Saturday, May 29, 2010

A Day in the Life of an Internist

I received what I think was the best clinical training in the USA, both at my medical school and in my internal medicine residency at a big-city hospital with a long and meritorious history of treating both private and ward patients. I learned from my mentors that the patient should always be treated with the utmost courtesy, and listened to as carefully as possible. It is absolutely true that a properly taken history will give the correct diagnosis 85-90% of the time, and the physical exam and lab tests usually just confirm your impression. Since I have observed both from what my patients tell me and from observing my medical interns and residents at work that human doctor-patient interactions have deteriorated (which does not, unfortunately, show up in the morbidity or mortality tables), I would like to describe to all my readers how I practice medicine.

When I started practice, I allotted 60 minutes to a new history and physical, 45 minutes for an annual physical, and 30 minutes for any other visit. I have had to reduce this to 45 minutes, 30 minutes, and 20 minutes respectively, because office fees keep on dropping, but I think what I have now is a irreducible minimum amount of time for a visit, and I could not lower it further in good conscience. My patients also know that if they call my office before 10AM I will see them that day. I also always maintain eye contact, taking very few notes, and NEVER looking down at the keyboard of a laptop (I don't have one in the office) while I am taking a history.

I begin by going out to the waiting room and escorting the patient into my consulting room. (No, I have no PA's or NP's, but only a lab tech who does EKG's and gives vaccinations.) After talking with the patient, I then escort the patient into the exam room, and then wait outside while they disrobe and put on an examination gown. I then enter the room (with a chaperone if it is a physical exam of a female patient) and examine the patient. I then leave the room, the patient dresses, and comes back to the consultation room. I then discuss my findings and tentative diagnoses, and discuss the lab tests and Xrays I am ordering, and review the EKG with the patient. Then I explain why I am prescribing medicine, what I am expecting the medicine to do, and when or under what circumstances the patient should call me (or I the patient). When the lab tests and Xray reports are received by me, I make a copy of them and mail the copy to the patient along with a note discussing with the patient our next plans, and always ask the patient to call or come in to see me for further clarification. A copy of my note is also placed in the patient chart.

I feel that a good doctor is a good teacher, and one of my obligations is to educate my patients as well as possible. I also suggest they use the internet only to look up diseases, and not symptoms, because all symptoms can be due to AIDS, Alzheimer's disease, and cancer.
I normally can explain things to my patients' satisfaction, and refer them to a specialist if I cannot. The problem always arises when the patient is satisfied with less medical information than the spouse, other family members, or friends want to know. I firmly believe in patient privacy, and that the patient is always right. (Although the patient can be legally right and morally unfair; e.g. in not disclosing a diagnosis of cancer to the spouse.) But if I tell a patient that his Chest X-ray shows a mass and I want to get a CT scan of the lesion to help diagnose it, and he does not ask me if the mass could be cancer, then he is not prepared to consider that diagnosis at this time.

Every patient has certain medical beliefs, and therefore will accept some treatments and tests, but not others. I have no Christian Scientists in my practice, but I do have some Jehovah's Witnesses who will not accept blood transfusions. At Yom Kippur, a few Orthodox Jews always ask me if fasting includes not taking any medicines, and I tell them to verify with their rabbi that health takes precedence over religious practices. I do have diabetic patients who will not take insulin, because in their belief system if you take insulin you are a true diabetic, while if you only take pills you just have a "sugar problem". I have patients who refuse mammograms, vaccinations, fecal blood tests, pap smears. I have patients who refuse to let me take their weight. I have patients whose spouses don't believe in sleeping pills, or perhaps in antidepressants, so they have to hide them, and pay for the drugs themselves if they are on their spouse's medical plan.

Every patient with "bad" habits knows that reform is needed, but they are not prepared yet to give up the pleasures of smoking, or deny themselves oral gratification to lose weight. The human brain doesn't handle the future very well, so to us a "bird in the hand is worth two in the bush", or $10 today is better than $20 one year from now. We'd rather look for amulets and gimmicks: copper bracelets to treat rheumatism, ear staples to reduce hunger, or magnets in your shoes (should the North Pole or the South Pole of the magnet face up?) to treat back pain.

So I give my patients the best advice I know and educate them as well as I can using anatomy books, skeletons, etc. But my ego is never on the line,so I never take it personally when a patient doesn't follow my advice, but I do ask them to let me know if they are going to stop a prescribed medicine. I also don't take it personally if they change doctors, since they have an absolute right to their body. Too many patients stay with a doctor or dentist with whom they are dissatisfied
because they don't want to be rude and hurt the doctor's feelings.

One frustration with HIPAA: In the "Old days", if I felt a patient had become an unsafe driver, I could write a letter to the DMV, and they would require a repeat road driving test within 60 days, or the license would be revoked. The DMV has now informed me that due to the HIPAA
laws, I cannot write such a letter without the patient's explicit consent.

I am on call from 8AM Monday morning until 5PM Friday afternoon. I split weekend coverage with another group (I am a solo practitioner, in part because doctors get paid more for doing the cardiac cath. than diagnosing that the cath. is needed). I tell my service to find me if they cannot find my covering doctor. I also tell my service that I don't do pharmacy refills after 6PM. I tell my patients that whether they call the office or my answering service, if I don't call them back within 30 minutes they should call me again to make sure I got their message. You might note that my total hours on call greatly exceed those allowed for medical residents, although I am 30 years older than most of them, and certainly don't have as much non-sleep stamina as they do. I also don't have the luxury of calling an older attending for advice. But if I told a patient who calls me at 10PM with a medical problem that I have been up and on call for 16 hours, and they should go to the Emergency Room to be seen by a well-rested physician, I don't think they would like the suggestion.

I might mention that for me physical diagnosis is fairly straightforward, and I see one of my main jobs as reducing stress in my patients. I have a T-shirt that says "Stress is when your gut says "No", and your mouth says "Of course. I'd be glad to." Therefore, I ask all my patients the same two questions at their annual physical: (1) Do you look forward to going to work in the AM? (or your spouse's leaving the house). (2) Do you look forward to coming home to your spouse and household at the end of the day (or seeing your spouse come home)?

Anything you do that your brain does not want you to do will cause stress, and the more stress, the more pain your unhappy brain will cause your body. As a trivial example, most females traveling away on a weekend business trip are constipated while they are away from home---something to do with strange toilets. This is just an observation and not an anti-female statement. Similarly, most males who have not served in the armed forces have difficulty urinating if another male is at the urinal immediately next to them. In this vein, I tell all my young adult patients to make sure they like their jobs before they acquire a spouse, 2 children, and a mortgage.

For completeness, but also to safeguard my patients, I keep a complete problem list (operations, treatable conditions, allergies, home stresses, medicines) in the front of the chart, but any fact that might cause embarrassment if read by a spouse is written in my private code(e.g. uses cocaine, has affairs, gave a baby up for adoption at age 14, etc.) Again, my patient is always
right, and I will defend this right as firmly as I can. And if you haven't already guessed, I think that internal medicine is the most wonderful field in the world!

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