More street side diagnosis

The stuff you diagnose on the street

With the people you see and you meet

Forget confidential

Just note evidential

And hope that the homeless can eat.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  After less time off than I planned, I did some more hospital work and vacationed in Israel and San Francisco.   Any identifiable patient information, including that of my wife, has been used with permission.

Confidentiality does not apply to people who are not my patients, nor to what I can observe on the street.

The country’s homeless problem worsened in the wake of the mass mental hospital closings, an example of shameful bipartisan cooperation.

They comprise a heterogeneous group.  One summer I derived my income from my music and I made enough to eat but not pay rent; during that time I was homeless, and I found the lifestyle seductive.

Those homeless by choice, though, comprise a minority.  Most homeless have major mental problems.  No one can usefully separate schizophrenic from bipolar or addict; the Venn diagram has too much overlap.

Wonderful climate attracts not only the yuppies but the homeless, and every trendy city has plenty of both.  Alaska, where the homeless comprise part of the food chain, has a very small summer problem and in the winter almost none.

No surprise then that the homeless gravitate towards the West Coast and the Sun Belt.

I walked out onto Mission in San Francisco and observed what I could observe.

It doesn’t take Sherlock Holmes to diagnose heroin addiction in a grimy young man with a sleeping bag who injects himself on a sidewalk and nods off before he can get his syringe into the soft drink bottle he uses for needle disposal.

You don’t need much training to diagnose full-blown mania in the thin man talking fast to anyone he saw (including those invisible to others) and moving quickly without stopping.  You wouldn’t need much more to call schizophrenic the people talking to themselves and watching things only they could see.

It took much more clinical experience to diagnose rheumatoid arthritis in the twisted fingers of the man in the wheelchair who accepted a quarter from me.

On the bus, although the man tried to hide it by drumming his fingers, I saw the intermittent, asymmetric pill-rolling hand tremor and I matched it with a blank facial expression to come up with Parkinson’s.

On the street I saw a man walking with a bilateral foot drop: with every step his toes touched before heels, and he had to pick his feet up higher than normal.  I knew that he had long-track disease: something had happened to the nerve bundles running down the back of his spinal cord.  But without lab and imaging I couldn’t tell syphilis from Lyme from B12 or folate deficiency, or a mechanical lesion pressing on the spine.

Females comprised less than 10% of the homeless I saw though statistically the genders have an equal burden of schizophrenia and bipolar.  I wondered where they had gone.

 

A happy lawyer, and a seat belt design flaw

The problem with the belts in the fleet

Caused me my neighbor to greet

We talked for a spell

Doing good, she does well

Those problems she seeks to delete.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  I have been vacationing in Israel and San Francisco.  Any identifiable patient information, including that of my wife, has been used with permission.

I paid extra for a bulkhead seat to San Francisco.  The seatbelts for Row 7 have thick padding over the fabric leading to the male part of the buckle.  The window and aisle seats fastened down ok but the passenger in the middle could not get her belt fastened.  Nor could the flight attendant until he used the demo belt as a splicer.

My fellow traveler took the problem in stride and did not lose her smile.

I struck up a conversation.  After we’d both talked about our spouses (hers is a chiropractor), I asked her profession.

Her legal firm investigates supply chains, looking for sweatshops and other social problems.

She started in the field while working for Reebok.  One day in 2003  the company president came into a meeting and tossed the New York Times on the table.  The lead article broke the Nike sweatshop scandal.  He said, “We’re next.”  He turned to her and said, “Fix it.”

She started by investigating the company that made the labels sewn into the garment.

Since then she established her own law firm.  Investigating human problems in the supply chain has become a legal specialty and a $1.5 billion industry.

Clients come to her to help with due diligence, when shareholders ask tough questions, or when they just want to make sure they’re doing the right thing. The firms involved range from clothing to electronics, but all outsource to 3^rd world countries. The end result of her investigations might be new schools or higher wages.

Those companies come voluntarily.  I have talked with a lot of lawyers who left the legal profession because of the way it has changed and because they burned out on conflict.

But this lawyer thrives on her work and she beams when she talks about it and she got me to feel passionate about it as well.  She does well by doing good.

I didn’t mention my grandfather, who worked in sweatshops in Ukraine and Irkutsk and New York.  But get out of New York as fast as you can, people said, before tuberculosis kills you.

It would not be till the return trip home that a flight attendant showed me how to properly fasten Row 7 seat belts by rotating the offending piece 180 degrees.  I emailed American Airlines about the design flaw, but, because I’m not a lawyer, I don’t think they’ll listen.

 

Israel road trip: shadowing a family doc

As a shadow, I sat in a chair

Next to a doc of primary care

At a no-nonsense pace

And for all, face-to-face

She brought health, and she did it with flair.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  After less time off than I planned, I did some more hospital work and am now vacationing in Israel.   Any identifiable patient information, including that of my wife, has been used with permission.

I got the chance to shadow an Israeli Family Practitioner for a day.  Originally from the States, she relocated about 5 years ago.

Compared to previous experiences, I found similarities and differences.

Much like New Zealand, the physician has an office with an exam table, and sits on one side of a desk with the patient on the other.  The nurse does not screen the patients.  When one patient exits, the next one comes.

Sometimes the next patient interrupts before the end of the current patient’s visit.  I did not find anything close to HIPAA’s slavish devotion to privacy.

In the US, non-clinicians have mandated a mountain of irrelevant data at each visit that Canada, Israel, and New Zealand find disposable. Thus Israeli notes run shorter and quicker than American notes.

Just like the US, the first patient of the session wanted care more than cure.  Those patients will always schedule for the first slot, and will always throw a wrench into the schedule.  (Hint to young physicians:  Get used to it; it’s a fact of life, just like rain.)

Respiratory problems predominate.

Three sore throat patients got prescriptions for strep test kits to retrieve from the pharmacy.  The physician runs the test.  All three had negative results and got advice for home remedies (in Hebrew, literally, grandmother’s medicine).

We briefly discussed the growing trend of antibiotic avoidance for those with sore throats and positive strep tests; neither of us want to jump on that bandwagon.

Just like Canada, many sought back-to-work slips, and the doc found the clerical intrusions as annoying as I do.  But she worked at the same rapid pace the patients have come to expect.

The state has four health insurers with different geography and slightly different styles.  With the exception of a few drugs, co-pays are minimal, and only for out-of-network. Family docs occupy the top of the physician wage scale, and, on a per hour basis, make close to US wages.  Specialists scrape along  by doing private consultations after hours; most people have secondary insurance through their employers to cover those costs. Such fees, very reasonable compared to the US, can be afforded by most.

Her clinic day ended before 2:00PM, 6 uninterrupted hours at the breakneck pace of 6 patients per hour.  She has a small fraction of the administrative and documentation headaches that burn out US docs.  She still works till 7:30PM two nights a week, and most clinic days till 4:30PM or 5:00PM finishing up labs and messages.

She commented that Israel has accomplished high-quality universal health care and has done so at a reasonable, sustainable cost to society.

The international character of the patient population resembled that of my Community Health experience; my mentor expressed surprise that I had worked with Amharic speakers in Sioux City.

Afterwards, we joined Bethany and Aliya for sushi lunch at a nearby mall.

 

 

Israel Road Trip 5: Sde Boker

A world leader (I’ll just call him Dave)

Had a vision so bold and so brave

That he founded a state

And it turned out first rate

From the desert out onto the waves.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  After less time off than I planned, I did some more hospital work and am now vacationing in Israel.   Any identifiable patient information, including that of my wife, has been used with permission.

We took the bus from Beer Sheva to Sde Boker (=Morning Field) to see the home of David ben Gurion, one of the most remarkable leaders in history who gets little attention because of the small size of the state he helped found.

We had visited before, but always with a tour group.

So we wandered through date and olive groves, enjoying the quiet after the noise of the city.

At a playground we asked directions of a young Israeli mother watching over toddler twins.

In Hebrew I ask questions better than I understand answers.  I found Rosetta Stone’s direction unit the hardest.

Real people rarely give directions as coherently as Rosetta Stone does.

She laughed and I hoped Bethany understood her.  We soon discovered that, no surprise, either we misunderstood or her directions lacked accuracy.

We meandered through the peaceful shade of the kibbutz’s residential area, avoiding private back yards, and ended up approaching the historic site’s entrance from behind.  We paid for tickets and started a self-guided tour.

David ben Gurion came to Palestine with the hope of establishing a Jewish homeland. He knew, after the Holocaust, that there would be only one chance at founding a Jewish state.  He guided the establishment of Israel, and served as Prime Minister, then retired to the quiet of his beloved kibbutz.  He never lost his sense of fun.  Israelis immediately recognize his iconic picture, elderly and white-haired, standing on his head.

At the tourist shop we ordered coffee and pastries, and turned down a chance to sample the kibbutz’s wines.

But I chatted with the vintner.

Originally from California, he learned wine-making before coming to Sde Boker.  The kibbutz’s vineyard did well for 20 years but perished from a virus.  He now buys locally produced grapes.

I asked about the soil and he laughed and asked if I were an agronomist.

No, I replied, but I am an Iowa farmer (true but not the whole truth).  So, I said, showing off my knowledge of soils, I would imagine here you have an aridosol?

He blinked at the question and told me that they have a loess soil, in some places 3 meters thick. Then it was my turn to be surprised

Loess soils come from wind deposition.  My area of Iowa relies on this wonderful, well-drained sandy loam, one of only two places in the world that has loess so deep as to make hills (the other place is in China).

I talked about how well my fruit trees do in loess in Iowa.  The area of the Negev, he said, grows stone fruits.

Those trees, like cherries, peaches, and apricots, cannot bear without adequate nights between 0 and 4 degrees Celsius (32 to 40 Fahrenheit).  Even here in the Israeli desert, winter brings frost.

After such stimulating conversation I consented to a sip of wine.  I found it delicious with a solid aroma and a complex finish.  Lightweight that I am, a teaspoon hit me hard and I staggered from the tourist shop to the bus stop, convinced I needed to hydrate better.

I’m Jewish and I’m visiting Israel.  I’ve written before about why I don’t write about politics, religion, or sex: https://walkaboutdoc.wordpress.com/2010/09/13/why-i-dont-write-about-religion-politics-or-sex/

 

Israel Road Trip 4: a day trip to Eilat

On the gulf there’s a beautiful spot

Where you can see what the tour bus brought.

But I’m not dissing the tourist

For I am no purist.

I just wanted to say thanks, Eilat. 

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  After less time off than I planned, I did some more hospital work and am now vacationing in Israel.   Any identifiable patient information, including that of my wife, has been used with permission.

I have been to Israel twice before, on guided tours, seeing tourist sights and visiting tourist towns.

Beer Sheva (= Seven Wells) has archeologic sites, but education, computers, chemical plants, and health care dominate the economy.  It lacks a large tourist sector.

The city sports the longest building in the Middle East, five stories of gritty, functional architecture dedicated to incorporating new immigrants.

Signs in Hebrew, lower prices, a dearth of 5-star hotels, and locals speak Hebrew most of the time. Restaurant staffers rarely speak fluent English.

Tourists come to Beer Sheva mostly on their way to Someplace Else, usually Eilat, Israel’s answer to Miami.

Bethany and I took the bus south out of Beer Sheva, across the Negev (literally, desert), to Eilat, on the Gulf of Aqaba, hard by the Jordanian border.

We found town maps, a sure sign of tourist orientation at the bus station.  Outside, scores of shiny new hotels dominated the skyline.  An enormous cruise ship lay at anchor in the Gulf. We found most of the signs in English, a language shared by the hotel check-in staff.

To my surprise, Hebrew dominated the languages heard on the Promenade, followed closely by Russian, then Dutch.

In the morning we sat down to the way-beyond-sumptuous Israeli hotel breakfast, as much an experience as a meal.

At the hotel beach on the Promenade I pulled off my boots for a dip in the Gulf of Aqaba: surprisingly cold, crystal clear and calm with barely a ripple.  A school of tiny fish broke water next to me and went on their way.

An hour later we boarded the bus back to Beer Sheva for the air-conditioned trip across the desert.  We stopped at a junction with a score of other tour buses and faced lines at the fast food and restrooms. Bethany and I, stretching our legs,  came around the McDonald’s corner and found the drive-through lane blocked by construction trucks; those unwise enough to bring a passenger vehicle to the window turned the corner and faced the uncomfortable necessity of off-roading in the sand to get back to the asphalt.

I don’t particularly like tourists in large groups, but I enjoyed the short trip to Eilat. Because those in this life are just passing through, we are all tourists, and some of us are day trippers.

I’m Jewish and I’m visiting Israel.  I’ve written before about why I don’t write about politics, religion, or sex: https://walkaboutdoc.wordpress.com/2010/09/13/why-i-dont-write-about-religion-politics-or-sex/

 

 

 

Israel Road Trip 3: Free advice if you take it.

If you take it, my advice will be free

If not there’s my usual fee

It’s not what you expect

‘Cause I won’t come to collect

And follow up is always the key.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  After less time off than I planned, I did some more hospital work and am now vacationing in Israel.   Any identifiable patient information, including that of my wife, has been used with permission.

Bethany and I traveled into Tel Aviv by train one morning to visit our neighbor’s cousin, who spent years in the States and during that time visited frequently.  We had lunch with her, her parents, and children.

I recounted the story of my uncle Pinchas, from his conscription into the Kaisar’s army through his Russian POW experience and release, the odyssey of his return to Galicia, the move to Palestine, the loss of my aunts and cousins to the Nazis, his fight in Israel’s War of Independence, and the reunion with my grandmother in 1965, after a separation of more than 50 years.

As I age I find myself choked up more and more when I tell that story, but tell it I did, stopping frequently to dry my eyes and unchoke.

We all told stories of our families, and I learned that Israel has a national holiday, Yom Olim that celebrates the immigrants. Part of the tradition includes school children telling the story of how their family came to Israel.

While Jews have always lived both outside and inside the Holy Land, Israel takes much national pride in its status as a nation of immigrants.

At the end, our neighbor’s cousin’s mother asked my professional opinion.  The pain in her feet, she said, had baffled half a dozen doctors and wasn’t getting better.  I said, “Tell me about your problem,” then I said, “Tell me more,” then I said, “What else?”  After that I went into directed questions.  I explained that I don’t have an Israeli license, and at the end I gave my opinion, strongly advised some lab tests, and a clinical algorithm.  I explained I suffer from the same problem that I think she has, and emphasized the necessity of pursuing the diagnosis and not just trying a supplement for a suspected deficiency.  She accessed her lab work on her smart phone and scratched several items off my list but found a vitamin deficiency surprising for an Israeli but almost universal in North America, that had not been addressed.

I wanted to show off my clinical technique.  I can’t always help the patient but I can always listen.

At the end, I said, “My advice is free if you take it.  It you don’t, I expect a payment of $50.”

I’m Jewish and I’m visiting Israel.  I’ve written before about why I don’t write about politics, religion, or sex: https://walkaboutdoc.wordpress.com/2010/09/13/why-i-dont-write-about-religion-politics-or-sex/

Israel Road Trip 2: Sephardi Services

The service, to me, was all new

Of the prayers I understood quite a few.

It was easy to see

They’re not just like me

But every single one is a Jew.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  After less time off than I planned, I did some more hospital work and am now vacationing in Israel.   Any identifiable patient information, including that of my wife, has been used with permission.

 

I attended a nearby Sephardi synagogue the first Saturday of my visit, and found as much alien as familiar.

The Ashkenazi tradition traces back to northern and eastern Europe, and predominates in the US. The Sephardi come from southern Europe, the Middle East, and to a lesser extent, Africa where they meets the Mizrachi.

To the extent that I think Ashkenazi when I think of Judaism, I fall prey to the stereotypes of most Americans. I like the Conservative service, uniform prayer books with Hebrew on one side and English on the other, with no gender division.  Most American Jewish houses of worship provide prayer shawls and skull caps, and don’t assume those attending possess or desire them.  Many congregants have little or no Hebrew but find generous accommodations.

I donned the tallit (prayer shawl) I borrowed from my son-in-law when I stepped into the sunny sanctuary. Each person had his own book, and I don’t have enough Hebrew to ask for one. Actually, I do, but I don’t have enough to understand the answer.

About a third of the congregation had identifiably African facial features. My complexion, dark by US standards, was lighter than 80% of those present.

Many looked Asian, a term I use advisedly. Some appeared to descend from the Indian subcontinent, and others looked like they had roots from much further East. I only saw two redheads.

The Jews of Ethiopia migrated to Israel in 4 or 5 major waves. The vast majority arrived speaking Amharic. The older generation stands surprisingly tall (my maternal grandfather, typical for an Ashkenazic man, never got past 5’5”) and the younger even taller. They remain very religious in an increasingly secular state.

The Mizrachi represent another branch of African Judaism, and remain less well-known than the Ethiopians.

I had never attended Sephardi services. I recognized 2/3 of the prayers despite the unfamiliar melodies and accents. At the end, the fathers stretched out their arms and tallitot and enfolded their sons, a tender. beautiful tradition I’d never seen before.

Afterwards, I stepped out into the late autumn morning, onto the plaza outside the shul. I knew no one, and even if I had, I didn’t have enough Hebrew to make small talk. I couldn’t explain the differences between what I’m used to in Iowa and what I’d experienced in Israel.

I’m Jewish and I’m visiting Israel.  I’ve written before about why I don’t write about politics, religion, or sex: https://walkaboutdoc.wordpress.com/2010/09/13/why-i-dont-write-about-religion-politics-or-sex/

Road Trip Israel 1

Ulpan is the way that they teach

To almost every and each

From the old and the young

You now hear Hebrew, the tongue,

From the desert, and down to the beach.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  After less time off than I planned, I did some more hospital work and am now vacationing in Israel.   Any identifiable patient information, including that of my wife, has been used with permission.

Hebrew flourished linguistically from 3,000 to 2,000 years ago when replaced by Aramaic.  And while scholars continued to write in it, and some adults learned to use it in commerce and academics, it joined the innumerable languages that have arisen and withered over the course of human history.

Because a language doesn’t live unless people learn it from infancy.  The first-language foundation laid during childhood sets the stage for the changes that inevitably follow.  Languages, like rivers, change.

About 130 years ago Eliezer Ben Yehuda raised his children speaking only Hebrew, thus making it the only dead language that has been successfully revived.  That seed fell onto the fertile ground of a people yearning for a national homeland.

In modern Israel, the Hebrew language is once again flourishing, used for passionate arguing and idle chatter, flirting and teaching, business, and contracts.  As a miracle, it surpasses the blooming desert.

For the last 20 years I’ve studied Rosetta Stone Hebrew, off and on.  I started cramming 2 weeks ago readying for the trip.

There is no substitute for doing your homework.  I landed in Tel Aviv capturing 10% of the ambient conversations, chagrined that I could pick up numbers better than anything.  Bethany, having lived here for 6 months in the ‘70s, could understand more.

Yet Israel continues to assimilate tens of thousands of immigrants every year, making sure they can speak, read, and write Hebrew fluently.,

They use a program called Ulpan in three levels, taught 5 hours daily 5 days a week for 5 months.  The government heavily subsidizes the olim (recent arrivals) while they learn.

Our daughter, Aliya, in Ulpan Gimel (the top level) moved to Israel a few months ago.  We went to class with her on Tuesday.

She has a gifted teacher who speaks clearly with a straightforward sentence structure, and I found myself understanding about half of what she said.  The students in the class spoke slowly enough that I followed them, as well.

During the break we chatted with our daughter and some of her classmates.  One of them, a young South American physician planning specialization in urology, I had noticed rubbing the big muscles running from the shoulders to the back of the neck (look up trapezius).  I recognized the pattern from my own experience with fragmented sleep, and I spoke to him in Spanish about it.

Indeed, he and his physician wife have a terrible mattress.  He accepted the offer of sidewalk massage.  Seated on stairs, I found the muscular knots, and had him breathe through deep-tissue pressure.   I felt the muscles relax, and then I stood him up and crunched his back.

Of course the idea of moving to Israel and learning Hebrew has occurred to me, but the prospect of trying to keep medical records in a different language with a different key board intimidates me.  Still, my skills could be useful in this vibrant country.

I’m Jewish and I’m visiting Israel.  I’ve written before about why I don’t write about politics, religion, or sex: https://walkaboutdoc.wordpress.com/2010/09/13/why-i-dont-write-about-religion-politics-or-sex/

 

 

Parkinson’s, hearing aids, and admitting ignorance

I know just when I don’t know

In fact, it seems I’m a pro

The surprise is in store

When I find who knows more

And a diagnosis can sure make me glow.

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 further travel and adventures in temporary positions in Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and South Central Alaska.  I split the summer between hospitalist work in my home town and rural medicine in northern British Columbia.  I am currently taking some time off.   Any identifiable patient information, including that of my wife, has been used with permission.

 

After several weeks off I said yes to a return to hospital medicine Friday.

I started the day with 16 patients on my roster, 10 on the post-surgical unit.

Three had severe, ill-defined pain with normal CT scans.

I had good reason to recall my medical school graduation speaker 40 years ago.  “First thing in the morning,” he said, “Look in the mirror, say ‘I don’t know.’  Practice it.  Get good at it.”  (He said a number of other things that I still remember.  I have done a lot of graduations but rarely heard as effective a speaker.)  And, indeed, for those 3 mystery patients, I said, “I don’t know.”

As a generalist, I don’t have to know everything.   I have to know who knows more than I do.

I had conversations with an orthopedist, a surgeon, a neurosurgeon, a pulmonologist, an intensivist, and a radiologist.

Two MRIs brought surprise diagnoses.

I used greetings in Hochungra, Umaha, Spanish, Lakota, and Greek.  In particular my use of Hochungra impressed not the patient, but the family.

In the ICU, I handled a discharge and found, once again, the Electronic Medical Record rigid, unforgiving, un-intuitive, and user-hostile.

Of my 5 ICU patients, I discharged 1 and found 1 already moved to a lower-rent district.  My main service in the ICU amounted to explaining in plain English what was happening.

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A patient in the ER and I share problems with hearing and I suspected her hearing aids functioned more as plugs than amplifiers.   After the history and physical, I retreated with them and a 27 gauge needle for about 5 minutes.  I cleared the intake and output channels to the point where I got feedback from holding them in my cupped hand.  Few doctors would go out of their way, said the family, and I agreed.  The patient’s smile brought me my reward. So little that I do in medicine brings such immediate gratification.

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I run into a lot of patients with undiagnosed Parkinson’s symptoms.  I might note a characteristic but subtle tremor on one side, quiet speech with little music, an expressionless face, a stiff gait with no arm swing, or a frozen smile.  Parkinson, who named the disease, diagnosed the sufferers from his window.  Because early treatment does not slow progression of disease, I can’t passionately advocate intervention if symptoms don’t bother the patient.   Four times Friday I educated patients about Parkinson’s starting with “I never want the treatment to be worse than the disease, and if taking a pill three times daily would bother you more than your symptoms, we can wait as long as you want to start medication.”  Most patients don’t want to add to their medication burden.   But a few do, and Monday, I went out of my way to check the effects.  What a reward!  Stronger voice with more music, an animated face that replaced a mask, and the small, nuanced, unconscious movements of body language that add so much to communication.