Thursday, June 30, 2011

Trying to prevent fires (in the office)

All a health care provider needs to have empathy for patients is to have a health related concern of his/her own, or within his/her family, to experience the many communication deficiencies in our health care system that exist.

Many times, a statement made in the midst of a patient encounter can help to establish or re-establish a relationship that might have been lost.

Things obviously don't always go smoothly in the office. Occasionally, I have to resort to a couple of old standbys to help defuse a tension filled room. Both have withstood the test of time, for the most part.

* When seeing a new patient that appears (by his body language/facial expression) to be upset, angry, disillusioned, etc., by the medical system: "You look upset. I'm sorry. I don't think we've ever met before. It's good to meet you. I'll certainly try to do everything I can to help assist with your medical needs and to be your advocate."

* When in the midst of an encounter that has, for whatever reason, deteriorated to, almost, a point of no return: "Would it be alright if we started over. I'm sorry that things got off to a bad start. I apologize. Let's start over, OK?"

Wednesday, June 29, 2011

Thanks for the feedback

A patient filled out a complaint form asking to leave my practice and gave it to an office administrator.

I was asked to "sign-off" on the complaint (as is always our practice).

It stated that he wanted to transfer to a partner since I always spent time telling him about my problems.

I had no comment since I wasn't sure what he was talking about.

It just so happened that, soon after requesting to transfer, he came in for an acute medical concern and my partner was on vacation.

It was a little awkward seeing him but I tried to be as professional as possible.

At the end of the visit he said, "thanks for seeing me, I hope you weren't offended that I asked to transfer to your partner."

I saw my opening. "Not at all, I was just a little confused by the comment that I was always telling you about my problems. I don't know what you meant by that."

"The last time I came to see you and was concerned about a mole, you told me it was nothing to worry about and then pulled up your pant leg to show me you had the same type of mole (a seborrheic keratosis). The visit before that I was concerned about a bump under my skin and you pulled up your shirt sleeve to show me you had the same thing on your arm (a lipoma)."

"Oh, OK, thanks for the feedback."

I learn something new every day.

I'll probably not change the way I interact with folks.

I'll just always wonder if someone else is thinking the same thing, whenever I show them some of my physical exam findings, while trying to reassure them.

Tuesday, June 28, 2011

My 3 goals as a parent

I see folks in the office daily that are disappointed in some aspect of their adult children's life. It's heartbreaking at times. The issues are variable-disappointments in choices made (careers, marriage partners, etc.), substance use/abuse, lack of motivation/resiliency, etc..

My kids will be heading to college in the next 2-3 years. Hopefully they will continue to evolve into young adults that are:

1. Happy (following their passion)

2. Healthy (of mind and body)

3. Independent (to the greatest extent possible in today's economy)

Monday, June 27, 2011

Looking at his possible future physique

My son is 16 and has been hitting the weights.

He got serious about weight training last year when he had a high ankle sprain and wasn't able to run for a couple of months.

He's been getting "pumped" at the "Y."

He hasn't met a mirror that wasn't a friend lately.

His usual household attire is a pair of boxer shorts.

Recently, my wife decided that she wanted him to wear a shirt while we were eating dinner.

My wife: Tom, go put on a shirt.

Tom: No Mom, I'm fine.

My wife: Tom, go put on a shirt. I would really like you to put on a shirt.

Tom: Mom, I'm fine. I'm more comfortable without a shirt.

I sit directly in front of him at the dinner table.

I hadn't yet joined in with the conversation. I took my shirt off.

Tom: Dad, come on, put your shirt back on (he could barely look at me-he had a disgusted expression on his face).

Me: No, I'm fine.

Tom: Come on Dad, you never have your shirt off (still with a disgusted look on his face). Your nips are breaking the plane of the table!

We all laughed.

Me: Tom, I'm more comfortable without my shirt (a complete lie-I still look OK by candle light but not under our bright kitchen lights).

Tom gets up, walks back to his bedroom and re-joins us wearing a shirt.

Me: Wow, that worked a lot better than I thought it would!

Maybe even better than I thought it would. Not sure it's a great thing that my son was so visibly disgusted looking at me without a shirt. Probably since we have photos of me when I was his age and we look so much alike. He was looking at his possible future and didn't like what he saw! Guess I better hit the gym harder and try to drop a few pounds!

Saturday, June 25, 2011

The Smallest Winner

A number of people have been motivated to lose weight while watching the TV show, The Biggest Loser.

That's a great thing!

I haven't watched every episode, but have tuned in from time to time.

The amount of weight loss is amazing.

It's crazy to see folks lose up to 1/2 of their body weight in 3-4 months through diet and exercise alone.

Success can be achieved without having to undergo a gastric reduction procedure (yahoo!)!

Most of us watching, however, don't have the same dramatic results.

But give yourself some credit. You're trying to lose weight in a real life setting. I'm a family man. I know it's not easy. Consider yourself to be the Smallest Winner.

The folks on the show are:

1. Removed from their families and other life stressors (being a husband/father/wife/mother, doing dishes, taking out the trash, walking the dog, paying bills, doing housework, doing yard work, working, eating on the run, getting kids to activities, dealing with health issues within the family, etc) and sent to a remote facility.

2. Given personal coaches who guide daily work-out routines and supply daily motivation.

3. Educated and re-educated on diet. It takes a lot of education to master many nutritional concepts and to apply them in all settings (eating at home, eating out, eating on the run, snacking, etc).

4. Given the added incentive of becoming "famous."

Try to stay motivated despite not being on a TV show. Any success is a good thing. If you fall off track one day, get back on track the next. If you can afford a gym, join one. Seeing others working out can be motivating and a lot of facilities offer free training and dietary/nutritional classes. Commit to improve the over-all health habits of everyone in the family. Learn and re-learn about nutritional concepts.

Eat less and exercise more.

Come on, why not start today?

Friday, June 24, 2011

A life outside of my office

I've known Mr. M. for a long time.

He has chronic pain from degenerative joint disease, as well as multiple other medical and psychiatric diagnoses.

Every time I see him, he appears miserable.

I always try, as I do with all folks with chronic pain, to have as much empathy as I can muster.

Recently, my wife, son, daughter and I went to see a movie. It was a comedy. We got to our seats during to the coming attractions so the theater was already dark.

After my eyes adjusted, I noticed that Mr. M. was sitting in the row directly in front of ours. I didn't say anything to him and it didn't appear that he noticed me (I often wear a baseball cap when not at work).

During the movie he was, at times, laughing loudly at the parts in which everyone else in the theater was laughing.

I found myself watching him more than the movie.

It was wonderful to see this fellow, that usually appears almost lifeless in my office, smiling and, at times, laughing hysterically. I had never seen him so animated.

It was great to see!

It was uplifting.

He actually seemed to be enjoying himself, and for at least this brief two hour span, life itself.

He left as soon as the movie ended. We waited until most of the credits were finished.

I've seen him since.

I haven't let him know I saw him outside of my office. It doesn't change the fact that he has chronic pain. It just sort of gives me feedback that he's doing a little better emotionally, and possibly physically, than I had thought.

I really wanted to tap him on the shoulder during the movie and say, "it's good to see you, thanks for making me feel better about how you are doing!"

Thursday, June 23, 2011

A pack on a day

While seeing a 56 y/o male:

Me: How much do you smoke?

Patient: Not much, I'll only buy a pack on a day.

Me: A pack a day, that's a lot, that's 20 cigarettes a day. That means you're smoking almost 1 an hour.

Patient: No I don't.

Me: Aren't there 20 cigarettes in a pack?

Patient: Yes.

Me: So you smoke 20 cigarettes a day?

Patient: No, when a buy a pack on a day it will usually last me 4-5 days before I have to buy another pack.

Me: Oh, I see. So you're smoking 4-5 cigarettes a day...hopefully you can continue to get even lower than that.

Actually, my initial thought was, "oops, my bad, ...sorry!"

Wednesday, June 22, 2011

Psychic powers

Warning: The following brief patient encounter is probably a good example of why my wife thinks I'm so bizarre. I'm easily amused, often finding humor in things that most "normal" folks would not.

A 78 y/o male came in for an appointment after undergoing a number of tests by his cardiologist.

Me: How did everything turn out (I hadn't yet received any information concerning the results)?

Patient: I have a premonition that everything is fine.

Quick review:  definition of premonition: An intuition of a future occurrence; a feeling; a hunch; a warning in advance; a forewarning; an early warning of a future event; forewarning; a feeling of anticipation of or anxiety over a future event.

Lets get back to the patient.

Me: Why's that?

Patient: Well, the cardiologist was sitting in the room while all the tests were being done (an echocardiogram and a nuclear stress test). He made the comment, a few times, that everything looked excellent and that my heart was in great shape for a 78 year-old man.

Me: That sounds like a pretty good premonition.

Later that morning his extrasensory, psychic powers were confirmed. The fax'd results were normal.

How bizarre am I?

I still think it's funny!

Tuesday, June 21, 2011

A timely public health reminder in a nice color

A 52 y/o male came in for a new patient appointment. He was wearing a bright blue rubber bracelet on his wrist that had the statement "Colon Cancer Screening Saves Lives." I read it while I was checking his pulse.

Me: Colon cancer screening saves lives.

Patient: I'm sorry, what?

Me: Colon cancer screening saves lives.

Patient: Oh, colon cancer screening saves lives?

Me: Yes, just like your bracelet says.

Patient: Oh (now looking down at his wrist), that's cool. I've actually never really paid any attention to what was written on it. I've just always liked the color. Someone gave it to me a couple of years ago.

We then talked about a screening colonoscopy since he never had one before.

He agreed to be referred for one.

Wow, that bracelet worked great!

Monday, June 20, 2011

The PG-rated version of a common primary care topic

I spend a fair amount of time (almost everyday I'm in the office) reviewing issues concerning E.D.. It's still interesting that, despite all the information available, folks are so uninformed on many of the issues involved.

Here are a few things I try to review:

1. If you want to perform like Tarzan, you have to feel like the king of the jungle. Therefore, if you are not confident in your ability to perform, for whatever reason, there will often be dysfunction.

2. If everything works while you are alone, your plumbing and hydraulics are intact.

3. If you are not physically or emotionally attracted to your partner, your chance of success is less.

4. The heavily advertised, and commonly prescribed, oral medications do not work by themselves. In other words, you can't take one and then stare and wait for things to rise on their own.

5. If you are in a relationship that does not have respectful communication at its core your chance of E.D. is greater.

6. If you are in a relationship in which you are not yet comfortable to talk about E.D. with each other, you should wait until you are prior to attempting to be intimate. See #7.

7. If you are not able to tell your partner that you are using medical treatments to assist with E.D., it's probably not a strong enough relationship yet.

8. Four of the best things to do, if applicable (even better if you do it together): stop smoking, limit alcohol, lose weight and exercise. See #9.

9. Smoking, excessive alcohol use, being overweight and lack of exercise are probably more the cause of E.D. than the low dose of  blood pressure or anti-depressant medication you are taking.

10. Something as simple as a retention ring, available on the internet without a prescription, might be enough to allow you to perform for all to be happy. A vacuum pump is also a good nonpharmacologic option.

11. Testosterone can play a role, especially if you lack desire.

12. Remember that satisfaction, as a couple, does not always need to include "the act."

13. Success can almost always be achieved; it just depends on how much intervention one is willing to accept. Most clinics that guarantee success do so with the assistance of a needle and syringe.

I usually let folks know that I would prefer to do numbers 1-12 before considering number 13. Most, who are willing to participate in the discussion, agree.

Sunday, June 19, 2011

Thanks Dad

I'm always amazed, and saddened, when I come across fathers that have been estranged from their kids.

Watching my kids grow up has been a joy, for the most part, the extent of which I never could have predicted prior to becoming a father.

I was fortunate to have a great role model. I know many guys did not.

Life lessons from my father included:

* never retire "to the couch." Even after he retired, and even after his Parkinson's disease was advanced, he was always up to something. He loved to tinker with electronics, model airplanes and was always thinking of things to patent.

* he always rallied to play catch, shoot baskets or play other sports, even when I knew he was tired from working all day.

* he always made it a priority to be there for events. I always knew he would be in the stands, with my mother, often before I had even arrived on the team bus.

* he always put the needs of his family first.

* he encouraged us to enjoy life, to never give up or to run away from our problems.

* he always treated others with respect, no matter their status in life.

*he showed us the importance of a good sense of humor.

* he modeled being an excellent husband and maintaining respectful communication, while working through all of life's problems, with my Mom.

To any fathers that are estranged from their kids: think strongly about trying to re-connect. Ain't nothing better in the world than to receive a card from your kids on Father's Day that says "thanks for being a great Dad!"

Saturday, June 18, 2011

Love of exercise

I've always loved sports.

I've been fortunate to coach my kids on local "Y" teams for years.

My son starts his summer "U16" basketball season today.

At the start of every season I always try to remember something my wife told me years ago: "kids don't ruin sports, parents and adults ruin sports for the kids."

Both of my kids seem to enjoy exercise. They seem to love the challenge of sports and the positive effect that it has on their self confidence and emotional well being.

Many adults "pick" their kids sports.

Many adults insist that their kids play the same sport year round.

Unfortunately, many kids either burn-out or don't have the skill set to continue to advance in their one sport, as they get older, and then appear lost, as do their parents who were trying to live vicariously through their kids and their kids accomplishments.

My son has played baseball, volleyball, basketball, lacrosse, golf, soccer, football, ultimate Frisbee, ran for his schools track team, earned a black belt in karate and recently took up weight lifting as well.

My daughter has also done karate, played basketball, soccer, volleyball, done gymnastics, is an accomplished equestrian and goes out for long distance runs almost every day.

Neither of my kids may ever get headlines in the newspaper or get a college scholarship but they love to exercise.

Both have narrowed their interests as they've gotten older but continue to be open to new challenges and appear to be very resilient. Every time they get knock down by something in sports, school or emotionally, they seem to be able to get back up.

That's a great thing.

Youth coaches: please have someone video tape you in action. If you're on the bench yelling and screaming at your players, if your players are on the bench with their heads down and/or crying, PLEASE re-evaluate what you are doing. If your players are not looking forward to the next season, no matter how skilled or un-skilled that player might be, or does not ask to be on a team coached by you in the future, you are failing in your job as a youth coach.

Parents: let your kids follow their passion. Don't force them to pick a sport that you want them to pick. Support and encourage them, skilled or not, winning or losing.

Sports and exercise will have a positive effect on kids as long as WE don't ruin it for them.

Friday, June 17, 2011

What the heck was I thinking?

To be completely honest, over the course of my career, I've had a recurring question: "what the heck was I thinking when I went into primary care?"

An article, written a number of years ago, by George S. Poehlman MD, in the Journal of Family Practice, has always helped to remind me of the answer to the question. We've never met but I've read and re-read his article many times. Here are some highlights:

* the best of what our profession has to offer remains a primary care approach to health care delivery that has its foundation on the relationship of the doctor and patient.

* never forget the power of the human touch. Each gentle act of touch provides comfort to someone who has need: in addition, the act keeps us in touch with who we are-humble healers who are uniquely privileged to serve.

* always ask your patients about something that is totally nonmedical before closing out the patient encounter. You will ensure that your life's work is made up of more than simply treating disease. You will become an amateur anthropologist on whom people's stories are bestowed. This is what makes men and women of medicine wise.

* challenge yourself to prevent rather than to cure. Where there is illness, help the patient or person in need to understand the illness within the context of his or her family and beliefs. Lots of things that go wrong with the body are "no big deal," and people want to know that; and when it is "big," they need to know that, too.

* medicine allows us to participate in the lives of others, sometimes from birth, often until passing. It is an advantage and trust given to a few-and none of us can take that for granted. Be humbled by the honor.

Thursday, June 16, 2011

The Dancing man

"Health is NOT the absence of disease. It's the state of mind that lets one live a full, rewarding and productive life REGARDLESS of their physical condition."

Mr. B. was a perfect example.

He died earlier today at home.

He was 90 years old.

He had more than his fair share of medical conditions over the years: hypertension, COPD, prostate cancer, colon cancer, recurrent deep venous thromboses, severe peripheral vascular disease and end stage degenerative joint disease.

He lived with his daughter and son-in-law.

He LOVED to dance.

Every Friday and Saturday, until a few weeks ago, he had the same routine.

He would dress up and then take a cab to arrive at his dancing establishment by 8 PM. He would take the cab so as not to burden his family, even though they always offered to drive him. He would dance until around 1 AM with the support of his partners and walker. From there he would go for coffee at Denny's and then take the cab home at 3-4 AM.

As he became frailer his daughter had appropriate concerns.

Was it OK for him to continue to do this?

Was she doing the right thing letting her father do this?

He really seems to want to do this, doesn't he?

Yes, yes, and yes.

He was a great example of HEALTH, despite his physical condition.

I've smiled every time I've thought of him today.

Wednesday, June 15, 2011

Mr. G's longevity recipe

I always enjoy seeing Mr. G. I've known him for close to 13 years.

He has, what others might term, a cantankerous personality.

He's an 88 y/o male that lives in the country, is a nudist, and smokes, chews and drinks excessively.

He has a history of hypertension, coronary heart disease, congestive heart failure, peripheral vascular disease, and emphysema.

He remains completely independent. He walks without a cane/walker. He's cognitively intact. He's continent.

He's compliant with  medications.

He's been married for 54 years but he and his wife have lived in separate homes, on the same piece of property, for the last 20 years or so. They were starting to get on each others nerves.

Me: Are you still using your special recipe every morning?

Patient: You bet, as regular as a goose going barefooted (he has an assortment of quotes-I usually have to have him repeat them at least once so that I won't miss anything).

Me: Can you review it for me again?

Patient: Yep, I drink a V-8, followed by 2 beers, then 3 cups of coffee, one more beer , eat a raw onion like an apple and have 2-3 cigars.

Over the course of a typical day he smokes 5-7 cigars, drinks 6-9 beers and chews tobacco. His favorite food, beside onions, are his "beans and weenies."

Patient: Go ahead Doc, get it over with...

Me: You shouldn't be smoking cigars, chewing tobacco or drinking so much.

We both laugh.

His clinical exam remains incredibly stable. At the end of most visits he always makes sure to remind me of one thing.

"Don't see many folks my age doing as well as I am, do you?"

"Nope, I don't, see you in about 6 months."

Tuesday, June 14, 2011

Three life lessons from the news

I'm not the smartest guy in the world but events in the news lately should lead to the following conclusions:

1. You can't walk into a bar and hire a hit man-the person the bartender refers you to is most likely an undercover police officer.

2. Anyone who is trying to solicit a sexual encounter on the computer is either conversing with a police officer or the Dateline News crew trying to do a sting operation.

3. It's never a good idea to send pictures through your cell phone, especially private pictures of your privates!

Putting things back in perspective

A 25 y/o male was very concerned about "bumps" on his penis.

His exam was only notable for the complete absence of body/pubic hair (a finding that seems to be extremely common now in the younger generation due to long showers and a lot of time with a razor) and Tyson's glands, also known as pearly penile papules.

I spent a fair amount of time trying to reassure him that all was fine.

He questioned how he could go through the rest of his life deformed.

He questioned how he could be intimate in the future due to their presence.

He wasn't completely satisfied with my explanation, even after showing him a number of pictures from a dermatology web site and reviewing patient education sites.

A friend of mine is a dermatologist in the next building.

He offered to do a quick curbside consultation.

He used a dermatoscope (sounds higher tech than a magnifier with a light).

He agreed with my assessment.

He did not recommend treatment. It was such a mild case.

Finally, the patient asked the dermatologist, "isn't there some way to get rid of them permanently."

Yes...he replied, amputation.

After a brief pause we all laughed.

"I guess it's not so bad after all...thanks."

Monday, June 13, 2011

No wonder I'm always running late...

A 61 y/o male came in for a follow-up appointment.

Me: Good to see you. Anything new?

Patient: We've been doing a lot of traveling lately.

Me: That's excellent, do you go by car or do you have an RV?

Patient: We have an RV.

Me: That's great.

I then, for some reason, decided to go on a long tangent reminiscing about growing up with my Dad selling RV's, taking family trips in RV's, having a job cleaning the rental fleet, and how the gas crisis in the mid 1970's crushed the business for many years. I had a lot of fun talking about it. The patient didn't seem to mind.

Finally, I stopped to catch my breath.

Me: How did everything go with finding RV parks to stay at while you were traveling?

Patient: What do you mean?

Me: Didn't you need to plan ahead to make sure there would be an RV park whenever you stopped?

Patient: We would have if we took the RV. This last trip we went in my car, a new PT Cruiser. We stayed in hotels.

Me: oh...that's cool.

This was an immediate reminder why I'm always running late seeing patients. I've gotta stop talking so much!

Sunday, June 12, 2011

Didn't mean for that to happen!

I've been following a 54 y/o male for many years. He has the "usual" assortment of diagnoses frequently encountered in the primary care setting. He also smokes 1-2 packs a day.

I had previously tried many different approaches to get him to quit smoking.

No idea why on this particular day, a routine follow-up appointment, I decided to ask, "are your wife and other family members prepared to meet your needs after you've had a heart attack or a stroke due to your smoking?"

He smiled, then laughed and said "yes they are...good try doc."

I'm pretty sure I then smiled as well.

He wasn't ready to quit.

We spent some time talking about the trip he was about to make up north to see other family members.

Unfortunately, I received a phone call message about a week later. He was still away on vacation.

"Tell Doc he was right. I had a heart attack and a stroke and am still in the hospital. My heart is OK but I don't have a lot of movement on my left side."

I've seen him since.

He's quit smoking. He still has left sided weakness. His family is helping to meet his needs.

I'm still a little freaked out about the whole thing.

Weird as it may seem, however, I think the patient thinks I'm smarter than I actually am, just because I was able to predict his future.

It hasn't changed my desire to get folks to quit smoking, just the phraseology I use with other patients.

Saturday, June 11, 2011

An under-recorded year

A 69 y/o male came in for a follow-up appointment. I had not seen him for close to a year.

Me:  It's great to see you, anything new?

Patient: Nothing really, except for that I was elected to be the historian for my local American Legion Chapter for the coming year.

Me: Congratulations, are you looking forward to it?

Patient: Sure, it'll be OK. It's funny though, I can't write due to my tremor, I don't own a tape recorder or a camera and I don't know how to use a computer. Even funnier, everyone that elected me already knew that.

He laughed first and then so did I.

Me: I guess the members just want to have a year off from being overly recorded.

Patient: A lot of folks take pictures all the time. Every once in awhile I'll just buy them some drinks so they'll give me some copies of their pictures to use for the end of the year party.

Me: Maybe that was their plan all along.

He laughed.

Friday, June 10, 2011

My initial attempts at medical writing (or should I say story telling?)

I had an excellent working relationship a number of years ago with an editor of Medical Economics. The attached site shows most of my initial attempts at writing medically related articles. Check some out if you get a chance.

Why a blog?

Had actually never given a blog much thought until I was asked if a letter to the editor of The American Family Physician could be used in the AFP community blog.
Thanks Kenny!

Thursday, June 9, 2011

Patients Say the Darndest Things-volume #4

     It's been almost three years since Patients Say the Darndest Things, volume #3 was published. This will be my first try writing in a blog. The three books were done through a publishing company, with an editor. Therefore, I apologize in advance for all errors that are sure to follow. I'm also not going to ask my wife to help with grammer (my grammer stinks); she's already busy enough with everything else.
     I'll be writing about humorous or unique, actual patient related stories (while keeping all identities secret), as well as about various issues in my own life, or on other medical related topics. I hope you will all get some laughs along the way. The patient stories are just a glimpse into the type of encounters that most primary care physicians deal with everyday. Feedback is always greatly appreciated.
     Warning: my writing style is nontraditional. It's just a style I've become accustomed to after years of documenting in patients records. Thanks for reading!