Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, October 29, 2007

Wait a Minute

Commercial for
We're so sure you'll meet someone special within 6 months that if you don't, we'll give you 6 months free.
Let me see if I've got this: If it doesn't work in six months, you should try it for another six months. WTF?

Sounds suspiciously like the patient who demanded antibiotics, then called when she didn't feel better:
That medicine didn't do anything. You have to give me more of it.

Wasn't it Albert Einstein who defined psychosis as doing the same thing over and over and expecting different results?

Sunday, October 28, 2007

It's That Time of Year Again

Well I went ahead once more and signed up:

Come November (next week!!!) I've committed myself to tapping out 1667 words of a novel each and every day for 30 days. Yikes!

It's been a while since I've done a serious chunk of writing and the ideas are flying around in my brain. Using NaNoWriMo as the impetus (cough*excuse*cough) to generate an actual draft of something might be fun.

Then again, in the two years I've done NaNo I've discovered that, for me, the difference between actually constructing something that works vs. nothing more than a series of gags is an outline. Not just a general sense of what I want to do, but something with enough detail so I actually know where it starts and where it ends. I've found that if I have those two things I can dance around all day getting from one to the other.

So here's the plan: My current WIP, 40,000 words strong, is on the back burner, per NaNo rules. If I get around to outlining one of my three main ideas THIS WEEKEND, that's the novel I'll do. If not, I'll do a series of essays on the ridiculousness of life, call them chapters, title it "WTF", self-pub it and sell it to my patients, many of whom bought my first two books and have been asking when my next will be available.

(Here are the three ideas, btw. Feel free to offer feedback, though if my muse doesn't listen to me I have no idea why she'd listen to you:)
  1. "The Phlebotomist": FP whose life falls apart and decides to chuck it all. She throws some clothes and stuff in her car and leaves her life behind, starting over in a small town where she gets a job drawing blood, living simply, hand to mouth. Since she's still a doc even though she doesn't admit it, she's very good and gets offered a job at a local FP group practice, where she falls for the widowed senior partner. They end up together in an O. Henry ending. (Theme: triumphing over materialism.)
  2. "Gunner" (hate the title; needs a better one): Two medical students, one a clean-cut, hunky blond Ivy Leaguer; the other a biker dude in all his full tattoo'd, bearded, stringy-haired glory. One brilliant, understanding, using his strength to protect and nurture; the other the ultimate horse's ass; bright enough only to steal from others and blame his own failings on them. Guess which is which. Told in first person from the POV of others they deal with as they go through med school. (Theme: not judging a book by its cover.)
  3. (no title) Allegory of 9/11 and the Iraq war, an alternate/future history casting the US in the role of Iraq as an intolerant nation (taken over with "Christian Nation" rhetoric) governed by a psychotic demagogue, and the Chinese in the role of the US as the sole global superpower dependent on the US for its food (vs. oil.) Russian terrorists attack China 9/11-style; China blames the US, invades in a pre-emptive war, finds and executes the psychotic demagogue, but ends up inciting civil war. (Only problem with this one is that I can't figure out an ending.)
Wish me luck.

Saturday, October 27, 2007

10 - 20 - 30

What the hell.

I've been tagged with another meme and although I generally don't like doing them on principle, it's been pretty slow at the blogging idea trough of late. Besides, this one seems pretty tame: What were you doing 10, 20 and 30 years ago:

1997: Stuck in that horrible limbo between separation and finalization of the divorce. It hadn't been my idea and I had fought it tooth and nail, but the papers were filed and I was just waiting it out. The kids were in elementary school, doing well but obviously feeling the strain of moving back and forth weekly between two houses, even though they were only four blocks apart. I drove a light blue Plymouth Grand Voyager minivan. I wrote in a journal every night before I went to bed.

1987: The twins were born in February, during my second year of FP residency. We had them together in the smallest of our four bedrooms, with the plan of moving each of them into their own rooms at the far end of the hall as toddlers (which we did. The Nestling was born in 1989, so that bedroom became his.) My mother's first Jahrzeit was in June. I was still driving the white Toyota Tercel I'd bought at the end of medical school.

1977: I graduated from high school and went off to college. Loved it. I didn't have a car yet, but was only a few months away from getting my green VW Rabbit.

As is my custom, I'll refrain from tagging anyone. If anyone else wants to play, though, consider yourself tagged.

Wednesday, October 24, 2007

Another Example of the Melting Pot

I just picked up the October 1 issue of American Family Physician and couldn't help but notice the collection of authors (all MDs) in the Table of Contents:
  • Joong Mo Ahn
  • Georges Y. El-Khoury
  • Christian L. Hermansen
  • Nandini Khatkhate
  • Kevin N. Lorah
  • Kalyanakrishnan Ramakrishnan
  • Robert C. Salinas
  • Jeffrey D. Teimstra
No way you could possible match them up with the articles either (two authors apiece):
  • Bell's Palsy: Diagnosis and Management
  • Peptic Ulcer Disease
  • Radiologic Evaluation of Chronic Foot Pain
  • Respiratory Distress in the Newborn
Assuming all are American, I think that's a pretty cool collection of names, and speaks well to the diversity of Family Practice.

Tuesday, October 23, 2007

Another "Oh Yeah" Moment

There's a nearby school district having parent-teacher conferences today and tomorrow, meaning the students are off. This means I saw six kids for physicals today with more scheduled for tomorrow.

Scenario: Perfectly healthy 14 year-old boy, tired because he was awake all night at a friend's house ("sleepover" is such a misnomer) has a blood pressure of 120/100 (120/90 on repeat) with both a regular and large adult BP cuff.


How much soda (caffeine) do you drink?
  • Very little.
Any tobacco, alcohol, drugs?
  • No.
What did you have to eat last night?
  • Cheese, peanut butter crackers, cheerios.
Any caffeinated soda?
  • No.
Mountain Dew?
  • No.
Do you have a cold? Any cold medicines?
  • No.
Normal weight/BMI. Nothing to explain his BP. Yes, there's a family history of hypertension, so I call in the mom and we start talking about re-checking it in a month or so.

Suddenly the kid says,
Oh yeah! I had an energy drink.
Cool. At least he remembered it while he was still in the office. Most of the time it's a call back several days later. We'll still re-check the BP, but at least mine went back down.

Saturday, October 20, 2007

ER Follow-Up

Chief Complaint: "ER follow-up"

No, it's not an oxymoron.

Virtually all ER visits include as a prominent discharge instruction:
Much of the time it's a good idea; often I have no idea you were there or what happened to you, and I appreciate the opportunity to get up to speed. If it was an acute illness for which treatment was begun (say, pneumonia) a re-check is often appropriate to make sure you're getting better. If it's something more minor, like a bladder or ear infection, then it can be a waste of time (though sometimes a chance for me to discuss the role of antibiotics in ear infections, even though they're universally prescribed by ER docs.) Obviously if you've got stitches or some other wound, it makes sense for me to check it out, remove the sutures when it's time, and so forth.

But what about the role of the ER in following up with what was done there?

Despite the impression given -- especially by trainees -- of Emergency Medicine as shift work, there's always follow-up. Just because one doctor goes off-duty, there are virtually always aspects of the patient encounter that remain to be followed up later. And make no mistake: ER follow-up is as vital to good medical care as it is to risk management (AKA not getting sued, or, more cynically, making sure the inevitable lawsuits are as defensible as possible.)

Any time you do a test that doesn't provide a final result prior to the patient's discharge, someone has to be responsible for following up. Making sure the results are back, taking note of what they are, and contacting someone -- patient, primary or other consultant -- is part and parcel of ER care.

Oh no, I hear you cry. We never discharge patients until we have all their results. Really? You mean you never send a urine, blood or CSF culture (not just rapid antigen tests) from the ER? You can't make bacteria grow any faster, you know. You really keep people in the ER for 48-72 hours, just waiting for cultures? You've never sent out a serologic test for Lyme or anything else? Or does every single one of you work in an enormous medical center where every possible test is run on site 24/7? Do you not have radiologists reading your films on a backup basis, and have they never found something you missed? It's appropriate -- and often vital -- to send these tests from the ER, but it's just as important to make sure the results come back, are noted and disseminated to the appropriate parties.

There are many ways to accomplish this, but ideally it needs to be systematic. Keeping track of (and tracking down) results can be delegated to clerical staff, but review of results should probably be done by physicians or nurses. During an ER rotation I did at CHOP during my residency, the job was assigned to one of the senior residents each day. (That's why they were always yelling at us to get phone numbers from parents, that often didn't work anyway. Things may be a little better now in the cell phone era, but I'll bet not by much.) In one small-ish community hospital I know, the chief of the department comes in on a day (not middle of the night) he's not working a shift and goes through them. (That's the guy who called -- during office hours -- about a concern with a patient seen earlier.)

There are good ways and not-so-good ways to handle this issue. At my current hospital, the policy is only to call patients back with sent-out test results if they're positive. I think this is a terrible idea. My patient was frantically calling me for her Lyme result. That's the only way I found out about their policy and believe me, I'm going to be calling someone about it.

So to all you ER residents out there, although you may not be involved with it or see it happening, and even though it's not nearly as sexy or exciting as actually moving the meat, following up on cultures and send-outs and unexpected radiology findings is part of the job. Being in training gives you the luxury of imagining that once you dispo the patient your responsibility is over. It's as naive as an FP or IM resident saying, "I just want to practice medicine, and not be bothered with the business aspects of practice." Don't kid yourself.

Friday, October 19, 2007

When Did This Happen?

When I was a college sophomore I took Organic Chemistry, then as now a rite of passage for pre-meds and other science majors. I don't remember it being much more difficult than inorganic, or first-year chemistry, but for some reason it was considered the course that, more than any other, separated the pre-med wheat from the chaff that didn't have what it took.

Over the last thirty years I don't believe introductory college chemistry has changed all that much, but of late I have become aware of a definite change in terminology (or, keeping in mind the subject, of nomenclature.) Back in my day (pause for deep sigh of "OMG I'm old") first and second year chemistry courses were known, respectively, as Inorganic Chemistry and Organic Chemistry. For short, we called them simply "Chemistry" and "Organic."

Nowadays, though, the courses are the same but the names are different. First year is now called General Chemistry (often short for something like "Principles of General Chemistry" or such) and referred to in certain circles as "Gen Chem." Short. Cute. Almost rhymes. No problem.

But instead of good old "Organic," they now have: Orgo.

Orgo. Sounds like a Star Trek villain, doesn't it? ("Captain Kirk! Orgo is threatening to blow up the ship!")

Here's my question: When did this happen? I've heard twenty-something med students use the term, so I know it's not just the Nestling. (Brag alert: The Nestling, who wants to complete his BS/MS in Biochemistry in his four years at college, placed out of the first year of chemistry with his AP of 5, so he's taking Orgo as a freshman (and doing well, I hear. WTG!) /brag)

I'd love to find out just when this semantic shift occurred. I figure by using the comments and comparing age to preferred term for "second year, carbon-based, pre-med humbling college chemistry" we can pin this down. Any takers?

Friday, October 12, 2007

How to Really Piss Me Off

Do all of the following:
  • Be an ER doc.
  • See a patient of mine seven times in the last two months for "migraines" that continue allegedly unabated despite prescriptions for multiple triptans, compazine, Topamax and Verapamil, among other meds, and who has specifically been told to call me instead of going to the ER.
  • Give him IM dilaudid and a script for Percocet, despite the fact that I've been ratcheting them down -- even though he swears they're the only things that help his chronic back pain -- because he keeps losing them and his alcoholic wife often "borrows" some, and that he can't afford NSAIDs or physical therapy.
  • Assume I'm an idiot who doesn't know any better while noting that he hasn't had an MRI of his brain, or a pain management or headache clinic referral.
  • Under no circumstances deign to notice that he has no insurance. Ignore the fact that his employer offers it but he has decided that it would take too much out of his paycheck.
  • Call me up to discuss the case.
  • At 4:30 am.
Please note that this is only one of several ways to accomplish your aim. It's just the most recent.

Thursday, October 11, 2007

Major Beverage Alert

Put the coffee down.

No, that's still too close to the keyboard. Turn around and set it on the counter, next to the printer, away from your elbow.

Swallow that mouthful of soda.



Actual words spoken to me yesterday:
The incontinence is getting worse. Those Jewish food exercises aren't helping at all.
Jewish food?


Ah: Kegels.

Management is not responsible for reimbursement of new keyboard or monitor purchases. You cannot say you weren't warned.

Tuesday, October 09, 2007

On Healing

I've been thinking a lot lately about words and how people use them; specifically about how we speak of what we do in medicine. I find myself wanting to articulate why I reject the term "Healer." Here is the essence:

"Healing" is neither a transitive verb nor a noun*.

My first clinical rotation of the third year of medical school was Surgery. One of the things we dutifully learned was things that interfere with wound healing: infection, foreign bodies, poor blood supply, and so on. It turns out that the best we could do was avoid those things to the greatest extent possible so the wound would heal. What that means is that there is a natural, maximum speed for wound healing that we can't increase, although there are plenty of things we can do to slow it down. Our job is to make sure conditions are optimal, and then wait.

Certainly there are occasions when things go seriously wrong with the body (and the soul.) Injuries; tumors; abuse; they happen, and frequently require skilled care in order for the body's innate healing mechanisms to fully do their thing. I believe that abuse, be it sexual, physical or emotional -- especially in childhood -- can cause cancer of the soul that, like cancer of the body, sometimes needs some pretty heavy duty "psychic surgery" to allow real healing to occur. Even though the surgeon or oncologist or psychotherapist has to take an active role in treatment (often inflicting significant suffering, knowing (hoping?) that greater health and wholeness will be the ultimate result) the intervention is not the "healing."

Disease can be treated; cared for; medicated; cured. Suffering can be eased; soothed; ministered to. Not "healed."

People don't heal other people, whether they are doctors, nurses, skilled psychotherapists, or even mothers. We can't make people heal; we can only let them heal. Wounds heal themselves. Healing and wholeness are the natural state of living things, and bodies strive for them at the cellular level. Like our heartbeat, breathing, digestion, gestation, growth and all those other wonderful functions our bodies take care of for us (that can go wrong but usually proceed apace quite nicely, thank you very much) healing happens.

*[Edit thanks to Lynn Price, my fellow word whore.]

Thursday, October 04, 2007

Question for Docs about DEA Numbers

The occasion arose today for me to call an antibiotic prescription (ie, not a controlled substance) in to a pharmacy in another state for a vacationing patient. It was a chain store, but because they didn't have a national database I was asked to provide my DEA number along with my address and phone number.

I'm used to this by now. I understand that many insurance companies use the DEA as a unique physician identifier and so require them even for prescriptions of non-controlled substances. But it still bugs me on principle. (ie, How can I be sure that some pharmacist or tech won't swipe it to forge controlled prescriptions?)

I was feeling polite today, so all I said was, "Ok, let's just pretend I threw a hissy fit," before rattling off the number. But then the pharmacist surprised me by saying, "You know, we get docs from all fifty states calling things in here, and the only ones who have any problem giving us their DEA numbers are the docs from Pennsylvania."


So let me throw this out there: Are PA docs the only ones:
  • concerned about drug diversion?
  • paranoid about unauthorized use of our DEA numbers?
  • insufficiently trusting of our pharmacy colleagues?
Do docs in other states not care about these things? Are we (Pennsylvanians) being overly cautious?

Or was this pharmacist just jerking my chain? That is, are there plenty of docs in other states also decrying the requirement to divulge their DEAs so promiscuously?

Whaddya think?

Tuesday, October 02, 2007

Eighteen Years

Eighteen years ago today, I hung out my shingle and began the practice of family medicine, solo.

I had graduated from residency and worked for a few months for a pair of other docs who, much to my surprise, indicated that they did not intend to hire me to join their practice on a permanent basis. Their practice was full, though, and they had no objection to my setting up shop in the same town. At the time, it actually seemed like a lot less work to open up on my own instead of seeking out employment somewhere else.

I sat down with paper, pencil, medical and office supply catalogues, mentally reviewing everything in the "office" at my residency program. I priced everything out, generated a shopping list, and wrote out projections for growth and revenue. Then I found a little two-exam room basement office, and went looking for financing. It took four banks, but I finally found one that gave me the $25,000 credit line I was looking for. On October 2, 1989 I opened for business.

I saw three patients that day, but none for the rest of the week. Still, the practice grew slowly but surely. After two years I moved out of the basement office into an old surgeon's office building. Two years after that, when we couldn't negotiate a sale, I moved to my present location.

A lot has happened over those eighteen years. I've been through an embarrassing number of staffers, learning hard new lessons every step of the way. I look back at a 1989 H&P with more than a little embarrassment; they really do call it practicing for a very good reason.

I've been through a divorce, the hell of dating, and found my way into a wonderful second marriage. And my children have gone all the way from infancy and toddlerhood, through elementary, middle and high school, morphing into three sturdy college students who still light up my life.

On the flip side, my income peaked in 1996. It's been a slow but steady slide downward since then. That trend may actually be reversing itself over the last year or so; can't tell if it's just a temporary plateau on the way down, or things are really turning around. I'm trying to remain optimistic.

I'm not at all certain what the next eighteen years will bring, but I can still honestly say that I'm looking forward to it. And -- bottom line -- isn't that what life is all about?