Thursday

7:00am; Lights on.  

Coffee, black and a banana. Paperwork.  27 patient visits, 3 emergencies, 35 phone calls.  Lots of computer time. Some laughs and a few tears. Paperwork.  Last family meeting.  Coffee, black.   In between: Thursday.

Was not completely successful in explaining to my frantic patient with the multi-page lab printout, how the problem was not that her tests were bad, but that the computer had used the wrong “normal” range to decide what to flag bright-scary-red.  The lab company is going to issue a new report.

I told 87-year-old Lil that she looked great and young.  She told me I was lying. “I know that I am an old hag and look like hell.  But, don’t worry, I’m a tough-battle-ax broad.”

Reorganized the therapy of a patient who got a second opinion and started chemo without the doctor contacting me.  The new treatment not only overlapped with prior failed therapy, it threatened major complications because of her general medical condition.  I do not understand why doctors do not pick up the phone, send an email or at least type a note.  I dream always of a universal EMR.

Gave my usual new patient instructions, which include the words, “this is not a time to go it alone.  I am here to help. This is a time to be whinny, so I want you to call with any problem. “  “No problem doc, you are the man, you call the shots.”  I asked if they would mind telling my wife.

Saw four new patients regarding therapy for cancer. Despite aggressive chemotherapy plans, I was able to counsel three of them regarding end-of-life choice. All agreed to complete an advanced directive, one of them a POLST and two decided they never want to be on a ventilator or have CPR.  I feel better knowing that whatever happens, we have a plan.

Paula requested a script for a wig.  I was surprised because she had made a big thing about just wearing a scarf or no head covering at all.  She believed that chemo baldness was just part of the battle.  She would “declare her disease.”  “What changed, why did you decide to get a wig?”  “Well,” she said, “It turns out my friends were more attached to my hair than me.”

Put a new patient in a tough spot.  I am advising therapy which is different than her primary oncologist’s recommendation and we were not able to completely agree, even when I called him. The patient must make a treatment choice when there is no good data.  I will support whatever decision she makes.

Ron is recovering from cancer, which spread to his hip, for which he had radiation.  I had given him a prescription for physical therapy; however, he has not gone to PT.  “Why?” I asked.  His wife had a better solution.  For 32 years, she has been trying to get him to go shopping.  Now, to regain strength, she takes him to the market and makes him use the shopping cart as a therapy walker.

A husband and wife were in to discuss her case. The medical records they provided are stunning; indexed, flow diagramed, converted to Excel, color-coded and mounted in spiral folders.  I told them these were the best patient documents I had ever seen.  The husband responded this was because the two of them were “CDO.”   I was not familiar with the term.  “Oh,” they explained, “that is when you take OCD one step further and put the letters in the correct order.”

I got two separate messages from patients regarding the same complaint.  Both felt well and were without pain, shortness of breath, dizziness or diarrhea.  However, they complained that their temperature was “too low.”  97.3 and 96.6.  I tried to explain that unless something truly terrible is happening a “low temp” has more to do with how it is measured than reality.  One required a rectal temperature to be reassured he was OK.

Marlene, who is 94, was in the office with her friend Maude, also a nonagenarian.  I needed to write a prescription for Marlene.  She asked that I call a specific pharmacy, even though it is across town from where she lives. ”Why?”  Well, it turns out that particular pharmacy has same-day-delivery, which involves a particular delivery “boy.”  This young man apparently has the admiration of the “girls,” such as Marlene and Maude, in their senior-restricted apartment building.  They rushed home to await the arrival of the “medicine.”

Told a 54-year gentleman he had “cancer.”  What made this odd is that he had already undergone complex surgery for the “mass” and the doctor had taken out a large “tumor.”  The surgeon does not like to use that most evil of words.

An advanced breast cancer patient of mine came in looking much the worse for wear.  For once, the cause was not I, nor her cancer.  Rather she was recovering from a “vodka drunk.”  The hangover lasted four days.  “Was it worth it,” I inquired?  “Absolutely.”

“What is your goal?” I asked Brian, trying to move forward a difficult conversation about cancer, chemo and life.  “I have no goal. I want nothing.  I want to know nothing. I just want to live today, and maybe tomorrow. One day, one step. Nothing more.”

Finally, there was Rich.  A once a Marine, always a Marine type, he is an ex-machinist who at 78 is strong and tough like drawn-steel, short military-silver hair, bright-blue eyes, and leather-tanned skin.  His complaint involved his surgical wound.  “Doc, I am a bath guy. I am not a shower guy. I am a bath guy. The surgeon says I can’t take a bath until I’m completely healed. This is killing me.”  “What is wrong with a shower for a week or two,” I asked.  “You don’t understand.  In the bath, I have my soaps, my scents and my bubbles.  How can you have bubbles in the shower?”  Rich had a point.  The cancer care was interfering with his daily foamed soak.  We agreed to invent a shower attachment that sprays cologne and bubbles.  I did not have the guts to ask about rubber ducks.

7:00pm; Lights out.

15 Comments

  • Your posts are increasingly insightful and entertaining. Keep up the good work Doc!
  • It is 6:19 am...about 90 degrees in this antique building. I always have my coffee with half a tsp. of sugar and a bit of 1% milk. I drank my coffee black in my poor years. Poverty has all kinds of definitions. My 10 year old 'hag' cat wants to communicate via bites on my ankles to let me know I have fed her, let her on the porch to go potty, and now she needs a half hour of brushing. My artist husband is basically retired? He has his coffee with half and half..works out, does yoga, lifts, vitamin regimen....looks better than most 20 year olds I see...and my post surgical treatment for breast cancer...left me with a broken collar bone..methinks..and cervical spine issues. Oh well...maybe someone did not like my politics. I was in shock when I dr told me I had a birth defect..my mom and dad laughed.
  • The vodka drunk patient may have been seeing one Dr. not so fine...he transparently recommends vodka .....
  • I always enjoy your posts, and often (like today) learn something about medical science and something else about human behavior. Today I also got a laugh -- and will add "CDO" to the expressions used among some of my over-meticulous family.
  • You oncologist are a rare bred. Take care of yourself. You are appreciated.
  • Yogamom
    Thank you so much for your post! I can tell you truly enjoy your patients. You are a breth of fresh air.
  • Paula Kaplan-Reiss
    I have to say just reading about your day makes me nauseous with anxiety. I'm struggling with figuring out POLST....something about life saving??
  • God bless you for what you do. I have Waldenstrom's macroglobulinemia and am blessed to be surrounded by caring family and physicians who really get involved. Like you do. Thanks for dedicating your life to the rest of us. And for sharing. Judy.
    • I have Waldenstroms. If you would like to e-mail me feel free. LSGOOD@aol.com
  • Penny egan
    You always and to my day in a positive way!
  • D Someya Reed
    An interesting snippet into a day in the life of...you. Some thoughts...it's 4am and I've been reading enough about desalinating sea water, fake cell towers being found and failed hypersonic missile testing. 1. If an EMR goes unread, does anyone benefit? 2. Who do advance directives and POLST serve if the only negative repercussion is to the patient when they are not followed? 3. Why is it that doctors (highly educated in medical care) struggle with granting the patient autonomy, get upset when the patient does not do as they prescribe yet when (the doctor) has no (or no good) data, the decision is left up to the patient saying 'I will support whatever you decide?' Who should really be "calling the shots" here? Who's the one educated for just such situations, the doctor or the patient? Or is it...now, under these not so obvious circumstances, you "patient X" can have all the autonomy you want? Makes you go....Hmmmm. Now back to the real reason I got up this early...to determine by what % the amount a school bond measure on the upcoming ballot has been inflated without any substantiation. They added 5% to their original estimate, another 25% for "contingencies" and topped it all off with another 21% with no explanation at all...just because. The math works out to an unexplained 47% increase over what they say they will need to do what they want done and what they want done won't reduce class sizes, student/teacher ratios or even help one student improve his/her test scores. The district is supposed to demonstrate these as positive effects but I guess can't be bothered with that minor detail. I wonder if Common Core will teach "not being duped" as a "real life skill" to prepare our youth for college and careers? Sorry for the digression...it's way early.
  • Marie
    Dr. Salwitz, As a cancer patient, I worry about how my oncologist can continue he to be so compassionate without burning out. It would be interesting if you wrote about how you unwind after a day such as the one you described, and how you regroup and refresh to avoid burnout. I thank my oncologist every chance I get: in person and in emails and written notes. Is there anything else you recommend that patients do in their partnership with their oncologists to help the doctors stay emotionally healthy? Thanks.
    • I do the exact same thing and also bring cut up fruit so he gets a snack. I find myself worrying about him. They are down a doctor and an NP and it seems impossible to me for him not to burn out. Such kindness, compassion, and excellent care. I am always grateful.
    • Very good point. Compassion is a draining effort. Let us know what we can do. Judy
  • me
    Dr Salwitz I thoroughly enjoyed reading this blog. You covered so many bases that I started to make notes. I especially liked the CDO and cant wait to share it with a friend who has a child struggling with OCD. I also saw my wife, or someone just like her, in your list. We always felt so fortunate to have had you with us through the difficult days. I think some times patients get confused and somehow think the doctor who give 'bad' news is the fault or part of it. We always understood you were only the bearer of bad news not the creator. Thank you for being there when we needed you most. RJN ps, the reply requesting a blog about how you unwind after a 'typical' day would be interesting

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