Thursday, December 25, 2008

When the doctor gets sick

I am ill infrequently and it that is a good thing for many reasons. The last time I was sick was seven years ago. I woke up in the early hours of a Saturday morning with the worst pain of my life. That is another story. It and this current malady illustrate how illness happens at odd hours.

My current affliction began as my family was getting ready for the Christmas eve service. Fortunately not as severe as the bowel obstruction I had seven years ago, this problem will need a prescription medication for treatment. I would never call a doctor on Christmas eve. I might go to an emergency room - if I believed my death to be imminent. As the night wore on and I had looked through all the medicine cabinets in the house for left over antibiotics. No, doctors and their families fail to finish prescription medications just like everyone else and no, we don't throw them out either.

Failing to find anything left over that I might take I have settled for home remedies that I remember my mother using. Wishing it were office hours and I could just call my personal physician I am beginning to think about plan B which will be to scrounge through the sample cabinet at work to see if anything in there might help.

No, I don't just call in medications for myself. What is that adage, "A doctor who threats herself has a fool for a patient" especially in a state that has as many nonphysician members on the State Board of Medical Examiners as mine. Plan C is to find a doctor, any doctor and a pharmacy owned by Jewish people (Walgreen's in case you did not know) to get a prescription filled before 4 PM today. Even Jewish people go home early on Christmas.
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Sunday, December 21, 2008

On call

Reading a catchy column on the editorial page this morning pleading with the President-elect to put down his Blackberry because it will make him a better President, I realize that I too need to be pager-less from time to time.

The problem of increasing connection through the series of wireless signals that span the globe is a hazard to both individual and collective health. As a medical student and even resident I was dependent on the page operator at the hospital calling me over the public address system or on the telephone in the call room, if I ever made it there.

"Dr. B please call 2116. Dr. B, 2116 STAT!" Anyone out there who trained in the same hospital I did will recognize 2116 as the oncology floor. Of course in those days the cornary care units and the intensive care units had their own live in residents.

I then graduated to a page that worked with certainity only in the hosptial. That meant that if I walked out the front door, got into my car and drove half a mile to my apartment I was truly off call. Of course, being the obsessive complusive resident that I was, the page operator had my home phone number. I also frequently left it with the resident who was on call covering my patients. Cell phones, Blackberries, even wireless computers and the Internet were in the future.

I remember marveling at the stories of my senior partner, who by the way lived in the hosptial during the first year of his training. All the interns, as they were called back then, lived in the hospital. One story he told was about a classmate who married his childhood sweetheart the week after medical school graduation. The couple had a two week honeymoon and then his internship began with the young doctor living in the hospital and the bride at her parents home. Surely there were conjugal visits and I believe he got two weeks of vacation.

Another story that my senior partner told was from private practice before pagers. If physicians wanted to go out for dinner, the phone number of the resturant was left with the answering service. Even the movie theater would take a call from the answering service and send an usher down the isle to summons the physician to the phone. This necessitated telling the usher who you were and where you would be sitting.

I remember purchasing my first cell phone to be able to go to the grocery store on weekends when I was on call. At the time I had two small children. Any emergency could be made worse by having a cart full of groceries, kids in tow and the pager ringing forcing me to look for a pay phone wondering all the while whether I would have time to go through the checkout line and get the food home before returning to the hospital.

These convienences of the modern world are costly. Without a cell phone the drive home was spent in silence. Or, I would look at the pager and immediately return to the hospital if it was an obvious emergency. Finally, the number of phone call was less. Currently I am trying to decide a fee structure for phone advice. Prior to this 24/7 access I would joke that the patient would call her mother and then call me. Now the order is reversed. And that is why I have a cell phone. I want my children to call me first.
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Friday, December 19, 2008

addendum 2

The X-ray report crossed my desk about the time the phone rang. "What do I do about my foot?" demanded Ms. F.

"Impression: No evidence of fracture" read the report on the radiography of the left foot.

"Ice and elevation" ordered the obstetrician gynecologist.

Perhaps I am a general practitioner at heart but if my foot hurt as much as I suspect this lady's does I would probably take the time to actually go to the doctor.
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Thursday, December 18, 2008

Nursing home

Much of this blog is a reflection on many events I wish I had written down as they were happening. Those days in medical school, residency and private practice that are so clear in my memory that I can picture them as if they were yesterday.

In my second post on this blog, Choosing medicine, I mentioned the summer job that I had working as a nurse's aide in a retirement center. In 1976 these facilities were called nursing homes and the one I worked in cared for clients that spanned the economic spectrum. I have many fond memories of the people there and it was also a taste of just how cruel life can be.

Roberto H was a man that I still think about. The youngest resident of the facility, Roberto was in his mid fifties. He was not an American citizen. Twenty seven years before he was legally in the United States working when a terrible car wreck left him paralysed from the neck down. He had limited use of his left hand. To this day I cannot help but think about the barriers that prevented his rehabilitation. I am sure they were economic and cultural and his plight was not helped by the fact that he had no family in the United States. He was one of the people that I wrote to for several years after I left that summer job and returned to school. Though Roberto I learned how patentedly unfair life can be and how gracefully some deal with this fact.

Two other residents that I think about these many years later are Tammy and Opal. They were roomates on the women's hall for patients who could no longer walk. Both woman were over one hundred years old. Neither could see and while they could carry on a conversation with you or with each other, neither would remember what she had said thirty seconds later.

I met these two ladies on my second day at work. The other aides, most of whom were middle aged, had not yet decided what to make of me. I was twenty years old, fairly naive, and eager to please. The women's hall A hall was the most difficult. Some of the aides would skip several of the reguired duties since the work of bathing these women and changing their bed linens was so physically taxing.

Jo, who in the end would be my favorite coworker, had decided to play a little trick on me. She ask me to go "feed the two women in room A-3. I went to the kitchen and got the two trays, noticing the card on both trays said "mechanical soft." This meant that all the food was like mush. Everything both these women would eat had to be such since neither had any teeth.

When I knocked on the door and wheeled the cart with the trays in the room I was greeted by two thin, old women with opaque eyes who both turned their heads in my direction following the sound of my voice. Opal was Caucasion. Tammy was Africian American. They both had thick, white hair cut short for easy care.

"Come in Honey!" Opal called.

"Yes, yes, yyyyesss!" Tammy chimbed. "It is lunch time and I smell that food." Both seemed enthusiastic and ready to eat. How difficult could it be to feed two ancient women.

I kept them talking, set up the trays and gave first one and then the other a bite of food alternating spoons and entering into the conversation that they carried on with each other. They seemed to enjoy each others company and as with most people who are blind, their hearing was remarkable.

Suddenly Tammy stopped eating. "I'm hurting, Honey! Hurting, hurting, hurting!" she repeated with her voice reaching a cresendo.

"I'm sorry, Tammy" I exclaimed moving closer to her, looking to she what could possibly be causing this her pain.

"Oh hurting, hurting, hurting!" Tammy kept repeating shaking her head.

"Tammy, I am sorry! What is huring? How can I help?"

"Hurting, hurting, hurting!" Tammy kept repeating.

"I am sorry, Tammy," I stated again becoming a little frustrated that she would not tell me why she was hurting.

Then it came, in a clear, serious voice, "You're not kidding your are sorry! Your are as sorry as the devil!"

With that Opal, Tammy and to my crigrin, Jo and two other nurses aides standing just outside the door burst into laughter.

"You're not kidding. Your are as sorry as the devil." And then that 'I got you' laughter. I think about it every time I say I am sorry but am afraid I am not serious enough for the situation. I think about it every time I know I am about to learn a lesson that is bigger than the one I bargined for in a particular situation.

I learned a great deal in that nursing home about myself, about life, about living and about dying. I am not sorry that I spent a summer working there. It was a turning point in my life.
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Monday, December 15, 2008


Lest you believe that I am out of touch or that I cannot support the claims I make in this blog I have two "proofs" from the first hour of my work day.

While making rounds this morning a patient who delivered yesterday complained that her pediatrician of the past four years would not see her new baby until after discharge. "That is true," I explained to her as I also praised the very qualified "hospitalist" pediatrician who had already seen her newborn. Both of these physicians are employed by the hospital and with the division of labor one sees the "inpatients" and the other sees the "outpatients."

Secondly, I arrived at my office (I still go both places) to receive a call from one of the imagining centers where I send patients. "Dr. LMD, we have Ms. Smith, your patient here and she thinks that she has a broken foot." I remember Ms. Smith well since I delivered both her children. "We need an order for an X-ray."

"I can give you and order for an X-ray," I replied, "But who will treat the patient? I am an obstetrician-gynecologist."

"I know that but the orthopedic surgeon will not see the patient without the X-ray."

Allowing the X-ray I knew that it would be within my rights to make the patient come over to my office and see me first. After examining her foot, I could then collect a co-pay from the patient while filing a claim with her insurance company who requires my name on the order for the X-ray. The end result would be the same but it would have been more costly.

I did not have time to see this patient. I was seeing another patient who was just treated for pnuemonia. During her illness she had an abnormal laboratory test, ended up getting a total body CT scan where an abnormality was found in her pelvis. Though quite a distance from her lungs she was now getting her yearly gynecologic care.
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Sunday, December 14, 2008

ALL the questions

"If you finish the history without a clue to the diagnosis, you have a problem." I remember those words well. Spoken by our instructor in Physical Diagnosis during the second year of medical school their corollary was, "And if, after your physical exam, you still have no idea what is wrong with the patient then you are in real trouble."

I doubt that such warnings are issued today when young, eager medical students are taught to take a history from the patient. Today the patient more often than not, will tell you what is wrong by sighting Internet sources where she read about her symptoms.

As a second year medical student I carried a five by eight inch light blue card in the pocket of my white coat. On this card, in very small type, were lists of signs and symptoms I was in the process of memorizing. Not only were these queried to patients in the process of taking their history but the answers were all carefully recorded for completeness in my own hand on the patients chart. In this computer age such things are now recorded by a key stroke.

Approaching my first patients with this list I was careful to ask about breathing, sleeping, bladder and bowel habits, skin problems, leaving the reporting of no symptom to chance in my quest of the diagnosis. Interestingly a second year medical student occasionally made a remarkable diagnosis even though he was the fourth or fifth person in the chain to speak with and examine the patient. The diagnosis often came as the patient answered a question everyone else forgot to ask.

This tradition of speaking with the patient and carefully examining her is what physicians refer to as the history and physical. H and P for short. Time taken to listen to as well as to ask about symptoms. Time taken to touch, peer into, listen, followed by time taken writing down these symptoms and signs. This is how a diagnosis is made and how a treatment plan is formed. Or at least that was the case before CT scanners and instantaneous blood test results. I am ashamed to admit that often I see the results of such tests before I see the patient. I will also admit that reversing this order frequently results in misdiagnosis.

Several weeks ago a patient was referred to me for treatment of pelvic inflammatory disease. A sixty-seven year old widow, she presented to her internist with pelvic pain and fever. The internist ordered a sonogram which revealed an ovarian mass interpreted by the radiologist as a pelvic infection.

One of my questions to the patient as I went over her history was when she had last been sexually active. She admitted that her husband was impotent and she had not had sex in many years. While all of her symptoms and the pelvic sonogram fit with the diagnosis of pelvic inflammatory disease, her history did not. As I began to ask her about bowel habits the fact that she probably had inflammation in her colon became apparent. Last week she had definitive surgery to correct the problem.

Saying all this is patting myself on the back and that is not my point. The point is that it is necessary to ask all the questions. This patient's sexual history was critical to the diagnosis of her illness and proper treatment. The diagnosis was not made by a laboratory test or by a scan of body parts. It was made by questioning and examining the patient. And yes, I had a pretty good idea of what the problem was when I finished asking ALL the questions.
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