Friday thoughts

I made a really good medical decision the other day. I can’t go into details of course, although some day it may end up anonymized and folded into a story, but it felt good (for me and the patient).   It involved using several different layers of knowledge to come up with  a solution, a bit like solving the Friday NYT crossword puzzle: not impossible, but difficult enough to be fun (when I say “difficult” about the crossword, I speak for myself, not my genius brother-in-law who could solve it blindfolded, upside-down, and drunk).

Medicine is full of puzzles, most of which aren’t particularly good for the patient.  It’s much better to be a boring patient than an interesting one.  There are no truly “boring” patients of course.  When someone relatively healthy comes in, I get to learn about the work they do, often something I’ve never heard of.  I hear unique family tales, tragedies and triumphs; this is one of the joys of medicine, being allowed to hear other peoples stories.  I never consider the time wasted.

I recently spent twenty minutes with a patient discussing recipes.  Not only did I learn a few tips, but I also learned about how this particular hypertensive patient prepares and eats his meals.  And I made a friend.  Medicine involves a lot of salesmanship.  I have to talk people into doing some fairly unpleasant things, so being on friendly terms with them helps grease the, er, wheels.

In past posts, there have been debates as to whether medicine is “special”:  is it a job like any other, or is it more of an identity?  I favor the latter in many situations.  Sure, being someone’s  banker involves a level of trust and intimacy, a sharing of private knowledge, but medicine takes it a stop further.   Just a few moments ago (while I was typing paragraph three) a heard screaming form the other end of the cafe.  A barrista had just spilled a pitcher of boiling water on herself.  I invited myself into the back to tend to her.  This was possible only because our gives a special trusted status to physicians (warranted or not).  Once I announced I was a doctor and I was willing to help, there was no argument, no fear, just a look of relief.  I left the office before five today, but I never truly leave the job.

The puzzles, the identity, the stories, the relationships all make medicine unique and enjoyable.  Whatever the instability in the business of medicine, I can never leave the job, because I am the job, and the job is me.

11 Comments

  1. Natalie Sera

     /  June 25, 2011

    I am so happy to be a boring patient. I’ve had diabetes for 20 years, and so far, NO complications whatsoever at all. I even had a normal angiogram (performed because I was having chest pains, and have a history of coronary artery spasm).

    The only fear I have about being a boring patient is that a doctor can get so used to me having no problems that he misses the rare one that pops up. Last year, my A1c went WAY up from the 6’s to the 10’s; my fasting BG was over 300 and liver enzymes were in the 100’s but my endo sent me home without doing anything. 6 days later, I was in a coma, and if my friends hadn’t come looking for me when I didn’t show up for a picnic, I would have died by the next morning. I can’t see how he missed the dramatic change, even if the individual indicators weren’t so alarming to him. It’s like, we zebras DO exist!

  2. DLC

     /  June 25, 2011

    anyone of average intelligence or better and average manual dexterity or better can cook, given a recipe card and a bit of training. However, it takes having a passion for the craft that makes a cook into a chef. Anyone can do the tasks associated with medicine too, given a certain amount of intelligence and some basic skills. However, it takes someone with a passion for it to be a good doctor. . . okay so I’m oversimplifying it, but I think you know where I’m going.

    • I don’t know that you are oversimplifying all that much. For 6 of the past 7 years, my insurance has assigned me to a primary care provider rather than giving me a list to choose from. I was re-assigned every year on average.

      Only two of these would I classify as good doctors (and one of them was a PA). The rest I think of more as technicians. I also think certain specialties are favorable to the technician personality type — orthopedic surgery, for example. Anesthesiology, possibly. Being a technician is not necessarily a bad thing and it doesn’t always preclude interest in and solving puzzles.

      At the moment, I find myself in a strange position as a patient. When I was finally allowed some choice in primary care docs, I went back to one I’d been very happy with before my insurance change. She’s changed and my layperson’s preliminary diagnosis is burnout. All I’m really sure of is that she no longer keeps abreast of current research, changing guidelines, new medications… etc. And that she has cut her office hours to 3 days a week.

      Just last week, she called after getting blood test results and said my cholesterol was elevated and she wanted to call in a prescription for me. I agreed without even asking questions since I’ve always been slightly surprised my cholesterol has stayed low for so long.

      The prescription was for simvastatin, 80 mg. Since I read this blog as well as other medical/science blogs, I was surprised. And since I had a relative’s much more urgent medical problems to deal with out of town, I simply decided not to take it until I got back home.

      This is the 2nd time I’ve wondered about whether she’s keeping her knowledge and practice current. Last spring, I asked for the tdap vaccination and she said she’d never heard of an adult pertussis vaccine. She did give me the tetanus booster. Should I have been more insistent?

      In between these two incidents, she’s been perceptive, open, and while I know she’s only getting paid for spending 10 minutes with me, very generous with her time. I still think she’s a good doctor.

      Heck, she even talked me into getting a mammogram. (I’d resisted for 20 years after my first one because it hurt so damn much and justified this with knowledge that no female blood relative for three generations had breast cancer.)

      I don’t want to change doctors again. I like many things about the group she works with — the receptionists and nurses are pleasant and helpful and when I call for help (as in asking for a klonopin prescription when a snake invaded my house) I get what I need in a timely manner.

      The snake incident was horrible… I saw the snake in the laundry room, but ran outside screaming leaving the door open. By the time a rational person arrived on the scene, the snake had disappeared. These rational people assure me the snake most likely left the house through that open door.

      I can go in the laundry room now without panic, but the upside to this story is that my husband is still doing the laundry.

  3. Speaking of doctors and boring patients… we just moved and I need an internist in the Denver area. Most of the time, all I need is routine asthma maintenance. Maybe you or your readers know of someone?

    Also a coffee roaster. This is actually more urgent than the MD at the moment since I have plenty of Advair, but I’m almost out of beans!

    • You are in the city with one of the best pulmonary hospitals in the country, National Jewish, who can probably provide a good referral.

  4. Awesome! I’ll give them a call. For years in my old Wyoming town there were no internists at all, then there were a couple..Denver is thick with doctors, which I think is great, but it’s hard to narrow my focus.

    Maybe they’ll have a tip on good coffee as well…

  5. Here’s the followup. Turns out that it’s not easy to just have someone suggest an internist. And possibly I misunderstand the medical care paradigm.

    In my own mind, I need an internist and my regular OB/Gyn annually. (Because she’s wonderful, and I’ve been seeing her for ten years.) Should the internist or my OB flag something, then they would refer me for more specific/specialized care. I think this is how it’s supposed to work….

    So I started asking around about an internist.

    1. My son sees a pediatric orthopedic doc at Children’s (amazing facility and docs…) who doesn’t visit a doctor regularly himself. He didn’t know of any internists in the area.

    2. My friend who is married to my old GP from way back (he sold his practice a few years ago to work for more lucrative pay and better hours overseeing medical care delivery in the state penal system…) knows someone who knows someone who once saw a nice internist here-but I think that doc is a longish commute from my house. I’ll take another look at a map.

    3. You suggested NJH. The nurse at the Lung Line said they don’t have internists, don’t know any internists, but they could do the asthma stuff. And they work with most insurance companies. Which is great, but I think I also/only need someone who has a view of the entire picture. The asthma is very mild and nearly always well-controlled. Well within the scope of practice of an internist.

    We just submitted paperwork to a new pediatric practice (the Children’s Hospital doc suggested this group). I’ll see if they can suggest someone.

    Independently, I found some good reviews of a coffee roaster, so things are moving along on that front…

  6. Mattie F.

     /  June 28, 2011

    “My genius brother-in-law who could solve it blindfolded, upside-down, and drunk”

    Is that with him upside down (I imagine him being suspended by his feet) or the puzzle?

  7. B.I.L.

     /  July 5, 2011

    Actually, it’s the Saturday NYT crossword puzzle that the *real* killer.

  8. CT

     /  July 21, 2011

    This is lovely, simply lovely.

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