What would you do?

A text lights up my phone late in the evening. It's from someone who is a patient but we've been together for so many years I consider her a friend. She has my phone number from other times she's needed medical advice. She knows me well enough that she can assume I am adept at texting though we've never communicated that way before. The patient is immune deficient and somehow managed to scratch her leg. It didn't originally look all that bad but in the last hour or two it has become red and swollen around the scratch and she is concerned about cellulitis. 

There are no Immediate Care Centers open this late on a Sunday night. It is not clear to me from the description, even after speaking with her on the phone, if it is bad enough to need hospitalization. If not, the best care would be to start an antibiotic tonight and check it in the morning. My choices: send her to the ER at the height of flu season (a terrible idea for anyone but especially an immunocompromised individual), have her wait eight hours until morning and I can see the wound, treat it empirically, or have her send me a picture. The picture can't be in a text because that's not HIPAA compliant. It also can't be email because that's not HIPAA compliant. SKYPE? Maybe but I'm not sure how good the encryption is. 

So I sit on my couch and weigh options--all the while thinking, "How did we get in such a quandary, where taking the best care of the patient is not first on my list of considerations? Where common sense is delegated to the back of the bus behind government regulations and insurance rules? And where the technology to make all this simple can't be utilized to help my patient or me?" Patient portals are great but can she figure out how to load the picture on it? And our portal only accepts up to a 50 MB file. What if it's larger? Will she know how to reduce the size? Yes, I could do what my 1950's MD ancestor would do, which is hop in the car and make a house call, but he only saw 12 patients in the office the next day and made relatively leisurely rounds at the hospital. Not the frantic 20+ I'll see tomorrow, needing all the rest I can get. 

What would you do?

The Expensive Process of Med School Application

Discouraged by her parents, my oldest didn't consider a career in medicine until after  graduating from college with a BFA in Art History. After taking an Americorps position and feeling lost at sea, she took a battery of aptitude tests. Interestingly enough the tests pointed her to a career in medicine, specifically as a physician or other treating provider. Growing up and watching her parents struggle through the difficulties of primary care, she certainly knew what she was getting into but somehow she must have seen the rewards we shared under the frustration.

So back she went to college, obtaining a 3.8 Science GPA. She took the MCAT, the dreaded test all pre-med students must do well on in order to be considered for medical school in the US, and made a decent if not stellar score. Then she began the application process.

Applying to medical school was an expensive and somewhat demoralizing undertaking. First she paid to send all the necessary materials-scores, transcripts, letters of reference, etc.-to each school through an organization called AMCAS. Then medical schools invited her to submit a secondary application.  At first she thought she'd made it through some sort of vetting process. Each school had a different set of requirements usually involving essay questions. Quickly she learned that they were all "interested" in her, well in her money. Amazingly paying $50-$150 per secondary application doesn't guarantee even a polite rejection email. Most students apply to about 20 schools. That's a lot of cash, considering that only about nine percent of all applicants are actually admitted[1].

As a bystander I have to wonder - is there anyone in the medical education community at least a little ashamed that so many of the hopeful individuals that apply to your "august" bodies are not granted even that tiny courtesy?

As a side note, she did get accepted. And despite all the frustrations I've been through and the issues that face her once she gets into practice, I'm proud of and happy for her. 

1. http://www.usnews.com/education/best-graduate-schools/articles/2011/04/05/10-medical-schools-with-lowest-acceptance-rates

Saying Goodbye

It's Friday afternoon and I check the day's schedule. A name jumps out at me and I groan a little and worry--what am I going to say to someone I've treated for twenty years, who's my age and just been admitted to hospice care? If this is goodbye, how do I as a physician, who is more than an acquaintance but not quite a friend, handle this appointment?

All kinds of things go through my head. Do I really want to charge for this? How bad will he look? Can I keep from crying? Is there anything I can do for him anyway? Will I ask the right questions? Will I say the right things?

He comes with a relative. He is living alone but they have found a nursing home that he liked today and he hopes to transition there quickly. He has one sorrow and one fear. He needs to find a home for his dog of 14 years. He shows me a picture of a cute lap dog of some sort. Amazingly, during his last hospital stay he met someone who is willing to take care of the dog. His fear is how breathless he will be near the end. I reassure him that every effort will be made to make him comfortable and he should not suffer.

We talk a little about his parents, with whom he has been estranged for some time. He assures me that he has spoken with them. They are older and have had their own medical challenges. I cannot imagine how they feel. He jokes a little about his relationship with them.

Finally it is time for him to go. He looks tired, but not that ill. He asks me if he should try to eat, he doesn't have much appetite, and I encourage him to eat whatever he wants. He stands up and gives me a hug, whispering "I love you" in my ear as he does. After reminding me that the phone is a good method of communication, he leaves.

I am lost in thought and emotion but still have two more patients to see. I take a breath, walk into the next room and apologize for my tardiness. It's probably obvious that I'm upset but the rhythm of seeing patients takes over and somehow, reassures me.

A Very Personal Understanding of Aging

My todo list is overflowing, my emails are piling up, I have 17 pages to read in my book and all of these are things I enjoy doing. But my mother has just called me for the fifth time in less than 60 minutes about the new safety monitor we got her for Christmas, the 5Star Urgent Response. New things challenge her and the idea of having both a cell phone and this device is beyond her ability to assimilate. As I sit at the kitchen bar trying to concentrate on any number of items the phone rings two more times. It's not that I don't want to work more but my spirit is broken by the phone calls. I give up and walk toward the stairs to the bedroom. My mother must have picked up on my frustration because when the phone rings again, it is not mine. My husband picks up his phone which is playing "Mother-in-Law" (see below).  

Over the years, as my patients have aged along with me, they have told me their woeful stories regarding their parents. I knew my time would come and over the last year my 84 year old mother has diminished with each month. She refuses to take any "more" medication and, like many of the dementia patients I've treated, doesn't see the problem. Since the evidence on the "Alzheimer's medications" is not all that convincing anyway[1], I am not willing to fight over it. She limits her driving mainly to daytime and to places she knows. But if you throw anything out of the ordinary, like the new device that she needs to clip on her person and charge every night, it becomes a nightmare. Not only for her but for me and my husband as well. 

My daughter has already approached her about moving into a personal care home but she will have none of it. She has good days and bad days. My job keeps me busy and disinclined to force the conversation. It is coming. My patients have prepared me for it and I thank them for this. But just like them, there is a black hole of dread that I see approaching. One thing for sure, while I will avoid discussing what is a personal matter, my empathy will go out to the next adult child dealing with their unwilling parent. 

1. http://consumerhealthchoices.org/wp-content/uploads/2012/08/BBD-Alzheimers-Full.pdf