Man struggles to find life outside himself, unaware that the life he is seeking is within him.Kahlil Gibran
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I love children. I won’t claim to ‘understand’ them, but I am comfortable with them, and happy to work in their universe rather than asking them to be part of mine. I find them easy to work with. The ED nurses occasionally referred to me as the “child whisperer.” I am often asked by friends and colleagues why I did not become a pediatrician.
As a child, I looked forward to the infrequent family outings that involved a restaurant. As the eldest of three, it gave me a chance to strut my stuff in front of my sisters: I was allowed to order without much interference, so it was a rare opportunity to have a cheeseburger, fries and the most chocolate item available for dessert.
“Just keep doing tests. Eventually you are bound to find something.” She was right, of course. But not in the way she meant.
After decades of hiking, camping, canoeing, kayaking and swimming in various back country environments, it finally happened. I have been colonized. Beaver fever, also known as giardiasis, caused by the protozoan Giardia lamblia. Enjoying my metronidazole.
I find myself a stranger in a strange land, or (more prosaically) a square peg being forced into a round hole.
I was recently told that ‘the problem’ underlying my often strained relationship with the institution where I work is that I am a revolutionary working in an institution committed to incrementalism.
Forty four good years, with more to come. I’ll honor it with some words we started with…
I don’t consider myself a laborer, though I surely work very hard. I work because I love to.
‘Taking a history’ is one of the first clinical tasks medical students are taught. The logic behind this is inescapable: without the history, attempts at diagnosis and treatment are doomed to failure. We start our training with the history, when we present patients for discussion with other doctors (in training or later, in practice) we start with the history. And except in rare emergencies, we start every patient interaction with the history. The history: it always starts there but it doesn’t end there.
The appointment was for his annual physical, and to review his well controlled hypertension and gout. After we had addressed these issues, I asked if there was anything else he was concerned about.
In a previous post I talked about some important questions I ask myself in my attempt to avoid missing the correct diagnosis.
I have a serious problem with the ubiquitous use of 'due' when talking with patients about what their medical options are. This came up recently when I was given a list of my patients who were ‘due’ for certain services, required if my institution is to receive a financial quality incentive. Typically, ‘due’ shows up in EHR alerts (the diabetic patient is 'due' for their A1c or microalbumin) and quality programs (patients are 'due' for a mammogram every 2 years, a DXA at 65, a pneumovax at 65, even well child visits at set intervals). Clinicians see it and hear it so often, it becomes part of our internal thought process. But it is wrong and harmful.
Treating patients with chronic pain is one of the more challenging tasks in primary care: how to measure pain, how to quantify disability and quality of life, how to balance to benefits of pain relief with the potential risks of medication, that it is usually multifactorial rather than simple, how to manage the almost always associated significant mood disorder. (If you hurt all the time and can’t sleep, guess what happens?) Some of the most troublesome issues, however, are not clinical. I recently wrote about the increasingly common - but problematic - use of urine drug screens (UDS). Similar issues underlie the (mis)use of ‘narcotic contracts’ as a requirement for prescribing opioids for chronic pain.
Ordering periodic urine drug screens (UDS) on patients being treated with opiates for chronic pain has become so common it is now the de facto standard of care. That doesn’t mean it benefits patients.
Every year when I brought my chain saw in to be serviced and have the blade sharpened, Reggie tried to get me to buy a set of chaps. They weren’t cheap, and, while I was not the least bit sanguine about the destructive power of the saw, I used it infrequently, only in good conditions, and with care. The chaps were a garish orange, and I always declined. Reggie always shrugged, looked disgusted, and rang up my bill.
I love taking care of patients and have enjoyed my 37 years (and counting) as a primary care physician. When I stop, it won’t be because I am rich, bored, or have lost interest. It won’t be because I am tired (though I am). It will be because of friction.
The 15 minute appointment slot is dead. To borrow from Monty Python, it is not resting, stunned or pining for the fjords, but definitely deceased, stone dead, is no more, has ceased to be, expired and gone to meet 'is maker, a stiff, bereft of life, run down the curtain and joined the bleedin' choir invisible.