Phorest & Trees August 2021

 

 

 

Phorest & Trees It’s me birthday week…And of course the old ones here.  Hope you enjoy!

Physician Finance, Workplace Attire, Overlearning, & lotsa Jobs out there

I’m married to a guju JD/MBA daughter of an accountant, so lazy me didn’t bother until now. You need to understand personal finance better than I did. I found this site to be useful and I’ve vetted it for you. Here’s the most recent evidence on how attire affects whether patients believe you know what you’re doing. I think this is required reading for the residents. Many trainees want to do “just enough” to get it right. But there may be some benefit to overlearning My friend Dr. John Norbury has joined Texas Tech University as new PMR Division Chief under Dept of Neurology. He tells of 3 positions: One is “for junior faculty, one who will be a consult/outpatient MSK physician and one will be inpatient...neurorehab would be a plus.   Both physicians would include a part time VA appointment and would have an medical education component and the ability to tailor to clinical interests or research, if desired.  They would also include public service loan forgiveness. Also, the VA here is looking for a CMO (outpatient clinic).  Great senior leadership team and beautiful brand new facility.  Having a more seasoned PM&R doc with some administrative talents in that role would be super helpful, but I'm sure any specialty which cares for veterans in the outpatient world would work.  And taxes are way less than New Jersey.“ Seattle VA / U Wash opportunity: “recruiting for a PM&R physician with clinical, education and also ideally research expertise in Amputee care. The position will be 100% based at VA Puget Sound in Seattle with clinical care focused on Amputee care with resident and fellow teaching responsibilities. VA Puget Sound has a large rehab focused research program and a candidate with a history of research funding and scholarly publications will find ample opportunity here for independent research and collaborations with current researchers.” TBI opening in Portland Oregon VA Not sure if Minneapolis VA is still looking but they wanted an amputee physiatrist too.

AANEM & EDx

Quantitative electromyography: Normative data in paraspinal muscles : talks about the “abnormal” findings seen in asymptomatic patients. Very similar to how we approach at the VA. There was a fascinating discussion thread recently posing the question as to how much of the distal onset latency prolongation can really be attributed to axon loss in the setting of low amplitudes. (Residents should have access through the training portal. The rest of you can feel the FOMO) Attached is a case of EDB pseudohypertrophy in the setting of peripheral polyneuropathy Prognostic indicators for Lumbar decompression for foot drop…Duh The AAN supports banning choke holds. Intro and Discussion of this study on MRI findings in Statin induced myopathy are helpful for the residents. “MRI features of statin-associated anti-HMGCR myopathy can be differentiated from other types of myopathies, such as sporadic inclusion-body myositis and dermatomyositis, in terms of distribution of tissue edema and fatty infiltration. In dermatomyositis, edema is often found within the fascia and subcutaneous tissue,13 which is uncommon in anti-HMGCR myopathy. In sporadic inclusion-body myositis, fatty replacement is most prominent in the anterior thigh, with relative sparing of rectus femoris,14-16 whereas anti-HMGCR myopathy demonstrates preferential posterior compartmental fatty infiltration. On the other hand, MRI features of statin-associated anti-HMGCR myopathy may share similarities with anti–signal recognition particle (SRP) myopathy, another subclass of immune-mediated necrotizing myopathy with shared histopathological hallmarks and proposed pathogenesis.17 In anti-SRP myopathy, an anterolateral pattern of muscle edema in the anterior compartment and fatty replacement of hamstring muscle has been reported,18 but with less symmetry and more severe fatty replacement than anti-HMGCR myopathy.”

MSK & PAIN

Semantics are important and the spine pain community is taking a step in the right direction by reassessing the word “Failed Back Surgery Syndrome.” See attached for the letter from IASP. It’s still woefully oversimplifying if you ask me. (more on semantics in the TREES section of this email) Residents may appreciate the attached brief review of Genicular nerve blocks/RFA for knee OA. Bottom line is that the literature is conflicting (esp the anatomy) but it’s an option I refer for in non-op endstage or post TKA patients. I somehow still get the RIC journal club emails and two were shareworthy (hoping to discuss with Dr. Ma) This 2018 ACORN study’s Intro section is excellent for R1s. The study was excellent too. I’ve included my “GMNR” on AC joint for R1s as well. The attached 2021 Multicenter GRASP RCT from Lancet found a course of PT no better than a single PT best practice advice session + corticosteroid injection. If you want the details of the interventions like I did, they are found here. Opioid Tapering Carries Significant Risks according to this JAMA study. There could be inherent bias as these are patients likely chosen for their risks pre-taper. I guess the take-home is to offer support while tapering. Ate JAMA saying statins may not be any more likely than placebo to cause muscle aches. This was the first time I had heard of “N-of-1 clinical trials.”  See this if you are confused as well.  Predictors for TFCC outcomes: above elbow splinting better than short-arm; worse with complete foveal TFCC tear and a dorsally subluxated DRUJ. My father used to pay 1 dollar for each pound his obese patients lost each visit and it worked (they had to pay him a dollar for each pound they gained). Financial incentives work but should CMS pay for them? Despite the possibility of responder bias, rheumatologic flare has not really been associated with COVID vaccine. I only read the abstract but this may open up options for RA patients that previously had cancer.

Trees

A great description of restrictive covenants (non-compete clauses) ZDOGGMD breaks down the complexity of the Delta variant and offers the possibility of hope. (Here’s a complete zdoggmd non sequitur sent to me by a fellow attending but do NOT click this link if you are easily offended by poop jokes.) More and more of my outpatients ask me about COVID Vaccine. This is a helpful description of base rate bias, an issue that contributes to confusing them. Previously infected may only need one dose of vaccine and unvaccinated are twice as likely to be reinfected than vaccinated. Scientific ways to motivate change Nanotech for potentially treating cancer. Where does the joy and meaning in medicine dwell? I tried this Harvard implicit bias test. Is it wrong for me to say that the test is biased? What the rest of us can learn from gay pride… A great narrative about our field’s role in advocacy and the AMA’s new policy opposing “excited delirium.” “If you want people in your practice to contribute toward its greater success, try making them feel valued and involved as a group. That may seem like common sense, but a new study in Health Affairs finds that when medical practices have collaborative management styles that incorporate better communication, burnout is lower and that's ultimately good for everyone." A quick video on gender bias in medicine and what we can do about it some of this was surprising. As a diabetic, I can’t wait to get one of these new monitors that were discovered by accident! Semantic clarification from this paper.