Monday, October 27, 2008


I haven't yet studied the theories of the etiology of somatization, but I'd like to put forth a few ideas of my own.

The term "somatic" simply means "of the body", so what I'm referring to are bodily symptoms that cannot be explained easily by bodily findings. "Psychosomatic" may be more accurate, as nearly all physical symptoms are actually "somatic"--only people with phantom limbs feel pain outside their bodies, for example. Somatoform disorders are those where mental disorders present largely as physical complaints. There are complex syndromes like somatization disorder that require multiple different types of complaints from pain to GI to neurologic, etc; conversion disorder, where neurologic findings don't make anatomical sense and don't have an organic basis that can be found; pain disorder, body dysmorphic disorder, hypochondriasis, and others.

There are people who don't necessarily fit these categories, but just have a lot of "somatic" complaints, especially pain. Patients with lipomas who complain of extreme pain, patients who have a ton of "allergies" to medications (like palpitations from a vaginal metronidazole preparation?), etc. I've seen a few men with small hydroceles/spermatoceles (no redness, no swelling, no pain on palpation during my exam) who complain of severe, disabling pain; a few women with small ovarian cysts, non-ruptured, who complain of the same. Some of these patients have a small physical finding that seems to bother them so much that they have constant pain and disability from a condition which should only rarely be painful. Is it anxiety? I'm not sure.

Sometimes, of course, there's an inciting trauma or injury that induces chronic pain or symptoms. Acute back pain has a pretty high chance of leading to chronic back pain. I've seen multiple patients who had car accidents and end up with years of pain afterward. Why is it that children break their bones all the time and only rarely end up in chronic pain, yet so many adults end up with unending pain?

Is it that having pain for too long leads to chronic pain? The body can become conditioned to things, so perhaps pain leads to more pain. Of course, pain is a poor example, though one of the most common, because pain is neurologically mediated. Other conditions, which have a lot of crossover between "physical" and "mental", such as irritable bowel syndrome, have some reliable clinical findings and may have more organic basis than was originally thought.

Is it possible that some of these syndromes have an organic basis? After all, if thoughts ultimately come from release of neurotransmitters and electrical pulses, then technically everything we think, feel, and do is "organic". The line is pretty hard to see.

Many of these conditions, even if they are ultimately found to have a neurologic basis, are still intimately tied in with psychiatric disorders. Multiple sclerosis patients often have comorbid depression, for example, and experience symptoms when under stress. In my very limited experience, many of these "hypersomatic" individuals, the ones who react badly to most medicine, the ones with chronic vague symptoms and normal physical exams (not the ones looking for drugs, either), often seem unhappy. My life sucks because of this knee pain. I can't work because my back pops because I was tackled at the age of 10. My marriage ended, but now I have 10/10 pain from a bruised finger. Some patients end up on disability, but still aren't happy and have symptoms. One man had vague symptoms every time he walked into his apartment--and then would come to the emergency room for a nosebleed which had stopped, nausea that didn't start until after leaving the apartment (but must be related), etc. He never found it strange that no one else got sick while inside his apartment, even when spending significant time there; he only knew that he felt extremely ill, with widely varying complaints, and his symptoms were not going to stop until he got a new apartment.

Is there a link between unhappiness and somatic complaints? Intuitively, I would say yes. I haven't looked up any data tonight, but I wonder how many happy people suffer from chronic pain or chronic complaints. Or if they have chronic pain, they attempt to go about their life, not spend all their days in the emergency room.

Of course, illness can make you unhappy, which can make your illness worse, and make you more unhappy. Perhaps the answer is just to sing "Don't Worry, Be Happy" all the time. Except that song really doesn't make ME very happy, but oh well.

Sunday, October 26, 2008

Hot Topic

My husband has watched all the political debates, while I only watched a few (and honestly, got bored within 20 minutes and kind of zoned out). It's surprising, though, that neither of us had heard about this until now.

I'm going to try to be politically correct, but I will express my opinion here: I am pro-choice. I do not like abortion. I do not like that there are some women who have multiple abortions because they cannot be bothered with birth control.

But neither do I like that so many women are so incredibly ignorant of their options or about sex in general. And I really don't like the idea of criminalizing a procedure which can actually be performed to save a woman's life.

John McCain has an opinion on this, apparently. He said in the third presidential debate that "health for the mother" has been stretched to mean "almost anything" by the pro-abortion movement in this country.

Is this true?

I not only believe that there are situations when abortion is clinically advised, but I have witnessed situations where a surgical abortion had to be performed for the health of the mother. I am making no statement about how often this occurs, and it is totally possible that this gets exaggerated by some in the pro-choice crowd. McCain may not be totally wrong there.

However, to just write off "health of the mother" as simply a "pro-abortion" tactic is to deny that this procedure exists for a reason.

I watched a woman have to undergo a surgical abortion because she had anhydramnios and a fever at 19 weeks gestation. It was a baby she and her husband really wanted, and she was devastated. To protect her health, wait, to protect her life, she needed the procedure. She had chorioamnionitis and the pregnancy was no longer viable without amniotic fluid. At 16 weeks, there was no way to try to save the fetus (which was not yet deceased), and she could not wait 2 months to viability. A horrible situation with a horrible solution, unfortunately.

Of course, being truly "pro-choice" means that had she chosen to refuse the procedure, we would have had to respect her wishes, even if it meant potential death from sepsis and hemorrhage. Some women would make this choice, and though I don't agree with it I understand why they would make it.

Am I exaggerating this case? No. I didn't make it up for the sake of making a point. Is this a rare case? I certainly hope so--I only saw this one. There are other scenarios where the mother's health would be placed in jeopardy by becoming pregnant, of course; renal failure is one, heart failure another, diabetes, etc. These cases all must be judged on a one-by-one basis between the woman and her doctor (and her partner, ideally). To make a sweeping statement that "all of these cases require abortion" is (to me) as ridiculous as saying "none of these cases could ever require abortion."

Of course, the best way to prevent abortion is to prevent unwanted pregnancy, or to prevent pregnancy in a woman who is at such high risk from becoming pregnant. Still, even wanted, planned pregnancies can have a terrible outcome. To mandate across the board that "health of the mother" doesn't matter (as by leaving it out of the partial-birth abortion ban) is to mandate at a legal level the choice some women are forced to make. Even if this is an extremely rare condition (and I think it is, although I do not have stats on this), it seems to me grossly unfair to have a law which makes the decision that a woman whose health is jeopardized and whose life may be in danger must not terminate her pregnancy.

And if Senator McCain thinks so little of the "health of the mother" then I think I know what side he will ultimately choose to vote for.

No comments on this post, please.

Saturday, October 25, 2008

Comment About Comments

I have rejected a few comments recently because they seemed like they were drug ads, or linked directly to drug company websites. Sorry if I rejected a legitimate comment, but I don't want ads (of any sort, drug or not) on this site, including in the comments.

Carry on.

Tuesday, October 21, 2008

Paying to Wait?

So, yes, it definitely sucks to wait 19 hours before seeing a doctor. Yes, broken legs hurt. Unfortunately, unless there is cardiovascular compromise, they're not an emergency to the same degree as that of a heart attack, stroke, major trauma, etc. Perhaps $136 is a bit steep to charge the patient, but then again, that helps cover the electronic kiosk where she checked in (equipment, software, and maintenance), the salary of the nurse who evaluated her, the chart that was generated for her (not sure if it was paper or EMR), and the upkeep of the lobby and clinic rooms. I don't know whether $136 is high, low, or appropriate.

Unfortunately, what do you expect in an emergency room that saw over 143,000 patients in 2005? ( And this patient, by declaring her intention not to pay, is just adding to the strain on large public hospitals like Parkland. Did she plan to pay for her xrays and cast?

Waiting 19 hours sucks. Not knowing how long you'll be waiting sucks, but is par for the course in the ER. If you say "20 minutes" or "2 hours" and then a massive MI comes in or a patient codes and takes up all the staff, then the waiting patient gets mad anyway. Lose-lose situation.

Just another example of our imploding healthcare system.

Addendum: an opposing viewpoint from The Happy Hospitalist.

Sunday, October 19, 2008

Magic Pills

I think it's interesting that, while it seems that many patients do not trust doctors, many seem to have absolute faith in what we prescribe. I could do the world's greatest ankle exam, according to the Ottawa Ankle Rules, and determine that it's a mild sprain and just needs an Ace wrap, but until we've given that therapeutic x-ray, many patients don't feel better. The Ottawa Rules are actually to determine who needs an x-ray, and they are very good at ruling out fracture. Yet, most people I've seen (observer bias) would much rather believe the x-ray than me. Then again, that could be wise, since I'm just the intern, but still.

I had a depressed, anxious patient who'd suffered a trauma in the past ask me about "the new medicine that will cure everything, you know, the one on TV. Why did my therapist tell me it would take years?" That one stopped me in my tracks. I'm not sure whether this is the fault of DTC advertising, poor education, denial, or all of the above, but that's an awful lot of faith in a medicine advertised by the people who make money off it.

I had a patient who requested an antibiotic by name for a sore throat. Said throat wasn't even red. Patient was a bit hoarse, and had post-nasal drip, so I made a diagnosis of allergies with post-nasal drip throat irritation and prescribed allergy medicine and over the counter throat spray or lozenges. "But why can't I take antibiotics?" "Because your throat isn't infected." "But it HURTS!" "Antibiotics aren't pain medicine. Use the spray at the store."

There seems to be something magic about that prescription, written on the pad. Writing ibuprofen 800 mg tabs is somehow so much more official than saying "take four Advil or Motrin from the store". Perhaps the reason the antibiotics relieve the pain more is simply because they're written on the prescription pad. After all, the expensive placebo is more effective than the cheap one.

Also, we want pills instead of other forms of medicine. Intranasal steroids sprays are front-line for chronic allergies, but don't seem (observer bias) to be very popular. I personally don't use mine as often as I should. Of course, nasal irrigation with saline is also extremely effective, but very few people do it (of those who even know about it). It's just not very sexy to run salt water through your nose (I did it tonight--I recommend pulling your hair back first), and much less messy to take a pill.

In some ways, I think we over-rely on medicine to cure what ails us. How many patients really try to get their cholesterol down with diet or their blood pressure down by cutting out salt? I think we need to re-think "preventative medicine". True prevention isn't about catching disease early by screening, it's about actually preventing disease. We're so focused on the pills that we forget that the best prevention means not to take any. Preventative medicine should actually be about encouraging exercise and healthy diet, but those aren't very sexy on a prescription pad. They're vital to preventing disease, but how much of our national healthcare budget is spent on exercise? We're doing better at smoking cessation, but of course, there are pills for that.

Preventative Medicine: A Way to Avoid Taking Pills. Will it catch on? I doubt it. We like our pills too much.

Saturday, October 18, 2008


Last month, I worked in a walk-in clinic off the emergency room/department (whatever). A "fast track" if you will, this is the clinic where the not-so-emergent patients get seen. If the chief complaint is "medication refill" or "back pain" or "tooth ache" or "suture removal", they get sent to this clinic. As always, this clinic is a victim of its own success: they take the pressure off the emergency room/department, which allows more patients to be seen, therefore more patients come to the emergency room/department for non-urgent complaints because this clinic exists. Lather, rinse, repeat.

I read several emergency room/department blogs, including WhiteCoat Rants, Ten Out of Ten, and Crass-Pollination, and while I hoped that they were all exaggerating, I had a suspicion they weren't. They're not. I occasionally saw people who really needed help, but more frequently (it seemed) I saw people whose whole existence seems to be about gaming the system for every free thing they can.

One person came in with a list of requests. Not complaints, but requests. He/she wanted pain medicine, refills of all other meds, a cane, free clothes, free food, dentures, and several other things which I can't even remember because the list was so long. I said no, okay, fine, no, no, referral. Since when is the emergency room/department a soup kitchen or the Salvation Army? And I wholeheartedly agree with today's post by Nurse K about the homeless "patient" with the bogus complaint. This same patient with the laundry list was homeless, but was currently NOT sleeping on the street, but instead staying with family. He/she also told me how many beers they drank in a day (the answer was a number >1). So, you have enough money to support your beer habit, but you get angry with me when I won't give you free clothes and insist that you go to a dental clinic to get dentures? Ugh.

Sometimes, it's a family affair. A brother and sister combo came in the other day, one asking for pain medication and a new cane as it had been "destroyed", the other asking for pain medication and a glucometer as it had been "destroyed". It was probably a little passive aggressive of me to document carefully in the chart that this was the patient's third cane in a year. Is there a black market for canes and glucometers?

I'll be totally honest. When I pick up a chart that says "tooth ache" or "back pain", I get put on my guard. I walk in, and make a split-second judgment. If the patient's face is swollen, or they're sitting all tense and not moving, I kind of relax. If they're all relaxed, and smiling as they tell me "doc, I'm doing TERRIBLE", and they have "10/10" pain from a skin rash, I get a little suspicious. One patient was sobbing hysterically when I came in, to the point I could hardly examine them because they wouldn't stop. "OH JESUS DOCTOR I'M HURTIN' DOC PLEASE HELP ME OH DOCTOR HELP ME!" I asked them to calm down, please calm down, TOLD them to calm down, but to no avail. I actually wrote on my physical exam "could not auscultate heart or lungs due to patient's crying". I looked in their mouth, and saw some brown teeth, but nothing red or swollen or infected, so I said "I'll give you the phone number for the dental clinic." "OH JESUS DOCTOR DON'T LET ME LEAVE WITHOUT PULLING MY TEETH OH DOCTOR THANK YOU DOCTOR I'M PRAYING FOR YOU DOCTOR!" This was also, coincidentally, a patient who had been seen previously, given the phone number they needed but failed to call, and somehow needed to call an ambulance to come to the emergency room for this pain.

WTF? So you can call an AMBULANCE for your tooth pain, just to sit in the ER/ED and complain to the nurse that we're wasting your Medicaid by sending you to a different clinic? Oh, the irony. I'm wasting your Medicaid, you're wasting my tax dollars with your ambulance call.

To those of you who may not know, here's a public service announcement: if your tooth is rotten, but not infected, no matter how much it hurts it's not a medical emergency. The emergency room doctors will NOT pull your tooth for free. Spread the word.

I'm being totally honest here because I'm not proud of this response in myself. Why do I feel like every chronic pain patient is scamming me? Why do I care? Seriously, what is it to me if these patients want pain medication? Why does it irritate me?

I could say it's that these patients are difficult, but really, only a few of these patients are actually nasty to me. Sure, it's hard to tell a patient "no" when they ask for Vicodin (by name and dose, and 'nothing else works'), but most of them accept my reasons and whatever I feel like I can give them (usually ibuprofen, sometimes tramadol). It's the few who get nasty who stick in my mind, though, and put my hackles up.

There's also the occasional patient who seems to "dupe" you into feeling sorry for them, or giving them pain medicine because their pain seems genuine, only to find out they were faking, or they start cursing you for taking too long reading their xray, or do something that makes you feel like a huge fool for believing them. This happens to me from time to time, because I really try to believe my patients. I keep trying to fight the cynicism, but it's hard.

A lot of it is in the environment. The attendings I worked with last month would say "Oh my god, another tooth pain? What a waste of time!" It's easy to spread irritation like that. In fact, it seems sometimes that it's easier to spread a bad mood than a good one...

Although not always. One patient had us all laughing hysterically with him (not at him). The attending came out and told me I HAD to go see this 80-year old guy's hand. I walked in, and his thumbnail was hanging off, dangling by a tiny piece of skin; he was totally nonchalant. "WHOA! I've never seen anything like that!" I said. "You've never seen anything like ME!" he said back. He also told us his only allergy was to "women" and that he was "a real tough guy." He was right. We all told his story for days to come, repeating it and laughing, tickled by this patient's attitude. So sometimes the good stories get passed around, too.

I just wish there were more of them, and less frustration. But still, why so much frustration? I haven't found the answer yet. I can totally understand some of the attitudes in the ER/ED blogs, though. There are some NASTY people out there.

Monday, October 13, 2008

A Radical Idea

I'm working on a post about the health care policies of both candidates, and a thought occurred to me. It all started while watching the second presidential debate the other night. I realized that both men were focused on access to health insurance, but neither fully realized that health insurance is not health care. Obama came near this point when referring to his mother fighting her health insurance company for a "pre-existing condition" in acknowledging that just having health insurance is only part of the battle, but did not encourage access to doctors, just to health insurance.

My thought was, why do we have health insurance?

I own a dog and a cat. I take them to a veterinary chain, where for $25-$50 per month per animal I pay for 2 full checkups per year, including blood work; annual dental work (and biannual for the kitty); required vaccines; and I get a free office visit + 10% discount on any further treatment they need. I can pay for a cheaper plan and get a little less, or a more expensive plan for a little more. I upgraded the dog a few years ago when he started needing dental cleanings, because it was cheaper and easier to pay for it over the course of a year than all up front.

Why don't we have similar plans? Why do we need large insurance companies to be our middle man? It seems like (to be overgeneralized) the insurance companies (and the drug companies, but that's a different story) are the only ones making lots of money here; they squeeze hospitals dry, they squeeze doctors dry, and they cut out coverage for patients with "pre-existing conditions" or for taking Drug X instead of Drug Y to dictate healthcare for their patients. Until insurance companies are run and staffed by doctors and other healthcare professionals, WHY do we let them dictate our care? Why do we have to argue on the phone with a glorified secretary* (who probably makes more $$ than this intern) about why we, the MD, ordered the MRI?

So why do we need health insurance? Or rather, why do we think health insurance has to pay for everything? Why don't we remember that "insurance" is something for a rainy day which we hope not to have to use, but we have it around just like the fire extinguisher under the sink? Since when have we become too cheap to take responsibility for our own bodies and our own health?

I realize that health care is expensive, and even visits to doctor's offices can be out of reach for some patients, but consider how much cheaper the system could be if we largely cut out the insurance companies. Doctors' office staffs could be smaller because they wouldn't spend all day on hold with Blue Cross Aetna UHC arguing over a $10 copay and begging them to cover a visit.

If we got rid of "managed care" entirely, and went to a system of high deductible "rainy day" policies for those people who were healthy, and got rid of the middle men so patients could negotiate care with their own doctor, health care prices would fall as competition evened out the playing field. Patients with chronic health problems or who needed more care would have to pay more under such a system (they do now, too), but even they could still negotiate with a doctor and then purchase insurance to help cover costs they couldn't afford.

Insurance companies get their $$ another way, too, by selling malpractice insurance to physicians, which may cost up to $250,000/year for some specialties. Putting caps on malpractice settlements may help, but does not solve the problem. Perhaps a solution other countries have tried may work: make the plaintiff pay for something if they lose. Or make the plaintiff pay a small court fee (a few hundred to a few thousand or so) in advance, to be refunded if they win. Or make the plaintiff's attorneys (another group making $$$ out of the healthcare pot) pay fines if they sue frivolously, or cover the defense's court costs for fighting the battle. Right now, plaintiffs and plaintiff's attorneys have nothing to lose by filing in court, where doctors have everything to lose just by getting named on the lawsuit. Oh, but what about the poor plaintiffs who can't afford to pay the court costs? Where does it say in our Bill of Rights that we are born with the right to sue?**

Obviously, this scenario leaves out a big player in this business: CMS. The rules would have to change dramatically for CMS, too, because they essentially dictate the amount physicians will be reimbursed for services, and then most insurance companies adjust their reimbursement rates based on Medicare's. I'm fresh out of ideas at the moment as to how to fix Medicare, but my main point is this: there are a lot of fingers in the healthcare pot. A lot of non-physicians are controlling healthcare dollars on behalf of patients, doctors, and hospitals, and currently very few players are winning. The ones who are winning are not the health care providers, the hospitals (at least, the non-profit ones), or the patients. So why are we letting all the wrong people benefit from our trillion dollar healthcare budget?

*I have nothing against secretaries. I am totally inept when it comes to those huge phones with the transfers and hold and multiple lines, gah!
**Lawsuits can occasionally be necessary or justified, including those against physicians and hospitals. I'm not opposed to all lawsuits, I'm opposed to irresponsible suing.
***Written when I was trying to go to sleep but couldn't. Sorry if it rambles or makes no sense.

Tuesday, October 07, 2008

Thoughts on Belief

"I think it's better to have ideas. You can change an idea. Changing a belief is trickier." -Dogma

I love that movie. It's so true.

As we prepare for the presidential debate tonight, I've been dusting off my long-standing, ever-evolving "Thoughts on Belief". I started really thinking about this during high school, when I was an evangelical Southern Baptist. I never really liked to proselytize, however. When I pondered why this made me uncomfortable, I eventually realized it was because if I was "witnessing" to someone, I was expecting them to listen to me and potentially change their mind to agree with me and whatever I was saying. However, I acknowledged that I wasn't willing to do the same. In other words, if I was preaching Christianity to a Buddhist, I wasn't necessarily willing to listen with an open mind to what they had to say back to me.

Out of this initial observation, I drew the conclusion that because I believed I was right, it was impossible for me to truly listen to another person's side and consider their (opposing) beliefs as if they were right. Thus, I could debate with them, and talk with them, and have exchange of ideas, but I would still leave convinced that my side was right, because I believed in it strongly. Only if I were able to suspend my own beliefs, or hold them less strongly, would I be able to truly listen to opposing beliefs.

Over the years, I've made many refinements to my initial theory (which, I admit is not original--I'm sure a philosopher probably reached similar conclusions 2000 years ago). Several corollaries emerged.

One: if I hold beliefs strongly, and someone else has starkly opposing beliefs that they hold strongly, and we debate, it is extremely easy to identify the person with their beliefs. You are no longer my friend A who happens to worship at X temple or vote for Y candidate, you are now an Xist or a Yican. If you identify the person with their beliefs, then the argument becomes intensely personal FAST. This is where a lot of internet chatroom nonsense happens, I think. I can't see you on the internet, so if you endorse a political theory I despise, and you think my theory is bunk, then suddenly we're calling each other Nazis and making comments about your mother's marital status when you were conceived.

Two: if I have a strong belief, and you present excellent evidence which directly contradicts my belief, I will make every excuse and rationalization possible against your evidence. It's one thing to argue for my side and present my own evidence, it's another to stand firmly by a belief despite TONS of evidence to the contrary. See the quote at the top. I'm emotionally invested in my belief, so your attack on it feels personal to me. I can't be wrong, because that feels bad, so I'll do everything I can to protect my belief.

Three: I think this is a normal human thought mechanism (forgive me my Freud-level hubris for applying my personal observations to ALL OF MANKIND). If I have opposing thoughts from you, then that implies that there is more than one way to think about that issue. I've made a decision, though, so I need to defend it in order to defend myself. For me to acknowledge that you are right, I have to change my mind, or continue to just be wrong (and who does that? Who says man, those Hindus have the right idea about God and the afterlife, so I'll just continue to be Muslim?) I'll go even farther and say that I think this is where a LOT of wars come about.

Four: I think this goes beyond just random beliefs and applies to things like choosing political candidates. As soon as we pick our candidate, the statements made by the opposing candidate seem completely ludicrous. How could they say that, are they retarded? we yell at the TV during a debate. What we don't usually think is that the opposing team is yelling the same thing at our candidate during that same debate. How many people wear a candidate's pin or sport their bumper sticker, yet will say openly and freely "Their ideas on such and such issue are really not so good" unless they then say "but the other guy's are even worse!"? I usually only hear such talk from people who are lukewarm, not the redhots.

I've never really put these thoughts into written form before, and so I apologize if they are rambling or completely unoriginal--it's just something I've been thinking about for years, including my philosopher days of college.

Now for a public service announcement: Go vote during this presidential election. Whether you vote Republican, Democrat, or third party, I don't care, just do it. I'm not sure if you can still register in some states or not, but if you can go do it.

And try to have a little tolerance for those who vote the other way. After all, whichever candidate wins November 4th, there will be close to half of the country's population who will be very disappointed.

Thursday, October 02, 2008

Healthcare Is Not a Right

Forgive me for just posting a link, but Shadowfax at Movin' Meat has written an amazing blog post which essentially summarizes my thoughts on universal healthcare, only MUCH better written and with a LOT more thought put into it than I usually do. Go check it out.

Oh, and I'll spoil the conclusion he makes: healthcare isn't a right, as we define rights, but an entitlement, and one we should probably extend to all citizens. It's okay if you disagree with this, but it's still a damn fine essay.