“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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The Boards

I'm finding it harder and harder to work up motivation to study for this test. I recently heard from two co-workers that the Boards, which MDs take to certify in their specialty (I'm Internal Medicine), are now open book.  This will make things somewhat easier, though there certainly is not enough time allowed to look up every single answer. Whether or no, I just need to keep pushing through on this and it will be over in two weeks. Then I can proceed to all the other issues competing for my attention... and that queue will soon be as long as the queue to view Her Majesty. 

(off topic: I plan to get up early tomorrow to watch at least part of the funeral.) 

But back to medicine: I have found that the longer I practice medicine, the easier it is to tie certain points to patients I have seen and worked with. Therefore, less rote memorization is required. That said, most of my primary care practice centers around a fairly narrow set of topics and I need to refresh my memory on many others. This is my fourth time taking the test, yet I'm still nervous. I keep reminding myself that I passed the other three times, so surely it won't be that bad this time. 

At any rate. Today is my good friend V's birthday and I need to get going; I am taking her and her daughter out to lunch. I also need to do some pickup and cleaning as my brother will be arriving later this week for the funeral of a good family friend. To be continued. 

 

Labels: Medicine

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Testing, Testing

Today while going through Twitter I ran across a tweet written by a woman mourning a friend who died of colon cancer at age 39. Her post states the friend's father died "young" (she does not say how young) of colon cancer, and therefore the friend requested a colonoscopy. According to the post, the screening was denied; insurance wouldn't pay for it. The friend was not diagnosed until her cancer had metastasized. The tweet has attracted thousands of retweets and hundreds of comments, many of which give other examples of friends and family members dying early of colon and other cancers. The responders' chorus: "Why wouldn't insurance pay for this? Why! This could have been avoided!" as well as the mandatory curses thrown at the US health system and insurance companies.

Make no mistake, this is a tragedy. Unfortunately there isn't enough information given in the tweet to fully critique what happened. My first question, however, was: was this person offered a FIT test? FIT is an abbreviation for fecal immunochemical test and is a test to check for blood in the stool. More recently, a more sensitive test called Cologuard has become available (it checks for DNA markers in the stool which are compatible with colon cancer or certain types of polyps). It is more expensive than the FIT test and many insurances do not cover it; however, it is still a lot cheaper than a colonoscopy. Either of these tests could have helped diagnose the woman at an earlier stage. If these tests came back positive, it would definitely have influenced the decision to proceed with colonoscopy.

Second: the current standards for colonoscopy in the US are that you begin screening at age 45 or, if there is a family history of colon cancer in a near relative, when the patient's age is ten years younger than the relative's at time of diagnosis - whichever is sooner. "Screening" here refers to colonoscopy, although many people decline them, in which case they can choose to be screened annually with a FIT test or with Cologuard every three years. The US screening recommendations have evolved over the years to become more aggressive, as I will discuss further.

As always, the benefits of the UK health system are being talked up. For comparison I will present the NHS testing policy for colon cancer, as follows: FIT screening every other year, not annually, and screening is recommended between the ages of 60 and 74 (it can be extended beyond age 74 upon request by the patient). The NHS is considering extending screening back to age 50 but this has not yet taken place. Colonoscopy is not part of routine screening. 

When I began my training, screening for colon cancer consisted of sigmoidoscopies rather than full colonoscopies and screening began at age 50. The sigmoid colon is the last 40 cm of the colon, about 25 percent of the entire colon. Initially it was thought that the majority of colon cancers originated in the sigmoid colon, but we now know this is no longer true. Full colonoscopies became the norm after the well-publicized death of Jay Monahan in 1998. He was the husband of a journalist named Katie Couric, and had been screened with sigmoidoscopy but not full colonoscopy; Ms. Couric made it her cause to urge more aggressive screening techniques and this was changed. More recently, the age to begin colon cancer screening has been pushed back to age 45, as noted above. This is due to colon cancers trending at a younger age. 

"Why not sooner?" - in general, colon cancer is not a young person's illness. There are very specific exceptions to this, involving genetic syndromes such as familial adenomatous polyposis, but they are rare. These syndromes have been closely studied and in many cases early colectomy, such as by age 30 or 35, is recommended to prevent onset of colon cancer. Now, screening recommendations can always be changed as I have outlined above; they are not set in stone. But there is always a balance between risks and benefits of screening. Colonoscopy involves anesthesia as well as the risks of perforation of the colon and bleeding. (These complications are rare, but they can happen.) The less invasive forms of screening, FIT and Cologuard, can give false negative and false positive results. This means that someone could wind up getting an unnecessary colonoscopy due to a false positive result, or that a cancer can be missed. Going on a snipe hunt to check a questionable result leads to increased risk and expense. In a very low risk population (such as below age 45), the risks and expense will outweigh the benefits. For every cancer found in this age group there are a lot of useless procedures. It's all about statistics, and this is why doctors as well as insurance companies - and the US preventive services task force, come to that - are generally reluctant to recommend screening at a very early age. 

Symptoms of colon cancer at an early stage are very nonspecific. Constipation, bloating and abdominal pain can all be symptoms; unfortunately the majority of the time, they are not. Functional bowel symptoms are incredibly common, meaning that the patient has symptoms but no disease can be found even with radiologic testing or colonoscopy. It is simply not possible to work up everyone who presents with these symptoms. Of course, trying to point this out to someone who has lost a relative or close friend to cancer is a loser's game. What I try to do is listen, do a good exam, run a blood count to check for anemia and encourage the patient to follow up or email me if the symptoms continue or change. Screening has done a lot to extend lifespan by catching problems early, but it is not perfect. 

Labels: Cancer, Medicine

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 Roses

My aunt loves roses and grew them in her backyard in the desert. (There are heat resistant roses available; a neighbor of hers once insisted on growing English roses, spent a fair amount of money on them and then watched them die in the heat and relentless sun.) Her friends who have come to visit have cut and brought the blooms with them. The living room smells of roses. 

Yesterday she developed chest pain, likely due to the tumor infiltrating into her chest wall. She is now on regular doses of morphine and benzodiazepine (for the anxiety and agitation). Hospice is coming daily. She is taking liquids by mouth but very little food. 

We vacillate between long hours of nothing as she sleeps punctuated by a concerted effort to get her to the toilet, calm her, change her clothing. I pass the downtime by cleaning the kitchen and clicking from Facebook, to Twitter, to email. The house is hushed. It is a waiting game now. 

I hope her passing is peaceful. 

Labels: Cancer, Family, Medicine

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 The Dying Patient

They don't tell you what it's like to be with someone who's dying. As in, being there all the time, day in and day out. Sometimes I wonder if even the hospice doctors and staff know. It isn't that they are not kind. But the nurse, who currently is coming twice per week, checks vitals and asks about bowel movements - "Do you have any questions?" and then she is out the door within 15 minutes. I do not say this to criticize, as I have done my share of such visits. But after a while it is hard to know what to do or say, how to pass the time when not focused on such minutia. 

My aunt is suffering. Not to say that she is in pain, but she is a very social person and has always been someone who likes to stay active and do things. At holiday dinners, rather than sitting around with a cup of coffee she was always the one cleaning the kitchen or getting the meat off the turkey carcass. Now she is too weak to walk and too confused to focus. She cannot get much enjoyment from reading; cannot remember which of her friends has called her from hour to hour. Her sole consolation is conversation and I am not the best source of that. I have tried to think of entertaining topics but have long since run dry. My father is too demented to talk to her and my mother is too hard of hearing; plus my aunt has suffered vocal cord paralysis due to the tumor and can barely make herself heard.

Two days ago she told me she wanted to pursue assisted suicide (I think the preferred term is "assisted euthanasia" these days). Her first discussion with the hospice doctor is scheduled for tomorrow. I don't see how she could not qualify, I just don't know whether she will be able to last the next two-plus weeks until all the criteria are met. We should perhaps have discussed this sooner, and I feel badly about that now. I told her that once again she was a groundbreaker, as she has been so often in her life. 

She was raised in a small Southern town and went on to teach as a career - not much else was open to women in those days. Her first marriage, the product of elopement, failed shortly after she moved to Alaska (her husband was transferred there). She went on to marry again, and eventually left her second husband for a female partner. That relationship lasted 25 years. She successfully fought cancer once and then developed lung cancer more than ten years later. She has traveled, volunteered, has made many friends and excelled at entertaining them. 

Religion is not a consolation for her, she puts her trust in friends and enjoying life. She has outlived her prognosis by nearly three weeks, but I don't know how much longer this is going to go on. All I can do is to be here, and it is humbling. 

Labels: Family, Medicine, Random Thoughts

posted by Dr. Alice at #

 

Update

Not much new to report here. I have signed up to work in the clinic on Saturdays in March (after talking about it for more than a decade, The Firm has finally opened on Saturdays - another instance of the pandemic changing work patterns). My aunt clinically is about the same, but I don't know how long that is going to last - so I did not want to commit to more than one day per week.

It's been stressful having her here, even though I know it's the right thing for her (and she knows it too). I know she feels isolated and depressed, though at least she is not in a nursing home but with her family. It is just too difficult to talk to my parents for any length of time, given my father's dementia and my mother's severe hearing loss. My aunt and my parents spend their days at opposite ends of the house. I have not been able to come up with a solution, as my parents claim a large part of my time and to be quite frank about it I do need some time to myself if I am not to implode. She has had many visitors, cards and letters and I think that is helpful but it doesn't make up for the fact that she is facing the end of her life. My aunt has asked for a television to be installed in the living room, where she sits; so we are going to be doing that next week. She loves to watch the news, so maybe this will make her feel better. 

My study review materials for the Medical Boards have arrived, so that is something else I need to start working on. I have to recertify every ten years to keep my Internal Medicine certification. It's a couple of years early, but I would like to get it over with and this seems as good a time as any. Formerly the test was given twice a year, but (again due to the pandemic) it has been cut back to once. This will be the last time I have to take the test - but then again I promised myself eight years ago that I would not be doing this again, so there you are. 

I had my colonoscopy done, but unfortunately I have to do it again! I followed instructions exactly but apparently the prep was not sufficient. That mixture you have to drink is the absolute worst. The archaic term for it was "saline laxative" and it works by pulling additional fluid into the intestine. This rinses everything out, so to speak. It contains magnesium, potassium, citrate and other lovely things. You also have to drink a lot of water with it so as not to induce dehydration. 

Lately I have been pondering what to do when I am free to travel again. I would love to go back to Australia, to see the Netherlands and Scotland; but first of all I think I would like to travel Route 66. I'd bring along my camera and seek out some of the old buildings and locations to photograph. The route was decommissioned in 1985, with the completion of the Interstate Highway System, but has refused to die. It has a stature in American lore that I don't think will ever be replaced, partly due to the song, of course, but it is even mentioned in works like "Fear and Loathing in Las Vegas" and, of course, "The Grapes of Wrath."  A sadder bit of travel history associated with it: "The Green Book," a travel manual specifically for Black motorists, listing places that were safe - and unsafe - for them to stay. There were plenty of  "sundown towns" along the route where African Americans were not allowed after dark.

And now I have to figure out my schedule for the week. More later. 

Labels: Medicine, Random Thoughts, Travel

posted by Dr. Alice at #

 

 Ash Wednesday 

I started Lent this year with a more introspective mindset than usual, what with my aunt on hospice and my elderly parents being themselves. (Deaf, stubborn, won't wear their hearing aids, a little confused.)  On Wednesday I had to go into the city in the hope of getting my first COVID vaccine at the hospital - most of my co-workers have completed it already but I was delayed due to contracting COVID in early January, though I feel fine now. 

It was indeed a fine and appropriate Ash Wednesday. The humbling process started early, as my staff ID was rejected when I tried to pull into the hospital parking lot (I had not been there in months, so it had been deactivated). The ID problem duly fixed, I wandered into the building and found the walk-in line for the vaccination. I was issued a ticket and a sticker marked 2/17 (for that day's batch of vaccine), answered questions regarding symptoms (none, thank you) and while in line passed a table stacked with envelopes of ashes for application. I helped myself to one, curious to see how the do-it-yourself penance kit would work. Stood in line for a while and eventually made it to the front, handed in my ticket and sat down with a friendly nurse to answer more questions and read through the information provided (we are using the Pfizer vaccine). The injection was painless; I sat and read my Kindle for the required 15 minute observation period and then left. My next injection is in three weeks and I have an appointment. It's a relief to finally get this done. 

Later that day at home I sat in my room and opened the envelope. It contained a cotton swab with a dab of ashes on it and a slip of paper with a two-sentence reading. I focused on "Dust you are, and to dust you shall return" - thinking of my aunt - and applied the ashes. 

Hopefully this year I will be more focused on Lent than I have been the last few years. As for Easter... we don't know whether my aunt will still be with us then or not. The good news is that the outreach of love and support from her friends has been nothing short of uplifting; come what may, I know I will hold these memories on Easter Sunday.

Labels: Holidays, Medicine, The Doctor's Life

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 Recent Developments 

I'm trying to blog more. Partly because of the new crackdowns and censorship on social media platforms (namely, F and T), and partly because so much has been happening here, most of it not good. 

I left full-time work a year ago and have not regretted it one bit, though I have been continuing to see patients part time. One main reason I left was my parents' and aunt's ill health. My mother in particular has been in a slow decline for months. Just before Christmas, their caregivers were diagnosed with COVID and my parents tested positive the day after Christmas; I tested positive one week later. Fortunately none of us had to be hospitalized. My father had basically no symptoms, I had the equivalent of a bad cold; my mother had a heavy cough and bronchitis but no fever. All the caregivers were out sick and it was a very rough two weeks, but things are much better now. 

Unfortunately my aunt has metastatic cancer and without giving details, she is not doing well. I will be staying with her to provide support as she tries to make a decision about stopping treatment. Ironically, my COVID infection could not have been better timed; I'm bulletproof now, at least for the next few months, and am no longer infectious. I tested positive 17 days ago.

The inauguration is tomorrow, I have no plans to watch. I am honestly disappointed with the results of the election. I don't see things going well, what with immigrants on the march from Central America and the president-elect's plan to shut down the Keystone XL pipeline (what the hell is that about?) - and the New Management hasn't even been sworn in yet.

As for the immigration issue, I have one word: COVID. Uncontrolled immigration into Southern California and other areas of the Southwest US, already a hotbed for COVID infection: what could possibly go wrong? Or to put it another way, how is our already overloaded health system supposed to cope with this? No one has thought to ask that question so far. 

I'm going to sign off for now and try to find something else to think about.

Labels: Medicine, Politics, Random Thoughts

posted by Dr. Alice at #

 
So Here We Are 

Labels: Los Angeles, Medicine, Science, The Doctor's Life, Twenty-First Century Crap

posted by Dr. Alice at #

 
When I retired in early January of this year I planned to come in to the office one week a month to see patients.  Then COVID came along and I found myself jumping right back into medical practice to help out my medical group. I had never done a telemedicine video visit in my career until March; turns out it isn't all that difficult. Now I work from home several days a week. I'm not going into the office for now, as I have three elderly relatives who need my help and I'm trying to minimize any potential exposure so as not to put them at risk.

Labels: Medicine, Technology, Twenty-First Century Crap

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Insomnia

"I'm having trouble sleeping" is one of the most common complaints I hear from patients. This is understandable, as up to 25% percent of the American population reports occasionally not getting enough sleep (though it seems like more to me). However the percentage suffering from the true definition of insomnia is smaller, about 6 percent. Per the DSM-5 definition, insomnia patients feel impaired from lack of sleep during the daytime; symptoms last at least a month; and are not associated with other medical conditions, substance use or other sleep disorders (restless legs syndrome would be a good example of this).

Certainly sleep issues are seen most often in the elderly but insomnia can hit at any age. Recently while sorting through a bunch of stored papers I found a literary quarterly published by my university which I had saved for some reason. The theme was "All Night Long" and at least two of the pieces dealt with insomnia... it could have been more, possibly three or four. (These were written by people in their late teens and early twenties, mind you, and they were complaining of insomnia!) There are plenty of factors other than age, however. Sleep problems are often connected to lack of physical activity, especially these days when so many people work sedentary jobs. Daytime naps are also not a good idea as they relieve physical fatigue just enough to make it difficult to fall asleep. And irregular sleep patterns, such as working nights or sleeping late, can also ruin a good night's sleep.

I empathize with patients as a fellow sufferer. I have had insomnia most of my life, to the point that if I sleep through the night I almost feel cheated. My nighttime awakenings are my "me time," when I ponder my work schedule, to-do lists and various deep thoughts. Certainly I need sufficient sleep to function, at least six hours. Back when I was a medical resident I realized that I was usually very depressed the day after being on call. It took a surprisingly long time for me to figure out the connection between my mood and lack of sleep.

The basic recommendations:

• Regulating your sleep pattern is a big one. Yes, you have to become one of those boring people who goes to sleep at the same time every night. 
• Don't go to bed too early. If you go to bed at eight-thirty, you won't sleep through the night unless you have to get up at four-thirty every morning - or even earlier than that. 
• Limit alcohol and caffeine. Alcohol can really screw with your sleep. No caffeine after noon. 
• Don't go to bed until you are ready to go to sleep. I once had a friend, a fellow MD, who stated that if he had his way every bedroom in the US would be deprived of its television. Likewise, no reading or crossword puzzles in bed. You should do these fully dressed and in a separate room until you are ready to go to bed. 
• Keep the bedroom cool, dark and quiet. 
• And now that we have computers and smartphones, the same applies. Don't grab for your phone if you awaken in the middle of the night. You don't want to be looking at a glowing screen. 
• Do try to get some physical activity in, it will tire your body and you will sleep better. 
• Don't use sleep medications if you can possibly avoid it. 

Labels: Medicine, Random Thoughts

posted by Dr. Alice at #

 
The Miasma of Work

I went to work this past weekend, early on a Sunday morning.

Here's the scary part: I don't work Sundays.

The scarier part: I sat down in my chair at my desk and thought Thank God, no patients are here. I can get some work done.

I had to finish several clinic notes from last week, review labs, log on to the state disability website and complete some forms. Oh, and go through emails, review my clinic schedule for the coming week, look at my calendar and see if I had any personal appointments and figure out when my parents were going to the doctor this month. It took me about four hours (but I was not in a hurry).

Over the past few years work has taken over my life chunk by chunk, weekend by weekend. I have not made much effort to fight it. Sadly, I have noticed that when I am on vacation I actually become twitchy after a day or so of not being online. Partly, I must admit, it is easier in some ways to spend time on patients and lab results than to

- run errands
- get dressed and go out to see friends
- exercise
- do any of the hobbies I have been meaning to do
- etc.

It seems that every time I make time for something other than work, I pay for it later by getting avalanched with emails, phone calls, test results, etc.

But things are about to change. A few months ago I sent an email to my medical director telling him that I wanted to resign my job. It's something I have been thinking about for over a year. But now, with three elderly and ill relatives who need a lot of help, I have finally made the decision to quit.

It won't be a complete retreat from medicine. After discussion with my medical director we reached a compromise whereby I would work one week per month as an hourly employee, basically a locum. ('Locum' is Latin for 'temp worker' and is a term applied to certain professions; we also still use 'curriculum vitae' instead of  'resume' in medicine. Not sure why.)

I can actually travel again. I can go out to see friends. But most importantly I have to figure out how to restructure my life around something other than work. My aunt, one of the relatives I mentioned above, has offered me a lot of valuable advice. She has said more than once that after retirement it took her a year to figure out what she enjoyed and what she wanted to do. So I will start with a few basic projects and keep going from there.

I will blog again. Brace yourselves.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
One of my CEO's favorite sayings is that the only field more heavily regulated than health care is nuclear power. Whether it's true or not, it certainly feels like it. Today medical practitioners are at the whim of online reviewers, insurance companies, federal and state inspectors... and on and on.

I would agree with those who feel that quality (meaning keeping screening tests up to date, checking cholesterol and sugar levels, and so forth has improved with these reviews. However, it does take time and overall the doctor's job has become more difficult while reimbursements are going down. The rate at which doctors are retiring is increasing significantly. A lot of the burden of documentation falls on the shoulders of primary care doctors, with the result that fewer doctors are going into primary care. How to handle this situation?

Right now my medical group is trying to solve this dilemma by changing our practice workflow. What that means is, we are trying to minimize no-shows, work down our backlog or wait time for new patients and see as many patients as we can per day. This all sounds good though so far I am not especially happy with what it takes to accomplish these goals.

First, it is a given that we are going to see other doctors' patients as well as our own. These are called "team visits" and if we have any open slots patients get slung into them up to three days in advance. We also have to "groom" our charts (sounds like a bunch of chimpanzees working on each other) to open up slots. In other words, if a patient is coming in for a follow up on diabetes or thyroid issues, maybe they just need labs. Maybe we don't actually have to see them. Fair enough; but I have wound up overbooking my own patients on top of full schedules, and it feels as if I am going mad.

__________
I wrote the above a few months ago. We have now been practicing in this new way for eight months and I have to say that I am not a fan. For one thing, we've had two female physicians out on maternity leave for a large chunk of this time which means that we other doctors have been seeing a lot of their patients as team visits. For another, the front desk staff do not seem to have a good grasp of the art of scheduling patients appropriately (one of my fellow MDs had two rather unnecessary visits scheduled this morning). We no longer have our own front office staff (aka secretaries) who knew our practices well, and most of the patient phone calls are being managed through a central call center.

The patients hate this. The doctors hate this, and the staff hate this. Our MD administrators have gone from assuring us "After the first year you will love how well this system works!" to "The groups we consulted with say this is a continuing learning experience even three years in..." Said MD administrators are practicing physicians who had to give up part of their practices so that they could administrate more - guess who winds up seeing their patients when they aren't in the office? Uh huh.

This system of "doctor widgets," as one of my co-workers calls it, is apparently the wave of the future. It is a future I do not want to be part of. I've been giving this a lot of thought and although I would like to keep practicing medicine for many reasons, I am becoming more and more certain that I will not be a practicing MD all that much longer. Maybe another year or so, but I would like to retire as soon as I can.

Sorry for the pessimistic attitude. Did I mention I'm on call tonight? That isn't helping.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Nine Days Later

Well. Dad got through the aortic valve procedure okay, I am glad to say. The one-week follow up did not go so well. I don't want to throw in too much detail but he had a lot of swelling and pain which developed after he was discharged from the hospital. He of course did not share this with anyone, including my mother, until the night before the appointment. He insisted on wearing an old pair of scrubs to this appointment, as he could not put on a pair of pants - but he could not tie the scrubs and his pants kept falling down. (I sent an urgent memo to my mother to get him some sweat pants ASAP.)

He had to have a lot of neurologic testing done that day which further delayed us, and the cardiologist who had presided over the AV replacement wanted him to have an ultrasound. Long story short, we did not get home until after 9 pm, at which point my mother realized that she had lost the key to her car.

So I drove the 30 miles or so to their home and picked up the spare key, then drove back, then realized I had lost my cell phone.

That was the worst day by far. The rest of the summer was still pretty hairy, but nothing like as bad. While all this was going on, one of my co-workers was out of the office due to a severe illness of a family member; add all this up and you can probably see why I have not posted in a while.

But it's fall now, things seem much better and I'm going to leave it at that. It's time to get back to my usual ramblings.

Labels: Family, Medicine

posted by Dr. Alice at #

 
Horse Manure! (It's Therapeutic!)

I invite you to read this eye-opening article run by the New Yorker some time back about therapy animals. It's truly ridiculous what people can get away with these days. I found the article entertaining, as I have run into similar requests at work.

About a year ago in my office my partner was confronted by a therapy rat. Yes, a rat. The rat was in a bag around the patient's neck and it perched on her shoulder while she was having her blood pressure taken. I give the medical assistant credit for not shrieking during this process. After a hasty discussion with risk management the rat was placed into the patient's mother's custody and evicted to the hallway. Legally speaking, the only formally recognized service animals are dogs and miniature horses. ("You mean ponies?" I asked. "No, miniature horses" was the reply.)

I have gotten my fair share of requests to write letters allowing patients to take their pets - they are not service animals - just about anywhere. I usually decline, unless the patient has a known psychiatric or medical issue which really requires taking the animal with them. If it's psychiatric, they need to be seeing, or to have seen, a psychiatrist. It bugs the heck out of me when I see people playing the system like this.

Labels: Medicine, Twenty-First Century Crap

posted by Dr. Alice at #

 
Plunged Into Caregiving

About four months ago my mother asked me to call my father's cardiologist to get clarification on something - "He wants us to do some testing. Is this really necessary?" So I did.

"Your father has aortic stenosis," the cardiologist said without preamble (he knows I'm an MD), "and it's pretty significant."

My attitude when we opened the conversation had been doctor-to-doctor. Now suddenly all that vanished and I was repeating, in a very small voice, "Dad has aortic stenosis?"

The gist of the conversation: yes he did, and furthermore it was getting worse, and the cardiologist wanted to do an angiogram. One angiogram later, Dad had a stent in his right coronary artery but still no clear word on the valve. Cardiologist #1 suggested that we see his pal, Cardiologist #2, an expert in aortic valve problems. By a stroke of luck #2 works at my hospital, Tertiary Care Medical Center.

This guy is hardcore. He has a large office in the very newest building on the hospital campus. Each room has a chair that looks a bit like a recliner, which doubles as a scale. Yes, they press a button and the chair raises a few inches off the ground and they weigh the patient sitting in the chair. He also has a fleet of nurse practitioners and technicians, high grade office equipment and the ability to perform echocardiograms in the exam rooms. The tech clearly knew what he was doing but still could not get a clear picture of Dad's valve. He pressed a button on the room's intercom, ordered a bag of contrast and this was infused through a vein, right in the exam room, by a nurse who appeared out of nowhere.

It's wonderful what money can buy. I guarantee you that no internist or primary care doctor has facilities like this.

After this, we found that the AS was really quite bad indeed. Dad needed a valve replacement as soon as possible. We all agreed that the traditional method (aka "cracking the chest") was not a good idea as Dad is not in the best medical condition. He has a history of several strokes and some dementia. Cardiologist #2 specializes in valve replacement via the femoral artery. How he does this I have no idea, but overall it is less stressful and risky than open chest valve replacement.

Today we go for the final round of preoperative assessments and tests. He is having more of a workup than average because he's been entered into a study wherein the surgeon places a filter in the aortic arch before doing the valve replacement, which should lessen the risk of additional strokes. Tomorrow, if all goes well, he has the procedure.

I have been in charge since the workup started: transport to the hospital, spending the night in the hospital with Dad postprocedure and translating developments to the rest of the family. I now really empathize with patients who get confused and lost, and who complain about having to go to the doctor all the time; I am learning exactly how that feels. As you can imagine, I've had to do some canceling and reworking of my office schedule, but I really don't care. All I want is for this to work.

Wish us luck.

Labels: Family, Medicine, Science

posted by Dr. Alice at #

 
Not My Best Week

Another wildly insane day is under my belt. It's hard to say exactly why I left the office feeling so jittery and tense. It may have been the phone call that turned into a 30 minute conversation with a worried son of a new patient. It may have been my current patient who has lost her insurance and now is on Medicaid, which means that for some mysterious reason several of her medications are no longer being covered; suddenly the pharmacy is demanding authorization requests for even the most basic of medications.

It may have been the new patient I saw today who turned out to have multiple unforeseen issues. This particular patient discontinued their diabetes medication three years before and then proceeded not to seek medical care for three years. Today this person turned out to have a random blood sugar of 311. Surprise!

It doesn't help that I am still jetlagged. This past weekend I attended the ACP annual conference. This year it was held in Boston. I did not have the luxury of extra time to adjust to the three-hour time difference between Los Angeles and Boston either going or coming. The conference was good and I think I learned quite a bit, but it is very hard to get spoonfed lectures for 10 hours a day for three days running without losing your mind. No exaggeration; the lectures start at seven in the morning and run until 5:30 PM (with breaks, of course).

And there is more. Two weeks ago my father's cardiologist decided that he needed a catheterization to evaluate his aortic valve. The valve turned out to be functioning reasonably okay but he had a stenosis in his right coronary artery which required a stent placement. This meant that he had to spend the night in the hospital. Guess who spent the night with him? Yes, it was I. I was somewhat philosophical about this turn of events until I was told by the nursing staff that they have no arrangements made for family to spend the night with patients. This meant that I slept in two chairs, continually getting up to remind my father that no, he could not get out of bed to go to the bathroom.

This week I learned that two of our physicians will be taking medical leave somewhat urgently. I don't know the cause and I don't need to know. What I do know is that their patients have to go somewhere, and they will be distributed among the rest of us. Is it any wonder that I am giving serious thought to running away screaming?

I don't have a good way to end this jumble of thoughts. Consider it a therapeutic brain dump. I will be back soon, hopefully in a better mood.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Hi There, Captain Trips

Let's start things off with a picture, shall we? Notice the complete lack of any bioprotective gear on the guy cleaning up the Ebola-laden vomit ejected by Patient Zero on his way to the hospital?

Sigh. OK, I used to think the US had one of the best public health programs in the world. All that stuff about immunizations, handwashing, treating TB, clean water supplies - you know the drill. But after seeing the way the Ebola case has been mishandled I am beginning to wonder. Read the following (lifted from the Ace of Spades site, and MAJOR props to blogger tmi3rd for his info on the case):

The patient's quarantined girlfriend Louise told CNN on Thursday that she had not been told what to do with the soiled linens used by Mr Duncan when he was ill and had not been given food. The woman has been legally ordered to stay inside her Dallas apartment with her 13-year-old child and two nephews, who are both in their twenties, as they came in direct contact with Mr Duncan. ... The quarantined family members of Ebola sufferer Thomas Eric Duncan had tried to escape their Dallas apartment after being told they had to stay inside because they were at risk, having been around Mr Duncan while he was contagious... It also appears that Mr Duncan did not mention his close contact with a severe case of Ebola to his partner Louise, with whom he has one child.

So, yeah. That apartment is LOADED with infected bodily fluids and the local health department (and/or CDC) is telling them to stay in there. I don't see that working out real well. The family is understandably terrified and has already left the apartment once. Why doesn't the city move them to a clean, isolated area?

Go read Ace, who's all over this story. You won't get better info anywhere.

Labels: Critiques, Medicine, Science?

posted by Dr. Alice at #

 
A New Life In Total Disbelief


Apparently, the zombie apocalypse may be upon us after all:

Two Ebola patients, who died of the virus in separate communities in Nimba County have reportedly resurrected in the county. The victims, both females, believed to be in their 60s and 40s respectively, died of the Ebola virus recently in Hope Village Community and the Catholic Community in Ganta, Nimba. But to the amazement of residents and onlookers on Monday, the deceased reportedly regained life in total disbelief...

The above quote came from a Liberian news site called The New Dawn. I'd like to have a chat with the author about dangling participles and such. In all seriousness, it speaks to the level of panic and lack of medical support in this epidemic that patients could be mistakenly pronounced dead - and to the amazing powers of the human body that these two women could revive after (I would assume) at least 24 hours without fluids or medical care.

That said, if any news breaks about brain eating zombie rampages, I'm heading out to find a nice safe bunker.

Labels: Medicine

posted by Dr. Alice at #

 
How to Skate Around Obamacare (Maybe)


This article appeared in the New York Times this weekend. It relates mostly to surgical fees and billing, but I found it interesting. The gist of it is that even when savvy patients go in for surgery with a surgeon they know is approved by their insurance plan, and make sure the procedure is scheduled at the hospital contracted with said plan, they can still get hit with unexpected fees if the surgeon calls in a noncontracted assistant. In many cases the assistant is in the same office as the surgeon in charge of the case. It's easy to infer that the assisting surgeon's higher fee is likely split with Surgeon #1.

In other cases, patients reported that a hospitalist or internist who appeared on their hospital bill as rounding on them daily never in fact showed up. Or they got an echocardiogram that they didn't actually need for surgical clearance. Or other things.

The surgeons, in many cases, blamed the hospital for the extra procedures and charges; they state that due to the drop in reimbursements this is the hospital's way of getting additional cash. As for the assistant issue, it actually is common for surgeons to have an assistant on their cases. It makes things much easier and faster in the OR to have someone retracting the edges of the wound, assisting with suturing, and so forth. My father, in fact, did this for many years on his patients. This was well before the era of managed care. His specialty was family practice, but he was deft and smart, and the surgeons loved working with him. However, he did not bill for the astronomical sums mentioned in this article; he was just an assistant, and "out of network" was not a concept that applied at that time.

If the surgeon knows he or she is going to need an assistant on the case it is his responsibility to explain this to the patient (including exactly why one is needed) and to make sure the assistant is contracted with the patient's insurance plan. As someone who works for a large group which employs lots of staff who deal with this exact issue, I'm kind of surprised this ploy is as frequent (and successful) as it apparently is.

Labels: Medicine, Money

posted by Dr. Alice at #

 
You may have noticed there has been a slight delay in posting. My apologies.  (Full disclosure: I started this post in May 2013.)

Quite a lot has been happening. I'll try to condense it for you.

- I once again went through the agony of recertifying in Internal Medicine. This happens every ten years and it seems to get worse every single time. The good news is that now all internists are equally discommoded by this process, instead of only those who were certified after 1990. The older doctors who were originally told that they would not have to go through this process are now stuck with it just like the rest of us. An online revolt began almost immediately; a torrent of protesting emails have been fired off to the Board and to the ACP (our academic organization for Internal Medicine). So perhaps we will finally get some relief from this torment.

In case you are wondering about ongoing medical education, there has been a longstanding requirement for licensure that all doctors must earn a certain number of CME credits every year. The certification process has been added on top of that requirement and, in my opinion, is the board's way of grabbing control of the lucrative medical-education pie. Many doctors are threatening to let their certification expire. You can still practice without being board certified, but most medical groups and hospitals will be reluctant to hire a doctor who is not certified in some specialty. The question is, would an established physician be dismissed for letting his or her specialty certification expire? No one seems to know.

- I turned fifty last year and celebrated it in a way I did not expect. On my birthday my mother passed out cold while walking to the refrigerator, crashed to the floor, was taken to the hospital and found to have a cardiac arrhythmia which resulted in her getting a pacemaker a week later. Fortunately she is now doing fine. But the month before my father had had a serious stroke. Add in an aunt who needed hip surgery and two cataract surgeries on my mother, and you can see it's been a very busy year.


So what shall we talk about then? The heat wave, perhaps. It has been really warm and humid for over a week, what with two rogue hurricanes tracking up from Mexico through the Gulf of California. In Los Angeles we got little or no rain, but Nevada to the east got enough to wash out part of Interstate 15. Like many older houses on the west side, mine has no air conditioning; and because the windows are French-style that open on hinges, rather than the slide up-and-down kind, I cannot use a window unit. I dug out the giant box fan my father gave me years ago and it has been a lifesaver. It must be 40 to 50 years old and still works like a champ.

Southern California residents are also now having to cope with the constant announcements that we are in a Drought. The Worst Drought Ever. We must save water. Well, of course we must; any fool knows that we live in a semiarid climate and the population count here is far too dense for the amount of rainfall we get. We were bound to run out of water at some point. Some years we get heavy rain and flooding, some years we get very little rain. This past winter we only had one significant storm and that was in February. California is working on desalination plants, but I think that water storage tanks in everyone's backyard to be filled during the rainy season would also be a good tactic to try. Strangely this idea has not been discussed in the local press (as far as I can tell).

And lastly, our medical director has decided that the medical group ought to have a blog. It won't be for the public, but available on company Intranet only. I wound up being one of the doctors picked to write for it and was happy to participate, but he came up with this idea over a year ago and we still don't have the website up and running. Enduring the various delays has been somewhat frustrating, but we are told that "any day now" the blog will be functional. Uh-huh.

The other problem regarding the work blog is that our Fearless Leader wants posts of 150 words or less. I told him that at 150 words I was just getting started. He says the idea is more to present ideas that will "foster debate" about the best methods of practice. Okay, I can see that would be educational and it will force me to stay current on topics such as vaccination recommendations, when to start treating high cholesterol levels, and so forth. But it won't be very entertaining. My idea is that after a month or so I will start mixing in a little entertainment as well. We'll see how it works.

He doesn't know about this blog. I aim to keep it that way. I'll post more soon.

Labels: Los Angeles, Medicine, The Doctor's Life

posted by Dr. Alice at #