Tag Archives: Doctor blog

Am I Crazy?

As a physician, I encounter patients who have complaints that seem to make no sense.  Either there are too many vague symptoms which point to absolutely nothing, or they are complaining about multiple different issues, that it seems they are trying to find something wrong with themselves.Others times, they are struggling to put into words exactly what they are feeling.

A lot of times physicians dismiss them as invalid or crazy. And sometimes they are right. Sometimes patients have mental disease that cause them to have paranoia or hypochondriasis ( Side note: I am not calling these people crazy, I do not refer to anyone with mental illness as crazy).Frequently you are faced with malingerers who are making up symptoms simply for some kind of gain such as  time off work, opioids, or government or disability benefits.

But sometimes we are very wrong.

A few weeks ago, I was having some vague symptoms. I was feeling feverish and had chest heaviness with mild discomfort breathing or taking a deep breath. It wasn’t the typical shortness of breath and chest pain of pleuritis that I’ve had before.I tried explaining my symptoms to the nurse at the doctors office so she could tell the doctor, but struggled to really express how I was feeling.She called back later ( Yes, the doctor never spoke to me himself) and said the doctor says ” Just go to the ER”.

At this point I’m starting to feel like I’m crazy. I know I’m not sick enough to go to ER, but I know I’m not well. I explain what I’m feeling to the people at work, all while looking perfectly healthy, and they are looking at me like I’m crazy. My parents are telling me I’m probably just getting sick and should rest. I go to a cardiologist, have an EKG and echo, and they find nothing. I listen to myself explaining how I feel, and realize as a physician it doesn’t even make sense to me.

Eventually it gets better on its own, and I’m left wondering what was really wrong with me. Perhaps I will never know. But it reminded me of a lesson I learned early on in the course of my disease. Always take everyone seriously. Listen to their complaints carefully and completely. And if I can’t make sense of it, send them to a specialist who might be able to. Never write anyone off as crazy.

Being sick is expensive!

Since moving to Florida, it has been a major change in medical care for me. And to be honest, I am not as happy as my care here as I was in New York. In addition to not liking my new doctor very much ( this is a post in itself), I am having to pay a lot of money out of pocket.

I am all of a sudden paying close to 200 dollars for my infusions, plus a coinsurance. I suppose that’s a rather cheap price to pay considering how much the drug and the infusion costs, but seriously, that’s like a car payment every month. And that’s not my only med. Luckily, I do 90 day mail order on all the others and it saves me a ton.I think about about the fact that I’m not working and how a lot of other people who have chronic disease are not working and wonder ” how can they afford this?”.

I never changed my insurance. I’m still on the COBRA, because it was good insurance that would cover my Benlysta infusions. My husband had checked with insurance companies to get us insured, and when he had looked, he couldn’t find anything that was guaranteed to cover the infusions, so we just stuck with the insurance he had got from his last job. Apparently, I never paid anything before because I didn’t have to pay deductibles because it was the hospital-provided insurance.

This whole experience has brought up so much sadness in me. I’m reminded of my patients who are hard working people, who despite having   ” good” insurance still struggle to pay for expensive prescriptions. I think of my parents and the elderly on Medicare, and my hearts breaks. Older people who should be relaxing now, getting social security, but it’s not enough to cover their million prescriptions, so they still work. I think of those living with lupus and other diseases who can’t work, who already suffer enough, and then have to struggle to find the money to see their doctors. And I remember that awful feeling of prescribing a covered drug because it was cheaper, even though I knew it wasn’t the best choice.

I always like to have some optimism in my posts, so I’ll just hope that maybe things will change soon. Oh and keep me in your prayers please. I start a new job next week.

 

Part time doctor

So I am back on the hunt for a job, and it’s not been easy. Apparently, no one is wanting to hire a part time doc. I mean I understand that patients want reliability and availability, but I don’t think that’s an impossible thing to accomplish as a part timer.

My last two jobs I was part time, and it worked out well.  The last job I worked three days a week, and rarely had an issue with being able to see all my patients when they needed to be seen. If it was urgent and they couldn’t wait, there was always another doctor to see them in the office, and for quick issues most patients didn’t mind seeing another doctor. It was like seeing a doctor at an urgent care center, but with the benefit of their chart  already being there. And I took phone call, so if they ever had questions I always available to answer, and had their chart on my mobile app. My patients loved me, and always made it a point to only see me.

So, how do you feel about having a part time Doctor? Would it be an issue for you? What would it take for you to be comfortable having a part time Doctor? There being another doc in the office? Having a special email or phone number for the doctor? Feel free to be honest, I really wanna hear your thoughts!

Taking your own life

I’ve been getting a lot of posts in my Facebook feed about Brittany Maynard. For those who have seen the news, she is a 29 y/o female who is dying of brain cancer. She has decided to take medicine to end her life because she didn’t want to suffer or have her family watch her suffer.

Now I don’t want to judge anyone, because it is not my place, but I wanted to share my feelings. And I’d like to know yours.

I’ve struggled with hopelessness before. A few times actually. Once in college when I was under a lot of pressure to be perfect, to please my parents, to get into med school, while dealing with issues of very low self esteem and low self worth. Then my boyfriend cheated on me, the only person who knew who I really was and saw my worth. I felt like a nobody again.

Again in medical school, I felt that hopelessness again. Everything was so crazy. I didn’t want to be a doctor, but knew I’d come so far that I couldn’t quit. I couldn’t disappoint my family, and I had 250 grand worth of debt. I was trapped in a situation I couldn’t control.On top of that, I suffered from a very traumatic experience caused by someone I trusted.

Then once again after being diagnosed with lupus, I considered once again that life was not worth living. I believed I wouldn’t be able to work or have children. I thought I’d always be sick and in pain. I thought for sure my boyfriend would leave me. My future looked bleak.

Each time I considered ending it all. But I got through. And I am happy. Not completely healthy, but happy.

Now I am not comparing myself to Brittany or the trial she is going through, but I believe in hope. A hope that I have in Christ. A hope that comforts me through a tough time. A hope of knowing that God always provides. A hope that reminds me to rejoice through trials, because I know it is making me a stronger and better person.

My heart goes out to her and her family, as does my prayers. I’ve shared my thoughts, please share yours.

Telephone Encounters

One of the things that happens in my office a lot is patients not wanting to come in for follow up visits.They’ve just gotten bloodwork and they want me to give them the test results over the phone, or they need a new refill on a prescription and want me to call it in to the pharmacy, but they haven’t been seen for several months. Or sometimes they have a seemingly minor health issue they want me to diagnose them over the phone. There are few things wrong with this situation.

1) I am not comfortable with diagnosing someone without really talking to them and taking an appropriate history and examining them. I can’t do this in a quick phone call. It’s not worth the risk for my patient or liability for me.

2) A lot of times further work up is needed. For instance, maybe I’d like to do some lab work to diagnose or make sure the medication you are taking is actually working and not causing any side affects. Sometimes abnormal labs warrant further testing or additional referrals.

3) I may need to prescribe something, and it’s important to review the medications that a patient is taking beforehand. Even if it is just a refill, I don’t know what other meds you’ve been prescribed since the last visit. I also need to make sure the medication isn’t causing any side effects. I usually give a three month supply on meds and bring a patient in for follow just before the meds run out.

4) Giving information over the phone sometimes causes miscommunication. I have a better chance of knowing my patient heard and understood everything I said if they are sitting in front of me.

5) It’s unfair to my other patients who are at the office.These non-urgent phone calls can take up time when I have other patients who are waiting to see me.

6) Visits are a great time to make sure patients are up-to-date on vaccinations and cancer and health screening, so when you don’t come in we miss important preventive measures.

7)And, lastly, office visits are how I earn a living. I don’t get paid for the time I spend with a patient on the phone, or charting, or filling out paperwork. If I don’t see patients, I simply don’t get paid.

I know it can feel inconvenient to go in to the doctor, especially when the weather is bad, or the drive is long. But it’s worth it because it’s for my health. It’s always better to go see the doc!

Flu shots!

Flu season has started and it is time to get your flu shot! Now I’m a total baby when it comes to needles, but I got mine last week. I firmly believe in the flu shot, especially for people who have weak immune systems and need the extra protection.

A lot of people don’t realize the difference between a common cold/ upper respiratory infection and influenza.The flu virus is actually pretty serious and can be life threatening in immunosuppressed patients. The symptoms are similar to a common cold, such as body aches, cough, fever, runny nose, but more intense. You can also develop nausea, vomiting, and diarrhea which can lead to dehydration. The flu can last longer, and keep you in bed for weeks.

The concern that most people have about taking the flu vaccine is that it causes them to get sick. Those flu-like symptoms after getting the shot is actually when your body is making antibodies to the influenza virus and usually is short lived. Sometimes people get a slight skin reaction at the site of injection or feel some pain and heaviness in the arm. A Tylenol usually works for any pain or fever, and you should always ask for your shot to be given in your nondominant arm. Overall the benefit of taking the flu vaccine outweighs the risk.

For patients with lupus, it is important to make sure you get the injection of the flu vaccine, and not the intranasal. Flumist intranasal is a live virus and shouldn’t be given to anyone who is immunosuppressed, lives with someone immunosuppressed, or has lupus.

You should always talk to your doctor first, and the vaccine is not recommended for pregnant women, those who have had a prior allergic reaction, or have egg allergies.

Take control of your health, and get the flu shot! I don’t want anything to keep me from enjoying my favorite time of the year!

Just Because You Can…..

Doesn’t mean you should.

As a family practitioner, my scope of practice is pretty broad. I can deliver babies, do GYN procedures, and even perform minor surgery. Technically my license states that I can practice medicine and surgery in the state of New York. Perhaps, I could do an appendectomy? I’ve heard of country doctors having to do these kind of surgical procedures because the nearest hospitals is miles away. But I would never do anything like that because I’m not comfortable and I live in a big city.

I feel in life, especially in living with lupus, I am faced with the dilemma of deciding if I should do something just because I can. I can go out late for drinks and dancing, but am I willing to be stuck in bed achy and exhausted the next day?

I can work full time, but would it be at the cost of my health and sanity? I remember when I did work full time. It was so stressful, I was constantly exhausted, and every day felt like a battle. I was constantly agitated and always had some kind of lupus symptom. I made a lot more money, but was it really worth it?

I can go on a strenuous hike or skiing while on vacation, but am I going to be in pain for the rest of the week. Will it keep me from enjoying the rest of my trip?

I guess my issue is that I hate limiting myself. I hate the idea of lupus holding me back. I like to believe that I can do anything I set my mind to, and encourage others to do the same.

But sometimes I just have to be realistic. I am not limited in what I can do. I just realize that maybe I don’t need to do everything. It’s my choice, and I’m okay with that.

Unnecessary Tests

So something a lot of patients ask me is “Is this test really necessary?” The majority of the times a test is ordered it is necessary, but there are times when they are not. Let me define what I mean by necessary and unnecessary. Necessary, to me, is any test that will rule in, rule out, or confirm a diagnosis. Necessary tests guide treatment, letting the doctor know the next step in treatment, how to alter treatment, or when to stop.

Unecessary tests are tests that don’t really give me any new information that would help determine a diagnosis or change my treatment plan. Here are some of the reasons these tests are ordered.

1) Patient demands it. There are times when I know the XRay isn’t going to show anything because what they have is not something that can be visualized on XRay, but despite my best efforts to explain reasoning and the risk of radiation, they still demand it. It’s horribly uncomfortable to argue with a patient, and when they don’t get what they want, they just go down the block to the next doc. The practice loses business, and the doctor gets in trouble with the administration or suffers low survey scores which can lower reimbursements.

2) To cover our butts. Sometimes we simply have to do it to ” just make sure” and protect ourselves. And we also want to make sure we are doing everything we can for our patients. Better to be safe than sorry.

3) For documentation purposes. Sometimes insurance companies need proof in the form of lab/ imaging results that the patient indeed needs this treatment. Also, sometimes insurance companies won’t cover a certain test or referral that I deem necessary until another test is done beforehand.

4) And, I’m embarrassed to say it, but  some doctors do it for money. Not all doctors do this or want to do this but sometimes we are forced to do so. The last company I worked for wanted me to order sleep studies and ultrasounds on every patient as they were procedures that were done in house and could be billed. My constant refusal caused me a lot of humiliation and reprimanding. Other doctors do them to make up the difference in what they are being reimbursed by insurance. I am not justifying this behavior in any way and I believe that it is a very small percentage of doctors that do this.

Hope  this sheds a little light into the issue of unnecessary testing.

“Work is killing me.”

So I know it’s been awhile since I’ve posted. The other doctor in my office was out of town so I was covering for him and then I got sick last week and am still feeling pretty crappy.The weather went from a blazing eighty five degrees to a rainy, dreary seventy in just a day and I had patients coming in with coughs and colds and sore throats for a week.

A few days later I started feeling chills and general fatigue. I figured it was a viral upper respiratory infection and started taking vitamin C. I had an appointment with my rheumatologist, who ended up doing a throat culture and nasal swab. I didn’t think anything would come up positive and figured I’d be feeling better by the weekend.

Over the past weekend, I developed a horrible cough, and it got me thinking. The purpose of my lupus treatment is immunosuppression. I take Imuran, and my last white blood cell count was about 2. This makes me really susceptible to catching some nasty bug. I should be avoiding sick people but instead I’m surrounded by them all day. They cough and sneeze all over me. I look inside their mouths and noses while taking swabs and cultures.

I remember when I worked in the hospital during residency. Any time there was a suspected case of tuberculosis or meningitis in the ER, I was warned to steer clear. I couldn’t even go into the ER to see my patients who were there for noninfectious illness, because everyone who went into the ER was at risk of contracting the highly- contagious disease and had to be given prophylactic antibiotics.

I work in an outpatient office now, so the likelihood of having an extremely sick patient is not as common, but it’s still a risk. I could never work in a hospital again.I could wear a mask at work, but that would make my patients uncomfortable, and make my staff suspicious. After getting sick this last time, it made me wonder how at risk I am putting myself everyday.

My throat cultures came back positive for bacteria, most likely strep. I’ve started antibiotics, but I’ve been so short of breath that my doctor ordered a chest X-ray to rule out pneumonia. I should get my results back today, which hopefully will be negative. I’m still going to work this week because I don’t get any sick leave (doctors aren’t supposed to get sick) and I shouldn’t be contagious anymore. I’m exhausted and weak from coughing all night, but I still have to keep going.

I’m optimistic that I will get better soon, and I am going to take better precautions to prevent getting sick again but this gives new meaning to the phrase “Work is killing me.”

Before the Visit

When I went to facilitate the lupus support group meeting, I gave a talk on how to make your office visit go smoother.  I gave several tips on how to be prepared before and during the visit, so that your time with the doctor is used most efficiently. I know it’s frustrating sometimes to only have fifteen minutes, and then at the end of it feel unsatisfied, because you didn’t get to ask all your questions and voice all your concerns. The participants found the topic useful, so I will share my advice with you over the next couple posts.

1) Choose a doctor you can be comfortable with. There are a lot of factors in choosing your doctor.Do you feel more comfortable with a male or female? Is there a culture or language barrier? Do you prefer someone more straight to the point, or someone you can talk casually to? Deciding upon a doctor is one of the most important parts in your lupus journey. They will be your guide and you need to be able to trust them and feel comfortable telling them personal information. If you’re not comfortable with your doctor, look into switching, maybe another doctor in the practice or a new office.

2) Give yourself time. Try not to book appointments within 3-4 hours of another appointment/meeting/errand. You never know if the doctor is running behind, or if there is an emergency, or if you will have to do tests or bloodwork after the appointment. I always advise one appointment per morning or afternoon session. I’ve had situations where my patients were rushing to pick up kids or go see another doctor and feeling rushed hindered me from being as thorough as I’d like, and the patient was so worried about the time that they couldn’t completely focus. Also, if you feel like you are going to have a lot of issues to discuss, ask for a longer appointment time, so that you have sufficient scheduled time. If your requiring some kind of form to be filled out, make sure your appointment is at least 2 weeks before the forms deadline.

3) Be prepared.
A) Write down any issues you had, preferably when they happen. Note what, where, when, surrounding circumstance, duration, intensity, other symptoms and how it went away. I know personally that sometimes I’ll have some joint pain or another symptom, but by the time I have my appointment I’ve forgotten about it so I don’t mention it to my doc. If I make not of it as it is happening, I can give my doctor an accurate description.
B) Write down all your meds. Read off the bottles and write the name, dose, and how often you take it. Write down not only the meds that doctor writes for you but all the meds, including the ones from the specialist. Also write down any supplements you may be taking. If it’s too hard to write, bring in all the bottles for review.
C) Bring in any reports or consults. Ask for copy of labs or radiology reports when you are at your other docs. Sometimes the info doesn’t move between doctors as quickly as we like. Also take notes at the appointments and write down any new diagnoses/treatments.

Hope this helps.In my next post, I will talk about ways to make the appointment day easier. It’s important to make the most of your doctor’s appointment.