Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Thursday, June 30, 2005

    Let me start off by saying, I could be completely wrong about this. Feel free to vote in the comments if you are so inclined.

    Last week I had a patient - young, healthy - who came to our after-hours clinic with a moderate cough that had been going on for about two weeks. No fever. The clinic doc prescribed an inhaler for bronchitis and recommended a chest X-ray. I called the patient next day to discuss. Frankly, because the clinic note and the patient's description of the symptoms sounded so mild I could have flipped a coin, but since the patient had not improved on the treatment suggested by the clinic doc I ordered the chest X-ray. Next day I was called by the radiologist, very excited, who reported a cavitating lesion in the upper lobe of the right lung. The radiologist thought it was TB. Naturally, I informed the patient; naturally, the patient was upset. There was no history of active tuberculosis or of a positive skin test. I reported the case to Public Health and held multiple (three) lengthy phone conversations with the patient, stating that it was most likely tuberculosis but that there were other possibilities. (Fungal or bacterial infection.)

    What I'm trying to say is, I spent a fair amount of time on this case. I should also emphasize that the patient looked remarkably healthy, clinically speaking (no high fevers, coughing up blood, etc. etc.). Let me also reiterate that the total amount of time elapsed so far is 48 hours - or less - since the X-ray reading.

    Late yesterday afternoon I got a fax from a lung specialist requesting STAT authorization for two tests (a bronchoscopy and a CAT scan of the chest) for this patient. I did not refer the patient to this doctor, I did not know who this even was until I looked up the physician in our on-line database. I had heard nothing about this appointment from the patient and received no phone call from the M.D.

    I took no action yesterday because I did not have time. Today I called the patient who stated that he/she (no pronouns here for security reasons) had gone to see the physician in question based on a recommendation from a family friend. "I wanted to get treatment as soon as possible," stated the patient.

    "Why didn't you call me? I've been calling you for the last two days. What made you do this instead of calling me and asking for a referral?"

    "I was uncomfortable that you referred me to Public Health. The only thing they will do is see if I have tuberculosis. I wanted to find out what was going on, and I don't want to get treated at the county hospital."

    "I talked to you about what the other possibilities could be. Remember? We spent a lot of time on this. I want to find out what's going on as much as you do, but I wanted to get the tuberculosis question settled first. If you had been really sick I would have put you in the hospital if necessary - you weren't even running a fever. I've been working with Public Health a lot this month on another tuberculosis case and I thought they could do the job most efficiently."

    "Well, I pay thousands of dollars for insurance and I have a right to get treatment I think is appropriate."


    Readers, let me tell you something. One way to really piss your doctor off is to pull the "I have insurance therefore you owe me" argument. Every day I see patients who have insurance, patients who don't and patients who used to have insurance but are losing their coverage; I try to treat them all the same. You do NOT deserve Treatment X or Test Y because you have insurance; you deserve it because you are SICK. This patient, with a legitimate problem, just lost all credibility with me based on that one sentence and on not giving me the compliment of a phone call to inform me of their concerns and intended actions. Unfortunately, that took nothing away from the fact that a problem existed here that had to be treated.

    On further review, it turned out that the specialist in question did have a contract with us - though it wasn't a doctor that I work with on a regular basis. The tests ordered, I had to admit, were perfectly appropriate in the circumstances. I wrote the referrals - after I made it clear to the patient that I was really pissed off and that I thought he/she had acted in bad faith.

    I didn't mark the referrals STAT, though; I downgraded them to "Urgent." Because, yes, I'm just that petty.

    Piss a waiter off and you run the risk that he'll spit in your food, unprofessional though that is. Piss a doctor off and... do you even want to go there? We aren't saints. I know that there are many, many docs out there who act like mini-tyrants and treat their patients like dirt. I try really hard not to act that way and not to have control issues (I can't deny that that may have been a factor in how I feel about this). But to put a lot of work in on a case, to try to be there for a patient, and then to get treated like this - yeah, if I were a waiter, at this point I sure as hell would spit in their food.

    Wednesday, June 29, 2005

    My last school board meeting ever ever was last night. I'm done. Thank you, Lord...

    I've been on the board of my parish school for the last five years. It has been a really good experience in a lot of ways, and I was lucky in that we had good, non-psycho members (I do not exaggerate; I have heard disaster stories about other boards that would curl your hair) but enough is enough.

    The last two years have been especially difficult. The previous head, a wonderful woman who had been there seven years, left and we hired a nice, well-meaning woman who just didn't work out. She got along well with the kids but her leadership skills were zero. Now she has left and we have an interim head who looks like he's going to do an excellent job.

    At the end of last year, my three-year term was up. I wanted to leave then but was talked into staying on by some of the other members. Halfway through this year, I realized the only way I would survive with my sanity was by promising myself to quit at the end of this year. I have done so, and I feel no guilt. Lesson learned: don't be afraid to say "NO!"

    Monday, June 27, 2005
    Six Flags Guy Guilty?!

    Former Klan Member convicted

    (via Ernie) - sorry about all the silly links, I haven't been in the mood to write anything at length. Hope to improve soon, and in the meantime, enjoy the jokes.

    Thursday, June 23, 2005
    To All the Lawyers Out There

    Some Advice from your Public Defender

    This is excellent. (Via MoebiusStripper).

    Tuesday, June 21, 2005
    L.A. Street Signs

    I had one of those "I thought I was the only one who'd ever noticed this" moments today: Somebody posted about the missing i dots on L.A. street signs. This always makes me do a double take, but I must admit the signs are easier to read that way.

    A Quote

    "Do you ever wait for the longest day of the year and then miss it? I always wait for the longest day of the year and then miss it."

    -- The Great Gatsby

    Didn't miss it. Happy Summer Solstice.

    For my friends in the Southern Hemisphere: remember, it only gets better from here.

    Wednesday, June 15, 2005
    Schiavo Autopsy Results

    No surprises here:

    An autopsy on Terri Schiavo backed her husband's contention that she was in a persistent vegetative state, finding that she had massive and irreversible brain damage and was blind, the medical examiner's office said Wednesday. It also found no evidence that she was strangled or otherwise abused.

    But what caused her collapse 15 years ago remained a mystery. The autopsy and post-mortem investigation found no proof that she had an eating disorder, as was suspected at the time, Pinellas-Pasco Medical Examiner Jon Thogmartin said.
    Autopsy results on the 41-year-old brain-damaged woman were made public Wednesday, more than two months after her death March 31 ended a right-to-die battle between her husband and parents that engulfed the courts, Congress and the White House and divided the country.

    Her parents cling to their belief that her condition could have improved, in spite of the autopsy report, their lawyer said.

    I do think the autopsy information is helpful regarding the extent of the damage to her central nervous system: "The brain weighed 615 grams, roughly half of the expected weight of a human brain," he said. "This damage was irreversible, and no amount of therapy or treatment would have regenerated the massive loss of neurons." That's pretty conclusive.

    I'm sure Schiavo's parents are going through a very difficult time. I hope they are eventually able to make their peace with the medical information now available.

    Tuesday, June 14, 2005
    Transfer Lambada Update

    Got a call from V. regarding the post below (she was on last weekend).

    It turns out the Tylenol OD patient had been at Valley Hospital for two days before the doc decided to transfer her at 9 pm Saturday night. That's right, two days.

    I have issued a fatwa for the MD at Valley Hospital. Shoot on sight.

    Monday, June 13, 2005

    Michael Jackson not guilty on all counts

    So much for that. Hopefully I'll never have to hear anything about this guy again.

    Sunday, June 12, 2005
    Old-Time Drug Advertising

    From Cut to Cure comes this link to a whole bunch of 1940s-1960s drug ads from old medical journals (as a reminder, pharmaceutical companies weren't allowed to advertise to the lay public until just a few years ago). They're hilarious, a little bit scary and very un-PC. My favorites include "Mabel is unstable" and the Thorazine ad ("for the agitated, belligerent senile"). Gee, that would encompass about 85 percent of my geriatric patients...

    Saturday, June 11, 2005
    The Transfer Lambada

    Yes, I did the Forbidden Dance this weekend... with any number of physicians and administrators. One may have an almost infinite number of partners for this particular dance, as we shall see. This is how it goes:

    I got a call tonight from a physician at what we will call Valley Hospital. (Not its real name.) He told me that they had one of our patients there with a Tylenol overdose who needed a transfer "because we don't have liver transplant facilities" and then proceeded to read off a list of labs that were not that abnormal. My mental response was "Because you're a lazy shit who doesn't want to be saddled with an OD." I may be misjudging him, I hasten to admit; I can't remember enough about Tylenol [aka acetaminophen] overdoses to know how soon somebody may turn on you and have their liver go straight into the toilet. So I asked further questions regarding insurance (a valid question because The Firm's call schedule for hospitalists is split into three groups because we're so freakin' big; we divide by insurance for billing reasons). The patient's insurance coverage meant that he/she would go to Hospitalist Group A - I am in another group.

    So, first question: does the patient's hospital, Great Big Tertiary Hospital, have a bed available? My first thought was no, because the patient would require cardiac monitoring and those beds are hard to get, but I called the transfer department to see. Wonder of wonders: there WAS a bed available. Okay. So then I called the doc in charge of Call Group A for that particular evening. I had to call him because he would be the admitting physician for the patient, I would not, so therefore he would have to call back the doc at Valley Hospital to confirm acceptance of the patient. But Doctor A called me back and said, "Oh, if you've talked to the doctor at Valley Hospital, that's fine. Just let me know when the patient gets here."

    So I'm accepting the patient by proxy? When did that start happening?

    Be that as it may. I called back the transfer department, called back the Valley Hospital doc, authorized the transfer and now all we have to do is await the arrival of the patient.

    Which will probably happen about two in the morning.

    And I will probably get called again even though I have nothing to do with it. Oh, well, at least I'm getting paid for this.

    Thursday, June 09, 2005
    This One's for V.

    ...who asked,"When are you gonna blog again? I've read all your links!"

    Here ya go. For those of you who, like me, have filthy minds, get ready to cackle with glee. For those of you who don't think much of phallic humor, you have been warned - but give it a try, it's NOT explicit and is actually quite funny.

    (Via Calculus Woman.)