I realize, with some of my older patients, that they do require more patience (no pun happening here!). What is sad, with some of them, is that I've known them for 20+ years, and seen them go from "older but vigorous," to "elderly and decrepit and confused." I realize too that what sometimes seems just an annoying character trait is in fact their trying to cover for no longer being with it mentally. Not completely gone, but worse off than they seem at first glance.
One problem I noted today, is that some of them were frankly annoying when they were younger. Becoming elderly doesn't make you saintly. If you were a total pain when you were 25-35-45, if you haven't worked on yourself (whatever that could mean), then you are still a total pain at 65-75-85. Some people were just annoying for their whole lives, plus they pick up more annoying character traits to try to cover for their losing it. I'm training myself to see past the annoying to what really needs doing.
Sibs and I were also discussing different ways of measuring intra-ocular pressure (testing for glaucoma), known as tonometry. I mentioned that I recall when air puff tonometry came in, as the hot new gizmo. (Prior to that, they numbed your eye, and pushed a small measuring rod against it. Our late Great-Uncle B was an Ophthalmologist. Quite prominent in his day, but was not big on shiny new gizmos if the old ones still worked. Part of that was his old-fashioned frugality. He was raised in the school of “you never know when the next famine (pogrom, stock market crash, whatever) was coming, so use things until they can no longer be fixed." Having been raised by Depression Era parents, we all have that streak in us. I’ve gotten away from it somewhat, and I’m not entirely pleased with that. Not sure how I’m going to teach the next generation the value of money. Just because you can afford something, doesn’t mean that you should. Back to Great-Uncle. Had a small office in his house - dunno if he actually saw any patients there, or if simply for tax purposes. Anyhow, after he passed away, we found a pair of magnifier glasses in a drawer in the living room(?). Inside was a piece of masking tape, labeled “B: better pair in office.” So we looked in the office. Sure enough, there was a pair of magnifier glasses there. Inside the case was a piece of masking tape, labeled “A: worse pair in living room.” The hat he wore to his wedding to Aunt C was older than any of his adult children. (This was his second marriage, both of them having been widowed for many years.) Yeah, there are the jokes about “I have a hat older than you kids,” he really did. BTW, I still have my original canvas duffel bag from when I was very first in the military. Newer ones (say, oh, the last 2-3 decades or so) are nylon. My last deployment, a young troop asked me, respectfully, why one of my duffels looked different. I explained, then realized that duffel was indeed older than he was. "I have boots (well, duffel bag) older than the young troops…" And was actually bringing same on a deployment.
Yeah, back again to Great-Uncle. He had a gizmo for measuring your existing eyeglass lenses, “reading” the prescription. He acknowledged that the then new-fangled (40 years ago?) electronic ones were more accurate, but pointed out that the human eye couldn’t perceive the difference, so why spend the extra money to get a new one that wouldn’t help his patients any better than the old one. I still have a quite old hyfrecator (what most people call an electric cautery) that is older than most of my Gentle Readers. (Possibly older than all of us, I don’t recall when or where I got it, but it was used then). The newer ones are slightly better, but they burn out after several years, so I keep it as a back-up.
He was with me in the car, taking him home, and I had visions of getting stopped by the police. Not that I seriously expected to get stopped, just a random paranoid fantasy about having to explain to the nice police officer man about why I had him in my car. I mean why I had it in the car.
I think I need to back up a bit.
Have always wanted a skull - well, actually, would like entire skeleton or three, but that would be too costly. Father of a friend (someone I was a Resident with) is a retired Anatomy Professor, downsized his home, including selling off some of his collection, and I’d thought I’d buy a skull. The Professor, quite prominent in his day (I googled his name and research, and got over 2-million hits, which puts him up there with the better porn sites), acquired it from India in the 1960's when "developing" nations such as India and China were quite happy to sell excess bones. He had two for sale, one a nicely bleached white, the other a mellow aged yellowish.
Discussed with friends and family, and the consensus was to go with the more aged-looking one. If I lived in Nevada (as some family and Gentle Readers do), the bleached white might have gone well with the desert theme, but the yellow goes more with the theme of "I live in the cold dark North and have delusions of being a wizard." Equally important, the yellowish color also makes it look like someone who had an interesting life... interesting death also. (Line from Dresden Files - TV show, not books.)
As to the name, was thinking of either Bob (again from Dresden Files) or Yorick (Hamlet - stage play, not TV show). For now going with Bob, since if I'm going with the "I think I'm a wizard" theme, then that goes better. Really, being a Dermatologist is just like being a wizard, except for the white coat instead of black robes, and, uh, yeah, I actually don't do any magic. (Although I confess that when patients insist on "natural" treatment, I sometimes claim I only do supernatural treatments. They don't seem to believe me.)
There was an additional consensus that it will be kept at my office, not my house. “Consensus” here being defined as what was decreed by higher headquarters (my wonderful and sensible wife). I must say, he looks quite fine sitting here on my desk in the back room of my office smiling benignly as I type this.
Got a somewhat flustered call from Nom today. Seems her mom had called an ambulance for her dad, then he was told "wasn't permitted to enter the ER." He was suffering from a sore foot. Or maybe severe pain somewhere. Or maybe couldn't breathe. Realize that this was from her dad, to her mom, then to Nom by telephone, then to me mostly by telephone. In-and-around this, I was (a) at my office, then (b) met Nom and the kids at the wading pool, then (c) had to go to one of the hospitals for a meeting about a research project (which got cancelled, as the other person had the date wrong). Eventually got myself over to JGH, where I clipped on my staff ID badge and strolled into the ER.
Dad, mom, and mom's brother were sitting in the waiting area. Dad in a wheelchair with a look of pain on his face (and he's not a wimp), but clearly was breathing. ER's do tend to rush you right in when that isn't happening. On the other hand, it was dinner time, and the worst times to go to Emerg is between after-work, and before-bedtime, when everyone else goes also. If you are still breathing and/or not bleeding copiously on their floor, there will be a long wait. Couldn't do much of an exam there, but asked a few careful questions, did some very limited exam, and realized he had sciatic nerve pain ("sciatica"). Although at the time he denied any trauma or straining, later came out that he had been lifting stuff too heavy for him earlier that day. Anyhow, since he was breathing, and was not bleeding on the floor, if he waited to get seen (allowing for appropriate triage), he'd likely be in the waiting room until the next morning (and in pain the whole time). I told them (both in French and via Nom's uncle translating into Vietnamese), to go home, gave them some basic instructions (mostly to ice it down), and I called in some pain and anti-inflammatory medications to their pharmacy, and told him to see his regular doctor in the next day or two.
Wasn't high level medicine, but they were most appreciative, and at least I remembered how to do this stuff.
One on my projects for over the holidays is to finish putting away the stuff in the last few boxes that have not yet been unpacked ("few" being a relative term). For now, a first approximation of where things go, then over several months going over the place with a fine toothed comb to put everything obsessionally in its place (for some stuff, that place will be trash/recycling).
Today I organized medical and language books. From my old condo, I had 2 lovely bookcases with glass fronts. I'm not sure I really like glass-fronted bookcases, makes it too hard to see and get to the books (like keeping animals in zoos), but they do look impressive. The big one has three sections, was in my den in my old place, and is now at the end wall of my tablinum in our new house. The smaller, but matching, one is single section, which was between two windows in the den in the old place. I was going to put it in the new office (almost finished *crosses fingers*) as a display case, having left it in the living room of our new house until then. I realized there is no good space in the new office, and it looks rather nice in the living room, so there it shall stay.
There are 6 shelves. The top two are respectively, books, and medical equipment, that was my late great-uncle's from medical school (plus a few antique medical books). He had graduated medical school exactly half a century before me. The next two are respectively books and medical equipment, that was mine from medical school. (My Derm books from Residency are in the bigger bookshelf in the tablinum. The last two shelves are ultimately reserved for Hedgefund's and Wallstreet's medical school books and equipment. (Does this count as optimistic, determined, or pushy?) Will be more than half a century after me, but can't time everything correctly; that's okay, as long as they go, and I live to see it. If they have kids who go to medical school, they can jolly well find some other bookcase to exhibit things. For the meanwhile, until such time, and in case of disaster and heartbreak (they don't go to medical school😱), those 2 shelves are for language books. The fifth shelf has the real languages. Which are those, you ask? English and French, you silly non-Canadians. If I ever get Vietnamese for Ignorant Round-Eyed Barbarians Made Simple, it will go on that shelf also. The bottom shelf is all other language books that have drifted my way over the years (books on learning those languages, dictionaries in those languages, and English-XXX dictionaries). Those are arranged west-to-east on the shelf to roughly match the geographical regions of origin of those languages. (I did mention obsessional didn't I? Not to mention whimsical.) I think I have: Spanish, Italian, German, Yiddish, Macedonian, Russian, Arabic, Pashto, Dari, Japanese. Plus Latin and Esperanto. I'd love to have the time to sit down and study a half-dozen languages or so. I could probably use that many in my office. Sadly, that's on the "C-priority" of the To Do List. (= "Get around to sometime this lifetime if I live long enough and all the B-, A-, and OMG-priority items get taken care of first."). I suspect that will never happen, unless the kids graduate medical school and take over the practice at, oh, age 12, or thereabouts. Still, hanging on to them just in case, and besides, they look cool and fit my self-image. (Worldy gentleman scholar. It ain't pretentious if you actually done it.)
Yeah, the second fact was sarcastic. Everything is made up of molecules, and they all exist in nature. Whenever someone wants “natural” treatment, I’m always tempted to state that I only employ supernatural treatments, and hope they don’t mind getting sprinkle with goat’s blood. That having been said, I rarely use the term “chemicals” instead referring to things as “molecules,” which of course, are much more healthy for people.
Molecules are molecules, your body treats them as such, and they have good and bad effects depending on the molecule and the dose, regardless of their origin. Whether evolution geared you to “process” certain substances is irrelevant. Plants can have good or bad effects on you or both: chocolate is yummy, strychnine kills you (although might be beneficial in low doses), digitalis can be life-saving or like-taking depending on dose. Which brings up the next key point ignored by naturalist and other mindlessly doctrinaire people: the dose makes the poison (Paracelsus, physician and alchemist, if you care). Entirely artifical substances can have beneficial effects, such as penicillin. Oops, penicillin is found in nature, named after the penicillium mold that makes it (however the penicillin you might be prescribed is produced synthetically to insure a purified, standardized, and we can have an adequate supply of it). Botox also found in nature. In high doses it kills you and/or gives you a plastic expression; in low dose it can treat many diseases (not just cosmetic). As for garlic, in low doses it tastes yummy, in moderate doses it wards off low-level vampires.
( New Yorker )
( Soldier )
( Doctor )
( Family Man )
New Yorker, Soldier, Doctor, Family Man. Not a bad CV.
( (Footnotes) )
Three facts and let you draw your own conclusion:
1. As you may know, I practice medicine in Canada, under one of those "horribly flawed, make you wait endlessly, crappy socialist medical systems."
2. I'm a physician, have my own practice which also makes me a small business owner, retired military including many years as a Commander. Bottom line of this pount is that I'm very much a bottom line kind of guy, both by nature and by experience/training
3. The average Canadian lives 3-1/2 years longer than the average American. Pre-Medicare, the difference was only 3-4 months.
Bottom line: who wants to live over 3 years longer?
Some marketing company hit a new low. They mailed me the 1-page survey, and enclosed a 5-dollar bill "as a token of our appreciation."
I sent it back with a note saying, "Are you for real? I don't have the time to answer surveys that offer me hundreds of dollars, much less ones that insulting tuck 5$ into an envelope. I'm returning your survey, your 5$, and adding another 5$ which you can use to buy coffee at the unemployment office, which seems to be where you're destined to end up."
( Medicare-how she works )
A consideration about any law or regulatory framework is that there are always gray areas (or grey areas as it is spelt in Canada and the UK). No matter how carefully you write the law, there are always ambivalences. Putting in more regulation doesn't eliminate those loopholes, it just creates more. Up until now, we've dealt with these gray areas by ignoring them, and everyone gives a little on their side: doctors accept that not everything is paid for, patients pay a little out of pocket for things questionably required, and the government ignores the situation.
( Medicare-how the Minister is screwing things up )
I'm not sure why all this is happening. Is it purely Minister Barrette's incompetence? Is it a back-handed way for the province to dis-insure some services? (Instead of dis-insuring them, they make them impossible to get, and put the burden on the doctors to be the heavies to explain it to the patients.) Is it the companies that provide drug and supplemental insurance got tired of paying for these supplemental (but legal) charges and pressured the government to outlaw them? Always hard to know if something is driven by avarice or stupidity (my bet is usually on stupidity which is harder to outsmart than avarice). In the end, me and every other doctor will find a way to protect ourselves without hurting our patients. Like most smart people, Minister Barrette fails to account for the fact that other people are smart also, and there are more of us than there are of him, and that we're motivated because it's our livelihood.
Stay tuned to this blog for further updates.
( The footnotes )
Most people cannot understand a conditional statement. I don't understand why they don't. In my case, part is that I've been scientifically trained, but part is that I am not a complete moron and can use my native language.
People need to be given instructions on how to use their medications, and other management of their condition. To me, that includes "if X happens, then do Y." Apparently that is beyond most people's comprehension, and they need instructions to the effect of "do X, then come back tomorrow for further instructions." Titrating a dose is wayyyyy to complicated for almost everyone. (Titrating - I don't use that term with patients - is basically, "raise how much you take every xxx days, until you get the effect you want, or you get side effects. Come back in yyy weeks/months and tell me what happened and how much medication you are taking.")
To me, it would be like being a driver's ed instructor telling someone, "if the light is red, stop your car."
"So you want me to stop my car?"
"Only if the light is red."
"What if the light isn't red?"
"How do I know if it's red?"
"Look at it."
"So when do I stop my car?"
"Only if the light is red."
Etc, etc, etc.
At least drivers ed cars have dual brakes.
When I got out of the Army, I knew I would spend more time on academics, or perhaps better to say on academia. I took on being the Director of Undergraduate Medical Education for Derm. (Isn't that a fancy title? Yeah, big whoop.) I thought I'd go on to Dermatology Residency PD (Program Director), then maybe Chief of Dermatology for McGill. Possibly somewhere in there take on being Chief of Derm at my hospital. (Every university medical school has "THE university hospital," and "the OTHER one." JGH is "the other one." Which, of course, is better.) I was offered PD a couple of years ago, but Hedgefund had just made her debut, and I was a tad busy, not to mention enthralled with that job. Then, just as I was getting on track with that, we had Wallstreet. Did I mentioned enthralled? And now renovating a house. Yeah, busy is an understatement. Plus, I looked at the jobs of PD and Chief at McGill. PD is 70% administrative blech, but at least at the end of the day, you know you've helped train the next generation of Dermatologists. It's satisfying. Chief is 70% administrative blech, followed by 30% even worse blech. If I'd been focused on the upward track (much as I had been in the Army), I would have gone for it. Ego usually beats common sense.
Fortunately, I was saved from this fate (although I would have loved it had I done it) by said family life. The prior PD stayed on, but took on a "co-director" (minion). He will likely move up to being PD in a couple of years. Good for him. He's bright and hard working and recently graduated. Yeah, recently graduated. Someone I recently trained is taking on the administrative role I had thought I would go for some day. Even though my choice, and a choice I would not change, there's a bit of feeling by-passed.
Recently we had a get together for the Derm staff at my hospital (we do these about once/month during the academic year - part educational, part social, in varying ratios). Our Chief (at JGH, not McGill overall) said he was looking for a replacement. I do take this with a grain of salt, as he's been threatening to step down since I was a resident, but he's sounding more serious now, which is reasonable with advancing age. We do want to bring on younger staff, but there are only a fixed number of places we're allowed to have. (Part of the meeting was discussing whom we wanted, and how to juggle places.) We suggested a certain resident who will be graduating soon. She's great: one of the smartest and sharpest people to come though our program in a long while, a good teacher, and super-pleasant. Although a bit young to be a hospital chief, she would be great. When she actually graduates. Someone I'm helping train. Taking a position I vaguely thought I might be interested in "later." Again, my choice, and a choice I would not change, there's a bit of feeling by-passed.
Not so much feeling by-passed by "the system," (heck, our current Chief at McGill was one of my residents - which is why it's amusing when she tells me about the "old days"). More feeling by-passed by life. Okay, feeling old. In my mind, I'm still the bright young thing, the youngest guy in the room. Now I'm one of the senior ones, and people I helped train are being looked at for positions I'd thought I'd go for "some day." I still have a lot of "some days" ahead of me, but fewer than I used to.
A minute or two of chitchat. Turns out she does 3-D molecular modeling software, which is used by biochemists and pharmaceutical chemists to model, amoung other things, potential drug molecules. Cool.
I suppose there is a remote chance she was hitting on me, but probably not. (Irrelevant to my life except as a very minor ego buzz, since I'm very married.)
Oh, for those who care, PDE-inhibitors are molecules that inhibit the actions of (you guessed it) phosphodiesterases, which are group of enzymes that do various different things. PDE-5 inhibitors include Viagra, whereas PDE-4 inhibitors are beginning to be used in Dermatology for inflammatory diseases (such as psoriasis). I hadn't had which group was which nailed down in my mind and was looking them up.
In an article in a recent journal, patient were asked their preferences of how they would prefer their Dermatologist to be dressed in different situations (eg Medical vs Surgical Dermatology) with the options being business attire (eg suit and tie), professional (eg lab coat), surgical (eg scrub suit), or casual (eg casual). For all situations, patients preferred professional dress; yes, even in modern, increasingly casual America. I'm pleased to see that my beliefs are validated. I've always worn a lab coat with shirt and tie (and yes, pants and socks and shoes, for the smart alecks in the crowd). My idea of "casual" is maybe once/month ditching the tie.
I didn't always do that, although I learned early on in my career. When I started out in practice, I was in the Navy, and I wore my uniform. When I was an intern, I wore either a lab coat over my uniform, or scrubs, depending on what service I was rotating through. That's how all the house staff dressed. When I was in practice in the Fleet and with the Marines, I just wore my uniform (there was a medical crest on the collar). That's how we all dressed. When I first got out of the Navy and was working in walk-in clinics and ER's, I decided not to be one of those dorks who wore a white lab coat. My g.f. at the time was the daughter of a small town GP, and her father never wore a lab coat, and she too made fun of those dorks who did so. What wasn't figured into the equation was that he practiced in a small town, and everyone know he was ole' doc XX. He'd delivered half the town - and their mothers - and didn't need a badge of office ("Badges? I don't need no stinkin' badges."). One day saw a patient in the ER. I introduced myself, did the exam, wrote out the prescription. Then the nurse came in to discharge him, and he asked, "but when am I going to be seen by the doctor?" In his mind, no white coat, no doctor. Easy to make fun of him, but in fact, I was at fault having not presented the image he was expecting, the simple sign saying MD (Me Doctor). I learned (I don't usually learn that fast about social clues, I guess I was having a good day).
I've been preaching the wearing of the white lab coat to students and residents since. Nice to have some office data behind what I say.
In the past week, had several new patients who said they had come for "the usual annual checkup." Two families were from other countries (Brazil and US) and both said something to the effect of "oh, you don't do that here in Canada?" when I looked perplexed. I don't know about Brazil, but I'm fairly sure that is not the case in the US (especially on young children as in this family). At least one other was from Canada, whose Dermatologist had recently retired.
I was pretty sure that my approach was right, but when a number of people come in in a short period of time expecting something different, I feel obliged to at least re-look and re-think my way of doing things. So, when in doubt, crunch the numbers. If we calculate the average Dermatologist in these parts sees 6 patients/hour, then in 8 hours of seeing patients (which is higher than surveys show, never mind time spent teaching, CME, or admin), that would be 48 patients/day. Round that out to 50/day and 250/week. If each works 50 weeks/year (again, a high estimate), that's 12,500 patients screened with TBSE/year, if each Dermatologist does nothing but. There are 200 Dermatologist in Quebec so multiplying 12,500 by 200 gives 2.5 million. The population of Quebec is about 8 million (ratio of 1 Derm : 40K population), so either we'd need over 3 times as many Derms, or we'd all have to do TBSE 120 hours/week. Canada-wide, there are about 600 Derms for 32 million people (1:50K), so the numbers are even worse. Again can't speak about Brazil, but the US has about 10K Derms for 320M people (1:32K), so the numbers aren't much better.
Yup, thanks to basic math, I know I'm doing the right thing.
All citizens and permanent residents are covered via public money. I often remind patients that in fact it isn't "free," it's paid for by tax money, which is not free. (I usually get a blank stare in return, but that's another lecture.) Doctors can be in- or out-, but not half-half (eg can't say I'll take Medicare for you, but not you). Visits to a participating doctor (eg almost everybody) are 100% covered for anything that is not purely cosmetic. Again, the doctor is supposed to be on- or off- the system, it is not legal to charge a supplement, however cleverly you try to diguise it. Hospitalizations are covered (private rooms, and renting a TV are extra). Labs and X-Rays and such are covered if done at a public institution; at a private facility, they may or may not be covered depending on what the test is, and what province you are in. Medications are not covered outside a hospital, including medications administered in a doctor's office. That can lead to friction (eg "why am I paying for this") and also abuses (eg "Did you want local anesthesia before I remove that mole? That will be 200$"). The latter is a bit of a kerfuffle right now in Quebec, with some doctors abusing the system, and some patients/administrators claiming anything over 35¢ is abusive. Paying for prescriptions (or reimbursing medications administered in a doctor's office) is done by a mixed system. In Quebec, everyone is required to have medication insurance, either privately, or be on the government plan (which is free to the elderly and indigent). Dental is not covered, nor eyeglass prescriptions except for children. I'm not sure about ambulances. Some private plans cover these things, some don't.
The great advantage of the system is that everyone is covered, and I personally like that there is no (financial) barrier between the patient and me. Since my early practice was in the US military, that is what I am used to, and I am comfortable with this both personally and morally. The disadvantage is that since it costs nothing out of pocket to get health care, it gets somewhat over-used, and waiting time to see a doctor, or get an operation, or some tests, can be excessive. In addition, as in every country, as the population ages, and as medical technology advances, the system is going deeper and deeper into the hole financially, and might break down at some point.