Archive for April, 2010

Signing up for an adventure

April 29, 2010

I have made a momentous decision,

I’ll be trying out a position

    I guess it’s the norm

   To fill out the forms

For the agencies employing physicians

I’m filling out an application for a locum tenens agency.  I spoke with one of their recruiters today, and the position sounds exciting though not lucrative.

Life is full of tradeoffs. 

The advantages: a reasonable pace of work, a fabulous location where we have friends, the opportunity for world-class hunting and fishing, another state medical license (paid for by agency), an adventure, a working vacation.  The disadvantages: lower pay than I’m used to.  But isn’t that what this transition is about?

The locum tenens industry is huge.  There at least dozens, and possibly hundreds of agencies, booking thousands of jobs.  Doctor shortages pop up on short or long notice all over the place.  The firm that I spoke with today has an entire division devoted to licensing.

The advantage of being a locum tenens doc is the variety and the travel.  The disadvantage is the variety and the travel, and to a certain extent, the money.

The forms you fill out to get medical jobs ask the same questions.  I make the answers brief, but the whole truth is much longer. 

Have you ever been convicted of a misdemeanor or a felony?

Not a felony.  But there was the time I spent four days in jail in Geary County, Kansas, for the heinous crime of being an illegal pedestrian.  (I’m not joking.  My real crime was having a ponytail in 1969.)  Being in jail isn’t that bad, and I felt safe while I was there and the blizzard raged outside.  When I got out I was glad I was out and my cellmates stayed in.

But being an illegal pedestrian goes with my record of four promptly paid parking tickets, and my ticket for failing to yield right of way on a left hand turn.  It gets disregarded if the question says, “other than minor traffic tickets.”

The item that I have to fess up to is my ticket for failing to promptly tag an antelope in Converse County, Wyoming.  Yes, it’s minor.  Yes, it’s a ticket.  But it’s not a traffic ticket.

Have you ever been sued? This question comes up a lot. Yes, I was, once.  It doesn’t matter that I was dropped from the suit two weeks before trial and was asked by the attorney to be a plaintiff’s witness (I spoke truthfully, which didn’t help his case, and he never paid me).  I have to give the capsule description whenever I’m asked.

Where did you do your premed?  I did a semester of calculus while I was at Yale and the rest I did at University of Colorado at Denver with two semesters of organic chemistry at University of Colorado at Boulder.  Try putting that in the little box.

Where did you do your internship?  Where did you do your residency? That’s pretty easy but the problem is that they were the same place.  I could have gone into general practice after the first year; really, after the first four months because of a hiccup in the law in Wyoming that year.  But I stayed on to get more training for two more years. 

Where did you take your initial licensing exam?  I remember the sunny summer day in 1979 well.  Denver’s brown cloud was near its all-time peak and you couldn’t see the mountains.  Three days of answering multiple choice questions 630 at a time.  I remember a female doc flirting with me over gyros at one of the lunch breaks.  I cannot remember her name, nor can I remember any of the questions.

It was before I learned about life and death and tradeoffs.

Advertisements

Allergies, joint pains, and nerves

April 28, 2010

If symptoms come in the spring

And don’t have a classical ring

    Allergies?  Please,

    You don’t have to sneeze

To enjoy the Hismanal zing

I won’t say when this happened except it coincided with call.  I got a call from one of the ER docs.  We have a sound working relationship.

A person, not my patient, came to the Emergency Room with some unusual neurologic symptoms, despite previous investigation.  The ER doctor didn’t know how much investigation, but before reinventing the wheel, wanted to know if I could access the medical records.  And strangely, I could, despite the late hour.

With a normal MRI, neurologic consultation failed to reach a diagnosis. 

“Yeah,” I said, “They got all the scans, but it doesn’t look like they did much in the way of chemistries.  Needs a B12 and a folate and a vitamin D, that’s for sure.  Nerve conduction studies are OK.  Spinal tap was normal, ok, yeah, MS is completely ruled out.  Oh, wait a minute, we’ve got a normal homocysteine and methylmalonic acid.  And here’s the B12, it’s 396, kind of borderline, but if the methylmalonic acid level is normal, the B12 is fine.”

(I didn’t mean to show off, my colleague understood me.  Without enough vitamin B12 or folic acid, two toxic products build up in the blood, methymalonic acid and homocysteine; a very savvy neurologist had investigated both chemicals, anticipating that the B12 might come back as marginal.)

“Now, hold on,” I said, coming to another page, “Looks like the symptoms were identical this year, last year, and the year before.  Patient’s been worked up three times already.  Always in the spring.”

We indulged in a thought pause.

“You know,” I said, “A while ago I knew a patient, came in every spring for seven years looking for all the world like rheumatoid arthritis.  All the blood work came out negative.  I tried seven different anti inflammatory drugs that didn’t help, and in the eighth year I gave a prescription for Hismanal [an antihistamine no longer on the market], figuring that if it happened in the spring it was probably allergic.  I got a call back a few hours later saying the pain had completely stopped.”

“Well,” the voice at the other end said, “That’s a thought.”

We agreed that the patient deserved a vitamin D level and a trial of an antihistamine.

If all diseases were textbook, we wouldn’t need doctors so much as textbooks.  In the real world, the five percent of the population who fall outside the normal parameters present eighty percent of the challenges.  Being a doctor requires being able to think outside the box while respecting the contents. 

I talked with that same doctor this evening.  We discussed a patient in the ER.  I broke the news about my coming career move, and my plan eventually to work with the Community Health Center.  When we finished talking I got the impression the other doctor was looking forward to working with me again.

I have 23 days and three call nights left. I talk with recruiters a couple of times a day, resisting taking jobs longer than two months.

Meetings? Not me. I’m a leaver, not an owner

April 27, 2010

The truism needs no repeating,

That nobody likes a good meeting

    I’ll bypass the flap

   For a ten minute nap

Let others fret cooling and heating.

 

The joke goes: What’s the difference between a meeting and a beating?

Nobody pays for a really good meeting.

We have met on Tuesdays since before my arrival; every Tuesday at first, but for the last couple of years we’ve only met about once a month.  We discuss issues with staff, business, protocols, the building, and our relationships with various institutions.

Today would have been my last meeting day and I skipped it.  My input would be superfluous.  I took a power nap instead.

Changing my mind-set from owning to leaving has radically decreased my stress level.  The computer I carry from room to room, three and a half years old, has lithium batteries that don’t hold a charge like they used to.  When I pick it up and turn it over, it makes alarming rattling noises like something is loose inside the case.  It runs very hot and I face the annoyance of having to change batteries in the middle of the day, sometimes two or three times.  As of today I only have 25 days left, and I don’t worry about how long the laptop will last or how much it will cost to replace.  I’m pretty sure it will get me through till the end of my tenure.

I have permission to write about a couple whom I saw in the second afternoon slot.  They are in their early fifties and have been together since they were fourteen.  The wife showed concern without controlling about her husband’s care; he stayed strong but not aloof from her love.  When I walked in, even before I washed my hands or shook hands with either one, I said, “Let me hear you say no cancer.”  I watched the relief play over their faces as I pumped Purell onto my hands.  Not my regular patients, they hadn’t gotten the letter announcing my professional plans.  Looking ahead to the future, telling them my last day at that job would be May 21st and making plans for follow-up, they expressed their disappointment.

Follow up visits come in predictable increments.  I have gotten used to letting go those patients who need a three-month check, but now I’m sending away patients who need a one month check.  Most will stay in-house, but about 15% plan to move to other offices. I still see people who will need a one- or two-week recheck.

Saying goodbye does not come easily.  I did two well child checks today on infants under three months; I probably won’t see the children again professionally.  I will miss out watching the magic of the smiling months and the toddler defiance.  I won’t be there for the first school physical or the painful blooming of adolescence and the first sports physical. 

About half of the parents of children will take their kids to pediatricians.

Leave taking is bitter but my coming freedom is sweet.  I suspect a lot of my patients have switched care to other physicians already, as my work load lightens with every day.  People remark how happy I look and express surprise that I’m near sixty. I find myself singing when no one is listening.  I dance when no one is watching.

Basic economics for fourth graders, yoyos, and life lessons

April 26, 2010

On a beautiful day in the spring

I play with a toy on a string

            I teach kids not to smoke,

            So they’ll live long and not croak,

And have plenty of money for bling.

 

I am playing with a yoyo in front of a crowd of about  fifty fourth graders, teaching them economics, and in the process saving lives and stamping out disease. 

I start out by asking if they’ve ever heard the saying, “You can’t have your cake and eat it too.”  They all have heard it, and when I say “Raise your hand if you DON”T know what it means,” all the hands go up. 

The essence of economics, I explain, is that if you choose to do something, you choose not to do something else.  Then I hold up a cheap wooden yoyo, I do a few tricks, and I compare the cost of the yoyo to the cost of a pack of Marlboros.  Currently the smokes run $5.87 a pack, and I paid $3 for the yoyo fifteen years ago.  I pull out a $15 yoyo and I do a few more tricks.  I hand my calculator to a nerdy (I can use that work because I am a nerd) looking kid in the front row and have him calculate the Marlboro equivalency. 

I turn out the lights for the next one, it’s an $18 yoyo.  It is not particularly a good player but the kids love it because it lights up in the dark.

Then the $25 and the $32 yoyos come out one after another.  With each increase in yoyo price comes an increase in yoyo quality.  The kid who is running the calculator gives me the number of packs of Marlboros (much like the number of days of smoking) that could have been bought with the price of a yoyo.  I tell a few stories about the yoyo that I’m using and then I ask the kids which they would rather have, the cigarettes or the yoyo.  Invariably, they choose the yoyo.

I bring my Radian out from the vest pocket of the fishing vest I use for my yoyo shows.  I don’t particularly like the Radian though I can make it sleep for decades; it’s very difficult to make return.  But I do a long, involved series of tricks without rewinding.  I flub the retrieve but the kids don’t notice.  Then I announce the price, $105, and the students gasp.

I now have seven yoyos lined up on the desk at the front of the room.  I open up an octagonal cardboard box just big enough to hold a yoyo.

“This is a Samurai,” I say, “It’s a $200 yoyo.  If you can get one.  My wife bought it for my on our anniversary four years ago.”  Then I do The Matrix.

My hardest trick, The Matrix goes flawlessly through two rounds.  I can hear the breathless tension as the children watch the action.  The yoyo thumps firmly back into my hand and the room lets out a sigh of relief.

My calculator crony figures the yoyo would cost the same as 34 days of smoking.  When polled, the class would really much rather have the yoyo than thirty-four ashtrays full of cigarette butts and the health consequences of smoking. 

I explain why teenagers start smoking at age 15 and why they start with Marlboros.  I talk about the animal experiments, which completely grosses them out.

They call the program Tar Wars, a way of getting doctors and nurses out into the schools to try to get the message out:  DON’T SMOKE.

I have a great time at it.  I make the teaching tool concrete enough to be age appropriate.

Afterwards one of the students tells me about an uncle who died of alcoholism at age 36.  He had been dying of liver failure till he got into a fatal car accident.

Drama and irony.

At the end of a very long day I go to one of Sioux City’s best restaurants for a very good piece of beef and a lecture on some of the more esoteric physiologic points of blood pressure control.  I enjoy the science review, but I find the potatoes lukewarm, and the propaganda transparent.  After the internet broadcast a noted endocrinologist from Omaha gets up to speak, adding nothing new.  My words to the fourth graders come back:  If you choose to do something, you choose not to do something else.  I give him ten more minutes and I quietly stand and exit by the back door.  I have a lot of other things I could do with that time.

Drug reps: an ambivalent relationship

April 26, 2010

The drug reps come by the bunch

They frequently bring in a lunch

     I try not to whine

    When they’re taking my time

And putting me into a crunch.   

 

Pharmaceutical manufacturer’s representatives, aka drug reps, are a necessary part of the medical industry in the 21st century. I couldn’t write about my work without mentioning them and our ambivalent relationship.

During my residency’s Supervised Rural Practice Elective in Thermopolis, Wyoming, a  drug rep made a sales call and took me and one of the other doctors out to lunch.  The rep pitched a high blood pressure drug, but the internist and I quizzed him about pathophysiology and he updated us.

Reps bring biased information.   I take that into account the slant of the presentation.  Invariably a competitor brings equally slanted information; in the long run, one balances the other. 

If a new drug has a truly unique indication I start using it within 3 months of release, but if it has a competitor I don’t start prescribing it for a year.  We’ve had some truly promising drugs that got pulled off the market because of problems. 

Drug reps do the same job as manufacturer’s reps do in any field.  I knew a person who represented a wholesale food operation. Just like the drug reps, his work involved a lot of driving, nice clothes, and great social skills. 

I pay the price of time for information.  Even if I spend only five minutes with a rep, at the end of the day, six reps have taken half an hour, down from a previous hour and a half a day before we limited slots for reps to six.  I try to ask politely for new information and if the rep says, “Well, I just wanted to emphasize…” or “just reiterate…” I will interrupt, and ask for NEW information. 

I resent the sales technique that asks the question, “How does my drug fit into your practice?”  I will respectfully point out that answering that question brings me no new data but takes up my time.

Sometimes I’ll dodge a canned presentation by asking information about physiology and metabolic pathways and I receive a mini refresher course. 

I don’t mind expending time with the reps as a doctor even when I don’t get paid for it.  I have given reps advice about migraines, sleep, family relationships, exercise, alcoholism and co-alcoholism, diet, and skin care.

Twenty-three years ago a lunch brought by the rep happened so rarely that it rated announcement the day before.  Now we have to limit the lunches to four weekly and the breakfasts to once weekly. 

Most of the lunches don’t come close to what Bethany packs for me.

The reps don’t bring the trinkets that they used to, which is just as well.  Most of the freebies were just so much junk.  I quit using drug company pens four years ago; I carry a Waterman, a gift from a patient.

Sometimes the rep brings a specialist in to pitch their drug, and those sessions have proven their worth.  I got started checking Vitamin D levels that way; another lecture improved my detection rate of bipolar disease.

Cost benefit ratio for drug rep info averages six to one; it takes six minutes to get from a rep the information I could have learned by reading for one minute.  Educational TV has the same ratio.

I’m not sure I’ll see drug reps in the year that I go walkabout.  I wonder how much worthwhile information I’ll miss.

Death without Kleenex

April 25, 2010

 She’s terminal, there is no denying.

She said with no tears and no sighing,

    Really it’s fine

    I know that it’s time.

Doctor, I’m sure I am dying,

 The two identifiable patients I discuss here gave permission to write about them.

 A man whom I hadn’t seen before had a pain in his left calf.  He was the third patient that day with leg pain.

Working his cattle a week ago, one of new calves butted him pretty hard.  Since then he had increasing swelling, pain, bruising and tenderness in the left calf. 

He didn’t have any other risk factors for blood clots, but I could see his lower leg was black and blue and swollen.  I had him put his heel on my knee, then I grasped his foot with my right hand, and while I squeezed his calf with my left hand, I pushed his foot up.  I didn’t have to ask if it hurt, I could see it on his face.

“Positive Homan’s sign,” I said.  Then I had to explain about eponyms.  Homan only did one memorable thing in his medical career, and that was to give his name to a physical diagnostic sign that points to a blood clot deep in the veins of the calf.  Doctor language has a lot of terms relying on someone’s name, the term having nothing to do with what the disease really is.  For example, most English speakers recognize the term Alzheimer’s disease, but the name carries no clue that it refers to a particular kind of dementia.

Another patient the same day came in with pain under the front right ribs, and radiating into the back.  I was able to come up with the term Boas’ sign: increased sensitivity to pin prick in the segment that sends nerves to the gallbladder.  Too esoteric a term even for conversation between doctors, I didn’t use it when talking to the surgeon.  I did use the terms heel sign, psoas sign and bunny hop (abdominal pain, respectively, when the heel is struck, on flexing the right leg towards the back while pushing on the hip, and when hopping up and down on one foot); those words rate usefulness  because the name includes a description of the test.

I sent the man with pain in his leg to ultrasound to look for deep vein blood clots.

Before he left he told me he’s retiring from his current job of 33 years in June, and he’ll go into farming exactly as full-time as he wants to.

I will let the patient who followed speak for herself:

“Well I went up to see the new young doctor that took Dr. Tan’s place and I almost cried, you know both of you at the same time was too much. I know she didn’t retire but I’m sorry she’s gone. I have a nice new young doctor, I don’t know if I’m going or not. He had been having me drink 8 glasses of water a day, and she had too and that seemed to keep me pretty level but for the last the month he wants me to go down to four. It’s not doing what it’s supposed to, it’s getting worse, it’s down to 30. 

“It does not look good. And I think this is the solution, I think I’m near the end of my problems.  I think I’m close to dying now. And I really don’t mind it. I had one time here after I talked to him I came back and felt terrible for about ten minutes but I really felt like it was my time. I’ve always said I would go when I needed to and I don’t want dialysis. I need to be with the Lord. I’ll miss my friends, but there’s no one who can’t live without me. You have to have a feeling that you are absolutely necessary but I don’t have that feeling and it’s OK, I don’t much care. It’s like you’re going on vacation. It’s good that you can do that and not feel guilty. We’re both in kind of spot where we need to be. My son and his wife didn’t take vacations and all of a sudden they’re taking vacations, he’s 61 and their children are gone and you have to realize that, that you’re not going to live forever. Bill and I had a time when we were never gone from the office, we never took a vacation.  I remember when he was dying, there was about five minutes there and he was just as clear as could be and he said, ‘Now don’t be too long,’ and then he died.  Those were his last words to me and that was a year and a half ago.  I know I’ve gone longer than we thought I would but I think my time is getting close and I want to be with him.”

I sat and I held her hand.  We didn’t need the Kleenex.  She will probably die in the year that I go walkabout.  We discussed pain control.  I determined that she wasn’t depressed, just realistic in her outlook.  I’ve known her for more than 20 years, and it was probably our good-bye visit.

My cell phone vibrated and I stepped out to take the call.  The man with the pain in his calf did not have a blood clot.  By phone I told him about rest and elevation, but his current job, from which he’ll soon retire, involves a lot of standing.  I considered the whole picture, and as I thought he said, “You know, I’ve got a lot of accumulated sick leave.”

I told him to come in and pick up a back to work slip for ten days in the future.

I needed a lot of Kleenex for the last patient of the day, with mysterious pains that haven’t yielded to a firm diagnosis.  “I feel like a hypochondriac,” the patient said as I wrote orders for more diagnostic tests.

“You want to be a hypochondriac more than you want any of the diagnoses I’m looking for here,” I said, “Remember that.  At the end you want to shake your head and complain about all the money I wasted and couldn’t figure out what was wrong.  We do not want me to be right.”

Hip sucking parasites: beepers

April 24, 2010

Ah, the relief that I felt!

When I took it off of my belt

     It was only a slip

     When it fell from my hip

And on the pieces of beeper I knelt

I hate beepers.  I’ve never liked them, even back in the 70’s when carrying one made you look important. 

My father was a doctor before cell phones and beepers.  If we went anywhere, immediately on arrival he would call his answering service and tell them where he could be reached.

I got my first beeper as a third year med student.  All the beepers in town looked and sounded the same, and if one went off in a group of doctors, everyone would grasp at their belt or pocket.  They had a button on top that would generate a white noise if you pushed it, to signal that the apparatus functioned.  Young and nervous at the time, we kept hitting the test button.  The second time I ran the battery down before the end of the day I quit testing so often even if I wanted to.

The pager issued to me as a Family Practice resident in Casper, Wyoming had its own phone number, accessible directly by telephone.  Back then touch tone phones remained a novelty and cell phones existed out of the price range of most doctors.  I carried dimes for a pay phone.  I carried my beeper all the time and started calling it a hip sucking parasite.

When I was in the Indian Health Service in New Mexico, I carried a pager even when I didn’t have call.  The hospital had its own radio tower, and the hospital operators knew its many quirks.  The era’s primitive battery technology resulted in a battery that would not hold a charge if you kept the beeper in the charger without running it down regularly.  I conscientiously rotated the battery out every morning.  A lot of the support staff carried their beepers rarely, the batteries lost their discipline, and on the weekends I lent out my beeper.  Gladly.  A pager then had neither memory nor visual text capability.  The most common message was “Please call the operator.”

When I came into private practice in 1987, my pager had a digital read out and would remember 18 messages.  It was powered with a NiCad battery that needed replacement about every seven years, and it came with a charger.  It was next to impossible to read in certain lighting situations, and the vibrate option quit working after seven months.  It lasted sixteen years, and it died it so outdated as to be unfixable.  By then I had a cell phone, as did most docs, but I carried a beeper anyway.

The next pager, a lot smarter, 14 options for alerts, an internal clock, and an alarm.  Still hard to read when the angle of the light was wrong, it worked well on vibrate. 

In the last ten weeks, in a series of shockingly Freudian slips, I’ve dropped and broken three of the hip sucking parasites.  One of those drops was from 18 inches onto a padded floor, but it still broke. I dropped a fourth one but it didn’t break.

Beepers or pagers will soon be a thing of the past; cell phones are taking their places.  They stand up better when they fall.  Or get pushed.

Cherry blossoms and rice wine in Iowa

April 22, 2010

For just a moment we’ll tarry

Beneath my blossoming cherry

   A moment in time

  For sipping rice wine

Both fleeting and pleasant, so very.

    

 

Three of my cherries are blooming and today I take a short time to just enjoy them.

The oldest one, an Oka Giant bush cherry about twenty feet tall, is at the peak of its blossoming beauty.  As the sun goes down I warm a shot glass with boiling water, then pour two ounces of sake and go outside. 

The point of cherry blossom time in Japan (Sakura), as I understand it, is to enjoy fleeting beauty and remember the transient nature and fragility of human existence.  I think of it as seize the day, existentialism, and stop and smell the flowers all at once. 

I don’t drink much in the way of alcohol, and two ounces of rice wine (beer really) slows me down.

Bethany comes home, and walks across the grass barefoot to me.  She’s taking a biology class as part of becoming a Certified Medical Assistant.  If we ever want to open a Mom ‘n’ Pop doc shop she can be Mom.

I tell her about the recruiter I talked with today.  The firm has more than 500 openings, many of them for primary care.  The agencies mostly want two and three-month commitments, but one place in Wyoming would want a doc for a much shorter time.  It would afford an opportunity to be tourists there and back.

The hazy western horizon darkens while we talk and I watch the half moon through the branches of the maple tree.

The scent of most fruit blossoms is strongest when the temperature brings out the bees and other pollinators, and much weaker when the sun sets.  In the middle of the day the Oka’s fragrance can be smelled from the street, and if you hold still near the branches you can hear the bees working.  Thus the bush cherry brings delight to the eye, the nose, and the ear in the spring.  The fruit comes ripe in late July.

But strong rains are forecast for the next three days, and by then the blossoms will pass their peak. Late in the day and the smell has faded.

A Japanese physician here in town came one year to sit under my blooming cherry trees.  He brought sake. He and his nurse and Bethany and I chatted while we sat on the grass.  He left town before the next cherry blossoming.

I remember it as a moment of peaceful, quiet conversation in an avalanche of a career.

The evening grows cool and the mosquitoes come out.  Bethany takes a sip of the warm sake and it’s time to go in.

Seize the day and smell the cherries.

Three bipolar patients, two of them out of control

April 21, 2010

I have a story I’ll tell

Bipolar depression is hell

     I’ll justify panic

     If the patient goes manic

And I might prescribe Seroquel

 

Back from four days in Florida, a mini vacation, and I’m feeling wonderful and well rested.

Care Initiatives Hospice will graduate another patient; removing Seroquel from the medication list has done a world of good.

Seroquel does well for certain phases of bipolar disease, but not so well when used, way off label, in the elderly who flip out and hit the people. 

The makers of Seroquel brought  a very good speaker to Sioux City a few years ago. They paid for a fine meal and drinks at Bev’s On The River, one of Sioux City’s four upscale restaurants.  I abstained from the drinks, and I listened and learned a great deal about bipolar disease from the lecture.

I prescribed Seroquel a lot right after that talk.  Since that time I’ve used Seroquel less and less, in favor of some of the older seizure drugs like Depakote and Lamictal.  I use lithium as a last resort.

Bipolar used to be called manic-depressive.  Mostly hereditary, found in all societies, it doesn’t hit any particular group harder than any other.  I’m not convinced of the accepted division between the more severe form, Bipolar I, and the less severe form, Bipolar II; I think of the disease as a spectrum.

During the manic phase the patient feels great.  They don’t need much sleep, they get a lot done.  But they engage in a lot of risky behaviors like gambling, drugs, drinking, and promiscuity.  They spend a lot of money and they tend to delocalize geographically.  Sometimes they lose contact with reality and become psychotic.

In the days when I hitchhiked I got picked up by a lot of manics.  In 1971, I rode from one end of Kansas to the other with one person who talked so fast I couldn’t understand him.  About every fifteen seconds I had to say “Yeah” to prove I was listening but aside from that I couldn’t get a word in.  He grew hoarser and hoarser till he let me off in Julesburg.

Those who cycled into mania have a lot of regret afterwards.  Having to have a spouse bail out your credit card debts every seven years is bad, but not as bad as having to come crawling back to your spouse after a six-week affair, or explain to a judge why you alone survived a suicide pact. 

The depressed phase of bipolar illness sinks the patient to the bottom of the blackest pit.  Partly the patient has tremendous remorse, seeing what a mess they’ve made of their lives, but mostly the biochemistry of their brains lets them down.  The majority of suicides turn out to have been bipolar. 

But the Seroquel speaker made me more sensitive to the less severe forms of the disease.  My touchstone question is:  “Have you ever had an episode lasting at least four days when you felt great, got a lot done, slept less than four hours a night, and didn’t miss the sleep?”

An awful lot of depressed people turn out to bipolar, and need to NOT be on SSRI’s like Prozac and Lexapro.  The tend to do much better on seizure drugs than on antidepressants, and a lot of epilepsy pills have been approved by the FDA for use in Bipolar I and II.

Vitamin D deficiency, a recurring theme in this blog, turns out to be very important in both seizures and bipolar illness.

This morning I saw three Bipolar I patients.  One takes the prescription as directed and the others don’t.

The one spent more years hospitalized than not till a psychiatrist started the patient on Depakote twent- five years ago.   After coming to terms with a disabling disease, the patient rejoined a strong social structure.  Generally coming in every year to get some blood tests, the patient hasn’t needed hospitalization for a very long time

Another patient readily admitted missing doses two or three times a week, and asked for something stronger.  After a bit of consideration we agreed that forgetting to take a more powerful pill brings the same result as forgetting to take a less powerful pill.

A third patient, smiling, was very up front about not taking the medication.  He was pleasant, and told me how great he was sleeping, awakening feeling rested an hour or so before the alarm went off.

Those last two patients were cycling into mania.  Telling them they’re not thinking straight does no good, though I told them anyway.  Then I told them they needed to take their prescriptions as directed.

I didn’t argue with them.

Never argue with a drunk, a crazy person, or a woman in labor.

Inherent conflicts of interest in worker’s comp

April 19, 2010

On the job the dangers will lurk

If your boss is a jerk

     Work compensation

     With no documentation

Can’t distinguish illness from shirk.

Workman’s compensation is a system whereby an employee, injured on the job, receives medical care for the damages that result.  It’s the right principle. 

As in a lot of other arenas, principles can be misapplied.

The law in Nebraska says an injured worker needs to first report the injury to the firm or its representative, then pick out a doctor; the workplace may provide medical care on site, but the worker can choose any doc he or she wants.  Parameters specify that in the face of inadequate progress, the employers can specify a different doctor. 

In Iowa, by law, the employer picks the doctor. 

The system leaves room for a  lot of abuse on both sides of the river, for both employer and employee.

Work comp constituted a third of my business before St. Luke’s started their Occupational Health division.  I enjoyed the work while at the time, but when it evaporated I didn’t miss it.

Because I have minimal ability in ASL, the language of our deaf community, several employers have sent difficult patients to me.  Sometimes the language barrier constituted the problem, other times the patient didn’t want to get better, and on at least one occasion, the problem fell outside my area of expertise.

Last week the John Morrell hog slaughter plant shut down, but even after most of the people left the clean-up crew kept working.  One employee, of whom I have no personal knowledge, mixed bleach with acid, releasing chlorine gas.   Several workers became patients after wheezing developed.  Because John Morrell conducts business in Iowa, and because of the probability of long-term residual lung damage, I advised reporting to workman’s comp.

Once, a very large patient came in with hand pain, claiming an injury a few hours before at a packing plant.  The x-rays confirmed my suspicions, and when I came back into the exam room I confronted the worker.  “This is what’s called a boxer’s fracture,” I said and pointed at the knuckle of the little finger.  “It happens when you punch a stationary object.  It doesn’t happen the way you claim, when you fall off a box car and try to catch yourself.  You’re lying and I’ll testify to that in court.  I’ve talked to your boss and they’re willing to forego prosecution on fraud charges if you’ll drop your work comp claim now and go find another doctor.”

Several months later, the same patient came in, quite ill with a non work-related illness.  I said, “Last time you were here, you threatened to throw me off a box car.  Do you remember that?”  The patient didn’t.  “Do you still want me to treat you today?”  The patient did.  As always, I gave the patient my absolute best. 

I have had more patients injured on the job who didn’t want to turn in a work comp claim than patients who fraudulently wanted workman’s compensation.  They feared, unnecessarily, for their job.   I suspect that those without good documentation don’t report on the job injuries as much as they should.

It’s been my impression that the Iowa system brings slightly more fraud than the Nebraska system.  Workers distrust the company doctor (a sentiment, alas, occasionally justified) because of an obvious conflict of interest.  They don’t see that every doctor treating on-the-job illness has a first obligation to the patient and a second obligation to the employer.

One patient had a legitimate work related injury with abnormal MRI findings.  Over the course of years I did the best I could and obtained consultations when progress slowed.  Eventually we found a combination of limited work for part of the day and unlimited work part of the day, and kept the patient working.  Till a foreperson ordered unrestricted work, and the injury got worse.  After the patient reached maximum medical improvement, the patient was effectively fired for being injured.

I haven’t said, “Get a lawyer.”  I don’t know if I should, or if I even need to.  We have enough of them advertising on TV.