Reality Check 2

Who told anyone that MRSA is a spider bite? Who told any patient that a copay entitles one to rx’s of their bidding?

Who told patients that a 100% pain free life was a thing?

If your hotel bed sheets are dirty or your car isn’t fixed correctly - you have a CUSTOMER service issue. When I explain the meaning of an A1c of 10 and you just don’t like what you are hearing - well, don’t shoot the messenger. This isn’t a hotel or store. This is the ART of medicine and healing. The pendulum cannot swing back fast enough for me. And, NO, you can’t have fries with that......

The VA wanted logs too. They accepted letters from physicians attesting to my skill in a particular procedure and dates. Also called for billing codes and made a list. It worked. At some point just put a chip in my neck and scan stuff in for later.....

We put small wipe off boards on each door of an exam room. No personal info on the boards - I would put - “neb and pfs” or “Orthostatics” or whatever and we had these goofy flags outside the door. I would put all the colored flags out to let the nurse know she was needed. When done, flags down and a check mark on the white board. I like old school easy communication. Now I use Skype instant messaging to locate my LPN or RN. Still no PHI, just last initial and last 4 of SSN and what I need with a please.

My seriously anxious patients tend to get just WHACKED on wellbutrin - it makes them meaner and edgier and generally intolerable. I prefer Lexapro for GAD with the rare zoloft patient. Lots of buspar in my world and then a boatload of atypicals. I don't ever start Paxil but have inherited patients on it. Our BHS dept handles it mostly. I don't like it but some patients are ok on it - for now.

What a disgrace to our profession and medical practice. And a stain to our profession trying to gain ground - the outliers could ruin our chances. What a jerk.

Many of my patients are older and polypharmacy as well. Prozac and Paxil are NOT recommended in elderly. Long half life and nasty side effects. Lexapro does a better job but can lower sodium. Can be a tricky balance. I am grateful for the Pharm Ds at work who can do the interaction profiles on those when the Med list hits 13+ trying to balance Parkinson’s, CHF, DM and the whole fruit basket of stuff. My biggest challenge some days is med box bingo during bridge games when Thelma samples Louises RLS meds to see if they help........

Prior to coming to the VA, I worked in a solo owned private family practice with the son of one of the founding docs who was retiring. I inherited an immediate 3500 patients - many on horrid combos of drugs, A1cs not monitored, etc etc etc. As one approaches retirement there is a complacency and fatigue - "just get them out the door happy". The fight is gone. Bad things happen. It took me a year to wean over 50 people off chronic ambien. I printed the data and handed it out. Had the conversation that if this person was my aunt, uncle, mom, etc - would not want them on it. It worked 98% of the time. I didn't give options - "we are going to work you off of ambien, it is not a good drug". No open ended flubbering - these are the choices. I got told to stuff it a couple of times and a few folks left. Oops. Next - the combo benzo and narcotic crowd. What a stupid idea in the first place. And using benzos for "muscle spasm" - WTH? Printed out any data on the bad mix - think about 5 yrs ago - handed it out. Laid out the concept - "it appears you are on a combination of medications that is quite dangerous according to new studies and data" - never dissed the old doc - just pointed out new data. Gave the plan - "we will be weaning off of lorazepam at 1 mg tid - slowly to avoid severe complications. Once you are off it or down to a rare dose, then we will address your narcotic use. There are so many other things we could do that wouldn't be so dangerous.....". Plant the seed, limit the options. Be polite. Use data. Got a lot more pushback on this end. Benzos are sooooo habituating and ugly. Why deal with life's stressors when you can be pretty stoned? Then, the random dx of adult ADD put on a stimulant with no testing or supportive therapy. In the same patient taking benzos and narcotics and maybe even ambien. It was not an uncommon combo in this little universe. Inherited one woman on HALCION for over 25 yrs - are you kidding me? After looking at the situation - zero chance I would ever get her off of it - gave her the spiel about all the badness - she didn't care. Charted everything, counted my losses and moved on. I had to decide that patients didn't necessarily have to adore me and want to buy me presents - do good medicine, use the data, stay strong and the cream will rise to the top eventually. Or I would win the lottery and float off to a private island. Guess which one happened? Sometimes doing the right thing doesn't feel great or win you a parade but in the end - you sleep at night and fewer people die unnecessarily.

I have had more bad outcomes and side effects with Paxil than any other SSRI - followed by Zoloft. Weight gain, flat affect, withdrawal symptoms from one missed dose, akathisia - just not worth it. For anxiety with depression I prefer Lexapro - more subtle, weight neutral, no withdrawals that I have seen. I think Paxil had an OCD preference but I haven't used it for such. Paxil is also category D for pregnancy so I don't want patients getting pregnant on it. Lexapro still carries a C rating. Also more sexual dysfunction with Zoloft over Paxil and both over all others.

I put in their hygiene and appearance. It is an objective finding that supports mental health and psychosocial situation. If I put delightful in a chart, it means the person is really nice and easy to work with. Pleasant means they are cooperating. Agitated, anxious and uncooperative enter my chart often as I see a group of folks with extensive mental health issues. Or dementia "limited historian, aloof, unable to provide information". "patient smells very strongly of cigarette smoke (sub - marijuana)" is very very common in my charts. "patient has inappropriate laughter and appears acutely under the influence of substances" - the contact high was overwhelming. "patient smells strongly of alcohol at 11 am. Patient denies drinking" is also a known thing. Stale booze just sucks for the examiner "limited personal hygiene" --- "moderate grooming" --- "disheveled" --- "work worn clothing and work dirty hands" "pt has odor of urine" "pt has odor of cat urine" - meth labs smell like ammonia and cat urine "pt unable to sit for history due to back pain" "pt pacing and fidgeting" --- "pt rocking back and forth" -- yep, common It is all relevant to the situation and context. I don't care if they can read it. I don't put in things like snarky, mean or dressed like a hooker --- that is inappropriate. I use terms when appropriate such as verbally confrontational or combative, loud, angry, agitated and then all the psych things like tangential, withdrawn, etc. Paint a picture in the chart. It means something. Just my crusty old 2 cents

In front of patients I always use Dr soandso but privately or socially I use their first name. I introduce my psychologist colleague as "my colleague, psychologist Dr. Ray" so the patient knows who I am taking them to see. The VA has a tendency to use Mr and Ms for many people - politeness and likely military formality. I get called PA Reality Check a lot or Ms Reality Check. I have encountered a few folks over the years who will only take Doctor from everyone. Bugs me - not a deity. Patients always ask me what they are supposed to call me. Military folks call me PA Reality Check but my older patients often fear offending me if they know I am not a doctor but not sure what to say. I give them my first name and tell them it's ok by me, no pretenses here. And whatever they call me is sooooo much better than "that lady" followed by complaints.....

RUN. BADNESS ABOUNDS RUN

Maybe if this passes, we can sign for diabetic shoes and home health someday - I know, dreaming.......

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5494092/#!po=6.81818 This is an article on the K vitamins. Has some evidence base in it. To date, no one has asked me about this one.... just cursed myself. Side note - used to work with a doc in Texas who got into the vitamin urine fad/nonsense where you had your urine tested and the “missing” vitamins were your deficit and the pyramid company she bought into would custom make you a vitamin based on what wasn’t in your pee. Amazing what folks will do to avoid eating real food - millions of dollars in supplements but won’t buy healthy food - go figure.