Posted by: notdeaddinosaur | April 18, 2014

Artful Dodge

Saw a 56-year-old woman the other day.

“Have you had your colonoscopy?” I asked.

“No,” she said. “I know I was supposed to get that at 50, but I didn’t. You’re supposed to get them every ten years, right? I guess I’ll just wait until I’m 60.”

Nice try, honey.

Posted by: notdeaddinosaur | April 18, 2014

Building a House (13)

Lots has been happening inside (plumbing, wiring, etc.) but nothing much that shows up in a picture Today, though, there was action: cutout done for the window over the garage, of which DSS sent me a picture.

Here’s the thing, though: when I downloaded and opened the image, the way it showed up against my computer desktop cracked me up. So here’s a screenshot instead of just the picture:

Screen Shot 2014-04-18 at 8.53.10 AM

Looks like a scary neighborhood we’re moving to, doesn’t it.

Posted by: notdeaddinosaur | April 10, 2014

Flower Power

Look here, now. I’m as sick of winter as the next person. And I love flowers just as much as anyone else. Far be it from me to take on the role of Fashion Police (especially loving Vera Bradley as much as I do), but this is a little much:

photo (9)h/t MBS

 

Posted by: notdeaddinosaur | April 8, 2014

Forests and Trees, or: Why I Don’t Take Care of Populations

We lost a branch off a big old tree a few weeks ago.

“Call the tree guy,” said DSS.

“It’ll cost us a grand,” I muttered.

“No it won’t,” he said, dialing Dan, the tree guy.

$300 later and the branch was gone. Such a deal. But Dan the tree guy discovered that the tree was starting to rot out. Also, without the fallen branch, the tree was now dangerously unbalanced and really should be taken down, as it could present a safety hazard. $700 later and the “big stick” (as he called it) was history.

“Told you so,” I muttered to DSS.

But I had the chance to talk with Dan the tree guy.

“So I guess your dream job would be something in forestry, right?” I asked.

“No. I take care of trees.”

“But isn’t a forest just a whole bunch of trees?”

“Well, yeah. But there’s much more involved in taking care of a forest than just taking care of one tree at a time.”

Hm. Sounds familiar.

I take care of patients. Many patients. But, contrary to the impressions of the medically naive regulators who somehow consider themselves competent to pontificate on health care, a “population” is more than just a collection of “many patients.”

My job is to take the best possible care of the patient in front of me. Then the next, and the next, and the one after that. At the end of the day, however many patients I’ve seen, I still haven’t taken care of a “population.”

Caring for populations is called “Public Health.” It includes such things as access to potable water, food supplies, and schools as well as hospitals, doctors, and medical care. Physicians can be involved in public health, but it really doesn’t have anything to do with “practicing medicine.”

If the patient in front of me needs an MRI, I cannot in good conscience tell him that he can’t have it because someone else may need it more. That’s a population calculation, and it falls into the realm of public health. If you don’t need whatever it is you’re asking for, it’s my job to explain to you why you don’t need it. It has nothing to do with “good stewardship of scarce resources.” If you need an MRI, a consultation, or a procedure, my job is to do everything in my power to see that you get it. Period.

All these calls for Primary physicians (in Orwellianly named “Patient Centered Medical Homes“) to “manage populations” are disingenuous at best, and counterproductive at worst. We don’t manage populations. We take care of patients. One at a time. Each to the very best of our ability, with the help of the best possible evidence, but still one at a time.

And then the next.

 

 

Posted by: notdeaddinosaur | April 4, 2014

Building a House (12)

We are progressing: garage framed out and doors installed.House-12

Several more things have happened that aren’t visible from the outside. We now have cement floors on the front porch, patio, garage and basement, plus stairs down to the basement. The half-wall that will eventually be the larger of our two kitchen islands is in place.

Still a ways to go, but getting there.

Posted by: notdeaddinosaur | March 24, 2014

Building a House (11)

Now with windows (some, at least):

photo (3)

Posted by: notdeaddinosaur | March 18, 2014

Building a House (10)

We have shingles! (Roofing, which is good; not viral, which is not good):

photo (2)

Posted by: notdeaddinosaur | March 16, 2014

Building a House (9)

Wrapped in green:

photo 1 (2)

Posted by: notdeaddinosaur | March 13, 2014

Rotten Low-Hanging Fruit

The topic for today is In-Home Assessments by insurers masquerading as “useful.” I’ve previously discussed my observation that only patients with few or no actual medical problems seem to be chosen for these assessments. What happens when someone with multiple, complex, longstanding problems is selected?

This:

PAIN QUESTION/RESPONSE:

  • Location of pain: All over body
  • Quality of pain: Throbbing
  • What causes pain: Everything
  • What relieves pain: Seeing the chiropractor
  • How long has pain been going on: 42 years

Um, okay then.

PAIN TREATMENT PLAN: Follow up with doctor

Always a great default response. Since you home-assessment folks are right on top of things, what else do you suggest?

Member is recommended for reassessment of pain in: 6 weeks

Right. Because at that point it will have been there for 42 years and 6 weeks.

Good for a laugh, even though there’s nothing funny about it at all.

 

Posted by: notdeaddinosaur | March 12, 2014

Building a House (8)

And roofing on the roof:

0312141611a

Posted by: notdeaddinosaur | March 11, 2014

Building a House (7)

…And a roof!

photo (2)

Posted by: notdeaddinosaur | March 10, 2014

Building a House (6)

We have walls!

photo

Posted by: notdeaddinosaur | March 4, 2014

The All-Knowing Google

Did you know that Google will display a special birthday doodle for you on your birthday?

I didn’t. Until today, when I saw this:

Birthday doodle-page-001

Oh, I thought. That looks like a doodle for someone’s birthday. Let me mouse over and see who…turns out that the alt-text mouseover message says, “Happy Birthday, Dino.”

Cool.

 

Posted by: notdeaddinosaur | March 3, 2014

Dinner

Udon Noodles with Doctored Peanut Sauce.

Some assembly required:

photo 1

 

Assembly instructions:

  • Go to medical or other graduate school to attain “doctoring” credential (optional step)
  • Cook udon noodles according to package directions. (Notice that directions are all in Japanese. Go to internet and discover that they need to cook at a full rolling boil for 10 minutes.)
  • Thaw shrimp according to package directions (gratefully noticing they are in English)
  • Coarsely chop red onion; slice scallions on the diagonal. Cook until tender in a splash of peanut oil (not shown) over medium heat.
  • Add about 3/4 cup of peanut sauce, pinch of red pepper flakes, and a handful of peanuts, stirring until heated through.
  • Serve over drained udon noodles:

photo 2

Posted by: notdeaddinosaur | March 2, 2014

Saving Lives with Primary Care, Part 2

I just didn’t like the looks of him.

It was the way he was breathing. I counted for a full minute: 24 breaths. (The ER would later document 40.) No accessory muscle use. Not even much coughing. He didn’t look overly anxious or uncomfortable, though he said he couldn’t breathe. No fever. No wheezing or other abnormal lung sounds on exam. No leg swelling or tenderness. Pulse ox 95% on room air. (97% in the ER.) Not terrible for a non-smoker in his 60s. Not much to go on. 

I was afraid he had a blood clot in his lungs. Pulmonary embolism; PE, for short. Life-threatening if not caught. Fever, cough, chest pain, anxiety, and leg pain (clots in the leg can break off and go to the lungs) would have been suggestive signs. Then again, their absence didn’t rule it out by any means.

Here’s the kicker: He was already on coumadin, a blood thinner, and his INR was 2.9 the week before. He was therapeutically anticoagulated. Blood thinners are supposed to prevent blood clots. He couldn’t have a blood clot in his lungs if he was already on blood thinners, could he? What was going on?

Pneumonia? Possibly, but with no cough, fever, chest pain, or abnormal lung exam, it seemed less likely. Asthma? Even less likely with a normal exam.

I just didn’t like the looks of him.

So I called the ER and told them I was sending him over.

“Already on coumadin?” asked the nurse.

“Yep.”

“Therapeutic INR?”

“That’s right.”

“Hmph. Probably not a PE. But send him over; we’ll take care of him.”

Later that afternoon, the patient called me.

“I just wanted to say thank you,” he began.

He had been admitted to the ICU with numerous blood clots in both lungs. The only other thing they could find was a little non-occlusive deep vein thrombosis in one of his popliteal veins; the kind that don’t typically break off and to to the lungs (especially when already on blood thinners.) The hematologist was stumped.

But he was alive. Which he probably would not have been if he had continued sitting at home, hoping to feel better, as he had told me he was his original plan.

That was a save. Based primarily on that sixth sense of the experienced clinician: I just didn’t like the looks of him.

[By the way, if there are any coagulation gurus reading this with any ideas for taking care of this guy other than an IVC filter, please feel free to shoot me an email. We really are stumped.]

Posted by: notdeaddinosaur | March 1, 2014

Building a House (5)

The foundation has been backfilled:

photo 1 (1)

Also, we have wood!*

photo 2 (1)

Despite the fact that another 6-10 inches of snow are expected within 48 hours, we have a house; some assembly still required.

*No, that doesn’t mean the Viagra just kicked in.

Posted by: notdeaddinosaur | February 27, 2014

How Do You Know Your Cat is Planning to Kill You?

All hail “The Oatmeal,” the source of all truth in the universe.

So how do you know your cat is planning to kill you? Answers here, but not the fully correct one. The real answer to the question, “How do you know your cat is planning to kill you?” is this:

You have a cat.

I was reminded of this the other day by a comment on a post by Rob Lamberts on KevinMD which began:

As an incurable compulsive introspect, I tend to brood, ponder, contemplate, and (of course) muse on “big ideas,” such as:

  • What makes people choose things which cause themselves harm?
  • Are some people better people than others, or are they just more skilled at hiding their problems?
  • Is pain really a bad thing, or is our aversion to it a sign of human weakness?
  • Does God ever wear a hat?
  • Do dogs watch Oprah?
  • Why did I put “big ideas” in quotes?

I love Rob.

One of his commenters, Eqvet215, added this at the end of a thoughtful response:

By the way, most tasteful dogs watch Ellen; Pugs watch Maury or Jerry Springer Spaniel. Cats watch Dexter.

Of course cats would watch Dexter; makes perfect sense.

Which led me to think of my little Bootsie; my BooBoo Bear; my sweet little 14-year-old tabby with no front claws (rescued that way) who sleeps between me and DDS each and every night. Planning to kill us? Not my darling kitty.

But he is a cat. And suddenly I realized what was going on.

He’s paralyzed by indecision. Every night he jumps up on the bed and tries to decide which one of us to smother first. And every night he lies there, torn: her? Him? Her? Him? All night long. Poor thing just can’t make up his mind. Then before he knows it, the sun is up and we’re gone. Another day to plot and ponder (and poop and barf; he’s nothing if not versatile in his talents), until tonight…

Posted by: notdeaddinosaur | February 26, 2014

The Power of “Reply All”

The guy was a curmudgeon. That’s all you could say about him. His blood pressure and diabetes were dreadful, and he insisted there wasn’t anything he could do about it. The meds were too expensive; the diet was far too limiting; he had no pleasures in life other than food. He lived alone, hated his job, saw few people, had no friends; so he told me at every visit. His visits were unpleasant in other ways as well. He didn’t bathe often, nor did he appear to believe in doing laundry. 

He sent me emails from time to time. Funny pictures of cats; sentimental powerpoint presentations on the changing of the seasons; the usual. Sometimes I read them, sometimes not; depended on how busy I happened to be at the time. Mine was just one in a long list of names in the header.

Then one night, everything changed.

I got a call from the emergency room. My patient had had a heart attack, found slumped next to his car. They’d been able to get a rhythm back, but not before he’d sustained some mild anoxic brain injury. I’m not sure how they figured out he was mine, because he really wasn’t able to communicate at all. I got to show off my spiffy EMR, rattling off his meds to the ER doc. (“Are you in the office at this hour?” “Nope. I’m logged onto my EMR from home.”) but not much else.

There wasn’t much they could do for him. Just wait for his brain to improve to whatever degree it could, helped along with intensive physical and occupational therapy. Frankly, I didn’t think he had much chance for any meaningful recovery, and would likely be bed-bound and completely dependent for whatever remained of his life.

Later that night, I saw an email. The header indicated it had been sent to everyone on the curmudgeon’s contact list. It read:

Does anyone on this list have Mr. C’s daughter’s phone number? VERY IMPORTANT.

I know what that’s about, I thought, though of course I couldn’t say anything. Confidentiality and all that. Besides, I had no idea how to get ahold of his daughter.

The next day, there was another email from someone with the same last name as the curmudgeon. It relayed what had happened to him and his current condition in far more detail than any other correspondence I’d gotten from the hospital (ie, none). Followup emails from others on the list relayed thanks for the info, good wishes, and prayers. When he was ready for visitors, it was announced through the list. News of his transfer to a rehab facility was next (again, before I’d received any official notice from the hospital), followed by continued improvement and transfer to a stepdown rehab. Finally came word that he was going to live with his daughter to continue his recovery.

Around that time, the daughter also called the office to make an appointment for a followup visit. I was as thrilled as I was surprised to see him walk into my office, unassisted except for a walker.

He smiled when he saw me; a surprisingly symmetrical smile. His neurological recovery wasn’t complete, but it was remarkable. So was his attitude. I’m not sure if the brain injury had caused a change in his personality, or if it was as simple as having nearly died, but he was a different man. Smiling, friendly, pleasant, and optimistic. Everything he hadn’t been before. And with a very long list of people who cared very much about him, that he either never before admitted, or had never believed.

As with everything else in life, there is a time and a place for “Reply All.”

Posted by: notdeaddinosaur | February 25, 2014

Dinner

Pan-seared sea scallops with clam risotto:

photo 2

Posted by: notdeaddinosaur | February 23, 2014

Dinner

Thin sliced top round, dredged in pan-searing flour and very briefly pan-fried, with carmelized onions and served over polenta:

photo 1

Posted by: notdeaddinosaur | February 22, 2014

Saving Lives with Primary Care, Part 1

I’m going to let you in on a little secret: not all doctors “save lives” every time they see a patient. Emergency medicine physicians,  trauma surgeons, oncologists can all rightfully brag about “saving lives.” Hell, even paramedics probably save more lives than I do over the course of a year. I admit it: more of my time is spent either relieving suffering (diagnosing and treating acute but self-limiting illnesses) or trying to prevent it down the road. Trust me: it doesn’t feel the least bit heroic to discuss diabetic diets, recommend weight loss, prescribe blood pressure medicines, and advise people to quit smoking over and over again, day in and day out.

Also, because primary care is an ongoing endeavor, there will always come a time when “saving a life” is not the goal. Helping patients with terminal conditions to remain comfortable — physcially, emotionally, and spiritutally — through the last stages of their lives is an important facet of our job. It just doesn’t make for compelling cocktail party conversation or blog fodder.

But I still have my moments.

A patient* came in for followup after a protracted hospitalization for sepsis, weak but well on the road to recovery.

“You saved my life, Dr. Dino.”

Those were her exact words.

She said it again: “You saved my life.”

Do tell.

“I give you credit: all those times I came in asking for antibiotics that you wouldn’t give them to me. If you had, I would have died.”

She was quite sure of it.

Who was I to argue?

She was probably right. If I had given in and prescribed antibiotics for previous conditions when they were clearly not needed, I would have killed off the susceptible portion of her microbiome and allowed the smaller population of resistant organisms to prevail. Had those resistant bacteria been the ones to invade her blood stream, she very likely would have succumbed.

We doctors may have “The power of the prescription pad.” But there are still plenty of times when we just need the power of “No.”

*Blogged not just with permission, but by request. h/t TC

Posted by: notdeaddinosaur | February 17, 2014

What a Difference a Word Makes

In the news this morning, there’s the story of an Ethiopian co-pilot “hijacking” his plane to Switzerland.

I’ll bet that if this had been, say, a Russian plane, perhaps at the height of the cold war, and a white pilot, given exactly the same circumstances (asylum requested, no gun), the media reporting the event would have used the word “commandeered” instead of “hijacked”. But since it was a black man from Africa (albeit from a country with a history of violence in the air) the more emotion-laden term was used.

Sounds racist to me.

Posted by: notdeaddinosaur | February 14, 2014

Breakfast

Once again my trusty Ratio cookbook comes through on a cold, snowed-in morning: Popovers! Surprisingly simple; amazingly delicious with just honey:

photo (5)

In the oven, just starting to pop.

Just out of the oven.

Just out of the oven.

And voila: breakfast as elegant as it is yummy:

photo (3)

Apparently they would have popped even higher if I’d put them in smaller tins. But all I have in this hypoplastic kitchen of mine is this new large muffin tin. I can’t bear the thought of buying more of what I already have, even though it’s in storage and I won’t be able to use it until summer. The popovers turned out fine, though.

 

Posted by: notdeaddinosaur | February 8, 2014

Dinner

Rosemary crusted rack of lamb with balsamic reduction, served over mashed potatoes:

20140206-194517.jpg
Yum.

Posted by: notdeaddinosaur | February 7, 2014

The Downside of Open Access

The term “Open Access” in the context of Primary Care means that patients are able to get an appointment whenever they wish.

The ultimate in open access is 24/7 availability. No, I don’t offer this, although I come pretty close. I’m available by cell phone virtually 24/7 (I rarely go away; too rarely…sigh) and I’m also almost always willing to come in and see someone if they really need to be seen. This seldom happens. Most of the problems that arise after office hours are acute enough to require a higher level of care than I can provide in the office; hence, I recommend evaluation in the ED. Most other issues can wait until the office is open. For things like colds, flu, and other self-limiting conditions, patients are often satisfied with advice over the phone. Still, I am always willing to meet them at the office for ear infections, UTIs, and the like. No muss, no fuss, and boy are they grateful.

Over my 20+ years in practice, I’ve done a fairly decent job of training my patients to call during regular hours for things like refills of ongoing prescriptions. They’re usually due for an office visit, though, as that’s how I’ve set up my refill policy (once or twice a year for hypertensives, two to four times a year for diabetics depending on their numbers) and I let patients know this. Therefore a refill request also means making an appointment. All of this is a piece of cake with my electronic medical record. I can log on from home or anywhere else and crank out those refills with three clicks. I can also tab over to the Schedule and make an appointment for them.

The primary focus of Open Access is on offering same day, next day, or short term appointments to anyone who wants them. When doctors first contemplate the concept, they freak out: essentially, it means seeing all the add-on patients who call in addition to those on their already full schedule. The best way to start is by not filling up the schedule in the first place. Most offices do this anyway, intentionally leaving room for those add-ons. The trick is to leave more and more space for them until you’ve caught up with your already-scheduled appointments.

Open access in its purest form means not having any appointments scheduled in advance. This doesn’t really work, as many people like to schedule their followup appointments at the end of their visits. Once you’ve gotten to full implementation, it’s not really a problem. Three months out, the schedule is usually completely blank. Even a few weeks tends to be quite open. 

So here we are. We’ve worked down the backlog. We are an office with full Open Access. You call; we offer an appointment whenever you want. Today; tomorrow; no problem.

Here’s the problem: what happens when the phone doesn’t ring?

First we agonize. What are we doing wrong? Why aren’t people calling? Is the practice going to go bankrupt? Why aren’t they calling? Is it Obamacare?

It helps to flip back to the same month last year and see almost exactly the same numbers for visits, charges, and collections. It tends to be cyclical, but it’s still scary.

And yet we sit. Twiddling our thumbs. Consider getting into marketing.

What do we do when the phone doesn’t ring?

Panic.

Or not.

The phone always starts ringing again. Once the weather warms up (cools down/dries up). It will pick up again.

It always has.

Posted by: notdeaddinosaur | February 6, 2014

When You Only Want a Little

On a cold winter’s night, I find myself craving something sweet. Just a little; on a diet, you know. And not too hard to make; I am working with an abbreviated kitchen. I’ve always loved cake batter. Not just licking it off the beaters, but actually eating it by the spoonful. Easy enough to mix up a concoction of flour, sugar, and milk to hit that tiny sweet spot. I’ve even taken to adding a pinch of baking powder to give it that nice zing.

Tonight, though, I tried baking it. With the help of a really cool cookbook called Ratio (actually just the cover) and my latest kitchen toy, a $25 electronic scale with “tare” feature, I can provide an actual recipe for an adorable little cake that just hits the spot. I know, I know; the Internet is replete with recipes for Mug Cakes. I’ve looked at them: they’re bigger, usually include an egg, and tend to weigh in at well over a thousand calories. This one is much smaller, and adds up to a not inconsiderable 344 calories. But hey, if you’re careful the rest of the day (or week) you can still swing it once in a while.

Ingredients:

  • 1/2 oz peanut oil (what can I say, I like the flavor)
  • 1 oz sugar (I use vanilla sugar, which I suspect is why I can get away without any other flavorings)
  • 1 oz flour
  • 1 oz milk
  • 1/4 tsp baking powder (I probably should have added a similar quantity of salt)

Put a small mug or glass custard cup on your kitchen scale and zero it out. Using the “tare” feature between ingredients, measure them out into the container in order. Stir until blended. Bake in microwave on high for 1 minute. Will be very hot, with soft coarse crumb. May be moist/slightly underdone at the very bottom (just how I like it.)

Optional (today only): Place candle in center of cake, light it, and sing Happy Birthday in absentia to DinoDaughter and the Jock.

 

Posted by: notdeaddinosaur | February 5, 2014

Headless Chickens Unite

Wait a minute. I think my head hurts.

This is from The Weather Channel:

in which the future King of England strongly condemns as misguided those who deny the accepted science of climate change.

Excuse me, but isn’t this the same Prince Charles who continues to embrace homeopathy (full article here):

‘I would suggest that the whole imposing edifice of modern medicine is like the celebrated Tower of Pisa, slightly off balance,’ Prince Charles declared in a speech to the British Medical Association in 1982

Really? Really??!?

In the video, Charles finds it baffling that “…we have such blind trust in science and technology that we all accept what science tells us about everything — until, that is, it comes to climate science.” And homeopathy. Just as baffling.

Supporters of homeopathy can legitimately be called “Chemistry Deniers,” and can also accurately be described as members of the aforementioned “Headless Chicken Brigade.” Talk about “…abandon[ing] all our faith in so much overwhelming scientific evidence.” I for one would love to hear that same speech by the good Prince, but with the word “homeopathy” substituted for “climate science.” I’m not holding my breath.

Posted by: notdeaddinosaur | February 4, 2014

In for the Long Haul

Comment in relation to the new house:

Do you mind telling your legions how long you intend to work?

Certainly. The short answer is, “Indefinitely.”

The more detailed answer (technically, the answer to “Why do you answer that way?”) has two parts:

First: I love what I do. Just about every part of it. I love it. I wake up eager to get to work each morning. Being continuously on call is an opportunity, not a chore. I love my office; I love my staff; I love what I do. Why would I ever want to voluntarily stop doing it?

Second, and the reason for the first: I love my patients. Well, most of them…no, pretty much all of them. Some drive me a little nuts, but the ability to (mostly) meet their needs, whatever they may be, is about as fulfilling as anyone could possibly imagine.

Is everything really all unicorns and rainbows at work? No. It’s been a real struggle financially of late; so much so that I’ve thought long and hard about various ways to address the issue. Sell the practice and become an employee of one of the competing local health systems? Take another job (or two; or more) at a nearby Urgent Care? Go concierge or direct pay? All those options and more have come under consideration, and all have been discarded.

Taking another job would mean being unavailable to my patients while I’m there. Selling my practice would be a nightmare for them. Many have come to me to get away from the huge practices that keep hiring more people for the “team” to supposedly help the doctor take care of them, but who in reality just serve as more layers between them and the doctor.

Switching to a concierge or direct pay model would be a betrayal to those patients who can’t afford to see me without insurance. I’ve hung in there this long; I have no plans to change that just yet. If more of the country moves toward direct pay, I may very well reconsider. But it has to be okay with my patients. They are and always will be my first priority.

I saw a new patient the other day who was totally charmed by me, by my practice, by my perseverence in getting a medication approved for him from his drug plan (quite an adventure, let me tell you.) He asked, as many patients have, the not unreasonable question to someone in their fifties, “You’re not going to retire any time soon, are you?” I replied without hesitation, “Nope. I’m not going anywhere.”

I am in a long term relationship with my patients. I’m not going anywhere anytime soon.

Except to a new house. Stay tuned.

Posted by: notdeaddinosaur | January 27, 2014

Building a House (4)

Foundation:

photo (5)

I guess that should be, “Foundation and Snow” (with apologies to Asimov fans.)

Posted by: notdeaddinosaur | January 19, 2014

Building a House (3)

House -3- Footings

Footings, the beginnings of the foundation. Here’s a closer view:

Footings - closeupHere we go…

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