Why is she really here?

For the Ragtag Daily Prompt: object. I strenuously and loudly object to medicine meaning pills.

During my three months temp job at a nearby Army Hospital in 2010, I wanted to work with residents, Family Practice doctors in training. I finished residency in 1996 and have worked in rural clinics and hospitals for 14 years. I want more rural family practice doctors and I agitated to work with the residents in training.

The Family Practice Department had actually hired me to do clinic. They are swamped and trying to hire temporary and permanent providers as quickly as they can. Six different temp companies called me about the same job, so the word is definitely out.

Initially the department head explained that I was there to do clinic, but she changed her mind. I was cheerful about the electronic medical records. Learning a new electronic medical record is awful, but I was happy to be there, excited about working with residents and in a hospital more than 16 times as big as my usual small town hospital. Most importantly, I was patient with the computer. I have finally realized that computers don’t actually speak English. They speak computer and they are dumb as rocks and they make no effort to understand what I am saying. They don’t care. So it is no use getting mad at the dumb thing when it crashes or when it doesn’t do what I want: I have to go find someone who knows the exact language that the stupid machine will understand.

Since I was cheerful, my department head let me do what I want. I was on the clinic schedule every day, but it was empty. I would arrive and see walk-in active duty people from 6:30 to 8:00. At the same time, I would email the department head and ask what I was doing that day. Half the time, a physician was sick or had a family crisis, so she would move people around and put me with the residents. If not, I would open clinic.

I enjoyed the “Attending Room” duty. Family Practice Residents have their MD but then go through three years of training. The first year residents must precept every clinic patient. That is, they see the person and then come discuss the case with the faculty. Second year residents were required to precept two patients per half day and third year residents had to do one; and all obstetric cases were precepted.

Back when I was in residency and the dinosaurs roamed the earth, no one ever read any of my notes. This has changed. Every note that is precepted must be read by the attending and co-signed. After three years hating the electronic medical record that my small hospital bought, it was very interesting to see a different system. In some ways it was better and in some worse.

We had one or two “Attendings” in the faculty room, no more than three residents per attending. One case stands out, more because of the resident than the patient. He was a first year.

He described an elderly woman in her 80s, there for headaches. Two weeks of headaches, getting a bit worse. History of present illness, past medical history, medicines, allergies, family history, social history and the physical exam. He said, “She’s tried tylonol and ibuprofen, but they aren’t helping that much.” He frowned. “She doesn’t seem to want another medicine.”

“No?” I said.

“No.” he said. “I started to talk about medicines. It doesn’t sound like migraines and she doesn’t have anything that’s really worrisome for a tumor……but she doesn’t seem to want a headache medicine.”

“Why is she really here?”

He looked more confused. “What do you mean?”

“Why is she really here?”

“I don’t know.”

“You already said why. Think about the history.” He frowned. I said, “Ok, you said that she was worried that she was going to have a stroke. Are these headaches likely to be a precursor of a stroke?”

“No.”

“Right. But that is why she’s here, because that is what she’s worried about. Look at her blood pressure, see what her last cholesterol was, talk to her about what symptoms ARE worrisome for strokes. Find out if a family member or friend has had a recent stroke. She doesn’t need a medicine. She is here for reassurance.”

“Oh.” he said. He left and came back.

“How did it go?”

“She was happy. She didn’t want a medicine. Her blood pressure is great, her cholesterol is great, we talked about strokes and she left.”

“That’s real medicine. Forget the diagnosis if the visit seems confusing. Ask yourself what is your patient worried about? What are they afraid of? Don’t focus on giving people medicine all the time. Ask yourself, why are they really here?”

And that is why I wanted to work with residents. It’s not all diagnosis and treatment. It is people and thinking about what they want and what they are worried about.

Why is she really here?

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previously published on everything2.com
According to dictionary.com, precept is a noun. Medical school and residency have verbed it. Hey, get updated, dictionary.com!

Mordechai on fleek

For the Ragtag Daily Prompt: fleek.

In October, Mordechai the plastic skeleton hangs out in the Quimper Family Medicine waiting room. She changes outfits. We had a 10 year old visitor who rearranged everything and now Mordechai is on fleek. She is holding out emergency preparedness pamphlets.

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Slow medicine

I am practicing slow medicine, just like the slow food movement.

It took a year to set up my clinic, because I wanted time with people more than anything. And how could I do that?

Low overhead, of course. The lower the expenses, the more time I would have with patients.

I did math and based it on medicare. I estimated what medicare would pay. I dropped obstetrics, can’t afford the malpractice and anyhow, the hospital was hostile by then. That cuts malpractice by two thirds. And I chose not to have a nurse, because people are the most expensive thing. Just me and a receptionist. And a biller once a week and a computer expert who rescues us when we kill another printer or need new and bigger computer brains for ICD 10.

My estimates were on target except that it took three times as long to build up patient numbers as I thought. Ah. Oops. I was advised to borrow twice what I thought I needed and that was good advice, because I had not counted on my sister dying or my father dying or me getting sick for a while…. but so far the clinic remains open.

Slow medicine. I schedule an hour with a new medicare patient or anyone new and complicated. People who say they aren’t complicated are lying, but we schedule 45 minutes for them. And for the really complicated, we have 45 minutes for follow ups. Most visits are 25 minutes: the only visit that is less is to take out stitches.

What does slow medicine allow? In the end it allows people to speak about things that they don’t know they need to talk about. A friend dying. Fears about a grandchild. Family fighting. The dying polar bears. The environment. This difficult election. And sometimes I think that freedom to speak about anything is the most theraputic part of the visit.

I had one woman last year who established care. Complicated. I think she was in her 70s. And the medical system had made mistakes and hurt her. Delayed diagnosis, delayed care. But she was laughing by the end of the visit. She stood in the hall and said, “This is the first time I can remember laughing in a doctor’s office. This is the first time in years that I can remember leaving with hope. And you haven’t DONE anything!”

….anything, except give time and listen.

Fraud in Medicine: Heartwood

Here in my neck of the woods, people are continuing to quit medicine. Two  managers who have worked in the clinics eaten by the hospital are leaving on the same day, after 30 years. And another woman doctor, around my age, is retiring from medicine. She is NOT medicare age.

Meanwhile, the Mayo Clinic is publishing articles about how to turn older physicians into “heartwood”.

http://www.mayoclinicproceedings.org/article/S0025-6196(15)00469-3/fulltext

“As trees age, the older cells at the core of the trunk lose some of their ability to conduct water. The tree allows these innermost cells to retire…. This stiffened heartwood core…continues to help structurally support the tree…. Here a tree honors its elderly cells by letting them rest but still giving them something meaningful to do. We non-trees could take a lesson from that.” Spike Carlsen

Oh, wow, let’s honor the elderly. Even elderly physicians. Instead of what, killing them? Currently we dishonor them, right?

But what is the core of the issue? Skim down to “Decreased patient contact”:

“Already, many physicians are choosing to decrease their work to less than full-time, with resultant decreased patient encounters and decreased institutional revenue. Prorating compensation to match full-time equivalent worked will aid in financial balance, but the continued cost of benefits will remain. However, when that benefit expense is compared with the expense of recruiting a new physician (estimated by some to approach $250,000 per physician), the cost of supporting part-time practicing physicians becomes more attractive.”

Ok, so the core of the matter. “Decreased institutional revenue” and the employer still has to pay BENEFITS. NOTHING ABOUT THE QUALITY OF CARE FOR PATIENTS.

Again, the problem is still that you can’t really “do” a patient in twenty minutes, and that full time is really 60 or more hours a week. To be thorough, I  have to absorb the clinical picture for each patient: chief complaint, history of present illness, past medical history, allergies, family history, social history (this includes tobacco, drugs and alcohol), vital signs, review of systems and physical exam. And old records, x-rays, pathology reports, surgical reports, laboratory reports. I fought with my administration about the 18 patient a day quota. I said: ok, I have a patient every twenty minutes for 4 hours in the morning, a meeting scheduled at lunch, four hours in the afternoon. When am I supposed to call a specialist, do refills, read the lab results, look at xray results, call a patient at home to be sure they are ok? The administration replied that I should only spend 8 minutes with the patient and then I would have 12 minutes between patients to do paperwork. I replied that they’d picked the Electronic Medical Record telling us that we could do the note in the room. I could, after three years of practice. But it nearly always took me twenty-five minutes. I would hit send and our referral person had so much experience that she could have the referral approved before my patient made it to the front desk. BUT I felt like I was running as fast as I possibly could all day on a treadmill. Also, the hour lunch meetings pissed me off. I get 20 minutes with a patient and they get an hour meeting? Hell, no! I set my pager for a 20 minute alarm every time I went into a meeting and I walked out when it buzzed. I needed to REST!

After a few weeks of treadmill, I dropped a half clinic day. But of course that didn’t go into effect for another month and I was tired and ran late daily. And every 9 hour clinic day generated two hours of paperwork minimum: nights, weekends, 5 am when I would not get interrupted and could THINK. Do you really want a doctor to review your lab work when they are really tired and have worked for 11 hours or 24 hours? Might they miss something? It might have been best if I had been quiet and just cancelled two people a day, since the front desk knew I was not coming out of any room until I was done, but I argued instead.

The point is, you would like to see a doctor who listens and is thorough. You do not actually want a medical system where there all these other people who read your patient history forms and enter them in to the computer and your doctor tries to find the time to read it, like drinking from a fire hose. If we want doctors and patients to be happy, then doctors need time with patients and we need to off the insurance companies who add more and more and more complicated requirements for the most minimal care. One system, one set of rules, we’ll fight over the details, medicare for all.

guns in the house

During wellness visits I used to ask, “Do you have guns in the house?” in the safety/accident prevention part of the visit. Along with helmets, seat belts, smoke alarms and not driving under the influence.

As a Family Practice Board Certified Physician, I counsel patients. Family Practice is a specialty, just as internal medicine and general surgeon are specialties. A three year residency training after medical school and I retake the Boards every 10 years. I counsel patients in “annual exams” or “medicare wellness” visits.

A patient reported me to the state board because of that question. I then got a letter from the state board saying that I was being investigated but not why. Later I got a letter saying that the patient had complained that I had asked about guns. The state replied that in fact, I am supposed to counsel patients about gun safety.

I changed my counseling. Now I say: “If you have guns in the house, I am to counsel you to keep them locked up with the ammunition locked up separately.”

I get three responses:

1. “My guns are in a gun safe, locked at all times, with the ammunition locked.”

2. “I don’t have any guns!”

3. Silence.

It is the silent ones that worry me.

I did not change my counseling because I was reported to the state and the state did not tell me to change it. I changed it in hope that someone who keeps their guns unlocked and loaded, in the bedside table, under their pillow, up in a closet, or where ever, will think about it. The question “Do you have guns in the house?” is too loaded for those people.

I met a woman with an impressive star shaped radiating scar on her chest. Her boyfriend kept a loaded gun under his pillow. One night she was returning from the bathroom. He shot her in the chest.

They are not together any more.

When my son went to preschool, over 20 years ago, I counseled him. “If another child says they can show you a gun or they have a gun, say that you have to go to the bathroom. Go and tell an adult right away. People can get killed.”

He reported an overheard conversation in preschool between two other boys. One said that he knew where his parents kept a gun. The two boys were planning to leave the school to go look at the gun. I called the preschool. They already knew about it and had talked to both boys’ parents. I don’t know if the parents locked the guns up.

In Portland one of my neighbors chased his upstairs neighbor into the street one day during rush hour, stark naked, trying to hit the upstairs neighber with a 5 iron. Yes, a golf club. I am very glad the downstairs neighbor did not have a gun right then, because he would have used it. Any of us could have been killed. And later the SWAT team was called to deal with him: he did have a gun that time. He threatened to shoot himself in the head. Then he did: well, except he only creased himself. He went to involuntary psychiatry, supposedly for six months. He was back in three months. The neighborhood was very very nervous. The house next door was sold and he disappeared and we were all relieved. He was strong, completely illogical and terrifying. We discussed how to deal with him but mostly we hid.

When he chased the neighbor into the street, I had already called 911 because I heard screaming next door. My voice shook. The dispatcher said, “Yes, we know the address, we’ve had three calls and they are on their way.” The traffic stopped dead at the sight of a nude man chasing another man with a 5 iron. I unbolted my door and stuck my head out. “(C—-)! Up here!” The upstairs neighbor ran up my steps and into my house. I slammed the door and bolted it and crouched by the front window with a baseball bat, ready to hit the downstairs neighbor as hard as I could if he came through my front window.

He didn’t. The police arrived. The whole thing was over the upstairs neighbor “playing music too loud” and “not turning it down enough”. The downstairs neighbor had broken down the upstairs neighbor’s door with the five iron. The upstairs neighbor had tried to defend himself with a butter knife and then ran. The police explained to the downstairs neighbor as he was arrested that if someone breaks your door down, it is not assault to defend yourself with a butter knife.

We discussed which illegal drugs we thought he was on. This was in the 1990s, so we thought it was crack. There was a big article soon after that about a crack house. We said, whew, glad we aren’t those neighbors and then realized that it was within two blocks of our house. Great.

Drugs and alcohol and guns and anger and grief….. it is a toxic mix.

Please, lock your guns.

It’s about caring

I described helping a woman bring her bad LDL cholesterol down from 205 to 158 with two clinic visits the other day, and someone said, “I can replace you with a teacher who is much cheaper. Why should you go to medical school to talk about the things people already know? Let’s free you up to do heart surgery or something important.”

Well? What about that? Is my career as a doctor wasted because I am in primary care? I am in Family Practice and I spend tons of time counseling people about diet, exercise, lifestyle choices.

My work is not wasted.

If all we had to do was give people information, we have the information. Every magazine and newspaper screams at us: “Obesity! Stop smoking! Exercise for health! Eat right! Don’t eat junk food!”

Why do two visits with me make a difference?

People do not feel valuable and do not feel cared for in our culture. In the same magazine with articles about losing weight, getting organized, shouting “You can do it!” there are multiple advertisements for sugary desserts and things to consume. My spouse used to joke, “If I get (whatever he wanted at that time) then I’ll be a better person.”

I see pregnant woman who can stop smoking while pregnant, to care for the baby on board, but who often can’t extend the same caring to themselves after the child is born.

The history is often listed as the most important part of a clinic visit. I agree, but not just for diagnosing illness. I am listening to the person, and now with a laptop, I am recording their history. Why are they here today, what medical problems have they had, allergies, surgeries, do they smoke, are they married, do they have children? I want a picture of the person and I must listen hard. What do they reveal about their trust in medicine, about favorable or unfavorable medical interactions in the past, about what they understand or believe about their health? The visit is a negotiation. I need their view of what is happening and their questions.

The physical exam is often an interlude for me. I look at the persons throat, in their ears, listen to their heart and lungs. And part of me is collating the information that I’ve gathered, so that we can move to the next step: analysis and plan.

If I am doing a preventative check, a wellness visit, a physical, whatever you want to call it, I name the positives and negatives. Are they exercising regularly, have they stopped smoking, are they trying to eat a good diet? I name these. Are they lucky enough to have four grandparents who lived to 102 or do the men in their family die at 52 of a heart attack? A 55 year old man who has lost multiple relatives in their early 50s is surprised that he’s alive, and starting to wonder if it might be worth attending a little to his own health. He is a bit shy about hoping that he might not die tomorrow, and ready for encouragement in taking care of himself.

The visit is really about caring. Many people in our culture do not feel cared for. Moms are supposed to care for everyone else. Parents are very very busy, trying to take care of children and have jobs. People are afraid that they will lose their job, their insurance, their homes. We try to do the tasks of adulthood: have the career, find the true love, raise the children, achieve the lifestyle, home and place in our society. And many people feel that they are failing or fear failing. They have not gotten the job they hoped for. They have a house, but it is a huge amount of work. They are working very hard, but there are still so many things they would like to do or see or have. They have become overweight, they have gotten hooked on tobacco, their children are not turning out as they’d planned, the ungrateful wretches. And their parents’ health is crumbling, and in all the chaos, why would the person attend to themselves? The cell phone rings, the computer beckons, it’s time to work, to cook, to clean, to stay on the hamster wheel of life.

In clinic, for a few moments, this person is the center. They explain their health to me. They are painting a picture of their life. A patient will say, “I’ve been worrying about my mother, my son, my spouse, and I don’t take the time to exercise or eat right.”

And I say, “I hope that your mother, son, spouse does better. But you are important too. It is wonderful that you have stopped smoking, excellent! But we’re both worried about your cholesterol, right? It is too high. How are we going to take care of you? What can you fit in?”

Most people do not want to start with a medicine. They want to take care of themselves, too. They are willing to make lifestyle changes. They need encouragement and permission and to come back to see how it is going. What they need is my caring. And I do care.

I used to think that somehow complex patients would gravitate to me. But that is not true: the truth is that everyone is complex. Each person has layers and thoughts and feelings: fears and joys. I barely scratch the surface. It is the caring that is most important and each person that I see is important.

At the end of the visit, I print my note. I give it to the person. “Check it. Tell me if something is wrong. I cannot change the note, but I can put an addendum.” I see that people are shy and often show some confusion. Two pages? Single spaced? About me?

Yes. About you.

written in 2010 and published first here: http://everything2.com/title/It%2527s+about+caring?searchy=search

I took the photo in 2004, a school overnight trip to explore settlers 100 years ago….