“Oh, by the way”: How to not annoy your doctor

It happens all too often.  I am done with a visit and wrapping things up.  Sometimes my hand is even on the doorknob to leave the room. Then the patient says it.  “Oh, by the way, doctor…”  This is inevitably followed by some symptom they have that is serious and needs further attention.  The classic case is when it is chest pain, a grave symptom that needs to be worked up and typically takes an extra 30 minutes at least.  

This is frustrating to say the least.  As doctors, we are trained to recognize serious problems and not ignore them.  But when tacked on to the end of an already complete visit, this can lead to getting behind on the day’s schedule (which is unfair to other patients) and frustration directed at the patient.  

Let me take a sidebar here and talk about a doctor’s schedule.  Unfortunately we are notoriously known for making our patients wait.  I’m sure you have had your fair share of waiting in the waiting room only to be moved into the exam room where you wait some more.  In some offices this process can be more than an hour!  I despise this!  I do not want to be lumped into the same boat as these doctors.  Yes, my time is valuable, but I respect my patients and their time.  The patient and I are a team and we work together.  This is built on mutual respect which can only come when I show regard for their time as well.  They are taking time out of their busy schedules to come and see me.  Because of this (and a mild case of OCD on my part), I do my best to not let my patients wait.  In the rare case that somebody does wait, I apologize profusely and try to find a way to make it better.

Back to the “Oh by the way” moment.  I get behind which is annoying and some of this can bubble up and be directed at the patient.  This is not right and I try to recognize this and combat it.  I do what I can on my end but some preparation on my patient’s part can help the situation. So how can you as a patient avoid this problem?  

The solution is actually quite simple.  Make a list!  Prior to your appointment with your doctor, make a list of all the concerns you have.  When it comes time for the appointment and your doctor comes in the door, hand him or her the list.  Allow your doctor to prioritize this list according to what they feel is most urgent or concerning.  You can mention the items you feel most concerned about and the doctor can take this into consideration.  Work together to come up with a plan that you both feel comfortable with. If the list is long, the doctor may want to schedule another appointment to be able to address all of the concerns.  Be open to this.

That’s it!  It’s quite simple and can avoid any bitter feelings developing between your doctor and you.  The biggest thing is always having a trusting relationship with open and honest communication with your doctor.  Be sure to check out my post on how to find a doctor like that here. Try this at your next appointment and let me know how it went in the comments below.  Best wishes!




The End of Life Option Act: My Take

My linear, black and white thinking was serving me well until I came across someone who had lived it.

On June 9, 2016 in California a bill called AB-15 went into effect.  This bill was also called the End of Life Option Act.  In brief, the law allows a person 18 years or older suffering from a terminal medical condition to request life-ending medication to decide when they want to die. A recent report by the California Department of public health stated 111 people have taken advantage of the law since its inception.  The law did make it onerous to go through with the process.  The patient needs to request the drug on 2 separate occasions and in writing.  They must be cleared by 2 separate doctors. They must have a life expectancy of less than 6 months.  They much reaffirm this request 48 hours prior to the date of death and the medication must be self administered.

Initially when I heard about this bill I was appalled.  I did not want the decision to actively assist in death to be in the hands of doctors.  I got into this profession to do the exact opposite.  I want people to live and be healthy. I remember my physician partner saying “we’re physicians not executioners” and I agreed wholeheartedly.  It’s easy to make these claims when you’re not the one suffering or are close to a person who is.  My linear, black and white thinking was serving me well until I came across someone who had lived it.

A few weeks ago I sat in one of our office rooms across from Nathan, an eighty something year old man in for a routine check of his blood pressure. His blood pressure was well controlled and I was ready to wrap up the visit and send him on his way when he wanted to let me know about something. “Doc, do you know about this Right to Die Act in California?”  He asked.  I said yes and briefly summarized my thoughts on it.  “Well,” he said, “Let me tell you about my sister.”

His sister was younger than he was but had been diagnosed with a progressive muscular disorder which he didn’t know the name of but equated to Lou Gehrig’s disease (or Amyotrophic Lateral Sclerosis).  The disease had progressed over years to involve her whole body except her head.  She had no muscular control of the muscles affected and she was only able to talk and eat.  According to Nathan, she was suffering and miserable.  She decided she wanted to end her life.  She went about the process described in the law.  

Nathan states this was hard in itself because finding a doctor who prescribed the medicine was difficult.  She eventually found a doctor in Irvine who worked with a doctor in San Francisco.  She completed the process and was approved to end her life.  When she received approval, Nathan states that her whole outlook on life changed.  She was finally going to be able to control something in her life.  She was “excited” to complete the process. The day of her death came.  

She was prescribed a liquid cocktail of high dose Morphine and Digoxin, medications that in high doses alter breathing and the heart to the point of death. Some family members had been vocally against the process but had come to acceptance and were there by her side.  According to the law, she had to “self-administer” the medication.  This was to be accomplished by having her use a straw to suck up the liquid and swallow it (some of the last bodily functions she had control over). With family surrounding her, Nathan stated she “slurped up every last bit of the medication.” Ten to 20 minutes later, she had died.

Nathan was very clear that this was a good thing in his mind.  His sister had been suffering for years and was finally at peace, which she entered on her own terms.  It was her way of giving this disease the “middle finger” as she exited life.  He praised the new law. At the end of our discussion he looked over at me and asked me again how I felt about the law. I fumbled my words this time.  

Let me tell you why I have such a hard time getting on board with this law.  There are 2 main reasons.  The first is a wonderful program called Hospice.  Hospice is for people in similar situations who are expected to live less than 6 months.  The focus in hospice is to switch from treatment that cures a disease to treatment that relieves suffering as a person transitions out of this life.  Medications are given to relieve pain, breathing problems and any other issues that causes suffering.  It is not given to hasten or aid in death. The other reason for opposing this law is a moral one.  In my mind prescribing a medication for the sole purpose of killing a person is akin to murder because it would be willful and premeditated.  Again, putting this decision in the hands of doctors is scary.  I became a doctor to help people live and be healthy.  Part of that is relieving suffering but I believe that can be done without ending life.

Also, I am also a little confused about when our society became okay with the idea of doctors aiding in killing.  I’m sure we all remember the conviction of Dr. Kevorkian in 1999 for second degree murder.  He had “helped” over 130 people die to relieve suffering.  Proponents of this law state that the current law is different from “physician assisted suicide” but I don’t see it.  How is something that a doctor was sent to prison for just 18 years ago now a law?

Nathan’s story questioned my beliefs.  I truly felt sorry for his sister and was relieved to hear her suffering was gone.  I had an internal struggle that started.  So it brings me to the question: Is it okay to end someone’s life it they are suffering? First what is suffering?  According to the dictionary it is a state of undergoing pain, distress or hardship.  We can treat all of these things and that is the goal of hospice.  In the end I have concluded that I cannot make the leap to accept or participate in this law because we have hospice which is specifically set up to relieve suffering and allow a comfortable transition from this life to the next.

So what will I do if someone comes through my door and asks for a life ending medication? Nathan’s story rocked me but I’ll have to say I can’t do it.  My conscience won’t allow it.  I don’t even know if I would be able to refer to a doctor who does because in my mind this could make me an accomplice.  I would hope I could convince this person of the benefit and beauty of hospice to relieve their suffering.  No matter the outcome I will lead with compassion and be there to the end as his or her doctor because abandonment would be the worst thing to subject someone going through that much suffering to.  I will care for, love and respect any and all of my patients no matter their feelings on this issue or others.

What are you thoughts in the issue?  Am I completely unreasonable? Do you have a similar story? I’d love to hear your thoughts.  Leave a comment below.

 

Loan Repayment: Worth the hype?

Medical school saddled me with an enormous amount of debt.  I wanted to stay in California close to family to study medicine and decided to do my training at Loma Linda University.  I am grateful for my time there and feel I received an excellent education.  I would highly recommend it to anyone pursuing a medical career.  That being said, it is a private medical school and with it comes a premium price tag.  I escaped undergraduate school without any debt but medical school was fully financed leaving me a six figure debt anchor.

Through residency I received a paycheck but decided to defer my loans until I was making a better income.  This allowed my loans to compile much more interest and when I graduated residency I was looking down the barrel of about $225,000 I owed.  A local community clinic had offered me a position and with it came the added bonus of loan repayment since it was a “Federally Qualified Health Center.”  

I spoke to the CEO and other doctors and they all stated the repayment plan was very attractive.  The government would pay $60,000 for the first 2 years and then $20,000 each year after for as long as you stayed with the clinic.  I was guaranteed that everyone from this particular clinic had received the repayment and they had never been rejected.   I agreed to a 2 year commitment with reassessment at the end to see if I would continue.

My troubles started early.  I started my position on August 1.  I quickly learned that the loan repayment application cycle ended on July 31.  Are you serious?!  I would have to wait until the application cycle opened again which wasn’t for a few months.  When this came around I was ready.  Everything was in order on my end but something had changed on the payment program’s end.  

The amount to be repaid had been decreased to $40,000 for the first 2 years.  No sweat, I thought, this is still a sizable dent in my debt and anything would be helpful.  The only downside would be extending my commitment another few months.  I submitted my application and waited.  And waited.  And waited.  Something was up.  I had talked to the other doctors who had applied in previous years and they stated that they had heard back with a decision in a few weeks.  It had now been a few months.

I decided to call the government program myself and see what was up.  I soon learned the reason.  Not only had the amount been changed, the way the applicants were prioritized had also changed.  In previous years it was first come, first serve.  Now it had changed to place those at a clinic in an area of higher need first.  This was calculated based on a HPSA score.  The higher the score, the more the need.  Ours was apparently low.  So low in fact that the repayment program ran out of money before they even got to my application.  I did not get the repayment.

I later learned there was a state based program.  I did my research and found that this one was not based on the HPSA score and I would actually have a chance.  Only one problem: While I was waiting to figure out why I didn’t receive the federal repayment the application deadline had passed.  I gave up.  I decided I would complete my 2 year commitment and then move on.  That landed me where I am right now.  I have continued my loan payments on my own and will complete them on my own.

I’m not writing this to be political or as an attack on that clinic.  While this sounds like a very clear “bait and switch” I am sure that the clinic had no knowledge of this.  I just wanted to parlay my experiences to allow you to again see behind the curtain, but on the financial side.  Yes, I do harbor some bitterness about this.  But it portrays an important point.  Most people think of doctor’s and quickly make the assumption that we’re rich and have it well off.  While I am not hurting financially, I am not rich by any means.  Just a few months ago was when my net worth first crossed into the positive.  

Most doctors do not get into the profession for the money.  It is an attractive incentive, but it doesn’t drive our decision.  We wanted to help people.  At our deepest core, this is what drives our daily medical activities, not a paycheck.  This is what makes us wake up at 3 AM to go into the hospital to deliver a baby.  This is what makes us drive to a patient’s house to check on them.  This is what makes us work 60 hour weeks.  We care for you and we want you to be healthy.  




The Other Side Of Medicine: Pole Vaulting Disaster

I landed awkwardly and slowly pulled my right arm out from under the pole but something was wrong.  Horribly wrong!

This was the first time I had made it over 8 and half feet!  I could feel my body clearing the height but as I released the pole my arm swung around and caught the bar as it fell off.  It all seemed like it was in slow motion as I slowly descended with the bar caught between my body and right arm.  I landed awkwardly and slowly pulled my right arm out from under the pole but something was wrong.  Horribly wrong!

It started 3 months prior.  I was a freshman in high school with aspirations of being a track star.  When surveying the events, I saw pole vaulting and was instantly hooked.  “You mean I can get up to over 12 feet in the air and land safely?  And I don’t need to run? Count me in.”  I had done cross country earlier in the year and had come to detest running (ironic now that I love it).  The team broke into groups for each event and I followed the studly, ripped upperclassmen pole vaulters over to the training area.

I should have known this wasn’t my calling.  I was over 6 foot and as gangly as an oak tree.  Nonetheless, I put in the hours and went through the tortuous training to develop my form.  It was still horrible!  I didn’t have enough upper body strength to lift my lower half up and push off the pole to do the pretty body arc that you see at the olympics.  It was more like a forward baseball slide in the air.

The first few meets were disastrous.  I didn’t even clear a height.  I now look back on it and can imagine the other more experienced pole vaulters thinking, “Okay… Lower it down to the lowest height and let’s get this over with.”  I still persisted.  Unfortunately, I was still horrible.

At about the 4th meet I was finally getting a little better and actually cleared 8 feet.  I had done this in practice but never in a meet.  This is a horrible height in pole vaulting but for me it was progress.  The bar was then moved up to 8 and a half feet.  My first attempt was a great display of me kicking the bar off the stand.  The second attempt was when it happened. My body cleared the bar but my right arm didn’t and I came down with my full weight on the bar which transferred all of the energy to the ulna and radius in my forearm.  These bones couldn’t take the pressure and snapped in half.  I didn’t feel a thing… until I looked at it.  The arm wasn’t responding to the input from my brain so I looked to see what was wrong.  Halfway up my forearm a new joint had formed into an awkward looking S-shape that instantly made me nauseous.  I became lightheaded and small sparkly stars appeared in my peripheral vision and moved to obscure the image of my arm. I sat there unable to move and let out a scream.  Instantly my coach and dad were at my side.  I closed my eyes and started breathing deep.  The nausea and stars cleared only to be followed by an indescribable pain that again made me feel like passing out.  I bit my jersey to keep from screaming again.  They brought ice. It helped.  I was escorted to the hospital in an ambulance.

At the ER, xrays confirmed the obvious fracture but it was displaced at an unacceptable angle and needed to be set.  The orthopedist, Dr. W, was called and he stated he would have to push the bone back into place.  What?! I thought.  The mental anguish and pain of the initial break flooded back into my brain.   I started to sweat.  “Don’t worry,” he said, “You’ll be sedated for this.”

I was hooked up to an IV with medication flowing into my body.  The room became fuzzy and a blissful feeling washed over me.  My dad and Dr. W were also in the room.  With the medication I didn’t have a care and was happy to oblige when Dr. W lifted up my arm.  “Are you ready?” he asked.  “Go ahead,” I slurred. He suddenly applied a large amount of pressure on my wrist opposite the direction the bone was angled.  Instantly the severe pain from the original break returned and I was snapped out of my blissful state.  The pain was unbearable and I screamed.  More accurately, I wailed like I was being tortured.  My dad couldn’t take it and had to leave the room. It lasted maybe 15 seconds but tears filled my eyes and my body gave out.  It was horrible.  That was twenty years ago.  It was so traumatizing I remember it like it was yesterday. The arm healed fine after that with Dr. W’s care.  He is a great doctor and now I refer to him often for orthopedic care of my patients.  He was doing what was best for me and I can’t imagine the emotions he was experiencing as well. If not for him, I would have a deformed arm.

Being a patient in a situation where I had to experience pain at the hands of a doctor was difficult.  Now I have been on the other side.  I have had to do procedures where the patient has experienced pain to fix a problem.  I have gone through the emotions Dr. W must have experienced and had to power through to complete the procedure.  It is hard. The next time you need to go through a procedure, please know that your doctor cares.  We hate having to put you through pain but know that sometimes it is necessary.  Don’t be surprised if you see our eyes steam up if you experience any discomfort.  We feel it too.

 

Photo Credit: Mark Vaughan, MD
Disclaimer: The photo above is of my cousin who is a very good pole vaulter (unlike I was).



How to Choose the Best Doctor that Fits You

Here is my step by step process on how to find a doctor that best fits your needs

We’ve all been there.  Our insurance changed.  We moved to a new area. We had a bad experience and want to start fresh. You find yourself in the no-man’s land of being without a doctor and trying to find a new one.  In some cases, your insurance will assign you a new physician, but you always have the choice of seeing anyone your insurance covers.  This in itself limits the physician you can see but you want to make sure you choose the one that is going to be the best fit for you and your family.

I can’t emphasize how important a good, trusting and working relationship between a doctor and a patient is. Being on the other side of this I have had experiences where the patient would be better served by a different physician.  Usually the patient initiates this but on rare occasion I have been the one who suggests they find another doctor.  There can be many reasons for this from differing personalities to different ideas on medicine.  A prime example is with vaccines.  I believe wholeheartedly in the efficacy of vaccines and recommend them as outlined by the CDC.  I have had patients who do not feel vaccines are necessary or feel they are harmful and disregard my recommendations.  In this case it is hard to establish a relationship built on mutual trust if they do not feel that I am making the best decision for them or their children. If they do not trust me in that regard, how are they going to trust me to appropriately diagnose an illness and treat is correctly?  The same goes for colds.  A cold does not need an antibiotic and treating with an antibiotic is actually more harmful because it increases resistance and can have side effects.  Some patients disagree.  When this trust is broken down, the patient should move on and seek another provider.  

Other times when you see a doctor, there can be bad experiences.  Your personalities may not mesh well.  You may not like their location or office setting.  There may be someone on their staff you do not get along with. In all of these cases finding a doctor you trust and feel comfortable with is appropriate. The therapeutic relationship built between a doctor and patient needs to be a safe place where you can be honest and open to get the best care.

Luckily, I feel I have great patients and get along well with them.  I work hard to establish a safe, honest relationship so I can best serve them and their needs.  We work hard to employ people who represent our office well so the entire patient experience from walking in the door to leaving is the best.  We are continually doing self evaluations so we can achieve a excellent care experience.  You should look for an office where this is evident.  

With that, here is my step by step process on how to find a doctor that best fits you:

1. Start with your insurance
So where is a good place to start?  I recommend first contacting your insurance to see who they cover.  You can get a list by a simple phone call or online.  Once this is obtained, make a list of things you are looking for in your doctor.  Do you want a male or female?  Do you want a family physician, internist or pediatrician (for your children).  Where do you want to go for care? Do you have any medical conditions that need special attention?  Does the physician treat these? (this may be answered later) Once these questions have been answered, you can go back to the list and whittle it down to a handful of candidates.  I will insert a quick comment about internists versus family physicians here.  Internists are trained in adults and more complex disease processes.  Family physicians get exposure to this as well but not as much.  Family physicians are trained more broadly in procedures and all age groups.  If you want your whole family to go to the same doctor, then FP is the way to go.  If you are very debilitated with multiple disease processes and take many medications, you may want to consider an internist.

2. Do some online research
Now that you have only a handful of candidates, you can start to do some online research.  This is where you can get a general feeling of how other people rate the doctors.  I recommend the website healthgrades.com. Here you can put in the name of the doctor and get a lot of information.  You get a short background on the doctor and ratings from other patients out of 5 stars.  This will also show you the average wait time and other valuable information. This website can help you rank your potential doctors. Please take this information with a grain of salt because those who rate doctors are those who really like or really dislike the doctor.  I have personal experience of doing the right thing and stopping a person who was abusing opiates and then recieving a poor review as a result.

3. Make the call
So you’ve done all the research, next you call the doctor’s office.  You should ask brief questions during this call about whether the doctor treats any conditions you have and if there are any prescriptions the doctor will not write for that you are taking.  If you like what you hear, then you should schedule an appointment. In some cases, you will be scheduled with a PA or nurse practitioner and you should decide whether or not it is okay with you. PAs and Nurse Practitioners are very capable care providers and I would suggest you not deny a visit solely based on this.  They work closely with the doctor(s) and are more than willing to get help if needed.

4. Time for the appointment
Last is the face to face visit.  Make sure you are prepared with all of your past medical history.  You will be asked about any medical conditions you have, surgeries you have had, medications you take and family history.  If this is extensive, then you may want to obtain records from your previous physician.  Often you will also be asked about any alcohol, smoking or illicit drug use.  Use this time to ask the doctor about any of your medical conditions, goals for the future to stay healthy and any other concerns you have. Sometimes, this visit is only a meet and greet and you can schedule another appointment to start tackling any medical issues or have your annual wellness exam.  If you do not feel a good connection with the doctor, he or she has differing views on medicine or does not treat a condition you have, then you need to consider trying another doctor and should move back to the list in step 2 and go through the process again.

Well I hope this helps. Navigating the waters of finding a new doctor can be daunting but with this guide I hope you can more easily find a caring doctor where you feel safe to open up and foster a relationship built on mutual respect and understanding.  Feel free to leave a comment with the good, bad and ugly doctor experiences you have had or send a link of this to a friend who may need it. In our changing medical insurance climate, who knows when this post may come in handy. Moving forward, I hope all future doctor visits and relationships are good ones.