New Blogs

Well, they're not new; but they're new to me.

Trench Doc
Medblog Addict

Between the two of you, you owe me a new keyboard to replace the one that's just been ruined by the coffee spraying from my nose.

Grand Rounds

Grand Rounds is up at Dr. RW, who has done a magnificent job of compiling a wonderful selection of the best of the blogs. How do I know it's the best? Because he included a post of mine, confirming his exceptional talent and keen eye for excellent writing.

(Would someone please pass me a tissue? I seem to have a little something on my nose.)

Family (Practice) Matters More Than You Think

There you go again, Sid.

Although you start your post oh-so-sweetly (about how much you admire FPs and the work we do) you then go off on a whole diatribe about how it "used to be." It's harder than you realize for the casual reader to keep your initial disclaimer in mind as you give example after example about all the FP screw-ups you've witnessed or stepped in to clean up. (And by the way, why include the last one, about a fucked up liver resection you referred to another surgeon? No FPs involved there that I could see.)

What's especially disingenuous is that most of your examples are of FPs "fresh out of training." Isn't it about time that we recognize explicitly that the acquisition of knowledge, skills and experience -- "training" -- is an ongoing process? An FP (or a surgeon, for that matter) is not magically more skilled on July 1st when they start practice than they were on June 30th of their last day of residency. I think there should be some kind of official acknowledgement that people in their first 5 years of practice, say, deserve some slack -- in the form of explicit (but not condescending) backup from the other docs in the community. I'm not saying restrict their practice or don't hold them responsible; just offer some support instead of griping about them behind their backs.

While we're on the subject of training: your recent discussion of how surgical training inculcates respect for one's limits was an eye-opener for me. Since I only saw it from the outside, I admit my perceptions were incomplete. So how dare you go criticizing my training on the basis of what you think you're seeing! What you call "having to be in charge of everything" translates to being castigated by the surgeons both for sending patients who turned out not to have surgical problems as well as for not sending them soon enough (as in your example of bowel obstruction.) My training has served me quite well, thank you, even if you don't quite understand its relationship to what I do.

You're right in that the gatekeeper concept was flawed from the git-go, especially when full-risk contracting was included. "Referrals" quickly became a joke as the malpractice advisors immediately declared that patient request should be sufficient grounds for granting one. But the one thing it did help address was something I still see all too frequently: I send someone to you to repair his hernia. You send him to the cardiologist for his blood pressure, who sends him to the orthopod for his carpal tunnel syndrome, who sends him to the pulmonologist for his asthma, who sends him to the urologist for his nocturia, who sends him to the endocrinologist when the nocturia turns out to be from his diabetes. And you're all getting paid at the considerably higher "consultant" rates than just the "evaluation and management" (E/M) levels I do. The patient goes along with it because, "Dr. Schwab/Jones/Smith/Wesson said I needed to go see that doctor." Who am I, poor little schlub, to go disagreeing with the great Dr. Schwab, to whom I sent him in the first place?

As for the sin of over-reaching: just because *you* have never made such an error, I know for a fact that it cannot be said of every surgeon. Nor of every medical specialist. On the other hand, especially with the recent changes in medicine (including the worsening malpractice climate) I think FPs are not only less likely to over-reach, tragically I think they are also less likely to practice to the fullest of their true capabilities, for example referring things like Irritable Bowel more readily because the GIs and surgeons have browbeaten us with tales of misdiagnosed ulcerative colitis.

Practicing to the fullest of your abilities while remaining aware of your limits is a much finer line than I believe you have drawn. In fact, you have demonstrated this yourself -- not once, but twice -- in your post: your surgical prof glowered at you for turning over your surgical ICU patients to intensivists, which you felt was over-reaching, but the patient you sent to the liver specialist (who, I believe your words were "fucked it up royally") would, in retrospect, might very well have done better if you had done the procedure (well within your capability) yourself.

As I listen to you bemoaning the sorry state of new FPs and modern residency training, and even your pondering whether your younger surgical colleagues' skills are diminished in response to the rising use of laparascopic techniques, I get a sense that your remarks could all end with something like, "What's the matter with kids these days?" or words to that effect. Allow me to point out that yours (ours?) is not the first generation to believe that their particular skill set constituted the zenith of their profession, and all those youngsters coming up are never going to be as good (or, as I've heard said about Family Practice, "will cease to exist altogether.")

If you're honest, can't you imagine (or perhaps remember overhearing) your old fogey surgical mentors complaining about you and your peers? "Remember when 'Residency' meant just that. You can't get adequate training unless you actually live at the hospital full time. How do these young guys think the can learn anything when they have homes and wives and kids (Gd forbid!) to worry about? Surgery will never be the same." Well, Sid, you guys seem to have turned out all right, and I daresay -- one way or another -- future generations of FPs and surgeons and specialists will find ways to muddle through, relating to one another, their patients and the practice of medicine in ways we can't even imagine -- and probably wouldn't approve of if we could.

To quote that great philosopher William Joel:

Well the good old days weren't always good,
and tomorrow ain't as bad as it seems.

Keep the faith.

Ninth Law of the Dinosaur (Tenth, too!)

Cathy is in a bit of a funk, but I have to thank her because in responding to her I realized that I have not yet articulated what I'm calling here the Ninth Law of the Dinosaur, but is actually my own personal Prime Directive in life:

Part A: It has to be fun.
Part B: If it isn't fun, see Part A.

The idea, of course, being that if it's not fun (whatever "it" is, be it blogging, practicing, writing, whatever) then something needs to change in order to make it fun again.

Simple, right?

Just remember, no one ever said that "simple" and "easy" were the same thing.

Hey hey hey!! There's Dino Law #10:

"Simple" and "Easy" are not necessarily the same.

Thanks, Cathy. What would I do without you!

I Won

Well, I did it.

Even with a full time office practice, family, house and pets to care for, not to mention a new blog to nurture, somehow I managed to write a 50,000 word novel in 30 days (26, actually.)

Full disclosure: it's not actually finished, even though I crossed the 50K word finish line this evening. But I have every intention of finishing the story, such as it is, sometime in the next four days, as I am very close to The End.

Is it any good? Who knows.

I can tell you that the story didn't turn out quite the way I thought it would when I started. I'm sure it has its moments, though I don't think it's as good as last year's novel (which I edited, polished and self-published.) Then again, I haven't gone back and actually read it yet, so I have no idea what -- if anything -- will become of it.

But for the moment I am just basking in the glow (and icing my fingers.)

Evidence Based Everything Else

While watching yet another Direct to Consumer (DTC) drug commercial on TV, my son said something that provoked a forehead-thumping moment of "aha!" His was a general (hopefully rhetorical) question about why drugs should be advertised at all. Shouldn't doctors be the ones to tell people what medicines they need? (To which the answer is, "Duh.")

But I got to thinking, and interpreting the question as "Why is there such a thing as DTC advertising?" generated the obvious, if dismaying answer, "Because it works."

How do we know it works? Because if it didn't, you know damn well Big Pharma wouldn't be pouring billions of dollars into it annually. And that's when it hit me: every other business in the world works on the basis of evidence; especially advertising. If a commercial doesn't have the desired effect of increasing sales, it's pulled. If a certain mode of advertising is shown to pump up the bottom line -- whatever legal, moral or ethical issues there may be -- it runs. Any downsides (such as fines) are just "the costs of doing business."

So why should medicine be any different? Why is EBM such a hard sell? Maybe what we need is to commission a couple of New York advertising firms to do our EBM research for us. Hell, it's worked like a charm for Big Pharma.

More About Ancillaries

From the comments to "Ancillary My Ass":

I am wondering how ordering these useless tests is different from stealing? Doctors who do these tests think they really need to supplement their income because the insurance companies don't pay enough. Well, the company I work for doesn't pay me enough either. If I had only one 4% raise in the last 2 years - and this is with pretty good evaluation, does it mean I can take somebody's money by convincing them they need to buy something from me that they really don't need just so I can get my income in line with the inflation? And there is a difference between selling people something they don't need and ordering a test: at least with the former nobody believes his/her life will be in danger if they refuse.

How is this different from stealing, eh?

Why, I don't think it is at all!

As for other commenters who pointed out the standard defensive medicine, CYA and "but he found all kinds of things" answers, I still say BULLSHIT.

Medical diagnosis consists of (in order!):

1. History
2. Physical
3. Testing

That is to say, if you've never seen or talked to the patient, you have no way of knowing what tests (if any) that particular patient is going to need. Get your history first; formulate your diagnostic hypotheses, then examine the patient. At that point a competent clinician will have a pretty good handle on some kind of differential diagnosis, and can make a rational decision about what further testing (lab, imaging, PFTs, whatever) is needed to clinch it. Enormous amounts of money, time and energy are wasted when this sequence isn't followed.

One scenario that annoyed the hell out of me was a patient assigned to my HMO panel who called and said that he needed a referral for an MRI of his brain. WTF? It turned out he had had what sounded like a TIA and a neighbor -- who was a retired chief of radiology at a large tertiary care center -- told him he needed to see his friend, the neurologist: chief of neurology at said tertiary care center. When he called for the appointment, he was told he needed to have an MRI before being seen. I eventually managed to get the guy to come in to my office, went through the appropriate workup, got him started on aspirin and controlled his blood pressure, all without an MRI or a referral to the chief of neurology at a big tertiary care center, who had much better things to do with his time than take care of an uncomplicated TIA.

I understand that in today's busy world of medical practice it is considered efficient to have as much as possible completed before seeing a patient. I have no problem with things like vital signs being completed before walking into an exam room. But however you slice it, PFTs are not "vital signs."

Defensive medicine is real, without a doubt. But routine PFTs literally on everyone who walks in the door is not defensive; it's indefensible. As for detecting clinically significant occult conditions on testing before they become apparent either to the patient (in the form of symptoms) or to an astute clinician on physical exam, it doesn't happen nearly as often as often as you might think.

So what's the difference between ordering unnecessary tests and stealing?

Nothing.

Limitations

Stop the presses! A conviction I have held deeply for quite a long time has been effectively challenged, thanks to Dr. Sid.

Here is the excerpt (full post here) that got me thinking:

Sick and brutal as it may be, the constant haranguing of trainees -- the endless reminding them that they know nothing, that they're a bunch of screwups, that there's a chain of command they must follow, that if something goes wrong they are responsible -- all that stuff that's unique in its severity in surgical training makes for a deep and abiding sense of limits. More than anything else, that's what keeps patients safe and their doctors out of trouble.

Wow. He's right.

Until the moment I read this, I felt strongly that the inhumanity of surgical training was nothing but gratuitous hazing that was unnecessary at best and cruel at its worst. What good could possibly come of brutal head games? What does humiliation and browbeating have to do with acquiring surgical judgement and skills?

I won't go so far as to say, "Now I get it." I will say that I better understand that one of the results of this training is recognition of one's limits. Apparently it works. I still wonder if it's really the only way to inculcate these values, or even, if there are other ways, whether it's the best. How would we know? Generate a "new paradigm" in surgical training, randomly assign trainees to one or the other, then compare how much trouble they get into once they're out in practice? Yeah, sure.

Still, I do believe the harshness of the training would be more palatable if it were made clear from the outset that this treatment was not personal, but that the internalization of limits was the true goal. And for what it's worth, the present system does not appear to work flawlessly. There are still far too many stereotypically arrogant and personally dysfunctional surgeons around who I'm sure were harmed more than they were helped by the abusiveness of their training.

But thanks, Dr. Sid, for the first rational justification for surgical training I have ever heard. You have given me a lot to think about.

From Generation to Generation

When I was a teenager I taught myself to bake. Actually, my mother taught me the basics (both by the example of watching her and during occasional joint projects) but then I went off on my own, so to speak. Every now and then I would feel like making something, usually a cake or some cookies. The most ambitious thing I ever tried was croissants, which actually came out quite nicely. (It's difficult for anything with that much butter to taste bad.) I never had any horrible catastrophes, though of course some things were better than others as I learned and experimented: what if I used this instead of that? More of this or not quite as much of that?

In the mornings, my mother would come downstairs to be confronted with the results of my experimentation: cake, or cookies, or whatever. It wasn't at all fair to her (or her diet) but she always expressed praise, and occasionally offered a constructive critique. I remember one cake was a little heavier-textured than it should have been, and I realized it was because the recipe had called for heavy cream -- which we didn't have -- so I had substituted milk. Through this trial and error process, I learned the finer points of the relationship between ingredients and results on things like texture and crumb, and in the fullness of time I would say I have become quite an accomplished baker.

Two nights ago my younger son said, "I feel like making something." So he pored through my cookbooks, settling on one called 1001 Cookie Recipes (disclosure: we have discovered more than one duplicated recipe going by different titles, so we have agreed that we were cheated) and finally selecting a recipe. Unfortunately we didn't have vegetable shortening, so he asked what he could use instead. The answer was butter, but the only butter we had was frozen. He took out a couple of sticks and put them on this nifty metal quick-thawing thingie we have, but it still wasn't quite the right temperature when he started to cream the butter. He managed, though. (That was always the hardest part for me too: softening up the butter when deciding to bake at the last minute and all we had was frozen. It's hard to get the balance just right between softening and melting when using the microwave, and patience was never one of my virtues, at least when baking.)

He checked with me from time to time about the texture, which was as good as possible when starting with butter that was a little too hard, but the end result was fabulous. The recipe he had chosen was essentially a Toll House dough but with only brown sugar instead of mixed white brown, and he had substituted chocolate chips for walnuts (which we had, but he liked the chocolate chips better.) He underbaked them slightly, just the way I (and he, obviously) like them: gooey, molasses-y flavored dough with bits of hot melting chocolate just waiting to drip down onto your shirt. He brought me one, along with a glass of milk, as I sat working on my NaNoWriMo novel. Heaven!

Yesterday afternoon he announced that he was making more, to bring in to his German and English classes' pre-Thanksgiving parties. We took the butter out of the freezer right away, so that by the time he was ready to start, it was too. He commented how much easier it was to cream the butter and sugar together, and I just smiled to myself. This time he used both chocolate chips and M&Ms.

This morning I came downstairs to several dozen cookies, beautifully arrayed on cooling racks and carefully protected from marauding felines (paper towels work just fine to keep the cats away.) It wasn't at all fair to me (or my diet) but I smiled and thought of my mother.

Grand Rounds

It's Tuesday, and that means it's time for Grand Rounds, now up at Dr. Anonymous.

Joining the Crowd

Everyone else has been talking about their lawsuits lately, mostly with angst and dismay (which is totally appropriate.) Fingers and Tubes, who has been giving us a rundown on his previous suits, expresses glee over his attorney's brutal (and totally deserved) treatment of the plaintiff in his #5 suit. It reminded me of my favorite moment in my own malpractice trial:

I was sued in 1997 for a failure to diagnose a base of tongue cancer in a 52-year-old non-smoker/non-drinker who presented with a small lymph node in her neck. Suffice it to say I did not breach the standard of care (lawyer-speak for I didn't do anything wrong) and the patient did not actually suffer any injury. (The treatment she received was exactly the same as it would have been if I had referred her five months earlier, when I had first seen her.)

The case dragged out for seven years, finally going to trial in 2004. The delay didn't bother me, because the longer it went on, the longer she was free of disease and the less impressive her claims were to a jury. The trial wasn't nearly as nerve-wracking as you might think, given how bogus her claims were. Having "right" on your side really does count for more than you'd think when push comes to shove in front of a jury.

I actually wrote about it at the time, mainly as a way to share it more efficiently with my family, so if anyone's interested in a more complete blow-by-blow, email me and we'll see what we can do. But just to share the fun part that F&T reminded me about:

The patient was a terrible witness, but her husband was worse. (Part of the suit was his suing for "Loss of Consortium", which means that because of her illness -- as caused by my alleged negligence -- he was unable to enjoy the "benefits" of being her husband.) In his deposition he had said that yes, they still were able to do the crafts and other things they had done together before the cancer diagnosis and treatment. But on the witness stand, in front of the jury, he said that no, they couldn't do those things anymore. On cross examination, my lawyer took a copy of his deposition up to him on he witness stand and made him read what he had said before (which was the opposite of what he'd just said.) "So which is it, Sir," asked my lawyer. It was great.

Then there was the economics expert, the plaintiff's witness who was supposed to explain to the jury why this high school drop-out deserved nearly a million dollars in lost wages and such because of my negligence. He was the most entertaining part of the trial. At one point, my lawyer wanted him to say that the patient had never had a doctor's note saying that she couldn't work (which she hadn't) but he prefaced his question by asking rhetorically, "You know when you were absent from school, and you needed a doctor's note to go back?" The economist clearly wasn't sure what he was getting at, and, as a professional witness, knew that he should never admit anything when he wasn't sure what a lawyer was getting at. The whole courtroom waited in silence as he tried to figure out how not to answer the question. His eventual answer cracked everyone up -- judge, jury, lawyers and me -- when he said pompously, "I was never absent."

Who ever said it couldn't be funny?

Best Line Ever

I love this statement by David E. Williams of Health Business Blog:

For all its disadvantages, sudden death is cheap to treat.

Here is the full post for context, but I still love that statement.

Ancillary My Ass

Ancillary: (adj) serving as a supplement or addition.

Much has been written about adding "Ancillary Services" to outpatient office practice. Bone density testing, radiology, counseling, cosmetic services...you name it; someone has looked into what it takes to add it to a practice. Follow the money, they say. The problem is that there are perilously few controls preventing utilization that is not only excessive but downright inappropriate.

I recently encountered this situation, which really pissed me off:

Patient who works as an MRI tech comes back with a positive PPD. (I saw and measured it; it was a true positive.) The chest x-ray is perfectly normal. She needs six to nine months of isoniazid prophylaxis. Piece of cake.

But because this comes under the heading of "Workmen's Compensation" she has to go through Occupational Health at one of the hospitals she works at (where I'm not on staff, not that it makes much difference.) Occupational Health is privately contracted to one of the FP offices (cool) but the hospital's policy is that their pulmonologist needs to be involved in treatment of positive PPDs.

So my patient goes off to see him as required, and I get a nice cc of the pulmonologist's letter to the Occupational Health FP -- which includes pulmonary function tests on my patient.

Why? She has no history of pulmonary problems or complaints. She's never smoked. She has a normal chest x-ray. There is no clinical justification for PFTs on this patient.

But apparently this guy does them on everyone. That's just the way he does things, tells me the Occupational Health FP. ("I can't tell him what to do in his own office," the guy tells me.)

Well someone should, dammit!

GYNs do useless heel DEXA scans to screen for osteoporosis; Cardiologists do echocardiogramss for every murmur; and everyone who possibly can offers cosmetic services like Botox injections and laser hair removal. For those of us trying to run evidence-based solid primary care practices, this is intensely frustrating.

To paraphrase the Abraham Maslow quote on DB's sidebar: let someone loose with a hammer and everyone is going to get nailed!

(Update: More here.)

Multiple Personalities

It wasn't the first time I've seen the concept, but about a month ago GruntDoc pointed out that he has a "work persona." He acts differently at work -- and among different people at work -- than he does at home or with his family and friends. Here's how his wife describes it:

Wife: "When I saw you first, you were on the telephone; I listened, and you were pissed. Then, when we talked you were your normal self, and then when you turned around you were pissed again."
Me: ?really?
Wife: "Yes, it was remarkable."

Then in response to this post of mine (about counseling an uncertain pregnant woman) Flea included this in the comments:

...It's an approach that I hope to take with me in my professional life (and perhaps other lives as well). But I hadn't thought of applying it to patient encounters.

These two comments make me realize anew something I have always thought of as one of my strengths as a physician (and as a person, for that matter): I am always the same.

Of course I speak and act differently in different kinds of situations and with different kinds of people. But the basic way I communicate with people is the same, whether I'm in an exam room with a new patient, a hospital room with a dying patient, or on the sidelines of the soccer field with the other parents. I have only one persona -- a flexible, almost chamelionoid one, granted -- with which I present to the world. I believe patients sense this, and it is the reason I have been told that I am "genuine."

I am not saying that GruntDoc and Flea are artificial, nor that their patients don't appreciate how they communicate. Not at all! Just that I believe I have integrated my various roles in life well enough so that different parts of my persona enhance, rather than subjugate. It also implies that I'm not afraid to share parts of myself and my experiences -- when appropriate, of course -- without fear of being thought "unprofessional." And that's the really interesting thing: somehow the idea of being "professional" and "genuine" have become separated.

An image that I used long before ever meeting Miliner's Dream was this: I don't wear many hats. I just wear one very large, elaborate one; one where all the pieces combine and enhance. (Cue the Las Vegas Showgirls hats.)

The 12 Steps of Coffee

Ok, so it's really only eight steps, but who can count before having had their coffee?

For the last few years I have had a cute little single serving automatic drip coffee maker. It actually has a really cool spout design that lets you drip your coffee into either one or two cups, but we usually just make one at a time.

There are several steps that must be accomplished in order to generate a cup of coffee:

1. Open the lid.
2. Insert a #2 cone paper filter.
3. Put in a scoop of coffee.
4. Pour water into the heating chamber.
5. Close the lid.
6. Set the mug under the spout.
7. Put a paper towel under the mug (optional, but useful to catch drips.)
8. Push the button to turn it on.

I must confess that over the years, at one time or another, I have forgotten almost all of these steps. Of course the consequences of each step missed vary in terms of frustration, time consumed and mess generated. Rarely has more than any one step been forgotten at a time, but at one time or another, just about each step has in fact been forgotten.

Except #1. You can't really do anything until that has been accomplished.

And #2. I've never forgotten to put a filter in. The filter has occasionally had holes in it, leading to a nasty mess of grounds that render the coffee undrinkable, so I've learned to be careful with the delicate paper.

I have forgotten to put in the coffee. The water percolates through; I hear the nice steaming noise, but eventually wonder why there's no welcoming coffee aroma. When I go back to get the coffee, there's nothing but a cup of steaming hot water. This is the easiest to fix. Pour the same water back; use the same filter; just add the damn coffee. Nothing lost but a few minutes.

Offhand I can't recall when I've forgotten to add water, but I do believe I would become quickly alarmed by the strange noises that would ensue. (I hope.)

I have forgotten to close the lid more often than you'd think. What happens is that the hot water spills back down into the heating chamber instead of onto to the coffee and then down into the mug. The noise it makes is louder than it should be, which is how I am alerted to this sitution. No loss at all: just close the damn lid.

*I* have never forgotten to put a mug underneath. I just haven't. I would never forget to do that. I just wouldn't.

Because the paper towel is optional, I forget it on a regular basis; then I just say "dammit" and get a paper towel later to clean up the drips.

Pushing the "on" button is a tossup, in that I've screwed it up both ways. I've forgotten to push it and then wondered why it was taking forever for the coffee to be ready. But on other occasions I have purposely decided to get everything set up, but not push the button until I get back in from walking the dog -- and then pushed it anyway.

Because at one time or another I have forgotten just about every step in making coffee, I am very slow to condemn others for their failures. Then again...

Last weekend, my dear spouse calls up from downstairs, "I pulled an 'oops'."

Pulling an "oops" is not good.

"What did you do?" I asked. (Or not do? I thought.)

"I forgot to put the cup underneath."

Now that's what I call an "oops."

"I cleaned it all up."

This is good.

"Really? All of it?" (Coffee tends to pool behind the machine and hide behind the knife block.)

"All of it."

"All cleaned up?"

"All cleaned up."

"Thanks."

(Later on I wiped up behind the knife block.)

Grand Rounds is Up (Ni!)

Go moose hunting over at The Rumors Were True, for a lovely collection of something completely different.

Is This Good?

Disclaimer: I find the whole sitemeter/hit count thing to be the blogger's version of navel-gazing, so I try not to get all bent out of shape over it one way or another. With that in mind, I apologize for this post.

I started this blog on August 25th of this year. I can't remember exactly when I added the sitemeter to it, but it wasn't right away; perhaps early in September, or about 2 1/2 months ago.

As of today I'm at 5000 hits.

Is that good?

The Insult

I have a very thick skin. I rarely take offense at things patients occasionally say to me, because most of the time I understand that they don't mean to insult me. But the other day I heard something that left me speechless (truly an unusual event) with indignation.

A man in his late 20's presented as a new patient for treatment of his asthma. As is my usual practice, I took a full medical history. The patient, who did most of the talking, was very self-assured as he related his history. For example, he didn't want Ventolin because he was afraid it would give him heart palpitations, but was insisting on Advair for treatment of his acute bronchospasm. (Quick explanation: Advair is a long-acting bronchodilator/inhaled steroid combo, NOT appropriate for use as a rescue med for asthma.)

In the Past History portion, he related a history of back problems and a course of treatment for "chronic Lyme disease" (a condition that does not exist, according to all reputable Infectious Disease experts.)

At this point, I should relate that I am quite tolerant of these kinds of announcements. My feeling is that immediately and spontaneously holding forth on the ridiculousness of useless medical therapies is not particularly conducive to good rapport-building with a new patient. When asked, of course I share my opinions; but when patients are merely relating what they've already been through, I just listen.

He went on to tell me that he was still in treatment with a specialist: an LLMD. Did I know what that was? he asked.

Unlike many other physicians, I have never been afraid to say, "I don't know." I look at it this way: who do you find more impressive: the person who tries to fake it when they don't know something, or the one who comes straight out and admits it? For what it's worth, many patients have been very impressed with me for being able to say, "I don't know."

I had never heard of an LLMD, and I told him so without hesitation. It was his answer that floored me:

"Lyme Literate MD."

So now my refusal to believe the woo of Lyme rendered me "illiterate!" I was too startled to say anything other than, "Oh."

I talked him into a Xopenex prescription for his asthma (he flatly refused any form of albuterol) and somehow managed to contain my fury until after he left.

I hope he doesn't come back.

I Done Good

I did a good thing yesterday.

It was one of those busy, crazy days when you think you're never going to get caught up; where there are always two people waiting to be seen (I run my office like a Russian railroad; it kills me to keep people waiting) and the pile of charts on my desk for callbacks just keeps growing (because I don't have time to go back and whittle away at it as I go.)

A lady had left a message on the machine: she thought she had a UTI, and she had just found out she was pregnant (and so was worried about what she could take.) My standard answer to a message about a UTI is that it needs an office visit. I like to have a urine culture cooking even after starting empiric therapy. I've picked up some weird bugs and some STDs, and sometimes it isn't really a UTI at all. So I try very hard not to treat these by phone. It's a quickie visit: pee, dip, pound on your back so I can document no CVA tenderness, prescription and off you go.

So this one wasn't supposed to take much time.

We went into an exam room and -- as I always do -- I took a history. My opening question to someone whose chief complaint is "I have a urinary tract infection" is "Tell me what's going on without using the words 'urinary tract infection'." Her complaints were mainly urgency and some frequency. It didn't really sound like much in the way of dysuria.

Then I added, "And I understand you're pregnant."

A strange expression came over her face as she told me about the two pregnancy tests she'd taken over the weekend. Her last period was October 1st. She took a second test because she couldn't believe the first one. She didn't look happy. I asked if it was a planned pregnancy.

It wasn't. Not exactly. Not *right* now. They had been planning to start trying in another couple of months. Her husband was thrilled; she was "still getting used to it." She still didn't look happy. She said she was in shock. She wasn't sure she was ready for it. But she also felt terribly guilty for not being completely happy. She couldn't think about anything else, but didn't want to talk about it at work. She was having a tough time, but, as she said, she was definitely "getting there."

I thought about it as I listened to her. I thought about the fact that things happen for a reason. I shared Flea's story about the "good" fortune of his colleague's wife's misdiagnosis in infancy. And then I added this:

"I don't know how or when or if you'll ever find out why this happened, but I really believe this is a soul that just couldn't wait another couple of months to come and be with you." We both teared up, so we helped ourselves to tissues.

"Does it help to think about it like that?" I asked.

"Yes it does," she replied.

I told her I wasn't at all certain she really had a UTI, as urinary frequency is a common symptom in early pregnancy and the urine dipstick was completely negative for white cells, nitrites and red cells. I sent the culture and told her I thought it would be best to hold off on antibiotics for the time being; she was ok with that. I offered her a hug, which she accepted.

Even though I was still running way behind, I felt good.

Blessed

I am truly blessed, even though I often forget it.

The universe likes me. Not just in big ways (I am healthy, as is my family; I have enough money to meet my needs, even if I worry about it; and so on) but also in small ways: when I run late with a patient who needs extra time, the next patient or two will come late or no-show. By and large, the universe gives me what I need exactly when I need it.

I'm not sure why, but that serenity has been somewhat more elusive of late.

Then last week -- right about the time I posted that whiny rant about how boring my life seemed -- I got a letter. A dear friend of mine, a local oncologist, sent me a note:

"I received the enclosed article published in JAMA in 1988 from the best friend of a patient recently deceased. I found it remarkable and intuitive and thus I thought I would share it with you."

Wouldn't you know that in addition to being remarkable and intuitive, it was just what I needed to see. It was titled The Rain:

"Please go away. Some other time."

I am a liaison psychiatrist. I'm accustomed to being turned away by patients. This one is an elderly woman who had a large pelvic sarcoma removed several weeks ago and lost a leg in the process. Things have gone badly with her since then. A wound that won't heal. Fevers. Intractable diarrhea. Your classic surgical patient gone sour. She won't eat. She won't look where the missing leg was. I've been by to see her several times and each time she has refused to see me.

"Please. Some other time." She smiles politely. I stand in the doorway. I never know quite why I persist when I do. Maybe it's because I like her. I like her smile, even though it's there to keep me away. It's diplomatic but not phony. She strikes me as warm and wise and considerate.

"The nurses are worried about you," I say.

"Oh, they try so hard. They try to get me to sit up, but I can't." The smile is gone.

"Sounds pretty bad."

"Oh, Doctor, you have no idea."

I make my way slowly around the bed.

"No, please. I can't talk." There is a moment of hesitation. "Look how they butchered me. I didn't want this operation. My daughter talked me into it. Now look at me. She tells me to fight harder. Fight harder? Doctor, you tell me. How can I fight any harder?" She turns away and begins to cry.

I am beside her now, standing at the bedside of this crying woman, as with her back to me she sobs into her pillow. "Those butchers...my daughter...how can I fight any harder?" She turns back to me and clutches my hand, transformed. "Doctor, could you just give me a pill? To make me go to sleep forever?"

My experience as such a moment is that of standing in a drenching rain. I can't use my education and I can't think of anything constructive. I just get wet. Depression? Adjustment reaction? I can't remember the criteria. Now I am falling with the rain, tumbling in the air. Medication? Transfer to psychiatry? I can never think clearly when it's raining.

"How bad is the pain?" I ask. Pain. Yes, good. A symptom. Someplace dry to stand. Pain I know something about. Butchers? Daughters? What can I do about them? With pain, I know what to do. The downpour in my mind lets up a bit. I ask her if she would like to learn to handle the pain better, and she nods. I instruct her to relax, which she does with surprising ease. I knew I liked her.

"Now," I say, "I want you to imagine yourself off somewhere peaceful and quiet. When you get there, tell me where you are."

"I'm in Cape Cod. We have a house there."

"OK, when the pain comes I want you to relax just we did now and go off there. Give yourself a vacation." This last phrase just comes to me, innocently. I like its sound. It feels good.

But when she opens her eyes, there is a faint cloud of suspicion and of hurt, which I don't immediately understand.

I promise her I'll come back later. All through the day, I'm turning it over in my mind. Butcher...daughter...vacation. Her hurt look. Then, gradually, the pieces fall together.

No one can stand this woman's pain. Or at least that's the way she sees it. The surgeon, the daughter, they can't stand it. So they try to take it away. But they fail. They can't take it away and they can't stand it. That's why she wants to die. Because no one can stand her pain.

Including me. I wanted her to take a vacation from the pain. But she was very perceptive and knew better. She knew that it was I who wanted a vacation -- from her, because I couldn't stand it either.

I go back in. She's expecting me. I begin right away.

"You know, I've been thinking about you. You've got cancer. You're sick. You've lost your leg. I can't even imagine what that feels like. Whenever I get even a hint of it I feel as if I'm tumbling over and over like a raindrop in the rain. And you know what? I don't have the slightest notion what to do for you."

Her eyes clear.

"Except perhaps to sit here until one of us thinks of something."

The tears stop. A truck skids on the wet street outside.

"Thank you," she says.

Weeks later, after her death, I wonder about the value of what I did, or didn't do, on the day I first saw her. I tell myself that in fact I was able to give her some relief, if not from the pain then at least from some of the isolation that went with it. And some of the responsibility.

How wonderful it would be, though, to restore what has been lost. How difficult it is to stand in the rain.

Stephen Snyder MD
New York
JAMA, July 8, 1988 -- Vol 260, No 2; p. 249

Try relaxing a bit; look around. Maybe the universe is trying to give you exactly what you need exactly when you need it. Accept the gifts that come to you.


NaNoWriMo Update: So much for not blogging as much while I write. I guess I just can't stay away.
Word Count to date: 12,032
Excerpt: First paragraph after opening (found at the bottom of this post)

"The electronic chirping that served as a telephone ringer went off next to Roger's head, inserting itself into the dream he was trying to have about sitting on a long sandy white beach, completely deserted; the only sound the droning crash of the waves on the deserted white sand. Suddenly -- in the dream, that is -- a flock of psychotic seagulls decided to alight on Roger's blanket, folding beach chair and head (in no particular order) squawking and chirping like a horde of malevolent teens squabbling over the last slice of pepperoni and anchovy pizza. Wanting to shout, "Shut up! I can't hear myself think!" even though the only thing he was thinking about in the dream was how wonderful the silence was, Roger instead reluctantly awoke to the electronic chirping noise that served as a telephone ringer."

Blogging 101

The International Council of Dinosaurs, District Nine (ICD-9) has appointed me their official blogging expert. Actually, because I've been reading blogs far longer than I've been writing one, my opinions about what makes a good blog have been honed over several years instead of just my few months of actual blogging.

I have distilled all my saurian knowledge into these three basic rules:

1. Write well.
2. Say something.
3. Mix it up.

What do they mean?

Rule #1 ought to be self-explanatory. The whole idea of a blog is communication. Don't believe all that nonsense about the internet as a new form of communication where the old rules don't matter anymore. Like it or not, blogging is writing. The basics are still important. Spelling, grammar and punctuation count, not because the Grammar Nazis will come rap your knuckles (things have gotten so bad they can't be bothered anymore; they just laugh at you behind your back) but because their absence is distracting. Engaging the reader is good; distractions are bad.

It helps to be eloquent, like Dr. Charles or Sid Schwab, but that's not what I mean by "write well." Complete sentences, correctly placed modifiers, not using commas like a stupid person (that's an actual comma rule; go read this book if you don't believe me) and noun-verb agreement go a long way toward making a blog readable. That does not mean there is a set of ironclad rules that can never be broken. Just as with other kinds of writing, you can break all the rules you want if there's a good reason for doing so. (The only good reason is if it makes the writing better.) And in general, it's hard to effectively break rules when you don't know them in the first place. So, just as with other forms of writing: read. Widely. Books. Blogs. Lots of blogs. Get a sense of what works and what doesn't.

Proofread your posts; more than once, if possible. Check and double check that you've said just what you want to say, and that the writing is the best you can make it. Make sure all your links work. Then really "proof"-read it. This is not really reading at all. Go over your post "looking" at each word to make sure it's spelled correctly; make sure there aren't any tpyos [yes, that's intentional]; that commas are all commas and periods are all periods; that there aren't any extra spaces; that all sentences begin with a capital letter. Make sure there's an extra line between paragraphs (but only one.) All the nuts and bolts stuff. Try not to hit "publish" until it's perfect.

The bottom line is that if sloppy writing makes your blog difficult or annoying to read, it won't be read.

Rule #2 is what separates an interesting, general purpose blog from a diary. If you don't have something to say, don't bother blogging. Even if you have a wildly popular blog visited multiple times a day by people who hang on your every word, nothing will discourage them from checking in quicker than too many "Nothing much happening today, but it's raining" entries. You may have 45 comments along the lines of, "Yeah; it's raining here too," "Bright sunshine here," "We're supposed to get eight inches of snow later so I have to go buy bread and milk," but unless you're the Weather Channel blog, who really cares?

Not every post has to be chock-full of weighty observations about life, the universe and everything, but I think it's important to at least say something each time you blog. It can be lighthearted, serious, profound, whimsical, funny (funny is always good) or whatever. But try not to post just for the sake of posting. Posts like "I took some great pictures that I'll be posting later" cheat your readers. Wait until you're ready to post the damn pictures. There's no rule that says you have to blog every single day. That's what's so cool about blogging: there are no rules at all (except mine, of course.)

Rule #3 is the most flexible, in that there are many blogs with perfectly good reasons to ignore it. Still, my favorites are the blogs that mix it up among different topics, tones and formats. It's the precise proportions of that mix which make each blog unique.

Even if your blog is primarily about, say, medicine, you can still toss in posts about sports, animals, family, politics, jokes, and so on. Within a given area (like medicine): flip around between funny patient anecdotes, ranting at the sorry state of the health care system, emotionally moving encounters, helpful hints, etc.

Mix up up your formats: long essays; one-liners; quoting someone else's blog and commenting on it; linking to a new blog you've found.

The bloggers I enjoy most also make it a point to vary their tone: serious; whimsical; whiny; funny; strident; indignant. You get the gist. The trick to keeping it interesting is not pissing people off too often, and not boring them on a regular basis.

Not everyone "mixes it up."

Kevin basically does link-and-paste, sometimes with an excerpt, and occasionally with a sentence or two expressing his agreement or disagreement. If you look back at his blog, you'll see he doesn't do much extensive writing of his own. That's fine. Kevin's got what I call a "nexus" blog: you read it more to see what he's found than necessarily for what he himself has to say, but wow: watch your hit count spike when he mentions you. Dr. Charles, Dr. Sid and Tundra PA tend more toward wonderful essays, usually long enough for them to suck you right into their fascinating worlds.

There are also bloggers whose sole purpose is to vent, and there's nothing wrong with that. They find their own community of readers to offer support and solace. The great thing about the internet is that there's room for everyone.

But in the final analysis, if someone were to ask, "How do you write a blog?" this dinosaur would answer:

1. Write well.
2. Say something.
3. Mix it up.

NaNoWriMo Status: Still technically behind, but with over 3000 words written today alone, still confident of catching up.
Word count to date: 5467
Favorite sentence: "The deserted lobby was empty."

Well Said!

Remember all the discussions we were having about new doctors and new patients and the doctor-patient relationship and trust and all that? Well I just found this blog (where I'm even blogrolled; what a nice surprise) with a post that says it all, more succinctly and eloquently than I could ever manage:

What exactly does contribute to trust in a physician/patient relationship?

• The subjective feeling that the doctor actually cares about the patient as a person as well as a constellation of diagnoses. To the doctor, you aren’t just a number or just another patient.

• Communication: knowing that the doctor is willing to answer questions as they come up. Knowing the physician will call you back when you have a question or a problem.

• The trusted doctor encourages patients to educate themselves on health issues and is not afraid to address an article or an internet reference.

• Knowing when it is time to call in a consultation or refer to a specialist. The doctor you can trust knows when they don’t know.

So the onus is all on the physician?

Not at all.

• The patient keeps appointments as scheduled or gives adequate notice if unable to do so. Doctors are busy and they run tight schedules. The appointment you don’t keep is an appointment someone else could have used.

• The patient exercises patience if the doctor is running late with their appointments, knowing that medicine is anything but orderly and urgent matters arise. The patient understands that the doctor does believe the patient’s time is valuable and tries to adhere as closely to schedule as possible.

• The patient is compliant with the medications and plan of care developed with the doctor. If they cannot be comply, they are honest with the physician in describing the issue(s) that interfere with compliance.

• If the patient disagrees with the way a doctor deals with a medical problem, the patient is honest about their feelings and discusses the issue with the doctor. The first inkling that there is a problem should not be the request for their records to be transferred to a new office.

If these factors are present, trust in the physician/patient relationship can flourish.

What more can we doctors and patients ask of each other? Well said!

NaNoWriMo update:
Way behind because of office craziness, but optimistic about catching up over the weekend.
Word count to date: 1912
Snippet: (opening)
"It was a dark and stormy night.
Actually, it was an unseasonably balmy fifty-seven degrees in the early morning Philadelphia late fall, but that's not really important."