Febrifuge

An update: I focused on the medicine, and I was specific, but I did say that this patient’s chronic medical conditions, as evidenced by the little changes and the big exacerbations in the last 6-12 months, compared to how things have settled down more recently, are clearly influenced by environmental factors. I said she’s not UNable to work from the office, but if she were able to continue working from home I would expect fewer complications and a better overall situation. I didn’t come right out and say anything provocative, but I tossed in enough Occ Med verbiage that it should be clear I know what I’m talking about. I heard today that the HR person was satisfied, which I take to mean they backed off. I see this as an appropriate level of advocating for the well-being of my patient, and removing unnecessary threats to her long-term prognosis.

Well, I’m thinking practically. If the question for your risk management or legal person is “is it okay for me to say x” or “is it okay for me to refuse to fill out form y,” then the thing they’ll want to consider is, is there some law on the books that governs how things are supposed to be handled. That’s all I meant, not that laws are always (or even usually) right.

The Oath is a nice historical footnote, but it’s not super helpful as an ethical guidepost, and it definitely doesn’t supersede state or local laws, the rules of any professional orgs you might belong to, or a health system’s standard practices. If you personally don’t feel like it’s in the patient’s interests to comply, then I think you always have the option of at least trying to decline to release the info. But depending on how things work, the decision might ultimately be up to someone else. So, if you’re okay with the idea of “someone might say yes to this, but it’s not going to be me,” and the chips falling where they may, then sure. Although, I would say it’s better to talk to your patient and give a heads-up, just in case the employer turns up the heat on them.

This right here feels like wisdom. And it’s true, I probably enjoy a little too much being able to bust out my liberal-arts writing skillz at these times. As the saying (attributed to Churchill, but never sourced or confirmed) goes, “diplomacy is the art of telling someone to go to hell in such a way as to have them look forward to the trip.”

Oh, I definitely see the wisdom of that. But still — focusing on just the medicine, there are risks to this person’s health that come with being forced to work on-site. Meanwhile, she’s been doing the same work from home for a year. I think they should provide a reason why it needs to be done in-person, but of course I don’t get to decide that. My medical opinion is, it’s healthier to leave it as-is and just let her work. Obviously it’s not my role or my place to comment too much on how they run their business. But I kind of take offense at their being able to frame it as “is the person capable of working in the office?” because that’s not the salient question, I think. They’re setting it up like we need to choose between her health and her job, when we just proved we can take good care of both. You want a healthy employee? This is what I think helps, this is what I think probably hurts. I feel like there’s a line, and I’m not sure which side of it I’m on, but my role as PCP is to advocate for this person’s health. If it’s okay for me to tell someone to smoke or drink or eat less, what’s the problem with me agreeing their job seems to come with health risks that should be avoidable? I’m also contemplating an opportunity that’s come up in Occ Med again, so it’s kind of interesting to think that if things go a certain way, I might be in a position to help direct policy a little, in how we relate to employers and approach these questions. I get fired up thinking it may be possible to advocate for people and reduce harms. I’m probably being too blue-sky about it, but it’s a nice diversion anyway. And I really do feel there are gonna be lawsuits, when employees/ patients get the Delta because some chucklehead at the workplace lied about being vaccinated, or the employer insisted everything was fine when they knew it was not.

My most recent outrage, the latest thing that got me all fired up and tearing through the work, was a patient today who has a few cardiac issues plus prediabetes plus asthma, your basic combo plate of mid-60s chronic stuff plus a few ambulance rides in the last couple years. BUT, the thing is, her job is one she can do from home, and she has been, and it’s been so much better for her. Not dealing with the commute, or the daily stairs, or the weather setting things off. Being able to rest if she needs to, being able to take daytime meds on time. So of course, her employer is trying to get her back in the office. Why? No reason. She’s missed fewer work hours since WFH has been a thing. The quality of her work has remained great. Her boss supports it, boss’ boss doesn’t care, but the HR manager is digging in their heels. I really do think it’s just a tiny HR tyrant control thing. So today my patient brings me this letter from HR Grumpystuff, asking me to comment on the question of is there any medical condition that makes it so this person can’t do their job in the office? Off the record my patient explains this is a smallish company that didn’t require or even really mention masks until the Governor made it a mandate, and even then they have grumbled. They don’t inform the staff when there’s a positive. But anyway, the HR creature has already made noise about how “this better not be about covid risk” because my patient is vaccinated. So, my inclination is to write a letter and surgically furnish this HR person a new poop-chute. I’ve done Occ Med work, so I flexed in one paragraph about how “restrictions” or “limitations” are specific terms with specific applications, and I don’t believe we are filing a FMLA claim or requesting disability, we’re just having a nice chat. So, I continue, instead of me answering that dumb question, how about you tell me why the patient can’t just continue to WFH? It’s a work modification. Not a restriction, and not a benefit. I will need to edit a ton and have my SP look at it Monday, and I won’t ever send documents while angry, but I’m wondering: have any of you had to write a “hey D***bag, please don’t be a d***bag” letter like this? How did it turn out?

Why did you sign the contract, then?

Here’s a counter-point, not necessarily because I have strong opinions but because it’s a worthwhile discussion: what value does the physical exam actually bring? One of my MD practice partners has been working on the concept of the “evidence-based physical exam,” and I’ve found it fascinating. It’s actually something of a return to the core Osler kind of point of view. History-taking should get you most of the way to any diagnosis, or so goes the theory, and any physical exam (or blood work, or imaging) should ideally be something you do to confirm the things you’re pretty sure you know, from talking and listening carefully. So much of what we do is very low in sensitivity and specificity. Most of the time, an exam finding is just something we use to reinforce the need for some other test, so our own bias about how important that test will be is what determines how we describe that finding. It’s art, not science. Now, obviously, there is value in the ritual and the tradition of laying hands on the patient, and there’s a kind of therapeutic touch aspect, in which people feel like they have been listened to and respected because of the attention that’s been paid. Lots of what we do provides important reassurance like that. So I’d never say there isn’t value in a physical exam. I do think it’s worth asking, how much of that value is truly diagnostic? This gets especially interesting for me, since my undergrad degree was in Theatre. I wore a long white coat when I was working Urgent Care, for purely presentational reasons. And it helped. As my beard has gotten whiter, my perceived expertise has increased even as I’ve been less connected to medical podcasts and the latest updates and developments. Telemedicine has given a lot of opportunities to test how necessary physical exam really is. Sure, there are things that can’t be done without a PE. I found an abdominal hernia in one recent patient, and another had a foreign body in an ear canal. Office visits will never go away. But there was the guy I led through a series of “Simon Says” type shoulder maneuvers, explaining as we went that we could tell frozen shoulder from biceps tendinitis from a full-thickness RC tear. And there have been so many people who say “thank you for explaining that” or “thanks for your time today.” TL;DR - physical exam is important, but I don’t think it’s all that important for reasons of diagnostic accuracy. It’s often most important as theatre, in fact.

Got my second Pfizer dose around 2pm Thursday. Had not pre-dosed with ibuprofen the way I had with dose 1, but I did take 600mg later that evening. Slightly sore arm Friday morning, otherwise fine. Started feeling achy and tired mid-day Friday, then by 2pm it was clearly on. Took 400mg ibuprofen then, and I managed to power through the brain fog and close out my clinic day on time. Went home, ate some comfort food, went to bed, and had chills and body aches all night. Still feeling tired and useless in the morning, but the effects had worn off by 2pm Saturday, pretty much. Today was a normal day, start to finish.

Got my first dose of Pfizer 7 hours ago. Feel absolutely fine. The injection didn’t hurt, and the deltoid is no more sore than with a flu shot. We’ll see how the rowing machine likes me tomorrow morning I guess.

They put it in writing? Impressive... most impressive.

Got my email today. Could have signed up for 6:30am tomorrow, but I went for Thursday afternoon next week, right before I have some days off anyway.

I am constantly looking stuff up, right there in front of the patient. Have been doing so for 11 years of practice. We even have a big flatscreen LCD on the wall that shows my screen to the patient. It doesn’t make you look dumb. Excusing yourself every few minutes like Clark Kent on a college football Saturday looks weird, though. I just click the UpToDate link right there in Epic and say, “hey, so what you have is ____, and the last time I dealt with a case of this, it all turned out great. I just want to check real quick and make sure nobody changed a guideline, or did a study that changes the recommendations.” Then I scan for what I need, and say something like, “okay, it’s still Cipro plus Flagyl,” or “aha, see, when I went to school they were still saying you needed to finish 14 days of treatment, but 7 should be plenty,” or depending on the patient I could crack a joke, like “yeah, okay, former head of the American College of Endocrinology, if that’s your *opinion* then I guess we can go with that.” Mostly though, as a new grad you just need to read. Set aside half an hour after dinner 4 days a week, and read up on what you didn’t know that day. Don’t obsess, and don’t berate yourself, but build up your knowledge base because that builds your confidence. And you need both.

Our org is back in the mostly-okay range too, in terms of revenue and margin, so as of the paycheck coming end of the month, we will be back to 100% of salary, up from 70% during June-August. And apparently in January the plan is to pay us a lump to get back almost all of the rest. It’s nice to be in MN, where HMO’s legally need to put profit into patient care.

Mostly Allen Edmonds lately. The key is to never wear the same pair two days in a row. Primary care work means I rotate between about 4-6 pairs, if you count the dress boots. Being at home two days a week makes those slipper days unless I have to run errands later.