Wednesday, August 31, 2011

Gut check

My wife and I started a "fit camp" last night at the YMCA.

It will meet for an hour every Tuesday and Thursday night for 8 weeks.

I try to exercise weekday mornings at the same "Y" from 5:30-6:15 AM and thought I was in decent shape.

However, after doing the initial assessment last evening it's crystal clear I need to:

1. Lose weight (after tipping the scale at 240 pounds)

2. Increase my upper leg strength (was only able to "wall sit" for a little over a minute-not good)

3. Improve my core strength (was also only able to hold the plank position for a little over a minute-pretty pathetic!)

I'll report an update periodically.

I'll have to figure out if/when to call upon my many previous orthopedic injuries/interventions for an excuse if a particular exercise is too painful.

I'll also need to actually start exercising to a level that makes me sweat again. goal weight in 8 weeks will be 225 pounds. Hopefully now that it's "out there", I'll have some extra motivation to stop snacking so much!

Tuesday, August 30, 2011

"Coulda" saved some time

A 66 y/o male came in for a new patient visit.

After taking his lengthy history, I stepped out while he undressed for the physical exam.

When I came back in the exam room I noticed he had a large tattoo on his chest.

On closer inspection it was a list.

On even closer inspection, I noticed it was his medical history.

Allergy: Penicillin

#1. Tonsils 1958

#2. Appendix 1967

#3. Heart bypass X 4: 1988

#4. Repeat bypass X 2: 1991

#5. Gallbladder 1998

Me: I've never seen such an informative tattoo before.

Patient: I just figured it would be helpful if I'm ever brought into an emergency room and can't speak.

Me: You got a point there.

I could have saved a lot of time taking his history, if I had only known. I can't help but smile thinking about the response I would get if I started all new patient visits by asking, "before we start, do you happen to have your medical history tattooed anywhere?"

Monday, August 29, 2011

Not a great start to the week

Mr. B. has been a challenging patient over the years.

He has chronic hepatitis C, cirrhosis, is awaiting a liver transplant and also has chronic non-cancer pain due to degenerative joint disease.

He has been on narcotics for pain after trials of other medications were not successful.

His son has been his caregiver.

I was always very impressed by his son.

He seemed genuinely concerned about his Dad and always said all the right things.

I came in today to a fax that was received over the weekend from the local police department.

His son was caught diverting his fathers pain medications to himself and possibly others through selling.

There will be a further investigation.

My name is on all the prescription bottles, of course.

Joy, joy.

Just another reminder, unfortunately, of the world we live in and also why health care professionals are often so ambivalent in taking care of chronic pain patients.

This is not the first time I have been burned.

Burned once-shame on you.

Burned twice-shame on me!

Sunday, August 28, 2011

You are welcome

My kids (aged 15 and 16) have been attending a church sponsored youth group on Sunday nights.

Both are very independent and have been very cautious in making and maintaining close friends over the years.

So far, they each have a few close friends who seem to be "low maintanence" and who also seem to make good choices.

My wife and I have been pleasantly surprised how much they enjoy the youth group.

Recently my daughter let us know that "everyone is just so nice. Usually, when you walk into a group of kids everyone just seems to be standing there, not really interacting other than with their closest friends, or you feel like you are being judged on what you look like or on the clothes you're wearing. At the youth group everyone says "HEY" the second you walk in and seems genuingly interested in you as a person."

The youth group leaders and other long term members have done a great job.

It's awesome to be that welcome.

I wish I could attend!

Friday, August 26, 2011

My favorite form

Filling out forms for patients is part of my job.

I particularly like to fill out FMLA (Family and Medical Leave Act) forms.

It's a real treat to answer a subtle variation of the same question over and over again.

For example:

Is the individual going to miss work while being treated for the medical condition?

Is the individual going to need to be absent from work while undergoing treatment for the medical condition?

Is the individual going to be unable to work a full day while being treated for the medical condition?

Is the individual going to need to undergo medical treatment while being treated for the medical condition?

Is the individual going to be treated by you while undergoing treatment for the medical condition?

If so, will the individual need to be absent from work while undergoing treatment by you for the medical condition?

If not, will the individual need to be absent from work while undergoing treatment by another medical provider for the medical condition?

If so, how often will the individual need to be treated by the other medical provider while undergoing treatment for the medical condition?

Will the individual be able to work less than a full day while undergoing treatment by the other medical provider for the medical condition?

Will the individual get the picture.

I wonder:

Did the developers of the FMLA form have a lot of fun devising it?

In devising the FMLA form did the developers have a lot fun?

Did developing the FMLA form lead to fun for those involved ?

Gee, maybe I should get a moonlighting job developing 5 page seems pretty easy!

Thursday, August 25, 2011

Hits home

I went to a funeral last night for a friend and fellow physician.

She died a few days ago.

She was diagnosed with ALS approximately a year ago.

We were the same age (51).

We both have two children.

I've coached her son on YMCA basketball teams for 4 years.

The service was inspirational.

Her husbands eulogy was excellent.

I haven't been this contemplative over a death in quite a while.

We had a lot of similarities in our lives.

I'm just so thankful for still being alive with my wife and kids for as long as I'm meant to be.

Wednesday, August 24, 2011

Supermans younger brother

Mr. R. is an incredible specimen.

He is 88 years young, runs, lifts weights, works part time at a health club and is a volunteer track and field official for high school and college meets.

I saw him the other day.

Me: Have you been up to anything new lately?

Patient: No, my younger brother was just here from New York for a visit. It was pretty sad. I hadn't seen him for about two years and he's really let himself go. I told him so.

Me: What's going on?

Patient: I don't really know. He doesn't really give me details on his medical problems but he has terrible teeth, has trouble with his eyes, macular degeneration I think, walks with a walker and wears Depends.

Me: How old is he?

Patient: He's 83, 5 years younger than me.

Me: Well, you probably just need to give him a break. You're in amazing health for someone 88 years old and I know you're very thankful for your health. The description of your brother describes most of the 83 year old patients I see here everyday. You're a tough act to follow.

He nodded but I don't think he agreed with me.

Post quake

My thoughts and prayers are with the folks in the northeast who experienced either physical or emotional trauma from yesterdays earthquake.

Many of the areas affected were in my old stomping grounds from years ago.

Best wishes to everyone.

Tuesday, August 23, 2011

Extra hours a day

1st day of school yesterday ($-back to school supplies).

Tom, 16, going into the 11th grade ($$-supplies and some back to school clothes).

Ellie, 15, going into the 10th grade ($$$-supplies and even more back to school clothes).

Both in the same school and Tom driving to and from school and to and from activities (priceless).

It's a new era, especially for my wife.

What's she going to do with all her "free time" now that she has extra hours a day?

Just think about a year from now when Ellie will be able to drive herself to the barn to ride her horse everyday!

Monday, August 22, 2011

Can I tell a fib (part 2)?

I've often felt we would have a much healthier society if all overweight folks could be diagnosed with type 2 diabetes.

Most of us go through a good portion of our life eating whatever we want, whenever we want and in whatever quantity we want.

A lot of overweight patients seem to want to get serious about dieting and weight loss only after they have been diagnosed with diabetes.

I always let folks know they can be healthier than they've been in years if they are willing to make changes in their lifestyle.

Resilient and motivated folks with diabetes actually learn the nutritional concepts that ALL folks should not only be taught, but also learn/master.

Can I just tell all my overweight patients they have type 2 diabetes, even when they don't?

Sunday, August 21, 2011

Can I tell a fib (part 1)?

Like most docs, my recommendation for an individual to stop smoking often seems to fall upon a deaf ear.

However, I can't tell you how many times I've seen tears well up in a persons eyes when I tell them a chest xray or pulmonary function test shows, at a minimum, some early signs of emphysema.

Sometimes, it has re-opened a closed door and allowed discussions concerning quitting to be re-started.

It often makes me think about wanting to tell all smokers the same thing, even when the CXR and PFT's don't show any signs of pulmonary disease yet.

Can I, pretty please?

Saturday, August 20, 2011

E.D. and wrinkles

I've had the most success in getting folks to quit tobacco over the years by offering the following information:

For men-tobacco smoking has been linked to a higher incidence of erectile dysfunction (E.D.).

For women-tobacco smoking has been linked to a higher incidence of facial wrinkles.

A quick discussion about the loss of sexual potency and looking older than others your age who don't smoke seems to create a lot more interest in quitting than reviewing the list of possible cancers (lung, oral cavity, pharynx, larynx, esophagus, stomach, pancreas, bladder, kidney, and cervix), especially in the younger population.

It's not surprising.

Whatever works is fine with me.

Friday, August 19, 2011

Work Zzzz's

A 41 y/o male was upset because he was just fired from his job working with a security company.

He worked the graveyard shift at a rental complex.

Me: Why were you fired?

Patient: Because my boss found me sleeping on the job.

Me: You were the night watchman?

Patient: Yeah, but there wasn't much to watch so it was hard to keep awake.

Me: Didn't they give you a second chance.

Patient: Yeah, they didn't fire me until it happened for the third time.

Me: Are you looking for another job?

Patient: Yeah, I hoping to catch on with another company doing the same thing.

Me: You still want to work the same hours?

Patient: Yeah, I seem to work best at that time of the day.

He didn't laugh or smile. I didn't either and decided to just move on to a more arousing topic.

Thursday, August 18, 2011

Why did I get home so late today?

A 60 y/o male with chronic hepatitis C, cirrhosis, HTN, DM, PVD, renal impairment, S/P BKA, S/P CVA, DJD and chronic osteomyelitis "dropped by" the office today, unannounced, in the middle of a hectic day.

Patient: "My daughter (who has been his caregiver for a number of years) is getting married this Saturday (two days from now) and will be moving out of the house on Sunday (three days from now). She does all my cooking, cleaning, helps with bathing and makes sure I take all my medications on time. I need for you to get me in to a nursing home tomorrow."

Oh yeah, that's why.

Wednesday, August 17, 2011

Office research

I have a bad habit of seeking chocolate in the the midst of a stressful day.

Today someone had placed Peanut M & M's, fun size bags, in the chocolate secret stash location.

While no one was looking (as is my usual modus operandi), I grabbed three bags and quickly retreated back to the bat cave (my office).

I opened Bag #1 and emptied the contents on to a paper towel.

There were only six M & M's!

Honestly, this was the first time I had ever counted.

I opened Bag #2; there were seven.

Bag #3 (you guessed it) had eight!

No kidding!

I consumed the 21 Peanut M & M's quickly.

I couldn't help but ponder the following:

Would a fourth bag have had nine, five or one of the previously mentioned amounts?

I'll let you know of any additional research on this topic in the future.

Also, it was a sobering reminder that not all fun bags are created equal.

Tuesday, August 16, 2011

11 minutes

I've been on a number of college tours recently with my son, who is just starting the 11th grade.

Prior to going, I came across an article that reported most high school kids can determine within 11 minutes of the start of a campus tour if it's a place he/she would be comfortable.

It's sort of like house hunting and walking in to a house that has everything you need but that just doesn't feel right.

So far, the 11 minute rule appears to be right on the mark.

On the most recent tour, after about 8 minutes, my son turned to me and said, "what kind of a college is this?"

I had to agree with him.

So here's a few quick pointers for when your time comes:

1. Definitely go on the tours. It's the best way to get a feel of the campus.

2. If things don't feel right after about 11 minutes, start to move toward the rear of the tour procession.

3. Look for an escape route. So far we've found that loitering in the college bookstore is the easiest way to make a break for it.

Monday, August 15, 2011

It's true

A number of years ago I wrote a chapter in Patients Say the Darndest Things, volume #2 entitled, "Possible antidotes for the primary care blues."

In one section I asked, "have you been sued lately?"

I then made the statement that "a study has shown most physicians report shame, anger, self doubt and disillusion with their medical career after going through litigation, regardless of the outcome of the suit."

I graduated from medical school in 1985. At the time I wrote the chapter (2006), I had never been sued.

This is no longer the case.

I can now confirm it's a true statement.

Sunday, August 14, 2011


I'm just finishing up a stay-cation and was able to do a lot of things:

1. Cleaned out our closets and made some salvation Army runs.

2. Went to the downtown section of the town I live in for the first time in a couple of years-couldn't believe all the new stores and restaurants. I only live approximately 3 miles from the downtown (I've got to get out more)!

3. Exercised a lot but only lost one pound (see #4).

4. Ate out almost every night (re-discovered a favorite Italian restaurant).

5. Did two college tours with my son who is going in to 11th grade.

7. Saw 4 great movies (and remembered how expensive it is for a family of four).

8. Chaperoned (helped drive) a trip to a horse sanctuary and breeding farm/barn with my daughter's horse camp.

9. Read two novels.

10. Caught up with all my medical journals-I'm not kidding!

11. Slept in and took daytime naps!

12. Got to see my son make a lay-up with one second left to win the U16 summer championship game.

I love to travel and see new places but all in all, the stay-cation was well worth it. As is the case with all vacations, however, I cringe at the thought of the work the awaits my return to the office tomorrow!

Sunday, August 7, 2011

Intact social graces

I got into the habit years ago of noting if a patient with dementia had intact social graces.

By this I mean they are able to converse and appear pleasant.

I always record this because these are the folks that sometimes need closer follow up to determine if their dementia is advancing.

They tend to be engaging and conversant, even when they can't answer orientation questions, etc.

They have errors of commission: they answer questions but the answers do not match the question that was asked.

They also tend to deflect direct questions by asking the provider such questions as "how are you and your family doing?"

This often causes a provider, such as myself, to go on a long tangent to give them a  family update.

At times, it's such a pleasant encounter that it's easy to forget they are even demented.

If/when I get dementia, I hope my social graces remain intact.

In my experience, it sure makes things a lot easier for the caregiver(s)!

Saturday, August 6, 2011

More than just a brave man

Social interactions during a patient visit usually are most enjoyable and enlightening for me.

I've actually always sort of prided myself in getting to know folks in the midst of a medical encounter.

Reading an obituary on a patient of mine, however, high-lited a missed opportunity.

Mr. C. was an incredibly brave and stoic man.

When I first met him he had already been diagnosed with three different cancers.

He was being followed at an acclaimed cancer treatment center.

He was on some accepted chemotherapy regimens, as well as some investigative trials.

In my role as a primary care physician, I admittedly felt overwhelmed in trying to counsel him whenever he would ask me questions such as "what do you think of this trial"?

I often wondered why I needed to see him because I never felt qualified to give much insight in to his current treatment or guidance on some of the various side effects he was experiencing.

I admittedly tried to keep the appointments as short as possible.

I never really got to know him as someone other than the unfortunate man with three different primary cancers, who appeared extremely brave.

I read his obituary yesterday.

He is survived by his wife of  44 years. He joined the Air Force after high school and was active duty for 4 years. After serving, he went to college, played basketball, broke every offensive record and was named to the All-America team in 1965. He was a successful small business owner and raised two children who went on to be college athletes and are now parents and productive members of society. His daughter is a teacher and his son is an attorney.

In retrospect, I sure wish I would have taken the time to get to know him better while he was alive, despite how uncomfortable I was in seeing him.

My loss; lesson learned.

Friday, August 5, 2011

All in the family

51 y/o male. He was an attorney.

Me (during the social history): How many children do you have?

Patient: Three.

Me: What do they do for a living?

Patient: They all work for me. None of them went to college but they're all real smart. My oldest son helps with bankruptcies. My daughter does investigations for my cases that go into litigation and my youngest son just started with me. He's does background checks and is a whiz with finances. They all do an excellent job. My oldest boy is as skilled in bankruptcy knowledge as any attorney I know. I'm very proud of them..

Me: Let me guess. Does your wife work with you?

Patient: Yeah, she's the office manager.

Me: Do any of them want to become an attorney?

Patient: No. I'm just hoping I can hang in there until one of my grandchildren goes to law school to take over the practice.

Isn't that cool!

Tuesday, August 2, 2011

Gotta a point there

An 85 y/o male was new to my practice.

He came to the appointment with his wife.

Wife (during the history): He also needs his memory pills.

Me: What pills does he take?

Wife: Honey, what's the name of your memory pills?

Patient: I don't know. I can't remember. Isn't that sort of a silly question to ask?

Everyone then laughed.

Monday, August 1, 2011

Medication reconciliation...not

I see folks all the time who have returned to Florida for the winter months or were hospitalized.

It's always great when they bring in copies of their medical records.

Almost every medical document now includes the words "medications reconciled" or "see discharge instructions for medication reconciliation."

What seems to be lacking, however, is a careful review of the medications and the instructions for use.

The computer generated print outs look impressive.

Reviews can reveal many errors.

Often, for example, one beta blocker was substituted for another beta blocker during the hospitalization but both still appear on the discharge medication reconciliation sheet.

Obviously, this can lead to adverse medication effects and/or the need for a repeat hospitalization.

Had a nice man recently return from up north, having been hospitalized just prior to returning, for new onset diabetes mellitus.

He was confused what dose of insulin he should take.

His medication reconciliation sheet had the following instructions (re-typed exactly as written):

Lantus 100 units/ml subcutaneous solution. Directions for use: 60 units subcutaneous of lantus a day (at bedtime), once blood sugar <100 decrease to 30 units of lantus, once BS < 100 decrease to 15 units of lantus, once blood sugar <100 discontinue lantus, X 30 days

He was discharged by a board certified endocrinologist.

The instructions were as clear as mud.

Easy rule: if a health care professional can't understand the instructions, it's appropriate to assume that our patients can't either.

A lot of computer generated signatures are entered on documents that have not been carefully read. The medication reconciliation page is one that needs to be carefully reviewed before signing.