We at Placebo Journal recommend that you embrace your midlevel practitioners with open arms by setting them up with your “chronics.” They couldn't do worse than you anyway. Let them taste this aspect of our job in all its glory. You can then sit back with your 80% of “normals” and from time to time huddle and reflect with your midlevels on how they are doing. When you are done laughing, pat them on the back and give them a little reassurance. Welcome them into the “club” and state “welcome to real medicine.” When they quit, we would then recommend you get cardboard cutouts of doctors (see offer below) with real empathic facial gestures to spend all the time in the world with your needy 20%.
Your friend, PJ
DOCTOR, I CAN't KEEP
IT UP MUCH LONGER…
Patients should take a more active role in their health …
Everyone knows the type, the patient who has no idea what medicine they are on or what they take that “little blue pill” for. It just seems odd to our anal retentive minds that they can be so clueless! So, when you meet a patient like Mr. X (no, that isn't his real name), it makes you feel good that there are indeed normal patients out there. I am an anesthesiologist practicing in a mid-sized New England hospital and take pride in what I do and how I interact with my patients.
I introduced myself to Mr. X and explained the plan for general anesthesia and reviewed his chart. I had him sign his consent form and ordered the standard pre-op meds. Mr. X was a very nice elderly gentleman with end-stage lung disease and was totally ventilator dependent. Don't get me wrong, his limiting medical condition didn't seem to suppress his enthusiasm for life at all.
He was an inspiration.
He had a very compact, quiet, portable home ventilator that he could close off at his trach site and force air through his larynx and talk quite well. Preoperatively he could manage his vent himself, but I asked him to go over the ventilator's functions with me as most likely he would be somewhat sedated in the recovery room and unable to operate it. It was quite simple to use and it would be easy for me to put him back on it upon leaving the operating room. After answering a few other minor questions, I went back to sit down in the anesthesia office as my chart work was ready, my anesthesia circuit and machine had been turned over and all of my drugs were ready for this next case.
While drinking my morning juice and talking with some department members in the office, the front OR desk let me know they were calling for the patient to come over to the holding area. I said, “Thank you for letting me know.” A few minutes later I was informed that he had arrived but they would not be moving him directly to the OR because the surgical team wasn't quite ready.
Again I thanked them for the information and asked them to let me know when he was going to the OR as I was all ready.
Five or ten minutes had gone by and again the front desk reminded me that he was in the holding area. It is nice that they are so attentive. Once again I thanked them for the information and reminded them that all they had to do was let me know when they were actually moving him into the OR. I thought their constant prompting was now getting a little odd, but I dismissed it and went back to my conversation.
Another five or ten minutes went by and the front desk nurse manager came to the anesthesia office door again. This time she looked a little flustered and reported that,
“The patient is starting to get tired.”
I said, “Excuse me, he's tired?” Perplexed, I looked at my partners and reluctantly got up to see what the so-called troublesome problem was. Upon arriving to the holding area I saw immediately in front of the OR desk what the problem was. There was Mr. X, no home ventilator in sight, looking up at me with his kind eyes and
SQUEEZING HIS OWN AMBU BAG!
Realizing he had been doing this for some time now, I happily took over bagging for him. He looked up and mouthed, “Thank you.”
In seven plus years of providing anesthesia I have never, ever seen a patient bag themselves That was a record for me With that, I shook my head with disbelief and proceeded to the operating room.
As I said before, patients should take a more active role in their health, but there are some limits.
BE CAREFUL!
Several years ago I was putting an 80-year-old lady on warafin anticoagulation. She was about to go home from the hospital and I was giving her my usual spiel about avoiding alcohol, calling me before she took any new drug, and trying to keep a consistent diet.
I had just eaten lunch in the doctors’ dining room and listened to some pediatricians talking about a baby born with birth defects typical of warfarin – another hazard with the drug that I may have known but forgotten because most of my patients can't remember back as far as their last period. At the end of my spiel, I thought I'd be cute and I told the old lady, “Oh, and don't get pregnant.”
She looked me straight in the eye, and said, “I'll be REAL careful!”
Things Your Mother Always Told You to Do
That You Wish Patients Listened To
10 Always wear clean underwear.
9 Brush your teeth twice a day.
8 Don't smoke.
7 Take regular showers or baths.
6 Don't pick at it!
5 Wipe good!
4 Always wash your hands after using the bathroom.
3 Don't play with sharp objects.
2 Cover your mouth when you cough.
1 Don't touch that or you'll go blind.
PHYSICIAN, HEEL THYSELF
A father recently came in I with his son begging for the ‘ child to receive antibiotics. ‘ The kid looked healthier than me. I was at a point in my day that I could probably be persuaded into prescribing anything. As I sat listening to the father go on and on with a totally nebulous story, my mind began to wander. Thoughts in my head included “What is that noise in the hallway?” and “Gee, I'm getting fat.” What brought me out of my coma were the father's implied demands for treatment. “In my opinion, he has walking pneumonia.” Personally, I can't stand it when a patient thinks they have the real diagnosis and is just coming in to see me as a formality; especially when that diagnosis is totally made up.
What the hell is walking pneumonia anyway? Is that an old Indian term, kind of like Chief Running Stream? Welcome to our office Chief Walking Pneumonia.
The bottom line was that the kid had clear lungs, clean ears, and a negative rapid strep test (I do this sometimes as a way to convince the patient that it's viral).
As the father continued with his diatribe it suddenly hit me that it was his wife who had called my employers about a month earlier complaining about her visit. She had felt rushed (even though we squeezed her in on a busy day as an acute) and felt that I didn't do much for her (she had a cold). We tried to call her back but she never responded. So here I am with this lady's kid who has a little virus (emphasis on little) and I just knew I was being tested to see if I would come through with the goods (the goods being a nice little Z-Pak). As the father pushed, I began to dig in my heels.
I actually don't wear heels as I am a man, but for the purpose of this story please picture that I have 10-inch heels dug deep into the ground. Picture them being mauve while you're at it (but that's another story).
He continued with his “evidence” stating that a virus wouldn't last two or three weeks (it would) and that Chief Walking Pneumonia needed something to cure him. Every time I would state a reason why not to treat with antibiotics he would counter with a reason to use antibiotics.
For example, I would say that his lungs are clear and he would say that CWP (Chief Walking Pneumonia) has a bad cough. I would say that it doesn't seem that bad and he would say you should have heard him an hour ago. I would say that there is no fever and he would say that last night CWP was very warm. I would say that his ears and throat are normal and he would say that it gets worse at the end of the day. We volleyed back and forth for five minutes, but I wasn't giving in. Finally, I closed the interview with the obligatory advice to call us if
things got worse but that it still might take a while to finally clear - as it was a virus.
The father of CWP wasn't happy and actually, neither was I. I don't really want to fight with patients (I can do that with my family). I really try to bust my butt to get patients in that are sick. That, unfortunately, isn't enough for some. I remember my former attendings stating that good communication and education about viruses would help this type of problem. Bullsh$t! I could have tutored this guy for an hour and it wouldn't have mattered. He wanted those antibiotics.
After work my partners and I were debriefing, as we often do. I was retelling this story to one of my partners and made a point of stating how good our office is in getting people in the same day they call (of course we don't do anything once we see them). He immediately chimed in that we use our “fund of knowledge” to reassure patients and that is what CWP's father was paying for. Basically what he was saying is that many times all we do is bless our patients. I thought to myself, if that is true then what I really need to do is bring my white jacket into the tailor's office and have flowing robes added to it. When I walk into the room with the patient I can do my exam and then dim the lights for special effects. With a loud voice and a British accent I can say, “I, Sir Douglas Farrago MD, declare you … WELL!” and then leave the room. Or I could just give the freakin’ antibiotics.
ADDENDUM: Later on that week the mother needed her other son seen. As usual, we put the kid in and my nurse told her up front on the phone that it would have to be quick because we were going to be swamped. She showed up later that day with flowers for each staff member and myself. Her kid had conjunctivitis and got antibiotics. I blessed him and off they went. Sometimes it's not a virus.
P J EXPLAINS
BOWEL OBSESSION
I have had patients in my time that are so obsessed with their bowels that they have decided the world revolves around their stool. I remember one patient had to explain every little cramp she had in her abdomen. And the gas! Terrible. The stool was just not the right color brown for her and it seems size does matter. After dealing with her constipation on a regular basis, I finally came to the realization that maybe I was never going to help her. She was always going to have something to complain about. The stools were too loose, too hard, too thin or not long enough. Like Goldilocks, except it was never just right.
I know this whole topic seems immature for a physician to talk about, but the problem is that it is all too common. Some doctors label these patients with a diagnosis of “Irritable Bowel Syndrome.” I am not a big believer in this term, as there seems to be a huge supratentorial component. Even the name “Irritable Bowel” is ridiculous. If you want to have some fun, try this. Talk as if you were a pirate and repeat after me, “You don't want to mess with him, matey, he's got eerrrtibill bowwwelUUl” Or pretend you are in a bar fight and state to the biker that is in your face, “Back off buddy, I've got irritable bowel”
The bottom line is that you cannot fix the unfixable. Try giving them laxatives, bulk formers, and antispasmodics. Try changing their diet, as more fiber should help. Try something for stress, an SSRI or counseling. Try, try, and try. The truth is that every conversation will begin the same way and end the same way. Their bowel movements are never perfect. It is as if they are looking for the perfect stool much as a surfer looks for the perfect wave. Man, that was a Tsunami turd!
Now we all have those times that good bowel movement makes your day. You feel light and airy and that post-parasympathetic high feels great. There is nothing wrong with that. These people, however, are on a quest for Nirvana and looking for it via their rectum.
You have choices. You could always send them to a gastroenterologist, but that would be dumping (no pun intended). I am sure specialists don't want to deal with these patients either. Maybe an alternative practitioner would work? “How about some Eye of Newt, Mrs. Jones?” It really doesn't matter. Anywhere you send them will only be temporary because, like a boomerang, they return. So how do we deprogram these patients who are being brainwashed by their bowels? I recommend that physi-I cians learn the art of distrac-[tion. Just like a good magician, never have them focus on that which they want. When they talk constipation, you talk about their eyes. When they mention gas, you go on a f soliloquy about their dry skin. I When they mention stool cal-f iber, you mention joint laxity. You can get so good at this that you will have five things to talk to them about before they can even hit you about their bowels. Like a role reversal, you now have the “list” and you go into each visit on the offensive. This stuff works. Then again, if it doesn't, there is always the gastroenterologist.
Your friend, PJ
Ways to Get “Hunkered Down” Patients
Out of the Hospital
10 Cut off all power to the room and pump in loud rock music (sort of like we did with General Noriega).
9 Three letters – ECT (electroconvulsive therapy, or shock to the brain).
8 Low calorie, soft mechanical, low salt, low fat, low sugar, low taste, and puréed diet.
7 Send in a new medical student every hour on the hour to ask for a full review of systems and to perform a full complete physical exam (including checking Cranial Nerve I with coffee grinds).
6 Hourly enemas.
5 Admit your favorite patient with sleep apnea or with dementia (that tends to sundown a bit) to the bed next to them.
4 If patient is a female – only have ESPN on the tube; if patient is a male – only have Lifetime on the tube.
3 Have interns master the skill of getting arterial blood gasses on this patient.
2 Have maintenance come in and install a “dripping” faucet.
1 Have nurse attempt to insert largest size urethral catheter he or she can find (easily found at a nearby large animal veterinarian's office).
years ago, I started my general practice in a small southern town of around 2,000 people. My first attempt began while moonlighting in a small, rented two-bedroom house. A radiological resident and I made the small office with no air conditioner and a gas space heater into our place of business. We furnished it with cheap plastic chairs and indoor-outdoor carpet from Sears. We were styling. Office visits were $7. Since malpractice insurance was only $130 a year, we weren't in bad shape.
One of our first patients was a white middle-class lady who brought her child in with a cold. What was nice was the fact that she really was there to support the venture of the two “new doctors” since the community hadn't had a physician in several years. Unfortunately, she became very uncomfortable with the dumpy surroundings and the odor from the poorly ventilated space heater. She never returned.
The next patient was an elderly black man who brought in his own special smell, that being the wood smoke with which he heated his own home. With complete sincerity, and even a sense of awe, he volunteered, “I really likes your house.”
My partner, the radiological resident, had his own issues. He bought a well-used portable X-ray machine from a tech at the nearby army post. The price included the tank for hand development. It took about 20 minutes to get “wet readings.” We jimmy-rigged the back porch to block the light out. This made it into a Plywood X-Ray Suite. The initial films took more than ten minutes to get a poor image at best. It took awhile for my partner to realize that he shouldn't leave the paper on the individually wrapped films. Once he started taking the paper off, the picture quality was actually pretty good and we were up and going.
Our first chance to get the Plywood X-Ray Suite some action came days later when a small older lady needed some chest images. Our film cassettes were black with an aluminum colored band around them. She stood in front of the cassette as instructed and while we were taking the film, she commented, “Sho is dark out tonight.” I nodded but really wasn't paying much attention until she jumped back, covered herself and blurted out “They took the window down!” when my employee removed the cassette that was in front of her.
Life was different then. And more simple. Rufus ep
itomized this “simpleness.” He began to appear at our clinic on a regular basis. His life was chaotic but happy. He spent his disability checks on lottery tickets. He usually lived in someone's barn or shed and was fed by the kindness of others. For 20 years he had insulin-dependent diabetes and nary a clue how to adjust his medicine or diet. He walked 20 miles most days and we would see him all over the county walking alongside the road. The only time he would get into trouble and need an admission to the hospital was when he was able to acquire an old broken-down car. This came as a result of some gooder convincing him to get a driver's license (which he did). How he passed the test without being able to read or write was beyond me. Unfortunately, the walking had prevented him from going into diabetic ketoacidosis so when he drove his car he got sicker. The beauty about Rufus was his carefree style. It would not be uncommon to overhear him propose to the local bank manager knowing well and good she was already married with children. The one thing, however, that I always envied about Rufus was his watch. It had no hands (and wasn't digital). Time stood still for this man - not unlike how time stands still for my old memories.
ur small rural hospital does not have house physicians or residents, so the handful of general internists on staff rotate “Medical Call” and “ICU Call” for unassigned patients. One evening, I was called to the ER to admit a man after an unsuccessful suicide attempt. The man was gay, about 60, and lived alone except for an undetermined number of cats. He was a diabetic with some heart disease, and was dating a doctor who did not have privileges at our hospital (naturally!).
He was evidently upset with his life and current boyfriend, and so decided to end it all (after a few too many drinks). He had heard that a person could die from too much insulin, but he wasn't sure how much was needed, so first, he injected one of his cats with about 50 units of regular. The cat F began seizing some-i time afterward, and died, but he really didn't like the way that looked, so he decided to try another method.
The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge Page 17