Bad Call Night, a House Call, a Doctor’s Moment

September 7, 2018

A change in the dose might be small

But to keep myself on the ball

It’s not about me

It’s rewarding, you see

Going out to make a house call

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in northwest Iowa.  Any identifiable patient information has been included with permission.

Last night I had the only really bad call night so far this assignment, not bad for a gig that started in June. Called to the ER just after brushing my teeth at 10:30PM, I stayed till after midnight.  I can’t give the details of the case that brought me in at 2:30AM, except to say that a very sick patient needed more resources than we have after hours, and left at 3:30AM with follow ups scheduled along with my exhortation to read Beryl Markham’s West With the Night.

Sleep deprivation hits me harder than it did 30 years ago. I try not to show fatigue around patients and staff, but I felt my steps dragging when I started this morning.

I prioritize ER patients when on call, even when scheduled to simultaneously make nursing home rounds. This morning the inherent conflict resulted in my delayed arrival at a nearby Long Term Care Facility (LTCF).  About half the patients didn’t note my tardiness to a place where one can so easily lose track of time.

When I finished long-term patient care early, I begged the nurse to leave me alone in the exam room for a power nap. Elbows on desk, head propped on my hands, I hit REM sleep in less than a minute and awoke 6 minutes later feeling better.  Not well, but certain I could make the 8 mile drive without falling asleep.

Another true emergency dominated the lunch hour as the afternoon schedule swelled from 3 patients to 8. I bolted lunch and squeezed in another 4 minute nap.  I started into afternoon clinic on time but feeling my years.

At 2:00PM I left with nurses for a house call, and fell asleep on the 5 minute drive.

The first house call to this patient found little hope, the second progress. This time the trip rewarded me with a physician’s moment, the gratification of seeing the effects of improved human health and function rippling through the family in front of my eyes.

Back at the clinic, I stepped out of the car with a bounce in my step I didn’t have before I left. I faced a packed afternoon schedule, behind on documentation and still a bit hungry, but full of energy and the joy of having the best job in the world.

 

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ATLS: because real emergencies don’t give you time for an open-book test

September 5, 2018

 

Between the chest and the lung there is air

You don’t have an hour to spare

To consider the drama

Brought on by trauma

One must think, in spite of the scare

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in northwest Iowa.  Any identifiable patient information has been included with permission

Friday I attended the Advanced Trauma Life Support (ATLS) refresher course in Lincoln, Nebraska.

The summer showed signs of drawing to a close on the trip down.

The geese, having spent the spring mating and then hatching, and the summer nurturing, flew training flights with their broods. The mass migrations south won’t come till later.

The corn, which shot up so green against the brown earth in June, has come to the end of its life cycle; some fields losing their green at the edges, and a few already dead and drying down for harvest.

The ATLS requires renewal every 4 years; I decided to go a year early.

I hadn’t forgotten as much as I’d thought. The morning lecture went quickly.

I chatted with my colleagues at lunch. On my left, a doc married to a doc plans to retire as soon as he can but doesn’t have an idea about what he’ll do then.

On my right, a well-preserved physician declared that she does locums to ease into retirement. We asked each other about ultimate plans but neither had a good answer.

The written test preceded the skills station.

Anyone who finishes med school excels at written tests. All the homework, papers and exams of secondary and higher education just prepared me for the next 40 years.  Every day I write (or dictate) essays.  Last year’s 200 Continuing Medical Education (CME) hours involved lectures, reading, and quizzes.

The real world gives open-book tests. Most of my daily clinical challenges give me time to look up answers. Real emergencies don’t, and the ATLS prepares the student to keep cool thinking in times of terrible crisis.

I proceeded on to the clinical simulation; the examiner sat on a chair and presented a scenario: alcohol-mediated single car crash with victim ejected and now in my ER with low blood pressure and oxygen, distended neck veins, and no right-sided breath sounds. The model victim, a live person, lay on a simulated gurney.

“Tension pneumothorax! Needle thoracostomy!” I cried, because doctors talking to doctors can’t say “Collapsed lung!  Run a needle over the top of the 2nd rib to release air so it re-inflates.”

The rest of the case came frighteningly close to a blend of the two trauma cases that inspired me to take the course early.

I was the last to finish my clinical simulation, but still 2 hours earlier than planned. Which gave Bethany and I time to do some leisurely grocery shopping in Omaha on the way home.

 

 

Talking Canadian Licensure With a Canadian

August 31, 2018

To her home the doc wants to go back

It took time, but she’s facing the fact

She has nought left to prove

So she decided to move

I told her she just needs to pack

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I had a good long phone conversation with a Canadian national, a physician working in the States considering going back home, for a lot of reasons.

Right now she attends patients in a high-crime area with brutal heat and humidity, in the sunniest part of the sun belt. She loves teaching, and she loves medicine.

She talked about her aging parents in Ontario. She asked me about scope of practice and professional climate for docs seeking licensure in Canada.  And how to go about the process.

Honesty seized me. I couldn’t talk about her specialty or academic medicine at all. I could barely talk about big city medicine.  I told her how much I loved my spot in northern British Columbia and what huge hassles I’ve been through to work in Canada.

I couldn’t tell her what difficulties she’ll find getting licensure in Ontario, because Ontario is not British Columbia. After all, my Alaska license came easily, my Pennsylvania license did not.   She will not face the 5 months of ricocheting emails caused by hard-to-read signatures on 35-old-residency certificates, nor another 5 months of frustration caused by accidents of history in the development of Family Practice training.

She probably won’t face a 7-month dead-end with a private recruiter.

She won’t need a work permit because she’s Canadian, and she probably won’t need a physical.

We swapped bits of our backstories. I talked about how my curiosity got me north of the border to start with, but how the practice climate keeps me coming back.

We talked about how the insurance industry and government (under the guise of Medicare) used the Electronic Medical Record systems to steal the joy from medicine. We face rapidly expanding nets of regulations that demand more work but do nothing for patient care.

In the end, we agreed that we love the work despite the administrative hijacking.

When I hear American physicians whine, I tell them they can move, quit, go to Direct Patient Care (where the doc gets paid out of the patient’s pocket), keep whining, or just lay back and take it.

The Canadian internist arrived at the same narrow list of choices, and decided to move back home.

Physician, anthropologist, and bike mechanic

August 28, 2018

In on a cycle she rode

Out to the car park I strode

I helped out her knee

With a Sharpie, you see

And stayed true to my bike-fixer’s code

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in northwest Iowa.  Any identifiable patient information has been included with permission

People in my generation have lived with gravity long enough that we all have arthritis somewhere, mostly in the knees and back.

I attended to a particular patient (who gave me permission to write more than I have) with joint pains; she mentioned she rides a bicycle a lot.

I said, “Chances are if your knees hurt your bike seat is too low, and if your back hurts your bike seat is too high. Let’s go out and have a look.”  On the way past the front desk, I picked up a Sharpie.

A long time ago in an ER far away, a young man presented with knee pain. I looked at him, noting his footwear.

At the time, some cyclists used toe clips. Few used the cleats that lock the foot onto the pedal.  I asked the usual questions, and when he’d moved his cleats.  Then I disappeared for 30 seconds and came back with a 6-inch crescent wrench.  “I need to see you ride,” I said.

His machine came close to the finest that the early 1980s could offer. (If you must know, a Reynolds 531 frame with Campagnolo components.)

I had him ride once around the parking lot, and when he got off, I used my wrench to raise his seat 8 millimeters. He later wrote me a letter that his knee pain evaporated within hours.

Fast forward several decades. Bicycles advanced as bodies aged.  My 21st century patient’s mass-market vehicle had some wonderful components; I adjusted the seat height without a wrench.

After three successive approximations and three laps around the parking lot, marking calibration with the Sharpie, she rode with her leg almost fully extended at the bottom of the stroke, and declared her knee already improved.

Not relevant to the medical problem at hand, but part of my bike-mechanic ethos, I fixed her rear brake.

The human leg’s last few degrees of extension, the most efficient and the ones we use the most as we walk, involve an exquisite locking mechanism that lets us stand with no more energy expended than sitting.

She rode off into the late summer morning, I returned to the chilly, air-conditioned clinic, reveling in the synthesis of skills: physician, bike mechanic, and anthropologist.

The front desk staff stared at me.

“I fixed the problem,” I said, and returned the Sharpie.

 

 

Not even a pound

August 19, 2018

Here’s a few things I can tell

This fellow has really aged well

He’s past decade 9

And he feels just fine

And his speech is clear as a bell.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

On the brink of leaving for the weekend, I saw one of my many 91-year-old patients.

The town has a lot of people who have aged well; they have maintained physical vigor and mental sharpness beyond threescore and ten. Partly because of genetics; partly because of community brakes on tobacco, alcohol and drugs; and partly because this particular generation has continued hard work since before WWII, I have the honor of caring for people with a perspective on the human condition that only age can give.

Most of these patients take few medications, despite the fact they’re walking around with artificial hips and knees. A lot of them have atrial fibrillation (now in common American parlance as afib, thanks to drug company direct-to-consumer advertising) and high blood pressure, but a lot of them don’t have diabetes, which I attribute to the town getting a lot of collective exercise, mostly in the form of daily chores.  Very few have depression.

Yet I have detected a trend towards the re-emergence of Parkinson’s disease, characterized by tremor and rigidity of movement and thought. When I finished training in 1982, the vast majority of Parkinson’s came from the 1918 influenza epidemic.  I thought Parkinson’s would evaporate with the death of that generation, but in the last 5 years I have noticed one or two elderly per week with the pill-rolling tremor, loss of facial expression, quiet and monotonous speech, shuffling gait with poor arm swing.

So if I mention a vigorous patient, still employed, in his 90s, with no Parkinson’s symptoms, I have released no identifying information, as so many of my patients fit that description.

And if I say I made a surprise diagnosis via CT scan showing a serious but treatable, potentially life threatening problem, I could be describing dozens of patients.

I could mention a marriage of 70 years duration but I might be referring to any one of a number of town inhabitants.

But this particular patient has not gained a pound since he finished high school, a very unique circumstance. He gave his permission to mention it, and the rest, in my blog.

 

House call=the opposite of telemedicine

August 3, 2018

Let me tell you a story that’s tall

This gig that I’ve got is a ball!

For symptom description

Won’t suffice for prescription

And I get to make a house call!

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

Current sociologic forces will undoubtedly lead to telemedicine, which I feel compromises patient care.  Doctors don’t get into trouble by examining patients, they get into troubled by not examining patients. Thus when requests for prescriptions by phone arrived, I asked to see the patients.  For a multitude of legitimate reasons, two could not come in.  With a morning schedule of only 3 patients, I readily agreed to make house calls.

I love making house calls.  I get out of the clinic and the hospital and experience the patient’s context.  And I always get a few breaths of fresh air.  The patients always appreciate it.

As the morning wore on, the three patients on the schedule became 4, then 5; not a heavy clinc load, just a good, solid pace. And by the end of the morning, I had two seriously ill patients in the ER.

I run a lot of CT scans, and most of them come up normal. The majority of the rest come up abnormal but with abnormalities best ignored.  Half of those with abnormal scans showing problems needing treatment will, for one reason or another, agree to the treatment; about half will not.  And of those, few require treatment the same day.

But in fact I found myself talking to consultants in Sioux City, requesting they accept a transfer. Later, concerned about the growing cascade of delays, I asked how long the ambulance would take.

I don’t remember the last time a patient transfer via ambulance went smoothly or well.  I suppose the problem is inherent in the ER genre. When one patient left our ER in an ambulance and started down the road to Sioux City, I inhaled the relief, then moved on to the next patient.

I asked for help from the emedicine in Sioux Falls  Perhaps telemedicine, but with the all-important physical exam.  I texted a specialist friend for some advice. The patient stayed in the ER close to 3 hours, but got handled in town, without needing transfer.

Emergent patient care precluded lunch at the scheduled time, so at 1:00PM I bolted for gas station fried chicken 3 blocks away, and took it to go.

I tried and failed to relax while I ate, and, sure enough, just as I finished the last bite the nurse came to tell me about the first afternoon patient.

Still, I finished the 3 scheduled afternoon patients. When I looked at my electronic inbox, the last two names seemed vaguely familiar, and then I remembered my two house calls.

And on a fine summer day, the nurse and I set out with an administrator, who knew where we were going.

Hot job, hot office

July 12, 2018

In my office I might take a seat

Depending on the degree of the heat

I’ll tell you, no fooling

I don’t get the cooling

And it’s hot enough to cook meat

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

Summer in Iowa brings sun, heat and humidity. The closer the temp gets to 85 degrees, the faster the corn grows; 2 degrees higher and the growth stops.  If the night fails to dip below 85 degrees the corn loses energy trying to keep cool.

You can find old farmsteads by their wood lots, 1-2 acre stands of trees that shaded a house from the sun in the summer, blocked the wind and snow in the winter, and provided fuel close to home.

Towering shade trees don’t fit in with 21st century American hospitals’ parking lots and helipads.  Air conditioning provides the necessary climate control.

(Last century, when I visited Cuba, I found hospitals, that depended on open architecture, breezeways, ventilation, and shade trees. But for obvious reasons, they don’t need parking lots.  And I visited in February.)

My clinic office has a great location on the west side of the building. Of all the rooms in the outpatient department, mine alone has no air conditioning.  More accurately, it has air conditioning but it doesn’t work.  On a good, hot, muggy day, I get some cool air in from the corridor in the morning, but as the afternoon wears on, my outside wall takes a beating from the sun, heats up, and radiates into the room.  And as the corn grows, I start to sweat.

Fans help by evaporative cooling. I got an aging tower fan that doesn’t work nearly as well as the desk fan Bethany bought at a hardware store on the square.  If I sit at my desk, the breeze on my face helps.  If anyone seeks to have a conversation with me after 3:00PM, I have to turn the fan so that they don’t suffer too much.  But then, I do.

When I worked in Barrow (now Utqiavik) in the winter of 2011, the hospital hadn’t had the heating updated since construction in 1964. Though the outside temp ran to -40, the clinic area stayed oven hot.  Entering a room, I opened by saying , “You can have privacy or you can have ventilation, but you can’t have both.  Door open or closed?”  And the patients always wanted the door open.  I could  stand by the window that no one ever closed, or I could even go outside without a coat.  Environmental services assured me they could not fix the system.  At the time, with the new hospital under construction, they weren’t about to try.

In New Mexico, my humble clinic’s windows always worked but the electricity didn’t. If the power went off, we opened the windows.  If the power went off in the winter, we kept on our coats.

The patient care here takes place in very comfortable surroundings, but I do my dictations and paperwork in the high 80’s.

Not surprisingly, I find myself spending more time with the patients, and trying to spend less time in my office.

A weekend call full of chest pain

July 9, 2018

This weekend I was hard pressed

And, as always I worried my best

The lilt in my song

Comes when I’m wrong

About the cause of pain in the chest.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I took ER and hospital call this weekend.

The chaos that suffused my time came as no surprise, but the consistent theme of the people seeking my services, chest pain, did.

The area involved can be anywhere between the diaphragm and the jaw. The complaint doesn’t have to include pain; so often the person says, “It’s not a pain, really, more of a discomfort.”  And, sometimes the patient doesn’t feel discomfort at all, but shortness of breath, or nothing more than fatigue.

Of course I worry about the heart. If the body’s main pump runs out of blood carrying vital oxygen, it can’t pause to rest, and parts of the heart muscle die.

But I also have to consider the possibility of pulmonary embolism (blood clot in the lungs), pericarditis (inflammatory fluid around the heart), aortic aneurysm (where the aorta, the main artery coming from the heart falls apart), cancer, broken ribs, pleurisy (an inflammatory roughness of the smooth shiny membrane that lines the chest), or esophageal spasm (a cramp in the in the swallow tube).

By the end of the weekend, the nurses had gotten used to my routine: an aspirin, chewed, and a nitroglycerin pill slipped under the tongue, both while obtaining an electrocardiogram and getting blood drawn for a series of tests. Sometimes I asked for chest x-ray, sometimes a CT of the chest to rule out pulmonary embolism.

Sometimes the studies revealed the problem, sometimes not. I saw a good cross-section of diagnoses including the profoundly serious and the mundane.  I sent patients out by ambulance and by car, and I kept a couple in the hospital for observation.

(Everyone in town knows the helicopter came and went; for reasons of confidentiality I will neither confirm nor deny it had anything to do with a patient I attended.)

I took care of patients from the age of 13 to the age of 88. I enjoyed talking to two consultants I knew from my private practice and Community Health days.

But the highlights of the weekend had to do with me thinking of serious pathology and being wrong.

 

Once a patient, always a patient

July 8, 2018

The story came as a surprise,

Perfidy, adultery, and lies.

Misuse of narcotics

And antibiotics.

And names I wouldn’t surmise.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I don’t have to know everything in the business; I have to know when I don’t know. I usually know who knows more than I do.

At my graduation from medical school, the speaker (so effective I still remember large portions of the address) told us to look in the mirror every morning and say, “I don’t know.” It took a few years but I got good at it.  Admitting ignorance does not bruise my medical ego anymore because reality has humbled me so often I don’t have one left.

Halfway through a laceration repair yesterday, I realized the wound went much deeper than I thought. I stopped immediately, doffed my surgical gloves, and called for help.

I put the call through a hospital operator who asked me to spell my name, which I did. Then I commented that she knew me but I hadn’t been around for a few years.  I could hear the smile spring back to her voice.

I had to re-introduce myself to the consultant, and, again, the telephone connection could not interfere with the smile.

Earlier in the day I needed to talk to a cardiologist regarding the proper time frame for a referral. I ran into that on-call doc at a dinner conference the week before.  He, too, smiled.

Still, medical communities qualify as living things: doctors come and doctors go. Change is inevitable.  I had a conversation this last week with a member of the Iowa Board of Medicine, and got access to some really juicy stories.  I cannot give the details here but I can give the moral lessons:  doctors should not have sexual relations with patients (and, once a patient, always a patient), they should not write narcotics prescriptions if they intend to use the narcotics for themselves, they should not misuse their position of power for financial gain.

None of those stories related to the local physicians, though some related to changes in the Sioux City medical community. Most came as complete surprises.

Most, but not all.

Looking for things I don’t want to find

July 1, 2018

Pessimism is my inspiration

When I’m testing for inflammation

Sometimes we’re stuck

With a run of bad luck

I’m hoping for no information.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I make my living by thinking up worst case scenarios. As my knowledge and experience grows, I can dream up increasingly horrific things to rule out.

A lot of people, for example, just plain don’t feel good. I listen to the story, I take all the details seriously, I try to figure out the context, and then I go looking for diseases.  My favorites are the ones I can cure without specialist consultation, intrusive interventions, or expensive drugs.  I don’t like to find conditions that will last for the rest of the patient’s life, disrupting the plans of friends and family, misery that echoes down the generations.

Most disease, about 70%, comes to us directly from our choices: nicotine, alcohol, recreational drugs, overindulgence, and exercise avoidance.

But a sizeable portion of my work has to do with bad luck.

No matter what the source of the problem, my task is to make the patient better, and help the patient meet their goals.

But to get to that point I have to listen to the patient.

I listen a lot. I think pessimistically, and I run a lot of tests.

I use two particular assays, the C-reactive protein (CRP), and the erythrocyte sedimentation rate (ESR or sed rate) to make a major division in my lines of inquiry. Both seek to confirm or deny inflammation throughout the body, and two normals mean I can rule out a lot of illnesses. A high number in either parameter means I have to keep seeking till I find an answer, and, generally, an answer I don’t want to find.

Too many times this week I’ve looked at a lab sheet and used words unbecoming to a professional vocabulary.

At this point in my career, I shouldn’t take an abnormal lab test personally. I can either handle the patient’s treatment or I can find someone who knows more than me.

I look at the consequences of illness not just to the patient, but to the surrounding community. Every one of my patients exists in a context, and, just as the patient cannot be understood without understanding the context, the context cannot be understood without understanding the patient.

I shouldn’t take an abnormal lab test personally, but I do. Every patient is part of my context.