Potpourri: WSJ, Coffee, and Why I am Still a Doctor

Greetings, ah, Wall Street Journal readers. What a happy Christmas surprise to find in today's Google Alerts:

WSJ links to Med Marg!

To my dear friends and loyal readers, no, that was not Photoshopped.

There was EVEN MORE GOOD NEWS. Dr. Latte might not ever become diabetic. This is important, because Dr. Latte loves cookies and potato chips more than life itself, but slightly less than Jeni's Ice Cream. Why? What important medical break-through has Dr. Latte so juiced? This:

Coffee, Tea may stall diabetes.

A shout out to my peeps at MedPage Today! Every cup of coffee I drink a day lowers my risk of diabetes by 7%. (Okay, yes, I left out the "may". I was too busy adding half and half to my joe.) I think that this week alone I have reduced my diabetes risk by approximately 5,683%, which means I have lowered my risk enough for everybody in the State of Ohio. You're welcome, Buckeyes.

Now, to the meat. The New York Times (where my blog has not yet been extoled on high) doesn't always get health care right. Even when they're not right, they get credit for thoughtful, by which I mean "full" of "thought" which if you watch local news for 4.3 seconds you will see if often in short supply. Today they shot me in the gut.

I have been chatting at length recently with my comrade in arms, Dr. Beardy, about how we've changed. What did medical school, residency, and years of practice do to our brains? Dr. Beardy shrugs and rolls his eyes at my endless fretfulness.

But I wonder. I kept a journal regularly before I went to medical school and for the first year. Entries became more spotty as time went on. I read them now and it's cute, and I mean to be patronizing. Pre-med and -clinical me is so earnest and exciteable. A Richard Selzer essay sends me to the moon. "Oh, noble savage, I am here to lay my healing hands upon you;" I was chomping at the bit to unleash my skills and empathy upon the needy masses.

That was before two years of rote memorization, then many years of a first row seat at some of the finest suffering the body has to offer. Before abscesses exploded at me, on me. Before I got amniotic fluid in my mouth; before I beheld a newborn before anybody else in the world, even its mother. Before stinky diabetic feet met my wrath at 3am in the emergency room. How many times did I cry in the bathroom at how helpless I was to help, really help?

My earnest yearnings were before drug addicts, alcoholics, and prostitutes introduced themselves and their STIs and kept me busy on weekend calls. Before I stuck sharp things in prisoners who promised retaliation and held the hands of felons as they died. Before I pronounced somebody dead on Christmas who had been breathing and warm moments before, then had to turn to the family and think of something not totally stupid to say. I had listened to the slow thump of their hearts. Then I listened to nothing. Silent stillness.

I've held hands, smoothed hair, listened to hearts, thumped livers, ordered blood, checked ears, smiled, cried, worried, fretted, and laughed through thousands of encounters. I've listened. I've catheterized, immunized, yearned, grieved, smiled, giggled, joked, talked, and hoped with thousands of people, most of whom, in fact, I've adored in one way or another. Not all, but most. Listen, listen, I tell myself when I'm starting to dislike somebody; you'll hear the hook. That thing that the patient will say that will reel me into their world, still, to this day, astonished to find myself a tourist in a life and a body quite alike and different from mine.

I remember, like most parents, before my daughter, my beloved, adorable, sparkly, vibrant girl was born, my husband and I worried. We were deeply, completely in love with our quirky, volatile, funny, handsome, curious, brown-haired toddler boy. Could our hearts expand to include another with the intense, physical love we had for our first? Impossible.

But then there was this.

My Lu. In labor and delivery after my semi-emergent section, on mag, exhausted, uncomfortable, worried, a nurse--such a dear woman--brought me a picture of her, so tiny, with oxygen and a giant IV. I had seen my daughter for a few seconds in the operating room before she was whisked to the NICU. Someday maybe I'll take a picture that means as much to me as this picture did, still does. In the wee hours of the night, lonely and a little afraid, I fell hard for a premie in a picture and I haven't gotten up yet. May I never rise. (Look at that face. How could I?)

So. I can't tell you all the ways I've changed because I just don't know. But I can tell you this. I'm bigger. I'm stronger. I'm quieter. My heart grew--like the Grinch's. My brain grew. (May that continue, too.) I know from my kids and from my patients that really, my ability to fret, to absorb, to hope, to love, to grow (my husband would add "to opine" and "to bitch") will go on. And that brings me back to the New York Times.

A picture is worth a thousand words. I should have started with these pictures, because what keeps me coming back, what gets me out of bed in the morning, what flips my switch to "on", what I love about being a physician is to reach out and touch, to help, to listen, to be near. I saw these pictures today of a little boy, with brown hair and eyes like my little boy, with tetanus. (Woe! This dear little fellow didn't need to be sick.) Tomorrow, for some other mother somewhere I will reach out, listen, laugh, hope, and try to help.

Pictures of the day: December 17th

Turns out, despite the agonies of call and the endless needs of the Axis II patient, the earnest little pre-medical journal-girl has survived. (She's much, much older and grayer and wider, now though.)

The gassy winds of change

So. The year is winding up. I am buffeted more by the winds of full-time working mommyhood at the holidays than I am by the winds of change in primary care. I am, though, getting cards and contact from old patients. Oh, how ambivalent I am about this. I am delighted to hear from these beloved folk, but so many tell me tales of woe. No callbacks about tests. Doctor in and out in five minutes. No explanation for an emergency referrals, sometimes no knowledge about the referral until the specialist's office called to find out why the patient missed the appointment. Inexplicable expensive tests based on miniscule probably benign findings. Where are the good primary care providers?

I know what physicians who are reading are thinking. "Iced, you weren't there. You don't know what happened." True, so true. But these aren't nutty patients. They're wonderful patients who never, ever brought anything but joy to my office. I'm only hearing the bad stuff, too. There's selection bias. Nevertheless, the stories make my hair and toes curl. I'm mad. I feel badly, and just a little guilty, not that I can do much about a corporation ramming an office closure down my throat with about 3 minutes notice. Grrrrrrr.....

In this context, I read this:

Primary care physicians spending longer time with patients.

Well, thought I, that's encouraging. Turns out it's only 3 more minutes, which isn't much when you're managing diabetes, hypertension, ordering labs, addressing depression and insomnia, arranging a mammogram, and asking about the kids, but it's something. But wait! During the time visits increased by 3 minutes revenue decreased by 10%. Physicians don't get paid by the hour, but by the patient. Spending 3 more minutes with each patient means I can see less patients in a day--20 patients a day times 3 more minutes=one whole hour lost. Can't make as much bacon. Oh, this burns my breeches. Bend over and receive a special award: Paycut. Yes, yes, but Dr. Latte, you still have a job. Many of your patients aren't having to suffer with paycuts 'cause of course, they don't have pay to cut. Yep. Read above, however, and see how your care is already suffering. The time has to come from somewhere. Didn't get a callback? Doctor had to see three patients rather than explain to you what happens now with your melanoma? Can't get in until three months from now? Have to go to Urgent Care because your doctor is 1. Out of business or 2. Out of appointments?

BUT! Help is on the way; change we can believe in. Two thousand billion pages of health care reform are coming our way sometime in the next hundred years maybe, and it's possible that if you don't have insurance now that you might be able to get insurance maybe in five years possibly and it might not matter than you had a pre-existing condition like fatigue 10 years ago. Here's my predication. Medicare works well for patients; not so well for physicians who are already losing money at it. Particularly if private insurance expands, more primary care docs--if they can without going to jail--will opt out. It's already completely, utterly impossible to know how to code 100% correctly for Medicare, and to not code correctly is to risk going to prison. Add 8000 pages of statutes and physicians rightly will run out of the room screaming.

That is, however, not to say that the present system shouldn't be napalmed, bulldozed, infected with H1N1 and left to die in a ditch full of vomit. To have to see a patient for a cold with 52 million pages of ICD-9 or -10, E&Ms and CPTs, Obama-Care EMR documentation laws attached just isn't going to be feasible for the average physician. Or even the super-human MD. I'm not hopeful. You can't get a straight answer now out of HCFA about some routine matters. How is that going to get better?

But here's something cool: Science. Pure, elegant, lovely, exciting science. From NPR an interview with a researcher who discusses the successful alteration of memory traces after they are accessed, and what that might mean for people with painful, traumatic memories:

Erasing fears by thinking about them.

Hats off! Wow. I'm smiling from ear to ear. Consolidation and reconsolidation. Shining the beautiful hard light of science at a nebulous subject, memory formation. Memory is a fluid, shifting thing, but here is evidence that it can actively be shaped in a more positive light. A little scarey with regard to the corallary--that you'd be able to shape a good memory to be bad--but to help all of us feel safe about traumatic episodes? That's powerful. I think there's some hope that I might be able to get over my medical school Gyn-Onc rotation after all.

One last thing. For now. First, let me be clear about my bias. I will use any excuse to continue to buy books often on Amazon. Here is proof that it is actually good for me and for my brain. I make my living using my brain. Thus, it is not just good, it is necessary for me to continue to shop:

Can neuroscience make you a better writer?

Yes, yes, you might be thinking, there are some caveats at the end about activation maybe not being an always all-good thing, but I'm going to ignore that because I want to continue to shop.

Oops, here's really the last thing. I see patients for a living, and usually twice in every patient encounter--before I lay my healing hands upon the patient and right after I am done--I use hand sanitizer. See twenty patients, that's ah, like 40 Purells a day. In reality, it's more, 'cause I reach for it reflexively after every sneeze or walk in the hall. I do WASH my hands, too, so don't go getting all jiggy on me, but I gotta tell ya. In the days I washed my hands 20-plus times a day the skin was falling off by mid-October and no amount of Vaseline, steroids, and socks would make it better until the following May. Hand sanitizer has made that better, although if you looked at my hands now, mid-December, you might be tempted to think that I am molting. So in my personal study of one, Purell isn't as bad for my skin as washing my hands 50,000 times a day. But how about the nails? The chemists at Beauty Brains have figured it out so you don't have to:

Are hand sanitizers bad for nails?

That's all for now!

USPSTF is mean to 40-49 year old boobies.

Image via Wikipedia

The USPSTF, as you might have heard, recently recommended that women stop getting mammograms and just suck it up, because our lives apparently aren't worth enough to save. Especially women approaching the end of their reproductive lives--as nature casts you aside, so does the USPTF. Don't examine your breasts, and don't get xrays of 'em either. You suck. You probably went back to work and left your children at home to fend for yourself while you saved for a fur coat.

Or did they? If you listened to the news or read almost anything, that's the impression rabid, frothing at the mouth "journalists" gave. Yes, I'm talking to you, Sanjay Gupta. You're about to get your MD taken away by the IcedLatte Medical Excommunication Squad. You're an obnoxious little twerp and spouting nonsense from your bully pulpit about which apparently you know nothing is getting on my last nerve.

Prevention and screening are so lovely and warm to think about. You go in to see your doctor for your (almost always useless for detecting disease) annual physical and leave with a prescription for your mammogram and a referral for a colonscopy, and once those are done, you feel great because you know you're cancer-free. Maybe.

A screen is by definition for detecting a disease in an asymptomatic patient. When I order any screening test, I think about:

• What is the prevalence in the population of the disease we're testing for? The less the diseases exists, the less the chance in general that a screen will be positive because most people simply don't have it.
  
• How good is this test? How many people who truly have the disease does it pick up? That is the "sensitivity." How many people with the disease will it miss?
  
• What are this patient's unique risk factors? For example, in a female who is 45 but still have regular periods with no sign of slowing down, is her breast tissue still going to be really dense making a negative mammogram not very helpful? What if her mother had breast cancer? What if her mother didn't have breast cancer, but a maternal aunt did at 35? Not all 45 year old women are created equal.
  
• As noted above, there are technical considerations with a test. Mammograms are better screens for some types of breast tissue. A negative test is less reassuring in others.
  
• What was the exam like? If then exam is negative, and only if it's negative, then I can do a screen. If it is positive, then forget the screen, we're going to do a diagnostic test. Screening guidelines don't have anything to do with that at all.
  
• What will I do if the screen is negative? If I'm suspicious--but only if the exam is negative--will I believe the test? If not, should I skip the screen and consider a diagnostic test?

But wait, there's more. I turn to various screening guidelines--the American Cancer Society, the USPSTF among them--to help me figure this stuff out. They generally make thoughtful, well-reasoned guidelines (not laws) based on evidence. They don't always agree with each other, and I have to plug that into my math.

These groups look at huge numbers of patients over time and tell me things like "How many mammograms does it take in women 41-49 to save one life from cancer?" Turuns out it's about 2000. That alone isn't a value judgement, it's just a number. One of the variables I plug into whether I should screen or not.

To make matters more complicated, they all rate their evidence and level of certainty about the evidence, in sort of a "Great data and lots of it. Go for it." to "One study with one guy who was half asleep and possibly drunk when he did it. Proceed with caution." I paraphrase, but I think you get my drift.

Last, but certainly not least, like every other physician in the world, I'm always plotting my next move. If you have a mammogram, say, and it's a little positive, what am I going to do? If it's a lot positive, what is my next step? A little positive is a problem. There is increasing evidence that some breast cancers spontaneously regress, perhaps 20%. The screening tests we have right now can't differentiate who exactly is in that cohort who won't go on to develop an invasive cancer. FURTHERMORE, will early detection make a difference? If we pick up a cancer early, does it go without saying that it will make you live longer? As it turns out, not necessarily.

Confused? That's for your doctor and you to talk about, sitting in an exam room. The USPSTF isn't trying to get between you and your mammogram. The recommendations are just trying to clarify some of the variables in the giant screening equation. Their recommendations will change. The screening tests will get better. In the meantime, don't go burning your bra at your nearest mammography suite.

For an excellent discussion in exhaustive but terrific details, check out:

The USPSTF recommendations for breast cancer screening: not the final word (written by a breast cancer surgeon and researcher
Truth squad needed on breast screening quotes from Gary Schwitzer
Screen saver from Slate, written FIVE YEARS AGO about the perils of breast cancer screening

One last thought. Screens cost money. I think about that with regard to you (Do you have insurance? If you do, do you have coverage for preventative services?), but not necessarily with regard to populations. This isn't pretend money, though, it's real money. To save a life in a female between 40-49, it costs (assuming the mammogram is about $150) $300,000. Yes, yes, what price life? But you just got a new job at an insurance company. You must decidie what is covered and what isn't. What are you going to deny--vaccines for sweet little babies? Cancer treatments? Knee replacements? Grandma's small bowel obstruction surgery? If you put the money in one pot, which pot do you take it out of?

10 ways to be irritated by your doctor

Hey, I'm a patient too. Here's my list. And by the way, my doctors, this isn't about you AT ALL.

1. Have stupid television playing in your lobby. I hate insipid health t.v. HATE. I don't want to watch Oprah, I don't want anything. Maybe I can listen to unobtrusive music, but nothing loud and nothing Brittny. I know the idea is that white noise or t.v. drown out the sound of actual patient care and decrease the odds of overhearing a dreaded convo involving protected health information, but really. Get a white noise machine and leave me some peace.

2. Have stupid stuff to read. Actually, given recent demonstrations of nasty disease-mongering germ covered magazines, don't have anything to read.

3. Ignore that I'm waiting. Listen, I know from personal experience that the 80 year old patient who scheduled for an upset stomach suddenly turns into a heart attack live and in-person, and suddenly you're six patients an hour behind, and suddenly it's two hours later and you're twelve behind. It sucks. When I check in, please have your staff tell me that you're really running late. Better yet, have them text me or call me to give me the option to reschedule. Leaving me to molder for 2 hours in your waiting room without so much as a "Could I get you a coke?" is rude.

4. Uncomfortable chairs are inexcusable.

5. Sure, I've walked out of a room and left the cap from a needle (not the needle). I've left the odd Bandaid wrapper on the floor. But dirty floors? Bugs? Not cool. Mice droppings?

6. Nasty staff. Your staff should not size me up like I am homeless and stinky, even if I am.

7. When I am back in a room at the OB/GYNs and I am sitting in a paper gown and paper sheet, please do have your staff tell me it's going to be an hour and a half of waiting in paper on an uncomfortable table. I will tell you that I would like to put on my clothes and reschedule.

8. When it's time for my pap smear, don't have your nurse come ahead of you, put me in stirrups so that you can walk in an go, "Spread 'em" and never look at anything but 'da business.

9. Seriously, I know margins are low, but get cloth. Gowns cost $0.25. Paper isn't that much cheaper.

10. GET ME A COOKIE!

11. Most of all, schedule appropriately. I understand if I come once or twice and you've had disasters, but if I come every time with my sick, cranky, twitchy children and I wait, please, please, stop overbooking.

10 ways to irritate your doctor.

From Dr. Rob last week was this post:

Top 10 ways to annoy your doctor

Very amusing. My personal favorite is #8, send your teenage son or elderly parents with dementia to the office alone, without letting anybody know what the appointment is for. Sound crazy? Ha!

To be fair, the next post was:

Top 10 ways doctors can annoy patients

Here's my own personal top 10 historical, real-life ways I have been pissed off by patients. Have I covered this before? If so I do apologize, but it's Friday afternoon and I'm too lazy to look.

Lie about reason for appointment: Never, ever say, "I told the nurse I had a cold, but really, I'm having an affair, I want to kill somebody, and I haven't pooped in a week, and I'm addicted to my sister's Ativan." I'm still angry about that one.

"I don't know why my wife scheduled this damn appointment. Ask her." She's not here and I'm not interested in being in the middle of your marital conflict. Don't come if you don't know why the hell you have an appointment. I'm a doctor, not a psychic.

Give ME some drugs: A mom lied once about getting her daughter an appointment ostensibly for a rash. As I was about to walk into the room, the mom jumped out of the bathroom and demanded that I confront her daughter about her drug use. Screamed at me in the hallway.

Argue with me about dibby dab: I once gave an elderly gentleman Darvocet for some moderate arthritis pain. He came back a week later and told me I needed to refill the medication I gave him, then he handed me a bottle of Percocet. I told him I hadn't prescribed it. He told me I had. I pointed out that the name on the bottle wasn't mine. And wasn't his.

A gaggle of thieves: If you have six kids, DO NOT schedule an appointment for one, then show up with six and ask me (after my receptionist has already told you NO) to look at everybody's ears. Then don't ask me if I can examine your breasts and talk about your anxiety disorder.

Could you babysit? Don't schedule your pap smear and expect to get it if you bring your three small children with you. Don't. Don't tell me it will be fine for them to sit by me on the floor during the exam. No. No. No.

If you're a dude: Don't come to see me for pink eye, then tell me that there's something in your groin you need me to check out, harder, harder. Seriously, now. Do I look like I care, or that I was born yesterday?

Don't ever, ever call my staff a name, any name. Ever. Don't yell at them. First, they get the job done. They call in your refills, they phone you about your test results. They schedule your appointments. Wanna be at the top of the stack or the bottom? Want the office staff at the urologist's office to hate you before they've even met you? My staff tells me everything. I live with these people. They have my back, and yours, too. Here's an example of what not to do, "Listen, I'm coming right over there, BIT$H, whether you have an appointment or not, and if your directions are wrong, you're gonna pay." No, you're not going to be seen, and the police are going to take you to your car.

I can't get out. When you see me knee deep with EMS laboring over a patient who is struggling to breathe, don't yell into the room, jangling your car keys that you're parked in by the squad in the parking lot, and could they move because you have a lunch date. We are going to turn as one and yell, "NO!" at you.

Last, but not least:

But I'm disabled! Your first appointment is not the time or the place to get 50 refills and lay on me your SSDI paperwork done. DO NOT tell me that disability and FMLA forms were due in HR two weeks ago and if I don't do the paperwork today, right now, that you won't get your check. Too badksi for you.

Here's one for bonus points, just for my fellow providers:

"I haven't had good luck with my last few doctors. They just don't understand me. I've had to fire my last five, and I'm suing at least one. I hope you're better than the last. " I don't! This is a true story, uttered from the mouth of a perfectly healthy patient with a little dyspepsia. We're not exactly a Band of Brothers, but few words send chills through my spine faster than, "I have fired your colleague....." and "Malpractice" at your first appointment, particularly when they're the first words uttered from your mouth.

College

So, as many of you know, I have joined the ranks of academia. Ha ha, no I haven't seen all ADD and STIs. You're funny. In fact, I haven't seen an STI in the four-plus months since I started. That makes me a little sad. I miss trich. I haven't seen a lot since residency and for some reason, the sight of that little protozoa swimming happily all over my microscope field always cheered me up. Our protocol for ADD/ADHD doesn't really involve initial diagnosis much. I write for less stimulants now than I did in private practice. Weird. Maybe two ADHDs in 4 month and no trich! No Chlamydia, no syphilis. Maybe some BV, but that's not exactly a world class sexually transmitted disease.

I find myself suddenly in possession of a lunch hour. A real lunch hour. I have oh, maybe 3 or 4 charts a day to do rather than 20-30 (on an easy day) and thus, I have time to kill at lunch. I stroll around campus and

I SEE DEAD PEOPLE.

No.

I SEE OLD PEOPLE.

Specifically, I see myself. I see my husband. I see old friends.

I'm working at the same midwestern university from whence I graduated from both college and medical school. I have gone home again. As I wander around in search of coffee, a sandwich, fritos, Columbian burritos, books, magazines, sushi, and kim chi at lunch, lost in my thoughts, I see myself. There I am, slinking along, 20 years old again, giant backpack at hand, giant sunglasses on, thrift store pants clad, flip flips on my feet (even then), on the way from skipping one class to skipping another class. I see my husband out of the corner of my eye, 20 years younger, NYTimes under his arm, smiling and overjoyed to see me (which, God love him, he still pretends to be). I see the guy I dated before Monsieur, riding his bike, rushing to his micro lab. "Yeah, sure, I can make some tuna noodle casserole on Friday. You wanna meet later at the library?" I see my sister dutifully trudging to class, pleasant smile on her face, cheery greeting at the ready.

It's a little disorienting. I snap out of my thoughts (no doubt mulling over how much I hate the flu) and for a moment, I'm 20 again. I compose my face to wave at my Monsieur, my sister, my friend, my organic lab partner. Then I remember my children. Huh? I have kids? What's the time? Oh, it's noon, 23 years later.

For just one moment, though, I am 20 years old again. It's a rather precious if fleeting interlude. How is it that my 20 year old state of mind is trapped and so easily called forth by my 45 year old brain? I can't remember my phone number half the time, but blam, there I am recalling a physics lab assignment and the nice guy (Michael) who was my lab partner.

I'm not alone. I saw a very depressed young student today who tranferred from the beloved undergraduate institution of her dreams to a college closer to home for financial reasons. She said, "I'm walking down the street and I see my roommate from last year out of the corner of my eye. When I look closer, she's not there of course, and I'm so sad. And I'm alone again."

I'm not so sad, but I do empathize. I see ghosts, too. I call forth younger, sillier, more fact-filled versions of me every day. Then I think of my children, my paycheck, my house, my comfy German blanket, my dear, old friends, and I wave goodbye to my ghosts of students past.

I think my depressed patient will make friends. She's adorable and charming but shy. I managed and I'm neither adorable nor charming. Until she does, my old bones will hold her young hand while we both watch for ghosts.

You might have too much time on your hands if you're doing this

Toilet paper sculptures via Sprayblog