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“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
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Saturday, September 14, 2013
ZORK: THE QUEST FOR INSURANCE INFORMATION - A Text-Only Adventure Game > START > You are facing north, looking at the mouth of a cave. You have a walking stick. You have a torch. You have a knife. You have one bag of jewels. You have a handful of magic beans. > GO NORTH > You are in a dark cave. A woman wearing a headset is approaching you. > HOW MUCH IS MY DEDUCTIBLE? > I don't understand that. > QUERY DEDUCTIBLE > She shakes her head. "That depends on your employer," she says. "You must go back to Start." > GO EAST > You are in a maze of twisty little passages, all alike. > GO EAST > You are standing in a vast underground cavern. Many confused people are wandering around it. There is a display with numbered cards. > TAKE A NUMBER > You are number 1,752. > WHAT. > You are number -- > YES I HEARD YOU THE FIRST TIME > I don't understand that. > USE KNIFE > The crowd scatters and you find yourself at the head of the line. There is a counter with computer terminals. Behind it a man is standing. > QUERY DEDUCTIBLE > He tells you your deductible is $750 per year. You have $650 left on it. > OH NO > QUERY PMD > He tells you that you have been reassigned to a different medical group without your prior knowledge. > USE MAGIC BEANS > You show the man your magic beans and his face lights up. After a delay of 45 minutes, he tells you that he has been able to assign you back to your original PMD. > QUERY COPAY > He tells you your copay for PMD is one bag of jewels. If you go to the ER it is three bags of jewels. Specialist: two bags of jewels. > FIND PMD > This is a quest, remember? > SIGH. GO NORTH > You are in a narrow dimly lit passage. The ground is rough here. > USE STICK > The stick helps keep you from stumbling. Suddenly as you move forward you realize the ground is opening up. Before you can react you have fallen into a large pit just ahead of you. > USE TORCH > You raise the torch above your head to see better and realize the pit is filled with... pharmaceutical representatives. > USE KNIFE > You fight them off and scramble out of the pit just in time. > KEEP GOING > You are in a maze of twisty little passages, all alike. > GO LEFT > It is pitch dark. You are likely to be eaten by a grue. > USE TORCH > You are in a chamber filled with smiling people wearing white coats. > QUERY PROVIDERS > You must be more specific. > QUERY PMD > The chamber is filled with physicians' assistants, nurse practitioners and pharmacists, all of whom are eager to help, but none of them is an MD. Do you wish to continue? > HMMM. GUESS I'LL CONTINUE FOR NOW. GO BACK > You are in a maze of twisty little passages, all alike. > NOT AGAIN > I don't understand that. > GO RIGHT > There is a light ahead of you and a trail of discarded cardboard coffee cups and donut boxes on the ground. > KEEP GOING > You are in a lighted chamber. There is a stethoscope here. There is a reflex hammer here. There is a tired looking person in a white coat here. > GIVE JEWELS > The person in the white coat is your PMD. Congratulations. You have won the game. Labels: Medicine Tuesday, March 05, 2013
A Really Good Headline As a good Stepford staff member of Tertiary Care Center, TCC's intranet web page doubles as my home page. Every morning when I fire up the box I am greeted by perky articles about the Star Safety Team Member of the Week, the latest blood drive/fundraiser/politically correct spokesperson for Disease X, or warnings about parking restrictions due to construction. There is nothing intrinsically wrong with this. It's just part of working for a big corporation (which, let's face it, I do). My complaint here is that whoever writes the headlines for Tertiary Care Center's intranet web page needs some remedial education. This morning the top caption reads: A Benign Brain Tumor, a Malignant Tumor, a Love Story and a Doctor's Reassuring Presence I haven't read the story, but I'm sure it is heartwarming. No doubt. Unfortunately when I read this, my twisted brain immediately produced the following: ...and a Partridge in a Pear Tree ...and Two Hard Boiled Eggs. Make That Three Hard Boiled Eggs ...and Six Weeks To Live Rewrite, people! Rewrite! Labels: Critiques, Random Thoughts Thursday, February 07, 2013
State of January Dementia is like a sinkhole. It erodes from within. Particularly with Alzheimer's, the social graces are preserved until late in the disease. You see someone who is clean, properly dressed, gracious and smiling, able to carry on a conversation - although they might seem a bit vague. It isn't until you start asking detailed questions that you begin to see what's behind the facade. What's there is a vacuum. Patient Gracious Lady, GL for short, has been my patient for many years. She would sometimes be brought by a family member, but often came alone. I usually see her about twice a year, as she has been in pretty good physical health. During her appointments nothing about her demeanor said dementia or struck me as unusual. She was recently hospitalized for a fairly minor problem, but the admitting MD warned me that she had been quite confused and the family member who brought her to see me for a post-discharge visit confirmed it. "She'll ask me a question and I answer it. Then five minutes later, she asks the same question again." "Who's been paying her bills? Are they getting paid?" - if you suspect dementia, this is always a good question to ask as finances are one of the first things to go by the wayside. In this case though it didn't help. "I'm paying them." It turned out that family members had been helping her pay her bills for the past several years. During this discussion, GL sat quietly with a calm smile on her face, divorced from the entire conversation. "I'm going to do something called a mini mental state exam." This is a fairly quick test which covers vocabulary, short term memory, math and orientation to place and time. It isn't perfect as even someone with early dementia will likely get the questions right. But sometimes, as today, the results can be quite striking. I held up a pen and she named it immediately. But when I tapped the object on her wrist and asked her to name it, it took her 45 seconds to remember that it was called a wristwatch. Time to test location. "What state are we in?" "January." Oh crap, I thought. Wait a minute. "Is it someplace like Wisconsin? Rhode Island?" "No, those aren't right." She pondered for a while. "It's January." I stole a look at the relative, who was looking pretty devastated. Every answer revealed another deficiency. To be brief, the maximal score on the MMSE is 30 points; she scored less than half that. There are tests that can and should be run if you suspect dementia, to rule out medical causes. You check thyroid, vitamin B12 and syphilis titers among other tests. I ordered them, but I am not really optimistic that her problem is treatable. Her MMSE score is probably too low for her to benefit from medication. The one blessing that I have seen in dementia is that the patients themselves don't seem to be aware that they have a problem - or if they are aware, it doesn't really bother them. When a patient comes in with a complaint of "I keep forgetting things and I'm really worried that I have a problem," you can almost guarantee that they are not dementing. It's when the family or friends bring the patient in that you have to be concerned. GL had that same calm, detached air. The good news is that she has caring family who will look after her, and I firmly believe that social interaction helps in this disease. Still, it is not something that one would ever wish for a relative or loved one. Labels: Medicine Sunday, February 03, 2013
Perfecto!  I say, Your Majesty, you know how to handle a weapon. Rumor has it Jack Bauer took lessons from you. Labels: Politics, Pop Culture Saturday, February 02, 2013
On Children
Sometimes patients will bring their children to their appointments - this usually means they are very young children and that the parents couldn't make arrangements for the kids. It doesn't bother me. In fact, on a tough day it invigorates me to have a baby in the room. My favorite trick for the young ones is to hand them a tongue depressor; it is wonderful to see them eyeing it, grasping it with both hands (what is this? I imagine them thinking) and then, of course, eventually gnawing on it.
I also remember one energetic two-year-old who entertained himself by opening the bottom drawer of the exam table and taking out, one by one, the small plastic jars of preservative fluid contained therein. The jars are for Pap smears. Don't worry, they were safely sealed and there was no way he could have opened them. The worried father asked if this was a problem. "As long as he's not screaming, I'm happy," I reassured him. The older ones find it interesting to look over my shoulder as I'm typing and especially to look at pictures of X rays. Or sometimes they will just stare at me, The Doctor, as I interview and examine their parent. Or they may even ask questions, which I love. Rarely a child will announce that he or she wants to be a doctor and I encourage them heartily. Pediatrics, though, I could not do. I realized that as a medical student the first night a neonate came in with a fever and we had to do a spinal tap on the infant. Now that my office is right next to the Pediatrics Department and I hear the wails of children echoing through the air vent on a regular basis, I am even more certain I made the right choice. Labels: The Doctor's Life Monday, January 28, 2013
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 Saturday, January 05, 2013
"As God Is My Witness, I'll Never Go Hungry Again!" Said the Dieter So I'm counseling a patient on weight loss. She mentioned that she goes to a fair number of social functions and has to eat what she's served there; which is often a problem. "You could always do a Scarlett O'Hara and eat before you go," I suggested. She looked blank. "Huh?" "Surely you know your Gone With the Wind?" She didn't. "Well, early in the book Scarlett O'Hara is getting ready to go to a barbecue at a plantation nearby. Apparently in those days ladies weren't supposed to have an appetite, or to eat much in public. So she eats a whole meal before she goes to the barbecue. Then she gets there, and the host is serving wonderful food that nobody's eating, and it's just like Beverly Hills!" She laughed with delighted recognition. That she got. And if I'm lucky, I may have even inspired her to read Gone With the Wind. (If you haven't, do give it a try; it combines the best qualities of the soap opera and the historical novel.) Labels: Pop Culture, Weight Loss 
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