Duck Hunting

A group of doctors went duck hunting one morning. As they sat waiting in their boat, a flock of ducks flew by.

The psychiatrist pointed his gun at the birds, took aim, but didn't fire. "It looked like a duck, but it didn't feel like a duck," he explained.

The next time some ducks flew by, a general internist took aim, fired and a duck fell from the sky. "I got a duck, rule out pheasant, rule out quail," he said to the others.

Next, a surgeon pointed his gun at some ducks flying overhead and shot and another duck fell from the sky. He fished the carcass from the water, picked it up and showed it to the pathologist, asking, "Is this a duck?"

Finally, when more ducks flew overhead, the family physician whipped out an Uzi and started spraying bullets in the general direction of the birds. After dozens of ducks landed in the lake around them, the family doctor said, "I don't know what I got, but I got it."

This joke was first told to me by my preceptor, Dr. Robert Millman, when I was a 3rd year medical student shadowing him in his family practice office. Unfortunately, he passed away several years ago from pancreatic cancer. I will forever be grateful for his warm demeanor, his sense of humor, his trademark handlebar mustache, and for the lessons he taught me that I pass on every year to new students.

One of the most important lessons I learned from him was "You can't help someone if they don't want to be helped." This has saved me many times as I found myself frustrated by patients who wouldn't stop smoking/drinking/snorting/shooting up or generally abusing their bodies in some way.

A few years before his passing, we ran into each other at an AAFP National Meeting. We were both attending a lecture on community preceptors. I was happy to point out to everyone there that I was living proof that being a preceptor made a difference, because through the inspiration of my former preceptor (pointing to him, making him stand), I became a family physician and a community preceptor, too. I remember how proudly he smiled as the room erupted in applause, never expecting anything more than the joy of teaching and sharing some pearls of wisdom, and a joke or two.

God bless you, Bob, and thanks.

I'll have to remember to tell my medical student that joke before she leaves.

Big Doctoring, Little Doctoring

Psst! Is everybody gone yet? I am appreciative of the recent publicity about this blog, but at the same time, I found the extra attention a little uncomfortable. Anyways, back to normal low volume hits.

I recently read a book review on "Big Doctoring in America: Profiles in Primary Care". The author, a physician, interviewed 74 primary care physicians and put 15 of the best profiles together.

From www.bigdoctoring.com:

Once upon a time, the general practitioner was America's doctor. The GP delivered babies, treated colic, extracted gall bladders and sat by the bedside of the sick elderly. As the 20th century progressed, though, and as scientific medicine advanced and differentiated, specialty medicine was born and the pattern of medical care in the United States changed dramatically. By 1960, the GP was almost extinct.

The last forty years, however, have seen the concept of general practice rebound with a new name - "primary care" - and with new practitioners. The general practitioner has been reborn as the family physician and has been joined by the general internist and the general pediatrician as providers of big doctoring - comprehensive care over time. Additionally, new clinicians - nurse practitioners and physician assistants - play important roles in the "general practice" of the 21st century.

Primary care is a way of medical life, an approach to health care and healing, a skill set and a mind set that is big doctoring. It is about care that is humanist, comprehensive, efficient, and flexible, doctoring that builds on the legacy of the past and the rich tradition of care that has characterized much of the history of medicine and nursing.

"Big doctoring" is a term coined by the author used to describe primary care, meant to convey a sense of the broad scope of problems/issues/organ systems that FPs/GPs/GIMs/GPeds tackle everyday. For me, however, it sounds presumptuous, even patronizing, aimed at boosting the egos of physicians who get too little respect, except perhaps from their own patients.

"Big doctoring" also sounds too similar to "Big Brother", "Big Government" or "Big Pharma". Shades of black monolithic towers, shadowy nameless figures in trenchcoats and institutional red tape up the wazoo.

"Little doctoring" is a more fitting description of what I do.

My exam room is small, my office is tinier still. I see 2-7 patients a day. I listen to the latest chapter in the stories of their lives. I reassure a mother whose child has a cold. I do a physical exam on a healthy young man who hasn't had a physical in 3 years. I freeze a wart. I give a shot. I talk with the slightly overweight woman about the best way to get in shape. I try to convince a diabetic to take his medicine without making him feel guilty. I share a woman's grief at the loss of her mother to pancreatic cancer 3 years ago. I wonder if a patient is late for his appointment or if he will be a no-show. I write a prescription for Cialis to an embarrassed senior. I do a rectal exam. I treat a cough. It's all mostly mundane, not the stuff of heroic 12 hour surgeries or emergency life-saving code blue action.

And yet, sometimes what I do makes a big difference. I recently referred an about-to-retire podiatrist for a colonoscopy because of heme positive stools on a routine rectal exam. 5 polyps. 1 turned out to have cancer. But because all his colon polyps were completely removed, he is cured. Not as dramatic a cure as cutting out a grapefruit-sized tumor, but when it's your own body and health on the line, drama is bad, boring is good.

This is the frontier and we primary care physicians are the scouts. We see, hear, feel and smell many things, and every once in a while, we hear distant hoofbeats and we think: horse or zebra? And often, we never come close enough to even catch a glimpse of what just went by. We're just glad it went away without trampling something we'd rather not have trampled.

Tomorrow is the first day a second year medical student will be visiting me and my solo practice. I remember what it was like for me in medical school, being the 4th or 5th person to ask a patient their symptoms and getting a diagnosis handed to you like a cold steak on a platter. The exception was when I got to visit my preceptor's family practice clinic. There I was sometimes the very first person to hear about a patient's chest pain or headache. It was like exploring uncharted territory.

To paraphrase Forrest Gump, a patient's visit is like a box of chocolates, you never know what you're gonna get. In the next two weeks, I hope to convey to my student the same sense of wonder that "little doctoring" can bring.

Confidentiality and Blogging

An article came out today on the LA Times website (and tomorrow in print) about doctor blogs, and this site was one of those mentioned. Perhaps that's why you're reading this now. During the interview with the reporter, she asked me if any of my patient knew about my blog. I said that I didn't know. Then she asked me if I would want to tell them about my blog. I didn't know what to say. It never occurred to me that any of my patients would want to read it.

My original intent when I started writing this was to tell other physicians and physicians-to-be what it was like to start a solo practice. I hoped that it might encourage some physicians who might be considering it, but felt apprehensive because of all the unknowns. That is how I felt when I made the decision to "leap" into solo private practice. Along the way, I happened to write about some of my experiences with patients (since it's hard to write about being a doctor without mentioning patients at least once).

From the beginning, I made sure never to put down anybody's name or any other "Protected Health Information", as stipulated by HIPAA. I am very careful to keep things vague enough so people cannot be identified. However, I realized, if any patient reads some of my entries, they might be able to recognize themselves. How would they feel about that? How would I feel if my doctor/lawyer/auto mechanic wrote about me and posted it on the internet? I think many of us enjoy reading stories about other people, but not about ourselves.

Other physician blogs, such as Shrinkette and The Examining Room of Dr. Charles have grappled with the issue of patient confidentiality, too. Some medical blog authors remain anonymous, probably for the same reason: to maintain as much confidentiality as possible.

In reading back over my past entries, I notice that I didn't start writing about patients until a few months ago. Prior to this, I mostly found articles pertaining to being a solo physician and commenting on them. I think this is because initially I didn't have that many patients, while lately I've had more people come to see me and consequently, more topics to write about.

I think it is unreasonable for a doctor to NEVER be able to write about their experiences. If that were so, then stories such as "The Use of Force" by William Carlos Williams could never have been written. But a physician's writings needs to be balanced with respect for patients' privacy. I guess I feel it is acceptable to share experiences about others as long as they cannot be identified. I believe that knowing what happens in a doctor's office can be educational for both doctors and patients. There is precedence for this in the medical literature in the case report, which presents an anonymous patient's usually enigmatic ailment and details the winding path that ultimately leads to the actual diagnosis. They can be thought of as a medical detective story with clues littered all over the place, and it is a test of one's diagnostic skills.

So after thinking about this for a while, I have come up with these thoughts:
1) In my professional life, the health and privacy of my patients come first.
2) I intend to continue writing my blog, but I will go even further to anonymize and remove any identifiable patient information.
3) If any of my patients recognize themselves in an entry and want any mention of them removed, then I will remove it.
4) I will amend my privacy notice to inform patients that I have a weblog and may write about them, but only anonymously with all identifying information removed. I think this is the fair thing to do, and what I would want my physician to do.

I hope that this blog inspires other physicians, residents and medical students to consider a solo career in primary care. It is not for everybody, but I believe it can be very rewarding for those who want a more personal interaction with their patients, and have the desire to control their own destiny. It can be wildly wonderful or extremely frustrating to be a solo family doctor. Most of the time, it's somewhere in between.

I also hope that non-physicians find this blog an enlightening view behind the scenes of a small town doctor's practice, and see that doctors are human, too.

And if any of my patients do happen to read this, I hope that you enjoy whatever you find here. And if not, I hope that you'll accept my apology if you feel that your privacy has not been honored. This is, after all, the work of a human and prone to (hopefully) infrequent errors and occasional truths.

Referring Back to Kaiser

I suppose my solo practice would grow faster if I didn't keep turning people away.

Several weeks ago, a mother called me to request an appointment for her daughter who injured a toe a few days before. Although she had Kaiser medical insurance (which won't reimburse for non-emergency out of network visits), she was willing to pay me cash in order to have her daughter be seen today and avoid having to go the the Urgent Care in Hollywood. I told her that I would be glad to see her daughter, but that I wanted to try to help her get an appointment at Kaiser first, since it seems, well, stupid, when people have health insurance but feel they can't use it.

So I called the Kaiser clinic I used to work at, spoke to one of the nurses who remembered me and I explained the situation. Even though there were no available appointments, she said that she would make sure this patient could be worked in as long as the patient came in right away. I promptly called the mother back and told her what the nurse told me. About a week later I ran into the mother at some school function and she thanked me for helping get her daughter seen. I figured I saved the patient at least $125, if you count my $50 office visit plus $75 for an x-ray of her toe.

This has happened two more times since then. Once for a family friend's son with a toe problem. And another time for one of my patient's mother who was having what sounded like cervical radiculopathy. She said she was told her regular doctor was on vacation, so she had to go to Urgent Care. I tried to explain to her that there are at least 15 other doctors at the Kaiser clinic, but she didn't understand. Anyways, both times I called the triage nurse, and somehow she worked them in.

So although I missed out on some income, I feel like I was able to help someone by NOT seeing them. Plus I hope that these patients will be so grateful to me that they tell others how helpful I was, and maybe I'll get a few patients that way.

But I think this will have to stop. I don't want to be known as a back door way of getting an appointment at Kaiser. Plus I don't want to abuse any goodwill I may have left with the Kaiser triage nurses, all of whom work EXTREMELY hard (thanks, Leni, Pat and Wanda!). Plus, I should commend the doctors who stayed late and squeezed in an extra patient so these people could get seen.

That used to be me. I'm happier where I am at now.

Hopefully Kaiser will improve its appointment system so it can see all of its patients at their regular clinic without having to send people miles away to Urgent Care. Until then, I'll be available to anyone who needs to be seen today.