Category Archives: rural doctor

by

Templates and the death of medicine

One of the many problems that are killing medicine in the US and especially primary care is templates.

Templates are a nightmare.

Why?

In a template, for back pain, there is a list of questions and in some there is also a list of answers. The “provider” asks the questions on the list and then checks off the answers. This is absolutely terrible brainless stupid failure of medicine. Because the most important answer that the patient gives is the one that does not fit the routine pattern of back pain or ear pain.

For example, I saw a woman for a new patient visit for back pain. Years ago. Half way through the questions about back pain I say, “How long have you been hoarse?”

She stops. She has to think about it. “Three months.”

“Continuously or does it come and go?”

Again, thought. “Continuously.”

On with the back pain. But she gets TWO referrals, one to an otolaryngologist. I ask other voice and throat questions.

When she returns she thanks me. Continuous hoarseness is worrisome for vocal cord cancer. You have to rule it out. She did not have vocal cord cancer. She did have vocal cord polyps and was going to have laser surgery.

But as a physician or “provider” you have to PAY ATTENTION. And ignoring the thing that doesn’t “fit” or isn’t relevant or isn’t on the god damned template — just don’t do it.

Another new patient. Back pain. Routine, routine, routine, one in four people get it in their lives. All the questions indicating that it’s musculoskeletal, not a disc, 99% are not discs, until:

“Sometimes my leg goes numb from the knee down.”

I stop. “How often? The whole leg?”

“Whole leg, yes.” She doesn’t know how often.

“If that happens I want to see you right away. Call.”

…because that is not a disc and it’s not musculoskeletal. And people say that but usually it can’t be confirmed on exam.

She calls. “Both legs are numb from the knee down.”

“Get in here.”

On exam she is not only numb but the muscles of her feet and ankles are weak and the reflexes don’t work right. I call neurology, anxious. “MRI from her head to her tailbone.”

She has multiple sclerosis lesions, more than one, in her brain. And a normal brain MRI from a few years before when she also had weird symptoms….

So it is NOT the template, the routine questions, that diagnose odd things in medicine. It’s the off hand comment, the puzzle piece that doesn’t fit, the symptom or sign that I notice and that gets my attention.

I hate the templates when we first get an electronic medical system. It sucks. It generates unreadable generic sentences: “The patient has ear pain. The quality of the ear pain is sharp. The ear pain has gone on for 6 weeks. The level of the ear pain is high.” Etc. Ok, that patient sounds like a robot. I quickly figure out how to type into the stupid boxes and avoid the templates as much as possible. I also start offering additions to the templates. “Ok, add this to quality of ear pain: It feels like being kicked over and over with the metal pointed tip of a cowboy boot.” Also to tachycardia: “It feels like a salmon is swimming upstream in my chest.”

See patients for one thing only. That would have really helped the hoarse woman, right?  Do the template. Do 10, 15, or 20 minute visits. The best doctors are rebelling and quitting, especially in primary care, because this is killing medicine. Why see people for one thing only? MONEY. MONEY MONEY MONEY. No. I like to work in medicine and I like to dig down, pay attention, listen and watch for the little details that stick out, the puzzle pieces that don’t fit….

….because that is what real medicine is. Not template robot medicine.

by

fawn call

This starts with my ornithology teaching assistant in college, at the University of Wisconsin, Madison.

I LOVE ornithology. A generalist class: bird wings, ecology, biology, zoology, physics of flight and they SING! Also we walk around in the woods with the teaching assistants trying to see and hear birds. We memorize their songs and markings.

We go out at night. Our teaching assistant hears a barn owl. He replies. He is an expert at that call. The barn owl answers. After a few back and forths, the barn owl swoops over us, coming to check out the caller! The barn owl is unnerving and gorgeous, passing just over our heads.

We all talk to the birds. We make pshhh, pshhh, pshhh noises and lbbs (little brown birds) will sometimes hop out on a branch, curious about us. Hooray! It’s a warbler!

We practice our bird songs.

Fast forward to the present. I walk with my friend and he is messing with his enormous zoom lens. We see crows harrying something in the top of a tree. A hawk, who calls. I start answering. The hawk is young and calling its parents. It’s the time when the parents say, you have to go hunt. My friend gets an amazing picture of the hawk looking right at us, mouth open, crying. I dig around on my cell phone, and think it’s a Swainson’s hawk. I play the Swainson’s song and then the young hawk REALLY cries: I feel terrible, as if I have teased the young one. Yes, it’s a Swainson.

We run in to two young bucks. I sing to deer. The deer are always alert and ready to run when I appear, but when I sing they just stand and look at me. My friend takes a photograph of the buck, just watching and listening to me.

My friend finds a fawn in his yard. The mother leaves the fawn for 8-24 hours. My friend has a low fence around most but not all of the yard.

The doe returns for the fawn one day. My friend is outside. The mother hops the fence. The fawn tries to, but it can’t hop high enough. It hits the fence and cries. It tries over and over. My friend goes up slowly and opens the gate. The fawn goes out the gate after he backs off. Both fawn and doe look at my friend.

I stop by his house to pick up a package for him. I park and hop out of my car. A fawn behind the fence startles and goes around the side of the house! It’s late afternoon and two fawns and a doe were lying in the shade in the front yard. The second fawn gets up and mom stands. I hold still and sing to them a little. Then I go in through the gate, get the package and slowly get back in my car.

Word gets around. The other day my friend has six fawns in his yard. He’s charmed and a bit shocked. He is outside. A doe comes and calls her fawn. It’s a bit of a meh or ma sound. My friend tries to make the same sound. Three of the fawns eating grass stop. They turn their ears towards him, alert. One fawn walks up to him….

….so now he’s a fawn caller.

 

For the Daily Prompt: gate.

by

diy

The other thing that I think of with Sam is tools and do it yourself. He told me once that when he went to college, he wanted to learn everything. He had tons of both practical and esoteric knowledge. I took these pictures at Lake Matinenda… so for those of you who don’t know, what is this? Can you guess?

That summer I helped wire an outlet attached to this and helped float the raft in the correct position, which fine tuned my motor boat driving skills. I had to hold the boat in position in wind and waves, while Sam yelled over his shoulder at me and connected lines and wires and an anchor.

705matinenda&walnut 070

 

 

by

play

I took this in 2005. My daughter is going after our friend Sam. She is wearing glow in the dark vampire teeth. He is going along with it and playing along. Three of us are playing because they are my glow in the dark vampire teeth. I have a strong connection with that playful inner child part and so I always have some toy in my dopp kit. Glow in the dark vampire teeth. Temporary tattoos. Glue and glitter for temporary tattoo stencils. A friend once looked in my dopp kit and was very surprised. His only contains toothpaste and toothbrush and razor and practical things.

Blessing on Sam and all the adults who play when the time is right….

dopp kit: http://shop.wingtip.com/why-is-it-called-a-dopp-kit