Beyond the White Coat

As Washington hurtled toward the fiscal cliff, I watched with increasing confidence that savvy politicians would announce a last-minute deal. However, I gained even more confidence that it would not actually deal with the problem. Far from forming a grand bargain, Congress just kicked the can a bit further down the road.

The next hurdle the federal government will face and crawl under will be raising the debt ceiling by the end of February 2013. I have no plans to write my next column on that subject. This column is not meant to be a fount for political analysis. But there are two important ways in which the fiscal cliff debacle impacts physicians. One is exemplified by the legend of the sword of Damocles. The other comes from an aphorism attributed to Mahatma Gandhi.

In 1997, Congress created a correction factor, based on a Sustainable Growth Rate (SGR), to control runaway increases in health care spending. Starting in 1999, Medicare fees were to be adjusted so that the rate of growth in Medicare spending was no larger than the growth of the gross domestic product (GDP). In short, if spending increased more than that, physician fees for a given service would be reduced by a proportionate amount. However, each year since then, an act of Congress has postponed, but not repealed, implementation of the correction factor. This has happened so repeatedly that it has acquired the nickname "the doc fix." In total, these accumulated corrections now exceed 27%. Once again, as part of the bill passed by the Senate on Jan. 1, 2013, a postponement was authorized. Physicians will not see a sudden 27% drop in Medicare fees in 2013. But the threat of such a reduction in fees for 2014 remains on the legislative books.

By legend, Damocles temporarily sat upon the throne of Dionysius, but could not enjoy its luxury because over his head was a large sword suspended by a single hair of a horse’s tail. For physicians, the sword of Damocles grows larger annually. As the size of the Medicare SGR correction has accumulated, fewer people believe it will ever be implemented. I am reminded of an adage that "experience allows us to repeat the same mistakes with increasing levels of confidence." The longer the sword remains over our heads, the less worried we become that it will actually fall. That may not be wise in a world of political brinkmanship.

The second take-home message from Washington’s paralysis is more cynical and insidious. Health care in the United States, particularly public health, has been very successful, adding 10 years to the average life expectancy over the past 50 years. But it has created a Faustian bargain with unsustainable cost increases. We’ve gone from 6% of the GDP to 17% spent on health care. Of course, if the average working person gets to live 10 years longer, he might be willing to pay for that with 11% of the GDP. But other countries have obtained the same benefit for half the price. The state of Oregon once tried to prioritize Medicaid spending, creating a list of which medical interventions would be covered and which were too extravagant. The process failed. The fiscal cliff debacle is further demonstration that our current form of government cannot handle these difficult choices over diverse ideals.

The financing of health care in the United States has fostered wasteful and futile care for the elderly while services for children, particularly dental and mental health, remained woefully underfunded. It appears to be irrational to continue to wait for government to create a just framework for allocating medical care. Inaction is collusion with this insanity.

Change is needed before the sword falls. Instead of relying on centralized planning, can we find salvation in the individual choices of physicians? What could you personally do to increase access to the most beneficial types of health care services rather than the most lucrative? As Gandhi suggested, "You must be the change you want to see in the world."

This column, "Beyond the White Coat," regularly appears in Pediatric News. Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. E-mail Dr. Powell at pdnews@elsevier.com.

As Washington hurtled toward the fiscal cliff, I watched with increasing confidence that savvy politicians would announce a last-minute deal. However, I gained even more confidence that it would not actually deal with the problem. Far from forming a grand bargain, Congress just kicked the can a bit further down the road.

The next hurdle the federal government will face and crawl under will be raising the debt ceiling by the end of February 2013. I have no plans to write my next column on that subject. This column is not meant to be a fount for political analysis. But there are two important ways in which the fiscal cliff debacle impacts physicians. One is exemplified by the legend of the sword of Damocles. The other comes from an aphorism attributed to Mahatma Gandhi.

In 1997, Congress created a correction factor, based on a Sustainable Growth Rate (SGR), to control runaway increases in health care spending. Starting in 1999, Medicare fees were to be adjusted so that the rate of growth in Medicare spending was no larger than the growth of the gross domestic product (GDP). In short, if spending increased more than that, physician fees for a given service would be reduced by a proportionate amount. However, each year since then, an act of Congress has postponed, but not repealed, implementation of the correction factor. This has happened so repeatedly that it has acquired the nickname "the doc fix." In total, these accumulated corrections now exceed 27%. Once again, as part of the bill passed by the Senate on Jan. 1, 2013, a postponement was authorized. Physicians will not see a sudden 27% drop in Medicare fees in 2013. But the threat of such a reduction in fees for 2014 remains on the legislative books.

By legend, Damocles temporarily sat upon the throne of Dionysius, but could not enjoy its luxury because over his head was a large sword suspended by a single hair of a horse’s tail. For physicians, the sword of Damocles grows larger annually. As the size of the Medicare SGR correction has accumulated, fewer people believe it will ever be implemented. I am reminded of an adage that "experience allows us to repeat the same mistakes with increasing levels of confidence." The longer the sword remains over our heads, the less worried we become that it will actually fall. That may not be wise in a world of political brinkmanship.

The second take-home message from Washington’s paralysis is more cynical and insidious. Health care in the United States, particularly public health, has been very successful, adding 10 years to the average life expectancy over the past 50 years. But it has created a Faustian bargain with unsustainable cost increases. We’ve gone from 6% of the GDP to 17% spent on health care. Of course, if the average working person gets to live 10 years longer, he might be willing to pay for that with 11% of the GDP. But other countries have obtained the same benefit for half the price. The state of Oregon once tried to prioritize Medicaid spending, creating a list of which medical interventions would be covered and which were too extravagant. The process failed. The fiscal cliff debacle is further demonstration that our current form of government cannot handle these difficult choices over diverse ideals.

The financing of health care in the United States has fostered wasteful and futile care for the elderly while services for children, particularly dental and mental health, remained woefully underfunded. It appears to be irrational to continue to wait for government to create a just framework for allocating medical care. Inaction is collusion with this insanity.

Change is needed before the sword falls. Instead of relying on centralized planning, can we find salvation in the individual choices of physicians? What could you personally do to increase access to the most beneficial types of health care services rather than the most lucrative? As Gandhi suggested, "You must be the change you want to see in the world."

This column, "Beyond the White Coat," regularly appears in Pediatric News. Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. E-mail Dr. Powell at pdnews@elsevier.com.

As Washington hurtled toward the fiscal cliff, I watched with increasing confidence that savvy politicians would announce a last-minute deal. However, I gained even more confidence that it would not actually deal with the problem. Far from forming a grand bargain, Congress just kicked the can a bit further down the road.

The next hurdle the federal government will face and crawl under will be raising the debt ceiling by the end of February 2013. I have no plans to write my next column on that subject. This column is not meant to be a fount for political analysis. But there are two important ways in which the fiscal cliff debacle impacts physicians. One is exemplified by the legend of the sword of Damocles. The other comes from an aphorism attributed to Mahatma Gandhi.

In 1997, Congress created a correction factor, based on a Sustainable Growth Rate (SGR), to control runaway increases in health care spending. Starting in 1999, Medicare fees were to be adjusted so that the rate of growth in Medicare spending was no larger than the growth of the gross domestic product (GDP). In short, if spending increased more than that, physician fees for a given service would be reduced by a proportionate amount. However, each year since then, an act of Congress has postponed, but not repealed, implementation of the correction factor. This has happened so repeatedly that it has acquired the nickname "the doc fix." In total, these accumulated corrections now exceed 27%. Once again, as part of the bill passed by the Senate on Jan. 1, 2013, a postponement was authorized. Physicians will not see a sudden 27% drop in Medicare fees in 2013. But the threat of such a reduction in fees for 2014 remains on the legislative books.

By legend, Damocles temporarily sat upon the throne of Dionysius, but could not enjoy its luxury because over his head was a large sword suspended by a single hair of a horse’s tail. For physicians, the sword of Damocles grows larger annually. As the size of the Medicare SGR correction has accumulated, fewer people believe it will ever be implemented. I am reminded of an adage that "experience allows us to repeat the same mistakes with increasing levels of confidence." The longer the sword remains over our heads, the less worried we become that it will actually fall. That may not be wise in a world of political brinkmanship.

The second take-home message from Washington’s paralysis is more cynical and insidious. Health care in the United States, particularly public health, has been very successful, adding 10 years to the average life expectancy over the past 50 years. But it has created a Faustian bargain with unsustainable cost increases. We’ve gone from 6% of the GDP to 17% spent on health care. Of course, if the average working person gets to live 10 years longer, he might be willing to pay for that with 11% of the GDP. But other countries have obtained the same benefit for half the price. The state of Oregon once tried to prioritize Medicaid spending, creating a list of which medical interventions would be covered and which were too extravagant. The process failed. The fiscal cliff debacle is further demonstration that our current form of government cannot handle these difficult choices over diverse ideals.

The financing of health care in the United States has fostered wasteful and futile care for the elderly while services for children, particularly dental and mental health, remained woefully underfunded. It appears to be irrational to continue to wait for government to create a just framework for allocating medical care. Inaction is collusion with this insanity.

Change is needed before the sword falls. Instead of relying on centralized planning, can we find salvation in the individual choices of physicians? What could you personally do to increase access to the most beneficial types of health care services rather than the most lucrative? As Gandhi suggested, "You must be the change you want to see in the world."

This column, "Beyond the White Coat," regularly appears in Pediatric News. Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. E-mail Dr. Powell at pdnews@elsevier.com.

This is the time of year when teaching to the test comes to the forefront. Standardized testing is endemic in medical training. Whether you are a high school senior taking the SAT, a college student applying to take the MCAT, a medical student struggling to pass United States Medical Licensing Examination (USMLE) Step 1, or a recent residency graduate sitting for the boards, taking a test can be a very anxious time. Careers can be markedly altered by the scores on the standardized tests. The reputations of educational institutions, including medical schools and residency programs, depend on the scores. So the anxiety is understandable.

On the other hand, the public – who are the future patients of these physicians – may have a different perspective. Do these tests really evaluate and select those who will become better physicians? Will those physicians have the optimal balance of scientific knowledge and the art of caring?

That has been a source of consternation since long before computers began scoring tests. This quandary has not been lost on medical educators. The MCAT itself will be undergoing an overhaul by 2015. The goal is to have "A Better Test for Tomorrow’s Doctors." A preview guide of those changes was released in November 2011, and the revised second edition was just released in September 2012.

The MCAT’s basic science questions, which previously focused on biology, physics, and chemistry, will now include a section on the psychological, social, and biological foundations of behavior. The intent is to select a more diverse group of medical students, some of whom have studied sociology or anthropology, rather than favoring the hard science majors. There will also be a "critical analysis and reasoning skills" section of the test. In modern medicine, regurgitated, memorized facts are not as important as being able to interpret and apply them. There are other initiatives, such as the Project to Rebalance and Integrate Medical Education (PRIME), seeking to overhaul the medical curriculum.

Medical education 30 years ago involved large didactic lectures wherein a vast amount of information was transmitted from professor to student, then crammed and forgotten. Memorizing facts was considered the key to being a competent physician. The most lauded professors were frequently referred to as walking textbooks. But that is no longer adequate. Medical knowledge is now a bookshelf of textbooks, well beyond the memorization of a single person. The photographic memory aided by cute mnemonics has been supplanted by a smartphone and Google.

The provision of medical care also has evolved. Rather than a solo practitioner in an office, now a team of subspecialists, aided by nurses and allied health personnel, provide care in inpatient and outpatient settings. My role as a hospitalist is to stitch together the various patches of expertise each team member has, to form a quilt that covers all the patient’s needs. Communication between team members is crucial. Accurate and complete handoffs of information also have become vital in the shift-based environment for delivering therapy in most hospital settings.

As a patient, I was quite annoyed when, after a day of tests and procedures, I was handed a computer form to fill out. It surveyed my "experience." Did I have any trouble making the appointment? Were the hours convenient? Was the staff courteous? It contained 22 items, but only one question seemed to have anything to do with whether my physician was competent. Perhaps we are in a consumer-oriented society, and the provision of medical care needs to reflect that with Press Ganey scores. But the engineer in me still focuses on those key goals of getting the diagnosis and therapy correct. Especially when I’m the recipient!

Will changing the test produce, and importantly, maintain, a more competent physician? What are the consequences of better patient satisfaction? Not necessarily better health, according to one large study. Higher patient satisfaction was associated with less emergency department use but greater inpatient use, as well as with higher overall health care and prescription drug expenditures (Arch. Intern. Med. 2012;172:405-11).

If medical educators teach to a better test, will society simply run into a better mousetrap?

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said he had no relevant financial disclosures. E-mail Dr. Powell at pdnews@elsevier.com. This column, "Beyond the White Coat," appears regularly in Pediatric News.

This is the time of year when teaching to the test comes to the forefront. Standardized testing is endemic in medical training. Whether you are a high school senior taking the SAT, a college student applying to take the MCAT, a medical student struggling to pass United States Medical Licensing Examination (USMLE) Step 1, or a recent residency graduate sitting for the boards, taking a test can be a very anxious time. Careers can be markedly altered by the scores on the standardized tests. The reputations of educational institutions, including medical schools and residency programs, depend on the scores. So the anxiety is understandable.

On the other hand, the public – who are the future patients of these physicians – may have a different perspective. Do these tests really evaluate and select those who will become better physicians? Will those physicians have the optimal balance of scientific knowledge and the art of caring?

That has been a source of consternation since long before computers began scoring tests. This quandary has not been lost on medical educators. The MCAT itself will be undergoing an overhaul by 2015. The goal is to have "A Better Test for Tomorrow’s Doctors." A preview guide of those changes was released in November 2011, and the revised second edition was just released in September 2012.

The MCAT’s basic science questions, which previously focused on biology, physics, and chemistry, will now include a section on the psychological, social, and biological foundations of behavior. The intent is to select a more diverse group of medical students, some of whom have studied sociology or anthropology, rather than favoring the hard science majors. There will also be a "critical analysis and reasoning skills" section of the test. In modern medicine, regurgitated, memorized facts are not as important as being able to interpret and apply them. There are other initiatives, such as the Project to Rebalance and Integrate Medical Education (PRIME), seeking to overhaul the medical curriculum.

Medical education 30 years ago involved large didactic lectures wherein a vast amount of information was transmitted from professor to student, then crammed and forgotten. Memorizing facts was considered the key to being a competent physician. The most lauded professors were frequently referred to as walking textbooks. But that is no longer adequate. Medical knowledge is now a bookshelf of textbooks, well beyond the memorization of a single person. The photographic memory aided by cute mnemonics has been supplanted by a smartphone and Google.

The provision of medical care also has evolved. Rather than a solo practitioner in an office, now a team of subspecialists, aided by nurses and allied health personnel, provide care in inpatient and outpatient settings. My role as a hospitalist is to stitch together the various patches of expertise each team member has, to form a quilt that covers all the patient’s needs. Communication between team members is crucial. Accurate and complete handoffs of information also have become vital in the shift-based environment for delivering therapy in most hospital settings.

As a patient, I was quite annoyed when, after a day of tests and procedures, I was handed a computer form to fill out. It surveyed my "experience." Did I have any trouble making the appointment? Were the hours convenient? Was the staff courteous? It contained 22 items, but only one question seemed to have anything to do with whether my physician was competent. Perhaps we are in a consumer-oriented society, and the provision of medical care needs to reflect that with Press Ganey scores. But the engineer in me still focuses on those key goals of getting the diagnosis and therapy correct. Especially when I’m the recipient!

Will changing the test produce, and importantly, maintain, a more competent physician? What are the consequences of better patient satisfaction? Not necessarily better health, according to one large study. Higher patient satisfaction was associated with less emergency department use but greater inpatient use, as well as with higher overall health care and prescription drug expenditures (Arch. Intern. Med. 2012;172:405-11).

If medical educators teach to a better test, will society simply run into a better mousetrap?

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said he had no relevant financial disclosures. E-mail Dr. Powell at pdnews@elsevier.com. This column, "Beyond the White Coat," appears regularly in Pediatric News.

This is the time of year when teaching to the test comes to the forefront. Standardized testing is endemic in medical training. Whether you are a high school senior taking the SAT, a college student applying to take the MCAT, a medical student struggling to pass United States Medical Licensing Examination (USMLE) Step 1, or a recent residency graduate sitting for the boards, taking a test can be a very anxious time. Careers can be markedly altered by the scores on the standardized tests. The reputations of educational institutions, including medical schools and residency programs, depend on the scores. So the anxiety is understandable.

On the other hand, the public – who are the future patients of these physicians – may have a different perspective. Do these tests really evaluate and select those who will become better physicians? Will those physicians have the optimal balance of scientific knowledge and the art of caring?

That has been a source of consternation since long before computers began scoring tests. This quandary has not been lost on medical educators. The MCAT itself will be undergoing an overhaul by 2015. The goal is to have "A Better Test for Tomorrow’s Doctors." A preview guide of those changes was released in November 2011, and the revised second edition was just released in September 2012.

The MCAT’s basic science questions, which previously focused on biology, physics, and chemistry, will now include a section on the psychological, social, and biological foundations of behavior. The intent is to select a more diverse group of medical students, some of whom have studied sociology or anthropology, rather than favoring the hard science majors. There will also be a "critical analysis and reasoning skills" section of the test. In modern medicine, regurgitated, memorized facts are not as important as being able to interpret and apply them. There are other initiatives, such as the Project to Rebalance and Integrate Medical Education (PRIME), seeking to overhaul the medical curriculum.

Medical education 30 years ago involved large didactic lectures wherein a vast amount of information was transmitted from professor to student, then crammed and forgotten. Memorizing facts was considered the key to being a competent physician. The most lauded professors were frequently referred to as walking textbooks. But that is no longer adequate. Medical knowledge is now a bookshelf of textbooks, well beyond the memorization of a single person. The photographic memory aided by cute mnemonics has been supplanted by a smartphone and Google.

The provision of medical care also has evolved. Rather than a solo practitioner in an office, now a team of subspecialists, aided by nurses and allied health personnel, provide care in inpatient and outpatient settings. My role as a hospitalist is to stitch together the various patches of expertise each team member has, to form a quilt that covers all the patient’s needs. Communication between team members is crucial. Accurate and complete handoffs of information also have become vital in the shift-based environment for delivering therapy in most hospital settings.

As a patient, I was quite annoyed when, after a day of tests and procedures, I was handed a computer form to fill out. It surveyed my "experience." Did I have any trouble making the appointment? Were the hours convenient? Was the staff courteous? It contained 22 items, but only one question seemed to have anything to do with whether my physician was competent. Perhaps we are in a consumer-oriented society, and the provision of medical care needs to reflect that with Press Ganey scores. But the engineer in me still focuses on those key goals of getting the diagnosis and therapy correct. Especially when I’m the recipient!

Will changing the test produce, and importantly, maintain, a more competent physician? What are the consequences of better patient satisfaction? Not necessarily better health, according to one large study. Higher patient satisfaction was associated with less emergency department use but greater inpatient use, as well as with higher overall health care and prescription drug expenditures (Arch. Intern. Med. 2012;172:405-11).

If medical educators teach to a better test, will society simply run into a better mousetrap?

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said he had no relevant financial disclosures. E-mail Dr. Powell at pdnews@elsevier.com. This column, "Beyond the White Coat," appears regularly in Pediatric News.

"The next patient is a 5-year-old who is unable to walk," reports the overnight resident at the morning sign-out. "He had a day of fever 4 days ago, leg pain beginning 2 days ago, and yesterday he awoke with refusal to bear weight."

As we get to the differential diagnosis, I try to expand on the list of possibilities rather than merely accept the working diagnosis of myositis developed in the emergency department.

Photo credit: Micah Young/istockphoto.com

We start with the common paradigm, "If you hear hoof beats behind you, you turn around expecting to see a horse, not a zebra. However, beware the hard-charging rhinoceros that will run you over if you don’t turn around fast enough." What is the rhinoceros in this situation? A septic hip. That needs to be ruled out emergently. If suspected, you get an immediate orthopedics consult and probably an aspiration of the hip, as destruction of the joint can occur in less than 24 hours. Physical exam had excluded this possibility. The hip was nontender.

The physical exam had revealed some mild tenderness of the calves.

"What if there were decreased or absent reflexes?" I ask. Several people jump on the diagnosis of Guillain-Barré syndrome. Correct, although I lament that only one of the four history and physicals obtained in the ED or by the admitting team had documented testing any reflexes. Teaching point made – do thorough physicals.

"What if," I asked, "you had detected weakness in the legs?" The room is silent as people consider the options. I hint, "It’s mostly of historical interest." After more silence, a medical student proffers polio. That is correct. A resident admits that she would never have thought of that diagnosis. Years of training had matured her book learning into a more honed clinical judgment. To a modern resident, polio isn’t a zebra, it’s nearly a unicorn.

I had the opportunity to check my e-mail prior to going on family-centered rounds. It contained two reminders that on that date in 1954 large-scale immunization with the Salk vaccine had begun.

The purpose of my column "Beyond the White Coat" is to provide updates, news, and perspective from the fields of law, philosophy, and the humanities that have an impact on clinical medicine. Historical events provide perspective. I was acutely aware that morning of the difference between what I faced and what one of my predecessors in the 1950s would have faced.

In that bygone era, the nightmare for many parents was putting an infant to bed with a fever, not knowing whether the baby would wake up paralyzed. Because of medical progress, I didn’t have to deliver such a grim diagnosis. I had good news to give. "Your child has a muscle inflammation that occasionally occurs after influenza and some other viruses. The muscle enzyme test this morning is improved from yesterday. The clinical exam is also better. He is now bearing weight. He’s going to be fine. I expect full recovery in another 1-3 days."

Parental refusal of vaccines remains a significant and growing problem. The Wall Street Journal last month carried yet another article about pediatricians who fire from their practice parents who refuse vaccines ("More Doctors Fire Vaccine Refusers," Feb. 15, 2012). The American Academy of Pediatrics has a policy statement discouraging such a response (Pediatrics 2005;115:1428-31), but many physicians disagree with that policy (Arch. Pediatr. Adolesc. Med. 2005;159:929-34). A wide variety of reasons are given to justify the practice. Other physicians, working locally such as in this Missouri article, are encouraging the virtue of accommodation ("Responding With Empathy to Parents Fears of Vaccinations," Missouri Medicine, Jan/Feb 2012). (Full disclosure: I’m proud to say I work with those two Missouri doctors.)

I have a research interest in parental refusals of care, as indicated in my September 2011 column ("A Parents Refusal and the Harm Principle," September 2011, p. 32). I won’t try to settle the vaccine controversy here. For me, this isn’t an issue of parental authority, parens patriae, and medical liability. The real motivation for spending the extra time educating and guiding parents who are worried about the safety of vaccines is rooted in my gratitude that I will never have to walk into a room and break the horrific news of polio to a family. It is a debt I owe those who came before me: the scientists, clinicians, parents, and children, who conquered polio. For those efforts, thank you.

P.S. My patient did get a flu shot before discharge.

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center, St. Louis.

"The next patient is a 5-year-old who is unable to walk," reports the overnight resident at the morning sign-out. "He had a day of fever 4 days ago, leg pain beginning 2 days ago, and yesterday he awoke with refusal to bear weight."

As we get to the differential diagnosis, I try to expand on the list of possibilities rather than merely accept the working diagnosis of myositis developed in the emergency department.

Photo credit: Micah Young/istockphoto.com

We start with the common paradigm, "If you hear hoof beats behind you, you turn around expecting to see a horse, not a zebra. However, beware the hard-charging rhinoceros that will run you over if you don’t turn around fast enough." What is the rhinoceros in this situation? A septic hip. That needs to be ruled out emergently. If suspected, you get an immediate orthopedics consult and probably an aspiration of the hip, as destruction of the joint can occur in less than 24 hours. Physical exam had excluded this possibility. The hip was nontender.

The physical exam had revealed some mild tenderness of the calves.

"What if there were decreased or absent reflexes?" I ask. Several people jump on the diagnosis of Guillain-Barré syndrome. Correct, although I lament that only one of the four history and physicals obtained in the ED or by the admitting team had documented testing any reflexes. Teaching point made – do thorough physicals.

"What if," I asked, "you had detected weakness in the legs?" The room is silent as people consider the options. I hint, "It’s mostly of historical interest." After more silence, a medical student proffers polio. That is correct. A resident admits that she would never have thought of that diagnosis. Years of training had matured her book learning into a more honed clinical judgment. To a modern resident, polio isn’t a zebra, it’s nearly a unicorn.

I had the opportunity to check my e-mail prior to going on family-centered rounds. It contained two reminders that on that date in 1954 large-scale immunization with the Salk vaccine had begun.

The purpose of my column "Beyond the White Coat" is to provide updates, news, and perspective from the fields of law, philosophy, and the humanities that have an impact on clinical medicine. Historical events provide perspective. I was acutely aware that morning of the difference between what I faced and what one of my predecessors in the 1950s would have faced.

In that bygone era, the nightmare for many parents was putting an infant to bed with a fever, not knowing whether the baby would wake up paralyzed. Because of medical progress, I didn’t have to deliver such a grim diagnosis. I had good news to give. "Your child has a muscle inflammation that occasionally occurs after influenza and some other viruses. The muscle enzyme test this morning is improved from yesterday. The clinical exam is also better. He is now bearing weight. He’s going to be fine. I expect full recovery in another 1-3 days."

Parental refusal of vaccines remains a significant and growing problem. The Wall Street Journal last month carried yet another article about pediatricians who fire from their practice parents who refuse vaccines ("More Doctors Fire Vaccine Refusers," Feb. 15, 2012). The American Academy of Pediatrics has a policy statement discouraging such a response (Pediatrics 2005;115:1428-31), but many physicians disagree with that policy (Arch. Pediatr. Adolesc. Med. 2005;159:929-34). A wide variety of reasons are given to justify the practice. Other physicians, working locally such as in this Missouri article, are encouraging the virtue of accommodation ("Responding With Empathy to Parents Fears of Vaccinations," Missouri Medicine, Jan/Feb 2012). (Full disclosure: I’m proud to say I work with those two Missouri doctors.)

I have a research interest in parental refusals of care, as indicated in my September 2011 column ("A Parents Refusal and the Harm Principle," September 2011, p. 32). I won’t try to settle the vaccine controversy here. For me, this isn’t an issue of parental authority, parens patriae, and medical liability. The real motivation for spending the extra time educating and guiding parents who are worried about the safety of vaccines is rooted in my gratitude that I will never have to walk into a room and break the horrific news of polio to a family. It is a debt I owe those who came before me: the scientists, clinicians, parents, and children, who conquered polio. For those efforts, thank you.

P.S. My patient did get a flu shot before discharge.

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center, St. Louis.

"The next patient is a 5-year-old who is unable to walk," reports the overnight resident at the morning sign-out. "He had a day of fever 4 days ago, leg pain beginning 2 days ago, and yesterday he awoke with refusal to bear weight."

As we get to the differential diagnosis, I try to expand on the list of possibilities rather than merely accept the working diagnosis of myositis developed in the emergency department.

Photo credit: Micah Young/istockphoto.com

We start with the common paradigm, "If you hear hoof beats behind you, you turn around expecting to see a horse, not a zebra. However, beware the hard-charging rhinoceros that will run you over if you don’t turn around fast enough." What is the rhinoceros in this situation? A septic hip. That needs to be ruled out emergently. If suspected, you get an immediate orthopedics consult and probably an aspiration of the hip, as destruction of the joint can occur in less than 24 hours. Physical exam had excluded this possibility. The hip was nontender.

The physical exam had revealed some mild tenderness of the calves.

"What if there were decreased or absent reflexes?" I ask. Several people jump on the diagnosis of Guillain-Barré syndrome. Correct, although I lament that only one of the four history and physicals obtained in the ED or by the admitting team had documented testing any reflexes. Teaching point made – do thorough physicals.

"What if," I asked, "you had detected weakness in the legs?" The room is silent as people consider the options. I hint, "It’s mostly of historical interest." After more silence, a medical student proffers polio. That is correct. A resident admits that she would never have thought of that diagnosis. Years of training had matured her book learning into a more honed clinical judgment. To a modern resident, polio isn’t a zebra, it’s nearly a unicorn.

I had the opportunity to check my e-mail prior to going on family-centered rounds. It contained two reminders that on that date in 1954 large-scale immunization with the Salk vaccine had begun.

The purpose of my column "Beyond the White Coat" is to provide updates, news, and perspective from the fields of law, philosophy, and the humanities that have an impact on clinical medicine. Historical events provide perspective. I was acutely aware that morning of the difference between what I faced and what one of my predecessors in the 1950s would have faced.

In that bygone era, the nightmare for many parents was putting an infant to bed with a fever, not knowing whether the baby would wake up paralyzed. Because of medical progress, I didn’t have to deliver such a grim diagnosis. I had good news to give. "Your child has a muscle inflammation that occasionally occurs after influenza and some other viruses. The muscle enzyme test this morning is improved from yesterday. The clinical exam is also better. He is now bearing weight. He’s going to be fine. I expect full recovery in another 1-3 days."

Parental refusal of vaccines remains a significant and growing problem. The Wall Street Journal last month carried yet another article about pediatricians who fire from their practice parents who refuse vaccines ("More Doctors Fire Vaccine Refusers," Feb. 15, 2012). The American Academy of Pediatrics has a policy statement discouraging such a response (Pediatrics 2005;115:1428-31), but many physicians disagree with that policy (Arch. Pediatr. Adolesc. Med. 2005;159:929-34). A wide variety of reasons are given to justify the practice. Other physicians, working locally such as in this Missouri article, are encouraging the virtue of accommodation ("Responding With Empathy to Parents Fears of Vaccinations," Missouri Medicine, Jan/Feb 2012). (Full disclosure: I’m proud to say I work with those two Missouri doctors.)

I have a research interest in parental refusals of care, as indicated in my September 2011 column ("A Parents Refusal and the Harm Principle," September 2011, p. 32). I won’t try to settle the vaccine controversy here. For me, this isn’t an issue of parental authority, parens patriae, and medical liability. The real motivation for spending the extra time educating and guiding parents who are worried about the safety of vaccines is rooted in my gratitude that I will never have to walk into a room and break the horrific news of polio to a family. It is a debt I owe those who came before me: the scientists, clinicians, parents, and children, who conquered polio. For those efforts, thank you.

P.S. My patient did get a flu shot before discharge.

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center, St. Louis.

In 1863, Abraham Lincoln established a Thursday in November as a national day for Thanksgiving. Previous U.S. presidents and Congresses had intermittently appointed days for thanksgiving. After 1863, November became an annual tradition.

A day of thanksgiving can become a day for reflection and self-renewal. It is a time to go beyond thankfulness for mind (knowledge) and body (technical skills). It is also a day to renew the spirit (psyche).

Stephen Covey’s book "The 7 Habits of Highly Effective People" lists habit No. 7 as "Sharpen the Saw." He points out that a sharp saw cuts wood faster, but many people behave as if they are too busy cutting wood to stop and sharpen the saw. This actually makes them even slower and less productive. Tools accomplish more when they are properly taken care of. The same is true for people.

Many other self-help books offer similar advice. Self-renewal is partly letting go of baggage that is weighing you down. It is partly adjusting attitude, as the motivational cliché proclaims: "You can’t change the wind, but you can adjust your sails." It is partly developing strategies for the upcoming week, month, or year.

Medical conferences offer opportunities to update one’s knowledge through continuing medical education. Occasionally these opportunities are training sessions to learn new skills, which might be surgical procedures or even tasks on a computer. However, the most critical item to be updated is the aspiration of the physician himself or herself. Medicine is a calling. In the long run, instilling and maintaining the attitudes and vision of a vocation, in one’s self and one’s colleagues, is the most important activity of a professional.

Instilling Values Through Initiation

The Hippocratic Oath has been around for millennia. One of the recent additions to the rituals of health care has been the White Coat Ceremony. In just 20 years, the annual ritual has become prevalent at the majority of medical schools, as well as colleges of pharmacy and advanced nursing programs. The ritual has even spread internationally. Detractors say there isn’t empirical data about the long term benefits of a White Coat Ceremony, but I find support for it in analogous examples that have a longer history.

Whether it is a church, a fraternity or sorority, or a secular organization, initiation ceremonies are ubiquitous. It is hard to believe that these rites would continue if the senior leadership didn’t reflect back on their careers and assess the rites as valuable. Recently, I had the opportunity to visit the Harry S. Truman Library and Museum in Independence, Mo. A small part of the exhibit was dedicated to his joining the Masons.

The exhibit noted that: "The Masonic Order offered ethical guidance, companionship, and acceptance among other Masons, wherever he might travel." And more specifically, it had a quote from Truman:

"The Scottish Rite has done its best to make a man of me, but they had such a grade of material to start with that they did a poor job I fear. It is the most impressive ceremony I ever saw or read. If a man doesn’t try better after seeing it, he has a screw loose somewhere."

Truman was initially known in Washington D.C. as "the Senator from Pendergast." T.J. Pendergast was a political boss in Kansas City very similar to the more famous Al Capone who ran Chicago. Pendergast was instrumental in getting Truman elected, which led many senators to shun Harry. But within a few years, he was the senator spearheading investigations into corruption and quality problems in the manufacture of military equipment during World War II.

Maintaining the Vision

Aspirational rituals alone do not guarantee ethical behavior. But history demonstrates that professional behavior is better with rituals than without them. Since an oath alone isn’t adequate, it seems prudent for a profession to add another layer of social regulation, such as empowering patients with lists of rights and responsibilities. But initiation ceremonies and regulation aren’t enough. To be a great profession, worthy of the public’s trust and status, individual physicians must periodically refine and reaffirm the values, ideals, and goals that called them to care for others. There are many ways this can be done.

The highly effective physician realizes that keeping up to date reading the medical literature is important, but she can help her patients even more by reading one less journal article a month and using that time to make a habit of renewing her commitment to her core values. On Nov. 19, 1863, 1 week before that national day of Thanksgiving, President Lincoln took a train ride to a small town in Pennsylvania. He went to dedicate a cemetery. He talked eloquently about dedication and devotion to a cause. It takes but 2 minutes each Nov. 19 for me to recite his Gettysburg Address. I am not devoted to exactly the same cause, but I still find it inspirational.

It is important to have an activity that prompts and promotes sharpening the saw. As you may have surmised, personally, I like to visit museums.

Dr. Powell is associate professor of pediatrics at Saint Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. 

In 1863, Abraham Lincoln established a Thursday in November as a national day for Thanksgiving. Previous U.S. presidents and Congresses had intermittently appointed days for thanksgiving. After 1863, November became an annual tradition.

A day of thanksgiving can become a day for reflection and self-renewal. It is a time to go beyond thankfulness for mind (knowledge) and body (technical skills). It is also a day to renew the spirit (psyche).

Stephen Covey’s book "The 7 Habits of Highly Effective People" lists habit No. 7 as "Sharpen the Saw." He points out that a sharp saw cuts wood faster, but many people behave as if they are too busy cutting wood to stop and sharpen the saw. This actually makes them even slower and less productive. Tools accomplish more when they are properly taken care of. The same is true for people.

Many other self-help books offer similar advice. Self-renewal is partly letting go of baggage that is weighing you down. It is partly adjusting attitude, as the motivational cliché proclaims: "You can’t change the wind, but you can adjust your sails." It is partly developing strategies for the upcoming week, month, or year.

Medical conferences offer opportunities to update one’s knowledge through continuing medical education. Occasionally these opportunities are training sessions to learn new skills, which might be surgical procedures or even tasks on a computer. However, the most critical item to be updated is the aspiration of the physician himself or herself. Medicine is a calling. In the long run, instilling and maintaining the attitudes and vision of a vocation, in one’s self and one’s colleagues, is the most important activity of a professional.

Instilling Values Through Initiation

The Hippocratic Oath has been around for millennia. One of the recent additions to the rituals of health care has been the White Coat Ceremony. In just 20 years, the annual ritual has become prevalent at the majority of medical schools, as well as colleges of pharmacy and advanced nursing programs. The ritual has even spread internationally. Detractors say there isn’t empirical data about the long term benefits of a White Coat Ceremony, but I find support for it in analogous examples that have a longer history.

Whether it is a church, a fraternity or sorority, or a secular organization, initiation ceremonies are ubiquitous. It is hard to believe that these rites would continue if the senior leadership didn’t reflect back on their careers and assess the rites as valuable. Recently, I had the opportunity to visit the Harry S. Truman Library and Museum in Independence, Mo. A small part of the exhibit was dedicated to his joining the Masons.

The exhibit noted that: "The Masonic Order offered ethical guidance, companionship, and acceptance among other Masons, wherever he might travel." And more specifically, it had a quote from Truman:

"The Scottish Rite has done its best to make a man of me, but they had such a grade of material to start with that they did a poor job I fear. It is the most impressive ceremony I ever saw or read. If a man doesn’t try better after seeing it, he has a screw loose somewhere."

Truman was initially known in Washington D.C. as "the Senator from Pendergast." T.J. Pendergast was a political boss in Kansas City very similar to the more famous Al Capone who ran Chicago. Pendergast was instrumental in getting Truman elected, which led many senators to shun Harry. But within a few years, he was the senator spearheading investigations into corruption and quality problems in the manufacture of military equipment during World War II.

Maintaining the Vision

Aspirational rituals alone do not guarantee ethical behavior. But history demonstrates that professional behavior is better with rituals than without them. Since an oath alone isn’t adequate, it seems prudent for a profession to add another layer of social regulation, such as empowering patients with lists of rights and responsibilities. But initiation ceremonies and regulation aren’t enough. To be a great profession, worthy of the public’s trust and status, individual physicians must periodically refine and reaffirm the values, ideals, and goals that called them to care for others. There are many ways this can be done.

The highly effective physician realizes that keeping up to date reading the medical literature is important, but she can help her patients even more by reading one less journal article a month and using that time to make a habit of renewing her commitment to her core values. On Nov. 19, 1863, 1 week before that national day of Thanksgiving, President Lincoln took a train ride to a small town in Pennsylvania. He went to dedicate a cemetery. He talked eloquently about dedication and devotion to a cause. It takes but 2 minutes each Nov. 19 for me to recite his Gettysburg Address. I am not devoted to exactly the same cause, but I still find it inspirational.

It is important to have an activity that prompts and promotes sharpening the saw. As you may have surmised, personally, I like to visit museums.

Dr. Powell is associate professor of pediatrics at Saint Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. 

In 1863, Abraham Lincoln established a Thursday in November as a national day for Thanksgiving. Previous U.S. presidents and Congresses had intermittently appointed days for thanksgiving. After 1863, November became an annual tradition.

A day of thanksgiving can become a day for reflection and self-renewal. It is a time to go beyond thankfulness for mind (knowledge) and body (technical skills). It is also a day to renew the spirit (psyche).

Stephen Covey’s book "The 7 Habits of Highly Effective People" lists habit No. 7 as "Sharpen the Saw." He points out that a sharp saw cuts wood faster, but many people behave as if they are too busy cutting wood to stop and sharpen the saw. This actually makes them even slower and less productive. Tools accomplish more when they are properly taken care of. The same is true for people.

Many other self-help books offer similar advice. Self-renewal is partly letting go of baggage that is weighing you down. It is partly adjusting attitude, as the motivational cliché proclaims: "You can’t change the wind, but you can adjust your sails." It is partly developing strategies for the upcoming week, month, or year.

Medical conferences offer opportunities to update one’s knowledge through continuing medical education. Occasionally these opportunities are training sessions to learn new skills, which might be surgical procedures or even tasks on a computer. However, the most critical item to be updated is the aspiration of the physician himself or herself. Medicine is a calling. In the long run, instilling and maintaining the attitudes and vision of a vocation, in one’s self and one’s colleagues, is the most important activity of a professional.

Instilling Values Through Initiation

The Hippocratic Oath has been around for millennia. One of the recent additions to the rituals of health care has been the White Coat Ceremony. In just 20 years, the annual ritual has become prevalent at the majority of medical schools, as well as colleges of pharmacy and advanced nursing programs. The ritual has even spread internationally. Detractors say there isn’t empirical data about the long term benefits of a White Coat Ceremony, but I find support for it in analogous examples that have a longer history.

Whether it is a church, a fraternity or sorority, or a secular organization, initiation ceremonies are ubiquitous. It is hard to believe that these rites would continue if the senior leadership didn’t reflect back on their careers and assess the rites as valuable. Recently, I had the opportunity to visit the Harry S. Truman Library and Museum in Independence, Mo. A small part of the exhibit was dedicated to his joining the Masons.

The exhibit noted that: "The Masonic Order offered ethical guidance, companionship, and acceptance among other Masons, wherever he might travel." And more specifically, it had a quote from Truman:

"The Scottish Rite has done its best to make a man of me, but they had such a grade of material to start with that they did a poor job I fear. It is the most impressive ceremony I ever saw or read. If a man doesn’t try better after seeing it, he has a screw loose somewhere."

Truman was initially known in Washington D.C. as "the Senator from Pendergast." T.J. Pendergast was a political boss in Kansas City very similar to the more famous Al Capone who ran Chicago. Pendergast was instrumental in getting Truman elected, which led many senators to shun Harry. But within a few years, he was the senator spearheading investigations into corruption and quality problems in the manufacture of military equipment during World War II.

Maintaining the Vision

Aspirational rituals alone do not guarantee ethical behavior. But history demonstrates that professional behavior is better with rituals than without them. Since an oath alone isn’t adequate, it seems prudent for a profession to add another layer of social regulation, such as empowering patients with lists of rights and responsibilities. But initiation ceremonies and regulation aren’t enough. To be a great profession, worthy of the public’s trust and status, individual physicians must periodically refine and reaffirm the values, ideals, and goals that called them to care for others. There are many ways this can be done.

The highly effective physician realizes that keeping up to date reading the medical literature is important, but she can help her patients even more by reading one less journal article a month and using that time to make a habit of renewing her commitment to her core values. On Nov. 19, 1863, 1 week before that national day of Thanksgiving, President Lincoln took a train ride to a small town in Pennsylvania. He went to dedicate a cemetery. He talked eloquently about dedication and devotion to a cause. It takes but 2 minutes each Nov. 19 for me to recite his Gettysburg Address. I am not devoted to exactly the same cause, but I still find it inspirational.

It is important to have an activity that prompts and promotes sharpening the saw. As you may have surmised, personally, I like to visit museums.

Dr. Powell is associate professor of pediatrics at Saint Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis.