happy internist

insurance insanity

2012-02-23T07:33:00.002-05:00

dear insurer,
please do not send me a four page letter telling me that my patient's medication is no longer on your formulary and then NOT INCLUDE A LIST OF THE FREXING MEDICATIONS THAT ARE COVERED. first of all, four pages? i am weeping for the trees. and second of all, no list of alternatives? how difficult could that be? really.

asking the tough questions

2012-02-22T16:14:00.001-05:00

so what does it say about me that someone googled 'ICD-9 code for farting' and got referred to my blog?

don't answer that.

guilty pleasures

2012-02-22T11:35:00.000-05:00

i have just conducted a totally non-randomized, unblinded, no placebo-controlled study and and can confidently convey to you the astounding results:

context: firm evidence is lacking regarding which magazines are most popular in patient exam rooms.

design: observational trial in which i move the star magazine somewhere deep in the pile and wait for it to resurface

setting: my exam room

participants: unknowing patients

outcome measures: number of visits until star magazine resurfaces at the top of the pile

results: based on my meticulous observation, it takes on average 1.75 patient visits for star magazine to resurface.

conclusions: we love our celebrity trash

i am submitting this to JAMA

getting political

2012-02-20T08:42:00.001-05:00

did anyone hear the piece on NPR this morning about jehovah's witnesses claiming that allowing insurance companies to pay for blood transfusions was a denial of their religious freedom?

no? you didn't hear that?

of course, you didn't. that would be ridiculous. there was no such report.

but just substitute rick santorum and birth control and then decide how ridiculous he sounds...

the masters of the form

2012-02-15T15:15:00.005-05:00

the health insurance industry has long had a love affair with forms. (maybe you've filled one or two out yourself.) the key purpose of the form is to allow them to ~~contain costs~~ improve patient care by carefully ~~denying~~ guiding physician's choices in the evaluation and treatment of the patient.

because i've filled out so many of these forms, i feel i have become sort of an expert and have some very solid advice to any up and coming insurance companies looking to replicate this artform that has become the guiding beacon of the insurance industry.

here are my suggestions for how to create the most effective insurance form:

1) for anything that might cost more than ten dollars, require the doctor to fill out a form at least 2 pages in length.

2) be sure to make the doctor include information that you already have, e.g. their insurance provider ID, a number you have assigned to them even though they already have a national provider number that was meant to replace the dozens of provider ID's that you are so fond of and that no one else cares about.

3) choose a very small font size so the doctors (especially the forty year olds who have yet to admit they need reading glasses) really have to squint.

4) ask for redundant information, e.g. be sure to require that the doctor write his or her name at the top and the bottom of the form. if you can request something be written a third time, by all means include that too.

5) ask for ICD-9 codes. this way, the doctor, or somebody in their office if they should be so lucky, will have to look up codes (also in a very small font size).

6) ask questions that the doctor can't possibly answer, like 'will the patient need surgery in the next seven years?' then be sure to put a correlating and menacing statement below the doctor's signature that says something like 'the above information is the absolute and entire truth now and in the future, and any misrepresentation on my part is punishable to the highest degree of the law.'

7) whenever possible, request obscure chart minutia, eg 'list the prior medications attempted, with start and end dates and outcome of each therapy for the past ten years.' so that the physician will have to hunt through the chart cursing themselves for not documenting things more carefully.

8) once you have mastered your own forms, hire another company to also inundate the doctor with forms. be sure that the company has an infuriating name like 'Putting Patients First' or some other such nonsense so the doctor will be mad just having to say the name, as in 'hey laurie, could you please bring me the Putting Patient's First prior authorization form for triptans dosed biweekly on tuesdays and saturdays. and be sure not to confuse it with the one for triptans dosed biweekly on mondays and fridays, thanks!'

9) set up a schedule to change your forms slightly every 6 months so the doctor does not become too comfortable with them. you do not want to foster any sense of familiarity in the physicians.

10) and remember, even if the doctor successfully competes your form, you can always say you never got the fax.

(how do i put up with this, you may be wondering. well, i sometimes inspire myself with small rebellions that allow me to believe that i am the master of the form. (i can't rebel too much or then it just pisses off the patient that is relying on me to fill this form out for them). so i do things like entering the date as m/d/yy when they clearly indicate that i must enter it as mm/dd/yyyy, or if they ask for my name a second time, i write ' my name is still the same as it was at the top of the page.' we all must chose our battles.)

happy valentines day

2012-02-14T19:05:00.000-05:00

my husband handed me a gift today, prompting me to grumble something about what a bum i was for forgetting about valentines day. but then he told me that i shouldn't feel too bad because the gift he was giving me was actually a stocking stuffer he'd forgotten about. you can decide which of us is lamer.

i pass another test of my moral compass

2012-02-06T12:01:00.000-05:00

my patient handed me his disability forms today and mumbled something like, 'i wouldn't want to ask you to lie for me or anything...' (how's that for saying the exact oppposite of what you really mean?)

i reassured him, 'don't worry, i won't.'

oh how they torture me

2012-02-01T12:43:00.002-05:00

why is it that, when i have all the hospital records in front of me, and i ask the patient, ' how are you feeling since you've been home from the hospital?' the patient immediately launches into a long and detailed accounting of how they were out shopping for a dress for their sister's granddaughter's eighth grade graduation party when they realized they just didn't feel right but they didn't want to leave until they had purchased a dress, but then their arm went numb so the clerk called 911... and so on and so on until eventually, now ten minutes into their fifteen minute appointment, i hear my self saying, 'so how are you feeling since you've been home from the hospital?'

we are very attached to our stories. i am, too.

...and yet another good reason not to bring your 5 year old daughter with you to your appointment.

2012-01-20T10:42:00.001-05:00

my patient is busily telling me how he's never smoked a cigarette in his life when his daughter pipes in with, 'except when you're drunk, daddy.'

evidence of the seriousness with which i undertook my medical studies

2012-01-18T18:52:00.002-05:00

i was trying to remind myself of some bit of foot anatomy today (i don't really want to admit it, but i couldn't remember the name of the first joint of the little toes), so i pulled out my Netter and found this.

i think the big toe invokes a gentle spaniard...

my theory of the mind-body dysynchrony of aging

2012-01-16T19:17:00.001-05:00

there is a common thread to my interactions with people as they age. they say things like, 'why am i so tired?', 'why do i need to take a nap after lunch?, 'but i don't feel xx (insert any age over say 40 or so).' when they use the term 'i' they are not referring to their physical selves, they are referring to everything else, call it your mind, your soul, your essence or being, or whatever else describes the non-physical you. the older you become, the wider the chasm that seems to develop between your physical self and your non-physical self.

so here is my theory: unlike our bodies, that are only ever one age at a given point in time, our non-body selves are every age we've ever been or at least can remember being. even at eighty, when our bodies are clearly and irrevocably 80 years old (except maybe that knee replacement), we are still the flirty teenager that fell in love with her high school sweetheart, or the young man that went to war. we actually forget at times what age our bodies have become, at least until they gently remind us.

as an extension of this, i believe it is a mistake, made easily in medicine when the focus of the work is so often in the here and now, so embedded in the physical self, to look at someone at 67 or 75 and see only the 67 year-old or the 75 year-old. it is much more fun and interesting to see the deeper, broader person that they are, the every-year-old in them. so that is what i try to do. and i hope some day that someone will do the same for me.

primary care moves a notch lower on the totem pole

2012-01-09T08:21:00.000-05:00

my partner took a call last night from a patient with a toothache. when asked if she had tried contacting her dentist, the patient responded, ' i would never call my dentist at this hour.'

some new year's resolutions i've already blown

2012-01-05T20:04:00.001-05:00

1) finish each note immediately after i see the patient.

2) don't leave any phone calls for the next day.

3) stop eating buckeyes. (unless the fact that there are no more because i've eaten them all qualifies.)

sounds great but...

2011-12-21T12:59:00.000-05:00

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...

2011-12-13T13:54:00.000-05:00

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

2011-12-09T15:03:00.000-05:00

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

2011-12-06T14:55:00.002-05:00

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

2011-12-01T07:45:00.001-05:00

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...

2011-11-30T09:20:00.001-05:00

not to have a 27.4% medicare pay cut.

somehow i dont think this is a compliment

2011-11-22T15:23:00.001-05:00

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

2011-11-19T15:32:00.004-05:00

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?

2011-11-16T18:51:00.000-05:00

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...

2011-11-15T21:35:00.000-05:00

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

2011-11-14T21:51:00.000-05:00

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...

2011-11-10T21:59:00.004-05:00

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

2011-11-09T07:46:00.000-05:00

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

2011-11-03T17:11:00.002-04:00

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

2011-11-01T10:39:00.001-04:00

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

2011-10-27T07:56:00.000-04:00

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

2011-10-26T12:47:00.001-04:00

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

2011-10-25T12:05:00.000-04:00

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

2011-10-24T12:12:00.001-04:00

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

2011-10-22T23:08:00.001-04:00

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)

2011-10-15T17:20:00.001-04:00

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

2011-10-14T12:32:00.001-04:00

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?

2011-10-11T19:03:00.000-04:00

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

2011-10-05T12:18:00.000-04:00

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

2011-10-04T15:26:00.000-04:00

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

2011-10-02T05:44:00.000-04:00

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

2011-09-30T13:33:00.003-04:00

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

2011-09-27T07:02:00.001-04:00

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

2011-09-26T13:32:00.001-04:00

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

2011-09-22T12:20:00.000-04:00

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

2011-09-20T07:16:00.000-04:00

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

2011-09-19T08:35:00.001-04:00

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...

2011-09-14T07:37:00.000-04:00

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

2011-08-31T11:49:00.002-04:00

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

2011-08-26T08:37:00.000-04:00

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.

small town doctor spurs economy

2011-08-25T13:04:00.000-04:00

i got an interesting summary of my prescribing habits from a national mail order pharmacy today. apparently i have written 2,609 prescriptions in just 6 months. that's a lot of prescriptions! and that is only one pharmacy. i think i should be recognized by the white house for the small but critical role i am playing in keeping our economy running. but it also informed me that i prescribe 0.7 fewer medications per member compared to my peers. so maybe i'm acutally slacking a little...

special request to the gods of medicine

2011-08-19T08:24:00.000-04:00

i'd like a day of chip shots please - sore throats, a rash or two, knee pain. it's been a long week of complicated patient care, and my brain is ready for a rest.

guilty scheduling secret revealed

2011-08-17T07:47:00.000-04:00

we have a few patients with a reputation for lateness. we try very hard to stay on schedule, and the flow of the office is definitely better when patients show up on time. so when we make appointments for this select group of patients, we tell them their appointment is 15 minutes earlier than it actually is. we give them a fake appointment card. so i always feel slightly guilty when i see them signing in, ten minutes late for their false appointment time, but five minutes early for me. emphasis on slightly.

healthy

2011-08-12T20:26:00.001-04:00

i don't have many memories of healthy people from residency. training in a tertiary care teaching hospital, we took care of the sickest of the sick, often seeing the most severe end of the spectrum for any given disease. most of our patients were older, and when they weren't, they were chronically ill, or if not chronically ill then they were so acutely ill as to be unrecognizable as healthy young adults. problem lists were long, whole organ systems were down, bodies were tired and scarred and ill-appearing. so to care for someone seriously ill and vibrantly healthy at the same time was unusual.

the young woman i am thinking of was twenty-two, healthy and full of life and, well, a normal young adult. the reason for her admission was progressive shortness of breath. by the time of her admission, she was in dire straights with her breathing, walking only a few feet before finding herself gasping for air. i don't remember the details of her outpatient work up but her diagnosis was this - severe idiopathic pulmonary hypertension.

the lungs have one job to do - gas exchange. bring oxygen in, move carbon dioxide out. to do this well they must have very low blood pressures. normal systolic blood pressure in your systemic arteries is 120 mmHg. in your lungs, normal pressure is only 10 to 25 mmHg. her pulmonary artery pressures were in the 80's and that is way too high to allow proper gas exchange. the right side of her heart, which normally has the cushier job of pumping blood into the low pressure system of the lungs, was now struggling to push against these tremendous pressures.

what i remember so vividly when i picture her now are her eyes - big and dark, beautiful really. she would sit cross-legged on her hospital bed leaning forward with her elbows resting on the bedside table, barely able to speak a full sentence despite the oxygen she was wearing, her eyes sparkling while the rest of her struggled.

at the time of her admission, there were only three things we could do, give her oxygen, reduce her afterload to take pressure off the right side of her heart (but if you lowered her systemic pressure below her pulmonary pressure she might suddenly die so that was tricky) and give her the only drug we had specifically for pulmonary hypertension - intravenous prostacyclin. the prostaclyclin drip was her lifeline. at one point she started crashing - oxygen saturations plummeting, panic in her eyes, and it was a frantic several moments before we realized her central catheter had become disconnected from the prostacyclin drip, she was that tenuous.

one day her father came in armed with stacks of papers, studies in their infancies about new and novel treatments for his daughter's disease. one of them was a very preliminary report about viagra. he begged us on morning on rounds to give his daughter viagra. at the time there was very little data to support the use of viagra in pulmonary hypertension, but turns out it actually helps and now it is a standard part of managing this disease. i remember my attending repeatedly saying no to his pleas. that poor father got so frustrated with us that he had his daughter transferred to a nearby hospital where she died a few weeks later.

why didn't we give her viagra? would she have responded? maybe she would have held on until a better treatment arrived. i remember my attending trying to explain that with so little data available regarding its use, she could just as easily deteriorate (for her to deteriorate beyond where she already was would mean to die) as improve. at the time it was a complete unknown, a complete gamble. how many times has a drug or therapy looked promising in early trials only to fall apart under more vigorous study? but what i remember most was that i was too young to understand a father's anguish over losing his daughter. and i still feel that way sometimes, too young, too inexperienced, too ill equipped, not for the medical aspects of medicine, but for everything else it demands of you.

the cult of personality

2011-08-12T08:52:00.001-04:00

why is it that i can tell my patient for 5 years that they should have a colonoscopy, but dr. oz says it once and they go?

pills i would invent

2011-08-07T19:30:00.000-04:00

the trend seems to be to take a problem, label it as a disease, invent a pill for it, advertise heavily, then sit back and watch the money roll in.... forget the holy grails of smoking cessation, happiness and weight loss, i say go for the niche market instead.

so here are some ideas for any of you capitalists out there...

how about a pill that improves coping skills? there are some days when i feel like a significant chunk of of what i'm seeing is the direct result of inadequate or misguided coping skills.

or a a true gas buster. this would be very popular with the baby boomers. from what i am repeatedly told, they seem to be suffering from an excess of gas. if you can't rid them of their gas, they still might buy if you could make their gas silent. we would have to find a brave and well-known spokesperson to come forward on this matter...

could we make habitual lateness a disease? we could call it ontimeophobia. we would need to educate our target audience about the devastating effects ontimeophobia has on other peoples lives. it may be a smaller market than the flatulent crowd, but still sizable.

it's a generational thing

2011-08-04T13:39:00.002-04:00

at least once a week i see an older woman for acute knee or back pain who starts her story off like this: 'well, i was on my hands and knees scrubbing the floor - ' ??!! - wait a minute, you were what? who does that? i don't know a single woman (or man) in my 40-something age group that scrubs a floor on their hands and knees. i think to myself, girl, you need a swiffer.

schooled

2011-08-03T11:48:00.000-04:00

today i was schooled by one of my patients. in a good way, not a bad way. i knew my patient had recently begun radiation and chemotherapy, so i thought i'd call her and see how she was doing, and let her know i was thinking about her. immediately she started telling me how kind everyone was at the cancer center and how nice and funny her surgeon was, how they were telling jokes and what a good experience she was having. and in hearing her say all this it struck me that another person could go through the same thing and have an entirely different take on it. it was her goodness and kindness and humor that brought those qualities out in the people around her.
the reason i say i was schooled is because when i picked up the phone to call her, i thought it would be me making her feel good, instead she is out there in the world making all the people around her feel good. what a gift!

another confession

2011-07-21T21:27:00.000-04:00

i think if some of my patients read my blog they would say that i was painting myself in too flattering of a light. so today i will say, i was completely swamped ('in the weeds' as we used to say in the restaurant world). i rushed through my visits, cut several people off, and was generally not as relaxed and pleasant as i know i am capable of being. tomorrow, i will try again.

confessions

2011-07-17T17:30:00.002-04:00

lots of medical journals cross my desk. usually i let them pile up with the good intention of looking at them, until a week or two later the pile is too big and daunting and i guiltily throw them all away. some i at least look at the article summaries to make sure i'm not missing some landmark study (or to finally see the article now available to me five days after i heard about it on NPR...why do they do that? don't they know i'm going to get a bunch of calls and not have any clue what they're about?). but the one thing i always read, i look forward to reading, is the regular feature in JAMA called 'A Piece of My Mind'. these are one to two page essays by physicians (and sometimes non-physicians) about the art of medicine, not the science. i think that's why i like them so much, they tell of our humanness, our vulnerability and our fallibility, our humility, and ultimately our thirst to learn and do better, to be better physicians. so much that we strive for in medicine is certainty, but so much that we struggle with is the very real uncertainty of it all. i like these essays for the small nod they give to that struggle. and many days, these essays seem much more relevant to my day to day work than the the studies that they accompany.

just do your damn jury duty

2011-07-08T12:04:00.000-04:00

i have nothing more to say about this. (but now you can imagine all the absurd requests i get for notes to excuse people from jury duty. it truly amazes me.)

someone please explain this to me

2011-06-24T08:24:00.001-04:00

here are two remarkably similar conversations i had yesterday:

#1) woman with known coronary artery disease:

ms. angina: i've been having chest pains for the last several weeks.
me (among other pertinent questions): when did you last see your cardiologist?
ms. angina: last week.
me: did you mention that you were having chest pain?
ms. angina: no.

#2) man with history of retinal hemorrhage

mr. bleed: for the past few months, when i stand up after sitting for a long time, my left eye gets blurry and gray.
me: have you seen the eye doctor about this?
mr. bleed: i went last week but i didn't tell him about it.

i have a few theories about this phenomenon:

1) to tell your cardiologist (or retinal specialist) that you are having chest pain (or blurred vision) is just making it too real. you don't want to admit you may actually be having a serious issue.

2 ) you thought the don't ask, don't tell policy was really a brilliant piece of legislation (was that legislated?), so you thought you'd try applying it to all areas of your life.

3) it's a conspiracy to thwart me.

i think terrible thoughts

2011-06-21T19:57:00.001-04:00

a big part of getting our electronic health record up and running is data entry - past histories, medication lists, diagnostic lists, surgeries, and on and on. it is a massive project and i am doing most of it myself. who else could decipher my handwriting? (sometimes even i can't figure out what i wrote.) down the road, when these patients come back in, it will all be there waiting for me, neat and tidy, in the chart. future visits will be easier. that is what keeps me going. so when i see my 94 year-old patient i think, what is the real return on my investment here? i'm going to take the time to enter all this data and they might not stick around long enough for me to reap the benefits. isn't that terrible? i enter all the data anyway. what can i say, i'm an optimist.

medical terminology repurposed

2011-06-13T22:43:00.000-04:00

anal verge - this is when you are about to refold the towels that your husband just folded, but he did it wrong. you are on the anal verge. don't go there!

psoriasis - the look you give your sister or girlfriend when you want her to shut up. girl, did you just give me the psoriasis?

abscess - a verb that means to harbor bitter emotions. don't abscess over that. better to express yourself.

PEA (pulseless electrical activity) - the eerily quiet sound your hybrid makes at a stoplight.

uvula - okay, i can't think of anything for this word, but i still love to say it. submissions are welcome!

my gray's anatomy moment

2011-06-10T07:07:00.004-04:00

no, this is not a post about steamy call room sex, but i did have one exhilarating moment when, with only the right background music, it could have been a scene straight out of gray's anatomy.

i was on the nephrology consult service. we were making our afternoon rounds, following up on labs and tests, and checking in on patients. we came into the room of a young man who had had a biopsy of his transplanted kidney earlier that day. he was lying quietly in his bed. he looked a little pale. actually he confessed, he was having pain in his left side and it was gradually getting worse, is that normal? as we helped him sit up to listen to his lungs, he fainted.

the kidney is a hard working but delicate organ, filtering up to two hundred quarts of blood each day, keeping the good and allowing the bad to pass through to the bladder as urine. i think of it as one of those finely strung fishing nets, the fish stay in and the flotsam and jetsam pass through. or you could think of it as the person in the back of the goodwill, accepting all the donations then sorting through them, keeping the good stuff to display in the store and tossing the rest in the trash. because the kidney is so richly vascular, a biopsy is a tricky thing. passing a needle through some one's flank to take a sliver of kidney carries a real risk of hemorrhage. and that is exactly what our young man was doing.

we miraculously had on the floor a handheld doppler, so we used it to confirm our suspicions. somehow, as we were pressing the transducer against his abdomen, we realized that with the right amount of pressure in just the right place, he stopped bleeding. that is where i came in. we needed to get him to the OR quickly and with the least further blood loss possible. i was the smallest one there, so i climbed onto his bed kneeling next to him and holding pressure against his abdomen as we rushed him and the whole giant entourage that had now formed to the OR. we raced down the hall, my hair blowing back away from my face, my eyes bright with just the right mix of fear and determination. okay i'm making that last part up about my hair and my eyes, but either way, it was quite a sight. and more importantly, our patient did fine.

and who the heck are you?

2011-06-09T12:13:00.000-04:00

every time i see one of my elderly patients, he comments that he can't believe i call him with his lab results. he says, " i've been going to the doctor for 80 plus years and i've never had a doctor call me. and then you say 'this is beth' and for a minute i have absolutely no idea who the heck you are!' (he also can't believe i use my first name.)

he wants to know why i make my own calls. first of all, i don't make them all. if your pap is normal or you don't have strep, someone else will call you. but mostly it will be me on the other end of the line with your results. what i want to tell him is that it is because i love him, but that is too strange to say out loud. so i tell him it is because he is my family. he shakes his head and smiles and i know he is satisfied with my answer.

a peculiar work related misery

2011-06-06T12:06:00.000-04:00

most of us have had a pimple in the hollow of our ear before.
as a matter of fact, they can be quite sore.
but try putting your stethoscope repeatedly into that ear
as breath sounds and bowel sounds you are trying to hear
and you will want to shout, arrrgggghhhhh, i can't take this anymore!

i believe this has something to do with the rotation of the earth...

2011-06-03T17:44:00.000-04:00

despite the fact that the highest elevation around here is about eight feet above sea level, the bike ride i just went on was uphill the whole way.

on a brighter note, being so far from realizing my full physical potential means i have something to work toward.

2011-05-28T19:58:00.001-04:00

it's memorial day weekend and i'm taking a break from medicine. but just so you don't think i only do foolish things in my exam room (click here for brilliant example), i will tell you about my weekend, ahem, yearlong project. i love to make things, and that, coupled with my unfailing overconfidence, leads me and my reluctant hubby down many paths. so i wanted to make a hanging daybed for my back porch. i worked on it last summer, but never quite got it done, but today was the day to finish it and get it hung.

if you've ever declared you could do it yourself, then you already know that every project has its 'duh' moment(s). this one came when i tied and fringed all the knots at the bottom of the ropes before putting them through the holes in the bed frame. i was just really excited to see what they would look like, all knotty and fringy. thankfully, my kind hubby, after just a brief gloating that it was me and not him that messed up, helped me untie and retie all the knots. now if only my porch wasn't swarming with stink bugs...

just pondering things

2011-05-26T12:23:00.000-04:00

if we live into our eighties, why do our bodies peak in our twenties?

rilke hits the nail on the head

2011-05-24T11:26:00.000-04:00

i can't say i'm familiar with his whole body of work, but my dad made sure my sisters and i each had our own copy of rainer maria rilke's Letters to a Young Poet. so today i was looking for a rilke quote to share with my niece who is graduating from high school this spring (i was looking for the one about living into the answers in your life) and i stumbled across this one (also by rilke):

The purpose of life is to be defeated by greater and greater things.

if you have been reading my blog (thank you for that!) you may have noticed that i haven't posted much lately. i am currently being defeated by my electronic health record. it is tedious, time consuming, tiring and just generally a huge amount of work. it is definitely sapping my creative energy. but, BUT, i will survive, i will ultimately triumph, and i will move on to be defeated by greater things!

not getting the logic

2011-05-19T12:59:00.001-04:00

my patient thought it would be helpful to take her left over bowel prep to 'flush out' her gastroenteritis. she'll be doing some flushing, that's for sure.

an aha moment, or two

2011-05-09T09:05:00.002-04:00

no matter how hard i try (okay, maybe not that hard) i can't seem to get in and out of the exam room as quickly as my male counterpart. then i read a study that showed that men spoke on average 2000 words a day, while women spoke 7000. aha, i thought, proof that my patients are more verbose! but then i had to acknowledge that i myself am female... and that was the second aha.

need a little inspiration?

2011-05-05T06:38:00.002-04:00

it still amazes me and somehow inspires me to know that we have single cells in our bodies that stretch all the way from our lower spines to the tips of our toes. what fearless little cells they are, traveling all that way. so intent and committed to their purpose!

bad idea, or how not to do your bowel prep

2011-05-02T19:52:00.001-04:00

just a bit of unsolicited advice based on the regretful experience of someone i know who shall remain unnamed -- it is not a good idea to schedule your colonoscopy so that you must do your bowel prep when one of your two bathrooms is under construction and you have house guests...

missing: one sense of humor

2011-05-01T15:37:00.000-04:00

has anyone seen my sense of humor? i think it's burried somewhere beneath my new EHR...

who's chart is it?

2011-04-26T11:18:00.001-04:00

is it mine? i paid for the paper (now the computer) on which the data is stored, i wrote it and compiled it, i am required by law to keep it safe and maintain it years beyond any actual contact with the patient.

is it the patient's? it is after all a record of their personal medical history, a repository of data that they may need access to in the future. does the patient have any real control over content? does a patient have a right to ask me to omit something from his or her chart?

is it the insurance company's? both the patient and i signed contracts giving the insurance company unlimited access to the chart, whether it is to be sure i am charting and billing correctly, or to be sure the patient has left no diagnosis, no matter how trivial, undeclared. (my least favorite task is filling out pre-existing condition forms for insurance companies, forms that basically hunt for some reason to deny a claim. i feel like i am doing their dirty work, and possibly causing grief for my patient to boot, but i am obligated to fill them out. they often have ridiculous questions like 'will this patient need surgery in the next five years?' i'm not making this up.)

is it the government's? they increasingly want and demand access to cumulative chart data that has for so long been fragmented and inaccessible, data that now, with electronic health records, seems tantalizingly close to their fingertips.

is it the free market's? electronic health records are already being mined by companies for marketing data, much as pharmacy records have been exploited for years.

i think the answer is e) all of the above.

if doctors named crayons

2011-04-24T07:41:00.000-04:00

black = eschar

white = morphea

gray = gray matter

brown = stool

purple = hematoma

blue = cyanosis

green = meconium

yellow = icterus

orange = carotenodermia

red = angioma

pink = erythema

i am so young

2011-04-22T19:55:00.001-04:00

my patient told me that today was his 57th wedding anniversary. he then put his face in his hands and burst into soul wrenching sobs. i didn't see it coming, this man who has generally been so reserved in our encounters. but i did know that the past six months had been rough for him, culminating in his wife ultimately being diagnosed with an uncommon form of dementia. i felt so young watching him cry, glimpsing just briefly before he pulled himself back together the depth of his sadness.

grief does not wait for the last word to be spoken or the last breath to be drawn. grief rushes in well before, when you can no longer say some day i may have to face this, some day i may lose my spouse. grief finds you the moment you learn that your some day is today, now, and is your constant companion as your spouse slips away one forgotten day at a time.

i don't think so

2011-04-22T08:11:00.003-04:00

i got a report on a patient from her podiatrist. it was an electronically generated note, and in the review of systems, that infamous pandora's box of the medical record in which you are supposed to ask detailed questions about symptoms pertaining to every part of the human body (leave no stone unturned! is the ROS's war cry), it noted that my patient did not have nipple discharge. did he really ask her that? i think i would consider getting up and walking out of the office if my podiatrist, in a clear departure from reality, asked me a question like that. lets keep it real folks. the pressure is on but i know we can.

i love medicine

2011-04-19T20:55:00.002-04:00

can i share with you for a moment the things i love in medicine?

1) i love knowing things about how our bodies work
2) i love the language of medicine, the descriptiveness and preciseness of the words
3) i love the quiet moment when i hold my stethoscope against someone's chest and listen to the sound of their beating heart
4) i love a well constructed consult note, one that doesn't leave out the pleasantries that remind me of an era in medicine that is quickly slipping away
5) i love the endless learning that comes with a medical career
6) i love the trust i feel from my patients
7) i love the giggle that follows the knee jerk when my reflex hammer hits just right (why does that make us laugh?)

is that enough? i could go on! and yes, there is an equally long list of the things i don't like, but we all have those things in our jobs, and for me they are mostly mundane and far surpassed by the things i love.

viva viagra

2011-04-19T15:49:00.002-04:00

sometimes i wonder, when i am writing a script for these little blue pills, is someone out there thanking me or cursing me?

beware the morning rounds code

2011-04-18T07:03:00.003-04:00

one of our responsibilities in residency was to carry the code pager. whichever residents were on the cardiology service were responsible for all the non-surgical and non-pediatric codes in the hospital. surgery and pediatrics had there own teams. typically there would be two residents and two interns carrying code pagers. the pager went off at about the same time as an overhead announcement, 'code 100, 6 west, code 100, 6 west, code 100, 6 west.' the sound of that pager and overhead call was definitely something to get your adrenaline flowing and your heart pumping. if for some reason that didn't work, there was always the long run through the hospital and up the obligatory three or four flights of stairs to get your heart going. invariably you were as far away from the code location as physically possible without leaving the hospital and you couldn't risk getting caught in the elevator. so you ran.

despite the gravity of each situation, there were some funny happenings. once, in the middle of the night when the two residents and i that comprised that night's code team were getting some precious sleep, a code was called. we were in a set of three call rooms that all opened into a little hallway. we each came racing out of our respective rooms, disoriented from sleep and blinded by the light of the hall, and ran smack into each other. two of us landed on the floor, then had to scramble to get everything back in our pockets before racing out the door.

some codes were not funny, but maybe ridiculous, like this code at 5 am. the alarms went off and we ran to the room. a thin muscular man lay on the bed, no rise and fall of his chest, no heartbeat. my senior resident immediately had me start chest compressions, as the second year started to work inserting a central venous catheter. the nurses were busy with the crash cart. the senior resident, observing my chest compressions, repeatedly asked me to press harder. i was kneeling over this guy, two hands on his chest, pressing as hard as i could. despite the board we'd put under his back, i was barely moving his chest. at this point the anesthesiology resident sauntered in (they never ran, knowing the nurses would use the ambu bag until they arrived to establish the airway), walked to the head of the bed, pried the patient's lips apart, noted the firmly clamped jaw, and walked out of the room shaking his head.

rigor mortis. this man had been dead for hours. the nurse had come in to get morning vitals, noticed the patient had none, and called a code. that certainly explained my inadequate chest compressions, and also the congealed blood the second year resident was pulling out of his central line...

i'll pass on that, thank you.

2011-04-17T19:22:00.000-04:00

did you ever walk by someone on the street or in the mall and they hold something out to you and you automatically take it - a flyer or a sample or something? you take it reflexively, partly because you are being polite and partly because it's easier to just take it and throw it away then to refuse. this happens in the exam room too.

sometimes when i hold the ophthalmoscope up to shine the light in my patients' eyes, they will reach for it like i am offfering them a microphone, and it always makes me laugh. i ask them if they are going to sing some karaoke for me.

but sometimes in the exam room, someone holds something out to me that i refuse to accept. now i'm not squeamish about too many things, but this just really grosses me out. the patient will reach into his or her pocket or purse and hold out to me a greasy looking used up tube of some unidentified ointment and say something like 'my other doctor used to prescribe this for my hemorrhoids, can you refill it?' i'll gladly refill it, but i'm not touching it!

nutella delivery system

2011-04-17T12:44:00.000-04:00

your specialist said what?

2011-04-15T21:34:00.000-04:00

many a patient encounter begins with an ear full for me about the specialist my patient just saw. i usually give them a minute or two to vent, during which time i listen sympathetically, but i've learned to keep my mouth shut and then quickly redirect the conversation toward safer ground. who knows what the specialist really said? certainly not me. secretly though i can't believe some of the things people tell me. one of my patients said she went to a podiatrist and he never touched her feet. another patient said the specialist walked into the room, laughed at her, walked out, then billed her for the visit. another patient told me he saw a neurologist for a gait disturbance and the only question the neurologist asked him was are you having any difficulty swallowing. huh?

i am sure some of it is a lost in translation sort of thing. it has even happened to me, where a patient will come back and say, well you told me... and it's something i couldn't possibly imagine myself saying, like try putting salami on it or call me back if your cold isn't gone tomorrow.

regarding the specialists though, a week or so later, after hearing these wild reports, i always get a very nice consult letter that is thorough and appropriate to the purpose of the visit. i scratch my head. life goes on.

another chink in the foundation of my self image emerges

2011-04-15T17:32:00.000-04:00

it is not just my fashion sense coming under attack. my son brought home a paper today that he wrote about our family. here it is, unedited:

My dad stays at home and does work for my mom. My mom goes to work all day and comes home to watch TV. My sister likes to watch TV and play with me. I like to play with my sister and go on the computer.

fortunately my mental mythology is robust enough to overcome this clear misconception about my role in the family.

fashion emergency?

2011-04-13T21:48:00.001-04:00

i may have proof that you really don't look the way you think you look. i wore a blouse to work today that i thought was really cute. two patients asked me if i was pregnant. (good lord, no!)

one woman then dug herself further into her hole (as we so often do) by saying, 'well, it's just that you usually wear such tight clothes.' really? i am choosing to believe that when she said tight she really meant tailored. i won't accept defeat until stacy and clinton come knocking on my door.

doctors are like shoes

2011-04-13T08:11:00.002-04:00

i'm sure some of my patients don't like me all that much. maybe our personalities don't mesh, maybe my approach to things doesn't suit them, or maybe there is a more specific reason, but one i can't do much about, who knows. for whatever reason, the relationship is like a shoe that doesn't quite fit, that always rubs in that one place. uncomfortable, annoying. sometimes you can brake it in, sometimes you can't. i always hope those patients will eventually find another doctor, a shoe that fits more comfortably. until then, i do my best to make it work.

and, yes, plenty of times i am the shoe, but sometimes i am the foot and the patient is the shoe!

top five things you probably shouldn't worry about

2011-04-10T20:48:00.001-04:00

1. gas
2. snapping, creaking, popping or any other noise your joints make that is not associated with pain
3. gradually thinning hair
4. toenail fungus
5. GAS (i felt this needed special emphasis as people seem inclined to tell me in detail about their troublesome gas problems.)

the following reasons not to worry apply to all of the above:

1. it won't kill you
2. you can't really do anything about it

i don't think that's what you mean to say

2011-04-08T16:59:00.002-04:00

we doctors have our very own language just so we can laugh when others misspeak. my patient pointed to his nose today and told me he thought he had a deviated scrotum.

mental mythology

2011-04-06T19:11:00.004-04:00

a woman told me today that her husband's claim (apparently unfounded) that he had improved his eating habits was just a bit of mental mythology. how funny! don't we all have a bit of mental mythology working for us? i hear plenty of it everyday.

'why can't i lose weight? all i eat is _____ .'
fill in the blank with any two tasteless, calorieless food choices such as skinless chicken or cucumbers.

'the reason my blood pressure is high today is because _____ .'
fill in the blank with any number of unlikely reasons for your blood pressure to be high today or any day.

'i always need an antibiotic for my viral respiratory illness because _____ .'
fill in the blank with just about any random reason you can think of.

it goes on and on. oh, what limitless deceptions and misconceptions our clever minds are capable of! of course, i'm sure i have absolutely no mental mythology of my own...

i make a big mistake

2011-04-04T21:17:00.002-04:00

it is a great relief to me that i did not kill anyone in my residency, but that is not to say that i did not make mistakes, even big ones. this one, although it ends as well as it could, still makes me feel pretty lousy to think about.

i have spoken before about the 3 west hallway of our training hospital, a long corridor of patient rooms tucked out of site of the not so central nursing station, the perfect setting for this unfortunate tale. 3 west was usually the 'GI' wing, home to all things gastrointestinal, but it was also the repository for any overflow from other floors. you sort of cringed when you learned that your non-GI admission was going to 3 west, if only for the smells they would have to endure.

one afternoon, my attending and i were checking in on our liver failure patient. she was jaundiced and ascitic, but stable. as we were leaving her room, an elderly woman ran out of the adjacent room and grabbed us. she had been sitting peacefully at her husband's bedside when he suddenly embarked on the deadly journey of anaphylaxis. fifteen minutes prior, he had been given an intravenous dose of a new drug in a last attempt to quell his raging lymphoma. despite a reported risk of serious allergic reactions being greater than 30%, there was no protocol for administration or observation of this new drug.

we rushed to his bedside. he was sitting up in bed, leaning forward, clearly struggling to breath. his mouth and tongue were visibly swollen and dusky against his otherwise too pale skin. he looked at us with such a startling mix of terror and pleading, his wife saying the words his swollen airway could not, 'please help!' but then, in almost the same sentence, telling us that he is 'DNR'. do not resuscitate. the dilemma could not have been more clear. call a code and intubate this man against his prior stated wishes, or watch him die. because he couldn't speak, and because his distress was so great that he couldn't even nod his head in consent, we had to decide for him. his wife, equally distraught, just wanted us to do whatever we could. there was no time to revisit the nuances of a hospital DNR order, no meeting of the ethics committee.

we quickly decided we would give him epinephrine subcutaneously. by that time the nurse was in the room with the crash cart, but the only epinephrine she could find was the kind used intravenously in cardiac arrest, the difference being its much greater potency. we, or rather i, because my attending was sort of hanging back and allowing me to take the lead, said give it anyway. so this poor man was given a dose of epinephrine ten times stronger than what he should have had. at this point he collapses, he's not breathing and his heart is pounding at what sounds like 300 beats a minute. his wife is sobbing, my attending is silent. i call a code.

i later learned that although he survived the code, his lymphoma had not responded to the new drug. he was discharged home with hospice, and died soon after. i also learned that a protocol for the giving of that drug had been made and included 30 minutes of post administration observation and epinephrine at the bedside.

i felt so guilty about that whole event, guilty about going against some one's end of life wishes, a man that i did not know at all, guilty for giving him the wrong dose of epinephrine and sending him in to ventricular tachycardia, guilty for not later finding that couple and telling them how sorry i was. i felt angry at the team to which the patient belonged for having essentially no plan in place for the administration of that drug, angry at my attending for not stepping in and helping me (maybe she was as unsure that day as i was, who knows), angry at my residency program for always seeming to give me more responsibility than i felt prepared to handle. but mostly i felt ashamed for panicking, for not behaving like the doctor i was supposed to be. i took an action that i knew was wrong because i was caught up in the panic of the moment. lesson learned.

doctor roboto

2011-04-03T17:23:00.000-04:00

did i mention we are transitioning to an electronic health record?

(thank you to my daughter for teaching me how to use brushes on our ipad.)