Don’t mess with your neck doing yoga either

For some reason the NYT is all about neck injury lately. In yesterday’s discussion of a possible chiropractic induced injury, Russell asked:

But given all the other stresses people put on their necks, from accidents such as headbumps, from purposeful athletics such as whacking soccer balls, and from just craning one’s head in odd positions when performing various kinds of mechanical labor, it puzzles me that the risk from a chiropractor would be much greater than the risks from these other kinds of use/abuse. Of course, this is not excuse for the chiropractor, who is imposing that risk, likely on those more susceptible to injury, under false pretense or treating disease. It’s more a general lament that we each carry so much haphazard anatomy.

Interesting he should mention this as today the NYT has an article How Yoga Can Wreck Your Body describing many ways that neck hyperextension during this popular exercise can also create similar injuries to the vertebral and carotid arteries.

The mechanism is similar…
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Nerds once again in control of government

And I breathe a sigh of relief. Working nights my schedule is a tad goofy, but I wake up today to see this guy describing the changes in the new budget:


This is Peter Orszag the new director of the Office of Management and Budget. He is a nerd and I instantly like him. I was not surprised to find he used to be a blogger.

It was especially refreshing because for too long our government has been run by this guy:

In particular I agree with their emphasis on health care as a necessary element for creating a viable modern economy. America has to compete with other countries that provide this for their workers, and we have a system that regularly ruins the finances of our citizens. I also agree with it as a moral necessity. Within the last week I’ve admitted several people for whom a hospitalization would result in significant financial stress. I talk about it with them, and they’re terrified. On the one hand, they need help. Sometimes their life depends on it. On the other hand, if they lack insurance a hospitalization can bankrupt them, and they’ll honestly admit, they avoided doing anything about their problems until they become life-threateningly severe because they are they can’t afford the help. This isn’t just stupid system, but immoral.

Additionally the need for reform of redundancy and costs in medicine would be a welcome reform. While the privacy issues with the electronic medical record are significant (I’d love if Chris would comment on this), the obvious need for it is undeniable. I can’t tell you how many times tests, expensive tests, are repeated because of incompatible records systems, delays in record transfer, and, frankly, the fact it’s sometimes just easier to duplicate the test than do the scut to find the answer. The emphasis on evidence based medicine, an attack on redundancy, and improvements in coverage will go a long way towards decreasing the terrible costs to insurers and the government, and terrible financial harm medical care can do to our countrymen. I am excited about seeing how this will be implemented, and relieved that once again we have people in charge who use words like “data” and “evidence” and seem that if there are problems generated by these reforms, they will be receptive to criticism.


My father-in-law wore his nickname without irony. His was the kind of nickname that would be tough to bear on the playground, but despite being a teacher for decades, any juvenile thoughts wouldn’t have crossed his mind. I don’t think he knew how to be insulted.

And while he may not have been easy to insult, he did have pride, and as he became more and more disabled by chronic illness, his frustration grew. His attitude and that of his wife was remarkable. Sure, he complained about being dependent on others, but when he needed to start dialysis, he took it in stride. When he became more and more physically unable, his intellectual life continued to flourish. He continued to be a film and theater maven, and read plays for a local theater group.

But certain things he just could not bear. When he became incontinent, when he could no longer lift a book or turn its pages, he began to lose hope. There are certainly some people who can go on living with dignity and vivacity, despite being locked in an uncooperative body, but Dick wasn’t one of them. The insult to his dignity was too much, and being deprived of his intellectual pursuits by weakness and delirium was too much. He was miserable, although he still had a smile for my daughter. He was afraid—afraid of being alone while unable to do for himself. He couldn’t even push a call button for a nurse.

But there was some hope. Despite his poor health, surgeons tried to decompress his spinal cord, and he was set to go to rehab, but recovery, such as it was, was slow, and medical complications kept him away from physical therapy.

This was a man who worked hard, and whose intellectual curiosity took him all over the globe, before diabetes and vascular disease robbed him of his ability to travel widely. Early in his life, when his country called him to duty, the Army made an uncharacteristically wise decision and assigned him to military intelligence. He seemed much less conflicted about his service than many others—while being a dedicated liberal, and strongly anti-war, he served his country proudly, although I think he was genuinely puzzled as to how such a bizarre institution as the U.S. Army could function without recourse to logical thought.

Dick taught high school most of his life, including history, social studies, and drama. He was proud of his students, and of his work with them. He loved to brag when a student “made it”—Sanjay Gupta, my fellow physician, was a former student, as was one of my medical residents. His students said wonderful things about him, and I presume this is because he was visibly fascinated by history and politics, and loved to share his knowledge and thoughts.

He and his wife adopted two children in the late sixties, when adoption wasn’t quite the common practice it is today. I was lucky enough to marry one of them.

Last night, when the hospital called to say he was in cardiac arrest, we rushed to his bedside. It was clear he never had a chance—whatever did him in happened quickly and efficiently. Earlier in the day, my wife was spending time with him, listening to his confused moans, and when she got up to say goodbye, he said, “you have a beautiful smile. Where did you get such a beautiful smile?”

Dick, she got her smile from you, her passion from you. How could you even wonder?


Over the last few years, as he became sicker, he was always cold. He wore a sweater even in the heat of the Midwestern summer. I’m reminded of nothing so much as the Robert Service poem “The Cremation of Sam McGee”, where a man, stranded in the Arctic cold, enjoins his friend to cremate him, no matter how impossible the task. And while our family’s cultural tradition calls for burial, I can’t help but think of Sam McGee, dead for days in the Arctic cold, finally delivered to warmth by his friend:

And there sat Sam, looking cool and calm, in the heart of the furnace roar;
And he wore a smile you could see a mile, and he said: “Please close that door.
It’s fine in here, but I greatly fear you’ll let in the cold and storm–
Since I left Plumtree, down in Tennessee, it’s the first time I’ve been warm.”

Dick, when I escorted you to the hospital morgue, you looked so small. I can’t believe that hours earlier, you were such a tall, imposing figure. But on this ice-glazed December morning you looked peaceful and warm, and for that, you and I are both grateful.

Everyday, every day

I love language, which I suppose is as good a reason as any for being a writer. I’m also terribly critical—I hate misuse of language, especially my own. I’m not talking about silly grammatical rules that real speech renders moot. I’m talking about the misuse of words that actually changes meaning.

Every day I give bad news. I hate it. For me, it’s an everyday thing—not routine, exactly, and not rote, but profoundly normal. For patients, it’s the furthest thing from normal. Bad news doesn’t come every day. No matter how everyday it is to me, my words can deliver the worst news of a person’s life.

Part of delivering bad news is helping guide people’s reactions. I can’t stop someone from being sad or angry, but I have to help them stay on course. If they find the news so devastating that they can’t function, the battle is lost. Thankfully, I have examples of survival to share with my patients.

Several years ago, I diagnosed an acquaintance with metastatic lung cancer. It really was a horrid diagnosis, and most people with her diagnosis die—quickly. She didn’t (but she’s gone now, a story for another time, perhaps).

One day, after her life had change completely, I ran into her in the hospital on her way to chemo. We sat in the lobby and chatted.
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So, would you do it again?

(I felt Doctor Signout deserved a more complete answer, so here it is.)

I’m surrounded by cynicism. Doctors make particularly good cynics (although not always the best skeptics). Why are we cynics? Pehaps because we see human behavior in the raw. On a daily—no, hourly—basis, we see people making decisions that destory their bodies. People who make good decisions end up at the doctor, but people who make bad decisions seem to end up at the a lot doctor more. Much of the pathology I see is preventable disease.

Still, doctors’ cynicism is often tempered by a good deal of compassion. I’ve seen the most hardened docs talking trash in the back office, only to moments later walk into the room of a patient, hold their hand, and find a way to reach them.

Medicine is a diverse set of professions. A radiologist can go through their career (nearly) without speaking to a patient, or can choose to spend extra time with a patient before a procedure explaining it, calming fears, in short, being a doctor. Other fields, such as mine, are dominated by interpersonal interaction. In the past, these interactions made up the bulk of useful medicine, as the “medical stuff” didn’t actually do much. The last few decades have seen remarkable advances in preventing and treating many of the big killers. In the past, it was the surgeons who perhaps had the best shot at saving a life. Now, we internists share that glory.
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Some days it’s harder

I’m a little down today. I’ve told you before that I take care of my own patients in hospice. I’ve also told you about watching patients and friends lose their battles with disease.

This week I had serious talks with several people about end-of-life issues (the details of which I can’t really share at the moment). I’ve also had to tell someone about an abnormal lab result (a very bad one). In fact, the best news I’ve delivered all week was telling someone they had mononucleosis (rather than something worse).

I’ve found, in my limited experience, that terrible illnesses don’t change people that much. If they were cheerful healthy folks, they tend to be cheerful (albeit appropriately sad and angry) sick folks. If they were curmudgeonly when well, they will usually be cranky when ill. Occasionally, some transformation will come over someone when they are confronted with a mortal illness, but I don’t think this is the norm. When thinking about these things, it is very tempting to wonder how I would deal with such a thing myself, but if I’ve learned one thing in the last decade as a physician it is this:

Don’t go there!

Empathy is a good thing, a necessary thing, but you cannot be an effective physician if your empathy turns into true identification. It is paralyzing. Everyone worries from time to time about what could happen to them if this or that illness struck, but doctors are in a bad position. We know too much. It’s far to easy to come up with realistic scenarios of our own demise. This is especially true when dealing with ill patients who are like is, in age, education, ethnicity, etc.

We don’t really talk about this much. I mean, we talk about “not going there”, but we don’t often acknowledge to each other what it means to “go there”. As someone who teaches young physicians, I deal with their irrational fears all the time. Every lump, bump, cough, in the mind of a young doctor, is the seed of their own death. It takes a while to build up a bit of a skepticism about your own ability to evaluate your health. It also takes a while to find the right balance between empathy and identification—how to feel for the patient, without feeling like the patient.

Still some days it’s harder. I was talking to a friend today (a fairly new friend, as it turns out) who is going through a particularly rough round of chemo. I grew up with her husband, she has a kid my kid’s age; it’s very easy to identify with her. If she were a patient, I would try to throw up that flexible fence with empathy on one side and pathological identification on the other. But she’s not my patient. Where do I build my fence?

I don’t. Sometimes it’s possible to over-think things. She’s one of the “cheerful” ones. She’s not crazy, not stupid, not in denial, just a good person with a good attitude and a lousy disease. When it comes to friends and family, sometimes you’ve got to set aside the white coat and allow yourself to laugh and cry with someone, allow yourself to get close to someone even if you don’t know where life is heading.

It’s not always an easy ride, but it sure is better than the alternative.

Adventures in staffing—a new physician

When a resident of student presents a patient with me and I help them formulate a plan, we call it “staffing” the case. Recently while I was staffing, I was presented with a patient who speaks little English, but speaks another language fluently. Unfortunately for us, this language wasn’t Urdu, Spanish, French, Romanian, or Hindi (languages spoken by the people immediately within my reach). The medical instructions we needed to give were fairly complex—too complex for Pidgin English, so I paged one of my interns.

“Hey, S.,” I said, “how well do you speak (insert little-known language here)?”

“Quite well, why?”

“Well, I have a nice older woman who speaks it as well, and her resident happens to be graduating. She could really use your care, both for your medical skills and your language skills.”

“You can put her in my schedule as soon as you need to. If there aren’t any openings soon, tell her to come right at 1pm and I’ll just see her before I start my clinic.”


It takes a lot to make a doctor. I’ve talked about teaching medicine: how to give bad news, how to help patients with difficult diseases, and I’ll probably write a lot more.

But some things aren’t taught—you just know them. My resident just knew the right thing to do. Despite her hellish schedule, she offered time to a patient in need. This behavior is not a given. It is the mark of a true physician.

How do you say it?

I am often the bearer of bad news. I don’t think I’ve ever been formally taught how to deliver bad news, but I’ve developed a style over the years, and I’m pretty good at it.

I work with medical residents every day in their outpatient clinics. Most of them have never had to deliver bad news. Some people are natural communicators, and some aren’t. Often, one of my residents just “gets it”—they have a great deal of empathy, can “read” the patient from moment to moment, and without any help from me, they can successfully give the news.

What does it mean to give bad news “successfully”?

In medicine, it means giving complex information in a short period of time, with proper emotional content, and in such a way that the patient takes it seriously, but doesn’t become so frightened that they forget the entire discussion. Once the word “cancer” comes out, little after that is retained. Over and over, I hear people say, “what was that thing you said I have?”

There is no substitute for young doctors giving bad news to their own patients, but it’s good to model behaviors and to pass along tips.

For example, if I have to tell someone they have HIV, I usually make sure to shake their hand, put a hand on their shoulder, sit near them, and keep my arms uncrossed. These signals set the tone for how they will view their illness. If you, as a doctor, seem physically distant, the patient will sense that, and may end up feeling stigmatized, isolated, and more afraid. Also, they may disappear out of fear, delaying further treatment.

Giving bad news has to be a flexible skill. All patients are different, and need to hear news differently. For example, I had a patient with a breast lump. She is a bright and straight-forward person, so I asked her, “Do you prefer a good surgeon who is warm and fuzzy and will hold your hand, or who will just get the job done?” She chose the latter.

I can only hope that my skills keep improving and that my residents keep learning. Unfortunately, there will always be people to give the news to.

I hate being sick

In the interest of blog synergy, I’m reposting this from my old blog.

I’m actually quite lucky. Despite being surrounded by infectious diseases for sixty hours a week, I don’t get sick all that much (OK, maybe more than most, but I don’t have data). I actually called in sick for part of the day, something I rarely do. And that got me thinking…

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