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The Angry Doctor

Updated: 2017-12-10T22:06:45.533-05:00




By a lucky accident, I stumbled upon one of the greatest books I have ever read. The book is “At Your Own Risk: The Case Against Chiropractic” by Ralph Lee Smith, who is some kind of genius. You can read it here.

I’m only halfway through it, and its forty years old, but the things you read in it are unbelievable. It is one astounding revelation after another about the origins of chiropractic, the drive to create a money making bonanza for its founders and “students”, the complete disregard for human life and morals, the love of pseudoscience and “gadgets” that do nothing, and the inability of the government to stop them.

Out of curiosity, I visited the American Chiropractic Association’s website, to see if 50 plus years and a lot of scientific discovery had changed their mission, or at least whittled away some of the more ridiculous ideas they purport. I love these quotes from their website

Doctors of Chiropractic are physicians who consider man as an integrated being

"Chiropractic is a drug-free, non-surgical science and, as such, does
not include pharmaceuticals* or incisive surgery.

With regard to the core chiropractic principle, which holds that
the relationship between structure and function in the human body is
a significant health factor and that such relationships between
the spinal column and the nervous system are highly significant
because the normal transmission and expression of nerve energy are
essential to the restoration and maintenance of health.

For those who don’t know, these guys used to state that they could cure every disease by manipulating out the “subluxations” of the spine. Of course there is no reason scientifically why this should be the case, but whatever.

I dispute that they are physicians of ANYTHING! And of course it’s drug free. Drugs would WORK and their treatments DON’T! And of course the nervous system is “highly significant”. It just isn’t the reason you had a coronary event or pneumonia or meningitis or gallstones or leukemia. And what is an “integrated being”? Is that like Dr. Manhattan from Watchmen?

Chiropractors are, at best, glorified massage therapists, and at worst, greedy fortune hunters with a license. My dream is that one day, all their “schools” will be closed and they’ll all have to get real jobs.



I haven't posted in a year??? That's just because I've been trying to make enough money so I can pay my taxes, so Barack Obama can just give it away to the poor banks. God, I feel so sorry for those bankers, having to beg for change, not knowing where their next meal is coming from, working long hard days trying to manipulate the economy. THEY'RE ENTITLED TO THOSE BONUSES DAMMIT!!! WE HAVE A CONTRACT!!!

I know this has little to do with medicine, but I work my ass off to make a living, and I make too much money to get any rebates/stimulus/etc, so I choose to vent.

Medicare gave a slight raise this year, I detect about 2 bucks for my visits. Medicine is in the toilet.



The Sunday Times Week In Review section contained this nifty letter:

To the Editor:

Thank you for bringing attention to the growing problem of access to primary care in Massachusetts. The problem has been worsened by our universal health care initiative, which was missing a strategy to increase the number of providers to serve the increase in patient load.

Your article, however, focused on increasing the number of doctors to solve the primary care shortage. Nurse practitioners have been filling this role for more than three decades by providing the best in health care.

We are the future of primary care. Make an appointment. We’re open.

Robb Stenson West Falmouth, Mass., April 7, 2008

What universe am I living in? The buffoon can’t be serious! It’s just not possible. Nurse Practitioners are the future of primary care? They are providing the BEST in health care? No one, and I mean NO one in their right mind could believe such a thing. Not even Robb Stenson (and by the way, why the two ‘b’s? Does that stand for BIG BUFFOON??) asks to see an NP OVER a doctor! That’s right! I don’t see any NP hospitals and people clamoring to see NP’s INSTEAD of doctors! They are ANCILLARIES!!! Did they forget that?

It truly makes me just want to give up. Can Internal Medicine be devalued any further? Why do I teach it to med students, when apparently NP’s are the future anyway? And they wonder why students don’t want to pursue a career in IM. Jackasses like Robb Stenson apparently feel they are better than IM doctors and they have a tenth of the training.

I give up. The Apocalypse of Medicine is surely upon us.



The New York Times published a story on the front page of Sunday’s paper about a drug used to treat Gaucher’s disease. The drug is a enzyme replacement for the inherited deficiency in glucocerebrocidase. I was not even aware that the disease can present initially in adulthood. I’ve never seen a patient with it. Not surprising, since only about 20,000 individuals in the United States have ti (according to UpToDate).

The drug in question, Cerezyme, is made by the Genzyme company. As the Times’ Andrew Pollack reports:

Sales of Cerezyme totaled $1.1 billion last year, making it a blockbuster by industry standards.”

Yeah, I’d say that’s a blockbuster by industry standards. Or ANY freaking standards. Of course, any drug rep whoring for Pfizer will tell you, it’s the R AND D costs that make these drugs so expensive. The article goes on to say:

But critics say the company’s development costs were minimal, because the early work on the treatment was done by the National Institutes of Health, which gave Genzyme a contract to manufacture it. And analysts estimate the current cost of manufacturing the drug to be only about 10 percent of its price.”

When the government hands out these “contracts” to private companies, they don’t seem to care too much about the general public, do they.

Now, I’m all for businesses making a profit. I’m no socialist. However, just as the public (and the government) have decided that doctors should not be aloowed to make too much money, so they (and the government) should not allow ANY healthcare providing entity to make any amount of money they want. This goes for Big Pharma, for medical equipment companies, for medical insurance companies, etc. etc. Since physicians are supposed to be putting patients first, why the HELL aren’t these other companies forced to do the same? It’s not as if they have different customers than doctors do. It’s not as if they are getting the money from a different place than doctors are.

And another thing, if this drug is costing insurers 1.1 billion dollars a year (and I’m assuming none of that is being paid for out of pocket by patients), then how can doctors be primarily to blame for rising healthcare costs? I don’t cost anywhere NEAR that much. Think how much money could have been saved if the United States had just set up the drug manufacturing for Cerezyme by itself. No profit would have been sought. The drug would probably be like 100 bucks a shot.

BUT NO!!! Let’s cut reimbursement to all Primary Care doctors, so we can heap billions of dollars for a drug that treats a few thousand people. Makes perfect sense. In CRAZYLAND!!!



I was just watching the travesty that is the CBS Evening News with Katie Couric. They reported that in Texas (and even Iowa) many people fly to Mexico for healthcare and prescriptions to reap the delicioso savings available in a town called Metmoros or something like that. Apparently a doctor’s office visit is as low as THREE BUCKS! (He says a visit to a US doctor is 125 bucks. Where the hell did he get that number?)

And then they plant some truck driver making next to nothing who says “The American Healthcare system is a TRAVESTY!”

Byron Pitts is, I am sure, a nice guy. But does he make any mention of the fixed costs that doctors have that they probably do NOT have in Mexico. Rent, for instance, for the Primary Care doctor in my office is FOUR Thousand DOLLARS A MONTH! That’s probably, like, a million bazillion pesos. But I’m guessing the rents are not so exorbitant south of the border. Also no mention of electricity costs, malpractice costs, billing and overhead costs.

If I charged each patient 3 bucks (which the CBS Evening News seems to be exhorting me to do) then I see my practice lasting about 4 weeks, until the rent is due.

I mean, three into 4000 is 1333, so I only have to see 66 patients day to pay the rent. What’s left for my bartender?

I’m guessing neither presidential candidate is going to advise people to go to Mexico for healthcare, a la Mike Bloomberg telling NYC residents to go to Starbucks if they need a bathroom. And doctors are scapgoated, once again, for the rising costs of healthcare. And one of their brilliant proposals is to lower the poverty rate so more people will qualify for Medicaid. I can't wait to get 30 bucks instead of three for an office visit. (and 7 bucks for a follow up in the hospital. Woo hoo!)



My apologies for not writing in so long. There are many things I read that I want to blog about, but then I watch television.

I want to get right back on the train with a round of applause for one of the best articles I have ever read in the New England Journal of Medicine. Their critical appraisal of “Chronic Lyme Disease” (and I LOVE the quote marks) was short and sweet, and there are so many takeaway messages.

The first, of course, is that there is NO good evidence of any such entity in the medical lexicon. What I mean to say is, it is NOT A RECOGNIZED INFECTIOUS DISEASE! Here’s a quote from the Infectious Disease Society of America website:

an extensive review of scientifically rigorous studies and papers available to date, has determined that there is no convincing biologic evidence to support a diagnosis of chronic Lyme disease after completion of the recommended treatment

But don’t tell the chowderheads at so-called “support groups” like this one. They are all over the country (even in places where Lyme is NOT endemic), composed of rich people, and have NOTHING BETTER TO DO but use the internet to obsess over their pathetic lives.

Apparently, for the believers, you do not even need to have a positive antibody test against Borrelia burgdorferi to make the diagnosis., because it might not be valid unless done by a “specialty laboratory”, which is, of course, a scam, since they are performing tests that are not even validated or supported by the FDA, and are using criteria that are based only on their own fantasy values.

This is the second takeaway message: that there’s a sucker born every minute. In this case, the sucker is the poor sap (or self-important “expert” patient) who seeks out the “Chronic Lyme specialist” (laugh heartily, men-of-science) for weeks, months, even YEARS of chronic antibiotic therapy which is proven to do NOTHING except cause complications of side effects and catheter infections (one resulting in DEATH, according to the article).

The article goes on to discount every theory that the “Chronic Lyme” fraudsters purport. But the most disturbing part of the article comes near the end. Here’s a quote:

The attorney general of Connecticut has begun an unprecedented antitrust investigation of the Infectious Diseases Society of America, which issued treatment guidelines for Lyme disease that do not support open-ended antibiotic treatment regimens

An attorney general is actually pursuing legal action against an academic society because they disagree with his unscientific view of a bogus clinical entity that is disproved by science. Saying I am shocked and nauseated does not begin to describe my true feelings. How is this possible in 2007? Why are lawyers pretending to be scientists??? Does this guy own a bunch of these “specialty” clinics or something?

That’s the final takeaway message: science is now being dictated to by people who have absolutely no idea what they’re talking about, and aren’t interested in real research.

Thank you Henry M. Feder, Jr., MD er al, and the Ad Hoc International Lyme Disease Group for the article of the year!!



My wife recently took my 18 month old to a pediatric neurologist that was recommended by our pediatrician. I like our pediatrician. She’s very direct and “old school” and is highly competent. So I trust a recommendation from her.

She may be right, and this pediatric neurologist may be great. However, I would never know because my wife told me that she NEVER EVEN GOT TO SEE HIM!!! No, she saw the Nurse Practitioner (cue scary music). And then when my wife protested, the staff told her “Oh, don’t worry. The doctor will come in to see your child afterward”.

Well, that turned out to be a gigantic load of bird-plop! He wasn’t EVEN IN THE OFFICE!!!

I called the doctor himself to protest this shoddy treatment. He reassured me that his NP was his “partner” for six years, that the NP had published more papers than the doctor had, that the NP’s capabilities were superb.

I told him that, while all of this may be true, there was one indisputable fact: I know what kind of training (for the most part) a pediatric neurologist has received. I have NO FREAKING IDEA what kind of training a pediatric neurology NP has received. And what’s more, I really don’t care! I don’t care if the NP has written 100 papers, published in every major journal in the nation (well, actually that would be pretty cool).

Also, I object to his use of the word “partner”, as if his credentials were somehow equivalent with the NP’s. What is he thinking?

Look, I understand why NP’s exist. It’s an economic reality of office based practice. It increases the number of patients that can be seen. However, when it comes to a very specialized group of patients, especially nervous parents who obsess about their little one, for whom they’ve lost so much sleep (SO MUCH) in the last 18 months, I think an NP is not good enough. And shame on his staff for lying about his availability. (He states he was stuck at another hospital, which I understand. But the staff completely misled my wife).

I will never employ an NP to see my patients for me. End of story. Ditto for PA’s. They can draw blood, they can do post visit counseling, they can hold a patient’s hand.

But they aren’t doctors.



There is a certain kind of blog poster that has been angering me. It’s the nuts on KevinMD that make the claim over and over that somehow I, and all doctors like me, are responsible for creating this system where insurance companies bilk doctors and patients, and that, after years of “doctor abuse” and “doctor fraud”, I am just now getting what I deserve.

What a complete load of garbage.

Just to clue all of these brilliant thinkers in, I completed residency training FIVE YEARS AGO!!! So the idea that somehow I am responsible for the current system is total crap. Does anyone think doctors made any substantial monetary gains in the last FIVE years? Or even the last FIFTEEN???

When I entered medical school, I had ideas about being a respected professional who could offer opinions and diagnoses to ease suffering, cure disease, and as my father told me “You won’t get rich, but you’ll never go hungry”. Well, truer words were never spoken my friends. I am not rich, and for the most part, I haven’t missed a meal (except on call of course). But I did manage to amass over ONE HUNDRED AND FIFTY THOUSAND DOLLARS IN DEBT!!!

So when I was slogging through Gross Anatomy and Physiology, according to the “just desserts” crowd, I should have KNOWN that HMO’s and insurances were perpetrating dwindling reimbursement on doctors and that Medicare was dropping their payments. I should have KNOWN that doctors in the 70’s and 80’s were doing unscrupulous things like putting pacemakers in dead people and charging for them (a fact told to me by an esteemed medical director who saw these things happen and did nothing to prevent it). I should have KNOWN to study these things just as hard as the Biochemistry and Microbiology and Pathology I thought I would need to be a good doctor.

After four years of school and three years of mind-numbing residency, I was, of course, desperate to find a job that would help me pay down this debt I had acquired. So I took the first job offered that paid well (I felt). According to the “just desserts” crowd I should have rejected all insurances, Medicare, etc, and just took cash only or raised my fees.

Well then, I just have one question… WHERE THE HELL AM I GOING TO FIND PATIENTS???

The people who make these statements are just clueless. And they blame doctors like myself for the way the system is. Just as you would blame me for slavery during the Civil War or I would blame Germans today for the Holocaust. It’s such a tired argument and serves no purpose, except to make the “just desserts” crowd feel better about blaming doctors for high health costs. They forgot that doctors become competent only through studying and hard work. The best doctors aren’t the most business savvy ones. They should ask themselves which doctor they want to see: the one who’s practice is booming because they’re making money hand-over-fist, or the one who paid attention in Path.



Anytime I watch the television news I get severe dyspepsia, but recently I had the misfortune of watching CNN headline news.

You see, CNN often has long boring stories about John Edwards’ haircuts, so sometimes I just want to hear the top stories before work. They’ve employed some Asian doofus named Richard Lui, who insists on peppering the headlines with “funny” comments. Hey, more power to ‘em.

But this is not why I exploded with rage.

After an obnoxious commercial for Aricept, Richard Lui returns with a shocking headline. His quote: “Lettuce could help wipe diabetes off the face of the map!”.

At this point, I’m pondering losing many of my patients to the “miracle” cure. I am awed at the possibility of curing an epidemic that plagues America and causes so much morbidity and mortality. I await Richard’s next words with razor-like attention.

He goes on to say that a study from the University of Central Florida is working with genetically modified lettuce AND… researchers are going to test it on humans to see if it affects insulin levels.” THE END!

Well, the weight of the headline is belied by the fact that the "report" is lacking in any substance. I’m not sure why I expected anything more from “CNN Headline News”, but the story was so misleading, that CNN and Ted Turner really ought to say a million Hail Marys and Our Fathers before they can even THINK about forgiveness. Mr. Lui doesn’t even make an effort to explain how this mutant lettuce has one damn thing to do WITH diabetes. It’s all left to the imagination, as if some aliens had left the recipe buried in Hanger 51.

Well, every obese diabetic who has a Devil Dog in one hand, and their insulin in the other just caaaaaaalm down. First of all, it’s only a potential cure for Type ONE diabetics, not Type TWO (the ones we see in the office). Apparently, Professor Henry Daniell at UCF has created a way to deliver insulin-producing genes that he is infusing into lettuce. He previously used tobacco plants and fed them to diabetic rats. (He’s going to give them a heart attack, I tell you…) You can read more about it here.

So good job Richard and your CNN brethren. Way to pump up the hopes of 20 million diabetics in America with your “psudo” news article. You really are true human excrement.



The New York Times published a story today involving the growing MinuteClinics at various Duane Reade pharmacies throughout the Northeast. They differ from the typical MinuteClincs which staff NP’s and PA’s and instead have actual doctors. This is an improvement, though it encourages the one-time visit, and leaves little chance for follow up, as the patient likely couldn’t make an appointment with anyone.

I love this quote:

“And doctors’ groups, whose members stand to lose business from the clinics, are citing concerns about standards of care, safety and hygiene, and they have urged the federal and state governments to step in to more rigorously regulate the new businesses”

Now why did they have to go and add that little gem? Couldn’t the statement stand on its own without it. It just undercuts the VALID concerns placed after it.

But anyway, this is not what made me angry about the article. That part is buried near the end. Apparently, Continuum Health, my former employer, is joining into an unholy alliance with Duane Reade to supply the very doctors I mentioned above. Here’s the quote:

“Under the partnership agreement, the doctors at Duane Reade will have admitting privileges at the Continuum hospitals and the drugstore clinics can streamline a patient’s journey to a specialist or through the emergency room, when that is necessary, because of the relationship, company officials said.”

So did everybody catch that? These doctors from Duane Reade will have ADMITTING PRIVELEGES!

Now, these Continuum hospitals hire numerous faculty attendings, and presumably by having these OTHER doctors staff these new clinics, they are undercutting their own faculty by siphoning away the business to these Duane Reade clinics. So at first this didn’t make sense to me.

But then a colleague explained it to me. They will be able to increase admissions to the hospitals, since these pharmacy docs have admitting privileges. So if they lose it on one end, they’ll get it back on the other. Good for them. It’s this kind of entrepreneurial thinking that makes me proud to be an American.

Of course, it will simply increase the amount of TOTAL CRAP that gets admitted to the unsuspecting medical teams. But hey, doctors can even learn from crap, can’t they?



An editorial in the NEJM this week concerns medical futility in Texas. Dr. Robert Truog MD writes about the case of Emilio Gonzalez.

Emilio had been diagnosed with Leigh’s disease, a pediatric illness which is fatal. Sometime before he was 2, he ended up on life support at Children’s Hospital of Austin for five months! Dr. Truog describes some of the painful events, especially how the mother refused to let the hospital move the child. She took the hospital to court, but before the judge could issue a ruling, the child died.

(Does this outcome vindicate the judgment of the doctors? Hmmmm….)

Anyway, it’s a sad ending to a sad case. But this is not what made me angry.

It’s Dr. Truog’s take on ethics committees themselves. Here’s what he says:

“ ...most members are physicians, nurses, and other clinicians from the hospital staff... they are unavoidably “insiders,” completely acculturated to the clinical world and its attendant values. This is hardly a “jury of peers” for a low-income woman of color and her infant son.”

He feels that the ethics committees agree too often with providers. (He states later that ethics committee at Baylor agreed with the clinicians 43 out of 47 times. Gee, I wonder why.)

I will tell you why: Because they know what they are doing.

First, I hate the seamy implication that because the woman is of “color” and is “low income”, that the doctors involved (pediatricians, I suppose) were more willing to treat them unfairly. They kept him on life support for FIVE MONTHS!!! And he died of his TERMINAL ILLNESS!!! (It’s like Terri Schiavo all over again).

Additionally, I do not understand AT ALL his beef that the committee is made up of mostly doctors, nurses and people who are “insiders”. WHO SHOULD IT BE??? Lawyers and people who have never cared for a sick person a day in their life!!???

I’m sure we’d all like someone with no clinical judgment or experience except what they’ve seen on TV to offer an ethical opinion. That makes as much sense as letting a postal worker manage your finances!

Ethics committees are correctly loaded with people who understand a life is at stake, and that family members are the best advocates of the patient. The fact that they agree with practitioners is a testament to the practitioners’ clinical judgment, NOT evidence of a “conspiracy”. I mean, did anyone ever meet someone on an ethics committee who wasn't a "touchy feely" do-gooder? I sure haven't.

Also, what is with his obsession with the whole “jury of peers” and “due process” systema? This isn’t a court of law. It’s an ethics committee. There is no need for a “jury of peers”. No one is on trial. Doctors, nurses, social workers and clinical minds are trying to come to a solution, much the same way a “tumor board” works. I don’t think anyone would call for a “jury of peers” at Tumor Board, if a patient’s cancer treatment was to be decided. That’s because it isn’t appropriate.

Dr. Truog has got it wrong.



A recent thread of posts about the relationship between PCP’s and specialists, spawned by Dr. Rob’s sardonic “open letter” has inspired me to comment on one particular beef I have with consults.

Specifically, in-hospital consults.

I won’t comment on the anger that bubbles inside me when a consult fellow will just outright “refuse” to see someone because they don’t think it’s an “appropriate” consult. That’s a whole different blog entry.

No, I want to comment on the annoying tendency of specialists to say absolutely NOTHING!

Here’s an example. An older patient comes with some bright red blood per rectum. They may have a history in the family of colon cancer, or maybe they were anemic. Whatever. The consult note usually reads thusly. First they mention the chief complaint, then they have a brief history, then there is the ubiquitous rectal exam.

And then at the end it says “Assesment/Plan: Colonscopy Monday.”

Ummmm, excuse me? That’s an assessment?

No, that’s a test.

So rarely is any thought offered in the note. Now, I’m sure the differential diagnosis is well scripted in their minds. But unfortunately, it doesn’t get put to page, and there is no communication until after the test, when you may get a courtesy call from the gastroenterologist who says “Yeah, colon looked clean. A few hemorrhoids.”

Well that’s just super. But of course, you never get an inkling of what they thought was MOST LIKELY! And it’s not just GI consults. Heme consults have irritated me with the annoying “So what do you want me to do? It’s medical management.” In other words, if they can’t do a bone marrow biopsy, and it’s a boring anemia case, then good luck to you.

(Oops, there I go, talking about fellows. Must … re…sist)

But I digress. Whether it’s a fellow or an attending consult, the note should be helpful and the PCP should not be left in the dark. Please just remember we didn’t call you only to do a test. Thought MUST occur!



Sorry for the lack of posts. I've just started my private practice and have been a bit busy.

I have some posts brewing, including my continuing series on "Blank MD".

Stay tuned.



I'm probably beating a dead hrose with the whole ER thread I wrote last week, but I just want to quote PandaBear. He writes a post about drug addicts, and says that one tried to fake his way through a chief complaint of rectal bleeding. He syas:

"It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit."

So even before he checks the guy's labs, he is saying he doesn't believe he's having a significant bleed. Probably what any sane internist/primary care doc would surmise.

But Panda also says this:

"And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry"

So he drew a stat hemoglobin and hematocrit, EVEN THOUGH he figured the guy was full of garbage. Why didn't he just kick the guy out of the ER if he was so sure? Why did he send the stat labs???

Because, my friends, even the Panda knows that liability is key, and just in case the guy is NOT full of it, he has protected himself. And he's in the ER, so he has access to those stat labs when he needs them.

So for those ER-heads out there who would laugh if an internist sent such a patient to the ER (or any other patient who could use a stat lab to rule out a life threatening condition), please reflect if you would have acted any differently had you recieved the call or lab result or whatever at your office or home. Clearly, the PandaBear is making the same mistakes the primary care guys are making.

I promise this is my last post on the topic. Until I get angry again, that is.



Here are four scenarios:1)A patient has their PCP paged at 6:30 PM, after hours, when the PCP is on the way home. They complain of diarrhea and abdominal pain that seems mild, but has not stopped.2)An older patient comes in without an appointment and complains she saw blood in her toilet. She has felt dizzy and wanted to run in to see her PCP. But the office is swamped and she’d have to wait. There is no nurse to draw blood.3)The lab calls with an emergency value. The potassium is 3.3.4)It’s the weekend. The lab calls: INR is 5.So what should a PCP do? Should he:a)Tell these patients to wait until they can be seenorb)Tell them to go to the Emergency Room?I don’t feel there is any other answer to the question than ‘B’. And I’ll tell you why. Because momma raised me to NEVER DIAGNOSE OVER THE PHONE! That is just something a doctor should not do under any circumstances. And unless the office has a nurse and a lab, as well as NG tubes, central line kits, and blood, you’d have to accept the fact that most PCP’s offices are not equipped to deal with these situations anyway.Case one is based on an actual gastroenterologist in Florida who was told by a man’s wife he was having these symptoms. He advised Maalox and see him the following day. He ended up having IBD and dying that night. Oops. Malpractice ensued of course.Case two is common enough. And I don’t want to personally wait on a CBC for a whole day, even with negative orthostatics, as that physical exam finding is notoriously unreliable (I can cite an ER doc who made this statement at a conference if anyone takes umbrage with that.)Cases three and four speak for themselves. Even if I called the patient with low potassium at home and asked him to check his pulse, I’d STILL not take a chance. Same goes for the INR patient.911doc made the following statement:Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me. What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.I say “Yeah, so what?" Is there something different an internist or FP could do in the office for these patients? I fail to understand the point and what should be different. What is an emergency room for? If the chest pain is even remotely possibly cardiac, that’s an emergency. At least for me it would be.Whether the PCP shows up at the ER, whether the PCP sends a note, whether the PCP’s midlevel made the call are all complaints that have NOTHING TO DO with the point 911doc is making, which I find is false and hollow.The fact is, is that hospital care doesn’t pay enough for the time spent. So if a PCP hasn’t placed a central line since residency, so what? An ER doctor probably doesn’t remember a lot of other things they once learned in medical school. Because they don’t need to know them anymore. And even if I placed a central line in my office, then what? I don’t have a 24 hour center in my office. Even if I ran a code, they still have to go to the hospital.I had an ER attending tell me he wouldn’t do a paracentesis because he wasn’t covered for that under his liability insurance. The resident under him couldn’t believe it any more than I could. He probably just hadn’t done one in years. And you know what? Big deal. So I did it. And now it’s been years, and I probably would have to remember how.Big deal.Hey 9[...]



In my last post I responded to 911doc's post about the decline of primary care by posting a vignette I experienced which crystallized one hallmark of ER medicine nowadays: DISPO!

Clearly the ER mentality is that the workup and stabilization are NICE, but the mindset has become that of an over-educated administrator: ADMIT EM OR STREET EM! Once the decision is made, the job is done, more or less. ER residents are inundated with this advice from the moment they start residency.

I want to address specifically the complaint about these lazy internists/hospitalists upstairs and their desire for "completeness".

What does "completeness" mean? Does it mean we want EVERYTHING done? Does it mean we expect a diagnosis if admitted?

No, of course not. What it means is basically not STICKING YOUR COLLEAGUES WITH SCUT!!

I will illustrate with one of my favorite personal examples.

When I was a third year resident, a famous incident occured between the ER and our department. It was a particularly busy winter evening, and during the night, there were so mnay patients in the emergency room, you could hardly walk without stepping over someone. There was a tremendous pressure to get people upstairs (naturally) and of course there were NO ICU beds.

One younger, sick patient had symptoms typical of meningitis. However, the ER was so desparate to get people out, they had assigned a bed on the regular medical floor, DESPITE that no LP had been done.

The famous part of this story, is that the third year IM resident, who was the liason between the ER and the IM department, LEAPED ON THE GURNEY and refused to let them move the patient. The ER was aghast, and they would NOT do the LP or anything else for the patient. So this IM guy gowns up (even though he's busy as hell), does the LP, and guess what... PUS comes out of her spine. So of course she has to go to the ICU, and he REFUSES to let them send the patient anywhere else.

Can you imagine?

So that's a good example of where "completeness" might mean one thing to the ER doctor, and something else to an internist/generalist.

The point is NOT to criticize ER docs. Its to point out that the system isn't perfect. So STOP lamenting how primary care docs are responsible for all your ills. It's not so.

Part III in my next post, where I'll address the idea about what kind of patient gets referred to the ER from the office.



Happyman referred me to 911doc's column about the downfall of Internal Medicine and Generalists... but then proceeds to rip Primary Care doctors a new one, including hospitalists (which I was for the last 5 years) because they demand "completeness". He faults IM and FP's for punting to the ER for many different complaints, unwilling to take on the "liability". He laments how we don't want to run codes anymore.So much is wrong and/or asinine about the column, I hardly know what to say. Being the Angry Doctor, I've decided to say the following: you are full of garbage, 911doc!Let me tell you my personal favorite story concerning the ER:One evening, I was admitting an 80 year old female who had multiple medical problems including heart failure, asthma, cancer, etc... yet despite this, she was a sweet old lady and still functioning well. I'm called to see her up on the floor at around 6 PM. I walk in and the woman is gasping practically. I check the ER "workup" sheet. This woman had gotten an X ray, the ubiquitus troponin, and Tylenol. Yes folks, they gave her only Tylenol for her shortness of breath.OK, so I slap oxygen on her, I go review the X ray, and then I whip down to the ER to confront the physician who sent her upstairs. The attending physician listened to my diatribe, and then called over his resident and said "Dr. Angry wants to talk with you."Fine, I said, if you want to sacrifice your resident to me, be that way.I begin my tirade: "Ms. so-and-so is gasping upstairs. You didn't do anything down here for her, so obviously you couldn't have been that concerned. Why did you admit her?""Shortness of breath.", the resident replied."Well, she had a history of asthma. Did you give her any nebulizers?""No." he repsonds."Why not?""Because she wasn't wheezing.""So then why did you admit her?""Shortness of breath" he replies."Her X ray was reported to have an infiltrate on it. Did you think about giving antibiotics?" I mused."Yeah, my attending and I looked at it, and we just didn't think she had pneumonia. She had no fever or cough.""So why did you admit her?""Shortness of breath" he replies."She has a history of cancer. Did you consider a pulmonary embolus?" I ask."Yeah, she just didn't seem like she had a P.E.""So why did you admit her?""Shortness of breath" he replied."She has a history of heart failure. Did you give any lasix?""No. There was no congestion on the X ray.""So what did you admit her for?"Do I even need to type his reply?I was shocked. Usually my complaint about the ER is that they perform and administer many unnecessary things, making it harder for those lazy internists upstairs to make a diagnosis. Here was the exact opposite: they had done NOTHING! (Oh, except they gave Tylenol. I forgot.)So I turn up her oxygen, I give her nebulizers, I give her antibiotics. I gave her lasix.It doesn't occur to them that maybe she doesn't have a fever because she's immunocompromised from cancer. It doesn't occur to them to check for a blood clot, even with her unexplained dyspnea and history of cancer. That maybe she's not wheezing because she's having what they used to call stage IV asthma.I get called two hours later and the nurses are like "she's still very short of breath." I say "OK, give her lovenox and get a stat CT angiogram" And guess what... she had THREE PULMONARY EMBOLI in her lungs. (Gee, good thing its not an emergency, right ER docs?)So it's just as easy for me to make disparaging remarks about the ER's complete lack of motivation to diagnose (DISPO DISPO DISPO... the mantra goes, right?) as it is for these ER heads to lament how lazy primary care docs have become. Why all the[...]



The New England Journal of Medicine published an interesting series of editorials this week about ESA’s. (erythropoesis stimulating agents, click here and here). For the non medically inclined, these are injectable agents which stimulate the bone marrow to produce red blood cells. I want to point out some fascinating things I learned from these articles.

One is that it is NOT indicated for anemia from cancer. It is only recommended for anemia secondary to chemotherapy, or at least it was only evaluated on that basis, an attempt to reduce the number of transfusions required.

Secondly, it is NOT approved by the FDA for alleviating fatigue or weakness or to improve a patient’s quality of life. In fact, the FDA has stated that there is “no evidence that [the agents] improve quality of life or cancer outcomes”.

I didn’t realize that, and from the commercials released by Amgen, you’d suspect otherwise. You remember those, right? An older woman is power walking and she describes how her fatigue was due to anemia and the Procrit had given her back her energy. Well, since there was no evidence to back up that little bit if play acting, why was it allowed to air?

Well, the FDA’s own Oncologic Drigs Advisory Committee recently criticized these very ads and director Richard Padzur made this helpful quote, saying the FDA should give “the American public…the reason why these ads were allowed to go on”.

I don’t think we need to look too far for the reason. My guess is, it’s green, made of paper, and can buy a lot of nice things.

Finally, I did not know that it INCREASED your risk of dying of your cancer. And I’m not just talking about hematologic cancers. Apparently HEAD AND NECK cancers! And METASTATIC BREAST CANCER! How in the world does this happen? No one has a clue right now, because there just isn’t any good test to detect if there are receptors on these tumors for the drug, or if its due to more angiogenesis and, thus, more tumor proliferation.

Talk about your poorly publicized facts.

I have given ESA’s to many anemic patients suffering from end stage renal disease and if they have chronic disease anemia without underlying bleeding, or if they required a lot of transfusions, but were refusing surgery or colonoscopy. I never tried to get the hematocrit about 30% and I don’t think these papers apply as much to my practice as an oncologist’s. But I still think its more evidence of chicanery between the FDA and Big Pharma, and 180 degrees removed from the best interests of patients.

Ok, off for a few days with the family. See you next week.

And STAY ANGRY!!!!!!!



I am fascinated by my recent revelation that melatonin somehow has effects on cancer. It originally came to my attention during my research on “Sleep MD”; specifically during a passage in a review article on melatonin in the NEJM in 1997. The mechanisms by which melatonin exerts this effect are not known. The following mechanisms are proposed:

1) inducing apoptosis in tumors with the melatonin receptor
2) stimulating production of IL2 (antitumor response)
3) modulation of oncogene regulation (???you got me)

Melatonin is an antioxidant, apparently it is a more potent free radical scavenger than vitamin E or the other antioxidants usually bandied about on TV.

Most of the studies have been done by a group of Radiation Oncologists in Milan, Italy. In 1995, one small study was carried out with patients who had metastatic breast cancer and it appeared to slow their disease. In 1996, they published a study in the journal Oncology which showed increased survival in a small number of patients with glioblastoma who got melatonin.

In 1991, a study by a different group of malignant melanoma patients showed a transient reduction in tumor size. Considering the miserable prognosis for such patients, it’s worth noting.

The most recent study from this group in Milan fascinates me. I went to my local medical library and had them print me out a copy. It was published just a few months ago and involved 370 patients, all of whom had either advanced non-small cell lung cancer, or advanced gastrointestinal tumors (colon and stomach). They received standard chemotherapy with or without melatonin (doses of 20 mg per day, which is higher than the typical sleep doses).

Turns out, there was statistically significant differences in overall tumor regression AND 2 year survival. (At the end of two years, there was 25% survival in the melatonin group, vs. 13% for the non melatonin group, p<0.05).

I am not a fan of nutritional and holistic supplements. But these studies illustrate the exact reason why: we need well performed, repeated studies with real results. THAT could make many physicians and science-minded people converts! So based on this data, I believe I would recommend melatonin to some cancer patients. It’s not a cure, but there is no cure for metastatic disease, is there?

And let the message go out to other supplements: if you want to be taken seriously, get your pathetic butts in the lab! Maybe someday, we can drive these herbalists/naturopaths out of business! (I can dream, can’t I?)



The New York Times offered an editorial by David Leonhardt, one of their economic writers, concerning the reason healthcare in this country is so expensive. Here’s his take:

The main reason so many people lack health insurance is because of its cost. And a big reason for that cost is the explosion of expensive, medically questionable care, be it knee replacement, preventive angioplasty or lumbar fusion

The example he cites is of lumbar fusion. Apparently, a tiny town in Idaho accounts for a disproportionate number of spinal fusion surgeries, and that the data on its efficacy is mixed. He also says that it cost Medicare 600 million dollars to provide these surgeries in 2003.

A large number, to be sure. I would note that after this introduction, Mr. Leonhardt abandons the topic of disparate medical procedures and manages to focus on Democratic presidential candidates’ plans for universal health care. I’m not sure why Republican candidates’ policies aren’t mentioned. Must be that ol’ “liberal bias” that seems to land George Bush in the White House every four years like clockwork.

But I digress. I have no idea if lumbar spinal fusion is medically questionable. I have not looked at the data. My personal feeling is that back surgery, in general, has disappointing outcomes. The newest one is “kyphoplasty”, but the data I was shown looked promising, as long as an orthopedist didn’t get greedy and try to do multiple vertebrae.

The point I want to make is that, while there may be too many lumbar fusions, that isn’t the biggest expenditure we should be focusing on. It’s EXPENSIVE ELECTRIC WHEELCAHIRS and other frauds! Consider this quote from a CNN article:

Medicare's 80 percent share for power wheelchairs grew from $22.3 million in 1995 to $663.1 million in 2002. That total already has been surpassed in the first nine months of 2003.

Some of these wheelchairs cost as much as used cars! Should a wheelchair cost so much? Of course not. I mean, a baby stroller is maybe a few hundred dollars. How does a wheelchair cost 5000 dollars? Isn't that what a Segway costs?

And I can’t count how many patients in my resident clinic asked me for a letter so they could get disability. One said to me that she couldn’t do her job because her “feet hurt”. I said “Why don’t you get a job on the phone.” She looked at me like I was crazy and said “Oh, I got schizophrenia, I don’t think so good.”

With so many “hard working” Americans sucking at the teat of Medicare and collecting disability and SSI, no wonder the system is going broke. If some of these deadbeats went to work and stopped defrauding their own government, maybe Mr. Leonhardt wouldn’t have to write this article. Why is so little attention devoted to this topic? I guess because it’s more fashionable to solely blame doctors and hospitals for exploding costs.



I will continue my investigation of the “BLANK MD” product line. Check here for the beginning of my series. The ingredients in SLEEP MD can be found here.The first ingredient listed, white willow bark, is also known as Salix alba. “Salix” is Latin for “willow” so that’s logical. They isolated salicin in 1828 from the bark. It is a derivative of salicylic acid, hence it does have ability to treat fever. Sometimes I hear NSAIDS make patients sleepy, so I suppose this may have utility, or if your insomnia is due to pain, in which case I might see a doctor (shudder).There is a delicious helping of “Valerian extract”. (it says “deodorized grade”, so the stinky version must not be so helpful). A journal called “Sleep Medicine” (gee, I wonder what that’s about) published a systematic review of the literature on this tasty herb and guess what? I’ll quote them:“The evidence for valerian as a treatment for insomnia is inconclusive.”So far, we have a weak pain reliever and an inconclusive stinky herb. What else is in this crud?There’s some lemon balm and hops extract. Maybe a Mike’s Hard Lemonade is in order.OK, what about our old friend melatonin? In the 1950’s, the hormone melatonin was isolated, and over the years it was discovered that the pineal gland releases more melatonin when it’s dark, and inhibits its production when it’s light out. A study in the Lancet from 1995 seemed to find melatonin helped in elderly patients, but there were only TWELVE people in the study!Studies done in the journal Sleep indicated young adults had faster time to sleep and a deeper hypnotic state (wheeeee…) There’s also inconsistent results in allieviating jet lag. Most of the studies are summarized in a nice review in the NEJM here. The most fascinating (to me) is that melatonin may slow METASTATIC BREAST CANCER! That’s right! You heard it here first folks (well, not first, but anyway.) Check out the citation here.A review of chronic insomnia in the NEJM in 2005 notes the following:Studies of melatonin, which have involved small numbers of subjects treated for short periods with various doses and formulations, have demonstrated conflicting results.So melatonin may (or may not) help sleep onset, jet lag, and sleep potency.Passionflower extract is also an old time medicine used for insomnia and anxiety. The problem is that no good scientific data exists to intelligently evaluate this compound. If you don’t believe me, just read these learned people here. Ditto for the Scutellaria lateriflora.Coenzyme Q10 rounds out the slop, but I couldn’t find treatment of insomnia as even one of the common uses of this supplement. You can find a nice list hereSo this is how Marvin Heuer, MD and this band of quacks make the big bucks. They package melatonin and valerian root together with some other garbage that has no science to back it up, and call it “SLEEP MD”!All in a days’ work for these chowderheads.By the way, melatonin from – 5.99 for 120 tabletsSLEEP MD from - 15.99 for 30 tablets..[...]



Two colleagues who are Cardiologists have decided within a few months of each other to abandon private practice. They both cited the same reason: dwindling reimbursement. One had just moved his office to a new site and after a month had had enough! He said that insurers just wouldn’t pay and office costs had gotten out of control. He said the whole thing was a mess.

The other was the first attending I ever had as an intern in residency (about eight years ago). As far as I am concerned, he is synonymous with my hospital. He’s an older doc who is very honest and smart. As such, he refuses to perform what Happyman calls the “trifecta” of ECHO, stress test and holter on every person that walks through the door. This left him the option of seeing, as he puts it “100 patients a day”. He is now joining a practice at a hospital across town.

So the message appears to be that if you are a smart clinical cardiologist, and you decide that a patient doesn’t need a bunch of expensive tests, you will actually LOSE money. If you are not clinically skilled, or if you just need to make more money, then doing a bunch of unnecessary tests becomes NECESSARY to stay afloat.

Obviously, if you put in an extra three years of fellowship in Cardiology, I think you are entitled to more money. I think you deserve it, primarily because of the liability factor. As an internist, if I’m not sure about something, I can just defer to you and then in court I can plead “Hey, I accepted that I wasn’t sure what was going on, so I appropriately called a Cardiologist.” So the buck stops with the specialist.

But I don’t think the extra money should ONLY come from unnecessary tests. That just encourages fraud and waste. And drives intelligent specialists to merge with hospitals to reduce costs and overhead. So then the HOSPITAL can foist unnecessary tests on the public.

I am doing the “reverse commute” soon, leaving the hospital for private practice. I’ll let all of you know whether I fall on my face or not.

Soon, I will return to the “BLANK MD” product line which so angers me.



“The business of America is business!” Calvin Coolidge once said. (Well, he actually said “the chief business of the American people is business”, but hey, close enough). Nothing wrong with that, right? Profiting from any new technology is as American as apple pies and facelifts.

So when I read in the New York Times’ Week in Review section that a startup company called 23andme is going to be selling transcripts of what it deems to be the important parts of your DNA genome, I thought to myself “Gee, what a great idea.”

And if you believe that was my first thought, then you haven’t been reading my blog. Companies such as Illumina, Applied Biosystems and 454 Life Sciences can supply your entire genome for the low, low price of $100,000! The Times tells us that some of the people who have already signed up include Paul Allen, co-founder of Microsoft, Stephen Hawking, and Larry “Loan me 50 dollars” King. Oh, and Michael Milken. Gee, what a treasure trove of information his genome will be.

So many problems exist with the idea of having your genome on a disk that I hardly know where to begin. One is the theft issue. If you think thieves can benefit from your social security number, just think what they can do with your genetic blueprint. I think your insurance company would looooove to get their hands on it, which brings up another thorny ethical problem. There are some laws that protect us against genetic discrimination, but that field is still being sorted out.

I also do not look forward to having a patient show up and say “It looks like I’m positive for a DR2 mutation. I want to get tested for vasculitis.” What do I say to such a patient? Do I have to spend a half hour explaining to them that they have no signs or symptoms of vasculitis? That the blood tests are not definitive? That insurance would likely not cover the tests? That there’s no preventive measure to take anyway? Will there be any time left to actually check their blood pressure?

On top of all of this, an interesting article appeared in the April 11, 2007 issue of JAMA. Researchers tested 85 variants of 70 genes previously reported to be associated with coronary artery disease. And guess what… they found that NONE… that’s right, NONE of the variants were more common in the patients with CAD.

What does that mean? That means WE DON’T KNOW S%&$ about genomics! So for those of you who are plopping down 100 GRAND to get your genetic code, GOOD LUCK doing anything with the information!

Jackassess! (That means YOU Larry King!)



Just to recap my series on Dr. Marvin Heuer, MD. Be sure to read each thrilling installment.

Dr. Heuer received a medical degree in the 70’s and actually saw real patients (I believe) for six years. Then he joined Smithkline in the 1980’s and started a journey where he sold his soul, and broke it into so many pieces, that all that is left is a powdery substance that, when added to water, produces a power drink that builds muscle mass.

Seriously, look back at Part II to get a sense of how many "medical" businesses he was a part of. From hawking pharmaceuticals, to infertility clinics, to “novel vaccines”, to bogus nutritional supplements, to an ANIMAL HYDRATING BEVERAGE (gee, I thought it was called “water”). How low can a doctor sink when he is spending time creating drinks for non humans???

Here’s a list of diseases his CV suggests he did research on:
Rheumatoid arthritis
Hormone replacement therapy
Overactive bladder
Acute exacerbation of chronic bronchitis
Community acquired pneumonia
Lipid lowering

Most researchers spend their whole life on one topic. Not Dr. Heuer. If a drug company comes calling, he ANSWERS the call with aplomb!

Here is a picture I find particularly amusing and apropos. Here’s Dr. Marvin posing with a fellow "researcher" marveling at a fabulous new product meant to better mankind:


Makes him proud, I bet. Shown with Jay Cutler (who the heck is Jay Cutler), Dr. Heuer has finally become a punch line. A very sad one.

This is the man behind the “science” of the “BLANK MD” product line.

Weep for him.



An overseas military newspaper called “Stars and Stripes” published an interesting article recently. Apparently, two soldiers currently serving in Iraq felt compelled to try the weight loss supplement Hydroxycut (I can’t imagine losing weight would be my first priority if I were in Iraq, but anyway…)

Both men ended up in the emergency room. One of them, 20 years old, had a change of mental status and collapsed. The other, a 19 year old, had a potentially fatal arrhythmia. Colonel Frederick C. Good, the treating ER physician wrote a letter stating:

“Hydroxycut … should not be used in a combat zone with the inherent problems encountered in regard to hydrating adequately and eating regularly,” according to the letter. “… The use of this product or any similar products is strongly discouraged, and any remaining product should be discarded. This product and any similar products are not a shortcut to fitness, and no substitute for a regular Physical Training program.””.

Seems like straightforward advice that’s pretty sound.

Starightforward that is, unless you’re Dr. Marvin Heuer, MD!!!

You see, Dr. Marvin is the head of Iovate, and they make Hydroxycut. Here’s his take:

“My gut feeling as a physician who has worked in the emergency room is that there were tons of other factors there that may have had an influence,” said Heuer in a telephone interview…

So he’s telling our soldiers “It’s perfectly safe!” and it sounds like he’s encouraging its use, EVEN THOUGH a military doctor is advising our soldiers to avoid it. Now, I’m not sure what effect these supplements played in these soldiers’ medical problems. However, since they are fighting for our country, and since there’s potential for harm, and very little benefit, maybe Dr. Heuer could do the responsible thing and just shut the f%$# up.