He meant to say kind of OK

A few days ago a male patient saw one of the female doctors at my office for an acute problem. She looked at his med list and saw that he was on Viagra and was asking how that was working.

Without thinking the patient said it was “up and down”. At which point the doctor burst out into hysterical laughter at the unintended reference. Patient loved it too and repeated the episode to me.

What is a professional?

For What Its Worth

 

One of the best definitions I have heard, was from a football color commentator. An dedicated amateur works on something until he gets it right, a professional works on it until he can’t get it wrong.

I have thought about this as it applies to the technical aspects of my work, in particular, suturing, draining wounds, removing nails, moles, etc. And I can see what he was talking about. I find myself continuous working on how to do it better, simpler, less painful, faster (if appropriate), I am never satisfied and every time it doesn’t go as planned I re-evaluate. I don’t have to work at it, that’s just the way I do things. The routine of the procedure is so automatic that several things happen: I don’t have to think about the nuts and bolts, I recognize immediately if something is not right, I know what to do about it. The lack of brain power required for the process is then freed up for other things, getting ready for the next two steps, considering other issues that might complicate the procedure, anticipating what I might need next, distracting the patient with funny stories. Many times I have finished suturing someone without remembering each step–just cruising on autopilot.

This became clear to me this morning while working on my car, something I am clearly an amateur (although perhaps an dedicated talented one?) . I was working on the exhaust manifold  and the oxygen sensor. Nothing hard except they are very hard to reach and it is very dark under the car. It generally requires a variety of tools that have to switched. I realized that as I took a socket extension off, I did not pay attention where I placed it and when I needed it I could not find it and had to crawl out from under the car to locate it. I began paying more attention and consciously placed the tools in a specific easy to locate and reach spot. That is when it hit me that I do that as a matter of course at work.

The car however is not as familiar to me as patients and a much larger part of my thought is on the immediate issue at hand. And there is the difference.

 

 

New Lesson

A month of so ago I saw a middle aged man whose primary complaint was chronic headaches. He had been suffering for many years, more than a decade as he recalls. There were two types, the severe disabling/overwhelming type he would occasionally get, and the basic daily run of the mill headache he had learned to live with.

As you can imagine, this did not promise to be a particularly easy challenge, if I could do anything at all. He had of course been to a panoply of doctors none of whom had accomplished much. He was making one more attempt out of desperation.

I went over the headaches symptoms as usual and all the treatments he had undergone. Unfortunatelly, after that much time and suffering it  is typical for the patient to not fully remember what has transpired. Nevertheless, it seemed to me that a couple of possibilities had not been fully explored. I was clear that eliminating the headaches completely would be unrealistic but that we should be able to reduce their impact on his life.

The next visit was one month later and to our amazement he was better! The severe headaches were gone! the daily ones were much better and easily lived with. Success beyond my expectations! I was tickled. We don’t get many of these successes. Sort of like a hail mary pass working for a TD  in overtime.

The lesson came next. The patient was not nearly as excited as I was. Actually he was not excited at all. I had to ask him several times to confirm that I had heard right, because I thought he should be ecstatic. We continued the treatment and I mulled his reaction (lack thereof) for some time. To be honest I had expected more, perhaps an ‘atta boy’ or something. For a little while I was bummed and confused. Bummed because it was a big deal and I had managed something that many others had not, confused because I have studied human nature for all my life and this did not fit into my five decades of careful study.

It took a long time to finally understand what was happening.

The patient returned and the headaches although not completely relapsed had worsened somewhat requiring tweaking of the medication. Not unexpected  and only slightly disappointing. Even now he was n0t outwardly happy about the significant improvement in his life.

It was weeks later when I was dealing with my Restless Leg Syndrome that I have had for decades that I finally got it! A new treatment completely removed the constant burning I have learned to live with. Absolutely gone! The intense burning was gone and I remember being confused because my feet felt odd. Then it dawned on me that they felt normal!  At that point I was not ecstatic but worried. And that was when I understood my patient. The problem is too overwhelming and too long lived to feel it will simply disapear. Instead the normal reaction is to worry about when it will return. The fact that it will return is not even in question, I presume it will take months for me to consider my foot burning won’t return. And that is what I suspect is going on in my patient’s head.

I look forward to seeing him in a few months and even later to see if indeed he continues to do better and to see when he accepts this as the status quo.

arranged marriage

An elderly patient was brought in by his daughter in law. He does not speak english (Pashtun) so she translates for me. Her husband sometimes brings him and I have chatted with him as well. They are fascinating people.

On this day I learned that theirs was an arranged marriage. I dont know why that surprised me. Perhaps it is that they both seem so ‘western’ and that this occurred in England. She is very happy with the outcome and indeed by all accounts he is a very good guy.

I was even more surprised (shocked) actually that she wanted her kids to have arranged marriages. Here in the States! I don’t know her kids but that seems rather unlikely, after being exposed to our culture. My own kids hardly listen to me when I tell them what time to come home, much less who they will date or marry.

I certainly do not think that choosing your own mate is all that superior. The decisions are made much more with momentary passion than cool judgement. But I certainly would not have accepted what my parents would have picked for me, for I saw them mired in a world long since passed.

I am still surprised by new things, part of the fun of being on the front lines of medicine.

What is the worst that can happen part Deux

A patient on hearing the last post of the 17 years olds smashing beer bottles on football helmets told me she could top that one for stupidity. A note, however, I dont think that the 17 years olds were being stupid, I think they were being boys. However, this lady’s son is 33 and his friend is 30, so they should definitely know better.

Apparently they needed to reach high for something and instead of getting a stool, or chair or ladder they decided that her son would get on the shoulders of his friend, who promptly lost his ballance. The guy fell and a sharp butcher knife that was laying on the counter ran deeply through his arm with blood spurting everywhere.

The friend ran through the house yelling he had killed his friend.

All turned out ok. It was  flesh would after all, (albeit a very deep one) and he recovered quickly. The mother just shakes her head and her thirty year old son being too lazy to get a step stool.

What’s the worst that could happen?

Yesterday I removed stitches from the top of the shoulder of a teenaged boy of about 17. He is in the honor society at a very demanding school and obviously very bright. He is also on the football team and extremely fit ( although that does not enter into the picture). The cuts were unusual in distribution and location, so I naturally asked how he got them. Because his grandfather was there he could not lie , like he did to the doctor placing the sutures in.

Apparently he decided to make a youtube video with a couple of friends of his. The patient put his football helmet on, then one friend would smash a heavy bottle (beer I presume) on the helmet while the other friend filmed it. What could possibly go wrong?

Had he thought through about the neck of the bottle the guy was holding and where that would go, he might have put on his shoulder pads and all would have been good, as it was, we have a good story and probably a better youtube video anyway. He has not put it up yet however. I encouraged him to do so and if I get the link, will post it up. Perhaps a what not to do video.

First Book Signing

My first book signing has been set at Constellation books in Reisterstown on Aug 14th at 3pm. There will be coffee/tea and cookies! I am excited and anxious at the same time. Should be fun. Will have to resist the temptation to stack the audience with friendly faces. Come if you are free, bring questions, comments, etc.

I am working on the the next two sequels to the book so any lessons from this one will be appreciated.

Vacation time

Sorry about the lack of posts. My wife and I went on vacation to the Northwest for an extended week and I erroneously thought I would actually do work. For the first time in years I let go of the office right away. I guess I am maturing a bit.

The Northwest is a wonderful place ( in summer!) the locals assure me that the 9 days we spent there are all the good weather they get. (I am not so sure, that they just dont want people to move there). I dont like the heat so much and it hardly got over 75 any day. It generally stays in the 60′s which is fine with me.

We got to see the Oregon Coast and it is truly amazing. Way too cold to get in the water, but it has a harsh beauty to it that I could stare at for hours. I did walk into the water and not only did I lose feeling nearly immediately, I thought my feet would have to be amputated, they hurt so bad.

We saw the non tropical rain forest of Olympic park. Wow! the scale of trees is hard to explain. Douglas Firs are absolutely amazing!

A mulligan please, I have earned it.

A patient who has been coming to see me for 18 years saw me yesterday . He clearly has been very happy with the care he has received (he stated as much) and for the most part the service at the office. He complained long and intensely about an event two weeks ago where he had trouble getting refills on two medicines. The problem started in that he had not been in the office for over a year. I have blogged before about this issue and a year is on the extreme end of what is acceptable, six to nine months is more typical. One thing led to another and my staff and him got into a verbal tussle, with him loosing his composure and my staff digging their heels in.

Although I will admit there was probably an easier way to handle it, my point is that after 18 years of excellent treatment I expect to have earned several mulligans. Many in fact. Yet this one difficulty let him to think of taking his business elsewhere! As if he can find another office that only has a bad day every twenty years!  Good luck with that.

I am not saying that my staff did things wrong, their point was valid as were the patient’s complaints. I am saying that it could have been handled much more simply on both sides, but nevertheless, I fell that for every year we do well by our patients they owe us one mulligan for a bad encounter. Perhaps a real bad encounter would use up two mulligans. Nevertheless this patient’s tolerance for frustration is so low that it was all I could do not to hand him the list of nearby physicians and wish him luck with his extremely low tolerance . The number of patients that do that and then come back is legion. They do not know what the norm is out there and when they discover that they return. The number of patients that move away, but still within driving distance and remain with us is also legion.  We are by far the most flexible and understanding office in our area.

Perhaps we have spoiled out patients and we need to reevaluate our policies and become more strict. Interestingly there are many patients to do ‘get it’. These are usually patients that have significant experience with the world and can appreciate how much we work with them to help them out.

Someone this fragile is scary to us. We are not perfect and occasionally we will mess up, how will they deal with that?

What are you thinking?

We received a call from a 45 year old insulin using diabetic who is a tradesman. He had just but his drill through his hand and wanted to know when his last tetanus shot was.

Whoa! we said, tetanus schmettanus, you need to come in right now, and have someone look at that hand. We are full to overflowing but we will fit you in.

Nope, can’t do that, my doctor is already mad at me because my sugars are all out of whack and I just need my tetanus. We did manage to force him to come in the next day, although this could easily have turned very ugly well before then.

He did show up the next day and although the hand was beginning to show the signs of an infection, it wasn’t terribly bad yet. His sugars however were way off his normal. It turns out that he had realized he lost weight if he did not use his insulin so he stopped.

He did not tell us that, his wife who had her own appointment earlier in the day rat finked him out.

I did find out that he was trying to put a screw into a hard surface when it slipped (because he wasn’t using the proper tool–a guy thing that I understand all too well.) and it went into his hand. At which point I remarked that he had just screwed himself. (in more ways than one.)