low expectations

i asked my elderly patient how he was doing.  'great,' he said, 'i got up this morning...'  i was waiting for more, but apparently that was it.

lesson for a young doctor

i was cleaning out some boxes in my basement today and found something i wrote my first year in medical school.  i had been assigned to a  family practitioner  for a week-long rotation and it was my first real glimpse into the realm of the exam room and the doctor-patient relationship:


The Woman With 37 Iguanas

The woman with 37 iguanas is one I will not soon forget.  I opened the exam room door and there she was, her seemingly miniature head resting on her over-sized body, and on top of her head a little upright ponytail like a fountain.  Red, orange and hot pink swirls covered her from head to toe, the fabric gaping between buttons over breast and belly.  Peeking from under her skirt were two petite feet.  I watched the gum stretch and snap between her teeth framed by bright red lips, themselves framed by her pale skin and shiny black hair.  She talked incessantly, interrupted only by the occasional redirection of Dr. H's questions.

She talked in circles, she repeated things, she overflowed.  Could she be allergic to the iguanas?  Does she need to keep taking her thyroid medicine?  Did I know that Robin Williams is bipolar?  Steve Martin?  Roseanne?  She bought 22 pairs of shoes last week.  I glanced guiltily at her feet as if to confirm this.  Yes, those shoes looked brand new!   Did she keep them all or take them back I wondered?

I couldn't help it.  I was drawn in by her bubbliness, her friendliness, her bizzareness.  I found my own mood rising higher, my thoughts coming faster, as if her mania was contagious.  She was a balloon and I was merely an ant on the string.  When we left the room Dr. H smiled at me knowingly, eager to see my reaction, amused at my need to take a deep breath and shake my head.  I knew then that Dr. H had wanted to give my this experience, this powerful pull on my psyche to say, Beth, it's unavoidable.  Your patients will come to you sad, angry, intensely happy, and you will find yourself drawn in all of those directions.  Thank you, Dr. H, for both the gift and the warning.


i think the lesson is this - as a doctor you are not a wall, you are not a repository, you are not even the same person each time you walk through the exam room door.  instead, you are like a well that ripples and reflects back when someone dips into it.  it is a great benefit to both you and the patient to tune into those ripples, they are telling you something.

two simple arguments for universal healthcare

#1)  a study came out recently about married people and happiness.  the researchers asked the participants who was happier, the subject or their spouses.  the interesting answer:  neither.  it turns out most couples' happiness is closely tied to the happiness (or unhappiness) of their spouse.  marriages have a collective happiness of sorts.  how does this relate to healthcare?  i believe we, as a society, have a collective health; the health of each individual has an effect on the health of all.  when we address the health needs of all our society members, our collective health will rise.  we will all benefit.

#2)  it is the right thing to do.  forget about whether it is constitutional or not, whether it is a privilege or a right, it is simply right. that is all we should need to move forward.

with that out of the way, we can move on to a single-payer system!

my computer has a twisted sense of humor

yesterday, i sent a script electronically for amoxicillin for a patient with strep throat.  a few hours later a got a call from the pharmacist because the script he received was for hemorrhoid cream, not amoxicillin as intended (i am not making this up!).  i have no idea how that happened but at least it was an obvious error.  a more subtle one may have gone unnoticed and that is scary to think about. okay, now this post isn't funny anymore.

all of my patients have excellent vision

my husband and i were measuring the hallway in my office lat night for some furniture we had to move, leading me to the realization that we've been putting our patients two feet closer to the eye chart than they should be.

ludicrosity abounds

if that is not a word then i must make its so, based on the paperwork a patient dropped off for me today.  the first was a form asking me to estimate the patient's medical expenses for the year, including dental, prescriptions, other doctor's visits, etc.  ask the patient, not me!  i'm her doctor, not her accountant.  the second was a form asking me to justify the disability detailed below.  the next part of the form was a series of blank lines. ??? !  somebody save me!

lost in translation

what i say:  "mr./ms. smith, you are due for a colonoscopy/blood test/mammogram.  here is a written order."

what they hear: "take this slip of paper, put it in your purse/wallet/pocket.  keep it there until next year so you can sheepishly retrieve it and show it to me when i ask you why you didn't get your test done."

bad name for a nursing home

i was delighted to hear that my patient who recently suffered a subdural hematoma after a fall will now be residing at the Great Falls nursing home.

a matter of semantics

when you are speaking to your friend, whose young child is about to undergo a delicate procedure, please do not ask, as my sister did, if he will have to be euthanized.  (we know you meant anesthetized!)

awkward doctor moments

running into your patient, the one with the drinking problem, outside the liquor store.

asking a patient how her mother (also your patient) is doing... a year after she died.

introducing yourself to the person who has accompanied your patient to their appointment, only to have them remind you that they are also your patient. (can you see a trend here?)

pulling off a patient's sock and discovering you've pulled off a toenail with it.

looking in the mirror at lunchtime and realizing you have a hickey.  that really didn't happen to me.  i'm just imagining that it would be pretty awkward if that did happen.  even though it didn't.

domestic tranquility

i am having trouble convincing my dear husband that the reason other people's kitchen sponges look so nice is that they periodically replace them.

embracing my inner nerd

one of my favorite books is my taber's medical dictionary.  i remember buying it in preparation for my first year of medical school.  i still use it sometimes, mostly when i get a radiology report and have no idea what the radiologist is talking about (my patient has a lesion near her clivus?  what the heck is a clivus?).  but sometimes i just pull it off the shelf and open it randomly.  i sort of quiz myself to see if i can find a medical term i don't already know.  i don't know why, but medical terminology makes me happy.  to me it is the perfect marriage of precision and descriptiveness.

my best friend in medical school and i would make lists of medical terms (a classic stalling tactic when you should be studying) - there were the terms we loved, like foramin of luschka - so fun to say out loud, it rolls off the tongue and makes you think of elegant russian spies...; terms we hated, like empyema - what an ugly word, or maybe it's the fact that it is describing a pocket of pus in a lung...; and terms we could name our children (gracilis is the only one from that list that i can remember and did we really think you could name a child gracilis?).

i was never one to easily pick up a second language. but if you consider the language of medicine to be its own language, then in that i would say i am fluent.

that probably won't make good leftovers

note from front desk staff:  'patient found bean-like object in stool today and froze it.  wants to know if it should be tested.'  alas, there is no known test (or treatment) for this ailment, but make sure your spouse knows what you're putting in the freezer!

at 90, it's all a gamble

me, as i leave the exam room:  'can you get up from that chair okay?'
patient: 'i think so.  if not, you'll hear a thud.'

i've got this

i read today that the body of medical knowledge doubles every 5 years.  don't worry, i'm completely on top of that.

if you want the good lord to take you, you've got to slow down

 'i am finding this aging thing to be no fun at all,' my nonagenarian grandmother said to me, after telling me about her various maladies and doctor's visits.   'i'm ready for the good lord to take me.'   this has been her constant refrain the past few years.

but my sisters and i had recently visited her and were in awe of the speed with which she raced down the hall from her apartment to the dining room.  we thought she needed some racing stripes on her walker, or at least a horn to warn the slower ones she was passing.  we found ourselves scurrying to keep up.  my sister told her that the reason the good lord wasn't taking her was that he just couldn't catch her.

let the buyer beware, particularly if taking sleeping pills

my patient took a sleeping pill for three nights and thought everything was great.  until, that is, she got a sales call regarding the instant face lift she had ordered from an infomercial the night before.  she had absolutely no recollection of this whatsoever.  maybe we better try something else for that insomnia...

insurance insanity

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

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

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

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

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

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

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

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.

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

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

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

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

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.)