There once was a llama of gold
Whose image was one to behold
The bloggers did love it
And unwaveringly covet
So to the new contest entrolled

A haiku is sort-of a poem
Though many who read them don’t know ‘em
The rules are unbending
From start until ending
Just one added word and you blow ‘em

And put these two in combination
And soon you have made a sensation
Just write health haikus
And aim to amuse
And you will earn gold acclimation

And now comes the part that’s unnerving
For lots of them were quite deserving
But I’ll end the drama
And hand out the Llama
But from what I choose I’m not swerving

So as I present my selections
The ones who have won my affection
Look down to the bottom
That’s where I have got ‘em
I sure hope you grasp my directions

The first choice had me singing gaily
By Hillary Gorman Israeli
A Healthcare lament
To put on the vent
The system’s survives only frailly
(1)

The second tells what may undo us
A fine haiku by Leigh St-Louis
“Cold” is her word
Of life uninsured
Oh how the Canadians must view us!
(2)

The third winner now I am tellin’
A reader who’s named Mary Ellen
A likeness so true
‘tween health and haiku
An entry that was quite compellin’
(3)

The next is from good doctor Smack
Who showed that for shame she does lack
Those socks from the llamas
Will match my pajamas
But why not use hair from a yak?
(4)

The final haiku I’m presenting
That Limpens gal who’s unrelenting
She wrote a whole post
But what touched me most
The hours of a life residenting
(5)

But wait, guys, the party’s not ending
For other gold llamas I’m sending
To those who unswerving
Have done things deserving
And so now my rhymes are extending

A nurse named Kim got us united
A medblogger track was farsighted
She got us to Vegas
Not having to beg us
And next year you all are invited

a blogger from far away nation
made blogworld his lone destination
so bongi’s awarded
his praise is accorded
given sans capitalization

And so now this rhyming is ended
My neruons’ last energy spended
Now please stop your crying
And always keep trying
To win a gold llama so splendid

——————————————————–

Haiku winner #1

our healthcare system
is on a ventilator
should we pull the tube?

Haiku winner #2

can’t afford health care.
and can’t move to canada.
situation: cold.

Haiku winner #3

Healthcare like Haiku
law bound and bureaucratic
theories change, rules same

Haiku winner #4

Distractible Mind
If you send me llama hair
I will knit you socks.

Haiku winner #5

Dark when he leaves home,
Dark when he returns from work.
Resident Life.

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Breast cancer makes me quite emotional.

My mother and two of my sisters have had breast cancer; all were picked up with mammograms.  A good friend of ours was diagnosed in her forties with aggressive breast cancer through mammography.  She is currently doing well.

I don’t like breast cancer and am definitely against women dying from it.

This is my backdrop when I consider the USPTF’s latest recommendations:

The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.
Grade: C recommendation.

The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
Grade: B recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
Grade: I Statement.

The USPSTF recommends against teaching breast self-examination (BSE).
Grade: D recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
Grade: I Statement.

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.
Grade: I Statement.

This has made the general public quite emotional.

There has been a huge public backlash.  People don’t trust these findings and are willing to talk about it.  Why in the world would they recommend against teaching self-breast exam?  Is this the Obama administration’s ploy to cut cost?  Are women’s health concerns being pushed aside for the sake of saving money?

Now congress is getting involved. There are going to be congressional hearings about the issue of how breast cancer screening is best done.

Why has this sparked so much emotion?  Nobody got worked up with the recommendations about car seats.  As emotional an issue as immunizations is to many, recommendations in that area do not spark congressional hearings, front page articles, and public emotion like these breast cancer recommendations.

There are several things that charge this issue beyond that of rational debate:

1. It is happening in the midst of reform discussions.  Anything that recommends less care is held suspect, as the timing implies that this is a politically motivated recommendation.
2. It deals with a disease that brings fear in most of us, pulling out the reassurance that it can be prevented.  People want to believe that science can keep them from harm and this makes us feel more vulnerable again.
3. It contradicts the previous recommendations that moved from simple science to public crusade.  Every woman who did not get mammograms or do self-breast exams were made to feel guilty about it.  Medical students and residents were scolded by attendings if they did not address this issue.
4. It is a “women’s issue” that makes some feel like women’s needs are being set aside.

To everyone else, this is a political, social, and scientific discussion.  The debate can rage in the halls of congress, on TV talk shows, and over the blogosphere.  But at the end of the day, I am the one who has to face the patient and discuss the reality of cancer screening.  All of this talk and debate is about what I do for a living.  I am at the eye of this storm, despite what grandstanding congressmen make, what accusations Obama-haters fling, or what eye-rolling scientific purists say.

That makes me quite emotional.

My job is being taken over by congressmen.  They will decide what is appropriate for me to order, and not doing so will go against the standard of care.  Medical science is being torn away from what’s best for people and is becoming fodder for stump speeches, talk shows, and attacks on political opponents.  Discussing mammograms in the exam room no longer centers around what is best or what has the best evidence, it centers on politics.

Please let me be a doctor.  Please let me get to know the patient, read the authorities I trust, and make the best decisions for that patient.  Stay away from this, politicians!  You are bad at making political decisions, so why should you be trusted in medical decisions?  Don’t say you do this in the public interest when it clearly involves what’s best for your political career.  I don’t like being a pawn.

Unfortunately, there is little chance of that.  If a recommendation by the USPTF causes this kind of brouhaha, do you think good reform can really happen?  I doubt it.

And that makes me quite emotional.

This post isn’t about the content of those recommendations.  I have read both sides of the issue and see rationale both ways.  I would rather not debate the issue itself (it caused an argument at home this morning already), as I understand how people’s emotions are high as well.  I am just frightened of a world in which science needs to be ratified by congress.  I don’t like it when Oprah has an influence on how I do my job.  I don’t like the USPTF to be accused of being a covert wing of the Democratic party.

My job is hard enough.  My decisions are hard enough.  My days are hard enough.  Why can’t I just be a doctor?

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The ongoing saga of ADD (and sometimes H) continues on today’s podcast.  I go into more details about how to diagnose it, and the why, what, and when about treatment.  (Go HERE for the podcast, or download it on iTunes.)

One point I make in the podcast is that I do think that stimulant medications are over-prescribed.  They are often used in cases so a person can “do better.”  Nearly everyone can increase focus and do better when taking stimulant drugs.  The real question when considering treatment is whether the ADD is really causing problems.

I am sad that our society seems to want to minimize all struggle.  Struggle is not only inherent in life, it is what makes us better and stronger people.  Somehow our society has changed from a mindset of facing struggle to that of avoiding it.  We do ourselves and our children no favors by removing all obstacles.

This doesn’t mean ADD should not be treated with medication; it just means that the criteria to treat it should be more than just “it’s hard.”

PS: If you want to know why I included the picture at the top of this post, you have to listen to the podcast.

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It’s that part of the job that I’ve never gotten used to.  I hope I never do.

I saw a man recently with an unexpected finding on his exam – a “lesion” that should not have been there.  I was seeing him for his diabetes and blood pressure, and was doing my “ritual” physical exam, when the “lesion” blared into my vision.

I say “ritual” exam because the exam itself had little to do with his medical problems.  It is just my practice to do a cursory  exam of the head, neck, chest, and lungs of most everyone who comes to the office.  I guess it’s the “laying on of hands” part of the practice of medicine that makes me do this; there is something about the human touch that makes a doctor’s visit different from a visit to the accountant.

I got a sick feeling in my stomach when I saw it.  I like to make people better, I like to make them happy; now I had to give some bad news.

When broadsided like this by an unexpected finding, it’s work to keep a calm composure.  I was surprised and very worried, but I tried not to show it on my face.  Why do I feel the need to keep calm?  My visceral reaction would be to exclaim, “Oh, no!  What is that??” but even a small amount of shock and surprise could have a negative impact.  I suppose it’s because people need to face hard things with confidence, and my reaction will have a big influence on his own outlook and perhaps even the outcome of his disease.  I am sending him off toward one of the hardest things in his life, and I want him to go with the best possible mindset.

“So, have you noticed this before?”  I asked, fighting to keep a calm expression.

“Yes, it has been there for a few months and since I had this appointment scheduled, I waited to see what you thought”, he replied while looking into my eyes, gauging my level of concern.

I took a breath and calmed myself.

“Well, I have to say that I am worried about this and I think you need to see a specialist for further evaluation.  It very well may be cancer, and if it is I don’t want to delay things.  There is no way to know if it is something serious, but I always err on the side of caution.  I am very concerned about it.”

As I explained, his expression changed little.  He kept studying my face, measuring just how much he should worry.  I wanted to convey to him the urgency and gravity of the situation and yet not over-state things.  Fifteen years in practice has taught me that sometimes “sure things” are not what they seem.  I don’t want him to skip the specialist visit and delay diagnosis and treatment, but I also don’t want to paint such a hopeless picture that he will think, “what’s the point?”  I craft my words as carefully as I can.

In his book The Anatomy of Hope, Dr. Jerome Groopman discusses the role of hope in a person’s battle with disease – in his case from the perspective of an oncologist.  One section of the book that I thought was especially important was his discussion on how to give bad news.  We are not taught how to do it in medical school, nor does our society prepare us to do this daunting task.  I did have a very good oncology rotation in residency, with a strong emphasis on our personal interaction with our patients, so I do have some examples to work by.  But overall, my method has been self-taught.

We physicians are not made differently than other people; we don’t have a stronger emotional reserve or innate knowledge on how to handle difficult situations.  I want people to like me.  I want people around me to be happy.  I don’t enjoy throwing emotional grenades into the lives of people I’ve cared for over many years.  Yet this is part of what I must do, and in doing so I have learned a number of things.

1.  Stay Calm – The person has put their confidence in me enough to make me their doctor, and so I need to honor that trust.  They want me to think clearly and make good decisions, which can be undermined by strong emotion.  The want me to be their guide and to take the situation in hand while they are overcome by emotion.

2.  Stick to facts – I start out with saying what I know.  “I see a lesion that has me worried” is a statement of fact.  “It could be cancer, but we don’t know until the specialist analyzes it” is also straightforward truth.  When I am asked “what kind of cancer?” or “how serious is it?”, I stay away from conjecture.  I answer: “I don’t even know it’s cancer now, and we won’t know until the biopsy is done.”

3. Don’t cloud things – I think it is important to use words like “cancer” if the concern is enough.  That is the patient’s worry, so my exclusion of  the word just leaves room for reading between the lines.  The human being in me makes me want to surround my words with others that cushion the sharp edges of a word like “cancer”, but doing so serves only to confuse the person, not help.

4.  Give a clear next step – Saying words like “cancer” is like dropping a bomb; people won’t hear much else in the visit after you say that.  But what they need to know is what the next thing they need to do. Bad things like cancer make people feel powerless and scared; giving them a plan on how to approach it is one of the most important things a doctor can do.

5.  No delays – I immediately got on the phone with the specialist while this man was in the exam room to make sure he could be seen right away.  One of the worst things I see doctors do frequently is to say things like “you may have cancer” and then leave the person to fight through the system on their own.  I could have just sent it to my referral coordinator, but who knows if the specialist may have a 2 month wait?  What’s to guarantee that my staff won’t fax to the wrong number or just forget to do the consult?  I need to do everything in my power to get the process going.  This makes the patient’s  feeling of powerlessness as short-lived as possible.

6.  Personal after professional – My first reaction is often one of empathy for someone who I know facing a difficult hard time.  But my duty is that of doctor first, and that emotion should not stand in the way of it.  Once I have handed the person off and made the plan, however, I think it is appropriate to show compassion.  I can’t make things go away, and I can’t fix the situation, but I can offer support and sympathy.  My relationship with my patients goes beyond the chart, the numbers, the studies; it goes to the human being across the room from me.  I think better care comes when there is some emotion shared between doctor and patient, although I always keep in mind that they are paying me to be their doctor, not their friend.

——————

The image of the “lesion” hung with me for the rest of the day.  I had to put most of it down and clear my mind when I entered the next exam room.  I need to offer my best to each patient, and allowing a hard thing to cloud my head could lead to mistakes.  But the putting down of hard things is never complete.  I still carry visions of “lesions”, of difficult conversations, of strong emotion that are many years past.

Yes, it’s “just my job,” but at one moment I have the opportunity and responsibility to play a huge role in one of the most important moments of a person’s life.  That is a great honor as well as a big responsibility that I accepted when I agreed to be their doctor.  If I do my job right, they leave me with understanding of the situation, with a clear plan of action, with knowledge that I know they are hurting, and most importantly, with hope.

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Yea!!

It’s the time everyone has been waiting for.  I even got a call from Oprah asking if I have chosen the winner (she’s just jealous, you know).  It’s time to give away Golden Llamas!!

Not so fast.  This post won’t actually award the GLA, but instead gives you all of the haikus in their glory (you are just going to have to wait, Oprah).  I am going to award GLA’s in a separate post so I can drag this out as long as possible.

Since there were a lot of them (31, to be exact), I broke the haikus down into categories.  Plus, I just like bossing around poetry.  So here they are:

Category 1: Reform – I originally asked for just haikus on this, but then I chickened out.  Here are the entries that actually followed my instructions:

1. Hillary Gorman Israeli

our healthcare system
is on a ventilator
should we pull the tube?

RL: Excellent poem tying reform to the practice of medicine!

2, 3. Jacqueline Limpens – (Jacqueline wrote a whole post inspired by this contest! She included several entries on Facebook)

Web 2 point ooh tools,
Might help to reform health care.
Change needs people 2

RL:  Clever play on words numbers.

Health Care Reform.
An unaffordable plan?
A matter of choice.

RL:  Referring to the abortion debate?

4. George Bennie

funny ’bout reform
it is health’s new social norm
though it causes storms

RL:  Note that haikus don’t have to rhyme (although there are no points taken off if they do).  This one pulls off the haiku, rhyme, and gives a cogent message.

5. Jenni Smith

The leaves are changing
Healthcare is being reformed
Hell just froze over

RL:  I think it’s premature to say Hell froze over; it’s just a high-pressure system that’s stalled out over purgatory.

6. Leigh Rhiannon Saint-louis

can’t afford health care.
and can’t move to canada.
situation: cold.

RL:  Excellent.  Perhaps the high-pressure system is over Manitoba.

7. Mary Ellen

Healthcare like Haiku
law bound and bureaucratic
theories change, rules same

RL:  I am very impressed at putting reform into haiku and haiku into reform.  Say hi to John Boy.

8. Amy Larsen

sad to be sick now
complicated costly
Please help us Dr. Spock!

RL:  I am not vulcan.

9. Gina Rybolt

Ah, healthcare reform
I know little about this
Thus ends this haiku

RL: That’s kind of cheating, isn’t it?  Just saying “healthcare reform” doesn’t get you in!

9A. Jennifer Dumford

Healthcare reform: porn
You know it when you see it
But can’t define it

RL: I left this one out in my first draft of this post.  It’s really good too.  My goof…

Medical Life - When a lot of medical people write poems, there will inevitably be a bunch about what they do all day.

10. Jacqueline Limpens

Dark when he leaves home,
Dark when he returns from work.
Resident Life.

RL: Yep.  That nails it!

11. Kim McAllister

What is the problem?
Internet search for data.
Holistic hokum.

RL:  Kim gets points for saying “Holistic Hokum.”  That just sounds good when you say it out loud.

12. Ramona Bates – Ramona did her own post inspired by this contest.

Vase broken, skin cut
Glue repairs grandma’s treasures
Blue vase, baby’s cheek

RL:  Baby and vase are both grandma’s treasures.  To those who don’t know, glue is sometimes used to repair lacerations in children (although I prefer duct tape).

13. Jenni Smith

Avoid disaster
Medical billing software
Gets you paid faster

RL:  You should write jingles, Jenni.

14. Neil Bonginkosi Lawrence Taverner

all bleeding does stop
better if the heart does not
tie that sucker off!

RL:  Bongi is always brilliant (except when it comes to capitalization) and doesn’t lower standards on this one.

15. Gina Rybolt

Epi, Levophed
I expertly titrate these
‘Cuz I am your nurse

RL:  Epi and levophed are medications used in the ICU to keep people alive.  This captures the day-to-day life of an ICU nurse.

16, 17. Medrecgal

I’m just a coder
Giving providers headaches
But not on purpose

In the hospital
I’ve seen both perspectives
Patient and coder

RL:  Good pair of haikus about medical coding, a subject that got me on NPR!  The first one sounds like an apology.

18. Jennifer

Slogging through the fluff
Battle for best DRG
Code the chicken scratch

RL:  Good reference to a previous post of mine (Fluff Kills) and a nice haiku to boot!

Blatant Groveling - I have previously made it clear that one way to get a GLA is to beg for it or try to bribe me.  I am not above giving things t0 people who go out of their way to butter me up.  I like butter.  I take it along with my Lipitor every day.

19. Tara Scheck

Distractible Mind
If you send me llama hair
I will knit you socks.

RL:  Tara – the award is a JPG file that has no hair.  Sorry.  I need more socks.

2o. Ken O

Haiku contest is ending
Dr Rob is drinking beer
Return of Llamatron*

* Llamatron is an 8-bit computer game, published by Jeff Minter’s Llamasoft company in the UK, back in the 1980s.

RL: Kudos to Ken for introducing my readers to the Llamatron.  You only get that kind of thing here, folks.

21. Peggy, RN

Dr. Rob, cool dude
Llamas, aardvarks and haiku
Poetic & odd

RL:  Blatant, over the top and…well, thanks!  ”Poetic and Odd” may end up as my life purpose.

Opinionated – Some folks couldn’t keep from voicing strong opinion, and I am fine with this. It makes me diaphoretic and a bit nauseated to voice my opinions like they do, but it’s OK to have opinions (as long as they don’t disagree with mine in some pea-brained way).  I won’t comment on them because…uh, my hands shake too much when I try.

22. Jacqueline Limpens

One trillion for war.
The poor denied insurance.
U.S. Death Panel.

23. Susan Schwartz

Let’s hope the Senate
Can help defeat this outrage.
Go, Joe Lieberman!

Humorous - Humor is something I am vaguely familiar with.  Once I had my third beer, I laughed hard at the following haikus:

24. #1 Dinosaur

*Yawn* Been there, done that.
Didn’t I win this last year?
(Thanks for the llama.)

RL: Dino’s haiku won her a GLA and is proudly posted on the front page of this blog for all to see.  She is getting pretty cocky, though.  I hope I don’t get that smug when I write my book.

25. Kim

WORK for the Llama?
No one ever told me THAT.
Thinking of haiku

RL: Kim captures the essence of writing something that basically says nothing.  That is a staple of this blog.

Huh? – Finally is a group of haikus that made me scratch my head.  I have a feeling it has to do with the density of the skull under my itch, but I just had a hard time figuring them out.

26. Catherine Fairchild Calhoun

If you give away
the milk for free who will buy
the cow (and llama).

RL:  This was inspired by this article in the NY times.  I think I am just being dense on this one, so can you please explain?

27. Lael Stimers Beckwith

I don’t want to pay
More than healthcare costs because
The “Man” can’t keep track.

RL:  I guess I would understand it better if I knew who the “Man” is.  Is it Richard Simmons?

28. Tanja Cilia

Snake oil, fish livers;
Antibiotics, asp’rin..?.
One and the same thing!

RL: I actually understand this one…I think.  I just wonder about telling a doctor that antibiotics and aspirin are like snake oil.

29. Catherine Fairchild Calhoun

When strangers in O
Canada offer to home
my sick son think hcrwtf.

RL:  Catherine’s son BB has a chronic genetic disorder.  I understand this one perfectly.  I just don’t quite know how to pronounce that last word.

30. Leslie Brockway

Stop the wastefulness
While jobs lost not an issue
Feds might hire one more

RL: Hire one more?  Which one?  I probably shouldn’t have had that third beer.

31. Cerulean Bill

Smiling politicos promise ,
The Grim Reaper cares
Not.

RL:  Perhaps the people in Cerulea have different rules about haiku, but this one goes 8-6-1 (which I think was the record of the Chicago Bears last year).

32. Jonathan Lamberts

Healthcare reform is
good for the people and stuff.
Llama llama yay.

RL:  I don’t know who this Jonathan person is, but he seems quite the scholar.  I am sure he’s doing quite well in college (He had better be).

That’s all of them.  Let me know what you think and if you are in the “Huh” category, please help me.  This shows that I am clearly writing up to my readers, as they are quite smart and talented people.

Thanks to all who participated!

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If you got a bunch of gunk in your reader yesterday, it was because I tried a new plugin and I guess I didn’t understand it.  If you enjoyed getting all of that in your reader, then you are welcome.  Here’s a haiku to express my emotions about this:

I am so sorry
About the gunk I sent you
Sometimes I’m a dope

Speaking of haikus, the contest is coming to an end.  Submit your haikus and over the weekend I will judge them.  There are so many good entries that I am not certain how I will decide.  Here’s a haiku to express my emotions on this:

Contest is Ending
Ingenious haikus abound
Need to buy more beer.

Yes, I’ll have to have beer while I judge this so I won’t get too stressed out.  You  guys have clearly outdone yourselves.  Here’s a haiku to express how I feel about that:

Wow, those haikus rocked
Even ones without llamas
Were really quite good

But I do sometimes worry about you guys.  Here’s a haiku I wrote about that:

My Readers are great
May need psychiatric help
Trauma from my blog

And finally, here is a haiku I wrote that comes from my heart.  I have really strong emotions sometimes, and verse is the only way I can express it:

Orange Julius
Power Puff Girls and Gumby
Flew to Oregon

I hope that touches you like it did me.

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I logged on to our EMR from home last night.  That is one of the “benefits” of EMR – access to information from home and the ability to finish your charts when at home instead of hanging around the office to do it.  It really is a benefit; it’s also an anvil.  Seeing the long list that had accumulated over the weekend and my Monday day off, it was deflating.

Yes, get out the violins and play a sad song.  Dr. Rob has a very hard life being a doctor!  Poor doctor who gets every Monday off!  All hearts should bleed for his terrible plight, right?  No, I am not trying to pluck heartstrings or pretend there are not incredibly great things about being a doctor.  I don’t blame people who get impatient when they hear doctors trying to paint themselves as martyrs.

I am no martyr; but I do sometimes feel the weight of my job full force.  Normally, I am enjoying the day to day interaction with patients, the joy of helping people, and the intellectual challenge enough that the burden is offset.  There are other times when that burden threatens to drag me down, pull me under, burn me out.

If I ever quit being a doctor, it won’t be because I don’t like taking care of people.  It won’t be because of paperwork or dissatisfied patients.  I won’t quit because they don’t pay primary care doctors enough or because specialists don’t send me their consult notes.  It’s not facing suffering, pain, and death that saps my strength.  All of these things are trouble, but not trouble enough to turn me away from a job.  The real threat is the slow and steady drain that I felt when I logged on last night.

If I quit, it will be because I love what I do and care about my patients.

What saps the drive is not the weight of the burden, it is the fact that it can never be put down.  When I have been away on vacation I come back to a long list of things that couldn’t be handled in my absence.  I know these people, I ordered the tests or started the medications; they are my patients.  Yet the burden is not even the work, it’s the emotion invested.  I do care about my patients and want to do them good.  The wonderful fact that I am meeting patients’ needs is followed by the shadow of patients needing me.  I am never let go by that need; or rather, I don’t let go of it.  I think both are true.

Parents of young children know the feeling; you can’t ever really get away.  Teachers know the feeling as well.  I have spoken with some very good teachers who, at the start of the school year, wonder how many more times they will be able to pick up the burden of that emotional investment they make in their students.  The best teachers don’t see what they do as a job, they care about their students.  The best parents are the ones who take the responsibility seriously and invest themselves in the child.  The best doctors are the ones who are doing it for more than money, prestige, and pats on the back; they do it because they care.

Sometimes I wish I didn’t care so much.  I wish I could go into work and punch the clock.  I wish I could help people without becoming emotionally invested.  I fantasize about really getting away from this burden.  But I know that I cannot step into my office without taking the next step.  I can’t not care.

So as I look at the labs, phone notes, consults, and hospital notes on my desktop I sigh deeply.  I wish they would just stop needing me.  But they aren’t just labs, phone notes, consults, and hospital notes; they are all people.  They are people who need me – people I care about.  It’s what I asked for, and it’s what I keep encouraging when I set foot in my office.  Would I really want to be without this burden?

No way.  I just wouldn’t mind a break every once in a while.

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Someone suggested I was being mean or making fun of patients in my previous post. Those of you who read this blog regularly (aside from needing serious psychiatric evaluation) are aware that I am quite sympathetic of my patients’ position in this relationship.  Mine is a position of power, while they are coming to me with an admission of weakness.  There is no doubt that I would rather sit in the doctor’s chair than that of the patient – and that’s not just because my chair has wheels on it.

My intent in writing this blog is to show the doctor/patient interaction through the eyes of a physician – a perspective most people don’t get very often.  Even though I have lots to be thankful for in my profession, I still have things that regularly annoy me.  For me to voice that annoyance in a light manner is meant to both educate people of my perspective, and entertain those who share it.

Enough of that.  Now it’s time to move on to the strategies we physicians use to get back at patients for their shenanigans.  You may not realize it, but we have a special class in medical school dedicated solely to the ways to annoy and embarrass our patients.  It’s an art, really.

Here’s my list:

1.  Require ridiculous paperwork

At every visit, a patient should be required to fill out paperwork that captures information that they have provided at every previous visit.  Certainly it makes sense to ask if a person has changed insurance since the last visit, and wanting an updated medication and allergy list is good practice.  The true art, though, is in asking questions like: “Has your mother’s maiden name changed since your last visit?” or “Please list all medications (including over-the-counter) that you have taken over the last 3 years?”

2.  Waiting Room Lottery

Being called from the waiting room to the exam room should not depend on when each person arrived; it should be totally random.  Few things frustrate as much as seeing someone who clearly came in after you get called back before you.  It is quite fun to watch the reactions of people when others are called before they are.  Many office staffs take bets on who will be the first to erupt.

3.  Use a complicated and unreliable voicemail system

It is unacceptable for people to be able to actually talk to humans unless they have spent a minimum of 15 minutes meandering through the voicemail system.  The reason for this are as follows:

1. It weeds out people who aren’t all that sick as well as those who are not going to be dedicated patients.
2. It increases the volume of patients coming in with high blood pressure and ulcers.
3. It creates a convenient scape goat if anything goes wrong.  ”Dang.  It must be our lousy voicemail system again…”

4.  Have unreasonable rules

Patients who are more than 30 seconds late for their appointment must be made to reschedule, and that appointment should be a minimum of two weeks after the missed appointment.  We only hope that patients don’t notice it when we are 45 minutes late to see them….  Charging $10 per page for people to get their own records is another way to create fury.  It’s good fun.

5.  Use the scale strategically

The scale in a doctor’s office is a powerful weapon that should be wielded with skill.  Many patients are as nervous to stand on the scale as they are coming to the doctor in the first place.  Increasing weight should always lead to a lecture about the dangers of obesity, and the weight on the scale should always be set to read at least 10 pounds more than is accurate.  Having the scale in a public place or having a staff member with a very loud voice can increase the trauma the scale can inflict.  Always check blood pressure immediately after weighing the patient, as the inevitable high reading can give extra fodder for lectures on the dangers of obesity.

6. Lecture

“Do you realize smoking is bad for you?”  That is one of my all-time favorites.  It assumes that the patient has missed the news about cigarettes not being a fountain of youth.  Perhaps they haven’t discovered that newfangled invention called television.  But lectures about the dangers of cigarette smoking, heavy drinking, or poor eating habits should not happen once – most patients expect that to happen;  they should be given every visit, even the ones that have nothing to do with these vices.  Have a foot fungus?  Expect a lecture about not exercising.

7.  Look frazzled

Some doctors are masters at always entering a room looking harried and rushed, which makes the patient feel guilty about burdening the doctor any more.  It really is bothersome for these patients to come with so many problems.  Giving a pained expression when the person starts talking about things is sure to shorten the visit.  So what if they are paying to be seen, the doctor is having a bad day and they should be nice to him!

8.  Don’t explain much

Prescribing medications or ordering numerous tests is part of the job.  We are paid to make all the decisions and patients should trust us!  Why should we have to explain to our patients why they should take the medication we give?  Why should they know the purpose of having a cholesterol rechecked every 3 months?  Leaving patients a little unsure about why tests are ordered will keep them from asking those pesky questions about interpretation.  Just tell them that “it looks fine” and that should be enough.

9.  Tell them there is “nothing wrong”

The baby was up all night screaming with a temperature up to 103.  Yet when they come into the office, the child looks fine and is sleeping…like a baby.  The best response from the doctor is to look at the parent with a “Why did you bring a healthy child in to see me?  Why are you wasting my valuable time?” expression.  Look the child over and declare the child healthy.  The fever and screaming are probably things the parents just made up to get attention; either that or they were hallucinating.

10.  Always somehow relate their condition to a mental health issue

Relating all problems to depression or “stress” is a great way to put patients in a difficult position.  Assuming it before any tests are run is even better.  ”I know how hard things have been for you over the past few months” is a good way to get things going.  The chest pain is probably hysteria of some sort and a good prescription of Zoloft will clearly make things get better.  This allows everything the patient says to be taken lightly, as it all represents part of their defense mechanisms in dealing with their mental problem.

—————————

This was actually a little harder to write than I expected.  I didn’t want to sound too harsh or cynical, but it kept coming out that way.  I am sure many people will have more to add.  I really do think there is a long legacy of doctors being in charge of the relationship and so abusing their status to patronize patients.  Thankfully, this is a legacy of the past and is hopefully becoming less common.  I do still, however, hear things that doctors do that make me wince with a disturbing frequency.

For all of the idiot doctors out there I offer my deepest apologies.  Don’t take it.  Leave them and put them out of business if they don’t clean up their act.

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Top 10 lists are back!

I forgot about this kind of post, and a reminder by a reader is bringing them back.  They are really a fun and easy kind of post to write, so you may see a fair number of them (read: Rob is getting lazy).  I thought I’d start back with some suggestions for disgruntled patients (or grutled ones, for that matter) to make their doctor’s day much worse.

1.  Require the doctor to keep things secret from your child or your elderly parent. Insist that they can’t know about their cancer, depression, ADD, or foot fungus.  Call the medication the doctor prescribes “vitamins.”  Alternatively, you can threaten your child by saying that if they don’t behave better, the doctor will give them a shot.

2.  Disguise the real reason for your visit with something simple. For example, if you have depression or chest pain, set up an appointment for a sore throat.  Make sure you leave all of the office staff in the dark as long as possible.  It’s a bonus if you end the office visit asking them to check your hemorrhoids or help with a certain discharge you have been having.

3.  Call your children nicknames that have nothing to do with their real names. Let’s say you have a son named “James Wadkins Smith”; you should call them “Trent” or “Flippy.”  A daughter named “Anna Rose Jones” can go by “Jenny” or “Eva Marie.”  You get extra points if you change what you call them every few months.

4.  Smoke a pack of cigarettes or several cigars just before going to the doctor’s office. Then when you are asked if you smoke, say you don’t.

5.  Ask for doctor’s notes for anything. If your car doesn’t start and you miss work, call to get a doctor’s note.  If you don’t like fluorescent lighting and want incandescent lights at work/school, ask your doctor to write a letter stating that this is a medical necessity.  Asking for a few days off of work because of “stress” is sure to have the desired effect.

6.  If you are an employer or school district, make your employees or students get documentation for every single sick day. Make the docs fill out FMLA paperwork for sinus infections, and disability forms if it lasts more than 2 days.  School districts should require a detailed asthma management plan on all patients with asthma.

7.  Call frequently stating that you have a personal issue you need to discuss with the doctor, refusing to talk to anyone else. It’s best to call the office acting like you know the doctor well, referring to them by their first name.  When you do get the doctor on the phone, start talking about your anxiety, depression, or bowel problems.

8. Send your teenage son or elderly parent with dementia to the office alone. Make sure you don’t leave any contact numbers and don’t tell the boy what you are sending him to the doctor for.

9. Invite friends and family. Having as many people in the examination room as possible is the goal.  Having young children with ADHD is the ideal.  Think clowns in a Volkswagen.

10. Bring your spouse or child to the office so the doctor will convince them that you are right. Open hostile arguments are important for the doctor to see just how wrong they are.  Make it clear to your family member that the doctor is against them.

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OK.

Some liked it, some didn’t like it.  At least my recent post that equated alternative medicine with magic wasn’t ignored.

Now, perhaps it wasn’t clear to some of my readers, but the purpose of that post was not to critique alternative medicine.  The point was that people like magic foot baths better than doctors who practice evidence-based medicine.  There is little flashy about what I do on a regular basis; I occasionally pull out my magic wand and dramatically help people, but most is little by little, day by day.  That is why some of my patients elect to go the foot bath route rather than follow my advice.

Oh yes, and I did paint all that is alternative in the light of magic foot baths, which isn’t really accurate.  But again, that wasn’t my point.

As I responded to those who felt I shorted alternative therapies, I saw that I needed to delve into a point I touched on in the post.  Here’s what I said: “The majority of healthcare dollars are spent on technological “miracles,” not the hum-drum treatment and management of disease.  When we in medicine go for the glamor, we sell our soul to the highest bidder and walk away from where we can do the most good.”  The more I thought about this point, the more I saw its significance.  Here’s what I mean:

1.  Magic Images

Have a headache?  You need your head imaged.  CT scans are passe’; MRI scans are OK, but PET scans are where it’s at.  The images are colorful!

I am sure that few physicians order PET scans for headaches, but I am also sure that few patients would complain if they did.  Doctors have ordered MRI angiograms, and ultra-thin slice CT scans when less expensive procedures would work fine.  Yes, these tests may have certain advantages, but is it always necessary to use the best possible procedure?  Is a test that costs 10 times more worth a 10% gain in quality of information?

The MRI scan of the back is a good example of “better”tests gone awry.  It took the heavy hand of insurance companies to stop the routine ordering of this test for simple back pain.  Patients didn’t object to getting the best technology has to offer, as it seems like they are getting better care.  But in truth, these MRI scans resulted in many people getting back surgery who did not need it.

“You have a bulging disc,” the doctor tells the patient who has back pain.

“Ah,” says the patient. “That is certainly the cause of my back pain.”

“Yes,” says the doctor.  ”If I remove that bulging disc, your problem will be solved.”

And so the neurosurgeon “fixes” the bulging disc in the patient’s back to “cure” the back pain.

Here’s the catch: just as many people without back pain have bulging discs as those who do have back pain.  The disc is an incidental finding on the MRI scan, but its presence with back pain seems to imply causality.  It is simply not true.

Did the patients complain?  They thought the smart doctor found the cure for their problem with the fancy machine.  Do the neurosurgeons complain?  They triple their business overnight, thinking the MRI scans are truly magical.  It took insurance denials of these unnecessary tests to eliminate this practice.  Yet I still have patients with back pain tell me about their “bulging discs,” as if these are clinically significant.

The technology makes the magic.

2.  Magic Tests

We need to get rid of cancer!  Cancer is causing all sorts of pain and suffering in our country.  What can we do to get rid of this scary disease?

Let’s do some magic tests!  Let’s screen the public with a test that shows the presence of cancer and then treat the cancer early.  Let’s call July national pancreatic cancer month and screen the entire population for this horrible disease.  We all loved that movie star who just died of it, and so now let’s prevent others from getting it!

That sounds great, but there is one tiny hitch: there are a pitifully small number of tests that are valid screening tests.  Most screening tests are flawed; they either falsely reassure people, falsely identify cancer, or cost a lot of money.

Yet with all of these tests we have celebrities campaigning on TV for us to urge our parents, kids, and coworkers to get them done.  They save lives. Well, at least we would rather spend a ton of money thinking we may be saving lives than sitting around feeling like we are doing nothing.  But there really are no good inexpensive tests.  Mammograms aren’t as good as breast MRI scans.  PSA testing will be replaced with a more expensive immunological test.  There will eventually be a line we can’t cross.

3.  Magic Drugs

I remember when Zantac was the wonder drug for heartburn.  It was amazing.  Then came Prilosec, and nobody was prescribing Zantac.  It just wasn’t very strong.  But wait; Prilosec goes off of patent and along comes Nexium to save the day.  Prilosec is now a weak drug and Nexium is all patients want, and all doctors want to prescribe.

Drug manufacturers have capitalized on the “new and improved” model.  This model works because it taps into the search people have for the “magic bullet.”  If these drugs were all the same price, why not get the best?  The problem is, of course, that Nexium is 10 times more expensive than Zantac.  But doctors and patients all want to spend more so they feel that the care given is better.

There is Nothing New Under the Sun

No, conventional medicine is guilty of the same magical thinking that they condemn alternative medicine by.  It seems far better to do the latest expensive thing than to do what has been shown to work: live a healthy lifestyle and take care of treatable diseases.  My job, primary care, is not at all glamorous.  I work with patients over decades.  I build relationships with them and try to help them to change.  But my patients will just as easily leave for the latest fancy scanner as they will the colored foot bath.

I do believe there is a basic difference between conventional western medicine and many of the alternative treatments: dependence on science.  Conventional medicine succeeds only as it depends on science to be its guide.  But if we forfeit the science and order expensive, unproven, yet glamorous tests or treatments, we are no different.  We forfeit our position for the sake of winning converts.

We also spend a bus-load of money.

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