Exam Room Miscommunication

In school were you ever challenged to explain to someone how to make a peanut butter and jelly sandwich using words only? It’s harder than it sounds. Similarly it’s sometimes difficult to explain to a patient what I want them to do, at times to humorous effect. If you see yourself in any of the examples below, don’t take offense. I’m laughing with you, not at you!

As I bring an exam light up to check patient’s eyes, they often open their mouth, thinking I want to check their throat.

When checking guys for hernias I tell them to turn their head and cough. Men often turn their head to the left when I check their right side, then turn to the right when I check the left. The only purpose of having them turn their head is to not cough on me! Before doing this part of the exam I tell them to drop their drawers so I can check them for a hernia. I like to then slide forward the 2-3 feet on my stool, that has rollers, but guys often take a step towards me first, then I have to make sure I don’t butt heads when they naturally bend to drop their underwear. I also like to go to their right side so I don’t have to bend my wrist back, but in an attempt to be helpful, they often turn to the right to face me, so I have to slide farther to the side, thus doing a hernia check dance.

When I have people sit up on the exam table, they often start to lay down. I just want them to sit first since I like to examine their neck and listen to their lungs first. If not doing a full physical, I usually just pull up the shirt to listen to their lungs from the back side. When I then have them lay down, patients usually reflexively pull their shirt back down, but then I have to lift it back up to listen to their heart.

When patients have pain, such as in their abdomen, I’ll ask them to tell me if it hurts as I press in various areas. In an attempt to be helpful, patients off start pushing on their stomach themselves to try to find the tender areas, and sometimes will spend a fair amount of time doing so. I usually joke that they can examine themselves on their own time, but now it’s my turn.

American College of Physicians Internal Medicine 2012

I recently attended the American College of Physicians (ACP) Internal Medicine 2012 annual meeting, held this year in New Orleans. It’s a very large meeting with thousands of physicians attending. At any one time there are dozens of courses one can attend. I try to balance learning about subjects I have a particular interest in, with those that I’m less interested, and consequently have more to learn.

Among the talks I attended was a talk on genetics issues in internal medicine by Matthew Taylor, MD, PhD.  He discussed an interesting case of a 19-year-old woman who had been in good health who had lifted weights, used a hot tub then went swimming in a lap pool and was found unresponsive in 4 feet of water in 1998. She was resuscitated but died in the hospital 12 days later. An EKG done during the hospitalization was mildly abnormal with a prolonged QT interval. This was dismissed by most cardiologists as probably or not significant when asked to review the EKG. A subsequent genetic analysis of autopsy material revealed a genetic condition associated with a prolonged QT interval, which itself increases the risk of sudden death due to an arrhythmia. Further testing showed her sister, mother and maternal grandfather were found to have the same genetic condition. Most physicians would not even consider a genetic condition as the cause of a drowning, yet making the diagnosis may prevent family members from dying due to an arrhythmia with appropriate treatment.

I attended a talk by Holly Holmes, MD on discontinuing medications. It’s much easier to start a medicine than to stop one, yet medications carry financial costs and may cause side effects. She went over some cases and discussed strategies to decrease medication use. Amusingly she pointed out that not only did she not have any financial disclosures that might cause a conflict of interest, but that no pharmaceutical company would want to pay her to recommend stopping medications!

Besides the vast number of courses, there were also hundreds of vendors from pharmaceutical companies discussing new medications, companies selling books, equipment, massage chairs and gluten free products, and many just providing free information. There were recruiters looking for doctors, and more.

There was also the opportunity to interact with colleagues from around the world. I spoke with some physicians in Canada, and one from Saudi Arabia. I usually attend the ACP national meetings every few years and always come away having learning things that will help my patients, and feeling more invigorated about my profession.

Acid Revelations – Acid Reducers and Asthma in Children

The Journal of the Medical Association recently published an article about the use of lansoprazole (Prevacid) for children with poorly controlled asthma. It had been thought that gastoesophageal reflux disease (GERD) contributed to asthma exacerbations because acid would come up from the stomach and get into the lungs.

By putting tubes down the nose and into the stomach and esophagus it was known that children often have reflux when they have breathing problems, even without having heartburn symptoms. Proton pump inhibitors (PPI’s) such as lansoprazole, omeprazole (Prilosec), pantoprazole (Protonix) and others, markedly decrease the amount of acid produced in the stomach. Even if the contents reflux into the esophagus (think of an old fashioned coffee percolator), there would be less irritation if it was less acidic.

In adults with asthma and reflux symptoms, studies have shown the PPI’s help their lung function. Despite lack of conclusive studies showing benefits in children, its use in them markedly increased between 2000 and 2005. It made intuitive sense and the medications seemed pretty safe.

In this study children with poorly controlled asthma without gastroesophageal reflux (GER) symptoms not only did not do better with lansoprazole, they had more adverse events with increased respiratory infections. There were also six times as many activity related fractures in those on the medication. Although it didn’t quite reach statistical significance because of the relatively small numbers, the PPI’s are known to be associated with osteoporosis in adults.

This illustrates the important difference in statistics between association and causation. Just because two things occur together, doesn’t meant that one causes the other, and even so, it doesn’t mean treating one will treat the other. There is an old joke of a man walking around carrying an umbrella on a sunny day. “Why are you carrying an umbrella when it’s not raining,” asked his friend. “To keep the tigers away,” he replied. “But there are no tigers around here,” his friend objected. “See, it works,” he answered.

The accompanying JAMA editorial called the use of proton pump inhibitors for asthma a case of, “therapeutic creep.” That’s using medications beyond what the scientific evidence shows. This is not necessarily wrong. For example I commonly recommend vitamin D for my patients even though we still don’t have definitive evidence. In such cases, though, it’s good to remember the limits of what we know and beware of potential risks. As Hippocrates reportedly first said, Primum non nocere – First do no harm.

Even my dog’s veterinarian suggested using using over-the-counter Zantac or Pepcid for reflux because my dog sometimes threw up on the rug. Now I don’t feel so bad that I ignored her advice.

Fine Tuning

A typical internal medicine patient has multiple medical problems, such as diabetes, hypertension and high cholesterol. Each visit I try and see if there is something to tweak. Perhaps the blood pressure is a little high or the cholesterol is not at goal. Maybe I can switch a medication to a similar one that recently went generic, or use a combination pill to simplify their regimen. I might correct the vitamin D deficiency I usually find, have them change their aspirin to an enteric coated one to lessen the risk of an ulcer, or try and persuade them to get a vaccination to prevent shingles. Most of us have room to improve when it comes to diet and exercise.

With each visit the patient is a little older, and on average, a little sicker. I hope my fine tuning, and occasional overhaul, will keep them going longer and healthier. In the rare visit where the patient has no complaint and I can’t find something to do, I feel like I’m forgetting something. The visit takes longer than it should as I struggle to come up with something other than telling them keep up the good work. That’s usually appreciated by patients, though.

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