“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






Email Dr. Alice

 

The Poem. 

So at ten past five today I got a text from my office manager, which went something like this: 

"Hi! We're starting a newsletter and thought it would be great to include a poem and I thought of you! Maybe something funny and light? We need it by Tuesday [four days from now]."

Well. See what comes of having a reputation as a semi-wit (not to say halfwit)? 

I replied, "Is it OK if it's a limerick? I don't think I'm up to a sonnet. And do you have a theme you'd like me to use?"

"Well, the new doctors are joining the group, so maybe something welcoming them?"

I replied that I would do my best. My mind started percolating. New doctors, huh? I thought. Welcome to the jungle.

And there I had it. I quickly looked up Guns N' Roses lyrics and came up with the following. 

Welcome to the jungle, we got fun and games

Like “Who’s the Doctor of the Day?” and “How do I file these claims?”

The paperwork will haunt you, we’ve all been there before

Feel free to ask unless you see us pounding on the door

 

Welcome to the jungle, we take it day by day

If the quarterback is freaking out, it’s best to stay away  [quarterback is our term for head nurse]

The patients all have Covid, at least they think they do

If we’re lucky they will wear a mask so we won’t get it too

 

Welcome to the jungle, it’s really not that bad

The staffing here is all top notch and Urgent Care is rad

We’re here to help, from unknown rash to “Name that Specialist!”

We look out for each other and we’re happy to assist.

Considering I batted this out in 45 minutes, I don't think it's too bad. Now they want me to do another one for next month... 

Labels: Pop Culture, The Doctor's Life

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Journal Post #1

I’m going to try something different here, cross posting pieces from my journal on this blog. At least doing this will ensure that I will be producing more posts to entertain any wandering reader who happens by. Briefly, several months ago I decided to start keeping a personal journal to document my decisions for the coming year. I had retired, or semi-retired, in January of 2020 to take care of my ill aunt and parents. As it turned out this was just in time for Covid to come along. My aunt passed away one year ago, followed by my father six weeks later, followed by my mother three months ago. Now I am in the process of selling my home and moving back to my parents’ to try and get the house on the market. Come along with me, won’t you? It’ll be fun. Hopefully at least engaging, in the way of a train wreck.

Yesterday I was able to get the mirror on my car fixed, and I feel much safer driving now. Did some more packing and moving. My mother’s celebration of life service is in three days, and the other fam members will arrive in two days. So I’m just trying to get the place pulled together, bedrooms ready, food in the fridge. I do wish they could stay longer, but everyone has to get back to school/jobs.

Last night, to distract myself, I wound up looking at housing prices and other facts about Provo, Utah as part of my research for my long-term plan to move out of California (why Provo? Only because I’m thinking of attending a conference there next year). But Utah, like California and much of the western US, is suffering from drought. This has reinforced my vague plan to move to the East Coast. I don’t like floods or hurricanes either, but it would be nice not to have to worry about water.

I also spent some time with my tenant, reading lines with her. She is an actress and currently is auditioning for a Netflix show called “Obliterated.” As far as I can tell it’s about a bunch of Navy SEALS who spend their time cursing, having sex and taking drugs when they aren’t saving the world. Good Lord, I’m glad I’m not an actor; I cannot fathom having to take roles like that.

More later.

Labels: Los Angeles, Random Thoughts, The Doctor's Life

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Personal Update 

I am settled in here in my mother's hospital room for her third admission in a month. 

At least, that's what I wrote back on the 22nd of January. My mother passed away on February 4; my father on June 19 of last year. My aunt died May 8 of last year. 

It's been a difficult time. I have been writing, just not on the blog. I started keeping a journal last December with the intention of using it to clarify what I want to do both for myself and for my mother. But my mother never really recovered from the twin blows of losing her only sister and her husband six weeks apart. My siblings and I are planning a celebration of life for her which will take place in about ten days; I am in the process of selling my house and moving to my parents' home so that I can get it into shape to sell. 

I'm not going back to work, at least not full time; I am considering working virtual sessions to keep myself busy when I'm not throwing out junk or battling spiders. (I sometimes think my parent's house is one solid cobweb.) But right now I am packing and sorting, and I hope to put together an estate sale at some point. And I hope to document the process here (at least the interesting part). 

Labels: Family, The Doctor's Life

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Therapy Session

Back I am at the blog, in search of counseling. Did I mention that this blog serves as my makeshift therapist? I visualize it as female, of no particular appearance, leaning forward, professionally caring but geared to forcing the truth out of me. 

Then we sit and look at whatever this truth is. 

Well, (I brace myself,) the past month has been a little tough. It's indisputable that my father's dementia is getting worse. His sister called last week to speak with him and then asked to talk to me; she wanted to know how he's doing. He can't really carry on a conversation any more, though he is always glad to hear from her. I think he had another stroke about a month ago; he has to be coaxed to eat, and often falls asleep during breakfast or dinner. He can't tell us when he has to go to the bathroom any more and is often incontinent without being aware of it. In addition to that my aunt, the one with metastatic lung cancer - remember? She's on hospice now - is becoming weaker and weaker. She is eating less and her weight loss is accelerating. A few weeks ago I made the decision to move in with them, and I've been staying there more or less full time. 

This means I won't be seeing patients for now. Not that I was seeing many, just one four hour shift per week, but it was something. It made me feel like a doctor again and not just an overloaded daughter, gave me a chance to dust off my skills rather than letting them atrophy. Even virtual visits are not an option, as it has become impossible to spend four uninterrupted hours online due to the needs of my parents and aunt.

My aunt is my main responsibility right now. She is becoming increasingly confused as well as having major memory loss (probably due to the chemo and radiation). She isn't able to keep herself occupied with much - she does read but I don't know how much of the book she retains day to day. In an effort to give her variety, I tried to show her how to use my Kindle but she simply could not fathom it, even after I set up a book for her with a large font. She could not remember how to tap it to turn the pages. Physically, she is wheelchair bound and requires oxygen at all times. Even taking her to the bathroom has become a significant journey.

Her friends have been very supportive and have made the drive from the Palm Springs area many times in the past two months to visit. Two came yesterday and two more are coming today; yesterday, two men (partners) and today two women (also partners). The women have a lovely long-haired dachshund that loves my aunt, and my aunt loves her right back. I will miss seeing her today as I had to go into town for an orthodontist's appointment (my treatments are over and I am graduating to a retainer, hooray!)

My aunt has outlived her prognosis, I think due to force of will alone. Major props to her for this. Taking care of her has taught me a lot, as I have never seen major illness from the family point of view before - only as a physician. Eventually I will go back to work part time, and I hope I will take what I have learned with me.  

I don't know whether all of this commentary adds up to anything or not. At least it is a relief to put it down.

Labels: Family, Random Thoughts, The Doctor's Life

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 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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So Here We Are 

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

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I sit here waiting for my first patient of the day, desk fan set up, coffee ingested. The iPad is set up for video visits and charging cords snake over the desk. A freshly charged phone is at hand for the inevitable telephone visits for our older patients and the telephone number for the translator service is within reach. All set to go.

Labels: Random Thoughts, The Doctor's Life

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Feral Cat Land

Labels: Los Angeles, Random Thoughts, The Doctor's Life

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Around the corner from my house is a large north-south boulevard that begins a couple of blocks south of me and runs north into the San Fernando Valley; it's often used by commuters as an alternative to the dreaded 405 freeway. The south end of this road is lined by apartment buildings and terminates at the local public golf course. As the road runs north into the hills, the apartment buildings disappear and are replaced by individual homes. I walk in the mornings for exercise and my route often takes me up this street. Therefore I have had plenty of opportunity to ponder the differences among the buildings as I wander. 

Labels: Los Angeles, The Doctor's Life

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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

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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

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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 #

 
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

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Labels: The Doctor's Life

posted by Dr. Alice at #

 
Flu B Gone

The flu has hit. Some years it's not so bad, some years it's worse. We don't have tents out in the parking lot or anything, but it sure has been busy around here. Today my suitemate and two nurses are out and I have the feeling it's going to be a bad day... a long, bad day.

On those days you grasp at anything to cheer yourself up. Like today, when I was ordering antiviral for yet another patient down with influenza and typed "Tamifly" instead of Tamiflu. (That's oseltamivir for you pedants out there.) Doesn't that sound like a much cooler name? A whole marketing campaign sprang to life in my head, fully formed.

Don't be flu. Be fly. With Tamifly.
Fly above the flu. Tamifly can help you too!

More coffee. I need more coffee...

Labels: The Doctor's Life

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Having been seduced by the likes of Facebook and Twitter, I have come to realize that maybe I would blog more if I settled for shorter posts. I feel the need to do this, just to share the madness of actual medical practice. Here is one actual conversation from yesterday:

Patient: I'm depressed. I think maybe it's because of global warming.

Me: ...um. Are you doing stuff about it? Like recycling, and trying to drive less?

Patient: yes, but I still feel sad. Maybe I need medication.

Me: Maybe you should turn off the news.

Labels: The Doctor's Life

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This Is Counterproductive

Reading food blogs while counseling patients on their diabetes... that's just wrong. Bad doctor.

Labels: Ingestion, The Doctor's Life

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I Used To Do That With Hawaiian Punch and a Straw


Today a patient told me how he kept himself entertained in the hospital during his admission for a GI bleed: he kept clenching and unclenching his stomach muscles to vary the level of blood in his NG tube. To each his own, I guess.

In other news, almost over my jet lag. Thank goodness.

Labels: Medicine, The Doctor's Life

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Head Meets Desk

Annnnnnnnnd today, we have the patient who needs approval for life insurance, whose insurance company faxed a form marked "urgent" in sixteen different places, who hasn't had a physical since MARCH 2008. FAIL.

Give her credit, when I called to explain she was horrified and offered to come in right away, but still.

Labels: The Doctor's Life

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Gonna Stay Where I Am


As is the standard after any vacation, I had a small mountain of mail piled on my desk to greet me when I came back. Sorting through it I found a pamphlet entitled "Non-Clinical Careers for Physicians: Your Action Plan for the Future." Good Lord, I thought. Are there that many cranky docs out there fantasizing about never seeing patients again?

Apparently there are. The inside cover pitches this seminar as follows:

This course is designed for physicians who:

Don't enjoy going to work anymore
Are interested in making more money than what clinical medicine provides
Want to explore their options [the world's biggest cop-out line - Ed.]
Are frustrated and dissatisfied with their current career

And many other reasons listed, but I think you get the idea.

The seminar includes meetings with employers and recruiters, lectures and 'breakout sessions' on topics like "The Physician Inventor" (OK, that one intrigues me), "Communicate and Network Your Way to a New Career," "Opportunities for Physicians in the Biopharmaceutical Industry" [and in other fields: disability insurance, consulting firms, medical device companies and so forth]. All of this in two days for only $1295 US!

At this point my inner red flag started waving. This sounds like a ripoff. Not in the sense that it's illegal at all, just that any doc who knows how to network could probably figure out a lot of this stuff by asking around. Specialists, drug reps, insurance company staff, talking to their medical school's alumni association... you know, what people who aren't doctors do when they look for jobs.

More to the point, none of these career options sound interesting to me. I do not want an administrative job. I like primary care and interacting with patients, and through good fortune I belong to a stable medical group which pays me a salary. My checks don't bounce; I don't have to worry about paying the office rent. I know not all doctors can say the same. But if I were in that position and money was tight I might moonlight somewhere or (as above) would try a spot of networking on my own first.

The back of the pamphlet offered a fiction writing seminar for physicians later in the year. Now that I may find harder to resist! I've got this idea. There's this primary care doctor, see, who uncovers a bioterrorism plot in between filling out disability forms and fighting drug plans for authorizing medications. It's guaranteed to be a bestseller... if I can just sit down and write it...

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #