Is It March Already?

How did it get to be March so quickly? Apparently, in his hiatus post Dr. D said he'd be back before the end of February. Oops!

But wait! I have an excuse:

During his hiatus Doctor D found himself on the other side of the exam room. Yes, D managed to destroy most of the bones in his leg and became an orthopedic patient!

I'll have a full report for you soon, but for now I can tell you that Dr. D's skeleton has been reinforced with Titanium and he is considering changing careers to become a bionic superhero.

Never fear, readers! Doctor D didn't forget his Clinic of Doctor-Patient Relational Awesomeness! So be mellow and keep the questions coming!

I'll have an awesome post for you to read by this time next week, and Tracy will make sure I keep my word!

Time Out

Last year Dr. D took the season of Lent to unplug from the internet for a while and contemplate the deeper meaning of life. It was an invigorating time of growth and reflection...

Yeah, you guessed it, Dr. D is putting his blog on "timeout" again.

We're going to pause AskAnMD for 2 months. Dr. D still has a lot of great stuff to blog about, but for now he just doesn't have the time. We'll be back sometime in February.

Why?

My grandmother as well as my favorite former patient died in November. This got me thinking... Dr. D keeps a list of things to do. That list included: "Call the Dude" and "Visit Grandma D" for many months. I procrastinated even when I knew the end was near for both of them. I could have reached out to either of them while they were still alive, but I was too busy.

Grandma D:
1918-2010

I love this blog, but it takes a lot of my time. I spend a lot of time thinking on the questions you write me, and writing, re-writing, checking, and formatting a post takes about 6 hours for me. Yeah, I'm that slow!

Going faster would make me put out rambling, useless junk, and I wouldn't do that to my readers.

So posting every week takes a significant chunk of my free time. So for the next few months I've decided to allot more time to my friends and family who are still breathing.

I Shall Return!

Doctor D will be back in his online clinic of doctorly wisdom and sarcasm soon, but for now you'll have to survive the long nights of Winter without him.

But be of good cheer! There are lots of great medblogs out there to keep you entertained and informed. The ones listed on the blog roll to your right are an excellent place to start.

You can also catch up on some of the really awesome stuff in the AskAnMD archives, and if you get board and desperate for a fix of Doctor D's inane observations you can follow him on Twitter.

You can also still email Dr. D your questions—just don't expect any immediate answers.

Then sometime in mid-February just when you had almost forgetten about Doctor D your feed for AskAnMD will roar to life and bring you awesome insights on that will totally blow your mind!

Until then:

I love you guys!

Merry Christmas, Happy New Year, and all that other cheerful holiday whatnot!

The Doctor Will Grope You Now

Doctor D, what are your thoughts on the TSA?

Okay, so no one actually emailed me this, but it’s high time Doctor D set things straight!

Dr. D’s prescription for America:

Stop being such snively, self-important, brats!

So what gives a medical doctor any right to speak on transportation and counter-terrorism?

Doctors also do full body searches. We call them physical exams.

During these exams we touch and look at every part of the body. I stick my fingers in vaginas, rectums, and mouths. I even sometimes do these exams on children—Oh, the horror! Lock up that sick man!!!!

How do doctors get away with this disgusting violations of your rights? We feel you up under the guise of keeping you safe. The TSA learned their trick from doctors!

These exams are theoretically voluntary, but most doctors will decline to take care of you unless you submit to some sort of medical pat-down. What an outrage!

Is All Touching Dirty?

Look, we all recognize that this is a weird situation. Touching a stranger’s body is awkward for both the toucher and the touchee. It is human nature to reserve close physical contact for family, intimate friends, and lovers. But sometimes we must do things that feel unnatural.

It is my job to touch every person who seeks my help.

Sorry, but when we spend all day touching bodies we kind of get used to it. You may see your body as a unique and private expression of yourself, but we see it simply as a dull object that must be checked for signs of danger.

You may feel violated because I had to check your prostate, but it didn’t bother me one bit. Checking your rectum is no more disturbing to me than checking your ear.

Of course, we try to be sensitive. Doctor D has had to do some invasive exams on little kids and sexual assault victims. We should take our patients’ feelings into account, but not not doing our job at all isn’t sensitivity—it’s incompetence.

Here's The Naughty Part (Stop here if skimming!)

What everybody's getting really worked up about is genitals! You only let people touch those in the most intimate of moments, except of course at the doctor’s office or the airport. Then you get a stranger poking around some sensitive spots.Doctor D will go ahead and answer your question now:

No. We are not thinking about sex, and if you are that’s your problem—not ours.

We aren’t eunuchs or anything like that—we are just focused on the job. Doctor D is a red-blooded heterosexual man who loves women as much as the next guy, but D can honestly say he has never once felt anything amorous about a patient during an exam. You could be a supermodel or an 80 year old grandmother and Doctor D feels exactly the same about touching you during an exam. Doctors learn quickly to see the bodies we work on as tasks to be completed rather conduits of passion.

Sure there is the occasional true sicko, but these people so rare that you chances of having one of them examine you is pretty minuscule. Doctor D has known quite a few doctors who were walking hormones and hit on everything of the opposite sex they ever met, and still these docs were nothing but professional and trustworthy when doing physical exams. A professional touching of the private parts is about as unromantic a situation as possible.

The attracting effect of the human body has no power over me when I wear the white coat! "Sorry, but I just don’t feel that way about you. It’s not you—it’s me"

Can We Handle This Like Grown-Ups?

I feel for the TSA agents. They are getting harassed for just doing their job. Physical exams suck. I’m sure pat-downs do too. But if they are necessary in order to ensure your safety and they are required to fly, then you should either grin and bare it or plan a long road trip.

This TSA fiasco irritates Doctor D to no end! It’s not that people dislike body searches. That is understandable. It’s the attitude of enraged entitlement that irks Doctor D. Everybody demands everything be done perfectly, safely, and cheaply and with no inconvenience to them whatsoever:

“I feel bad! I demand your full attention. Don’t make me wait; don’t poke at me; and don’t you dare tell me the treatment has risks or side effects! I have a constitutional right to everything I want right now and without any bother!”

And we wonder why the rest of the world thinks we are spoiled assholes?

Doctor D will be flying over the Christmas holidays, and when it’s time for his pat-down he will thank the beleaguered TSA agents for keeping us safe.

Your thoughts?

Any of you out there who's had a TSA pat-down that thinks it is worse than a pelvic exam?

Do you think patients should get treatments they want while “opting out” of the physical exam?

While Doctor D always loves to hear your thoughts, if your comments are too whiny or bratty Dr. D will hunt you down and administer a punitive rectal exam!

Growing Up Sick

A teacher asks Doctor D about a diabetic teenager in his class:

“His sugar readings are often over 400. His mom says this is normal. Can this be normal?”

Before we start Doctor D has to throw out his usual disclaimer: No medical treatment advice shall ever rear it ugly head in this post! Okay, I feel so much better! Now on to normalcy:

What is NORMAL?

a) A state of harmony within the body and mind that leads to health and well-being.

b) The typical or status quo for a person; the way things usually are. [eg: “Doctor D’s weekly posts are normally late.”]

c) WTF? There is no such thing as "normal" for a teenager in the clutches of puberty.

I’m guessing that mom meant something between B and C.

The Trials and Tribulations of Puberty:

The teen years are some of the toughest in a life. You suddenly realize that you are no longer a child and find yourself drowning in a sea of raging hormones. You don't want to hear your parents advice or follow their rules, you are desperate to fit in with your peers, you feel invincible, and you can’t wait to take risks (especially the ones adults tell you not to). The only people more stressed than teenagers are their parents.

Now add to a chronic illness to all the “normal” teen drama and you have a really volatile mix! If having a chronic illness and being dependent on doctors, tests, and treatments can push even a stable, well-adjusted adult to the limit, just think of the havoc it can wreck when you are 13!

Type I Diabetes is a perfect example of this:

Patients are often diagnosed as small children. They often don’t remember a time they weren’t constantly counting carbs and taking insulin under their parents direction. Doctor D has seen it again and again: a diabetic kid does fine until about 13 when they suddenly decide they have to live a “normal” life. The teen acts as if there is no illness and begins ignoring all the rules that keep them alive. In my experience chronically ill teens have difficult identity issues and can be in dangerous denial about the seriousness of their illness.

Parent during these times get frustrated and burnt out. The harder they try to manage their teen's illness the more the child resists.

"I SAID take your insulin!!!!"

These power struggles between parents and teens happen in most homes, but when the teen has a serious chronic illness the tension can rise astronomically!

So why did mom say everything’s okay?

Parents of chronically ill teens often feel helpless and very guilty that they cannot protect their kid's health the way they used too.

A teacher asking about his illness could be a very sensitive issue for the the teen and the parent. I can understand the mother just answering "oh that's normal for him" to avoid discussing the extreme stress and difficulty of the situation.

Sometimes when everything’s going to hell in a handbasket it’s easier just to pretend we’re all fine.

So you really want to help?

But if you know things really aren’t fine, and you’re someone like a relative, teacher, doctor, counselor, friend, etc. you really should try to help the frustrated family.

Here’s how you offer assistance without making things worse:

1) You must be sensitive to what the teen and the parents are going through. If you act like you are just going to ride in on your white horse and save everybody you will get shut out by the parents and teen pretty quick. (Doctor D has learned that one the hard way!) Start by acknowledging how difficult the situation is to both the teen and the parent.

2) Make it clear that you will protect their privacy. The teen should know you won’t embarrass them in front of their peer by exposing their illness against their will. The parents should know you won’t shame them as bad parents because their teen’s care isn’t working.

"Embarrassed? Us? No way! We're like the the smoothest guys we know. ...did we seem embarrassed? Because we totally aren't."

3) Talk to them like they are normal. (Normal definition A) Even sympathy can be irritating and isolating for a family dealing with chronic disease. Talk to the teen and the parents like you are talking to normal people dealing with normal problems.

4) Use your strategic position. Parents and teens often struggle to a stalemate. Being neither the parent nor the teen offers you a huge tactical advantage for breaking the deadlock. Let’s say you’re an adult such as a teacher or doctor. Sure you’re authority figure, but you aren’t the parent therefore the teen is much more likely to listen to your advice about sticking with treatment. So many of the stresses in a teen’s life are social so if you are in or around the social environment you may be in a unique position to explain the stresses the kid is going through to the parents. If you are a peer then you can help the teen "normalize" their chronic illness and see that it’s not something to be ashamed of.

Being a semi-independent semi-adult is a weird state that strains the therapeutic partnership with the parents that previously worked so well for the chronically ill child. As an outsider you can help both parties create the new strategy that will help the young person manage their disease for years to come.

5) Be patient. Unhealthy patterns usually don’t straighten out overnight. Nor do strained relationships between chronically ill teens and their caregivers. Often breakthroughs are followed with setbacks. Take the long view and remember the tumultuous teen years don’t last forever.

Thanks to this awesome reader for caring about his chronically ill student!

Doctor D always enjoys hearing your thoughts in the comments.

Have any of you worked with chronically ill teens or their families?

I know some readers have had chronic illnesses since childhood. How did you successfully navigate your teen years?

My Favorite Patient Died Today

I just got a call from one of his relatives who found my number in his wallet:

“The Dude” was one of Doctor D’s first patients. He was assigned me when I was a new doc starting out in residency.

The Dude was one of those people that we all go into medicine to “help.” He was poor, and on disability, and had never gone any further than high school. The Dude also weighed about 400 pounds and smoked 4 packs a day, and he hated taking medicine ...and it was new Doctor D’s job to “take care of him.”

Medically speaking, I never was much good for The Dude. He kept doing all the things that eventually lead to his demise. In the end though, it was he that did me immeasurable good.

He actually preferred residents to our better-trained teachers, “I love these new Baby Docs when they come each year!” he exclaimed when he met Doctor D. From then on Dr. D and the Dude were always together. The Dude had a lot of office visits and hospitalizations. He was the epitome of the “difficult patient” and D spent his first year as a doctor stressing about how to save The Dude from impending death.

But it was The Dude who won out. His infectious kindness and joy in the face of pain and illness inoculated Doctor D against the harsh medical world around us.

One day D visited The Dude in the ICU and muttered, “How am I going to save you, Dude?”

The Dude let out a gravelly, smokey chuckle, “You don’t need to save me Doctor D! You’re just nice to me and I appreciate that.”

The Dude is laid to rest

Our doctor-patient relationship evolved over our years together. I did less telling him what to do and more sitting at the feet of one of the wisest human beings I have ever known. The Dude lacked any book smarts, but I know he was brilliant. He understood how a joyful attitude can keep you alive when every textbook says you should have died years ago.

The Dude had about the most unhealthy body and physical habits you can imagine, but he had the healthiest soul of any person I have ever met. He taught Doctor D that there is so much more to life than diagnoses and treatments.

The Dude promised he would try to stay alive long enough to see me graduate from my residency. He ended up outliving his promise by years. I moved to another state after graduation, but we stayed in touch. I was no longer his doctor, but we remained friends.

I took my son Little D on a road trip when he was just a baby to meet my sage friend. It was well worth exposing the kid to a little second-hand smoke. It was like taking your child to be blessed by a living saint.

The Dude and I would write or talk on the phone every couple of months. I started this blog with The Dude in mind. I wanted to answer questions for real folks like him that didn’t give a damn about medical stuff, but found themselves stuck in doctors offices and hospitals anyway. He's the only patient I ever cared for in real life who knew about my secret identity as Doctor D. He read regularly.

We last spoke about 6 months ago. I had “Call The Dude” on my long list of things to do last month, but I never got around to it. I sure wish I’d called my jolly, smokey old friend!

It came as a shock that he's dead—which is strange considering I expected him to die at any moment for the first few years I knew him, but once you really love someone you kind of expect them to live on forever.

Now The Dude is in a place where he has no need for doctors or medicines.

Enjoy heaven, my friend! I wish I'd told you that you were the best teacher Doctor D ever had!

Warnings and Witch Hunts

An addition to our ongoing series on Incompetent Doctors:

If one of your patients asked your opinion of another doctor whom you know to be incompetent what would you tell your patient?

Incompetence in a physician is a scary thing! Doctors deal with problems of life and death and try to heal you with dangerous tools. A doc that isn’t competent can be seriously dangerous.

But how do you know who’s on their game
and who’s falling down on the job?

It’s tricky for patients because they often don’t know enough about medicine practice to judge competency. This makes putting your body under the care of any doctor scary.

So scary, in fact, that an entire malpractice industry has sprung up to reassure patients that incompetent doctors will be severely punished. Unfortunately malpractice usually ends up a witch hunt that can burn good doctors at the stake and let bad ones go free.

“I saw Goody Doctor D dancing in the woods with the Devil!”

“Tis true! One of his patient died!"
"It can only mean he dabbles in the witchcraft of incompetence”

Wouldn’t it be nice if you had someone who understands medicine who could tip you off on the bad ones?

Yes, but it’s a complicated thing to ask your doc if another doc is incompetent or not.

Judge Not, Lest You Be Judged

Competence is not always as black and white as you might think. There is a good bit of gray and ambiguity involved. The real world practice of medicine involves a lot of educated guessing and trial and error. Even the best doctors occasionally make mistakes or use unorthodox treatments.

The real dangerous doctors are the ones that recklessly disregard patient safety and don’t even care about doing things right. And yes, unfortunately there are lots of doctors like this.

Incompetence may be common, but it is hard to prove. Doctor D occasionally sees signs of suspected incompetence in patients that have been treated by other docs. An incorrect diagnosis or an unorthodox treatment that seems way out of the expected margin of error and puts a patient at risk.

But these clues in the crime can be misleading. Sometimes Doctor D will see something and say to himself, “Self, what this doctor is doing makes no sense. I wonder if he is incompetent?” Later I met the doc only to find that he had an excellent reasoning for what he did, and was obviously acting in his patient’s best interest.

The Medical Gestapo

But there are some doctors that are all too happy to accuse their colleagues of incompetence. These docs believe there is only ONE competent way to practice medicine, and it is the way THEY practice.

These doctors want to be the to secret police who keep medicine in line. They are typically jerks with a massive god-complex. They gleefully tell every patient who will listen which doctors they think suck.

Doctor D has had encounters with the medical gestapo. They shoot first and ask questions later. They see the world in black and white. There is no gray area for them.

“Doctor D you didn’t follow the protocol! Are you thinking for yourself? Are you adjusting the protocol for individual patient's situations? Off to the firing squad!”

Dealing with Dr. Danger

Witch hunts both from within and without medicine have soiled the names of a lot of good doctors. So Doctor D is always careful about fingering another doctor as a dangerous doc, even when he has his suspicions.

I currently know a doc who I am about 70% certain is a walking public health threat. I’ve seen a pattern of “WTF?!” medical decisions that make me highly suspicious that this dude either doesn’t know what he’s doing or doesn’t care.

How certain do I need to before turn Dr. Danger over to be burned at the stake? Well 100% actually.

"We still only have circumstantial evidence, but let's burn him anyway!"

I’ve been a target of the Medical Gestapo myself, and I know how damaging misguided doctor purges can be. I’m not blowing the whistle on Dr. Danger unless I know beyond a shadow of a doubt that he’s really what I think he is.

I’ve only been 100% certain one time before and that time I blew the whistle as loud as I could.

Subtle Warnings

Although I’m not absolutely certain he’s incompetent, I wouldn’t want any of my family seeing Dr. Danger. It would be too much of a risk!

I can’t flat-out denounce him publicly, but I do want to steer patients away from the danger I suspect.

This is where subtlety comes in handy:

I might say "Dr. Danger does some really unorthodox things." Or I might just fail to praise him, while my facial frown indicates I might not be totally cool with Dr. Danger. Or I could just change the subject and suggest you see Dr. Awesome instead.

This is how we doctors subtly steer you away from potential danger.

But you have to read between the lines, because if you flat out ask, “So Doctor D are implying you think Dr. Danger is a totally incompetent fuctard who has no business practicing medicine?” Doctor D will smile and say, “Oh no, Dr. Danger is a delightful person! You have totally misunderstood me!” Then D will give you a wink.

Doctor D puts the B in subtle!

What do you think?

Docs and Nurses: How do you manage doctors whose competency you doubt?

Patients: Do you think you are able to pick up subtle cues from your doctors?

Should Doctor D go gestapo on Dr. Danger?

Any ideas for a better process than this ridiculous system of innuendos and secret winks to keep patients safe? I'm sure there has to be something better.

It Gets Worse!

So 2 days after Little D broke his leg Lady D his mom goes and breaks hers too! She's never fractured a bone in her entire life and she does it the same week as our toddler broke his. WTF?

So everyone's asking: "Why all these injuries? Does Doctor D beat his family?"

No, of course not! But I might want to look into getting rid of the new seesaw:

Rodeo Bull See-Saw Stunt - Click here for this week’s top video clips

This is going to be a long 3-4 weeks in the D-house with them both grumpy and in casts!