Swamped.

For the first time in the almost-10 years that I’ve been a family doctor, do I actually feel like I’m a family doctor.

I’m busy!  I am pretty much fully booked every day that I am here and often don’t leave the office until at least an hour after I finish seeing patients.  I’ve been back to work for two months and initially the busyness was expected, and I thought things would have settled down by now. But no, it hasn’t.

Don’t get me wrong, I’d rather be busy when I’m at work then sitting around twiddling my thumbs with unbooked appointments. I’m glad that I am available for my patients. I’m glad they don’t have to go to a walk-in clinic.  Sure, a few will go regardless if I’m available or not, after all, I can’t accommodate everyone’s schedule, but when it’s a steady stream of patients all day with no break, it gets pretty exhausting.

Gone are the days, I fear, where I could see my last patient and be out the door a little after 5pm. Now I have to finish charting my notes, call those two patients, do that referral and finish that insurance report.

When did I grow up to be the typical busy family doctor? It seems to have happened overnight.

I used to pride myself on running an efficient day and not being late. But then fifteen minutes behind turned into twenty, and now sometimes thirty-five to forty minutes. Thankfully it’s not often because those days when I run late stress the hell out of me. I don’t want to keep people waiting, I know they have places to be and busy lives and lord knows I don’t want to be getting home well after 6pm every night – that’s when my kids go to bed! I want to tuck them in and tell them a story. I feel guilty when I’m late because that means husband has more to do and doesn’t get a break. Thankfully he totally understands and knows it comes with the job but still, if our roles were reversed I could see it getting to me.

My practice is growing, patients are getting older, and life just happens. I can’t control the mother of two small children who comes to see me at 4:45pm and then takes a half hour to explain how she found out her husband is cheating on her and feels like her life is falling apart. How am I supposed to tell her that her time is up at 5pm? I can’t, obviously. These situations don’t happen often but they always seem to happen on the days when I am already running behind. It’s like the universe knows or something.

More importantly, illness happens. On any given day there is no way to predict what will walk through my door. The majority of the time family medicine is pretty run of the mill and preventative care. But when illness happens it throws a wrench in my day.  Sometimes I feel like I’m drowning in a sea of paperwork and lab results; in insurance and medico-legal reports. Some days I wonder what was put in the local water supply because all the “crazies” show up on the same day.

But most days, I love being here and seeing my patients and even though I’m tired and hungry and may not want to listen to someone else complain about their life, I really couldn’t imagine doing anything else.

Too Close For Comfort

Day 21. National Blog Posting Month.

Every now and then, I get an email from my son’s preschool about an outbreak of Hand, Foot and Mouth disease, or Fifth’s disease.  These are viral infections that are generally self-limiting and not a whole lot to worry about.  Except if you’re a pregnant woman exposed to Fifth’s disease.  In that case, there is an increased risk of miscarriage if exposure occurs in the first trimester and if exposed after 20 weeks there are certain biological effects to the fetus, in particular a life-threatening form of anemia.

Last night, around 1am, while I was nursing the baby, I decided to check my email.  In my Inbox is a note from the preschool announcing that there has been one confirmed case of Chicken Pox.

And so it begins ….

At this point, my son has already been exposed and has likely exposed all of us, including the baby.  Thankfully, both my husband and I have had the infection in childhood, our daughter was immunized and got a booster last year, and the toddler was immunized at 15 months.  My first thought was to get my son his second dose immediately, if for any other reason than to protect the baby.

Where I live, children are given one dose of the Varicella vaccine at 15 months of age and again at age 4.  According to the CDC, one dose of the vaccine is “85% effective against any form of varicella and close to 100% effective against severe varicella.” However, two doses of the vaccine is 88%-98% effective at preventing all varicella disease.

Don’t get me wrong, 85% effectiveness is pretty darn good, but is it good enough for me?  Especially having a 2 month old in the house?  My instinct as I mentioned was to bring my son (the toddler) to his pediatrician today for the booster.  Instead, rational heads prevailed and I called instead.  Our pediatrician assured me that my son’s immunity should still be strong enough to protect not only himself, but his little brother as well.

Phew.

Still, I can’t help but be pretty pissed off at those parents.  Given the type of preschool my son attends (okay, it’s a Montessori school in an affluent area of the city and quite frankly, not cheap), I have to assume these parents are well-educated and probably know that a vaccine against Chicken Pox exists.  But, I’m also quite sure they’ve heard all the “horror stories” on the Internet or from Ms. McCarthy herself and decided it was best for their child to skip the vaccine.  Right.  

Ugh.  I’m sorry if this offends any of my readers, but these kinds of parents are putting other children at risk.  As a mother, I’m not okay with that, but there is zero I can do about it.

As a doctor?  Well, you know where I stand on that.

End rant.

 

A Frightening Trend.

Day 12. This is actually a lot easier than I thought it would be, writing a post everyday.  I actually look forward to it!

And, yes, I’m back, despite my little rant yesterday, which in case you missed it, you can read here.

What’s on my mind today?  Vaccines.  I know, I know, it’s a volatile topic and I’ve discussed it before, but you see, the baby is 8 weeks old today (my goodness, when did that happen?) and he will be going for his first set of vaccinations next week. For me, it’s a no-brainer that he will be vaccinated.  All of my kids were vaccinated.  I didn’t even give it a second thought.  Now, that’s probably because I am a physician and a rational, logical human being.  Okay, that last part was a bit of a dig.  I am just so sick and tired of parents thinking that just because they’ve done their “research” on vaccines (ie. have read about Wakefield, everything that Jenny McCarthy has to say on the subject, and discussed it with their “friends” on countless message boards), does not mean that they understand the science and study behind creating a vaccine.  These parents haven’t seen the devastation that Polio caused, they haven’t seen what congenital Rubella syndrome looks like, nor have they had to tell their son that they may never be able to father children because the Mumps caused orchitis and has the potential to limit his fertility. And let’s not forget the risks of meningitis from certain strains of pneumococcal pneumonia, Measles, and rarely, chicken pox.

I was a resident in family medicine working on the Pediatric ward when a 15 month old girl was admitted with seizures.  She had been diagnosed with pneumonia 2 days earlier.  Blood cultures revealed a particular strain of bacterial pneumonia.  This strain is one that is covered by a vaccination available here, called Prevnar-13.  A review of this child’s medical records showed that her parents declined all vaccinations.  The seizures were eventually controlled, she was diagnosed with encephalitis and a few weeks later was found to be completely deaf.  Totally preventable had she only been vaccinated as an infant.

At least once every few weeks I see a news article about an outbreak of a vaccine-preventable illness.

It’s becoming so common these days, it’s actually starting to scare me a little bit.  If we continue down this path of non-vaccination, herd immunity is going to fail.  We will see the resurgence of illnesses we haven’t seen in twenty or thirty years.  I have never seen a case of measles but I’m sure one day, at this rate, I will.

What’s next?  A North American outbreak of Polio?

When the Alternative Approach Conflicts with Western Medicine.

I had one of those encounters a few days ago that left me angry and irritated.  Angry because I can’t understand how a woman, in her mid- 40s and pregnant (first trimester), can walk around comfortably knowing her blood pressure is high, yet refuses treatment.  Irritated, because she will be coming back in a week or so to check her blood pressure again, and it’s going to remain high and I will have the same conversation with her and she’ll refuse treatment.  She intends to treat her blood pressure the “natural” way – acupuncture, massage therapy, herbal teas, naturopathy and Reiki.

Uh huh.

Did I mention she has 4 other children at home?

Her blood pressure wasn’t just a little elevated, it was 150/100.  Two years ago, her blood pressure was 140/80.  She likely had some early essential hypertension then.  Now, being pregnant, not only does she have untreated essential, chronic hypertension, she is also hugely at risk for developing preeclampsia.  I explained this to her. I told her all the risks to her own health (seizure, stroke, death), as well as to the baby she is carrying (spontaneous abortion, intrauterine fetal growth restriction, intrauterine fetal demise, stillbirth).  She still refused treatment.

I have several patients in my practice who want to have a family doctor but don’t actually prescribe to a lot of Western medicine.  These patient will see their naturopath, osteopath, chiropractor and acupuncturist first.  Sometimes they come to see me when those approaches aren’t working.  Some patients accept that those approaches didn’t help and come to me seeking the “Western” approach, which more times that not, relieves their problem.

A lot of these patients actually “interview” me at their first visit and ask me how I feel about these approaches. My answer is generally pretty straight forward. I don’t really have a problem when patients seek the alternative/complementary approach.  It is their money to spend.  Sometimes a chiropractor can be quite helpful for mechanical back pain.  I would know as I saw one in my 20s and it helped immensely.  But sometimes these approaches don’t work.  I saw an acupuncturist for my migraine headaches.  Countless needles in my skull and a few hundred dollars later, and my headaches were unchanged.  What worked were the triptan drugs, thank you very much.

When alternative medicine becomes an issue with me is when the patient with a blood pressure of 180/110, and now complaining of headaches, repeatedly comes to the office to check how the alternative approach is working (it isn’t), then refuses to take my advice on treatment.   When confronted with this, the patient responds with, “Okay, I’ll go back to Dr. So-and-So ND, and change the herbs. Thank you.”  Uh huh.   My job is, according to the patient, apparently done.  This is when it gets tricky.  How many times can I see this patient with dangerously high blood pressure before he strokes out?  My job is to make sure he doesn’t. Yet, after explaining the risks to him, he still refuses the anti-hypertensive medication that has proven to work.  So, I have to ask him why he continues to return to my office for visits?  Clearly we are at a stalemate.  And this is when I go back to the rest of the answer to that question he asked me two years ago.  “Remember the conversation we had when we first met?” I ask him.  He looks at me, puzzled.  After a moment, he understands.  This is when I say,  “It’s time to re-evaluate our doctor-patient relationship.  I am afraid I can no longer, in good conscience, continue to be your physician if you repeatedly refuse treatment for your hypertension.  You are at great risk of having a stroke.  By continuing to be your physician when you refuse to treat your hypertension, I am violating my Hippocratic Oath.”

I fear this may be how my relationship with the pregnant woman will end.  She will return to my office in a week or two to check her blood pressure.  I expect it will continue to be elevated.  And I suspect she will continue to refuse Western medical treatment.  Not only is she risking her own life, now she is risking the life of her unborn child, not to mention risking the well-being of her four other children at home who need their mother.

How, in good conscience, can I continue to be her physician?

January blahs.

January has always been a “blah” month for me.  After all the lead-up and hyper over Christmas (especially now having children), January comes with a brutal hangover.   Suddenly, the reality of days on end of eating huge meals, sweets, chocolate, not to mention copious amounts of wine at family functions, catches up to you when you put on your work pants and they are just a bit more snug than they were a week ago.  There’s the task of taking down the Christmas tree, and explaining to the kids why the tree is out on the curb waiting for the garbage man to pick up.  There’s 10 days of having to entertain your child while she is off school.  Really, there is only so much Play-Doh I can handle.  There’s the late, late nights with husband watching Taxi Driver, the entire Lord of the Rings and Alien trilogies, which by the way, is a lot of fun.  Oh, and did I mention I was also working and covering two other practices?  Yeah, so no wonder I greeted January with one measure of fatigue, two measures of new flab and a measure of low mood.

I’ve been quite grumpy for the past week or so, mostly because I don’t know how to say no.  I agreed to cover for my two colleagues during the holidays – paid, of course.  We have an arrangement where we pay each other for lab review and patients seen.  We are all paid a salary, so we get paid whether we see our patients or not.  So, when a colleague is on vacation for 10 days and getting paid for it, I’m at the office seeing their folks.  I agreed to it, so I have no one to blame but myself.  It was busy.  One afternoon, I saw 24 patients (when I usually see that many in a full day), and the other morning I saw 16.  I got tired.  And grumpy.

It’s also winter.  Really?  Yes, it is!   I don’t remember the last time I felt the sun on my face.  Which might also explain the horrific acne these days.  TMI?   So, while at Costco the other day, I decided to finally take some of my own advice and start taking some Vitamin D – you know, just to make sure the advice I’m doling out is actually correct.

Vitamin D is a fat soluble vitamin.  It is present in a few foods, can be synthesized in our skin by natural sunlight, or taken as a supplement.  Vitamin D has to go through certain biochemical processes to become active and useful in our body.  There is some metabolism through the liver and the rest is done through the kidney.   (To read more – go here).  Vitamin D is important in maintaining adequate calcium levels in our body, as well as phosphate.  To put it simply, vitamin D helps make our bones stay strong.   Insufficient levels of vitamin D in children can lead to rickets, and in adults to brittle bones. But vitamin D has other important functions –  these include functions in cell growth and immunity, as well as reducing inflammation.

Many of my patients take vitamin D, for many different reasons.  I recommend it for all the children in my practice as well as the post-menopausal women, and I usually tell the patients who are struggling with depression (especially in the winter) to also take extra vitamin D.   I’m finding more and more people (men and women, alike) are taking vitamin D.  Apparently it’s the go-to supplement these days.  Did you know it can fight 3 different forms of cancer?? <insert eyeroll here>

In any event, I decided it was time to take some of my own advice.  A few days ago I started taking 2000 IU of D3.  To my genuine surprise, I was amazed at how quickly I started to feel better.  Yes, likely a placebo effect, but who cares?  Suddenly, after 10 days or more of darkness and bleak mood, the sunshine is back.

Oh, and did I mention that I am nearing the 10km running milestone?  For a few weeks now, I have been increasing my running distance by 1km per week.  Yesterday, I ran 8.2km.  It felt great.  I’m a little sore today, but it’s that good kind of soreness. Exercise really is nature’s best medicine.  I need to remember that on the dark days.

The Autumn Classic In Doctor Land.

Ah … Fall.

Some people mark the beginning of fall by the calendar date, the changing of the leaves, others by the start of the World Series.  Me?  Fall begins when the shipment of flu vaccine arrives in the office.

Fall came last Friday in a pretty package containing 160 doses of flu vaccine.

Influenza.  The Flu.  Most people use the term “flu” synonymously with “cold”.  The two are very different.

I’ll never forget the first (and only) time I had Influenza.  It was January, 2000.  I was heading back to medical school after the Christmas holidays.  While on the train, I started getting a scratchy, sore throat.  I woke up the next morning, feeling like I got hit by a truck. Within 6 hours, I had a fever of 39.8C (103.5F), my entire body was wracked with rigors, my head felt like it was going to explode.  My friends watched me deteriorate in class, apparently I looked weaker and paler by the minute and someone took pity on me and drove me home.  That night, I slept on the couch and watched re-runs of “The X-Files”.   I had to change clothes at least once very 2 hours due to drenching sweats.  My roommate called her mother who was a family physician and offered me an anti-viral, but I was pretty incoherent from the fever and declined.  In retrospect, I probably should have taken it.  The next day was no better, and there was no way I could go to class, so I basically lived on that couch for a few days.  Tylenol, Advil and Gatorade were my friends.  By the end of the week, the fever had broken, the muscle aches were gone, but I was left with a horrible cough which lasted about 4 weeks.  (Turns out I also got bronchitis after that).

Did I mention that was the first year I’d gotten the flu shot?

Riight, so it was also the year that I had influenza, bronchitis and laryngitis, pretty much back to back.  It was also the first year I trekked back and forth inside a hospital to get to my classes.  Such a glamorous life that was.  (I secretly loved it). I had never been that sick for that long.  It’s interesting to note that I haven’t been that sick since!  Obviously, I contracted a different viral strain which the flu shot didn’t protect me from.  It happens.  I was young (hey, still am!) so was able to fight the virus.  The extremes of age often aren’t so lucky when it comes to influenza.

It wasn’t always the case though.  The great flu pandemic of 1918 wiped out close to 50 million people.  The Spanish Flu decimated the world’s population (then, 1.36 billion) in a little over a year.  Most victims were healthy young adults, in contrast to most influenza outbreaks, which predominantly affect juvenile, elderly, or weakened patients (from Wikipedia).  Its been said that the Spanish Flu was deadlier than the Black Death and in fact, this flu killed more people in 24 weeks than AIDS has killed in 24 years, more in a year than the Black Death killed in a century!

Remember H1N1?  Much ado about nothing, in my opinion.  Not to be nihilistic, but we ain’t seen nothing yet.  The big one is coming.  I don’t know when, I don’t know how, but we’re due for a real pandemic again.

So, I got my flu shot again.

It’s not candy!

I’m reminded today of why baby-proofing your house is so important.

But let me start by saying that we didn’t really baby-proof our house before daughter arrived.  Oh, sure we covered the electrical outlets, but that was pretty much all we did.  We never put up gates, we didn’t put locks on the cabinets until she was about 2 years old and started opening them.  Our medicines were always tucked away in a cabinet above the sink.  When daughter sees me taking an Advil for migraines she always wants one.  I tell her it’s medicine for mommy, but she insists it’s candy.  It never really occurred to me that as a child, grown-up medicines look like candy!  Damn those pharmaceutical companies!

I arrived in my office this morning at 9:55am.   My 10 am patient was waiting for me and as I’m getting the EMR running, I notice I have an “add-on” at 9:45am.  The reason for visit – “possibly swallowed allergy meds”.  Child’s age – 9.5 months.

I’m sure the parents in the audience can totally relate to this story. I certainly can.  Father takes his allergy pill, caps the bottle (he thinks), 9.5 month old is crawling around him, he and mother are busy running around getting ready for their day.  Child somehow gets a hold of the bottle, starts shaking it like a rattle, then there’s silence.  Parents find bottle emptied of its contents and child playing around it.   Panic ensues.  Did child eat a pill?  Did he eat 5?

Thankfully, parent brought the bottle with him.  It was Benadryl.  I quickly called Poison Control.  There was no evidence of pill residue in the child’s mouth, she was alert and quite active.  The woman from Poison Control reviewed the over-dose information with me and we quickly surmised that the child would have had to ingest 3-5 pills to cause enough concern and if that was the case, there would definitely be signs of residue in her mouth. In all likelihood the child didn’t ingest anything.  Parent was reassured and instructions given when to seek further medical attention. Parent also went home with a minor scolding — put all medications away as soon as you’re done with them!

Lesson learned.

 

Good Advice

One of the reasons I love family medicine is for the chance to make a difference in someone’s life.  It’s my job, as a family doctor, to prevent disease in my patients.  This is done in a few ways:

  • asking patients about their smoking status, alcohol intake, exercise and diet habits, and counselling regarding the risks/benefits of these habits
  • ensuring proper screening measures are undertaken, i.e. prostate, breast, cervical and colorectal cancer screening
  • ensuring the periodic health review is done, i.e., screening for diabetes, heart health ( cholesterol and blood pressure)

When I diagnose a patient with diabetes, or high cholesterol, or high blood pressure,  a small part of me feels like I’ve failed my patient.  I feel like I should have been more aggressive in making sure they knew the consequences of having impaired fasting glucose, high cholesterol or uncontrolled high blood pressure.  But I can only advise.  Ultimately it’s the patient’s responsibility to take control of their own health.

Which brings me to the reason for this post.  I wish I had something in the exam room that patients could read while they wait for me.  Something that is short, simple but to the point on how to stay healthy.  The closest thing I could find was actually on the back of my father-in-law’s bathroom door.

“HOW TO STAY YOUNG”,  BY GEORGE CARLIN

1.  Throw out nonessential numbers.  This includes age, weight and height.  Let the doctor worry about them.  That is why you pay him/her.

2. Keep only cheerful friends.  The grouches pull you down.

3. Keep learning.  Learn more about the computer, crafts, gardening, whatever.  Never let the brain idle.   “An idle mind is the devil’s workshop.”  And the devil’s name is Alzheimer’s.

4. Enjoy the simple things.

5. Laugh often, long and loud.  Laugh until you gasp for breath.

6. The tears happen.  Endure, grieve, and move on.  The only person who is with us our entire life, is ourselves.  Be ALIVE while you are alive.

7. Surround yourself with what you love, whether it’s family, pets, keepsakes, music, plants, hobbies, whatever.  Your home is your refuge.

8. Cherish your health:  If it is good, preserve it.  If it is unstable, improve it.  If it is beyond what you can improve, get help.

9. Don’t take guilt trips.  Take a trip to the mall, to the next county, to a foreign country, but NOT to where the guilt is.

10.  Tell the people you love that you love them, at every opportunity.

 

It really is quite simple, isn’t it?

Well, if it were, we wouldn’t need doctors, now would we?