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.