Monday, July 30, 2007

Ask a stupid question....

...get a stupid answer.

Saw a chronic alcoholic today. He's not a closet alcoholic, freely admits to it. I see him only for acute visits, he politely declines any attempt I make to talk about his blood pressure, health maintenance, or quitting drinking.

He's had a rough year. The church that used to employ him as a janitor burned down. So he tried to take up groundskeeping, but no one has had to mow anything for 6 weeks around here due to the lack of rain.

Still, no complaints. Nice guy. Just wants his refills.

Hi, Mr. Pabst. How've you been?

"I feel great."

Good, how much are you drinking?

"Pretty much all day long. But nothin' hard, just beer. I ain't no hog."

Through the entire conversation, he's been smacking his lips. Very rhythmic, not so subtle. Smack, smack, smack.

Mr. Pabst, whaccha doing with your lips there?

Smack, smack. "Eh? What do you mean?" Smack, smack, smack.

That thing you're doing with your lips?

Smack, smack. He points to his lips and looks at me like I'm 2 beers short of a six pack. "What, talkin'? You asked me a question, didn't you?"

Smack, smack, smack.

Got my answer, didn't I?

Sunday, July 29, 2007

Garden update, midsummer

Here's the skinny on my garden this year. Hopefully, now that I'm writing it down, it will help me plan for next year.

1. I can't get anything exciting to grow from seed. I need to stop trying and plop down the $3.99 for the young plants. I learn, and subsequently forget, this lesson every year.

2. Tried some heirloom tomatoes this year. Have yet to taste one, but the Brandywines should ripen by the end of the week. Also got a Striped German. My lesson learned about heirlooms is that they produce about a third of the fruit that the super-steroid hybrids do. Not bad, just different. Hopefully the flavor will make up for it.

3. Verbena bonariensis never poked it's head above the soil. It's that seed thing again.

4. Damn bunnies keep eating my summer phlox.

5. I killed one Tamora rose before I potted the current one. Smells lovely. Blooms are a bit on the small side. We'll keep her, might improve over a couple years. Now I'll have to figure out where to store her over the winter, since she can't weather outside agove ground.

6. Gadzooks zucchini is a keeper. Yummy, yummy, yummy, from a non-zucchini fan in general, and really neat to look at when sliced.

7. Planted Straight 8 cucumbers. They mock me. They are vining all over the place, covered in happy yellow blossoms, with nary a fruit to be found. Could my cucumbers be infertile? Or just incontrovertible flirts?

A few months more of garden 2007 to go...

Saturday, July 28, 2007

So nice to see him again...

A few years back, a young, thin, heavily pierced woman came for an new patient acute visit. Chief complaint was "I want a shot to dry my milk up."

Uh, we don't do that anymore.

And, where's your baby?

The baby was premature, and was at Big Academic Center Hospital in the NICU 90 miles away, without his mother.

Through some more conversation and observation, I deduced that there were some serious mom-baby bonding issues (sharp as a tack, I am), and there were likely some mental health/substance issues as well. She was planning on keeping the baby, though in the way one might decide to keep a purse.

And she clutched the baby like a purse, too, when they showed for the baby's first checkup with me a few months later. I've never seen anyone so unemotional with a baby. Hell, I've never seen anyone so unemotional with a hamster.

So, skipping past the underfeeding and emotional neglect, she lost custody of the baby to a distant family member who intervened just at the right time. And took a new infant with medical problems into her family of 5 children.

And I hadn't seen any of them again, till this week.

Adoptive mom (who is not my patient), through a scheduling glitch, needed to see me for an incidental appointment. And she brought baby, who is 18 months or so now. Baby has some medical issues, and mom (who is facing her own medical issues) is a little harried.

But they were like two peas in a happy little family pod. I shudder to think of the emotional neglect this baby would have suffered had he stayed where he was. And I applaud all those who give of their homes, their families, and their lives to make such a huge difference for those who need it.

Tuesday, July 24, 2007

Greener pastures...

Lost a patient today. No, not that way. She transferred to another doctor.

Transfers happen a lot, both in and out of a practice. Often it's due to an insurance change. Second runner up is patients who see me or another doc in my practice very irregularly, or haven't been seen in years. There's also a group of people who were rude, demanding (usually of controlled substances or unneccessary antibiotics), or otherwise distasteful who are looking for greener pastures. I don't take any of the above transfers personally.

Then there are patients with whom it's difficult to connect. Perhaps I rub them the wrong way. Perhaps they rub me the wrong way and I'm not as skilled as I'd like to be in hiding that fact. Or the patients who experience something negative: a rude nurse, an incorrect diagnosis, a prescription error. If they don't have much history with you they are less forgiving of a small error, understandably. These two groups I do feel bad about. Not to the point of losing sleep, but enough to wish that things had gone differently.

But today was my first that really bothers me. Delightful lady, been seeing me for years. I look forward to her visits. She seems to enjoy me. I'm not aware that I've done anything to upset her, or missed something I should have caught.

So I picked up the phone to call her, to ask why the transfer.

And then I hung it back up.

Monday, July 23, 2007

Harry Potter - I promise no spoilers!!!

Finished Harry Potter and the Ghostly Hallows tonight.

I gorged on it like a cop at a donut shop with free kinklings.

I was terrified someone would spill the beans, and I'd find out who died at the end before I actually got there. I've been avoiding the news, the internet write-ups, any blogs where Potter, Rowling, or He-who-must-not-be-named was mentioned.

So no review, other than to say if you liked 1-6, you'll enjoy 7 as well.

And it won't be me who spoils it for you.

Wednesday, July 18, 2007

A bit of a confession...

Abcesses are collections of pus and infected tissue that can occur virtually anywhere in the body.

The ones I see tend to be superficial, meaning visible on the skin. They're red, swollen, and painful. And in general no fun to have.

And I love to lance them.

Really, a good I & D (incision and drainage) makes my day. There's something that takes you back to the satisfaction of being 13 and pressed up against the bathroom mirror squeezing that bad boy on your forehead for all it's worth.

They're not all fun and games. Sometimes you think you've got it and after torturing some poor soul with cutting and squeezing all you get is blood. Sometimes they are a real behemoth, unexpectedly, and you're not prepared for the overwhelming stench and fluid. Anaerobic bacteria really know how to turn on the fumes.

I'd probably tire of them if I saw them much more often than I do.

But the average primary care I & D, with no complications and a few CCs of pus...

It's really fun.

Tuesday, July 17, 2007

Read this book...

Suite Francaise, by Irene Nemirovsky. What a read.

The author is new to me, heard a review on NPR somewhere. The book is a compilation of two novelettes, planned to be two of five. Tragically, the author (a Russian Jew) died in Auschwitz prior to completion of the remaining three sections, a victim of the war of which she was writing. So what's great about it?

To start with, her prose. It's just lovely, there's no other word for it. Like putting on a cashmere sweater. Soft, rich, and warm.

The plot follows the course of several unrelated characters as they negotiate the German invasion of Paris in 1940, and then their experience with the German occupation of a small French village. I'm not a history buff - I can't even quote you the dates of the World Wars without looking them up. And I'm certainly not into the war genre. But this book grabbed me. Madame Nemirovsky chose to follow war from the point of view of the ones left behind: the wives, mothers, elderly, young, and infirmed. She tackles class divide, nationalism, patriotism, heroism, and loyalty. There was scarcely a character I couldn't relate to.

Most impressive, though, was her ability to nail the common human emotions that we all feel. I found the relationship between the German soldiers and the French townspeople fascinating, and very relevant to our current military situation.

All in all, highly recommended.

Pace yourself. You'll be sad when it's over.

Thursday, July 12, 2007

A stylin' repair

Question out to all my ER colleagues (and that may only be you, 10 out of 10):

There's a podunk ER in my community, that is frequently doing things that make me cringe. (How they are even open as there are several excellent community ERs within a short drive is beyond me, but I digress...) I got an ER report this week of a child with a scalp laceration that was repaired by braiding the hair over it to close the wound. Discharge instructions were "Remove braid in one week."

Is this legit? Is this a bladeless suturing technique that I'm too ignorant to know of?

Or are they making this up?

Tuesday, July 10, 2007

Yahoo health news roundup

Potentially changing years of practice tradition, it appears that using prophylactic antibiotics for kids with ureteral reflux (urine that washes up into the ureters from the bladder) is not helpful, and may in fact be harmful by inducing resistant infections.

This study showed what we already knew: electronic medical records don't make doctors into better doctors. However, with some research to back it up, perhaps it will be easier to have a sane discussion regarding the real pros and cons of EMR.

And, from the "good-thing-we-spent-US-taxpayer-dollars-on-this-one" category, a shocking study shows that women prefer men with muscles. much do you think it would cost to figure out if men prefer women with big boobs?

Monday, July 9, 2007

One at a time...

Dr. Topicalsteroid, one of our local dermatologists, has the GALL to refuse to see patients for more than one issue at a time. I'll send a patient to be evaluated for a rash, and while she is there she'll ask him to look at a mole on her arm. "You'll have to schedule another appointment" is the reply.


The average dermatologist makes well over $200K, almost twice what primary care does. Do they really need to milk patients too?

If primary care started playing this game, you wouldn't be able to hear your iPod over the screeching halt of the American medical system.

Dr. Smak: Well, Mr. Smith, your blood pressure looks like it's doing great. Let's set up your appointment tomorrow for your diabetes checkup.

Mr. Smith: But Dr. Smak, what about my knee pain?

Dr. Smak: Oh, I forgot. Let's do your left knee tomorrow, your right knee Thursday, and we'll talk about your sugar next week.

Yeah. That will work well.

Every time I see a patient for a chronic checkup I handle the problems at hand, review vaccinations, bloodwork, health maintenance items like mammograms and colonoscopies, and usually fit in whatever else ails 'em, like the new mole, the aching shoulder, or the sinus symptoms. About twice a month I'll see a patient who hits me up for too many issues, and I'll have to schedule a second visit to fit it all in.

And you can't look at a freakin' mole?

Saturday, July 7, 2007

Live Earth

Random Live Earth observations from a casual viewer:

1. I never figured out what the donations were intended for. They should have been more clear on that one. (OK, funny now that I've figured out the "pledge" was not a solicitation for money, but for a personal commitment to make a change. Still, probably could have been clearer. Or maybe I shouldn't have been blogging while watching and I would have figured it out.)

2. Al Gore has made the image comeback of the decade.

3. Kudos to Sting, for being an aging sex symbol who is actually married to a woman his own age.

4. Shakira's performance proved my theory that she had a catchy song and hips that do unnatural things, but she sucks.

5. I haven't heard the Beastie Boys in 15 years. Somehow their lead singer still sounds like a whiny teenager.

6. How funny is it that I can't see the Chili Peppers without thinking about Dr. Flea?

7. My boy Dave wasn't great. Disappointing. He and his wife just had a baby, I bet he's not sleeping much. I hope he gets it together before I see him on August 10th.

8. Did iphone underwrite the entire thing? I'd love to know how much they paid for advertising. Incidentally, I got to play with one today. I'm not really a gadget person, but it was really cool. I'm not sure but I might need one. Mr. Jobs, you done good.

Wait a minute, did I just succumb to consumerism while watching Live Earth?

Tuesday, July 3, 2007

Why I chose Family Medicine...

I've been reading a lot of posts lately about what's wrong with Family Medicine. Truth be told, it's a long list. But all in all, I love my job. Maybe my tune will change as the years go by and burn out sets in, I'm still a newbie.

I had a lot of trouble deciding between Family Medicine and Emergency Medicine, and went so far as to interview for both programs. I liked Emergency Medicine a bit better, but what tipped the scales in the other direction was the burnout factor. Emergency docs spend more time dealing with unpleasant people than most professionals, and it wears on them. I certainly worked with a few community ER docs who had been in the business 20+ years and were still enjoying it. Unfortunately, they were the exception. I leave my office 4 of 5 days a week feeling great about myself, and great about my patients. I wouldn't have been able to do that as an ER doc (but they still have better blogs).

Here's my list of what's right with Family Medicine:

1. It's Life-friendly. I was going to say family-friendly, but it's more than that. Sure, you can be a workaholic in family medicine, but you don't have to be. It's easy to find an outpatient job where you can spend weekend and holidays with your kids, or your garden, or your fishing pole.

2. It's flexible. Like skin procedures? Great, everyone in your practice who doesn't will send them your way. Hate kids? Avoid them. Love OB? Move to Alaska, they need us up there. You can pick your poison.

3. You're in demand. Unless you are trying to practice in a dwindling population center, you'll do fine. I supposed this could be said of all physicians, but the predicted primary care shortages are looking like job security for me.

4. It's challenging. I knew a family medicine resident who had quit her ophthalmology residency after her first year. She said that she knew within 30 seconds of speaking with her ophthalmology patients which of 5 problems she was dealing with, and was immensely bored. That's a problem I'll never have.

5. The Marcus Welby effect. A lot of patients trust their family doctors more than their specialists. They realize you have a view of the whole person, not just their left kidney. True, some patients treat me like the bottom-of-the-class idiot who couldn't get into a better program, but they are few and far between. It's super-cornball, but you meet a lot of really nice people.

Family Medicine has some big issues to tackle. Reimbursement is right up there. Getting bitch-slapped routinely by the insurance companies is on the list. You've got to be able to handle not knowing. You've got to be able to handle the Monday morning quarterbacking that the specialists will do to you. You've got to be damn good at multitasking.

But I love my job.

Monday, July 2, 2007

A good while...

I touched on this on a previous post, but for my own therapy it needs to be said again.

I'm continually amazed at the number of ways that patients can NOT answer this simple question:

"For how long?"

It's been some time....

A while.

Oh, a good while.

A really good while.


Since my dog died.

A good bit.

Since last time.

After I had my tooth pulled.

A real long time.

So let me reiterate, I'm looking for a number followed by a unit of time. "Two months" is fab-ooo.

There are two reasons for this. First, and most importantly, it helps me figure out what is wrong, or at least points me in the right direction.

Second, it turns out that many (most?) insurance companies will refuse to pay me for my services without a date of onset for most conditions. Why is that? Because they can, and they'll look for any inane reason hey can tto avoid paying on claims. So I'll get denied, my billing department will have to call me two weeks later to ask me how long your knee was hurting when I talked to you about it two weeks prior. And do you know how long it will be until my office gets payment?

Yep, you guessed it...