Well, I'd like to say that something amazingly weird/funny/irritating happened today, but it didn't. I think this was probably the most normal day at Disability Physicals I've had since starting this job. Go figure. Maybe tomorrow will bring something worth writing about.
And now for the disability quote of the day - this one is from a while back:
Me: "So you say you have difficulty with your bowels, and that's what is keeping you from working. How so?"
Claimant: "Well, if I eats, I poop. If I don't eats, I poop. All I do is poop, I can't do nothing else. I even dream about pooping!"
Me: "Talk about a crappy dream..."
Claimant: "You ain't funny."
Anyway, have a good one,
-DD
Wednesday, December 30, 2009
Tuesday, December 29, 2009
Idle Hands
I arrived at Disability Physicals this morning in a great mood. I don't know why, maybe it was because I got to have breakfast with my family, or maybe it was because I slept pretty well last night. Regardless of the reason, I settled into my freezing office, looked at my full morning schedule, and thought, "this will probably be a good day." The clock read 8:01 AM. At 8:25, I thought, "well, one no show, no big deal." At 9:25, I thought "Well crap, that's three no-shows in a row, there goes a nice chunk of change." Thankfully, at 9:45 my 9:30 showed up.
He was 19 years-old, 6'2, 302 lbs, and his chart read he had a learning disability that caused him to need a tutor in math and English. He also reported that he had "some leg pain that causes me pain." Great. Anyway, I introduced myself, and lead him into the office, at which point, I asked him, "So, what keeps you from working?"
"Well," he responded, "I've never worked before, but I thought that my leg pain would probably keep me from working, as my leg gives out sometimes."
"Wait," I replied. "You've never worked before, you're just worried that you might not be able to?"
"Right, and I've got this learning problem - I needed a tutor in math and English."
I'm sure I probably rolled my eyes, although I tried not to. I honestly was a little shocked. Here's an apparently healthy teenager who is trying to get disability because he's worried that he couldn't work? It just didn't make sense to me. I continued with the questions.
"So when does your leg hurt?"
"Oh, once in a while...it'll probably go out 1-2 times every 3 weeks."
"So besides that it doesn't hurt?"
"Not really, although one time it gave out while I was holding a door open for my sister."
"Well, at least chivalry isn't dead," I replied.
"Who's dead?"
Anyway, the questions basically led nowhere. He ended up stating that his pain was transient, and he was just trying to find some way to make money. Apparently getting a job wasn't an option. His exam was totally normal, as you might image, with the exception of very bloodshot eyes, and the faint smell of marijuana wafting from his clothing. He left the office, girlfriend and little boy in tow.
As amusing as this encounter was, it also made me think. Why is a getting disability check for the rest of your life a better option than getting a job - even a minimum wage one? I've had grown men cry in my office because they were so embarrassed they were applying for disability, and this guy comes in, never having worked a day in his life, and expects me (and you) to pay for him until he "retires?" It's total arrogance, not to mention extremely lazy. Since when did working hard become hardly working?
We strive as a society to provide for those less fortunate than ourselves. Whether you call it religious charity, personal altruism or whatever, we have developed a "need" to care for those suffering from loss - be it physical, emotional or otherwise. What do we do, then, when those in "need" abuse the systems that were created for them? Obviously we can't remove social security, welfare and so on, there are too many people who actually need those programs to justify scrapping the thing as a whole. We have to treat the root cause of the problem, which in my opinion is laziness. My wife recently told me that she was reading an article in which they interviewed some very well known "workaholics." The main reason, she told me, that these people worked so hard was that they never wanted to be called lazy. Now, while I by no means think that being a workaholic is a good thing, I do think that as a whole, our society could use a little jumpstart to its work ethic. Call me callous, but I hate to think that a portion of my earnings are going towards paying a person a monthly check because they're "worried they couldn't get a job."
If you think about it, we're really amazing creatures. The testament to our God-given gifts of creativity and dedication are all around us. With the New Year approaching, I think that we should try and focus on working just a little harder at all the things we do. Rome definitely wasn't built in a day, but if everyone gave 100%, who knows what might be.
And now for the disability quote of the day:
Patient's mother's written response to the question, "Has your condition affected your ability to drive? If so, how?"
"He only drives when the car's not running."
Until next time,
-DD
He was 19 years-old, 6'2, 302 lbs, and his chart read he had a learning disability that caused him to need a tutor in math and English. He also reported that he had "some leg pain that causes me pain." Great. Anyway, I introduced myself, and lead him into the office, at which point, I asked him, "So, what keeps you from working?"
"Well," he responded, "I've never worked before, but I thought that my leg pain would probably keep me from working, as my leg gives out sometimes."
"Wait," I replied. "You've never worked before, you're just worried that you might not be able to?"
"Right, and I've got this learning problem - I needed a tutor in math and English."
I'm sure I probably rolled my eyes, although I tried not to. I honestly was a little shocked. Here's an apparently healthy teenager who is trying to get disability because he's worried that he couldn't work? It just didn't make sense to me. I continued with the questions.
"So when does your leg hurt?"
"Oh, once in a while...it'll probably go out 1-2 times every 3 weeks."
"So besides that it doesn't hurt?"
"Not really, although one time it gave out while I was holding a door open for my sister."
"Well, at least chivalry isn't dead," I replied.
"Who's dead?"
Anyway, the questions basically led nowhere. He ended up stating that his pain was transient, and he was just trying to find some way to make money. Apparently getting a job wasn't an option. His exam was totally normal, as you might image, with the exception of very bloodshot eyes, and the faint smell of marijuana wafting from his clothing. He left the office, girlfriend and little boy in tow.
As amusing as this encounter was, it also made me think. Why is a getting disability check for the rest of your life a better option than getting a job - even a minimum wage one? I've had grown men cry in my office because they were so embarrassed they were applying for disability, and this guy comes in, never having worked a day in his life, and expects me (and you) to pay for him until he "retires?" It's total arrogance, not to mention extremely lazy. Since when did working hard become hardly working?
We strive as a society to provide for those less fortunate than ourselves. Whether you call it religious charity, personal altruism or whatever, we have developed a "need" to care for those suffering from loss - be it physical, emotional or otherwise. What do we do, then, when those in "need" abuse the systems that were created for them? Obviously we can't remove social security, welfare and so on, there are too many people who actually need those programs to justify scrapping the thing as a whole. We have to treat the root cause of the problem, which in my opinion is laziness. My wife recently told me that she was reading an article in which they interviewed some very well known "workaholics." The main reason, she told me, that these people worked so hard was that they never wanted to be called lazy. Now, while I by no means think that being a workaholic is a good thing, I do think that as a whole, our society could use a little jumpstart to its work ethic. Call me callous, but I hate to think that a portion of my earnings are going towards paying a person a monthly check because they're "worried they couldn't get a job."
If you think about it, we're really amazing creatures. The testament to our God-given gifts of creativity and dedication are all around us. With the New Year approaching, I think that we should try and focus on working just a little harder at all the things we do. Rome definitely wasn't built in a day, but if everyone gave 100%, who knows what might be.
And now for the disability quote of the day:
Patient's mother's written response to the question, "Has your condition affected your ability to drive? If so, how?"
"He only drives when the car's not running."
Until next time,
-DD
Monday, December 28, 2009
Lesson of the day
Since it's been a few days since my last entry, I thought I'd take it easy tonight and share a funny story that happened this morning. It was a busy Monday at the Juvie - the Christmas holiday had brought a number of new detainees, one of whom had been in the "observation unit" since yesterday, apparently coming off of some drug concoction. About 9:00 AM, my nurse and I received a call that the kid was "acting very erratic," and should be evaluated. We packed up our blood pressure cuff, pulse oximeter, etc, and walked down to the observation unit, where a tall African-American male clad in a green t-shirt and ”tighty whiteys” sat holding himself, rocking back-and-forth, in one of the holding chambers. We asked him his name, if he knew where he was, and what was going on. He stated that his name was "John," and that "if I told you what happened at her house, they'd kill me." We assured him that we were not going to tell anyone what happened, we just wanted to know what drugs he had taken. He started crying more at this point, and said, "What's so wrong about sitting in a hot-tub and smoking a joint?" We tried asking more questions, but to no avail. He kept repeating himself, and then promptly passed out. Checking that his vitals were stable (and they were), we headed back to the clinic, and had a fairly normal rest of the morning. We later came to find out (by another detainee, none the less), that he had mixed some "crazy-ass shroom sticks with his weed while staying at his sister's house." "That's why you don't smoke with other people," the other detainee added. "You never know what's going on with their weed." That was my lesson of the day. Never mix shroom sticks with weed while chillin' in your sister's hot tub. Word.
And now for the dsability quote(s) of the day:
Patient's son's written response to the question, "Has your illness/injury caused any changes in behavior? If so, please list what."
"His problems with drugs and alcohol made him free-ball"
(I hope that's a spelling error or something, but who knows)
Me: "Are you allergic to anything?"
Patient: "My allergies."
Me: "I can imagine that would be terrible."
Until next time,
-DD
And now for the dsability quote(s) of the day:
Patient's son's written response to the question, "Has your illness/injury caused any changes in behavior? If so, please list what."
"His problems with drugs and alcohol made him free-ball"
(I hope that's a spelling error or something, but who knows)
Me: "Are you allergic to anything?"
Patient: "My allergies."
Me: "I can imagine that would be terrible."
Until next time,
-DD
Wednesday, December 23, 2009
Socket to me
Working at the Juvie has allowed me to see a side of the world that my middle-class, straight- laced upbringing never allowed me to see. Not that I'm complaining, mind you, it has just amazed me how naive I really was (and still am, for the most part) when it came to the differences in healthcare among the incarcerated. I know, and I knew as a child, that if I needed to go to the ER for some reason, I would be taken seriously upon admission, and treated (or even over treated) for my complaint. For the kids I work with most of the week, that's not always the case. Last Friday morning, a detainee was brought into the clinic because he had been elbowed in the eye while playing basketball. When I first saw him, he had just returned from the ER, and had been diagnosed with a contusion (a fancy name for a bruise), given a script for Lortab, and had been told to "take it easy for the next few days," by the ER physician. His stay at the ER had been brief, no imaging had been performed, no lab work drawn, and his only complaint when I saw him was some bleeding from his nose, as well as pain in his upper molars. I performed a quick exam, and aside from some impressive swelling and bruising around that eye, everything appeared normal. I was a little confused as to why they didn't get an x-ray of his face, but since he wasn't complaining of much, and his vision was 20/20, we sent him back to his room, without gym privileges until I could see him again on Monday.
Monday came, and when he returned to the clinic, something didn't look right. The swelling around the lower part of the eye socket had increased, and now his sclera (the white part of the eye) had blood in it. In addition, he stated that the nose bleeds had started coming more frequently, and the pain in his molars had grown to encompass most of his upper jaw. I re-examined his eye socket, and since I was a little more suspicious this time around, really tried to feel some sort of boney deformity along the orbital ridge. Much to my surprise, I felt a small...outcropping, for lack of a better term on the lower portion of the socket. In addition, when I palpated his nasal bone, something felt off as well. At this point, I was getting increasingly frustrated with the care he had received in the ER. Now, I'm not saying that they didn't take good care of him because he was in Juvenile Detention, but it's not like that hasn't happened before. Anyway, I called one of my friends who's a pediatric resident, and after telling her about the situation, she agreed to see him at her next available appointment, which due to the holiday season, was first thing this morning.
To make a long story short, I received a call from her this afternoon stating that she had seen the detainee earlier today, and after confirming what I had told her with her own physical exam, had ordered an x-ray of his face. It was a little suspicious, so she went ahead and ordered a CT of his head. The radiology report came back:
1.) Blow-Out fracture of the inferior portion of the orbit
2.) Free air in the surrounding subcutaneous tissue
3.) Soft tissue infiltrate into the maxillary sinus.
Holy crap. So not only had he broken the bottom portion of his eye socket, but air had leaked into the surrounding tissue, and the fracture had forced some of that same tissue into the sinus above his jaw (thus explaining the nose bleeds and the jaw pain). He now has an appointment with Facial Plastics on Monday. The sickening thing is, any one of those conditions could have warranted an immediate ENT or Plastics consult. I'd like to say that everything will be fine, and that he'll recover without having to undergo surgery, but I think those odds are slim. I know that medicine is not perfect, and you all have heard me go off on how we often over utilize x-rays and lab tests, but this is one example where using those technologies could have been a great boon to the patient.
I tell you this story not to try and point fingers at the ER, or to make myself look cool or anything like that. I simply want to point out that we all are often guilty of taking one look at someone, and immediately judging them. Just because this kid is in Juvenile Detention doesn't mean that he can't get injured – we all get sick, sometime. We as physicians should strive to give the same quality of care to all patients, be they prisoners, homeless, or multimillionaires. Never forget, it’s about seeing and treating the person as a whole.
And now for the disability quote of the day:
Written response to the question, "Have you ever worked before? If yes, in what capacity."
"Job - Shirt Runner. I was a Shirt Runner at a pizza place."
If someone could enlighten me why pizza place's need their shirts...ran, I would appreciate it.
Look beyond the handcuffs,
-DD
PS, This will be the last post until 12/28/09. Have a Merry Christmas!
Monday came, and when he returned to the clinic, something didn't look right. The swelling around the lower part of the eye socket had increased, and now his sclera (the white part of the eye) had blood in it. In addition, he stated that the nose bleeds had started coming more frequently, and the pain in his molars had grown to encompass most of his upper jaw. I re-examined his eye socket, and since I was a little more suspicious this time around, really tried to feel some sort of boney deformity along the orbital ridge. Much to my surprise, I felt a small...outcropping, for lack of a better term on the lower portion of the socket. In addition, when I palpated his nasal bone, something felt off as well. At this point, I was getting increasingly frustrated with the care he had received in the ER. Now, I'm not saying that they didn't take good care of him because he was in Juvenile Detention, but it's not like that hasn't happened before. Anyway, I called one of my friends who's a pediatric resident, and after telling her about the situation, she agreed to see him at her next available appointment, which due to the holiday season, was first thing this morning.
To make a long story short, I received a call from her this afternoon stating that she had seen the detainee earlier today, and after confirming what I had told her with her own physical exam, had ordered an x-ray of his face. It was a little suspicious, so she went ahead and ordered a CT of his head. The radiology report came back:
1.) Blow-Out fracture of the inferior portion of the orbit
2.) Free air in the surrounding subcutaneous tissue
3.) Soft tissue infiltrate into the maxillary sinus.
Holy crap. So not only had he broken the bottom portion of his eye socket, but air had leaked into the surrounding tissue, and the fracture had forced some of that same tissue into the sinus above his jaw (thus explaining the nose bleeds and the jaw pain). He now has an appointment with Facial Plastics on Monday. The sickening thing is, any one of those conditions could have warranted an immediate ENT or Plastics consult. I'd like to say that everything will be fine, and that he'll recover without having to undergo surgery, but I think those odds are slim. I know that medicine is not perfect, and you all have heard me go off on how we often over utilize x-rays and lab tests, but this is one example where using those technologies could have been a great boon to the patient.
I tell you this story not to try and point fingers at the ER, or to make myself look cool or anything like that. I simply want to point out that we all are often guilty of taking one look at someone, and immediately judging them. Just because this kid is in Juvenile Detention doesn't mean that he can't get injured – we all get sick, sometime. We as physicians should strive to give the same quality of care to all patients, be they prisoners, homeless, or multimillionaires. Never forget, it’s about seeing and treating the person as a whole.
And now for the disability quote of the day:
Written response to the question, "Have you ever worked before? If yes, in what capacity."
"Job - Shirt Runner. I was a Shirt Runner at a pizza place."
If someone could enlighten me why pizza place's need their shirts...ran, I would appreciate it.
Look beyond the handcuffs,
-DD
PS, This will be the last post until 12/28/09. Have a Merry Christmas!
Tuesday, December 22, 2009
No Left Turn
Since things are pretty busy right now, and yesterday's blog was rather heavy, I thought that tonight I'd just share an encounter from disability this AM. Social Security allots 30 minutes for the History and Physical, but as long as the patient doesn't talk too much, I can usually get everything done, including the paperwork, in around 20. Of the seven people scheduled this morning, three showed up. As you might imagine, this was rather frustrating since I get paid by the patient, not by the time I spend in the office. Sometimes, however, these massive gaps in the schedule can be nice, as they allow me catch up on my reading, chat on the phone or deal with really crazy patients who don't know how to stop talking, and proceed to tell me everything that has ever gone wrong with them and how that affects (or doesn't) their ability to work. My first patient this morning was one such yapper, and while I've seen some talkers this year, no one so far could hold a candle to this lady's ability to just talk and talk, often without any sense behind the words she was saying.
She walked into the exam room wearing a dark blue sweat suit, her nails painted bright yellow, and the bottom of her sweatpants tucked into what I assume were Ugg boots, although it's was difficult to tell since the boots were covered in Christmas garland. "Merry Christmas, doctor!" was the first thing out of her mouth (which contained two teeth, by the way). I responded in a similar fashion, and asked her to have a seat in the chair next to my desk. She walked across the room and sat on the exam table. Sigh. Then it began.
"So, what keeps you from working?" I asked.
"Well," she responded, "it's my back...pain, yep, pain in the back of my back, but that was probably caused from the seizures, which came from getting my head slammed in a door."
"...So your back pain keeps you from working, is that correct?" I asked, my mind reeling from what she had just said.
"Well yeah, but the seizures are pretty bad too. You know, I have seizures that cause me to shake! Have you ever heard of that? It's crazy...although I don't remember the seizures, I just assume I have them, since I black out, and when I wake up, I've peed on myself."
"...How often do you have these seizures?"
"Well anytime I'm in an ambulance, I can get them, especially if my blood sugar gets below 40. I was told I was a type II diabetic, and that means I have too much sugar, so I have to watch how much candy I eat, but that's ok, I'd rather not have a seizure."
"...About your back pain, you said that was caused by a seizure?"
"That's what did it, that and falling down during my job at Long John Silver’s. I loved that job, but they wouldn't let work after I almost fell into the fryer - boy, would that have sucked. Imagine that," she started waving her arms around. "Ah, the fries are burning me, death by fries - that could've made the news!"
As you might imagine, it was very hard not to just burst out laughing. I bit my tongue, however, and pressed onwards.
"Ok, so back to your back..."
"Let me ask you something," she interrupted. "Are you a medical doctor?"
"Yes I am," I replied (I get asked this question a lot more than you would think).
"Ok, because I've been wondering why I can't turn to the left after I have sex."
"You can't turn to the left after you have sex?" I was honestly perplexed.
"No, I'm like, 'boom, that's a wall' after I hit the wall, since I can only turn to the right."
"Well," I replied, "I have no idea. There's no physiologic reason why you shouldn't be able to turn left after sex, but let's get back to your back pain."
"Oh, ok." She hopped off the exam table. "I should also tell you that my back pain could be caused by my foot." She began to take the garland off the right boot. "You see, I was in the hospital for like...three months because I had an infection in my foot. I thought that someone had stabbed me in the foot, probably with a paring knife, by the looks of it, while I was sleeping. As it turns out, it was a spider bite!"
So far I had been able to write down almost everything she said. After that last comment, though, I just sat my pen down and let her talk. I believe that all in all, she talked for about 15 minutes straight - pretty impressive for a lady with two teeth. With the exception of a large scar on her foot, her physical exam was negative, and the exam concluded around 40 minutes after it started. Luckily, the patient scheduled to follow her no-showed, and I was able to finish everything and stay on schedule. Sometimes having that extra time is nice, especially if you can laugh about what happened.
After that, do we really need a disability quote for the day?
Until next time,
-DD
She walked into the exam room wearing a dark blue sweat suit, her nails painted bright yellow, and the bottom of her sweatpants tucked into what I assume were Ugg boots, although it's was difficult to tell since the boots were covered in Christmas garland. "Merry Christmas, doctor!" was the first thing out of her mouth (which contained two teeth, by the way). I responded in a similar fashion, and asked her to have a seat in the chair next to my desk. She walked across the room and sat on the exam table. Sigh. Then it began.
"So, what keeps you from working?" I asked.
"Well," she responded, "it's my back...pain, yep, pain in the back of my back, but that was probably caused from the seizures, which came from getting my head slammed in a door."
"...So your back pain keeps you from working, is that correct?" I asked, my mind reeling from what she had just said.
"Well yeah, but the seizures are pretty bad too. You know, I have seizures that cause me to shake! Have you ever heard of that? It's crazy...although I don't remember the seizures, I just assume I have them, since I black out, and when I wake up, I've peed on myself."
"...How often do you have these seizures?"
"Well anytime I'm in an ambulance, I can get them, especially if my blood sugar gets below 40. I was told I was a type II diabetic, and that means I have too much sugar, so I have to watch how much candy I eat, but that's ok, I'd rather not have a seizure."
"...About your back pain, you said that was caused by a seizure?"
"That's what did it, that and falling down during my job at Long John Silver’s. I loved that job, but they wouldn't let work after I almost fell into the fryer - boy, would that have sucked. Imagine that," she started waving her arms around. "Ah, the fries are burning me, death by fries - that could've made the news!"
As you might imagine, it was very hard not to just burst out laughing. I bit my tongue, however, and pressed onwards.
"Ok, so back to your back..."
"Let me ask you something," she interrupted. "Are you a medical doctor?"
"Yes I am," I replied (I get asked this question a lot more than you would think).
"Ok, because I've been wondering why I can't turn to the left after I have sex."
"You can't turn to the left after you have sex?" I was honestly perplexed.
"No, I'm like, 'boom, that's a wall' after I hit the wall, since I can only turn to the right."
"Well," I replied, "I have no idea. There's no physiologic reason why you shouldn't be able to turn left after sex, but let's get back to your back pain."
"Oh, ok." She hopped off the exam table. "I should also tell you that my back pain could be caused by my foot." She began to take the garland off the right boot. "You see, I was in the hospital for like...three months because I had an infection in my foot. I thought that someone had stabbed me in the foot, probably with a paring knife, by the looks of it, while I was sleeping. As it turns out, it was a spider bite!"
So far I had been able to write down almost everything she said. After that last comment, though, I just sat my pen down and let her talk. I believe that all in all, she talked for about 15 minutes straight - pretty impressive for a lady with two teeth. With the exception of a large scar on her foot, her physical exam was negative, and the exam concluded around 40 minutes after it started. Luckily, the patient scheduled to follow her no-showed, and I was able to finish everything and stay on schedule. Sometimes having that extra time is nice, especially if you can laugh about what happened.
After that, do we really need a disability quote for the day?
Until next time,
-DD
Monday, December 21, 2009
Back to Basics
I should warn you that tonight's blog might seem a bit fundamentalist in timbre, but I've been thinking it over for some time, and I feel that it needs to be said. I'll start with a little background information. The first year of medical school is traditionally focused on learning what's normal about the human body. Anatomy, physiology, biochemistry, all the things that provide the backbone for a medical education, and allow one to begin to view the body as a working unit, not just a randomly connected network of organ systems. Beginning second year, the fun starts and students learn what goes wrong when the body becomes diseased. In addition, students are taught how to apply the fundamentals they learned first year to return the body to an un-diseased state through pharmacologic, surgical, osteopathic or psychiatric methods. Third and fourth years allow fine tuning in the clinical sciences, and provide necessary exposure outside of the classroom to allow the student to "get their hands wet," and really see medicine in action. By the time most students reach the end of their fourth year, the fundamentals they learned way back in first year have all been but forgotten, as the glamour of working with patients has replaced the ardors of the anatomy lab. Herein, I believe, lies one of the main problems in the medical profession today.
As one progresses through their medical education, the amount of information required to pass to the next level is immense. Once one enters practice, the amount of knowledge required is even more, as people's lives depend on what a physician does or does not do in a given clinical situation. When I started doing disability physicals, I was shocked to see that quite a number of claimants were applying for benefits due to conditions that were not being properly treated by their physician, and therefore had been allowed to run rampant. I'm aware that some of the claimants are being treated by physicians who have been in practice since before I was born, and that my whole clinical experience amounts to a medical school, an internship and what I've learned so far this year, but come on - if a patient continually has blood pressures above 180/90 (normal is around 120/80), and has evidence of end-organ damage (visual changes, decreased urination, etc), maybe you should consider doing something besides upping the dosage on their HCTZ (a very mild diuretic, mainly used in mild cases of high blood pressure). It's like the physicians treating these people stopped caring about their health once they began writing scripts for Lortab. Another disease that is commonly mistreated is diabetes, something that with the increase in obesity across our nation is becoming more prevalent yearly. I understand that by its nature, diabetes is a very difficulty disease to control, especially since the patient has to do so much on their own. But, if you have a patient that continually brings in blood sugar logs that read over 200 most of the time, maybe you should add something to that Metformin (useful as an insulin sensitizer), and take them off of their corticosteroids (steroid throw blood sugars all out of whack) for their mild eczema. It's getting back to basics, people. It's about understanding the body's physiology, the pathophysiology of the disease, and the mechanisms by which the pharmacologic intervention seeks to mend the problem. My favorite example of this breakdown occurred three weeks ago, when a woman presented to my office stating she needed disability because she could hardly breathe.
This woman was in her 30's, had never smoked a day in her life, but had struggled with lung disease in the form of asthma and hereditary emphysema since she was a child. Due to poor roll of the genetic dice, she had had a heart attack a year prior, and thanks to the cardiac damage from that event, had gone into heart failure. She currently was using an inhaler and an anti-histamine for her lungs, and was on a slew of medications for her heart - aspirin, an ACE inhibitor, and two beta-blockers, which helped reduce cardiac oxygen levels, and allowed her heart to pump better. Recently, however, the woman had begun to get incredibly short of breath if she moved from one room of her house to the other, and had been fired from her job because she took too many breaks to catch her breath. She was concerned about this symptom, and had asked her doctor what could be causing it. He stated that her heart failure was probably worsening, and upped the strength on her beta-blocker. The symptoms became worse. As she told me her story, I couldn't help but think about the relationship between beta-blockers and lung function. Both the lungs and the heart have beta receptors. In the heart, they control rate and contractile ability, while in the lungs they control dilation and constriction of the airway. If you use a medication that blocks beta receptors in the lungs and heart (a non-selective beta-blocker), you cause the heart to slow down, and basically take it easy. In the lungs, however, you cause constriction of the airways, which, as you might imagine, doesn't really help with breathing. So, looking at this patient's med list, I discovered that both of her beta-blockers were non-selective, and her physician, who I'm sure meant well, had just increased the strength of one. It's no wonder that she had difficulty breathing - the medication that was helping her heart was also causing her lungs to constrict, thereby explaining her symptoms.
Medicine as a whole is ever progressive. We love to talk about new cancer drugs and robotic surgery, but tend to laugh when someone mentions physical diagnostic skills or basic pharmacology. Why do we need to listen to our hands when a CT shows us what lies beneath? Why do we need to remember how drugs work when certain online tools tell us everything from geriatric renal dosing to the price of certain medications in Chile? Don't get me wrong, I love technology too, but we have to remember that people were correctly diagnosing and treating diseases with nothing more than their God-given senses, herbs and plants and a little intuition. We as a profession cannot forget that people don't always fit into little evidence-based medicine boxes - just because Harvard says "give beta-blockers to a patient with heart failure" doesn't mean that you can forget your basic knowledge of the human body. "Harvard made me do it," is a poor defense for a malpractice trial.
And now for the disability quote(s) of the day:
"When I take those meds, I get zombie feelings."
Patient's written response to the question "Has your disability kept you from doing any activities? If so, please explain."
"My pain keeps me from loving on my cat."
Get back to basics,
-DD
As one progresses through their medical education, the amount of information required to pass to the next level is immense. Once one enters practice, the amount of knowledge required is even more, as people's lives depend on what a physician does or does not do in a given clinical situation. When I started doing disability physicals, I was shocked to see that quite a number of claimants were applying for benefits due to conditions that were not being properly treated by their physician, and therefore had been allowed to run rampant. I'm aware that some of the claimants are being treated by physicians who have been in practice since before I was born, and that my whole clinical experience amounts to a medical school, an internship and what I've learned so far this year, but come on - if a patient continually has blood pressures above 180/90 (normal is around 120/80), and has evidence of end-organ damage (visual changes, decreased urination, etc), maybe you should consider doing something besides upping the dosage on their HCTZ (a very mild diuretic, mainly used in mild cases of high blood pressure). It's like the physicians treating these people stopped caring about their health once they began writing scripts for Lortab. Another disease that is commonly mistreated is diabetes, something that with the increase in obesity across our nation is becoming more prevalent yearly. I understand that by its nature, diabetes is a very difficulty disease to control, especially since the patient has to do so much on their own. But, if you have a patient that continually brings in blood sugar logs that read over 200 most of the time, maybe you should add something to that Metformin (useful as an insulin sensitizer), and take them off of their corticosteroids (steroid throw blood sugars all out of whack) for their mild eczema. It's getting back to basics, people. It's about understanding the body's physiology, the pathophysiology of the disease, and the mechanisms by which the pharmacologic intervention seeks to mend the problem. My favorite example of this breakdown occurred three weeks ago, when a woman presented to my office stating she needed disability because she could hardly breathe.
This woman was in her 30's, had never smoked a day in her life, but had struggled with lung disease in the form of asthma and hereditary emphysema since she was a child. Due to poor roll of the genetic dice, she had had a heart attack a year prior, and thanks to the cardiac damage from that event, had gone into heart failure. She currently was using an inhaler and an anti-histamine for her lungs, and was on a slew of medications for her heart - aspirin, an ACE inhibitor, and two beta-blockers, which helped reduce cardiac oxygen levels, and allowed her heart to pump better. Recently, however, the woman had begun to get incredibly short of breath if she moved from one room of her house to the other, and had been fired from her job because she took too many breaks to catch her breath. She was concerned about this symptom, and had asked her doctor what could be causing it. He stated that her heart failure was probably worsening, and upped the strength on her beta-blocker. The symptoms became worse. As she told me her story, I couldn't help but think about the relationship between beta-blockers and lung function. Both the lungs and the heart have beta receptors. In the heart, they control rate and contractile ability, while in the lungs they control dilation and constriction of the airway. If you use a medication that blocks beta receptors in the lungs and heart (a non-selective beta-blocker), you cause the heart to slow down, and basically take it easy. In the lungs, however, you cause constriction of the airways, which, as you might imagine, doesn't really help with breathing. So, looking at this patient's med list, I discovered that both of her beta-blockers were non-selective, and her physician, who I'm sure meant well, had just increased the strength of one. It's no wonder that she had difficulty breathing - the medication that was helping her heart was also causing her lungs to constrict, thereby explaining her symptoms.
Medicine as a whole is ever progressive. We love to talk about new cancer drugs and robotic surgery, but tend to laugh when someone mentions physical diagnostic skills or basic pharmacology. Why do we need to listen to our hands when a CT shows us what lies beneath? Why do we need to remember how drugs work when certain online tools tell us everything from geriatric renal dosing to the price of certain medications in Chile? Don't get me wrong, I love technology too, but we have to remember that people were correctly diagnosing and treating diseases with nothing more than their God-given senses, herbs and plants and a little intuition. We as a profession cannot forget that people don't always fit into little evidence-based medicine boxes - just because Harvard says "give beta-blockers to a patient with heart failure" doesn't mean that you can forget your basic knowledge of the human body. "Harvard made me do it," is a poor defense for a malpractice trial.
And now for the disability quote(s) of the day:
"When I take those meds, I get zombie feelings."
Patient's written response to the question "Has your disability kept you from doing any activities? If so, please explain."
"My pain keeps me from loving on my cat."
Get back to basics,
-DD
Friday, December 18, 2009
Stereotype Me
I have a personal beef with Geriatricians. It seems as though every time some elderly member of my family switches from their regular Internist to a Geriatric specialist, their health goes downhill fast. While I understand this could simply be due to advancing age, I've heard too many stories about medications given for no reason, or healthcare decisions based on age, and not on the individual. My wife's grandmother recently switched to a Geriatrician, and much to her (and my) dismay, her experience was approximately the same as every other elderly member of my family.
First, a little background information. My grandmother-in-law is 91. Her mother lived to be 113. Her aunt lived to be 111. Longevity definitely runs in her genes. She's lived a full life, and for the most part, has done a very good job at taking care of herself. She has been told she's a "borderline diabetic," and suffers from mild hypothyroidism, but all in all, she's a very healthy woman. Her new doctor decided that because of her age, she needed to be placed on a slew of medications - blood thinners, anti-depressants and so forth, and when questioned about why she needed these medications said something to the accord of, "Well, you've obviously never heard about our sacred oath. We swear to do no harm, and if I don't put you on these medications, I would be doing that." If you read the blog entry last night, you know how I feel about that statement. Anyway, the doctor also told her that she also needed imaging to "just check," and that she should probably have blood drawn "just to make sure we don't miss anything." On one hand, I can applaud the doctor for covering all of her bases from a medicolegal standpoint. On the other hand, she's playing "cover your butt" medicine, and should have to take a class in basic patient skills. The thing that really ticked me off, however, was that my grandmother-in-law spent half of her yearly income (social security and retirement) on medication, lab work and physician fees last year, the majority of which were unnecessary. The single most detrimental thing for a senior citizen is a lack of purpose, purpose that is found by doing things they enjoy, be that traveling, volunteering or a hobby. How can we expect them, therefore, to find that purpose when they can't afford to do said activities, because all of their money is tied up in unnecessary health costs?
Just because someone reaches a certain age milestone does not mean that they suddenly needed X medication, as well as a total body CT to check for badness. I'm reminded of a story about a Cardiologist, who after taking his car in for a tune up, was asked by the mechanic, "You know Doc, we both work on engines and pumps, so why is it that you make six figures, and I make little more than minimum wage?" The Cardiologist replied, "Because I do my work while the engine is running." It's true, our bodies need tune ups from time to time, but just because we hit "70,000 miles" does not mean we automatically need our transmission replaced.
Unfortunately, this medical stereotyping affects not only age, but also socioeconomic class, gender, education, or even ethnicity. We as physicians, especially nowadays, are trained to make split-second judgments based on the first few words out a patient's mouth. The advent of corporately-run clinics have made this fact even more apparent, as physicians are allotted 5, 10, maybe 15 minutes with a patient, and if you don't see your quota in a month, you're fired. Language barriers provide similar amounts of stereotyping. If a patient doesn't speak English, or speaks it very poorly, then the obvious answer is to speak the Universal Language - slow, loud English, because come on, everyone understands English. We have to remember to take the patient as a single, unique entity, with a genetic/biochemical makeup that is unrelated to randomly controlled trials, age groupings or chosen tongue. Our goal as physicians should be to treat the patient, not the disease, and we lose sight of that goal when we reduce patients to lab values, radiographs and age ranges. Never forget that at its heart, medicine is an art form, not a science. If it was a science, every treatment outcome could be reproduced in a lab 100% of the time, and our bodies would be nothing more than a collection of mathematical formulas representing current physiologic functioning. Luckily for us, this is not true, and we are all unique beings that just so happen to share similar genetic codes. Consequently, as physicians we need to respect that uniqueness, and seek to find the health that is hidden within that genetic code, irrespective of the age, economic status or gender of the body containing it.
And now, for the Juvie quote of the day,
"I'll get my GED, just you wait and see. Next time I'm in here, I'll have it, you'll be surprised."
Embrace your individuality,
-DD
First, a little background information. My grandmother-in-law is 91. Her mother lived to be 113. Her aunt lived to be 111. Longevity definitely runs in her genes. She's lived a full life, and for the most part, has done a very good job at taking care of herself. She has been told she's a "borderline diabetic," and suffers from mild hypothyroidism, but all in all, she's a very healthy woman. Her new doctor decided that because of her age, she needed to be placed on a slew of medications - blood thinners, anti-depressants and so forth, and when questioned about why she needed these medications said something to the accord of, "Well, you've obviously never heard about our sacred oath. We swear to do no harm, and if I don't put you on these medications, I would be doing that." If you read the blog entry last night, you know how I feel about that statement. Anyway, the doctor also told her that she also needed imaging to "just check," and that she should probably have blood drawn "just to make sure we don't miss anything." On one hand, I can applaud the doctor for covering all of her bases from a medicolegal standpoint. On the other hand, she's playing "cover your butt" medicine, and should have to take a class in basic patient skills. The thing that really ticked me off, however, was that my grandmother-in-law spent half of her yearly income (social security and retirement) on medication, lab work and physician fees last year, the majority of which were unnecessary. The single most detrimental thing for a senior citizen is a lack of purpose, purpose that is found by doing things they enjoy, be that traveling, volunteering or a hobby. How can we expect them, therefore, to find that purpose when they can't afford to do said activities, because all of their money is tied up in unnecessary health costs?
Just because someone reaches a certain age milestone does not mean that they suddenly needed X medication, as well as a total body CT to check for badness. I'm reminded of a story about a Cardiologist, who after taking his car in for a tune up, was asked by the mechanic, "You know Doc, we both work on engines and pumps, so why is it that you make six figures, and I make little more than minimum wage?" The Cardiologist replied, "Because I do my work while the engine is running." It's true, our bodies need tune ups from time to time, but just because we hit "70,000 miles" does not mean we automatically need our transmission replaced.
Unfortunately, this medical stereotyping affects not only age, but also socioeconomic class, gender, education, or even ethnicity. We as physicians, especially nowadays, are trained to make split-second judgments based on the first few words out a patient's mouth. The advent of corporately-run clinics have made this fact even more apparent, as physicians are allotted 5, 10, maybe 15 minutes with a patient, and if you don't see your quota in a month, you're fired. Language barriers provide similar amounts of stereotyping. If a patient doesn't speak English, or speaks it very poorly, then the obvious answer is to speak the Universal Language - slow, loud English, because come on, everyone understands English. We have to remember to take the patient as a single, unique entity, with a genetic/biochemical makeup that is unrelated to randomly controlled trials, age groupings or chosen tongue. Our goal as physicians should be to treat the patient, not the disease, and we lose sight of that goal when we reduce patients to lab values, radiographs and age ranges. Never forget that at its heart, medicine is an art form, not a science. If it was a science, every treatment outcome could be reproduced in a lab 100% of the time, and our bodies would be nothing more than a collection of mathematical formulas representing current physiologic functioning. Luckily for us, this is not true, and we are all unique beings that just so happen to share similar genetic codes. Consequently, as physicians we need to respect that uniqueness, and seek to find the health that is hidden within that genetic code, irrespective of the age, economic status or gender of the body containing it.
And now, for the Juvie quote of the day,
"I'll get my GED, just you wait and see. Next time I'm in here, I'll have it, you'll be surprised."
Embrace your individuality,
-DD
Thursday, December 17, 2009
The Placebo Effect
Have you ever heard of the placebo effect? Most people have, but if you haven't, I'll give you a quick rundown. The word placebo literally means (in Latin) "I shall please," and has come to describe a treatment that causes a patient to feel better because the patient believes it will work. There was a time when a physician could write a prescription for a placebo pill, but due to lots of ethical brouhaha, that is now considered a breach of doctor-patient trust. Interestingly, most physicians have given their patients placebos, although they come in the form of dietary supplements, unique vitamins and the traditional "You'll be better in a few days," instead of the old-time sugar pills.
We live in a society that has created an "all or nothing" form of healthcare. If someone goes to their doctor complaining of a sore throat, runny nose and a "fever" of 99.2, they better receive some sort of medication. In most cases, and especially in situations where a previous doctor/patient relationship doesn't exist (i.e., urgent care clinics), the above patient would want some sort of antibiotic, and maybe even a pain killer for their throat. It doesn't matter that the patient probably has a viral infection, and therefore would receive no benefit from the antibiotic, or that a gargle of warm salt water would help their throat as much as a Lortab, they "want it all," and would be very angry if the physician simply said, "you'll be better soon, just rest and let yourself heal." My only patient this AM at the county clinic was one such individual.
He was in his mid 20's, and when I entered into the exam room, two things struck me as odd. Number one, he was wearing a tank top tucked into his jeans. Never mind that it was in the 30's this morning, this guy worked out and wanted everybody to know. Number two, the woman that was with him, who I assume was his girlfriend, was about 6'2". He was approximately 5'6". I guess there really is someone for everyone. Anyway, after introducing myself and asking what brought him to the clinic, he told me, in a very quiet whisper, that he had been sick for two weeks. He stated, however, that he was feeling better now, although he still had a cough that "occasionally makes me have to turn my head to cough stuff up," in addition to "annoying laryngitis." He went on to let me know that he was never sick more than one day, and that the guys at work were worried because his voice was gone. I asked him if he had taken any OTC medication, to which he responded that his friend had lent him some antibiotics a day ago, and although he couldn't remember the name of the drug, he knew that the pills were green. Obviously I knew the medication based on the pill color...oh wait. He then proceeded to show me that he could still yell by giving an example of what he yelled at work - "Hey you motha' f*ckers, you f*ckin' need to get back to work before I f*cking feed your balls to your mom." I told him that yelling could prolong his vocal healing time, and that that alone could explain the reason for his laryngitis. He then asked me, "So if I don't yell, how am I supposed to give people directions?" I told him maybe he should buy a bullhorn, or write his instructions on picket signs. He said that that wouldn't help, and then stated, "I guess I'll just use my eyes," after which he proceeded to squint "menacingly." At this point, I performed my physical exam, which was normal, and told him that he appeared to be getting over a cold, and that things would heal on their own without any help from me. Of course he was not happy with this, and said, "But I never get sick, what if I have pneumonia or something." I responded by saying his lungs were clear, and that the green pills had probably helped out, and since he was out of them, he probably didn't need any more. In addition, I told him that hot tea with honey could help his voice. He was adamant in wanting some medication, however, so I wrote him a prescription for an over-the-counter cough syrup. The change in his mood was almost magical, and he walked out of the clinic with a smile on his face. In an instant I had gone from being a bad doctor to a good one by simply writing the word "Robitussin" on a script pad.
This is one instance where being able to write a prescription for a placebo pill would have been extremely useful. The patient obviously wanted some sort of medication, and while I didn't think he actually needed something, the change in his attitude was apparent after I wrote him a script. I know that the placebo issue causes lots of debates about trust and medical misdirection. Opponents of placebos state that prescribing them violates the Hippocratic Oath - the oft quoted "First do no harm." What many physicians forget is that the Hippocratic Oath goes far behind this, and states "As to diseases, make a habit of two things. To help, or at least, to do no harm," and can we not say that giving patients placebo pills is helping them? It's amazing to me that you can say, "you'll be fine," or "your symptoms are normal," until you're blue in the face, but if you hand someone a 3x5 piece of paper with some scribble on it, you instantly transform into some sort of medical superhero. We tend to forget that we haven't always had antibiotics, and amazingly enough, the species didn't die off. The body has an innate capability to heal itself, and while medication or surgery can amplify that ability, so can physical contact, a good diet, or something as simple as the right word.
And now, the disability quote(s) of the day,
"I can't work because I get fired. No one will hire me, not even Wal-Mart."
You'll be fine,
-DD
We live in a society that has created an "all or nothing" form of healthcare. If someone goes to their doctor complaining of a sore throat, runny nose and a "fever" of 99.2, they better receive some sort of medication. In most cases, and especially in situations where a previous doctor/patient relationship doesn't exist (i.e., urgent care clinics), the above patient would want some sort of antibiotic, and maybe even a pain killer for their throat. It doesn't matter that the patient probably has a viral infection, and therefore would receive no benefit from the antibiotic, or that a gargle of warm salt water would help their throat as much as a Lortab, they "want it all," and would be very angry if the physician simply said, "you'll be better soon, just rest and let yourself heal." My only patient this AM at the county clinic was one such individual.
He was in his mid 20's, and when I entered into the exam room, two things struck me as odd. Number one, he was wearing a tank top tucked into his jeans. Never mind that it was in the 30's this morning, this guy worked out and wanted everybody to know. Number two, the woman that was with him, who I assume was his girlfriend, was about 6'2". He was approximately 5'6". I guess there really is someone for everyone. Anyway, after introducing myself and asking what brought him to the clinic, he told me, in a very quiet whisper, that he had been sick for two weeks. He stated, however, that he was feeling better now, although he still had a cough that "occasionally makes me have to turn my head to cough stuff up," in addition to "annoying laryngitis." He went on to let me know that he was never sick more than one day, and that the guys at work were worried because his voice was gone. I asked him if he had taken any OTC medication, to which he responded that his friend had lent him some antibiotics a day ago, and although he couldn't remember the name of the drug, he knew that the pills were green. Obviously I knew the medication based on the pill color...oh wait. He then proceeded to show me that he could still yell by giving an example of what he yelled at work - "Hey you motha' f*ckers, you f*ckin' need to get back to work before I f*cking feed your balls to your mom." I told him that yelling could prolong his vocal healing time, and that that alone could explain the reason for his laryngitis. He then asked me, "So if I don't yell, how am I supposed to give people directions?" I told him maybe he should buy a bullhorn, or write his instructions on picket signs. He said that that wouldn't help, and then stated, "I guess I'll just use my eyes," after which he proceeded to squint "menacingly." At this point, I performed my physical exam, which was normal, and told him that he appeared to be getting over a cold, and that things would heal on their own without any help from me. Of course he was not happy with this, and said, "But I never get sick, what if I have pneumonia or something." I responded by saying his lungs were clear, and that the green pills had probably helped out, and since he was out of them, he probably didn't need any more. In addition, I told him that hot tea with honey could help his voice. He was adamant in wanting some medication, however, so I wrote him a prescription for an over-the-counter cough syrup. The change in his mood was almost magical, and he walked out of the clinic with a smile on his face. In an instant I had gone from being a bad doctor to a good one by simply writing the word "Robitussin" on a script pad.
This is one instance where being able to write a prescription for a placebo pill would have been extremely useful. The patient obviously wanted some sort of medication, and while I didn't think he actually needed something, the change in his attitude was apparent after I wrote him a script. I know that the placebo issue causes lots of debates about trust and medical misdirection. Opponents of placebos state that prescribing them violates the Hippocratic Oath - the oft quoted "First do no harm." What many physicians forget is that the Hippocratic Oath goes far behind this, and states "As to diseases, make a habit of two things. To help, or at least, to do no harm," and can we not say that giving patients placebo pills is helping them? It's amazing to me that you can say, "you'll be fine," or "your symptoms are normal," until you're blue in the face, but if you hand someone a 3x5 piece of paper with some scribble on it, you instantly transform into some sort of medical superhero. We tend to forget that we haven't always had antibiotics, and amazingly enough, the species didn't die off. The body has an innate capability to heal itself, and while medication or surgery can amplify that ability, so can physical contact, a good diet, or something as simple as the right word.
And now, the disability quote(s) of the day,
"I can't work because I get fired. No one will hire me, not even Wal-Mart."
You'll be fine,
-DD
Wednesday, December 16, 2009
221 Baker Street
It has been my project over the last few months to use my powers of observation to help weed out fakers at disability. If you recall from my first blog, approximately 20% of the patients I see are trying to get free money, even if that means faking symptoms, buying wheel chairs or bringing in pill bottles with someone else's name and hoping I don't catch it. One such gentleman presented this morning. He limped into the office, a quad-cane helping his balance, and told me that he had suffered a "very severe stroke" earlier this year that rendered the left side of his body useless. As he told me this, he emphasized his words by waving both arms, gesturing with both hands, and crossing his left leg over his right. He proceeded to tell me that he had been discharged from the hospital after "seven days because I had no insurance," and that he had relearned how to walk, talk and eat on his own. He stated that he used the cane for balance, because "without it, I can't really walk at all...and if I walk more than a block without it, I get really tired." In addition, he stated that he couldn't use his left hand to open doors, jars, whatever, and that his girlfriend helped him bathe and dress himself every day. So, as you might imagine, my suspicion that this guy was a faker began as soon as he started waving his arms all around. Now, people can make amazing recoveries from strokes, but usually there is quite a bit of rehab therapy behind that recovery, and according to this guy, he had been able to do everything by himself. To make things even fishier, he was not on any typical post-stroke medication; his entire med list consisted of aspirin, folic acid, and Lortabs (of course). The physical exam was even more non-convincing, as he proceeded to basically crush my fingers with his grip strength, and he was able to walk on his toes across the room, despite his previous statement that he couldn't lift his left leg.
Since I was already about 1,488,659% sure that this guy was faking, I decided to see if there were any other things that seemed out of the ordinary. First of all, his cane was almost brand new, without a scratch on it, not what you'd expect from someone who used it daily for support. Secondly, the nails on his right hand were clipped in way that the lateral portion of the nail was longer, just as if he had done the clippings himself. Thirdly, while the top of left boots was obviously dirty, the sole of the boot showed no signs of scuffing, which would be present on a shoe that was dragged along. I know, there are a number of things that could explain these "abnormalities." Maybe the cane (or boot) was new, and maybe his girlfriend never learned how to use a nail trimmer. I don't know. What I do know, however, was that these observations, coupled with his already dubious history and physical, lead me to believe that this dude was just in it for the free money. To cement my opinion, after the interview concluded, he proceeded to walk into the waiting room without his cane, and without any apparent balance issues. He stopped at the office door, turned around, walked back into the exam room and said, "huh, I guess I need that."
Being a good observer, much like being a good listener, is a skill that seems to be vanishing in our world today. Our daily lives are filled with so much junk that it makes it difficult to try and take everything in and really process the world around us. All of us have had experiences in the past that could've been avoided if we had just taken the time to really observe our surroundings. Think about the number of car wrecks that could be prevented if we just paid attention to the road, and weren't trying to change the radio station, put on makeup, eat or text while driving.
And now, for the disability quote of the day:
Patient's written reason for not working, and I quote:
"Disgrtv disc in lwr bck and diab"
(Apparently he lost control of his vowels)
Keep your eyes open,
-DD
Since I was already about 1,488,659% sure that this guy was faking, I decided to see if there were any other things that seemed out of the ordinary. First of all, his cane was almost brand new, without a scratch on it, not what you'd expect from someone who used it daily for support. Secondly, the nails on his right hand were clipped in way that the lateral portion of the nail was longer, just as if he had done the clippings himself. Thirdly, while the top of left boots was obviously dirty, the sole of the boot showed no signs of scuffing, which would be present on a shoe that was dragged along. I know, there are a number of things that could explain these "abnormalities." Maybe the cane (or boot) was new, and maybe his girlfriend never learned how to use a nail trimmer. I don't know. What I do know, however, was that these observations, coupled with his already dubious history and physical, lead me to believe that this dude was just in it for the free money. To cement my opinion, after the interview concluded, he proceeded to walk into the waiting room without his cane, and without any apparent balance issues. He stopped at the office door, turned around, walked back into the exam room and said, "huh, I guess I need that."
Being a good observer, much like being a good listener, is a skill that seems to be vanishing in our world today. Our daily lives are filled with so much junk that it makes it difficult to try and take everything in and really process the world around us. All of us have had experiences in the past that could've been avoided if we had just taken the time to really observe our surroundings. Think about the number of car wrecks that could be prevented if we just paid attention to the road, and weren't trying to change the radio station, put on makeup, eat or text while driving.
And now, for the disability quote of the day:
Patient's written reason for not working, and I quote:
"Disgrtv disc in lwr bck and diab"
(Apparently he lost control of his vowels)
Keep your eyes open,
-DD
Tuesday, December 15, 2009
Praise and Poop
Recently, my wife and I were flipping through the channels one night before bed, and stumbled upon one of those Mega-Church Televangelists. Normally, we would have kept channel surfing, but for some reason we stopped and listened to the last part of his message. The subject of the sermon was blessings and the power they have to change lives. He relayed multiple stories about how blessing someone could heal the sick, defeat drug addiction and so on, and stated that people should continually tell others how much they mean to them. He especially mentioned that parents should let their children know that they're proud of them, and that they are truly a gift from God. I thought about the people I see on an almost daily basis at either disability or at the Juvie, and wondered if their parents had told them "I'm proud of you," or even "I love you." My conclusion was probably not. Personally, I know that if someone says, "hey, you're doing a really good job at that," or "I really appreciate your hard work," I'll usually work that much harder at the task I'm doing. I know that it may seem superficial, but I'm a glutton for praise, and deep down, I think most people are too. With that in mind, I set out this week to try and "praise" at least one of my patients...something that, as you might imagine, is difficult to do when their ideas and activities contradict your own almost 100% of the time.
Today was like any cold day at Disability Physicals - lots of late-comers and cancellations. The first claimant showed up 30 minutes late, didn't apologize for being late, and wanted to get disability because she had back pain...which started when she was pregnant. She had since delivered a healthy baby, and admitted that the pain was a lot less. Amazing. As I was finishing her exam, I began to notice a strange smell coming from the waiting room. A group of four large individuals had waddled through the door, and I overheard one of them say, "Hey, this place smells like old people." The post-partum pain patient left, and in walked a 5'1'', 288 lbs lady, reeking of feces and cigarettes, her unsupported bosom hanging below her waistline, and stretching the Tinker Bell on her shirt into some grotesque female Jolly Green Giant. She took a seat in the chair, and told me she was applying for disability because "I got the squirts all the time." Biting my tongue, I proceeded to ask her all about her bowel history, and she gave me around five Disability Quotes of the Day in the first 30 seconds of the interview. Proceeding through her history, she told me that she had been smoking three packs a day (that's 60 cigarettes, or one every 12 minutes if you account for 8 hours of sleep), but had dropped to one pack a day, because she was concerned about her health. In addition, she had dropped 100 pounds since last year. Aha! I thought to myself, here is my chance to praise someone. I told her, "that's excellent that you've decided to take charge of your own health, and I'm really proud of you that you've cut down to just one pack a day." She responded, "Well, I know it's bad for me, but you know, soon it'll be 1/2 a pack, then 1/4 of a pack, then none. I'm going to do it, just you wait and see!"
As a physician, one aspect of my job is being a cheerleader for my patient's health. While I doubt my little "I'm proud of you," made much impact on this lady's desire to quit smoking, if everyone in her life gave her the same positive feedback, who knows, maybe she would be tobacco free by now. The power of praise is immense, and we as people, parents, physicians, whatever, need to embrace that power. They say that "behind every great man is a great woman," and while that adage might not always hold true, especially in today's society, I do believe that behind every great person is at least one "believer," who told them, "don't quit, I'm proud of you."
And now, the Disability Quote(s) of the Day:
"I get this pain under my left boobie...a lot."
"Nothing makes my diarrhea any better, not even lettuce."
"I hit myself, and then get angry because it hurts."
Plant a seed,
-DD
Today was like any cold day at Disability Physicals - lots of late-comers and cancellations. The first claimant showed up 30 minutes late, didn't apologize for being late, and wanted to get disability because she had back pain...which started when she was pregnant. She had since delivered a healthy baby, and admitted that the pain was a lot less. Amazing. As I was finishing her exam, I began to notice a strange smell coming from the waiting room. A group of four large individuals had waddled through the door, and I overheard one of them say, "Hey, this place smells like old people." The post-partum pain patient left, and in walked a 5'1'', 288 lbs lady, reeking of feces and cigarettes, her unsupported bosom hanging below her waistline, and stretching the Tinker Bell on her shirt into some grotesque female Jolly Green Giant. She took a seat in the chair, and told me she was applying for disability because "I got the squirts all the time." Biting my tongue, I proceeded to ask her all about her bowel history, and she gave me around five Disability Quotes of the Day in the first 30 seconds of the interview. Proceeding through her history, she told me that she had been smoking three packs a day (that's 60 cigarettes, or one every 12 minutes if you account for 8 hours of sleep), but had dropped to one pack a day, because she was concerned about her health. In addition, she had dropped 100 pounds since last year. Aha! I thought to myself, here is my chance to praise someone. I told her, "that's excellent that you've decided to take charge of your own health, and I'm really proud of you that you've cut down to just one pack a day." She responded, "Well, I know it's bad for me, but you know, soon it'll be 1/2 a pack, then 1/4 of a pack, then none. I'm going to do it, just you wait and see!"
As a physician, one aspect of my job is being a cheerleader for my patient's health. While I doubt my little "I'm proud of you," made much impact on this lady's desire to quit smoking, if everyone in her life gave her the same positive feedback, who knows, maybe she would be tobacco free by now. The power of praise is immense, and we as people, parents, physicians, whatever, need to embrace that power. They say that "behind every great man is a great woman," and while that adage might not always hold true, especially in today's society, I do believe that behind every great person is at least one "believer," who told them, "don't quit, I'm proud of you."
And now, the Disability Quote(s) of the Day:
"I get this pain under my left boobie...a lot."
"Nothing makes my diarrhea any better, not even lettuce."
"I hit myself, and then get angry because it hurts."
Plant a seed,
-DD
Monday, December 14, 2009
Dramatic Pause
So, a new week, a new set of experiences. My day was, amazingly enough, fairly uneventful. I did, however, have a "fun" chat with the detainee who I sent to the Hospital on Friday. It seems that Einstein decided that eating dog poop, barely breathing and withdrawing from "a pretty good high," didn't need medical attention, so he AMA'd from the ER upon arrival. Lucky for me, spending the weekend with "the shakes," and having constant supervision put him in a spiritual mood this AM, and we proceeded to have the following conversation.
Me: "You know, that stuff will kill you. You're actually really lucky that you didn't die over the weekend."
Dude: "Well, I'm done with that, I'm swearing off of all of it - I mean, I'll submit to random drug tests or anything. You know why?"
Me: "Why is that?"
Dude: "Because I've been praying, and I told God that if he got me out of here, I'd stop."
Me: "Well, while I believe that God can do anything, you also have to take responsibility for your own health."
Dude: "All I know is that my daddy told God the same thing, and when he was driving drunk one time, he hit a telephone pole. It crashed into the passenger seat...where I had been sitting FIVE MINUTES BEFORE."
Me: "God does work in mysterious ways. Have a good day."
After that thrilling encounter, I headed to the county clinic, where I saw one patient. And read lots of Angels and Demons, which is actually pretty good. Next, after a quick lunch with the wife and daughter, I began my afternoon at Disability Physicals by helping a patient get her wheelchair out of the trunk of her 4-Runner. While that in itself is nothing too bizarre, the other articles in her trunk were: Kitty litter, three containers of motor oil, anti-freeze and a box of donuts. Apparently, if she were to get stuck in the ice or run out of oil (?) she wouldn't go hungry. The remainder of the afternoon went without too much drama, and the majority of people actually showed up. All in all, a pretty good day.
And now, the disability quote(s) of the day:
Me: "So tell me why you can't work."
Clamaint: "I was having a great day off. Then I had a stroke."
"Sometimes I get so angry that I want to kill myself. Or my dad. Or the neighbor. Ah, maybe I'll just blow up the dog. Or this building."
Have a good one,
-DD
Me: "You know, that stuff will kill you. You're actually really lucky that you didn't die over the weekend."
Dude: "Well, I'm done with that, I'm swearing off of all of it - I mean, I'll submit to random drug tests or anything. You know why?"
Me: "Why is that?"
Dude: "Because I've been praying, and I told God that if he got me out of here, I'd stop."
Me: "Well, while I believe that God can do anything, you also have to take responsibility for your own health."
Dude: "All I know is that my daddy told God the same thing, and when he was driving drunk one time, he hit a telephone pole. It crashed into the passenger seat...where I had been sitting FIVE MINUTES BEFORE."
Me: "God does work in mysterious ways. Have a good day."
After that thrilling encounter, I headed to the county clinic, where I saw one patient. And read lots of Angels and Demons, which is actually pretty good. Next, after a quick lunch with the wife and daughter, I began my afternoon at Disability Physicals by helping a patient get her wheelchair out of the trunk of her 4-Runner. While that in itself is nothing too bizarre, the other articles in her trunk were: Kitty litter, three containers of motor oil, anti-freeze and a box of donuts. Apparently, if she were to get stuck in the ice or run out of oil (?) she wouldn't go hungry. The remainder of the afternoon went without too much drama, and the majority of people actually showed up. All in all, a pretty good day.
And now, the disability quote(s) of the day:
Me: "So tell me why you can't work."
Clamaint: "I was having a great day off. Then I had a stroke."
"Sometimes I get so angry that I want to kill myself. Or my dad. Or the neighbor. Ah, maybe I'll just blow up the dog. Or this building."
Have a good one,
-DD
Friday, December 11, 2009
The Parent Trap
Ah, Friday. Mornings at the juvie and county clinic, afternoons at home, and the wonders of the weekend looming ahead. There's an interesting rhythm to the influx of detainees at the juvie - as the weekend approaches more "troubled" kids are brought in. Come Friday and through the weekend, however, the majority of the newly detained are simply kids out having "too good of a time." Unfortunately, I was forced to send one such detainee to the ER, this AM as his nightly tonic of marijuana, alcohol, Morphine and Trazadone proved to be too much for his system to handle, and he proceeded to begin withdrawing on my shift. Nothing like having someone say to you, "Did I eat dog poop last night? Because man, I think I did." Yeeha for drugs. Anyway, after dealing with that situation, I headed to the county clinic, and saw a whopping...five patients. I should note, however, that four of those were from the same family, which brings me to my message of today, responsible parenting.
First, a caveat. As a parent myself, I know that having a child (or children), while a blessing, can be a very emotionally draining and tiring job. Anyone who says "being a stay-at-home mom/dad is just a cop out" is either a very crummy parent, or doesn't have kids of their own. That aside, if you have children, you should at least act concerned for their general welfare. The foursome I saw this morning was composed of sick nine- month old twins, a "sick" two year old, and a mom with the apparent interest of a crab cake, who stated that she had had a cold for "three months." Her affect was flat, her teeth rotting, and she didn't seem to care that her children had snotty pools instead of noses, and from the smell of it, had been in a pooping contest half an hour before. As I listened to her complain about how her kids were keeping her up at night, how they interrupted her meeting yesterday, and how sick her three-month cold was making her, it occurred to me that she had not once mentioned what was affecting her children. After (unsuccessfully) redirecting the conversation multiple times back to her sick kiddos, I finally just gave up, and proceeded to perform my physical exam.
With the exception of one of the twins, everyone was fine. The mother had allergies, and the older kid and the other twin had colds. The first twin, however, had bilateral wheezes in his lungs, and had lots of pooling snot around in his nose. Since it 'tis the season for RSV (Respiratory Syncytial Virus - a potentially deadly respiratory virus that affects infants), and I have jack squat at the county clinic for pediatric patients, I decided that the twin needed to be referred to one of the free peds clinics. I explained the situation to the mother, who simply sat there and responded..."do you think I need braces?" I almost went ninja on her. If someone told me "hey, your kid might be really sick, and might have to go to the hospital," I would like to think I would be able to concentrate on my child, and not the alignment of my teeth. Once again, I'm not trying to say "hey, poo poo on this mom," because Lord knows, if she's in the shelter she has a lot more problems than I do. I simply think that if you become a parent, especially if you're a repeat offender, you need to take responsibility for your children. While dental health is very important, all the orthodontic work in the world won't take away the pain of a deceased child.
Unfortunately, this is not an isolated case. Everyday children are born to parents who either don't want them or have no idea how to care for them. We as a society like to think that these cases are unique to the ghettos and urban barrios of our country, while in fact they exist in the poshest neighborhoods across the nation. The question then arises "what do we do about it?" Are there enough social funds available to educate potential parents about childrearing? Is it the role of government agencies to teach these, in most cases, children how to raise children of their own? My opinion is no. As parents we have the responsibility to lead our children, not only by word, but by example. Social change has to come from within, and from the bottom up. That said, we can't expect 9 month olds to understand the importance of safe sex and good citizenship. The onus lies on us to "teach our children well," and hopefully their children, and their children's children will benefit from the work we've done.
And now for the disability quotes of the day:
When asked if the patient ever saw or heard anything that other people didn't, he looked around and responded, "Oh yeah, I see...(whispered) dead people."
Me: "So, is there anything that you can identify that causes your chest pain?"
Claimant: "Well, this one time, my husband was mowing the lawn with a ridin' mower, and I got chest pain for three days."
Me: "That's an excuse to get out of mowing the lawn if I ever heard one."
Claimant: "Huh?"
Have a great weekend,
-DD
First, a caveat. As a parent myself, I know that having a child (or children), while a blessing, can be a very emotionally draining and tiring job. Anyone who says "being a stay-at-home mom/dad is just a cop out" is either a very crummy parent, or doesn't have kids of their own. That aside, if you have children, you should at least act concerned for their general welfare. The foursome I saw this morning was composed of sick nine- month old twins, a "sick" two year old, and a mom with the apparent interest of a crab cake, who stated that she had had a cold for "three months." Her affect was flat, her teeth rotting, and she didn't seem to care that her children had snotty pools instead of noses, and from the smell of it, had been in a pooping contest half an hour before. As I listened to her complain about how her kids were keeping her up at night, how they interrupted her meeting yesterday, and how sick her three-month cold was making her, it occurred to me that she had not once mentioned what was affecting her children. After (unsuccessfully) redirecting the conversation multiple times back to her sick kiddos, I finally just gave up, and proceeded to perform my physical exam.
With the exception of one of the twins, everyone was fine. The mother had allergies, and the older kid and the other twin had colds. The first twin, however, had bilateral wheezes in his lungs, and had lots of pooling snot around in his nose. Since it 'tis the season for RSV (Respiratory Syncytial Virus - a potentially deadly respiratory virus that affects infants), and I have jack squat at the county clinic for pediatric patients, I decided that the twin needed to be referred to one of the free peds clinics. I explained the situation to the mother, who simply sat there and responded..."do you think I need braces?" I almost went ninja on her. If someone told me "hey, your kid might be really sick, and might have to go to the hospital," I would like to think I would be able to concentrate on my child, and not the alignment of my teeth. Once again, I'm not trying to say "hey, poo poo on this mom," because Lord knows, if she's in the shelter she has a lot more problems than I do. I simply think that if you become a parent, especially if you're a repeat offender, you need to take responsibility for your children. While dental health is very important, all the orthodontic work in the world won't take away the pain of a deceased child.
Unfortunately, this is not an isolated case. Everyday children are born to parents who either don't want them or have no idea how to care for them. We as a society like to think that these cases are unique to the ghettos and urban barrios of our country, while in fact they exist in the poshest neighborhoods across the nation. The question then arises "what do we do about it?" Are there enough social funds available to educate potential parents about childrearing? Is it the role of government agencies to teach these, in most cases, children how to raise children of their own? My opinion is no. As parents we have the responsibility to lead our children, not only by word, but by example. Social change has to come from within, and from the bottom up. That said, we can't expect 9 month olds to understand the importance of safe sex and good citizenship. The onus lies on us to "teach our children well," and hopefully their children, and their children's children will benefit from the work we've done.
And now for the disability quotes of the day:
When asked if the patient ever saw or heard anything that other people didn't, he looked around and responded, "Oh yeah, I see...(whispered) dead people."
Me: "So, is there anything that you can identify that causes your chest pain?"
Claimant: "Well, this one time, my husband was mowing the lawn with a ridin' mower, and I got chest pain for three days."
Me: "That's an excuse to get out of mowing the lawn if I ever heard one."
Claimant: "Huh?"
Have a great weekend,
-DD
Thursday, December 10, 2009
28 and Counting
My Thursdays are usually pretty light. I work at the Juvie in the AM, and then depending on the week, I might see a couple of patients in my Dad's office. The second Thursday of the month, however, the other doctor that works with me at the Juvie sees all the patients, and I get the morning off. This morning was especially nice, since it's also my Birthday, and I have had a plethora of people wish me well (thank you all). Unfortunately, my Birthday sucked, and personally, I think it's because a stupid black cat walked in front of my car as I was pulling out of the neighborhood this AM. Superstition aside, the car broke down, had to be towed, and is now being worked on for an undisclosed amount of time. In addition, both of our dogs had to go to the vet - just maintenance, mind you - but a "mild flea allergy," and a year's worth of Sentinel pills later, my birthday has already cost me around $800. Google would like for me to add "monetizing" to this blog, and if things keep going this way, there might be adds for Viagra and Match.Com on the sidebars.
Anyway, no poignant message tonight, just watch out for black cats and birthdays - nothing good can come of them.
To lighten things up, here are some Disability complaints from the past few weeks:
Patient's written complaint: My doctor told me I shouldn't lift anything more than 10 lbs after my surgery. I told him I saw an Ultimate fighter still fighting after this surgery.
Doctor's written response: Unfortunately, this patient is not in the physical condition of an Ultimate Fighter.
"I got really sad after I lost my mother....to death." (As opposed to gypsies, aliens or in Wal-Mart)
"Everyone is stealing my white socks. I've started wearing black ones, so I'll know who's stealing them!"
(I was very glad my socks were brown that day).
Until later,
-DD
Anyway, no poignant message tonight, just watch out for black cats and birthdays - nothing good can come of them.
To lighten things up, here are some Disability complaints from the past few weeks:
Patient's written complaint: My doctor told me I shouldn't lift anything more than 10 lbs after my surgery. I told him I saw an Ultimate fighter still fighting after this surgery.
Doctor's written response: Unfortunately, this patient is not in the physical condition of an Ultimate Fighter.
"I got really sad after I lost my mother....to death." (As opposed to gypsies, aliens or in Wal-Mart)
"Everyone is stealing my white socks. I've started wearing black ones, so I'll know who's stealing them!"
(I was very glad my socks were brown that day).
Until later,
-DD
Wednesday, December 9, 2009
The Art of Listening
The average physician interrupts their patient in the first 11 seconds of an interview. This is an amazing fact when you think about it. How often do we, in other types of relationships, value the importance of being a good listener, but throw it out the door when we come face-to-face with a medical challenge. The importance of good listening is taught in many medical schools - "90% of your diagnosis is a taking a good history" is an adage repeated multiple times through a medical student's career. It seems, unfortunately, to get quickly forgotten when the student steps out of the classroom, and enters into the realm of the doctor/patient relationship.
It was brutally cold this morning, and while that might not bother you or me, to the types of people I routinely see in my practice, it has a huge influence on whether or not they leave the comforts of their homes (if they have one). My normally busy Wednesday morning schedule was filled with cancellations this morning, as people decided they would just rather reschedule, than brave the weather to wait for the woefully inadequate city buses. One of the gentlemen I did see, however, had decided to embrace the cold, even though it meant walking a mile from his home to the nearest bus stop. He was 30 minutes late, and while that normally would result in an automatic reschedule, the weather-induced vacancies in my schedule allowed for him to be seen. He entered into my office, a tall African American male in his early 60's, gray beard stubble on his face, and MC Hammer (I kid you not) pants under an oversized parka.
His main complaint was depression, and he had been without a job for three years due to an acquired distrust for people - as he put it, "the same 'ol 'I can't trust the white man' song and dance." I asked him about his depression, and simply listened as he proceeded to unfold a story about trust, the breaking of said trust, and now an inability to trust anyone. I'm sure there was another side to the story, but for his sake, I let him just speak. It took about 15 minutes, with me "emphatically listening" to what he had to say. Afterwards, he said, "You know, I've never told anyone what I just told you. I've always felt like people have their own agenda, but you've totally put me at ease. I feel, so...like a weight has been lifted off my shoulders." I responded by thanking him for sharing his story, and the rest of the history and physical proceeded without any aberrations.
The power of just sitting there and listening is immense. Think about your own life, and how different things would be if people actually listened to you, and you listened to them. Keep in mind, the type of listening I'm talking about is not simply a short-term ability to relay facts, but a true empathic connection with the speaker. It makes you realize how important it is to put aside all the interruptions, preconceived thoughts and notions (very difficult for an "evidence based physician"), and just let someone talk.
And now, the disability quote of the day:
"I started having back problems after my disc got raptured in an accident."
Have a great hump day,
-DD
It was brutally cold this morning, and while that might not bother you or me, to the types of people I routinely see in my practice, it has a huge influence on whether or not they leave the comforts of their homes (if they have one). My normally busy Wednesday morning schedule was filled with cancellations this morning, as people decided they would just rather reschedule, than brave the weather to wait for the woefully inadequate city buses. One of the gentlemen I did see, however, had decided to embrace the cold, even though it meant walking a mile from his home to the nearest bus stop. He was 30 minutes late, and while that normally would result in an automatic reschedule, the weather-induced vacancies in my schedule allowed for him to be seen. He entered into my office, a tall African American male in his early 60's, gray beard stubble on his face, and MC Hammer (I kid you not) pants under an oversized parka.
His main complaint was depression, and he had been without a job for three years due to an acquired distrust for people - as he put it, "the same 'ol 'I can't trust the white man' song and dance." I asked him about his depression, and simply listened as he proceeded to unfold a story about trust, the breaking of said trust, and now an inability to trust anyone. I'm sure there was another side to the story, but for his sake, I let him just speak. It took about 15 minutes, with me "emphatically listening" to what he had to say. Afterwards, he said, "You know, I've never told anyone what I just told you. I've always felt like people have their own agenda, but you've totally put me at ease. I feel, so...like a weight has been lifted off my shoulders." I responded by thanking him for sharing his story, and the rest of the history and physical proceeded without any aberrations.
The power of just sitting there and listening is immense. Think about your own life, and how different things would be if people actually listened to you, and you listened to them. Keep in mind, the type of listening I'm talking about is not simply a short-term ability to relay facts, but a true empathic connection with the speaker. It makes you realize how important it is to put aside all the interruptions, preconceived thoughts and notions (very difficult for an "evidence based physician"), and just let someone talk.
And now, the disability quote of the day:
"I started having back problems after my disc got raptured in an accident."
Have a great hump day,
-DD
Tuesday, December 8, 2009
Fat Tuesday
One of the main medical problems plaguing our country is obesity. The fast-food nation in which we live has given rise to not only unhealthy adults, but also to an entire generation of children raised on Happy Meals, processed meats, and Cheese Whiz. There's an old adage that goes something like, "give a man a fish and you'll feed him for a day. Teach a man to fish, and you'll feed him for a lifetime." I think a more updated version should be, "give a man a fish and CHOMP CHOMP CHOMP I want McDonald's now." As a physician practicing in a very unhealthy state, I have seen my share of obese people - adults and children alike. Today, however, I saw one that took the proverbial cake, not in the actual poundage this lady was packing, but in the utter ignorance of the dangers her weight carried.
It was a busy morning at Disability. Everyone, for once, was showing up, and for the most part, people were demonstrating some physical impairment. Towards the middle of the morning, a claimant entered through the door, and stated that she was here "to get a second opinion about her heart." After informing her that there would be no second opinion today, my secretary proceeded to get her social security number, her height (5'1"), and then asked her to step on the electric scale to be weighed. The scale went through its calibration, blinked a few times, then read ----. The scale had worked just fine earlier in the day, and after the claimant stepped off the scale, it proceeded to work fine again. The claimant again stepped on the scale, and the scale numbers turned to ----. With a shrug, the claimant stated that she usually weighed around 400 lbs, and then proceeded to walk into my exam room.
After a brief history, it turned out the claimant had "very bad heart failure," and that her ejection fraction (a measure of pump capacity of the heart), was around 13% (normal is above 60%). She admitted to smoking a 1/2 pack of cigarettes a day, and stated that her back always hurt, and she just didn't know why. The remainder of the history was fairly typical for a heart failure patient, and her physical exam revealed typical signs associated with decreased cardiac pump capacity. As the exam was ending, she looked at me and asked, "I'm on Lasix (a typical medicine for heart failure), but it just doesn't seem to work. Is there anything else I can do?" Normally I don't give out medical information in this setting, but this lady seemed so uneducated about her condition that I felt compelled to speak. "The best thing you can do for your heart is lose weight and stop smoking." She looked very puzzled at this. "But it hurts too much to exercise," she said, "how am I supposed to lose weight?" "Diet. It sucks, and it takes a long time, but if you want to really lose weight, you're going to have to change your lifestyle, and the foods you normally eat." She started to cry a little at this point, and said, "well, I guess I'll find some other way to lose weight, then, because dieting just won't work for me."
We are all responsible for our own health. I can't make you eat carrots and tofu every meal, nor would I want to. There's too much good stuff to eat out there. However, it's our responsibility to take care of our own bodies, as well as set an example for future generations to cherish the bodies we've been given. No pill will reverse a lifetime of poor choices.
And now, the quote of the day from disability physicals:
"My kids got taken away from me because I bit them too hard, and this really depressed me."
Cherish your body,
DD
It was a busy morning at Disability. Everyone, for once, was showing up, and for the most part, people were demonstrating some physical impairment. Towards the middle of the morning, a claimant entered through the door, and stated that she was here "to get a second opinion about her heart." After informing her that there would be no second opinion today, my secretary proceeded to get her social security number, her height (5'1"), and then asked her to step on the electric scale to be weighed. The scale went through its calibration, blinked a few times, then read ----. The scale had worked just fine earlier in the day, and after the claimant stepped off the scale, it proceeded to work fine again. The claimant again stepped on the scale, and the scale numbers turned to ----. With a shrug, the claimant stated that she usually weighed around 400 lbs, and then proceeded to walk into my exam room.
After a brief history, it turned out the claimant had "very bad heart failure," and that her ejection fraction (a measure of pump capacity of the heart), was around 13% (normal is above 60%). She admitted to smoking a 1/2 pack of cigarettes a day, and stated that her back always hurt, and she just didn't know why. The remainder of the history was fairly typical for a heart failure patient, and her physical exam revealed typical signs associated with decreased cardiac pump capacity. As the exam was ending, she looked at me and asked, "I'm on Lasix (a typical medicine for heart failure), but it just doesn't seem to work. Is there anything else I can do?" Normally I don't give out medical information in this setting, but this lady seemed so uneducated about her condition that I felt compelled to speak. "The best thing you can do for your heart is lose weight and stop smoking." She looked very puzzled at this. "But it hurts too much to exercise," she said, "how am I supposed to lose weight?" "Diet. It sucks, and it takes a long time, but if you want to really lose weight, you're going to have to change your lifestyle, and the foods you normally eat." She started to cry a little at this point, and said, "well, I guess I'll find some other way to lose weight, then, because dieting just won't work for me."
We are all responsible for our own health. I can't make you eat carrots and tofu every meal, nor would I want to. There's too much good stuff to eat out there. However, it's our responsibility to take care of our own bodies, as well as set an example for future generations to cherish the bodies we've been given. No pill will reverse a lifetime of poor choices.
And now, the quote of the day from disability physicals:
"My kids got taken away from me because I bit them too hard, and this really depressed me."
Cherish your body,
DD
Monday, December 7, 2009
Manic Monday
Monday mornings start early around my household. The alarm goes off at 6:30, I have to shower, dress, take my daughter to school, and be at the Juvenile Detention Center by 8:00 AM. Like most Mondays, this morning went off without a hitch. Shower, check. Get ready, check. Daughter to school, check. Arrival at the Juvie, check. All hell breaks loose, check. For those of you not familiar with our penal system, juvenile detention centers are NOT jail, they are simply a holding area for troubled kids, or troubled kids with equally troubled parents that shouldn't have had them in the first place. The latter unfortunately makes up the majority of the kids I routinely see.
I had just settled into my rolling chair in the clinic, when an emergency call came over the phone that a fight had broken loose on Unit A, (the unit for female and "nice male" detainees), and that a resident had to be physically restrained on Unit B, (the unit for the traditional male detainees). After the nurse on duty went and examined the residents in said incidents, they were brought to me for medical clearance to return to normal activity. Aside from a few bruises, both kids were fine. In fact, the male detainee told me that "a man can only be pushed so far before he just kicks someone in the crotch." While this logic is very true, I found it fairly amusing that this "man" was 13 and his voiced cracked twice during that sentence. If you step back from this situation, however, it's actually a fairly sad one. This 13 year old kid's parents called the cops on him because he got in a fight with his dad. Granted, he did take a box cutter and "rough the old man up," but only after his dad, in a drunken fit, choked him, and gave him a black eye.
The Juvie is littered with this type of family dynamic. Kids having kids of their own, getting angry, taking it out on their children, who in turn rebel, get pregnant and perpetuate the cycle. Entire families have grown up in that place, with the counselors and social workers acting more like parents, and the detainees themselves growing in a close-knit household of urban dysfunction.
Fortunately, the rest of the morning was uncomplicated. After giving a lecture on safe sex, and treating a case of strep throat, I drove to my Monday afternoon job - Disability Physicals. Highlights from this afternoon's claimants included the following statements.
"I can't drive no more because my ex-boyfriend burned up my car and my stereo"
"I hear voices and music. The voices don't bother me, but the music...I hate it."
Previous employment: Fast-food daycare
If someone can please explain to me the last one, I would greatly appreciate it.
Until next time,
DD
I had just settled into my rolling chair in the clinic, when an emergency call came over the phone that a fight had broken loose on Unit A, (the unit for female and "nice male" detainees), and that a resident had to be physically restrained on Unit B, (the unit for the traditional male detainees). After the nurse on duty went and examined the residents in said incidents, they were brought to me for medical clearance to return to normal activity. Aside from a few bruises, both kids were fine. In fact, the male detainee told me that "a man can only be pushed so far before he just kicks someone in the crotch." While this logic is very true, I found it fairly amusing that this "man" was 13 and his voiced cracked twice during that sentence. If you step back from this situation, however, it's actually a fairly sad one. This 13 year old kid's parents called the cops on him because he got in a fight with his dad. Granted, he did take a box cutter and "rough the old man up," but only after his dad, in a drunken fit, choked him, and gave him a black eye.
The Juvie is littered with this type of family dynamic. Kids having kids of their own, getting angry, taking it out on their children, who in turn rebel, get pregnant and perpetuate the cycle. Entire families have grown up in that place, with the counselors and social workers acting more like parents, and the detainees themselves growing in a close-knit household of urban dysfunction.
Fortunately, the rest of the morning was uncomplicated. After giving a lecture on safe sex, and treating a case of strep throat, I drove to my Monday afternoon job - Disability Physicals. Highlights from this afternoon's claimants included the following statements.
"I can't drive no more because my ex-boyfriend burned up my car and my stereo"
"I hear voices and music. The voices don't bother me, but the music...I hate it."
Previous employment: Fast-food daycare
If someone can please explain to me the last one, I would greatly appreciate it.
Until next time,
DD
Sunday, December 6, 2009
In the Beginning...
Much like any social situation, this blog calls for an introduction. I'm an Osteopathic Physician who graduated from medical school in 2008, with every intention of pursuing residency training in Obstetrics and Gynecology. After completing my intern year at a major University Hospital, I left my program due to ethical conflicts with the way patient care was being managed. Currently I'm in the process of waiting for another residency spot to open, and such have been working as a contracted general practioner since July of 2009. I have four jobs from which I draw the majority of the subject material for this Blog. Not only will I relate some funny stories and interesting medical tidbits, but I hope to bring light to the way in which (some) doctors think when approaching their patients. This is not a definitive look at the medical profession, but it is, at least in my mind, a unique one.
My current work schedule involves performing disability physicals for Social Security, seeing patients at the Juvenile Detention Center, and staffing an urgent care clinic for low-income people. I also teach at a local medical school in the Osteopathic Manipulation Department.
I should note that I have been called both cavalier and irreverent in my views on doctoring. While that may be true, I care very deeply about my patients, and consider myself their advocate. If something I say offends you, I apologize - it is not my intention to belittle anyone, their condition or their beliefs. I will say, however, that medicine is a dirty business, and that to survive the horrors that medical professionals deal with daily, some develop a rather unique sense of humor.
Now that I've explained a little about myself, as well as what you can expect from these musings, let me give you an example of the type of patient I routinely see while performing disability physicals. The building in which I perform these exams was probably constructed in the early 70's, and has not been updated since. My office is a 12 x 9 cinderblock room, with two dirty, poorly insulated windows and faux-wood wainscoting that wraps around the perimeter. Disability exams usually consist of me asking "What's keeping you from working?" followed the patient giving me a speech on how everything from their childhood history to yesterday's lunch affects their daily lives. About 20% of the people I see should qualify for disability. 60% of the rest probably have something wrong with them, but "back pain that happens if I stand more than two hours," or "getting too hot when I work in front of the furnace" does not require government support. The remaining 20% are the people that think they should get free money because "my left breast swells if I eat hamburger," or they "just can't swing a rake no more after cleaning that mop."
Unfortunately, I don't get to say whether or not the claimants get disability, I just report what I find. It is my sincerest hope, however, that my tax dollars are not going towards paying a monthly check for someone who "can't work where there's air."
I'll be adding stories as they happen, so check back often!
-Disillusioned Doctor
My current work schedule involves performing disability physicals for Social Security, seeing patients at the Juvenile Detention Center, and staffing an urgent care clinic for low-income people. I also teach at a local medical school in the Osteopathic Manipulation Department.
I should note that I have been called both cavalier and irreverent in my views on doctoring. While that may be true, I care very deeply about my patients, and consider myself their advocate. If something I say offends you, I apologize - it is not my intention to belittle anyone, their condition or their beliefs. I will say, however, that medicine is a dirty business, and that to survive the horrors that medical professionals deal with daily, some develop a rather unique sense of humor.
Now that I've explained a little about myself, as well as what you can expect from these musings, let me give you an example of the type of patient I routinely see while performing disability physicals. The building in which I perform these exams was probably constructed in the early 70's, and has not been updated since. My office is a 12 x 9 cinderblock room, with two dirty, poorly insulated windows and faux-wood wainscoting that wraps around the perimeter. Disability exams usually consist of me asking "What's keeping you from working?" followed the patient giving me a speech on how everything from their childhood history to yesterday's lunch affects their daily lives. About 20% of the people I see should qualify for disability. 60% of the rest probably have something wrong with them, but "back pain that happens if I stand more than two hours," or "getting too hot when I work in front of the furnace" does not require government support. The remaining 20% are the people that think they should get free money because "my left breast swells if I eat hamburger," or they "just can't swing a rake no more after cleaning that mop."
Unfortunately, I don't get to say whether or not the claimants get disability, I just report what I find. It is my sincerest hope, however, that my tax dollars are not going towards paying a monthly check for someone who "can't work where there's air."
I'll be adding stories as they happen, so check back often!
-Disillusioned Doctor
Subscribe to:
Posts (Atom)