Vol. 185 January 15, 2018 New High Tech, Now and in the Future

January 15, 2018

Hub thumbnail 2015

The start of a new year is a great time to look at some new medical technology and speculate a bit about how it might evolve.  This blog space is too limited to cover the inundation of new medical apps, so we will largely ignore them.

DIGITAL ADHERENCE MONITORING –
The title alone has an ominous ring, and that is not altogether an inappropriate feeling. A pharmaceutical company is testing a pill with a built-in sensory that can track AND REPORT ON whether or not the patient is taking a medication. The sensor is called an Ingestible Event Marker (IEM), which I think is only a slightly less ominous label. The IEM is activated when gastric contents reach it as the capsule dissolves in the patient’s stomach. The activated IEM sends a signal to a patch worn on the patients abdominal skin. The patch, in turn, alerts a cell phone app that reports the event to monitoring physicians. If the patient doesn’t take his medicine, of course, there is no electronic beep from the cell phone to the monitors. This gives the prescribing physician real-time data on the patient’s “adherence” to the prescription (used to be called “compliance”, but that was declared politically incorrect during the peak of concern with patient’s rights and autonomy). The same app can also track patient-reported activity, mood, and quality of rest. This package of new technology is called Digital Health Feedback system (DHFS), and, as you might guess by these tracking elements, this clinical test involved patients with a mental illness, schizophrenia to be exact. As one reviewer commented, “”It is ironic that this technology is being piloted with a drug used for paranoia.” (NEJM, Jan. 11, 2018, pg.101)

We are assured that the use of this technology is completely voluntary, and the patient can remove the reporting patch anytime they wish. A preliminary study of 28 patients using the IEM pill found that 27 completed the study, 24 of them thought that the technology would be useful to them, and 21 said they would like to receive reminders on their own cell phone if they forgot to take the medicine. (Ibid)

Despite the apparent compliance with this adherence pilot test, I can imagine how this might evolve in association with other new technology:
Alexa at 8:00 AM – “Good morning Herbert. Today’s weather is going to be unseasonably warm, you have a 10:00 AM appointment in your office, and be sure to take your high blood pressure pill after you eat breakfast.”
Alexa at 12:30 PM – “Keep up the good work Herb. You have only one scheduled appointment this afternoon, and I notice that you haven’t taken your blood pressure pill yet.”
Alexa at 5:30 PM – “Now Herb, remember that this pill should not be taken with alcohol. I know it must have been a hard day, but you don’t want to make it any harder on your body.”
Alexa at 8:30 PM – “Hey Herb! Not only have you not taken your pill, but I noticed that you skipped your regular visit to the gym today. Wha’sup? By the way, congratulations on your Weight Watchers dinner tonight.”
Alexa at 11:45 PM – “HEY STUPID! You forget to take your pill ALL day. Take your pill NOW, turn off Colbert, and go to sleep. Your family is counting on you, … not that I care, of course.”

VIRTUAL ENCOUNTERS –
Kaiser Permanente, the large California-based health system, reported that last year a majority (52% actually) of their 100 million patient encounters were “virtual visits”. (NEJM, Jan. 11, 2018, pg.104)  Virtual visits involve secure email and video engagements. Patient portals into medical offices, use of Skype, and teledermatology programs are familiar virtual tools. Telemedicine that allows monitoring of blood pressure, weight, blood glucose, and even EKG for home-bound patients with chronic disease are commonplace now. Future innovations could include cell apps that monitor the “total hours spent in high-allergen zones” for an asthma patient, or that deliver “intensive behavioral counseling” to people with obesity-related disease (“HERBERT! Step away from that refrigerator!”), or that make assurances that the patient’s near-empty automated pill dispenser (remotely monitored by the pharmacy, of course) would be filled soon by a forth coming home visit.

One author suggests that in the future “a face-to-face, in-person encounter would be reserved for the patients with the most health care needs – the 5% that account for 50% of costs. In-person encounters would become Option B”. (Ibid)  Obstacles to such progress could be patient fears of getting trapped in endless “phone menus”, lengthy voice message instructions, or numerous, sequential mouse clicking. Physicians might fear being marginalized, and, of course, no one is currently paying for these virtual encounters. A future evolution to mostly virtual visits would require a significant reorganization of and changes in reimbursement of medical care delivery. Kaiser Permanente’s virtual visit capacity is supported by the 25% of its annual $3.8 billion capital budget it spends on information technology.

Though I am tempted, I won’t go into what might happen if a future patient portal, an automatic pill dispenser, and Alexa signals got all mixed up together by mistake. Might a patient request for a 10:00 AM home visit on Tuesday result in 1000 AMbien pills being delivered to the patient’s home by AMazon on two days?

 

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Vol. 98 October 1, 2013 “Today’s The Day” for Obamacare*

September 30, 2013

hub

Today is the day that Obamacare really begins.

Thirty million uninsured and underinsured Americans can start signing up today for affordable health care insurance through healthcare insurance exchanges. A key factor for the success of the Affordable Care Act (ACA – the real name for Obamacare) is the addition of these new insurance premiums to the national health insurance pool from Americans assumed to be younger and healthier than people already insured by Medicare or Medicaid.

Though government “defunding” is hanging in the balance today, this day is pretty tame compared to that day in 1965 when Medicare was implemented. Several states actually mobilized their National Guard then in fear of the predicted “hordes of people descending on hospitals seeking medical care”. It never happened, of course, and Medicare benefits, as political candidates found out this past year, have become a “political sacred cow”, resistant to most attacks.

Obamacare elements that have already been implemented include requirements that insurance companies cover “essential benefits”and can not reject coverage of pre-existing conditions. As we muddle through this next stage of Obamacare implementation, here are a few things to keep in mind:

1. If you are on Medicare, Medicaid, an employer’s health insurance plan, you don’t have to do a thing. Just sit tight and let the dust settle.

2. You have until March 31, 2014 to buy insurance (“enroll”) through an exchange. The only other deadline is December 15, 2013 if you want your coverage to begin on January 1, 2014.

3. Don’t try to enroll in the first month. Let the glitches in websites get ironed out and wait for “navigators” to appear to help you understand your eligibility for and coverage of the various plans offered. Navigator training funding has been delayed by Congress. Navigators, by regulation, can NOT give you a specific recommendation, but will clarify your choices via internet and even “live chats”.

4. In those thirty-six states which have opted not to set up state exchanges the federal government has taken on the responsibility for providing this service. Unfortunately, the feds have a different name for these exchanges, “marketplace”, but they will offer the same help in finding the right health care insurance for you. Establishment of federal “marketplaces’ has been delayed in some states by “subpeona harrassment” from Congressional Committees trying to distract, or even cripple, the fledgling efforts of healthcare insurance marketplaces.

5 . If you are not eligible for Medicaid or Medicare and have no insurance now you may be eligible for a federal subsidy of your premium. To find out just plug in your own figures at the Kaiser Family Foundation website at http://www.kff.org and see what you could get. The short list of your information the website requests is : 1. income, 2. family size, 3. age, and 4. tobacco use (That last one is really interesting)

6. Verification of income for eligibility (by the IRS) will not be operational until 2015. In 2014 it will be based on the “honor system, so you can count on some tabloid bombshells about individual insurance frauds under the headline of “We Told You So!”.

7. The tax penalty for the individual who can afford health insurance, but opts out this first year is a paltry $95, so don’t sweat it.

8. The state exchanges and the federal marketplaces will be offering comparisons of four levels of insurance (Bronze, Silver, Gold, and Platinum) with increasing premiums and decreasing predicted out-of-pocket costs from different insurance companies. The plans offered in these exchanges will be better than 98% of current policies available to individuals according to www.healthpocket. com, a free website that collects no personal information.

The hoped-for long-range result is less of a tax burden on taxpayers who are currently paying for medical care for the uninsured via state and federal taxes.

During dinner the other night the conversation drifted to Obamacare, gradually became more intense, and with a soupçon of agitation one Obamacare opponent ** blurtd out, “How can anyone vote for a bill that is 3000 pages long?! Who the hell would read the whole thing?” The rejoinder, “How many pages does the Bible have?” was a non-sequitur conversation-stopper, but it got me to thinking.

Like the Bible, Obamacare is open to interpretation, and your view of it may depend on your political party rather than your religion. Both are vulnerable to quoting out of context in support of opposing viewpoints. Both have overall, encompassing goals which can often be lost, or at least obscured, by the minute details of excess verbiage.. Both have, and will continue to have, “unintended consequences” (like the Inquisition or the Crusades) that we mere mortals have to deal with.

Everyone certainly agrees that Obamacare is NOT divinely inspired. Congress has clearly rejected the idea of a central authority (the Pope, or Donald Berwick, MD as “Czar” of CMS). The Bible is no longer chained in the dark in the back of the church, and Obamacare is now out in public, out in the market place. We shall see eventually how well it meets the needs of our citizens for affordable health care.

It’s success or failure will be clear only after Obama is out of office .
What will we call it then?
ACA won’t stick because we have learned to distrust most three letter acronyms like FBI, CIA, and NSA.
“Christicare” might do, but it sounds awfully religious.
“Cruzcare” sounds like an automobile speed controller.
If Hilary becomes President, she’ll probably put up with the name Obamacare as it is successfully implemented during her first term. Then, during her second term, she’ll dust-off her previous plan for universal health care and call it, what else but, “Clintoncare”.

By the time the Republicans win the presidency the Affordable Care Act will have so many beneficiaries (voters) that they won’t dare to kill it, and they will have to rename it.

I wonder WWJD? ***

* This was Mel Fisher’s  rallying cry every day for 16 years when he and his crew set out in boats searching for sunken Spanish treasure in Florida waters. He found the treasure of the Atocha  with the help of an archeologist named R. Duncan Mathewson.

** I call them “opponents” not “critics” because they really do desire Obamacare to die. In my mind “critics” suggest ways to improve plays, films, books, or programs and rarely ask for their abolishment. We should all act as “critics” of Obamacare in the coming years.

*** “What Would Jesus Do?”


Vol. 63 March 28, 2012 “Low Back Pain…Oh, NO!”

March 28, 2012

All I said was, “My back pain is a little worse”, in response to the casual “how are ya?”

Suddenly I was engulfed in four other back pain stories. Just try it yourself at the next cocktail party, political rally, or “wherever three or more are gathered”. At least 80% of us Americans have back pain at sometime in our life. Almost 30% of us have it at the same time. (1)

About three years ago I decided to actually do something about mine when I found that I couldn’t complete the short walk from Fenway Park to the MBTA station with my grandson. I suspected that my back pain and stiff, wooden-like, sore thighs were side effects from Lipitor. I stopped taking it, but after no improvement in a month, I went to my primary care doctor. He quickly sent me to a neurosurgeon, passing “lumbar MRI for $1300.”

The neurosurgeon said he could fix my gait by straightening out the “rubber band tangle of spinal nerves” of spinal stenosis by chipping away a little of my backbone. After surgery on L4 and L5 (just in case you are taking detailed notes) my thigh muscles were no longer stiff, wooden, and sore after 100 yards of walking. But, I still had a funny walk, and my low back pain remained. I walked funny because I couldn’t get up on my toes, and my balance was off. The neurosurgeon sent me back to the neurologist saying “I fixed him above the knees, but have no idea what is going on below them.”

The neurologist performed his medieval-torture test called an electromyogram (involves sticking needles into muscles and shocking them with electrical pulses), and sagely announced that I had “diabetic neuropathy”. As diplomatically as I could, I told him that I didn’t have diabetes.  I also blurted out, “ …and I don’t know where the stolen microfilm is hidden.” Several tubes of blood later, the neurologist had ruled out all but two diagnoses, “a peculiar gait” (thanks, but I already knew that) and CIDP (“Chronic Inflammatory Demyelinating Polyneuropathy” or “Chronic Idiopathic Demyelinating Polyneuropathy”). “Idiopathic” is the cover term for “I don’t know”. I am repeatedly impressed by how well we physicians can cover up our ignorance of causation with such lofty sounding terms.

At least CIDP was a diagnosis that had a treatment. Three months after starting monthly intravenous infusions of gamma globulin, I ended up in the hospital in the middle of the night with a pulmonary embolism, a “known but unusual” side effect of the infusions. So I went off the gamma globulin and onto coumadin for a year. I still walked funny and had back pain. By this time my neurologist had joined my children in recommending physical therapy and more exercise, but my children had since moved on to recommending Pilates, Yoga, and meditation.

“I’m an American. Just give me a pill” was my plea to my rheumotologist. He had struggled over 20 years to place me in the correct category of arthritis diagnoses. Whichever one of my three “revolving” diagnoses was the correct one; it had caused both hips to need replacement 10 years before my back pain started. Replacement resolved the hip pain, but one leg ended up an inch shorter than the other.

Many of my friends assumed that my funny walk was from my hips. I grew weary of repeatedly trying to explain things while standing in a bathing suit on the dock, sot that summer I started handing out this card.
.                                 “Yes, I walk funny. My hips are fine. I have some back pain.
.                                   My spinal stenosis was fixed in April. The muscles in my
.                                   lower legs and feet have grown weak because of a rare nerve
.                                   condition, a peripheral neuropathy. No, I am not diabetic.
.                                                         Thank you for caring.”
The card was not entirely true. I have discovered since then that peripheral neuropathy is NOT a rare condition at my age.

My rheumotologist did not think that my back pain had anything to do with my underlying arthritis, whatever that was. He suggested I go back to see the neurosurgeon. Much to my surprise the neurosurgeon said that my repeat MRI looked great, and “he couldn’t see anything else to operate on.” He also said, “You probably should get more exercise.”

Desperate for relief I then turned to Pilates and Yoga, much to the amazement (and joy) of my daughters. Pilates aims to strengthen your core while Yoga seeks to relax it. Both use poses and exercises that mimicked those of physical therapy and the self-help back exercise book one of those afore-mentioned cocktail-party-story-tellers recommended. (2) My flexibility and general well-being improved, but I still woke up with a stiff, sore back that usually resolved by my second cup of coffee, only to return in the evening after walking and standing for the day.

My best friend asked, “So, is this what you are going to settle for for the rest of your life?” By chance, I had my annual exam with my primary care physician the next day. I entered the office determined to get relief. He read my lumbar spine MRI report out loud to me. It sounded like a fly over of the Bad Lands or the Grand Canyon. He followed with, “You are not on anything for degenerative arthritis. What has worked in the past?” Restraining myself from punching him in the mouth for calling me a degenerate (back pain can make people cranky) I responded that my rheumotologist had tried several different ones in the distant past and that Indocin helped the most. “Well, let’s try 50mg. a day and see how that goes.”

Two days later I woke up without back pain.   Thank God, I’m an American!

References:
1. Arch Intern Med. 2009 Feb 9;169(3):251-8. The rising prevalence of chronic low back pain. Freburger JK
2. The Egoscue Method of Health through Motion, Pete Egoscue, HarperCollins 1992.


Vol. 58 January 1, 2012 Top 15 Medical Fun Facts of Hubslist 2011

January 1, 2012

“WHAT IS PAST IS PROLOGUE”
-William Shakespeare, The Tempest

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1. Measles vaccination does NOT cause autism and the author of that study, discredited as a physician in the U.K., now runs a profitable private clinic in Texas without a U.S. medical license. 1/15/11

2. Many hospitals, physicians and more than half of consumers currently favor a single-payer system. 5/1/11

3. Fishermen die at work 15 times more often than policeman and 45 times more than firemen. 5/15/11

4. Four men jogging can produce MORE carbon dioxide emissions than a hybrid car driving them the same distance. 5/15/11

5. 93% of 44 children who were avoiding 111 foods because of non-threatening allergic reactions (eczema, atopic dermatitis, and hives) were NOT allergic to those foods. Milk allergy was the most common over-diagnosis. 5/30/11

6. Your parenting style has less effect on your child’s “success” than your own educational level, income, and where you live. 9/1/11

7. Watching Sesame Street is entertaining for infants and toddlers , but it is NOT educational until they are 2 ½ years old. The educational benefits to the over 30-month old viewers persist to age 17 years. 11/1/11

8. Eating turkey is no more apt to make you sleepy than eating chicken, pork chops, lamb chops, or salmon. 12/1/11

9. The average DAILY number of text messages by a high school kid is 300-500. 11/1/11

10. 85% of teenagers take their cell phone to bed at night. 11/1/11

11. The five-year trial of “managed competition” between private health insurance companies in the Netherlands resulted in increased health care costs, increased percentage of people receiving government subsidy for health insurance, and increased number of uninsured, now called “defaulters”. 8/15/11

12. The many modes of obesity treatment other than surgical gastric bypass are only 4% effective. 8/1/11

13. Ninety million (90 MILLION) swine flu (H1N1) vaccinations were given in China and only 11 cases of Guillian-Barre syndrome (GBS) occurred. This rate was less than the rate expected in a general, unvaccinated population. 5/15/11

14. Baseball players CAN see better than umpires. 2/15/11

15. If your friends on Facebook are obese, you are more apt to be obese. 1/1/11


Vol. 37 January 15, 2011 Let’s Call A Quack a “Quack”

January 14, 2011

“Since the introduction of the first vaccine, there has been opposition to vaccination…Since the 18th century, fear and mistrust have arisen every time a new vaccine has been introduced.Ultimately, society must recognize that science is not a democracy in which the side with the most votesor the loudest voices gets to decide what is right.”
– The Age-Old Struggle against the Antivaccinationists, Poland and Jacobson, NEJM 1/13/11, p.97

It is time to call a Quack a Quack! Dr.. Andrew Wakefield’s bad science suggesting a link between measles vaccination and autism has been revealed to be also fraudulent! Besides faking and altering data on the 12 (yes, only twelve) patients in his original report, Dr. Wakefield received close to $643,000 for helping lawyers sue pharmaceutical companies working on rival vaccines. “Quackery” is usually defined as selling for profit a medical notion, or lotion, whose benefits are not supported by reason or knowledge.

The U.K. Grand Medical Council has “erased” his name from the medical register. This is the same as stripping him of his medical license, and don’t you just love the British for describing it as an “erasure”. In another quaint British linguistic quirk the act of actually administering the vaccine was often called a “jab”, and so the proponents of giving the vaccine were labeled as “The Jabbers”. The charges and counter charges can get a bit murky, but this several minute annotated video of Dr. Wakefield’s own statement clarifies the issues very well.  Dr. Wakefield currently resides in Texas continuing to attract desperate parents with autistic children, but does not have a U.S. medical license.

It seems incredible to me that his assertions based on 12 patients has stood up for so long in the face of several studies of thousands of children in different countries, numerous peer reviews, and, even, a U.S. federal court decision debunking the connection between measles vaccine and autism. Will this new revelation of false data and fraud quench the voices of superstition?

I doubt it. A recently published book, The Panic Virus by Seth Mnookin explores the reasons this particular superstition has persisted.  His list includes (1) :

1.the democratization of information via the Internet,
2.Americans’ negative response against anything “perceived as infringing on individual liberty”,
3. skepticism of the medical establishment,
4. shoddy shock-seeking journalism,
5. the romance of lone-wolf skeptics tilting against establishment windmills,
6. the development of a sense of community among anti-vaccine activists,
7.journalism that not only tolerated misinformation but also validated “the notion that our feelings are a more reliable barometer of reality than the facts.”

Quackery, of course, existed and thrived a long time before the Internet, before America, before journalism, and even before the establishment of a “medical establishment” though that it is what actually defined it, so this contemporary list fails to fully explain the phenomenon. Professor Michael Shermer, editor of Skeptic Magazine, lists 25 fallacies that lead us to believe weird things (2). Michael Barrett MD explains in detail how quackery sells.

People who continue to rail against MMR vaccinations due to the fear of autism are no longer quaint nor merely superstitious. They should be called “quacks”. They put hundreds of children, and themselves as young adults having their own children, needlessly at risk of a preventable disease with serious complications..

References:
1. The Panic Virus: A True Story of Medicine, Science, and Fear, Seth Mnookin, Simon & Schuster , 2010
2. Why People Believe Weird Things, Michael Shermer, 1997



Vol. 34 December 1, 2010 Understanding Medicare Reimbursement?

December 1, 2010

“I CAN SEE CLEARLY NOW…”

.                     – Johnny Nash and countless other singers

I opened my “Medicare Summary Notice” from CMS (Centers for Medicare and Medicaid Services) with great anticipation to see the explanation of Medicare benefits for my recent medical care. At last, I might have a chance to understand Medicare reimbursement, an understanding that has to date eluded me both as a pediatrician and a hospital administrator

The ER physician’s bill for both the visit and the suturing of three lacerated fingers was $448.00. Medicare “approved” $163.88 and “paid” $131.10. It also stated that I could be billed the $32.78 difference, but I knew I wouldn’t because “balance billing” is not permitted in Massachusetts. A reminder that even though Medicare is a federal program, its reimbursements and reimbursement rules vary by state, by region, and even by county.

Then I noticed a small “a” in the last column to the right that instructed me to “See Note Section”. On the bottom of page 2 that little “a” in the Note Section told me that “Medicare paid the provider for this claim $197.81” a figure quite different than $131.10. I tried, but could not reach the new figure by adding up any of the other amounts. I had no clue as to where that number came from.

Moving on to the next encounter, a scheduled spinal tap in the Ambulatory Procedure Area of my hospital for a different clinical problem, I was surprised to run into more complexity. The hospital charged $697 for the procedure and  $634 for the 6 lab tests done on the spinal fluid for a total hospital charge of $1,331.00. No “approved” amount  nor “paid” amount was listed, but then I noticed…again far over to the right, another set of little letters; “b” and “c”. Note “c” on the bottom of the page told me that Medicare paid $388.23.  There was no clue what that reimbursement of 29% of charges was actually for.

OK, OK, I know that hospital charges and reimbursement are complicated, so I moved along to the physician’s claim summary information. Surely this will be easier to understand.

My physiatrist charged $181 for an office evaluation of the clinical problem that had occasioned my spinal tap. Medicare paid $82.13 as indicated under “Note e” on the bottom of the page. If the physician thinks that his evaluation is worth $181 and Medicare thinks it is worth less than half of that, which one is right? How does that difference get negotiated? Who decides?

This was followed by the whopper of them all. The hospital charged $4090 for a scheduled CT scan and Medicare paid $588.96  or 15% of what the hospital thought it was worth ! The radiologist charged $425 to read the scan, Medicare “approved” $127.59, and “paid” $102.07. It did call to mind that credit card commercial: Hospital $4090, Medicare $588.96, Patient “priceless”.

Thoroughly exasperated by now, I moved on to the summary of other physician visit claims. My neurologist charged $150 for doing the spinal tap. Only $150 for the only action that involved the laying on of hands, that depended on good clinical training, and the only thing that could potentially harm me if not done correctly. The lab charged $275 for just one of the six tests on the spinal fluid; a  test performed by a machine remote from the actual patient at a time convenient for the lab. (But, that is another subject) There was no listing for “Medicare Paid Provider”, and another little letter “a” to the far right led me back to the Note Section: “Medicare paid the provider for this claim $197.81” Sound familiar? See above, different encounter, different claim.

I gave up, stuffed all the papers into a big envelope, just in case I needed to look at them again in the future…and went to bed worrying about the present, health care reform, single payor, and “transparency”.

 


Vol. 32 November 1, 2010 Laying on of the Hands

November 1, 2010

It appears that except for physical therapists, masseuses, and priests no one lays on the hands anymore. Certainly contemporarily trained physicians do not.

Recently I went to my local ER because a 2-day old pain in my back “due to a strained muscle” from a gym work-out was now, at 11:00 PM, causing me to be quite short of breath and unable to lie down. The ER reception desk was empty and, as the sign instructed, we picked up the phone and announced our presence. An ER nurse came out, signed me in, registering me as a new patient, escorted me back to a cubicle, recorded my vital signs, took a short history, listened to my chest (“A few crackles there in your back”), started an IV, ordered an EKG and a chest x-ray, and drew a whole bunch of bloods, one tube of which revealed that I was probably having pulmonary emboli (clots to my lungs). The CT scan confirmed the diagnosis of “multiple bilateral pulmonary emboli”.

Then I saw my first doctor. While standing at the bottom of the bed juggling a clipboard that was barely controlling various colored sheets of paper, she took a short history, listened to my chest (“A few crackles there in your right posterior chest”), told me that the CT scan was positive, and that the admitting hospitalist would come to see me soon. The nurse explained that the ER doc was busy with a very sick patient being transferred into town.

The admitting hospitalist was a true gentleman. He even sounded like a gentleman with his clipped British accent and Eastern Indian last name. He took a longer history, listened to my heart and lungs (“A few crackles on the right side there”) and outlined what was to happen next; a stay in hospital for three days at least, immediate anticoagulation, and tomorrow an ultrasound of the legs and an echocardiogram looking for a source of the clots. He explained things very clearly, was reassuring, and answered my questions succinctly and thoroughly. I felt that I was in good hands, …but I was a little uneasy that no one had done a complete, or even a semi-complete, physical exam.

What has happened to all that we were taught in second year Physical Diagnosis?

No one stretched my calf looking for a positive Homan’s sign. No left lateral decubitus positioning to listen for that subtle, easy to miss heart murmur. No confirmation that my extraocular movements were normal. No listening intently for a carotid artery bruit. Forget looking for splinter hemorrhages on my retinas or even under my fingernails. My abdomen could have been hiding an enlarged liver or spleen, but no one would have discovered it that night. Come to think of it, I do remember the admitting hospitalist briefly pushing two fingers against my shins and commenting, “trace edema”.

After a day shadowing a physician in a program sponsored by our local medical society, a banker summed up his impression with, “A physician’s job is a day-long quest for credible data”. I agree, and it is clear to me that the physicians caring for me that night were doing just that as efficiently as possible. Why bother checking for Homan’s sign when an ultrasound tech the next morning will tell you if there is a clot in the leg, its location and how big it is? The echocardiogram will give so much more information about my heart dynamics than an application of a stethoscope for a minute or two. With a dramatic CT scan showing all the clots and some pleural fluid, and with me having significant pain every time I took a breath, why spend a lot of time percussing my chest, feeling for vocal fremitus, or switching back and forth from bell to diaphragm on the stethoscope?

As technology has advanced, objective test results have replaced many physical findings as the foundation of a correct diagnosis. The job of the physician has become in large part that of deciding which test will give the best information. That is not bad, but I remember that our Physical Diagnosis professor won more “Best Teacher” awards than any other faculty member, … or any imaging machine. He not only provided us with our first glance into the real magic of clinical medicine, but he imprinted us with the appreciation that “laying on of the hands” was a vital part of a respectful relation with the patient.

I received excellent, efficient care. I was diagnosed quickly and treated appropriately, courteously, and was fully informed. But, in remembering Eliot Hochstein, MD I have to say that as a patient I sure do miss some parts of the “good old days”.

One part of the “good old days” hasn’t changed. At about 1:30 AM after all the tests that night were done and I was being prepared to be moved upstairs to a bed, I was still really uncomfortable because  I had not yet received any pain medication. I asked for some, and got my first dose at 2:00 AM.

References:
1.Physical Diagnosis, a textbook and workbook in methods of clinical examination 
by Elliot Hochstein and Albert L. Rubin. Published 1964 by Blakiston Division, McGraw-Hill in New York .


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