"I don't Judge people”

"I don't judge people in my business" he said. An attribute that we share, I suppose – but for different reasons. My job is to help my patients achieve their health goals. His job is to sell them beer.

But he made me a little six-pack sampler that has been truly enjoyable. I used to enjoy Yeungling Porter but apparently it's no longer available. I asked him to bring me some .. and he said "no dice." I liked it because it was cheap and pretty good.

Here's what I've tried from the sampler:

Day 1:

SmuttyNose Porter hmm .. just OK. Better than an amber beer, but not full enough.

Day 2:

Sinebrychoff Porter   Wow  Very (very good)  Finnish Porter.  Rich. Complex taste – not too thick .. but not too thin .. juuuust right.

Day 3:

D. Cargagie & Co Stark Porter  Swedish.  Not as good as the Finnish, but better than the SmuttyNose.  Big bottle.  Couldn't finish it. (yeh – I'm a lightweight) ..

How we act at the bedside

Dr. Bob rants about how we interact with patients and how we interact with each other.  He says that we need to model professionalsm, and I would concur.

How we act at the bedside is an entirely different discussion which we may have another time.

Now seems like a good time, eh? 

Last summer, I made note of Carl Gandola's weblog.   Like Dr Bob, Carl is an attending physician in a residency program.  Carl describes sitting down at the bedside and listening to his patients.   While the quote on Dr Bob's post today may be accurate ("some doctors put on a better show than others") … listening can't be faked.  We say much more with our actions than with our words:

We know that physicians interrupt their patients:

Patients spoke, uninterrupted, an average of 12 seconds after the resident entered the room. One fourth of the time, residents interrupted patients before they finished speaking. Residents averaged interrupting patients twice during a visit. The time with patients averaged 11 minutes, with the patient speaking for about 4 minutes. Computer use during the office visit accounted for more interruptions than beepers.

I find that I sometimes bite my tongue (literally!) to remind myself to keep quiet.   I've posted on this in the past as well  .. so follow the link and take a look if you like …  it's a real-life example of how listening just a little can save a lot more time and money than you think.

Quinolones and tendon rupture

JABFP — Gold and Igra 16 (5): 458

Treatment with the fluoroquinolone class of antibiotics has become increasingly popular. Clinician preference for quinolones stems from their excellent gastrointestinal absorption, superior tissue penetration and broad-spectrum activity.1,2 However, this has led to widespread and indiscriminate use, affecting microbial resistance patterns and increasing drug-related morbidity.3 Although quinolone-induced tendonopathy and tendon rupture have been previously described in the literature, reports of tendon rupture in association with newer quinolones such as levofloxacin are now emerging.4,5 We describe a patient with levofloxacin-induced partial rupture of the Achilles tendon and review the literature, pathophysiology, predisposing factors, and treatment recommendations.

I can remember vividly how my grandmother's ruptured achilles tendon was blown off by her physician 9  or so years ago.  She had asked whether it could be the Cipro that she had been taking for a UTI that caused the tendon rupture, and he said "no way."

Of course it could.  At that time, there was only letter in NEJM that I could find .. but since she was paying for much of my medical school tuition … I guess I did more research on it than he did. 

The report above reminds us that even the newer quinolones can do this – yet another reason to avoid them.

Clinical Pearls

Today's unrelated tidbits:

  • A great tool for helping men with a decision for/against PSA testing.  This thing is buried deep in the guts AAFP website – so deep that I couldn't find it.  Here it is
  • A very good review article on dx/work-up of fatigue.
  • Excellent guidelines on Otitis, pharyngitis and bronchitis
  • Baysean Calculator.

The last one is the best of many calculators out on the web.  Here's why – it combines the calculations of likelihood ratios with the calculation of PPV and NPV.  Huh?  Terms for normal humans: 

a) How good is the test that I'm doing for this disease? (sensitivity) let's take one that is VERY common:  the "rapid strep" test.  It's pretty good, but not perfect.  Let's say it's 85% sensitive.  This means that 15% of the time it will miss strep throat.  So … does a patient in my office with a sore throat and a negative "rapid strep" have a 15% chance of having strep throat?  Nope.  Read on.

b) How accurate is the test? (specificity).  If I get a positive result – how sure can I be that the patient really has it?  In the case of the rapid strep – darn sure.  Let's say 99%.

c) How likely is THIS patient to have this disease given their symptoms?  Long story – Kids are more likely to have it than adults.  Let's say an adult has a 10% chance of having a sore throat caused by strep – and a kids have a 25% chance

So now we can use the calculator.  Enter a prevalence of 25% (it's a kid with a  sore throat) and a sensitivty of 80% and a specificty of 99%. 

PTL- .. The post-test likelihood of a negative test = .048  So a kid with a negative rapid strep has only a 5% chance of having strep throat – not 15% like we thought above.

But we can play with this plot even more.  We know from the long story above (click it – it's a very good article) that the kid with a cough and no adenopathy is much less likely to have strep than the kid with no cough and positive anterior adenopathy.  So let's say our patient has a cough and runny nose and not much of a fever.  Hmm .. doesn't sound much like strep.  But he does have a sore throat.  Let's move his "prevalence" score to 10%.

Yikes.  Now the PTL- is .01 — not very likely that this kid has strep.

So now you see why I'm not compelled to send a follow-up culture (with sensitivity of 90% rather than 85%) if I get a negative rapid strep.