Jonathan Schwartz, M.D., currently is serving as a Chief Medical Resident in Internal Medicine at the University of Colorado Denver and will begin a fellowship in Cardiovascular Disease after his chief resident year.
Learn more about Insights on Residency Training.
(1 votes, average: 5.00 out of 5)
Loading ...Recent advances and discussions in medicine are the cornerstone of Journal Watch. Here’s the fifth installment of the articles that made the biggest impression on me in the past 2 weeks. I hope you enjoy the articles I selected.
Please feel free to leave a comment on the articles — Do you like them? Dislike them? Agree, disagree, state your opinion, and participate in the discussion. And if you know of another recent interesting article, post a link to it. I would love to read it.
Greg Bratton, MD
Articles of Interest:
Physicians Recommend Different Treatments for Patients Than They Would Choose for Themselves - This interesting article brings the dreaded question, “What would you do, Doc?” to the forefront. We have all been asked how we would proceed in a given situation. This article suggests that our answers are not always truthful. A group of primary care physicians were presented one of two hypothetical clinical scenarios. One scenario involved choosing between two treatment options for colon cancer, and the other asked about two treatment options for avian flu. For the two treatment options in each scenario, one had a high rate of side effects but low risk for death, and the other had a low rate of side effects but a higher risk for death. In analyzing the data, in both scenarios, a large percentage of physicians chose treatments with higher risk for death for themselves, but only offered them to their patients between 25% and 50% of the time. Which begs the question, “Are we, in fact, treating our patients like we would our mother??”
(5 votes, average: 4.60 out of 5) Loading ...
I joined a gym today.
It has been 18 months since I last lifted a dumbbell, ran on a treadmill, or attempted anything else to tune my body. In my own defense, I didn’t stop working out because I was lazy; in fact, quite the contrary. Truth is, 18 months ago, my son was born, and, since then, I couldn’t justify spending an hour more away from him than I needed to.
So, over the last year and a half, you could say I became a bit “soft.” Soft around the mid-section; soft in my dietary choices; and soft in my commitment to a healthy lifestyle. Chicken nuggets, macaroni & cheese, donuts, and French fries are so hard to turn down when the precious little hand of your son is feeding them to you, and you see the smile on his face every time you take a “dinosaur bite!”
But, if I have learned anything over the last 6 weeks of working in the ICU and on the Cardiology service, it is that dinosaurs are extinct, and I will be too if I don’t start changing my ways.
Specifically, over the last 2 weeks, I have seen four patients my age (+/- a year or two) who suffered heart attacks and required intervention. Let me be clear here, I saw FOUR patients in a span of 10 days who suffered non-fatal MIs not far from their 32nd birthdays!
One patient I am caring for is a 63-year-old gentleman who also recently suffered a heart attack and subsequently received angioplasty and stent placement. He had no risk factors, no family history, and was not obese. He simply awoke one day with chest pain and decided to get it checked out. Thank goodness he did, because he had near- complete blockage of his left anterior descending artery.
When we rounded on him this morning, he was sitting at his bedside alongside his wife, full of life and with a notebook full of questions. As my attending began to debrief him on the recent events and procedures that were performed, I could see his mind going into overdrive trying to absorb all the information. When it came time for him to ask his questions, he scanned his premade list, took a deep breath, and asked, “How can I prevent this from happening again?”
When I heard this, like a cowboy had jerked on the reigns of a horse, my head perked up. For some reason, this fortunate man’s simple question struck a chord in me. Why should I wait until I am 63 years old and recovering from a heart attack to change my ways? Why should it take an adverse event to convince me that I need to live healthier? I am young and knowledgeable. I need to do it now, if not for me, then for my son and future children. I need to be healthy for them.
When I left work today, I turned over the proverbial leaf. Instead of heading straight home to sit on the couch and wrestle with my little man, I made a quick stop with longstanding benefits.
I joined a gym.
(2 votes, average: 5.00 out of 5) Loading ...Recent advances and discussions in medicine are the cornerstone of Journal Watch. Here’s the fourth installment of the articles that made the biggest impression on me in the past 2 weeks. I hope you enjoy the articles I selected.
Please feel free to leave a comment on the articles — Do you like them? Dislike them? Agree, disagree, state your opinion, and participate in the discussion. And if you know of another recent interesting article, post a link to it. I would love to read it.
Greg Bratton, MD
Articles of Interest:
Glycemic Control in Hospitalized Patients: Hold On Loosely? - A common topic on Medicine rounds – whether in the ICU or on the wards – is blood sugar. Likely, this is because of the preponderance of diabetics that require hospitalization. However, keeping tight control of their sugar in the hospital might not be as crucial as keeping tight control of it in outpatients. According to this study, intensive insulin therapy (IIT) “… did not improve short-term mortality (at 28 days), and no consistent evidence showed that long-term mortality (at 90 or 180 days), length of stay, or infection rates were better with IIT.” The major side effect of IIT was hypoglycemia, which might be associated higher mortality, dementia, and adverse cardiovascular events. The American College of Physicians have now recommended a target blood glucose level of 140 to 200 mg/dL while in the hospital. And suddenly, I hear nurses in the background scream in excitement as q4hr Accuchecks become a thing of the past!!
(9 votes, average: 4.56 out of 5) Loading ...For a week, the patient in bed 301 had been fighting.
After being found unresponsive and hypothermic in the field, this 48-year-old male was brought to the ICU and was treated for metabolic acidosis, end-stage liver disease, hepatic encephalopathy, and an acute upper GI bleed, all in the context of presumed alcohol intoxication/withdrawal. It was not until later that we discovered that, in conjunction with everything else, he had ingested a substantial amount of ethylene glycol, better known as antifreeze.
From what we could gather, he was a transient and had spent the last several years living in the streets and his family members’ couches. In fact, 3 months ago, he left his aunt’s house one morning and “disappeared,” not to be heard from or seen again. It wasn’t until we called the number in his chart to obtain collateral information that his family discovered his whereabouts.
He had a past medical history significant for hepatitis B andC but continued to abuse alcohol and other substances. As a result, his liver had been so severely damaged that he suffered from esophageal varices, recurrent ascites, and altered mentation. Now, as a result of his antifreeze ingestion, he had grade D esophagitis as well; hence his GI bleed.
While in the ICU, he was on a ventilator for respiratory failure, hemodialysis for acute kidney failure secondary to the ethylene glycol intoxication, pressors for hemodynamic instability, and serial paracenteses. And despite our best efforts, he simply did not improve. He failed multiple weaning trails from the ventilator and could not maintain his blood pressure without medication. We all knew early on that his prognosis was poor.
One night, while I was on call, I stopped by his room to see how he was doing. With the beep of an empty IV bag in the background and the timed inspirations and expirations of the ventilator blowing precisely every few seconds, I stood beside his bed and quickly realized that his prognosis had gone from “poor” to “fatal.” Sometime during the last hour or so, he had begun to bleed out of everywhere. His foley, rectal tube, endotracheal tube, and nasogastric tube were all full of blood; his central and peripheral lines had saturated their dressings. His body had gone into DIC, disseminated intravascular coagulopathy, a poor prognostic sign which carries with it 10%-50% mortality. Casually, DIC stands for “Death Is Coming.”
I quickly contacted family and advised them to come as soon as possible. For his mom, it meant driving 3 hours from Oklahoma. I assured her that I would do everything I could to keep him alive until she arrived, but I could make no promises. She said, “Please, do your best.” So we began to hang blood and clotting factors to try to limit his body’s destruction. The family arrived to bedside around midnight.
It was about 3 o’clock in the morning when I got the page from my nurse. After what had to be a very painful and difficult couple of hours, his family had decided to withdraw care. Out of respect for the family, I wanted to be present to answer any last questions and to show my support for their decision.
We extubated him, turned off the pressors, gave him some pain medication, and made him comfortable. Then, I left the room to allow his family to share in the moment privately, but sat outside within view of the patient, just in case.
As I sat and waited for nature to run its course, I found myself staring at the monitor. This 20” black screen with a black background captivated me like nothing has before. I watched the red cardiac rhythm line, anticipating its demise to asystole. I watched the blue respiration line, waiting for it to cease making upward movements as his breathing failed. And I watched the green pulse line and rate number continue to fall toward zero. I was enamored with the little black box and all the information it was feeding me.
But then, out of the corner of my eye, I saw my patient’s mother, aunt, and brother, leaning over his bed, whispering caring remarks into his ear, holding his hand, and crying. They were doing everything they could to demonstrate to him their love and heartbreak. They ran their fingers through his hair, caressed his legs, and kissed his cheeks. It was a terrible, beautiful sight.
Suddenly, I realized that I had fallen victim to what happens to so many doctors. I stopped feeling. I stopped seeing Bed 301 as a person. To me, he was a critically ill patient that needed to have care withdrawn because Medicine told me he would not survive. I had accepted that he needed to die because his condition was deteriorating rapidly. What else could we, as doctors, do? Dump tons of blood and blood products into him, at the cost of depleting the blood bank and his family’s bank account and delaying the inevitable??
I forgot that he was someone’s son, someone’s brother, someone’s love. I forgot that even though Medicine told me he would not survive, it meant nothing to his family who relied on faith and miracles. I discounted that all his family wanted was a chance for him to survive. And I thought of my own son and family and, abruptly, the power and emotion of the moment became real to me.
I was affected that night.
I am nearing the end of my residency and, perhaps, have become jaded and skeptical and insensitive to many situations. I find myself doubting a patient’s pain level due to presumed drug-seeking; questioning the truth behind a patient’s story; and not giving a patient the benefit of the doubt when a treatment regimen fails.
What Bed 301’s passing did for me was reinforce to me that patients are not objects. Their conditions are not black and white. In fact, they are people, dynamic and colorful, just like the rainbow of colors bouncing on the monitor.
And, although I was focused on the right thing the night the patient in Bed 301 died, my context was way wrong. Those colored lines in the little black box represented life, not vital signs.
So, thank you, Bed 301, for reintroducing me to the colors of life. When I stop and look at them, they are beautiful.
(2 votes, average: 5.00 out of 5) Loading ...Recent advances and discussions in medicine are the cornerstone of Journal Watch. Here’s the third installment of the articles that made the biggest impression on me in the past 2 weeks. I hope you enjoy the articles I selected.
Please feel free to leave a comment on the articles — Do you like them? Dislike them? Agree, disagree, state your opinion, and participate in the discussion. And if you know of another recent interesting article, post a link to it. I would love to read it.
Greg Bratton, MD
Articles of Interest:
Sterile Gloves to Obtain Blood Cultures? - Although it seems intuitive, a study published in the Annals of Internal Medicinereveals that the rate of positive blood cultures went down when sterile gloves were used. Mentioned in this review was the fact that the current guidelines from the Clinical and Laboratory Standards Institute do not require the use of sterile gloves. From personal experience, making this small procedural change would save time, money, and potential antibiotic resistance by limiting the number of “coag-negative staph in clusters” found in routine blood cultures.
(3 votes, average: 5.00 out of 5) Loading ...
I was talking to the third-year medical student who was rotating on my Medicine service the other day about what type of medicine he thought he might end up practicing and, astutely, he said, “Family/Internal Medicine.” I raised my eyebrows. Shortly thereafter, he conceded with a chuckle that he wasn’t sure.
“I hope I figure it out soon,” he said. “It is really nerve racking.” I told him not to sweat it. I also told him that things would work out like they are supposed to and that one day he would wake up and just know.
When I went to medical school, I had no doubt in my mind that I was going to be an orthopedic surgeon and work with elite athletes. Coming off of a collegiate sports career myself, that’s all I knew. So for my first 3 years of medical school, I did everything I could to make sure that this would be my reality. I joined the orthopedic interest group and served as an officer; I did research; I schmoozed with the faculty to assure quality letters of recommendation; and I surrounded myself with orthopedic friends. I did everything I could be become a member of the fraternity.
But when I did my orthopedics rotation as a third year, I found that I enjoyed it, but I didn’t love it. I tolerated the operating room and the surgeries, but I never found myself getting excited about scrubbing in like I thought I would. Initially, I chalked it up to being a MS-III and not really being able to participate — other than to retract — and possibly to not having the best residents and faculty on my team to introduce me to the specialty. But as time went on and the ERAS application began to stare me in the face, I felt just like my medical student does now — scared about my future.
Daily, I would try to convince myself that things would be different in residency and out in practice; that I could learn to love the operating room; or that orthopedics was still what I was supposed to do. Then, one morning in late May of my third year, out of the blue, I awoke and saw things differently. As if I had decided in my sleep, my worries were gone and my mind was clear. I realized that I was not going to pursue orthopedics, but rather Family Medicine.
What!!?!?! Family Medicine?? Out of nowhere, I jumped ship from the specialty for which I had been grooming myself to primary care??
My only experience with Family Medicine was a 6-week rotation at the very beginning of my third year. Sure, I loved it, but I figured that was because it was my first rotation, and I was finally out of the lecture hall. Heck, I probably would have loved basket weaving at that time! When I analyzed my decision, a determining factor was the ability to have more consistent time with my family. With Family Medicine, I could coach little league, go to the school plays, and take my kids camping — things I couldn’t do if I was tied to the operating room. Plus, I could envision myself seeing patients in a clinic at age 50, but I couldn’t see myself in the OR at that stage of my life.
This week is “Match Week” for the 4th-year medical students. By Friday, these young physicians will be learning their professional fate. Whether they’re ready or not, they will open envelopes that will tell them where they will be spending the next 3 to 5 years of their life. And, if they are like I was, the anxiety of this moment is killing them because the future they were so scared of as third-year students will soon be reality. Their fear and anxiety now likely isn’t about making the right choice, but rather is about not getting into their number one choice, ending up living in the middle of nowhere, or of not matching at all.
However, on my Match Day, my fear and anxiety was centered around whether I had made the right choice by not pursuing orthopedics. Now, though, 3 years later, I am about to graduate from JPS as a Family Medicine physician, and I am happier than I could have ever imagined. And I can say without a doubt that I absolutelymade the right decision. Family Medicine has afforded me every opportunity that I want out of medicine. I think critically about medicine patients; I perform procedures ranging from colonoscopies to skin biopsies to joint injections to delivering babies; I develop relationships with my patients; and I get to see my family. I get to live the life that I always dreamed of!
So if I could talk to this year’s graduates, I would tell them what I told my third-year medical student, “Don’t sweat it. That things will work out like they are supposed to.”
Believe it or not, dreams do come true. Mine did. Happy Match Day!
(3 votes, average: 4.67 out of 5) Loading ...Recent advances and discussions in medicine are the cornerstone of Journal Watch. Here’s the second installment of the articles that made the biggest impression on me in the past 2 weeks. I hope you enjoy the articles I selected.
Please feel free to leave a comment on the articles — Do you like them? Dislike them? Agree, disagree, state your opinion, and participate in the discussion. And if you know of another recent interesting article, post a link to it. I would love to read it.
Greg Bratton, MD
Articles of Interest:
Cribs, Playpens Pose ‘Unacceptable Level of Danger’ (and the original Pediatrics article) - Stories of children walking into their parents’ rooms one morning asking for breakfast after climbing out of their cribs could be a thing of the past. In a retrospective review of 19 years worth of emergency room data concerning injuries to children younger than 2 years, 80% involved cribs and roughly 2 in 3 involved falls, proving an “unacceptable level of danger.” So although using the baby crib you were raised in could save some money, maybe you’ll want to think twice.
(5 votes, average: 5.00 out of 5) Loading ...
I admit it. International medicine and I don’t dance.
Whereas a lot of my former classmates and current colleagues have gone to Brazil, Ghana, Haiti, Israel, Thailand, and Papua New Guinea for medical missions, I typically travel only as far away as high school football buses can go on a tank of gas. I prefer the comfort of stadium lights and training rooms to that of lean-tos and thatch huts. And I much prefer the smell of fresh cut grass on a Friday night to the odor that still lingers in the streets of Port-au-Prince or the smell of disease in Ghana.
I don’t think this means I am less of a doctor or less of a person; it is just that my passion resides elsewhere. I have great admiration for my colleagues who have braved harsh living conditions and social turmoil to provide care to the indigent of other countries. I learn from their stories of treatment under duress, operating with limited supplies and unsanitary conditions. I embrace their creativity, spontaneity, and resourcefulness. But most of all, I respect their unwavering dedication to serving others.
Ironically for me, international health is a huge player in our residency here in Fort Worth. Not only do we have a rather large contingent of Family Medicine residents who participate in mission trips, we have our own International Health Clinic that provides care to refugees living in Tarrant County. On any given day, we might treat patients from Somalia, Burma, India, or any other remote area of the world. In addition, we have several faculty members who have made international medicine a huge part of their career.
Dr. John Gibson and Dr. David McRay, both graduates of our program, have each spent a significant amount of time in foreign lands. Dr. Gibson lived in and practiced medicine in Thailand for 20+ years, doing everything from primary care to surgery. Dr. McRay, meanwhile, leads multiple medical missions every year, most recently to Haiti and Israel.
But probably one of the most impressive men associated with our program and involved in international medicine never actually was a part of our program. To be honest, I never even met him. Although in reading about him, I wish I would have had the opportunity. Luckily, though, I have the privilege to train alongside his daughter, Kate, who is a third-year resident with me here at JPS.
Dr. Thomas Little, an optometrist from upstate New York, was 1 of 10 medical missionaries murdered while returning home after a humanitarian mission in northern Afghanistan in early August 2010. In the late 1970s, Dr. Little and his wife, Libby, went to Afghanistan as relief workers and ended up raising their three daughters in the war-torn nation while treating thousands of needy patients each year. Their mission: offering vision care and surgical services to those in regions where medical assistance of any type was virtually absent.
Unlike my passion, Dr. Little’s passion was always teeming with risk. But Little was reportedly a natural for the job. He spoke the language, knew the local customs, and had the patience and diplomatic skills to handle sticky situations. In fact, in an interview he gave before he died, he recounted times when family picnics ended after attempted Taliban kidnappings. Yet, he and his family stayed “out of a love for the people and a passion for providing eye care for the needy.”
“We raised our three daughters through what was, at times, just hell,” Libby Little said. “A hundred rockets a day was a good day.” She went on to say that warfare in Afghanistan didn’t deter her or her husband. “If you’re in medicine, I think you feel you can’t leave. If you’re propping up a hospital that’s the only hospital, then you can’t leave when it gets bad.”
Before paying the ultimate price, Dr. Little helped to coordinate the National Organization of Ophthalmic Rehabilitation Eye Care Program in Afghanistan, which is charged with overseeing hospitals and clinics, teaching optometry and administering care in the most rural of areas. Through their work, NOOR is able to bring eye care to millions of Afghans. “He died right where he loved to be — and that was doing eye care in remote areas,” Mrs. Little said from her home in New York. “Our daughters are missing him terribly. But I think their feeling is, too, that this is a real passion that he had.”
Recently, as an “example of generosity and goodwill,” Dr. Little was posthumously awarded the Presidential Medal of Freedom as a way to better know the meaning of sacrifice and the necessity of peace. Along with Dr. Little, other recipients included George H.W. Bush, Dr. Maya Angelou, Warren Buffett, Stan Musial, and Yo-Yo Ma.
“The Medal of Freedom is the Nation’s highest civilian honor, presented to individuals who have made especially meritorious contributions to the security or national interests of the United States, to world peace, or to cultural or other significant public or private endeavors.”
And although he is in great company with those who have also received the award, I believe he was in great company before his death. Dr. Little was in the company of thousands of selfless individuals who also stare death in the face on a daily basis just to bring health and peace and resolution to troubled lands all across the world. In my mind, when his wife received this award from President Obama in honor of her husband, she was receiving the award for all the Dr. Gibsons and Dr. McRays out there who sacrifice their time and money, as well as risk their lives, to fulfill their passion.
So I want to take this opportunity and say thank you to all those who fall into this category. Through your efforts, our world has a better chance of healing its wounds.
I might not be able to dance to your music, but I do love listening to it.
(1 votes, average: 5.00 out of 5) Loading ...Recent advances and discussions in medicine are the cornerstone of Journal Watch. To provide some insight into what I believe is potentially the most practice-changing current medical information for busy clinicians, I will be highlighting three articles every other week that I think are interesting, relevant, and, in some cases, just plain fascinating. I hope my selections allow you, the followers of this blog, to expand your knowledge without spending too much time (that you probably don’t have), and I hope you enjoy the articles I select.
Please feel free to leave a comment on the articles — Do you like them? Dislike them? Agree, disagree, state your opinion, and participate in the discussion. And if you know of another recent interesting article, post a link to it. I would love to read it.
Greg Bratton, MD
Articles of Interest:
Diet Soda Tied to Vascular Risk, With Caveats — Although this was a weak study that was not controlled for variables other than drinking diet soda, the results hint at things to come. For me, I think it is addressing people who order a Big Mac, large fries, and a Diet Coke at McDonalds. Change your eating habits and start exercising — then diet sodas won’t be an issue.
(2 votes, average: 4.50 out of 5) Loading ...
Believe it or not, it snowed in Texas this week. Mixed between our normal seasonal 60-degree days, were 5 days of ice, snow, and wintery chaos. To most outside of the Lone Star State, snow days aren’t that big a deal. You put on a heavier coat, grab the snow shovel, strap the chains on the tires, and trudge your way through life as if nothing happened.But not here in Texas.
In Texas, when it snows, life stops. No one leaves their house. The roads become barren ice lands. The hardware stores sell out of their limited supply of space heaters — usually enough for the occasional power outage — and grocery stores sell canned goods as if the Apocalypse is coming and the only way to survive is to bunker down for years on end.
Case in point, for the 5 days that the Arctic decided to visit North Texas, all the clinics I had scheduled were cancelled, leaving me at home with my wife and son. Sure, I enjoyed myself – making snowmen, sledding, relaxing by the fire, and snuggling under a warm blanket — but the thought did cross my mind, “While I am here enjoying myself, where are my patients, and what is happening with them?”
Unlike a lot of professions, being a doctor dictates that even when most have time off, we don’t. We don’t have Christmas breaks or government holidays. We work. We work because we have patients, and patients don’t schedule their sicknesses or their traumas around a predetermined calendar. In fact, while in residency, I have had to work or be on call every major holiday for the last 3 years. But what are you going to do? Stop practicing medicine? Nope. So, naturally, as I remained homebound, something felt amiss.
The other day, as I relaxed in my pajamas with a hot cup of coffee and the morning paper open to the sports section, I realized that I was beginning to feel guilty. Guilty because the people that count on me most — my patients — were potentially at home struggling with their COPD, fighting a fever, or cursing the heavens because their arthritis pain was out of control. And, yet, here I was, soaking in a few extra days with my son, finally catching my breath after a hectic month on Medicine, and loving it. Truthfully, I was enjoying life.
But what else was I supposed to do? It was snowing in Texas.
Doc Dohner, as the people of Rushville, IL, call him, has been working as a small town physician for the past 55 years. He works around the clock. In fact, in his 55 years of providing care and service to the people of Rushville, Doc has never had a day off. It is reported that, even after he broke his back and suffered a heart attack, he treated patients from his home. “I have to take care of my patients first,” he said.
So how does he do it? How does he maneuver around the environment and the unpredictability of life to continue to place patients first? How does he not feel guilty about always working and being away from his family?
Lynn Stambaugh, Doc’s office manager and a former baby that he delivered, thinks that it is because “every day he makes a difference to at least one person, and if you can do that, you can go on.”
After I came across this story, my guilt shifted to shame. Here is a man that not only has sacrificed holidays, but his entire life to serve his patients. And then there was me, at home, playing with my 15-month-old son, and thinking to myself, “I wish I could stay home every day and not go back to work.” I have always said that family will come first in my life, regardless of where I am or what I am doing. This is a belief that I hold dear and vowed, not only personally, but to my wife on our wedding day. However, this fantastic physician in rural Illinois places patients first every day.
So I questioned, “Am I being selfish? Does this reflect on my capacity as a doctor? Are my priorities twisted?”
Then I realized. My priorities aren’t twisted. Doc Dohner has the same mindset that I do. But whereas my family consists of my wife and son, his family included the 4,300 people of Rushville and the 3500 babies he has delivered. He wasn’t trudging through life taking care of patients; he was taking care of his family. He cared when someone was in the emergency room or was in distress, just like I would care if my wife was in the same situation.
I had it right. I should want to be home. I spend way too many nights away, pouring my heart and soul into treating my patients “as if they were family,” — a few days for myself with my real family is just what the doctor ordered.
Plus, I am pretty sure that as I built Frosty with my son, shared a blanket beside the fire, and held him tight to keep warm, I made a difference to him. And that erases any guilt or shame that I may have temporarily experienced.
Now, does anyone know how to treat Cabin Fever?? I have a bad case of it.
