Club Soda

Me:  Your blood sugars of 300’s are very elevated.  We need to add a medicine, or else you may have a heart attack or stroke one of these days.  Let’s add metformin.

Mr. Adamant:  No, I cannot take that because it makes me feel “weird.”

Me:  What do you mean “weird”?

Mr. Adamant:  I don’t know, I just can’t explain it.  I just don’t like it.

Me:  Ok, then we can add pioglitazone.  It’s more expensive, but we don’t have too many choices at this point.

Mr. Adamant:  No, I tried that before and it makes me gain weight.

Me:  Did you lose the weight after you stopped it?

Mr. Adamant (while attempting to conceal the soda can clutched in hand):  No.

Me:  Ok, then the only other choice we have left is insulin.

Mr. Adamant:  Oh, no -- I definitely won’t take that!  Over my dead body!

Me:  There are no other choices.  Why won’t you consider insulin?

Mr. Adamant:  I tried that before and it didn’t work.  In fact, nothing the doctors have given me works to lower my sugars. 

Me (while pointing to soda can):  But perhaps it’s because you refuse everything we give you!

Sigh…

Three-Ring Circus Clinic

When I was a little girl, attending the circus was the highlight event of the year. I remember looking forward to it each year – perhaps because it was something fun, and each year something new. Never the same show twice. Very busy behind the scenes, yet at the same time, quite organized and appearing smooth on the surface.

In the same way, the clinic can be a truly hectic scene. But with me as Ring Master, I was able to magically eventually learn to conduct my three rings of fire for a much smoother overall show, with spotlight on the dedicated patients, meticulous staff, and me with my super chic top hat.

I have to admit that there have been days in which I have magically seen up to nineteen patients in one half day. However, I wouldn’t say that I am proud of that, or that it went smoothly. That is how many patients the average physician sees in one full day. But, I did learn greatly from the experience. I was forced to learn how to become very efficient. It’s survival of the fittest. If you aren’t efficient, you can easily become prey to your tigers and lions when seeing this many patients a day.

It was a gradual learning process, one that included some trial and error. But I have learned a few magic tricks to make my days run smoother. Here is what I learned as the clinic Ring Master, which may perhaps be helpful for others who put on a similar show:

• Practice Your Magic Tricks: Review the patient chart thoroughly before you walk into the exam room. First of all, it’s too distracting to review the chart when the patient is talking to me. Second, I may be construed as “rude” by the patient while doing so. I need to refresh my memory and review pertinent details of the patient’s case. I write all over the progress note and come up with their diagnosis list and my plan for them before I even walk in. For instance, if I have a diabetic that comes in for headaches, I come up with a plan for their diabetes – retinal photo, diabetic foot exam, and a pneumonia vaccine that they are overdue for. I write this in the chart. Then I walk in and address the patient’s concerns about the headache, and at the end take care of their diabetes. Reviewing and writing in the chart before I walk in saves me a lot of time, and gives an idea of how I want to manage my time with the patient knowing that they need other items addressed besides their headache. In this way, I am prepared to show off my magic tricks before I perform for my audience.

• Aim for the Cirque De Soleil: I train my medical assistants (MA) and aim for the best show. We have an occasional shifting of MA’s in my clinic. That means that every once in a while, there’s a new MA that needs to be trained on how I expect them to room my patients. Therefore, I have made a list of how I would like the patients to be roomed based on their symptoms. For instance, every patient with chest pain gets an EKG. Every patient with burning with urination gets a “urine dip” test. Every patient with a breast complaint needs to be dressed in a special gown for examination. This saves me time since I have these items completed before I even see the patient. I may even make a “pocket version” of this list and dispense one to each new medical assistant. My MA’s are then the elite of all performers.

• Construct the Stage and Props Meticulously: Take Photos of Rooms. When I have to leave the exam room to look for a band-aid, or goodness forbid a pap smear speculum in the middle of performing a gynecological exam, this wastes a lot of time (not to mention is also quite a disturbing experience for my patients). Rooms should be stocked frequently, and with items that I personally use frequently. Simply telling the staff to “stock the room” is not sufficient. Stock the room with what? One trick I learned is to create the ideal exam room myself, and then take photos of each cabinet, drawer, and tray. I then printed those photos and labeled each item in the photos. These photos were placed in a central location that the staff grabbed to take with them when stocking the rooms. And the stage is ready for show!

• Print Your Show Itineraries: Keep a stack of commonly used forms and handouts in the exam rooms. This saves me time; I no longer have to walk out of the exam room to fetch the handout from my office and return to dispense it to my patients. Every seat is prepared with an itinerary.

• The Ring Leader Calls the Shots: Delegate. Seeing this many patients a day, I am not able to respond to every patient message or request. I am not able to call every patient with their normal lab results. I delegate a lot to my very-efficient staff. This delegation has truly been key to running a successfully busy clinic. As Ring Leader, I call the shots and put on the show.

Now, let the show begin!  Lights!

Shifting Speculum Gears

New national Pap Smear guidelines have been revised by the American College of Obstetricians and Gynecologists Committee (ACOG) to commence at age 21, regardless of the first age of intercourse. Prior, we were screening for cervical cancer within three years of first intercourse, or sooner depending on patient risk factors.

This has caused some confusion amongst patients and the staff. Patients often still come in asking for a pap earlier than age 21 (because that is what they are used to doing), and the staff is continuing to room these rather confused patients. Like with everything else, when shifting gears, it takes a period of transition and acclimation to new guidelines every time they are revised.

Why the delay in screening age, my patients often ask? For several reasons:

1. Studies show that screening prior to age 21 does not prevent enough cases of cervical cancer to warrant screening. Let’s face it, the pap is not a pleasant visit. We all dread it. Why place these helpless youngsters into an uncomfortable position year after year when it may not even prevent cervical cancer?

2. Cervical cancer is rare in this age group, and accounts for one to two cases per million women per year.

3. The risks of having procedures performed on the cervix in those less than age 21 may place them at risk of preterm labor later in life in pregnancy.

4. Most Human Papilloma Virus (HPV) infections, the main cause of cervical cancer, in women of this age group are transient and self-resolving.

5. Cervical cancer is a slow-growing cancer that takes years to develop, allowing ample time to be discovered after age 21.

There are a few exceptions, however, that may require screening prior to age 21 (which you should discuss with your personal physician):
• Those with a diagnosis of HIV.
• Those with a prior organ transplant.
• Those with a history of long-term steroid treatment.
• Those deemed higher risk by their personal physicians for any other reason.

Knowing all of this, I personally wouldn’t want a pap before I was 21 years old. Would you?

Stray Cat

Moving sure is no fun; not in the least bit. A seemingly endless to-do list has kept me busy and feeling quite like an anxious cat. This just goes to show that even positive changes in our lives can be stressful, something I always find myself saying to my patients. I feel like an anxious stray cat searching for a home.

This experience reminds me of a favorite patient handout of mine that I ran across while cleaning house, depicting the CATastrophic signs of anxiety and what you can do to combat it (I don't know who designed it, but it's brilliant):

Life isn't always “purrrfect” (or perhaps even close)…

Gross Emotions

Here’s a true story from the Operating Room:

Surgeon: “Intern, what is the story behind this patient?”

Resident Intern: “Patient is a 51 year old female with breast lump on the left side, and 17 out of 20 lymph nodes positive for cancer.”

Surgeon (speaking in a rather ‘as a matter of fact’ tone): “Oh, she’s F_ _ _’d.”

Resident Intern: shocked, frozen and unable to respond.

'How do some physicians become so stoic?' I was once asked by a frustrated student. In one of my recent posts, Breaking Up is Hard to Do, I wrote about feeling sad in regards to saying goodbye to my patients, despite this unsettling feeling that somehow I was not “supposed to” allow myself to feel.

It wasn’t until one of my favorite physician bloggers, Dr. Synonymous, wrote a comment in response that made me think about why I felt that I was not supposed to get attached to my patients. This is what he said:

“Dr JAT, You KNOW you don't believe the above comment about "refrain from getting attached". In family medicine, We are SUPPOSED TO GET ATTACHED to our patients. That is the definition of compassion. That is what separates our specialty from many others."

Family physicians are stereotyped for being a rather pleasant, friendly, and compassionate bunch (in general). But there is still this underlying unspoken culture amongst some physicians (not all) across all specialties, including primary care, that perhaps frown upon the notion of allowing yourself to express emotions in your practice.

However, it is often necessary for physicians to build this rather concrete wall around their true feelings as a coping mechanism, in order to be able to function optimally in their careers. Because truly, after seeing patient after patient, if you allow yourself to feel too much it can wear you down in a big way.

Imagine this: you are a physician with approximately twenty patient encounters a day. Several of those twenty are very ill or dying. A couple of others are with major depression entrenched in helplessness, and perhaps contemplating suicide. And then another one or two who get angry at you for not prescribing them the medication that is driving their addiction. Several may be frustratingly non-compliant, and don’t take their medications like you prescribed, and now their health is deteriorating irreversibly as a result. Then, there are a few more that really make your heart sink, because frankly, they are the nicest people you have ever met, and there is something very serious going on with their health, and it is so unfair.

Now multiply that by a minimum of 5 days a week, 52 weeks a year, which comes to 260 days a year.  This gives perspective as to why some physicians may appear to be stoic on the outside.  It’s about survival of the fittest in this profession.  Because how else can we function otherwise?

When were we all first taught of this unspoken ideology encouraging us not to feel? Is it passed down from generation to generation as a culture while in training?  While contemplating Dr. Synonymous’ remarks, I can recall as far back as my Gross Anatomy class. I remember in the very beginning of the course, my small group was forced to confront our first real deceased human being lying before us. He was so real. He had a tattoo on his arm, with presumably his significant others’ name on it, and many surgical scars. Who was he? How did he pass and leave this world? Who did he leave behind? We all contemplated the answers to these mysterious questions while we respectfully dissected our cadaver as a team.

When the course commenced, we had a sort of a required "support group," in which all medical students were randomly assigned to a small group with an instructor, in order to discuss how we are dealing with actually knifing through deceased human flesh.

I remember the instructor asking, “What are your thoughts on dealing with this issue?” I was relieved to hear this question, because I had heard some students discuss their struggles (whether it was spiritual, religious, or personal) with the challenge of a face-to-face encounter with a body that was once alive. However, when we went around the room, no one voiced their thoughts. No one spoke. I knew that even though several had shared those difficulties with me in private, they were perhaps afraid to voice their emotions in an atmosphere where “sharing your feelings” is not encouraged. How can you blame them?

Finally, there was one student whose words I will never forget. He expressed that he personally tried to view the cadaver as an “object” and that it was only when he looked at his cadaver’s hands that it seemed so “real” to him. “You do a lot with your hands,” he stated. He too was struggling to feel.

But there is something about going through the medical school and residency training process that begins to harden your soul, in preparation for protection against the potentially emotion-draining life as a physician. Is it a bad thing? I don’t think so. Perhaps it is a necessary, hardening process to experience in order to survive mentally.

At the same time, however, I think it is very important to maintain compassion. There has to be some balance. It’s a primal instinct to want to be loved and cared for, and physicians who are able to feel and convey this compassion may have much more influence over their patients’ health. And it ultimately makes us much better physicians if we just allow ourselves to feel once in a while.