On Selecting A Physician

Finding a new doctor can be a daunting experience, especially with hospitals and clinics going all out with media campaigns to corral new patients. So, if you are unable to find a doctor, it's more than likely that one will find you. 

A favorite method to capture patients is to circulate filmed interviews of doctors that can be widely seen on television, the internet and DVDs.

The clinicians are asked in the filming to reveal their values, interests and style of practice; giving the patient a brief look under the hood.  

Somehow, most of the interviewed seem to say more or less the same things: they like to take walks (by a lake is best),  read books, drink fine wines, bicycle and play with their Labradoodles.  None have yet referenced pub crawling or pick pocketing as forms of recreation and fulfillment.  Their style of practice is relentlessly collaborative - a partnership, whether you want to be a partner or not. 


Altogether a picture of sameness and similarity emerges from the interviews, right out of the Big Mac playbook, which seems to make choosing a new doctor less burdensome, less of  a choice.

The interviews suggest clinical competence which should be true for the vast majority of doctors.

Still, sniffing out a good doctor from advertisements can be perilous, especially at a time   when medicine has evolved from craft, to profession, and now to commodity.

So what strategies exist as an alternative to the media blitz?

One tried and true method is word of mouth recommendations, which generally expose the fakers (uncommon) and bloviators (not so uncommon).

Nurses, moreover, are excellent referral sources as they, more than most, get to see physicians with the mask off.  Most doctors I know are flattered when a patient is referred to them by a nurse.

Furthermore, don't hesitate to take the measure of the doctor yourself by scheduling a getting to know you appointment.  Your intuitions and observations can be telling.

And don't forget the medical assistant.  If they are bruised, the doctor probably is and you, by fallout, might be too.  If the assistant cares about whether your dog recovered from his accident, the doctor probably does too.  If the assistant seems out of control, the doctor might well be out of control too.

The point is that the assistant's manner and style often reflects the doctors, giving a sense of how the doctor's practice is run, a key variable in picking a doctor (read does it take four days for the doctor to return phone calls).

Finally, advice from George Bernard Shaw, who counseled patients to acquire a doctor whose father was rich, believing such a caregiver would order tests and procedures in a more measured way and might be able to spend more time with patients.

Outrageous, of course.

Worth a thought, of course.

Not So Fast

Dear Reader -

The link which follows is to an important and welcome article in the New York Times.  Nine premier medical societies have joined forces and endorsed frugality in the ordering of forty-five commonplace tests, scans and medications.

For example, sinusitis is rarely improved with antibiotics and MRIs of the back are much overused.

Some of us, brought up in the more is better school, might want the targeted tests regardless, believing they are an unmitigated good, especially attractive for individuals with health insurance.

Misguided use of monies is a big concern, but an even bigger one is that inappropriate testing can lead to errors of thought and judgement which can cause significant harm.

What you will read in the article has been known by the majority of physicians.  The issues have remained under the radar for a number of reasons, none more compelling than the staggering profitability of testing.

So here is the link Link NYT Article.

Your opinions and comments are hoped for.

On Starving and Smuggling

At the beginning of my years of practice, I noticed that there was a certain number of patients hospitalized for heart failure, who remained resistant to treatments, especially to diuretics, the main weapon at that time. Rigorously low sodium diets were standard as even tiny amounts of salt will oftentimes sabatoge the effectiveness of diuretics.  Nonetheless patients who seemed like they should respond did not.  It was a puzzlement.

It was while interning at a predominantly Jewish hopsital that the explanation for this became apparent. One day I walked into a room to find heart patient Irv, surrounded by his loving family, with his oxygen mask off, wolfing down a bagel with lox and cream cheese.  With the normal heart this is one of life’s great pleasures, with a weak heart lox, suffused with salt, is toxic.

Irv and his family turned out to be the tip of the iceberg, many families, upon investigation, were smuggling in salt laden food, a mainstay of Jewish cuisine.  The contraband poured into the hospital despite regular alerts to families regarding the dangers of salt for failing hearts.

Given the ubiquity of tasteless and ropey hospital cuisine it is therefore not  at all surprising that food came into the hospital, under the radar, giving pleasure where it was otherwise in short supply, while hopefully harnessing the magical healing powers of mother’s chicken soup.

In some cases where there was marginal heart function this trafficking in salt was tantamount to “killing with love” and shows that dietary retrictions can be very important.

But not always.  Sometimes they are so Orwellian as to make compliance nearly impossible.  Consider the low sodium, low potassium diet, commonly deployed in  hospitals for cardiovascular and or renal patients.  For some of these patients the restrictions are key.  More often the dietary bans amount to painting by the numbers, producing dietary decisions that lack common sense and balanced thought.

Sometimes caregivers will bend, but there are a good many who strictly follow the rules.  The result is that a number of patients find their diets so objectionable that they choose not to eat.  After drawing on, and depleting, sugar and starch stores, protein is marshalled by the breakdown of muscle, leading to profound weakness, which compromises healing, decisively at times, along many fronts.

So there are times where we, despite the best of intentions, starve patients by not allowing them foods they enjoy or can tolerate.  When it comes to this, smuggling pastrami, raisins, bananas and avocados into the hospital just might be life-sustaining and certainly humane.

Professor Motherbleeper

The setting for this blog posting is a neighboring university where, in my retirement from medical practice, I am auditing classes.  Names, places and scenes have occasionally been fictionalized.  This piece is dedicated to my classmates who have unwittingly provided most of the material for this essay.  They treat me well though more than a few seem to think I just might be a senior undercover agent for the drug and alcohol bureau.

My professor was droning on about a political figure prominent during the Civil War, and I felt myself slipping into what promised to be a satisfying nap.  But as the shades were just about to be closed down around me, I bolted up in my seat hearing my teacher say, "and he was a motherbleeper."  I quickly scanned the lecture hall and discovered, to my amazement, that his word selection seemed to have gone unnoticed by everyone but me.

I attended college in the early 1960s where we freely used the expression everywhere on campus with the exception of the library and the classroom.  The faculty never deployed the word in the classroom, or we imagined, anywhere else.  If they did, especially in front of students, they almost certainly would have been censured, or worse, by the Dean, because motherbleeper did not mix well with veritas and similarly high-minded words commonly carved into the facade of university libraries across the country.

Upon reflection, I felt that the professor had conveyed, with clarity, just what kind of guy this politician was.  The meaning of the expression was unambiguous, a linguistic victory.  While a teacher and practitioner of bleeping words might be asked to tone it down by their Dean (who would snitch other than someone like me?), my lecturer's word choice is arguably covered by principles of academic freedom and even freedom of expression as guaranteed in the first amendment.

But if racy language has gained a seat in the classroom, then it should be called upon judiciously, a light garnish rather than the main course.  

One might intuit whether or not a word is obscene by its purpose.  If it is meant to injure or diminish someone then it is probably obscene and should remain locked up. Motherbleeper did not injure the long dead politiican, but did paint him as a rather unsavory character.  Mission accomplished.

Altogether, the motherbleeper episode reminded me of just how much the college experience has changed since my graduation in 1965.  Salty language is just one element.

For one thing, students seem to talk to each other as little as possible so as not to interfere with text messaging and other social media chores, such as making sure that everyone of your nearly fifteen hundred facebook friends (of whom they personally know, say, two hundred) hear about the new shoe polish you discovered that decreases scuffing by at least twenty percent.

Walk into the typical university building and you will likely find lines of students, waiting for their next classes to begin, silent, with necks flexed, eyes locked on tiny screens, thumbs galloping, gathering information on movies, celebrity news and shopping tips.  During lectures some students continue text messaging with their smartphones strategically placed below the table, again with the neck in a tell-tale flexed (bent forward) position, feigning headaches, exhaustion or perhaps a spiritual awakening. 

It is this flexion of the neck which worries most as, who knows, it might just lead to a permanent flexion in adulthood, opening the possibility that  today's college students will lose the capacity to see far, even when standing on the shoulder of giants.

While conversation is increasingly rare so is visual contact.  Mired in  tiny smartphone screens, students seem not to see one another.  While this  ironically provides relief for many women who resent  being objectified by up and down staring, it is curious that young men seem uninterested in looking at, or innocently flirting with, young women.  Why is this?  Could it be that students of both sexes have such easy sexual access to each other, that the mystery and magic of sexuality becomes hobbled and looking is subverted by texting?

On another front, there is a growing sense that more and more people are developing romantic and sexual ties to their computers and social media devices, rife with pornography, well suited for people with many time constraints, who favor efficiency over intimacy, and prefer, as it were, to fly solo.

So college life has indeed changed greatly in the past half-century, as have  our cultural norms, charged and fueled by a ubiquitous technological revolution in which the internet and social media define our times. These changes make colleges more fascinating places to be in than ever.  The challenge for today's college students is to find ways to stay connected, both digitally and personally.  

Either or falls woefully short of the mark. 

                         

                         

On Being Late

In an increasingly consumer minded era more and more patients, understandably upset with long office waits,  express the belief that their time is as valuable as the doctors and deeply resent having to, now running late themselves,  sprint out of the clinic to meet other needs, obligations or appointments.  When they are late for subsequent meetings or responsibilities a pile up, a chain reaction of tardiness,  can occur.


In addition to physicians chronically falling behind their appointment schedule, patient tardiness is a major factor, especially if despite arriving late  (beyond ten minutes), patients are immediately seen, pushing back appointment times for those who follow.


This is especially galling to patients who rightly feel a sense of ownership of their appointment times and believe their scheduled visit with the doctor should not be usurped, especially without their permission. (Mr. Jones may we delay your appointment fifteen minutes?)

There are numerous reasons why someone might show up late for their appointment.  The time on their appointment card was recorded incorrectly.  They are so sick or confused that they initially went to the wrong place.

For these reasons an accommodation needs to be made regardless of its effect on the schedule.  In my experience, these kind of reasons for being late are not as common as one might think.  But when they occurred, these patients were brought to the head of the  line.  I cannot recall a single objection raised to my either seeing an acutely ill patient immediately or spending a prolonged amount of time with them.  

Much more common are reasons falling into the categories of either late by choice or chance.  The patient was, for example, winning at cards and couldn't pull himself away while he had a hot hand.  After avidly exploring a frozen metal lamp post,  the families Doberman Pinscher, now mystified and irate, found himself tethered to the post by his tongue.  A group of firemen, were called in to defrost the post, carefully and slowly, hoping that when the tongue sprung loose the Doberman would show only gratitude.  The drama resulted in the patient arriving one hour late. 


Early in my career I began, after satisfying myself that there was no urgent problem afoot, to ask those late by choice or chance to either make a new appointment or take a later appointment that day should one be open, explaining that I could not, in good faith, give another persons appointment time away.  Moreover, I indicated that  I was not at my best when rushed and I believed they would have  a much more satisfying visit when I was not galloping to make up time.

These conversations generally did not go down very well with many patients who seemed to regard me as a small time dictator.  They reasoned, I feel certain, that since doctors were notoriously late, it was a  minor blemish to be, say, thirty minutes  late.


But when the vast majority understood that I meant to run on schedule, and that they could almost always count on being seen when scheduled, they warmed to my style and were rarely late.  A number of new patients came to me because they heard that I ran on time.  Over the years,  not a few patients thanked me for being prompt and guarding their appointment slots. 


Lesson?  Run like a Danish train (relentlessly on time) and doctors and patients get home less bruised and angry.  The occasionally clever and imaginative explanations for being late are sometimes hard to deflect, but making an earnest effort to keep on schedule is respectful of patient's time.  Moreover, it makes it far less likely that patients and doctors will feel as if they have been on a cattle drive.  

On Foppery

Our personal style of dressing broadcasts to others how we see ourselves and how we would like to be seen by them.  It's quite amazing how effective the strategy is. 


For example, wearing striped ties to class from middle school through college might accomplish your longstanding desire to become president of the local golf club. Wear three piece pin striped suits in your law practice and clients just might begin to believe you are actually worth eight hundred dollars per hour.  After all, clothes, as it is said, makes the man - and woman.

Without saying so we want people to know if we are gentle or rough,  liberal or conservative, heterosexual or homosexual, playful or serious.  Our clothes billboard the answers with laser accuracy.


Clothing also permits us to indulge ourselves in various fantasies.   That's why we drive our Ford pick-up wearing leather racing gloves or take to coming to the office decked out in a Stetson hat.    


Even the survival of the species benefits from a Darwinian fashion show of clothing.  While other animals attract each other and preserve their species utilizing color markings, we depend heavily on clothing to propagate ours.


So it was a big shock to me when I commenced my internship and discovered that my wardrobe was to go in storage and be replaced by a uniform which would do very little to either preserve the species or promote the persona I hoped to cultivate.


The uniform consisted of a short white jacket, white pants and white shirt.  They were all starched to a point that one had more of a  feeling of breaking into them rather than putting them on.  This cold, stiff, white landscape was relieved only by our neckties.  While it was mandatory to wear them, we were given free rein in buying them, leading to a cacophony of colors and patterns, which gave us a modicum of individual expression.


So we held on to our neckties as if they were lifeboats.  Most of us packed as much individuality as we could into our very limited haberdashery.  I favored ties with interesting color combinations hoping, I suppose, to be seen as 
artistic and sensitive. 


But selecting my own ties did not dispel for me the feeling of anonymity and enforced conformity.


So why were we exiled to this fashion Siberia?  What message was our hospital attire supposed to convey?   


The relentless white was possibly to project a pure and sanitary image despite our regular tramping around in gobs of purulence.  


It was widely believed at the time that germs (any bacteria, almost all friendly) were public enemy number one and television ads were awash in pitches for toilet bowl cleaners (Mr. Clean was an icon) and kitchen sanitizers.  The sparkling white color of our hospital clothes must have, as a result, been very reassuring.


The stiffness of our outfits might have subconsciously suggested moral rectitude though it is equally possible that the hospital laundry got a sweet deal on starch and felt free to starch the daylights out of our uniforms.  Which ever the case, my cohort  and I had, by common consensus, more starch than rectitude.


So when I finally entered practice, escaping three years of a deflating dress code (and two years in the army where I came to detest the color olive nearly as much as white), I vowed to never wear anything white.  This included white shirts and lab coats, long or short.  It surprised me how commonplace it was for practitioners to wear long white lab coats and I was grateful that the group I joined did not.


Long white lab coats on internists seems to  me like over - egging the omelet.  They give the impression of  a doctor who not only talks to you and takes your blood pressure, but also conducts animal studies in the basement and is regularly splashed with blood and an assortment of nasty discharges.  In fact, these contingencies are pretty far-fetched.


Moreover, the lab coats suggest priestly robes, giving them an air of authority which is disturbing.  While studies have shown that a majority of patients find doctors who wear the lab coats more professional and trustworthy, donning of the robes can create a divide which does not accommodate  open discussion.  After all, who will challenge or question a man or woman wearing priestly robes?


There are of course many internists in lab coats who encourage and successfully create open dialogues with their patients, but the coats are in many ways institutional props that, under the radar, stifle communication, and thereby deserve to be mothballed.


My second vow on entering practice was to not wear neckties.  In part I saw them as superfluous and uncomfortable and in part I admit to playing the gadfly.  But my chief aim was to cultivate a persona that painted me as open, flexible and somewhat unconventional.  Tossing off my ties was a metaphor for these qualities.


My seniors were scandalized by my open collar look which they regarded as subversive and unprofessional.  On the other hand, my  patients barely noticed and I doubt that I lost any patients as a result.


Today, at least thirty-five years later, the open collar is the rage among politicians, celebrities,  doctors, pundits, even lawyers. 


Furthermore, the tie is now regarded as a pariah in the medical world by some researchers who have shown them to be a breeding ground for pathogens and a rich source of hospital acquired infections.  Some hospitals in the UK have banned them and many others, here and abroad, discourage them.  


In some ways then, clothes indeed can make the man or woman.  At the very least, their presence or absence (my long gone ties) are vehicles for how we see ourselves and hope to be seen by others.  Whichever style we might adopt, it should feel natural or else it flops. Otherwise, most fashion sorties hit the target as long as there is not even a hint of sloppiness. 

Perhaps the best advice  I ever received about clothing was from my father who exhorted my brother and I to dress British and think Yiddish.  Its pretty good advice for anyone: create an image but remember where you come from.

Dress British, think Indian; dress British, think Polish; dress British, think Mexican and so on works equally well.

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Pack Your Bag

The blog that follows is based on my actual experiences but the names are fictionalized.


Dr. Gregory Tuddle, Chief of Medicine at a teaching hospital where I trained, taught me one of the most important and enduring lessons of my 
medical practice - all walls are to be breached.  This meant that knowledge and information that could benefit a patient need to be secured at all costs, whatever the obstacles.  

If walls blocked the way, the physician should climb over them, smash through them, dig under or sweep around them.  A trojan horse was fine by Tuddle too.

Dr. Tuddle never actually articulated this lesson.  It was his choreography of morning report (where students, interns and residents were required to present   the patients that they had admitted over the previous twenty-four hours, giving a critical analysis and defense of their management of the patients to him) that brought the lesson indelibly home to me.

Here is how the dance went.

One morning I presented a case to Dr. Tuddle regarding a very sick man with an infected heart valve. Tuddle listened intently before he went on a talmudic spree of the "on the one hand and on the other hand." That was his way: there were always more questions than answers.  One of his questions dealt with the wisdom of the particular antibiotic regimen I prescribed.  He challenged me to defend my choice, always preferring independent thinkers to parrots, even if it meant disagreeing with him.  (Tuddle loved when we disagreed with him.  While he insisted on politeness and fairness, he shaped us not to be intimidated by authority).


As we sparred (I hadn't landed a single punch), he asked an unusual question that flummoxed me - who knew more about infected heart valves than anyone else in the country?  I had no idea at first but then remembered an infectious disease super star from Boston, Dr. Lawrence Waldman, who had given a lecture at our hospital some years ago.


"Good, call him," Tuddle said.


I thought my  mentor had a flash of temporary insanity.   Afterall,  I had never heard of an anonymous resident calling a famous medical figure for advice.  The Chief of Medicine was asking me to break into the ivory tower and  provided no clues on how to do it.


I found Waldman's number and as the phone rang, prepared my introduction.  A woman answered, his secretary.  In just seconds, I realized that it was unlikely that  I was going to talk with the great man without her approval.  I imagined that her previous employment was in the secret service and that she must be a doyenne in the protection field.


But, after an immodest amount of groveling and flattery, I was put through to the doctor who, strangely enough, seemed thrilled to hear from me. Initially, I couldn't imagine why but the thought occurred to me that his secretarial protection was so thorough that he was essentially under house arrest in the ivory tower.  Even I was welcome.


He was very generous with his time and made many helpful suggestions that improved my patient's care.  He advised on at least two more cases  and was always welcoming when I called. While we were not equals, he made me feel that we were colleagues.  I hoped I could be as magnanimous as him one day.


So lesson learned - connect with anyone who can help a patient no matter how far away or exalted they may be - and a wall was breached.


Subsequently, my report on another case  at morning sessions resulted in Tuddle sending me on a fantastic journey that would leave many walls in ruins.  


The case involved a middle aged man with what appeared to be terminal liver failure of uncertain cause.  I was hoping Tuddle could pull the rabbit out of the hat but he was stymied too.   The only hope might be a liver transplant, but he seemed too far gone for that.


"So who knows more about liver transplantation than anyone in the country," Tuddle asked me.  This time I was ready.  " Dr. Sundale in Denver," I quickly replied.  "Good, call him, "he replied, true to form.


Emboldened by my experiences in Boston, I made the call with a trace of  confidence.  Sundale picked up the phone on the first ring and like Waldman was gracious.  After hearing the patient's history, I asked him if he had any suggestions.  He did - bring the patient to Denver - today.


I couldn't imagine how we could do that with such a sick patient, in such a short time, but told him I'd relay his thoughts to Dr. Tuddle.


Upon hearing Sundale's advice Tuddle got very quiet and asked me to check back with him in twenty minutes.  When I did he told me,  "Pack your bag, you are going to Denver with your patient today."


Impossible.  He had somehow commandeered a regularly scheduled Boeing 707 jetliner (no security checks back then) to take us to Denver just three hours after he first went into action.


Our entourage consisted of the patient, myself and two nurses on loan from the intensive care unit.  The airline removed about twenty seats for us then placed a curtain around the area, our makeshift hospital.  When we entered the plane, the passengers seemed both curious and animated to be rubbing  shoulders with what appeared to be modern medicine at 34,000 feet.


While the passengers seemed fascinated, I was intimidated by the responsibility that had been given me in a singularly unconventional environment.  Much could go wrong.


But the experience was heady too.  The captain came to me in the makeshift hospital to ask if  everything was ok.  I said things were going just fine and thanked him for his concern.  He then asked if the cabin pressure was ok.  I didn't have a clue, so  I asked him what he thought.  He thought it seemed good and I, after pausing a few moments, as if in deep thought, agreed.


We landed in Denver, thankfully without incident, where a waiting ambulance took my patient to the medical center.  He, alas, did not live more than another week but the trip might have been his best chance.


Lesson learned again.  Doctors should go far and wide when necessary to get their patients the best information and treatments and never be intimidated by celebrity.  When walls interfere, as they did in these cases, they must be breached, brought down and left in ruins even if you have to hijack, so to speak,  an airliner, Tuddle style, to do it.


During my career I had the great fortune to work shoulder to shoulder with some outstanding doctors.  They were a rich source of advice and consultation and I often called on them.  But at times, when we were stumped, I would hear a faint but distinct echo of Tuddle's voice exhorting me to cast the net wider still.