Scylla and Charybdis

"So, hon...what'll it be today."

"What are your specials today?"

"We just got a shipment of personal responsibility in. It's really healthy (not one bit of trans-fat) and real satisfying. There are some folks here who religiously have this one. Oh yes, and it's free of charge."

"Sounds great. I'll...."

"Hold on there, sugar! There is a catch to this one."

"A catch?"

"Yeah. You have to eat all of it. If you don't eat it all, then you have to pay $100, and it's a big plate! Plus you have to keep coming back every week and get it again or we charge you another $100."

"$100??? How can you charge me for not eating it?"

"It's our restaurant. Can't we do what we want?"

"I guess so. What else is on the menu?"

"Well, one of the standard American favorites is individual freedom."

"Tell me about that."

"Well, baby, you get to eat as much or as little of it as you want, and the taste...oh, honey, it is sweet!"

"Sounds great! Ummm.... is there a catch?"

"You guessed it, darlin'. It's loaded with carcinogens, trans-fats, thimerosal, and synthetic estrogens. You will probably die young if you have this one."

"Hmmm...I guess I don't feel hungry."

There is a war going on between personal responsibility and individual freedom. This is nothing new - anyone who has raised teenagers can tell you that - but the venue it is taking is new. The raging battle has reached into the doctor's office.

A recent set of editorials in the New England Journal of Medicine discusses a plan put forth to improve the health of Medicaid recipients. The first article by Robert Steinbrook, M. D. outlines the nature of the plan:

The redesign of the West Virginia Medicaid program has recently become a leading but controversial example of efforts to reward personal responsibility. West Virginia has a population of 1.8 million; as compared with the United States, it has a higher percentage of residents with Medicaid coverage and near-poor or poor incomes (see graphs). In May 2006, the federal government approved the state's plan to provide reduced basic benefits to most healthy children and adults who are eligible for Medicaid because of low income while allowing them to qualify for enhanced benefits by signing and adhering to a "Medicaid Member Agreement." The enhanced benefits include all mandatory services as well as additional age-appropriate services that focus on wellness. Examples include diabetes care beyond basic inpatient and outpatient services, cardiac rehabilitation, tobacco-cessation programs, education in nutrition, and chemical-dependency and mental health services. Under the basic plan, prescriptions are limited to four per month; under the enhanced plan, there is no monthly limit. According to Nancy Atkins, the commissioner of the Bureau for Medical Services in the West Virginia Department of Health and Human Resources, the goals of the redesign are to streamline administration; tailor benefits to specific groups; coordinate care, especially for members with chronic conditions; and "provide members with the opportunity and incentive to maintain and improve their health."

To remain in the enhanced plan, members must keep their medical appointments, receive screenings, take their medications, and follow health improvement plans; West Virginia will monitor "successful compliance with these four responsibilities."³ Members whose benefits are to be reduced because they have not met these criteria will receive advance notice and have the right to appeal. Those who meet their health goals will receive "credits" that will be placed in a "Healthy Rewards Account" to be used for purchasing services that are not covered by the Medicaid plan. Although details about how these accounts will work and what services will be eligible for purchase are forthcoming, the services might include fitness-club memberships for adults or vouchers for healthful foods for children. In July 2006, transition to the new plan began in three West Virginia counties; the program will eventually include about 160,000 people — or about half the state's Medicaid beneficiaries. Beneficiaries who are 65 years of age or older or who have disabilities will retain their current level of coverage, as will some others, such as children in foster care. (NEJM 355:8 pg 754)

The plan seems sound: give patients motivation to change by enhancing their benefits if they do achieve certain goals that will lead to improved health. But there is a problem with this:

There are many reasons why patients might not comply with medical recommendations. These include poor physician–patient communication; side effects of medication; advice that is impractical to follow for reasons that include job responsibilities and difficulties with transportation or child care, psychiatric illness, cost, the complexity of the recommendations, or the language in which they are communicated; and cultural barriers.⁵ Patients who may benefit from additional services, such as diabetes care, education in nutrition, or chemical-dependency and mental health services, include many who might have difficulty with compliance, thus increasing the likelihood that they will not be eligible for these services under the West Virginia program. Moreover, as compared with elderly Medicaid beneficiaries and those with disabilities, healthy children and adults are inexpensive to cover. Any savings for these groups could be offset by the costs of administering the changes in Medicaid or by increased costs for mandatory services for patients who remain in the basic plan.

In a subsequent article, Gene Bishop, M.D. and Amy Brodkey, M.D. underline the difficulties more succinctly:

Mary Jones is your 53-year-old patient with diabetes and obesity. These conditions developed after she began to take an atypical antipsychotic drug for schizophrenia. Jones signed a treatment contract stating that she will keep all her medical appointments, attend diabetes education classes, and lose weight. She attended one class but became paranoid and left halfway through it, and she has gained 5 lb. You gave her educational materials to read, but you have discovered that she doesn't understand them. She has just missed her second consecutive appointment with you; last time, she didn't have bus fare. Neither her glycated hemoglobin nor her blood lipids are at target levels. You are now legally obligated to report this information to your state Medicaid agency, and Jones may lose her mental health benefits and some of her prescription coverage as a result. (NEJM 355:8 Pg. 756)

They go on to raise what is, to me, the crucial problems:

The plan makes explicit the belief that persons must behave according to set norms in order to deserve health care and health insurance. What physician has not sighed in frustration over the patient who continues to smoke after angioplasty? Yet while promoting healthful behaviors, we continue to offer care. The West Virginia plan risks the application of an actuarial value to every behavior. Is riding a bicycle to work good for your health because of exercise or bad for your health because of the risk of accidents? Is it irresponsible to refuse to take a medication if it makes you ill and you cannot reach your physician to ask for advice?

The plan asks physicians to violate all three fundamental principles enumerated in the Physician Charter on Medical Professionalism: the primacy of patient welfare, the principle of patient autonomy, and the principle of social justice.⁵ It raises potential conflicts by placing physicians in a reporting situation in which the public health is not at issue, possibly asking them to harm their patients or their relationships with patients. As physicians become agents of the state, poor patients' distrust of the medical system can only increase. Although the plan's member agreement mentions the patient's right "to decide things about my health care and the health care of my children," it does not recognize that noncompliance can be an expression of disagreement with the physician. The plan promotes discrimination not only on the basis of socioeconomic status, but also on the basis of diagnosis: surely, people with mental illnesses who have trouble managing activities of daily living such as keeping appointments will be discriminated against under a plan that rescinds their mental health benefits because of such lapses.

So here we are stuck between Scylla and Charybdis, either being sucked down by the self-indulgent waste of individual freedom or eaten by the dragon of legislated personal responsibility.

This is a problem basic to this country. The conflict is always between the individual freedom (championed by the libertarian) and governmental control (championed by the socialist). Clearly there are pitfalls in both, but where should we end up?

So, Sugar, what'll you have?

Wellness

My older brother, who is an ecologist (a limnologist, to be specific), once told me that he was sick of hearing people talk about the "balance of nature." He went on to point out that the natural world is in a constant state of flux - anything but balanced. Scientists believe, for instance, that when trees came into existence, they caused nearly 95% of the species present at the time to go extinct. This is not to say that you should not be responsible with the natural world we live in (he is, after all, an ecologist), but it points out the fluid nature of things; the only constant is change in our temporal world.

There is a school of thought in certain circles that embraces the idea of wellness much in the same way that certain naturalists embrace the balance of nature (see http://www.wellness.com/ and http://seekwellness.com ). Much of these ideas are put forth my more alternative practitioners (such as Andrew Weil, MD) in the guise of mainstream medicine.

Wikipedia (the ultimate source of all reliable information, of course) divides wellness into two different definitions:

1. Alternative Medicine - Wellness is generally used to mean a healthy balance of the mind-body and spirit that results in an overall feeling of well-being.
2. Mainstream Medicine (under the heading health) - In any organism, health is the ability to efficiently respond to challenges (stressors) and effectively restore and sustain a "state of balance," known as homeostasis. Sickness is merely the absence of health. All organisms, from the simplest to the most complex, reside on a spectrum between 100% health and 0% health.

These definitions beg the question: does wellness really exist? Is our goal as physicians to promote wellness, or simply more wellness? I believe that wellness is a concept, not a reality. It may be worthy of our striving, but accomplishing this is not possible. Here are the reasons I think this is the case:

1. I disagree with the Wikipedia definition of Homeostasis as a "state of balance." I prefer the dictionary definition: The ability or tendency of an organism or cell to maintain internal equilibrium by adjusting its physiological processes. The body does everything it can to get to a state of "balance," but there are constantly forces moving it out of balance. Even if balance were achieved, it would soon be out of balance again.
2. Aging - Aging is the continuing process of anti-wellness. Everyone dies due to a process that is built in to the DNA itself. This is true for every organism. Could wellness really occur when aging is happening. Even children aging, growing bigger and stronger, are in a state of unbalance (as witnessed by my 13 and 14 year olds!). The implication of growth in a child is that the current state needs to be changed. It is pathologic when change stops happening (growth delay, etc.).
3. All of nature goes against this. Organisms ultimately die, and this happens because the need for increased diversity and the need for adaptation to environmental changes. We do not exactly fit into our environment, and so there is a homeostatic force on a ecologic basis that pushes toward adaptation to these environmental mismatches.
4. Entropy - This is the tendency of things to become increasingly disordered. Although the evolutionary trend toward increasing complexity goes against this in a small area, the overall force is toward disorder. This is one of the laws of thermodynamics (and not one of the suggestions of thermodynamics).
5. It is immeasurable. Conceptually it is impossible to prove wellness, even if it were reached. Some of this has to do with the concept of observer effect (as displayed in the Heisenberg Uncertainty Principle). If we measure something, we change it by our act of measurement. This means that if homeostasis is actually attained, it will be disrupted when we assay for it. On a more basic level, however, science deals with disproof much easier than proof. To prove wellness, you have to disprove all forms of illness. This is simply impossible.

Aside: My father is a physicist, and one of his favorite signs he saw was one that read "Heisenberg may have slept here."

So what does this mean for physicians? I think it has a big effect on how we approach problems. Problems are normal and certain problems are physiologic. A good example of this is the rebellious teenager. When a person is transitioning from the dependency of childhood to the independence of adulthood (both relative), there is a period of increased disorder as this transition is made. The child acts up, but does so to some extent to make this transformation. As a parent, we do not always see this behavior as pathological (as annoying as it can be). If this disorder is not present, it is a sign of problems. Our goal as physicians is to oversee this disorder and discern if there is any signs of "abnormal disorder." This poses a great challenge, but is a very important lesson to teach parents. Expect challenges.

Another area of application is in the psychologic realm. We want everyone to be happy all the time - it is part of our natures. Yet we do very poorly when we do not go through hard times. Again, a good example is the "spoiled" child. If a child is given everything they want, they will become a pathologic personality. If a parent does not cause the child to go through sadness and anger, then they are harming the child. I always tell parents that our primary goal is not to make our children happy. Our primary goal is raise good children. If you raise a child with happiness as the primary goal, you will make them neither good nor happy. If you raise them to be good, then they will (more likely) be both.

Treating depression is always a challenge for me. Sometimes I think people are pathologically trying to avoid pain, when that may be what is best for them. But it is very hard for me to be the one to decide what they need in this arena. I do think that sometimes I am doing them a disservice to treat their depression. We need pain to allow us to grow emotionally. Pain is just evidence that we are not yet where we need to be. I use the analogy for patients of chest pain. If we seek simply to treat the pain and ignore the cause of the pain, we can kill the patient. We need to be able to feel pain so that we can know when something more serious is going on.

This is a line that all physicians must draw. To some extent, we are managers of pain, and not promoters of wellness. I do think that wellness as a goal has some merits, but I think that sometimes we "lose the forest for the trees" by not paying attention to the discreet details of illness prevention. There is no balance, just homeostasis. As we help people we need to keep in mind that we are ultimately here to relate to our patients as they go through life and not treat them as a project to complete.

Good News

I have posted previously about the emotions of being a doctor, bringing the stress home, and when patients make the ultimate bad health decision. That makes it seem like all of my days are bad - they aren't. It makes it sound like I have second thoughts about being a doctor - I don't. There is no other job I can see myself doing.

But despite that, it helps to be able to have good days to offset the difficult ones. I had the opportunity lately to give good news to some of my patients. That good news followed the sinking feeling of potential bad news in both instances.

The first was a 37 year old gentleman who I had cared for the past 10+ years (both him and his family). He came in to see me for a testicular mass. Normally, testicular cancer only affects men in their 20's. Since I trained at Indiana University, home of Larry Einhorn - the doctor who discovered cis-platinum - the cure for testicular CA. This is where Lance Armstrong went for treatment of his cancer. This patient came in with a lump on his one of his testicles, worrying if it may be cancerous. Palpating it, I could not deny that it was worrisome. I sent him to get a testicular ultrasound which soon came back as "worrisome."

Then I had to make the phone call I never like to give. I called the patient and told him: "I want you and your wife to come in to talk to me." They knew what this meant. It meant that there was bad news.

I never beat around the bush when they are in the office - they know what I am going to say: "the ultrasound showed something very suspicious of cancer. I am going to send you to a urologist and he is going to set you up to have the testicle removed." I reassured them that even in the worst-case scenario, testicular cancer has a good prognosis. I knew this did not mean much to them; cancer is cancer.

My nurse, whose husband had testicular cancer at the same age, told his wife that if she could do anything for them, they just needed to call. Since he was in his upper 30's, the most common cancer is seminoma. When I trained, this was a little harder to treat than the germ-cell tumors common at younger ages. This is what my nurse's husband had, and it became metastatic after the first round of treatment. He required fairly aggressive chemotherapy, and is now a cancer survivor.

The day of the surgery, we got a call from the urologist - the diagnosis was teratoma, a benign tumor. Who knows how long it had been there, but it had probably gone from a germ-cell tumor to full maturity as a teratoma. Germ-cell tumors are similar to stem cells in that they can develop into many kinds of tissue. Teratomas are tumors resulting from the full development of germ-cells into mature non-cancerous cells. In women, these are the tumors that can contain hair and teeth. I once heard a joke that to diagnose a teratoma in women, you put some ice to the abdomen and use your stethoscope to listen for chattering teeth.

The end result: good news.

My second patient was a 65 year-old gentleman who was new to the practice. He said he had been having lower abdominal pain on the left, which he suspected was a hernia. Upon exam, he had a large mass in the left lower quadrant. It is really hard to know how to respond when you find something significantly worrisome on exam. I asked him if he had noted the mass and he said he had. I told him that this was worrisome, but we had to get a CT scan to figure out what it was.

There is not much good that it can be when there is a mass like this. I went over the possibilities - certainly there was cancer as a possibility, but maybe it was just an intestinal obstruction causing what felt like a mass. It was not real tender, so I doubted that an infectious etiology was the cause.

I usually do what I can to minimize the wait for patients in this circumstance. It is tough to say, "I think it could be cancer, but you have to wait until next week to find out." I know that every night of waiting will be sleepless, so I get it the test as quickly as possible. Yesterday I got the surprising news that the CT scan showed "probable diverticulitis." This was a shock to me, as diverticulitis is usually tender to touch on exam. But he reminded me when I called him that he was on antibiotics for his prostate. This was a phone call I was glad to make.

There is a great honor to be able to stand by people during their hardest times. I really find it is one of the more satisfying parts of what I do. But it sure feels good to take a big weight off of people's shoulders. It sure feels good to give good news.

Stick to it

I learned to draw silly faces while in boring classes. I remember doodling endlessly in certain classes to pass the time. I would say that I was paying attention, but the fact is, I never did all that good in these boring classes. Fortunately, I was able to overcome my doodling and get into medical school.

To my delight, I found that this odd talent could be very useful in pediatric practice. I now put young children at ease by drawing a silly face on a tongue depressor and making it kiss them on the nose. This usually gets a smile and gives them something to play with. Some kids have kept these sticks for months after I gave them one. Others ask for different faces on both sides of both ends (I am not talented enough to draw 4 different pictures like this, but I do my best).

Much of pediatrics is about creating comfort. There are some children who scream no matter what you do. There was a period of time where I took care of several of these children who went to my church. The problem was that they would scream loudly whenever they saw me, even in church. This was somewhat annoying for me and very embarrassing for the parents. Most children, however are capable of being drawn in if you are creative enough.

For almost as long as I have practiced, I have had a Scooby Doo sticker on my stethoscope. This is a lot of fun for kids, making them less scared of this otherwise medically intimidating object. I have Scooby kiss their back and chest while I am auscultating their lungs and heart. This at least gets me a few seconds. Since I am also an internist, it is interesting to see the reaction from the older segment of my patient population. I have yet to hear complaints about it, but I doubt they would complain about it to me. I am who I am, however. I am not a formal guy (I posted earlier about wearing sandals), foregoing the tie and white coat for the more casual look. If patients don't like it, they can find another doctor. I have 5000+ who do like it, so I am satisfied.

Stickers are especially important. I am fanatical about having good stickers in the office. For boys, having Spider Man (more popular than Batman and Superman), Hot Wheels, and some sort of heavy construction equipment stickers is a must. For girls, Barbie, Strawberry Shortcake, and Dora the Explorer stickers are equally important. A mini-crisis ensues if we are without these. For the 6-8 year old boys, I like to hand them a Barbie sticker and see their reaction. They treat it like it is coated with Ebola virus or radioactivity. The parents get a good laugh.

I often find that the younger children are more comfortable if you give them a sticker before starting your exam. Getting a gift can improve the visit considerably. I am also fond of tickling children. I have said that pediatrics is one of the only professions where you can tickle someone without being arrested. You have to pick and choose who you tickle, but doing so has gotten me labelled by some children as the "tickle doctor" (others have called me "doctor macaroni" for the fact that I find it in their ears).

The bottom line is that I like the kids to see the experience as enjoyable and even fun. I know that this is not always possible. Cleaning out ears and giving shots can greatly dampen my public relations efforts. Some children are not ever charmed. But it is the laughter and smiles that makes pediatrics so enjoyable for me, and such a nice contrast to my internal medicine practice.

We do not EVER give Precious Moments stickers
They are of the Devil!

Heaviness and Hurt

Hurt so deep
Saber of emotion
Blade of pain
Cuts through the thin veneer
The skin we coat our lives with
Protecting us from the unwanted intruders
Of sickness, loneliness, emptiness
Fear

They walk in
Day after day, month, year
All hoping for a cup of cold water
To soothe their parched lips
The endless flow of need coming through the door
Tugs at my tired arm once again
Bidding me come, help
Hold

Some days are heavy
Room after room
Heart after heart
All with hands open and insides exposed
Bruised, bloodied, bludgeoned, buried in despair
Looking for slivers of hope
Looking for escape, relief
Rest

On my way home
Power totally drained
Thoughts on hold
I try to put down the load
Shoulders still aching from the weight
The heaviness of hurt, the immensity of pain
Turn to face my own life now
Take a deep breath in
Sigh

A painful honor
A noble burden
Standing in the gap
When all other hopes have disappeared
That I should share suffering tears
That I should hold hopeless hands
I’m not that special or wise
Just me, tired, insecure
Weak

No praise to give
Too deep, too real
I wonder why I have been called
To be the one they come to when others fail
I had no teachers in this lesson
Aside from my own scars
Healed wounds, yet hurting still
My many mistakes
Failures

Dying, hurting, scared, alone
It is my hand they come to hold
I can only give thanks
For the honor given
The weight can crush
I daily ask for strength
To carry some more loads
To hold some more hands
To open that door
Again

All Ears

Fellow bloggers, lend me your ears.

I can probably attribute a substantial percent of my lifetime income to ears (although I have never done the math). In pediatrics, otitis media (middle ear infection) is a staple for office visits during the winter, and otitis externa (swimmer's ear) is a frequent reason for visits during the summer. So I have spent a substantial amount of time (probably several weeks) of my life looking in people's ears - especially children.

Over the years, I have made several observations. First I have noted that people tend to be very apologetic about the wax in their ears. I am not certain why this is the case, as it is a natural condition to have wax in the ears, in fact the absence of wax can cause problems (I once heard that wax keeps bugs out of people's ears, but I could not verify it). People often say something like, "I'm sorry about my ears. I didn't get to clean them out." What are they thinking? Do they really think I am offended by the sight of wax? I got some understanding of why people apologize in this situation when I went to get my teeth cleaned and found myself apologizing for the tartar on my teeth. Same thing.

Second, there are a number of odd things I have discovered in ears. Kids tend to put things in their ears and never tell people about it. I have found beads, breakfast cereal, and other assorted small objects in the ear canal. One older gentleman had a toothpick in his ear that he did not know about. The worst thing is when cockroaches get in ears. I usually get my nurse to irrigate ears, but with roaches I just do it without telling her as she has a strong aversion to these critters (as we say in Georgia). Roaches enjoy the warm and dark atmosphere, but can't back out well and so usually die (maybe the wax kills them).

One of the most important skills for a pediatrician is to clean wax out of ears. This is an acquired skill that you perfect over years of practice. Since otitis media is a common problem, it is important to get a good look at the eardrum. We use a tool called a "cerumen spoon" - cerumen is the fancy-schmancy name for earwax - and dig wax out of the ear. Sometimes this is an easy task (easier for adults than children), but sometimes it is a high-decibel experience which leaves both parent and pediatrician physically and emotionally exhausted. Occasionally the ear canal is very sensitive and bleeds when you clean it. I hate it when this happens, because it is hard to explain to parents why you caused the child to bleed from their ear. An interesting phenomenon which happens when you clean some people's ears, they have a strong need to cough. This is a phenomenon called Arnold's Reflex, caused by a branch of the vagus nerve going to the external ear canal. Why it decided to be this way is a mystery to me, but Dr. Arnold has to be happy because let him go down in posterity (I always felt sorry for Dr. Cowper). As an aside, one of the causes of chronic cough is earwax or a hair on the eardrum - due to our dear friend Dr. Arnold.

I generally don't mind cleaning out people's ears (even the children). When you get a "Mother Load" of wax out of someones ear, I have found the most common thing for people to say is, "Good Lord," followed closely by "Oh my God." I am not sure why wax brings out the religious side of people. Perhaps Dr. Arnold can explain that too. One thing I will never do is to clean out my own kids' ears. I did that once when they were young and it was terrible to have my wife watching with great suspicion as I subjected my son to external ear torture. I have never done that again.

Finally, I have found that I have made a progression over the years I have practiced as to what I say when I look in ears. Probably one in two adult patients (or parents of teenagers) say "can you see through to the other side?" when I look in the ear. I have resorted to saying "No, the spider webs are getting in the way." For young children, telling them you see something in the ear is a well-used way to get them to cooperate. Over the past 12 years I have made a progression of what I tell kids I see:

1. I started out seeing Barney in the ears - Even thought I detest this character almost as much as Precious Moments (that's saying something!), I found it was quite popular for a time. After a while, thankfully, the popularity of this fingernails-on-a-blackboard character waned and I no longer had to profane the air with his name.
2. Then I started saying I saw birdies or butterflies in the ears. This worked well with girls, but the boys just sneered.
3. I have tried multiple other characters, such as Dora, the Wiggles, and Sponge Bob (I never did stoop so low as to do Telletubbies), but their acceptance was never as wide as "He who should not be named" - the dinosaur thing.
4. My most popular ear finding is to say there is food in their ear. I have started saying I see peanut butter in the first ear, and another food in the second (usually macaroni and cheese or spaghetti and meatballs). This works up to older ages as well as the younger kids. They think it is absurd to have peanut butter in their ears. I ask them if they put it in there or if it squished out when they were eating. I get a lot of belly laughs from that.

I would love to hear any other interesting foreign body stories (keep it to the ears, please - no GI or GYN stories! I would also like to hear any other successful ear inhabitants used to calm the nervous child.

Just for my good friend Clark Bartram, I found a couple of interesting sites on the homeopathic and chiropractic treatment of ear problems. Simply astounding.

Losing Focus

I am generally a pretty laid-back person – at least I like to think of myself that way. I rarely get rattled by stressful situations at work. My modus operandi when I am in a crisis is what I learned when I was a resident: the first thing to do in a code (when a patient has stopped breathing and/or has no heartbeat) is to take your own pulse. The bottom line is that you are of far more use when you are calm than when you are in a panic. So the normal grind does not really bother me – or so I have thought.

I was going through some personal stresses a few months back and was having some problems sleeping. I try not to bring my personal experiences into work, and had done fairly well at keeping this at bay. My fatigue, however, was starting to build up. When I did sleep, it was not really good sleep and so I woke up with significant fatigue even after an acceptable number of hours of sleep. I found that I was dozing at lunch and at significant pauses in my day and became alarmed.

I came to realize at this point how much pressure I put on myself to think clearly. Since I am primarily a problem-solving physician (I say that the main procedure I do is scratching my head – maybe an explanation for that bald spot), my bread and butter is my thought process. People don’t pay me for my skills with my hands nearly as much as they rely on my problem-solving ability. So any lack of focus is a real problem. I don’t want to give a poor-quality product to any of my patients that come in. Even the relatively simple problems like sinus infections and cough can be a more serious problem lurking just below. It is my job to listen for any aberrations from the typical pattern that may suggest something else going on. I take great pride in my ability to do this. So the thought of having a “bad day” really had me upset. I basically shoved the coffee IV in my arm and slogged through the fatigue as best as I could.

Everyone is entitled to have a bad day at work, but do you want to go to your doctor when he/she is having one? It had never really occurred to me that I have done my best to have the mental discipline to not allow bad days to happen. So was this pressure always there? Doing the inventory of my life, I began to see that I often came home with a lot of fatigue that I could not explain. I often was little use to my wife upon coming home and just dropped on the couch and either watched TV or played on my computer. The main reason for this fatigue, I concluded, was the sustained mental concentration of a typical day. This was often magnified by difficult cases, either emotionally or medically, that I faced on that day.

So how are we supposed to face this pressure? Is it the inevitable consequence of a job where people’s lives may be in your hands? Is there anything to do to escape from this, or am I condemned to being useless when I come home? Since that day I have been much more conscious about giving myself breaks during the day. This does not mean that I necessarily take more time between patients, but I just put on some music, talk on the phone to my wife, or chat with the staff about something non-medical. Beyond that, I have made my trip home from work one which allows me to mentally recover. I consciously change my mind out of the “work” mode and relax. The work at home does not require the intensity of my job and can actually be relaxing if I let it be.

The bottom line is that we need to be more self-aware. It is good t know what your stressors are. I was fooling myself thinking that I did not take work home with me. I was letting my job take big nasty swipes at something much more important: my family. I am grateful for the lesson being learned before it caused too much damage. Maybe my learning this lesson can help other physicians.

The shortness of life

Warning! Those of you expecting a goofy and silly post, this is not one (in fact it is quite serious).

My nurse cried. He was one of our favorite patients. He missed his appointment today, and since that was not his nature, I called to see what was up. I got his son on the phone who told me, "He's dead. He shot himself on Sunday." I couldn't believe it and confirmed that this was, in fact, the right number. He left a note saying he was tired of being sick all of the time and he was sorry to do it this way.

The thing is, he would have been one of the last patients I would expect to do something like this. He was in his 70's and had been fairly sick over the past week, but I was doing what I could to get him better. He had multiple long-term illnesses, including diabetes, but they were generally well-controlled. He was very fond of me and especially my nurse. He seemed to truly enjoy talking and would make me laugh with some wry comment when he came in.

We first won him over when he transferred care from another doctor. He was surprised at how aggressively we went after his diabetes, but felt so much better for it that I had won a lifelong patient. Then we were able to get him his medications for free through patient assistance programs. After that, he started sending his friends (mostly women) to me to be their doctor. He was well-loved by the ladies, but not in a sensual way - they seemed to have a genuine affection for him. That affection is what we too felt for him.

He spoke slowly and with a gentleman's southern drawl. He was known to my staff by his first name, and he was one of those patients I was always happy to see. He gave us absolutely no warning about what was going on inside of his head. When I saw him last week I was concerned about his health, but he never told me how he was feeling.

This abrupt ending makes me take stock of my actions. I do my best to spend enough time with my patients, but tend to get behind and have to hurry to not get any later. I try to listen to what they are really saying (as the famous saying among doctors goes: the patient will always tell you what is wrong with them - you just need to listen to what they are really saying). I try to practice by that rule and listen to what they are really trying to tell me. Yet I get caught up in the rush, the phone calls, the drug-seeking patients, the anxious mothers, and the pile of forms that I have put off filling out. I am trying to manage their diseases by evidence - getting their numbers just right and making sure they have gone to the right specialists. That's good care, right?

There are other distractions too. I spend (too much) time blogging and reading blogs. I go around giving talks to doctors about computers. I am the senior partner of a business, so we have all of the financial headaches to worry about. Dare I leave out the fact that I have a wife and four kids at home who need me? Life is busy. Life is busy.

So what does it mean in this context that I laid my hands on a man who later in the week committed suicide? I was one of the last people to physically touch him while he was alive. Did I miss anything? I don't really think so. He wouldn't have wanted me to worry about him. But I am glad for all of the time I did spend with him. I am glad that I got to enjoy him as a person for the time he was on this earth. I am glad I was one of the good things in his life. I am strangely glad that I knew him enough to be so saddened by his abrupt end.

There will be no funeral. There will be no good-bye. We just have the memory of this gentle southern man who kept it all inside. Maybe I could have done differently, but I won't go there. I can't go there and keep from going crazy. I got to add more to his life than most did. I need to carry that fact into the exam room tomorrow when I see other patients. Yes, there is a lot to do. But there is really no greater honor to be allowed to serve these people. I can't forget that. We all can't forget that.

Good-bye, Jimmy. Thanks.

Losing your patients

In a recent post, a fellow doctor talked about the difficulty one feels when a patient leaves your practice to see another doctor. I strongly sympatize with the emotion he felt, since it has happened to me plenty as well (not too often, though - I don't want you to get the wrong impression!). No matter how good of a job you do, someone is going to be dissatisfied and not everyone is going to be happy with the job you did.

The truth is, I tell patients that once they lose their trust in me as a doctor (or any doctor, for that matter), then they should seek another physician. What physicians sell to their patients is trust. The patient trusts that the physician will seek to do what is medically best for them. They look to us to "worry more than they do," knowing what to be concerned about and when to become alarmed. The more patients feel that we are doing this, the more satisfied they are with the care we give.

It always bothers me when patients apologize for coming in. They feel that they are wasting my time with their problem. Their child, for instance, has a fever and is irritable and they wonder if they have an ear infection. When I look and see that it is not, then the parents feel they shouldn't have brought the child in. But my job is to do exactly this. This is why they pay me. How would they know if they should be worried if they don't come in to ask me. I think this is one of the keys to keeping patients satisfied. You need to respect their fears and address them. When a person has abdominal pain, they worry about appendicitis. When they have bad headaches, they worry about brain tumors. If they come in out of that fear, even if unfounded, I need to make sure that I have thought about that problem and usually I try to address it clearly.

The hard part is that some patients/parents have a hard time communicating what exactly they want. I do my best to get this from them, but am not always successful. I try to do my best, but there are times that the patient and me just don't communicate on the same level. As a doctor, you usually blame yourself, as it is in our nature to want our patients to like us and think we are a good doctor. When that does not happen, it is very important to find a new physician.

To you patients out there: don't feel bad when you change doctors. You need to find someone you can communicate with. Most physicians can sense when you don't trust what they are saying and as long as an attempt is made to communicate, it may be the best for everyone that you find a new physician. After all, who is paying who? It is your money, and if you are not satisfied with what you are getting for it, you should go somewhere that you feel it is well-spent.

Still, I would rather just make everyone happy...

Sigh.

Openness of Patients

It happened again yesterday.

"Gosh doc, you've put on a bunch of weight."

There is no other job where people feel free to say that kind of thing. I have learned to take it in stride, even when my stride is more and more brought down by the cruel force of gravity. Why do people feel they can openly comment on my weight? I think there are several reasons for it. First, they know I have the right to comment on their weight. I am one of the few people who can do it and get away with it. Actually, it is the only place I can do it. I can't comment on my wife's weight. I certainly can't comment on people's weight outside of the office..."well, Susan, it is good to have you over. Gosh, you have gotten way heavier!" Nah, it just wouldn't fly.

The second reason people feel they can comment on my weight is that they know I can take it. I doubt if I was a female doctor they would do it. I also doubt they would do it to a specialist they don't see too often. But when they have been coming to me for a while (for some, over a decade), they get to know me and know that this kind of thing does not bother me. Well, it doesn't bother me too much.

It actually bothers me a little. I am usually caught a little off guard when they say it, and come back with some clever remark like, "yes, I keep getting ambushed by cookies." or something like that. It is nice in a way, because I think they are doing it in kindness - trying to hold me to the same standard that I hold them. I have never felt that anyone meant bad when they said it.

I can't overlook the fact that when they say it, it usually is true. I do need to start eating better and exercising (I actually just got back from the YMCA). I also must point out that they tend to be much quicker to comment when I have lost weight.

Such is the life of a doctor. It has it's ups and downs, but I would not trade it for another job.

Making friends with your patients

I had a bad start to the day today. My computer was messing up and my son just suddenly flew off the handle with my wife. Things just seemed to be conspiring to make me irritated. Then the first few patients of the day this morning were folks I had taken care of for the better part of 12 years. They are both diabetics with whom I have gone through a lot in their lives. I have to say, it was good to see both of them and it really picked up my spirits.

As a doctor, you have to stay a certain distance from your patience emotionally. If you get to close you start to lose the objectivity that they are coming to you for. You have to be able to look for bad stuff in people you like (I just diagnosed a woman this morning with metastatic cancer in her back). Yet I have found that this line gets more and more fuzzy as you practice for more time. You definitely enjoy the company of some of your patients. It is very satisfying to feel that you have been a significant part of their life, and a positive one at that. Maybe I am just getting more sentimental as I grow older (which I definitely am), but I am enjoying this aspect to my practice more and more.

I have gotten so that I routinely hug my little old ladies at the end of the visit (the ones I have seen for a while) and it really brightens their faces. The physical touch that is not "professional" but instead one of genuine affection/friendship is very well received. I think it aids in the healing process. The same is true for playing with the children. I have this thing where I pick up their arm and say, "Uh,oh, what is that there?" and I start tickling them under the arm. This makes them appreciate coming to the doctor more and hence more willing to trust me. Plus, it is just plain fun.

Of course, their are limits to this. I don't hug anyone under 55 and don't tickle anyone over 10. What is funny or nice in one situation can get you arrested in another. But I am not sure I would want to practice if I did not have the chance to have this personal relationship with my patients. It is often therapeutic for me as well.

Doctors in Sandals

OK, I admit it, I am a card-carrying member of the casual footwear society (CFS). Not that I don't like wearing shoes, but I just like the feel of sandals. When I started doing this in the office, I got mixed reviews. Some seemed to like the fact that I was somewhat laid-back in my attire, while others are offended. Once a lady left my nurse with a newspaper article that referenced the following article:

BACKGROUND: This study examined patient perceptions and attitudes toward various aspects of the male and female physician's professional appearance in the family practice setting. METHODS: Four hundred ninety-six patients from two family practice clinics in Knoxville, Tennessee, completed a valid and reliable questionnaire. Questionnaires were offered to all patients on registering at their respective clinic during a 2-week period. RESULTS: Most patients had no preference regarding the age or sex of their medical care provider. A nametag, white coat, and visible stethoscope were the most desirable characteristics, whereas sandals, clogs, and tennis shoes were the least desirable items. Younger patients were generally more accepting of casual attire than were older patients. Office clinic location was the most important predictor of preferences in six of the significant characteristics. CONCLUSION: Our findings support the results of both studies published two decades earlier and more recently. Patients prefer a traditionally dressed physician as opposed to one who is dressed more casually

My nurse was furious and told me: "Dr. Lamberts, never change!" I thought it was humorous.

The fact is, I am not an overall casual dresser. I wear a button-up shirt and kahkis usually, never wearing jeans or a non-dress shirt. But my sandals are one of the trademarks. On the days that I either can't find my sandals or just have the desire (or, "hankerin" here in God's country) to wear regular shoes, I will invariably get a comment from a patient asking me why I am not wearing my sandals.

My theory on all of this is that patients may respond this way on a questionnaire, but if you ask them, "what is more important, whether you can have a good relationship with your physician and feel that he listens to you, or whether he dresses nicely?" Most people would choose the doctor who gets along well and listens. I don't put on airs like I am different from my patients. I don't want them to feel I am above them. I am the one who is lucky to be there and want them to know that.

And if they still don't like my sandals, they can go see "Dr. Kildare" down the hall.

I am an Internist

My training was in both internal medicine and pediatrics, but I have told people that if you held a gun to my head and told me to choose one, I would choose Internal medicine. I would also think you had far too much time on your hands.

So why would someone choose to be a "flea?" Flea is a derogatory term people use for an internist. Why Flea? A flea is the last thing off of a dead person. While I cringe a little at the comment, I am proud to be an internist. The things I do daily as an internist that I enjoy include:

1. I like elderly people. You get to be good friends with some of these people. They are happy to see you and I am genuinely happy to see many of them.
2. I like the problem solving side of internal medicine. If I was to just do pediatrics, I would get bored after a while. Most kids have a single problem. It is usually not much head-scratching I have to do to figure out what is going on.
3. I like the long-term interactions. Often it takes a while to figure out a problem or to stabilize a medical condition. I find that the process of working on a chronic problem or the untangling of a medical mystery is a good way to build a relationship with people. The give and take between doctor and patient is much of the joy.
4. I find there is honor in being the one to stand by my patients in their hardest hour. Many people feel that it is depressing to be around sick and dying people. Yet I find the attitudes they carry and the way they face suffering is amazing. It is an honor to be with them as an observer, but even moreso as someone who can help in the time of the greatest need.
5. The great variety you see every day. Whereas with pediatrics, you expect to see a lot of URI's, ear infections, and well child checks; the internist never quite knows what is going to come through the door. They don't teach a class in medical school about "What to do when a person's feet tingle every week - worse with stress." Now, some of these complaints are just plain weird and impossible to figure out, but I pride myself in my ability to untangle what the person is really saying.
6. Chronic problems like Diabetes and Hypertension are very satisfying when you get them well-controlled. It is great to show a patient how much they have decreased their risk of future problems.
   

OK, I know that some will read this and say, "Eeeww! None of that sounds good to me. That is why I am NOT an internist." Good. I am glad there are people who are different from me. Personally, I would much rather build relationships and solve problems than do a procedure. So, now you know why some of us are fleas!

Top 10 Perks of Being a Pediatrician

People think of pediatrics as "Veterinary medicine" or "just all those screaming kids," but there are a lot of perks:

1. As much Pedialyte as you could ever drink.
2. Being able to tell your spouse: "I should know about this, I give advice on this for a living" when you get into a parenting discussion. (They subsequently get mad at you and don't talk to you for the next day).
3. Seeing the expression on a young boy's face when you give him a Barbie sticker.
4. Having a "Fan Club" comprised entirely of girls in the range of 4-10 years of age.
5. Getting paid for tickling kids.
6. Earwax, lots of it.
7. Having the pleasure of sitting in a small room with a hyperactive child and the mother yelling "stop that!" every 5 minutes.
8. Justifying all of the doodling you did in boring college classes by now drawing goofy faces on the end of a tongue depresser.
9. Being wonderfully popular at parties and at church, as people hit you up for advice on rashes, behavior problems, bedwetting, etc.
10. The grin you get from a 6-month old when all you do is look at them.

By the way, that is a picture of my daughter when she was much younger. The eyes just cut right to my heart.

Inhale, Exhale

I like to have fun with my patients in the exam room. One thing that happens a lot is that when I tell people to breathe deeply and I listen to their chest, the other people in the exam room take deep breaths with the patient. I am not certain if they are displaying to the patient how to breathe (in case they have forgotten) or if it is just a way of being encouraging, but it is a very common thing. One part of this that bothers me is that it lowers the air pressure in the room if there are enough people in the room - the shades in the window are drawn in, it just messes everything up.

The other thing that happens commonly with the stethoscope is that I have patients hold their breath while I listen for Carotid bruits (a whooshing sound that suggests cholesterol plaques in the carotid artery). If I forget to tell patients they can start breathing again, the sometimes keep holding their breath. It really gives me a sense of power that they need my permission to breathe (although the weight of the responsibility keeps me up at night).