Knowing your Limits

I mentioned some posts ago that for the Spring Semester, I would be teaching in the Clinical Skills labs at the local medical school. Well, today was my first day as a "clinical instructor," and I think it went pretty well. The topic of the lab was how to properly perform an eye exam, and while OB/GYN doesn't usually lend itself to frequent ophthalmologic exams, the lab was a good refresher for my own physical exam capabilities. As I was teaching the first-year medical students, my mind drifted back to when I was in their shoes. I found myself remembering asking my instructor questions like, "How do I turn this stupid thing on," and "where's the optic disc?" I also remembered becoming excited about finding the optic disc, only to discover that I was looking at my partner's illuminated eyelid. Well, times have changed, and now I'm in the instructor's shoes, distinguishing optic discs from eyelids, and (hopefully) looking like I know what I'm doing.

It's amazing to me that after a few years of training, hard work, and getting their hands dirty, students can progress from asking "where's the optic disc again?" to caring for patients, performing surgery, or even (gasp) teaching medical students how to be competent physicians. We often take the knowledge this progression entails for granted, especially among other medical professionals. Unfortunately, just because someone graduates with a medical degree does not mean that they know everything about, for example, the eye. The first-year Ophtho resident who was helping instruct the lab today knew more about the eye than I ever would want to know. Likewise, I'm sure that my knowledge of pelvic anatomy and reproductive endocrinology could, forgive the pun, blow his eyes out of their sockets. As physicians, however, we're ok with this fact. It's the reason that specialties exist - I don't care about the eye, he doesn't care about the vagina, but we can still get along. Outside of doctors, nurses and what-have-you, however, those specialty lines often become blurred, and the layperson can incorrectly get into the "one doctor's the same as another" mentality. This often leads to incorrect management of the patient's disease, which, as you might imagine, can have dire consequences on their health. Now, don't get me wrong, I'm a firm believer in being a "total physician." Yes, I might be a Gynecologist, but that doesn't mean I can't treat Strep Throat, check cholesterol levels, or order an EKG for a weird heart rate. What it does mean, however, is that if my physical exam/history finds something, I will do something about it, be that treat (if I'm comfortable), or refer to someone who is comfortable for treatment.

So many of the patients I see while performing Disability Physicals are applying because their physician has been mismanaging their care. I know that I've talked about this before, but it needs repeating. If the management is not successful at treating the problem, maybe it's time to consider referring the patient to a specialist. There's nothing wrong with saying "this problem is too much for me," and sending them to someone who deals with said problem daily. Here's an example: my medical license gives me the right to perform surgery or prescribe medicine as I see fit, and if I opened my own surgery center, I could perform brain surgery if I wanted to. Seeing as I have no training in brain surgery, that might not be such a good idea, but I would legally be able perform that procedure. Now, imagine you have a brain tumor. You're applying for disability (of course), and therefore receive your application physical from yours truly. I say, "I know that you've tried some things before, and since you still have your tumor, they obviously didn't work. Why don't you let me do some surgery, and we'll fix things up in a jiffy." Would you let me perform surgery on you? I hope not. So why would you let a generalist try and manage your uncontrolled diabetes, heart disease, or whatever? Many physicians let their egos get in the way of patient care, and ultimately it's the patients that pay for it. We must remember that it is our sworn duty to protect the health of our patients, and to give them the best care we can, even if that means saying, "this is out of my league." It's much better in the long run to send them to a specialist than it is to try and manage a condition that you've only read about. Handing them a Wikipedia article about their condition and saying, "now you know as much as I do," does little to inspire confidence.

And now for the disability quote of the day:

Me: "So you say that your shoulder pain keeps you from working. How so?"
Very muscle-bound man: "Well, it really hurts me after lift a lot of weights, especially if I've been doing an upper body day."
Me: "So you're saying that weight lifting causes your shoulder to hurt, especially if you've really been pushing it?"
Man: "Yeah, that sounds about right."
Me: "What type of work do you do?"
Man: "Desk job, typing, that sort of stuff."
Me: "Well, it sounds like your pain is keeping you from working out more than it is from working."
Man: "Haha...yeah..."

Know your limits,
-DD

Late night

Well, it's late, and I'm tired, so I thought that I'd give you all some quotes to help you get through the weekend.  I'll be back again on Monday!

And now for the disability quotes of the day:

Me:  "So why did you stop working?"
Claimant:  "Well...I don't really remember...but it was bad!"

Me:  "So you say that your Oppositional Defiant Disorder has caused you to lash out against other people?"
Woman:  "Yeah, I hate people that get in my face.  One time my baby daddy got up in my face, and I stabbed him in the neck."
Me:  "Wow, was he ok?"
Woman:  "He didn't really say, he just went 'gurgle gurgle.'"

Written response to the question, "How has your condition caused your interactions with others to change?"
"I get angry at those people, so I get mad, then I explore."  I realize that this is probably a typo for "explode," but it made me laugh none the less.

Me:  "You mentioned that you were injured on your previous jobs.  What type of jobs were those?"
Claimant (big, burly guy):  "I used to work construction, but then I found my true calling, and went to beauty school to be a hair stylist."
Me:  "So you got injured styling hair?"
Claimant:  "It was the perm from hell!"

Have a safe weekend,
-DD

Healthcare reform - the first problem

The following is the first in a series of blogs about healthcare reform. I'll be adding more, usually about one a week, since they're rather heavy.

Well, it was bound to happen sooner or later. I was asked by a patient at the county clinic this morning what I thought about the upcoming healthcare reform. Actually, I'm surprised I haven't been asked this question before, seeing as the majority of my patients are on Medicare, or are lower-income individuals and without insurance. My reply was somewhat brief, seeing as I didn't know how in-depth she wanted the answer, but basically I said that the entire system needed to be reworked, including the way that we view patient care. She said that she agreed, and that was that. After she left, I started thinking more about the issue, and these are some of the thoughts I came up with. Warning: disillusioned opinion ahead.

So many of the issues our government endlessly debates relate to costs, state allowances, and eligibility for healthcare coverage. While these things are no doubt important, the real focus of the reform should be on the patient, and not on how much the government can save (or earn) from the insurance system. I understand that the people debating these topics are for the most part not doctors, and therefore their focus isn't on health CARE, but rather on heath COVERAGE. Here lies problem number one: how can we expect the system to change, when the people attempting to change the system have little to no knowledge about the components (patients) of said system? Even though they work with plants every day, we don't expect gardeners to debate the consequences of global warming. Why, then, should we allow lawyers and politicians to determine how you and I receive medical care? It simply does not make sense. Oh sure, I understand that politicians know how to write bills and talk for a long time, but that doesn't qualify them to make decisions about how I practice medicine. "But the senate has lots of think-tanks and people with multiple degrees helping them make decisions," you say. That's all great and good, but how many of those people are physicians, let alone practicing ones? I personally wouldn't want my care decided by someone who hasn't seen a patient since medical school, even if they had won the Nobel Prize in Medicine.

We have to do something about this.  I’m sorry if I sound like a broken record, but non-medical people should not be making decisions about medical things. The insurance world already has "veto" power over physicians by requiring pre-authorizations (basically a "mother may I?") before the physician can order a test, perform surgery and so on. On the positive side, at least there's a medical director for each insurance company that you can reason with. If we allow politicians to run our healthcare, however, how are you going to reason with them? I guess "I'll vote for you in the next election if you let me have that appendectomy," will have to do.

And now for the County Clinic quote of the day:

Me: "So you say your son developed that rash last night?"
Patient's Mom: "Yeah, right after dinner."
Me: "It looks kinda...orange...and crusty."
Mom: "Yeah, I know! It's so weird."
Me (to the patient): "Have you been picking at it?"
Patient: "Yeah, it tastes like Cheetos."
Me: "I think he'll be fine."

Until next time,
-DD

A rose by any other name...

When my wife was pregnant, a large portion of our time was spent trying to find the "perfect name" for our little girl. After about three name books, and lots of hours pining over syllables, cadence and so on, we finally decided on something that we felt would be strong, yet feminine, and that could serve her well in any given situation. It amazes me, therefore, that there are parents out there that choose one of the most important identifiers a person possesses seemingly at random. Now, I understand that it's extremely difficult to pick a name you think "personifies" your baby when they're still in utero, but it seems that more and more, people are just stringing together random collections of letters and grammatical marks and saying, "hey, that sounds good, let's name him/her that!" My current work environment at the Juvie and Disability land, not to mention my stent on labor and delivery, has blessed me with an abundance of interestingly-named patients, and it seems that each day I encounter more people whose names defy convention. A caveat: I'm not trying to point a finger at ethnic or family names - I understand that there are multiple cultures out there that I'm not even remotely aware of, and so if I offend someone with such a name, I apologize. That said, the majority of the patients I see are not from remote, ethnically isolated areas, so we'll just chalk it up to family origins, and call it even. Caveat part two. The following names have been changed (slightly) to protect their owner's privacy. If you know someone with this name, it's purely coincidental.

I had seven patients on my schedule at disability this morning, two with very unique names. My secretary commented on this as she handed me my first chart, and so with great interest, I opened it, and read the name appearing in the center of the page. "C'D'Marcus Andrewvyion Orionus Jones."  Wow. My first thought was "how is this kid going to fill in standardized bubble sheets. I don't think they have a "bubble" for apostrophes." My second thought, unfortunately, was, "Well, he probably won't be filling in too many of those." Terrible, I know.  The next patient was a super thin, platinum blonde named Aiessence Princess Strong. I asked her how to pronounce her first name, and she responded, with a "how stupid are you" glare, "Essence." Ah, ok, two silent vowels at the beginning of the name. I've seen that before...
Speaking of silent letters, I had a patient at the Juvie earlier this week whose name was Jernesha. When the nurse said, "Good morning Jernesha, what can we do for you today?" the patient corrected her, saying "it's Jeresha, the "n" is silent." I personally have never heard of a silent "n," let alone in the middle of the word, before, at least not in English.
The list goes on and on. I'm sure that most of us have heard of at least one or two names in our lives that make us say "what were those parents thinking?" My wife thinks that the naming issue is exacerbated by Hollywood, and the random assortment of names celebrities give to their kids. Names such as (and I'm not making these up) Fifi Trixibelle, Moxie Crimefighter and Miller Lyte send the message "it's ok to mix random nouns; your kids will love you for it." I mean, why not just open the dictionary, pick two words at random, add a hyphen and call it a name. If I were to use that method to name my next child, their name would be Estrus-Agronomics. Personally, I think that name is pretty sweet, but I would never subject my child to being associated with the menstrual cycles of animals. The fact of the matter is this: we as parents have the responsibility to bless our children with names that they will be proud of, and that will set them up for success. This is not to say that uncommon or strange names will keep one from advancing in the professional world, but how many Fortune 500 executives are named Dweezil? Likewise, giving a child a name that is incredibly difficult to pronounce, spell or has multiple interpretations can lead to frustration, not to mention name-calling, at school, and therefore be detrimental to their psyche. Not every child can live up to a name like Vercingetorix (a Gaulish warlord) or Temujin (Genghis Khan's real name), Lord knows those bubble forms aren't long enough for such monikers.

And now for the disability quotes of the day:

Patient's written response to the question, "How does your condition keep you from working?"
"When I talk on the phone too long, my head starts spinning, and nothing helps. Not even loving my cat."

Me: "So what keeps you from working?"
Her: "It takes me too long to shave in the morning, so I can't get to work on time."
Me: "How long does it take you to shave your legs?"
Her: "It's not my legs that take a long time, it's my beard. It's very thick."
Me: "Oh...sorry about the confusion."
Her: "I get it a lot."

N'aame Winth (silent n) Kaire,
-DD



see more Epic Fails

The Darkness

As always, the office was cold this morning. I'm not sure whether it's the single-paned windows, or the lack of adequate heating in the building, but after about ten minutes at my desk, my hands and feet are freezing. On the bright side, this usually affects the claimants too, and therefore they're less likely to yap like there's no tomorrow if they're shivering. My first patient of the morning, however, was not one of those patients.

I had passed her in the hallway leading to the office, her extra-large Harley Davidson of Las Vegas t-shirt hanging off her "old lady smoker" frame. She was dressed all in black, complete with a black driving cap, and large black sunglasses which she wore as she entered the exam room door. I had had the chance to look through her medical records before seeing her, and found that she had suffered a minor stroke that left no residual problems, and that she had previously applied for disability stating that she couldn't work because "I'm all messing [I kid you not] up." After a brief introduction, she stated that she couldn't work because she had "difficulty seeing." Her vision, according to the exam performed by my secretary was 20/30 (in case you didn't know, that means that she can see at 30 feet what a "normal" person can see at 20 feet." I asked her if she wore glasses or contacts, she replied no. I then asked her if she had seen an eye doctor recently, and she responded that she hadn't seen a doctor in four years. She also stated that she had lots of medical problems, but stopped taking her medications because her 1st husband had died of liver cancer, and she just knew that if she took medication, she'd get liver cancer, too. I tried to direct the questioning back to her vision, and the following conversation occurred.

"So you say that you can't see very well. Does that mean you can't see objects near or far or what?"
"It's really the lights that bother me...I tend to stay in the dark most of the time, and I can't really see well in the dark."
"So your main issue is that you can't see well in the dark?"
"Yeah, and that fluorescent lights, just like these," she gestured to the ceiling, " they often give me mini-strokes."
"And that's why you stay in the dark most of the time?"
"Yeah. That and I like the dark. No one can see you if it's dark."
"Well...that's true...I guess. Is that why you're wearing sunglasses right now?"
"Yeah, that and I like to play poker."
"...Ah, I see."
"Oh! I sometimes see things, too, when it's dark."
"Oh really? Like what?"
"Well, steak knives...mostly. I'll go to reach for them though, and I miss them."
"Because you can't see well in the dark?"
She clicked her teeth. "Now you're thinking."
She proceeded to tell me that her loss of...dark vision...also hampered her ability to play pool. In fact, she related, that was the main reason she sought disability, to help her regain her night-sight to play pool in "really smoky joints." The history complete, I moved on to her physical exam...which was negative for anything. Granted, I performed it with the lights on...maybe I should've turned them off. Eh...no.

And now for the disability quote of the day:

Me: "How tall are you?"
Claimant: "Around 5 feet, 3 and 3/8ths inches"
Me: "That's very specific"
Claimant: "I got a big scale..."

Wear your sunglasses at night,
-DD

Chomp Remix

Well, it's the first real post of the New Year. First of all, I'd like to say "thank you" to all of those who have contributed to the site - it's been awesome to see that ticker number climbing, and to see the poll numbers go up as well. I've tried to keep the posts a good mixture of comedy and commentary, and if there's anything that you would like me to talk about, please let me know! I said in one of the first posts that one of my goals for this blog was to provide an insight into the medical profession as a whole, and the introspection that has occurred while writing these entries has let me think even harder about the type of physician I am, so thanks for that as well.  I think that there's a lot of stuff to talk about in the healthcare arena these days, so expect some commentary about those topics in the upcoming weeks. All right, on to the blog!

It was a nice drive to the Juvie this AM. The roads were, for the most part, clear after the winter mix of last week, and the parking lot was thankfully clear of huge ice patches. There is an apparent rhythm to the rate in which detainees are brought in - it peaks during the summer months, and then drops down exponentially during the months of December and January - apparently it's more important to stay warm than it is to steal cars. As you might expect however, the majority of the kids that are brought in are "domestic offenders," or kids that get cabin fever and decide to do stupid things like "drink a half-gallon of vodka and play with knives." If you ask the majority of the kids whether they think such behavior is smart, they'll say "no, not really," and after a short stay, many of them go home, never to return to the Juvie again. It's interesting to me, however, that many of these domestic disputes involve biting, and often, it's not only the detainee that's guilty of the oral assault.

The last patient to present to the clinic this AM was a 5'7," 250 lbs Native American kid who was complaining of left arm pain. When asked about the source of his pain, he slowly turned his forearm over, and displayed one of the most perfect total mouth impressions I have ever seen. Both the nurse and I were impressed by the quality of the bite, and when asked who had bit him, he responded "my mom, of course." Of course? I mean, I know that I had a very sheltered childhood compared to most of these kids, but if someone asked me "Hey, who do you think bit that kid?" my first response would probably not have been "why, his mother, of course." Anyway, we asked why she bit him, and he responded "because I bit her..but I didn't draw blood." I guess that makes it ok? After a little more questioning, he divulged that his mother had bitten him a second time, this time on his back, right where the shoulder blade meets the back of the armpit. I didn't know what to say. The bite on the arm I can at least anatomically understand - maybe he was trying to hit her mouth with his forearm...but the shoulder blade? That's a sneaky bite, you know? You're not going to see that one coming. To make things worse, the bite on his back had started to show signs of infection, which warranted antibiotic treatment. I've said it before, but I'll say it again - I'm not here to judge parenting tactics...but I think this is an extreme example of "take a bite out of crime." He later admitted that lots of alcohol had been involved, and as he was walking out of the clinic, stated, "did you know that men with big beer-bellies are less likely to die in a head-on collision? That's a good reason to drink, right there." I almost said that men with big beer-bellies are less likely to see their penis on any given day, but instead said "That's the spirit, you'll be fine."

And now for the Juvie quote(s) of the day:

Nurse: "Are you ill or injured?"
Detainee: "I was cold last night, so I put on a blanket on me. Then I got warm."
Nurse: "Good for you, blankets do make people warm!  So are you ill or injured?"
Detainee: "I don't know, am I feeling ok?"
Nurse: "Um...you have to tell me..."
Detainee: "Oh..."

Don't bite your kids too hard,
-DD

Happy New Year!

Sorry for not posting last night, but with the festivites around my household last evening I didn't get a chance to.  I hope you all had a wonderful New Year's eve, and that you rang in the new decade with merriment and joy...and, according to two of you, a better relationship with the Police.  Things will be getting back to normal on Monday, so I look forward to blogging with you all then!

Have a good one!
-DD