Physical Examination Saves Lives And Money

I just attended an M&M done by one of our chief residents at our hospital and it raised a few issues that I wanted to write about.

A 50 year old man, originally from Ethiopia, sought medical care for progressive weakness for the past three months or so, so severe that he was unable to do his job of working as a cab driver. He had emigrated to the US about 15 years ago and his chief complaint was taken to mean "dyspnea on exertion" which lead to admission under a cardiomyopathy service- his then documented physical exam was positive for abdominal distension without any other cardiac, lung or peripheral extremity findings. Lab tests of note BNP was 35, hemoglobin was 10, renal and liver function tests were within normal limits.

He had a cardiac echo, right heart catheterization- which were all normal and was sent home for follow up with Neurology for "weakness". When he came back for his Neurology Clinic appointment, it was noted that he had abdominal distension and striae and they referred him to Endocrinology for "further work-up" of Cushing's syndrome.

We failed this man in many ways- his words were mauled into a "good fit" for a cardiac story which was milked with all sorts of testing without any Bayesian thoughts. The clinicians that cared for him seemed not to have really seen him- it took an inpatient stay and an astute neurologist to consider the diagnosis that brought him to the hospital. This is a disease that is ripe for questions during USMLE steps, shelf examinations, pimping sessions during rounds and yet this man got a gazillion tests- cardiac catheterization, inpatient lung functions tests, CT chest, Ultrasound of the abdomen and many, many blood tests before someone really looked at him.

As I walked out of the conference room, I chatted with my colleague saying that a good internist would have caught that, don't you think? He replied, "I'm not sure- a good internist would have completed all the clinical reminders,for sure."

Thoughts on Ebola outbreak

There has been such a lot of over the top coverage of Ebola..everyone from the @realDonaldTrump to @CNN has weighed in; so I thought why not me. A blog post to summarize what I learned and what I thought about the whole thing would be useful for my approach to medicine, and maybe useful to anybody that might care to read it.

One of the first things that struck me was the heroism of the clinicians- people who left comfortable lives to help others. It reminded me of my medical residency during the era of SARS and the death of Dr. Carlo Urbani who first identified the disease as a dangerous, life threatening syndrome and died from SARS. http://goo.gl/K1gbdx I remember the sadness and pride that I felt in his life story, that I was a part of a profession that had a few heroes.

In learning of Dr. Khan's death I felt the same sense of pride and desolation.  http://goo.gl/TmWd23 I think that this short piece in the BMJ, by Margaret McCartney, a GP from Glasgow, expresses well what I would like to share- a homage to "real courage".goo.gl/HPWTDm

Ebola is not a new disease- it has simmered, off and on - for a long time. This is an older article about the ecology of the virus which was useful for me to read http://goo.gl/SgGQnN as the disease is not something I think of, very often. This is a simpler life cycle cartoon from the CDC site.

There seems to be a seasonal, cyclical nature to these illnesses, maybe related to food insecurity leading to eating alternative protein like bats, bush meat. It is also likely related to loss of forests, habitat destruction.

The mistrust of clinicians by the people is something that I see often in my work but it is usually related to certain topics like vaccination; but I think I can understand the West African public thinking that Ebola is a conspiracy. It is hard to trust people especially when they are suited up, as if going on a space flight, rather than taking care of people. This is the hardest barrier to fight- an outbreak will only go long for as long as there is fear, mistrust and lack of true knowledge about the disease.

It is important to get accurate information to the affected people rather than the hype that is all over. I was glad to see this intervention from Liberian natives in Boston who are volunteering to spread good information so that rumor does not take hold. goo.gl/riUJ4C 

There have been diseases like these, modern day plagues, which all of us need to get good information about, especially if we work in healthcare. Diseases can be just a plane ride away but humanity is poorly served by paranoia; to this end-  I thought that this piece by an Emory RN on why we need to take care of people with Ebola, here in the US, was an informative read. http://goo.gl/yfGss1

Earlier today I read in the NYT http://goo.gl/C4kfOK about how Ebola affects immigrants who have not even been to West Africa recently. An outbreak has a domino effect and brings forth our deepest fears of illness and stranger anxiety. After all this frantic reading on the subject, I for one, feel better prepared that if I came face-to-face with Ebola, I'd know what to do.

Lets Talk About Death.....

Death is inevitable. In my work as an internist in Southern California, taking care of patients in the hospital, I see it often. Sometimes, in my darker moods, I joke just a tad sarcastically, with my team of trainees, reminding them that in So Cal, no one ever dies. This is in the context of memorably rare instances of conversations in the flavor of  "Do everything" and  "I'm waiting for a miracle to happen for my loved one ". Now, I may sound flippant but it is not my intention. It is frustrating to see patients and family members suffer from over treatment, sometimes due to over ambitious physicians care and sometimes due to misunderstanding and overestimating the role of Medicine.

Recently, I heard Dr. Paul Farmer talk about " stupid death"  which he explained as a death that ought not to have happened. When a person dies, usually in a resource poor setting, due to a health condition which would be treatable if they had got the right health care at the right time....that is a stupid death. He talked about how a woman working for his organisation in Haiti, died during pregnancy and that is an example of stupid death- one that is preventable and should never have happened, when it happened.

As a physician, it is my duty to prevent this sort of a death. All my training, my medical reading, my professional obligation is to prevent " stupid death". But what about the other extreme. I read the NYT piece "A 'Code Death' for Dying Patients" by Jessica Nutik Zitter, MD who is a rare breed of physician- one who is board certified in critical care medicine and in palliative care which is often, mistakenly seen as a do-everything versus do-nothing specialty. In this piece she talks about how it is important to be aware of impending death during a patient's illness and then participate in a 'code death' which is palliation at the time of death. This is an important article which should inform our care of patients.

We, as a society and both patients and doctors, need to get comfortable with talking about death, planning for death, just as we do for life. We need to talk to our patients about advance directives, POLSTs and MOLSTs, what they and their family members can expect at the end of life. Whenever we can, we need to prevent stupid death but in case of the good death, the inevitable  death, we should not prolong suffering but simply allay it.   

Cost of Care

We had Chris Moriates come and talk at our grand rounds about cost of care and the need for physicians not to do financial harm in course of caring for our patients. Briefly, he called on the need to be mindful about what we do to patients and think about all our actions.


As I work in our inpatient unit, I have been thinking about what we do in health care and how factor in cost in daily work. Traditionally, costs have been in the domain of health economics and abstruse disciplines that we rarely think of while working with patients. Most patients, however are aware of co-pays, medication prices, ambulance charges and assorted deductibles. Even the ACP ( American College of Physicians) has said in its ethics  manual that equity and cost effectiveness is an important consideration in health care.


These are all meta considerations which can be best done when we consider the whole population even as we treat the individual patient. During bedside rounds, I've been trying to question every investigation we do on our patients by asking why are we doing this test? Is this the best way to get the information we need to care for our patient? Will this test change management? This mindful approach helps us cut down unnecessary testing and is my way of doing "slow medicine" in the hospital. Talk before testing, works for me.