Musings from the Disenchanted Doctor: an unscientific blog






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Lightsabers!

For a little humor today, I give you a collection of pictures with lightsabers photoshopped in. Great fun.

Labels: Pop Culture

posted by Dr. Alice at #

 
Saying Goodbye


It's the hardest thing in the world.

The process of dying being what it is, it's rare that you get a chance to sit and talk with someone knowing that this will be the last time. The Last Time. This is because dying patients are usually confused, narcotized or comatose and aren't aware enough to carry on a conversation. They don't teach this stuff in med school - well, that's not a fair statement. These days medical schools and residency programs do teach end of life care, or at least try to. But there is no way to explain what's going to happen when you go in the room to talk to a patient, someone you know, knowing that you will never meet again in this world. It's scary. It's puzzling (is it okay if I weep? Should I be professional?) and it can be incredibly rewarding. These are the conversations I remember, the moments that keep me practicing medicine.


I had one such conversation many years ago with the mother of a patient who had AIDS and was dying of progressive multifocal leukoencephalopathy (a particularly nasty and slow way to die). He was living in a long-term care facility where I was on staff and she had come to be with him; we worked together for months. Although the other doctors on staff were involved with his case I know that she felt the most comfortable with me. I had scheduled a vacation abroad with my mother months before, and as the weeks passed and the patient slipped into a near-comatose state it became clear to me that he was going to die while I was out of town. His mother had asked to meet with me the week before I left, and during our conference I said: "I need to tell you that I'm going out of town next week. I would cancel this if I could, but I made these plans months ago and I can't. So I wanted to tell you..." I paused... "that I won't be here."

She understood what I was saying and said thank you, and hugged me, and we cried. I told her how much I'd liked taking care of her son - and I had; he was a wonderful guy. When I returned from vacation the patient had in fact died and I never saw her again.


This weekend I met with a patient in her nineties who was diagnosed with cancer months ago. We gave her treatment for her symptoms and she improved for a while, but now she's been failing for a month or so. She bounced in and out of the hospital a few times and the hospitalist raised the issue of hospice care; she and her family agreed to stop treatment. She was transferred to a nursing home pending hospice arrangements and I went to see her there.

She took my hand and we sat on the side of her bed. "I'm so glad to see you!" she beamed. It was stunning to see the good spirits she was in. Denial was not an issue: she was completely aware of her prognosis and accepted the fact that she would not live much longer. Every time she comes to see me in the office she tells me that she loves me and she said it again today: "I love you, Doctor. You're the best doctor I ever had. My family's so glad you've been taking care of me. I've known you for what, now, fifteen years?"

"Close," I confirmed.

"Well the first time I saw you in the waiting room, I said to myself: 'That's my doctor.' And I was right."

We were sitting on one of three beds in a three-person room, curtained off from the other occupants. I stared out the window at the alley for a moment and thought what a strange place it was to have such a conversation bordering on eternity, then thought: well, what would be a better place? There is no appropriate place.

"Do you feel okay?" I asked her. "Are you in pain?"

"Not right now, but doctor, I been in some terrible pain. Some nights I used to ask the Lord to take me now. I don't want no more pain."

I reassured her and told her the hospice staff would set her up with medication: "All you have to do is ask for it." She had asked to go home rather than staying in the nursing home and I promised her I would make those arrangements. Then I took a deep breath and, fighting a lump in my throat, told her how much I had enjoyed being her doctor.

"I love you," she repeated.

I hugged her. "I love you too."

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Sentence You Don't Want to Read


When the radiologist who did the biopsy forwards you the path report you don't want his email to read simply "Hi, she needs an oncologist."

The sentence you don't want to say to the patient: "The biopsy did show cancer."

It's especially hard to get those words out when you hear a happy infant burbling in the background.

Labels: Medicine

posted by Dr. Alice at #

 
Evil Doctor Conversations

Tonight in my usual evening telephone chat with V. I began reading to her from the Phobia List, which I had just discovered online. As with so much medical esoterica, one could probably spend hours just reading through this list. The sheer entertainment value of phobias is incredible.

"Lachanophobia," I read aloud."Fear of vegetables. That's probaby why I don't like going to nursing homes."

We both dissolved into laughter.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
My Take on Healthcare Reform


You knew it was coming.

I don't really have the time or, at this point, the functioning thought processes to give you a heavily-researched, well-worded essay on the pros and cons of government health care. I'll just give you a few points that have occurred to me as a primary care physician. When it comes, and I have no doubt it will, a government funded health care program will fail unless a few points are straightened out first.


Before such a program is implemented we need more primary care doctors. There is a huge shortage of primary care providers in this country. There are a lot of reasons for that; compared to the specialties primary care is poorly reimbursed and involves much longer hours. We also get most of the scutwork - jury duty excuses, disability paperwork and Pay for Performance. This last issue is huge, but that's something for another post. The reason I say we need more docs in primary care is that in order for a huge unwieldy national program to work it has to be implemented at ground level. We are ground level.

Medicare has a big problem, and that problem is that no one doctor is in charge of the patient. In other words, it isn't uncommon for me to see patients who float from doctor to doctor, go off to see specialists, get tests and get their meds changed, and then turn up on my doorstep completely unable to tell me what type of test they had done or what the specialist's take on it was. Now, many times the patient does have a PMD, who does call the shots and is aware of everything, and that's great. But too often that is not the case. Before instituting a national plan I think the federal government should run Medicare more like an HMO, in that every patient needs to get a PMD to coordinate workups and testing.

Another problem with Medicare is that the government is slashing reimbursements to doctors and has been doing so for years. This means that a lot of doctors are now no longer accepting Medicare. These patients either need to pay cash, have a fallback private insurance plan or find a doctor or clinic who will agree to see them. This problem is not going away any time soon, and no proposal of which I am aware has addressed this issue, either.


Another issue is that there has to be tort reform. That could mean malpractice capping, or it might mean mandated arbitration. Did you ever wonder how Kaiser keeps its rates so low, or how the VA program holds its costs down? The answer, my friend, is arbitration. Before suing you must go through meetings in which both sides try to reach a compromise. I'm not claiming it's perfect or the best way to go, but I am saying that in order for the President to even come close to meeting his wild claim that a national health program wouldn't cost the country any additional money, something has to be done about runaway malpractice rates.


People will need to get used to waiting and being told "no." There's going to have to be a huge cultural change in the U.S. before the public will be happy with national health care. What do I mean by that? I'll give you a few examples. I have a British friend who lives in Brighton, but grew up in Nottingham. When she first moved to Brighton she couldn't find a doctor to take her, as all the medical practices were full. Yes, full. For over a year, if she needed to see the doctor, she had to travel to her MD in Nottingham. In case you are wondering, the two cities are 150 miles apart. She told me this story as though it were nothing unusual, and I'm sure it wasn't. The big, dirty secret about nationalized health coverage is this: just because you have insurance, it doesn't mean you'll get a doctor. As I said above, if there aren't enough docs to go around, the situation hasn't improved. Also, I accompanied her to her doctor's office the day she had an appointment for a Pap. Five minutes later she was back in the waiting room. You aren't going to have a chance to spend time with your doctor or to get many questions answered, if this is anything to go by.

"But what about physicians' assistants or nurse practitioners?" you might ask. "Can't they handle basic health care?" Yes, they can; but NPs and PAs are nobody's fools, either. Most of them get specialty jobs too. They work with plastic surgeons or orthopedic surgeons, or in outpatient oncology programs (most of my aunt's care is coming from NPs and PAs right now; she sees an MD only once a week). That means you're still SOL when it comes to finding a primary care provider, MD or otherwise.


Let's talk about wait lists for other stuff. Mammograms, for instance. The reimbursement for mammograms is minimal and it comes with a high malpractice risk. This means there's a shortage of radiologists who are willing to read them and there's a shortage of facilities providing them. When every woman in America over the age of 40 gets insurance and runs to the phone to schedule a mammogram, what do you think is going to happen? You got it. Say hello to six month waits for mammograms.


None of this is to say that people shouldn't have access to insurance, or that coverage should be predicated on their having a job. It shouldn't. And insurance companies should not be allowed to deny policy coverage to someone with diabetes or other chronic illness who's trying to buy a plan. I don't have a suggestion for a workable national insurance plan, though I wish I did. I'm just pointing out that it isn't going to be all rainbows and unicorns once everyone has insurance.

Labels: Medicine, Politics

posted by Dr. Alice at #

 
Thank You, I've Been Screened


Every day after taking the shuttle and checking in at the medical center, we patients and caregivers are given a sticker to wear. What do the stickers say? It's the title of this post. The stickers are distributed to us after we have filled out forms stating that we are not coughing, do not have a runny nose or a fever, and so on. Bottles of hand sanitizer are everywhere.

No, I am not the Boy in the Plastic Bubble, but I am pretty damn close. I am currently acting as caregiver for a relative who's undergoing outpatient treatment at the Seattle Cancer Care Alliance. She's not in the hospital and I am doing my best to keep her that way. The best way to do that is to observe the many, many precautions on the handouts which the hospital distributes at every possible opportunity. Food hygiene, home hygiene... nuking sponges in the microwave to kill bacteria, avoiding whole grain breads and crackers, scrubbing bananas before you peel them. It never ends. I actually turned this experience to some good use by writing another guest post for the Home Ec 101 website, which you can read here if you are so inclined.

Spraying Clorox and wiping things down is a lot of work but worth it. It has given me a new appreciation for the marvels of our immune system, for one thing, and I now have some new ideas for my patients who are plagued with MRSA infections. MRSA is a nasty bug and can affect anyone... you don't have to be immunosuppressed to get it. We are washing sheets and towels twice weekly, using a lot of hand sanitizer, using paper towels and napkins (cloth being a bad idea for someone who is immunosuppressed... it can harbor germs) and so forth. Earlier this week my relative's white blood cell count plunged from 10K to 2K, then to 1K, so I am keeping an eye on her. Today it will be lower still but we are hoping that her count will bottom out over the weekend and then start to return.

In a frenzy of planning for this visit I packed my otoscope/ophthalmoscope kit, a box of rubber gloves, a stethoscope and my portable blood pressure kit. So far none of them has been needed. Her treatment has been relatively uneventful so far and I hope it stays that way. I'll post more updates later.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Must See Site

Go take a look at these incredible, one-hundred-year-old, color photographs of Russia. Yes, color. They're absolutely stunning.

(h/t to Jo of Head Nurse)

Labels: Pop Culture

posted by Dr. Alice at #

 
Random Bits of Info



Voice dictation update: "fenofibrate" comes out as "phenol fibroid."

Today V. and I learned that the ophiasis pattern of hair loss means "a bandlike pattern of hair loss encircling the head, resembling the laurel leaf crowns of the Greeks." This information came to us courtesy of Derm.

Subway is not a half bad place to go for lunch. A Subway store opened just down the street from us and it's always packed at noon. As I wait in line I see many customers wearing scrubs; this place is getting a lot of business from the staff of doctors' offices nearby.

Oh, and I got a gig as guest poster at Home Ec 101. Go take a look.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
Not an Option, Evidently

Had a conversation today with a patient who is adamant about wanting non-hormonal birth control. I referred her for the IUD, but it is not covered by her insurance.

"What are my other options?"

"You're looking at barrier birth control. That would be the diaphragm or condoms."

"Yuck."

"Well, there's celibacy."

"Oh, you're funny."

And that was the end of that.

Labels: Medicine

posted by Dr. Alice at #

 
Beware Cartoonists Bearing Gifts

You may have heard of Stephan Pastis, the cartoonist who draws Pearls Before Swine. I think it's one of the best comic strips currently published, and one of my favorite aspects of the strip is his ability to parody other comics. Most recently Pastis brought Mary Worth onto PBS as a guest (she stood stock still for four panels and said nothing, alluding to the glacial pace of the strip). He's also thrown a few zingers at Sally Forth and others, but he's saved his best jabs for Family Circus.

Back in July there was a big comics convention in San Diego, and Pastis attended. The night before he was to speak on a panel he was in a bar having a quick drink when he ran into Jeff Keane, one of the authors of Family Circus. Pastis got a brilliant idea:

“Hey Jeff, you have to come to my panel tomorrow,” I told him.

“Why?” he asked.

“Because every time I do a panel, someone inevitably asks me what other cartoonists think when I parody their strips.”‘

“So?” he said.

“So if somebody asks that question, I can surprise everyone by introducing you and showing them that we know each other and are actually good friends.”

Keane agreed to come.

What happened the next day? Well, you'll just have to click to read it...

Labels: Comix

posted by Dr. Alice at #

 
A Rare Restaurant Endorsement


"Okay," my cousin demanded a few weeks ago, "'fess up. Who went to 'Wise Guys'?"

"It was me," I humbly admitted, raising my hand.

We were standing in my aunt's kitchen in western Pennsylvania. Earlier that day my parents and I had been driving to Aunt D.'s house from the Pittsburgh airport, and things had been a bit tense. We had left at crack of dawn from Stratford, Ontario, and had gone through customs at six a.m. without breakfast. Plus my dad had displayed his classic stubborn argumentative self at the Pittsburgh rent-a-car counter and I had come very close to braining him with my suitcase.

I won the "honors" of driving from the airport to my aunt's house and we were all starving. Dad had let it be known that he would be very happy to stop any old time for a bite. So when a certain red-and-white sign had caught my eye from the road, I shrieked "We've got to stop here!" and promptly pulled in.

The sign read: Five Guys Burgers and Fries. Had it not been for a chance conversation a few weeks before this would have meant nothing to me. In fact the conversation was so random that I still cannot remember who my conversational partner was (a patient? a drug rep? not sure). Nevertheless the name of the business stuck in my head, and since I was driving, the decision was easy. Into the parking lot we went.

This chain (it is a chain) is awesome and reinforces my adage that there is no restaurant recommendation like a personal recommendation. The unknown person who clued me into Five Guys swore up and down that it was the best burger they had ever had. All I can add is, YUM. First point: they have free roasted peanuts in the shell. The peanut presence totally escaped me but it did not escape Dad, who had a little cardboard box of the luscious legumes loaded up before I had finished ordering for the three of us. Second extremely important point: you have carte blanche to order your burger as you like it. Which is to say, you make your choice of multiple condiments, relish, onions, tomato, lettuce... etc. (Sorry, Australians, no beetroot available.) If you study the menu you'll see what I mean. My mother changed her toppings order three times and I felt sorry for the poor fellow at the register, but he handled the situation with aplomb.

Third point: portions are HUGE. I mean, a "regular" burger order is a double. A "small" has a single patty. French fry orders are fresh, delicious and HUGE. I ordered a large standard fries and a regular Cajun fries for three of us and there were way too many fries, probably enough for five or six people. I kept apologizing to my folks for over-ordering and trying to explain that all I really knew when we arrived was the name of the place. I don't think there are any Five Guys in California, at least not that I know of. And fourth and final point: everything, everything, is cooked to order. They also have hot dogs, which I bet are delicious, but we wanted nothing but the burgers. We agreed that the regular fries are better than the Cajun (way too salty).

Five Guys are also very fast. We hit the place in the middle of the lunch crowd, but I just had time to get sodas and paper cups of ketchup for the three of us before our order was called. After we finished I studied some of the rave reviews posted on the walls and deduced that "Five Guys" was started in the Virginia/Washington D.C. area about 1996 and has since then expanded up and down the Eastern seaboard. Given that there are three such restaurants within an hour or so of my aunt's place I have to believe that they are doing pretty well. For those of you who know western PA, there is one on Rte. 22, one on Rte. 30 and one in Johnstown.

My cousin confessed that she can never remember the name "Five Guys" and always calls it "Wise Guys." Whatever you call it it's a darn good burgers-and-fries place and I would highly recommend it.

Our collective mood improved greatly after our visit. As we piled back into the car on that humid afternoon my father announced, "You know, even King Tut didn't have air conditioning. Or a car."

"He didn't have Five Guys either," I retorted, backing out of the parking lot and back onto Rte. 30.

Labels: Ingestion

posted by Dr. Alice at #

 
Team Bonding! Or, We're Totally in Dilbert Territory Now

I have great admiration for my boss in many ways. He has overseen The Firm from its small beginning with just a few doctors to its current status as one of the largest medical groups in L.A. His schmoozing skills are unparalleled - make no mistake, this is a major asset and one I wish I possessed. And he believes in the value of corporate culture, which has kept us together and going strong for lo these many years.

Having said that, he's come up with some mighty hairbrained ideas in his time and he has just emailed us the latest of such. He wants us all to do Myers-Briggs personality testing prior to the next corporate retreat.

Yes. Personality testing. I can see where this might be relevant if he were dealing with a group of managers, but I don't really see the point when applied to physicians. Granted, diplomacy and tact are relevant when it comes to running a practice but doctors are trained to treat patients, not to herd cats. When it comes to running a practice you find the rhythm that works for you and stick to it. I'd say also, at least in our group, that the physicians who don't like how we do things self-select and leave. That doesn't mean they aren't good doctors or that we had horrible disagreements; it just means the group practice model didn't work for them. And I admire them for realizing this and striking out on their own.

I guess what I'm really asking is, what is this supposed to accomplish? And my answer is not a lot. The docs who are talented holy terrors (and we have a few) already know this. Those of us who are eclectic (not to say eccentric) already know that. No matter what my Myers-Briggs results show, I don't see that they would change my practice style any... I've been doing this for sixteen years.

V. sent me a succinct email after we got the news: "OMG!!!" I responded as follows:

I seem to recall during our mandated pain management training that there was a chapter on Myers-Briggs which included the results for serial killers like Ted Bundy. I think I may go look up those results and copy them onto my test… ought to be good for a laugh.

It's a delicious thought, but I want to keep my job. I thought better of it.

Labels: Medicine, Pop Culture, The Doctor's Life

posted by Dr. Alice at #

 
This Pretty Much Says It All

Labels: Pop Culture, The Doctor's Life

posted by Dr. Alice at #

 
Birth Control: an Underused Option

Via Not Martha I found this link to an excellent article about IUDs. I agree with the writer: I can't understand why more women don't use them. You do have to pay up front if your insurance does not cover the device, and this can cost from $300 to $500; but they are good for up to ten years. Even if you only used it for five years that would come to less than ten dollars per month, cheaper than the pill. I always offer it as an option, especially if the patient is looking for a birth control method which does not involve hormones.

Labels: Medicine

posted by Dr. Alice at #

 
Tech Support? Hello?

Well. It's been brought home to me once again that when it comes to technology you can file me in the "epic fail" category. For months I've been struggling with an extremely slow computer line and have done nothing about it - mainly because I didn't know where to start. This afternoon, having a recent phone bill handy as a reference, I finally called the 800 number for Verizon and was directed to their website. It ran a program, checked the speed of the line and reported that yes, I did indeed have a speed problem. I clicked around some more and finally found a FAQ which suggested turning off the modem, waiting fifteen seconds and plugging it back in again.

It worked.

I can't believe it was that simple. I really can't believe I waited months to do something about this. At any rate, at least there's a happy ending.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
How To Celebrate a 50th?

I always enjoy reading Mark Bittman's food blog, Bitten. Over the last several months he's accumulated a few guest posters whose writing and recipe ideas are also excellent. A recent post by Daniel Meyer, dealing with his efforts to create a nice fiftieth birthday dinner for his mother-in-law, contained a suggestion that made me laugh out loud:

My first thought was to buy her a quart of ice cream, a bottle of whiskey and a box of Kleenex, but that seemed insufficiently celebratory.

I have not yet reached this milestone, but several of my friends and colleagues have. Perhaps when it's my turn I will mark the occasion in this manner. We shall see.

Labels: Ingestion

posted by Dr. Alice at #

 
Bons Mots

1. Last week I was examining an older patient. When I tested the range of motion in his knee I noted some crackling and noted that he had "crepitus" in the knee.

"Why do you call it that?" he fired back. "Does that mean I'm decrepit?"


2. Reviewing notes from urgent care today, I saw that the medical assistant had listed the patient's chief complaint as a "staff infection." She had a boil which was likely staph, all right, but I could not help thinking that an infection of the entire office staff would indeed be something to complain about.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #