“What makes them venture beyond city limits?” they ask one another. “And more importantly, what keeps them out there?” More fruitless head-scratching. Suddenly one of them leaps to his feet. He looks excited. Head Boffin arches a bushy eyebrow in the direction of his impulsive young colleague.
“Yes?”
“Sir, I’ve got it! Let’s send them all surveys!”
“Surveys?”
“Yes! We’ll ask them each a few hundred questions and then have our quantum computers analyze their responses!”
Head Boffin nods; slowly at first, then with increasing enthusiasm. Finally he breaks into a wide grin.
“Splendid idea, Dilton! First class! We’ll start immediately.”
And so it begins.
My receptionist unceremoniously dumps the morning mail onto my already overflowing desk. Junk, bills, test results, insurance forms, more bills… and two objects that look suspiciously like surveys. Shoulders sagging, I open the first one.
“Dear doctor, we truly appreciate you dedicating your life to rural medicine yada yada yada and we hope you won’t mind filling out the enclosed survey. Please review the following 200 items and rate their importance in terms of the impact they have on your desire to continue practicing rurally. We estimate this survey should take you no longer than 45 minutes to complete.” What?! 45 minutes? Are they nuts? I’ll be lucky if I get 10 minutes for lunch today! I wad the oversized monstrosity into a ball and three-point it into the recycling bin across the room. The crowd goes wild… .
Item two is a follow-up letter from a group whose survey I completed a few weeks ago. As I recall, this particular survey had asked more personal questions than most, but its authors had gone to great lengths to assure that all responses would be held in the strictest confidence. They also promised names would not be linked to the forms, so it would be impossible for them to trace answers back to the individual respondents.
“Dear Dr. 655, thank you very much for taking the time to fill out our survey. We notice, however, that you neglected to answer questions 19 and 99. Please complete them and return the form to us in the enclosed self-addressed envelope.”
Okay, this I can handle. I quickly finish off the questionnaire and drop it in the outgoing mail tray. Several hours later the penny drops – if they claim to be incapable of tracking the doctors filling out their surveys, how did they know the incomplete one was mine? Egads! I’ve been duped! With my luck the study will turn out to be the product of some nebulous federal intelligence-gathering agency. Good thing I didn’t mention my fluffy pink slipper fetish in the “deviant tendencies” section… or did I?
Although surveys can be a real nuisance, I’ll probably continue to fill out the shorter ones for years to come. Why? I figure those poor research eggheads need all the help they can get in their noble quest to decode the enigma of the rural physician. If they eventually succeed, perhaps one day we’ll be featured on a segment of Hinterland’s Who’s Who. First will come the familiar, haunting flute melody, followed by that unnaturally calm voiceover: “The Canadian rural physician is a peculiar beast that appears to thrive on challenge and adversity. Only recently have scientists come to understand why this curious creature voluntarily makes its home in the underpopulated nether regions of our great land… .”
Prescription for Parenting Skills
A few months ago one of my patients brought her three-year-old son in to see me. Although little Genghis had only recently begun attending daycare, the workers there were so alarmed by his pervasive aggression and impulsiveness they insisted he be assessed by a physician ASAP.
I walked in to find the rambunctious little fellow gleefully dismantling my examination room. His mother seemed oblivious to the crime scene unfolding around her. After reining him in a bit I obtained a history and wrestled my way through a physical. By the time I was finished, ADHD and suboptimal parenting were highest on my list of potential diagnoses. I spent several minutes reviewing my findings with his mother, gave her some reading material and made arrangements for a follow-up visit.
As I was about to leave I remembered Genghis had a five-year-old brother who had always struck me as being excessively busy. The last time I saw him I had suggested we schedule an appointment to explore the matter further, but his parents hadn’t taken me up on the offer.
“Did Anakin start school this year?”
“Yes, he did.”
“How’s he making out?”
“Super!”
“I’m glad to hear that.” I began leaking towards the door.
“At first we were getting a lot of notes from his teachers about his behaviour, but a few weeks ago I figured out a way to stop that.”
“How?”
“I just give him some Gravol right before he leaves for school every morning. It works great – he hasn’t brought home a single note since!”
Introspect/Apologia
Lately I’ve been reviewing my medical narratives. Some are autobiographical, others reflect patient encounters, and most of the remainder relate to parenting. One thing I’ve noticed is that a few of the narratives depicting my interactions with patients are slightly cynical. Usually it’s just my warped sense of humour at play, but once in a while there's a bit of an edge to it. Some of this can probably be attributed to representational bias. I'm no neurobiologist, but I suspect difficult experiences engender higher rates of memory protein synthesis than neutral events. In addition to that, stories involving conflict are intrinsically more interesting to write about and analyze than their more peaceful counterparts. Who wants to read a book about unicorns frolicking in the sunset? For the purposes of discussion, though, if we suppose that I do in fact have an embryonic case of misanthropy gestating, is it being nourished by my patients, my job, or me? I think it’s probably a combination of all three.
For starters, I am definitely not the touchy-feely type. I tend to favour a linear, problem-solving approach to medicine. Within the first few minutes of most interviews I’ve usually assigned my patient’s presenting complaint to one of four categories:
1) I can fix this.
2) I can’t fix this myself, but I know someone who can.
3) I’m not exactly sure what’s going on here, but I get the impression it’s something fixable.
4) Jesus and Gandalf combined couldn’t fix this.
The instant I realize I’m probably not going to be able to help the person I’m seeing in any meaningful way, I start getting fidgety. The way I see it, every morning I arrive at work with a finite amount of expendable energy. Once it’s used up, I’m pretty much done for the day, psychologically speaking. This means I have to ration my resources wisely in order to try to do the greatest good for the greatest number of people. There’s nothing esoteric about this - it’s basic Utilitarianism 101. Unfortunately, a small percentage of patients are like black holes – they’ll pull you over their event horizon and suck all the energy out of you in a single sitting if you allow it. Trying to help them is akin to watering the Sahara with a garden hose. Over the years I’ve treated a number of these unusually needy people. It’s been my experience that no matter what I do for them, no matter how much time I spend, they never seem to get significantly better. Working with this challenging subgroup requires a lot of patience. Unfortunately, patience is not one of my strong suits. In fact, some days it seems I have none at all. This regrettable character flaw of mine undoubtedly contributes to the frustration felt on both sides of the desk from time to time.
I also have some difficulty dealing with the fraction of patients I classify as canaries. What's the story behind the term? Coal miners of yesteryear often brought caged canaries underground with them for use as low-tech early warning systems. Canaries were known to be disproportionately sensitive to methane and carbon monoxide. This made the birds ideal harbingers - if a canary suddenly stopped chirping and belly-flopped off its perch, the miners knew it was time to get the hell out of Dodge. Poor canaries. Always the
first to keel over whenever the environment is anything less than perfect.
Another obstacle stems from the fact that although I’m always hoping to receive a reasonably concise, coherent history, sometimes all I’m offered is a vague mishmash that meanders all over the place. At the end of some of the more tangential interviews I leave the room wondering if I just went through the looking-glass again. I need to work on not getting so bent out of shape when the story being related to me is more circuitous than I’d prefer.
According to the True Colors personality test, I’m off the scale at the gold-green end of the spectrum. This means I’m analytical and organized to the max. The good news is that these are both useful traits when it comes to things like running an efficient office practice or maintaining control of an ER that’s trying to go nuclear. Unfortunately, my high scores in these areas come largely at the expense of the orange-blue characteristics, namely impulsivity and empathy. I can manage just fine without the impulsivity, but a little more compassion would certainly be a plus, especially considering my chosen profession.
What else am I guilty of? Misdemeanours, mostly. I’d probably quit my job tomorrow if I won the 6/49 jackpot, so I’m guessing that means I’m no Mother Teresa. I’m chronically late. I biorhythm down to zero at about 10:00 every morning. I get crotchety when I’m tired. I’m set in my ways. I’m a tad OCD. I get antsy when I can’t logic things together. I have a tendency to display exit-seeking behaviour during futile patient interviews, particularly those of the asymptotic variety. And sometimes I can’t help but wonder if my helping keep certain individuals healthy and reproducing is a direct violation of Darwin’s law of natural selection.
Lastly, there’s the matter of my smouldering cynicism. For the past couple of years it’s been quietly modifying my worldview. I don’t think cynicism is chic. I agree with Bruce Mau, founder of the Massive Change Network, when he says that anyone can be cynical, but it takes guts to be optimistic. Nevertheless, I suspect I’m losing the battle. I think part of the reason I’m getting jaded stems from the fact that every day I observe people taking advantage of the system. To make matters worse, not only do I have to witness it, I’m often conscripted into helping them do it. How does this happen, you may wonder? Due to the nature of my job, I have the power to grant certain things. I never asked for this privilege – it comes with the title and there’s no way to divest myself of it. Modern-day family physicians have somehow been transformed into living cornucopias expected to generate an infinite supply of sympathetic off-work slips, welfare letters, disability pensions, tax credit papers, insurance forms, subsidized housing recommendations, accessible parking permits, travel grants, etc. This, of course, is in addition to the usual prescriptions, tests, referrals, and so on. After a while the endless stream of requests starts to wear you down. Usually the things I’m asked to provide are fair and reasonable. Sometimes…not so much. I try to be as accommodating as possible, but I do have to draw the line somewhere. Whenever I say no, conflict ensues. Here are some of the less reasonable requests I’ve had to deal with over the past few months:
1. A patient asked me to provide her with a prescription for foot orthotics. She had been seeing an alternative health care professional for sore feet for several months and in the end he fashioned her a $400 pair of shoe inserts. Her insurance company refused to reimburse the money unless the inserts had been ordered by an MD, so she dropped in to inform me I needed to write a prescription for them. The catch is she had never seen me for that particular problem before. She ended her request with “…and make sure it’s dated before June 5th, because that’s when I submitted the claim.” What should I do? If I agree, I’m participating in a low-grade swindle. If I refuse, I’m labelled mean-spirited and difficult. I guess you could say the money’s not coming out of my pocket, so why should I care, but it just doesn’t seem right.
2. Someone with mild quasi-depressive symptoms who has repeatedly eschewed offers of counselling asked for a note stating it was medically necessary for him to take a paid six-month leave of absence so he could “rest up a bit.”
3. A fellow who bumped his head at work two years ago and hadn’t mentioned any problems related to the accident since it occurred came in to see me. He had recently been laid off, so he’d decided to launch a Worker’s Compensation claim over the incident. He wanted an MRI of his head, neck, shoulders and back as well as a referral to a neurologist “right away.”
4. A few people with no particular musculoskeletal disorders asked that letters be sent to their insurance companies informing them that in my opinion it was medically necessary for them to have prolonged courses of massage therapy at their chiropractor’s office. “It’s covered under our plan, so we might as well get our money’s worth.”
5. A fit senior who hikes and rides his mountain bike all over the place insisted I sign a form stating he is too disabled to walk in order to allow him to qualify for an income tax disability credit. He was surprisingly irate when I declined.
6. A patient wanted me to send a letter to the town’s subsidized-rental housing administrator saying I felt it was imperative she and her equally able-bodied spouse be given the next available ground floor apartment. Why? “We don’t like stairs.”
7. A squadron of shady transients drifted into town looking to score prescriptions for OxyContin, fentanyl patches, sedatives and other goodies. Don’t even get me started on those con artists – in the Periodic Table of Society, ER drug seekers are plutonium!
8. One of my patients showed up at the office saying he’d missed the preceding week of work due to a bad cold. He assured me he was fine now, but he needed a return to work note to present to his employer in order to collect his sick pay. Neither I nor any of my colleagues had seen him during the week he was off, so there was no objective way to corroborate his story. This isn’t the first time he’s pulled this stunt. How do I know he wasn’t out moose hunting with his buddies?
9. Another patient had some money locked into a GIC. In order to withdraw the funds prematurely without incurring the standard financial penalties he wanted me to advise his bank that it was medically necessary for him to get his money right away. The reason he needed the money in such a hurry? He wanted to buy a new snowmobile.
And the grand prize winner:
“Can I get a letter saying you feel it’s necessary for my health for me to have carpets installed in my apartment?”
“Why?”
“I like carpet!”
I wonder what a prescription for carpet would look like?
Pssst… Want to Buy Some Medical Products?
A couple of months ago I was in the middle of doing a Pap test when my receptionist knocked on the door.
“Donovan? There’s a Dr. Julep from Ottawa on the line for you.”
“Who?”
“Dr. Julep from Ottawa. She says it’s very important.”
“Okay, I’ll be right there.” I handed my nurse the cervical brush and hurried out of the room. “Hello?”
“Hi Dr. Gray. Listen, I really liked that story you wrote for the Medical Post about drug seekers in the ER.”
“Uh, thank you. What did you say your name was again?”
“Dr. Mint Julep.”
“Do I know you?”
“No, I don’t believe we’ve ever met. Dr. Gray, in light of the recent tragedy in Walkerton, do you have any concerns about the condition of the drinking water in your town?”
“What?”
“As a respected health care professional in your community, you could be generating a substantial amount of additional income by selling high-quality home water purification systems.”
“What?”
“You could offer them to the patients in your practice. I guarantee you, they’d sell like hotcakes.”
“Are you serious?”
“We also have an exceptional line of vitamins, tonics and natural products.”
“Let me get this straight – you want me to use my o
ffice to peddle the medical equivalent of Amway?”
“Our products are of the highest calibre and - ”
“Goodbye!” Click!
Last week I got a phone call from Montreal. This time I was prepared.
“Good afternoon, Dr. Gray! This is Dr. McQuack. Loved your article on cancer in the Medical Post.”
“Do I know you?”
“Ah, no, but Dr. Gray, is it safe for me to assume you have a genuine interest in the health and well-being of cancer patients?”
“No.”
“Uh… but that article you wrote… .”
“I made it all up.”
“Really?”
“Yep.”
“Um, well, anyway we offer several lines of very exclusive biloba vera colonics as well as specially enhanced carrot juice enemas that have been scientifically proven to put most cancers into permanent remission – ”
“As a matter of fact, I don’t even like cancer patients.”
“But – ”
“Have a nice day!” Click!
Sahara Mouth
I once had a sweet little old lady in my practice who complained bitterly of having dry eyes. None of the regular treatments for dry eyes seemed to have the slightest effect on her. I began to wonder if she might have Sjögren’s syndrome, a condition in which autoimmune destruction of the salivary and lacrimal glands leads to chronic dryness of the mouth and eyes. It’s possible to have either problem in isolation, but usually the two coexist. Every month or two when she came to see me at my office I’d ask, “Do you have a dry mouth?”
“No.”
“Are you sure?”
Dude, Where's My Stethoscope? Page 14