Not my favorite rhino

Hands down the worst thing about my job is this little bastard:

and the little bas cherubs who spread it: rhinovirus, in other words. I’m sentient enough that if I hear a child coughing, I’ll put a mask on before entering the room. But I have no defense against the kid who coughs after I enter the room.

So now I’m suffering through the first crud of the season. Coughing. Stuffy nose. Headache. This is old before it even has a chance to be young. And it’s not like I can stay home. Oh, I could stay home, but then something like 20 patients would get appointments days from now, maybe a week or two, and our schedule would take a hit, and some of these patients would take a hit, and so unless I’m feeling like death I always tend to come to the same conclusion: that it’s better to drag my ass through the day. I mean, it’s not like staying home accomplishes anything — the cold will run its course no matter what I do.

Meh. It all sucks.

D.

And more work

We moved into the new building. First thing I did, I lowered the drape. I’ll worry about the abysmal view later; for now, I’ll focus on making the space more pleasant. (Hey, I worked six months in Walnut Creek in an office with NO view, and did just fine. I’ll adjust.) (It may take a little terrarium with a peppy lizard or two, but I’ll adjust.)

Turns out my new computer is Abby Normal. The IT person came down and declared it such. I doubt anyone would have believed me, but when an IT person says a computer is fucked, people listens. She said they’ve rebuilt this one in the past, and the fact that it is still fucked (my word, not hers) means it’ll be sent back to HP, to be roasted in their eternal flame reserved for Slow Computers.

Meanwhile, I’m getting used to the new split-screen computer, trying to figure out how to get things sized appropriately so that they’re not hanging off the corner of one screen or clinging for dear life to the other. Since my computer is Abby Normal, I’m unsure whether it’s my problem or Abby’s. Guess I’ll find out when the new computer gets installed.

We’ll be doing a bit more work over the weekend . . . Patients coming Monday afternoon, so we need to be rarin’ to go by then.

D.

The last 20 years

I was wondering today about this question: what’s the biggest thing that’s happened in my field in the last 20 years?

I think it’s the advent of combined modality chemotherapy and radiation as an alternative to surgery for advanced head and neck cancers (here, for example). This may not sound like much to you, so let me explain.

In the old days, if you had a small laryngeal cancer, docs could cure you with radiation. If the cancer came back and you were lucky enough to have the cancer limited to one vocal cord, you could have a hemilaryngectomy, leaving you with a crappy but mostly normal voice. But most folks had to have a total laryngectomy, which is not a nice thing to have. Not only do you lose your normal voice, but you also lose your sense of smell (since air no longer circulates within your nasal cavity) and, because of that, most of your sense of taste.

The VA study changed all of that. Soon it was being applied to other head and neck cancers — most significantly, in my opinion, tongue cancers. So consider tongue cancer for a moment. Once again, if the lesion were small enough, you could have removal of a part of your tongue followed by radiation therapy. With any luck, your voice and your ability to swallow would be unscathed. But if you were unlucky enough to have a larger tongue cancer, especially one of the base of tongue, then you would need a total glossectomy (removal of the tongue).

And it’s worse than you can imagine, because if the tongue goes, the larynx has to go, too. You can’t protect your airway without a tongue — you end up aspirating your own saliva. I suspect some folks managed to avoid the laryngectomy, but I know that a lot of our patients ended up with everything going. Thus in exchange for surviving cancer (which was by no means a given — the five-year survival from such tumors could be as low as 20-40%) you lost your ability to speak, eat, smell, and taste. Without a tongue, speech rehabilitation is impossible. Nowadays, you’d be stuck with one of those Stephen Hawking-style speech pads.

Now, 20 years later, I can’t remember the last time I saw one of those glossectomy/laryngectomy patients. Chemo/radiation protocols are that good nowadays. I have a few laryngectomy patients, but even they are a rarity nowadays — the radiation oncologists do an awfully good job keeping them out of our hands.

Which in my opinion is a really, really good thing.

So: what’s the biggest development of the last 20 years in your field?

D.

Another nose cleared

I had intended to write a post tonight explaining that 2 Girls, 1 Cup is merely the natural heir to goatse.cx, and that with multimedia’s evolution, some day soon we will doubtless be treated to 1 Cup, 2 Girls, 3D, or its equivalent, but instead I was called into Urgent Care to pull a bead out of a two-year-old’s nose.

I tried to save my employers some money (they pay me overtime for “call-backs”) by telling the Urgent Care pediatrician to spray the child’s nose with a decongestant. With any luck, she’d blow it out, a smooth, shiny, pink projectile. Alas, my trick didn’t work this time, and the pediatrician asked me to come in.

I’m not sure I understand the affinity of toddler noses for smooth, shiny, brightly colored things, but it’s something akin to black holes and matter. The child sees this bead, this corn kernel, this Tic Tac, and thinks Must! Shove! Or perhaps it’s the pediatric version of Will It Blend? Call it: Will It Fit? (Hint: it always fits. It rarely comes out without my help.) In any case, children and beads make me happy because it’s easy overtime money: fast, low stress, inevitably successful.

Which leads me to wonder whether we have it all wrong, giving the kids in our office stickers of Tinkerbell, Dora the Explorer, or Batman. Perhaps they’d rather have something smooth, and shiny, and brightly colored.

D.

Work

I’m listening to Bob Marley singing “Buffalo Soldier” on Pandora . . . and I’m wondering whether this song came first, or the theme song to the Banana Splits. Because they have more than a little in common, you know. Okay, here goes:

“Buffalo Soldier” — 1980-1983 depending how you date it.

The Banana Splits — 1968-1970

So Bob Marley borrowed from the Banana Splits. That’s cool.

My pager goes off while I’m making dinner (taco soup). I know what this is. No I don’t. I can’t be sure that it’s the ICU patient bleeding again. I don’t know this. And even when the Service tells me it’s the ICU, I’m still thinking: You don’t know for sure. Maybe the nurse has a question. Anything is possible.

But no, he’s bleeding, and I need to go in. It’s still early, not quite 7, so if it’s gotta happen it may as well happen now. So I tell Karen how to finish things off and then I try not to break too many laws speeding into the hospital.

When I’m there, I realize how much I like being there. (This is a difficult admission. Doctors are natural complainers. It feels wrong, somehow, to admit that I enjoy my job.) I like the fact that I know what to do and that no one else here can do it. I like my nurses, who seem remarkably young and good-looking (men and women both) and helpful tonight. I like the banter. Where else can you converse lightly about how you want to die? And what would be the best drugs to have with you on your way off the stage?

More than anything else, I like feeling useful.

I feel fortunate that I flopped as a scientist, that I had an adviser who told me to hedge my bet and get the MD, that I had the wisdom to follow her advice. (She was cute. Of course I listened to her.) Otherwise, I might still be cloning and sequencing and hybridizing and generally hating my every working moment. True, I never tired of seeing that little gray smear of DNA at the bottom of my Eppendorf tube, but it was the same glee that five-year-old me brought to a steaming beaker of water and dry ice. (I like mixing shit.) The good result brought me pleasure only inasmuch as it meant I was that much closer to completing my PhD.

I should have known as a medical student that I had come home. I really should have known. It should have been obvious when I would round on ICU patients in the middle of the night, checking urine outputs and blood pressures, just one last round before bedtime, chatting up nurses. Feeling useful. But how to shake a youth of thinking myself a scientist despite all evidence to the contrary?

And now I’m wondering what adjective I should use to describe this trait: of needing to belong to a profession where one’s usefulness is never in question.

Pandora is being very weird tonight. Bob Marley one moment, Bauhaus the next. I think I may have to switch from “Pink Floyd Radio” to “Mellow Radio.”

D.

Why we do it.

Yesterday, I removed a bug from someone’s ear, cut a little cyst off someone else’s lower lip, fixed a nosebleed, fixed a broken nose, and reassured a few people, No you do not have cancer. Today was my OR day (yes, all that other stuff I can do in the office), and I took out a bunch of polyps from two people and removed facial masses from two others. A productive couple of days, I’d say.

One of my teenage patients asked me the other day how long I had to go to school to do this. I never know when to start counting, but I’ve learned that high school students DO add in the four years of college. I told him, and then I said, “You have to like school,” which I did, of course. In fact, if there’s one thing I regret about my job, it’s that I am no longer in school (if that makes any sense). No, CME (continuing medical education) doesn’t count. It just ain’t the same.

Also: I told him that the one remarkable thing about my job is that at the end of the day, it’s rare that I can’t feel at least some satisfaction that I’ve helped someone, and usually several someones. There aren’t many jobs like that, I suspect. And I’ve come to realize, this is why I do it. (Well, that and the fact that I don’t know how to do much else.) But I don’t know why other doctors do it.

It’s not something we talk about. We talk about the interesting cases we see, we share tips and tricks, we gripe about the non-medical aspects of medicine, but we never ask each other why we do it. But isn’t that the interesting question? I think so. Maybe some people are crazy enough to do it for the money. Trust me, I always tell the kids who ask about life as a doctor, if money is your only motivation, forget about it. If you’re smart enough to get through med school and residency, you’re smart enough to do something easier and make just as much, if not more*.

As much as I’d like to think we docs all have some sort of calling to this world, I kind of doubt that it’s true. I mean, I never had a calling. I may have one now, but it was a late development.

And now is when I regret that I have no readers who are doctors. Because I really would like to know if it’s the same for the others as it is for me.

D.

*Though there is one thing medicine provides that some of those other high-paying jobs might not provide: job security. With the doctor shortage being what it is, we can always find jobs. Might be in the middle of Teabag Country, of course.

The barbarous craft

One of the reasons I like my particular branch of medicine is that I occasionally get to do things which are 100% the right thing to do. If someone’s ear is full of wax, it’s never a mistake to remove it. Same goes for a kid with a bead up her nose. There are times, happily many times, when I know exactly what to do and then I do it and then I have a happy patient (or parent).

But like any doc, there are times when I don’t know what’s going on, when my best guess is probably no more accurate than a Magic Eight Ball, when my only asset is that semi-mystical laying-on-of-hands thing. When success depends upon my shine as a huckster, a salesman hawking something he really doesn’t believe in but knows that if his pitch is good, he’ll still have a happy client.

There are, for example, patients who have so many varied aches and pains and dysfunctions that I have to wonder if I’m either (A) missing something that only Dr. House could figure out (I know — it’s palladium poisoning!) or (B) dealing with a patient with a conversion disorder. That’s when the patient’s mental/emotional ailments “convert” into physical problems. Not terribly common, I’m afraid. I mean, I can remember one patient who developed a ball in the throat sensation the same week her husband died, and pointing out that “coincidence” was enough to cure her problem. But I have to think that conversion disorders are extremely uncommon.

Which leaves me in the dark, of course. If I’m not bright enough to apply Occam’s Razor and come up with the one brilliant diagnosis that knits it all together, and if I’m not willing to consider every stumper a psychological issue clad in physical symptoms, then I’m forced to admit ignorance. I do this most of the time, but I realize I’m not making anyone happy, least of all my patient. Some people want honesty. Most don’t.

Fortunately, no one else has been able to figure out my patient, either, and most of my predecessors haven’t even tried. So the first thing I discovered long ago is that trying matters. The mere fact that a doctor cares enough to want to figure things out is, pathetically, therapeutic. (Pathetically because it’s sad how often people are blown off by their other doctors.) And that’s step one of Good Hucksterism Good Doctoring. Step two is Doing Something. Doesn’t always have to be a prescription, and in fact I had one angry patient today who said his doctor “admitted he prescribed antibiotics for his patients because it made them feel better to get a prescription.” (Step three: the wizard never peeks out from behind the curtain. Never.)

Doing Something could mean framing the problem to make the patient realize that it truly is multifactorial. Your weight problem contributes to your sleep apnea, which exacerbates your nocturnal reflux (as does your smoking, by the way), which is giving you that cough (and the smoking doesn’t help your cough much either), and if you got a little more exercise you’d lose some weight and your apnea might improve and your fatigue would lessen etc. etc. Now, suddenly, all these disparate symptoms start making sense. It’s not so much that your body is falling apart and it’s not age. It’s your damned lifestyle.

Interestingly, my theory — the way I’ve framed the problem — need not be correct. It helps if I’m right, but it’s not essential. Because sometimes what people want is not so much relief of their symptoms as relief from worry. If I can exclude life-threatening illness (and yes, I can do that most of the time with imperfect certitude . . . but nothing is perfect . . .) and I can help them understand what’s going on, more often than not they’ll say they can live with their symptoms.

But getting back to the stumpers: it’s true, sometimes I play the Magic Eight Ball*. And if I make my pitch with verve and style, and if I make them think someone cares, and if I can sell them on the wisdom of this or that treatment strategy, well, the patient might get better. Often does.

And I’ll never know if I was right, or merely skilled at slinging the bull.

D.

*Mind you, I’m not so proud that I won’t send such patients to other specialists, or to other ENTs for a second opinion within the specialty. But what do I do about the patients who have seen all the other specialists and who are coming to ME for a second, third, fourth opinion? Do I tell them, “I’m as dense as everyone else you have seen,” or do I try to help, even if helping carries with it a dollop of dishonesty?