May 14, 2008
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I am skipping town this week to go to the ACP meeting in Washington DC (and am giving a talk on Saturday). Any med blogger types going to be there? There don’t seem to be a lot of IM bloggers (I guess we are generally too boring to be of interest to most).
Please drop me a line if you will. I am planning on visiting the very famous Dr. Val while there (although I think she is just trying to meet a lobster).
My talk, by the way is entitled: Being a Real Doctor in a Paperless Office.
I am not sure they realize I am neither real nor paperless.
The above picture came up when I Googled "Dull and Boring." Quite an interesting picture, with his eyes being kind of creepy-looking. There are also some sort of ceramic pots in the background. It seems that Humpty spends a lot of time in pretty bad neighborhoods. It does not surprise me that he got cracked.
Maybe he was doing crack.
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Posted in Just Stuff Kind of Thingies 
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May 8, 2008
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I don’t want to sound like a whiner. I hate it when doctors seem like malcontents, complaining when their income is much greater than the national average. I am very lucky to be doing what I do.
But sometimes it can be exasperating. It infuriates me to be subjected to a system where quality is rewarded with less pay; where doctors are motivated to not communicate or cooperate. Especially when my patients pay the price.
I am not psychic. I cannot know what happened in a three month hospitalization by placing my hands on a patients head and reading their brain waves. My staff can’t know that a “hospital follow-up” visit is really a major dump because a patient’s “insurance ran out”. I don’t have the supernatural ability to slow time down so that I can decode the crying of a spouse and confusion of a sick patient and put together a good plan in fifteen minutes. I am not a faith healer. I have no crystal ball. I lost my magic wand. The kryptonite has sucked out my power.
I am funny this way. I like to be called on the phone, not read Tarot cards. I want to know what is going on. Discharge summaries are better for me than tea leaves.
Yet somehow the impossible is expected of me. I am expected to pull the rabbit out of the hat - and do so with a smile of appreciation of what a great job I have. But I don’t smile; I get angry. It is not fun; it stinks.
As much as it stinks for me, however, it is far worse for the patient. I can go home and complain about my day, but the patient has to survive when the system lets them down. The patient’s family has to live in fear when nobody can tell them what to do. Doctors get frustrated, but patients get sick and die.
And that makes me furious.
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Posted in Rants, Being a Doctor 10 Comments »
September 12, 2007
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Rant sequence activated: 10,9,8,7,6,5,4,3,2,1….
I got a call today from the daughter of a patient.
The overhead page in the office was "Doctor Call on line 2," so I picked up quickly and answered it. The doctor on the phone did not identify herself as such, but I knew her to be the daughter of one of my patients. She then proceeded to critique my care of her mother and question whether certain tests had been done. She was very aggressive in asking why a specific test had not been ordered and strongly implied that I had been negligent in my care in not ordering this test.
Looking through the patient’s chart, I could go through the list of complaints over time, and this "chronic severe problem" that I was presented with was only complained about on occasion. I also noted that the times that I had seen the patient for this problem, I had actually been quite concerned and ordered lots of labs and other studies. Everything had come out OK. Most recently, I saw this patient a few weeks ago, but she had rebuffed me on my desire to order more tests.
I told this doctor, "if what you tell me is true, then I agree that more tests need to be ordered. The problem is that I have no record of complaints along these lines being given on a consistent basis." I told her that I would do what is necessary when her mother got back. When I hung up the phone I was furious.
I understand this doctor’s concern over the health of her mother. She would be a bad daughter if she was otherwise. The problem is that she called me assuming that she knew more about medicine and more about the patient’s problems than I do. Clearly she was wrong in both cases. She had a set of tests that she had determined needed to be ordered (not entirely unreasonable ones, I might add), and I will be judged by her (and now her mother) by my ability to follow their orders.
This was a really bad move on the daughter’s part. If you want your mother to get good care, don’t send the message to your mother that her doctor is making mistakes. Call and ask questions. Find out why things had not been ordered, assuming there might be good reasons for it. Now this patient trusts me less, and may have a totally poisoned relationship with me. I will do my best to undo some of the damage, but clearly I know more about this area of medicine than the daughter does (given some of the questions she asked and statements she made), so I can’t just do what the daughter asks me to do. I can’t let the mother believe that I will somehow be on "remote control" by her daughter. This is not a pride issue, it is a care quality issue.
The bottom line is that this daughter heard a completely different story than I heard and was judging me based on her history, not mine.
So, doctors out there, even if you are worried that your parents are getting bad medicine "practiced" on them, don’t assume that you know the whole story. I don’t mind calls from family members who are in the medical field (they actually are an asset more than a liability). I will talk at length about my thought process and take suggestions without hesitation (as long as they are reasonable). Just don’t poison the most important thing a patient can have in their doctor: trust. If you think their doctor doesn’t deserve that trust, then tell your loved one to find another doctor.
The same thing holds true for doctors in academic medical centers. I remember as a resident having contempt for "LMD’s" (local MD’s) and their care for patients. This is hubris, and nothing else. You don’t know what went on in the exam room nor do you know what was said. If you have questions, call and ask. If you still think there are things wrong, then you were right. Just don’t jump to conclusions.
Rant completed.
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Posted in Personal Musings, Being a Doctor 18 Comments »
May 7, 2008
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Fomite
Pronunciation: 
f
-
m
t
Function: noun
Inflected Form(s): plural fo·mites /-mts; fäm-
-t
z, fm-/
: an inanimate object (as a dish, toy, book, doorknob, or clothing) that may be contaminated with infectious organisms and serve in their transmission <the much maligned toilet seat is a remarkably ineffective fomite — M. F. Rein> <what are the most common fomites for rotavirus in day-care settings — Pediatric Report’s Child Health Newsletter> (from Merriam Webster)
There was a study done recently regarding the cleanliness of computer keyboards (from Science Daily):
ScienceDaily (2005-04-18) — Some potentially harmful bacteria can survive for prolonged periods of time on the keyboards and keyboard covers of computers, a study conducted at Northwestern Memorial Hospital has found. Gary A. Noskin, MD, who is medical director of healthcare epidemiology and quality at Northwestern Memorial and who led the study, advises periodic cleaning of computer equipment and hand washing after every computer use.
"The problem is especially important in hospitals and other healthcare environments where patients are at risk of contracting bacterial infections from healthcare providers who use computers," Dr. Noskin says. He presented his findings at the 15th Annual Scientific Session of the Society for Healthcare Epidemiology of America (SHEA) in Los Angeles this week, and the study generated coverage from various news outlets including CNN, the Chicago Sun-Times and Reuters.
Noskin and his colleagues studied bacteria commonly found in the hospital environment. To determine the ability of bacteria to survive on computer keyboards, the researchers inoculated the equipment with three types of bacteria: vancomycin-resistant Enterococcus faecium (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PSAE). VRE and MRSA are examples of bacterial strains that have developed resistance to the antibiotics (including vancomyin and methicillin) commonly used on them. Although VRE and PSAE seldom cause problems except in hospitalized patients whose immune systems are compromised by other disease or illness, recent outbreaks of MRSA skin infections in otherwise healthy persons (community-acquired MRSA) have raised concern among infectious disease experts.
I believe in Electronic Medical Records. I believe they can save lives if used properly through better care. We have been using EMR for the past 12+ years with terminals in every exam room.
While it is common to worry about patient contact with the computer and access to data (or little kids turning it off), I have honestly never considered the cesspool we may harbor in each room. There are moments when I am tempted to swat people with the keyboard, but the risk this may expose patients to needs to be considered by anyone with an EMR.
Afraid of toilet seats? Be more afraid of keyboards.
I see an opportunity for an entrepreneur here: make a washable keyboard and market it to hospitals and doctors. We really don’t need Electronic Medical Fomites.
Perhaps we need a sign that says: Employees must wash their hands after touching the keyboard.
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Posted in Medical 12 Comments »
May 5, 2008
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It is a moment etched into my deepest being.
I looked at the baby in the basinet. I was tired, happy, confused, hopeful, and scared. He just laid there, barely moving. I thought to myself, this child will be in my life until the day I die. It happened in an instant. There was now a person for whom I would throw myself in front of a bus without hesitation. The child had done nothing except exist, but that existence radically changed my life.
My oldest turns sixteen today.
To say that it just seems like yesterday would be a lie. It seems like a long time ago. The cobwebs are creeping into this old mind (along with llamas and lobsters), and so it helps me to recount the whole experience. Here is how I remember it:
We are Pregnant!
We had just been married for a couple of years, but my wife and I were quickly approaching thirty and biological clocks are hard things to ignore. I was still in my residency, but we were living fairly comfortably and felt it was time to start a family. Somebody must have thrown Miracle Grow on us, because fertility was no problem.
I was suddenly living with a pregnant woman - an experience that one needs to go through to adequately understand. We could not store enough Popsicles in the freezer. Emotional? Yes, and changing without a moment’s notice. “That time of the month” for nine months. We did enjoy the kicking in the belly: the “Alien” movements I could see and feel.
Because it seemed the thing to do, I chose one of the OB/GYN attendings at my program for my wife. The visits seemed nice enough, but there was little bonding between my wife and her doctor. We got an ultrasound and found out it was a boy (even though we asked not to be told). We bought any and all baby supplies we could afford - and hunkered down to wait for the day.
Delayed Gratification
Finally, the day fast approached for the babe to be delivered (yes, I am referring to my wife). We reached her due date. Nothing. Days went by slowly, each day waiting for my beeper to say it was time. Still nothing. The office pool at my wife’s workplace was quickly losing possible winners. A week past the due date, and we talked with the OB about plans. It was the practice at the time to go as much as two weeks past the due date before forcing the issue.
So we waited more.
Day 12 past the due date was a Saturday. The entire previous night, my wife had contractions every ten minutes, sometimes closer. When the morning came, they all but stopped. To encourage our baby to come out, I convinced her to wash the car. We got a clean car out of it, even waxed, but few contractions.
The next night the same thing happened, but the contractions were more severe. The next morning, when they slowed down, we went out for a walk to try to encourage them again. It had rained the night before, and so the sidewalks were covered in worms. My wife hates to see worms die, and since the ability to bend over to pick up worms had left her a few months before, I became the official worm-savior. There were enough worms to practically put me into labor.
Still nothing happened.
Hard Labor
Day 14 finally arrived, only to see the same slow-down in contractions. I was not going to tolerate any more waiting, and the OB did say that two weeks was the expiration date on this pregnancy. So to avoid late-fees, we went to the teaching hospital where our son would be born.
Of course, at a teaching hospital, you get the guinea pig finest experience. We were met by interns and residents. The first check of the cervix showed she had gotten to two centimeters. Two? All of that work and only two centimeters? All of those contractions, lost sleep, worms, and all we got was two lousy centimeters? We demanded a recount, but no dice. We did, however, get a Pitocin drip.
For those who do not know, Pitocin is a hormone normally produced in a woman’s body that causes (among other things) her uterus to contract. My wife’s body was on week 42 of a Pitocin strike, so hooking up the bag seemed like a more likely solution than to negotiate a settlement. Once hung, it did quite well to increase her pain at more frequent intervals.
After a few hours of pain, walking the hospital (with no worms to pick up, thankfully), and more pain, she had progressed to a whopping 3 cm. The pain, however, was getting intense, so we asked for anesthesia. The anesthesia guy they pulled off the street resident came in to put the epidural in. Once in, we were assured that the pain would go away. She lay on her side, with contractions hurting more and the bozo resident blindly expertly putting the epidural needle in her back.
The pain went away…somewhat. It went away on her left side, but not the right. Now she was having hard labor pains on her right, and blissful pain-free labor on the left. She was not happy. We had, however, made it to four centimeters.
The nincompoop anesthesia resident came back sheepishly and tried to make things better by putting her on her side and doing something with a shrunken head on the end of a stick, but it helped little. By now the labor pains were getting difficult to stand. It had been nearly eight hours since coming into the hospital, and nearly three days since the labor process started, and we were all the way to five centimeters.
The Ice Man Cometh
My mother-in-law came with us to the hospital (did I forget to tell you?). She was a great comfort to my wife, and allowed me to take a break and go to the bathroom, eat, or find some worms to pick up. She held my wife’s hand, comforted, coached, and soothed her.
My job was to feed her ice with a spoon. Sure, I had trained to be a doctor and knew the anatomic reason the stupid epidural was not working, the physiologic reason the pitocin torture drip was making her hurt so much, and I was the one who knew everything there was to know about babies and children - after all, I was a resident. But now I was only the ice man. She would let out a pained moan that my MIL would interpret as a need for ice (through some psychic woman power, I guess), and I would jump up and feed her the ice with the expert precision afforded me by my extensive training.
It was getting near midnight, and we were up to 8 cm. Still the anesthesia wasn’t working on one side, much to the chagrin of the microcephalic anesthesia posse. The heart monitor was doing its usual “wooka, wooka, wooka” in the room between contractions. The nurse was repeatedly saying “push, push, push, push” whenever contractions came. I have never been to a delivery when someone did not say “push, push, push, push” in the exact same tone of voice. It must be part of the training of labor nurses.
Lizard Boy
Another hour passed, and we were finally getting somewhere. The repeated “push, push, push, push” must have been the key. I was now so good at ice spooning that I was teaching other fathers how to feed ice to their screaming wives (although I still needed my MIL to translate). We were complete and full.
My wife threw up.
“That’s a great sign” the OB resident reassured us. “It means she is going through transition.” Good. I thought something had gotten into the ice. I hoped that “transition” meant that the end was in sight.
Finally, at 1:23 AM, my first son came into the world. He was scrawny, wrinkly, and covered in goop. Babies get skinny when they spend too much time in the womb. He cried a pathetic little cry (the best sound I have ever heard), and everyone in the room commented on how wonderful he looked. I thought he kind of looked like Marty Feldman - skinny, with big eyes that bulged out. Yet I said to my wife, “He looks wonderful, honey” as I held him up for her to see for the first time.
She paused. “He looks like a lizard” she said in a voice that seemed to question if all the effort was worth it. I reassured her that this was due to placental insufficiency as the term of the pregnancy had passed the due date. She looked at me strange, and then looked back at our boy. “Awww….he’s crying. Give him to me,” she said as the look on her face softened. I handed handed him over and came close to her. We were a family now: mommy, daddy, and lizard boy.
The Aftermath
I got home after 3 AM, and fell on my bed exhausted. Three hours later, the phone roused me from my hibernation. I picked it up to hear my wife’s sobbing, “He’s crying and crying, and I can’t make him stop.” Being a resident, I was used to be awakened for lots of reasons, but I was far better at making children cry than stopping it. I decided that now was not the time to explain this, and went back to the hospital.
He was sleeping again. Somehow the thought of me coming to see him had convinced him to go back to sleep. I looked over at my wife, now sleeping without contractions.
Then I looked over at my boy.
Then my life changed.
Happy birthday, Lizard Boy.
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Posted in Favorites, Personal Musings 14 Comments »
I am skipping town this week to go to the ACP meeting in Washington DC (and am giving a talk on Saturday). Any med blogger types going to be there? There don’t seem to be a lot of IM bloggers (I guess we are generally too boring to be of interest to most).
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