Salvation is Near!

There is nothing like prying your kids off of each other for the fifteenth time before 10AM to make you question your parenting skills. 

And your sanity.

We are on day five of me at home with my kids. I don’t have anyone reliable to watch them when they are out of school for the holidays (there is entirely too much time off of school nowadays if you ask me šŸ˜‰) so their father and I split the time. Currently, it is my turn. Tomorrow I get to go back to work for a few days.

Yippie! (You didn’t hear me say that…)

Stay at home moms, I don’t know how you do it day after day, week after week, month after month. Honestly, I am not as strong as you are. I am beginning to think I look pretty sexy in sweats. That’s right. Not to mention the fact that all of the cookies I have baked have snuck off to hide somewhere… I couldn’t possibly have eaten all of them. AND I am talking to rising bread dough as an equal. 

All of this has convinced me that I am a much better parent in smaller doses. I had suspected this, but in the past my kids still napped. 

Now they don’t. 

So. 

I say all of this to say that if you hang with your kids all day every day and still like them and yourself, you have my respect. I send you a virtual fist bump of solidarity. 

Meanwhile, I am going to quietly sneak off to pack my work bag for tomorrow morning so as not to draw the attention of the angry hoards demanding that I fold yet another origami frog.

Woohoo! (You didn’t hear me say that…)

Reading Into Things


“I don’t want to see the oncologist you referred me to. I checked the online ratings and he got some pretty bad reviews. Find me someone else,” the phone message read.
The patient had multiple myeloma. The specialist I had picked was the best in the area for this condition. I had no idea what the reviews said. I just knew that this patient wanted to live. 

No amount of discussion would dissuade them. Even when I explained why I had chosen this specialist.

What do you look at when you are trying to pick a physician? What qualities are you looking for in a physician? Skill? Personality? What is the most important to you? How do you as a patient measure what is important? 

An interesting article I read the other day in the Journal of Medical Internet Research looked at cardiovascular surgeons in five states that allow reporting of outcomes data and compared the risk adjusted post-operative mortality rate with that physician’s online reviews from patients. 

Guess what?

There was no correlation. 

Now, here is something else provocative. In USA Today there is an article entitled, Don’t Want to Die Before Your Time? Get a Female Doctor. It is referencing a study published in JAMA today that found patients in the hospital who had female physicians were more likely to survive and less likely to be readmitted within 30 days of discharge.

“The researchers estimated that if male physicians could achieve the same results as their female colleagues, they would save an extra 32,000 lives among Medicare patients alone each year — a feat that would rival wiping out motor vehicle accident deaths nationwide.”

Practice differences between men and women translate into real, measurable differences in outcomes.

So, when we talk about income disparity between male and female physicians, one recent study showed that women are paid on average $20,000 less per year than their male counterparts

What a bargain, huh?

Getting Harder

Forge and anvil in black and white

“Doc, I just want to die.”

I nodded my head sympathetically. At a certain age, all patients say that. She was in her 90’s…. 

“I am so tired of hurting.”

She groaned and worked her way through her usual litany of aches and pains starting at her head and working all of the way down to her toes. She had pain medicine she could take for the arthritis so I knew that wasn’t really the issue. Not all of it, at least.

“I pray every day that the Lord just takes me away.”

She’d had a gentleman friend at the center. For a few months she positively glowed. He sent her roses for Valentine’s Day, bought treats for her little dog, left her love notes, told her she was beautiful. Never mind that he was twenty years younger than she was. 

At that age, what does twenty years mean? Nothing. It means nothing at all.

“I think they might be having sex…,” her granddaughter said. “Can’t you make them stop?”

My patient was not demented. She was not handing over her life’s savings. She was a consenting adult in an assisted living community who met another consenting adult and while there were significant physical challenges to a sexual relationship at her age if she really were having sex, who was I to meddle?

Then, he died. 

Here she was, left behind again. Sure, she had aches and pains but the real issue was this last man standing thing, or in her case last woman standing. She had already buried two husbands. Now this man. She could not bear to lose anyone else.

But what do you do? Give her a pill? Tell her to get counseling? Pat her on the hand and tell her the sun will come out tomorrow? What do you do for a grieving woman in her 90’s who wants to die but is not suicidal?

Outcomes

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His voice shook.

“She’s in ICU. I thought you should know.”

I felt my body grow cold. She and her family had been patients of mine for almost ten years. She was so young. Younger than me, in fact….

“They aren’t sure if she is going to make it.”

“What happened?” It was supposed to be a simple cyst removal.

“Her small intestine was perforated. They have her belly open, said they couldn’t close it yet.”

I had used a new surgeon, someone I had never used before, because the mass was blocking the tube from her kidney to her bladder, causing quite a bit of pain and endangering the kidney itself. She needed surgery quickly and no one that I typically used was available to work her in. 

“That’s just awful. Keep me posted on how she’s doing. I’ll be saying a prayer for her and for you.”

“Thanks, Doc.”

As I hung up, the guilt welled up. I felt personally responsible for the bad outcome, even though my hands weren’t the ones actually in her belly. MY hands had hit the referral button, signed the order. 

She trusted me. 

She ended up making it, but it took a huge toll on her both physically and emotionally and financially. It affected her relationship with her husband. It affected her kids. They had almost lost their mother and it left them all shaken and ungrounded for almost a year. Things are only now starting to look up.

I feel guilty when patients don’t like someone I refer them to. I feel that I have let them down. I feel guilty when I find a cancer, as if somehow it was my fault. I should have prevented it. Maybe I could have found it sooner somehow? And, yes, I feel responsible for surgical errors and outcomes.

So when I tell patients they need to see a different specialist than the one they picked out, I worry how far to push it when they aren’t agreeable. When I know a back surgeon is bad, how much do I tell a patient who is not listening to my gentle suggestions to seek a second opinion elsewhere? Where is the line professionally and legally? 

These are my thoughts on this Monday morning….. 

Shaded

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I always block my ID when calling patients. If I don’t, I start getting direct calls from patients. Those kinds of patient calls are the minority, to be sure, but they are exhausting and disruptive and are sure to occur when I am on the toilet having a rather tough poo (lots of noisy grunting) or whilst in the midst of mind blowing sex (also lots of noisy grunting) or something else equally awkward like changing a high lightbulb while precariously balanced on a ladder (probably also involving lots of noisy grunting).

One consequence of this is that patients don’t answer my calls. I have to leave a message and wait for them to call me back, sometimes an hour later. It happens almost 50% of the time when patients call the answering service, even though they are expecting me to return their call. It occurs 90% of the time when I have to call unsolicited, like when the lab alerts me that a patient’s potassium is 2.3 or their platelet count is 10 or maybe the hemoglobin level is 4.5 (these are very bad things by the way) and I need for them to go to the emergency room.

OR, the patients have the feature activated on their phone that will not allow unidentified callers through. That requires that I call the answering service back, then they have to call the patient and walk them through how to deactivate the phone feature, then call me to let me know I can try the call again. Sometimes that still does not work because they are unable to deactivate the feature and I have to call the answering service to call the patient back for an alternate number. 

What I really, really want is a way to ID myself when calling without showing my phone number. “Dr. Victo, phone number unavailable.” Or some such thing. 

Maybe that already exists and I am just a dork when it comes to telecommunications… 

The Lump

“How long has this been here?”

“I don’t know. Maybe six months.”

“Why didn’t you tell me? You have been in for a head cold and a sprained ankle in the past several months. Why didn’t you bring it up?”

Truthfully, I don’t know why we ask these questions. 

What does it matter in the grand scheme of things, the why? It could be one or several of over a dozen things but knowing why does not change the what or the now. Asking why only makes the patient feel… worse. 

Actually, I do know why we ask. 

It is our way of saying, “Look, if you die, remember it isn’t my fault,” because we feel guilty, somehow. Responsible. It is our way of conveying that we are hurt that you didn’t trust us without saying those exact words out loud. And to be honest, we are in shock, scared, terrified of what this might mean for you. We know the fear and the pain and the hair loss and depression and everything else that may come your way because of this little lump in your breast.

I have been on both sides. 

I can tell you that as the patient I understand the not bringing it up thing. I consciously chose to ignore it myself. Not because I was depressed or was in denial that it was there. It was certainly there. Nor was I lazy. Or ignorant. I knew full well the implications of a slow growing mass in my breast. I simply did not want to know. If it was breast cancer, fine. So be it. It wasn’t going anywhere. Death didn’t scare me. In some ways, I was probably playing chicken with death, with the mass.

Who was going to flinch first, I wondered.

Then one day my own doctor was saying those words to me… “What the hell were you thinking?!?!??!”

And the truth is, I don’t know. 

Please note, that I do not have breast cancer. I’m not dying from anything, not yet anyway. My breast is just fine, thank you! I was just reflecting on this whole phenomenon last night, the ignoring of things we shouldn’t really ignore. 

Embellished

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I used to be an author.

Every day I wrote two dozen or more short stories. 

Some were comedies:

“The pain in the right knee started after a snowboarding accident in Aspen two months ago during a spring break trip with friends. He swears that a tree suddenly jumped into his path and evasive maneuvers failed.”

Some were tragedies:

“The patient states that she learned last night that her husband has had a two year long affair with a coworker. She would like STD testing and something to help her sleep for a few days.”

Now I am supposed to point and click predetermined text to generate my note. It comes out something like this:

“The episode started two months ago. Pain is in the right knee. It is worse with movement. It is better with nothing.”

Where is the patient in that? Gone.

Then it is followed by a long list of smart text that generates an office note so full of crap that it is impossible to get to the meat of things quickly. I routinely get 4 page notes from specialists. I read the first paragraph and then the last page to hopefully figure out what is going on. The rest is meaningless drivel that is tacked on for billing purposes. I scan through hundreds of pages of documents every day. You know how I can read so many blog posts so quickly? Years of practice…

We are losing our humanity. 

Change the human body from a person to a machine.

Change the healthcare providers into automatons.

It is inevitable, isn’t it? Dehumanize the patient. Dehumanize the doctor. Dehumanize the nurses and medical assistants and other providers. Do it little bit by little bit. If you do it in one fell swoop, there will be rebellion. Whittle away at it in small bites so it is easy to swallow and then one day we will all look up in horror at what we have become but by then it will be too late.

Once you have done it to healthcare, do it to every other aspect of our lives. 

Little bit by little bit. 

I think, perhaps, it is already too late.

Homework assignment! Ask to read what your doctor writes about you next time you go in…. 

Virtual Perfection

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My new electronic health record (EHR) likes to be helpful. Very helpful. It is full of all sorts of suggestions to ensure that my care is better than best.

For instance:

When I prescribe a birth control pill, a warning flashes up in the form of a red and yellow pop-up to remind me that it is contraindicated in pregnancy. Um. Duh? The patient isn’t pregnant. Not yet anyway. 

Similarly it wants me to know that metoprolol, a medication used for blood pressure and the heart, is contraindicated in chest pain. Well, Ok…

Dozens of commonly used medications have absurd warnings. What I am most afraid of is getting to the point where my brain blocks out all warning pop-ups because at some point I am going to get alerted about an allergy that I forgot about. I don’t want to automatically click through that alert. It would help if the medication allergies were listed on the same screen as the order entry screen. Wishful thinking, I guess.

The EHR wants me to add “Morbid Obesity” to everyone with a BMI over 30 and “Overweight” to everyone with a BMI over 25. For many of my patients, rubbing their noses in their weight is counter productive AND the bigger question would be is being overweight by BMI standards really a medical condition? I don’t think so. THEN it wants to suggest that I send the patient for nutrition guidance. That would be all well and good but when was that ever covered by a patient’s insurance company? Almost never. Even for diabetics, thank you very much. I have yet to have a patient volunteer to pay $1,500 for nutritional guidance with a dietician. I sure as hell wouldn’t.

Are you coming in for strep? Well, the computer wants to remind me that you also need your tetanus booster. Except that I already gave you a tetanus booster two years ago. You are good for another eight years, technically. In fact, the computer has that immunization in the shot record, it just isn’t giving you credit for it. Or me credit for it, apparently. I have to go through a complicated series of maneuvers to “properly” record that you had the vaccination. It cannot be easy. Oh, no.

Oh! I have patients that are finding their records merged with old records from when they saw an unrelated doctor in another part of the state over fifteen years ago. Kinda fun, except that their name is now reverting back to their maiden name or some other nonsense and I have to delete those ancient meds off of their current med list before anyone gets confused.

Speaking of the magical appearance of meds, do you have something you don’t want your PCP to find out about? TOO BAD! If you fill an antibiotic or any other medication at a pharmacy from another provider, I’m gonna find out. That has made for some awkward conversations with patients about their over utilization of teledoc services… I hate it when they cheat on me with another physician!

The EHR fills in quantity and refills on many of the meds I order automatically, except it often isn’t correct. For instance, a Z-pack (azithromycin) that it says to take two pills on the first day and then one pill every day thereafter, auto fills a quantity of two rather than six. Or amoxicillin three times a day for ten days sometimes auto fills a quantity of 20 rather than 30.

It is still early. We will see how this continues to shape up as I get more proficient.

CostumeĀ 

Interior, Boston church
I am standing there, handing out candy to the hundreds of kids that file by in their costumes when I see him and see that he sees me…

The world is too small.

It’s been years.

He stares at me in my costume and wig and takes a second to recall how he knows my face. Another time, another place. Recognition washes over him.

I know his secrets.

No matter the masks. No matter the past, present, or future. 

I know his lies AND his truth.

“Hey, Doc!”

I smile. He stares at me with a mixture of dread and embarrassment. I wait to see what will come next. 

Finally he sighs. “I promise to call and schedule my physical tomorrow.”