Country Doc Rule Number Three- Apologies are Necessary

        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

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The Disruptive Patient

        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

The Country Doc Rule Number Two- 16 Seconds Won’t Cut the Gig

        “Sixteen seconds won’t cut the gig.”  There’s  a song in there somewhere.

         I think it was Dr. Groopman who quoted the study.  On a routine encounter Docs let their patient talk sixteen seconds before they interrupt them, make a diagnosis, and reach for a script pad.   

          Wow.  I hope I am not that bad.  If I am, me and Julius are gonna go to the River and get baptized and rededicate ourselves to our profession.  Sixteen seconds is unacceptable.

        There is an old saying in medicine, and like many cliches it is true.  “If you let the patient talk they will tell you what is wrong with them.”   And I have found it only takes them a little while to do it.

        It is time well invested.  I have been told I have a reputation as a good diagnostician.  If I am I’m humbly grateful for that and hope to never take that blessing for granted.  Today though I must tell you this reputation is because I have good patients. 

        My standard routine is to ask the patient, “Hey Ms. Smith, what’s troubling you today?” and then let them talk until they have finished telling me.  95% of the time they have done so in five minutes.  At what it costs to go to the Doc these days, it doesn’t seem like much to ask for to me.

         Some of this works because most of my people have been seeing me for decades and I know them inside out.  What I can’t figure out has been sorted through by the best army of specialists on the East Coast this old boy could assemble.  I know which ones are reliable (and most of the Docs out there) and I count on them to help me out.  The few who proved indifferent were cast aside long ago.  I don’t give a $@^^ if they send me a country ham ever Christmas till Hades freezes over, they ain’t gonna see my people.  

        Here is a technique I recommend.  If we have anything close to a slow day, and sometimes we do mid summer, Julius and I will go into a room and I’ll issue my standard greeting.  Then I’ll sit down, prop my feet up and say,  “Look.  We’re having a good old lazy summer day, and I had a cancellation.  We got time for you to tell me anything you want.”

        The only problem is often folks are so shocked they can’t remember why they came to to the Doctor.  Then I’ll say, “That’s O.K.  Everyone has the same reaction.  It is a sign I haven’t been giving you enough time.”  Then they relax again and we get serious about the issue at hand.

         I wish I could tell you I am perfect, and do it right every time.  I don’t.  But when I fail I am sorry for it.  I remember one day when everything was going wrong.  I was rushed and distracted.  Late that morning, one fellow called me back.

        “Doc, I know you were having a bad day, but you cut me short.  I didn’t get to tell you what was wrong with me.”

          Dang it.  “Tell you what, Joe.  You come back over here at 12:30 and we’ll sit down and eat lunch together.  I’ll hear out anything you need to tell me.  We go back a long way, and if I get run over by a truck tomorrow I don’t want your last memory of me to be that I let you down.”

          He is still my patient.  In fact I am proud to say my last chart transfer other than someone moving has been a long time.  If we have someone leave, I’ll call ’em and ask why.  That what I did with the last one and  think it was three years ago.

         16 seconds.  Man, I am not sure how I am gonna be remembered, but I want it to be better than that.  I believe Julius does too, so I think I will make the 16 second rule my next lesson for him.

Dr. B

Medical History Repeats Itself

        My daughter says some things never change and I am one of  them.  I saw a patient not long ago who reminded me of that fact.

        This lady’s mom was one of my first patients.  The mother had several chronic medical conditions.  I looked after her until she died and was always impressed with her outlook on things.  In spite of her medical troubles the lady was a fun person to be around, and always had a joke or a story.

        I saw the daughter last week.  She has the exact same list of medical conditions.  She deals with them with equal grace.  Not only has she come to look just like her mom, she also tells funny stories, laughs just like her, and even has the same mannerisms and inflections in her voice.  Their idiosyncratic similarities are downright spooky. 

          I treat her with similar meds as what I used with her mother.  I think we would do just as well with the old ones, but the administrators and bureaucrats get upset if you don’t look modern, and I am afraid they might fuss at her or not cover her regimen. 

         One time I explained treatment options for her kidney stone and she said, “Dr. B you do what you gotta do.  I don’t care if you have to latch an alligator to my ass to help me.”  It was what her mom used to say when she had a stone.  Like her mom, my patient likes my music and comes out to our shows when we play. 

        I guess Marie is right.  Some things never change and I am one of them.  So are my people.  It makes being a small town doc all kinds of fun and such an honor and privilege.

Dr. B

Something To Do With Money

        We used to have an old Doc in town who had the same answer for every problem.  Regardless of the issue at hand, when something was wrong he’d say, “I don’t know what the problem is here, but it has something to do with money.”

        Most people in health care want to do right by people, and they are easy to work with.  But, whenever I run into folks who will not act in the patient’s best interest old Doc’s adage can be used as a powerful  motivational tool.

       Take a case last month.  I had a patient with a couple risk factors and a good story for a pulmonary embolus.  (Blood clot).  I wanted  a CT chest to rule out a clot.  The little chart review person at the insurance company told my people we would have to do a plain chest x-ray instead.  With the diagnosis in question, that is a little better than a coin flip, but not much.  They would not budge.

       Often I have to call, but this time our referral tech was able to make them understand.

       “What should I tell them Dr. B?”

       “Hmn.  Why don’t you go with the BBQ speech?”

       “O.K.”

       In a minute she was back with an accession number.  The CT was approved. 

        The BBQ speech goes like this:

        “Y’all like BBQ?” 

        They usually say yes. 

        “Well, I’m glad, ’cause Dr. B says you might need to visit us for an extended stay.”

        “Why is that?”

        “He wants you to know if anything happens to his patient while you obstruct their care he keeps a lawyer on retainer.  And boy does this lawyer love BBQ.  We have the best down here.  He thinks it won’t take more than two or three years to sort out.  With her being a mother of three, he believes a jury would have enormous sympathy in the event of death from a delayed diagnosis of pulmonary embolism.”

        “Really?” 

        “Yeah.  He said not to worry too much.  This is a rural area, he doubts it would go for more than three mill or so.   Old Dr. B is  a very patient man.  Why he’s like a little terrorist; he ain’t going away.  You’ll love it here.  Like I said, the barbeque  is great.

         There are all sorts of variations on the theme, but the fundamental principle is always the same.  You have to speak to what motivates them.  I gave a up a long time ago trying to make them understand I hoped to help a human being; that matters to them not in the least.  But when you start to talk money they will often listen.  Like the Old Doc said, there’s something wrong here and it’s got  something to do with money.

        By the way, my patient’s blood clot treatment went well, and she should do fine.

Dr. B

When Doc gets Sick

         Old Doc is sick today, but don’t feel sorry for me.  It is just laryngitis, and it’ll pass.  As Indie would say, it’s just a thing.

        I didn’t stay home, ’cause I don’t know how not to go to work.  (That is if you call it work- it’s just doctoring to me- no heavy lifting involved.)  I’ve been lucky.  A couple days out in the third grade for the mumps, and two Fridays post cataract surgery is all I have missed through the years.  I’ve been at this business long enough to know your luck can change overnight, so I ain’t bragging.  I’m just thankful for my good fortune.

        For the most part I am against sickness, not that I have much control over it.  I will say one thing for it, though.  If we were never ill, we could not appreciate being well.  When ever I am sick, I always think of my patients and friends afflicted with a chronic illness.  They live that way every day, and the good days are the exception.  I reserve my sympathy for them; they have it far worse than a guy like me who only deals with it sporadically.

         A doctor needs to be sick every so often.  If for nothing else, we need to be reminded what out patients go through.  And I’ll be well in a week or ten days; just in time for Neuse River’s next gig.  

Dr. B

The Ranks of the Rinky Dink/Hoop Jumping 101

        Like all modern professions there is a certain amount of hoop jumping that goes with the territory.  Some of it is a bit silly, but I figure you gotta roll with life.  I take it for what it is.

        For example, we Docs have to periodically take some on-line kind of test to prove we know our business.  This is no problem for me.  I never forget a patient, and if you know them you can figure out the right answers to the questions every time.  

        I decided to have a little fun this last go-round.  I was done with the simulation in no time flat.  To tell you the truth, I am concerned for any Doc who can’t blaze through that no sweat.  Here ‘s where the fun came in.  After you got all the basics down, you could start to enter questions the computer had to answer.  I started out with the easy ones:

        “Does your head feel bigger than a peck bucket?”

        “I am sorry, I do not recognize.”

        “O.K.  Your  knee be swolle?”

        “Sorry- do not recognize.”

         “Let’s talk about your diet.”

        “O.K.”

        “Last time you were in you said you had three thirds of a biscuit for breakfast.  Any change?”

        “Pardon?”

        Pretty soon the machine began to beg me to leave.   “You may exit the simulation.  You may exit now.”

       “Hell, no.  I have some more questions for you.”

       “Pardon?  You may  exit now.”   Then, “Congratulations, you have passed this clinical simulation.”

        “Wait a minute.”

         “Have a nice day.”

         Of course, this all has little to do with doctoring, but everything to do with life lessons.  I have learned to deal with people, and if you make enough of a pest out of yourself those kind of folks will go away.  And too, I have to give my kids a lot of credit.  They are computer geniuses.  As for me when I was a kid I used a slide rule, and as I have said before a bluetooth was something in need of a dentist, but this old man is adaptable.

        I can jump through hoops with the best of  em.  It’s like GOEMA, the government office for the elimination of medical abbreviations.  To stay in compliance, I have to join the ranks of the rinky dink to continue to play ball, but I do.  For my efforts I get to be a doctor.  Other than being a husband and father, it was my most sacred privilege on earth, so I do what I have to to keep being Dr. B.

Dr. B

Rural Health Reform

        My friend and colleague, Dr. Therese Zink, is on the move.   She is the Med School Professor organized the Country Doc Compilation due out in 2010.  (I ain’t gonna let y’all forgot old Dr. B has an article in it!)

        Well, she’s done it again.  She’s now joined forces with the blog world, and has a new forum to address the problems faced by Docs like me.  Man, I heard Obama’s people will read this thing, so it is big.  

        I have a notion before it’s all over, Dr. Zink is gonna be like a female Moses and lead us all to the Promised Land.  One thing is certain- she has a very good handle on the problems faced by everyday Country Docs like me.

        Y’all check her out.  Here is her address:

http://healthcarereformrural.blogspot.com/

Rude Doctors

        Blog pal Ted Lehmann ( www.tedlehmann.blogspot.com) sent this link from the New York Times, and I thought folks would enjoy it.

        It is sad but true; some Docs can be downright disrespectful. 

        Believe it or not, the study of what to do about this has become a science.  There is a Doctor from a famous institution in Tennessee who has studied the phenomenon in quite a bit of depth.  He is the South’s (maybe the world’s) leading authority on disruptive Docs and the impact they have.

        His institution began to realize the bad actors were not only a frequent target of litigation, but they had a negative impact on patient care and the overall quality of the institution.  They set out to develop a program to try and rehabilitate these guys.

        I’ll never forget the first conference of this Doc’s I went to.  He told the story of having to confront a Doctor who was rude to everyone in his path.  The Doctor studied the data.  (Doctors like science)  

        When confronted with the mound of scientific evidence compiled in charts and graphs, the Doctor looked at it all and said, “I knew I was an ass^*!$, but I didn’t realize I was the worst ass^*!$ in the hospital.” 

        What a legacy!

        Y’all check out the Times article.  I ‘d enjoy your comments on the subject.

Dr. B

The Six Habits of Highly Respectful Physicians