Archive for October, 2012

Limits of normal

October 27, 2012

The neurologist I saw face to face.

We discussed a clinical case.

Involving depression

And a bad drinking session

And an interesting diagnostic chase.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

The lower limit of normal for Vitamin B12 has moved from 200 during my residency in the 80’s to a high of 287 in the mid ‘90s and has hovered at a more or less constant 220 ever since.  The lab report always comes with a  caveat: if the level is over 400, replacement rarely benefits the patient, but between 220 and 400, some people will benefit from B12 shots.

In the hospital parking lot a couple of decades ago, I stopped a neurologist for advice in generating an algorithm to deal with B12 deficiency.

In med school and residency, they taught us not to test anyone under 40, and not to test if the blood count (CBC) showed normal looking white cells without extra lobes in their nuclei, and normal, rather than large, red cells. 

By the time I’d been out of postgraduate training for ten years, I recognized I’d gotten a poor substitute for truth.  I’d tried pumping wisdom out of a hematologist (blood specialist) but quickly realized he didn’t know more than me. 

Then I spotted the neurologist in the parking lot while I puzzled over a patient, age 38, with numbness and a normal CBC but a B12 level less than 150.

Curbside consultation, the discussion of cases with colleagues on an informal basis, remains a vital institution even in the digital age, and comes with its own etiquette.

The neurologist smiled, and in less than 30 seconds slaughtered enough sacred cows for a Texas-sized barbecue.

Forget the CBC, concentrate on the symptoms.  In a patient over age 70 with symptoms and a level under 400, treat with injectable B12, don’t do any follow-up testing unless they deteriorate neurologically.  If you really, really want to know if B12 lies at the root of the problem, you can do further testing (methylmalonic acid and homocysteine levels) if you want, but at the rate of $3.50 per year of treatment, extra testing rarely justifies its cost.

Since then I learned that alcohol interferes with a body’s ability to utilize B12, thus most alcoholics have big red blood cells and levels of B12 over 3000.

B12 deficiency, formerly known as pernicious anemia because before B12’s discovery the patient always died, remains one of my favorite diagnoses.  I get to save the patient’s life for less than a penny a day, with an injection given once a month.

Yesterday on rounds I sat in a patient’s room and leafed through the lab work.  With very large red cells on the CBC, and some vague neurologic symptoms, I had ordered a B12 level two days before.  I suppressed a whoop of delight when I found a 188.  “We can help you,” I said.

One floor down, I talked with an alcoholic about a marginal B12 level, 244, and recommended starting B12 shots.  Your depression won’t improve, I said, if you don’t have enough B12, and it’s hard to control your drinking when you’re so depressed.

Then I walked, grinning, down the hallway.  My favorite diagnosis, twice in a morning.

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Cramming

October 20, 2012

It’s one of the things I do best,

And better if I feel pressed.

I know how to cram

For any exam.

I good at taking a test.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I picked up really good study skills in high school, but the teachers emphasized teaching us to work under pressure.  After a few years of learning how to deal with surprise quizzes and papers, I learned that I could acquire a great deal of information in a short period of time and remember until the test. 

Some people, including my wife, assert I don’t forget anything I learn.  I wish I could agree.  But I can remember the standardized test I took in first grade that diagnosed me as mildly retarded. 

An undergraduate psychology course taught us that effective learning depended on motivation, and motivation to a certain extent depends on stress, but every person had an optimal level for the stress.

I’ve been taking tests now for more than half a century, and, judging from results, I’ve gotten good at what I do.  I’ve learned how much stress I need to learn effectively, and I know how to get to that level and stay there for as long as it takes.

If a doctor wants to call him or herself board-certified, he or she has to take Continuing Medical Education courses, generally 50 hours a year, and periodically pass an examination.  The American Board of Family Medicine has a 10 year track, which I bypassed in favor of the 7 year track.

Currently I spend about 4 hours a day cramming for my Boards, coming up on November 8.  Because of scheduling, I missed the Board Review lecture course in Kansas City a few weeks ago, and I ordered the American Academy of Family Practice’s online materials.  Things have changed in the last seven years.

Evidence Based Medicine (EBM) has taken over the test questions.  The Strength Of Recommendation Taxonomy (SORT) now rules.  SORT-A comes from high quality, double-blind, placebo-controlled, randomized prospective studies.  Fewer or lower quality studies get a SORT-B rating. 

Consensus opinions, SORT-C, based on expert panels, does not come from data; like as not the opinions come down to That’s The Way We’ve Always Done It.  The youngest doctor in the family calls those recommendations BOGSAT, for Bunch Of Guys Sitting Around a Table.  Regretfully, most of what we do comes from SORT-C.

The AAFP’s course has 38 half-hour lectures with 15 minutes of practice questions.  The format lets me work at my pace, hit the repeat button as often as I need, and start work early in the morning.

On average, one of my sacred cows ends up slaughtered before the end of the lecture.  I no longer will scrub lacerations with Betadine, nor apply Silvadene to burns. 

I understand the need to keep current, and most years I get more than 200 hours of CME.  I appreciate the update information that I can access 24/7, and I grudgingly enjoy taking tests as long as I do well on them. 

But one of the prime qualities of a good doctor remains listening, and to this day we have no way to measure it.

When the doctor asks the patient for advice

October 14, 2012

Figuring when I should sell

Is a game I don’t know very well.

When it comes to such grain

And the loss and the gain,

I’ll see what my patient can tell.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

The best single investment I ever made, aside from my wife and my education, came in the form of a land deal.  My next door neighbor and real estate agent, Michelle, found a 120 acre parcel owned by a motivated seller when land prices bottomed out, and I became the owner of a piece of Iowa.

A section of land, a square measuring a mile on each side, has 640 acres; one quarter-section extends a half-mile on each side, comprising 160 acres; my parcel would be a quarter section but for the ¼ mile square taken out of a corner. 

The federal government, under the Conservation Reserve Program, paid me not to farm.  I made enough of a down payment that the government check paid my mortgage.  The price of corn fueled rising farm rent prices, and at the end of the 10-year contract, I rented the land out to farmer eager to till the land, even when the rent tripled last year.

Real farmers would have considered my piece of ground a respectable farm three generations ago, and a small farm two generations ago.  Nowadays it ranks as tiny compared to most agricultural operations.  Still, my land ownership got me into the game, and brought respect from my farming patients. 

I bought another piece of land with Dolf, my good friend, who grew up next door: a flat 160-acre parcel of Missouri River flood plain a half hour from Sioux City.  Dolf bought equipment and went into farming this year.  For a silent partner, I talked a lot.

Dolf put the crop in early.  My pulse quickened when Dolf told me the corn was up.  The stalks came to knee-high by the fourth of June, and then the rain stopped.

With the worst drought on record, we saw the phenomenal growth slow before tassling, and worried when the ears appeared.  No clouds darkened the beautiful blue skies when the silk came forth from the ears, which failed to fill in the heat and the dryness.  Then the dirt cracked open, and we shook our heads along with the other farmers and hoped for the best.

Despite the drought we had to wait till the corn in the field dried down to under 15% moisture.

Even when precipitation doesn’t favor your land, even when I had no part in the planting, nor the contracting of the combine crew, harvest time brings excitement.   Dolf and I drove down to our farm Friday.

One of the combines had sucked in a rock the size of a pillow, ruining a section of conveyor chain, and our first stop checked on the progress of repair.

Dolf and I walked the remaining rows.  We saw where the early pooling of water stunted the plants, giving ears barely a palm’s breadth in length when, 10 feet away and three inches higher in elevation the ears filled out a foot long.  We talked about getting GPS enabled earth work done, to take out lows and highs and let water drain gently.  We picked up other rocks from the abandoned railroad bed. 

I rode in one of the combines which left the detritus (called stover), and separated corn from cob.  When we arrived at the edge of the field I thrilled to watch the golden stream of kernels pour into a grain wagon.

My share of the harvest came to 8000 bushels, roughly 20 tons.  Now I start into the uncertain game of selling it.

I think I’ll call up one of my patients and ask for advice.

Getting fired and liking it

October 11, 2012

Some patients just can’t be rewired,

We go out of our way, but get fired.

It comes as relief,

Way out of belief,

And gives energy back to the tired.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Not all patients like me.  I have a sense of humor, not everybody does, and my patients with no sense of humor generally find doctors with no sense of humor.  I don’t mind; everybody wins if the patient sees the doctor they want to see most, and no one wins if the patient gets assigned to a doctor they can’t stand.

My work week theoretically ends on Wednesday, but today I needed to come into the office for paperwork.   While there, I went out of my way to tell my partners we’d been fired by a particular patient.

Docs divide patients up into the easy and the difficult.  Different difficult patients are difficult for different reasons.  We make a show of saying that we just don’t get along, but, in fact, most difficult patients don’t get along with anyone, and especially not doctors.  I used to worry that such patients might besmirch my reputation, till a colleague pointed out that bad advertising from someone who nobody likes constitutes great advertising. 

By the same token, a doc who speaks badly of the majority of his or her patients tells me that the problem lies with the physician and not with the patient.  Such doctors don’t last long in my town.

I can’t give specifics as to why all of our docs don’t get along with this patient, but every one of us has encountered the same frustrations.

I saw the patient in the hospital and did a great job of not judging.  I used my motivational interviewing skills; I asked, “Well, how’s that working out for you?”  when I might have yielded to the temptation of trying to point out the error of his/her ways.  At the end of the interview I received a thorough dressing down.

I didn’t leave upset; I left relieved, but our clinic has a process and protocol to formalize the termination of the relationship, and I made sure I sent the right emails.

Yet within the same twenty-four hours I spoke to two patients whose lives I had saved.  They still thank me effusively when they see me.  I believe they’re among the lucky ones who wake up appreciative and thankful for every day they have alive.

Contrast is the essence of meaning.

Three Community Health Clinic Doctors in an Evening Colloquium

October 5, 2012

It turns out my daughter’s a doc,

So’s her fiancee, no shock

At Community Health

You get lots, but not wealth.

Last night we sat down to talk.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Our oldest daughter, Jesse, finished her Family Practice residency in July.  Bethany and I came to visit her and her fiancee, Winfred, also a family practitioner, in Tacoma.  Jesse represents the third generation in her family in medicine; Winfred the second.  Both grew up with medicine discussed at the dinner table.

All three of us currently work in Community Health Centers; my position permanent part-time, theirs full-time locum tenens.  We had a great colloquium last night.

Patient falling with urinary incontinence and memory loss?  “Normal pressure hydrocephalus,” Jesse said, even before I got to memory loss, and we talked about the handful of cases we’ve seen between the three of us.  The discussion included the human drama of the cases along with a recounting of the physical exam and the MRI.

The question of “What’s your personal best TSH?” came up.  Jesse had a patient with a 56, but once I saw a lab slip come in with “>105.”  The TSH remains the most important thyroid test; the higher the number, the more desperately the body screams for thyroid hormone.  My case dates from the last century, and I told the story, including pseudofractures, hyperparathyroidism, hypercalcemia, familial dysfunction, and bad physician communications.

All three of us serve underserved populations, which in this country means that our patients have very little money.  For a variety of reasons, poverty and diabetes go hand in hand.  Long a staple of therapy, insulin comes in a variety of strengths and costs, but none are cheap and we talked about the high cost of essential medications.  I recounted my experience bringing insulin to Cuba on a medical humanitarian aid mission.  In a small town, word spread quickly that I had brought a refrigerated package with me.  A young woman, a prostitute who worked the hotel where I stayed, approached me. Her younger brother had diabetes and couldn’t get insulin because of the inefficiencies of Castro’s system.  She made it clear she’d do whatever it took to save his life, ignoring my teenage daughter standing beside me.  It broke my heart to tell her I’d turned the insulin over to the Red Cross the day before.  Twenty years ago, $200 only bought 4 vials of an injectable medication that made the difference between life and death.

What beta blocker do you use?  Jesse knows generic propranolol rates as one of my favorite drugs, but I prescribe it mostly off label, for migraines, panic attacks, blushing, and performance anxiety.  Labetalol, which should be cheap because it’s been generic for so long, turns out to be very expensive; but the least costly one in my clinic, carvedilol, only lost its patent four years ago, and has a lots of good qualities.  All three of us use a lot metoprolol.  None of us start patients on atenolol, though we’ll keep people on it if they’re doing well.

None of us like prescribing narcotics or tranquilizers; Jesse and Winfred won’t prescribe sleeping pills at all.  Not even trazodone?  I asked, naming an antidepressant with good effects on sleep and chronic pain.  Well, they said, maybe trazodone.  How about Rozerem?  I asked.  It’s effective, minimal interactions, and no potential for abuse.  But it’s so expensive, and insurance won’t cover it.  I paused and thought and then admitted I’d given out samples but never written a prescription for it.

An afternoon off

October 3, 2012

Doctors are in short supply,

Demographics can tell you why.

Agencies try to recruit

By offering loot

But most of us come off as shy.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

On my afternoon off I got 11 business phone calls in an hour, as I tried to nap.

A radiologist paged me, to report a very odd set of findings. 

I’d like to tell about the patient, the drama and the irony, the impact of the illness for the person and their social context, the facts and the meaning.  I did not obtain the permission; I ordered the study more as a formality than with the expectation I’d have to launch a full-court diagnostic press. 

But I called the nurse back and ordered MRI’s and magnetic resonance angiography, on the advice of the radiologist.

That radiologist doesn’t call me for routine findings.  I wouldn’t mind if he did, I enjoy him and his conversation and we have a very good working relationship.  He has a lot to teach me, and every time we talk I become a better physician. 

After that flurry of calls, while I started to close my eyes, my phone rang, and I took the call from a physician recruiting company.

During my year of walkabout, one of the recruiters from that company rubbed me the wrong way with pushiness.  I kept my words calm, respectful, and professional, but made it clear to him that I wouldn’t work with him or his company, ever.  Which, in the 21st century means not for three years (by then it’s a different company).

I told the recruiter I’d had a lengthy call from one of her coworkers the day before.  I learned that their primary care department has 10 full-time recruiters, and the company employs more than 400.

No wonder I get so many calls; that company competes with 80 other agencies. 

Yes, I still toy with the idea of going back walkabout, and if I had enough annual leave hours built up, I’d go on a working vacation.  And I’d go for spots mostly shunned by other docs.  I’d enjoy rural, Indian reservations, even prisons or Armed Forces installations.  I like low population density and the opportunity for outdoor adventure.  Even if it means lousy weather. 

I had barely hung up when another recruiter from a different agency called.  One of the places where I worked suffered a leadership crisis, making them critically short-handed.  I had to turn him down; I have a contractual obligation here.

Yet rural America’s health care force runs chronically short, and a lot of people in Western states live hours away from the nearest health care. 

The radiologist called me back; a CT scan I ordered showed an ominous set of fractures that hadn’t shown up on plain x-ray.  I called the nursing floor back and ordered calcitonin, highly effective only in fracture pain.  I put out a page to Utilization Review; and on the strength of the findings got approval to keep the patient in the hospital another day.

I got in a short nap, and cleared up documentation at two hospitals and the office, while fielding another 8 calls.

But I never got rushed.

After all, it was my afternoon off.