Dear John

Dear Mr. Disgruntled Patient,

I am sorry that you are unhappy with the care that you have received. I appreciate you letting us know of your concern by writing us a letter. Please allow me to address those concerns.

First, I ordered that bloodwork twice because that is what is required to confirm your diagnosis, as we discussed during your office visit. Without confirmation of your diagnosis (again, “but I know I have it!” doesn't count), your insurance will not be willing to pay for your very expensive medication.

Next, we had addressed how you were going to administer the medication when I informed you that we had confirmed your diagnosis. You decided to have your domestic partner, who is a doctor, inject the medication instead of coming back to the clinic every few weeks. Apparently, you must have forgotten this conversation as you state that I just mailed you a big box filled with medicine and needles just out of the blue.

I apologize that you received syringes that were too small. If you had called, we could have addressed this much sooner. You will get the correct size in the mail.

I appreciate that you want to alert my program director of my “incompetence”. However, you addressed the envelope to me instead of him. I have taken the liberty of passing your letter on to him. I'm sure he will file it in the appropriate place.

As you are unhappy with my care, I will make sure to reschedule your follow-up appointment with one of my colleagues. Dr. Timely's next opening is in five months.

Sincerely,

Real Medical Doctor, MD

"It's gotta be my thyroid!"

Thyroid conditions is the second most common problem I see as an endocrinologist (diabetes is first).  A that little butterfly-shaped gland on top of your windpipe can cause a lot of problems.  Those problems can range from weight loss to weight gain, being too hot to being to cold, diarrhea to constipation, and anxiety to depression among other problems.

For some reason, thyroid problems are more common in women than in men.  Most women will develop their thyroid problems between ages of 20 to 40.  So I see a lot of 30-year-old women with thyroid "problems".

Some have seen their doctor and have gotten the appropriate work-up.  Others are self-referrals.  They just call the hospital appointment line and viola!   An appointment with the thyroid specialist.

Many have not seen a doctor to have any work-up.  They generally have read on the Internet that fatigue or weight gain can be a sign of thyroid trouble.  Or their sister/mother/mother-in-law has a thyroid condition and now the patient is having those exact same symptoms.

But there are several other things that can cause those same symptoms that have absolutely nothing to do with the thyroid.  Depression can make you tired and fat.  Deconditioning (lack of exercise) can make you tired and fat.  Stress can make you tired and fat.

It's not always you're thyroid.

Conversely, if you do have a thyroid disorder, not every thing that happens to you is due to your thyroid.  I've had people call me after hours wondering if sudden swelling in their legs is due to their thyroid condition (no, but I would worry about a blood clot).  Or the three times they've fainted that day (why are you calling an endocrinologist?! get to the ER!).

But if you're problems are due to a thyroid condition, the condition is generally easily treated.  Just remember that everything is not due to your thyroid. 

Sugar, sugar

I see a lot of patients with diabetes.  Most people sent to my clinic are on insulin but still have very high blood sugars.  Hence the referral to the "diabetes expert".



There are many reasons why these patients have uncontrolled diabetes.  Some are just not on high enough doses.  Others unknowingly take their pre-meal insulin after they eat.  A few will have times when their blood sugar drops too low and then their body reacts with the stress response driving the blood sugar back up (and usually too high).



But most are uncontrolled because they aren't with the program.  They don't check their blood sugars regularly.  Or they don't take their insulin shots regularly.  Or they don't follow a diabetic diet--which does NOT include doughnuts.

And it is amazing how many show up to the diabetic clinic without their glucometer or any record of their blood sugar readings.  They are surprised when I ask for these things.  More than one has been offended when I say that I can't help them control their sugar without knowing how their blood sugars are running.  Sorry, but otherwise I'm shooting in the dark here.

Don't get me wrong.  Diabetes is a huge pain.  But diabetics have to deal with checking their blood sugars regularly and taking insulin on a regular basis if they want their diabetes treated.


And please remember to bring a record of your blood sugars to clinic.

Pump me up

An endocrinologist is a specialist in hormonal disorders.  I'm a "gland doctor" as my sister so eloquently put it.  I see a lot of diabetics in my clinic.

Usually, when you require insulin, you have to give yourself anywhere from one to four or more shots a day.  It's a pain, literally and figuratively.  Some patients require insulin for the rest of their life.  A few will qualify for an insulin pump.

The pump is the size of a deck of cards and delivers a continuous stream of insulin.  You put a new site in every 3 days.  One "shot" every three days instead of 3-4 times a day. 

Sounds great, right?  Really easy? 

Well, it's actually a lot of work.  You have to check your blood sugars 6-7 times a day.  You have to accurately judge how many carbs you are going to eat and tell the machine accordingly so you can receive an accurate dose of insulin.  And if there's a problem with any part of the pump, your blood sugar can skyrocket really fast and make you seriously ill.  If you aren't on top of this, things will go south fast.

But patients don't want to hear that part.  They hear one "stick" every 3 days instead of several times a day and want one now like Veruca from Willie Wonka and the Chocolate Factory.  And woe be unto you if you're the endocrinologist who dares to say no.

One patient who wants a pump won't take her insulin on a regular basis.  Her blood sugar hasn't been below 300 in months (normal is around 100).  She won't check her blood sugars and doesn't follow her diet.

But I'm suppose to approve a $5000 piece of equipment on the basis that you want it because you can't "remember" to take your shots.  Sorry if your buddies in your same situation got a pump.  No, I don't know how their doctor managed it.  Let's focus on getting your diabetes under control now instead of several months down the road when your pump may or may not come.

Unfortuately there are no quick fixes in diabetes.  Diet, exercise, and taking your medications regularly are the best treatments.  An insulin pump isn't always the answer.

How to Be a Better Patient

Now I've seen several things in the media about how to be a more empowered patient, how to get the most out of your doctor, and how to read the signs that you need a new doctor. And don't get me wrong, it's important to have a good relationship with your doctor. If that relationship isn't there, then the two of you won't accomplish much no matter how empowered you are.

Yet I haven't found much expounding on how to be a better patient. And given my three years of working in two continuity of care clinics, I have encountered some patterns of behavior that tend to drive doctors up the wall. Which really works against that whole doctor-patient relationship thing.

So here's my guide on how you can get along better with your doctor and be a better patient.

#1. Bring all of your medications to each doctor's visit.
#2. Bring all of your medications to each doctor's visit.
#3. Bring all of your medications to each doctor's visit.

I can't stress this enough and for a lot of reasons. One it allows me to know what meds you actually have and I can judge if you actually taking it. If I gave a month's supply with five refills six months ago and your blood pressure medicine bottle is still nearly full and still boasts five refills, I'm pretty sure that you haven't been taking it. Therefore I would stress actually taking the medication instead of cranking up your dose.

Also, I can see what your other doctors have been giving you and they can see what I have you on. Some medications, like people, don't play well together. The consequences could be range from one or both not working to something very serious like renal failure.

And sometimes a change in your medical condition will make a once safe medication not so safe. So, while your kidney doctor will likely not treat your diabetes, he or she may note that your diabetes pill isn't such a good idea in someone whose kidneys are failing and tell you that you may need to stop it. Or that a medication you're on may be causing your kidneys to fail. They wouldn't be able to do this if they don't know what all you are taking.

#4. Have some idea of what you medical problems are.

Know the game “Twenty Questions”? Yeah, it's fun on road trips. It's not fun if I have to play it with you to figure out what's wrong with you. For example:

Me: Do you have any medical problems or conditions?
Patient: Nope.
Me: Nothing that you should take medication for?
Patient: No.
Me: You have a big scar running down your chest like you had heart surgery.
Patient: Oh, that's from my second quintuple heart bypass surgery last year. I only take aspirin, a cholesterol pill and three blood pressure medicines.
Me (still trying to be civil): Any thing else?
Patient: No.
Me: But you asked for a refill on insulin. How long have you been a diabetic?
Patient: Only for twenty years.

Sadly, this is very close to an actual conversation with a patient in clinic. Consider this a corollary to #1-3.

#5. Lists are good.

No matter how good your memory is, there is something about a doctor's office that makes you forget everything you wanted to discuss, mention, or ask me about. And you will not remember until about 2 am that night when you suddenly wake up remembering it. So bring a list. I will actually thank you for it.

#6. Be polite.

Especially if this is our first interaction. The old saying is true: you will get more flies with honey than vinegar. Doctors are only human and if you are nice, your doctor is more likely to work with you than if you are difficult.

#7. And be polite to everyone.

During my receptionist days, I was amazed at the number of people were incredibly rude to me or the nurses but were as sweet as they can be to the doctors. This is a bad idea in general. Word of your behavior will make its way to the higher ups eventually and I have seen patients fired for continuing this type of behavior.

#8. Remember that I'm here to try to help you.

I'm not running behind to deliberately piss you off. I'm not increasing the dose of your blood pressure medicine because I don't like you. Nor is the blood work some form of punishment.

Unless you violate #6 or #7. (Just kidding).

#9. Not everything you read on the Internet is true or applies to you.

If there have only been 6 recorded cases of French Fainting Fever since the beginning of time, chances are that you don't have it. While the Internet is a great tool and can provide some great information, you have to be careful of your sources and how you apply it to yourself. And remember, in general, reading WebMD for ten minutes doesn't trump years of medical training.

10. Remember that this is YOUR health.

And nothing can replace your health. It is important that you take your health seriously. Because it's true that if you don't have your health, you don't have anything.

So take ownership of your health and your healthcare.

If I said that I was going to send you to a specialist at your last appointment and you've haven't heard anything about it a month later, pick up the phone and call the clinic. Or write a letter. Or send smoke signals. Something other than waiting until your next appointment two months later to yell at me about it. Generally they send the patient the appointment notice, not the referring physician.

You will not be bothering your doctor. I thanked a patient who noticed that I didn't rewrite one of his blood pressure medications and didn't talk to him about stopping it. It was an oversight and he should have been continued on the medication. By taking responsibility for his own health, his blood pressure remained controlled instead of sky high for the next few months. And all it took was one phone call.


The End

"I'm a doctor, not a ...."

A few weeks ago, I found a Wikipedia article listing famous graduates of my alma mater. Among those listed was Leonard McCoy, physician. Wondering why the name seemed familiar, I clicked the link.

Dr. McCoy was the chief medical officer on the Enterprise. The Enterprise, as in Star Trek. And while I’m not a die-hard Trekkie by any means, I was surprised that I didn't recognize the name.

So, why is he on the list? Supposedly “Bones” attended (or will, since it’s in the future) my alma mater, Ole Miss. God bless Wikipedia.

Of course the character is know for the line “I’m a doctor, not a(n)…” An industrious author from Wikipedia compiled a list, which includes examples such as bricklayer, mechanic, and escalator.

I realized that over the years of my training, I have muttered "I'm a doctor, not a ..." several times.

For example, “I’m a doctor, not a personal maid.”

I don’t mind doing small things for my patients. An occasion glass of water or help to the bathroom isn’t beyond my realm of responsibilities. However, I’ve had a few who wanted me to wait on them hand and foot. Sorry, I'm not going to call the cafeteria and demand they send you a cheeseburger and fries, especially if you came in because of a heart attack. Your diet starts now.

No, we don't have HBO or Cinemax or other premium cable channels. No, we don't have a DVD player in every room. The Xbox is in the children's hospital and is reserved for the sick children. This is a hospital and not a hotel.

“I’m a doctor, not God.”

I had a patient who was recently laid off from his job and he asked me what I was going to do to get his life on track. Um, I can help your back pain. The rest is up to you, my friend.

On another occasion, a patient's daughter wanted me to guarantee that her father wasn't going to die before Thursday because that's when the rest of family was coming in. Sorry, my magic 8 ball says, "Ask again later". I'll get back to you.

“I’m a doctor, not a drive-thru.”

I don't mind answering a couple of questions from people who accompany a patient about their health. However, some people go above and beyond. If you're that many questions and/or problems, you need to schedule an appointment for yourself rather than trying to share one with Grandpa.

There is one woman I remember from my pediatric ER rotation as a fourth year medical student who was definitely guilty of this. She had brought her son in for chest pain. Before I could even being to question the boy about what happened, Mom wanted to know how she could tell she was dehydrated, what she could do about it, and how to treat dry skin. I quickly answered her questions (dark urine among other things, drink more water, and try lotion) and tried to return the focus back on her son. When I got to the physical exam, she wanted to know if I could check her ears, too. I responded that this was the pediatric ER. And the boy, he just had reflux.

What's in a name?

Some people seem to have trouble accepting me a true blue, no kidding doctor.  For some, I appear just too young to be a real doctor.  Others can't seem to get past my gender as if a female physician is just so odd.  Surely I'm the nurse or the respiratory therapist.  When is the real doctor going to get here?

My friends and family have listened to me gripe about this treatment over the years.  It's been the source of numerous inside jokes.  One of my friends even gave me a copy of "Reflections on Nursing" by Florence Nightingale as a gag gift when I graduated from my internal medicine residency.  

So that's why I chose RealMD as my ID for this site.  Well, that and I didn't want to use my real name.  And, yes, I'm really a doctor.