Tag Archives: patient

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!

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!

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.

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.

Hobbies

I believe whole-heartedly that people should have hobbies. For me it usually changes every couple of months. Sometimes I’m interested in scrap booking, other times it’s painting. I’ve gotten into embroidery and sewing, and even knitting. When I’m feeling really inspired, I take to writing poetry and songs. This season it’s gardening.

I’ve started a little herb garden in pots in my backyard. I’m growing cilantro, thyme, parsley, basil, dill, and oregano, but my favorite is the red chili pepper plant. It’s exciting to watch how they grow everyday. And the best part is I get to use fresh herbs in my cooking.

Hobbies help keep us engaged and motivated. I have not started my new job yet, and being at home alone becomes very lonely and depressing. Sure I have tons of housework and paperwork to keep me busy, but there’s nothing to give me a real sense of accomplishment. I’ve noticed that when I’m having a flare, and I feel like I can’t do anything, I feel the same.

For a lot of us living with lupus, we can’t always work. But that doesn’t mean we can’t do anything. We can still keep our minds active even when our bodies are out of commission. I find hobbies that allow creativity or involve helping other people give me the most pleasure and satisfaction. There are a lot of low energy hobbies that you can do such as reading or drawing. If you don’t have a hobby, I encourage you to find a passion or try something new and run with it.

So, what are your favorite hobbies?

Self Diagnosis

One of the most frustrating things for a doctor is when a patient walks in handing them the diagnosis they believe they have. They’ve been online and they’ve compared all their symptoms, and they even know what treatment they need. They just need the prescription.Now I am all for patients educating themselves and being proactive about their health, but there are a couple things that are wrong with this situation.

First, not all sources are accurate or up to date. There is a lot of information on the web, some of it is good, some of it is not. Some articles are simply just someone’s opinion and have no study behind it. In truth, as a physician there are only a few sources I trust. I will share that in a later post, as well what a real clinical study is.

The second is that it creates a dangerous bias. The patient becomes so adamant about what they believe is their diagnosis that they are unwilling to hear anything else. So what can happen is the patients start telling their symptoms, guiding their doctor to believe what they think they have. They inadvertently leave out other important details or exaggerate other details. The doctor now has inaccurate information, and sadly sometimes doesn’t dig any deeper because the patient has already handed them a lot of information that does fit a diagnosis.

Take for instance Patient A. She has been having some abdominal pain for the past few days. When she does her search online she notices that her symptoms are similar to those who have gallbladder infection. The pain isn’t quite upper right quadrant but it’s close. She has had some vomiting and diarrhea. She thinks she had a fever but she didn’t really check. She thinks maybe the pain occurs after she eats. She fails to state that her urine has been smelling a little funny and cloudy, and that she has been peeing more frequently because she doesn’t see it as being important for her diagnosis of gallbladder infection. The doctor hears all symptoms leading to gallbladder infection, and treats it as such, missing the diagnosis of kidney infection.

I’m not saying that patients don’t know what’s wrong with them, because truthfully a lot of them do. We know our bodies.  But doctors have years of education, training, and experience that helps them determine your diagnosis. We know what questions to ask, and know what information is important and what information is not.If you are at the doctor’s anyway, might as well let them do their job and take advantage of their knowledge.

Work Environments

As many of you know,  I have been job hunting. My first job after residency was a complete nightmare, and I am terrified of getting into another situation like that.In my interviewing process, I’ve come to notice there are three types of work atmospheres- profit driven, patient centered, and physician friendly.

My first job was very profit-driven. My employers were so focused on the bottom line that  patient care and my physician well-being was suffering. The administration would make sure the schedule was double-booked and I would be pressured to order unnecessary tests and referrals. Medicine becomes like factory work, just putting forth product to pay the bills.Every day was a battle with my ethics and the miserable feeling of coming home knowing I was unable to care for my patients the way I wanted to.

In the completely patient centered environment, the focus is on the patients and providing the best care without regard to money or cost. A doctor could spend as long as the patient needed and handle all issues in one visit.The doctor would always be accessible. They would stay late, come in every weekend and holiday, and always be on-call. seems like an ideal practice model, but leaves a lot of room for a physician to be taken advantage of, and not be able to make the money necessary to run the practice.

In a physician friendly atmosphere, the doctor’s lifestyle takes priority. They would only have to see ten patients a day and still make enough money. They could choose only to see the friendly, compliant, and easy patients and refuse to see the demanding, untrusting, and challenging ones. They wouldn’t work weekends, or evenings, or ever be interrupted at home for a patient calls. A great situation for the doctors and their families, but not so great for the patients.

I think the ideal practice is a combination of all three. There has to be a drive to work harder and have the ability to earn more and be rewarded for going above and beyond.There also has to be an environment where a patient can have the access to quality care, and have the time to discuss most of their issues. And there has to be an environment where the doctor is not overworked or over stressed, and can focus on giving the best care possible. I truly hope I can find a balanced practice, and that wherever I go, I will be able to practice medicine the way I believe.

Take time to rest!

Well I’m finally moved in and am starting to unpack. I have to say yesterday was a grueling day, even with the movers. We have two sets of stairs in our place, and it was a lot of running up and down. I woke up early this morning completely drained, but I knew I had a lot of work today. I got up, ate some breakfast, helped the cable guy set-up, and started to open up boxes. And then it hit me.

Sheer exhaustion. Like I had been hit by a truck and thrown across the street. Ok, so I’ve never been hit by a truck before (thank God!), so I don’t know how that feels, but I felt pretty crappy. Just achy, and foggy, and lethargic.

I realized that I wasn’t going to get anything done without some much needed sleep. For a long time, I’ve felt guilty about taking naps when there was work to be done. I always feel like I can just work through it. But I realized I can get more work done in less time when I am well rested, than when I am dead tired.

I think it’s really important, especially for people with chronic illness, to listen to your body.Pushing yourself when your body is tired, not only produces inefficient work, but also hurts your body. Our bodies need rest, and our pain, fatigue, cloudiness, is our bodies’ way of communicating that. I took my little nap, and am awake and refreshed! Now, let the unpacking begin!