We will still have our special meeting of the Leadership Council Wednesday but now the topic for discussion will be recruitment of new physicians for the group. Do we need more physicians and if so what specialties? My personal opinion is that we have enough primary care physicians but need some other specialties like otolaryngology (ear, nose, and throat) and dermatology. Both of those specialties are lacking in our area, there is one of each and the dermatologist is very difficult to work with and doesn't send back good notes at all. Our patients who need to see an otolaryngologist will have to wait longer if we don't get another one here or go to the Portland area. We are trying to prevent some of the outmigration of patients from here to the Portland metropolitan area by providing the physicians they want to see here. Our primary care patient base is now well covered by the current primary care physicians here so until we have a broader patient base or lose one or two more physicians, I think we need to stay the size we are, build up our practices some more, and get our group on more solid financial ground.

I heard today that one of my patients died this weekend. She was in her middle seventies and had a history of heart disease but continued to smoke. She had been bothered by recurrent chest pain for a couple of months and I had sent her to a cardiologist who, after doing some tests, felt her chest pain was not coming from her heart. I was therefore trying to find the cause, be it gastrointestinal or lung. She was scheduled for a CT scan of her lungs this week because of a possible mass on her chest x-ray and if that was OK then I was going to get a gastroenterologist to see her. She was seen in our urgent care clinic Saturday with chest pain again then supposedly died Sunday. I don't yet know if it happened at home or at the hospital. I hope I find out what happened.

The lady with the out of control diabetes and the abscess on her leg is getting better. I understand she is out of the intensive care unit and is fully awake and talking to people. She still faces a long road ahead. Hopefully her primary physician can help her change her lifestyle so she will be more healthy.

It seemed, today, that all my chronic pain patients were calling and had run out of pain medications early. My medical assistant, Kathy, and I were keeping a list of who had called and betting if so and so was going to be next. By the end of the day most of the people we had put on the list had either called or stopped by the office needing more medication. Two I had seen late last week and we had carefully discussed exactly how much pain medication they would need until their next visit and, with their agreement, had written prescriptions for that number. Today they called, out of their medication. Since they both had been written enough to last more than the three days that had elapsed, I refused to refill their medication early. The others wanted me to call in refills when they run out instead of seeing them, I refused since that is against my policy which I had explained to them in great detail before and they had signed statements saying they understood this policy. I expect more of the same tomorrow, for some reason this looks like a full moon week even though there is no full moon at the present time.

My day at the office ended on a frustrating note also. I had called our new cardiologist about a patient who I felt needed a stress test to rule out heart disease. He had agreed and his office was going to schedule it. Today her insurance company informed us that I would have to find her another cardiologist to do the test since our new cardiologist had not been officially added to their panel of physicians yet. There were no problems with his credentials, just the official vote of their board had not been taken yet. So now I have to talk to another cardiologist to get the same test that the first one was going to do. Delays like this are supposed to be good for the patients according to the insurance companies.

I decided it was my turn to cook dinner tonight, so, after stopping for some garlic bread and a few other things on the way home, I cooked spaghetti again. When I got home, the local Portland station had live coverage on about the Alaska Airlines crash off the coast of California. Alaska Airlines is based in Seattle and has a lot of flights into and out of Portland also, so this is very big news here in the Northwest. My prayers are with the family and friends of the victims. I'm sure the media will put pressure on the airline and the NTSB for answers into what caused the crash in the next few days. They will also speculate endlessly on possible causes and find any number of "experts" who are willing to give their theories on what happened. The news here will keep the crash in their headlines for several days you can be sure.

I called the husband of the woman who died over the weekend today to offer my condolences and to try and find out what happened. He said she began having chest pain again then told him he needed to call an ambulance and proceeded to stop breathing. The paramedics and the ED staff were unable to resuscitate her so she was pronounced dead at the Emergency Department. Today, I had to sign a death certificate certifying what caused her death. Without an autopsy, which was not requested by her husband, I am simply guessing what happened. I cannot just say that she went into cardiopulmonary arrest and died from that, the government demands a cause which many times is impossible to say for sure. For instance, one cannot put the cause of death as old age or the patient's heart just stopped, there must be some diagnosis to cause the heart to stop. In this case, I put cardiac dysrhythmia (irregular heart rhythm) caused by coronary artery disease as the cause of death but we will never know for sure.

I will cut this short now so I can go to bed and get some rest. Hopefully I can write more tomorrow afternoon since I will probably be home and will have the extra time.

I began this morning by attending the special meeting of the Leadership Council. We talked about recruiting and everyone accepted my recommendation that we not recruit any more primary care physicians at this time. Everyone agreed that we need to let the demand catch up with the supply then begin recruiting again. There will be some minor restructuring of the teams to make job sharing easier but no major restructuring will be needed.

We then had a confidential discussion about some present physicians who may be asked to leave our group or offered an easy exit if they so desire. We have two or three physicians who just are not team players, they refuse to come to meetings most of the time and when they do they do not participate. We have one whom none of the other physicians wants to work with because that person is too critical of everything that the other physician does. That does not leave anyone to cover for this person if no one wants to work with them. This person has also tried to get out of taking call which was a condition of their being hired. All of these physicians are good physicians, they just need to be in solo practice so they can run their own office the way they want to and not have to be subject to any requirements other than the ones for hospital staff membership and medical licensure. They will be offered an easy exit if they choose to not change their habits; if they really want to change their attitudes and habits then we will help them as much as we can. Personally, I like them all with the exception of the one who has had problems getting along with everyone including me. I hope they can change and stay in the group and if not that they find a practice more suited to their tastes.

After this meeting, I went and checked on my patient in the hospital. She is 91 years old and having abdominal pain and vomiting. This may be from a urinary tract infection and also some diverticulitis which is an infection in the colon or large intestine. She has a history of colon infections and about ten years ago had to have a portion of her colon removed due to a blockage caused by scar tissue from past infections. I am getting a surgeon to check her too but I don't think she will need surgery this time. More than likely, a couple of days of IV fluids, bowel rest, and antibiotic and she will be much better and wanting to go home. With my hoarseness and reduction in volume of my voice, I had to get right next to her ear in order for her to hear me.

Now it is time to begin getting ready to go to church tonight. I've enjoyed having a day "off" again; I have gotten a lot of errands run that I don't ordinarily get done. I also ordered a new NiMH battery for Delanae's cell phone, the old battery is a victim of the "memory effect" and will not hold a charge for very long (it was not a NiMH). She was given this one by the radio station so was not responsible for it not holding a charge. It should be in in about seven days and if it is significantly smaller than the one she had before as it is supposed to be, I may order me one for my phone. See you tomorrow......

My hospitalized patient continues to improve. She has been able to drink today without problems and is starting to get up and get around some now. If she can eat some tomorrow and walk around the halls I will probably let her go home tomorrow afternoon. She is missing her cat and her home now which means she really is improving. It looks like her main problem was her bladder infection, in patients who are her age (>90) an infection like this can cause a temporary slowing of her intestinal function, called an ileus which can cause vomiting and abdominal pain. Her white blood cell count is going down which is a good sign that the infection is responding to her antibiotic treatment. I have now changed her to an oral antibiotic since she has improved so much.

My first patient in the office this morning turned out to be a sixteen year old girl who came in for her first PAP smear and to discuss contraception. She was with her mother who she asked to leave the room so we could discuss whether or not she was sexually active. You can guess the answer so I talked to her about the benefits of abstinence as the preferred way to prevent sexually transmitted diseases and pregnancy. Since that did not go over well with her, I also discussed using condoms with other contraceptive methods to prevent sexually transmitted diseases. She and her mother finally settled on DepoProvera which involves a shot every three months since she was afraid she would forget to take a pill every day. The first pelvic and PAP smear went well from my standpoint with no tears being shed by the patient. I always show and tell women what I am going to do and with what before I do it. I also warm the speculum first.

The rest of the day was fairly routine. Influenza and complications from it are still here. I am seeing patients who are having relapses after thinking they were well, me included. This has been a bad winter so far for viral infections. The hospital, particularly pediatrics, is pretty full and some of the patients are really sick. Tomorrow morning, I will be rounding for one of my associates on a patient who is a non-smoker and developed a lung abscess that had to be drained surgically. She was otherwise healthy before this infection. Most people who develop abscesses like this have some chronic illness or are smokers. Like I said, this has been a bad winter for viral infections and their complications.

Finally, here is an e-mail that has really helped Delanae and I a lot, followed by my commentary.

Thought this might be of interest:

"New Scientist" magazine of January 22 2000 had an article entitled "Rebels with a cause", and starting: '

"Stop sulking Kevin."
"But it's not fair."
........

"Stop treating me like a kid."
"Only if you stop acting like one."

Does this conversation sound familiar? '

It then goes on to show that in fact (probably) teenagers' brains haven't stopped maturing, and don't until their early twenties. "The frontal and parietal lobes, responsible for such things as planning and self-control, continue maturing through the teenage years."

Unfortunately, it's not part of the one third of their content that made it to their web-site. However, you could follow up through http://www.newscientist.com/ and get a reprint, or get someone to get a copy from a library. I'll even mail you a photocopy, if you like. It is suprising how much of each week's news starts in "New Scientist". It's the one magazine I would subscribe to, now that dead-tree "Byte" is no more.

In this particular case, it's comforting to know that there is (probably) a real physical reason for the behaviour of adolescent boys - at least one of mine, and maybe yours. Of course, you can't let it be an excuse - they've got to come to terms with the way they are, and learn to act in a mature manner - i.e. thinking of consequences. The one of mine I'm thinking of was a very slow developer - not stupid, but physically and in terms of outlook and attitude about three or four years slow, although the end result turned out to be something to be proud of (he's 23 now, and his mental outlook and maturity worried me until last year). I agree with your and Delanae's attitude: you can't let a young man with fast reflexes, a testoserone overdose (that's a physical fact of being a young man, not a criticism), and no ability to think of consequences drive a motor vehicle without supervision. Those are the ones who kill people - possibly including their passengers and themselves.

However, it occurs to me that it might even be useful to be able to say "See - in writing - read and understand - people mature at different rates for different facets - physical, emotional, sexual, ability to reason, attitude and forethought which lets them apply that reasoning". If you could get him to recognise that, he might also accept that he could be physically skilled enough to drive, but his judgement not trustworthy enough to drive unsupervised - in other words, you get a chauffeur.

As a doctor, you might even be able to tap some resources to show a young man why driving while only reacting, not thinking, is not a good idea. Dan Bowman might be able to give you some advice on this one as well. There are certainly legally mandated courses for dangerous (particularly drunk) drivers - I am not thinking of the whole schmeer, but some of the content as a little prevention might be preferable to the alternative.

Best wishes,
Don Armstrong

Thanks Don for reminding me of something I had read and learned about in the past but in the "heat of battle" had forgotten or had not thought about like I should. It helps for someone not directly involved to take an objective view of a conflict. I realize that we should not expect Stephen to be perfect because he is not mature enough yet to do all we ask, but we do have high expectations for him and want to trust him. We will try to get a copy of this article to help remind him and us that he still has some physical maturing to do.

In the meantime, he is still grounded for an undetermined time which will probably be about a month. He did bring home his report card today and he has improved all his grades; I still think they could be higher but his personality is to just get by and not overachieve like his sister who brought home straight A's. Hopefully, he will wake up one day and realize that the grades he is making today may have some effect on his future plans. I sound like he is failing, he is not, his GPA is 3.2 on a 4 point scale. I know he can do better though if he will just apply himself more. He obviously has some more maturing to do or stop being so much like his mother <grin>.