Tuesday, June 30, 2009

The gift of July

Every year, July brings with it a new beginning. Brand new, fresh faced, eager, and probably terrified new doctors and nurses dot the hospital. With them these newly minted professional bring a wealth of knowledge and some experience from their respective professional schools. Most importantly though they bring with them the gift of enthusiasm.

For these new professionals medicine is fresh and exciting. Yes, it takes longer to do everything. From the initial history taken from the simplest patient to surgical procedures that almost double in length I will be watching every move that each one makes. Though most aspects of hospital practice slow for a few months as these young women and men acclimate to their new roles, I don't care.

Even the residents who have been here for a year or more are moving up a step. They are more alert, eager, excited. This enthusiasm for medicine serves to invigorate all of us. This all comes at just the time when we need it.

So in those moments when I am watching every move, count the number of throws in each knot and making sure they are square, questioning each and every finding, asking for that complete differential diagnosis, checking the lab tests myself, I will also take some time to enjoy working here. The privilege that surpases that of practicing medicine is the privilege of sharing the experiences of others who are new to learning to practice medicine.
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Saturday, June 20, 2009


On a trip to the emergency room yesterday I caught this glimpse of the problem.

The young woman I saw was a renal dialysis patient transferred from an outlying suburb due to left sided pain and severe anemia. Gynecology was consulted immediately based on the results of a CT scan done at the other hospital.

I will admit, I looked through all the lab tests and read the CT scan report before I spoke to the patient. She even had a battery of blood work ordered by the physician who accepted her transfer. He had not seen her yet either.

She was a 24 year old woman with systemic lupus erythematous. This is a debilitating disease that can affect every organ but usually goes straight for the kidneys. She was currently on dialysis, a whole bunch of blood pressure medicine and the anticoagulant Coumadin. She was married and yes, she was sexually active, using condoms for contraception. She and her husband had a four year old son and she had a miscarriage 2 years ago when all her problems with the lupus began.

After talking with her, I took her blood pressure and pulse both sitting and lying. They did not change very much. She did not "tilt," a term used when the blood pressure decreased and the pulse rate increased as the patient sat up. This was a good sign.

My first problem came when I ask the nurse if a pregnancy test had been done since I could not find one in any of the lab work from either hospital. "Well get me some urine and I'll order one," what the terse reply.

"She doesn't make urine. She is a dialysis patient." I calmly told her. "There is all that blood work. If you will show me how to enter the order into the computer I will call the lab and ask them to run it on the blood they already have."

"Well, hasn't she had a hysterectomy or something?" The nurse frowned at me. I could tell I was too much trouble.

"No. She is still menstruating. She has a four year old and a miscarriage two years ago." I waited patiently. "After you do that I will need some help with an exam."

"Why do want to do an exam? She already had a CT scan."

I could have said something like "well, I am a doctor and I am writing up this history and physical exam." I didn't. I got all the things I needed and when into the room.

In the room the patient told me that no one had examined her at the other hospital. As a matter of fact she had not had a pelvic exam since her miscarriage. I was busy setting everything up. When we were ready the nurse said, "I haven't ever seen this before. What do I do?"

"Just stand there," I replied as I positioned and draped the patient. Five minutes later I was done. Helping the patient, I thanked the nurse.

The patient was not very tender. Her blood count was low. Her pregnancy test was negative. All the fluid on her CT scan was probably blood from a ruptured ovarian cyst. Because she is on the Coumadin to prevent her blood from clotting, bleeding was far more likely than in most people. I explained to her that we would need to watch her blood count closely but it had been stable all day while the transfer was taking place so she probably would not need surgery.

As I was leaving the ER, I thanked the staff for their help. There were three techs and an RN. Each had a computer console where they could look minute by minute at everything that was going on in each of the patient rooms. Pulse, blood pressure, EKG tracing, oxygen saturation and all of the laboratory tests right there at your finger tips. Modern medicine.

Still, there is nothing like seeing, talking to and examining the patient.
"duh"SocialTwist Tell-a-Friend

Sunday, June 14, 2009

The loco MD

Today I am considering a change in the title of this blog. Loco MD seems more fitting. Recently I left the security of a well respected group to practice as an obstetrical hospitalist. Every day I have at least one second thought. This morning it came as I was delivering a 17 year old patient. The "baby daddy" was there very curious about all that was taking place. I was equally curious about how he was keeping his pants from falling down. The pants were riding about 4 inches below his waist to allow more than adequate exposer of his underwear.

Two days ago my second thought occurred as I dealt with a patient laboring after she had taken PCP. I had forgotten about the vertical nistagmus. The patients eyes oscillate up and down very rapidly. I know of no other instance when this happens. Patients on PCP can also be quite agitated which is understandable if your eyes are jerking up and down about a hundred times per minute. Have you have seen that commercial with the fried egg - "your brain on drugs"? Believe it!

I also spend way too much time thinking about who is taking care of those toddlers left at home. One of my standard questions after I find out the ages of previously delivered children is "who is taking care of them." "My mom" is a common response. In a short time I have concluded there is a large group of children being raised by their grandmothers. I am hoping the grandmothers do a better job the second time around.

I have also become way too familiar with filling out and signing death certificates. These dead certificates are for babies who died before their mothers came to the hospital. Many times the delivery of their dead baby is all the care these women get for their pregnancy. Drugs are frequently involved.

I came to this job through a series of events that have happened over the past two years. I could be seeing patients in a high profile wellness clinic in the wealthiest part of the city. That job was my second choice. At the time I believed it was too tame. I still do.

I write these things to say that I was not as well prepare for this job as I thought. Still it is what I wanted. And still it is work worth doing.
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Wednesday, June 3, 2009


Every profession has it's own vocabulary. The vocabulary of medicine is notorious for it's complexity. "Inspection of the malar area revealed a patch of vitaligo next to a maculopapular rash that the patient states is puritic." Translation: "This patient has an area on her cheek that has both lost it's pigment and a rash that is visiable, palpable and itches." Dysuria means it hurts when you pee, excuse me urinate. A cholecystectomy is the removal of a patients gall bladder as opposed to a cystotomy which is making an incision in a cyst, even that big cyst that all of us have, the urinary bladder.

Today puzzling over what it is that physicians do, I realized that I went to school for four years to learn all these words. Then I spent another four years learning how to use them with other physicians while also learning to translate them back into a language patients can understand. Now that I am in practice, to get paid I have to use an entirely new language: Current Procedural Terminology or CPT for short.

CPT codes are numbers that insurance companies use to determine payment. The reimbursement I receive for a patient visit is based on the number of questions I ask, the number of body parts I examine and the time I spend explaining the diagnosis and treatment to the patient. All of this must be properly matched with a numerical code that is put into the computer and sent to the insurance company in order to receive payment. No one is ever told in medical school that the system is run this way. Why would anyone spend all that time learning a complicated language only to then learn some sort of Morse Code system so that the insurance company will pay you?

As I write this, I realize that in the practice of medicine I now use three languages. There is the language I speak to the patients. It is much the same that I use with friends and family. This language is English, hopefully as plain and simple as I can make it so that the patient I am caring for will understand what I believe is happening to them and what my plans are for treating this condition.

My second language is the one I use with other physicians and the health care team. I love this language. I have spent years learning it. I enjoy reading medical journals, talking with colleagues and attending conferences where it is used. The preciseness of this language is helpful in the diagnosis and treatment of patients.

This third language I consider a necessary evil. Without it I will not get paid. I am not proud of the fact that I know a 99213 is a specific level of office service or that V25.1 is the code for contraception counseling. These are facts that seem to clutter my brain. They do not make me a better physician or even a nicer person. Knowing this language only allows me to succeed at billing for my services.
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