Several weeks ago, I was running late to my afternoon clinic. Literally, I could not move my feet fast enough. Reminiscent of 1990’s childhood computer games, my Oregon Trail tempo was somewhere between strenuous and grueling. Lunch in hand, I slid into clinic just as the nurse was readying the chart of my first patient. I stuffed my lunch into the desk drawer, read the name off the chart, and called him into my room. The encounter proceeded as usual. I sauntered through the patient’s complaints with ease until we came to the subject of his diet – something I attempt to discuss with every patient. As I broached the subject with an inquiry into the quantity of fruits and vegetables he ate, I was rebuffed.

“How many fruits and vegetables do you eat? Doctors have the worst diets!”

I bristled and was surprised that my patient had kept the pulse of my profession’s dietary discretions. This was the first time the proverbial (dining) table had been turned on me. And for good reason, my lunch, quietly ensconced in the desk drawer, was a personal pizza. Adorned with cheese and overflowing with fat, calories, and cholesterol. So delicious yet so un-doctor like. Never did I regret purchasing a pizza more than that day – and I hadn’t even eaten it yet. Unsure if I was sensing a poor coping mechanism or he smelled my pizza, I brandished my defense: I eat lots of fruits and vegetables as a vegetarian (but I may eat a pizza “once in a while”). Of course, I could have invoked that pizza is a vegetable, like Congress did back in 2011, but I didn’t want to entangle myself further¹. Also, I didn’t dare reveal my pizza tucked away lest losing all credibility.

Straddling hypocrisy and Hippocrates, I counselled appropriately. The counselling, coming from my mouth, went into his ears. And mine. 69% of American adults are overweight or obese². Physicians – who by default are adults unless you are Doogie Howser- are not far behind, trailing at a rate of 44% according to the Physicians Health Study³. And these numbers don’t take into account those of us who are “skinny fat,” like myself. My BMI is 23.9, but it used to be lower. Since starting college, I have gained nearly 15 pounds – half of which occurred during medical school and residency. In a study of military residents, the nascent physicians gained an average of 4 pounds, and that’s despite all the pushups they were doing⁴. Although I can readily hide my adiposity with a loosely tucked shirt, I know I am overweight for me. And I have gained more than G.I. Joe, PGY-3.

Whatever pressures that led me to gain weight probably won’t go away when I get out of residency or fellowship. And my specialty (internal medicine) is not alone. Being overweight or obese affects all specialties. According to Medscape’s Physician Lifestyle Report of 2014, general surgeons have the highest rates of being overweight or obese – approaching 50%⁵. Family practitioners are a close second. Dermatologists come last overall. Even among internal medicine subspecialties, gastroenterologists are the heaviest and allergists the lightest.

Things get really interesting when we start looking at how other physicians’ own health and habits affect patient interaction. We don’t judge a book by its cover, but patients judge their physician by his or her size. In one study, patients reported more mistrust of physicians who were overweight or obese, were less inclined to follow their medical advice, and were more likely to change providers if the physicians was overweight or obese⁶! Before judging our patients for their insensitivity, we should pause. Wouldn’t we instinctively distrust a broke financial advisor despite a litany of credentials?

As much as we would like to keep our personal and professional lives separate, they might be more intertwined than we think. Obese and overweight physicians are less likely to engage in conversations about lifestyle and are less likely to value the importance of physicians being “role models by maintaining [a] healthy weight” and by “exercising regularly⁷.” Obese or overweight physicians may not bring up these issues because their patients, as has been shown, may not take them credibly.

Since Wells et al. published their landmark findings in JAMA in 1984, we also know that physicians who live healthier lives (regardless of their BMI), counsel more frequently and more aggressively⁸. This has been confirmed repeatedly, and has even been shown in medical students^9,10. Exercising and eating right not only have salutatory effects for yourself but inform the lifestyle narrative you provide to your patients. Understanding how important and difficult these changes are is just as important as the counselling itself. Saying what has worked for you individually – and not as a physician – ironically establishes a closer relationship with patients and provides more meaningful advice than tactlessly saying, “You are fat!” which I have seen other physicians do when I was a medical student.

Passing judgement is taboo. We are vulnerable to same pitfalls, tastes, and blithe overeating as our patients, if not more. Doctors, like patients, make nearly 200 food decisions daily. We are part of a profession that is fraught with pizza-plated, educational lunches and chocolate mousse-musts at dinner meetings. In the September 2012 issue of JAMA, Lesser et al. likened the universality of our poor dietary choices in medicine to smoking amongst physicians decades ago¹¹. The parallels to smoking continue. If you are to broach the subject of weight loss or lifestyle change, the Five “A’s” – Ask, Advise, Assess, Assist, and Arrange – should serve as a guide¹². They worked for smoking and they can work for eating and exercising. Doctors who regularly advise patients to be healthier had increases in motivation and confidence to change. Doctors, like patients, make nearly 200 food decisions daily¹³.

What works for us will likely work for our patients. For me, I watch calorie contents, eat whole foods (like fruits and vegetables and not processed foods), eschew meat, exercise (nearly) everyday, and make my own meals. I don’t lie about my habits but do tell them my goals. I tell my patients to make incremental changes that are realistic for themselves and to set their own goals. And, I also try not to bring pizza to the clinic, even if it is hidden in the desk drawer.

References:

1. http://www.foodpolitic.com/how-pizza-became-a-vegetable/
2. http://www.cdc.gov/nchs/fastats/obesity-overweight.htm
3. Ajani, Umed A., et al. “Body mass index and mortality among US male physicians.” Annals of epidemiology10 (2004): 731-739.
4. Arora, Rajiv, Christopher Lettieri, and John R. Claybaugh. “The effects of residency on physical fitness among military physicians.” Military medicine7 (2004): 522.
5. http://www.medscape.com/features/slideshow/lifestyle/2014/public/overview#2
6. Puhl, R. M., et al. “The effect of physicians’ body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice.” International Journal of Obesity11 (2013): 1415-1421.
7. Bleich, Sara N., et al. “Impact of physician BMI on obesity care and beliefs.” Obesity5 (2012): 999-1005.
8. Wells, Kenneth B., et al. “Do physicians preach what they practice?: A study of physicians’ health habits and counseling practices.” Jama20 (1984): 2846-2848.
9. Lobelo, Felipe, John Duperly, and Erica Frank. “Physical activity habits of doctors and medical students influence their counselling practices.” British journal of sports medicine2 (2009): 89-92.
10. Abramson, Scott, et al. “Personal exercise habits and counseling practices of primary care physicians: a national survey.” Clinical Journal of Sport Medicine1 (2000): 40-48.
11. Lesser, Lenard I., Deborah A. Cohen, and Robert H. Brook. “Changing eating habits for the medical profession.” JAMA10 (2012): 983-984.
12. Alexander, Stewart C., et al. “Do the five A’s work when physicians counsel about weight loss?.” Family medicine3 (2011): 179.
13. Wansink, Brian. Mindless eating: Why we eat more than we think. Bantam, 2007.

With all the talk of it being difficult to be a doctors – something I have published on before, being a patient is not easy either¹. My disease: kidney stones. Let’s make no mistake; I am fortunate enough to have never had cancer, been in a disabling car crash, or dealt with any actually serious malady that other people have had (including my friends), but experiencing medicine from the other end was an eye-opening and unnecessarily cumbersome experience that gave me a new appreciation for my patients.

The process of being a patient hadn’t always been difficult. In fact, it was fairly straight forward when I was a child and still under my parents’ insurance plan. Having a physician-father also helped in navigating my disease and the healthcare system. Being a patient couldn’t have been easier. Not having to worry about copays and preferred providers, I could focus on my disease.

My first brush with having a kidney stone came as a surprise. I still remember the moment: I was eating lunch in the English room during the 11^th grade. And then I was supine on the reading couch cringing from unbearable flank pain. My first thought was indigestion, but as the pain exploded past 10 on the 10-point scale, I realized I had something more sinister going on. My mother picked me up from school and took me to the emergency room. They told me I passed a kidney stone. I got the care I needed and that was it.

Now in my residency, I had a recurrence and the experience was much different. For my 29^th birthday in July, I spent the day out on a boat with maximal sun exposure. Replacing water with beer – a known risk factor for kidney stones – and being subject to an unforgiving sun, my stones re-emerged, literally. Instead of having the tell-tale renal colic, I had persistent blood in my urine for the week following my afternoon soiree. I knew that these Goldilock-sized stones – not too big to obstruct my ureter and render me infantile, not too small to go completely unnoticed, but just big enough to cause some bleeding – were the cause because I had it first present this way in medical school. My primary care physician then, who after doing a few tests, told me it was nothing to worry about it and to drink water. I forgot to drink water and was now worrying. I was particularly worried because the bleeding went on for days – as opposed to just once or twice in medical school. Again, I needed those “few tests” to ensure I was still O.K. I needed to see my primary care physician.

I tried to make an appointment. Easier said than done. According to my employer, my insurance was no longer contracted with my previous primary care physician at the University of Man Hospital^a. The change had preceded my hematuria by only a matter of weeks; I didn’t even have a chance to find a new primary care physician. I attempted to find a new physician, but who? Who does my insurance take? I called My Insurance and they directed me to their website which included more than 1,000 providers in a 15 mile radius based on my zip code. Narrowing this down to a 5 mile radius produced 427 results. Who do I call? I called a reputable and prominent facility near me: Mount Everest Medical Center. The first time I called they said they take My Insurance and connected me to “scheduling” where no one answered after waiting for ten minutes (an incredibly long period of time when you are the one waiting on the other end listening to a pre-recorded message on loop). I called again, no answer even from the operator. I called again the next day and they said they didn’t take my insurance. I called for a fourth time and same story – they don’t take my insurance despite what My Insurance’s website says. I gave up on Mount Everest Medical Center.

I went back to My Insurance’s website and now had 426 results to sort through. With each hematuric day, I grew weary of the blood and the listings on the website. Clicking through, I found my original primary care physician at the University of Man Hospital. I called the office of my primary care physician to see if they were listed on the website erroneously, and they said they still took my insurance. An insurance agent from My Insurance verified this. But the insurance representative at my employer was adamant that I could not go there. I threw my proverbial hands up in the air and decided to make an appointment regardless of the provider was “in-network” or “out-of-network.” I thought that I will know for sure if they are covered or not when I get a bill in the mail.

“The next appointment we have available for you is in six weeks.”

I told her I couldn’t wait that long.

“Have you thought about going to the emergency room?”

“Yes, I have but this is not an emergency.” I’ve worked in an emergency room. Me peeing blood feels like an emergency but doesn’t compare to the guy having a heart attack, the mother about to give birth, the baseball player with a broken finger, or the family of three that’s in a car accident. My problem is urgent. Not emergent. Emergency rooms are for emergencies.

Thinking about this for a few more days and realizing the predicament I was in, I knew that I wouldn’t be seen any faster as a new patient with any primary care provider within a 15 mile, let alone 5 mile, radius. I was one of the 62 million Americans without adequate access to a primary care physician². Even more ironic, I am a physician myself and am surrounded by doctors. During this time, I even treated a patient with kidney stones. His stones had progressed to the point that he had obstructed his kidney and needed urgent decompression. He, like me in high school, went to the ER because he was bed bound from severe pain. In the back of my head, I couldn’t stop wondering was this happening to me – perhaps silently? Although completely silent stones are uncommon, they can cause partial or complete obstruction in up to 20% of patients³. Was I having silent obstruction? Would I be destined to a life of chronic kidney disease or, worse, kidney failure? Of all the causes of kidney failure, stones are the cause only 2% of the time. When considering that kidney stones affect 5% of the entire population, the total number of patients succumbing to kidney failure from stones is quite small⁴. As the days and blood passed, logic waned and hypochondria took over. With nephrology being my ultimate field of study and choice of specialty, I found it ironic that the physician-turned-patient was now beset by the very disease he had been studying.

And, I was not the first physician to self-diagnose his own disease of study. Armand Trousseau – famous for Trousseau’s sign of malignancy – found his namesake sign on himself when he had pancreatic cancer. And of course, generation after generation will remember Leonid Rogozov – the Russian surgeon who diagnosed himself with appendicitis while on an Antarctic research expedition and performed his own appendectomy⁵. Although only a resident, I knew the tests that I need to be done – after all, I had ordered them countless times for my patients. Yet, self-prescribing and self-treating are taboo. According to the most recent edition of the American College of Physicians Ethics Manual,

Except in emergent circumstances when no other option exists, physicians ought not care for themselves. A physician cannot adequately interview, examine, or counsel herself; without which, ordering diagnostic tests, medications, or other treatments is ill-advised⁶.

For urgent problems, there are urgent care centers, and some of them are covered by My Insurance, but they are only open during normal business hours – when I am at work. I suppose I could have taken a day off at work for the issue, but what if they weren’t able to do the blood work or imaging on the same day? Would I have to come back on different days for both the blood work and the imaging? Would I have to come back a third or fourth time for the results? How many times would I have to take off work? Anyone who has a full-time job understands my predicament. And now after being in the predicament myself, I better understand the hurdles my working patients have to overcome to see me during my business-hours-only clinic.

There are after-hours urgent care centers near me. But finding which ones were close by, covered by my insurance, open during business hours, and had same-day imaging and blood-testing available became a time-consuming and administrative nightmare. After much thought, I realized that I just needed any physician to order the most basic of tests. Once I had the prescriptions, I could have it done at the hospital I worked at before or after my shifts and have it covered by my insurance. Since I couldn’t write the prescriptions myself, I called a friend – a friend who happened to be a physician – to do it. And he did. Since the first episode of hematuria, it took me nearly three weeks to get a prescription for an ultrasound and blood work to check my kidney function and another 1-2 weeks to complete them and get the results, all of which were normal.

It was not an optimal choice, but perhaps the easiest solution for me. Although I did not self-prescribe and self-treat, in theory it is what I did. My physician-friend trusted my judgement and ordered the benign tests under his name using my judgement. I was not in the same situation as Leonid Rogozov, but I was becoming increasingly impatient and frustrated with the locating and seeing a primary care physician. What if I weren’t a college-educated, health-literate, English-speaking, American-born, middle-class physician with physician-friends? What if I didn’t have health insurance or couldn’t get the imaging and blood work at the same place as my employment? How does everyone else without all these advantages navigate the system and obtain healthcare? Maybe it is an urgent care facility requiring several half-days of missed work. Or maybe it is an emergency room visit followed by a hefty bill or two later^b. Or worse, maybe it is accepting defeat and letting diseases thrive unfettered. Or maybe it’s my expectations that healthcare should come easily?

Again, I have to state that I only had kidney stones. I can’t imagine what it is like to require chronic treatment for a serious illness like chemotherapy or repeated surgeries. It reminds of a statement one of my healthier, pentagenarian patients told me about after he repeatedly declined to have any form of colorectal cancer screening, which is recommended as routine for all over the age of 50. “I don’t want to spend the rest of my afternoons dealing with lab results, insurance companies, and doctor visits like all the rest of my friends my age,” he reasoned. Although most people don’t refuse screening so adamantly and most have normal cancer screening results, my patient was unmoved. I, however, was moved. His statement introduced something I had never thought about before: medicine, and the insurers of it, can so cumbersome that it inhibits healthcare.

Despite my advantages in navigating the health-care system, it still took me nearly three weeks to get the orders I needed and five weeks to get the results – which I obtained the way my patients do when they want a copy: through medical records. The process of getting my blood work done, having my ultrasound done, and retrieving my results was a time-consuming process that required patience and determination.

I knew what I did was not ideal, but it is not uncommon. Others have documented it regarding varying circumstances^7,8. There are merits to having a friend that is a physician or, in some cases, your physician. The very same American College of Physicians Ethics Manual that I cited earlier acknowledges this. Read the excerpt (specifically the last two sentences):

Physicians should usually not enter into the dual relationship of physician–family member or physician-friend for a variety of reasons. The patient may be at risk of receiving inferior care from the physician. Problems may include effects on clinical objectivity, inadequate history-taking or physical examination, overtesting, inappropriate prescribing, incomplete counseling on sensitive issues, or failure to keep appropriate medical records. The needs of the patient may not fall within the physician’s area of expertise. The physician’s emotional proximity may result in difficulties for the patient and/or the physician. On the other hand, the patient may experience substantial benefit from having a physician-friend or physician–family member provide medical care, as may the physician. Access to the physician, the physician’s attention to detail, and physician diligence to excellence in care might be superior [emphasis added] ⁶.

I did not gain any additional benefit from having the prescriptions written through my physician-friend other than simply having them. But having the tests done was what mattered the most. I know I can’t do this continually, but it allowed me enough time to find a primary care physician at a time that was convenient for me. As such, I called back my original primary care physician and scheduled an appointment within two weeks. They initially tried to give me an appointment months away, but I pestered and pleaded, and they added me on as an “over-book.” When my visit came, I did have to wait nearly two hours past my appointment time to be seen.

After nearly six weeks from the original episode of hematuria, I saw my primary care physician. My copay was $15, and I haven’t received a supplemental bill in the mail. Yet. I also haven’t had any more instances of bleeding in weeks. However, things could change, and I may still be charged in full for the visit if my insurance truly doesn’t cover my primary care physician. My primary care physician agreed that my blood work (creatinine) and ultrasound were normal. But he referred me to a stone specialist and ordered a special urine test for people with recurring kidney stones. The urine test is, of course, not provided by the laboratory that is contracted with My Insurance. And so, the saga continues…

Footnotes:

1. Names of all health-care establishments have been fictionalized.
2. While in medical school, I went to the ER after injuring my arm. In total I received three bills, one was the deductible up-front. The second bill included the items the insurance company decided not to cover. And finally the third bill was for the services of the ER physician himself who was contracted separately from the ER. I am surprised that the nurse, nurse tech, janitor, plumber, line cook, and electrician didn’t also send me individual bills for their services during my brief 5 hour stay in the ER.

References:

1. Joshi, Shivam, Roger Nehaul, and Monica A. Broome. “Declining proportion of physician-owned practices possibly related to increasing burnout.” JAMA internal medicine8 (2013): 710-710.
2. http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/affordable-care-act/access-primary-care-remains-challenge-62-million-?page=full
3. Wimpissinger, Florian, et al. “The silence of the stones: asymptomatic ureteral calculi.” The Journal of urology4 (2007): 1341-1344.
4. Asplin JR, Favus MJ, Coe FL. Nephrolithiasis. In: Brenner BM, ed. Brenner and Rector’s the kidney. 5th ed. Philadelphia: Saunders, 1996: 1893-935.
5. Rogozov, Vladislav, and Neil Bermel. “Auto-appendectomy in the Antarctic: case report.” BMJ 339 (2009).
6. Snyder, Lois. “American College of Physicians ethics manual.” Annals of Internal Medicine1_Part_2 (2012): 73-104.
7. Latessa, Robyn, and Lisa Ray. “Should you treat yourself, family or friends.” Family practice management3 (2005): 41-44.
8. http://www.kevinmd.com/blog/2012/10/doctors-treat-family-friends.html

People can wear what they want in America. Whether you want to debut the latest vogue or your midriff rife with adiposity, you are free to do so. But just because you can, doesn’t mean you should. In the span of one week, I found two people – on two separate occasions – wearing white coats, each eliciting a different reaction from me.

In the past few months, I have made a conscientious choice to buy more of my groceries in the form of fruits and vegetables – and less in the form of boxes, cans, containers, and cartons, and you may want to do the same. Although Winn-Dixie does not sit at the pinnacle of grocer quality – like perhaps Whole Foods, it does offer a reasonable produce selection at a reasonable price. As I happened to be picking out nectarines, I glanced up and felt that I was hallucinating. In escaping the hospital, I found it inescapably in front of me: a man in his white coat. In one of those moments where you realize something is wrong but don’t know what, I thought maybe I had not seen him correctly – maybe he was a chef and was wearing a white apron? Or maybe I was still in the hospital and this was normal? Snapping to reality, I realized he was at Winn-Dixie, and I was too. He was wearing a white coat, but I was not. I took out my camera and snapped away.

My first reaction was: What the hell? This is gross. First, I don’t even leave the hospital without washing my hands. This guy brought 20 square feet of a microbiological zoo to buy fried chicken! Maybe he has a really good excuse. Maybe he got fired from the hospital (and couldn’t leave his white coat at the hospital), his car got stolen (so he couldn’t leave the white coat in the car), and was so busy talking on the cell phone that he didn’t realize he could disrobe and fold his white coat for placement in a shopping cart or basket. Maybe he also didn’t realize that he had committed a more heinous oversight: wearing sandals with his white coat – the coup de grâce. I was apoplectic that more people were not pausing their purchasing activities to gawk at this unfathomable fashion faux pas.

White coats are dirty. In one Israeli study, more than half of physician’s white coats harbored pathogenic bacteria, like Pseudomonas, Acinetobacter, Staphylococcus aureus, Enterobacter – even some with antibiotic resistance¹. The concern over the transmission of disease had led Britain’s National Health Service to ban doctors wearing white coats in the hospital, and the United Arab Emirates’ Ministry of Health to ban it outside the hospital. Washing your white coat doesn’t help – unless if you’re washing it several times a day. According to one study, white coats worn just 8 hours after washing have as much contamination as one that is washed “infrequently” ². Wearing your white coat for just 3 hours gets you to the 50% level of contamination.

No one has shown that doctors wearing white coats outside the hospital increases illness in the general public, but one study showed transfer of multidrug-resistant organism from cloth to pigskin was possible ³. In theory, transfer from cloth to human skin should also be possible. Whether that translates into morbidity and mortality remains to be seen, but why risk smearing methicillin-resistant Staphylococcus aureus (MRSA) on every surface in Winn-Dixie?

I myself have worn scrubs, albeit begrudgingly, outside of the hospital, but never a white-coat. Doctors, like everyone else, have lives to live and errands to perform. Sometimes, I’ve had to pick up dinner or go to the ATM on the way home. But, I don’t wear my white coat. I’ve never even thought of wearing it out of the hospital, let alone with sandals. To me, it is so unorthodox it rivals opening an umbrella indoors. When I do wear scrubs out, I sometimes take off my scrub top and wear my plain and completely unfashionable T-shirt to minimize any possible bacterial trail and, more importantly, to avoid signaling to the rest of America that I work in a hospital.

The second time it happened, I was again not prepared. I was driving home, listening to the BBC on the radio, when I had reached the tail of a line of cars waiting on a red light. As I waited, I listened to the latest headlines being rattled off. And then I saw it, less than a week’s passing from the first sighting. Again, I thought, It couldn’t be. But it was! A white coat on a person outside of the hospital! I stared at her and wondered, What the hell? Again, I snapped away (see above picture on the right). Not only are you wearing a white coat outside the hospital, but you are really wearing it outside! In the middle of summer, the heat and humidity in Miami is unbearable. Even if you forgot you were wearing a white coat as you sat in your car and turned on the air conditioner, you would definitely remember wearing it as you opened your car door and the sauna-like environs slapped your face. You would definitely remember you were wearing a white coat as your core temperature rose, your back started to sweat, and your thalamus went into overdrive to keep your body cool.

The only way a person would wear a white coat in such a setting is if they actively chose to do so. There is no excuse as she could have easily laid her white coat down in the back seat or trunk. The most logical explanation for a person to elect to wear a white coat in public is to signal that they are in the health care profession and, more specifically, are a doctor, whether they are or aren’t. White coats are associated with doctors as toque blanches are associated with chefs. One could easily wear a white coat in public to signal to others that they are not just any “Joe” or “Jane.” If being doctor confers special treatment in public, then one could use it for such a purpose. I don’t know if any such promotional sale or treatment by the major gas stations for physicians, but maybe I am wrong. Chefs don’t wear their hats in public. Neither do judges wear their robes in public. Imagine if they did – what a farce! Doctors, and anyone else possessing a white coat, should follow suit and refrain from using the white coat in a personal situation.

White coats are easily removable, unlike scrubs, which is what makes it a point of contention. Even though I consider scrubs being barely socially acceptable, many do not⁴. I am actually not even the first to post about someone wearing a white coat at the gas station. I found a medical student posting about another instance of the exact same situation⁵. In his/her blog, they write that perhaps this white-coat wearer was attempting to signal their perceived lofty status as a doctor. However, any attempt to do so backfires as it more blatantly reveals the “doctor’s” lack of awareness.

The use of the white coat for secondary gain is actually a violation of the medical professions’ ethos. Doctors are doctors to be doctors. The only time it might – barely – be appropriate to wear a white coat out is if one was making a house call. When I was a medical student, one of my family medicine attendings did make house calls – something of a rarity these days – and he didn’t even wear a white coat. I assume if you’re knocking at someone’s house, the tenants already know you are their doctor. Second, doctors are human – just like our patients. Wearing a white coat does not separate us from disease, emotion, or people. Although the white coat signifies our profession, it shouldn’t be used to distance ourselves from those around us – whether we are inside or outside the hospital.

But maybe all of these out-of-place doctors had valid reasons. I don’t know. I am curious to know what you think. Maybe if this keeps up, people will start saying, “You can take him out of the hospital, but you can’t take the hospital out of him.”

Or not.

References:

1 Wiener-Well, Yonit, et al. “Nursing and physician attire as possible source of nosocomial infections.” American journal of infection control 39.7 (2011): 555-559.

2 Burden, Marisha, et al. “Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8‐hour workday: A randomized controlled trial.” Journal of Hospital Medicine 6.4 (2011): 177-182.

3 Butler, D. L., et al. “Transmission of nosocomial pathogens by white coats: an in-vitro model.” Journal of Hospital Infection 75.2 (2010): 137-138.

4 http://www.physiciansweekly.com/scrubs-wearing-in-public/

5 https://medschooltrap.wordpress.com/2013/09/06/wearing-your-white-coat-in-public-is-not-cool/

In residency, they say the days are long and the years are short. Buried beneath the hours and work, it can be hard to find joy in the work we do. The work of a resident isn’t always filled with life-saving moments and wind-blown hair. In fact, moments where we personify our Grey’s Anatomy or House counterparts are scarce or implausible. Babies are not delivered pristinely clean and patients rarely walk out of a hospital after having had CPR. For internal medicine residents, our work of taking patient histories, performing physical exams, analyzing data and pinpointing the right treatment is less glorious and more repetitive. Given what we actually do, it is not surprising that 76% of internal medicine residents have experienced burnout at some point.

However, what we do is still important. We treat chronic heart disease, obesity, diabetes, high blood pressure, low blood pressure, and many other things in between that Hollywood never shows because the effects are more subtle, especially in the clinic setting. It was in one of these moments that I unexpectedly fell upon the sense of fulfillment. I had been in clinic, typing a visit note – my attention fixed on the computer in front of me – when my patient had started to talk about his smoking. My patient had smoked for decades and would be nearly breathless every time he arrived in my clinic room after calling his name in the waiting room. Smoking was part of his biker, jean-clad persona. I never had the time to lay out a few minutes to discuss all of the aspects of his smoking given all of his other medical problems but in previous visits I at least had covered the first two “A” of the five “A’s” of smoking cessation counseling: asking about smoking and advising to stop if they do smoke. In fact, nearly 80% of smokers don’t receive any further counseling during the average office visit.^2,3 A woefully high number that has been attributed to simply the lack of time doctors have.⁴ In one study, the minimum amount of time for smoking cessation was determined to be three minutes – less than the amount of time to microwave a bag of popcorn. But when you add up the time needed for all the other things doctors have to do in a clinic visit – 190 other tasks (yes, people did count this and published it) – it adds up! ⁵ One study looked at the amount of time it would take to just cover prevention – all the things you should be doing to prevent a disease or its complications down the road, like getting enough, wearing a seat belt, being checked for sexually transmitted diseases, having a mammogram, et cetera. For one physician’s clinic patients, that physician would have to spend no less than 4.4 hours of each and every day just on the sole task of health care prevention! ⁵ Clearly, physician time is constrained and we are forced to make decisions on which area of a patient’s health care we should focus on. It is not an ideal situation, but this is one of several hard realities in health system with limited resources.

At the least, I try to see my patients more often to cover all those other things. Every time I did see this particular patient, I felt compelled to tell him to stop smoking. In studies, barely any intervention has been shown to be better than nothing at all. ⁶ If you don’t have time to spend the minimum three minutes, at least telling your patients that it is one of the worst things they could do for their health and they should stop is better than waiving the white flag and letting them walk out. In my limited attempts to have my patient stop smoking, I somehow managed to pull this off and it felt great.

“Doc, I have to tell you something,” he said.

“What is that?” I replied, barely listening while my face was buried in the computer screen looking up notes of his cardiac history.

“I took your advice and quit smoking.”

My response was nothing short of a contained tonic-clonic seizure. It was surreal. “Really?” I stammered from my mouth while my mind thought differently, “You listened to me? I was solely responsible for you giving up your twenty year habit of smoking that probably has given you heart disease, COPD, erectile dysfunction, and who knows what else? I struggle with basic life tasks like avoiding ketchup on my shirt and I somehow convinced a real live person to give up smoking!” I looked around the room half-expecting to find it was a prank, half-hoping to find somebody recording this life-changing moment – life-changing for him and for me – but found none. It was a quiet victory that deserved a loud celebration. For this person’s health, I single handedly had altered the course of his future health by getting him to quit smoking. In a parallel universe, I had avoided my patient perhaps going down the road of having heat attacks, being hospitalized for breathlessness, or succumbing to an early death. For example, quitting smoking can add a whole decade to one’s life expectancy. By not inhaling cigarette smoke, patients avoid exposure to the 70+ known carcinogens and thus reduce their risk of cancer. After several years, risks of cancer and heart disease can approach those of non-smokers. After his casual announcement, I stopped my note browsing and gave him the congratulations he deserved. On the inside, I felt like I had received my own reward: fulfillment as a doctor.

Finding fulfillment in smoking cessation is not easy because quitting smoking is not easy. On average, it takes a patient 8 to 11 attempts before they successfully quit smoking. ⁷ The longer a person goes without a cigarette, the greater the chance of successful cessation.⁸ Although smoking is not as common as it used to be, nearly 1 in 5 Americans smoke and nearly 1 in 5 deaths are attributed to it. ⁹ Kicking the habit is worth it for the patient. As a result, physicians should participate in some form of counselling with every patient at every visit. ¹⁰ In time, patients will quit. Resounding victories are rare in medicine, but when they do happen, they are a reminder of our purpose as physicians. And despite not being shown on TV, moments like this certainly are a bright spot in my day.

References:

1. Shanafelt, Tait D., et al. “Burnout and self-reported patient care in an internal medicine residency program.” Annals of internal medicine5 (2002): 358-367.
2. Ferketich, Amy K., Yosef Khan, and Mary Ellen Wewers. “Are physicians asking about tobacco use and assisting with cessation? Results from the 2001–2004 national ambulatory medical care survey (NAMCS).” Preventive medicine6 (2006): 472-476.
3. Thorndike, Anne N., Susan Regan, and Nancy A. Rigotti. “The treatment of smoking by US physicians during ambulatory visits: 1994-2003.” American journal of public health10 (2007): 1878.
4. Yarnall, Kimberly SH, et al. “Primary care: is there enough time for prevention?.” American journal of public health4 (2003): 635-641.
5. Wetterneck, Tosha B., et al. “Development of a primary care physician task list to evaluate clinic visit workflow.” BMJ quality & safety1 (2012): 47-53.
6. Stead, Lindsay F., Gillian Bergson, and Tim Lancaster. “Physician advice for smoking cessation.” The Cochrane Library (2008).
7. Women and smoking: A report of the Surgeon General. [US Public Health Services], Department of Health and Human Services, 2001.
8. Hughes, John R., Josue Keely, and Shelly Naud. “Shape of the relapse curve and long‐term abstinence among untreated smokers.” Addiction1 (2004): 29-38.
9. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
10. http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions

Photo credit: https://www.flickr.com/photos/gracekifer/5042922854

I remember the first time I met Seamus Kennedy*. I was rushed, he was not, which is ironic, considering that he was a man facing death, and my only curse was to admit a patient five minutes before I was supposed to leave. Being on the inpatient hematology and oncology service at the private hospital, it wasn’t unusual for patients to come after working a half day or even a whole day, which, unfortunately, meant I often had many admits strolling in the final minutes of my own shift, necessitating me to stay additional fraction or multiples of an hour to complete their admission, depending on how fast or slow I worked.

Like I had done with all others admissions, I reviewed his chart and learned of Seamus’s advanced cancer. I learned how his CNS lymphoma had failed to respond to first-line chemotherapy, radiation, and second-line therapy. I walked briskly into his room, past an empty bed and the dividing curtain, to find Seamus being basked by the bright white of the overhead hospital lights as if to remind those around him of the inevitable. As I approached, Seamus’s bald head reflected the lights, his face hinted at a smile, even though his eyes were closed. I said hello, stated my name, and told him that I would be his doctor. I was automated, proceeding from one step to the next. But before I could, I was enveloped by the presence and personality of the person that was Seamus Kennedy. Seamus was a large person, but his personality was larger. For somebody who had months to live based on the last outpatient note – “will now refer to palliative care since we have no other options” – Seamus seemed to be as relaxed as somebody you would find in the lobby of the Ritz Carlton on South Beach, and just as happy. For every question I asked Seamus, he doubled back, and I patiently answered all of his queries. It became clear that Seamus didn’t come to just get palliative chemo, he was hell bent on living every moment of his life, just as he had done until the moment he was diagnosed with brain lymphoma. I lost track of time and even strayed far away from the usual script of asking about nausea, vomiting, and the other usual cancer questions. I asked him about his Irish heritage, whether he bore any relation to the Kennedy family, even a distant one, even a really distant one, and where his favorite parts in Ireland had been on his many return trips to the Emerald Isle. His responses were never short and not without his own set of questions for me; Seamus’ grandparents had immigrated to America in the late 19^th century, he bore no relation to the Kennedys of American politics (not even a really distant one), and his favorite place had been Galway, a part of Ireland I did not have a time to visit during trip there only a few months before I started my internship.

Even though I had changed my tempo during our initial encounter, I regret that I had initially started the interaction so mechanistically. I had not expected to find a friend in that setting or that hour, but I did. I am glad that I was able to appreciate the beauty of the person that was Seamus, something that is rare as so many patients lose their personality to the disease process and we, as physicians, make little effort to uncover the person underneath. William Osler, one of the founding physicians of Johns Hopkins Hospital and perhaps of modern medicine itself, once said, “It is much more important to know what sort of a patient has a disease than what sort of disease a patient has.” The reference to Osler is ironic as Osler established the 24/7 residency program, where interns were interred in the hospital and residents had no other residence. More than a century later, interns and residents are fortunately allowed to have homes and visit them, like myself.

Over the ensuing days, Seamus and I became fast friends. I would spend moments in my day with Seamus, visiting him to fill the void while his wife was at work at the corporate office for a company that made cable boxes for America. During my encounters, I came to learn how real his lymphoma was. In showing me pictures of himself, I saw how much weight he had gained after starting chronic corticosteroid therapy, on which he was now dependent. The corticosteroid – oral dexamethasone every 8 hours – was the difference between him telling me stories of Ireland’s Aran Islands and him drooling on himself, mumbling incoherently, half-asleep. The lymphoma created a lot of brain swelling and the dexamethasone slowed this process down. One morning, I saw the lymphoma beginning to efface the Seamus that I had come to know; I had come to find Seamus slurring his words and drooling. I didn’t know what was happening, but Seamus had mumbled that the nurses didn’t give him the dexamethasone the night before. I chased down the night nurse who thought she had given him the medication but in actuality didn’t because she had gotten confused with another patient. A medical mistake that paled in comparison to the gaffe to be committed later. Shortly after getting the medication, Seamus started to return to his usual self.

After a few days of chemotherapy, Seamus was done and it was time for him to go home. On the day of his discharge, our team rounded on him in the morning and said their goodbyes. His presence and now departure was palpable among the team. We had walked out of the room, and well out of earshot, our attending had begun talking about Seamus’ care and prognosis going forward. It was dismal. Months. At best. I took the moment to write down his discharge medications on the prescription pad that I kept in my pocket. As the attending stopped rounds to teach about therapies for CNS lymphoma, I wrote down all of his medications on small prescription pages the size of index cards, including his dexamethasone and an antimicrobial – Bactrim – to prevent a type of pneumonia that can occur in patients taking dexamethasone for long periods of time, as Seamus had been doing. After rounds, I put the prescriptions in the patient’s chart, just as I had been instructed, for the nurse to photocopy, document, and ultimately give to the patient.

A couple weeks after Seamus had been discharged, I was nearing the end of my rotation in the hematology and oncology service at the cancer hospital when I found out that Seamus was returning with same type of pneumonia that I had hoped he would never get. If he had been taking the antimicrobial I had prescribed for him, how did he get the pneumonia? There was no question that Seamus had the type of pneumonia I had dreaded: Pneumocystis jiroveci pneumonia. Seamus was short of breath, the oxygen saturation in his blood was low, his x-ray showed random patches and the CT was even worse. This type of pneumonia occurs typically in people with advanced immunosuppression, like patients with HIV or taking medications that can lower the immune system’s ability to fight infections, like dexamethasone. In an attempt to thwart the fungus from ever gaining a foothold in patients who may be susceptible, physicians give Bactrim (also known as TMP-SMX or trimethoprim-sulfamethoxazole). Seamus, struggling to breathe, told me he had never taken the Bactrim. In fact, he never saw the prescription that I had written. Being responsible for his prescriptions and his care, I felt that I had erred gravely. I felt like all of my training and my efforts were worthless.

Worse, Seamus had been feeling short of breath for more than a week and had been trying to get our attention. He and his wife had called the hematologist’s office several times to state their concern for Seamus’ worsening shortness of breath. The first time they could not get through and left a voicemail and nobody called back. The second time Seamus’ wife called and got through to a nurse who informed her that the doctor had been out and she couldn’t take a message for liability reasons and to try calling again later. The third time she called she was repeatedly put on hold and could never talk to a physician. The fourth time she called she was told that Seamus had a follow up appointment the following week with his hematologist and not to worry. When Seamus finally arrived in the hematologist’s office, Seamus could barely stand up before feeling like he was going to pass out. While walking, his oxygen saturation plummeted to the 70^th percentiles, by comparison anyone less than 88% percent should be on continuous oxygen. Seamus was skirting the line of needing to be intubated and a breathing machine for life support. As if Seamus’s medical care had not experienced enough problems, Seamus came in minutes before shift change. My resident shot one look at the clock and, without giving it a second thought, told me to “handle it” and walked out.

As a new intern, handling a respiratory emergency was like tasking a monkey to land the space shuttle. She didn’t even come to see Seamus. When I first saw Seamus, he looked like a goldfish that had been plopped out of the fishbowl. My plan had been to give oxygen and he was already on it. I needed help. I knew that if I went straight to the day attending, I might be ridiculed for my lack of knowledge, be viewed as the intern that throws his resident under the bus, or experience retribution from my resident. I skirted the issue entirely, I paged the night attending, who happened to be a specialist in critical care. I told him the whole story in painful detail. Without judgement or complaint, he walked me through Seamus’ management like a dad holding his hands around a child learning how to ride a bike. Seamus did well overnight and slowly recovered over the ensuing days.

What didn’t improve was how I felt about the whole situation. Seamus recovered, but I shaved two, maybe three, weeks off his remaining few months left, precious weeks that could have been spent living his life at home. Adding the time he spent in the hospital, the time he felt sick before arriving, and the time he spent recuperating at home afterwards, the total amount of time likely could have been three weeks. And, I had no way to give him those three weeks back.

Nowadays, mistakes like this are entirely averted by the use of electronic medical records and electronic prescribing, where physicians can electronically send prescriptions to a patients pharmacy as easy as an email. In my attempt to understand why Seamus got all of his other medication prescriptions and not the fateful Bactrim, I reanalyzed all the surrounding events. I even went to medical records to look for the photocopies of the prescription. I even doubted that I had ever written the Bactrim in the first place, or if I had written it, it never made it into the chart. In the bewildering repository that is medical records, I was never able to find the photocopy of any of his prescriptions. Even now, I wonder if I actually wrote the prescription or thought I wrote the prescription. I had no proof to show that I wrote it and no way of obtaining it.

Worse, I didn’t know who was responsible and who was going to apologize. Being the closest member of the medical team to Seamus during his first admission, I felt responsible for the mistake and for the requisite apology. But for what was I apologizing? For not handing the prescription to him directly? For it being lost? For him being unable to get through to us when he was trying ask about his shortness of breath? My attending did not apologize, nor did the hospital, my resident, the nurses, or anybody else. In studies, only one third of physicians explicitly apologized in a way that acknowledged the error, most just detachedly express regret, as everyone else had done with Seamus¹; “oh, you didn’t get the medication. That’s too bad.”

Despite medicine’s increasing commercialization, we are still the face of the care we provide. Beneath our white coats, beneath our degrees, we are still humans. We have made mistakes and will continue to make mistakes, but we also have the capacity to acknowledge the mistake and apologize. The apology is so important; 98% of patients surveyed “desired or expected the physician’s active acknowledgement of an error”².

The words did not come easily. In the days after his re-admission, my heart grew so heavy that I felt like I could not enter his room. I was ashamed to see him, wearing the oxygen mask, gasping between words. The encounters were distinctly less often and less enjoyable. Being genuinely good people, Seamus and his wife never complained about the serial mishaps or noticed my withering spirit. The fact that they did not notice made it at all the more difficult to break the ice, to form an eloquent apology and explanation, and to actually voice the words with my own voice. It felt like I was bringing out an issue that had conveniently been swept under the rug. With each passing day, I felt the pressure to apologize.

My last day arrived on the rotation. It was a Sunday, and Seamus was still requiring oxygen to breathe, albeit much less than before. Even during the day, I delayed the inevitable. Finally, late in the afternoon, I walked into his room, much different than the very first time I walked into his room. I wasn’t walking in like a robot; I was walking in as a human, a very small human. Feeling the pressure that we as humans – humans who are entrusted with the care of other humans – owed an apology to Seamus, I apologized. For all of the mistakes, mistakes that were mine, could have been mine, and definitely were not mine. Fearing anger, yelling, disparagement, and tears – mine or theirs – I voiced everything and took responsibility. The Kennedy’s accepted my apology and understood my explanation. I gave them my personal cell phone number for emergencies. They thanked me for the apology and for providing Seamus with the care that I had given. There was no yelling. There was no blaming. There were almost no tears. Despite being delayed, the apology could not have been better. I hugged them both, and I left.

I never saw Seamus again. I knew that his time was limited. I had promised to follow up with them but I never did. The speed of intern year – new patients, new medications, new diagnoses – distracted me from the incident. Periodically, I would google the local newspaper obituaries for Seamus Kennedy’s name. Finally, one day, I found it. I was heartbroken. A part of me wanted to believe that Seamus would never die, that I would never find his obituary, but I did. Since that experience, I remember three cardinal rules that were once bestowed upon me by a surgical oncology fellow when I was a medical student, but had not realized their value until this incident. The rules are written to minimize the number of medical mistakes, even though it maximizes our own paranoia. The rules:

1. Trust no one.
2. Expect sabotage.
3. Do it yourself

The rules are overly cynical but are necessary if we are to be proactive about medical mistakes. When I have medical students and interns of my own, I now impart these rules to them. Now that most prescriptions are now electronic, I rarely find myself telling people to hand prescriptions in person. I hope that others can learn from this mistake, even if the mistake was mine or not, and also learn the importance of the apology. And, of course, we can remember Seamus Kennedy for his personality, and not his lymphoma.

*Patient’s name has been changed to preserve anonymity and is completely unrelated to Seamus Kennedy, the musician. Other pieces of this story may have also been changed to preserve anonymity.

References:

1. http://www.ncbi.nlm.nih.gov/pubmed/16908791
2. http://www.ncbi.nlm.nih.gov/pubmed/8951299

(Kionex = Kayexalate = Sodium Polysterene Sulfonate)

Photo Courtesy of JYR

Once, when I was a night intern presenting to the day team an admission, I was questioned, then berated, regarding my management regarding hyperkalemia. Mild hyperkalemia. The specifics of the case I don’t remember. However, I remember running through the presentation:

Lung sounds were clear blah blah blah Patient was alert an oriented blah blah blah.

Labs: Sodium normal Potassium 5.5 mEq/L, for which we gave 15 grams of kayexalate…

 The patient didn’t have any reason for the hyperkalemia. None of the classic effects of a potassium sparing diuretic, renal failure, or the surreptitious – or not so surreptitious – use of an angiotensin converting enzyme inhibitor. The patient had plain, ol’ hyperkalemia. The red blood cells in the sample had not hemolyzed, or ruptured releasing all of their intracellular potassium stores and falsely elevating extracellular concentrations of potassium – more on this later. And, the patient’s heart had not ceased beating from a cataclysmic change in cardiac myocyte action potentials.

As I attempted to continue my presentation. I was stopped by the attending – the king of my medical audience, “What else did you do for the potassium?” I was puzzled.

I errr gave kayexalate…(Damn, I just said that.. There must be something I am missing. Did he want me to load this patient up with other medications… The potassium was only 5.5, only 0.5 mEq/L above the upper limit of normal. Only a 10% change from being normal!)

 Most people would say that clinically relevant, or moderate hyperkalemia, doesn’t start until 6.0 mEq/L or higher. Normal potassium being between 3.5 and 5.0 mEq/L plus minus a few. Life in the Fast Lane, a popular website for those within the emergency medicine circle and close-by, does not classify hyperkalemia until it is greater than 5.5 mEq/L – an upper limit that would have allowed me to pedal my way through my admission presentation without questioning and sooner to sleeping.¹ Alas, my attending probably had neither visited the website nor cared to, I assume.

Management techniques vary from administering beta-2 agonists, like albuterol, to the combined administration of insulin with dextrose – all of which abscond potassium into the cells of the body and away from the all-important cell membrane of the heart, but only for a short period of time. After a couple hours, the potassium re-emerges from the body’s intracellular storehouses as the effects of albuterol and dextrose abate. The only way to truly remove potassium from the blood is to remove it from the body, either by peeing it out or pooping it out. Bodily excretion is facilitated renally by the water pill furosemide and gastrointestinally by the potassium binding resin kayexalate. In some emergent cases, potassium can be removed by dialysis.

The danger with moderate or severe (> 7.0 mEq/L) hyperkalemia is the genesis of fatal, cardiac arrhythmias, whose non-fatal progenitors can be seen on electrocardiograms by the creation and absence of peaks in places where there shouldn’t be any. As I learned in the ensuing seconds of my presentation, my transgression was in my failure to obtain an EKG. I never obtained the electrocardiographic tracing because of the reported lack of seeing anything with such mild elevations. Most medical students learn that the earliest changes can be seen with serum concentrations starting at 6.0 mEq/L, assuming the other electrolytes are in order. Regardless of the appropriateness, I had forever been molded to get an EKG for a serum potassium level 5.5 mEq/L.

Months later, I found myself dealing with mission creep when a different patient’s serum potassium level was 5.4 mEq/L. Do I get an EKG now? Reminiscing of Catch-22’s Captain Yossarian, I found myself wondering if 0.1 mEq/L made all the difference between when I would get an EKG on a patient or not. If 5.4 mEq/L was high enough, then what about 5.3 mEq/L? 5.2 mE/L? As the resident on the team this time, I had an intern that I could defer to management and override as I saw appropriate, as the attending had done to me earlier.

“I gave him 15 grams of kayexlate,” my intern said. 15 grams of kayexalate, or sodium polystyrene, was enough to lower his potassium to a theoretical level of 4.4-4.6 mEq/L based on nearly five decades of experience since its first use and in accordance with American Heart Association guidelines.^2,3 For some fateful reason, I found myself looking at the actual lab report of the patient’s electrolytes and found the archetypal asterisk next to the potassium measurement. It had marked the sample as hemolyzed – the potassium level measured was higher than the patient’s true serum potassium level. The patient’s potassium level could have been normal, or even low, and giving a medication to lower serum potassium levels further could have been just as unfortunate as having too high a potassium. I felt knowledgeable educating my naïve intern about the subtle asterisks trailing lab reports. More importantly, I was relieved that I didn’t have to deal with the vexing question of whether to get an EKG for mild hyperkalemia.
Mid-way through residency, however, I could not escape the question. I found myself with another intern treating the same serum potassium level of 5.4 mEq/L on an entirely different patient. This time the patient’s measurement had not been hemolyzed. Feeling anally-retentive, I ordered an EKG and gave kayexalate. Probably both of which were unnecessary, but I had been pre-programmed by my previous experience to obtain EKGs in mild hyperkalemia. And, I could not make the same mistake twice.

As my intern was presenting our management, he met a cavalcade of criticisms for now over-testing and over-treating mild hyperkalemia. I jumped in, blurting

I just wanted to be sure that we didn’t…

My attending cut me off with the same fervor the previous attending months ago had for doing the exact opposite management for nearly the same situation. I felt like I was in the twilight zone. Or the hospital of Catch-22. I was the Captain Yossarian of medicine. The situation left me wondering if 5.4 mEq/L was all that different from 5.5 mEq/L? Or not? Our attending this time was content to have mild hyperkalemia and would have preferred us not to have given the kayexalate or ordered an EKG. True, kayexalate has the rare and unpleasant side effect of intestinal necrosis requiring emergent surgery, and an EKG can lead to more testing and intervention than otherwise would have been necessary.⁴ We as a medical team also had more pressing issues, like the persistence of a fever in the other patient across the hall. But probably the biggest reason to not intervene would be because mild hyperkalemia is called mild for a reason. The best course of action would be to repeat labs the next morning, or perhaps earlier if one was absolutely concerned that the serum potassium level was rising.

The differences in management within healthcare can be considered to be the so called “art of medicine.” However, to borrow another adage, beauty is in the eye of the beholder. To some, the varied and polar managements in the same setting might be called the “craziness of medicine.” This is repeated over and over in many other situations, like the physician’s preference for PSA testing in older men. For more permanent and serious issues, it is worthwhile to include the patient in the discussion and have them pick their management. In the age of ever-increasing patient awareness and involvement, some would argue that I should have presented the various treatment strategies with all of their associated risks, benefits, and alternatives and allowed the patient to make an informed decision for mild hyperkalemia. In effect, I would be consenting the patient for a minor electrolyte abnormality, but patient-centered decision making will always trump physician-centered decision as we, as a medical community, have made a conscientious effort to value patient autonomy. However, if we started doing this for mild hyperkalemia, where would it stop? Would we consent patients for the blood draw to check the electrolytes in the first place? A blood draw, or venipuncture, gone wrong can cause a hematoma, an abscess, thrombophlebitis, a blood infection, and worse when one patient’s blood is mislabeled as another and physicians then treat the wrong patient. The possibilities of the risks are endless. To consent for everything individually would bring healthcare to a halt. Hospitals have circumvented this by consenting patients for most “non-major” things with a general consent. Patients are consented for treatment upon admission with some variant of a “General Consent for Treatment” form that most of us usually don’t pay attention because it doesn’t explain the details of something like the treatment of mild hyperkalemia.

In the end, attending physicians will have their own personal preferences towards medical management. Their preference is a product of their learning and experience, which may have been as confusing and contradictory as their residents’. When following suit, we should understand their choices as best we can, even if they are at odds with what we have learned in the months or days prior. Someday, we will be attendings of our own and be making our own decisions. Some of us will even have our own interns and residents to guide. In the future, I will only observe a potassium of 5.4 mEq/L but likely intervene for a potassium of 5.5 mEq/L.

Citations:

1. http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/
2. http://onlinelibrary.wiley.com/doi/10.1002/jhm.834/abstract
3. http://circ.ahajournals.org/content/112/24_suppl/IV-121.full
4. http://www.ncbi.nlm.nih.gov/pubmed/21463839

The question of how much physical activity is enough is one that will persist as long as there are physicians. The recommendations that I have heard from the professional organizations and pundits stewarding our health vary as much as the patients asking them. 30 minutes three times a week. 45 minutes daily. Exercise as often as you can. The permutations go on…

Perhaps it is of use to think of the purpose of exercise. Yes, exercise is a way to be healthier – however effluvious and variable the concept is for you. But the purpose of exercise is to recreate what humans – and our ancestors – have been doing millenia: moving! Since the advent of bipedal locomotion 4.4 million years ago^1,2, our prehistoric brethren have been walking and, later, running. Some have argued that the development of our wanderlust is rooted in the necessity for being able to travel far and fast to capture prey while hunting³. Since the development of bipedalism precedes our ancestors ability to become effective hunters (at least 40,000 years ago, if not more), it is likely bipedalism evolved to expand the foraging range of early homonins. As our primate-like ancestors became more human, ambulation served other purposes, likes evading dangerous animals and perhaps intra-species foes. It is difficult to truly know the distance our ancestors were traveling since their remnants are fossilized bones and not pedometers. However, we can look at extant hunter-gatherer groups to draw inference.

The best studied hunter-gatherer group of the twentieth century may be the Ju/’hoansi (formerly the Dobe !Kung) of the Dobe area of the Kalahari desert. In the 1960s, the then young Richard Lee, now Professor Emeritus of the University of Toronto, undertook a series of field studies learning about the livelihoods of the Dobe Ju/’hoansi. He found that these people were walking a variable distance daily. The distance they traveled was based on the availability of food sources. After establishing a camp site, they would progressively exhaust their food in a circumferential pattern, initially traveling 5-9 miles⁴ and later reaching 10-15 miles in search of food – a distance that does not take into account other activities⁵. Some days they traveled less. Some more, especially when in the pursuit of prey⁶. Others have found described similar values⁷.

Into how much time does this translate? Well, that depends on your ability to traverse 5-9 miles daily. Time may not be as important as distance, which may be more representative of our absolute fitness. A recent study has shown that the average American takes 5117 steps, or the distance to cover 2.5 miles assuming there are 2000 steps in a mile – half the value of the minimum 5 miles the Dobe Ju/’hoansi were traversing on an easier day⁸. On harder days, the Dobe Ju/’hoansi were traveling 15 miles or more. Who is traveling 15 miles or more these days in America today? Using your Subaru or the subway does not count.

The World Health Organization (WHO) recommendation for adults between the ages of 18 and 64 is to get either 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week⁹. According to the WHO’s lengthy report on physical exercise, moderate intensity is 5-6 on a ten point scale of physical exertion that is solely determined by the one exercising. Vigorous ranks a 7 or 8 on our own personal scale. For the sake of simplicity, assume running an 8 minute mile was a moderate- or vigorous-intensity aerobic activity. All of my readers save for those that are ultra-marathoners, would agree with this. If an 8 minute mile is a vigorous activity for you, then you should be running 1.3 miles a day. If it is a moderate activity for you, then you should be running double. Yet, how does this compare to the Dobe Ju/’hoansi? Well, it may not. The original studies describe the Dobe Ju/’hoansi as walking and, at times, running when in the pursuit of prey or for other reasons. The studies do not describe what their individual ranking of their intensity level or the times spent at varying intensity levels. What the WHO and Dobe Ju/’hoansi do suggest is that if you aren’t walking ten miles regularly, then it would be of benefit to you exert yourself further via moderate- or vigorous-intensity aerobic exercise according to the WHO guidelines.

As living beings, we are self-interested in conserving energy. The advent of combustible engines, electricity, and other labor savor technologies allow us to exert ourselves less and expend less energy. As such, it is vital we continue to find time AND ways to move. We should be moving more. We may not have enough time or knee cartilage to traverse 15 miles every day, but we certainly are more static that our hunter-gatherer comparison, and likely our ancestors.

References:

1 Haile-Selassie, Yohannes. “Late Miocene hominids from the middle Awash, Ethiopia.” Nature 412.6843 (2001): 178-181.

2 Galik, Karol, et al. “External and internal morphology of the BAR 1002’00 Orrorin tugenensis femur.” Science 305.5689 (2004): 1450-1453.

3 Bramble, Dennis M., and Daniel E. Lieberman. “Endurance running and the evolution of Homo.” Nature 432.7015 (2004): 345-352.

4 Lee, Richard. The Dobe Ju/’hoansi. Cengage Learning, 2012.

5 Lee, Richard Barry, and Irven DeVore, eds. Man the hunter. Transaction Publishers, 1973.

6 DeVore, Irven, and Richard Borshay Lee, eds. Kalahari Hunter-gatherers: Studies of the! Kung San and Their Neighbors. Harvard University Press, 1976.

7 Eaton, S. Boyd, SB 3rd Eaton, and M. J. Konner. “Paleolithic nutrition revisited: a twelve-year retrospective on its nature and implications.” European journal of clinical nutrition 51.4 (1997): 207-216.

8 Bassett Jr, David R., et al. “Pedometer-measured physical activity and health behaviors in United States adults.” Medicine and science in sports and exercise 42.10 (2010): 1819.

9 http://www.who.int/dietphysicalactivity/factsheet_adults/en/

With the New Year only a few days away, people all over America are putting pen to paper and partaking in the tradition to begin something a new – to make a New Year’s Resolution. For the patients in my continuity clinic, I hope they use the calendarial homage for change as an opportunity to really seize their health! Carpe sanitas! In my utopian vision at the Veteran’s Affairs outpatient clinic, I see my patients slimming to their ideal weight, living lives without boxes of rolled tobacco in their pockets, foregoing their gastronomic affair with the unhealthy, attending to their medication regimen, and becoming exercise enthusiasts! What an ideal! Yet, I know that if history is any indication of the future, people everywhere, including my patients, are cursed to return to their old habits and to depend on me to keep them from spiraling out of control. However, I have hope: the hope that most of my patients will be better off in 2015 than they were in 2014.

In parallel, I, like so many of my patients, have set my own New Year’s Resolution. Apart from the universal, pre-written resolutions of eating healthier and exercising more, I had one unique and important resolution: to start a blog – a seemingly trivial resolution. In today’s world, a blog could not be easier, but my personal restraints to this blog’s success are not trivial. Time, the enemia major of many resolutions, afflicted me and delayed the creation of the blog for six months. I, like my patients, must overcome these barriers. For all resolutions, their purpose is in something better. For this blog, it is to provide a haven for all things unsaid during daily rounds. It is an opportunity to remember the dying in their last moment, a forum for improvements in health care, a respite from the hum-drum of daily medicine, and likely many other topics of discussion.

I realize that many of my patients who embark on their flavor of a New Year’s resolution diet will have failed within the ensuing weeks. However, some will succeed, and I hope I do too. In thinking of my journey of this blog, from fleeting thought to contemplation to now reality, I think of the quote from the 13th century Francis of Assisi:

““Start by doing what’s necessary; then do what’s possible; and suddenly you are doing the impossible.“