4/1: another last day. No foolin’

If your marriage is headed for court

Consider some online support

I’ve got the cred

What it does to your head

If your mom is the borderline sort

The laughter came in a burst

Just because on April First

Name profusion

Brought patient confusion

When first and last were reversed.

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 Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  2019 included hospitalist work in my home town and rural medicine in northern British Columbia.   I did 10 months of telemedicine in my basement, followed by 5 months staffing a COVID-19 clinic in southeast Iowa.  Since autumn, I’ve relaxed, exercised, done some telemedicine, and worked on administrative stuff for the next adventures.  A week in Pittsburgh, 8 continuous call days, almost a day at home.  We went to San Francisco for a funeral.  I am working as a contractor for 1 of 10 South Dakota Veterans Administration clinics.  Any opinions expressed are mine; any resemblance to VA opinion or policy is coincidental.

The VA identifies vets by the first letter of the last name and the last 4 digits of the Social Security number.  Put those two parameters in the dialogue box and you get a series: last name followed by a comma followed by no space and a first name.  If too many people have the same last 4 with the first letter of the last name, we turn to the date of birth.

But consider the problem of people who have names that can be interchanged first for last.  For an example, I’ll use Steven Gordon (not the veteran in question but who agreed to let me use his name) who could be Gordon Steven or Stephen Gorden or Gordon Stevens or any one of 18 possibilities.

I got an electronic message to call a vet back: a letter and 4 digits.  The computer replied that the vet had died in 2005, and was I sure I wanted to open the chart? 

Sure I did not, I laughed.  After all, my last full day coincided with April Fools.  The staff laughed with me nonetheless, assuring me that they had not misled me on purpose.  It took 3 more tries to get the right chart.

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At the end of the clinic day, I talked with a young man for his first VA visit.

He came from a branch of the service noted not noted for chastity, sobriety, or seeking counseling.

He failed all stereotypes.

I listened. 

“I hate you.  Don’t leave me,” sums up borderline personality disorder.  Their marriages tend to chaos, the central core bond tends towards violence, drama, blame, and arrest of emotional development.

I know.  I grew up in such a home.  My upbringing brought me strengths and weaknesses.

The patient (who gave permission to write more than I have) did as well.   

He wanted a mental health consultation.  I agreed.  I told him that if I were a real counselor I would let him talk till he came to the insights I gave him. But he had the last 1-hour slot on my last day.  And I’m not a real counselor.  

I also told him to find an online support group for sons of borderline mothers.  I’m sure they’re out there. 

The script our parents give us

To the problems I can relate
My family was in a sad state
Let’s call a halt
To blame parents’ faults
We’re obliged to master our fate.

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, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m back in Pennsylvania. Any patient information has been included with permission.

After a week off, I addressed the drama and irony behind the first patient’s very real physical problem from the perspective of my own experience. My mother had borderline personality disorder, my father had narcissistic personality disorder; no medication exists for either of those two problems. I observed that we don’t get to write the script that our parents hand us, but we have the obligation to edit it, and that obligation gives us freedom. Stressed people get sick, and sick people get stressed. Some of the stress that life brings us we cannot avoid and we just have to deal with it, but some of our stress we make for ourselves.
I saw a lot of people sick in the aftermath of a death in the family. For some I mentioned my brother-in-law’s untimely drowning and we had a mini support group. With others I talked about my 11 culture proven strep throats in the 10 months after my mother’s death.
Early in the day I recounted two stories to the PA I worked with. The first had to do with a different clinic in a different century, during the days of paper charts, when I caught myself over emphasizing the importance of thyroid testing to a med student. “Think thyroid!” I pontificated. “Depression? Think thyroid. Weight gain? Think thyroid. Weight loss? Think thyroid. Diabetes, hypertension, or cholesterol? Think thyroid.” We walked up to the next exam room, and I pulled down the chart so we could read the chief complaint on the routing slip.
“C’mon,” she said, “Sore throat? Think thyroid?”
And with a trifle more certainty than my experience justified, I said, “Think thyroid!” We walked into the room, I said to the patient, “Take one finger and point to where you hurt the worst.” She pointed to her thyroid, and turned out to have Hashimoto’s thyroiditis, with an anti-TPO about 100 times the upper limit of normal. I hope the med student recognized the luck that played into that impressive bit of diagnosis, but still went on to test the thyroid for the least justification.
The second story had to do with a patient in another clinic in another state, who might have come in for one thing but routine exam picked up an irregular heartbeat and EKG showed atrial fibrillation.
All in all, the day went well. The PA stayed till 2:00PM. I ordered delivery Chinese, and inhaled forkfuls of fried rice between patients.
The last patient of the day teaches high school history. We had a marvelous but all too brief conversation about that subject. While some might complain that current history curriculum includes an excess of politically correct material, I remember clearly the Cold War propaganda from my own high school days; we students recognized that material as a pack of lies. Which inspired me to study history on my own, and to find out the real story.