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Doc's Progress Notes

Week of November 8, 1999

Last Updated: 11/14/1999 at 6:39 PM

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Monday November 8, 1999

Monday morning at the office. Trying to find out what happened with my patients over the weekend. Answering phone calls from patients who did not get something done that was supposed to be done or not understanding why I can't be available to them 24 hours a day seven days a week. This, of course, is in sharp contrast to what we talked about at the retreat over the weekend; namely we have to learn to say no in order to have some time to ourselves and our families. So you say no I can't be available all the time and people get upset. I don't know the ultimate answer to this dilemma but the older I get the more I realize the value of learning to say no and being realistic with patients. Trying to apply some time management techniques we discussed this weekend also so I can get out of here earlier.

After a morning catching up, a pleasant lunch with my wife and one of her clients and his wife. Very nice couple and very good food (salmon piccata with pasta and a Caesar salad for those of you who have to know; much better than my usual fare of a sandwich and chips on the run). He is a physical therapist who has his own clinic and will be advertising with the radio station and she works in the executive offices at a local mill. They have two children about three years older than ours so a lot of stories about raising kids. Hopefully we can get together in the future again when we can spend longer talking, maybe a friendship will develop.

This afternoon brought two people with distinctly different reactions to similar problems. First, one of my patients with a neurological disease causing muscle weakness came in to see me. She uses a motorized three wheel cart to get around on the streets of our city and is always out and around and visible. Today on the way to see me she was hit by a car while she was in the crosswalk and luckily was not even knocked off her cart but the cart is damaged and will have to be fixed. She was thankful not to be injured more but was more concerned about her cart since it is her only means of transportation.

In contrast, the other person is 18 years old and was the driver of a car that was rear-ended in July. Since then she has had back, hip, and shoulder pain with normal x-rays and MRI's. Her mother wheeled her in in a wheelchair although this girl lives with her boyfriend in an apartment. She supposedly works for her parents company but has not worked for more than four weeks and her mother has been paying her bills for her. Her mother was with her saying that despite the tests being normal she has just not found the right doctor who can find out what is really wrong with her and can therefore cure her pain. I will of course check some blood tests to be sure there is no rare muscle disease involved here but I suspect that her mother will decide that I am not the right doctor to find what is really wrong with her daughter. I don't think either one of them realizes what secondary gain means i.e. the daughter keeps hurting because she gets attention if someone thinks something is wrong with her. I will discuss this with them, will talk about the possibility of fibromyalgia, and will discuss the need to get the daughter back up and active to help her overcome her pain. I hope it is not too late to get her back active again, otherwise we face the prospect of another person "crippled" by her pain, the source of which can never be found because there is no one source.

I made it through Monday at the office and then really had fun. The worship team that I am sound man for practiced tonight. We always have a great deal of fun and tonight was no exception. I got to be a percussionist on the last song which was a hoot. Part of the enjoyment is to see my wife really shine when she is singing backup vocals. Yes, we are lucky enough to be on the same worship team. We also had a new sound system we are trying out and that made everything sound much crisper which warms a sound man's heart. We have a wonderful team which really enjoys being together and really loves one another. That makes it even more fun.

Enough for today. If you are new to this site and want to see the first installment of this journal, which was last week, follow this link. I must find somewhere else on this page to put this link but I will think about that another time.

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Tuesday November 9, 1999

While perusing the Daynoters sites and other sites I normally read daily I found that a letter I had written to Dan Seto had been published on his site. I wrote it to encourage Dan after Brian Bilbrey had taken exception to Dan quoting Bible verses in a message sent to Brian. Dan could not understand how an e-mail dated Thursday Nov 4 had not reached him until Sunday night Nov 7 and blamed it on insufficient postage perhaps. I find Dan to be very entertaining always and appreciate his sense of humor although I do not always agree with his political views (especially DOJ Vs Microsoft). This diversity of views though is what makes reading these sites fun and there is a sense of community that develops reading them.

Now to get back on track again after wandering off after that rabbit. I had originally started this thread to say that the e-mail to Dan was about his Nov 4 entry and was actually sent to him on the day he received it, Nov 7. There, now that is cleared up. I also wanted to join Dan Bowman in nominating Dan Seto for membership in the Daynoters gangand highly recommend visiting his site daily.

Today at the office is starting out kind of slow. Maybe the weather has something to do with it. We are beginning a week of rain with a storm coming in from the Pacific. It will be classic Pacific Northwest weather this week. Being 60 miles from the coast we don't get the high wind here that they do on the coast but it is windy and unseasonably warm before the front comes through. Running is tough in this weather because you want protection from the rain but it is also too warm to make wearing completely rainproof running gear comfortable. For me, it needs to be in the low 40's for that gear to be comfortable, preferably in the 30's.

The no-show problem I discussed last week seems to have spread to other physicians today who are normally pretty immune to the disease. No one is completely immune but a lot of today's patients seem to have gotten together and said let's all not keep our appointments today but no one call them and tell them we are not coming. We physicians thrive on routine and anything that disrupts that routine makes us uncomfortable. Intellectually I know that today is an aberration but we walk around today saying what is going to happen and who is it going to happen to since our sense of routine has been disturbed.

This afternoon was busier for everyone. No real emergencies but plenty of sick people, we seem to have very hearty viruses around at the present time. The lady with congestive heart failure I wrote about last week was back today having been discharged from the hospital to a nursing home over the weekend. She is better but her long term prognosis is not good. Her heart is only functioning at about 40% of its normal function, it is enlarged, and she has lung disease secondary to her past smoking. This combination makes it unlikely that she will ever be able to be active enough to care for herself and therefore live by herself again. We will give her that chance however; we'll do progressive therapy at the nursing home for the next month and see if she improves enough to be independent. If not then her family has to decide where she will live with help. Her daughters are not ready to face that decision yet to say nothing for her having to face that eventuality. This is one of the tough parts of this job, having to tell people they will never be as healthy as they were x number of weeks, months, or years ago. Everyone expects to be "fixed" by modern medicine but in a lot of cases that can't be done.

On a much lighter note, tonight is my mens group meeting then practice for the worship band that I am in. I always enjoy both a lot and they help relieve a lot of stress that builds up. Music is something I have always loved, just never got a chance to become a musician due to lack of talent and lack of opportunity to participate. I'm trying to make up for the missed opportunities now but the lack of talent is still a problem. I still enjoy doing what I can do however. Maybe more after or I just may upload this update and go to bed early.

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Wednesday November 10, 1999

Today started out with a meeting at 7:30 but we actually made some decisions which is unusual. It started out with just talking but eventually it got headed in the right direction, namely sticking to an agenda and making decisions where they needed to be made then dismissing until next month. If all meetings just would follow this formula then we would not feel like we had too many meetings by the time next year's retreat rolls around.

I think I am finished with my application for hospital staff privileges. I got my picture taken today since we couldn't find any suitable pictures among the hundreds (ok thousands) at home. Seriously, my wife loves to take pictures so we have LOTS at home. Anyway, I look like a convict in this picture but that is the fault of the camera angle not my face (stop laughing Dan who has never seen be by the way). Now I will go over all the documentation to be sure I haven't left something out then turn it in tomorrow. After that it will take about two months then I will be back admitting to the hospital again and having to take call. It has been a very nice sabbatical.

This morning's highlight was the patient who was convinced she needed a sulfa antibiotic to get over her cold. She had had symptoms three days and knew she needed an antibiotic because it had always taken one in the past to get her well. I spent a long time explaining that she had a viral illness, how antibiotics had no effect on viruses, and potentially antibiotics can kill good bacteria in the body and lead to resistance to different antibiotics. By her body language I could tell she did not think I was doing the right thing by not prescribing an antibiotic for her. I held my ground however and also talked to her about quitting smoking. This really frosted the physician-patient relationship with her so I am sure she will be back to see someone else in the next two days trying to get her antibiotic to get over her cold. Oh well, you can't win them all.

I appreciate the increased mail I have gotten since I posted the fix to the HTML for this page (thanks again to Dan Bowman for that tip). More people have been able to read it and have responded favorably. I didn't realize how many people have their browsers set to frames only and could not read the page until we fixed the /table problem. I have had a couple of requests for topics to cover and will try and incorporate those into the regular updates as the days go by.

Monday I mentioned the eighteen year old girl with the back and hip pain four months after an auto accident and how I was going to see her back today to go over test results. This afternoon she did come back, this time without her mother and walking without using a wheelchair. I told her she has fibromyalgia, which it turns out her mother also suffers from, and I was going to help her with her problems sleeping and she needs to get back to work as soon as possible. Today she was very receptive to this advice so hopefully she will do better than I had at first predicted Monday. I love to be wrong in situations like this but only time will tell. I will see her in three weeks again and I will try to update you then.

Thanks for the messages about the broken link above to my home page. I have now fixed it. I am planning this weekend to put a better link to the previous week, probably under my other links at the top of this page and start a page for archives. I also need to try and see if I can use FrontPage 98 and 1stPage 2000 to maintain this site as it is about to grow. Talk to you tomorrow.

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Thursday November 11, 1999

Since this is Veterans Day let me start with some memories of my father. He died 14 months ago; thankfully rather suddenly rather than a lingering death. He served in the Marine Corps during World War II, fighting in the Pacific. He was never one to talk much about what happened (sound familiar Delanae?). He had a yearbook of sorts published by the Corps about his regiment detailing their campaigns that my brother and I used to look at on a fairly regular basis. It was hard, however, to get him to talk about any of his experiences. He was an artillery observer which is about all we ever got out of him. After seeing Saving Private Ryan I began to understand that he wanted to simply forget all the things he had seen and experienced. This was his way of dealing with the pain and stress. After seeing that movie I think I have a better understanding of the horrors of war and what his generation sacrificed to make the world what it is now. Every generation has veterans however and we who have not served owe them our eternal gratitude. I know I said a special prayer in his memory this morning and a prayer of thanks for all veterans of the past and the future.

As a country I believe we tried to take care of our veterans the right way but unfortunately that begat the Veterans Administration medical system. Having worked in two VA hospitals and referred patients to several more, I feel I am qualified to talk about this system. The people of this country wanted to give their veterans the best medical care at no cost but you can't trust the government to accomplish something with which they have no experience. The result is a huge bureaucracy which tends to exclude the people it should help or at best make access to the care they deserve very difficult for the patient and/or referring physician. I could tell horror stories about countless telephone calls to VA hospitals trying to get a veteran admitted but being turned down for bureaucratic reasons such as we can admit him or her if he/she can drive themselves but if they need ambulance transport we won't pay for that. If they could drive themselves they probably don't need admitting, don't you think. I could tell stories of patients being admitted for testing then having to wait several days for those tests, meanwhile tying up beds needed for much sicker patients in private hospitals. You might ask why weren't the patients in need of tests but not really sick admitted to wait for tests? Because that is the VA way. Please note I did not say there was substandard medical care; I personally know many excellent physicians in the VA system especially those affiliated with medical schools. The medical and nursing staffs working in the system have to function by rules and regulations not developed by them which leads to the problems I have mentioned.

So how do we fix this problem? I wish I had a good answer, I don't. How do you dismantle a huge bureaucracy? I don't know that this country has ever accomplished that. I do know that it will be a long and painful process but the system can and does need to be reformed. Enough personal ranting for now, stay tuned and I will take on the HMO's at another time.

One other thing about the VA system (I just thought I could stop) is that the patients feel disconnected; they don't feel they have one doctor who they can get to know. This building relationships is one of the main reasons why I like what I do. This morning, for instance, I saw a lady because of menopausal symptoms which I could treat fairly easily but, because I had built a relationship with her, we also discussed her husband, the grandson who they are raising because his mother (their daughter) is a heroin addict, and their church. I know I felt better after the visit, not because I could cure their daughter's problem, but because she had enough trust in me to risk talking about some things that were bothering her. If you are directed from physician to physician (or provider to provider as we are now known) you don't build up a trust for any one. One of the major keys in helping someone get well is the trust they have in you to help them get well or solve their problem.

Life has a way of getting you back. This afternoon was the drug seeking patient. Lots of times you can see them coming a mile away, other times they are not so transparent. The one this afternoon fit into the former category. His shoulder, knee and (pick your joint) hurt terribly, so bad he could not even ride in a car. It was the worst pain ever. He had had numerous surgeries on the affected joint(s) and this was the worst pain ever. Only one of two narcotic pain meds would work and he told you in no uncertain terms that anything else was a waste of time. Although knowing the answer already, you call the pharmacy he listed as his primary; they laugh and ask what name is he using this time and tell you some of the long list of physicians he has seen before you. Armed with this ammunition you go back to face him. He tells you that he really is hurting and it is the worst ever. You kindly but forcefully tell him we will not prescribe any narcotics for him; he stands his ground saying he needs something; you write him a prescription for Ibuprofen. He says this is a waste of time; you more forcefully tell him that he will get no narcotic prescription from this office and the exit is that way. He begs the nurse on the way out for a narcotic prescription; then stops at the next medical office down the hall and tries to be seen to get pain medication. The nurse there asks us what happened, we explain, and they refuse. He threatens to go to the emergency department of the hospital our building is connected to so we alert them that a drug seeker may be headed their way. They laugh and ask what name he is using this time also and promise to let the social worker there, who has been trying to work out some management plan for him, know about this. Of course, we had already called the social worker, got his voice mail as usual, and left a message that whatever he has been trying to work out for this man isn't working.

The day ended well however. The lady I told you about Monday who had been riding her scooter and was struck by the minivan as it turned out, was back today because the driver's insurance company wanted her seen again to be sure she was ok. She is, just sore which she understands. She is more concerned about the damage to her scooter which is her only means of transportation. She brought the police report of the accident and we laughed about the fact that it listed a drivers license number for her and she hasn't had one in at least 20 years, it had her address wrong, and the driver who hit her had a handicapped license plate. She wonders if it was for impaired vision. A good laugh is the perfect end for this day at the office.


Home on time, for me. Post the first part of this update, help Delanae deal with a minor problem with Stacey (daughter) then go for a run in the rain. Good run since the temperature is near 60 and therefore the rain was not cold then on the way home I hear this woman's voice doing a radio commercial for a local internet business. Near the end of the commercial I realize the voice I like is my wife's; it is her first commercial in more than two years and most of her midwest accent is gone. I tell her I love the new voice when I get home; of course she says the commercial is one of her worst ever but I know the company she is doing it for is going to love it enough to cut some nationwide commercials as they have talked about doing before.(Sorry about the long sentence I couldn't get it to stop) Now to eat dinner then watch ER which is the only primetime show I watch. I watch it to heckle the show's mistakes; I catch myself yelling at the doctor actors "you can't do that" or "no real ER doctor would do that". Sometimes worse! My wife hates it when I heckle the show but I can't help it. See you tomorrow.

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Friday November 12, 1999

This update is later than usual. Locusts or something ate up the time I normally have during the day to write some thoughts so I am doing this at home after my day has ended. Therefore this update will tend to be a little shorter probably. Weather report today is rainy and mild but more winter like weather expected next week.

The day began with a meeting of the Managed Care Committee for our group. We reviewed referrals for medical necessity, most of these are for retro referrals ie requests after the visit to the specialist. We end up approving most of them since they were medically appropriate. These decisions are made by physicians only today there were four of us around the table. It is not our most favorite thing to do but important if our group is going to enter into contracts with insurance companies where we have financial risk. We decided we would have to start meeting every week rather that twice a month like we do now.

Today's highlight as far as patients are concerned was probably the man I saw for hemorrhoids. His hemorrhoids were not the interesting part however (no kidding). It turns out he came in with a back brace on and being naturally curious I asked how he had sustained his fractured vertebra. One week ago he was passing someone on I-5 when he hit a dead deer lying in the fast lane of the interstate. This caused his small pickup to flip over 4-5 times then slide on its roof about 400 yards in the median of the interstate. He said he just hung onto the seat as this was happening then crawled out once it came to a stop. Of course, when the paramedics got to his vehicle, which was flattened, they expected to find a fatality in it, but there he was walking around saying nothing hurt very much. On x-rays he had a fairly small compression fracture of one of his lumbar vertebra that will heal on its own and he will have no neurological damage. This accident happened at 4:30 AM so there wasn't a lot of traffic on the interstate and he did not hit another vehicle was rolling over and over. Someone was watching over him.

One other interesting thing so far today, my wife and I went to look at a house today at noon. This house turned out to be the house we had not gotten to build before. Let me explain. About four years ago we had decided to buy a lot and build a house on it in the town where we used to live. We picked out the plans, modified them to what we both wanted, had a contractor lined up, then decided instead to buy a house already built. We never got to see the house we had planned until today. The house we saw today was it with a few modifications. My wife felt like she had been in it before then realized why, she had walked through it in her mind many times before. Even if we don't end up purchasing it was interesting to see what our house would have looked like.

Enough for tonight. This weekend have to do some construction work on this site. I am doing this update with 1stPage 2000 tonight, I like it so far. Until tomorrow.......

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Saturday November 13, 1999

Today has been a great Saturday already. Final score: Hogs 28 Vols 24. To translate for those of you who have no idea what I am talking about, my Arkansas Razorbacks 28 Tennessee Volunteers 24. Yes, I am a rabid Arkansas Razorbacks fan having grown up in Arkansas and lived there most of my life until two years ago. My Washington license plate, for instance, is RZRBAKS. Some of you may remember last year when both teams were undefeated and my Razorbacks lost in the last minute in Knoxville, TN. This year Tennessee was ranked number three in the nation but had to play in Fayetteville, AR this year. Arkansas is rebuilding some this year but has now demonstrated they are the team I knew they were with this win. GO HOGS!

I will try to calm down now. I wanted to mention the web page of my friend and accountant Kerry Kerstetter. He publishes a newsletter called The Kerstetter Letter which has a definitely libertarian and politically incorrect view of economics and politics. Kerry was the owner of a large CPA firm in the San Francisco Bay Area when he decided to move to the top of a mountain in Arkansas near where we used to live. He continues to do tax preparation for a large number of people around the country including me. His advice has literally saved me thousands of dollars in the last several years. Check out his site here and you will find a link to the Kerstetter Letter where you can check it out for yourself. Highly recommended 'cause it will make you think and plant some seeds of doubt that you are getting the whole truth from the Clinton Gang.

Yes, I know that Bill and Hillary are from Arkansas, I have tried to live that down for the last almost eight years. I joke that they were elected President to get them out of Arkansas. All the things he has done were commonplace when he was governor of that state. It was common knowledge to everyone that he was a womanizer and he used his security guards to arrange his trysts with other women. We also knew that he would lean whichever way the political winds were blowing. He is incredibly smart but never had the courage to stand for what he really believed in, always wanted to take the easy way out. He has continued to do that as President and I fear the damage done to our country by his presidency.

I am trying some new color combinations here over the next couple of days, let me know how you like them. Change is coming slow here but is coming. I still have to add an archives page this weekend and start a links page and redo my index page and ........ It is raining again outside today so I may have time to do that this afternoon. I think we are going to a local high school production of Grease tonight. My son, the football player, wants to go because he knows some girls in it. I also need to clean out the gutters and was planning to do it today when the forecast was for dry weather but looks like the weather forecasters were off a little again.


We went back out to the house we looked at yesterday to walk the property. We took our dogs and kids this time (we have a purebred Australian Shepherd and an Australian Shepherd/Border Collie mix). The dogs and our son had a great time walking the property but my daughter got tired and had wet feet so she didn't have as much fun. The views there are awesome. We may go back out there on a clear night and try to see the Northern Lights which are visible this far south through the middle of March. You have to get up away from the city lights which this property is. Should be an awesome sight, we've never seen them before. The only reason they are visible this far south this year is the intense solar winds this year.

I have now had the time to play with 1stPage 2000 some today and generally like it. One thing I do not like is that when saves a file it puts a ~1st- prefix on the file name so for instance I had two index.html files listed after I modified my index.html file. I can't find a way to turn off this behavior and it will get very confusing if I forget to delete the original file and rename the ~1st-*.* back to the original name. I will keep looking for ways to modify this behavior. I did get my archives page built and my index page modified today, now I just need to build a links page. Tomorrow I still need to clean out the gutters if it doesn't rain. I will get that pleasant chore after church. Have a great night.

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Sunday November 14, 1999

I realized while I was taking a shower this morning what 1stPage 2000 is doing when renaming files (I thought). It is making a mirror image of the unmodified file so if I want to undo the changes to the original file it can restore the original file. This is what Word does and I understood that but sometimes we think too much and it gets us in trouble. I still like 1stPage 2000 but have not tried to modify this page directly on the web. I still modify it locally then FTP it to my server Softcom. I'll leave that experience for another weekend.

Great worship service this morning, no major problems with sound even though we reran all the inputs just before the service started. This warms a sound man's heart when he can reroute everything then it works and he actually gets compliments on how good everything sounded. Musicians, remember to tell your sound man (or woman) that you love them the next time you see them; they are the one who makes you sound good. More later, must go rake leaves and clean out the gutters.


Gutters are cleaned out and leaves are raked. No rain today but fog this morning and late this afternoon. I had an e-mail from a friend in Harrison, AR today and he says they are in the midst of a drought and had temperatures in the low 80's yesterday which is highly unusual for November in northwest Arkansas. Yesterday, Portland set a record for November, recording their first day ever in the 70's during that month. Temperature will be back to normal levels tomorrow.

Tonight I still have to get my page ready for tomorrow since that is the start of another week. I also have to do my twice weekly online banking. I use Quicken for this and I can send my Quicken files to my accountant whom I introduced to you yesterday. He can then use those files to do our tax return more quickly and cheaper than having to enter the data by hand. I also have to enter some of my wife's business receipts tonight into Quicken. Then maybe I can catch a little of the Sunday Night football game on ESPN before getting ready for tomorrow. Until tomorrow then........

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