sounds great but...

this is the clinical impression i recieved from a physical therapist recently:

'Symptom centralization in unloaded cervical retraction with pt. overpressure with increased mechanical response, classification extension bks.'

i have absolutely no idea what that means.

there are problems with being an optimist...

when i got my mail today, i thought the nice thick envelope with my name hand written in cursive was a christmas card from a patient.  instead it was two forms they needed me to fill out.  ahh, well.  i'm sure the next one will be a christmas card.

data entry black hole

i told my staff today if i'm wearing the same outfit monday morning it means i never left.  fortunately there are plenty of christmas cookies in the break room.  i will not starve.

i love little old ladies

i suppose if your age is greater than your weight then 'the wind blew me over' becomes a plausible explanation for your fall.  i'm glad you landed on the grass.

my apologies

okay, that last post is depressing me, so here is something funny a patient said:

me, looking for possible strep exposure:  'have you been around any children lately?'

patient with sore throat:  'only if you count adults that act like children.'

all i want for christmas is...

not to have a 27.4% medicare pay cut.

somehow i dont think this is a compliment

my patient returned from a visit to a specialist and said if someone was going to guess at what medicine she should take she wanted it to be me because i'm a better guesser.

a mind forever warped

a medical education definitely results in some serious brain remodeling.  it has some intended consequences, as i tried to explain here, but also some unintended consequences.  for example, riding in the car today with my twelve year old daughter and listening to the music she loves, my daughter says 'mom, i don't even want to know what you think of those lyrics*.'

normal mom brain thinks, well, those are some pretty angry and depressing thoughts he's expressing...

doctor mom brain thinks, that young man is about to get a vocal cord polyp.


*'monster' by skillet

have i got this right?

so, newt gingrich can accept millions of dollars in "consulting fees" from a major mortgage broker, but i cannot accept a ballpoint pen from a drug company for fear of undue influence.  clearly, he is a man of greater moral fiber than me.

i can still feel the sting...

i was very pleased to see kurt hummel make a stand against dodgeball tonight on glee, i myself having received a D in gym class one marking period for refusing to play dodgeball on the grounds that it was a cruel and barbaric sport.  kurt,  you have my vote for president.

fart, aka the post i can no longer suppress

so, if i fart, but don't hear it because my stethoscope is in my ears, does that mean the patient didn't hear it either?  not that that really happened to me or anything.  i'm just wondering.

and the other nine are...

here is the rest of my list for why primary care doctors like me need a good sense of humor:

reason #2:  at some point in your career you will be vomited/urinated/defecated/bled upon, and/or doused in perirectal abscess pus

reason #3:  you will make pennies on the dollar compared to you specialist colleagues.

reason #4:  someone will ask you to look at their mole at a party and you will be able to say 'i'd be happy to look at that mole right after i examine your prostate.'

reason#5:  every year, congress will threaten to cut your medicare pay an ever increasing percentage and then expect you to rejoice when they postpone the cut one more year.  if you didn't have a sense of humor, you'd surely be insulted.

reason #6:  your dear but tactless grandfather, when he sees your corolla, will say 'why are you driving a nurse's car?' (if i am somehow insulting a nurse, i beg you, please be mad at my grandfather, not me!)

reason #7:  you will be tempted, and you will succumb, to doing something gross on your kitchen table.  hey, the kitchen has the best light.

reason #8:  you will be called 'provider' more times then you will care to count.

reason #9:  someone will have you paged in the middle of the night for a prescription that can't be filled until the pharmacy opens at 9 am.  monthly.

reason #10:   you will have access to the only medicine without side effects - laughter.

 (reason #1)

doctoring dilemas

you ask your elderly patient's spouse, whom you haven't met, to come in with her for her next visit so you can discuss her worsening cognitive impairment.  you find him to be equally impaired...

your patient's spouse insists he is drinking heavily and you must do something to help him but without telling him she told you, yet when you ask him about his alcohol intake he states he doesn't drink...

you know your patient has a cold.  you know they will raise hell if you don't give them an antibiotic.   you know that even if you could get them out of your office without one, they will call you tomorrow and insist they are worse...

blue stethoscope or black?

i heart ringtones

the next time someone's catchy ringtone goes off in my exam room i am going to stop whatever it is i'm doing and bust into one of my signature dance moves.  that would be in direct violation, however, of my daughter's emphatic decree that i never dance in public.  she would say it like this, with just the right amount of that endearing twelve year old flare for the dramatic:  'mom, swear to me right now, you will  NEVER.   DANCE.   IN   PUBLIC.'

careful with your assumptions

my 84 year old patient told me that the only people that want to see him anymore are his doctors.  so of course i said, 'who said i want to see you?'  he really set me up for that one, didn't he.

the opposite of open

i am fascinated by gallows humor, that dark derogatory humor that many a resident has taken up as a shield in the face of overwhelming stress.  is it good?  is it bad?  i really don't know, but my thoughts are this - at the time, it helps.  why else would it exist?  i am thinking of internship and residency, typically the most intense years of any physician's young life.  the pressures are tremendous.  you spend your days in a state of mental and physical exhaustion, your responsibilities always falling just beyond where you think you can reach.  as soon as you become comfortable in one setting, you are advanced to something else.  there is no moment for complacency.  each month is like starting a new job over and over again, each ward with new people to integrate yourself with, new knowledge and skills to master.  and all the while you are caring for some of the sickest people in the world.

so under that tremendous pressure, you bond with your fellow residents by making terrible, inappropriate, dehumanizing jokes.  typically at the expense of your patients, but also your superiors and even each other.  you are too vulnerable and fragile to make fun of yourself.   the more stressed you are the more cynical and dark your humor.  but when i think about that humor now, the least biting of it still makes me laugh. a mild example is the diagnosis we gave to patients who refused to leave the hospital - adherent mattressitis.  saying it still makes me smile.  but shall i admit now that we referred to an older man in our medical ICU as the roach?  he resided there for months, one complication after another, yet still he lived, unkillable.  i hope you are aghast.  even i cringe as i see those words written on the page.  it seems unthinkable.  if a patient were to be a fly on the wall of the resident's lounge, the only feeling we could have would be shame.  but that is not the case.  the patient is not in that room. (in the presence of our patients we were different, we were professional and careful and caring, and all the things we knew were right.)    at the time, that dark humor lightened our mental loads.  it was the levity that served as a much needed counterbalance to the gravity of what we were doing.  for the worst of it, we can only forgive ourselves.

now i look back and see that dark humor as coming from a closed posture, a posture that removes you and limits you in some way, the opposite of open.  thankfully i no longer have much of a need for that type of humor in my life.  i would much rather seek out the humor that draws people in, that humanizes and opens us to each other.  it is one of the reasons i started this blog, to explore the possibilities of my own evolving sense of humor and its place in medicine and in my life. i am still exploring and i thank each of you for reading or commenting.

self revelation, don't leave home without it

whiney people are everywhere.  they are in line with me at the old navy check out counter.  they are in my home.  they are in my exam rooms.  there is even one sitting at my desk right now, in my chair.  look!  she is typing on my computer!  hey, wait a minute...

post-op instructions: there for a reason, or, how to get an incisional hernia

you had abdominal surgery three weeks ago.  now if you could just show me where your post-op instructions said 'after three weeks, feel free to have a go at chopping and stacking firewood.'

therapeutic intervention

my 89 year old habitually grumpy patient told me he didn't want to turn 90.  so i told him we could just go out back and i'd shoot him. that at least got a smile out of him.

how not to give bad news

part of my job is giving bad news.  it goes with the territory of doctoring.  and of all the bad news i give (i consider diabetes bad news) nothing is tougher than telling someone they have cancer. i really can't think of any other single word that can turn someone's life upside down so entirely and so succinctly.  i don't even like saying the word.  the "cer" part makes me think of slicing knives.  sometimes i catch myself going to great lengths just to avoid saying it, using stand-ins like growth, mass, tumor.  these are marginally better.  and i know once i say that c word, my patients will hear little else. but i try very hard to do this part of my job right, face to face, with plenty of time, because i feel that if it isn't done right, then the trauma of the diagnosis is heightened.   before we end our conversation, i try to give my patient the sense that we have a plan, or if not an entire plan, then at least a next step.

but as difficult a conversation as it may be, if someone has to tell one of my patients they have cancer, i want it to be me.  not the surgeon, for instance, that left the message, 'it's cancer, call me back.' on my patient's answering machine this week.  and anyway, how could i possibly complain about having to give someone bad news?  after all, it is not me that is being diagnosed with cancer.

top ten reasons primary care doctors need a good sense of humor (or at least a generally cheerful disposition)

reason #1:  you will get paged during how shall i put it an intimate moment.  you will then listen sympathetically as your patient describes their diarrhea to you in great detail.  your dear spouse will have to listen to you saying things back like, 'is there any blood or mucus in your stool?'

well after that reason do i need to give you more?

change

i drive by this house on my way to my daughter's school.  i know it's vandalism, but something about this particular graffiti grabs me.  when i see this, my heart beats faster.  my soul jumps up and shouts, 'yes.  yes!  we must change!'  okay, soul, what must we change?  i have no idea.  but i still like the message.

maybe it's because i was raised by two parents that have both shown me in their own unique way that change is good, that change brings growth, whether personal,  professional, or spiritual.  to me, that type of good, forward-moving change is the opposite of fear, it is fearlessness.  to change in a way that contributes to our growth as individuals is to say to fear, i see you and i recognize you but i will not be stopped by you.  (i know i am not saying this very well...)

so if there is something you have been thinking of changing - go for it.  be fearless. change.

can you get a refund?

me, pointing to the exam table and speaking loudly to my patient, 'CAN YOU SIT UP HERE?'

my patient, with her apparently expensive hearing aids, answering me, 'i better be able to hear, with what i paid for these.'

phlegm: the reason i'm not a pulmonologist

it's okay that you just coughed something up in my exam room, but please suppress the urge to show it to me.  if it's okay with you, i'll just use my imagination based on the sound of it making its exodus from your chest to surmise what it might look like.

apparently, your guess is as good as mine

my 92 year old patient was found dead on her kitchen floor this morning.  maybe not a bad way to go compared to some other options, but she leaves me with a dilemma.  in the state where i practice, you cannot list 'unknown' as the cause of death.  you must write something, anything, to satisfy the powers that be.  so we called the medical examiner's office and were essentially told to just put any probable cause. heaven forbid we reveal that we don't know everything...

and to my lovely now-departed patient - you were as mischievous in death as you were in life.  i will miss you!

it's a terrible condition

last summer my lovely niece spent two weeks chained to a desk helping me enter past medical histories into our electronic health record.  this involved the challenging task of interpreting my handwriting (i like to think of it as 'minimalist').  so i had a good laugh when i opened a record the other day to see that my patient suffered from chronic enema.  i think that was supposed to be 'eczema'.

we should all be physical therapists

i saw a physical therapist today for her yearly check up.  she was very healthy and it reminded me of something from residency.  to get to the hospital from the staff parking lot, you had to walk up a huge hill.  for most of us residents it was more like trudging up that hill than walking, our shoulders sagging under the weight of our over burdened coat pockets, our psyche sagging under the weight of our coming day (or days if we were on call.)  it never failed that as i was slumping up that hill, trying to return a page, comb my hair and eat a poptart all at the same time, along would come a perky, well-groomed physical therapist.  they would cruise by me with such pep in their step, such enthusiasm for their day, their happy little running shoes flashing past me.  in the thin grocery bag they held i could see the yogurt and orange and water bottle that is the physical therapist's trademark lunch.  so damn healthy!

moral of the story for the medical residents of the world: don't look around you as you walk to the hospital from whatever remote parking space you've been deemed worthy of.  preserve your self worth and keep your eyes on the ground!

doctor fantasy #2 - house calls

when i first started out in private practice i had extra time on my hands, so i would occasionally make a house call, usually to a home bound senior.  i always enjoyed it.  there is just something about entering another person's home, being a guest, that personalizes and humanizes the encounter in a way that no time in the exam room can match.  it isn't always necessary to have that, but it is something i perceive as having real value in the right setting.  interestingly, i can easily remember the details of each house call i've made.  ask me to remember an office visit from two days ago and i guarantee the recollection is far less clear.
currently there is just no time in my day to drive to someone's home for an appointment.  (i once read an article that suggested that to maximize their efficiency doctors should have a charting station right outside their exam rooms, and that they should never stray from that triangle  --  who comes up with this stuff?) so the house call feels like a luxury beyond my reach.  but i do fantasize about how nice it would be to travel from home to home to visit my patients. i imagine that i would spend my mornings in the office, seeing my more able-bodied patients, making phone calls, and handling all the minutia of my practice (i.e. filling out forms), and then i would grab my bag, head to the car, and spend a reasonably paced afternoon making house calls.
i know there are some doctors out there that still incorporate house calls into their practices, or even build their practices around house calls, but i just don't know how they manage it financially.  i suppose they have lower overhead if they don't have an office.  for now, i appease my fantasy by making an occasional visit to someone to whom i know it will mean a lot, usually more of a social visit, one that says i'm thinking about you, i care about you.  in fact, i will be making one today, and i am looking forward to it.

here's a link to doctor fantasy #1:  http://happyinternist.blogspot.com/2011/03/doctor-fantasy-1.html

happy internist is always trying to keep it real

no, i cannot recode your visit for tendonitis as a physical just so you don't have to pay your co-pay.

a tale of two struggles

i see a really nice thirty-something couple in my practice.  when i first met them, he weighed a little over 300 pounds, clearly obese despite his tall frame, and already suffering the consequences with several weight related problems.  she weighed around 150, just a little heavy for her height.  together they embarked on a diet.  they made dramatic changes to their dietary and exercise patterns and they really stuck with it.  over the course of a year he lost almost 100 pounds, she a more modest 25 pounds.  he came off most of his medications.  life was good and all seemed well.

about 6 months later, she came in for a routine follow-up and i saw that she had lost another 10 pounds.  this put her just under the lower limits of normal for her height, but she assured me that she was done dieting and was going to just stay at this weight now, which she did for several years.  her husband was not as good about keeping up with his visits and i didn't see him for another year, at which point he had sadly regained most of the weight he'd lost.  life goes on.

recently she came back in for a check up.  she weighed a startling 98 pounds.  she was lost in her paper gown, her collarbones and shoulder blades standing a little too proud of their skin.

after her exam, we had a long talk about what was going on in their lives, and more importantly what was going wrong. she was, if not intentionally then at least subconsciously, still dieting for her husband, thinking that by sticking to it he would somehow get back on board with her.  but did she know that at twenty percent below weight she was now swimming in the dangerous waters of anorexia?  at some level she did, because she admitted to being as equally scared of regaining weight as she was of watching the scale creep steadily down.  she declined counseling, which i was encouraging, but we set a small weight gain goal and she will see me back soon.

so here are two very different and equally unhealthy end results of what seemed like a good plan in the beginning.  why?  in an effort to corral her husband's uncontrolled eating she also lost control, not of her appetite, but of her health.  i will think about this for a long time, but not have the answers.  but i do know this, it doesn't matter if you are 100 pounds or 300 pounds, most of us struggle at some point in our lives to create and maintain a healthy relationship with food.  if this comes easily to you, then consider yourself fortunate.  if it does not, then please do not consider yourself alone.

on a lighter note, why don't 'height' and 'weight' rhyme?

delirium, it would be funny if it weren't not funny

the physician's take on delirium:

delirium represents an acute confusional state marked by cognitive and behavioral disturbances and fluctuating levels of consciousness caused by a medical condition, intoxication, or a medication side effect.



the layperson's take:

two hours ago your hospitalized mother was fine.  now she's trying to call someone on the remote control to get the crying baby out of the corner of her room.

i might think that, but i would never say it out loud

a new patient with a complicated history came to my office last week.  when i asked her why she was changing physicians, she said that when she met her last physician, he looked at her list of medications and said, 'boy, you're going to be a tough one to take care of.'  the relationship just foundered after that tactful opener.

you don't, and without a doubt can't, always know when something you say will offend someone.  i once had a patient yell at me that her toenail fungus may not be important to me but it was a big deal to her.  this was after i spent half an hour working through her acute issues of angina, major depression and anxiety. when she brought up the toenail fungus, i asked her if we could address it at her next visit because i felt the other issues were more pressing and we were out of time.

i am sure there are countless other instances when i've offended patients and not known it, but i do try to conduct myself professionally at all times.  sometimes that just means keeping your mouth shut and your expression neutral and not saying the thing that is blaring in your brain.  you have to have a strong edit button or you will get yourself in trouble.

so here are somethings i've thought but haven't said out loud:

1)  dude, you are wearing way too much cologne.  my nurse is in the break room using her inhaler for the asthma attack you've triggered, and after you leave we will all be smelling you for the next four days.

2)  neon orange is not your color.

3)  no, i will not prescribe a stimulant for you just because you thought it was a good idea to commute 2 hours to your 30 hour per week job while going to school full time.  oh wait, i did say this one out loud.

4)  what the hell were you thinking?  fill in the blank with any number of tempting but unsuccessful self remedies - i stuck a pin in it, i put bleach on it, i tied a string around it, 1 didn't work so i've been taking 4 at a time...

5)  leave him.

and let's not forget that i can be inadvertently offended too, as i mentioned here.

they say we share 99% of our DNA...

yesterday my patient informed me that she won't start any new medicine i prescribe until she runs it by her daughter-in-law, a doctor (of veterinary medicine).  i tried not to look surprised.

sometimes i behave like a kid with dirty underwear

a small child i know, who shall remain unnamed, had a habit for a while of hiding his dirty underwear in the back of his closet.  perhaps with the not unfounded logic - out of site, out of mind.  if mom doesn't find these underwear, then she won't know i had an accident. makes sense, doesn't it?

i recently tried that with an FMLA form.  seems i just sort of slipped it into the chart, as blank as the day it was born, and let it get refiled. i should have known it wouldn't work.  the FMLA is a savvy mom, it knows to look in the back of the closet for your little secrets.  guess i'll be filling it out now...

i'll be the heavy

my patient had gained a few pounds since her last visit, pushing her blood sugar further along its trajectory toward diabetes.  turns out her already diabetic husband was bringing lots of goodies into the house.  he wouldn't eat them, but wanted her to eat them.  for whatever reason, she didn't think she could ask him to stop.  he seemed to enjoy getting her these things.  (i know, twisted on many levels, right?)

fortunately, the answer to this age old dilemma (spouse undermines partner's dieting effort) is simple - make me the heavy.  go home and tell your spouse that The Doctor Said you must cut back on sweets. and then tell him to buy you flowers instead.