Doctor’s Day

Cute butterfly on a blossom

Doctor’s Day was yesterday. Did you know that?

Caught me completely by surprise.

It used to be a big thing ten years ago. The hospital hung banners up and handed out logo emblazoned umbrellas, bags, pens, and whatnot. My staff signed a big card the office manager picked up and a new potted plant would now sit on my desk. Drug reps dropped off cards and swag. There would be emails celebrating doctors sent from the suits. Well not really from the suits. From their secretaries. The point was, though, you just could not escape what day it was. 

To be honest, all of the hoopla back then made me feel very uncomfortable. 

This is not why I am doing this. I am not here for the accolades or the potted plants and I resent the insinuation that these things matter to me. Please leave me alone.

Each year it is less and less of a big deal. This year? Silence. Not a single frickin word from anyone. In fact, my only clue was a post from someone else on WordPress. 

Yesterday I told a woman she has metastatic ovarian cancer. I told a man that he now has diabetes and we developed a treatment plan together. I did a newborn visit on a precious two week old baby. I cried with a woman over her divorce and saw a man whose mother just died from the same disease he now has. Then I watched the last few minutes of my son’s karate class and picked up cupcakes for my daughter’s class party. 

This is life. My life. Every day. 

And you know what? Despite any bitching and complaining that I do here, I really, really love my job. It is such an honor and a privilege to care for people, to be there when they need help. THAT is what keeps us going… keeps me going.

In truth, I’d do this job for free. Just don’t tell the suits that I said that. 😉

Cash Flow

Fountain at the Alamo in San Antonio

“You tell that doctor to write me a prescription for something affordable!”

*Click*

My medical assistant glanced up at me with a shocked look on her face. There was no need to repeat the conversation. I had heard every word.

“That does not make any kind of sense. It is a generic medication. It should only cost $40. Max. Call his pharmacy and find out what that med is going to cost him there.”

Later in the day I read the computer message that said it was going to cost $340 for a one month supply. Hell. I wouldn’t even pay that. 

I typed out a quick message and routed it back, asking why it was going to cost that much.

It is the brand name. If you want them to fill the generic you have to write for the generic. 

Except that I HAD written for the generic. I always write for generic. 

I sent back a stongly worded message pointing this out and telling them to fill the frickin’ generic. 

This was followed by a string of other patients with similar complaints all from the same pharmacy chain. Insurance companies refusing to cover prescriptions that patients had been getting without issue because the pharmacy chain was filling brand name instead of the generic option. It makes them more money. I would have never known this was occurring if the insurance companies had not denied coverage. 

From a drug coverage standpoint we love to hate on insurance companies but pharmaceutical company and pharmacy shenanigans are one of the reasons healthcare costs in the US are skyrocketing out of control. 

So I tell patients to be aware of what they and their insurance companies are paying for. If there are significant changes, please ask questions. Shop around to other pharmacies. The variability of cost from one pharmacy chain to the other is astonishing. AND, talk to your doctor. The only way I find out about these kinds of things is from patient complaints.

Just maybe don’t yell at my staff… 

Behind Your Back

Detail of building in San Antonio

So. 

One of the biggest time drains in my life is sorting through paperwork from insurance companies telling me that Mr. or Ms. So-and so is not filling their medication and therefore “likely noncompliant”. 

My question to you good people is this:

Do you want your doctor calling you to say your insurance company sent us this message and you need to take your meds, or else? Or do you prefer that we pretend that never came across our desk?

Power Lines

Power lines

“Hey, Doc. Remember me?”

I quickly glanced again at the name on the chart. He was a new patient. His name did not ring a bell. I squinted at his face. Dark beard and hair with some gray in it, a bit shaggy, but fairly well groomed. Lips. No. Then his eyes. I remembered the eyes from somewhere….

My heart caught and my fingertips went numb.

“How do I know you?” I asked, playing dumb. 

I knew good and well who he was. 

He smiled at me. “February 14th, 2016.” He paused a second to let it sink in. “That was the day you found me guilty of aggravated sexual assault and sentenced me to 10 years in jail.”

I quickly tapped a help message on IM to my office manager. 

“I don’t remember…”

“Sure you do, Doc.” He leaned forward close, too close, and spoke again in barely a whisper. “They made a big deal about who you were during jury selection. Got out a bit early. I had very, very good behavior. Not a day went by, though, that I did not think about what I was going to do to you when I got out. I have a very good memory.”

He sat up straight. There was a knock on the door and my office manager popped his head in. 

“This visit is over. Leave,” I rasped, embarrassed that my voice caught in my throat like a frightened fool instead of conveying strength and force. 

Damn.

A look of mock hurt crossed his face and he laughed. “Fine. See you around, Doc.” 

He sauntered out, slowly, pausing before rounding the corner to look over his shoulder and wink.

*********************************

In case it needs clarifying, this IS a work of fiction. 

Showing Up

Empty barn at a livestock show

“Well, at least you will have some time off!”

I marvel at this well meaning sentiment because truthfully, jury duty does not feel like time off. It is more work than my real job.

First, I am spending hours on the computer trying to make sure patients’ results are communicated, orders and refills get sent, questions are answered.  I do this in the mornings before I go to court and at the lunch break if they give us enough time. I have a ton of anxiety… that someone is going to get hurt, that a patient is going to get upset, that a ball will get dropped. The office is terribly short staffed right now and I have to be out next week for my kids’ spring break. My jury summons could not have come at a worse time.

Second, while it is mind numbing, it is necessary to pay attention to everything that is presented so as not to miss the details. Someone’s future hangs in the balance here. It isn’t like I can sit in the jury box tapping away on my phone or reading a good book. I still have to focus on what is being said, boring or not. In the clinic I get to talk, interact with people, use my hands. Here? I am a fly on the wall, watching. Always watching. Never speaking.

My fingers and toes have frostbite. Why the heck do they have to keep the room so cold? So the one big man in robes doesn’t sweat while the rest of us freeze our asses off? A sweater is just not enough. I need a parka.

Here is something else: I don’t like any of my fellow jurors. They are annoying as all get out. What are the odds of selecting a room full of crazies? And what does that say about me, getting picked to sit here with them? Hmmm?

I hate that the judge and the attorneys have made a big deal over what I do for a living. “We have a doctor here, let’s pick on her.” I have to give my employment details on all of the forms. Why is it then necessary to announce to the entire court room who I am, what I do? They did not do that to anyone else. I hate the silly, ridiculous and even inflammatory medical statements people like the bailiff make around me as if they are wanting to goad me into weighing in, handing out free medical advice. It isn’t the free that I mind, it is the fact that I know nothing of their history and we do not have time to do a proper consult about their chronic cough right here, right now. 

This whole experience has been eye opening. 

Rant over. For now.

‘Tis the Season

Dried flower

There was a time I believed that the longer I was practicing medicine the easier the dying would get. Practice or callous formation, call it what you will. I just thought it would be easier.

That is not the case, though. 

These long standing relationships, the people I see for years and years, are the hardest to part with even when you are expecting it. It still hurts. And with each passing it brings me closer and closer to my own end.

This is the dying season, it seems, those couple of months after the holidays when everyone who was holding on is now ready to let go. 

Everyone but me. 

Not yet, anyway…

The Light At The End Of Your Tunnel

Torpedo tube on a submarine.
The floodgates open

Murky waters flow

In preparation 

For an invasion 

Down below

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Founders Keepers

There is a term in population genetics called the founder’s effect and I have caught myself thinking about it a lot lately.

Basically, in a founder’s effect a small subset of a population is isolated from the larger population. For instance, maybe seven people went on a three hour boat tour but instead ended up stranded on a deserted island. The Professor and Mary Ann mate and reproduce, as people are wont to do, and several generations later the resulting population on that island looks very different from the larger population that it originated from. There is a loss of genetic variation and certain traits get reproduced at a greater rate than you would find elsewhere. Sometimes this is benign, like with a greater proportion of blue eyes or brown hair. Sometimes it is bad, like when you have a higher predisposition to develop colon cancer or maybe a higher rate of growing an extra leg out of your backside…

EPIC is one of the largest electronic health record in the US. It is highly customizable. Therein lies its power AND its weakness.

Keep in mind that I have only a small part of the picture and I am making certain assumptions, but here is what I have gathered:

When a healthcare system decides to go with EPIC there is a build out, or personalization, that occurs. The EHR that I see is very different from the one used by a physician in another healthcare system across town or in one across the country even though they are all called EPIC. 

From that initial build out, there are changes made as the product is tweaked. For instance, when we went live, we had to enter our password to log in but then had to enter it again with each and every note we signed, every single order we placed. Hundreds of times a day I was typing in my password. Now? I only type it in to log on. Good thing, too, as I was at risk of destroying expensive equipment.

I have staff in my clinic who have worked for three other major hospital systems in the area who also use EPIC. What they describe is much, much easier to use than what we have currently. In fact, they regularly threaten to leave and go back to those other organizations so they can feel at peace again.

How does that happen? 

How do they have such different products? 

Because they are all starting with a basic product. It is thrown out onto a deserted island with a few people making decisions and then everyone waits to see what you get down the road. 

The founder’s effect.

No one from the other hospital systems is sharing what works for them from what I can tell. There is no collaboration. So each one has parts that work well and other areas not so much. Why can’t we help each other?

THEN you have smaller islands. We are a small clinic in a huge system. We did not get support staff who came out to help us after going live until the following week and then only for two days. The bigger clinics? They had trainers there on day one. Some clinics never got anyone. Training classes done before had very little to do with the reality of the EPIC we were presented with on day one. So we have muddled through figuring out our own work arounds. Some good. Some bad. We need an infusion of fresh genetic material to correct our problems. 

That only works well when you have someone visiting your island to add to your gene pool and that only works if that person is genetically diverse themselves. Getting people to leave their islands is difficult. Distance to travel, time constraints, don’t know how to swim, etc… 

So we get this perpetuation of problems and errors… fractured systems. It has been really interesting to watch from my vantage point at the bottom, looking up. I wonder what this will look like in six months.

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?