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!