Tuesday, October 07, 2008

Grandly Rounding, MDOD Style...

"Outta the way, fancy boy! I'm a-commandeering this here clown car!"


Thanks everyone for visiting for MDOD's first hosting of internet medblog Grand Rounds. Folks have asked if there is a theme for this week and since I'm new to this the answer is... well, maybe. I am going to post everything that was sent to me and some stuff we found. I hope you enjoy it.

We have a bit of a reputation amongst our twenty or so regular readers for being hard right smart assess and we confess, it's true. But since you can't turn anywhere today without being bombarded with politics, financial armageddon talk, nor can you dine at home without getting phone calls hustling you for money for candidate X, Y, or Z, we will steer clear of all that as much as possible. If a theme emerges here it is merely due to synchronicity and alcohol. So, without further ado, let's take a trip through medical cyberspace...

Our sincere apologies to the Happy Hospitalist whose submissions were lost in my transition to GMAIL and they are great ones sure to stir the pot a bit. First, we lament often here that the 'rules of business' are not applied to medicine and that physicians are only professionals who are mandated to give their time and skills away by the federal government. When we complain, we are seen as greedy, uncaring, or any other number of pejorative terms. Check this interesting explanation offered by the HH, and then read about how lifestyle choices have impacted the hallowed halls of surgery. I wonder if any reader can give an educated politically incorrect guess as to a synchronous event that may have led to the demise of the specialty of Surgery as detailed by HH?

White Coat Rants makes a tear well in our eye with his post detailing the idiocy produced when committees morph into bureaucracies and then into government oversight entities. And this all for the sake of money shuffling and vote buying. Outside of the academy, Medicine is dying, patients are dying, and doctors are the whipping boys of the moment. Check this one out too.

Those of you in Emergency Medicine will recognize the name Paul. S. Auerbach, MD. Dr. Auerbach is one of the fathers of a relatively new offshoot of Emergency Medicine- Wilderness Medicine, and is currently on the faculty at Stanford University. As an instructor I can tell you that this discipline is low on theory and high on practicality (and that's just my style). I think you will find his post, a part of a series on Desert Survival techniques, very interesting. Dr. Auerbach, if you need anything just give a shout-out, you know, expedition doc for the Pussycat Doll's tour of the South Pacific, or for the Swedish Bikini team's naked ascent of the world's tallest peaks (bad pun intended)?

Benjamin Disraeli (and Mark Twain following) made famous the quip that there are three kinds of lies... "Lies, damned lies, and statistics." David Harlow fleshes this out in an interview with the general counsel for UMass Memorial Health Care System in the kind of depth that is far beyond the immediate comprehension of a simple car-crash physician like myself. Shutting down all CABG procedures at his facility may seem a bit drastic based on these statistics, but decide for yourself.

We empathize with the post from The Dragonfly Initiative which gets to the gritty reality of practicing Emergency Medicine as seen from the provider side. We wish we had written this.

Over at Mother's in Medicine FreshMD explores an interesting problem... how should a female physician respond to patient's compliments about her looks? The post was inspired by Pakistan's President Zardari's comment to Governor Palin that she was, in a word, 'hot'. We agree. We too would like to 'hug' her.

Bongi, over at Other Things Amanzi, gives a detailed account of a poor outcome (in spite of his best efforts late in the ninth inning) in a case of pseudoaneurysm presenting to a makeshift medical facility in South Africa. Want to know what a pseudoaneurysm is and why this particular patient ended up losing a limb? Check this one out.

How does the mainstream media do with its reporting on complex medical topics like genetics? Not very well according to Walter Jessen.

Dr. Jolie Bookspan sent me a nice post about living under the sea. Really. During her studies in extreme human physiology she actually worked in a lab tethered to the bottom of the sea. I always wanted one of these... it rated much higher than having a tree house when I was a kid. Never did get to do it though. Lots of good links here regarding how the human body responds at extremes and even some fun stuff to do with your kids to introduce them to scientific concepts and the scientific method.

A doppelganger from South Africa lays in on the line at Just Up the Dose about choosing medicine as a career. Sounds like our South African brethren have a model for training physicians which might just make its way here soon. Great.

Dr. Bruce Campbell, an accomplished head and neck surgeon draws an interesting analogy between learning to drive a car and learning how to perform surgery. This hits particularly close to home as, in my years in the military I was involved with an aviation training squadron. I came away from that experience thinking that surgeons and pilots were cut from the same cloth and were trained in very similar fashion. Thanks Dr. Campbell.

A medical student at Twenty-four Hour People posts about his 'sub-I', or, 'sub-internship' recounting some very interesting patients with a bit of sarcasm and sharp wit here.

Dr. Carty at Hot Medical News scratches us on the back a bit (ahhhh, nice...) with his post regarding the rise of the new medical power-players... the 'people with clipboards'.

Captain Atopic from Australia enters a post about medication errors and how Murphy's Law tends to rule in the land of medicine.

Could we really make it through an entire Grand Rounds without mention of the election and it's impact on health care? No, here are some common sense tips (from the Poked and Prodded blog) for all on how to save on health care in spite of whether we spin left or middle come November.

Can you imagine that the government might be very inefficient and silly at administering one of it's multi billion dollar programs (Medicare/Medicaid)? Neither can I, but evidently it does happen as explained here at InsureBlog.

Over at Nurse Ratched's place you will find a post detailing the life of one of the first "tough women of Alaska", a nurse known as the "Angel of the Yukon." Very interesting.

An humorous slap-fight is underway at the Clinical Cases and Images Blog. I must admit that I'm on the side of the radiologist in this one... we scan because we would rather defend a malpractice action with a radiology read under our belts than try to convince the jury that our physical exam skills are 'better than a CT'. I'm not saying a neurologist is not 'better than a CT', I just don't ever have one around when I need one.

The horrors of first year Medical School lecture are detailed here right down to the penny. Thanks to our friends over at The Week or Some Derivative of Said Length of Time. Memories.

The Law of Conversation of Mass is given a humorous twist by Val Jones here and don't tell me this doesn't make sense!

Do you all remember your surprise at learning that maggots and leaches had made their way back into modern medicine? Another ancient technique aimed at allergy and sinus infection sufferers is detailed here. Honestly, this cut my sinus infection rates almost to zero (though it's a bit uncomfortable).

Barbara, at In Sickness and in Health, writes with admiration about the great love demonstrated every day by ordinary people taking care of terminally or chronically ill partners. Barbara, thank you for this.

At Laika's Medliblog you may learn about an enterprising new genetics company offering, for a fee of course, to analyze your DNA and determine whether you may be at risk for certain diseases. This raises a host of ethical issues which Laika explores with a raised eyebrow.

Laurie Edwards at A Chronic Dose speculates about the impact of the financial crisis on the already extant crisis in managing chronic illness.

Ever hear of Complex Regional Pain Syndrome? No? A Plastic Surgeon in Arkansas educates us here.

Is there gender bias in medical texts? In the classroom? Personally I don't care as long as the women who go into medicine are hot and speak only when spoken to, but check this out...

Concerned about the supply of 'organic food' and the prices thereof? Can't find a good organic apple at a good price? My solution is to buy the inorganic apple and poke fun at those buying the organic kind (if you are right then you will have your revenge), but here you go. Going to polish off a few inorganic beers... back in a minute.

I think if the good Doctor (a psychiatrist) over at How to Cope With Pain were a regular reader that she would have been scared away, I mean erdoc85 just posted on 'fibro', but... All I can say is God Love 'ya doc, I could not do what you do, and, while I'm thinking about it, what percentage of your patients are 'cures'.

Yet another submission from someone who does not follow this blog, but, since I'm posting all that are sent I will let you decide about whether fibromyalgia should limit one's ability to purchase long term health insurance. Now being schooled in basic economics it seems to me that insurance companies should be allowed to manage their risk as they see fit, for the alternative is to do away with insurance as we have known it. I do not say this as someone without any 'disqualifying conditions', but, even being only partially insured, I understand why insurance companies do not want to cover me for an ailment which is likely to make me a losing proposition.

MDOD Grand Rounds comedy award winners for the week...

First, a wonderful bit of satire from Canadian Medicine lamenting the lack of 'journalistic ethics' in the medical blogosphere. We hope this wry bit of humor will lead to the establishment of at least a baseline of what might be termed 'ethics' in journalism.

Second, and again on the satire front, Colorado Health Insurance Insider takes a poke at a scary development in the American mindset, one that elevates access to health care to the level of life, liberty, and the pursuit of happiness. They almost had me with this bit of cheek until I realized that with a little bit of reading between the lines the operating mantra here is "from each according to his ability, to each according to his need". Great one guys. Really funny!


  1. Awesome Grand Rounds. Thanks for all your work on this!!

  2. Nice edition! I love Yosemite Sam!

  3. Ratzin-fratzin good job, folks!

    Thank you for hosting, and for including our post.

  4. Very nice edition of Grand Rounds. Warner Brothers would be proud. Thank you for including my post.


  5. You Call THIS a Grand Rounds?!?!?! I leave better material on Bathroom Walls! And all that Brain Power but no one has an opinion on Florida-LSU?, Damn pointy headed Yankees. Just Kidding, but like an actual Grand Rounds, a little Dry.

  6. Another great Grand Rounds. Thanks for hosting.

    I'm bummed my post didn't make it in. I must have botched your email address or it got scarfed up by your spam folder. Rats, now what will I do for my weekly ego boost?

  7. hey there, thanks for including me in your grand rounds this week - great job! but i don't know why you think i don't follow your blog - just because you posted about the pissed-off mom of a girl with a fibro diagnosis doesn't mean i'd be scared off from submitting a fibro-related piece. i don't scare that easy, guys! ;)

    in fact, i can't help myself: i have to argue my point that if you look at my entire medical history since diagnosis, i am so NOT a losing proposition just because i have fibromyalgia. in fact, my tenacity in managing it so thoroughly should make me more insurable in a sense; unlike many insurance consumers, i take a daily interest in staying healthy. most people wait until they feel like total crap before going to the doc and then have to completely change their lives to try to get a little healthier; instead i do all kinds of stuff (daily exercise, eating right, not smoking, meditation, following my meds and doctors' orders) to make sure i go to the doc the LEAST amount possible.

    of course, insurance companies are allowed to mitigate their risk. i just don't think i'm that much of a risk in the big picture. i was diagnosed 11 years ago and since then i've still been an extremely active person, starting two successful companies, running a non-profit, etc. YES, plenty of people use fibro as a trashcan diagnosis, and plenty of fibromyalgia folks are loafers, just like the rest of the population. but we're not ALL loafers. a few bad apples give the rest of us - who are busting our butts to be productive and fulfilled in spite of fibro - a bad name. despite the negative stereotype of the typical fibromyalgia patient, there are a ton of us out there who work hard to live the best we can, and we don't use the diagnosis as an excuse to take advantage of others. at least, i sure as hell don't.

    anyhoo. thanks for including chronicbabe, and for keeping the debate going. happy to discuss this with y'all and the online health community!

  8. dear chronicbabe,
    not arguing with you and indeed you seem to be really on top of your health, just saying that it's hard to see an individual in an actuarial table. why not take out catastrophic and start an HSA?

  9. I get it! You don't really think the posts at CM and CHII are satire - you just don't like what they have to say. So you pretend you're too stupid to take their posts at face value, and then link to Wikipedia because that totally proves you right.

    So let me pretend stupid for a bit: why, exactly, are you unable to take their posts seriously?

  10. oh i don't know DX, maybe because they are laughable on their face and i didn't know how else to take them?

    until reading CH i didn't know that bloggers were journalists, i have certainly never been tagged with that insult. also, until reading that i am 'all that and a bag of chips' (to the extent that my hard won knowledge and skill are therefore not economic commodities but more like gifts bestowed from on high) i had always understood that our most precious resources were most efficiently managed by market forces. silly me.

    those two posts must be satire, otherwise they are just silly and i gave them the benefit of the doubt.

  11. Not that you answered my question, but let me try two more: so you got into medicine for "economic" reasons? There was never a hint that maybe, just maybe, being a doctor had some kind of social obligation attached?

    If you can honestly answer those questions "yes", you need to revisit your decision to go into medicine. If not, you only need revisit your decision to blog. Either way, you're in the wrong business.

  12. if you want to argue instead of preach then let's argue DX.

    first, tell me how i didn't answer your questions?

    readers, did i give a rational answer to the initial question from DX whether or not you agree with my opinion?

    second, whose damned business is it why anyone does any profession? yours? why don't you go to med school, do a residency, then come talk to me. about why you did it. since you identify yourself as a conspicuous consumer of health care resources how is your post not extremely self serving? if there's questions regarding motivation to be lobbed then i think i'm lobbing from the mountain and you are deep in the valley.

    really, i have not seen anyone post here in a long time with such a high opinion of themselves. if you want to know why the doctors on this blog chose medicine then read on.

  13. Thanks for including me - although the link you included doesn't work.

    The post on Palin being hot, and how physicians respond to similar comments, is at:


    Martina Scholtens

  14. well dr drackman, florida v lsu, here's my take...

    i want florida to lose because i have heard the word 'tebow' more than any human would reasonably expect to hear it (excluding the tebow family of course).

    i want LSU to lose because they rarely do.

    i imagine that you want them both to lose and i wish it could be so.

  15. broken 'freshMD' link is fixed. please give it a click.

  16. dx

    you are a douchebag/homo. you, nor anyone else have a right to my labor, you socialist dicksmack. if i chose to provide you a service for free, that's called charity, and i don't mind doing it. but i don't have a social obligation to do so, you shithole.

  17. 911doc -

    1. You restated my premise. That's an answer, of sorts, I suppose. I'm underwhelmed.

    2. You're still missing the point of the post (at least, the one I think you're referring to): medicine has for centuries had social obligations attached. You'd have to be pretty naive to go into the profession unaware of those commitments, more so to ignore them once in. I don't think you're naive, but I do think it's easier for you to argue your self-interest if you pretend those traditions don't exist. You want to answer a question: what do those traditions mean to you?

    As for me, the reason I'm not a doctor is because I'd only be doing it for selfish reasons (can you even write your own Rxs?); that is, I recognize there's more to the profession than my own self-interest, and that this view is shared by many doctors, and certainly most patients, so I apply my talents elsewhere. (I'm not interested in your views on that aspect of my life, so I don't blog it.)

    On my own blog, I've pretty clear about my motivation: the question isn't what those motivations are, but whether they're expressed honestly or disingenuously. Here's my motivation: I want a health care system that is more fair, transparent, and accountable. The thing is, I actually do fine in the current system, so if it was only about my care, I would shut up - but it so happens that what's good for me is also good for millions of Americans less fortunate than me.

    I didn't choose my illness. You chose your profession. If you don't like the demands it makes of you, you can choose another.

  18. Well done and controversial - very refreshing. Thanks for including my post.

  19. Don't you just love it when non-physicians lecture physicians about their "social obligations"? Before I was a parent, I was an expert on child rearing. Before I became involved with EMS, I was an expert on how it should be done. Even now, I'm an expert on lots of things that I've never actually done, so chances are that I don't know what the %#^@ I'm talking about in those areas.

    Of course almost everyone going into medicine recognizes a social responsibility. I knew one guy in my med school class who was interested in the economics of medicine. He's now out of medicine after just 4 years of practice.

    You'd have to be an idiot to go into medicine for the "economic reasons". You can make 10 times the money with 1/2 the training in law or business (where no one expects anything for free...even public defenders are paid by the taxpayers). Every day, we take care of people who need our help with no regard to compensation, so how dare you lecture any of us on "social obligations".

    What physicians mind is the Federal Government and it's attendant bureaucrats mandating that we provide free care. It's not the legitimately needy people who come to my ER that I resent. It's the ones who believe that the ER is free for them and that the Federal Government pays us if the patient doesn't. It's the patients who think that I'm rich so they don't need to pay me for my knowledge and services. And, it's the ones who think I'm griping about my "social responsibility" when I decry the volume of uncompensated, non-emergency care that I'm expected to provide out of the goodness of my heart.

    The Government refuses to recognize uncompensated care for what it is...charity and a business loss. It's the involvement of Government in medicine that has caused many of our problems. If you haven't read this article, I encourage you to do so.

    I encourage drx to fulfill his societal obligations by working 2/5 of the year for free. That's what I do. That means that you'll start getting paid on May 26th of each year.

  20. Very interesting

  21. Great GR:

    Dx: Resorting to ad hom attacks against 911 does not prove your argument. erdoc85 makes a great point that puts it all in perspective.

    Then again, when people ask me why I went into medicine, I say "I lost a bet with God."

  22. I went into medicine for the same reason 90% of guys do(100%-the Homos)to pick up Chicks.

  23. erdoc85:

    Thanks for a substantive and helpful response. Just for the record, I know the ER is not free, and I do think you should be paid for your services. I don't think 911doc and I were talking about "charity care", but that would be the sort of thing that would have made his answers more robust. I'm not asking for charity - only that you recognize that medicine isn't like other businesses for some very good reasons.

    I understand your interactions with government have been unpleasant, and I can see how that would make you sympathetic to the Objective Standard's viewpoint (if you weren't already). I have to wonder if your interactions with insurance bureaucrats has been so much better, but in any case the problem with the OS is their fundamental assumption that just about anything government does is wrong. If you really want government out of medicine, be prepared to lose the licensure and certification monopolies that government enforces on your behalf. I happen to think these rules are at least somewhat helpful and necessary, but I think I'd be okay if government stopped enforcing them. You can have the same "rights" as auto mechanics and plumbers and nail salons - but you'll probably also get the same pay, privilege, and prestige, and most of all the competition.

    You want to get paid for your care. I want to be able to pay you for your care. We're not quite sides of a coin, but there's a lot of common ground here. Yet your colleagues seem to think that they can get paid (well) for their work, absent any mechanism to ensure that people like me have the ability to pay. Good luck to them! I think we can (and must) build a system that makes sure patients can pay so that doctors get paid. That might make me a "douchebag/homo" around here, but it's more or less common sense on the outside.

  24. Erdoc85 - one more thing: I more or less do work more than 2/5ths of my time free. I don't complain because I recognize this as intrinsic to the nature of my profession.

  25. dear dx,
    i have already chosen another. i am out of full time emergency medicine and searching for another career. so is schrodinger's cat. we are halfway through our careers. we trained 8 years after college to do it. we were motivated both by a desire to help people, a desire to do something unique, and a desire to do something which would pay us well. we are quitting because of a general attitude in american society which is just like yours.... like somehow what we do is 'too important to be left to the market'. that's just silly. it's too important to be left to the government.

    you want health care as a right? you may get it. you just may not have many doctors left when you do.


  26. Know what we called "Complex Regional Pain Syndrome" in residency?? CRP, pronounced just like its spelled K-R-A-P. And it used to be called RSD for "Reflex Sympathetic Dystrophy" or more accurately, "Really Seeking Demerol" quick hint, if they keep changing the name, probably not a real disease. Now excuse me, gotta go for Physical Therapy for my Mechanical Low Back Pain.

  27. one more thing DX... only 2/5 of your time for free? all of us here on this blog have you beat by at least one fifth. you are arguing with the wrong people. what's wrong with you anyway? only 2/5ths huh? greedy.

  28. You're taking an unnecessarily and deceivingly narrow view of the term "journalist."

    I think you'll agree with me that someone who publishes their writing -- blogger, journalist, whomever -- has at least a few minimum obligations to his or her readers, accuracy being perhaps the most important. Is that too much to ask? Unfortunately it seems so: 71% don't publish corrections, and 41% don't spend extra time verifying facts, according to the Journal of Medical Internet Research study.

    You'll notice I didn't write that bloggers should strive for objectivity in their writing. No need: most are writing subjectively and don't purport to be doing otherwise. But opinions should be based in fact. If not, they become meaningless.

  29. dear sam,

    i agree and disagree. perhaps we disagree on what blogs are and should be.

    i thought we already had research journals, medical reportage, and the like, all of which are, usually to an annoying extreme, extensively fact-checked and referenced.

    the reason i reacted as i did to the suggestion of the importation of 'journalistic ethics' into the medblogosphere is that the medblogosphere is a place where you can hear straight from me and nurses and paramedics and other health care providers what our jobs are actually like.

    to the extent a medblog purports to offer advice or treatment to its readers then i agree with you, but i don't think that's why doctors blog and if that's why they are blogging then they are opening themselves up for legal action should they offer bad or misleading advice.

    also, i find the notion of 'journalistic ethics' a bit absurd since it's hard to find a single media outlet today that reports the news without adding, in subtle and not-so-subtle ways, their interpretation of the news. this used to be called editorializing, but today it's 'journalism'.

    also, in an age of relativism, i wonder (and this is a completely different subject) who gets to define 'ethics' and what they are, exactly. in academia, for example, and in the highest office in the land, there is argument over what the word 'is' is. i say this partly to jab at our former President but mostly to lament the fact that without a moral foundation 'ethics' can be whatever you want it to be.


  30. The satirists will be happy to know that the One has decreed that healthcare is a RIGHT, not a responsibility.
    There is a democrat running for congress in my area - he's an ER doc. I'd love to ask him if he's willing to repeal EMTALA. But since I'm registered in an opposing party doubt he or his mignons would answer my question.
    Me thinks you got out in time 911.

  31. Grand Grand Rounds, guys! But, is Yosemite Sam the right mascot? I see you guys as more the Tasmanian Devils...


  32. Love your rantings...ummm I mean blogging !!!!

  33. interesting...very interesting

  34. Sorry I'm late to the party, but wanted to commend you for an excellent job and thank you for the links.
    Anyone that uses the "blood thirstiest, shoot-em firstiest, doggone worstiest hombre to ever drive a cattle train" as a grand rounds mascot is my kind of guy.

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