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, August 25, 2005
    Waiters and Drug Pens

    Most doctors, except those who virtuously eschew even the smallest freebie from drug companies, are overrun with ballpoint pens. Every drug rep hands out fistfuls of the things whenever they visit an office. In case you haven't figured it out, I am not a virtuous doctor, and I have tons of these things all over my desk. I have livened up church meetings by loaning people pens ("Do you want the diabetes pen or the depression pen?"), but the waiter of Waiter Rant has taken this idea far further than I have. His simple but brilliant idea to get back at those pesky, demanding customers:

    Match the pen to the personality disorder.

    The man's a genius. He's also a great writer; check out his site if you haven't already. I do wonder, though: just where did he get all his drug pens?

    Raiders of the Lost Lunch

    Again with the hospital rounds this week. It's been nonstop work, but I have enjoyed a little free entertainment with it. Eavesdropping on the little workplace dramas playing out around me against the background of admissions and discharges is fascinating. Let me give you an example:

    Setting: the nurses' station.
    A nurse hangs up the phone: "It was delivered to the wrong floor," she says disgustedly.

    Another nurse looks up and asks, "So where's the lunch?"

    "It's gone. They ate it. They were happy to get free food."

    "They ate our lunch??"

    "Yeah. I am so mad at them..."

    Oh, the tragedy. No sarcasm intended: it's little things like that that'll ruin your day. I hope the nurses track down their lunch scarfers and collect their money back.

    Wednesday, August 24, 2005
    Sears: Art Vendor?

    The Wall Street Journal had a wonderful article yesterday about the glory days of the Sears catalog, when the company sold art - genuine works by Picasso, Rembrandt and other artists - by mail. Their spokesperson was none other than Vincent Price (yes, that Vincent Price), an enthusiastic art collector who started his career studying art history before he switched to acting. When approached by Sears, he thought selling art to the public through the catalog was a great idea and worked with their marketing department to develop the Vincent Price Collection of Fine Art. Sears started selling works of art in 1962; the program ran for nine years, and during that time Sears sold some 50,000 artworks. Read the entire story, it's fascinating.

    Friday, August 19, 2005
    Site of the Weekend

    If you like movies, especially opening credits, you'll love this. It's a site dedicated to Saul Bass and contains many examples of credits he designed for films (including Anatomy of a Murder, North by Northwest, Spartacus and many more). The site allows you to pick a film and then flip through the credits frame by frame; great fun. Me, I love movie credits; not long ago I sat watching a film called The Wrong Guy, starring Dave Foley, in great anticipation because the credits (clearly inspired by Charade and other chase films) were so much fun. Unfortunately, the credits turned out to be the best part of the movie - although I'll still give it a limp thumb up for the scene in which Colm Feore (playing a hired killer disguised as a priest) busts out of his motel room with guns blazing. And then somersaults off the balcony onto a car roof. Oh yeah.

    Bass worked with master film directors including Otto Preminger and Alfred Hitchcock (in fact, he co-directed the shower scene in Psycho). It has been said that if you go to a movie in which Bass designed the credits, you can walk out of the film after the first three minutes because he shows you exactly what's going to happen. Go to the site and judge for yourself.

    Thursday, August 18, 2005
    Gee, It's Just Like Baseball! (without the steroids)

    Try this online cricket game (via Tim Blair) if you're looking for an office giggle. Tip: play the Brit side first, then the Aussie (aka "convict") side.


    Got an impassioned comment response to my TB-patient post below. You might want to skip down and reread it. In part, the poster says:

    Regarding your post about the patient who saw a specialist rather than have his condition evaluated at the county hospital.. You need to put yourself in his shoes and stop thinking and acting like someone who has a difficult stressful job. It's one thing to feel frustration about complete irrationality or someone who acts like an a-hole, but that's not really what happened here, is it?

    First of all the patient doesn't know you. You're not his regular Physician. He doesn't know the doctor who orginally treated him. In fact YOU hadn't even seen him! He came to your clinic because you were open. Given all the media attention on shoddy medical care, penny pinching insurers, niggardly HMO's and the state of the American healthcare system in general, do you honestly expect him to trust you with his life just based on your medical license? I haven't read much of your blog, but I'm under the impression you're the one who makes many if not all of the administrative decisions for the clinic regarding treatment, referals, tests and such, which right off the bat is a great big corporate bottom line red flag, justified or not. We don't care who you have contracts with, we want the best medical care available.

    Secondly you didn't tell the patient he may have a cold, you told him he may have a potentially debilitating condition--I suspect that's more than likely what he heard anyway.. I'm not a medical practitioner so I don't know how serious a condition TB is nowadays. Furthermore since you couldn't precisely diagnose what he did have (not to mention "didn't have time" to deal with his case more promptly) he may well have been worried about something else. Doesn't AIDS cause those lesions?

    It's not only petty to downgrade/upgrade patient status because he hurt your ego, it's unethical and I'm sure against the law.

    As far as the insurance comment is concerned, you're both right. Although I wasn't there to hear the tone of the conversation, I don't think he probably meant he was entitled to better care than the uninsured, I think he meant "I spend thousands of dollars I work hard to earn to safeguard my health, and I'm ENTITLED (and YES we are) to whatever care best guarantees it.

    I agree with the patient's decision to seek treatment outside the protocols of your office just based on this post. It tells me you're unprofessional and not to be trusted.

    Where the **** do you get off giving someone who is struggling with the emotional ramifications of poor and possibly debilitating health a hard time about seeking treatment he thinks is appropriate? So what if he was wrong. Did you learn anything about depression in medical school? Hypochondria? Humility? I know they didn't teach you anything about bedside manner because nearly every younger MD I've had the misfortune of encountering couldn't hold a candle to the guys who were trained 30-40 years ago.

    Up until the post in question, I was actually enjoying your blog. I suspect you know what you did was wrong, otherwise you wouldn't have posted and asked for feedback.

    My response:

    Clearly reading this touched a nerve for you... but if you had read more closely you would have seen that your accusations are wrong. I spent a lot of time on the case. I had multiple phone conversations with the patient. I encouraged the patient to call me back with further questions. And, though I didn't specify this in the post because it was not relevant to the situation, I had seen the patient several times before and in fact had performed a physical on this person. So, they knew me. Your speculation is incorrect.

    There are two sides to every story, which is why I asked for feedback. I've certainly got yours. One of the nice things about having a blog is that you can say whatever the hell you want. I think it's a good thing for people to see what a doctor is REALLY thinking sometimes and why. And as for the "old time" MD's you extol, let me tell you I've seen them with their hair down and they're the biggest bitchers of all. If you think what I wrote was bad, you haven't seen ANYTHING.

    I do think you should comment again. I know patients can burn out just as much as doctors can and I think it is, in fact, healthy for people to air their concerns. We might learn from each other. I did not pull punches in this post for just that reason. I knew I might very well come off as a self absorbed asshole but after drafting and thinking over the post multiple times I didn't see a reason not to post it. And it was cathartic to write.

    Just to be clear, I didn't write the post to look like a put upon saint and I didn't mind if it made me look bad. I never expected everyone to agree that what I wrote was OK. I do feel more like a real blogger though now that I've gotten my first piece of hate mail. (Kidding. No, I do not consider this hate mail.)

    Perhaps I should change my blog title to 'The Disenchanted Doctor'. On second thought, no - but I do have a new entry for my sidebar. And perhaps I should be more articulate about HMO's, medical regulations, and other issues that health care providers face. It might provide readers with some useful information. Something to think about for future posts.

    Summer Burns

    Saw a patient yesterday with the chief complaint of "sunburn." It turned out that a tanning salon had opened next to her gym and she was offered a free session at her initial visit. Apparently, they'd set the tanning bed on "Broil," or perhaps "Nuclear Power"; her entire bikini area, above and below the waist, had been burned. She presented with a bright red set of unmentionables but fortunately no blistering. I told her to use hydrocortisone and cold packs.

    This led me on to remember what I like to think of as the "Christmas in July Affair." One hot summer a few years ago a patient came in complaining of a wound on her ear. She'd gotten an insect bite and decided to control the itching by applying ice packs... for a really long time. The pinna (outer ear structure) was blistered and peeling. Diagnosis: frostbite. She did fine, but it still cracks me up to think of someone presenting with frostbite in the middle of the summer.

    Sunday, August 14, 2005
    Medical Porn and Good Intentions

    One of the bathrooms in my office has a small poster on the wall next to the toilet. The poster, courtesy of Unnamed Drug Company (which manufactures a certain antibiotic used for treating urinary tract infections), contains instructions for both men and women for collecting urine specimens without contamination. The instructions are accompanied by explicit black-and-white line drawings - this benefits those who aren't fluent in English and those who have trouble reading fine print.

    Or so I thought until recently.

    A patient of mine presented for an appointment complaining of UTI symptoms and accompanied by her daughter, a very cute six-year-old. She went to the bathroom to produce a specimen, taking her daughter with her. I thought nothing of it until later as I was writing her prescription. She said hesitantly, "Uh, you know that poster in the bathroom?"

    "Yes..." it suddenly hit me what she was driving at. "Oh. Yes, yes I do."

    "Well, my daughter saw it. It was right at her eye level."

    "Oh dear. Well, you know it's there to show people how to, um, collect urine for testing, that's all. I hope it didn't upset her."

    The mother looked as though she were about to laugh. "She said it was gross."

    I glanced at the daughter who wrinkled her nose in corroboration. I suddenly had to bite my lip really hard to keep from bursting into giggles.

    So now I'm corrupting six-year-olds. What next?

    Friday, August 12, 2005
    Conquering Mount Hummer; or, Kicking a Midlife Crisis in the Nuts

    First off, thanks to so many of you for your posts/emails/voicemails of support. I am feeling better and have decided over the past few weeks to do more fun stuff and try to get a kick or two out of my daily life. In this resolution I have been helped along by my invaluable neighbor, Deb; as we paced the neighborhood at the crack of dawn (as we do three times a week), she announced that for the foreseeable future we would do something fun once a week. Deb is a tad bit older than I and a widow. She finds her job (finance) frustrating sometimes, as I do mine; therefore we were both motivated to do Something Different. A few weeks ago we both got postcards in the mail from General Motors about a soon-to-take-place Motor Show at Hollywood Park (Motto: "We hand you the keys").

    "We're going!" she decided. "They have Hummers!"

    "Okay," was my reply. I've always wanted to drive a Hummer. So, on the agreed-upon Sunday, off we went to the wilds of Inglewood. We registered, watched a thirty-second video, got our plastic bracelets and marched onto the parking lot - which was hotter than 12 yards of hell. Tents were set up everywhere for the different car types. Rules were, in order to drive the Hummer you had to drive either a truck or SUV first, and in order to drive the Corvette you had to drive either a luxury car or passenger car first (and get your bracelet stamped to prove it). We started with the trucks. I tried the Sierra, a hybrid truck; the Colorado, a classic pickup (a rougher ride than I expected, but fun) and their new model, the Chevy SSR. This is a very cool-looking truck with great acceleration and handling. Two thumbs up.

    We meandered on to the Luxury Car area where I looked across to the next tent, poked Deb and said, "Look, nobody's in line for the Hummer!" Next thing I knew, I was in the drivers' seat of the H2 with a very laid-back type named Jason in the passenger seat (he was our mandated escort). Deb was hyperventilating in the back seat.

    Let me just say, these suckers drive great. The suspension is wonderful and even when I drove over the "obstacle course" (some soft rubber inner tires, they looked like) I couldn't feel anything. "Gee, this is great... oh shit" was my review, as I found myself confronted by a mound of sand with a 25-degree upgrade (a.k.a. Mount Hummer).

    I looked, panicked, at Jason. "What do I do?"

    "First, you push this button," he said soothingly. Apparently this puts you into Low Gear/Four-Wheel Drive/Mount Everest Mode. Button hit.

    "Now what?"

    "Hit the gas slowly, don't let up, and when you get to the top hit the brakes." With blind faith, I did what Jason said and it worked. Down the other side, back onto level ground again and then there was another mound of damp sand ahead of us. It was much smaller, so I looked at Jason and said with mild interest, "What do I do with this?"

    "Drive to the right and get your left tires on the center of the sand." Which I did and found that the car canted over to the right something fierce. Deb was mumbling in the back, "We're gonna tip over... we're gonna tip over... we're gonna tip over" but we didn't, thanks to my expert handling - or to the idiot-proof design of the course, take your pick. We made it back to the starting point and Deb and I switched places. On this second round, we chatted to Jason and found that he worked in marketing, that he had applied to GM on the recommendation of a friend of his ("I just sent in my resume. It was the easiest job I ever got!") and that he was making the rounds of Southern CA with the auto show - next stop Orange County, then Pomona, and in a few weeks Las Vegas. The weather had been very hot at the various showplaces but he was enjoying the job. I told him, "You deserve a medal for this."

    On to the luxury cars. I tried the Lexus ES330 and the BMW 325Ci - both awesome drives and great fun. The courses weren't long enough to get any decent acceleration in though. Of note, Deb drives a Jaguar and we both noticed that no Jags were to be had at the show - but this was probably to be expected, as Jaguar is now owned by Ford and GM hates Ford's guts. Other cars available for test drives were the Mercedes C240 and E320, Audi A4, and various Cadillacs and Saabs.

    Finally we got to the Corvette, which like the Hummer had a tent all its own. I chose the manual-transmission model; Deb took the automatic. I walked out to the bright-red car pointed out to me and found another fellow sitting patiently in the passenger seat. "Are you my designated escort?" I asked.

    He guffawed and answered, "I wouldn't put it that way." I hastily replied, "Let me rephrase that," and we were off. This car is your classic low-slung sports vehicle, and true to cliche, I had trouble squeezing in under the steering wheel. It is marvelous to drive; you can go pretty fast even in second gear. As I headed around the course I had flashbacks to my dad's Jaguar XKE he had years ago and felt like a five-year-old again.

    We finished off with a visit to the refreshment tent and headed back to the car. I suddenly realized that I was feeling better as we both replayed our fearless climbs to the top of Mount Hummer and extolled our friend Jason (both his sterling character and his physical virtues). I now know why guys seem to like cars so much... they just make you feel good.

    Wednesday, August 03, 2005
    True Confessions

    ... so y'all are probably wondering why I haven't been posting.

    Or maybe not.

    Suffice to say that I've been having a crise de coeur (sounds so much better than "midlife crisis," doesn't it). Funny thing is, when I turned forty it really wasn't that big a deal. I was too busy to notice. But in the last two years, I have lost friends to suicide and cancer; my brother got married, and in fact he and his wife have just had a baby (which is wonderful, but hit me with a bit of a thud as I am still single); and I realized I had bitten off more than I could chew in my work when I took on extra duties to pay for the Renovation Project. Plus, one of my emotional mainstays - my church - has become more of a rope bridge with multiple planks missing than a place of rest and renewal. Also, I couldn't help noticing how many of my fellow bloggers are dealing with challenging situations or in fact have embraced change gracefully - as opposed to me. If you viewed me as sitting in an armchair with my feet up scarfing Cheetos for the last year you would not be too far off. I should be doing better than that but I can't seem to summon up the strength to contemplate change.

    I lost it at work a few weeks ago, and was taken in hand by my medical director. (I don't mean that I was screaming at a patient, rather, I was crying uncontrollably.) She got me some help, and I'm doing better now. Just to reassure at least one of you, no, I am not rifling through the medicine cabinet for the cyanide pellets. I am, in fact, hanging out with my neighbor quite a bit. She decided that we should devote ourselves to doing something fun or challenging every weekend, and it seems to be helping. I will share a bit of this with you soon. Just wanted to let you know what was going on, and to let you know that I have not given up blogging.

    Dr. A

    P.S. Going on vacation, will be back next week.