Caring for family

January 30

Caring for your own family members has always been problematic for physicians, but a recent episode involving my mother-in-law cured me forever of being her doctor.

Ima is 78 years old with a history of a porcine aortic valve replacement and double CABG four years ago. Since then she has been largely non-compliant with medicines that I prescribed for her hypertension. One morning several weeks ago, she called me to say she was having severe chest pain unrelieved with baking soda. She sounded like she was in trouble and, on my advice, took an aspirin and went straight to the ER, where upon arrival she experienced sudden death. I arrived there to find her intubated and being resuscitated. Since she hadn't established herself at another doctor's office, I was the physician of record. I was flooded with emotions while trying to do the right things medically. At once, I realized why I shouldn't be doctoring my own.

Fortunately, her pulse and blood pressure were re-established, and we moved Ima into the ICU, where an ECG revealed that she had had a major anterolateral MI, and a TPA infusion was begun. I asked one of my colleagues if he wouldn't mind giving me a hand with the ventilator settings, and to my relief he graciously offered to assume her care.

As the days went on I realized that taking care of the patient (in this case, my mother-in-law) was really the easy part; simultaneously dealing with the family, when they were my family, would have been too difficult.

Ima survived her infarct and was discharged a week later on more medicines than she could ever have imagined, but she hasn't balked about taking them. She was last trying to decide whom to see for follow-up, but I told her I was not an option. From now on I'm playing the caring son-in-law role, which suits me just fine.

Making it

February 3

Michael, a local family physician in his first year of practice came to me today bemoaning his practice overhead and projected net income. “My overhead is 55 percent of my gross income! I'll be lucky to clear $40,000 this year!” he exclaimed.

“You know, Michael,” I teased, “most pharmaceutical companies start their reps out at more than $40,000 —and they have expense accounts and stock options. Maybe you should be detailing drugs.” Mike didn't think it was a bit funny.

His plaint is common in my neighborhood, where many doctors refuse to run their offices like businesses. Michael, for example, is overburdened with employees and doesn't understand that they are expensive. Besides paying their salaries, you have to pay for workers' compensation, unemployment insurance, vacations and so on. “It's great that you're employing half the town, but it's detracting from your bottom line,” I said. I suggested that he might train one person to do all three jobs, as I have done, or that he might learn how to run his office management software himself.

Will, another colleague, was recently talked out of using electronic scheduling by his two employees who were resistant to change. “They protested when I asked them to switch from paper,” he said, citing loss of data in the event of a power outage as their reason. I explained to Will that daily backups were the easy solution, but I sensed that he wasn't about to overrule his employees. Democracy can be great, I thought, but not when you're running a business.

I now know how managed care was able to take control of our profession. We were pushovers.

HealthTrends

February 11

HealthTrends, my wellness program, has just entered its 14th year. When we started in 1987, we had 80 patients taking part in it; in 1999 we had 312! As part of the program, patients are asked to complete a lengthy questionnaire, which is in part a health-risk appraisal, stress-event test and food log. Then, they undergo a traditional physical exam and return two weeks later to receive a report of their personal health information.

Of particular pleasure for me is using the computer to show patients their changing health patterns and to let them query their own databases for whatever concerns they may have. “Show me my cholesterol for the last 10 years,” one patient asks, and with a few keystrokes it's on the screen.

“Would you like to see your LDL as well?” Done. “HDL?” No problem. “How about your weekly alcohol consumption, miles driven each year, stress-event scores or weight?” Patients are transfixed by the graphs, and with 152 variables stored for each patient each year, the opportunities for health education are endless.

The best part of the program is telling my HealthTrenders how much they've improved and that we don't need to see them again for another year. They walk away with a big smile — as if they've just been to the dentist and been told they have no cavities.