Taking a break for a few weeks

 See you next year!

Up front

Several months ago Mary and her family got a new puppy. He's still a puppy, but these days he's a 70 pound puppy.

He has a lot of energy.

She and her husband both work, and the kids are in school, so for a few hours each day Monster puppy and his den mates have free run of the kitchen and family room, with a doggie door when they want to venture out. The other dogs are older and sedate. Monster is anything but, and began randomly destroying things he found (toys, clothes, furniture, wall hangings, light fixtures, Amazon drivers, etc.).

So, since Mary spends her office day staring at a screen scheduling my victims patients, she hooked up some cameras and a speaker in the dog area at home. So now she sits at work and keeps an eye on Monster, occasionally telling him to get off the couch or stop mangling the postman. The other 2 dogs don't care, but the effect on Monster is hysterical. He looks up and around in terror, like people in old movies when God speaks to them.

Anyway, one afternoon last week Mary was doing her usual thing. She'd just checked in a new patient, who'd picked up a copy of "Good Housekeeping" and sat down in the lobby. She was then rescheduling another patient when she happened to glance up at the corner of her screen and saw Monster in the process of destroying one of her kid's toys.

Without thinking she grabbed her microphone and yelled "YOU DROP THAT RIGHT NOW AND GO OUTSIDE!!!"

The elderly woman in the lobby startled, dropped the magazine on the floor, and ran out of the office in terror.

She hasn't come back.

Research

 "What should we name our stroke study? Something positive, scientific sounding, helpful..."

Up front

Mary: "Okay, on Tuesday Dr. Grumpy can see you at 11:00, or on Thursday we can do 4:15, or on..."

Mary took a sip of too-hot coffee and began coughing.

Ms. Miasma: "I'm hanging up. Can someone else call me back? I don't want to catch whatever you have over the phone."

Be prepared

Body armor? Check.

Taser? Check.

Pepper spray? Check.

Marie riding shotgun on the cart with a baseball bat and tranquilizer gun? Check.

Heading to Costco for pies.

Dynamics

Dr. Grumpy: "Any major illnesses run in your family?"

Ms. Daughter: "My dad had cancer. That's about it."

Ms. Mother: "I have high blood pressure."

Ms. Daughter: "No you don't."

Ms. Mother: "Yes, I do. I take Petrolololololol for it."

Ms. Daughter: "You have high blood pressure, and you take medication for it? How come I never knew this?"

Ms. Mother: "It's not a big deal. Most people my age are being treated for high blood pressure."

Ms. Daughter: "It's like my whole fucking life I'm living a lie."

Sigh

Dr. Grumpy: "Are you allergic to any medications?"

Ms. Sesame: "I'm allergic to all medications that have a letter 'D' in them, regardless of whether it's the brand or generic name, or both."

Math

Dr. Grumpy: "What have your blood pressures been running at home?"

Mr. Decimal: "They average 127.384 over 73.879"

Vivisection in the headlines

 

Happy Halloween!

With the costume party season upon us, I'd like to remind everyone of what was probably the single greatest newspaper headline ever.

Six Degrees

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Mr. Bacon: "Hi, Dr. Grumpy, I need to get in to see Dr. Needle urgently, and she's booked out for 3 months. I was hoping you could call her office and ask them to work me in?"

Dr. Grumpy: "Did I refer you there? Are you one of my patients? I'm not finding you in the system."

Mr. Bacon: "No, but I'm a friend of one of your patients, Heddy Paine."

Dr. Grumpy: "Look, I really can't help you... She's not in the system either."

Mr. Bacon: "Well, she says she saw you a year or two ago. She was visiting her uncle in the hospital, and says you were talking to a nurse outside the room of the patient next door."

Thud

Dr. Grumpy: "So... this visit is to follow-up on how you're doing with the medication - Fliniberzap - that I prescribed about a month ago."

Ms. Headdesk: "Yeah."

Dr Grumpy: "It's been a month, so how are you doing?"

Ms. Headdesk: "I'm not any better... I mean, I filled the scrip, but then I left it in a rental car and returned the car."

Pause

Dr. Grumpy: "So you haven't started it?"

Ms. Headesk: "Not really, I mean... no."

Dr. Grumpy: "Why didn't you just call so we could send a new script in?"

Ms. Headdesk: "I left your phone number in the car, too."

Touché

Mary: "Okay, Mrs. Humor, I have your follow-up down for next Tuesday, at 8:15 a.m. I should warn you that Wednesday's test of the national Emergency Alert System activated our microchips and turned Dr. Grumpy and all of the staff here into zombies."

Mrs. Humor: "Like anyone would notice."

FML

 Current insurance company hold music is an endless loop of "O Fortuna."

Stayin' Alive

My 11:00 patient, while we were talking at my desk, took cans of Red Bull and beer from his backpack, mixed them together in an empty water bottle, and is drinking it.

Sunday morning, 5:58 a.m.

Dr. Grumpy: "This is Dr. Grumpy, returning a page."

Ms. Simon-Bond: "Hi, Dr. Grumpy... there's a dead cat on my back patio."

Pause

Dr. Grumpy: "Why are you calling me?"

Ms. Simon-Bond: "I... I guess because I didn't know what to do about it."

Pause

Dr. Grumpy: "I didn't know you had a cat."

Ms. Simon-Bond: "I don't... I don't know whose cat it is."

Dr. Grumpy: "Okay, this really isn't something I can help you with, or even a reason to call me."

Ms. Simon-Bond: "My internist said the same thing."

Your EHR is making you look stupid

EHR (or EMR) is the generic name given to the various medical chart systems that have been crammed down our throats. Most are worthless.

The problem is that they're primarily designed to meet regulation-required "quality metrics," to show that we told someone to quit smoking, wear a seatbelt, or take prenatal vitamins regardless of whether the patient is a 6 month old infant, 28 year old guy, or 97 year old woman. Because, you know, those things are for more important then talking about the patient's chest pain or new-onset hemiparesis.

As a result, the EHR's are full of horseshit that tell you absolutely nothing about the patient that  relates to, say, WHY THEY CAME TO THE DOCTOR.

When I was in training I was taught that, within the SOAP format (subjective, objective, assessment, plan) your note should tell a story of sorts: what's happened to the patient, what do you think it all means, and what are you going to do about it. It should be written so that the other doctors involved in the person's care can understand what you're thinking and doing. It also should be that way so you can pick up the thread when the patient returns.

That, sadly, isn't the case anymore. Now a note is just a string of vital signs, discontinued prescriptions, the same family history that's in every previous note in the chart, cut & pasted test results (some going back years and completely irrelevant now) and boxes that have either been checked or unchecked.

Physical exam, for example. To describe the tongue, most neurologists include it in a stock phrase like "Cranial Nerves II-XII are normal." If something isn't normal, most ad an "except for..." or "with the exception of..." and go on to describe the issue.

Of course "normal" isn't good enough for an EHR. Neither is "intact," "unremarkable," or "within normal limits." You have to have computer-generated shit like this:

After all, why use one word when 36 will do?

Here's another example. It's no longer enough to just put something like "family history is unknown" (you often hear that in the adopted) You need a whole, stupid, repetitive, idiotic, PARAGRAPH to say that:

Then there's horseshit like this. Although labeled as "Previous Therapy" it doesn't even mention therapy, just a nonsensical sentence:

 

 

Or similar gibberish which basically says "we didn't do any of this, we aren't sure why we did or didn't, but it met some quality measurement goal so it doesn't matter."

 

Then there are things that are just plain ridiculous, like this:

Or this:

This doesn't exactly inspire confidence, either:

 

Or this strange complaint:

 

On that note I think I'll save the rest of my bad EHR excerpts for another day. Fortunately or unfortunately, I doubt I'll be running out of them any time soon.

Keep the party going

Demented Church Lady: "I can't believe you and my kids won't let me drive! All of you are going to hell for this!"

Dr. Grumpy: "Okay,  at least I can go to the Jimmy Buffet concerts."

Her daughter nodded and gave me a fist bump.

Phrase

 If this guy doesn't stop saying "I don't know, you know?" I may have to throttle him.

Thank you for the music

"Some of it's magic,

Some of it's tragic,

But I had a good life all the way."

 

Goodbye, Jimmy. Thank you.

'Murica

 1:00 patient called me a "Pinko Jew." What a country.

Hard at work

Your hero, Dr. Grumpy, is (along with a lot of other docs) certified by the American Board of Psychiatry and Neurology (ABPN).

You can be certified in either or both (I have no idea why anyone would want both).

All of us neurologists and psychiatrists pay the board a hefty amount to stay certified. It's a few hundred bucks a year, and every 10 years it's a few thousand more to prepare for and take a written test to maintain certification. This is in addition to all the continuing medical education required.

What the ABPN does with this money, besides writing new test questions and issuing certificates, I have no idea. But, in a recent newsletter I received, it was nice to see that the money is being put to good use:

Show and tell

My 11:00 brought a friend to the visit, who was silent for most of it.

Dr. Grumpy: "Okay, Annie will get your tests set up... do you have any questions?"

Ms. Patient: "No. It sounds like a good plan."

Ms. Friend: "I have a question, I, um , had surgery on my coochie last month, and am worried that the scars aren't going to heal..." she stands up, drops pants "do you think those will go away?"

My dementia patients at work

 

Thank you, Mike!

Cephalopoda

Seen in a chart:

 

Thank you, Mike!

Saturday morning voicemail

“Hi, I keep calling and getting a message that your office is closed, and am kind of confused because on Friday the message said it was open. Can someone please call me back and let me know if you’re closed or open?”

Fun with Google

My 10:30 came in because when she hears running water she has to pee, and she read online that this means she has a brain tumor.

Air time

Last week, for less-than-relaxing reasons, I had to do quite a bit of flying. So I read a lot of P.G. Wodehouse, which is my eternal go-to for travel reading, no matter how many times I've read it before.

On one flight we ran into a fair amount of turbulence and the pilot ordered everyone, including the flight attendants, to strap in, put all tray tables upright and locked, etc.

As we bounced around at 35,000 feet one of the flight attendants got on the microphone and said "Folks, please do not press your call button unless it is an emergency, as movement around the cabin is restricted at this time."

As soon as he said that the guy next to me in the window seat, IMMEDIATELY reached up and pressed his call button (no really, he did. Like he'd been waiting the whole flight for that moment).

Flight attendant unbuckles himself, runs back, and says "are you okay, sir?"

Guy next to me points out the window and says "What are those mountains over there called? They're really beautiful."

Brief pause

The flight attendant says "I have no idea, sir," then turns around and walks back to his seat.

As he's heading back the guy the next to me says "well, can you ask the captain? They're really beautiful."

Back after a few weeks

So going to just put up some random pics you guys sent in, and stuff I saw on my trip.

 This fan mail was posted at a local burger place:

 

From the "when I was your age" file is a pic of a 3 gigabyte external hard drive seen at a thrift store, I assume intended for a museum.

 

 

 

 

 

 

 

Next, in the "gross overuse of adjectives" category is this margarita sign, which needs to have "artisanal" added to really bring it home.

 

Then there's this Albert DeSalvo inspired car decal:

 

And this question on a survey to make sure you're paying attention:

Next!

Dr. Grumpy: "Hi, thank you for coming in today. I'm Dr. Grumpy. Have a seat."

Mr. Leon: "Hello."

Dr. Grumpy: "Let me get some notes ready... Okay, are you right or left handed?"

Mr. Leon: "Excuse me?"

Dr. Grumpy: "Are you right or left handed?"

Pause

Mr. Leon: "What kind of woke bullshit is that? Seriously, I am so sick of you people."

He got up and left

Surveys

As many of you know, occasionally I'll do online marketing surveys as a side job.

 

Sometimes they'll ask if I know another doc who might be interested:

Ones like this show that they either don't know who I am, or vastly overestimate my abilities, or both:

 

 

Sometimes they'll throw in a question just to see if I'm paying attention:

Other questions show that they're the ones who aren't paying attention:

 

 In this case I guess the computer wasn't paying attention:

 

When I get invitations like this I kind of wish I wasn't paying attention:

They often want to know how things progress if patients fail treatments (1st line therapy, 2nd line therapy, etc.). Sometimes the person writing the survey gets confused.

Then there are questions like this:

(For the record, there is absolutely NFW I am going to attempt to manage a patient's diabetes. I'm a neurologist. And any patient who would ask me to manage a non-neurological condition has a death wish).

 

 There are ones I have no clue about:

 

My favorites are when, after I've slogged through and completed a survey, it asks if I still want to get paid for it.

 

 

 

Life is a highway

So, although my academic goal of medicine was to get through my career unpublished (which didn't quite happen), I still occasionally get dragged into research peripherally.

Let me be clear here that I have nothing against research. It's very important. It's just not my thing.

But my call partner, Dr. Cortex, loves it. So when she's out of town I occasionally get dragged into seeing a research patient for her, or signing off on some papers, or whatever. It keeps peace in the local neurology community.

Currently she's on one of her far-flung skiing trips (I think to Hoth this time) so I got roped into doing a pre-study screening visit on a lady for one of her Alzheimer's drug trials.

I showed up at the research office and sat down to look over some papers. There were 2 older ladies in the lobby. The study coordinator told me the visit had become a doubleheader, because the one who'd come in for it had been joined by another lady who'd heard about the study from her and also wanted to participate. Not a big deal. We need volunteers to find out what works, so the more willing souls the merrier. This is where all medical breakthroughs come from.

So I saw the first woman and did her paperwork, then went into another room to meet the add-on.

Dr. Grumpy: "Hi, I'm Dr. Grumpy. Thank you for coming in today. So, I guess you heard about the study from Thelma and decided to join her?"

Louise: "Well, she and I were talking on the ride over and she was telling me about it. I've also been diagnosed with Alzheimer's disease by a neurologist, so I thought I should get involved, too."

Dr. Grumpy: "Are you a friend of hers?"

Louise: "No, I'm her Uber driver."

Weekend On Call

On Friday I admitted a lady who fainted at the store. After talking to her I wrote "seizure unlikely" in my impression and wanted cardiology to have a look at her.

I then turned her over to my call partner, Dr. Nerve, for the weekend.

He apparently agreed with me, but is under the impression her insurance pays by the word. He wrote:

 

For this we invented the internet

An email saying you are about to get more email.

Thank you, Mike!

Life in these United States

Mary: "Dr. Grumpy's office, this is Mary."

Mr. Hatt: "Hi, I need to make an appointment with Dr. Grumpy."

Mary: "Okay... Sorry, we've gotten a lot of calls the last few days... our next opening for a new patient is in 2 weeks, on..."

Mr. Hatt: "TWO WEEKS? ARE YOU KIDDING ME? That's ridiculous!"

Mary: "I'm sorry, it's just been crazy this week. If you'd like I can make you an appointment and put you on a waiting list if anyone cancels?"

Mr. Hatt: "So how many of those people with appointments ahead of me are illegal immigrants?"

Mary: "Excuse me?"

Mr. Hatt: "I know you people give preferential treatment to illegals instead of real citizens. It's all over the news. So how many illegals are on your schedule ahead of me?"

Mary: "Sir, I don't know if any of them are, and I schedule people as they call in and the calendar fills up. There is no preferential treatment."

Mr. Hatt: "Oh, bullshit. I'm not that stupid. I bet I could call the DHS and they'd clear out your lobby in a heartbeat. Actually, they probably wouldn't, since they favor them, too."

Mary: "Okay, I'm going to hang up the phone now."

Mr. Hatt: "So you're an illegal, too? Figures."

 click

1-star review

Craig and his team are at an out-of-state competition, representing Big State University. The other night I was dozing off when he texted me.

 

Unsolicited offer

Dr. Grumpy: "This is Dr. Grumpy, returning a call."

Mr. Ink: "Hi, I'm Mike Ink. I have some extra rooms at my place and was hoping to sublease them to a doctor looking to expand his practice with a satellite office. I was wondering if you're interested?"

Dr. Grumpy: "No, thank you. I try to keep it small."

Mr. Ink: "Do you know any other doctors who might be looking to expand?"

Dr. Grumpy: "I can give them your name. What kind of practice do you have?"

Mr. Ink: "Well, technically it's not a medical practice, it's a tattoo parlor."

No comment

 

Memories

Following our first year of medical school, my roommate Enzyme and I returned to our home states for the summer. He (of course) found a girlfriend.

Enzyme saw it as just a summer fling, but failed to properly communicate this to her before returning to school (he claimed he had, and that she was crazy). Regardless, she had our apartment's phone number when he returned to school, though fortunately was over 1,000 miles away (back in those days, kids, you actually had to CALL people. Not e-mail or text. And you didn't each have your own phone, either).

So, in the time-honored tradition of single males sharing a cave, it somehow fell to the roommate (me) to answer the phone so he could hide. As many people of both sexes before him, he was hoping that if he ignored the calls, she'd stop calling. And we all know that never works.

I couldn't just ignore the phone, it might be for me.

So one day, as the phone started ringing, I said, "Enzyme, this isn't working. She's still calling." He agreed, and told me to try something else to get rid of her. Of course, he didn't offer any suggestions, either.
 

 
I answered the phone...


Medical Student Grumpy: “Um, hello?”

Summer Girl: “Hi! Is Enzyme around?”


...my mind went completely blank. I couldn't think of a single thing to tell her that might make sense, like "Enzyme has broken up with you."


Medical Student Grumpy: "Um, he, um, I mean..."


I had a complete mental block. Not one idea jumped to mind.


Summer Girl: "Hello? Are you still there? Can I talk to Enzyme?”

Medical Student Grumpy: "Enzyme, um, he, uh... Enzyme is dead."

Enzyme (whispering): "Holy CRAP! Don't tell her I'm dead! She might call my mom's house!"

Summer Girl: "Excuse me, did you just say Enzyme is dead?"

Medical Student Grumpy: "No, I mean, he's, um, he's... gay."

Enzyme (whispering): "WHAT THE FUCK?!!!"


Long pause.


Summer Girl: "So. Is he dead or gay?"

Medical Student Grumpy: (dazed and stammering) "Um, he's either dead, or gay, I don't remember which..."


Enzyme took the phone out of my hand and hung it up.

Although it wasn't planned that way, it worked. He never heard from her again.

Modern technology

Dr. Grumpy: "Okay, so did the medication make a difference?"

Mrs. Timex: "Sort of, it..."

phone beeps, patient looks at watch

Mrs. Timex: "OH MY GOD! CALL 911!"

Dr. Grumpy: "What? What's wrong?"

Mrs. Timex: "MY WATCH SAYS MY HEART JUST STOPPED!"

Dr. Grumpy: "I don't think that's accurate..."

Mrs. Timex: "Of course it's accurate! I just got it last week! Call 911!"

Dr. Grumpy: "I can assure you that your heart hasn't stopped."

Mrs. Timex: "HOW DO YOU KNOW? You haven't even made a move to check my pulse! Or call 911!"

Dr. Grumpy: (picks up blood pressure cuff) "Let me..."

Mrs. Timex: "This is ridiculous! My heart has stopped, and you're not doing anything! I'm driving to ER!"

she ran out

Mary's Desk

Phone rings

Mary: "Dr. Grumpy's office, this is Mary."

Mrs. Brush: "Hi, this... Brush... appointment... won't be able... there."

Mary: "Hello? Mrs. Brush? I can barely hear you. There's a lot of noise."

Mrs. Brush: "I... appointment."

Mary: "You have an appointment in 10 minutes. Is something wrong? It sounds like you're in a big storm."

Mrs. Brush: "Won't be there... stuck."

Mary: "Hello? That wind and rain are pretty loud. I can't hear you."

Mrs. Brush "I..."

 

click

few minutes pass

phone rings

 

Mary: "Dr. Grumpy's office, this is Mary."

Mr. Brush: "Hi, this is Mr. Brush, my wife just texted and asked me to call you. She has an appointment soon and won't be able to be there, she'll call later to reschedule."

Mary: "Is she okay? It sounded like she was driving through a bad storm. Did she have to leave town?"

Mr. Brush: "She's fine. She stopped to get a car wash on the way there and it broke and now her car is jammed in it and they can't turn it off to get her out for another 15 minutes."

We seem to be made to suffer.

Dr. Grumpy: "I didn't get that report... I'll try to track it down. Did they tell you what the MRI showed?"

Mr. Daniels: "There was a herniated disk at C-something. Ummm... Maybe C3-PO? Does that sound right?"

Saturday night, 11:45 p.m.

"Hi, this is Sara Phone. Your nurse called the other day and asked me to call back or leave a message on how I'm doing, so I am, thank you."