Today began with our monthly group meeting. We had an interesting presentation from two surgeons who are helping to develop a comprehensive breast center here locally. This center will deal with all aspects of breast disease with an emphasis on breast cancer of course. It will deal with both diagnosis and treatment and will include reconstructive surgery also. There will be a multispecialty team of specialists who will discuss all breast cancer patients to be certain each one is being treated with the most appropriate treatment for her stage of disease. A unique aspect of this center is that a large part of the planning was done in consultation with a board of thirty some local women who had been diagnosed and treated for breast cancer. Their input was especially important in planning the diagnostic aspects of the center.

After that, it was time to see patients. Today was a real mix. It varied from the patient with his ear canals obstructed by earwax to a patient with chronic back pain. People had especially interesting stories today which slowed me down because I like to really listen to those stories. I found myself too far behind several times today and did a lot of apologizing for being so late seeing someone. No one seemed to get mad however but I felt bad. New patients with chronic pain take a lot of extra time because there is so much you need to find out and so much that needs to be gone over as far as treatment including requirements if we are going to use chronic narcotic pain medication. Unfortunately, this patient was not scheduled for the usual appointment length we use in cases like this so that put me further behind.

We had another meeting at noon today to discuss yet another change in a form to meet Medicare requirements. The lab requisition form had to be changed to add a release statement saying basically although your physician has ordered such and such test to help him or her treat you the most appropriate way, we are obligated by law to tell you that it is possible that Medicare bureaucrats, in their infinite wisdom, may decide that this (or these) test(s) really aren't needed; in that case, Medicare will refuse to pay and this lab may bill you but you are not required to pay for these tests unless you sign this. Yes, Bill and Hillary's government feels they know better than the physician treating the patient what tests are appropriate to use in help diagnosing and treating. Further, they feel they know better than you, the lowly patient, what is best for you and will protect you from all those greedy physicians out there. Don't you feel more safe now, come on don't you? Sorry, I will get off this rant now. Boy, I feel better though.

Delanae brought home a Palm IIIe today. She was given it at her work today because the general manager believes she will be more productive by using it. She brought it home so we could learn to use it together (has Leah let you play with hers er yours yet Tom?). It is so cool and I have just barely played with it, excuse me evaluated it. I think I am going to really want one in the near future.

This morning I finally captured enough time to catch up on all the other Daynoters' sites. I try to read all of them daily but with my day being so busy yesterday and some sites being down parts of the day due to pair networks move I did not get them all read until today. If you haven't checked out Steve Tucker's site lately, do so. His posting about his son's disappointment yesterday brought tears to my eyes. Highly recommended but have Kleenex ready. I know, as a parent, it is hard to get over that look of disappointment in your child's eye, no matter the age. Steve manages to capture all the emotion he felt and shares it with the reader through his writing. Thanks Steve for a brilliant essay.

Today in the office has started slow. I am always hesitant to write statements like that since things can change in an instant so we will see as the day unfolds. Slow days are common during December before Christmas, I guess everyone is too busy getting ready for Christmas to come to the doctor. It really picks up immediately after Christmas, however and our busiest time is Jan-May. The last week of December it seems everyone is trying to get that last minute test or procedure before the new deductible kicks in Jan 1.

Christmas brings out the best in some people, in others..... One of my patients with chronic pain brought me a wreath today which she had made herself. She climbed trees to find just the right fir and holly, falling out of one tree but doing no major damage. She wanted to give me a gift but could not afford to buy me anything. The wreath, by the way, is beautiful. All I can say is a sincere thank you.

In contrast one of my other patients this morning was telling me about his brother who has had children with two different wives. One of the children is living with my patient and his wife and the brother is supposed to pay the grand total of $25.97 a month in child support. The brother came down to try and force my patient to stop trying to collect this amount and in the process fractured my patient's arm. My patient has forgiven him now. I wonder about the judge who ordered that small amount of child support, what was he or she thinking? That amount would pay for less than a week's worth of food but is important to my patient who lives on disability. Yes, we can argue about whether he should be on disability or not, but he and his wife have opened up their home to this child, and his sister by the way, and need some help paying for their living expenses. That's what I thought child support was supposed to be; if so, that small amount is a joke. Let's set a more realistic amount, say $100.00; don't you think that's closer to fair?

Preparations are underway for our office Christmas party. This Christmas party is not the official hospital Christmas party or the very formal medical group Christmas party which is Saturday night. This party has been set up by our office staff and we clinicians are providing the food and drink. It will be held at one of my partners' house which has limited parking. This means there will be a lot of car pooling and therefore there will be designated drivers available for those who consume too much wine or beer. There will also be some sort of gift exchange where everyone brings a wrapped gift valued at no more than ten dollars and then you can choose your gift. If someone doesn't like theirs then they can ask for yours and this goes on and on until someone is left with the worst gift at the end of the night. It should be interesting.

The afternoon remains slow. One patient in particular stands out. He is an ex-heroin user who has Hepatitis C due to the IV drug use from years ago. He told me that yesterday he was with a friend of his who got a call that his fourteen year old son was in the Emergency Department here. He drove his friend there only to discover that the friend's son was dead on arrival from a heroin overdose. This is the first time that my patient has had to experience the trauma of an overdose death from the standpoint of a friend of the family. It is especially hard on him and on me that it was a teenager. For me, it was a boy who is my son's age. I thank God every day that Stephen and I can talk about things and will talk some more on the way to Portland tonight. I cannot imagine the trauma of losing a son at this iwc replica age and especially from a heroin overdose. Stephen understands the danger involved with drugs and we keep reminding him that he has to say no to peer pressure.

I see that Dr. Keyboard has given December two 4th's (see here). Let's not anyone tell him, OK? Let's see if he discovers it on his own. Of course, he will try to cover up his mistake by diverting our attention with some witty daily updates while he sneaks in and corrects it; then will say what mistake? He did mention me today which I think(?) is praise.<grin>

The Blazers lost. Enough said, must get ready for tomorrow. More details in this space then.

Today was also very frustrating at the office. Actually, there was one patient who is turning out to be very puzzling. She has a ruptured disc (technically known as a herniated disc) in her upper spine and is awaiting definitive surgery for it. While awaiting surgery she is taking narcotic pain medication. I have been prescribing it to her using the usual agreement I have with patients that they will get their pain medication prescriptions only from me and I will not call them in.

Just after Thanksgiving she came in to say that her brother-in-law had just been killed in Texas where the family lived and she needed to be there for the funeral past the time she would ordinarily come in for her refill. With no hint of problems before, I gave her a refill about a week early. The next day, I got a call from her back surgeon that she had been calling him for refills which he had been granting and one other physician in his office had also done that. We called the pharmacy they had called them in to and they faxed us their records of her refills (this pharmacy was different from the one she had told us she was using to fill my prescriptions) and sure enough there was documentation that she had been getting about double the amount of medication I thought she was getting.

Today she came back to the office saying she and her husband had just arrived back in town Monday with her sister and children after the funeral and the neurosurgeon had called her to tell her he knew what she was doing and would not see her again. She proceeded to tell me that she had not called the neurosurgeon's office to get refills from him and had not been to the pharmacy he had called them into for several months. She told me it was probably her sister who had done it as she has done something similar before; calling in pretending to be her and then going to pick up the prescription that was called in. Whom do I believe? I asked my patient to go and get documentation from the pharmacy involved that she had not signed for the medication and report this to the police. If she brings back the documentation and the police report then I guess I have to believe her. Situations like this are why physicians have to be very careful about calling in narcotics; you cannot know for sure who is calling if you don't see that person. Patients sometimes think I am being overly demanding when I make them come in so I can write the prescription but this situation is why. If her neurosurgeon had been as careful this situation would not have developed.

In other news, Delanae also had a puzzling day. She got a call from a company about a man who was applying for a position with them. She had worked with him at her last company and he had made sexual advances toward her as well as other women there. She had, of course, been very frank when she rejected the advance. When applying for this new position, for reasons known only to him, he had listed her as a reference. She said that she just laughed when told that and the caller asked what was the matter. After being assured that the information she gave would be kept confidential and they wanted her to be completely straight with them, she proceeded to tell them the truth about him. Before hanging up, they told her he was not what they wanted working for their company but she sounded like she was and proceeded to ask her if she would be interested in working for them. The also sent her this link about the company. She is very happy where she is for now, but they are offering her more money if she is interested so she is going to talk to her boss about this tomorrow. We'll see what happens.

Great worship tonight as usual. Our Wednesday night worship band is getting tighter and tighter (musicianspeak for better and better, I think). Even if we are not noticeably better, we are having fun. Personally speaking, I had more than my fair share of wrong notes but it is a blast and I am learning more and more. Now if I could just become a full-time musician with a great computer setup who had time to write and post as much as some of the other Daynoters....... NAAAAAH! I'm happy doing what I'm doing, I'd just like a little less hassle from managed care and the guv'mint. I think I will end on that note. See you tomorrow.

Once I got to the office I was feeling better but felt kind of washed out all day. The patients weren't a lot of help. During this time of the year, we tend to get people who are very emotional because of the extra stress of the holiday season. One lady almost broke down in my exam room today; her daughter is a long time heroin user and is talking about suicide. She is afraid that she might try and overdose and to complicate matters, she has a young child who is living with the grandparents. The daughter has been through drug rehab several times and no one believes her if she says she is going to quit again. What could I do other than listen, so I did. As she left she thanked me for being such an understanding doctor; all I did was listen, no therapy was offered.

Then, there was the woman with panic attacks. She has a history of alcoholism and multiple drug abuse so when she came to see me to discuss her crippling panic attacks I was naturally a little suspicious. With her permission, (I didn't say she was smart)I did a urine drug screen; sure enough it was positive for amphetamines and benzodiazepines (downers). I suggested to her that she quit the drugs and that might cure her panic attacks along with the antidepressant I suggested for her (it helps reduce true panic attacks). She was not as happy with me, especially when I refused to give her any benzodiazepines which her other physicians had always given her for the panic attacks in the past. I asked her to come back in three weeks, care to take bets on if she will?

One good thing about today, though I got to eat lunch with my wife. She surprised me by coming to the office just about the time I was finishing up the morning so we went to lunch together. Of course, we ate at the hospital cafeteria but still it was nice. It was a good time to talk about what we're going to end up giving Stephen for Christmas. He has decided he has to have an Electro Harmonix Deluxe Memory Man guitar effects pedal. We're looking at new and used ones on the Web, especially the auction sites.

Delanae's really learning to use the Palm III which is making me want one even more now that I see all it can do. She's keeping all her business expenses and appointments on it and now has come up with a way to keep her mileage on it. She has decided to stay where she is now rather than look at the other opportunity, at least for the foreseeable future..

Tonight was Stacey's Christmas concert. If I haven't told you before, she plays violin and is in the sixth grade orchestra. She began playing last year in the fifth grade orchestra and really enjoys it. She had originally wanted to play the flute but that instrument is not offered to fifth graders, so she took up the violin. Now she wants to buy her own violin and keep playing it. She did great tonight, playing a small solo part during one of their Christmas songs. She is very funny though telling us that we are wrong if we compliment her. My little girl is growing up more and more every day.

What an appropriate way to end this day! I'm sitting here tonight after the concert finishing up this post when my daughter runs in and tells me the toilet is flooding. Sure enough, the toilet in the bathroom off the room I use as an office is flooding as well as the one in the laundry room on the other end of the house. We had just spent almost two hundred dollars getting that drain from the laundry unplugged last week and now it is plugged again. We mop up the water from the laundry room floor and call the sewer and drain service people again. They will be here at 8:30 in the morning to try yet again to get this drain draining properly again. The joys of home ownership!

I just realized that both last night's flood and this morning's occurred while I was checking e-mail. Think the two events are connected? Perhaps it's a comment on the content of the mail I receive, most of which is from the other Daynoters by the way. Of course not, it is just my mind playing tricks on (or with) me.

Amazingly, almost everyone today thanked me after their visit. Let's see, first there was the lady who may have asthma. She was told this by another physician and given an inhaler to use without sufficient explanation. I spent probably thirty minutes with her explaining what asthma is, how to use and inhaler, and a treatment plan if she does indeed have asthma. First, we'll do some lung function studies to be sure she does then talk about an individualized treatment plan for her. She left thanking me.

Next, was a man with panic attacks and agoraphobia which is a fear of being around people. This phobia is so severe that he cannot even spend 10 minutes at his mother's house with his family at Christmas. He is OK at home with his wife and kids but would rather be living by himself. He will need intensive medical therapy as well as psychological therapy to be able to even be a little social. No one had ever sat down and discussed all this with him frankly before, he had heard bits and pieces before from various clinicians but never had it all tied together. Hopefully, he will continue to thank me even when he does not respond to some medications until we find the best regimen for him.

The other memorable patient who said thank you was the young (under 30 years old) lady with shoulder pain probably secondary to a bursitis. This had been treated with anti-inflammatories and pain medications which had not given her relief enough to do simple things like put on her bra or blouse without help. I offered to inject the area with a combination of cortisone and local anesthetic which is know to give a lot of relief to people with a bursitis that doesn't respond to oral medications. She agreed and had almost instant relief of her symptoms. She was able to put her blouse back on by herself in the exam room and was very thrilled.

All three of these patients simply said thank you to me for helping them. I know I enjoy hearing that and I think most physicians do because most of us went into medicine to help people. Those simple two words, for most of us, are enough to make us forget all the hassles we encounter in the practice of this profession and remind us that we really are here to help people through their illness and/or pain.

Tonight is the big office party. Well, big is a relative term but the staff has looked forward to this for several weeks. It should be fun and we will probably be back late so I will post this now and give you details about the party and the plumbing repair tomorrow. Good night and sleep tight.