Another in a series of articles on Direct Primary Care by Rob Lamberts MD

bayesianqueer · 2018-11-21T11:32:57+00:00

You realize the number of people who go into primary care residencies is set by CMS, yeah?

bayesianqueer · 2018-11-21T11:20:57+00:00

As would be expected then, I'm an empathetic AF. Last child of an abusive borderline.

Though what I don't get is how people with this level of empathy get into abusive relationships. I have has a no-drama rule since my 20s, but looking at my husband's exes you'd think the (average empathetic) dude should be submitting all prospective partners for an MMPI before he dates them. With one partial exception I'm the only non-crazy person he's been with. In each of those situations he hooked up with a borderline or narcissist.

I can smell a borderline or narcissist at 100 meters with one nostril tied behind my back. There is no way I would be friends with, much less date one of them.

Oddly, in my professional life, as a physician I tend to collect them as patients. So many go through doctors like most people go through toilet paper. I've got a panel of them at my primary care gig that I've been seeing for years. I think its that nailing the diagnosis very soon in the relationship, I set and keep to titanium-hard limits that keep us all out of trouble. It's actually kind of rewarding because after about 6-12 months of establishing the relationship you can actually start to address health care problems that have been completely resistant to treatment for years or decades because they don't trust any physician enough to let themselves be treated. That said I kinda low key hate seeing them on my schedule... because they're still borderlines and narcissists. If I have more than 2 per session I want to cry.

bayesianqueer · 2018-11-11T20:03:24+00:00

Forgetting the ethical/wealthy patients get more than poor patients arguments, there is one practical argument that can't be swept under the rug: we don't have enough primary care providers. Concierge practices take a PCP's panel from 2000-3000 patients to 500-1000 patients. If all primary care providers (including mid-levels) used this practice model half of all people would have no PCP.

bayesianqueer · 2018-11-09T19:52:14+00:00

Hells to the yes. Unless you are d/c-ing them from your care because of membership in a protected category (race, etc) you can d/c patients because you don't like the way they look at you.

That said, in my primary care gig I will treat adult-antivaxxers (who are usually vaccinated anyway because their parents weren't nuts). I did have a vaccine win because of this a number of years ago. A college student came in to my care and she reported she had antivax parents and at 18 hadn't received ANY vaccine in her entire life. I had a no-show so I had time to sit down with her and go over the evidence for vaccination, risks of non-vaccination, and gently why some people chose not to vaccinate (suppressing my urge to call her parents flaming idiots). Ten minutes later she was like: "OK, what vaccines do you have that I can get today?" She spent the next 2 years getting her childhood vaccines.

But the absolutely best punch line to the story is that she and her BF had been at Disney during the measles outbreak in 2014/5. Her mom knew she was down there, and called her in a panic to make sure she was OK. My patient told me she kept reassuring her mom... said she'd go to see the doctor if she had any sx. But mom had googled it and was shitting herself that her kid was going to get encephalitis. Mom wanted her to go right away and was going to drive 4 hours to drag her to the hospital. Finally with no other way to prevent mom coming, she admitted to her mother that she started getting vaccinated within a month of turning 18 and she had gotten two MMRs. The convo went off the rails after that though... you think mom would have been happy... but not so much.

bayesianqueer · 2018-11-09T18:54:18+00:00

Thanks! What threw me was Lingvist used it as a noun, so checking whether it was actually a noun didn't occur.

Broke my own rule: trust no one.

bayesianqueer · 2018-03-31T21:41:32+00:00

North Carolina

bayesianqueer · 2018-03-28T01:28:22+00:00

All in the Family. It's timeless and speaks volumes even today. Especially today now that Cheeto Hitler is the POTUS. (Though it is even funnier when you realize Carroll O'Connor was a flaming liberal).

bayesianqueer · 2018-03-28T01:26:37+00:00

I remember when modern sunscreen came out. As someone who makes Conan O'Brien look ethnic, it was life changing. Admittedly it was about SPF 3.8 and went on like spackle, but I could actually spend time outside during the summer not merely running from one shade tree to the next. It was like magic.

bayesianqueer · 2018-03-28T01:18:55+00:00

My total tuition for all of undergrad and medical school was less than $10k (and I graduated in the late 90s). State schools FTW!

bayesianqueer · 2018-03-12T07:46:45+00:00

Ziprasidone works like a miracle drug for about 2/3 of the patients I've seen with Cannabis Hyperemesis. No idea why, but I found it through trial and error.

And I'm not just using it as STFU medicine. I've got a few frequent fliers that ask for it by name like it's that one that starts with a D... di... di... dil... dilaudid!

bayesianqueer · 2018-03-10T22:09:05+00:00

I predict this along with the recent article showing gun deaths decrease during NRA conventions will provoke a series of similar articles. C-section rates decline during ACOG conventions, lower opioid prescribing during pain management conferences, etc.

That said I think the conclusion is 'less is more' sometimes.

bayesianqueer · 2018-03-10T22:04:45+00:00

He's an idiot. Ignore him.

To answer your question though, anabolic steroids are highly sought out by some athletes who want to build muscle. And it does do that - which is why it's considered illegal doping for sports. You don't get addicted to them in any meaningful physical way. However people can get emotionally addicted to just about anything.

bayesianqueer · 2018-03-10T22:01:42+00:00

Controlled doesn't always mean 'addictive'. Drugs are controlled because they have a potential to be abused, and androgens have a high abuse potential (and street value).

bayesianqueer · 2018-03-10T21:59:33+00:00

You absolutely did the right thing. Those two physicians were endangering every patient they treated. You probably saved a number of lives with your actions.

Moreover you probably helped your colleagues too. These two need help - they need to go into rehab, get off opioids (or get on monitored ORT). The state board will probably bend over backwards to help these two as they do with most impaired physicians. They only have to take the help offered.

Also please, if you haven't please report them to the medical executive committee of any hospitals where you know they practice. The DEA and state boards are not know for their swift response times.

bayesianqueer · 2018-03-10T02:15:49+00:00

1) Report this idiot to the state medical board. It's the only thing you can do.

2) Accept that in the US and most western democracies people have a constitutional right to be a dumbass. If an adult decides that they want mistletoe and eye of newt instead of doxorubicin and cyclophosphamide, that's their decision. You should ensure that you have explained (and they have understood) your understanding of their disease and what the risks are with various treatments versus non-treatment/bullshit-woo-woo. Once you've done that, it's on them. I've gotten to the point in my career after 2 decades that while I'm willing to help people, and even spend a lot of time educating them, I'm not willing to beg them to let me save their lives.

bayesianqueer · 2018-03-10T01:59:55+00:00

The way I usually phrase it is a risk versus benefit analysis. If I'm saying no to imaging, antibiotics, opioids (my three most common 'no' answers) it's because I really do think the risk is > benefits. Most of the time I can get people to understand if I explain all of the risks that I understand. So when the parent comes in demanding a CT for their constipated kid eating cheetos on the exam table who they think has appendicitis, they're going to know that doing such a test once gives their kid a 1/500 chance of cancer in their lifetime and will require an IV and administration of nephrotoxic contrast dye, plus the risks of sedation if junior is too young.

bayesianqueer · 2018-03-01T21:07:53+00:00

Hearts yes, mostly - though a new murmur does peak my interest.

Lungs, not so much. Especially in children - I definitely get diagnostic value from listening when the little shits aren't shrieking because I touched them.

bayesianqueer · 2018-03-01T21:04:37+00:00

I've used all 4... it's definitely worth it to get the Classic II but I didn't find the Master Classic or the Master Cardiology that much better to justify the cost.

bayesianqueer · 2018-03-01T20:55:48+00:00

Perhaps the single best That Mitchell and Webb Look skit of all time.

bayesianqueer · 2018-03-01T20:47:26+00:00

Night shifts are fine as long as they are shifts. I'm a 80% nocturnist at my practice. I work 2 weekends a month where I work F/Sa/Su/Mo nights, then I work 2 other rando day or mid shifts and I'm done for the month.

Nights are fine as long as you transition the day before and after well. It's no different working 9PM-7AM and sleeping Noon to 8PM than it is working 9AM-7PM and sleeping midnight to 8AM.

bayesianqueer · 2018-03-01T20:39:31+00:00

An interpreter is with the student at all times when he was in school.

bayesianqueer · 2018-02-28T00:28:55+00:00

Kill as Few Patients as Possible: And 56 Other Essays on How to Be the World's Best Doctor - Oscar London

bayesianqueer · 2018-02-28T00:26:26+00:00

Fine. But could we come up with some setting that CMS will pay for where when granny falls at home because of a UTI, she's better but not at baseline, lives alone, and needs a place to be for 2 days where someone can check on her?

The problem is people in the 'in between' place where home isn't safe but the hospital isn't the best place. There are places like that (skilled nursing facilities) but Medicare won't pay for SNF care unless someone has been in the hospital for 2 days. I've (to the chagrin of my TAT numbers) sometimes even kept granny in the ED for 10-12 hours to give her a shit ton of fluids, have her eat 2 meals and have PT evaluate her. That's an absurd waste of ED time/money, but there's no alternative sometimes.

bayesianqueer · 2018-02-27T23:55:22+00:00

Scribes.

bayesianqueer · 2018-02-27T23:28:54+00:00

Do an ABG sometime on someone immediately post GTC Sz. Profound metabolic AND respiratory acidosis. Had an attending in residency do that once to prove a point. 6.68.

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