When Keeping a Straight Face Causes Actual Pain

Today I saw a 67-year-old smoker with hypertension and diabetes who only comes to the office for acute problems. The last visit was three years ago for a sore throat; his blood pressure was 180/80. He promised to come back in two weeks to address his other health issues. Today (three years later) he comes in worried about a week of diarrhea (that's getting better.) His blood pressure is now 190/90 and his pulse is 130, though he's afebrile and in no distress whatsoever.

His exam is basically normal, though I can easily feel his aorta (he's skinny.) I want to do an EKG, a blood test (worrying about kidney function, diabetes control and anemia, among other things,) get an ultrasound to rule out an abdominal aortic aneurysm, give him a dT booster and suggest a colonoscopy. All he lets me do is draw the blood. I want to give him samples of Toprol 25 XL but all I have are 50's; it takes twenty minutes of explanation to get across that I want him to take half a pill every morning, and that I need him to come back in two weeks.

This is what I say to him (many times; he will not stop talking, asking the same questions over and over):

If you don't do what I say and come back to take care of these things, you are probably to have a stroke (or a heart attack) within five years, and probably less.

I wish to Gd I was kidding as I report his response (no sarcasm; not trying to be funny; deadly serious; a statement, not really a question):

"You're levelling with me, aren't you."

Disclosure (sort of): yes, there are intellectual issues somewhat beyond not being the sharpest tool in the shed. But still...geez!

Telling it Like it Is

By way of welcoming a newcomer to my blogroll, On the Pharm had a great post the other day about convincing someone that they really did need to get the series of rabies immunizations if they had been exposed.

His story reminded me of a call a few winters ago from the wife of a patient with diabetes and hypertension who smoked (of course):

Wife: My husband says he feels some pressure in his chest, and his arms feel really heavy from all the snow he's been shovelling. And I don't like his color; he's kind of gray.

Me: It sounds like he may be having a heart attack. I think you need to take him to the ER.

Wife (after conferring with patient): He doesn't want to do that.

Me (in a very calm, reassuring, almost cheerful tone): Ok. Is his will up to date?

Wife (with little hesitation): I'm taking him.

True story. Outcome: acute inferior MI. He's still with us.

"Yo": Where has it Gone?

I had occasion to speak with an old friend the other day. We now both have kids in college (having met when they were two years old) and I asked him how they -- his kids -- were getting along now that they're at different schools. My kids, who are at the same school, hardly ever see each other unless they arrange it online first. He told me that his kids are closer than ever, also thanks to the internet and cell phones -- which to their generation includes text messaging, or texting.

Verbify: to create a verb out of a noun.

We got into a lovely discussion about the generational differences in maintaining contact with other people. His contention was that the world is a scarier place today, and our kids reach out more because they find comfort in the connections. I don't think the world is necessarily more scary than in previous years, but the widespread interconnectedness made possible by modern telecommunications, including the internet, make it seem so. To be sure, in our day, large disasters made the papers wherever they were. But today the medium and even the small disasters that are and have always been a part of life are stream across the bottom of the TV screen and are discussed endlessly in various forums online.

Then again, perhaps the world always was terrifying; it's just that we weren't as aware of it.

At any rate, one of his points was that kids today are much more verbal than we were. Communication relies so much more on the written word (which includes posted and texted) even though the phone remains ubiquitous -- all the more so for having been freed from its wires.

Thinking about that, I realized that our kids are part of an enormous force on the English language: slowly but surely, the word "you" is disappearing. With two fewer keystrokes, the letters "Y-O" are becoming nothing more than a South Philly greeting. Between texting, posting and instant messaging, I'm not sure if my kids even remember that the second person prounoun isn't really "u." (Never capitalized either.)

With words like "nite" and "lite" having achieved semi-acceptable status as at least "alternate spellings," I suppose it's only a matter of time before "u" become official. Once my kids and/or their peers are the ones in charge of editing the dictionary...watch out! No more "yo."

A Timid Foray into Politics

John Edwards made his living -- and a very good one at that -- convincing people twelve at a time of things that were not true. The ability to convince people of things that are not true, whether it's the fact that Iraq has weapons of mass destruction or that cerebral palsy is caused by birth trauma, does not strike me as a particularly appropriate qualification for president.

Perhaps the excuse can be made that they believed what they were saying was in fact true at the time they said it. If that were the case, then when the truth came to light and the falsity of their previous statements became obvious, the honorable thing to do would be admit and apologize.

Although it looks like the current president will never admit he was wrong, we are at least requiring the issue be addressed by presidential candidates in terms of their justification of previous positions supporting a war now known to be based on falsehoods.

What about Edwards? Anyone seen him out there apologizing for claiming that birth trauma causes CP? Hell no. That information was already known even as he was convincing juries otherwise. He's probably still holding to the idea as tenaciously as Bush is to the idea of Iraq's involvement with 9/11.

I'm scared by the idea of another president who can persuade others that things he knows are false are in fact true -- in other words, lying.

Elizabeth Edwards and Breast Cancer

I suppose being a public figure -- or a member of the immediate family of a public figure -- means that "privacy" is an oxymoron. We all know by now that Mrs. Edwards has had a recurrence of her breast cancer. At this point, I wonder if more people are aware of this than are aware that her husband is running for the Democratic presidential nomination.

The blogosphere has weighed in: Kevin, Orac, Sid, the Cheerful Oncologist, not to mention CNN, MSNBC and everyone else with an email address.

I was even talking about it with my office staff yesterday afternoon. With more than a little personal experience watching people go through the final stages of life with breast cancer, our conclusion that John Edwards' intention to continue with the campaign is short-sighted and one he will come to rue is widely shared. There are others who parse the decision as "her will to live" fighting on, continuing with as much normalcy as a presidential hopeful can possibly muster.

On the other hand...

IT IS NONE OF OUR BUSINESS.

Period.

Full stop.

Our president is still trying to become a king by firing lawyers who don't kowtow to him sufficiently and innocent American lives are still being lost every day on foreign soil so that rich American businesses dependent on oil can continue to rake in the bucks, and all we can do is voyeuristically weigh in on one family's tragedy-in-progress.

Enough, people. Let's get a life.

At least we'll soon know who the real father of Anna Nicole's baby is.

Subject Not Yet Beaten to Death

Surprise! The comments from the Chronic Lyme Disease community continue, pleading for "dialogue":

All I can say now as I read the blog dated March 10th 'Growing a Thicker Skin' is that I must admit that I am beyond disappointed, dismayed and frustrated by the response of Dr. Dino and the other medical bloggers to the concerns of patients with Lyme Disease and Lyme-like illness.

Personally I feel that there is more than enough science behind the existence and persistence of the spirochetal bacteria that causes this disease including such technologies as dark-field microscopy.

However, I am not a scientist and so once again as a patient I must bow to the God of science. There is nothing more to be said. I must accept that Dr. Dino, myself and my Healingwell friends can only agree to disagree.

I am sorry Dr. Dino but for you this means nothing more than one slightly perturbing everning and a fresh, bright start in the morning.

For me, my friends on Healingwell and other suffering patients it means waking up to yet another day of constant pain or fatigue. Another day without answers, without an effective cure, without healing and most of all without hope.
...

I had hope that lines of communication would be opened, that true dialogue could exist.

There is no "God of Science." As a non-scientist, you are being manipulated by those who promulgate fake "science" regarding persistent Lyme infection to explain vague symptoms in the absence of objective proof.

My point is that you -- and suffering patients like you and your friends at HealingWell -- are being disserved by LLMDs and others who claim that the answer to your problems is "chronic Lyme disease" (or "reactivated mono" or "heavy metal toxicity") and that pumping you full of antibiotics for months on end (or subjecting you to "detoxification" or "chelation therapy") is going to help.

I think these were key words:

"For me, my friends on Healingwell and other suffering patients it means waking up to yet another day of constant pain or fatigue. Another day without answers, without an effective cure, without healing and most of all without hope."

I believe a good part of your suffering is the lack of an answer, and as such, anyone who claims to have one for you (like your warm, caring, understanding LLMD) becomes a savior. I wonder if by providing that kind of comfort, understanding, respect and empathy (but not the antibiotics) I could produce similar results for patients with similar symptoms.

Grand Rounds 3:26

Grand Rounds is up at BlogMD, and a grand Grand Rounds it is, too. Much reading pleasure awaits to those who go forth and click.

God Bless You, Kurt Vonnegut

I've just finished reading the latest book by one of my all-time favorite authors: A Man Without a Country, by Kurt Vonnegut.

Not that it's much of a book. More like a cross between a collection of essays and the ranting of an angry old man. It's only 145 pages, with wide margins and lots of space between lines. And pictures; entire pages with handwritten quotes; some graphs. All the strategies I'd use if I wanted to publish a book but didn't have quite enough material to make it look like a legitimate book.

That said, it's wonderful! It's pithy; it's too the point; it's funny as hell. In a word -- vintage Vonnegut. This from someone who's read almost everything he's ever written, from Slaughterhouse Five as a kid at camp, through the short story collection Welcome to the Monkey House, all the way up to Time Quake a few years ago. If Vonnegut were to die tomorrow, which he claims to wish he would:

I am going to sue the Brown & Williamson Tobacco Company, manufacturers of Pall Mall cigarettes, for a billion bucks! Starting when I was only twelve years old, I have never chain-smoked anything but unfiltered Pall Malls. And for many years now, right on the package, Brown and Williamson have promised to kill me.

But I am now eighty-two. Thanks a lot, you dirty rats. The last thing I ever wanted was to be alive when the three most powerful people on the whole planet would be named Bush, Dick and Colon.

this book would make a most satisfactory obituary.

The main thing about Vonnegut as a writer, though, is that once I read him I realize that he has already said what needs to be said so thoroughly and so elegantly that there's really nothing else to say. Least of all by little old moi. Regarding the Dark Ages into which I see this country slipping so inexorably, as I try to rant and rave and explain, Vonnegut says this:

In case you haven't noticed, as the result of a shamelessly rigged election in Florida, in which thousands of African Americans were arbitrarily disenfranchised, we now present ourselves to the rest of the world as proud, grinning, jut-jawed, pitiless war-lovers with appallingly powerful weaponry -- who stand unopposed.

In case you haven't noticed, we are now as feared and hated all over the world as the Nazis once were.

And with good reason.

In case you haven't noticed, our unelected leaders have dehumanized millions and millions of human beings simply because of their religion and race. We wound 'em and kill 'em and torture 'em and imprison 'em all we want.

Piece of cake.

In case you haven't noticed,we also dehumanized our own soldiers, not because of their religion or race, but because of their low social class.

Send 'em anywhere. Make 'em do anything.

Piece of cake.

The O'Reilly Factor.

So I am a man without a country, except for the librarians and a Chicago paper called In These Times.

And he goes on:

My last words? "Life is no way to treat an animal, not even a mouse.

Napalm came from Harvard. Veritas!

Our president is a Christian? So was Adolf Hitler.

What can be said to our young people, now that psychopathic personalities, which is to say persons without consciences, without senses of pity or shame, have taken all the money in the treasuries of our government and corporations, and made it all their own?

What else is there to say? Except of course, God Bless you, Kurt Vonnegut!

The Thinking Blogger Award

Many thanks to Cathy for tagging me with the Thinking Blogger Award:



And yes, I must admit that the Dork outdoes me, humility-wise, on this one. But what the hell.

Here are my 5 tags:

First, an honorary tag, as the blog is no longer active. But if it were, I'd nominate Barbados Butterfly in a heartbeat. Miss you, Barb.

First: Indexed, for making me laugh, but not until after making me think.

Second: Tundra Med Dreams, for making me think about far away places and fascinating people; things that never would have entered my mind, that now I can't stop thinking about.

Third: OncRN, for making me think until I cry.

Fourth: Gentleman's C, for making me think about another profession's point of view.

Fifth: The Well-Timed Period, for making me think about contraception and women's health issues more clearly than I would have believed possible.

I've purposely tried to stay away from the "usual suspects" such as Orac, Kim, DB, Flea, GruntDoc, Sid, RW, TBTAM, etc., knowing that some have already been tagged and the rest are certain to be in short order.

More on Vaccines

Possibly contrary to the impressions of some anti-vaxers, I am not in favor of all vaccines. Not only are all vaccines not created equal, but not all vaccine-preventable diseases carry the same risks.

Specifically: I agree with Flea in his recent rant against the chickenpox vaccine. I can go him one further: from the beginning, I was against it for fear of a very specific unintended consequence. It turns out, in the fullness of time, that I am likely to be right.

Chickenpox is a mild disease of childhood that, prior to vaccination becoming widespread, killed fewer people annually in the US than cervical cancer. Children with suppressed immunity due to cancer chemotherapy or other conditions, of course, are at higher risk of chickenpox complications and therefore it makes sense to have a vaccine available to offer them. Chickenpox disease appears to confer longer-lasting immunity than vaccination. The problem is that chickenpox in adults is much more serious, with something like a 10% risk of pneumonia, which also carries a not-insignificant risk of dying. My fear was that immunizing children would lead to waning immunity in adulthood, with a corresponding increase in adult chickenpox, complications and death. Sadly, this is the road we appear to be taking.

I would also like to go on the record about the pros and cons of certain other vaccines that I feel are either unwarranted in children (or which should be considered optional, to be given at patient/parent's discretion instead of mandated across the board) or which should have research accelerated so they can be added to the standard vaccine assortment.

Hepatitis B

My problem with Hep B is that it was the first vaccine mandated for children that was not targeted against a childhood disease. World wide, the burden of Hep B is significant. In this country, this is not the case. So in the final analysis, we have a large population immune to a disease to which few will ever be exposed.

Human Papilloma Virus

I have ranted against the HPV vaccine -- Gardasil and others -- at length. Suffice it to say that at a minimum, I have issues with the marketing strategies used to promote this vaccine targeted against an organism that, again, causes a huge burden of suffering globally although much less in this country. The Blog that Ate Manhattan, among others, has posted far more eloquently (though not nearly, I daresay, as obnoxiously) as I on this topic. HPV vaccination should be optional, with informed consent being the operative paradigm.

Meningococcal Disease

Meningitis caused by Neisseria Meningitidis is a scary disease. It's the "meningitis" that kills healthy children and adolescents overnight. It's the one you read about in the papers. In young children, it used to be the third leading cause of meningitis after H. flu and S. pneumoniae ("pneumococcus") although it's been bumped up to second now that H. flu is gone the way of the dodo. It's fighting for first, too, as pneumococcus succumbs to Prevnar.

There are two vaccines against this frightening bug: Menomune and Menactra. Each protects against the four most common serotypes, and are currently recommended for students entering college and young people in other group living situations (ie, military recruits.) My heart was warmed by the recent expansion of indications for this vaccine to include all adolescents at age 11-12. I would love to see research completed so that this vaccine can be included in the routine vaccination schedule for infants.

Do You Really Want to Know?

Ok, Poll question:

Yes, there is a story behind the dog and the chair. Yes, I've written about it (and was plenty pissed when it was rejected by Medical Economics. They've published pieces like What I Learned When my Father got Sick and What I Learned When my Kid got Sick, but didn't feel that What I Learned When my Dog got Sick was "appropriate" for them.) However it's longer than a typical post (and besides, I'd have to re-write some of it to make it suitable for the blog) though maybe I could divide it up and post it in chapters.

So what say the masses:

To blog or not to blog the story of the Rolling Peke?

Vote in the Comments.

The Rolling Peke

From the comments on the previous post:

The story is hilarious, but I think this might be my favorite part:

So the other night I'm walking my dog (well, rolling her; she's a paraplegic Peke who uses the most adorable little wheeled cart) minding my own business.

Sorry, but do you have a picture of that?

As it happens, I do, even though her eyes are closed:


She's even cuter with her eyes open. Especially when she smiles. And for anyone who doesn't think that dogs smile, all I can say is that you haven't met this one.

How Stupid Can One Cat Be?

So the other night I'm walking my dog (well, rolling her; she's a paraplegic Peke who uses the most adorable little wheeled cart) minding my own business. I turn the corner, and I see a man lying in the street.

Not the middle of the street; up against the curb, just before the corner. He had white hair, and one of his arms was stuck way down inside the storm drain as he lay sprawled on his stomach.

Being both a friendly and curious sort, I stopped and said, "Are you ok?"

He pulled his arm back and sat up, wiping his face.

"Yeah. Yutz-brain here decided to go see what was down there."

I stepped to the curb and peered down into the storm drain. Sitting on some dried leaves, about two feet down, looking up at us, perfectly content, was an orange cat.

"How did he get down there?"

"He just jumped in."

"Why?" Despite the fact that it was a meaningless question, I couldn't help myself. Kind of like when patients ask, "Why did I get sick?"

"Who the hell knows why? He's an idiot."

I looked back down at the cat to see if it had any reaction to being called an idiot. It looked back up at me as if to say, Don't mind him. He does this all the time.

"Can he get himself out?" I asked.

Interestingly, the man didn't actually answer me. He just lay back down in the street and sprawled against the curb. He reached back down into the storm drain and managed to grab the cat by the scruff of the neck and drag it out. The cat shook himself, none the worse for wear, and went over to a nearby bush which he proceeded to sniff and then spray.

"Come on, Dude. Let's go home."

The man walked off down the block, the cat following him. Not exactly walking along with him; more like a teenager in the mall. Stalking up to a house and sniffing the shrubbery; investigating a car in a driveway; sort of keeping him in sight, but maintaining enough distance so that no one would think they were together.

I was exceptionally proud of myself for keeping a straight face until they were out of sight before doubling over in helpless laughter.

Pediatric Grand Rounds

PGR is up at BlogMD. I really should pay more regular attention to PGR. This collection, the first I've read completely through in a while, is quite wonderful.

Growing a Thicker Skin

About four months ago, I blogged about a patient -- likely an "altie" -- who subtly but, I believe deliberately, insulted me about my conventional views of Lyme disease. Two days ago I noticed a spike in my traffic. It turns out that someone at HealingWell.com discovered that I do not believe that there is such a thing as chronic Lyme disease, and blogged about it indignantly.

Needless to say, that didn't sit too well with their community. Despite the fact that the Infectious Diseases Society of America has this to say about chronic Lyme disease or post-Lyme disease syndrome:

Following an episode of Lyme disease that is treated appropriately, some persons have a variety of subjective complaints (such as myalgia, arthralgia, or fatigue). Some of these patients have been classified as having “chronic Lyme disease” or “post-Lyme disease syndrome,” which are poorly defined entities. These patients appear to be a heterogeneous group. Although European patients rarely have been reported to have residual infection (or perhaps reinfection) with Borrelia burgdorferi, this has yet to be substantiated either in a large series of appropriately treated European patients or in a study of North American patients. Residual subjective symptoms that last weeks or months also may persist after other medical diseases (both infectious and non-infectious). It has also been recognized that the prevalence of fatigue and/or arthralgias in the general population is greater than 10%.

In areas of endemicity, coinfection with Borrelia microti or the Ehrlichia species that causes human granulocytic ehrlichiosis (HGE) may explain persistent symptoms for a small number of these patients. Randomized controlled studies of treatment of patients who remain unwell after standard courses of antibiotic therapy for Lyme disease are in progress. To date, there are no convincing published data showing that repeated or prolonged courses of either oral or intravenous antimicrobial therapy are effective for such patients. The consensus of the Infectious Diseases Society of America (IDSA) expert-panel members is that there is insufficient evidence to regard “chronic Lyme disease” as a separate diagnostic entity.

apparently a group of patients and or doctors decided that they didn't agree, and so they began an organization called the International Lyme and Associated Disease Society. It is a non-profit organization, with voting membership limited to:

those persons who have earned a recognized Doctorate degree (MD, DO, or PhD) and who have an interest in the care of patients with Lyme and associated diseases and/or are involved in research related to Lyme and associated diseases.

How does one become a Fellow of the Society?

The special status of Fellow of the Society shall be earned by those members who have:

1. Completed the in-depth workshop on the diagnosis and management of Lyme and associated diseases
2. Taken the examination prepared by the faculty of the workshop
3. Demonstrated acquisition of the most up-to-date scientific knowledge as related to the care of patients with Lyme and associated diseases.

A certificate of accomplishment shall be given to members having achieved the special status of Fellow. To maintain the status of Fellow, the in-depth workshop and examination must be taken every two years.

Seems kind of circular. Furthermore, the ILADS Treatment Guidelines include things like this:

New Chronic Lyme Disease Presentations

A detailed history may be helpful for suggesting a diagnosis of chronic Lyme disease. Headache, stiff neck, sleep disturbance, and problems with memory and concentration are findings frequently associated with neurologic Lyme disease. Other clues to Lyme disease have been identified, although these have not been consistently present in each patient: numbness and tingling, muscle twitching, photosensitivity, hyperacusis, tinnitus, lightheadedness, and depression.

Most patients diagnosed with chronic Lyme disease have an indolent onset and variable course. Neurologic and rheumatologic symptoms are characteristic, and increased severity of symptoms on wakening is common. Neuropsychiatric symptoms alone are more often seen in chronic than acute Lyme disease. Although many studies have found that such clinical features are often not unique to Lyme disease, the striking association of musculoskeletal and neuropsychiatric symptoms, the variability of these symptoms, and their recurrent nature may support a diagnosis of the disease.

And this:

Physical findings are nonspecific and often normal, but arthritis, meningitis, and Bell’s palsy may sometimes be noted. Available data suggest that objective evidence alone is inadequate to make treatment decisions, because a significant number of chronic Lyme disease cases may occur in symptomatic patients without objective features on examination or confirmatory laboratory testing.

Factors other than physical findings, such as a history of potential exposure, known tick bites, rashes, or symptoms consistent with the typical multisystem presentation of Lyme disease, must also be considered in determining whether an individual patient is a candidate for antibiotic therapy.

And this:

Seronegative Lyme Disease

A patient who has tested seronegative may have a clinical presentation consistent with Lyme disease, especially if there is no evidence to indicate another illness.

Although many individuals do not have confirmatory serologic tests, surveillance studies show that these patients may have a similar risk of developing persistent, recurrent, and refractory Lyme disease compared with the seropositive population.

So basically, if a specially trained Lyme doctor (training available only from other doctors with the same training) says you have Lyme, that's all it takes to make a diagnosis. I wonder whether some of these folks would be diagnosed with "heavy metal toxicity" if they happened to consult one of the mercury-poisoning adherents instead of an "LLMD." Careful reading of the ILADS site reveals many other features consistent with Orac's definition of "Altie." (Edited: check out the definition of a fad diagnosis at Quackwatch.)

None of which, frankly, is my point. They -- the chronic Lyme community at HealingWell, ILADS and elsewhere -- are not going to change my mind, and I'm not going to change theirs. I accept that.

What surprised me wasn't so much the name calling ("moron"; "bully"; "turd"; "tool"; "A-hole"; "stupids" [sic]; "coward"; "Dr. Stone Age"; "Dr DinoSOUR"; "angry ugly old man") but how much it hurt.

I know. It's just the internet. I'm anonymous. They're anonymous. It's only words on a screen. What's to be hurt about? Chill. Why should I give a moment's thought -- much less get all mopey for an evening -- over comments by people who not only don't know me, but haven't bothered to read more than one post on my blog (and somehow succeed in taking that out of context, too.)

Here's why: I refuse to brush them off as "crazies", "alties", "nut-jobs" and so on. That kind of labelling is what allows us to de-humanize people, objectify them, and render their words "not worth getting upset about;" ie, not paying attention to. Even though I know I will never meet them face to face, I remain acutely aware that most of them have suffered -- often at the hands of my colleagues. It isn't rational, but I feel badly about that. I understand that many of them are too deeply invested in the idea that B.Burdorferi is the cause of their suffering to ever really hear what I'm saying, but that isn't as relevant as you might think. People are in pain, and I can't help them. They won't even accept my empathy, seeing it instead as condescending and insulting. That's what hurts.

So I did what I've learned to do when I feel badly about something I can't do anything about. I waited. I got a good night's sleep (at last.) As usual, things were better in the morning. They almost always are.

Getting a Simple Answer

(Edited: Elevated to Marble Dinosaur Egg status)

Poor TBTAM. All she's trying to do is get a straight answer from her patients about whether or not they are sexually active, and everyone wants the question asked differently.

Here's my strategy:

All female patients get asked, "What do you use for birth control?"

Just about every possible answer leads naturally into clarifying questions and answers, providing useful and needed clinical information while generating rapport with a new patient.

One set of answers is simply the method: the pill, the diaphragm, condoms, etc. The natural next question is, "How is that working for you?" or some variant, to determine how satisfied the patient is with whatever method she's using, how effectively she's using it and so on.

Another answer is, "Nothing." Although there are several possibilities, in real life they divide themselves by whether or not the patient continues explaining on her own. Here's how the first set of answers usually plays out:

"Nothing; I've had my tubes tied."
Response: "Cool. Do you also use condoms to protect against STDs?" etc.

"Nothing; my husband's been fixed."
(Vasectcomy. My favorite method. I tell women whose husbands are considering it, "It's great; you won't feel a thing.")

"Nothing; I'm trying to get pregnant."
Response: "How long? Have you ever been pregnant?" etc. (fertility issues)

"Nothing; I'm not in a relationship right now."
Response: "Ok. What do you use when you do have sex?" (also presents the opportunity to find out how she feels about the lack of a relationship.)

Best answer I've ever heard:
*glaring daggers at me*
"I have a 2-year-old. I don't have sex."
(No response; if looks could kill, I would have been dead on the floor.)

Then there's the second group of women who say, "Nothing," and then fall silent. There are several options for the next question, and which way to go is a bit of a judgement call based on the woman's age, demeanor, and just a gut sense on my part. Here's what I usually say:

"Female partners?"

If the patient is a stupid teen (or 20-something) the answer is usually a disgusted, "Eeew! No."
Response: "So how do keep from getting pregnant when you have sex?"
The answer is usually something like, "He pulls out," or, "I don't know," etc.
Note: these patients are usually pregnant.

Lesbians are usually very impressed with me at that point, and answer simply, "Yes." This gives me the opportunity to go on with, "That's nice. Are you in a relationship?" etc. No shock; no surprise; just moving on to find out more about her (which can include, from a GYN standpoint, whether she has ever has sex with a man in the past.) Rather than trumpeting how tolerant and accepting I am, I have demonstrated it by matter-of-factly bringing it up as part of my routine history.

(By the way: males starting about age 14 are asked, "Do you use condoms when you have sex?" thus forcing the explicit answer, "I don't have sex." I call it the "Have you stopped beating your wife yet?" approach.)

The Hatchling

I have a medical student in my office this week.

He actually shadowed me for a week as a high school student five years ago, went off to college where he played Division 1 football for four years, somehow ended up in medical school instead of the NFL* and is now doing his first year primary care preceptorship with me.

*(I'm not 100% sure why. I believe it's because he's always wanted to be a doctor -- something he and I have in common -- and that he wasn't quite big enough. Then again, he does have a specific special teams skill that he probably could have parlayed into a respectable NFL career. I'll have to ask him.)

He is a joy. He's as knowledgeable and self-assured as anyone can be who is acutely aware that he doesn't know squat. His med school thoughtfully sent a packet of information (to me; apparently they didn't send him anything) about what he was supposed to accomplish in his time with me, so I'll make sure he gets to see a patient he can write a SOAP note on. We went over "taking vital signs correctly on patients of various ages and sizes;" yesterday he discovered the joys of measuring a wriggly toddler. I've been trying to teach as well as I can, but when they're not even all the way through the first year of med school, the balance between throwing out way too much info just totally over their heads and being obnoxiously elementary ("slip that probe into one of those plastic covers until it clicks and tell the patient to hold it under her tongue until it beeps") is tougher to negotiate than one might think.

Yesterday we had a snowstorm. Sort of. One to four inches called for, starting in the morning but going on through the day. No school cancellations. Hatchling called me at 6:30 as agreed upon, and we concurred that it was going to be a bust and we were going to have a regular day. My staff felt otherwise, though. They didn't want to struggle through traffic (always a sore spot in my poorly overdeveloped neck of the woods) only to have the weather worsen, the patients all cancel, and then have to try and make their way back home over treacherous roads. They bailed.

I got to the office just fine, as my commute is against traffic. Hatchling made it about forty-five minutes later, mainly because the color white makes drivers around here psychotic. I asked him if he was willing to be thrown into the deep end of a completely different pool than he'd bargained for, and he was a trooper. I gave him about five minutes of training: what information he needed to get for referrals, prescription refills and appointments. How to answer a question with a question. (The answer to "Is the doctor there?" is "Can I help you with something?" One of my staffers had a terrible time trying to learn she didn't have to say "yes" and then try to come up with an excuse why she couldn't just get me on the phone.) And so the Hatchling spent the day answering the phones while I saw patients. He saw some with me, but when the phone rang, he knew it was his job to go get it. He was awesome.

None of the patients cancelled. We even added three appointments, including a new patient.

In addition to fielding phone calls, he learned to call in prescriptions, use the fax machine, how my filing system works and how I like to schedule appointments (not nearly as straightforward as one might think.) What he gets credit for is not copping an attitude about performing tasks that someone more small-minded might think of as "beneath him." Actually, since one of the objectives listed for me as a preceptor is to "model the attitudes and skills of a primary care physician," (in this case, also those of solo practitioner/small business owner) I think I did a pretty good job of showing him that *nothing* is "beneath me." We traded off tasks like filing, packaging blood samples for the lab and straightening up exam rooms. It was beneath scut. But it had to get done, and he pitched right in. We ended up having a regular day after all, and I couldn't have done it without him. Thank you, Hatchling.

I wish I could be a fly on the barroom wall to hear him regale his buddies with his preceptorship experiences over a beer next week.

Purim Fun

The venerable Flea has already discussed Purim, calling it the "Jewish Mardi Gras" (although I have been known to call it the Jewish Halloween.) I wanted to share the final product of another very special interlude with my youngest nestling who wanted to bake a cake for "Esther's Cake Walk," one of the games at our synagogue's Purim Carnival. The game is basically Musical Chairs, where the winner of each round wins a cake; thus they need as many cakes as possible donated for the event.

Young Nestling began talking about it with me on Friday night: he wanted to make a jack-in-the-box cake. He couldn't quite convey the image he clearly had of it in his mind, but over the course of an hour's conversation (incredibly rewarding for its collegiality and total lack of rancor -- imagine that with a 17-year-old) it turned out he didn't really have all that clear an idea of what he wanted. After further discussion, it morphed into this, from the old Addams Family:

"Thank you, Thing."

The glove was filled with lemon jello, giving it the perfect disgusting fleshy consistency. The three layers were frosted so as to give the appearance of a table. The cake itself was made from scratch; my suggestion, thinking that a scratch cake would be sturdier to work with than a store bought "super moist" one (correct) though the frosting was store bought. Saturday was baking day (and jello-filled-glove setting day) and Sunday morning was the final assembly and picture taking. It was a wonderful project for us to share.

And a hearty Chag Purim Sameach to all!

You Might Be an Altie, but...

Over at Respectful Insolence, Orac has given us an amusing run-down -- a la Jeff Foxworthy -- of "You Just Might be an Altie if..." It was cute. It was fun to read. There was little with which to disagree. However now it is time to return to our regularly scheduled life.

Although Orac correctly writes:

Alties are often militant and always highly suspicious of eeeviiilll "allopathic" medicine and doctors. Part and parcel of being an altie is an anti-intellectual and antiscientific attitude that does not allow a little thing like evidence to sway one from one's belief in the power of alternative medicine.

there are many people who show up in our offices with "altie-type" ideas who must be dealt with. Let me re-phrase that: We often see patients who, despite the fact that their understanding of medicine, pharmacology, physiology and anatomy, etc. may be incomplete or suboptimal, deserve to be treated with courtesy and respect. While Orac's litany is amusing, what he is actually doing (in good fun, of course) is defining a stereotype. Painting "alties" as objects of ridicule and derision puts us at risk of brushing them off as a group, thereby doing them a disservice as patients.

People don't walk into the office with the letters A-L-T-I-E stencilled on their foreheads. In practicality, there is a large middle ground of patients who consider themselves open-minded regarding science who nevertheless hold "alternative" ideas about various conditions and treatments, with varying degrees of tenacity. Because I have to deal with them -- granted not those quite so hard-core, who of course wouldn't be caught dead visiting an old allopathic doc like me -- on a regular basis, I would like to submit that certain strategies are perhaps more appropriate than blanket ridicule.

Of course the first step is education. The lady who comes in looking for a new doctor who discloses with pleasure her success with the passage of "gallstones" with "liver flushes" as part of a routine history is an example. Discussion of the physiology of bile and gallstones, perhaps along with some internet references about the analysis of said "gallstones," might be sufficient for one person. Another may remain unconvinced. Question: Is this patient-physician relationship doomed, or can an "agreement to disagree" work for both parties? How much negotiating should a given physician be expected to do regarding these issues? Should we simply refuse to accept as patients anyone who appears to be "rejecting science?" Remember, we don't always know what we think we know. What would we have thought twenty years ago of the patient who swore her ulcers were cured by a high-dose course of antibiotics? Back then, she'd have been an altie; today we've "discovered" H. Pylori.

Out in the real world, things are often not as cut and dried as the internet helps make them appear. Many people who do "liver flushes" also understand the need for pap smears, colon cancer screening and blood pressure control.

I believe this is a topic ripe for discussion: finding a middle ground with "alties" so as to provide them with competent, compassionate care in spite of the views they espouse -- to the extent they are willing to accept it, of course. Obviously I am not talking about the true extremists -- the blog fodder, that is. But if we could please take a step back from the wing-nut sensationalism and help find ways to persuade, educate, and above all care for these, some of our more difficult patients, I think we -- and our patients -- would find it rewarding.

(Yes, today is my birthday. Many thanks to all for the good wishes.)

Book Deal! (Not Mine, Though)

Congratulations out the wazoo to one of my favorite blogs, Indexed!

Laws at Work

I find myself quoting from the Laws of the Dinosaur more than usual of late, so I thought it would be fun to give some real-life examples of the applications of some of them:

From the email, a doc named Hashimoto (who isn't an endocrinologist; he tells me the name is as common as "Jones"; good thing the eponymous condition was first described in Japan; doesn't "Jones' thyroiditis" sound boring?):

Don't you hate it when a patient calls for an "emergency" appointment for a boil, you tell them to come right now, and then they tell you they can't come in until tomorrow!!!

Eleventh Law: Poor planning on your part is not an emergency on my part.

Patient I saw this week with hypertension and hyperlipidemia who has coronary disease for which he has already had stents placed, about why he only takes his Lipitor off and on:

But I feel fine.

Second Law: It is impossible to make an asymptomatic patient feel better.

Teenager with poorly controlled diabetes:

I know what I have to do. I just have to do it.

Tenth Law: "Simple" and "Easy" are not necessarily the same.

And finally, regarding the other 85% of the patients I saw this week with colds, viral syndromes, gastroenteridities, sinus and ear infections (mostly viral) and bronchitis (almost all viral) there is first and foremost, this:

First Law: The art of medicine consists of amusing the patient while nature takes its course.

And for the record, I can be very amusing indeed.