Doc's Progress Notes
Week of November 8, 1999
Last Updated: 11/14/1999 at 6:39 PM
Most Recent Update
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
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
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
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
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
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
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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