M.I.A.

Sorry. A few people have contacted me, wondering why I'd dropped off the face of the earth. Well, in a bizarre act of karma (considering my last post) I have been sick. And on vacation. Yes, I spent the majority of my week off unable to speak above a whisper, and only able to whisper between bouts of hacking cough. Lovely.

I'm recovering. More pithy observations of the world of medicine to follow. Promise. Don't give up on me.

Ah-CHOO!

At the family practice where I work, my preceptor books patients every 15 minutes with a few last-minute emergencies squeezed in. I, on the other hand, see patients every half hour to allow for the fact that I'm still learning. Not to mention the fact that I'm still sneaking out of the examining room to look up drug dosages, fumbling though the sample closet for ages to find what I want and occasionally waiting for my preceptor to finish with his patient to confirm my treatment plan with him. So I take longer.

All in all, I'm seeing about 12 patients a day. Par for the course, according to my impromptu discussions with fellow residents during our academic half days. Out of those 12, at least 2-3 are coming in with a cold. Every single day.

Why on earth would anyone see their family doctor for a cold? I really don't get it. You have a stuffy nose, a cough and you generally feel like crap. And it's been going on for three days. What on earth do you think that seeing your family doctor is going to do? If there was a magic pill that cured the common cold, don't you think you would have heard about it by now?

So now I have a "spiel"-- I explain all the things that I can rule out based on the physical exam. No swollen tonsils with white crud on them? Not strep throat. Ears look fine? No ear infection. Lungs sound clear? Not a pneumonia. Then I go on to tell them that since there is nothing going on that we can treat with antibiotics, they just have to let the virus run its course. Usually people are okay with that, and if they seem to want more I'll perscribe a cough suppressant with slightly more codeine in it then you can get over the counter. Or a swish-and-spit mouthwash that is only slightly better than placebo at helping a sore throat. But it makes people happy.

My preceptor, after 10 years as a family physician, is slightly more accomodating. If people honestly think they need an antibiotic, he'll occasionally give it to them even if it goes against evidence-based medicine. I can understand the urge to keep your patients happy, but I also don't think that patients should dictate their own treatment. It may sound paternalistic of me, but that's why we train for so damn many years... so that we have to knowledge and the tools to make treatment decisions for them. Otherwise, ALL drugs would be available over the counter. My preceptor good-naturedly refers to me as The Antibiotic Nazi. At least, I'm hoping it's good natured.

But back to the point. Why do people come in with a cold? Do they honestly think it's something worse? Even if everyone in their family has a cold, they've had a cold in the past and there's nothing new and interesting about this particular bug? I can understand in the case of a child, because parents always err on the side of caution when a kid has a sniffle. And kids are much more likely to have strep throat or ear infections. But when a healthy 35-year-old comes into the office with a two day history of stuffy nose, cough and fatigue, I have to be honest and say that I'm rolling my eyes in my head...

Sigh. But that's what a family doc is there for, right?

Paging Dr. Hypocrite...

As a family doctor (or in my case, a reasonable facimile) a big part of my job is preventive medicine. The idea behind this is that by taking care of the 'big picture' of our patient's health, we'll prevent larger problems down the road. The fee schedule that my preceptor works under actually encourages this... in place of a fee-for-service model that encourages assembly-line medicine and rewards procedures over counselling, under this new model a family physician is paid a monthly fee for every patient enrolled under his care. Regardless of how many times or for what reason each patient actually comes into the office. This isn't quite as wacky as it sounds. The monthly fee for an elderly woman, for instance, is substantially higher than a young adult. Young adult males, who traditionally are the lowest users of the medical system, are worth the lowest monthly fee... unless they have a serious mental illness, which makes the fee higher. Get the idea?

So anyway, this alternative funding system lets us spend time doing things like helping patients stop smoking, improve their diet, cope with their stress and other things often deemed 'touchy-feely' but that pay off in the long run. The problem is, the medical system makes it pretty damn hard to practice what you preach.

Before medical school, had a pretty healthy lifestyle. I ate well, I managed stress in a constructive manner, and I was pretty active. I hit the gym 4-5 times a week, and picked up a new sport every year-- most recently I had learned to row, play touch football and golf. And I maintained a weight, which although I was always unhappy with, translated to a healthy BMI. All in all, I was doing okay. Then came clerkship.

The hours got longer and the gym visits got fewer and further between. Healthy meals gave way to take-out on more evenings than I care to admit. Sleep became a valuable commodity, and I wasn't getting nearly enough of it. And the stress grew. Some people coped... some didn't cope so well. I did okay, mostly thanks to a kick-ass support system in the form of two close friends and an amazing significant other. But many of my healthy habits went right out the window.

So here I am, 25 lbs heavier than I was before I started medical school. Before this week, I haven't seen the inside of my gym more than once in the past month. I'm relying less on take-out thanks to the joint efforts of myself, my fiance and our slow-cooker, but diet alone isn't enough to undo the damage. And that makes me a hypocrite. What are people thinking as this overweight, overtired doctor advises them on improving their diet and finding time to exercise? How can they take me seriously when I can't take me seriously?

Patting Myself on the Back

I did good last week.

After feeling like family medicine was a whole new world where I didn't speak the language, I'm finally getting my bearings. I still don't know the childhood vaccination schedule off by heart, I'm still not 100% sure when to recommend routine colonoscopy for colon cancer screening, and I'm still at a loss with most eye complaints and skin rashes... but I made a few good calls last week, so I'm going to brag. And I'm bragging here cause my significant other is tired of hearing about it.

Patient #1

A 43-year-old guy came into the office for abdominal pain. He had a long standing history of gallstones. When I came into the room, he was kneeling on the floor vomiting into a plastic bag. He was literally writhing in pain. A few questions and an abdominal exam later, I called over to the emergency room to tell them that I was sending over a guy with suspected renal colic (i.e. a kidney stone). My preceptor comes in and asks me why I didn't think it was gallstones, which he's known to suffer from. Easy... gallstones wouldn't make him jump through the roof if I tapped him on the back (costo-vertebral angle tenderness, to you med-folks).

Verdict from emerg? Renal colic. A stone big enough to require a trip to a larger centre for treatment. Score one for Dr. Couz.

Patient #2

A girl came in with a long standing sore throat. She's 11, and it had been going on since November. Mom (a nurse) was convinced that she had thrush, a fungal infection, as she had it a few times as a baby. I get her to describe the symptoms, and at one point her mother mentions the fact that she knew it was thrush when her tongue went white. I was intregued. I questioned further. Turned out her tongue was only white briefly, before the skin sloughed off and left her tongue strawberry red. Hmm. And yes, she admitted, now that you ask... she DID have a rash over her trunk sometime after the sore throat started.

Diagnosis? Strep throat and scarlet fever. I got complimented on the good pickup. Score two.

Patient #3

34-year-old guy, new to the practice, came in complaining of flu-like symptoms. The usual viral stuff-- dry cough, fatigue, aches and pains... sure sounded like the flu. But just to be safe, and since he was new and we had no information on him, he got the full workup-- CBC (rule out anemia), TSH and T4 (rule out hypothyroid), and even a monospot test to cover all the bases.

The verdict? Atypical lymphocytes, positive monospot. He had mono. My preceptor asked me what made me think to order the monospot. I wasn't even sure. It was just part of a full workup for fatigue. Either way, it made me look good. Or lucky. Whatever.

So I'm not saving the world, but I'm starting to feel like I might actually make a reasonably good family doctor in the next 17 months or so. It's nice to not feel completely incompetent for a change!