Oh, The Things We Do to Our Ears...

Since the Dawn of Time, people have messed with their ears. Primitive man (and primitive woman and primitive teenagers!) thought it was a good idea to adorn these convenient appendages with jewelry. The Africans took it to extremes by placing large objects, like bones, pretty stones, and carved pieces of wood into the fleshy part of their earlobes The bigger the bone, the more status, apparently. Some of the stretched lobes could hold a satellite dish.

Personally, I have no problems with most piercings, although I have never been tempted to get my own ears pierced. I grew up in a time and geographic area where these things were frowned upon. The only wild thing that I really did in my younger days is to grow a ponytail for a while. I had a good one - although it was grey. One day, one my elderly patients said, "Hey, Ponytail Boy, when are you going to cut that damn thing off?" Apparently, she grew up at a time and geographic area that frowned on grown men wearing ponytails. I cut if off. I still have it in my desk drawer. So much for my misdirected efforts in trying to be "cool".

I am not a big fan of the piercings through the tragus or cartilage, since they can develop some nasty infections, but those cute, conservative ones in the earlobe are fine. Yes, they can get infected or form some horrible-looking keloids (scars), but all in all, they are pretty. How people can stand to have earrings the size of Christmas tree ornaments, I don't know. As a matter of fact, one of our friends actually wore Christmas bulbs in her ears. She wasn't amused when I asked her if they lit up.

Those big loops get caught on things, such as sweaters, fingers, and other objects. Since metal is a bit stronger than human tissue, I have to suture an occasional rip, even in little children. Most heal beautifully if treated promptly.

Any bodily hole, whether natural or created by body modification, can become infected by those opportunistic bugs among us. The ears are no exception. Probably the most common complication of a pierced ear is a retained backing, or a localized infection. Cysts can also form behind the ears of lobe piercings. At least once a week, I am digging out a retained backing or even an entire earring, or lancing an infection.

Today, on the ENT board, I had two postings that are related to this subject. One person wanted to use an ear candle to cure her middle ear fluid; and another person admitted to rupturing his own eardrum with a Q-tip and wanted to know when it will heal.

I think ear candles are one of the most ridiculous quack practices out there. I even found videos of idiots on You Tube catching their hair on fire trying to use these wax cones. One site stated the ear candles were invented by the people of Atlantis which added to their credibility. I mean, if an advanced race used them, then they must be good. I guess when Atlantis blew up, the ear candles floated across the Atlantic, only to eventually end up in health food stores. Ear candles don't work, folks. There is absolutely no suction created by smoke, at least none that will pull wax and poisons out of your system. Yes, you can get a chunk of soot-covered earwax out of your ear canal, but there are better and safer ways of doing this.

Q-tips (not just the brand, of course), should not be inserted in the ear. We all know that, but most people tend to ignore the warning. Earwax has always has a bad reputation as being dirty. When it is visible by others, it reflects adversely on our personal hygiene, so people really want to get it out. In an effort to be thorough, they twist it around, pulling it in and out of the ear canal like some sort of piston; checking periodically for that yellow staining indicating success. More often than not, you push them in too far. First, comes the pain. Then, comes the blood. Congratulations, you have successfully ruptured your eardrum. Most traumatically ruptured eardrums heal in time, but some will require a surgical patch - a tympanoplasty. Eardrums are also ruptured by paper clips, pencils, and just about any object that fits in there, often done by seemingly intelligent people.

Finally, children love to stick things in bodily orifices. A significant part of my clinical practice in pediatrics is to dig 'em out. I remove beans and peanuts from little noses, and a variety of things from the ear canal: sponges, beads, toys, etc. I even removed an eyeball from the ear canal! A toy eyeball, of course, but it was interesting to look in an ear and see an eye looking back at me. One Christmas, many years ago, I pulled a little plastic baby out of a toddler's nose. It turned out to be a tiny baby Jesus that he took from a miniature Nativity set. Hallelujah! That would be a good holiday song: "Away in a nostril, no crib for his bed..."

As humans, we need to have a bit more respect for our ears. We need to stop sticking things in them, limit the number of holes we drill in them, and stop hanging so many decorations on the outside. And, we need to understand and appreciate the protective qualities of good ol' earwax. If God created humans in his own image, do you really think he intended for us to modify the unique anatomical appendage that is our ear? I think not.

Related Topics:

• WebMD Video: Repairing Damaged Earlobes
• Ear Infection Health Center

Technorati Tags: ears, piercing, Q-tips

Holiday Buying Frenzies, Hunting, and Leftovers

The Friday after Thanksgiving has been termed Black Friday, a term that did not amuse my African-American receptionist. She thought it was something else and was a bit upset. I pointed out that there is also a January White Sale that I am not fond of either. One must always try to be politically-correct at all times, especially when people are upset anyway because they have to work the day after Thanksgiving.

So, on B-word Friday, stores open at 5 AM with super-sales and people are running through those doors like stampeding cattle, snatching up those bargains (only three per store?), and trying to complete their holiday shopping obligations in one day. Today is the day after Thanksgiving, and I am seeing patients. I would still rather be here than the mall. Actually, I would rather be sitting in my reclining chair.

The clinic parking lot was practically empty this morning. People that have the day off were either sleeping, doing dishes from yesterday, or traveling from family get-togethers. Personally, I like the day after Thanksgiving better because of the leftovers. Some foods are even better the next day. Unfortunately, I did not bring a turkey sandwich today, because tonight is our delayed Thanksgiving feast. My wife has been preparing for it all week, except for remembering to take out the frozen turkey to thaw. When I left this morning, it was swimming in a sink of warm water in an effort to expedite the process.

With five adult children with conflicting obligations, we often have to negotiate for holiday time. This year, not only will we have Thanksgiving on Black Friday, we will have Christmas on December 21st. Getting together as a family is really more important than those specific dates. One must be flexible.

If it continues to be slow today, I will just work until early afternoon. I will head home and try to rescue my wife in the kitchen. I love to cook, but she will not let me at the turkey. I tend to experiment with various marinades and cooking methods. She keeps reminding me of the black, charred turkey we had a few years ago when I left it unattended in the Weber. This was a real Black Friday. The turkey was edible; good on the inside, but looked like it survived a forest fire. We did not take a picture of it. I only tried to cook one deep-fried turkey. It, too, was not successful. Not only was it greasy, I nearly burned down the neighborhood. There is nothing like five gallons of peanut oil bubbling in your backyard, starting random little grease fires, to get your undivided attention. I also cooked a small area of my lawn in the process. Now, I know I am going to get some postings from successful deep-fry specialists out there. I am happy it worked out for you. Regional Burn Centers are on full alert during Thanksgiving.

This morning on my way to work, I spotted our resident flock of wild turkeys. It appears that most survived the holiday as well. Although I would not put it past some of my neighbors to shoot one of them, I counted all nine this morning. I didn't get a chance to see the news, but every year the President pardons a turkey. I always wondered if Richard Nixon said, "I pardon this turkey, because I am not a cook."

In my youth, we all went hunting. I even worked summers on a game farm that raised quail and pheasants for the hunters to shoot in the winter. Perhaps, this is what turned me off to hunting. On cold winter days, I had to go to the bird enclosures, catch a dozen or so live birds and put them in burlap sack. Then, about 10 minutes before the paying hunters arrived at the designated field, I would dump out or carefully place the birds so the dogs could find them. Fortunately, most of the hunters were not very good, so the vast majority of our farm-raised birds escaped to freedom. Escaping a hunter's bullet is not as good as a Presidential pardon, but it is still better than the alternative.

I like animals, so I was really glad to be a bad hunter. Before hanging up my hunting gear at age 17, I bagged one wild turkey, a few rabbits, and a squirrel. While I do not like the idea of killing animals, but I do love to eat 'em, so I am glad there are people out there to do it for me. Please don't link my Blog to PETA. If God didn't want us to eat turkeys, he wouldn't have made them taste so good.

Now, it is Sunday...Fat Sunday. (Hopefully, this will not insult fat people. ) I call it Fat Sunday because I have been eating non-stop since Thursday. Pumpkin pie...apple pie...leftover turkey/gravy/mashed potatoes...cranberry sauce...some kind of jello-crap...and my famous ginger sweet potatoes. Today, we made turkey soup and I must say I am getting tired of it now. We have about five gallons of soup that my wife promised pack for my lunch tomorrow, along with the obligatory turkey sandwich. I will try and eat it, but right now, the thought of it makes me sick.

Maybe I will call it Vomit Monday.

Related Topics:

• Beyond Thanksgiving: A Week of Healthy Meals and Recipes
• Thankfully Light Leftovers

Technorati Tags: Thanksgiving, Black Friday, turkey, leftovers, hunting

Turkeys!

Benjamin Franklin wanted the wild turkey to become our national symbol. I am sure glad we picked the noble bald eagle. While a wild turkey is a clever bird (the domestic ones are dumb), it does not imply the strength that should represent a nation. I can't imagine seeing a turkey on our coins or national emblems, and eating bald eagle on Thanksgiving.

If you have been reading my blog for awhile, you know that I live in a rural area. We have a lot of turkeys here, and I am not referring to my neighbors (although one does meet the standards). For the last several weeks, we I went to mow my grass, I found that there was redwood bark from my planter areas all over the place. Initially, I thought one of the dogs was digging; perhaps looking for moles. But, no...it was turkeys. I spotted about a dozen of them yesterday, routing around the yard, scratching in the bark, and making a real mess. I chased them away, but I know they will return. My new little dog did chase them, but I suspect she will not be diligent enough to keep them at bay.

I used to own a turkey; two, in fact. When I worked in family practice about twenty or so years ago, I was given a pair of turkeys as a gift for making a house call on a disabled patient. To be honest, when the turkeys were offered, I just assumed they were frozen and ready-to-eat. Thanksgiving was only a few weeks away, so why not? Not to appear ungrateful for this unusual, live gift, I loaded them up in the back of the car and drove home. They were looking out of the windows, gobbling at startled drivers. Perhaps, they thought I was just taking them for ride. I knew my wife would be surprised when I put them in the back yard.

The person that gave me the turkeys could not kill them for food. They were more like pets to her. Of course, I assumed that I could fatten them up for the holidays and do the dirty deed. Besides, I grew up in Appalachia where we hunted turkeys. I actually shot one when I was about 16; pretty much the last time I went hunting. It wasn't very good. Too stringy, and not as tasty as those corn-fed, hormone-infused, big breasted birds from the grocery store. I really felt that I could eat these gift turkeys, but I couldn't. They became pets.

Tom and Tiki (their real names) lived in my back yard for about two years. I estimate that they ate several hundred dollars worth of turkey feed and unsold, several-day-old bread (their favorite). They got bigger and fatter. They also got more friendly. My two-year old son, at the time, was Tom's favorite. Tom was apparently a homosexual and interested in other species (like humans). I must say it was shocking to see a big 'ol turkey trying to mount your little boy. My son, now 29, informed me this year that he does not eat turkey. Perhaps, he is having some latent trauma from being sexually molested by one in his childhood. I don't know what we are going to feed him this year. We can't have ham, since his wife is Jewish.

When I moved, I couldn't take Tom and Tiki with me, so I gave them to my neighbor. He assured me that he would kill and eat them. Several years later, they were still happily residing in his backyard. Tiki eventually died, and Tom was donated to the Folsom Petting Zoo, where he secretly practiced his lust for humans. I wonder if they had a "Beware of Humping Turkey" sign?



We are going to have a traditional turkey meal this week using a store-bought bird, not those guys tearing up my garden. I am not going to deep fry it in oil, or cook it in a big metal garbage can like I saw on the news this morning. The turkey is just going to go in the oven. Last year, I cooked a goose (I bought it, if you must know). A goose is perhaps the worst-tasting bird on this planet; at least the way mine came out. I spent sixty bucks on that goose. I was the one that ended up getting goosed.

I like turkeys. I like them more on a plate, or as turkey sandwiches, rather than pets. In my humble opinion, they could be the National Symbol, unless of course, the vegetarians object.

Have a Wonderful Thanksgiving. Enjoy your bird.

Related Topics:

• WebMD Video: The Dangers of Frying Turkeys
• WebMD Video: Good and Bad Holiday Foods

Technorati Tags: turkey, Thanksgiving

MRSA - The New Cooties

As a child in rural Pennsylvania, one of the first afflictions that boys learned about was cooties. We assumed that cooties were a subspecies of head lice that usually just affected girls. If a girl had cooties, it would be best not to sit near them, or God forbid, bump in to them. Simply touching a girl (anywhere; not in those taboo places) would give you cooties. Cooties could be cured simply by touching someone else; transferring the affliction.

The other day in my clinic, I asked a six year old boy if girls in his school still have cooties. He replied that they do not. He nonchalantly said that girls have MRSA! I could not believe that a six-year old knew this highly-technical, medical abbreviation.

"MRSA!" I said. "Do you have any idea what that is?"

"Yes, it is a Staph infection." My jaw dropped. This kid has been watching the news.

There have been several cases of MRSA - Methicillin-Resistant Staphylococcus Aureus - reported in the local schools and day-care facilities and our local, sensation-gathering news media has again, scared the heck out of everyone. Some schools have been closed while janitors, masked and wearing hazardous material suits, are disinfecting everything. Parents are bringing kids into the clinic with innocent-appearing rashes; hoping that their child does not have MRSA.

The last time that I saw a panic like this is when a local high school had three cases of meningitis. The very next day, every lethargic-looking teenager (most of them) with a stiff neck was hauled into our office by frightened parents so they could be tested.

MRSA has been around for long time. We have been regularly finding it on some of our patients, especially the last few years. In one week, I found two different teenagers with abscess on their buttocks that tested positive for MRSA. Another doctor in the clinic, found two more MRSA-positive skin abscess in the same week; also on the butt. The kids went to different schools; unlikely that they would have been sitting on the same toilet. A few weeks later, I saw a nine-month old with an odd diaper rash that was blistering. Although Strep is commonly found in this area, I sent it out for culture. This little girl had MRSA, too. This time, a source was narrowed down. Dad was an RN; Mom was a respiratory therapist. They both worked in the hospital. It is likely that MRSA hitchhiked home on their scrubs, or hands...or both.

Fortunately, all of these cases were cured with a simple antibiotic; one that we rarely use anymore for skin infections - sulfamethoxazole (Bactrim, Septra). In the past, we used to use this older drug for ear infections and it is still the number one drug used for urinary tract infections. As new antibiotics were developed, medical providers jumped to use them instead. Now, thanks to this old sulfa drug, we are able to cure some of these cases, but unfortunately, not all of them. One of the reasons sulfa is working is because we stopped routine using it. MRSA, so far, hasn't developed a universal resistance to it.

A few weeks ago, my elderly father-in-law passed away. Although there were several causes of his demise listed on the death certificate, one was septicemia - an infection throughout his body. As a diabetic, he recently had a partial amputation of his foot performed at the hospital and acquired a post-operative infection. Septicemia due to MRSA was partially responsible for his death.

I started worrying about myself. Since I decided to limit my practice to pediatrics, I get my share of upper respiratory infections. A few times per year, I get a difficult-to-treat sinusitis. A month ago, I developed my first case of pneumonia. While I don't have any skin sores, I did swab my nose for MRSA. Negative. Since I see newborns; even a few micro-preemies (babies that only weigh a few pounds), I definitely do not want to be carrying a potentially deadly bacteria.

I literally wash my hands three times with each patient; including the use of a hand sanitizer. I gave up my wild collection of pediatric neckties after reading a study that neckties can carry germs. I disinfect my stethoscope. Although I do wear the same clothes all day, I try my best not to contaminate them. This is a more difficult task since I really like picking up kids, accepting hugs, and playing with babies. I try to keep my distance from children that I know have infections, but you never know when a free-flying sneeze will hit you square in the face. I certainly glove up for kids that have skin infections and I routine culture suspicious wounds for MRSA.

MRSA is a super-bug. Although Staphylococcus has been around since there were humans, we have only been using antibiotics since the mid-1930s. Guess what? The first antibiotic that was ever developed was sulfa; even before penicillin mold was observed growing on bread. Sulfa saved countless lives in World War II. Right now, we can use sulfa again for some of these infections, but for how long? If medical providers start randomly using sulfa again for all infections, MRSA is certainly going to adapt. Then, we will be left with a few, potentially-toxic, ultra-potent IV antibiotics. Some hospital-borne infections are resistant to ALL antibiotics. When that happens, the patient often dies.

While MRSA is not freely jumping from kid to kid in our schools, or affecting every patient in hospitals and nursing homes, it is a real threat and the numbers of community cases are growing. I am not surprised that teachers and health care workers are frightened. We are now at the threshold of MRSA Madness, when every sore, zit, scratch, or red spot is MRSA until proven otherwise. Kids are being excluded from school and sports, and of course, medical clinics. If diagnosed in the early stages of a skin infection, community-acquired MRSA is treatable. Now, hospital-acquired MRSA is another issue altogether. Some of those bugs are resistant to ALL antibiotics. We definitely don't want these strains showing up at day-care.

MRSA - Coming Soon to a School near you. Personally, I think they should have been disinfecting those school rooms long before MRSA made its debut. Picking up the trash and moping the floor is NOT the same as thorough disinfection. Unfortunately, even if school rooms were operating room clean, they would immediately become contaminated again, as soon as the children return. We really don't have a good way of decontaminating kids so MRSA is going to keep spreading.

Kids and germs have always been inseparable pairs. As much as we love them, children have always practiced a lower form of personal hygiene than most other humans. When kids start bringing MRSA home from school, we need to take notice and we need to take action. Newer and safer antibotics are in the works, but those, too, may become ineffective if MRSA continues to adapt. There is even a MRSA vaccination in the works.

We ain't dealin' with just cooties anymore.

Related Topics:

• MRSA: Experts Answer Your Questions
• WebMD Video: Preventing Staph Infections

Technorati Tags: MRSA, staph infection, Methicillin-Resistant Staphylococcus Aureus, health and wellness

Telephone and Internet Medical Advice

I posted a blog on this subject before, but it is time to re-visit this controversial and touchy subject. Before I begin, I want you to guess what color shirt I am wearing right now (not the same one in the picture)? Did you guess? Trying to guess what color shirt I am wearing is about the same as someone posting and asking me to determine the nature of their rash.

Suppose you saw a medical provider today because of a mysterious rash. He has never met you before and does not know your history. Before examining you, he places a big paper sack on his head, or puts on a blindfold. He will need to place his hands behind his back (so he could not touch that rash) and just listen to your story; no matter how brief or medically incomplete. He is prohibited from carrying on a live, one-on-one, real-time conversation. He cannot hear your voice for subtle clues of anxiety, fear, or other emotions. He cannot see you raise an eyebrow, look puzzled, or angry. Yes, he can ask you a few questions, but he will not get the answer for a day or so. This, folks, is the Internet when it comes to diagnosing. We have no ability to use all of the five senses bestowed to us by God.

I had a posting earlier in the week from Anonymous (probably not his/her real name) that was frustrated because I do not diagnose and treat people on the ENT board. In this person's opinion, if I can't do that, then what good are the boards? What purpose do the boards serve?

Long before the advent of the Internet, we had the telephone. People would call their medical providers at all times, including the middle of the night, asking questions that we cannot answer. Fortunately, medical providers were able to carry on a dialogue - a two-way conversation with a patient that they actually knew. We knew their medical history, but we still could not Reach Out and Touch Someone. For a medical provider, the key, essential component of a medical encounter is that face-to-face interaction and the ability to touch...to examine. Even when telephones progress to interactive, live video, we still will not have that tactile, unique, hands-on opportunity.

Medical providers are taught to examine patients, and this requires touching, feeling, and poking around in places that may be painful, or even embarrassing. If you see your medical provider for a painful wrist, you can be certain that he or she is going to have it touched...or squeezed...or moved around, even if it hurts. Why? No, not sadism! This is how complex information is obtained in order to formulate a working diagnosis. It would be nice if fingers had x-ray capabilities, but they do not. If it is determined, based on the examination, that an x-ray is needed, then your medical provider orders it so we can add to the information pool. Even with an x-ray or diagnostic laboratory tests, a diagnosis may remain elusive, so your medical provider refers you to a specialist, and the dance begins again - more touching, more probing, more medical history. At some point (hopefully), a diagnosis is determined and appropriate treatment can be initiated. Sometimes, even with all of those tests, touching, probing, disrobing, consultations, and talking, a diagnosis is never found. It happens all of the time. This is the world of medicine.

I have always felt that it is better to educate than medicate. Education lasts much longer and has fewer side-effects. The main function of the message boards is to provide an educational forum for an open discussion. Basically, readers of the board are privileged to snooping in on a medical encounter. You are able to read what others post and see how I respond. In essence, you are sitting in a virtual examination room. Of course, no true examinations take place in this room. And, unlike the rules of medical confidentiality, you get to read what is happening. As a matter of fact, you get to participate. This is not unlike having an intimate medical encounter in the waiting room, where other patients can throw in their two cents.

Another of our functions as a WebMD Health Expert is to maintain order. If someone on an open board posts a dangerous suggestion, I certainly need to intervene. If someone is posting symptoms that could indicate a serious, or even life-threatening medical event, I have to say something. There is nothing more anxiety-provoking for a medical provider than to read a story about someone's severe headache, sudden loss of vision/hearing, who has one--sided numbness, and to discover that this person chose to post a question instead of calling 911.

Unfortunately, the boards are not conducted in real time. If the person is fortunate to catch me online at the time of the posting, they do get a rapid response. Most of the time, there can be a delay of a day or more for various reasons. Lately, I have been dealing with the Worst Internet Service ever that has prevented me from getting on line. Additionally, Health Experts on not online 24/7, unlike a group of Indian tech support people in a huge boiler room in Bombay waiting to help you. In most cases, the Health Expert is one person; a person that sleeps at night, uses the bathroom, works during the day in an active practice, and has a family life of sorts.

I have been answering postings for over eight years now; thousands of them. I suspect I have helped many people, because they have been grateful enough to post a thank you. I have not been able to help everyone, but I take pride in the fact that I try to answer EVERY posting, even though I am not required to do so.

For the people that I have helped, I am honored. To be able to help someone navigate the confusing world of medicine; to point someone in the right direction, or to hold a frightened, cyber-hand, if only for a few moments is a privilege. This is why I do it.

For the people that I have NOT helped, I ask for your kind understanding. The Internet poses significant barriers that cannot be overcome, even if you don't have health insurance or financial resources to see a medical provider. Health Experts would love to reach out and examine you. We would love to be able to provide a diagnosis, or an inexpensive, over-the-counter treatment plan, but more often than never, this cannot happen. We would love to be your medical provider, but we are not.

We are but one person with a big heart, apparently with extra time on our hands, and a desire to participate in one of the most innovative (and free) health web sites on this planet. All that we ask is for you to help us, too.

Yes, the picture is me. I am sitting at my desk in my clinic office. It is lunch time and I am posting between bites of food and patient calls. My calendar says 2004; I have not had time to change it (just kidding, this is an older picture). WebMD is on my screen, as it is most days. My hair is white; my fingers are tired; and my back is sore, and yet, I am happy because my Internet is working. Life is good.

Related Topics:

• Internet-Savvy Patients
• Emailed Health Warnings: Hoax or Fact?

Technorati Tags: message boards, health education, internet, health and wellness

Don't Let Your Medical Provider Lie to You!

One of the reasons that the WebMD message boards are so successful is because medical providers are not doing their job. There is nothing more frustrating for a patient than (a) not knowing their diagnosis, (b) not having their treatment explained, and (c) not knowing their prognosis (when they would expect to get better). If your medical provider is NOT doing this at every visit, then you will be left hanging in limbo.

This week, I had a message from a person on the ENT board that exemplifies this problem. The person was simply informed that her dizziness was due to fluid in her ear. She was asking me what can be done to treat it. I hope she did not pay for this doctor's visit, because she sure didn't get her money's worth.

First, the doctor was vague. Exactly where is this fluid? Is it in the ear canal? The middle ear? Or, perhaps, is it in the inner ear? I am assuming if the doctor actually saw fluid, then it had to be in the middle ear. If so, why didn't the doctor explain it to the patient, and why didn't he provide some sort of treatment? The doctor just sent her out the door, still dizzy, and still confused as to what is going on. This is poor medical care, and people should not stand for it.

I think I have a highly-developed lie detector. I can smell it when it happens. As a clinical instructor for medical training, one of my past jobs involved clinical evaluations of PA students actively seeing patients at their clinical teaching sites. One student in particular comes to mind.

Tony (his real name) was a first year student that had logged a few hundred patient visits under the instruction of his preceptor in a large family practice office. I arrived at his office that morning to watch him examine and treat random patients. I would critique his mannerisms, his professionalism, his thoroughness in taking a medical history, his examination skills, and his ability to formulate a diagnosis and treatment plan - all essential components of any medical encounter. Although the presence of another clinician in the room while a student is seeing patients can be a bit intimidating, this is how a good clinician is trained. Basically, I introduce myself to the patient as an instructor and immediately melt back into the exam room, allowing the student to take charge.

The woman was sitting on chair wearing a paper gown. She was crying. Tony asked her why she was crying (a good move). She said that she has been having low back pain and is afraid it is her gallbladder. This caught my attention since the gallbladder is not in the low area.

"Do you think it's my gallbladder?" She cried.

"Yes, it could be", replied Tony.

"Really. Where exactly is my gallbladder?" She asked.

"Oh, your gallbladder is posterior to your spine", he said.

The patient just accepted this very, very incorrect explanation. I did not. If a gallbladder was posterior to your spine, it would be sitting in the chair! There was no way under the sun that her low back pain was due to a gallbladder problem.

I allowed Tony to complete his cursory examination, develop an entirely incorrect diagnosis, and step out of the room so we could discuss the case.

"So, Tony, where is the gallbladder?" I asked.

"It's posterior to your spine."

"No, it is not, Tony. It is in the abdomen."

"Oh, you mean LOCATION. Well, yes, of course, it is in the abdomen."

"Okay, with your finger, will you please point to the location of your gallbladder?"

"Well, it sort of varies, depending on the person, but it is somewhere in here." Tony moved his finger in a big circle indicating the entire abdomen.

"No, Tony, the gallbladder is right here." I purposely pointed to the left upper quadrant - the exact opposite location of the gallbladder.

"Oh, that's what you mean. Yes, of course, that is where the gallbladder is located."

"No, it is not. I was just testing you. The gallbladder is in the RIGHT upper quadrant of the abdomen. I cannot believe that you do not know where the gallbladder is located."

"Yes, I knew that, but since you were pointing to the left, I did not want to embarrass you by proving you wrong. You are my instructor, and I should not challenge you."

I watched Tony stumble through another four or five patients for the rest of the day, having to constantly correct his many errors in both judgment and management. It was obvious that Tony had chosen the wrong career path.

Needless to say, Tony did not get a passing grade for this clinical evaluation, nor did he continue with his training. I will try and keep this delicate, but Tony was stupid; pure and simple. There is really no other logical explanation. I was amazed that he was accepted into a medical program, and equally amazed that he had been caring for a hundred or so patients before I evaluated him. He had absolutely no business caring for patients. He did not have the basic knowledge base, and he did not know what he did not know. Up to this point, Tony had survived on his skill at telling lies. His philosophy was "If you don't know the answer, just make something up. Keep it vague. Maybe the patient will believe you."

Tony is probably working at Taco Bell, making wrong change, or maybe he went to a different medical program somewhere else and eventually graduated. There are a lot of "Tonys" out there who have jumped through the hoops, made it through the system, and are now licensed and seeing patients. Your own medical provider could be a Tony.

Here are the Warning Signs:

1. If your medical provider does not take a sufficient medical history - cuts you off in mid-sentence and does not appear to listen (or care) what you have to say; then YOU MAY BE SEEING TONY.


2. If your medical provider does a cursory examination, such as listen to your heart for one second in one spot, or examine you entirely with your clothes on (even though you are there for a rash), then YOU MAY BE SEEING TONY.


3. If your medical provider fails to answer your questions in a professional and logical manner and attempts to BS you, YOU MAY BE SEEING TONY.


4. If your medical provider does not tell you what you have (a diagnosis), but yet treats you, then you MAY BE SEEING TONY.


5. If your medical providers gives you an unnamed and unexplained medication for a diagnosis that you do not understand, you are definitely SEEING TONY.


6. If your medical provider is suspiciously wearing a surgical mask, solely so that he will not be recognized, then you MAY BE SEEING TONY.


7. If you notice that your medical provider has a book entitled, Medicine for Dummies, on the books shelf, then you MAY BE SEEING TONY.


8. If your medical provider is listening to your heart and failed to put the earpieces of the stethoscope IN his ears (I have seen this!), then YOU MAY BE SEEING TONY.


9. If your medical provider fails to introduce themselves, doesn't wear a name badge you can read, or jumps if someone knocks on the door, then YOU MAY BE SEEING TONY.


10. And finally, if your medical provider has no idea where your gallbladder is located, run as fast as you can, paper gown and all, and get the heck out of there. The person chasing you IS TONY.

Related Topics:

• Study: Doctors Don't Explain Rx Drugs
• Tips for a Successful Doctor Visit

Technorati Tags: medical care, medical training, health and wellness

The Doctor will See You Now, Insurance or Not

Not all people can afford insurance...health insurance, car insurance, renter's insurance, long-term care insurance, cancer insurance, life insurance, liability insurance, malpractice insurance, etc. You name it, and some company will insure it. Millions of people in this country either choose not to spend their resources on insurance, or do not have the financial resources. Either way, when you don't have insurance, you are at the mercy of the system when unexpected tragedy happens. I expect that some of the thousands of people who recently lost their homes and possessions to the Southern California fires were uninsured, or inadequately insured.

There are so many different types of insurance out there (by different, creative names), that it is becoming silly. My wife bought a bug-zapper a few years ago for $15 dollars and they sold her an "extended warranty" (another name for insurance) for another five dollars. She bought it. It broke after one season, but I have no idea where she put the receipt and I wasn't about to go through the HUNDREDS she keeps stuffed in her purse. I wrote it off as a bad decision. You buy a cheap product, don't expect it to last. Buy a better one next time, or better yet, just swat the bugs with a rolled up newspaper.

If you have terrible health insurance, stop complaining about the high co-payments, high deductibles, or limited drug formularies to your medical provider. You get what you (or your cost-conscious employer) pay for. The innocent front desk person who must collect your $40 co-pay, the pharmacist that tells you the medication is not covered, and the medical provider that has already provided the care, have absolutely no control on the quality or your choice of health insurance.

My refrigerator bit the big one yesterday, so I had to go out and get another one. I did not have refrigerator insurance. This fridge has been a real stinker and I am tired of putting repair money into this lemon. After buying the new appliance, the salesman immediately tried to sell me some repair insurance...preying on fears that I would have to shell out huge amounts of money to repair this new refrigerator future. I refused. He persisted. I refused again. I strongly believe in health, car, life, and house insurance, but I am not a big fan of extended warranties. I take my chances in this department. I think I can get by without refrigerator insurance.

I have worked with my medical assistant for about six years. During this time, she has gone through about four cars. She wrecks 'em and abandons them. Why? She does not carry the mandatory car insurance. Many of those vehicles were financed, so those bills keep coming in and those creditors keep calling (even at work). Feeling sorry for her situation, a philanthropic person gave her a nice car, free and clear. After a few months, she traded this free car in for another, more expensive one that she financed. She wrecked this one, too. She told me that she was late for her insurance premium by a month or so, and for some reason, they did not cover the accident. She doesn't have a car now and has to find other ways to get to work.

My automobile mechanic charges $100 per hour for labor (not including parts) - more than I charge for private-paying patients in my office for a routine visit. Knowing this, I did buy the extended warranty on my truck. Recently, the latch on the back seat broke so I had to get it repaired. I was told it was covered on my extended warranty with a $50 deductible. That was great. Of course, the entire bill was $58 dollars. So far, I saved eight bucks on a $1200 policy.

Gone are the days when people just paid (or bartered) for medical services. Uncle Sam would be going crazy trying to tax chickens or home-grown tomatoes that I would happily accept in exchange for looking in your ears.

Sometimes, I would rather give away free medical care than hassle with insurance. As a matter of fact, that often happens when insurers fail to pay because we didn't put down the proper code, or didn't dot an "i" or cross a "t". Many medical offices simply write it off, rather than go to the time and expense of resubmitting those bills to the insurance companies. The loss of revenue to some medical practices is staggering. And, the cost of trained personnel just to do the billing for hundreds of different insurance companies helps raise the rates to those that pay cash or have decent, doctor-friendly insurance polices. I wish that medical providers didn't have to deal with insurance, but of course, I also wish that it rained during the dry season. Neither one will happen.

Americans feel they are entitled to free medical care from the government or their employers, but no one expects free car repair, free food, free gasoline, or free electricity. We do not want our often-inefficient government to mess with our troubled health care system, so our representatives routine vote against universal health coverage. Many say they are jealous of the Canadians with their national health insurance, but we often bump into them at the border when they are heading south to pay cash for needed and delayed medical services.

Illegal aliens and uninsured Americans know that they can go to any ER, get high-tech care, and just walk away without paying...ever. ERs can't turn you down for emergency care, nor can they track you down and haul off your furniture or vehicles for payment. The result is that billions of dollars are spent on "indigent" care, and the state or federal government picks up much of the tag. Overburdened taxpayers eventually get hit with some of those unpaid bills, and some hospitals eventually go bankrupt.

Nearly every week, on the ENT board, someone is asking me to diagnose and treat them via the Internet because they do not have health insurance. As much as I would like to help them, there is really no way that I could adequately take a complete medical history or reach out through cyberspace and diagnose their problem. Trying to evaluate someone's hearing loss or tinnitus on WebMD is not the same as those medical sites where you can get prescription Viagra by answering a "few, simple questions from a licensed medical practitioner".

I am really not sure that people know they can get medical care by paying cash or credit card. Many do not realize that the costs of some medical visits are less than you would pay to get your car or refrigerator fixed. Sometimes, you just have to use your creative resources to get the things that you need. Charge your visit on a credit card and pay in installments if you must. Borrow some money from a friend or relative. Negotiate a lesser price with a compassionate medical provider (Always inform your medical provider at the visit about your lack of insurance). Or, find a free clinic. Do what you must to take care of your medical needs. If you have an arrow stuck in the top of your head, please go the ER. Worry about paying for it later.

I know that many people get miffed when I inform them that I cannot (a) diagnose them, (b) e-mail them a prescription, or (c) perform surgery on them via the Internet. As much as I try to be compassionate since I know medical care is expensive when you don't have insurance, there is really little that a medical provider can do via the Internet, other than some sound advice and education.

Many health message boards (like WebMD's) are open boards. Any board member can offer comments and advice. It is up to you to decide if the advice is sound, or provided by someone that is medically trained. I am often surprised that people will take medical advice from just about anyone. There are a lot of people in health food stores practicing medicine out there.

I read a cartoon many years ago (Born Loser) that showed a man tripping on a sidewalk.

"I think I broke my leg!" He cried.

An old dog walks by, looks down at his leg, and said, "No, it's not broken. It's only a sprain."

Startled by this talking dog, the excited man hops down the road and sees a local street-person (aka, bum). "Did you hear that? That dog over there talked! He told me that I didn't have a broken leg."

The bum replied. "Don't listen to that dog. He doesn't know squat about orthopedics."

So, if someone answers your posting on the Ear, Nose, or Throat board, make sure that they offer some common sense advice, or at least know something about otolaryngology. Insurance or not, we do try to help everyone.

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• WebMD Video: The Doctor is Always In -- For a Fee

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