Archive for July 2009

OBAD (The Dark Side of Doctoring) -Rule Number Four

July 31, 2009

        OBAD stands for Official Begging Armistice Day.  I’m sure that will require some explanation.

        If ‘The Mandolin Case’ sells more than four books, I have a sequel planned.  It is called ‘Acquisition Syndrome; the Doctoring Business.’  As far as what it’s about, legal advises me all I can tell you at this time is this:  A wise patient of mine, a farmer, told my nurse Lynn O’Carroll, “Dr. B knows something and he ain’t talking.”  But the gist of the saga is that along the way Dr. B learned a few tricks of the trade and figured out ways to get people taken care of even if some fool does their best to stonewall the process.  It happens more often than you might think.  To their dismay, over time I am gonna tell what I know. 

        Fifteen years ago if I wanted to get a CT head scan Lynn  O’Carroll would call and say, “Dr B. needs a CT today.”

        And they’d say, “Sure sweetie, what time?”

        It is no longer that way.  Now mind you I’ve never been one to order a CT on every headache patient.  A history will usually do it.  But if there is even one ‘red flag’ warning sign I’m on the warpath and will not be denied.

       When you have a lady who has fallen in the last month and has a new headache like she’s never had, and you run into some insurance guru who finds a scan unnecessary, I always ask what he would want done if it was his mama.  If he doesn’t want to rule out a subdural hematoma then there are only a few logical conclusions.  Either he is poorly trained, doesn’t care, is more interested in money than truth, or hates his mama.  None of them are good.

        The idea of ‘managed care’ is if you make the Doc jump through enough hoops he’ll stop hopping and take a few chances.  Sorry, I made an A+ in Hoop Jumping 101.  Nowadays a Doc not only has to care, read like a wild man to ace his Boards (O.K. I’m gonna brag on my 94th percentile) and work hard, but he also has have an iron will to force the system to do right when it has created more inertia than a barge that lost it’s tugboat.

          I call it OBAD.  Official Begging Armistice Day.  I never beg anyone for help.  If they aren’t willing, I proceed to plan B, go to door number two and lumber on in anyway.  It is the power of the lessons of Acquisition Syndrome; the 80/20 rule.  (Rule number four)  80% of the time people will do right because they want to.  The other 20% have to be positioned where they have no choice but to do right.

        I can’t tell you the details of this week’s case.  It is too fresh.  Even if I fictionalized it, it would be recognizable and a breach of patient privacy.  So instead I have to make it into a parable.  But as I told Julius; “if they won’t do right make ‘em.” 

        On our flight this week, I was the pilot and Julius was my co-pilot.  On Tuesday we hit some awful turbulence.   

        “Hey pal, my rudder is balky and she don’t wanna trim out.  We’re losing oil pressure on the right engine.  We’re gonna have to feather the starboard side and put her down in a cow pasture.  I know one we can get to from here.”

        “If anyone knows Harvey County, it’s you, Doc.”

        “Go back there and get approval.  Tell that arm chair QB it’s an emergency.”

        Julius was back in a minute.  “He’s say his computer simulation says it’s doesn’t meet the criteria.  Procedure denied.”

        “Tell him to look out the window.  The dadburn engine is on fire.”

        “I did.  He said they have to go by protocol.”

        I tossed Julius a chute.  “Take this to him.  Tell him he can jump if he wants to, but I gotta get this dude on the ground.”

        “O.K., boss.”  Julius turned to head for the back of the plane.

        “Hey, kid.  Tell him one more thing.”

        “What’s that Doc?”

        “He might as well take his computer too.  It’s no good to us here.  He might want to play some video games at least if he survives the fall.”

        “Yes sir.”

         “By the way, tell him I’ll go ahead and call in my dictation.  If this thing doesn’t make it I’m gonna document the fact he got in the way here.  Legal will tell him not to worry too much.  It’s only one passenger.  She’s just some country lady and I know he doesn’t think she’s that important.  I know the husband.  He thinks right much of her, but he’s reasonable.  My guess is five mill will cut the gig.” 

        Julius smiled.  “I expect that man in a suit and tie in a Harvey County courtroom would have a hard go.”

        “Yeah, remind him a dead Dr. B is gonna be a difficult opponent.  You don’t diss dead people.  Tell him it’s against the law.”

        Julius did just that.  The man froze.  He was scared to go against us. When it’s your own life on the line, people see it in a different light, and besides the guy was tighter than Jack Benny.

         We got her down, got the lady off the plane, and put out the fire.  I told the little regulator man I believe I’d get some new software for his simulator.  One of these days he was gonna convince someone more naive than me to go along with him when he’d never laid eyes on the patient.  When he does he’ll have to hope I remain as obscure a writer as I am now.  By the way, he admitted he’d never flown a plane.  I wasn’t surprised.

        The patient did fine, and I wasn’t scared until it was over.  Then I cried.  Medicine made me tough as a pine knot, but it ain’t gonna make me mean.  I’m gonna go play some music.

        I’m glad I did not spend my life as some insurance chart jockey.  As hard as it was, I’d rather be Doc, even if the pay wasn’t as good as those executive guys.  l’ll close with a favorite quote.  It is from Sir William Osler, the father of modern medicine. 

        “Seeing patients without reading books is like going to sea without a compass, but reading books without seeing patients is like not going to sea at all.”

        I love books, but I love patients more.  Some things and people are forever.  Osler was, but I assure you all those little regulatory guys will be lost to history. (as they should be)  They are nothing but a nuisance to be thwarted, but I have learned to do it well.  I’ll probably be lost to history too, but at least I tried to do right.

Dr. B

You Know Your Doc is Country If…..

July 29, 2009

        If your Doc drives a truck to work on a summer day and rolls down the window so he can listen to the crickets sing along with Hank Williams on his CD player while he eats a cold piece of last night’s fried chicken for breakfast ’cause he didn’t have want to stop studying Wayne Benson mandolin at dawn he might be a country Doc.

          And when his med student is gonna be an intensivist, but has already promised to bring the boss Nip Chee crackers and Co-Cola and put Bill Monroe is his ear and coffee down his NG tube at he Nursing Home to keep him mollified in his old age, then that boy is a Country Doc in training.  Country Docs feel sorry for folks who have ‘Bill Monroe Deficiency.’  (A life with no fun)

        His coffee is black and his socks would be be white if it weren’t for his country girl wife’s gentle diplomacy.  And speaking of sugar, even though it’s sweet, he doesn’t put sugar (or cream) in his coffee, and always orders high test.  (with caffeine)  

        If the office staff can order a take out and know to get fried chicken, hominy, fried okra, and field peas, and if the local cafe knows it’s for Doc without asking, that guy is country.  If his day was crazy and he feels bad that he held up his 90 year patient he’ll invite her to lunch to share some chicken.  

          He might have to eat fast so he can have enough time to work up a mandolin break for ‘So Lonesome I Could Cry’ before afternoon patients, and if he can reach deep inside and make it sound like a tear-jerker when the boy hasn’t had a lonely night in a half century, well he’s a country Doc.  

         He plays his golf at the local muni with guys like Rocky or Jake or Crash instead of the bank president at the Club.  But he is just as at home to play Don Gibson’s ‘Can’t Stop Loving You’  for the Country Club crowd when they want a country show as he is picking the ‘Clinch Mountain Backstep’ at Fat Boy’s Barbecue.

        If his idea of a fancy vacation is to jam all night at Galax and eat streaky meat sandwiches or ‘maters on light bread with Duke’s mayonnaise and plenty of salt and pepper, he’s country.

        He’s the kind of fellow who makes himself memorize his American Academy monthly home study program before he’ll allow himself to listen to his favorite bluegrass band CDs, but isn’t disciplined enough to practice his mandolin the way he should.  He’s the only cat in town who reads both the ‘New England Journal of Medicine’ and ‘Bluegrass Unlimited.’

        Doc knows his people on a first name basis but out of respect calls them by their last until they tell them otherwise.  Most everyone is ma’am or sir and if they object he’ll forget and call ‘em that anyway ’cause that is what his mama taught him.  You never go against your mama.  He gets a haircut ’cause he afraid she’ll think he is ‘looking woolly.’

        He goes to funerals but waits to shed any tears until he is on the way home listening to some sad bluegrass song.  It wouldn’t be right to cry at the funeral home; the situation is much harder on the family than it is for him.  Besides, he tries to do all his crying ahead of time.  When somebody lays down for the last time ain’t when this Country Doc is gonna start to think what he might do.  By then he’s run the table on every option he can think of, at least if he had any shot to figure it out.

        He sees his folks not only as patients but his people and intends to do his best for them.  He’s that way ’cause he’s the best true Country Doc he knows how to be, and doesn’t know any other way.

Dr. B

Country Doc Rule Number Three- Apologies are Necessary

July 27, 2009

        Years ago there was a movie (was it ‘Love Story’?) where there was a line that said, “Love means never having to say you’re sorry.”

        I’m not so sure that is true in love.  If I forget to take out the garbage I tell my wife I’m sorry.  I can be a dumb man testosterone poisoned lug at times, but with all she does for me I figure it is the least I can do.

        I am certain a ‘no apology’ policy is not good practice as a Doc.  When things go wrong, at least we can say we are sorry.  And I think we owe to to folks to try to figure out why and how it wrong if we can.  I will tell you that is not always easy and often requires some study, but I at least promise folks I’ll work on it.

          Some people say Docs shouldn’t apologize, and that it might make them more at risk for litigation.  Well if that’s true, so be it.  The truth is the truth, even if hard to find at times, and and we should always search for it.

         And if you want to get practical about it, most of the big shots believe it lowers the risk anyway.  It’s a good thing, ’cause I can’t be any other way.

        Like all Docs I’ve had to do a few depositions along the way.  Each time the truth proved to be a powerful ally.  It never let me down, and things worked out fine each time.

        So, at least as far as this Doc goes love means it is best to say you’re sorry if things go wrong.  I don’t give  d@^# as to the assignment of individual blame.  That makes no difference to me.  The main thing is to try to figure out how to tweak the  system and lower the odds a bad event might happen again.  I don’t view apology as a sign of weakness,  although I know some folks do. 

        Julius and I are going to make this our lesson plan for a few days.  While he has been here things have gone well.  But I am in a lower profile job now that I am older.  When I was working day and night it is a wonder more didn’t go wrong than what did.  He is considering a career as a hospitalist, so he might as well start to ponder the issue now rather than later.

         What do you guys think?  I hope you’ll let me know.  As my agent said in the beginning, “Son you are going to learn a lot from your readers.”

Dr. B

Mafar and Holly Brown

July 26, 2009

        My wife travels to quilt shows with a lady named Holly Brown.  I like to think I’m Marfar’s best friend but a woman needs a lady best friend too.  

        I don’t know what they talk about when they ride down the road, but I am confident the subject of husbands must come up from time to time.  I can hear Marfar now.  “I cooked a nice tenderloin for the Quilt Guild and Tommy and those Neuse River Boys ate the whole thing after band practice. 

        Holly might respond, “I understand.  Matthew got off the tractor yesterday and washed off his boots in the tub.  Then he started singing ‘Red Clay Halo.’

        “Oh well, gotta love ‘em.”

        Holly is smart.  One thing I like about her is when I do something dumb I bet she helps Marfar figure out how to live with me rather than get shed of me.

        I go out on their trips every so often.  I sit in the back seat and play my mandolin, and they say it is more entertaining than the radio.  It’s about like a little boy going to the park on a summer day.  They drop me off at a local golf shop while they go to the show.  I can always get a game.  You can count on there being a grill where they have the best hot dogs in the South, and sometimes after the round I’ll hit a bucket of practice balls.  By the end of the day I’ve made a bunch of friends and all but joined the club.  At the appointed time I change shoes and wait in the parking lot.  Marfar and Holly don’t miss by more than five minutes.

        They drive me back home.  Sometimes I’ll fall asleep and they wake me up when we get there.  In my job, and much of my life, I’m always taking care of someone.  On those outings though, I am but a child in tow, and they take care of me.  Every time I’ve tagged along I’ve had a good day of it.  Even an old man enjoys a couple pretty ladies making a fuss over him and taking him to the park for the day. 

 Dr. B

A Rich Man’s Watches

July 24, 2009

        Years ago my daughter wanted to study in Europe for a summer.  Her Mama and I both had the same advice.  “Sweetie, if adult folks want to go to Europe, we have no problem with that, but they have to earn the money to go.”

        She had a part time job, and the next summer she showed me her bank account, passport, and itinerary.  The kid knew we were good for our word. She had a nice trip.

        While she was there she bought me a black faced Swiss Army watch.  I wear it every Friday.  It makes me feel young, and makes our regular Friday phone call all the more special.

        My everyday watch is a regular Swiss Army my wife gave me.  It is very reliable.

       My son and I played a lot of golf when he was growing up.  One year he depleted his piggy bank and bought me a Timex Iron Man.   That was about a decade ago.  Like the commercial says, it keep on ticking.  I have worn it on every golf outing since that day.  It keeps me young too.  I close my eyes, think of that boy’s limber back, take a deep breath, and still manage to hit it 250 (O.K. Smitty, downhill and downwind) on a good day. 

        On Saturday night gigs I have an old pocket watch Indie restored and gave me for my birthday.  No one had more soul than Indie, and I believe it allows me to play like a musician rather than a Doc at least once I can forget my patient’s troubles for a moment.

        My Dad gave me a gold watch and pocket knife on my 21st birthday.  I only use the knife to open letters, and only wear the watch when I go to my Mom and Dad’s for dinner, but it is still special.

        Sunday mornings I wear a pocket watch my wife gave me for our 25th wedding anniversary.   My daughter helped her pick it out.  The kid also helped me decide on a ring I got my wife at that very same jewelry store.  One time I called and asked Marie to meet me there and she hemmed and hawed around something awful.  Months later I learned she was already at the jewelry store with her Mama, and they had to spilt to keep from running into me.   I wear that watch on Sundays to remind me to thank God for my good fortune.  I have been a very lucky man.

        I have nothing against anyone who owns a Rolex watch (for I long time I didn’t know any better and called it a Rolidex) but if a stranger was to give me one, I wouldn’t be able to wear it.  I’m already committed to a time piece every day of the week, and I will never give them up.   

        If you put my watches in a poke and took ‘em to Johnny’s Jewelry and Pawn they wouldn’t be worth 500.00 all togehter, but they are priceless to me.  I can’t afford a Rolex, but I consider myself a rich man.

        Oops, gotta go.  It’s Friday afternoon.  I have seen all my patients and it’s time to call my Miss Marie.  She’s all grown up now, but the kid is smart enough to pretend like she still needs the old man.

Dr. B

The Disruptive Patient

July 23, 2009

        This post was inspired by my Facebook friend Bob Rupe of ‘Bluegrass Motors.’  He recalled an interaction with a less than cooperative customer.  It brought to mind a patient encounter from years ago.

        It was a late night at the hospital.  Back in those days we did not have hospitalists on the staff, so we picked up a lot of cases on unassigned call.  (folks who needed admission but did not have a regular Doc)  A husband demanded to see me about his wife’s condition in the I.C.U.   I was down in the ER and went up to check on things.

        “My wife needs to check out.  You need to fill out the paperwork so she can leave.”

        “Uh, well, sir.  I understand that you want her home.  I tell you the truth though, it isn’t safe yet.  She needs to be on the cardiac monitor another 48 hours.”

        “Well, by God, I say it’s time for her to go home.”

        Uh oh. This was trouble.  “Why do you say that?”

        “For her to be in here looks bad for me.”  (Her problem was self-inflicted)  “It’ll get out in the community why she’s here, and I won’t allow it.”

        I tried one more time.  “Honest to goodness sir.  It isn’t safe.  It’s possible she could die.”

        He glared at me.  “You gonna sign her out or not?”  His voice grew louder.  “Do you know who I am?”

         I wanted to say, ‘Yeah, you’re the guy who is driving his wife crazy,’ but I held my peace.   I thought for a minute.  “Hm.  Let me go look over her chart.  I’ll be right back.  I need a cup of coffee; can I bring you one?”

        “I’ll wait.”

         In those days, we had just hired our first hospital security people.  I had seen Ben down in the ER.  Ben was my patient, an ex-Marine, about 6’4″ and 250 pounds.  He was imposing even without his side arm.  I went to the ER.

        “Care for a cup of coffee, Ben?”

        “Sure, Doc.”

        “I’ve got a fellow up in the I.C.U.  we might have trouble with.  Can you troop up there with me?”

        “No problem.”

        I went back to to the room.  Ben tagged along behind and waited at the door.

        “My friend Ben brought your coffee.  Care for cream or sugar?”

        “No.”

        “Me neither.  I like it black too.”  I sat down and sipped on mine.  “I went over your wife’s chart.  It isn’t safe for her to leave.  Ben here will see to it the word doesn’t get out in the community.  It’d be bad for a man of your standing.”

        “Hmph.”

        “Don’t worry.  Ben’s very effective.  Through the years I only recall him shooting one person.”

        Silence.  He seemed to lose his resolve to intimidate. 

        I was glad.  Use of force is against my code of ethics.  I always call in a specialist for that.

       The man’s wife recovered and went home in three days.  We lined up all the right follow-up.  They never came back to see me.  In a way I hate that.  I wondered how things went for her over the years.  That was one more mean-spirited man.

Dr. B

Turn Back the Hands of Time

July 22, 2009

        Indie loved his cabin.  He used to say it was the only place on earth where you could turn back the hands of time.  When he died the T.V. was still analog.  He had an old stereo but one speaker was blown out.  He’d keep the same Bill Monroe LP on the turntable for months on end.

        Indie had many talents.  He liked to work on antique watches.  One time he restored an old pocket watch and gave it to me for my birthday.  His casual outward appearance belied a meticulous side few knew of.  It made him a wonderful Doctor, a fine fiddler, and an expert craftsman.  He never bragged on it though, which is one reason I have always been compelled to write of him.

        As he got older, his Parkinson’s got worse.  When he’d work on watches he’d get into Barney the skeleton’s skull and for a nip of Jim Beam.  He said it steadied his hand, and toned down the tremor enough for him to do the fine work involved.

        Indie worried over me.  “Son, you’re a fine Doctor but you invented type A.  When you’re here at the Cabin you don’t need to worry about time.  I never think about unless you remind me.  Here time can stand still.  Hell, it can go backwards if you get your mind set right.” 

        I would laugh, but I knew Indie was right.  He taught me a lot about being laid back, at least when I was off duty.

        Not long ago Marfar was in the cabin kitchen and broke out in a big laugh.  The kitchen clock is an old Greensboro, N.C. Pilot Life Insurance company model.  (Indie gave her the bronze piggy bank to match.)  It dates back to the fifties.  You remember the song on the early ACC basketball games.  ‘Sail with the pilot…’  The center of the clock features the Pilot at the wheel.  He has on a yellow rain slicker.  Time has worn the old sea salt’s once chiseled features into an unrecognizable sand-blasted look.  His right hand serves as a second hand like a maestro’s baton.     

        “What’s so funny?” I asked.

        “Look at the clock.”

        “The Pilot?  Yeah, he’s a fixture.”

        “No, look again.  Check out the hands.”

        Good Lord have mercy.  They’re going backwards!”

        “What do you make of that?  I’ve never seen a clock do that.”

        I laughed.  “It’s Indie, hon.  He said time could go backwards at the cabin.  I bet that rascal got into his Jim Beam before he died and rigged up the Pilot’s hands to run backwards.”  The thought of Indie with a Barney brainstorm to remind me to relax after he was gone was too much.

        Indie always did get the last laugh.  I could just picture him and St. Peter yucking it up as they waited for me to figure it out.

        I’d try to get one on him, but his current location precludes it.  You don’t diss folks in Heaven.  But old pal, when I get there, you just wait…..

        By the way, I ain’t about to ‘fix’ that clock.  Indie already did that for me.

Dr. B


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