Doc's Progress Notes
Week of November 22, 1999
Last Updated: 11/28/1999 at 6:10 PM PST
Monday
Tuesday Wednesday
Thursday Friday
Saturday Sunday
Most Recent Update
Monday November 22, 1999
Long day today beginning about 4:30 this morning when I had to get up to get ready to leave for Eugene by 6 AM. Three hour drive down in the rain, then sat for four and one-half hours in meetings. The meetings were good and we learned some things to do and not to do when dealing with managed care and contracting especially. They don't teach these business principles in medical school so we have to learn them the hard way, by experience which is not always easy. Then, three hours back but I had a good conversation with the other physician who went which made the trip shorter. He has been in the group for 13 years and I learned a lot about the group's history from him.
Got a chance to run after we got back then off to church for worship team practice. Great time as usual and I got to try playing various percussion instruments including congas which was a lot of fun. I can't give up my main position as sound guy yet though until I find someone to take my place running sound.
My son's football awards banquet was afterward so we just got home. I do want to share one letter with you then I must get to bed. Sorry for the short update today, maybe more tomorrow.
-----Original Message-----
From: Dan Seto[mailto:mail@seto.org]
Sent: Monday, November 22, 1999 3:11 PM
To:jim@docjim.com
Subject: Diary Notes
Just thought I'd send you my two cents regarding your daynotes site. I've been reading it off and on for a couple of weeks and find it very interesting. Especially since it differs so much from the other more computer centered sites. There are some very deep dilemmas that are germane specifically to medicine and, as they come up, I'm sure you will continue to mention them.
You mentioned the problem of what to do with patients, such as schizophrenics, who if they take their medications (meds), can live productive lives. But what to do when they don't? Good question. If they are not functioning well they can temporarily be kept in an acute setting. But as soon as they are on medication, they no longer can/need to be there so you release them. Upon which they stop taking their meds again. And round and round we go. I don't think long-term hospitalization is the answer (and if it was, we probably could not afford it), but are there any half-way houses that can deal with this kind of client? We, as a society, need to find an answer to this. But what it is I don't know for sure either.
Aloha,
Dan Seto
I don't know what the answer is either, I just wanted to bring it out for discussion. Yes, there are halfway houses but this man was not in one; how do you make him live in one if he has the right to refuse it. Again, I don't have an answer, just questions. I agree we as a society have some very tough decisions to make, which we have avoided making in the past. We have a real vacuum in leadership in our government which is a big reason why we can't come up with answers. I don't want the government to answer the questions for us, just help stimulate us to come up with answers as a society. Hopefully, bringing this out will force some discussion and will help us come up with those concrete answers.
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Tuesday November 23, 1999
I am alive and well today, it's just this day was devoured by some kind of flesh eating bugs. However, I am going to get an update posted, no matter how short, before midnight PST so I can say that I posted something today. It is now 11:20 PM so the race is on.
Today was catch up day because I was out of the office yesterday. Today I had refills to do that weren't done yesterday, phone calls to return, lab to check on, and x-ray reports to report to people. These are the detail tasks that will eat up a day before you know it. At noon today was our monthly team meeting then after work Delanae and I met a contractor at the house we are looking at to discuss what it would take to finish it. After that was my mens group at church then worship team practice then home to recap my day with Delanae before I recap it with you. Now you can see why this update is so late and will be short tonight. I will make up for it later in the week I am sure.
One thing I would like to discuss tonight is web statistics. I have been offered free statistics by HitBox.com if I will put their box on my pages. This box is a portal to their website where there is advertising and I have found out it is hard to get back out without typing a new URL into your browser. Using the back button on your browser doesn't always work. They do give you good statistics for the right price (free) though. I would put an explanation above the box if I use it so readers would know what happens if they click on it. I may try it and see how my readers feel about it. In the near future I will be adding some sort of search function also, although there is not enough material yet to really need a search engine. I am trying to not put a lot of graphics on this journal page to keep the loading time down as much as possible. Opinions from you, the reader, are always welcome.
There, I made it. Now I officially have an update for today. Talk to you tomorrow.
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Wednesday November 24, 1999
I'm back, at an earlier hour than last night. I have gone back and read what I wrote last night and it wasn't written very well. I really was tired last night. Today was busy but a little less hectic. Somehow, though, I did not have time to write any of this update during the day. I was very busy doing paperwork between patients. We had an inordinately large number of refill requests today probably because people are leaving for a four day weekend or more and want enough medication to take while they are out of town.
Speaking of medication, check out Brian Bilbrey's site here where Dan Seto admits he is on medication. (big grin) To set the record straight, I have not prescribed any medication for him but since he lives in Hawaii offered to come meet him so if he needs medication I could prescribe it for him. See, I don't prescribe medication for anyone I have not met in person.
It never fails that the day before a holiday or before a vacation is about to begin, you get a patient with a problem that you would really like to follow up on the next day. Today was no exception. I had a 48 year old man come in with the sudden onset of upper abdominal pain in the early morning hours today. After determining it was not his heart, I checked some lab and got an ultrasound of his gallbladder which was negative for stones. So now I'm thinking the problem is probably his stomach so I will put him on some antiulcer medication and some pain medication and see him back tomorrow to be sure he is better. Oops, tomorrow is a holiday so I will have him back Friday but tell him to come in to he hospital emergency department if he gets worse before then. I will be interested to see how he is doing Friday.
Delanae and I are meeting with the couple who own the house we would like to have tomorrow morning to discuss our options since they are leaving for Ohio on Saturday. We are not trying to go around the realtor but need to deal with them without a middle person. The couple also want to meet with us without the realtor in the middle. In order for us to be able to purchase this house, we need time for our other house to sell (the one back in Arkansas). It will be interesting trying to work out this deal both tomorrow and by long distance after that. I will keep you updated on the process.
Sjon Svenson and Bob Thompson both have sent me messages about a search engine for this site and ideas about how to get statistics for this site. I appreciate their ideas very much and will probably use the atomz search engine that Bob mentioned. I have seen it before and actually checked out their web site and learned about them but forgot to mention it last night. Sjon has given me a way to open another browser window when someone clicks on the Hitbox icon so they can get back here by simply closing that window. I will play with that then publish the method for doing it once I have it right. Thanks again Bob and Sjon for your ideas and taking the time to send them to me.
Tomorrow is Thanksgiving of course and a time to say thank you for all we have. Our minister talked tonight about how hard it is for us humans to say thank you for all our blessings. We find it much easier to criticize our circumstances and think how much better off we could be. I know this is true because it is our nature to be negative about things, it takes more effort to force ourselves to think positive. It is my hope and prayer that each of us can take time tomorrow to say thank you for all we have been blessed with and also to think for a moment what we can do to help our fellow man.
One more thing before I close, all of you who are home Friday and live in an area where CBS is carrying the Arkansas-LSU game please cheer on the Hogs for me. A rousing hog call would help a lot. Also, the basketball Hogs are playing in a tournament in Hawai'i this coming weekend so I need to e-mail Dan Seto to get him to root for them also.
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Thursday November 25, 1999
We are all stuffed here now after a great Thanksgiving meal. True to tradition, ours was about 3:30 this afternoon. It has turned out to be impossible for us to eat before about 3 PM on Thanksgiving for some reason. Last year I think it was closer to 6 PM which is the latest but that was because we were supposed to have a smoked turkey, opened it up and it was not smoked. Then, we had to go and find one at the store on Thanksgiving morning. This year was much smoother.
We had all our traditional food here in the Crider household for Thanksgiving. Delanae always fixes herself sweet potatoes which only she eats, mashed potatoes, stuffing, green bean casserole, corn, turkey (of course), rolls, and this year asparagus. It was all great. As usual, Stephen ate very quickly and wondered why no one else was finished yet, Stacey ate about three bites and proceeded to say she was full, and Delanae and I stuffed ourselves. She then retired to take a nap and I to watch football until we have enough room for dessert which is always French Silk pie and for the first time this year key lime pie. I am doing this update while waiting for everything to settle enough to eat some dessert.
Back to the turkey story; last year we ordered a smoked turkey from a local meat market then picked it up the day before Thanksgiving and put it in the refrigerator. We got it out late Thanksgiving morning expecting to put it into the oven for a couple of hours to heat it up for serving early in the afternoon. That was when we found out it was a raw turkey instead. We had to call around and located a sliced turkey which I went out and got so we did have turkey for Thanksgiving. Well, this year we called one of the grocery stores we use to see if they had smoked turkeys last weekend. They weren't sure if they were going to have any so we went ahead and bought a frozen turkey. Tuesday the store called to say they did have a couple of smoked turkeys we could have so we bought them and will freeze one to use at Christmas. The raw turkey we had we were able to give to a family who otherwise would not have had turkey for Thanksgiving
This morning we did meet with the owners of the house we are looking at. It was a good meeting but there are a lot of details to still be worked out if we are to get that house. They are willing to consider leasing it to us for a period of months but have to see how much they would have to have to do that. Meanwhile, we need to get this house sold so we will be in a position to do the lease if(or when) everything falls into place. We are praying it will work out for us to have the house and the owners are too. They are leaving Saturday for Cincinnati driving a U-Haul and towing a car. They aren't looking forward to driving there this time of the year not knowing what the weather may be like across the Rocky Mountains. I've made that drive once before like that but it was in the summer and still was no fun at all. We will now get to deal with them by telephone and E-mail.
I will end on that note since Stephen and I need to get the dishes done and the dogs their Thanksgiving turkey leftovers. This is a great day to be a dog in this house since none of us eat the dark meat from the turkey. The dogs end up getting most of it along with a few bones and other parts we don't eat. Then I must have dessert and get ready to go to work tomorrow.
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Friday November 26, 1999
The day after a holiday is always busy and today was no exception. We get calls from people who are sick and who think they are sick. We see people who truly are sick and those who think they are. People seem to be more emotional after a holiday, their illness, injury, or whatever the problem seems to affect them more. I presume that is a natural reaction by people since emotions seem to run higher around the traditional holidays this time of the year. Add to that it is winter and people get less sunlight and you have more depression and anxiety which magnify their illnesses.
The man with the abdominal pain was back today (see Wednesday's update here). He is a little better but not well yet. I'm continuing his present treatment and if he is not a lot better by Monday will probably get one of the gastroenterologists (stomach specialists) to look at him and maybe look in his stomach with an endoscope. For you nonphysicians out there (you know who you are) an endoscope is a flexible instrument with a fiberoptic light source and tiny video camera that is swallowed and allows the operator to view the esophagus and stomach as it passes into these organs. With this instrument, you can see the actual wall of the organs and look for ulcers, tumors, and other abnormalities. No longer do you have to do exploratory surgery most of the time to find out what is wrong.
Today also brought the discharge from the nursing home of the patient of one of my partners. This partner had left word that she could be discharged but had failed to order the discharge or make it clear what medications she needed to continue on at home. Being "the doctor" in the office I am supposed to automatically know what he was thinking even if he did not leave notes about it. I ended up doing the best I could and will once again remind him to leave me some idea about patients like this so I don't have to muddle through on patients I don't know. You might ask if this is dangerous for the patient. It could be but in cases like this, covering physicians tend to be very conservative and continue them on all their medications, even some they probably don't need at home and have them see their regular physician in a few days who can then make changes in their medication regimen.
I also had a patient who I saw today who had had diarrhea for a month. When you've had it that long there are certain tests that need to be done to find the cause so you know what treatment to prescribe. She had the tests in progress or scheduled and they were appropriate. Predictably, she came in today because she just knew we could give her something that would magically stop her diarrhea today. Even though she had been on multiple medications to help stop the diarrhea and they had not worked, she knew she just had to find the right doctor (me) who had the magic pill. I tried to bring her down gently by explaining we had to find the cause before we could stop it and did not want to expose her to medication side effects if there was no reason to be on that medication. I know that the possible diagnoses left will have to be treated with medication that can cause significant side effects. I'm not sure she was satisfied with this explanation for why she was not getting any other medication today but I spent a long time with her explaining.
All in all it was a good day because I did meet some really nice people during the day and got to teach some people about their disease. I enjoy teaching but don't get to do enough of it. I enjoy teaching about diabetes and asthma in particular and got to teach two new patients about asthma today. The treatment of both asthma and diabetes is very standardized today so it fits into an algorithm very well. That is how my mind works also so I have become very comfortable with those diseases.
I smell turkey warming so I know it is time to eat Thanksgiving dinner leftovers. Delanae and I like them a lot for a day or two afterward then we can get tired of them. Tonight they should be really good. Then, I have heard that we are going to watch "The Blair Witch Project" to see if it is suitable for our fifteen year old to watch. He thinks that just because some parents have allowed their 11 and 12 year olds to watch it that he should be allowed to also. He tried this argument on his mother so I wasn't around to point out that that age children have also committed crimes such as murder and did that make it okay for him to commit murder also. So now we are going to watch the movie without him although I don't think my opinion that he should not watch the movie will change. I am also feeling bad tonight since my Hogs lost today to LSU. Hopefully I will have overcome the disappointment tomorrow.
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Saturday November 27, 1999
Good morning everyone. I am going to try and do two updates today since it is Saturday and I do not have to go in today. Ordinarily, first thing I do in the morning is scan the sports sections from a couple of online Arkansas newspapers for Razorback news but I can't bring myself to do that today with their big loss yesterday to LSU. Probably later I will read a little about the game.
Then, I go to the Daynoters page and link to each of their sites to read their updates. I usually do this two or three times a day since not all of them update their sites at the same time each day. Imagine my surprise today when I saw that my name was listed on that page along with Dan Seto's. I had expected Dan to be asked to join the gang (or is coerced a better word?) but never expected to see my name listed there. I am humbled to be included with that august group and only hope I can live up to the pressure that comes with being included with them. Of course, this may all be an early April Fool's joke by Tom Syroid and I may get a message from him later today telling me that. Or, maybe they all want free medical advice and this is a way to bribe me into doing that. Or......... Naw, I'm just being paranoid.
My system has just slowed down to the speed of dripping molasses for some reason. The only way to fix it is to reboot. I will do that after I post this then go and run. We have to go to Ace Hardware this afternoon and buy a replacement toilet seat and I am going to do some work on this site. I will post another update later this evening.
******
Delanae and I went to Ace Hardware and did indeed get a replacement toilet seat this afternoon. I will install it either this evening after I am through here or tomorrow afternoon. While there we looked at some things for the new house we are hoping to get, mostly bathroom fixtures and closet organizers. I also picked up a shoe organizer for my closet here to try and prevent my shoes from just spilling out of the closet floor.
Delanae ended up watching "The Blair Witch Project" mostly by herself this afternoon. According to her, it has very little plot, the ending is stupid, and the only objectionable thing about the movie is the language. We therefore decided to let our fifteen year old watch it but first warned him that his little sister was not to watch it and he was not to think we would approve of him using that language.
I now have independent confirmation from several Daynoters that what I read this morning was not an April Fool's joke. They did warn me that I was not official until I completed their inquisition (or was it a questionnaire?) however. I replied that my being accepted to medical school proved that I have enough of a personality disorder to qualify. They agreed that enjoying subjecting oneself to ridicule for no pay was the main personality disorder needed to qualify for membership. Too bad Dan Seto has missed out on the repartee this weekend but he now has a backlog of messages in his inbox to deal with Monday.
I have been learning more about 1stPage 2000 this afternoon. Like Bo I have been working with Project Manager and so far really like what it does. It allows you to keep up with the various documents on your website and with the to do list shows you which ones are complete and which ones are not. You can also use it to right click on a document and open it in the editor to work on it. If you are managing multiple websites it would help you keep straight which document is on which site. When I tried to open an entire subdirectory worth of files by clicking on the subdirectory however, the program crashed. I had to go back and individually select each file to open them or add them to a project. It would be nice to be able to import an entire subdirectory into a project simply by selecting the subdirectory name.
I also tried Tidy HTML which is included with 1stPage 2000. On my first attempt however, it inserted a lot of extra code which I had to go back and remove. I must go back and recheck the configuration settings for font tags which is the code that Tidy HTML entered in abundance. It certainly made the document larger rather than smaller. For example, the following line:
<a font face="Verdana" size="3">Back to Top</a></font>
was rendered by Tidy HTML to:
<a font face="Verdana" size="3">< font face="Verdana" size="3">< font face="Verdana" size="3">Back to Top</font></font></font></a>
I obviously have some configuration settings wrong in TidyHTML so I will go back and work with it some more tonight. Talk to you tomorrow after church.
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Sunday November 28, 1999
We've had one of those rare clear days in the Pacific Northwest at least in the winter. Thanksgiving Day there were floods along the coast and some inland but we got a break today. Tomorrow the rain is supposed to be back and some heavier snow for the mountains which will make the skiers happy.
I watched football and napped this afternoon. Except for the Dallas Cowboys, this has not been a good long weekend for my football teams. First, the Razorbacks lost Friday then the Seahawks stunk up the Kingdome this afternoon. If things continue on this course, the 49ers will look really bad tomorrow night.
It doesn't look like I will get time to play with TidyHTML tonight. We are addressing Christmas cards and I have to put a new toilet seat on (remember the replacement we got yesterday?). The template I use for my current page was the one I ran TidyHTML on yesterday so the HTML should be cleaned up starting tomorrow. I will also have a new hitbox banner on the bottom of the page so I can get web statistics free. I have been unable to get the free program provided by my web hosting service to work properly. It is evidently a demo for a full featured program which costs about US$300. I will keep talking to customer support to see if they can get their program working the way it is supposed to. In the meantime, there is no need to click on the banner unless you want to go to the Hitbox website where they have lots of advertising. I did change their HTML so if the banner is clicked on, a new window opens and you can simply close that window to get back to my page. The original script was not so well behaved.
I have been reading a free magazine that comes to me called "Physicians and Computers". We call these throw away journals because they are free and are usually simply thrown away unless you are interested in the subject matter. They are paid for by advertising, of course, and the advertisers are interested in getting their product name in front of you, the busy physician. This magazine has mostly medical software advertising and usually contains reviews of software packages. This most recent edition has an article about Windows 2000 written by Norman E. Sondak who is a professor of computer science at San Diego State University. I thought this review might be of interest to you beta testers of Windows 2000 who happen to also read this journal so I went to the website for this magazine (http://www.physicians-computers.com) to copy the link to this article. There are no links to the articles on the website, just a listing of the current articles and articles in previous editions. Imagine, the website for a journal about computers has NO links except for E-mail to the editor and advertising manager. I find it hard to believe that in 1999 a magazine like this does not store their articles on a server where they would be available for review even if you had to pay a fee for the full text of that article. There are other free journals I receive that do have links to the full text of their articles on their websites.
Must go play plumber now and help address Christmas cards. See you tomorrow.
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