Sermo Blog: Highlights from the MD community

The mother is wearing a halter top. On her back shoulder are two very black nevi, irregular, >5mm. Her other moles are brown and nothing like these.

So the question, do you say anything? Do you identify yourself as a physician?

Response from a Family Physician: "Of course you say something and you identify yourself as a physician to lend some creditability to your observation. Whats the worst thing that could happen?? She thinks you're a quack and she goes on about her life, the best thing that could happen—you save her life. Seems like the risk benefit ratio is favorable here.”

Response from a Family Physician: “No. The moment you say something, jeopardy attaches. At that point, You need to provide documentation to cover yourself."

Response from a Dermatologist: "I would say something also. You have to live your life as you should and not be hostage to the legal system."

Response from a Emergency Physician: "Similar to airplane emergencies and roadside accidents. I stop and inquire. It's the human thing to do. To help each other, just don't be intrusive. "I'm sorry to bother you, but I am a physician and I noticed an abnormal looking mole on your back. I encourage you to have your doctor look at it, soon." Nod your head pleasantly and walk away."

Response from a Pediatrician: “Do what you would want done if the situation were reversed. Suppose you had missed a melanoma in your child and a stranger noticed it."

Response from a Family Physician: "Do you routinely stare at strange women and study their...moles? I have always been taught that staring / studying a stranger was rude and impolite.

Given that I would not have noticed a stranger's moles, I would not find myself in your conundrum.

And had I noticed the moles, I certainly would not have thought it my place to tell her my career choice and then share my concern that she might have cancer.

Put yourself in her shoes. You're in line at the store, minding your child, and waiting to check out while some individual (? pervert) behind you is staring at your back like it's a Tom Clancy novel. Then he abruptly introduces himself and says you probably have cancer. Do you feel reassured? Or would you think the guy was a crazy? I'd think you were crazy.

And perhaps she's had those her entire life and her personal dermatologist (who she's known for years) has told her she's fine. You just don't know, it isn't your business.This scenario has high likelihood of causing unnecessary anxiety and low likelihood of actually helping the person.

Keep your eyes to yourself."

Response from a Radiation Oncologist: "How can you not notice a potential melanoma? I have no problem mentioning that kind of thing."

Response from a Pediatrician: "About 25 years ago I warned a bank teller she needed to get a mole looked at, and then promptly forgot about it. Fifteen years later this woman's daughter came in with her newborn, and told me that the grandmother's mole had been a melanoma, "they told her they got it just in time," and she was alive and well! One of those very precious things about being a doctor!"

Response from a Dermatologist: "Although you can be sued for anything, I don't think you can be successfully sued for saying something like: "Excuse me, ma'am, I couldn't help but noticed that the mole on your back is a bit irregular in its shape. I think that you should have it evaluated by your doctor."
Where is the wrongdoing that a suit could be based on? Some of the people posting on here are paranoid."

Response from a Family Physician: "I have this patient in my practice. I asked her about a relatively large surgical scar on her posterior shoulder. Yrs ago she was in line for a movie. A gentleman behind her tapped her on the shoulder, and apologetically explained that he was a dermatologist, and could not help noticing an abnormal looking mole on her back, and encouraged her to have her own doctor check it soon. That was the end of the conversation, but she did have it checked, and it was a melanoma. Her doctor told her that if it wasn't caught soon, it likely could have metastasized. The dermatologist saved her life and she explained to me that she has no idea who he was (only explained that he was a derm - didn't give his name), but that she is alive today because of him, and she will be eternally grateful.”

Response from a Pediatrician: "Beware the curbside consult, as I have said in the past and someone has said above. If you can suggest a visit to PMD in an offside manner, in a friendly manner, just avoiding work when you are not in your legal element, you and your carrier may sigh more easily. for some whose conscience urges and compels them to talk up so they can rest more easily, you need to learn some self control. You do not know this woman's situation or how your uninvited offside remark may be taken. Do not assume legal liability unless and until you are ready to do so. Then do so in an offside manner and go about whatever you are doing.”

Unusual Foreign Bodies Removed From Patients

Posted: Wednesday, August 18 2010

Intro from Daniel Palestrant, Founder & CEO of Sermo
The Sermo community discusses the many strange foreign bodies they have removed from patients throughout the years. Highlighted below are a handful of the responses. To read more of the 230+ comments, contact pr@sermo.com.

Originally Posted to the Sermo Community
By: An Anesthesiologist on Sermo

This weekend I had an unusual case. The urologist wanted to remove a crochet needle from a 23 year old female's bladder. Yes, a crochet needle, the type with the little hook on the end. It was bright green and easy to find. Got there by "accident".

Click to view

We got to discussing the most unusual objects removed from a patient. The list included lightbulbs, carrots, flashlights and gerbils.

What is your most unusual object removed from a patient?

Response from a Pathologist: "Large zucchini (rectum). The spiral from a spiral-bound notebook (male urethra). Pencil (male urethra). Cigarette lighter (stomach)."

Response from a Family Physician: "Small (5-6mm) seashell removed from a lung on bronchoscopy about 1 year after visiting a beach and sucking in too much sea water trying to surf."

Response from a Urologist: "Real string of pearls knotted in bladder. (50 yo diabetic and his mother's pearls)."

Response from a Urologist: "At our hospital recently the general surgeons removed from the stomach a bound and gagged barbie doll that the patient had swallowed."

Response from a Anesthesiologist: "I was called in by a General surgeon for a little boy who had swallowed two small toy dogs when asked why he had swallowed two his reply so the first wouldn't be alone!"

Response from an Allergist & Immunologist: "I once retrieved a plastic helicopter from a child's nose."

Response from an Ophthalmologist: "Firecracker and gunpowder particles which had to be microscopically removed from a boys cornea after he had placed the explosive in a bicycle handle; and when it did not explode immediately, he took a peek!"

Response from an Ophthalmologist: "While an intern on the general surgery, service assisted in removing an open safety pin from the esophagus of a resident at the local psych hospital. Two weeks later we repeated the effort on first resident's room mate who just wanted a change of scenery. Second patient was a bit more challenging in that a small esophageal perforation that was missed at surgery went on to become a tension pneumothorax at 3:00 am while I was on call. First time I ever inserted a chest tube in an actual emergency setting."

Response from a General Surgeons: "5 pens, 2 permanent markers, 3 straws, 2 toothbrushes, 4 Oreo cookie wrappers. All at the same time from the stomach of a patient."

Can't get enough foreign body removal stories? Contact pr@sermo.com for more.

Doctor Leaving USA

Posted: Wednesday, June 23 2010

Intro from Daniel Palestrant, Founder & CEO of Sermo
The Sermo community responds to a physician who has decided to leave America and practice elsewhere after the passage of health care reform. Many physicians feel their interests were sidelined in the reform debate and passage.

Originally Posted to the Sermo Community
By: An OBGYN on Sermo

I'm sorry.

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Some may say i'm weak, some may say I've given up too soon. What they CAN'T say about me is that I didn't try. I stood out on the street on my Saturdays off and tried to rally for "real" health care reform. I've offered to hold forums for other docs to discuss ways we can inform the public and our patients...I've passed out fliers in the doctors lounge at my hospital. I've done it all and I've seen everything fail. I'm tired. I can't go on in this country for another 20+ years.

I've been sued once already and now (icing on the cake), I have a former patient, an illegal alien who is considering suing my practice. I don't see the light at the end of the tunnel. I've been beat up and I'm not doing it anymore. I love this country and I LOVE my practice and even worse, I'm damned good at what I do. But now, I chose to do it somewhere else. Somewhere where people don't expect me to produce the world for them and say "thank you" for the care I've provided and don't argue with me about EVERYTHING.

I know I'm not a martyr but someone can let Mr. Obama know that a perfectly good, board certified physician is deciding to call another country home because I can't take it anymore!!!

From the Founder: The Justice Department Declares War on Doctors

Posted: Wednesday, June 2 2010

A recent article in the Christian Science Monitor, titled " The Justice Department Declares War on Doctors", explores the impact of a newly DOJ in enforcing government price controls on physicians (click here). Not surprisingly, this article has already sparked quite a discussion in the Sermo community (click here). However, the timing of this development is particularly concerning for a number of reasons.

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With a 21% physician payment cut looming this coming week, CMS has decided to delay all physician payments for at least two weeks while Congress passes this political hot potato around (click here). We are also seeing several states attempt to link medical licensure to participation in these very same programs (click here). In effect, this boxes in physicians, giving them little choice but to accept these arbitrary payment terms or loose their ability to care for their patients.

It should be noted that a provision in the healthcare reform bill that would have repealed the McCarran-Ferguson Act, taking away insurance companies' anti-trust exemption was removed from the final version of the bill. This means that insurance companies (and now the government) are exempt from any anti-trust or price fixing scrutiny, while physicians are legally banned from coordinating their efforts, much less unionizing.

With the evidence now mounting that the government is going to "back door" a socialized healthcare system, what steps should physicians be considering in order to safeguard our profession and provide the best possible care for our patients?

Daniel Palestrant, MD

Founder & CEO

Sermo, Inc.

You want to have it both ways

Posted: Tuesday, May 18 2010

Intro from Daniel Palestrant, Founder & CEO of Sermo
Over 200 physicians respond to a letter penned by a physician on Sermo to American citizens and patients.

Originally Posted to the Sermo Community
By: A Physical Medicine & Rehab Specialist on Sermo

Dear Mr. and Mrs. America,

You live in one of the greatest countries on earth, one of the richest ones, yet arguably not one of the best for medicine. You may question why that is. I think I may have some answers. Essentially, you want to have your cake and eat it too.

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When you are sick or injured, you want the best healthcare money can buy. But you want someone else to pay for it. You feel should not be made to pay for things that are not your fault, as you perceive it.

When you do not feel you have gotten the best healthcare someone else's money can buy, you scream, yell, threaten and generally act like a child. Then you demand to be respected as an adult. You take the same approach to "free" care, such as telephone calls, disability paperwork and public aid.

When your treatment does not go as you planned, you want to keep the legal option to sue a doctor for "everything he's got", but want to keep "good" doctors in your community so you don't have to drive 6 hours to get your brain tumor operated on.

You want to be able to drink and smoke as much as you want, and then when years of beating the crap out of yourself makes its presence known, you want us to rescue you. We told you 40 years ago not to smoke. Now you want us to save your life from the CAD, emphysema and lung cancer you caused.

You want to drive a car at 90 mph while drunk, "because I'm having fun" but want us to put all the pieces back together when the inevitable happens.

You want a single-dose pill to take care of anything that ails you, aka the "magic pill." But you complain about the realistic medications you will need to take every day for the rest of your life. 20 years ago, these pills did not exist and you would have had only a few years left to live. Now we can keep you around for many more years for you to keep complaining about the pills you have to take.

You complain about the 3 antihypertensives, the 2 cholesterol-lowering drugs, the glucophage and other pills keeping you alive and adding years to your life, while refusing to quit smoking, cut down the drinking, eat healthier and get some exercise once in a while.

You spend a ton of money on highly-processed, marginally-tasteful, completely unhealthy food, and then ask us for a pill to help you lose weight. 90% of the treadmills you own are collecting dust or acting as coat racks.

You want a "lifestyle" pill for every unpleasant symptom you have. You'd rather not do the therapies that can effectively treat your insomnia, you just want a sleeping pill. Besides, all those commercials on TV for Ambien, Sonata and the others tell you you are entitled to a good night's sleep, by pill if necessary.

You use the ER as your primary care provider, then complain about the wait to be seen there for a URI.

You give us vague complaints, with vague histories and onsets of symptoms and then ask us to make a specific diagnosis.

You demand tests without any knowledge of what "false-positive" means or its potential implications for you. You don't consider the downside of testing.

You have asked for, and now get "informed consent" before any treatment, but don't want to be held responsible for your part in the decision-making process when things don't go well.

Birth control is an option, one you have often declined to use. Now the rest of us get the pleasure of helping to pay for that little bundle of joy you didn't want and the "father" declines to acknowledge. Hopefully we can help you finish your GED so you can meaningfully contribute to society rather than live off of it.

You want to legalize marijuana, "because it's safer than alcohol" or so you think. Two bad things apparently make one good thing.

You want opioids to be available anytime you deem your pain severe us to deserve them, but don't want us to restrict them simply because a bunch of yahoos use the recreationally or for income. The fact that we have been burned so many times by so many people should have no bearing on you, the seemingly-legitimate pain patient.

You want us to trust you implicitly to follow our recommendations, yet you don't trust us enough to finish taking an antibiotic for 10 days when we tell you to. Many times you don't even trust us enough fill the prescriptions we write.

You take whatever the guy at GNC says you should take, and pay him ridiculous amounts of money for unproven therapies, then question us on every potential side effect for anything we prescribe that has gone through a full FDA approval process. And you reserve the right to sue us and the pill manufacturer (and the pharmacist who sold it to you) should you have a side-effect from it, even if we warned you about it.

You argue with us about co-pays, deductibles and out-of-pocket expenses that we have no control over. Take it to your insurance company or employer.

You want your doctor available 24/7/365, but you want him or her to be well-rested when you come in.

You raise hell when you are made to wait 15 minutes in the waiting room, while your fellow citizens arrive 20 minutes late, with 3 young kids in tow for the annual pap smear. You then want to take up 30 minutes of my time addressing every health concern you have despite booking only one 15-minute time slot.

Unfortunately, Mr. and Mrs. America, you cannot have things both ways. You cannot have "free" healthcare that covers anything and everything. You cannot have an unhealthy lifestyle and expect to be kept healthy by us.

You have been given the knowledge and resources to prevent or treat most any disease or injury known to man, and you have declined the opportunities repeatedly. Instead, you have opted for the "quick fix" so you can get back to your life of self-destruction.

And I'll still be here, for a while anyway, trying to fix the things you've broken.

Do you shake your patients' hands?

Posted: Wednesday, May 5 2010

Intro from Daniel Palestrant, Founder & CEO of Sermo
Over 700 physicians weighed in about their office hand-washing habits, a question posed by a physician on Sermo.

Originally Posted to the Sermo Community
By: A Family Practice Physician on Sermo

Click to view

Did you shake your patients hand to start a visit and to end a visit? I am concerned about disease transmission. Do you wash your hands 100% of the time?

From the Founder: Madness in Massachusetts

Posted: Wednesday, April 21 2010

Lately I have been watching with complete horror the events playing out in my home state of Massachusetts. A bill currently under review by the state legislature will make participation in the state and federal Medicare/Medicaid programs a condition of medical licensure, effectively making physicians employees of the state.

MA Bill 2170

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This is particularly alarming because Massachusetts is essentially a leading indicator of what will happen in the rest of the country. Several years ago the state passed a series of laws mandating health coverage. Like the recently passed national health reform bill, the Massachusetts law did not address any of the well known causes of runaway costs, including tort reform, drug costs, or insurance regulation. Although the state now has one of the highest percentages of its population insured, it is grappling with exploding healthcare costs. In response, it is imposing capitation schedules, reductions in payment rates and now mandatory participation in the health programs by physicians. What most people don't understand is that the private insurers are also free to lower their physician payments, based on the Medicare/Medicaid benchmarks. This is all the more concerning given the fact that the Federal reimbursement rate is now scheduled to be reduced 21% on April 15. We will no doubt see the same sequence of events play out across the country as the current versions of healthcare reform are implemented.

The net effect of these laws is that it will make it close to impossible for physicians to stay in private practice. Patient access to physicians will suffer as more and more physicians retire and/or move to different states. For our academic colleagues who think this turn of events can only "help" them because they won't have to compete with physicians in private practice, just wait. 28 states are now imposing "comparability" laws that allow nurse practitioners and other allied healthcare professionals to work without the supervision of a physicians with equal pay. Few academic departments can avoid hiring "physician extenders" if they want to stay competitive. As this gains momentum, physician payments will be pushed downwards. As the "going rate" goes lower, academic salaries will also get pushed downwards.

I knew this reform effort would be bad for the practice of medicine and even worse for patient care. I just had no idea things would deteriorate this fast.

Daniel Palestrant, MD

Founder & CEO

Sermo, Inc.

A Life Saved...thank you Sermo

Posted: Wednesday, April 14 2010

Intro from Daniel Palestrant, Founder & CEO of Sermo
One physician on Sermo recounts how he harnessed the collective wisdom of his colleagues on Sermo to help him make a life-saving diagnosis.

Originally Posted to the Sermo Community
By: A Hospitalist on Sermo

Click to view

https://md.sermo.com/medical/ticket/details?id=48903

A Life Saved...thank you Sermo

Last week I posted a case of a very perplexing and frustrating patient.

Briefly - he was a 57 yo with status epilepticus requiring intubation and mechanical ventillation for 4 days until his seizures were finally controlled. He was successfully extubated but remained restless and agitated. He developed a high fever with no obvious source. He was also tachycardic and hypertensive. There was NO response to benzos or pain medication.

The most frustrating part was that he would not stop moving. Not abnormal movements, just contantly moving all over the bed. We had to restrain him just to keep him from flying out of bed and pulling out all of his tubes. This went on for nearly 3 days with NO relief!

I posted the case and got various suggestions, including Neuroleptic Malignant Syndrome, Seratonin Syndrome, and benzo withdrawal. One suggested just giving him amantadine and that would rule out/in NMS.

I was desperate to help this man, so the next morning I gave him a dose of amantadine. Within 1 hour he was asleep...and he slept all day. I went off-service the next day but just ran into one of the nurses at the grocery store - he is back to "normal" and should be discharged soon.

I am convinced that he might have died if Sermo docs hadn't helped me. How else can a small-town doc on a remote island get specialty consults from all over the country? In less time than it would take me to get a neurologist to come to the phone, I had 10 opinions on what to do.

Thank you!

From the Founder: Sermo for your family?

Posted: Tuesday, April 13 2010

Growing up as the child of a physician, it was always a sign of the utmost respect when one physician would ask another to treat a member of their family. For each condition or need, there was that one physician that all the other physicians trusted with their loved ones. Of late, I have noticed a steady increase in "Saved-with-Sermo" cases, where the Sermo community provided the decisive input on a clinical situation, leading to an improved outcome. The number of times that I have seen physicians turn to physicians on Sermo for help for themselves or their family members is nothing short of staggering. This week's Sermo Pick, is a great example.

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Sermo is almost four years old now, there have been more than 3 million comments and just under 50,000 posts. I recently did an interview with a reporter to discuss the "Sermo phenomena". The reporter's first question was "What has been the most rewarding part of Sermo?" My initial response, "not failing," was perhaps too honest. After thinking for another moment, it hit me that the real treasure of the Sermo experience has been seeing an impact on the actual care of patients in this country.

Later this year, Sermo will introduce an entirely new platform that promises to be a quantum leap forward in terms of user experience. As we gear up for that milestone, I want to ask the community to share your experiences [with links, if possible] where Sermo has impacted patient care and how this community believes the Sermo Team can best deliver on our commitment of supporting physicians and improving patient care.

Daniel Palestrant, MD

Founder & CEO

Sermo, Inc.

Truth cannot be legislated!

Posted: Friday, April 2 2010

Intro from Daniel Palestrant, Founder & CEO of Sermo
A physician on Sermo reflects on medicine post-healthcare reform. Over 750 physicians weighed in.

Originally Posted to the Sermo Community
By: A General Surgeon on Sermo

Click to view

Truth cannot be legislated!

The sun came up this morning in upper Michigan. The air is crisp and clean as usual and another beautiful day is beginning. As always, I'm operating on Monday. I saw my first patient, a middle aged man with a hernia. He smiled at me, we shook hands and I answered his last minute questions. Soon I'll be in the OR doing the same work that I still love.

My patient didn't watch the vote last night. He wasn't aware of Pelosi's grand victory. All that matters to him this morning is that I am his surgeon, he trusts me to do my job well, and I will.

What we saw last night was a political manipulation of history. A re-write of law to move the money around and change some rules. I don't agree with what was done. My disagreement is the same this morning as it was last week, last year and 30 years ago.

Politicians are still trying, with complex systems and regulations, to change immutable facts. It is a grand illusion that only will have a transient political benefit for them, if that. No amount of ink on paper can change the fact that people cannot purchase services for nothing.

No amount of government regulation will change the science associated with the medical care that we provide. No new ruling or designation will elevate unqualified individuals into the positions that we have worked so hard to attain.

The stroke of the President's pen won't do any of that. Most of the nation knows this, even though they may not be able to articulate it easily. But, those of us in medicine, the working physicians who care for patients everyday know this very well.

History takes a long time to play out. We saw what happened in Massachusetts earlier this year. People know a scam when they see it. I am confident that we will weather this "storm". But, don't be complacent. Washington is once again messing with your freedom. That is too important to ignore.