Reading Roald Dahl out loud should be required to decline MMR vax

The current calls for childhood vaccination can’t be overemphasized. Another great one by @DrJenGunter….

Dr. Jen Gunter

The impact of not vaccinating children based on “personal beliefs” (i.e. science denialism) has come home to roost. The measles outbreak is growing exponentially due to the large numbers of unvaccinated people coupled with the extreme contagious nature of the disease. It can live on surfaces for 2 hours and a lot of people can ride Peter Pan in that time frame (never mind the crammed line).

One of the main battle cries of anti-vaccine doctors and their acolytes is that the measles is no big deal, but they are wrong. Here’s the thing, medicine doesn’t invest time and effort in things that are no big deal. Prior to the measles vaccine 48,000 people were hospitalized annually in the United States and 450 died.

Let’s put the severity of 450 deaths a year in perspective. Over nine years 32 children died from drop side cribs, that’s 3-4 a…

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Refusing the MMR vaccine or personalizing a vaccine schedule isn’t thoughtful it’s the opposite

With the expanding numbers of #measles cases we are witnessing a #PublicHealth emergency in slow motion…… Great commentary from Dr. Jen Gunter.

Dr. Jen Gunter

The measles outbreak from Disneyland is a potent reminder of A) how infectious measles actually is and B) what happens when people don’t vaccinate.

However, despite a mountain of evidence that vaccination is safe and does not cause autism or immune dysfunction or really anything terrible at all people still refuse. I live in a county which is on the leading edge of this scientific ignorance, but we are not alone in Marin as there are several “very special” Bay Area counties when it comes to vaccines. Personal exemptions appeal to people here. After all, vaccines might be fine for your children, *sniff,* but mine are special. That people in these counties likely hold more post-graduate degrees per capita than elsewhere even makes it worse because the science that proves vaccine safety is not challenging. So it can’t be about the science, unless of course all the “research” came from…

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Palliative Care and the Lost Art of Communication

Looking at death and dying from a medical perspective would not be complete without a discussion involving the roles and value of Palliative Medicine.

markmdmph

The following is Part 2 in a series about end-of-life care. For Part 1, see here. This article addresses my own experience on a Palliative Medicine elective in my fourth year of medical school.

Despite the growing number of U.S. hospitals with Palliative Care teams, there remains a real lack of understanding about the benefit that specialized Palliative Care providers can bring for patients with advanced illness. This form of care is especially valuable in patients with end-stage illness (and has even been shown to extend life by several months), but it can also help any patient at any stage of illness (regardless of prognosis). Indeed, even prescribing an NSAID for headache can be considered a form of palliation. The focus is about improving quality of life now instead of later.

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Medical Students Don’t Learn About Death

Great perspective on a process that generates so many conflicting emotions in physicians.

markmdmph

The following is part 1 in a series about death and dying in the medical context. This reflection was written by me earlier this year, before I sought out a Palliative Medicine elective. Part 2 will follow soon.

death_and_dying-300x239

Until the last week of my sub-internship, I had never had a patient die on my watch. To be sure, I had patients on the cusp of dying – and some who did die, of course, when I was already on another rotation. I have been around dying patients who were on our team but were being taken care of by the other resident/medical student. But never a patient of my own, until my final year of medical school.

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Is Giving Surgery Videos to Patients Prudent?

This week I was asked whether it is prudent to give patients videos of their surgery in digital format to promote transparency. My knee-jerk reaction was of course it is; how can giving patients access to details of their health care not lead to greater transparency?  Having video of a procedure an individual has undergone augments the detail of the written operative report.  There is no better example of images being worth thousands of words.

While thinking about this I consulted the opinions of leaders in the field. One of the leading proponents of promoting transparency in this manner is Martin Makary, MD, MPH.  Dr. Makary is an academic surgeon, author, a pioneer of minimally invasive procedures and a proponent of patient safety – a man after my own heart.  He rightfully believes that transparency aids in educating patients, enhances the completeness of their electronic medical records and improves their satisfaction.  But this is the 30,000 foot view; there is a lot more intricacy when you get down in the weeds.

Although I am a strong proponent of transparency, simply giving patients a video of their surgery on a thumb drive does not achieve this. Transparency not only requires access to information but also an understanding of the information. A video of procedures performed may not be comprehensible to all patients.  In my community patients are critical thinkers and ask questions.  This is not unique, many in the 21st century are savvy health care consumers.  If they do not understand something they will ask you about it.  This critical thinking would undoubtedly result in many questions relating to surgical videos.  In addition, there may be images or sequences that would be disturbing to many because of a lack of explanation or context when independently viewing a video. We will not have increased patient satisfaction if patients are incompletely informed, confused, or disturbed.

This scenario immediately brings with it a spate of questions. If explanation and context are to be provided to patients who provides it?  A logical answer is the surgeon or a member of the surgical team who performed the procedure(s).  What part of the provider’s schedule should be devoted to these explanations?  From where do we take this (substantial) time? How do we weigh the relative benefits of taking time to explain surgical videos versus using that time to increase access and see more patients in clinic?  Is the time the surgeon spends to go over videos with patients compensated?  If so, by whom – the patient, health insurance or some other party?

Additional questions arise: How are videos of extremely long procedures handled? Is it ethical to edit out portions of patient procedure videos? What is done in cases of patients who do not have the intellectual capacity to fully understand the explanation and the context of what is going on in procedural videos? How do we handle the emotional aspects of the videos?  Is any aspect of the surgeon’s technique proprietary? These and other issues would also need to be addressed.

After careful consideration I do not think dispensing patients videos of their surgeries should be universal (or even widespread) policy at least until we account for some of the foreseeable consequences. What do you think?  I look forward to hearing your thoughts on this subject.

Orthopedic Care for the Homeless

The Brigham Foot & Ankle Center (BFAC) returned to the Pine Street Inn on 19 Nov 2014 to give foot & ankle care as well as socks and shoes to many of the homeless in Boston. This was our fifth consecutive year that we were at the shelter.  The number of people we help continues to expand every year. This year we dispensed over 100 pairs of new shoes and provided about the same number of pairs of moisture wicking thick pile socks socks to the homeless.

High level orthopedic foot and ankle care was provided by Christopher Chiodo, MD,  Jeremy Smith, MD, myself and our fellow Brandon Hayes, MD.  Our physician assistants Shari Vigneau, Samantha Noonan and Adrienne Bonvini not only helped with clinical care but also deserve a huge thank you as they provided the logistical support to carry this event off.  Joe Hartigan, DPM also lent his expertise.  The services we provided consisted of examinations, small soft tissue procedures, nail care and advice on daily foot care and cleaning.

BFAC has made this an annual event to assure Boston’s homeless population benefits from the national Our Hearts to Your Soles program.  Despite generous donations from our sponsors, who provided shoes and funds for socks, we still are not able to get all the clients who desire them season-appropriate footwear. One of my goals for next year is to get surplus boots from government contract manufacturers so that proper winter-weather shoe gear is available.  Please consider contributing at the site below so that we can continue and expand our efforts to provide this valuable service to the homeless.

The Pine Street Inn is one of the largest shelters for the homeless in the city of Boston. They provide a full line of services for the homeless including daily meals, emergency sheltering, job training & placement and social enterprise.

Please support BFAC Program!  http://giving.brighamandwomens.org/orthopaedic

Patients should not be hamburgers but rather petite filet mignons!

Four days ago Joel Cooper, DO (@joelrcooper) published a blog post titled “Patients: accept your fate as a hamburger”. In it he describes clinical medicine as becoming more and more like a fast food restaurant. As reimbursement for healthcare services continues to decrease providers must see increasing numbers of patients to maintain the bottom line. Given that most providers do not substantially increase the duration of their office hours this means that they must see more patients per hour. As a result, each patient gets less time per office visit.  If Dr. Cooper’s perspective were accurate, at some point health care providers would have to “generate business” by creating patient visits that were not medically necessary to keep their schedules full.  This bleak scenario is not reality.  In actuality, many of us see increased numbers of patients per day to maintain access to care without having “next available” appointments months in the future.

He is right that we no longer see patients as we were taught in medical school.  This entailed sitting down with them for 40 minutes or more while eliciting and recording all components of the patient history, performing a complete physical, obtaining laboratory and radiologic studies as well as finally instituting a plan of care.  Technology has helped the patient encounter evolve. We now obtain and integrate much of this information into their medical record before we even walk into the examination room.  A concentrated digest of pertinent clinical history is available as a part of the electronic medical record. We are able to glean a significant profile of the patient before meeting them. This is not only efficient for the provider but also for the patient who no longer needs to spend a sizable chunk of time with the doctor for each new practice in which they are seen.  Size is not the most important factor. Even in the “good old days” a doctor frequently could get a better perspective of the patient with multiple shorter visits rather than one long visit – the same applies today.

Overall, I don’t think the absolute duration of the encounter is as important as the quality of the time spent with the patient. We can and do make proper diagnoses and provide excellent treatment during shorter patient visits.  Most patients don’t mind that the doctor only spends 15 minutes with them as long as a genuine connection is made, understanding of their problem is shown and quality care is provided.   Efficient care does not have to treat patients as fast food hamburgers; if done well, each patient can be a petite filet mignon.