ACP Internist Blog


Friday, August 20, 2021

How do we reach herd immunity against COVID-19?

Last week I conjectured that the Center for Disease Control and Prevention (CDC) obfuscated when they recently recommended that vaccinated individuals resume indoor masking under certain circumstances. My speculation was that the policy was justified but that the CDC was not forthcoming in explaining the rationale for the policy revision.

The revised re-masking recommendation, as with every other aspect in this pandemic, has only further polarized a nation that seems to be trying very hard not to heal itself literally and politically. I predict that our collective political affliction will long outlast the coronavirus plague.

I routinely ask patients if they have received the COVID-19 vaccine. Recently, a patient replied that has not received one. I asked what his concerns were and he firmly responded that he would never get vaccinated against the coronavirus. Not much space for dialogue here.

The CDC and public health experts admit that masks are not the antidote. The shortest and surest pathway to the other side is for the unvaccinated to vax up. The government hasn't yet figured out a strategy of how to get this done.

Here are 3 options.

Educate the public so they will voluntarily accept the vaccine to protect themselves and rest of us. Highlight the rather incredible safety and efficacy statistics. Begging, pleading and downright bribing may be incorporated into this policy. This has been our current policy which thus far has failed rather spectacularly.

Mandate vaccinations for every eligible person, either immediately or when official Food and Drug Administration (FDA) approval for the vaccines is granted, which is anticipated in the near term. While you might be tempted to choose this option with zeal and enthusiasm, you may wish to consider what may follow the vaccination edict. One of the pandemic's lessons is that Americans, unlike many other countries, are individualists who are not swayed by serving the greater good. A mandate would fuel protests and refusals to succumb to governmental tyranny. Politicians and candidates would pander to this aggrieved group which might serve to elect and re-elect anti-vaxxer officials. The nation might end up being further divided and not much closer to herd immunity.

Discomfit the unvaccinated sufficiently such that the voluntarily accept the vaccine. If concert venues, airlines, restaurants, public transportation, hotels, employers and retail establishments increasing required proof of vaccination for entry, it might serve to induce vaccination compliance.

What have I left out here? What would you suggest? Give it a shot.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Wednesday, July 7, 2021

Transitioning to a new doctor as a challenge or opportunity

Over the past few weeks, several patients I saw faced a common challenge. This is a situation I have confronted in the past, but what was unique recently is that multiple patients in a short period of time were in the same situation.

This was not a medical issue. In fact, many of the individuals were feeling perfectly well. This was not a financial issue, such as the patients were in the dreaded insurance “doughnut” or their particular medications were not covered by their insurance companies. This was not a second opinion request from patients who suspected that their gastroenterologist (GI) of record may have missed something.

Here's what happened. A gastroenterology practice that had been in the community for decades closed down. Suddenly, tens of thousands of patients with an array of digestive maladies were let loose to find a new digestive nest to occupy. I'm sure that every GI within 20 miles of my office has been affected. Many of them have landed on my schedule and I expect this will continue over the weeks and months to come.

This is a challenge both for the patients and the new GI specialists. The patients I have seen all loved their prior GI some of whom were treated by their practice for decades. These were not dissatisfied patients who were seeking advice elsewhere. They were happy and satisfied where they were. And now they were forced to sit across from a new doctor—a perfect stranger—who faced the task of trying to lay out a pathway to a new relationship.

This isn't easy and both parties must contribute to the success of the effort. The physician must be mindful of how disruptive and anxious this process is for the patients and their families. Patients must recognize that the physician cannot be expected to quickly replicate a rapport that may have taken years to establish. Additionally, physicians, as individual human beings, cannot be expected to have similar personality trains and practice philosophy. Patients and physicians need to exhibit some understanding and flexibility as they both enter the new nest.

Change is always challenging and particularly so when it is unexpected. There may also be some unexpected upside. The new physician, who brings no bias to the case, may offer some fresh insights on some old and stubborn medical issues.

The doctor-patient relationship is the foundational unit of medical care. Like all relationships, it needs to be cultivated and nourished from time to time. Both sides need to give the other some space to maneuver and shift a position when necessary in order to make progress together. So, if life conspires to put you in front of a new doctor, consider it an opportunity rather than a challenge.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Monday, May 17, 2021

Is my new doctor qualified?

When one applies for a job or a position, it is expected that the interviewer will assess if the applicant has the necessary skill set and experience. Doesn't this make sense? Consider these examples.

A clarinetist applies for a position in a symphony orchestra. While many criteria will be assessed, he will surely need to audition to demonstrate his musicianship. Would he ever be hired without playing a note?

A college student wants to join the swim team. The applicant can expect to show off her speed and technique as she cuts across the pool. Would any coach accept a new swim team member without watching her swim?

A journalist for a town paper applies for a job at a large metropolitan newspaper. The interviewing editor will surely review the applicant's prior work product to gauge his competence and suitability for the new position. Would an editor bring on a new reporter without ever reviewing his writings?

A college graduates applies to the State Department as a translator. Would such a hire ever occur without determining if the applicant has the requisite language skills?

So how does the medical profession hire on new medical professionals? I should certainly know this since I've been in the trade for 3 decades and have had enough job interviews to know how the process works. I'll ask readers to peruse the following 5 sample gastroenterologist applicant questions. Can you spot the ones I was asked during my prior job interviews?

Which antibiotics do you typically prescribe for diverticulitis?

What is your age cutoff for offering screening colonoscopies?

What is your complication rate for colonoscopy and other medical procedures?

When is the right time to prescribe steroids in Crohn's disease?

Does a patient who is having a gallstone attack and a fever need to be hospitalized?

Which ones were I asked? None of the above. For reasons I cannot easily explain, I have never been asked any medical question during any prior job interview. Similarly, when I have interviewed job applicants myself, I have never queried them on any medical issue. The profession, at least in my experience, assumes that physician applicants have all of the necessary medical skills and knowledge, even though this does not seem to make much sense. Shouldn't the applicant at the very least be asked to review case histories of assorted patients and to comment? It seems it's a lot tougher to get a job as a clarinetist than as a gastroenterologist. Does this put your mind at ease?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Tuesday, April 20, 2021

Some thoughts on diagnostic reasoning

Yesterday I tweeted about our success in making some worthwhile diagnoses in the category of unusual presentations of common diseases. As I consider these successes, the principles of diagnostic aggressiveness become central to my thoughts.

For arguments sake let's imagine three types of diagnostic reasoning. The first occurs when there is no diagnosis but we know something is wrong. These patients generally require a broad differential and much clinical thought. We often go back and collect more history, repeat the physical exam and think broadly about labs and imaging. We often need several consultants and often biopsies.

The second version includes the majority of patients – a straightforward diagnosis. We need not spend much time on diagnosis unless the respond to treatment raises warnings that we might have the wrong diagnosis.

The third version involves patients whose presentation involves some subtleties. These are the patients who too often do not stimulate diagnostic curiosity. Yet, when we pay attention to the subtle clues, we often reopen the diagnostic process. The most fulfilling diagnoses that I and my teams have made occur in this latter category.

This fits an Osler quote, “The value of experience is not in seeing much, but in seeing wisely.” The astute diagnostician observes a lab, or physical finding, or imaging finding that does not fit the assumed diagnosis, and has courage to question that diagnosis. Sometimes the trigger finding does not yield a new diagnosis, but we still have the responsibility to wonder, think, and pursue another diagnostic possibility.

We have presented two such cases in our @unremarkablelab YouTube videos: https://t.co/EWwezNBhiE and – https://www.youtube.com/channel/UCVQ3Na5zXk5lpdUfPKhZ_Ew

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.