Primed and Pimped

(The essential part of rounding with medical students and interns) Pimping is an essential part of medical education that seems to be so often missed in our kinder and more gentle brand of medical education that seems to be the rage these days. Pimping is an art form that is slowly perfected over the years and is passed on as a write of passage. A Crucible of sorts that is very specialty specific and never forgotten by young doctors. Pimping consists of asking the ever studious medical students and half awake interns questions that are essentially unanswerable. Dr. Fred Brancati, M.D. in his immortal work "The Art of Pimping" explains that lawyers often call this Socratic education but really there is so much more. He writes that pimping inoculates the intern with profound and abiding respect for his attending physician while at the same time ridding the intern of needless self-esteem. Eventually, as the interns become residents they learn the art of pimping themselves and how to dodge and bluff the questions and become the pimpers themselves.

Here are some of the great pimp questions:

Where is Meckles Cave? (Fifth cranial nerve bundle prior to ducusation)

What is an Otis Elevator used for? (To go up and down floors)

Why are some organs paired? (Surgical answer is so you can cut one out)

What is a Hasselhoff? ( An emergency patient with bizarre explanation for their injury (David Hasselhoff's had a bizarre shaving accident in which he hit his head on a chandelier; the broken glass severed 4 tendons and an artery in his right arm)

What did Rudolf Valentino die of? (A perforated ulcer, his surgeons thought it was appendicitis when they saw imflamation in the right lower quadrant. The moral is check everything, not just the obvious.)

What is the first thing that you check on an x-ray? (The name of the patient)

What is the sensitivity and specificity of the cryptococcal csf antigen test? (the answer is not important, you just have to look frustrated when they dont answer.)

Do identical twins have identical finger prints? (No.)

What did Dr. Moniz win the Nobel Prize in medicine for? (The prefrontal lobotomy. Often asked when looking at trauma head cts.)

How much spit do we make in a day? (1 litre)

There are a bunch more. I'll try to remember more.

Non Secular Party

The children on our local public schools could not have a Christmas party this year. They could have a "Holiday Party" as long and there was no secular references. The school district stated that they were trying to avoid all the legal hassles that may arise from a "Christmas Party" do to discrimination lawsuits and suits based on the seperation of church and state. The superintendent also stated that he could just see the lawyers salivating hoping that he would allow the Chorale to sing "Silent Night". "The schools budget is tight and their is not room for more frivoulous lawsuits."


I think I know why attorneys are so fierce in their interpetation of the seperation of church and state.The last thing that they want is an outside reference to what is moral. Further, the Bible seems to call “a spade a spade”.

Luke 11:46 King James

“And he said, Woe unto you also, ye lawyers! for ye lade men with burdens grievous to be borne, and ye yourselves touch not the burdens with one of your fingers.”

Luke 11:52 King James

“Woe unto you, lawyers! for ye have taken away the key of knowledge: ye entered not in yourselves, and them that were entering in ye hindered.”

So, what the schools teach is determined by lawsuits, what the children do is regulated by lawsuits and what do the children learn? To file lawsuits.

Anemic MedMal Insurance

Bad news from the state meeting of the AMA. One of the arguments that our local trial bar has used to fight med mal reform is that the medical liability insurers were flush with cash and that high medmal insurance rates were due to greed and had nothing to do with frivoulous litigation. The insurance companies which are physican owned cooperatives countered that the surplus was do to strongly perfoming investments and that the surplus was needed secondary to the increasing cost of litigation. Well, the bottom has dropped out of the market. As a result, the surplus is projected to be gone. The rate of litigation is also expected to increase. So, guess what? It looks like we are getting an across the board rate increase.

I checked into what I could do to decrease the cost of my medmal. First, I could stop teaching. It seems that educating medical students, interns and residents puts you at higher risk. Oh, big discount if you dont supervise ARNPs or PAs. Stop doing any procedures. Move to purely office based practice and not have to cover an ER. Go to work for the VA fulltime. The last big one was to swith to a different specialty. (or to another career)

2:1 (JD:MD)

I came across some amazing statistics. Last year the American Bar Association reported that US law schools graduated 40,000 new attorneys. In the same year, the number of graduating physicians from US medical schools remained the same at 16,000. This means for every new doctor there are over 2 new lawyers. 70% percent of the world's attorneys practice in the US but we have only 5% of the worlds population. There are 1,130,000 practicing attorneys in the United States in 2008 and 805,000 MDs, 24% of the MDs are foreign graduates. (The good news is that several new medical schools are opening up and it is hoped that we will be able to increase the number of US med school grads to 20,000/year within the next 8 years. There are over twice as many new law schools opening up!.) 36% of House of Representativess and 53% of the Senate are trial lawyers. 25 presidents were attorneys. Less than 1% of the House and Senate are physicians. Physicians have almost twice the suicide rate of the general population.

Scary stuff!

One Good Deed equals one Good Lawsuit

In California, four coworkers were driving home and ended up in a bad accident. One of the cowokers pulled another from the car fearing that she would be burned when the car exploded. The woman that was saved has paraplegia from the accident but has chosed to sue the person who pulled her from the car. The California Supreme Court is letting the suit go forward. The plaintiff claims that even though she had a broken neck from the accident, it is the person who removed her from the car that caused the paralysis. (I can only imagine the chase for who has the big pockets)

This case is sending waves throughout the medical community and the people in California. There is nothing like the threat of a lawsuit to further push people away from helping in a crisis. In medicine where fear of lawsuits is the norm, there is great confusion about what the "Good Samaritan Laws" actually mean. Most of my collegues are afraid to stop at the scene of an accident and render aid for fear of being sued. The Good Samaritan Law is supposed to prevent this fear of suits but no one seems to believe that it will offer any protection. I have tried to find cases where physicians and nurses have been sued for helping at accidents or sporting events and so far have not found them. Not that they haven't occured. When I ask other physicians, everyone seems to have heard of a doc being sued but nobody has any first hand experience. I personally always try to stop and help and for the most part there is not much that I can do except hold pressure and wait for EMS but I have had to help them intubate and performed CPR.

I think it is sad enough that people would rather go their own way and not help in an emergency without the courts now opening the door to suing those that are trying to save your life.

As Clear as the Colostomy Club's Swimming Pool

(Health Insurance companies pre-certification processes) We had a patient that no matter what we could not get an MRI pre-certified. If this is not done the insurance will not pay and the patient will get the full bill. Trying to stay up on all the latest hoops that the insurance companies want before they will approve a test is almost impossible. We try to get some kind of protocol but of course they will not release it. So, you can only find out by trying. If you do get something in writing from them it is about as clear and the colostomy club's swimming pool. This is usually how it works. If we order a MRI, our team has to call the insurance company, then fax the clinic notes. A person at the insurance company who has no medical training then looks the notes over and checks to see if the right words are there and if there is the correct previous tests and then checks her protocol to see if it can be approved. (the protocol is not to be distributed outside of the insurance company). They then automatically deny the request unless it is 100% within their protocol. This is becuase they make sure the responsibility of getting the test approved is on the physician, not the patient. (If you make it hard to get a test, the office will not order them. Keep the hassle away from the patient so they think they have great insurance.) So, we get the denial and then have to talk to someone else to find out what else they need. They also have no medical training, This goes nowhere becuase you cant explain to them that the test is needed because you think the patient has a brain AVM and might stroke out. All they say is that if we think the patient really needs the test they should get it done and pay out of their pocket or go to the ER. Finally, in the battle you get a manager who will let you talk to the medical person who has authority to approve the test. This will always have to be scheduled at a later date to make it as inconvient as possible. (Another trick to see if yo will just drop it.) This is supposed to be a peer to peer, but the person you talk to usually has no clue what you are talking about. (The classic was a retired OB and I had to talk to him about a tumor of the skull base!) Finally, the insurance company will pre-cert the test. This whole process took one of our office staff three hours and me 30 minutes on the phone. All this for one test!

All I want for Christmas is a Hysterectomy

The hospitals are busting at their seams right now. The insurance companies business model is in full effect. Health insurers know that people will defer getting elective procedures done until their deductable is met. They also make sure that the deductables follow the calander year because most people take time off in December over the holidays and the hospitals and health providers will try to take time off as well so people will have a hard time getting things done. So, what happens? People generally meet their deductable about the end of November and then want all the medical care and procedures they can before the end of the year so that they don't have to pay another deductable. As a result, there is a huge rush at the hospitals. It seems that "all I want for Christmas" is that hysterectomy that I have been putting off, or hernia, or knee replacement, etc. It is amazing. The OR volume from Thanksgiving to New Years doubles! The hospitals are at limited staff because the staff wants to have time off or their elective surgeries as well! One good thing though, the insurace companies give their staff extra time off during this time of year so that all these elective procedures can not get pre-certified and they can still stick the patients with added expenses.

Shocking Situation

An ER doc friend of mine told me this story that happened a few weeks ago. He had a patient come in to the ER complaining that he had one of those "bad pacemakers" that he had heard so much of on those lawyer commercials. In fact he had even called the 1-800 number to report his problem. He had been on the phone for several hours and that was why he didn't come right in. His problem was that every few minutes he was getting a shock. At first the shocks were really strong but now they were relatively weak. He explained that the attorney site said that there was a problem with the wires in the device and he may be able to participate in their lawsuit. I guess telling him to go to the ER was not part of their sales pitch. The patient didn't think that there could be anything wrong with his heart because the commercials all said that the pacemakers were defective so he stayed on the line and gave them all the information he had. Name, address, he even read them the information on his medic ID bracelet and the card that he carried that identified the "Automatic Implanted Defibrillator" that he in his chest, including the company and model number.

The first thing the ER did of course was hook him up to the monitors while he went on an on about what the attorney had said and sure enough his "pacemaker" was shocking him. He was having runs of vtach and the pacer was actually a defibrillator and was keeping him alive! He was so busy talking about his possible lawsuit that he didn't mention that he had been feeling really bad and passing out. He also didn't mention that he had gained some weight and since it must be water had increased his lasix dose. His "defective pacemaker" stopped shocking him when his potassium was corrected.

Somehow, I get the feeling that he will still try to sue.

Blister pack panic

OSHA and JACHO have conspired again to hinder the care of patients in the name of more bureaucratic meddling. When a trauma patient comes in, the first thing everyone does is put on goves and a gown. As the patient is getting his primary survey at least one large bore IV goes in to help get meds, fluid blood etc. Here is the problem. It was hard enough to get the old IV catheters out of the plastic bubble wrap they were in. They had a little part that you could peel off but with gloves on it was impossible. So you just twisted the whole thing and the catheter would pop out. But that little bit of sabotage was not enough. We now have to use these special pre-bubble wrapped packs that has a latex free touriquet, aseptic swab stick, guaze, and finally the catheter. Not only is the whole thing in blister wrap, but each component is seperately blister wraped. There is no way you can open these things with gloves on. So, now you have to make sure that you tie up a whole person whose sole job is to open the stuff instead of helping the patient. This is in addition to the other person whose sole job is to stand there and document. They are documenting that you used the JACHO and OSHA approved IV start kit of course.

Half time = Half trained

The kinder and more gentle days of residency are upon us. Residents are limited to 80 hours a week. This is a big change. The term resident came from the fact that doctors in training resided in the hospital. You litterally ate, breathed and lived medicine. This was the way to cram as much training and experience as possible into the years you spent after medical school. Residencies got longer and longer as there was more to know. In surgery, the saying was that if you were on call every other night, you missed half the cases and had half the experience. This came from the fact that the days were filled with the routine cases but the emergencies that came in while on call prepared you to handle anything. Now we have surgery residents checking out like they work in a factory. "I reached my limit and its time to go!" In many cases the hour limits have decreased the experience by a third to a half.

Here is one of the problems. Is a surgeon who has only 2/3 of the experience handling emergencies as good as one who has done more? Should we increase the length of residencies? Surgery is already 5 to 7 years. Neurosurgery can be 7. This does not count fellowships. All this is after 4 years of college and 4 of medical school.

Was I tired in residency? You bet, I learned to catnap, eat standing and to follow the rules of "The House of God". See a bed, lay in it. See food, eat it. See a chair, sit in it. When I finished residency it was better but I still had the long hours because I was supervising residents.

Here is another thing. Out of residency, you cant have your beeper go off and tell the ER that "no, I cant help with that emergency, I have already worked my hours." "Sorry that the baby has decels and a c-section is needed, Ive reached 80." Residency prepares you for what its like in the real word. There are no work hour restrictions in the real world.

I tried to expain our work ethic to a friend who is an attorney and explained that you go home when the work is done and get called in when there is more work to do. We base things on the job to do. You go home when the patients are stable. He didn't understand, he gets paid by the billable hours, the longer something takes, the more money he makes. It is to his advantage to drag things on as long as possible. He can go home anytime he wants. It not like people are dying!

Acute Thespian Syndrome

(The sudden need to fake an illness.) In medicine we learn to ask questions and to believe the answers. Even when things don't seem to make sense, we error more on believing the patients. The problem are those patients with Acute Thesbian Syndrome. These are those wonderful citizens who are on their way to jail who sudden have chest pain, or mind splitting headaches with neck stiffness, or the classic sudden abdominal pain. My favorite was the women who claimed that she was in premature labor (fat dont make you pregnant). Their goal is that the police will bring them to the hospital, and leave them there instead of pressing charges. The police will often do this so that they dont get stuck with the bill or for minor offenses they just cite the person and hope that they will show up in court. The patients know that there will be tests ordered and as long as they keep complaining the work up will continue until the police lose interest. The "patient" then suddenly gets better and then is discharged or leaves AMA. It is amazing how good patients can fake chest pain after watching "ER"! This weekend was no exception. We had several cases of ATS. The good ones know to complain of severe pain in the hardest areas to evaluate such as deep in the pelvis or abdomen. Several were in with severe kidney pain from stones. We have to have several people watch them pee into a cup to keep them from picking a scab and dripping blood into it. They not only wanted the police to leave them but were hoping for some narcs. One patient with ATS this weekend had severe vomiting. We were lucky that the radilogy tech saw him taking ipecac when he went behind the screen to set up the abdominal film.

Acute Thesbian Syndrome is also a good way to get out of jail or prison for a few days and enjoy cable and the presence of nurses of the opposite sex. The prisoners know that the best way to do this and to help their cause is to fake a psychiatric illness. They parlay this into getting out of jail for a time and then use it as an excuse for their criminal behavior in future parole hearings. We catch them with our "patient safety cameras" in sudden lapses of normality.

I wish we could be like those stores that have signs and lists that say "We do not take checks from these people". Ours could be "We do not take chest pain from these people!"