family practice issues and general life events

Archive for April, 2012

Attitude is everything

Or my self serving whiny post, which does nothing, teaches nothing, and is merely in existence for no other reason than it makes me feel better.

Sometimes I have days like today. Where when I walk into the room, and ask the patient how they are doing, and today is the worst day of their life. If it is one or two, well that is well not ok, but feasible, because at some point you will have the worst day of your life. This morning however, it seemed like it was everyone’s worst day ever. It improved somewhat this afternoon, in that only half of the patients were having their worst day ever, the rest just have multitudes of complaints

In reality, dealing with a couple patients who view everyday as the worse day ever is tiring, a whole morning is exhausting and mind numbing. It is enough to wish for a fully stocked bar in the office. (I said wish, I rarely drink, so much more that a glass or two of wine would make for a bad idea, especially in the middle of the morning, er I mean the afternoon.

Anyway, it is in those patients you realize how important one’s attitude is to their health. Patients who believe that everyday is terrible never seem to be getting better, and while it might be my doctoring skills, I have patients that seem to improve. So that gives me some hope for my skills. I have patients who have their diabetes under control, their blood pressure looks good, and sometimes walk in and say “I am all better.”

And then there is the others. The ones that despite running ALL the possible tests, you still cannot find a reason for their worst day ever, which by the way is worse than their previous visit that was also the worst day ever. They have pain that is a 12 on a 10 point scale where 10 is being caught on fire currently. And then the mention a random surgery were half of the bowels were removed 15 years ago, that they forgot to mention previously. (Not really, pretty sure I would have seen that scar) But there are unmentioned surgeries, medications, and dietary factors that they neglect to mention. Or other doctors that are prescribing medication. (Sometimes the same medication and sometimes one causing side effects that you are treating.)

And then when you do the workup for a condition, you find out that even though their symptoms scream gallstones, they had that removed 5 years ago, and well they didn’t think it was important to mention. I mean after all they no longer have that organ so how can it be the problem? Though I have been told that they didn’t mention it, because they thought that it might have grown back.

Back to the attitude mentioned in the title. Those with an overall positive outlook in life really do seem to heal better, they are healthier. They try, they are not hoping for a magic pill to cure all. And some of them have significant medical diseases. They have the belief that things can get better, that there is something in life worth living for. And they are living life. This does not mean that they don’t have pain. They may, they might not, but they are trying to experience and live. There is some purpose to their lives.

It is not that they don’t have pain in their lives, some have significant tragedies. Death of spouse, child, fighting disease, but they are looking for a greater meaning. They accept that bad things happen, and maybe just maybe these events help you to appreciate the good times. The understand the need to experience everything that life has to offer. And just by seeing them, you feel better. They make your world better just by them being in it.

Attitude is not the end all, cure all. But it is a necessary component to improve one’s life. It helps with healing, it helps to give strength and motivation. It is what makes one successful in life.

Professionalism and Courtesy

Today a patient made me terribly mad.  It was not at her, but what she told me occurred at her last hospital admission.  The first angering part was that she was admitted without even the courtesy of a notification.  Per her ER chart, she listed me as the physician, and in our case, it is routine for all of my patients to be admitted to my husband.  I don’t take call because when we opened up practice I was 7 months pregnant and had an active 2 year old at home.  If I took call, there was the potential for both my husband and I to be called at the same time, and being forced to take two kids to the hospital in the middle of the night.  So I don’t admit to the hospital.  I never lost my privileges.

Now she did need a specialist, and I could have been merely annoyed if this was not the fourth patient in the past month that this has happened to my husband and I.  Someone elected to admit to the specialist without the courtesy notification, regardless of what the norm admission procedure of admitting to the PCP and consulting the specialist.  However, this is minor compared to the rest of the patient’s story.

Apparently, nursing staff at the hospital decided to bad mouth me and several other physicians, in the hearing of my patient.  Apparently she overheard them say that I was lazy (because I don’t take call) and that I didn’t know what I was doing, that the medications she was on was not appropriate, etc.  She states that she heard many other comments not only about me, but about most of the other physicians in the hospital.

Now as a little background, morale in the hospital is currently low.  And when asked what needs to be done to improve patient care, every physician I know has repeatedly said, “Do something to improve morale.”  or “How can you make nursing and other staff feel that they are valued and that they are desired in their job.”  There has been a lot of changes in the past 18 months with a change in CEO and the changes that go along with it.  While I don’t agree with all of the changes, it is what it is.  I fully understand why the staff feels a little under-appreciated, but there is also a need for professionalism regardless of what you think of someone.

As a common courtesy, you should at the very minimum have the guts to speak to the person that you don’t think is doing a good job.  But if you don’t have the guts to do so, courtesy dictates that you don’t speak poorly of the physician in front of their patients.  Or at the very minimum, make sure that you have evidence.  Speaking poorly of people does not make you appear better.

I try to have a good relationship with my patients.  Many due to the nature of their disease processes or medications I see monthly.  So the short term hospitalization full of bad mouthing does not usually do much but cause people to doubt the care they are receiving in hospitalization.  Show pride in yourself, and not bad mouth others.

Don’t get me wrong, there are providers that I disagree with and specialists that I prefer not to use.  I don’t however, bad mouth them in front of the patient.  My staff might know how I feel about the person, but there is no excuse to bad mouth them in front of someone else.  It does not improve your standing in front of the patient.

This does not only apply in medicine, but few other professions is trust so integral to the health of the patient.  Since I don’t know who made most of the comments, I may sound hypocritical here, but I would approach these people if I knew who they were.  And unfortunately I doubt any would admit it.  It has been reported to the appropriated channels, but I don’t know if things will improve from doing so.  I hope so, but I am now currently considering other options.  

But in this case, reporting is absolutely necessary.  My patient was visibly upset.  I had to answer whether my privileges were revoked and why “I refuse to see patients in the hospital”  And why I don’t mind answering the questions when they ask on the initial visits, it is entirely different when the patient believes that I have deserted them in the hospital.  So now, I have to be their advocate.  This is not to say that nurses don’t have a right to their own opinions, but to be so vocal about them that patients are uncomfortable is not professional.  

Part of my job is to advocate for the patient, to make sure that their needs are being addressed, and if there is a problem, to make sure that their concerns are being heard.  This is not to say that every nurse she had taking care of her didn’t do an excellent job, that some didn’t do their best.  She told me there were some that did good, and were concerned about the care that she had received prior to them.  However, after this hospitalization she had concerns about her care and whether she would want to be seen there in the future.  Remember that, you represent not only yourself but your employer.  And if you are miserable, people know, and they worry about the care that you provide.  So show some pride and act professional.  To do otherwise, it only reflects bad on you.

 

Why double pneumonia is like irregardless and why it matters

Something that I really agree with-

Dr. Jen Gunter

MSNBC is reporting that Rick Santorum’s daughter, Bella, has unfortunately been hospitalized again. Considering she has Trisomy 18 multiple hospitalizations are sadly expected.

The article started out well enough, using the National Library of Medicine and a pediatric palliative care expert as sources and reviewing the medical issues faced by children with trisomy 18 who survive. And then I saw it. The dreaded doublepneumonia.

Sigh.

There is no such medical diagnosis. Just like the word irregardless, people use it, but that doesn’t make it correct nor prevent it from sounding like fingernails down a chalk board. I once broke up with someone because he used irregardless 3 times in an evening. I mean, really.

So let’s get one thing straight. Double pneumonia is not a medical diagnosis. When I hear it, I wonder do they mean:

A) twice as bad
B) 2 lobes
C) both lungs
D) 2…

View original post 141 more words

What does the new data from the CDC actually mean regarding autism?

With this month being autism awareness month and the CDC’s publishing that autism is now 1 in 54 males, and 1 in 212 females with an overall prevalence of 1 in 88, I am inclined to write about how I feel about this.  And in reality I am not sure.   If you take it at face value, autism has increase 23% since 2006.  This is when there was 1 in 110.  And if compared to 1980, the increase is even more incredible.

The problem with looking at this increase is the change in the inclusion criteria.  Whereas in 1980, only the most severely affected was diagnosed.  Those with Aspergers would not have been included, and neither would others on the spectrum.  And if you look at the spectrum, well the entire one actually includes ADD/ADHD.  And recent reports indicate when DSM-V will actually narrow the inclusion criteria, so will the numbers go down?

I thought about my own practice, am I seeing these numbers or am I missing some.  While I might be able to accept the number of girls, I am uncertain about the amount of boys diagnosed.  Am I missing that many?  Or is my practice just not have that many in particular, and some other practice has a greater proportion?

Another angle to look at is the fact that there is increased awareness of the disorder and an increase in the ability to treat.  This happens with all disease states, and often the increase occurs after treatment has been accepted and become routine.  So there is also that.

The other concerning bit of data, is that those that are diagnosed earlier are still sitting at the same frequency.  The diagnosis of the older child (meaning 6 to 8) is actually increasing.  Why wouldn’t it increase in the earlier ages?  Are we still lacking in the ability to fully diagnose the younger children?  Or are those that are getting diagnosed at an earlier age actually suffering from something else?  Maybe that is why they didn’t show the signs earlier because they aren’t autistic.  This is purely a thought on my part

And I often wonder about those doing the diagnosis.  I don’t have time in my office to do the entire diagnostic test.  I wonder if these children with the diagnosis are from the physician (pediatrician or family practice) or if they went to a developmental psychologist or developmental physician.  Sometimes what appears to be true in a 15 minute office visit might be masking something else.  I am not saying that this is the case for all those with the diagnosis, but without access to the entire set of data, the report raises more questions than it answers.  And to be honest, I don’t have time to pour through the data, but I do have many questions, as I compare it to my practice.

In the end, the new report doesn’t answer much.  There are many dedicated scientists who are working on the answers as to who and why.  And they are determining why it appears in one child in a family and not necessarily others.  They are looking into environmental factors and what triggers the expression and why presents in one why and why another.  And there is seeming to be an increase in incidence in children with older fathers, as opposed to many of the other developmental conditions with increased risk in the mother.  Dr Kevin Pelphrey discusses this in his talk with the Autism Science Foundation.(1)

If anything, the report indicates the need for further research.  The need for diagnostic tools to diagnose earlier to start therapy earlier and other recognized effective treatments.  And the need for making sure that it is the diagnosis.  Unfortunately, there is no blood test for autism.  The tests use diagnostic tools which help to indicate whether or not the child meets the criteria.  There are new studies using functional MRI underway which are showing some differences in brain function in infants that later on have the diagnosis of autism, and while exciting, there are still in the study phase.  And in reality, out of reach for many clinicians across the country.  And how do you justify ordering a functional MRI on a seemingly normal infant?  

So to me, this report raises more questions than it answers.  And I will wait to determine whether I accept the report on face value until more data is released.  What it does do is illustrate the need for further research into early detection, and why some children develop autism and some don’t.  We need to look at the environment, both what is around us and what we are ingesting, and above all look at siblings, why does one sibling show signs and another doesn’t.  And why is the incidence so much higher in boys than girls?  But we do need to have a consistent diagnostic criteria, because right now the  ever changing criteria means that we are comparing granny smith apples to apples in general.    

 

1.  Autism Science Foundation: Chat with a Scientist- Transcript: Chat with Yale Autism Scientist Dr. Kevin Pelphrey, April 6, 2012 found online at http://www.coveritlive.com/index2.php/option=com_altcaster/task=viewaltcast/altcast_code=ce2c575ca5/height=550/width=470

Decision making

Making decisions is often a more complicated process than we give it credit.  It is not always a matter of what is right or wrong, that would be a lot easier.  Most of the time it is shades of gray.  It is easy to make a decision when it is popular and everyone is cheering you on, but what about when your decision is not popular?  When it makes those around you well if not angry, at least not happy?  Does that make it the wrong decision?

It could fully be the best decision, but maybe it affects them in some adverse way.  Maybe it means a little more work, or they have to get things put in quicker, but it doesn’t always mean it is the wrong decision.  In my business, I have found myself at one time being forced to lay people off, because financially well we were in trouble.  It was the best decision for the business, but not necessarily for those individuals.  Though I will tell you that the staff left was able to perform their functions just as well without them as with them.  So it actually revealed more to me about those that were no longer with the company. 

Earlier this year, I had to forego a paycheck personally to keep my office running and make sure that my employees get paid.  Terrible decision personally, professionally well we are still going.  And doing ok.  Unfortunately for them it makes me a little less sympathetic when I don’t think that they are doing the job, I would like them to do.  Something about working for free does that.  And yet at the end of that time, I find that I have found better solutions for somethings, and have identified areas that don’t work

Decisions in business, while we like to pretend that they are not personal, well they always have a personal effect on the person they are done to.  It is not like we live in a vacuum.  Losing a job due to downsizing is terribly personal to the person that is no longer employed, even if it had nothing to do with their performance.  But sometimes like all tough decisions, cuts have to be made, and unfortunately in many places payroll is both the most expensive of the overhead, and the easiest to cut.

The key to being successful overall is running a business with the most efficient and lowest amount of overhead possible.  this means making sure you have the staff you need, but not too many that someone is allowed to slack or you start running into one another.  This is something I have yet to master but I strive for.  And hopefully someday I will acheive

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