horner syndrome.  The moral of the story is that I should have looked at the photograph first.  That would have avoided the futile task of elaborating an expanded differential diagnosis which, after all, is a nothing but a list of wrong answers followed by the right answer. 

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The Science of Clinical Intuition

By HANS DUVEFELT

In 2002, Dr. Trisha Greenhalgh published a piece in the British Journal of General Practice titled Intuition and Evidence – Uneasy Bedfellows? In it she writes eloquently about the things Christer Petersson and I have written articles on and emailed each other about. He mentioned her name and also Italian philosopher Lisa Bortolotti, and I got down to some serious reading. These two remarkable thinkers have described very eloquently how clinical intuition actually works and describe it as an advanced, instantaneous form of pattern recognition.

Clinical Intuition (should we start calling this CI, as opposed to the other, electronic form of pattern recognition, AI – Artificial Intelligence?) begins with clinical patient experience but is cultivated through reflection, writing and dialogue with other physicians. And as Petersson and I have both written, there isn’t enough of the latter in medicine today. Both of us do as much reflecting and writing as we can, but we both know that more collegial interchange can make all of us better clinicians. Greenhalgh writes:

The educational research literature suggests that we can improve our intuitive powers through systematic critical reflection about intuitive judgements–for example, through creative writing and dialogue with professional colleagues. It is time to revive and celebrate clinical storytelling as a method for professional education and development. The stage is surely set for a new, improved–and, indeed, evidence-based–‘Balint’group.
— Read on www.ncbi.nlm.nih.gov/pmc/articles/PMC1314297/

Bortolotti, the philosopher, makes the case that experts are more intuitive than novices, a skill that only comes with experience, and have developed advanced pattern recognition abilities that allow them to make decisions faster than possible when only using analysis and reasoning. Her article is quote-heavy. She writes:

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Screening for Depression: Then What?

By HANS DUVEFELT

Primary Care is now mandated to screen for depression, among a growing host of other conditions. That makes intuitive sense to a lot of people. But the actual outcomes data for this are sketchy.

“Don’t order a test if the results won’t change the outcome” was often drilled into my cohort of medical students. Even the US Public Health Service Taskforce on Prevention admits that depression screening needs to take into consideration whether there are available resources for treatment. They, in their recommendation, refer to local availability. I am thinking we need to consider the availability in general of safe and effective treatments.

If the only resource when a patient screens positive for depression is some Prozac (fluoxetine) at the local drugstore, it may not be such a good idea to go probing.

The common screening test most clinics use, PHQ-9, asks blunt questions about our emotional state for the past two weeks. This, in my opinion, fits right into the new American mass hysteria of sound bites, TikTok, Tweets, Facebook Stories, instant messages, same-day Amazon deliveries and our worsening pathological need for stimulation and instant gratification.

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Some People Don’t Think Like Doctors (!)

By HANS DUVEFELT

This may come as a surprise for people with business degrees:

Doctors don’t really care when a test was ordered. We care about our patient’s chest X-ray or potassium level the very moment the test was performed. We also don’t care (unless we are doing a forensic review of treatment delays) when an outside piece of information was scanned into the chart. We want to know on which day the potassium was low: Before or after we started the potassium replacement, for example.

In a patient’s medical record, we have a fundamental need to know in what order things happened. We don’t prefer to see all office visits in one file, all prescriptions in another and all phone calls in a third. But that seems to be how people with a bookkeeping mindset prefer to view the world. In some instances we might need that type of information, but under normal clinical circumstances the order in which things happened is the way our brains approach diagnostic dilemmas.

Yes, I have said all this before, but it deserves to be said again. Besides, only 125 people read what I wrote about this six weeks ago, while almost 10,000 people read my post about doxepin.

Patients’ lives are at stake and, in order to do our job, we need the right information at the right time, in the order we need it, even if the bookkeepers prefer it a different way.

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Driverless Cars or Keyboardless EMRs? Which Do We Need Most?

By HANS DUVEFELT

I love cars and dislike computers.

My car takes me where I need to go, but it also gives me pleasure along the way. I have had it for just about ten years now and I have driven it almost 300,000 miles. It feels like an extension of me. Everything about it is just perfect for the way I drive and the things I need to do with it. From the sumptuously cavernous interior to the rugged all wheel drive features and the studded Finnish snow tires, it takes me pretty much anywhere, anytime. Why anyone would want to travel in a car without the sublime pleasure of driving it is beyond my comprehension.

My computers, on the other hand, are things I avoid whenever I can. My work laptop is an awkward Windows machine. Need I say more? Whatever it does happens stiltedly and unintuitively behind layers of barriers and firewalls that make me sign in again and again until I get to a pathetically clumsy EMR.

My MacBook Pro is slimmer and slicker but it gives me no pleasure to use it, I’m sorry to say.

Every word I have written and published – about as many words as I have miles on my car – has been put down on the virtual keyboard of my iPad. It feels more like an extension of my brain. I use it in bed, by the fireplace, in the barn or on the lawn. I can even talk into it without a microphone or any special software. I touch the screen and magic happens: Apps open, fonts and colors change and the world is at my fingertips, wherever I am.

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A Stretched Profession: How Much Longer Can Healthcare Workers Hang On

By JUDY GAMAN

Among those in the field, it’s been referred to as the Covid Tour of Duty. Doctors, nurses, and support staff working around the clock on high alert, in many cases seeing the worst effects of our world-wide battle against the pandemic. Even those non-hospital workers, especially those in primary care, are being pushed to their limits with no definitive end in sight.

Long before the pandemic, the alarm bells were sounded due to an aging population, which by nature requires more healthcare. That population was being met with shortage of physicians and nurses. Couple that with the pandemic—which has claimed the lives of many healthcare workers, and burned out those that remain—and the shortage becomes the next industry crisis.

Patients with post-Covid sequelae will need ongoing care and may require more visits to their primary care for years to come. Without an adequate push for educating more doctors and nurses, the American population will be met with a continued shortage, now of massive proportion. Opening borders during a pandemic is equivalent to pouring gasoline on the fire, as the country is currently short pressed to take care of their own.

A survey from Mental Health America ( https://mhanational.org/ ) that surveyed healthcare workers from June through September 2020 showed that more than 75% were frustrated, exhausted or overwhelmed. In addition, 93% were experiencing symptoms related to stress. Those same workers are still going full-speed-ahead five months later.

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The Art of Explaining: Starting With the Big Idea

By HANS DUVEFELT

We live in a time of thirty second sound bytes, 280 character tweets and general information overload. Our society seems to have ADHD. There is fierce competition for people’s attention.

As doctors, we have so many messages we want to get across to our patients. How many seconds do we have before we lose their attention in our severely time curtailed and content regulated office visits?

I have found that it generally works better to make a stark, radical statement as an attention grabber and then qualifying it than to carefully describe a context from beginning to end.

Once a person shows interest or responds with a followup statement or question, you have a better chance for a meaningful discussion. Just starting to explain something without knowing if the person wants to hear what you have to say could just be a waste of time.

Here are some of my typical conversation starters – or stoppers, if you will:

“The purpose of a physical is to talk about stuff that could kill you, more than about symptoms that annoy.”

“Nothing makes a cold go away faster.”

“Urology is about plumbing, nephrology is about chemistry.”

“Most headaches are migraines.”

“Sinus headaches don’t exist in Europe.”

“I don’t care what your blood pressure is today if you’re scared or in pain.”

“A healthy lifestyle is at least as effective as taking Lipitor.”

“We now know that eating fat makes you lose weight.”

“Cholesterol only causes damage if there is also inflammation.”

“Fat free means high in sugar.”

“I don’t believe in vitamins.”

“Osteoporosis happens to every woman around 80, so is it really a disease?”

“You have to treat 35 men for prostate cancer to save one life.”

“You know how many cases of testicular cancer I’ve come across in 40 years? Three!”

“It takes 45 minutes of walking to burn 100 calories, but only 10 seconds to drink them.”

My brief experience as a substitute teacher for junior high school students as well as my many years as a scout leader taught me that you can’t assume you have people’s attention just because you’re standing in front of them. They will give it to you if they believe you have something interesting to say. You often have less than thirty seconds to prove that you do.

Is our medical knowledge alive enough in our minds that we can share it in a quick, easy and captivating way with our distracted patients?

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

Meaningful U’s

By HANS DUVEFELT

Meaningful Use was a vision for EMRs that in many ways turned out to be a joke. Consider my list of Meaningful U’s for medical providers instead.

When electronic medical records became mandatory, Federal monies were showered over the companies that make them by way of inexperienced, ill-prepared practices rushing to pick their system before the looming deadline for the subsidies.

The Fed tried to impose some minimum standards for what EMRs should be able to do and for what practices needed to use them for.

The collection of requirements was called Meaningful Use, and by many of us nicknamed “Meaningless Use”. Well-meaning bureaucrats with little understanding of medical practice wildly overestimated what software vendors, many of them startups, could deliver to such a well established sector as healthcare.

For example, the Fed thought these startups could produce or incorporate high quality patient information that we could generate via the EMR, when we have all built our own repositories over many years of practice from Harvard, the Mayo Clinic and the like or purchased expensive subscriptions like Uptodate for. As I have described before, I would print the hokey EMR handouts for the Meaningful Use credit and throw them in the trash and give my patients the real stuff from Uptodate, for example.

I’d like to introduce an alternative set of standards, borrowing the hackneyed phrase, with a twist. MEANINGFUL U’S for medical providers:

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Medical Education Must Adapt to Support the Broadening Role of Physicians

By SYLVIE STACY, MD, MPH

As a physician and writer on the topic of medical careers, I’ve noticed extensive interest in nonclinical career options for physicians. These include jobs in health care administration, management consulting, pharmaceuticals, health care financing, and medical writing, to name a few. This anecdotal evidence is supported by survey data. Of over 17,000 physicians surveyed in the 2016 Survey of America’s Physicians: Practice Patterns and Perspectives, 13.5% indicated that they planned to seek a nonclinical job within the subsequent one to three years, which was an increase from less than 10% in a similar survey fielded in 2012.

The causes of this mounting interest in nonclinical work have not been adequately investigated. Speculated reasons tend to be related to burnout, such as increasing demands placed on physicians in clinical practice, loss of autonomy, barriers created by insurance companies, and administrative burdens. However, attributing interest in nonclinical careers to burnout is misguided and unjustified.

Physicians are needed now – more than ever – to take on nonclinical roles in a variety of industries, sectors, and organizational types. By assuming that physicians interested in such roles are simply burned out and by focusing efforts on trying to retain them in clinical practice, we miss an opportunity promote the medical profession and improve the public’s health.

Supporting medical students and physicians in learning about and pursuing nonclinical career options can assist them in being prepared for their job responsibilities and more effectively using their medical training and experience to assist various types of organizations in carrying out missions as they relate to health and health care.   

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More Women Are Pursuing Majority-Male Specialties and Changing Patients’ Perceptions

By AMY E. KRAMBECK, MD

With the exceptions of pediatrics and obstetrics/gynecology, women make up fewer than half of all medical specialists. Representation is lowest in orthopedics (8%), followed by my own specialty, urology (12%). I can testify that the numbers are changing in urology – women are up from just 8% in 2015, and the breakdown in our residency program here at Indiana University is now about 20% of the 5-year program.

One reason for the increase is likely the growth of women in medicine – 60% of doctors under 35 are women, as are more than half of medical school enrollees. I also credit a generational shift in attitudes. The female residents I work with do not anticipate hostility from men in the profession and they expect male patients to give them a fair shake. They may be right – their male contemporaries are more egalitarian than mine – but challenges still exist in our field.

Urologists see both men and women, but the majority of patients are male. Urology focuses on many conditions that only affect men such as enlarged prostate, prostate cancer, and penile cancer.  Furthermore, stone disease is more common in men, as are many urologic cancers such as bladder cancer and kidney cancer. So the greatest challenge for young women in urology is to gain acceptance among older men who require examination of their genital region and often need surgery. I’m hopeful that women entering urology today can meet that challenge, largely because we have already made significant progress. For the barriers we still face, leading urologists have blazed a clear path to follow with these three guideposts.

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