My Mental Week

I called this entry My Mental Week because sometimes patients and their lives can...weigh in on me. This week I had a lot of patients who I spent a great deal of time thinking about.

In Smalltown USA, I see so many people, so many sick people that need help - with no insurance. We have a sliding fee based on income, so we welcome them. This is quite different from Residency. As a Resident, I would be quick to treat a bladder infection with levaquin and not think twice. The vast majority of patients were insured and did not have a problem getting meds. But it is crazy it is to prescribe Levaquin to someone who's husband just lost his job and is struggling to feed 3 kids. Rarely do I prescribe something that is not available on the $4 list and hope that they can get that or treat various ailments with a shot or something available at the clinic or available through a perscription drug program.

Yesterday I saw a man who suffers from chronic pain after having a GSW many years ago. He confessed that he never filled his last script (for Meloxicam and Amitriptyline) because he could not afford it ($30 something dollars). I explained that if he could go to the next town to walmart and they would both be on the $4 list but soon learned he has no way to get to town and does not have $8. So he got a toradol shot. I don't know, I wish I could do more. I then offered him the flu shot and he declined saying "Every one I knows that got the flu shot got sick!" I quickly replied that I got it and I'm not sick (hoping not to jinx myself shortly after I said it). "But you're a doctor!" I couldn't convince him. lol.

Then I saw a lady regarding rapid weight loss - 35 pounds in 7 months! and only 51 years old! She weighs less than 90 lbs and just looking at her I know she has cancer (well, I don't know, but I'm pretty sure). I took a very detailed history. She smokes heavily (lung cancer?) has problems with constipation and bloody stools (colon cancer?) and she still has her ovaries (ovarian cancer?) and has not had a breast exam or mammogram in many years (breast cancer?). She asks me if we can just do some blood work to find out what it is and see if maybe a pill can fix it. She is very pleasant, jovial, and optomistic. As I ponder with how to approach this, I tell her that whenever someone has such rapid weight loss cancer is a definite possibility and she says "Oh, I know! I know! But if it is cancer, I don't want any drastic measures done, just keep me comfortable and let me die!" I counsel her about colon screening and my concerns with her bleeding and she declines. "I don't want to go through a lot of tests! Nothing invasive" I suggest pelvic exam (declines) and a breast exam and mammogram and give her the breast care pamplet as they will pay for that. She says she will think about it. I set her up for a chest Xray which she agrees too and basic blood work. Rapid HIV screen was negative. I will see her next week to review results. I considered ordering tumor markers like CEA, etc, but our lab can't do those and they are very expensive. I don't know if the basic lab will suggest any etiology (like liver metastisis or high alk phos / bone mets) but we shall see I guess. **sigh**

Also, I saw two young girls with Chlamydia. One acted like it was no big deal and the other was so hurt perhaps by her significant other that she could barely speak. I remind them that free condoms are always available here and give them some and encourage them to take care of themselves.

And I found out one of my sweetest patients is a drug seeker. I happened to talk with the ER doc in the next town who I did my Residency with and apparently she is in there several times a month scoring pain meds for various reasons. My nurse confirmed this with two pharmacies. On one visit, she had told me specifically that the ER gave her something for nausea and not pain and I actually believed her and gave her something. She filled a script for Darvocet and Vicoden (from 2 different doctors) at the same pharmacy on the same day!! SUCKER on my head I guess. She has an apt next week and I'll have to tell her no more narcotics from me. I don't know why I am so offended. I guess I thought I was pretty good at detecting drug seekers, but my radar completely missed her. No it's not the first time a patient lied to me, but...idk.

A New Chapter Begins...

It has been almost 3 months since I completed my Residency in Family Medicine and started my new job - a small town Family Practice Physician. I absolutely love it! I work in a town with a population of about 1500 people, but services about 3000 including surrounding areas - and just 20 minutes from where I live! Staff of three at the moment, a nurse (RN), the office manager / receptionist, and...me.

I enjoy the patients - variety of ages and pathology. Ofcourse the bread and butter of medicine - Diabetes, High Blood Pressure, Heart Disease, but even the rare like a young girl with Phenylketonuria, a teeager with Von Hippel-Lindeau, and a few with Lupus, Rheumatoid Arthritis, and other ailments. The staff is absolutely great. And at the moment, I am doing clinic work only with no hospital call which has many benefits! I have a regular consistent schedule, enough time for a few activities with the church, and time to spend with my young daughter.

I am in the process of applying for hospital privileges so that I can follow a few patients in the hospital (20 minutes away but in the town where I live), but I won't have to take call. A new chapter in my life has begun.

Oh, and I passed my Family Practice Boards! Yay!

So professional wise things are going great. The family and I are preparing to move to a nicer neighborhood in the next few weeks. We closed on our first home a week and a half ago.

And my baby girl is just getting bigger and bigger! 18 months old now! Excellent speech skills and overall a very bright baby - of course I am biased. But even the daycare workers say so. She knows her body parts, even her eyebrows. She can say her name, knows her age and she is sooo loving and playful. She is my absolute joy!

Rural Medicine - LOVE IT!

So this past month, I had the wonderful opportunity to work in the rural community which I plan to practice in about 25 minutes from my hometown and I LOVED IT! I love the clinic! The staff, though small (only an office manager / receptionist, a nurse, and a medical assistant) was very friendly and helpful. The physicians that I worked with were nice and the people, and I enjoyed taking care of the patients. A great deal of the time is spent not just treating the patient, but helping them in all aspects. Not just prescribing the drug of choice, but checking if they had an insurance that would help cover, seeing if they qualified for a patient assistance program to help with costs, and / or trying to choose medicines that work for their illness and are on the $4 list - taking care of the whole patient, not just their ailment.

I am really excited about it.

I have turned in my paperwork for the job at this community clinic as they have physicians covering on different days, but no full time physician. The only issue now is that a different community under the same management became available and they are trying to get me to go there as that physician is leaving in July. But someone has a contract to start there in 1 year and if the place I want to go finds someone else, I may be left to find a different job altogether after only one year of work! (I have a rural obligation because my loan-sholarship for medical school paid a great portion if I agree to work in a rural area.) I am supposed to meet with him Friday and hopefully we can work something out. I fell in love with that place!