tag:blogger.com,1999:blog-4341536726535008632024-03-04T21:17:41.301-08:00JoThoughts of a radiation oncologistJoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.comBlogger120125tag:blogger.com,1999:blog-434153672653500863.post-7308958648318620012010-03-29T20:44:00.000-07:002010-03-29T20:54:09.376-07:00Comfort ZoneOne thing I've run across lately are a lot of radiology reports that seem to make statements or recommendations that are a little, well, <span style="font-style: italic;">off</span>. First, let me make clear - my field is <span style="font-style: italic;">radiation</span> oncology, NOT <span style="font-style: italic;">radiology</span>. Another thing that I have to make clear is that in most cases, the radiologist that looks at images from a CT scan, MRI, ultrasound (etc.) never meets the patient, and often doesn't know their clinical history.<br /><br />So why is it that I often read in radiology reports things like, "fibrosis and scarring consistent with radiation-induced pneumonitis"??? Sometimes the patient hasn't even had radiation! Moreover, pneumonitis is a clinical diagnosis, not just a radiologic one. In a day and age when patients can access their own results, including radiology reports (which I am in favor of), this can be very dangerous to claim. And sometimes downright wrong.<br /><br />Another thing that happens is that in the report, it reads something like, "5 mm area of enhancement not clearly imaged by CT. Recommend follow-up with CT in 6 months," or "Recommend additional MRI study." I find that it's interesting they can recommend this without even knowing the clinical situation. For example, what if the patient had some clinical condition that easily explained the imaging abnormality, but now because of this report, it's almost necessary to order this additional (and sometimes costly) test. If the reports said something like, "based on clinical scenario and judgment of the ordering physician, a follow-up CT scan may be indicated," I think everyone would be much happier.<br /><br />Just to give an example - I certainly do not tell a cardiologist how to prescribe or dose anti-hypertensive medications. I expect other specialties to respect the same boundaries.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com13tag:blogger.com,1999:blog-434153672653500863.post-7926444682814075082010-03-02T18:45:00.001-08:002010-03-02T19:01:39.423-08:00Heavy thoughtsWell, I don't know if I'm back for good, but I've been thinking about things sufficiently to write again... the world of lung cancer is not the most uplifting of worlds.<br /><br />For example. I was talking to a patient that I like very much - one I empathize with, one I like personally, and one I even identify with. She's a hard worker, in a demanding career, still working through radiation we had given her previously, and chemotherapy, funny, witty, smart, had 3 children relatively late in life. We had a great conversation about how her daughter just went off the pill and was hoping she would get pregnant soon. I shared my story about how I got pregnant only a few months after stopping the pill, and the patient had the same experience. So she was hoping she would have a grandson or granddaughter soon. Her time is limited - she has metastatic lung cancer. In the world of lung cancer, her average survival would probably be about a year. And that's with chemotherapy, which, let's be honest now, will make her feel lousy half the time.<br /><br />She started coughing up blood lately, and so we are going to give her radiation to her lungs at a low dose to shrink her tumor and hopefully stop her from losing blood. It's not serious. Not yet. I was doing what I do with a million other patients, I was explaining the side effects of radiation:<br />"You'll feel tired. But fortunately, that will pass."<br />"You might get a sore throat. But that will eventually go away too."<br />"You might develop a cough, fever, or shortness of breath, but that's not common."<br />ETC.<br /><br />One of the last things I say is something like "Very rarely, radiation can cause a second cancer in the area we are treating you, but this doesn't happen for 5-10-20-sometimes 30 years."<br /><br />She snorted and said "if I get another cancer in 10 years, I'll be very happy. Right?" And I nodded my head in understanding and made an mm-hm sound. Then she started crying. I gave her some tissue, she coughed up some blood, and I put my hand on her back. Nothing to say. She pulled herself together, and said, "okay, let's get on with this." And she thanked me for being honest with her.<br /><br />Here I am, feeling horrible about mentioning a side effect that realistically, she will never ever have the chance to feel, and she thanks me for it. Maybe this is a lesson that I should stop mentioning this particular side effect to certain patients. Or maybe it's not that deep, it's just a manisfestation of a really sad situation, one that I will have to get used to.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com4tag:blogger.com,1999:blog-434153672653500863.post-17947068653367198462009-09-27T18:50:00.000-07:002009-09-27T18:54:54.807-07:00HiatusWell, it's been a while since my last post. I have every intention of starting up again, but first let me explain why:<br /><br /><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dxKvfwrVS6fJj5uHXTM7UNusyZ7RY0B0jMlRcRea6aLH2Yw87oDMJ1W-KXQUonGjhBaULAJUJiKzDBpWPLvOg' class='b-hbp-video b-uploaded' frameborder='0'></iframe><br /><br />My daughter, Cecilia Jang Lubetsky, was born on May 21st, 2009. Having her and raising her is the hardest thing I've ever done (and am doing), including med school, my PhD, internship, everything. She's also the most rewarding thing I've ever done (and am doing) and I would not change a thing.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com3tag:blogger.com,1999:blog-434153672653500863.post-72344303111868329872009-05-18T05:12:00.000-07:002009-05-18T07:00:17.650-07:00Doctors as patients, part 1It has often been said that the doctor's working in the hospital are the unhealthiest people within the whole hospital. I think I already made a reference to this in a previous <a href="http://jojojangjang.blogspot.com/2009/05/keeping-fit-as-intern.html">post</a> about doctors exercising. I think I can expand this thought and say that in general, doctors are horrible about taking care of their own health and make horrible patients.<br /><br />I'm reminded of something that happened while I was in med school - one of the most respected surgeons at my hospital suddenly was diagnosed with lung cancer. He never smoked, it was just bad luck. He had been ignoring his symptoms for years and years, and even though he went through surgery and chemotherapy and his colleagues did everything possible to save him, he was dead within something like 4 months, which is very short, even for lung cancer.<br /><br />I think there are a few reasons why doctors take such bad care of their own health. One is simply a time factor. When you work 80 hours a week, even if you only work 60 hours a week, it's hard to find time to go to a doctor or dentist appointment. Often, even the time you have off from work is spent catching up on the latest medical news or journal articles, which is necessary to stay current. Moreover, since most doctors have daytime working hours, it's nearly impossible to take time off during the day to make it to an appointment - you have to either cancel your own appointments, or arrange for coverage, both of which are costly, time-consuming and extremely inconvenient for you, your patients, and your colleagues.<br /><br />Secondly, I think it's the medical culture. Even when doctors are deathly ill, they try to come into work unless it's a risk for their patients. This is partly because calling in sick means that you have to inconvenience your colleagues and your patients, and since doctors don't really get sick days, you have to make up the work at some later date, usually on a day off. Additionally, doctors like to be tough, and seem tough, and illness, even for doctors, is a sign of weakness. As a result, many doctors become trained to ignore their own symptoms, even when they are persistent or become serious. <br /><br />Finally, many doctors feel that they can treat and diagnose themselves, and don't need to go in for an appointment, even though this is often not the case. By treating themselves, doctors again often ignore or miss important symptoms and miss out on getting valuable input or a second opinion from a colleague. Doctors tend to treat themselves very differently from their patients.<br /><br />In the end, my point is that doctors need to take care of themselves as they tell their patients to do so. They need to go for their yearly checkups, screening tests, etc and not try to manage it all on their own, for their own sakes as well as to be good role models for their patients.<br /><br />In a very different way, doctors can be bad patients even when they do seek medical advice... I think I'll leave that for another post...JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com5tag:blogger.com,1999:blog-434153672653500863.post-26042156113677413232009-05-17T05:31:00.000-07:002009-05-17T06:01:30.149-07:00Doctor ShortagePeople have been reporting about this for quite a while, but a friend just recently forwarded me this <a href="http://www.nytimes.com/2009/04/29/education/29iht-riedmedus.html?_r=1&emc=eta1">NY Times article</a> about how there will be a severe shortage in doctors in the future, especially in the primary care field. It seems many people, including the current <a href="http://www.nytimes.com/2009/04/27/health/policy/27care.html">Obama administration</a> are becoming increasingly worried about this problem. While some steps are being taken to try and delay this crisis, there are many many roadblocks.<br /><br />Of the ideas that have been proposed or already instituted to try and solve this problem, one includes increasing the sizes and numbers of medical schools. Medical schools may have to admit more students that don't have science backgrounds - while some worry that this may decrease the quality of medical students and eventual doctors, I don't think this is a problem and may even be of benefit. Medical schools already admit plenty of students with non-scientific backgrounds and as long as they can build up a significant fund of knowledge either in medical school or in a year of study before entering, I think it's not a problem. In fact, it may even build diversity and bring new ideas and perspectives to the table, which is definitely a good thing. <br /><br />Another idea is to increase the use of non-MD sources of health care, including nurses and other health care professionals, which I think is a great idea. However, there is also a nation-wide shortage of nurses, so this avenue may be limited as well. Finally, it has been suggested that we use more minority as well as international doctors as there are many MDs from other countries who would like to practice in the U.S. Obviously this presents many problems as training in other countries can be vastly different than training in the U.S. and currently, depending on the country they come from, international doctors often have to retake licensing exams, as well as complete full residencies (after having already completed residencies or full training programs in another country) in the U.S. This is a <span style="font-style: italic;">huge</span> deterrent for MDs coming from other countries to try and become MDs in the U.S. - I don't know how many international MDs I know who have instead become lab technicians or Ph.D. students or post doctoral students because the requirements for them to practice medicine in the U.S. are so overwhelming. However, I don't have a great solution for this as I do believe the training is different from country to country and that international MDs <span style="font-style: italic;">should</span> practice in the custom of U.S. training, for legal purposes as well as medical. <br /><br />Despite these efforts, I see a lot of hurdles for which there are no easy answers or solutions. One is that even though medical schools may be increasing their enrollment, there are a limited number of residency training spots available. These are being increased as well, but they cannot be increased as easily or at the same rate as medical school spots. Residencies are much more complex to set up, and must go through a thorough accreditation process every couple of years, which is not only cumbersome, but can be difficult to arrange and maintain. <br /><br />Moreover, there is heavy competition for competent people by other professions, the major competitors being business and law. Now, with the economy being the way it is, business has been less attractive the last few years, and perhaps the medical pathway is getting a boost from the decrease in business school applicants or business jobs. However, law and business careers can be much more attractive than medical careers - the training is <span style="font-style: italic;">much</span> shorter. School takes half as long, and after school you start earning a relatively good salary right away whereas in medical school, it can take 4-6 years, with 3-5 year of low-paying residency afterwards, sometimes followed by 1-2 years of low-paying fellowship. Once you finally get out of all this training, doctors (especially primary care) often still make lower salaries than lawyers and businessmen, and have to contend with other headaches and costs associated with malpractice insurance, insurance paperwork and red tape, etc. Until there is good health care reform, or salaries become more equalized (either doctors' salaries have to come up or other salaries should be lowered - probably the latter is better for various reasons), there's not much that can be done about this problem.<br /><br />Finally, even with the increase in medical school admissions and residency spots, many people are still attracted to practicing in medical specialties rather than primary care, in which the doctor shortage is the most severe. Again, this likely is due to a salary differential as primary care doctors make much less than doctors in medical specialties. As with competition with business and law degress, not much can be done about this problem until the salaries equalize - in this case, I think primary care doctors should be valued more highly and their salaries increased.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com2tag:blogger.com,1999:blog-434153672653500863.post-17985018589223845572009-05-13T06:43:00.000-07:002009-05-13T06:45:32.327-07:00Bruce's Asia Travels BlogBruce (my brother) is traveling in southeast Asia for about 2 months, and he'll be keeping a <a href="http://noodlesnmore.blogspot.com/">blog</a> about it. I'm so jealous. :)JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com1tag:blogger.com,1999:blog-434153672653500863.post-53053710811404667482009-05-11T10:01:00.000-07:002009-05-12T02:20:29.727-07:00Sympathy vs. EmpathyI remember in medical school being taught the difference between sympathy and empathy - a lot of people tend to use them as synonyms. In my line of work, when you empathize with someone, it means that you can feel what they are feeling. For example, if they have some type of cancer, and you've had that exact type of cancer, you can feel something similar to what they must be going through and you "empathize." If you feel sympathy for someone, then it's more that you understand, or try to understand as best you can, what the person is going through but you may not feel or have not felt that way yourself. In my opinion, it's very difficult to empathize with someone unless you've gone through a very similar process or situation that they're going through.<br /><br />Having said all this, I highly <span style="font-style: italic;">empathize</span> right now with all the 9 month pregnant ladies out there who like to deliver soon. :)JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com2tag:blogger.com,1999:blog-434153672653500863.post-70014143414485754702009-05-08T14:58:00.000-07:002009-05-14T15:18:10.065-07:00Doctors in trainingA family member sent this <a href="http://well.blogs.nytimes.com/2008/11/06/no-praise-for-doctors-in-training/?ei=5070&emc=eta1">article</a> to me, and there's a link within the article to another related <a href="http://www.nytimes.com/2008/11/07/health/chen11-06.html">column</a>. <br /><br />They basically talk about the culture of negative reinforcement for medical interns and residents. It's fairly common for residents to get yelled at or chewed out by attending doctors for various things in the hospital. Moreover, these episodes can often be about relatively unimportant things, or things that are in no way the fault of the intern or resident, and the attending if often venting their anger and frustration on those that are beneath them. As the article points out, I think most people can agree that such public displays of anger and criticism are not useful or constructive in any way. As the second article explains, positive reinforcement and constructive criticism is much more useful. However, this doesn't stop certain attendings from taking out their anger on their subordinates, which clearly isn't right and can often drive interns and residents out of the medical field altogether.<br /><br />Being an intern, I've definitely seen plenty of things like this first-hand, although thankfully I've very rarely been on the receiving side. I think the best way to deal with people like this is to simply provide the best medical care you can, and, to be perfectly honest, ignore the attending for the time being! Obviously, if something should have been done differently, either medically or otherwise, you take that lesson with you, but if someone is yelling at you unnecessarily and unhelpfully, you would probably make the situation worse if you speak up about it at that time. It can be a very difficult position as the attending has a lot more power and influence than you and it can be very intimidating. If you feel very strongly about it, there are usually avenues you can follow (such as taking the issue to a program director or an ombudsman) to address it later. I think the best lesson to learn from an episode like that is how you do <span style="font-style: italic;">not</span> want to be an attending like that in the future, knowing how it made you feel as an intern or resident. I think also, that interns and residents should have a thick skin and be prepared to shrug things like that off as long as the abuse was truly unwarranted.<br /><br />For what it's worth, I think certain specialties are more prone to this type of abuse by attendings, and I also think the incidence is declining as programs and doctors become more aware of it and interns and residents are more outspoken about it.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com2tag:blogger.com,1999:blog-434153672653500863.post-16472928940513095462009-05-05T01:08:00.000-07:002009-05-05T01:18:24.474-07:00Mira Loma High School and the Science BowlI just have to post something unrelated. I went to Mira Loma High School, and (shockingly) I was pretty nerdy - I competed in all the science and math competitions, including Mathletes, Science Olympiad, Science Bowl, etc. There were a few others that I can't remember off the top of my head right now, but our crowning achievement was winning third place in the National Science Bowl competition under our chemistry teacher, Mr. Torgeson, wayyyy back in 1994. This won us a week-long all-expenses-paid trip to Hawaii. Needless to say, for a bunch of high school students, we were ecstatic!<br /><br />Well, it seems we've been outdone, as this year's team took first place, getting them a trip to Australia! See the link below for the article in the Sacramento Bee:<br /><br /><a href="http://sacbee.com/topstories/story/1833334.html">http://sacbee.com/topstories/story/1833334.html</a><br /><br />Congrats!! I'm glad to see the legacy continuing.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-78313642379322846372009-05-04T07:56:00.000-07:002009-05-04T08:02:23.418-07:00Keeping fit as an internIt's impossible. Especially now that I'm pregnant. But even when I was really busy before, I still was able to get some exercise in, sometimes at the gym, and sometimes playing ultimate frisbee, which has basically been my most enjoyable form of exercise for the last 6-7 years. It's well-known that interns often gain 10-15 pounds during their intern year, and in general eat a lot unhealthier and get a lot less exercise. They say (jokingly) that the doctors are often the least healthy people in the hospital... obviously it's important to stay healthy, for their own sakes as well as to set a good example for their patients, but it can be extremely difficult.<br /><br />I think the best way to combat it is to try and get into something active you really enjoy - for me, that's ultimate frisbee. To be honest, this post is really just a plug for my sport. :) I guess since I'm a woman, and play ultimate frisbee (not to mention captained a women's club team and multiple league teams in the past), many people have forwarded this <a href="http://www.nytimes.com/2009/04/30/fashion/30fitness.html?_r=1&emc=eta1">New York Times article to me</a>. It's mostly about women and ultimate frisbee, and I think it's great that the sport is finally getting mainstream attention.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-74894443812104240422009-05-01T08:28:00.000-07:002009-05-01T08:37:21.887-07:00Kaiser and their electronic systemThis is an interesting <a href="http://www.businessweek.com/technology/content/apr2009/tc2009047_562738.htm">article</a> about how Kaiser instituted their electronic medical record system.<br /><br />I had written a <a href="http://jojojangjang.blogspot.com/2009/02/universal-electronic-medical-record.html">previous post</a> about this subject and still think it's a great idea, although possibly prohibitively expensive. However, one argument is that electronic records could eventually lead to cost -savings- as medical tests and studies are not unnecessarily repeated. Interestingly enough, the article says that the costs savings aren't really there as people are living longer with better care, and thus require more health care resources in the end, which off-set the potential savings in medical costs. Nevertheless, the article does point out that shared electronic medical records lead to better care and for that reason, it's still worth it to attempt implementation of these systems in all hospitals. Hopefully they will all eventually even be compatible with each other, if not already part of a common universal electronic medical record keeping system.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-30932750229635287922009-04-30T07:53:00.000-07:002009-05-01T08:06:58.076-07:00Doctoring OnlineThis is a very interesting <a href="https://www.hellohealth.com/main/how/index.html">concept</a>. It's a service that allows you to mostly connect with your doctor online through video chat, IM, and email after an initial face-to-face office visit. I think it's a great idea for simple problems that people have that can be diagnosed over the phone or email. I think it breaks apart when a patient comes in with more complex problems or health issues, making a good physical exam necessary. Then you need an actual doctor's appointment, just like with any other private practice.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-33291117068396159502009-04-23T23:33:00.000-07:002009-04-23T23:44:47.736-07:00Perspective on CostsI hear arguments or complaints all the time about how we're denying so many people health care because "an insurance company won't pay for it" or "it's too expensive for them to cover it". For example, many times, patients and their families (and their doctors) will fight with insurance companies to get them a really expensive treatment or get an exception to get a certain patient a treatment that usually the insurance company would not approve, either because it's too expensive or isn't indicated. While I'm the last one to support the insurance companies and I think they could be doing a lot more to cut costs and provide more and better health care, I think that many people are lacking perspective about this topic.<br /><br />I don't think anyone would disagree with the statement that the budget for healthcare is limited. We can't spend all the money we want to save everyone in the world. In the US I think this is often not understood well because we have a relatively wealthy country, but it 3rd world countries, like many in Africa, or in countries that have 3rd world elements (like India or China), this is readily apparent. <br /><br />When someone or a group of patients can't get a treatment because it's too expensive, many people react with indignance and outrage. While I certainly understand this sentiment, and probably would feel it myself if I or one of my family were the patient, there's another side to the story... By providing that one patient (or group of patients) with that expensive treatment, you are essentially denying health care to another group of patients. Just take for example that a treatment costs $100,000 per patient to save their life. Of course you can't put a $ value on a life, but say that $100,000 could be spent on 100 other people to treat something else to save their lives. Or maybe to, say, treat their hypertension and prolong their lives for 20 years each. It's hard to say which is the right way to go, but personally, I think it should be spent for the greater good.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-79060389555594990302009-04-21T11:35:00.000-07:002009-04-24T07:28:57.216-07:00PersonalityPersonality plays a large role in many different careers - it's no difference in the medical world. If you have a good personality, patients often like you better and think you're a better doctor. Similarly, if other medical colleagues get along with you well, they usually think more highly of you as a clinician. This all leads to more referrals, by patients and doctors alike. I think personality is supremely important in a doctor, and certainly is part of being a good doctor - you don't want a clinician who is callous or unfeeling, or someone who does not deliver bad news well. <br /><br />However, personality is not everything. I think many good clinicians often lack in the personality area, or at least the empathy/sympathy area simply because they are too busy. And unfortunately, many times patients will label them as bad doctors because they don't like their attitude or the way they present themselves. I think that's totally valid, but I also think sometimes patients may be losing out on very good care because they may be too demanding and not understanding enough of their doctors.<br /><br />I think it's even worse when other medical professionals assume that someone is a good doctor just because they get along with them well, or that person has a good personality. I've met plenty of people who I like to hang out with, but who I don't necessarily thing are the best clinicians. I don't necessarily think they're horrible, or even bad, but some people think they're great because they are really easy and fun to get along with, and I just think they're ok clinicians. I think that first and foremost, a doctor has to be a good clinician (making good clinical decisions, etc) and then secondly, should be empathetic and have good relationships with his patients. If the doctor can do both well, then that's great, but the first characteristic is the most important.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-59940189434022236872009-04-17T23:45:00.000-07:002009-04-23T23:48:48.732-07:00Being a health care professional in bad economic timesOne good thing (of many, I think) of being a doctor during bad economic times - you pretty much are guaranteed a job. Especially in this day and age, with more and more people living longer and longer, people will always need doctors and nurses, and other health care professionals. In fact, there's an increasing demand for them. I'm sure salaries may go down, and people may have to work (even) longer hours and care for more patients in a shorter amount of time, but at least they're usually not at danger for losing their jobs. At the worst, people may have to relocate or take less-than-ideal jobs or situations in order to keep their incomes flowing in.<br /><br />It's a reassuring thought this year considering 2,000,000 people have lost their jobs so far in the U.S.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-49728938552783159872009-04-10T17:14:00.000-07:002009-04-10T17:22:26.798-07:00Hospital ClosingsThere are all these rumors flying around that Methodist Hospital in South Philly is closing. This is in addition to Northeastern Hospital in NE Philadelphia already closing! If Methodist Hospital closes, that will really put other hospitals in a difficult position. If the other city hospitals are anything like Pennsylvania Hospital, they're already overfilled with patients currently. How are they going to handle the load and stress of another hospital closing? It's a very sad state of affairs when hospitals have to close because they're losing money.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-24670805045083127162009-03-17T08:00:00.000-07:002009-03-17T06:52:27.874-07:00Abusive, Arrogant Doctors<div>This is an interesting <a href="http://www.nytimes.com/2008/12/02/health/02rage.html?pagewanted=1&_r=1&emc=eta1">article</a>. It talks about how arrogant and abusive doctors can (not surprisingly) really affect the health care of a patient, not to mention affect the workplace and those around them. I've definitely run into plenty of them myself and experienced it firsthand, not to mention heard of other abuses plenty of times. It's a very unfortunate and inappropriate problem. As the article points out, I think the good thing is that there is awareness of the problem and steps are being taken at every hospital to minimize and eliminate it. Interestingly, many of these doctors happen to be surgeons - go figure.<br /><br />I just also wanted to mention that I've been on the receiving end of this from not just doctors but also nurses, physicians' assistants, nurse practitioners, you name it. So although I will agree that it's much more prevalent in doctors than other medical staff, it is definitely not phenomena limited to MDs alone.<br /></div><div> </div>JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-36471052766447098892009-03-16T13:00:00.000-07:002009-03-17T06:45:26.563-07:00Difficult DecisionsSometimes people have so many different diseases that it's difficult to decide which one to treat. For example, one common conflict is between the heart and the kidney. If you have too much fluid in your blood vessels, and if your heart is weak already from other processes, that can make your heart even weaker and it can't pump all that fluid around. As a result, the fluid can build up in your legs and arms, and in your lungs, making you short of breath. The treatment for that is to "diurese" a patient - that is, use medications to make people urinate and decrease the amount of fluid in their veins. However, if your kidneys are sick, you need a higher dose of these medications, which can actually harm your kidneys even more. However, the higher doses may be a necessity to keep your heart healthy. It is not uncommon for there to be a natural conflict between the cardiologists (heart doctors) and the nephrologists (kidney doctors) over this very situation. In the end, often the cardiologists win out because while we can treat kidney failure (at least temporarily) with <a href="http://jojojangjang.blogspot.com/2008/08/dialysis.html">dialysis</a>, if your heart fails, we don't have any sort of substitute for that.<br /><br />There are many such decisions that clinicians often have to make. I tend to think that usually things work out ok - if we see signs that we made the wrong decision, we can always change and go the other way the next day. Unfortunately, some people are on such a fine balance that choosing the wrong path for even a few hours can sometimes be hugely detrimental. Hopefully through collaboration and talking together with many specialists, we can make the right decision the majority of the time.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-50970213942175870072009-03-14T23:30:00.000-07:002009-03-16T12:10:36.903-07:00Little FishWe just went to <a href="http://littlefishphilly.com/">Little Fish</a> for dinner tonight. It was excellent - enough so that I have to blog about it. :D<br /><br />For appetizers, we had diver scallops with orange, almond and serrano ham as well as peekey toe crab with red beet, tarragon butter and shaved fennel. The crab was very flaky with an excellent texture - a little plain, but still good. However, the diver scallops were excellent - cooked to perfection with a wonderful flavor, and surprisingly good with the almonds and mandarin orange slices.<br /><br />For entrees, I had the skate (a type of ray) with truffled spaetzle and shredded leeks. I think this is their most praised entree. This was absolutely amazing! The skate was fried lightly so that it was crispy on the outside but very soft and moist on the outside. The sauce was a salty parmesan broth that complemented it very well. The leeks were also tasty and complemented the strong-tasting fish very well. Pete had mahi mahi with a sweet potato puree which I believe was also very good, but not nearly as good as the skate. I would go back to eat skate at this restaurant any time.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-45037639215532671062009-03-06T02:07:00.000-08:002009-03-16T12:01:15.188-07:00Transfer of CareAt almost all hospitals, interns and residents go through rotations that last about 4 weeks at a time. That means at the end of the four weeks, you transfer care to another team. Like I mentioned in the previous post, at Pennsylvania Hospital, we use a night float system. So what happens at the end of a rotation, one team signs out to night float with a paper signout describing all their patients (like a normal night) and the next morning, the new team picks up the paper signout with news about whatever happened overnight from the night float person. As the night float intern takes care of about 100 patients (or more) a night, they don't know any of these patients in detail unless they're pretty sick, so they don't really have any details to hand off to the new team in the morning. There is really no verbal communication between the new intern and the old intern regarding the patients. The best continuity comes from the resident of the team, who is on for about 4 days before the interns switch, so they know the patients at least to some small degree, although they often do not know the small details, or the really complex patients well.<br /><br />As a result, the new intern is really dependent on the paper signout for active issues and things to do for the patients. In addition, if a patient has been admitted for a relatively long time (on the order of weeks to months), there should be an end-of-service note written by the previous intern for the new intern. Usually if all these things are done well, there are no problems.<br /><br />However, I cannot believe how angry I was at the start of one of my months. I had 4 long-term patients, none of which had an end-of-service note. The paper signout I received from night float, who had been given this signout by the previous intern, was horrendous - it was lacking in detail, disorganized, and did not point out what the active issues were. It didn't feel appropriate to me to approach the other intern personally, but I did contact the chief resident and hopefully the importance of these notes will be emphasized. I also think instituting a verbal signout, in which one intern calls the other intern to verbally tell them about the patients and what's going on would be a great idea. It wouldn't take that long and I think it would go a long ways towards improving continuity of care.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-36285761548309383532009-03-01T18:14:00.000-08:002009-03-06T02:08:59.776-08:00Night CoverageClearly, doctors can't be at the hospital 24 hours a day, 7 days a week, so for at least some of the time, their patients have to be cared for by somebody else. Different hospitals handle this in different ways. At Pennsylvania Hospital, there is a night float system. Most of the interns leave the hospital at night and sign their patients out to a single night float intern who works from about 5pm to 7am. The good thing is that most interns actually get to leave the hospital at night and are refreshed the next day to do work. The bad thing is that the night float intern is taking care of probably about 80-100 patients a night, and since you get signout on so many patients, it's not that detailed and you really only remember the really sick patients or make a note of specific things you have to do for certain patients. That means that night float doesn't know most of the patients very well at all - they just handle critical issues at night. Most patients are sleeping at night, and there's not much going on, so it's manageable, but if there are quite a few sick patients that night, it can get very busy and complicated. The good thing is that there is a resident or two for backup if things do get ridiculously busy.<br /><br />Some other hospitals do it differently. They have teams that round together, and at night, 3 interns will sign out to one other intern for the night. The good thing is that that since they all round together, that intern staying overnight is supposed to know all the patients relatively well. The bad thing is that one out of every 4th intern stays overnight, making 25% of the interns extremely tired and miserable the next day (since usually they get very little to no sleep) and also decreasing the work force by 25% the next day since they have to leave by noon.<br /><br />It's hard to say which is the better option. It's bad to have so many interns tired working the next day as studies show that the more tired doctors are, the more mistakes <span style="font-style: italic;">can</span> be made (not that they are common by any means). This is an argument for the first system, like at Pennsylvania Hospital. However, newer studies are starting to show that the more times care is transferred between different doctors, especially doctors who are not super familiar with the patients to begin with, the more mistakes <span style="font-style: italic;">can</span> be made (again, not that they are common). This would be an argument for the second system.<br /><br />In fact, there are rumors of new legislation in the works that forces interns to take a nap (!) in the middle of call for at least 3-4 hours. During this time, they would have to somehow sign off their patients to someone else, and then get them back at the end of their nap. This is all part of ongoing legislation reform about duty work hours (a whole other post). However, the problems with transfer of care may be an argument against doing this sort of thing. Until hospitals have more money to hire more helpers (e.g. RN's, NP's, etc) that can at least do part of the work of interns, I guess we'll have to make do.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-12939562062178667642009-02-22T19:44:00.000-08:002009-02-22T20:12:02.759-08:00Proper Use of the Emergency RoomI had a patient the other day who came in to the emergency room (the ED) at the suggestion of his primary care doctor. He had extremely high blood pressure at his doctor's office, but by the time he came into the ED, he had taken the blood pressure meds he was supposed to take, and his blood pressure had dropped significantly - almost normal! In addition, even though he had extremely high blood pressure, he never had any symptoms from it, and so although we might take steps to lower it in the ED, we likely would not admit him, especially now that his blood pressure had come down to almost normal after taking his blood pressure medications, which is how it should be.<br /><br />The patient was livid. He had paid his $50 to get evaluated in the emergency room and demanded that he be admitted. He claimed his doctor had promised him an admission, which was not true, as we talked to that doctor ourselves.<br /><br />Although not great, I use this as an example of how people misuse the ED and have the wrong preconceptions about it. Some people I understand - they don't have insurance, so they basically use the ED as their primary care. I don't like it, and I think there are better ways to deal with this or solve this problem (a whole topic in itself), but I understand. What I don't understand is why some people come into the ED at all when they have good primary care or have non-urgent problems.<br /><br />The Emergency Room is supposed to be for EMERGENCIES. It is for people who can barely breath from pneumonia, not for people suffering from run-of-the-mill colds. It is for people who have broken bones and fractures, not for people who have had lower back pain for the last 6 months. It is for people who are vomiting so much or have so much diarrhea that they are seriously dehydrated, not for people who may have one episode of vomiting or diarrhea but are still able to eat and drink just fine. It is for people who are having a heart attack, not for people who have had "chest pain" that has been proven to be not related to their heart for the 10th time.<br /><br />Not only is it a huge waste of public and hospital funds, but I don't understand why people would want to spend hours and hours in the uncomfortable waiting room of an emergency room when they can make an appointment with their primary care provider. In fact, when it gets super super busy, and people stay outside in the waiting room for hours and hours waiting to get seen, you can actually see people start to leave. In my opinion, if they weren't sick enough to stay and wait, they shouldn't have been there in the first place.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com1tag:blogger.com,1999:blog-434153672653500863.post-1825035028720556542009-02-19T06:38:00.000-08:002009-02-21T19:50:46.863-08:00When things don't go as planned...<div>Several months ago, I met a patient who had already been in and out of the hospital for months. He already had had many complications and was pretty sick. This guy had bladder cancer and had to have his bladder taken out. His ureters - the tubes that carry urine from your kidneys to your bladder - were instead fused to a part of his colon so that urine was diverted to his colon instead of his bladder. Immediately after the surgery, he had a heart attack, which is not common, but can happen because surgery takes such a big toll on your body, including your heart. He recovered well from this, and went home. Unfortunately, two days later he came back to the emergency room looking incredibly sick. It turns out that his wound had started to come apart, which is a potential complication of any surgery. His ureters were de-attaching from his colon, leaking urine into his abdomen, and he possibly had an infection within his abdomen. They had to open him back up and fix everything. In the end, it was all still leaking, so they had to place stents within his kidneys that led outside his body to drain the urine instead. He was discharged to rehab.<br /><br /></div> <div> </div> One week later, he was having his stents changed, and he suddenly became very very sick - he had a fever, the chills, and looked really sick. That's when I saw him. He had developed a very serious infection called sepsis where the infection is basically all throughout your blood. His blood pressure started becoming way too low and he had to eventually be transferred to the ICU where they could start him on special medications to keep your blood pressure up and your heart pumping. It turned out he had multiple types of bacteria growing in his urine, as well as fungus growing in his blood! That's pretty rare, but he had many potential sources of infection - not only did he have the normal sources that every else has (lungs that can develop pneumonia, urine that can develop urinary tract infections, and blood that with even just a blood draw can potentially develop bacteremia or sepsis), he had stents in his kidneys as well as an ostomy (his colon came to his skin and his stool came out through a bag) that were at high risk for infection. Moreover, he was a pretty sick guy, and he'd been in the hospital quite a lot over the last few months, so he was immunocompromised and at higher risk for infections, including hospital-acquired infections. Eventually, he was discharged about two weeks later to yet another rehab facility after being treated with multiple antibiotics.<br /><br />Two weeks later he came back again. Actually, he had two emergency room visits in between as well. This time, he had developed serious bleeding from his gastrointestinal tract, requiring many blood and platelet transfusions. Over the next 6 weeks, he developed sepsis again and multiple infections, and also developed respiratory failure requiring intubation to help him breathe. Although after several weeks we were able to take the tube out and he could breathe on his own, he was still incredibly sick and his prognosis was very very poor. After many discussions and having dealt with this for nearly 6 months, his wife decided to make him DNR. After 6 more weeks in the hospital and the ICU, he eventually died.<br /><br />I tell this story because sometimes, it can be amazing what a relatively simple procedure can lead to. I would not call a bladder removal a simple procedure, but I'm pretty sure this patient and his wife went into the operation with an optimistic attitude. He had bladder cancer, but it would be removed, and he would have to pee in a bag for the rest of his life. Traumatic, perhaps, but something you could live with. Instead, he had 6 months of increasing medical complications that eventually led to his death. I don't think the doctors did anything wrong at all, or could have done anything differently - sometimes it's just bad luck and unfortunately, patients and their families are often not prepared for things like this.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com0tag:blogger.com,1999:blog-434153672653500863.post-20994483386900401942009-02-10T20:56:00.000-08:002009-02-17T20:57:07.520-08:00Smallwood<table style="width:auto;"><tr><td><a href="http://picasaweb.google.com/lh/photo/ONpY5myWIYzsmAOVs5cnRg?authkey=VGuB0_KokVY&feat=embedwebsite"><img src="http://lh6.ggpht.com/_a3jkwkcJr8o/SZuTR3LznJI/AAAAAAAACKw/4VfCMwD-o_A/s144/IMG_0132.jpg" /></a></td></tr><tr><td style="font-family:arial,sans-serif; font-size:11px; text-align:right">From <a href="http://picasaweb.google.com/jojojangjang/SmallwoodFeb72009?authkey=VGuB0_KokVY&feat=embedwebsite">Smallwood Feb 7, 2009</a></td></tr></table><br /><br />That was a fun weekend.JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com3tag:blogger.com,1999:blog-434153672653500863.post-63939212307262192042009-02-04T05:54:00.000-08:002009-02-04T05:55:42.861-08:00A Universal Electronic Medical Record System<div>I have an ongoing discussion with my husband about this - the need for a universal electronic medical record system. I don't think anyone really disputes the benefit we would have from such a system. The only thing I could think of is that it may be easier to access the system and there may be more breaches of individual privacy. </div> <div> </div> <div>The potential benefits are enormous. I can't count the number of times patients come into the hospital or the emergency room with inadequate histories of their own medical care, or without a list of their medications. With a universal electronic system, there would be improved continuity of care, resulting (hopefully) in improved medical care. Not only would we have all their lab and imaging results at our fingertips, but we could get in touch with all the primary care doctors and specialists much more easily for additional information. This can be especially difficult to do if you are trying to contact a doctor at a different hospital or clinic after hours. Secondly, there would be a huge savings in health care costs. More often than not, laboratory and imaging tests are repeated unnecessarily because we don't have the results from another hospital or clinical setting or are unable to personally view imaging ourselves, such as chest x-rays or cat scans. This isn't good for the patient either, as multiple blood draws can introduce more infection or deplete already sick patients of their blood, and expose patients to more radiation than necessary.</div> <div> </div> <div>Unfortunately, the costs to implement such a system are also enormous. The majority of hospitals still run on a paper system and of the hospitals that are on an electronic system, very few of them are 100% paperless. Moreover, these hospitals all run on separate systems. To get all hospitals on the same electronic system would be incredibly time-consuming, logistically a nightmare, and costly beyond belief. During the transition, there would probably be many records lost, confusion regarding how to access records or results and much worse and slower health care. The hospitals themselves probably all have their own systems in place already and would be reluctant to switch to yet another system, especially if they just spent all this time, effort and money to implement their own electronic system. Many hospitals would probably just want to make their system compatible with whatever universal system is being implemented, which is not ideal. And who would pay for this? The government?<br /><br />Despite all the roadblocks, I still think it's a worthwhile investment, and hopefully the eventual benefits would outweigh the costs and the inconveniences and temporary lapses in health care.<br /></div>JoJoJangJanghttp://www.blogger.com/profile/06928837374844952276noreply@blogger.com1