Monday, July 20, 2015

The Sh$t You Read In The Newspaper

Jim almost convinced me.  The burning in his chest, after all, could have just been gastroesophageal reflux.  He assured me that the sensation was nothing new; that he got it from time to time after a large meal and took Tums.    I couldn't, however, ignore that it seemed to worsen with activity.  The pain was bothersome enough to drag him into my office, without taking the time to make an appointment.

Jim and I argued over the EKG.  He wanted to take his prescription and go home.  No hospitalization, no blood tests, no diagnostic studies.  I grabbed his shoulder, and did my best to convince him to reconsider.  He slowly turned back toward the exam room.  A few minutes later, I gulped as I looked down at the electrocardiogram.  He was having a heart attack.  Right there in my office.  We called an ambulance and rushed him to the ER.

Jim's story is nothing new.  I can recall countless episodes of personal beliefs contradicting my strongly held suspicions as a clinician.  I have begged, pleaded, and occasionally dragged unwilling patients back to the office or into the emergency room.

And occasionally I have saved their lives, or interrupted a malignant disease process before the effects could become irreversible.

Sometimes we are not so lucky. Many clinicians can recall a case in which they had been lulled into a false sense of security by a patient's own certainty.  There is nothing worse than a call from an emergency room, specialist, or coroner notifying you of a deadly misjudgement.

Conversely, everyday we face patients who are utterly convinced that they know what is wrong.  These beliefs, occasionally correct, but often heretical can be terribly difficult to dispel and lead to over-testing and over-diagnosis.

It's quite a slippery slope.

So when I read in the newspaper about the latest story of the mishap patient who was certain of the correct diagnosis, yet their pleas fell deaf on their doctor's ears, I kind of get it.

The layman's diagnosis is often wrong, but sporadically on target.  It takes great courage and concentration to accurately weigh the data, the patient's beliefs, and empiric science.  We actually get it right far more often than not.

We often listen to our patients, and take their beliefs into account.

But you mostly don't read about that in the newspapers.

Sunday, July 12, 2015

Are You Proud Of Your Patients?

It was only afterwords that I wondered if I had been condescending.  The words had come out so naturally.  We were sitting across from each other in the nursing home.  It didn't take a doctor to recognize that his leg was visibly less swollen.  I had seen him walking down the hallway with the physical therapist.  His face a mix of pain, concentration and triumph.

Each day had brought improvements.  The range of motion was returning.  His strength was growing.  His body balanced now with only the most minimal of assistive devices.  What had once been disability had transformed to normal physiologic functioning.  

In medicine we often talk in the most passive of manners.  We say that the knee is improving, or the wound is closing.  We talk as if healing is a mere act of God.  A blessing that is bestowed on the weary from time to time in a somewhat whimsical manner.   

And I am not a denier that randomness pervades our experience in hospitals and medical clinics.  But I have been trying to be more cognizant of the role that human will plays in the rehabilitation of both body and soul.  The force and strength, the sweat and tears, the physical act of becoming healthy.

So I said what was on my mind.

You know, I'm really proud of you!

Funny words coming from a middle aged doctor to his geriatric patient.  But his face lit up, and I could see that he was thankful for the recognition of the difficult road he had travelled and barriers that still lay ahead.  It wasn't condescending.  It was a truthful moment that transcended the artificial barriers between doctor and patient.  I was just an innocent bystander acknowledging the remarkable personal will it took to get better.

I feel both awe and pride, frequently, at the strength and endurance of those patients that fill my moment to moment existence.  

From time to time, when appropriate, I try to let them know that.   

Friday, July 3, 2015

Sticking It To The Man

Like two ships passing in the night, we sidled up to each other at the nursing station on the hospital telemetry ward.  I had already been home, ate with the kids, and returned, while he hadn't left floors all day.  We typed away at our computer stations, and chatted from time to time.

After we exchanged common pleasantries, we jumped into local politics.  We were hungry for news.  Battle worn and weary, we were searching for signs the tide was starting to turn.  The gossip was mostly pessimistic, but I saw a glimmer in his eye as he abandoned his screen and turned to face me.

I bet you haven't heard about...(fill in the name of your favorite academic medical center).

He was exited now.  The words came from his mouth faster than the keystrokes that disdainfully filled the electronic medical record that had become his slave master.  An academic center had taken over a hospital, and felt that it had every right to bully the large allied medical group.  The physicians, tired of being pushed around, silently vowed to steer their admissions to a local competitor.  Months later, the academic center was on it's knees with empty beds and an angry community to boot.

We both basked in the glow momentarily before returning to our respective tasks.  Although we wanted to go back home to our families,  there remained a need to share a fleeting moment with someone who could relate.  Someone who could understand.

And I imagine that conversations like these are taking place across the country where physicians congregate: hospitals, clinics, and doctor's lounges.

Meaningful Use, EHR, PQRS, ACA, ACO, Value, Quality, Patient centered Medical Home, Medicare Fraud, The Physician Sunshine Act.

A once humble profession is struggling desperately to find it's soul.

I find it rather disconcerting that a decade ago, colleagues used to revel in a recent save, discuss a difficult prognostic dilemma, or brag about a diagnosis of a rare ailment when happenstance caused their paths to cross in the middle of the night.

But now, now all we talk about is sticking it to the man.

And I wonder how those, at the moment, dying to find appropriate medical care,

are feeling about this.

Monday, June 29, 2015

Utility and Functionality

It is one of the most ancient stories wending it's way through modern history.  The hotheads of late have coined the term creative destruction.  But this concept of replacing old with new,  or innovation upending tradition, is no more novel than the concept of change itself.

There is nothing truly original in the world.

I ease off the gas pedal of my already outdated hybrid Prius.

My job will eventually fall prey to a computer named Watson.  My practice will be gobbled up by the nearest Goliath medical center as history scoffs at the arthritic physician bending over a doorbell with leather bag in hand.

There is no flash of glory here.  No smart technology.

The echo vibrates through cracks in the sidewalk and drags me unwillingly forward to the unkempt house at the end of the block.

Adapt or perish.

I open the door without knocking and find a decrepit figure slumped into a reclining chair in front of the television.  His car keys were long ago taken by some relative or another.  He waits for nothing in particular.  Scraps of food have been left on the side table by a home health aid.

There are memories of being gainfully employed.  Road trips across barren lands and such.  His son is now grown up and makes decisions on his behalf.  A nursing home is a far safer environment than this empty old house.

My visits to the end of the road are numbered.

Old is replaced by new.

Utility and functionality apparently are relative terms.  

And by and by something is lost.

Thursday, June 4, 2015

Those Dumb Physicians Aren't Getting The Job Done

The insurance company insisted that they would be saving money in the end.  So they sent the PA (physicians assistant) to my patient's house.  They didn't take in to consideration that I was just there a week before.  Or that I made home visits on a regular basis.  In fact, they didn't even inform me about the appointment.

My patient later told me that the exam was exhaustive.  The PA, who incidentally graduated school the day before and had never seen an actual patient as a licensed practitioner,  poked and prodded the ninety year old woman for over an hour.  He asked her about drugs and sexually transmitted diseases.  He examined every joint and performed a Babinski test.

A few days later I received a call from him.  He tried to leave a message with my secretary, but I intercepted the call.

He had two recommendations.  He thought I should do a better job of addressing the patient's knee pain.  When I asked if he thought it was a result of her polymyalgia, rheumatoid, or osteoarthritis, he had no idea.  When I mentioned that the pain had been treated in the past with various medications (and physical therapy) and the patient had stopped them all due to fatigue (even Tylenol), he was surprised.  When we discussed that she was in the hospital multiple times for pain control before I met her, and now had avoided hospitalization because of better symptom control, he said he was unaware.

His other recommendation was to start the patient on Detrol for overactive bladder.  He, of course, had no idea that her urologist had tried the same thing a few years back and she had become dizzy and broke her hip.

It wasn't the poor PA's fault.  There was no way he could have known what I gleaned from a year's worth of hospital, nursing facility, and home visits.

He just didn't know the patient as well as I did.

Which, of course, brings us back to the insurance company.  They believe that complex problems can be solved with simple solutions.

Just get some PA to go over there and make recommendations.

Those dumb physicians aren't getting the job done.

Tuesday, June 2, 2015

Till Death Do Us Part

Even though they were such carelessly spoken words back then, Jill took her vows seriously. Till death do us part.
She was just a child when she married Tim. He, a few years her senior, was like a father figure. But they grew together: first professionally and then personally. 
When the kids came, everything changed. He spent late nights at the office, and she transitioned her schedule to part-time so she could be home in the afternoons. 
Jill’s love grew and expanded. Of course the romance was still there, but what she valued as she grew older was the companionship. Her and Tim were partners in every sense of the word. They traversed life’s paths together, avoiding roadblocks, and choosing carefully for their little family. 
The kids were well into high school when Tim developed the numbness and tingling. Jill wasn’t concerned in the beginning, until his symptoms progressed. A flurry of doctor’s appointments later, they held hands in the neurologist’s office and listened attentively to his description of multiple sclerosis....

Read the rest of this post at The Medical Bag.

Tuesday, May 26, 2015

Safe Zone

When I first began the practice of medicine, I used to think of the entranceway to the exam room in mystical terms.  How else could I explain my patient's willingness to suspend all social rules and norms upon passing through those magical doors?  They would sit down in front of their baby faced-doctor and talk about things.  Private things.  Scary things.

Conversations occurred that would be unthinkable if two strangers were to meet in the outside world. I learned of abuse and infidelity, pain and yearning, secret joys and countless regrets.  I bore witness to the inner pain and struggles that often were hidden from one's closest friends and family.

People undressed.  They replaced their clothes with unflattering gowns.  They demonstrated their body parts unabashedly.  Pointing to that which looked out of place.  Wincing from pain induced by my clumsy touch.

The exam room became a safe zone.  A place where judgement was replaced by support and understanding.  A place where one's darkest secrets could be revealed but not allowed to consume them.

When I abandoned my traditional practice for home visits, I feared that something important would be lost.  I often wondered if there was a certain element of depersonalization that came with such sterile environs.  Maybe my patients revealed their inner needs and fears because the institutional setting of the exam room was a sufficient departure from normal life.

Then there was the question of my lab coat.  The wizard's frock symbolized a certain otherness that separated me from the rest of society.  Again I conjured up visions of a magnificent veil that allowed me special access of a most personal nature.

It's been almost two years now, and I have visited countless homes without the comfort of the exam room nor the lab coat to hide behind.  My fears, of course, were completely unfounded.

My patients still tell me their triumphs and tragedies.  They still pull their shirts up unashamedly to show me a rash or lump or bump.

And I have come to realize that it was never the sanctity of the exam room nor the long gray coat that droops from my shoulders.

With both great awe and humility,

I have come to the conclusion that it is me.

I am the safe zone.