On this day, a great battle

Once again, I ready for battle with an implacable foe. I prepare for the latest foray as best I can: cotton armor, leather gloves, boots of Spanish leather. My weapons are sharp though I know this will be a close quarters fight, main a main.

I approach the champs du bataille warily, my step slow. Had I a true squire, he would wipe the sweat from my brow; instead, i must be content to blink it away. I cannot raise my hand because the Foe is most unforgiving. His wounds seem light but the misery does come, if days after the encounter.

At the last moment I’ve brought my fickle friend Mont-de-Santo. He has failed me so many times, but he is the only one mad enough to join this folie a deux.

I pick my way through the hedge, my weapon lowered at first. And then I see the advance line: trefoil, edged by rubor of spite. And this is a warning, a shaking of spears, for its poisoned edge is a harbinger of erythematous misery.

I can delay no longer. I begin to hack my way through his ranks, but he seems unfazed. He bobs up and down, perhaps thinking me risible. He isn’t wrong. I look down, his line unfazed by my attack, no breach to sally through. I check my leather and cloth and bend down to do the work of a true knight. I grasp the enemy one or two at a time, by the neck, and pull, hoping to unseat him.

Have I found a weakness? Why does he seem to give way so easily? Oh! Woe! He has struck! I have unseated him, yes, but his hind has flown forward striking my wrist below the gauntlet. I should retire from the field and tend to this as I know it will inflame at a later time, but the heat of battle is upon me. I tear at him, no longer careful of his strikes but amok with rage. For each I unseat, more take their place to unleash their insidious poisons (not poissons for that is a different story altogether).

Finally, nearly surrounded, I retire and find my sometimes-friend Monte-de-Santo at the edge of the champs with that same look he always has, the one that says, “you may not want to but you will always return for my help and in return I will ask you for a favor.”

And it is done. The outcome unsure. Monte-de-Santo has returned to his place up high, my edged steel has been sheathed, my armor soaked in sweat. I strip it off carefully, not knowing where the Foe may have struck.

“A bathrobe?? Are you naked? In the laundry room? What the hell is wrong with you? You know the poison ivy is just going to grow back!”

Ah, a maid who cares more for my welfare than her gardens. I may just live to fight another day.

Flu???

Every fall I bring flu shots home for my family. My wife has a hard time getting to the doctor, and my child uses wild, sadistic gestures to explain how it’s done at the pediatrician’s office. She reminds me every day to bring home the shots, and when I have it, she dutifully drops trou and takes her mediicne. My wife not so much—she requires a bit more wrangling.

Still, it has served us well. I haven’t had the flu in recent memory despite multiple exposures and the Pal Family has steered clear as well. But as of last week, I’m the captain of a plague ship.

MrsPal started coughing last week, then wheezing. Later my phone rang and she told me that her body was aching and she had a fever of 102. It was obviously flu, but I still had her come to the office for a test. Influenza b. Yuck.

So we sent PalKid to a friend’s house for the weekend to keep her away from the bug. This morning at 4am she came into the guest room (where I was isolating myself) to say, “Daddy, I’m shivering worse than when I get out of Lake Michigan.” Shit.

No reason to keep mother and child apart any longer, so I plopped her in bed with mom, hopped in the shower, and skedadled.

PalKid likely has influenza b as well. This year there were two basic flu vaccine formulations: a trivalent and a quadrivalent. Both vaccines contain two types of “a” and one of “b”. The quadrivalent has an additional “b” strain.

The CDC didn’t recommend one over the other. Both matched the circulating flu strains well. So there are couple of reasonable hypotheses as to why my family is down for the count.

1) The flu vaccine covered their strain but it didn’t work well enough
2) They both got the “b” strain not covered by their shots
3) The vaccine covered the strain but has worn off

All of these are plausible and it doesn’t matter too much at this point. Next year’s shots are likely going to be identical to this year’s, but next time, I’m bringing home the quadrivalent.

Meanwhile, PalKid is eating ice cream and watching Minecraft videos. She may end up liking the flu a bit too much.

April, vernal and triumphant

Running season has finally risen from its wint’ry grave and the trails are crowded with celebrants. My running calendar pinpoints my sloth as beginning in mid-November, coincident with the start of the Worst Winter Ever.

Excuses melted away with the last of the snowbanks and my sneakers stiff with un-use are getting some fresh air. Unfortunately, this weekend’s lovely weather was accompanied by a miserable case of influenza b which has left my spouse bed-bound. The trail will just have to wait for her a few more days.

With the warm air (which is expected to take a quick break this week allowing a bit of last snowfall) comes tornado season marked by the whines and howls of my terrified child. Not that she’s ever seen a tornado but every time the sirens go off or the weather even looks threatening, she’s grabbing her favorite stuffed animals and heading for the basement.

At the moment though I’m at one of those trampoline places where pop music blares, whistles whistle, and kids scream as the leap from platform to platform. It’s a migraine-inducing hell, but the kids do seem to love it. It’s strictly a no-shoes affair and I just saw some adult walk out of the bathroom in bare feet. I’m not squeamish, but I can’t imagine what twisted circuitry would allow a grown man to stand at a urinal in bare feet. Yech.

I suppose I should just be grateful I’m not holed up in the plague-house. I’ve enjoyed serving up meals in bed and all, but if I want to escape unscathed I’d better keep myself anywhere but home.

Start spring out right. Go for a walk. Look down at the crocuses. Enjoy the rumble of spring storms. Shake off the long winter and get outside.

Thanks, Kid

I’m not gonna lie—I’m a fat, lazy slob. Last summer and fall I moved my sorry but motivated ass down the trail 4-5 days a week, doing my lame but effective intervals. I was all ready with my cold weather gear—and then a winter that would have frozen off the Stark’s cojones.

Like the parade of tired patients slouching into my exam room, I basically gave up, and as you know, once you give up, it’s hard to get out there again.

But the roads are finally back in their pot-holed glory. The lawns, yellowed and battered by unrelenting snow are looking, well, dead, but at least I can see them. And PalKid asked me to pull out her bike.

There are people out walking! Lots of them! And we took off tonight, she in her pjs on her bike, me in my muddy-weather running shoes. These were intervals, alright. I kept up with her on the flats, and lost her when I took a break to walk. I didn’t bring my Garmin, but we probably did a couple of miles and would have kept going but for the dark.

So, I think I’m back. Join me out on the trail and get your asses moving. The world won’t run out of cookies.

The yearly physical that isn’t

I realize that most of my readers are below Medicare age, but as goes Medicare, so goes the nation, so pay attention my friends.

Nearly all healthcare plans now include so-called preventative care, including some sort of yearly check-in visit. Medicare’s version of this is the “Annual Wellness Visit”. Most patients think this means they are getting a complete physical, and often they do, but this isn’t going to continue.

Medicare’s Annual Wellness Visit has a very limited set of requirements, including screening for depression and dementia, making a list of all the doctors someone is seeing, and calculating their body mass index. It’s really a brief visit, and doesn’t pay all that well.

Despite this, many of us have been including a more traditional physical. This adds on considerable uncompensated time to the visit. A time will come when AWVs are brief visits done by assistants, and the patient will have to come in for a physical on another day (which will not be covered at 100%, as the AWV is). I suspect many patients won’t like this.

The same may happen with non-Medicare plans. Doctors’ offices may have patients come in for a brief prevention visit with a physicians’ assistant, fill out any health screening forms, and make them come back at another time for a real physical.

It’s all better than being un-insured, but don’t be surprised when your doctor tells you that your yearly physical isn’t your yearly physical.

Pi day thoughts

Kids don’t get pi. Neither do most adults. For we non-mathematicians, it’s disturbing. Numbers are so concrete. You can hold two apples in your hands, but pi apples?

We humans like concrete answers, especially when they conform to our beliefs and worldviews. And this scares me.

Yesterday I was sitting at the cafe and the woman next to me struck up a conversation. Turns out her kid is autistic. “He got that stupid MMR shot, you know.”

Yeah, I do know, but what do I say to the irrational stranger about it? Do her friends also just sort of shut up when she goes off on the “MMR causes autism” thing?

There are plenty of nice people who believe destructive things. We don’t like pi. It doesn’t fit with how we see the world. Yet, it exists. So now what?

Let’s talk about your doctor’s office

Going to the doctor starts as a disconcerting experience: getting naked, physically and emotionally; talking about your weight, your smoking, your divorce. You count on your doctor’s ear and her discretion. Often enough, a patient will apologize for taking my time or for crying or whatever. I remind them that this is what the exam room is for, this is what they pay me for.

How far does this special relationship extend? Primary care doctors can’t bill for time with their patients unless it’s face-to-face. This is one of the reasons your doctor might not want to spend a lot of time on the phone or email with you. It’s also one of the reasons we may require you to come to the office to complete complex forms or change a prescription. These activities require work, and our main work is thought. Without you in my exam room, I’m not sure about that medication change or that disability form. And I can’t ignore the fact that I’m not paid for my time unless you’re in the office with me.

In my opinion, some doctors go too far, requiring monthly visits for simple prescription refills, but there are times when it’s necessary to drag someone in to make sure the drugs are working and not causing harm, or to make sure you are working on your dietary habits and exercise.

Saying ‘no’ to patients isn’t easy; we’re in this job to help. But it’s often the right thing both clinically and economically. This brings up another question, one we don’t often talk to patients about: how should we treat our time when the office is closed? The tradition has been to take patient calls after hours and on weekends, perhaps rotating this time on call between partners.

But there are murmurings out there about this uncompensated time. After all, what can I do for someone on a weekend? It’s not usually wise to diagnose someone over the phone. It’s also not so good to renew prescriptions on the weekend; it’s a poor use of time and for those of us with paper charts, it’s nearly impossible to know what’s appropriate.

For a primary care doctor, the answer to many phone calls is, “Call the office on Monday,” or, “Go to the ER.” 

As a patient I want to be able to reach my doctor on a weekend, but I would understand if he should decide to change his policy.

What say you? How can we maintain communication and deal with the problem of uncompensated care?

Helplessness

Many years ago, someone I loved was in the hospital and whenever I would visit, I would display my badge prominently. She wasn’t inmy hospital; my ID badge opened no doors; it didn’t get me free food in the cafeteria. It was a talisman, something to ward off the evil I would wade through, something that might have some magic—any magic—to help us through this hell.

Some people respond to this helplessness not with magic but with anger. It’s one of those things doctors have to learn to deal with. When families lash out, it’s not about you. Your white coat is the magic that wasn’t, the shield that let through the plague arrows.

Some get bossy—very bossy. They focus on the minutiae, the things that doctors and nurses know aren’t important. The shades aren’t drawn right, the medicine is ten minutes late, the meal tray is all wrong. What about that bandage, doesn’t anyone see it’s bunched up?

We are all at some point powerless in the face of disease, and we reach for what little power we have. We huddle together against the biting wind, cobbling together what shelter we can, and wait for the storm to pass.

Liberals: stop apologizing

If elections results are to be believed, about half of US voters are “conservative”. Why are liberals so apologetic? Why so willing to compromise beliefs?

Submitted as an example, abortion. Conservatives have no problem making it a dichotomous issue of good and evil. They are unapologetically against a woman’s rights over her own body. They continue to act as if humanity comprises two creatures: people, and women.

We liberals, as human beings, find this abhorrent, but we have diverse views. This diversity can sometimes lead to a willingness to compromise amongst ourselves, but that willingness sometimes bleeds into our interactions with conservatives.

“Abortion should be legal, safe, and rare,” is a common rallying cry on the left, and a stupid one. If you truly believe in a woman’s physical automony, then abortion should be “legal, safe, and none of my damned business.”

This wishy-washy bullshit opens us up to the bullying of the right. Many liberals may believe the “rare” part, but many of us see that as a related but separate reproductive rights issue. Access to contraception, something the right also abhors, does not guarantee fewer abortions; it is another layer of autonomy for women, one that shouldn’t have to be “added”.

If we really believe in human rights, in the right to work with dignity, equality of all people, freedom from hunger, access to healthcare—if we are to call these “rights”—then we cannot be apologetic. The Right succeeds with their base by being uncompromising in their defense of inequality and prejudice. We need to be equally unapologetic, unwilling to compromise on human rights.

Patients aren’t perfect and neither am I

I get it. I really do. If a patient won’t trust you on the most fundamental of medical facts, how can you be an effective doctor to them? An article circulating on social media argues this effectively–to a point.

If I were a pediatrician, I would be wary of allowing unvaccinated patients into my office. They may bring diseases into my office and infect kids who can’t get vaccinated for medical reasons. They may be more likely to catch diseases in my office. But that’s not what was argued. The argument was one of trust. How can I care for someone who doesn’t believe the most important things I tell them?

My answer to this “grow the fuck up.” People are imperfect and irrational. That’s how we’re built. The patient who believes they can can cure diabetes with cinnamon rolls may also take your advice to go on a statin for heart attack prevention. They may agree to medicine for blood pressure even though you think exercise and diet changes would be better.

Caring for other people is not about fulfilling your own needs but those of your patients and of public health. I do everything I can to persuade patients to take my advice, including getting recommended vaccines. I am blunt about the consequences of their decisions. But after that it’s up to them. Paternalism is a useful tool, but a useless rule. A good doctor must collaborate with patients and should only give up on their care if there is a real breakdown in the relationship.

If you choose only to treat rational people, your waiting room is going to be pretty quiet.

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