I Love This Guy

I love it when I see posts that remind me of the Madhouse Madman. I love them more when I see them as comments on my blog. Charity Doc left this comment on my primary Care post below. And...please take it with a sense of humor. I'll have no bickering on my blog:

Don't do it!! Spend the extra 2 years and do a fellowship.

Here are some ideas:

Cardiology - you will work like a dog and be consulted every time a patient c/o chest pain (which is roughly 30%+ of all ER visits). You'll cath every middle aged and old people that have a femoral pulse. If they don't, you put a pacemaker in. If they're also dizzy, make it a pacemaker/ICD combo. But on the other hand, you'll be stinkin' rich and paid very handsomely. As far as hospital politics go, you'll be coveted and treated like a god, while us lowly, replaceable ER docs wish we have your clout with the hospital administrators and other medical staffs. I've been at this hospital for over 5 years now and the CEO, COO and CFO of the hospital still don't know who the heck I am every time I see them at the staff meetings.

Nephrology - you'll work like an ox and get consulted for every Creatinine level above 1.5 But you'll make money out the wazoo because every dialysis patient is fully funded so your reimbursement rate is...CHACHING. You'll even volunteer to dialyze road kill if it has an AV shunt in. But somehow, and for some stinkin' reason, you'll moan and groan every time you look at your census list which takes up a whole page, front and back, single spaced. Those damn dialysis patients sure have a lot of medical problems. DM, CHF, PVD, HTN, CAD...the list is endless. You'll find yourself arguing with the cardiologist whether CHF is a disease of the heart or a disease of the kidneys.

Hem/Onc - You may find it too depressing. Consult the Happy Oncologist blog for this one.

Rheumatology - No pt. seems to get any better do they? Another depressing discipline.

Endocrine - how many endocrine consult have you done? As an ER doc, I've never had to called one. Maybe you should forget this one. The chaching bell ain't ringing here.

Pulmonary/Critical Care - I'm just not feeling the big chaching factor here either. They seem to bronch everybody and scan everyone's chest. Vent management ain't that much of a mystery. It just seems that way. They're the only ones that get all excited about sputum. Sloogy docs. Everyone gets PFT's. What would you do without the cigarette industry?

GI - Oh my God! While the rest of the world upchucks and toss their cookies whenever a GI bleeder shows up, the GI guys sniffs it all in and says..."Can you smell the money??!!!" Poopy docs and Golytely pushers. They do make a very decent salary though, scoping from above and below all day long.

Neurology - Every since the NIH touts tPA for ischemic strokes, these guys are consulted all the time now from the ER. They're all over the TV and radios being spokepersons as every hospital compete to get that Stroke Center designation. What a load of crap, heh? Stroke Center. The standard of care, the 3 hours window for thrombolytic from onset of symptoms is the flipping same at every hospital. Every hospital has a OT/PT department, too. So why should any "stroke center" be any different from any other hospital? Yet, they're all over the newspaper and radio touting so.

Don't get me wrong, we need primary care providers. But why be one, work just as hard as the other guys and get pay less? Do the extra 2-3 years fellowship. It's all worth it. If I had to do it all over again, and if someone were to point a gun at me and force me to, I'd choose cardiology and nephrology as a second choice. Just my thoughts. Good luck on your decisions.

www.fingersandtubesineveryorifice.blogspot.com

ER docs are crazy and because of that they have the best sense of humor in the entire hospital.

The Case of Slobodan Milosevic

Talk about jumping on a case too late. Due to an extremely busy week of interviewing and clinic rotations I was unable to write about the case although I’ve been following closely.

Slobodan Milosevic, former Yugoslav president, who was on trial for war crimes, was found dead in his jail cell at the UN detention center in Hague. Mystery surrounding the cause of his death immediately emerged. Specifically concerning traces of a drug called Rifampin which was found in his blood on an earlier exam.

Rifampin is mainly used as one of the multitude of medications used to treat tuberculosis. It is unclear how traces of the chemical were ingested by Mr. Milosevic since he was not being treated for this condition at the time and the pharmacy at the detention center does not even carry the drug.

In addition, Milosevic, who later found out about the traces of the drug found in his system, wrote to the Russian embassy concerned the possibility that he was being poisoned. In November, Mr. Milosevic was complaining of headaches, fatigue and hearing problems, possibly as side effects of Rifampin use. Speculation about how traces of the drug were found in Milosevic still ruminate and includes poisoning and self ingestion. How Milosevic could have obtained the drug is unclear although reports say that he was in a “privileged setting” where many normal prison procedures were not always followed.

As for using Rifampin for the purpose of poisoning there are certainly better options. The side effects of Rifampin toxicity are numerous, however, they are generally not lethal. In addition, Rifampin can decrease the effects of other medications and there are speculations (I know you don’t like ‘speculations’) that Milosevic was ingesting the drug in order to prevent adequate treatment of his high blood pressure, possibly as a means of earning medical leave.

An Autopsy revealed the cause of Mr. Milosevic’s death to be, as one newspaper put it, a “mild” heart attack. As a matter of policy, I limit my use of the word “mild” to non-lethal myocardial infarctions.

In addition, as an anticlimax to this issue, traces of Rifampin were not found in his blood.

Reality Check (Ruthlessly Candid)

I am looking for a job.

After three years of residency in Internal Medicine I have decided to forgo fellowship and go into Primary Care/Internist or Hospitalist work. I thought it would be interesting to share with you some of the offers as well as my thought process.

I think this can be interesting because due to my anonymity I can afford to be ruthlessly candid. The other reason is that as some have stated you would like to read about the true experience of being a resident, look no further.

In the past, I have done my share of complaining: about the job, the hours, the pay, the future etc. etc. I’ve stopped all that. Not because I don’t still have those same concerns but because I realize that some of my audience likely make a fraction of what an internist makes these days and so my complaining seems kind of “funny”. So please don't view anything I write here as complaining, just my honest thoughts.

And, since I always believe that two, or two hundred, heads are better than one I would certainly welcome any tips that my readership can provide, maybe something I haven’t thought about.

Before I do, I think I have to be candidly honest about my goals and current situation, so that all of you can give me the best advice:

Overall, this is the plan: My wife and I would like to be able to return to Israel to live there within 5-10 years. Since doctors make roughly $30-40,000 in Israel I do not think that I will be able to pay my medical school loans there, this is the reason why I returned to the U.S. after attending medical school in Haifa. I would also like to be able to purchase the apartment/house I will live in there, since that can be very expensive. The plan is to pay off the private loans before I go back and make enough investments in the U.S. so that I can have income that can pay off the rest of the loans by itself. Currently, we are hoping to finally purchase a home and stop renting. Preferably in a good community with good schools so that Jordan can be safe.

Current financial situation:
1. Private Student Loans: $80,000 at 6.25% variable interest. Current monthly payment can vary but minimum is rough $600.
2. Stafford Student Loans: $96,000 at 3.25% locked, monthly payments $400 over 30 years.
3. Savings: $40,000
4. Currently renting but hell-bent on buying something soon. I currently live in a major urban city and the housing prices here are on the level of prohibitive.


Thus Far: I have been to 5 primary care interviews and 3 Hospitalist interviews here is what I have come up with: I have multiple offers, here they are:

Primary Care Positions:
1. $120,000 a year. No bonus. Partnership, maybe, after two years. Housing reasonably priced.
2. $115,000 a year. Bonus once surpassing three times your income. Partnership after 3 years. Opening Concierge service possible. Housing extremely expensive.
3. $80,000 a year. No bonus. 10% of whatever you bring in. Housing extremely expensive.

Funniest trend: The more expensive housing is in the area the smaller the salary.

Hospitalist Positions:
1. $110,000 no bonus, known to be a hard hospital to work in with lots of hours of work. Housing in area extremely expensive.
2. $125,000 no bonus. Work hard. Housing expensive.
3. $140,000 with bonus. Two hours away from family and outside current city. Housing cheap. Good community. Work hard.

My current inclination is to take the third Hospitalist position since I will likely be able to save the most there. The wife and I think it is our best chance at achieving our goals even though we will have to leave the family behind.

I had intended to go into clinic based medicine but will likely hold off until I move to Israel. It is an unfortunate truth which I simply have to confront and that is that currently I cannot allow myself to enter primary care and achieve my short term goals. When I listen to my friends who entered other specialties and the offers they are getting I am extremely jealous and if I had to make the same decision again I would have chosen differently.

I Applaud Her Effor Although I Do Fear For Her Life

Check out this NY Times artcle on Dr. Wafa Sultan. And here's the video they're talking about.

Hat tip to Enrico for the info.

My Conclusion

Friday, I asked the readership of this blog to express their opinion on my posts which dealt with Ian Thorpe, an olympic australian swimmer, who is currently suffering of an unknown respiratory condition. My question specifically was to inquire if I was being "Unethical" in publicly stating my opinion of what I felt was the likely diagnsis. Your views were mixed. for example, Moof said:

1) Ian Thorpe is a public figure.
2) You didn't make an accusation, you made a speculation.
3) Physicians have as much right as anyone else to speculate about whomever they will - even (and especially) when the subject matter is in their field of knowledge.
4) The only problem that I can see isn't one of ethics, but perhaps one of indiscretion (gossip?) ... depending on how you see 1) public figures and 2) the nature of the speculation.

And Graham reiterated similar concerns with:

It's definitely rubbed me the wrong way since you first started posting about it. If you were speculating about something a little more benign, I don't think I'd mind. But you're speculating about something serious and terminal; I'd feel the same way if you were speculating about something like cancer or ALS, I think I'd feel the same way. (Not to mention all the stigma that comes with HIV.) I think as a physician you're automatically able to know more about some people from your training--perhaps something that a non-physician would call strange or different or normal variation, you would know it to be disease.

And then there was an anonymous blogger (a physician) who stated:

I think ethically you have to ask yourelf several questions:
1)In publically speculating, did you bring harm to the patient's character? ( gossip)2) If so, do the needs for society to know outweigh the respect for an individual's privacy?
3) By virtue of your M.D., do your speculations have greater weight, and therefore carry more potential for grater harm?

I thought all the comments were great and quite thoughtful and I appreciate you all taking the time to write them. I did have difficulty though seperating if the problem was the fact that I was speculating about HIV? Or was the problem that I was speculating at all?

Speculation by its very nature is gossip. I get paid to speculate. People pay me for my services to speculate on their medical condition based on what information I have. Most of the diagnosis that physicians make are based on "the most likely" etiology. Isn't that speculation?

So I think what bothered everyone was the fact that I speculated that Ian Thorpe may have HIV. Probably due to the fact that HIV is a disease which still carries great stigma.

It was likely my fault. I had intended to begin trying my hand at speculating on general medical issues in the media, a la CodeBlueBlog (although, I profess, could probably never be as good as he was adn I so enjoyed reading his entries). For example, was Sharon's stroke due to medical error, or more recently, what is the true reason for Milosevic's death. I just so happened to pick up on Ian Thorpe's condition as the first and in this particular case HIV was my leading diagnosis, stigma or not.

Perhaps the best advice came later in the commentary from Echo Mouse and I urge you to read it carefully. I believe some of you may be taking what you read here a little too seriously:

My view is that blogging is personal unless it's part of a business or organization. You don't affiliate your blog with your hospital, private practice or any other agency. So I view your blog as a personal blog, despite the fact that you are a doctor.

Now, when it comes to expertise, everyone has enlightenment on certain things by virtue of their occupation. A blog is a place to express personal viewpoints. Your personal views include your training as a doctor. So while speculation about someone's health might be considered wrong in your capacity as a doctor, you are not at work here, you are blogging here. Based on all of this, I don't see that you have broken the H.Oath or spread gossip. You mused on something of interest to you. On your personal blog. Granted, HIV status can kill a career but you have never claimed to be an expert on HIV nor are you being consulted about this person's health. You're just stating your thoughts. That's okay as far as I'm concerned.

One of the reasons I took a break from blogging was because it was seemingly too political for a while there. People need to stop and think. Your blog is not the NY Times nor do you work for Reuters or the AP. If they stop in to read, they need to remember it's the same as stopping in to have coffee or tea with you. You're entitled to your opinions. Trying to limit that by throwing your profession at you is the sort of thing society does to shut people up, which definitely goes against free speech.

So you see, when you stop in to read here it's just like stopping in to have a cup of coffee. So what will it be regular or decaf?

I won't have the coffee, it gives me a case of the runs.

Friday Intern Topic of the Day VII: Is the Doctor Displaying Ethical Behavior?

I love comments. Yes, I agree, I do tend to be less “responsive” to commentators than other bloggers but I certainly read each and every comment that’s left here. So if you ever have something to say please take the time to leave a comment, I do love to read them.

There are, however, comments that go in one ear and out the other and others that make me think. Earlier in the week I posted an entry about Ian Thorpe. I speculated that based on the information available to me, that Ian Thorpe may have HIV. I gathered the information from press releases released by Ian and from whatever I could gather that was released by the general media. I even submitted the post to Grand Rounds. Where, somehow amid the thousand and one entries this week, it managed to get a certain amount of attention.

There was one comment left by a certain Dr. Steve that I’ve been thinking about for quite some time now and I would like to comment on it. And, I would like to hear your comments on it too:

As a fellow physician, I think it is marginally unethical of you to openly speculate, based on extremely thin second-hand guesswork that a prominent figure like the "Thorpedo" has HIV. I don't think you would like that if the tables were turned (especially if it turns out that the guess is wrong).

I actually thought it was a great comment. It didn’t contain any foul language or derogatory remarks and yet drives the same point home. Everyone, I would like you to take this as the perfect example of how to display dissatisfaction with a certain post without displaying lack of taste. Wonderful stuff and it made me think. Am I being somewhat unethical in speculating about Ian Thorpe’s condition openly on the internet?

Lately I’ve been contemplating the purpose of blogging. Other than the occasional sharing of something creative that I wrote is there really any other benefit to what I’m doing, and by extension, to blogging at all? (I contemplate too much, I know)

Here’s what I concluded:

If there is anything that we as bloggers can contribute in the big spectrum is that we are all experts at something. Likely, our level of expertise far outweighs that of the reporter who writes the column for the big media conglomerates whom we are all reading. These reporters don’t know what questions need to be asked because they are not lawyers, doctors, cops or accountants. They are reporters and that is the only thing they know.

Ian is not my patient. I took an oath to protect the privacy of my patients. It would be unlikely that, Ian Thorpe being who he is, other doctors have not already discussed the possibility on big media in Australia. In addition, Ian’s condition is being discussed everywhere, last I checked, 300 articles around the globe this week alone.

But boy does he have a point and I mean that honestly. I can totally see what he means and a certain part of me is still contemplating if I should continue this. But I really do enjoy trying to piece the information together. Is it unethical?

What do you think?

Ian Thorpe Drops Out AND Expands the Differential

In a sudden and unexpected move Ian Thorpe, by far Australia’s best swimmer, has dropped out of the Commonwealth games. During training Ian, who was said to be quickly improving, was unable to complete his usual regiment, becoming winded after twelve laps. Afterwards, on national television, he announced his withdrawal from the Commonwealth games.

Previously I stated that after reading the reports issued by the press I believed that Ian Thorpe may have HIV. This was due to the following factors:

1. Ian has now been ill for more than three weeks with a “viral” syndrome and I do not believe that this is likely.

2. His coach, Alan Thompson, stated that: “The antibodies in his blood were beginning to rise”. I believe that he was referring to Ian having a certain type of immunodeficiency and by far the most likely diagnosis in his age group is HIV.

3. The Doctors and Ian himself are being extremely vague concerning what is going on and the result of his testing.

4. Ian has been placed on antibiotics for a viral condition and this is not commonly done unless the doctors are suspecting something deeper.

During his press conference Thorpe revealed that during his childhood he had to take a three month vacation from school for another bout of “viral bronchitis”. This is interesting because it hints to another diagnosis that is less likely, although possible.

Immune deficiencies are a group of disorders characterized by the dysfunction of the immune system. There are a number of disorders but each expresses itself differently depending on the specific disorder present. Although a lengthy discussion of the topic would surely not be appropriate here, you can find more specific information elsewhere.

Generally, immune deficiency would manifest as recurrent infections. However, due to Ian current age and his known health status I think that we can rule out the more malignant ones. In addition if you remember Alan Thompson, the coach for the Australian Olympic team, stated:

“He got some blood tests back today and they were positive and showed an improvement in the blood parameters and the anti-bodies are doing well"

In my earlier post I speculated that Mr. Thompson may have been misinformed and that more likely he was referring to the White blood Cell (WBC) count that is often checked on a cell count. But what if he wasn’t misinformed? What if Mr. Thompson knew exactly what he was saying?

Are there any immune deficiencies that would express themselves as a decrease in the amount of antibodies in the blood and would not present with consistent recurrent infections. I placed consistent in bold type because if Ian Thorpe was consistently ill he would not have been able to achieve all he has until now and so I believe we can assume he is healthy most of the time.

One diagnosis jumps to mind more than any other: Selective IgA Deficiency

This deficiency may be congenital or acquired (meaning people get it later in life). More importantly, it’s not altogether uncommon and many of those who have the disorder lead normal healthy lives. In addition, it is not uncommon for it to manifest as recurrent upper respiratory infections. the same condition Ian has ahd for three week now.

Ok, I admit, my bet is still on HIV. But a good differential always includes a number 2. All that’s left now is to wait for someone to leak some more information.

Go Read Grand Rounds! It's an Emergency

Kim at emergiblog has this week's Grand Rounds and she's decided on an Emergency Department theme.

Future Intern: One Year Old Today

Most of the readers who’ve been with me for a while know what my favorite and shortest post of all time is. It was exactly one year ago today.

I am profoundly amazed at how one year has passed so quickly and how far my little intern has come. I’m so proud of her. After all, she’s already mastered how to perform lumbar punctures and central catheters and she’s not even in medical school (Not for another three years).

Today the Future Intern, and my little girl, is one years old.

Kirby Puckett in Critical Condition

Former Minnesota Twins center-fielder Kirby Puckett had a stroke at his Arizona home yesterday and was taken to a hospital for surgery, the team announced from its spring training camp. The 44-year-old Puckett, who led Minnesota to World Series titles in 1987 and 1991 and is a member of the Hall of Fame, was taken to a Scottsdale hospital where neurosurgery was performed to evacuate the bleeding in his head. Mr. Puckett is in critical condition.

This is the second famous case of hemorrhagic stroke in as many months. The most common risk factor is hypertension, which causes nearly 60% of all strokes of this type. Other causes include amyloid angiopathy, trauma, cocaine and ruptured arteriovenous malformation.

Mr. Puckett is pretty young for this type of condition. Which can make causes other than hypertension more likely. However, it is unclear is Mr. Puckett did suffer from Hypertension although his recent weight (>300 lb.) makes it likely that he did. Some of his history may suggest risky behavior and makes cocaine use likely (Although I am by no way claiming that he had).

In terms of need for surgery to evacuate hematomas. evacuation of the hematoma is generally not helpful except in cerebellar hemmorhages. Most hematomas more than 3 cm in diameter also require surgical drainage. There are other indications for surgery that include clipping of an AV malformation or placement of shunt. Regardless of the cause, the need for surgery often indicates a poorer prognosis.

More to come as information is released.

Is Ian Faking?

A second differential diagnosis for Ian Thorpe:

The coach of South African swimming star Ryk Neethling has sensationally claimed Ian Thorpe's illness could be a ploy.Neethling's coach Dean Price said he had heard reports from the Australian camp before that swimmers were sick on the eve of major competition only to watch them dominate.

Thorpe is due to clash with three-time Olympian Neethling and fellow South African sprinter Roland Schoeman in the 100m freestyle.

It seems I didn't incorporate the "clashing" factor present in swimming competitions into my differential.