Interview Wrap Up

We had an interview trip over August 11^th to the 25^th.  It was quite a trip.  The good news about being a family medicine doctor interested in practicing rural medicine is that I could move anywhere in the country for work.   After looking for more than 2 years at different places (calling CEOs, making lists, calling government offices) I realized that there were simply too many to look at all of them.  We happened to get a postcard in the mail from a recruiter (I get tons of these and throw them all away).  Melinda happens to look at it and it’s a lady who specialized in rural recruitment.  We talked on the phone and talked about what type of places I want and don’t want and started sifting through the choices from there.  We got about 10 quality options, 6 of which didn’t really work, and we were down to four. 

• 1.     Bandon, OR
•  Coquille, OR (We also got a interview a week prior to our visit for a town 15 miles away because a doctor was looking to retire.)
• 2.     Prineville, OR
• 3.     Orofino, ID
• 4.     Anaconda, MT

I’ll give you the brief highlights tour of each location. 

Bandon, OR – This is a town of about 3000 right on the ocean (sometimes called Bandon by the sea).  It’s a tourist and retirement community, so it has a lot of old people around, but a quaint downtown.  It’s cool (average high in summer is 70, but average high in winter is 60).  It rains a lot and is very green.  Overall it’s very pretty.  The doctors that I would work with are very nice people, but don’t really have the same goals in life or medicine as me.  They do a lot of cosmetic stuff (for wrinkles, etc).  they are also interested in hCG-mediated weight loss.  My approach is more lifestyle intervention stuff (changing diets, exercise, weight loss, etc).  I think it would be isolating medically to be the only one there who thinks like that.  It would also be a clinic-only practice (no ER, no call, no hospital work, no OB).  This would be very difficult to get my skills back after only being in clinic for a couple of years. 

Coquille, OR – (this one came up about a week before we left on our visit) It’s also a very pretty location.  It’s about 10 miles inland from the ocean but that makes a huge difference in temperature (about a 10 degree difference).  Beautiful valley ringed with mountains and pine trees with a river running through it.  It does have a surgeon who is big into prevention through diet/exercise/etc., which is exciting for me, but they might require me to work ER shifts on the weekends.  That’s kind of a deal-breaker for me.  I’ve done that in residency, I’m done with that.  This one is still in the running.  We might go back for a second-look interview at some point. 

Prineville, OR – After spending 4 days on the Oregon coast, and a drive through the beautiful Cascade Mountains, to come out the other side into the high desert was somewhat of a let-down.  As we drove into town we looked at each other and said, “Let’s keep an open mind about this place.”  They really impressed us with their community and the people we met there.  It’s a small town, but everyone we met really seems to have bought into the community.  They aren’t pretentious and are very down to earth.  They know what they can do at the hospital, and they try to do it very well.  We loved how they included other people from the community in the tour for Melinda and for the dinner the night of my interview.  The other places had varying amounts of including stuff for Melinda, but Prineville did a great job of selling the community to us. 

Orofino, ID – This is about an hour east of Lewiston/Clarkston.  It’s right in the mountains, and a very pretty drive up through the valley alongside the river to the town.  We got into town at around 2PM and spend the rest of the day on our own around town.  We decompressed a little bit and then took a walk to the “downtown”.   In a town of 3000 it isn’t much of a downtown.  Most of our walk was through the older part of town, and since this was/is a lumber town the houses are all small and on top of each other.  Not the best impression.  The next day however, we got a tour of the surrounding areas of town.  Wow.  You don’t have to go that far up on the mountain/hillside to find some nice houses with amazing views.  That was a relief.  One interesting thing about Orofino that we liked was that people that we talked with did a lot of outdoor stuff.  They didn’t just talk about doing stuff, they did it.  One member that Melinda met with at lunch says they are at the river all the time and out in nature 6 days a week.  One of the doctors was bicycling to Moscow, ID (60mi) the following day, and one of the other doctors just emailed me letting me know he would be out of town for 10 days on a backpacking trip to the Sierras.  It was pretty cool to see.  One of our concerns about this place is that it is pretty remote.  The nearest big town is Lewiston, Idaho with a population of 30K, with a Costco and such stores, but it’s an hour away. 

Anaconda, MT – This was our last interview.  Thankfully we only had 4 interviews this trip, it was grueling driving every other day and interviewing all the other days.  Anyway, we drove through town and the lower part of town is an old mining town (actually a smelter town where they refined the ore brought in) and looked like Appalachia in West Virginia; one house build almost on top of another.  Overall it was rough looking and a little disheartening.  Thankfully we went to church and saw that there was another part of town with much more normal houses.  Church had a lot of older people, but 3 younger families.  Unfortunately all three families were visiting their grandparents in the ward.  It’s a pretty aged town.  I liked the people in the clinic and the hospital, but we heard a lot of the same story from different people.  Summing it up was from a Nurse Practitioner that I spoke with.  He has lived in the town for 35 years and raised his kids there.  He posed the question to himself, “would I do it again if I knew what I know now?” [long pause] hesitatingly, “I suppose I would”.  He doesn’t like the town and the school district, but loves the outdoors and that’s what keeps him there.  Not a resounding endorsement of the town.  I think it’s pretty much off the list for us, but they almost have a guaranteed loan forgiveness.  Still not enough of an incentive to move there.

As of right now it goes as follows for where we're going to live

1 Orofino Idaho and Coquille Oregon

2 Prineville, Oregon

3 Bandon, Oregon

4 Anaconda, Montana

Further updates as they are coming.

Being (a) Patient

Young Caleb was born on August 2, 2011.  This was a wonderful experience in many ways, but not least of which was because I got to deliver him.  Not many people get to do this in their life, and I really enjoyed it.  However, the first thing I noticed about Caleb (aside from all the gross fluid and general gunk on newborns) was that his forehead was funny looking.  I believe my exact words to my faculty was, "He looks like a Klingon".  She did not approve.  In any case we waited a couple months to see if it would improve.  He was developing beautifully and meeting all of his milestones, but his forehead didn't get any better.  At our 4 month well-child visit we talked with our doctor and started to see what we needed to do.  Luckily there was a Pediatric Neurologist who would be coming out to La Crosse for his monthly visit the following week so we pulled a couple of strings and got in to see him the following week.  He diagnosed him with Metopic Craniosynostosis (the two bones on either side of the forehead fused in the middle sooner than they should have) and referred us to a Pediatric Neurosurgeon in Rochester, an hour and a half away.  This was also expedited because we were coming to the end of the year and our deductible had already been met for Caleb.  The Neurosurgeon also diagnosed us with Metopic Craniosynostosis and then we talked about surgical options
1) We could get an endoscopic surgery in the next month or so.  It would be a small incision on top of his head, they would surgically separate the bones of his forehead and he would have a quick recovery.  The only downside is that he would have to wear a helmet 23hrs a day for a year while the bones remodeled and grew back in.  These helmets would have to be replaced every 3 months at about $3000 per helmet and we would likely have numerous visits for fittings and the like.  Plus they end up stinking like crazy as you can imagine from being worn all the time.
2) We could go with the standard open surgery.  This is a more involved surgery but the outcomes are comparable.  It would be a one-and-done surgery.  This would also be costly and we would meet our deductible (so for us the cost would be the same).  For this one we would have to wait for him to be 9 months old so the bones are hard enough to change shape, but not so hard that they are like adult bones.  He would have to stay in the hospital a couple days longer with this one due to the surgery.
We opted to go with the second option as the results were the same and taking a bunch of trips up to Rochester all the time, dealing with a 1-year old in a stinky helmet for a year didn't sound great.  Let's be honest, neither of these options sounded great (who wants a head surgery for their little boy), but there you have it.
People have asked what would happen if he didn't get this surgery.  Bones grow out from suture lines.  Without a suture line (as it already fused) the bones of his face wouldn't separate from each other.  His forehead is already really pointy and would continue to get worse.  His eyes are already a little closer than they should be and this would also get worse as the rest of his head continues to grow.  Basically he would look really funny for the rest of his life.  The other medical complication is that he can have decreased room for his brain to grow and increased pressure inside his skull.  (this is why insurance will pay for it)

So our journey continued.

After our discussion with the Neurosurgeon he wanted to have us back for a visit within the month for some tests.  These included a CT scan to make sure there weren't any other sutures that were fused (and the last thing surgeons [or parents] want is a surprise when they're doing surgery on someone's head), a laser scan to see the outside contour of his head, a visit with the neurosurgeon again and a visit with the plastic surgeon.  The neurosurgeon is the one who opens up his head and removes the bones, the plastic surgeon is the one who reshapes the bones and makes them look like they are supposed to, which is the whole point.  The day went fine for the CT scan, and we really enjoyed talking with the plastic surgeon, but the other two events lacked a little something.  The laser scan for his external head shape is apparently for a study the neurosurgeon wants to do.  Of course, we have to pay for that anyway.  She also talked with us for 20 minutes about different helmets and things even though we had already decided to not do the helmet thing.  Whatever.  Caleb is tired and we're ready to meet with the neurosurgeon (who is late).  He breezes on in and proceeds to have a nearly identical conversation with us as he did a month ago.  It was painfully obvious that he had totally forgotten who we were or why we were there.  After we told him that we already knew the diagnosis he looked at us and asked us why we had come back to see him.  Really?!  Because you freakin' told us to!
One funny thing did happen this day that is somewhat redeeming of the experience.  Caleb is fine for most of the morning and does the tests fine.  We are then waiting for the plastic surgeon and Caleb starts getting fussy.  We look him over and discover a nice mess in his diaper that has leaked onto his pants.  We were just about to lay him down to change him when...of course...the plastic surgeon with his two nurses comes strolling in.  We explain the situation and they were very understanding and just told us to change him while we chatted.  I get his diaper off and start cleaning him off when he starts pooping again.  A lot.  I'm discretely trying to cover his butt with the diaper so it doesn't get all over their linen hamper (which is made of wood and a nice size for changing diapers) and trying to not appear panicked that it might cause a huge poop mess all over the room.  "Uh huh, that is interesting (oh geez, not on the wood hamper).  Yes, I understand what you are describing to me about the surgery (please don't notice how much is coming out and what a mess he's making).  Nope, we don't have any questions at this time.  (Gaaaah, it won't stop coming)".  For a brief moment there I really started to panic as it looked like the poop was coming too fast for the diaper and wipes to hold out against it's onslaught.  Thankfully we had enough wipes...just barely.  We finished with one lone wipe left over.  After the doctors and nurses left I went out to the front desk to ask for some plastic bags to handle the casualties from this battlezone and they hand me a ziplock baggie.  "Um, yeah.  [nervous chuckle] I'm going to need a much bigger bag...or two".
So a couple of months have come and gone and we're a mere 3 1/2 weeks from our surgery date when we get a call from the plastic surgeon's nurse.  Apparently the neurosurgeon thought his schedule was blocked out on the date of Caleb's surgery, but the computer showed it as open, and his nurse had scheduled in our surgery, and now we're going to have to reschedule.  WHAT?!  So I got on the phone and called this guy and basically said, this is a big deal, you need to find another neurosurgeon who can do this for us.  I don't have another time that I can take vacation for this and my mother has already bought her ticket from Utah.  After a long weekend of sweating it out, they called us back and had indeed found another surgeon to do his portion.
The week of the surgery, Melinda had to make a trip up to Rochester on Monday for a meeting with the doctor and to sign a bunch of paperwork.  We both came up on Tuesday to meet with the new surgeon.  Then we had to get up here at 6:15AM, Wednesday morning, to register and check-in for his surgery.  Seven hours later we're sitting here waiting for the surgery to finish in a couple more hours, but so far all is going well.

Some things I've learned on my journey as a patient-proxy.  It's is confusing and often not explained very well what you have to do and when.  We needed a referral to be sent from our primary care doctor to the insurance for the initial Neurologist visit because his visit wasn't going to be covered without one.  His subsequent referral to the neurosurgeon also wasn't covered including the CT scan and laser scan.  After some terse words with our insurance we finally got it figured out, but it was ridiculous.  I also thought the first neurosurgeon was a total jerk.  He wasn't very helpful and although I understand better than most how easy it is to run behind schedule, you could at least apologize for being late.  Plus not even remembering why we were there when you told us to come back for a visit...weak sauce.  I also learned that it's a mixed blessing knowing as much as I do about medicine and surgery.  I know that most surgeries go well especially in healthy individuals without a lot of other diseases or stuff going on.  But I also know what goes on in a surgery and where things can go wrong.  Overall I'd rather have the knowledge than not, but it is still enough knowledge to make me nervous.

Change

Much of what I do in my clinic with patients who come in is education, sometimes medication, and almost always trying to elicit change behavior. It goes without saying that America has something of a weight issue and a smoking problem and a poor eating habit and a serious lack of exercise problem and...you get the point. For me, this is one of the most frustrating and exciting parts of my job, and I LOVE it. In many ways I view myself as a health adviser; I give people health information and if they choose to follow my advice it will get them a host of benefits, and if they don't then at least they know the consequences of said choice.

This leads us to the real question; how does one get another people to want to change and to actually follow-through with the change. One fact it nearly universal with people, they hate being told to do something. People dig in their heels and even if you have authority over them they will only do it grudgingly and half-heartedly unless it comes from within as well. So simply telling people to quit smoking or start exercising or lose weight simply doesn't work very well at all.

One strategy is to ask people what they really want out of life (usually this is very different than a blood pressure of 120/80). It's usually simple things like being able to play with their grand-kids, or to have their clothes fit better, or because they hate doing what they do. Then you try to tie the change behavior to the goal that they really want. Unfortunately when you ask them what they are going to do about it they usually say something vague like "eat healthier" or "get in shape" or something unrealistic like "lose 60 pounds in 2 months" or "not eat sugar again". These either don't get people very far or simply aren't a sustainable way of life.

So that leaves us with our main question, how do I get people to want to change.

I recently read an interesting article about will-power in the NY Times about New Year's resolutions. It was very insightful. Combined with a recent book I read called "Switch: How to change when change is hard" has changed how I approach my patients and myself.
(http://www.nytimes.com/2012/01/08/sunday-review/new-years-resolutions-stick-when-willpower-is-reinforced.html?_r=1&scp=4&sq=new%20year%27s%20resolutions&st=cse).
Some of the most interesting points were these.
1. "To keep a New Year’s resolution is to anticipate the limits of your willpower."

2. "People with the best self-control, paradoxically, are the ones who use their willpower less often. Instead of fending off one urge after another, these people set up their lives to minimize temptations. They play offense, not defense, using their willpower in advance so that they avoid crises, conserve their energy and outsource as much self-control as they can"

How do you incorporate these into your life and actually have the changes stick. Don't overestimate your willpower for starters. People start out all full of spit and vinegar (as evidenced by the packed gyms around New Years or the first two weeks of a diet) and then quickly fade out. People need to admit that they have limits to their willpower and simply wishing it to be different won't make them less likely to be tired at times and likely to cheat on their diet or stop exercising. They also need to set up limits and avoid situations that will test their willpower.
- Set out your clothes the night before
- Agree to meet with a friend
- Have a workout plan already set up that is reasonable with your schedule
- Make a plan to go to bed early enough to not be tired in the morning
- Set up your meals ahead of time and buy the ingredients ahead of time to avoid simply ordering pizza and go grocery shopping when you are full and (relatively) well-rested.
- Get rid of the snacks in your house so you aren't tempted (people pay a lot of money for weight loss, just think of this as an investment ahead of time)
Our willpower has limits and is finite, people who overtax it or are overly tired will find that they will make poorer choices.

The last thing that has stuck out to me had to do with smoking cessation, but is applicable to many areas of life. The average smoker tries to quit 10 times before he actually does quit. Some only try once, some try twenty. If someone comes into my office and says, "Doc, I've tried to quit once and it didn't work", what do you think I'm going to say? Try again. The same goes for any change behavior, keep trying. Set up the path you want to go down to be as easy as possible and set up the path you usually go down to be harder one. If this doesn't work the first time, back up and re-assess the situation, analyze why it didn't work and then try a different tactic. Eventually one of these will work, but too many people throw in the towel with one failure.

Going under the knife

A couple of weeks ago we had an afternoon lecture/demonstration with an ENT (Ear, Nose, & Throat) surgeon. I walked in late and they were doing laryngoscopes (looking at the voice box through the nose) and I asked him how bad my deviated septum was. He asked me to plug my right nostril and try to breath in through my left nostril. Nothing. No air movement at all. He took a look at my nose and about 30-45 seconds later he was on his phone with his nurse setting me up for surgery.

As an aside, I haven't been able to breathe right out of my left nostril for probably 15-20 years. Likely this is from some bonehead move when I was in high school or college. Now, this is nothing that I would pay out-of-pocket for, but if my insurance will cover it and we've already met our deductible and a surgeon is offering it to me...I'm gonna take it.

There are some interesting things about being a doctor and seeing what happens on the other end of surgery. We don't really get called until the patient in on the OR table and getting ready so when the surgeon comes in the room they are ready to cut. That means that I got to the hospital 2 hours early, proceeded to tell each nurse that came in the room that I was a doctor so they could skip all the inane questions (I didn't really say that last part, but wanted to). That means that I got to sit in a very small and flimsy hospital gown nearly naked for 2 hours and read my book that I had the foresight to bring.

We then went down to the OR and I remember moving to the operating table (and probably mooning a couple people in the process), lying down, feeling something cold go in my IV, look back at the anesthesiologist who told me it was Versed and then...nothing. I honestly don't remember a thing. Very weird. Who knows what gibberish I might have been spouting off. That happens to be one of the properties of Versed...amnesia, not spouting off.

The post-op for me was actually pretty uneventful. I was wondering what it would be like to take narcotics, but I didn't really need any, so I didn't get to find out. Alas. For just a septoplasty the recovery entails some pink/red nasal drainage like you have a runny nose and a sensation of TONS of sinus pressure from these small plastic splints they had shoved up my nose. A part of me (a small part of me) wishes that it would have been more involved so I could get a real sense of what surgery is like for my patients, but I'll take the glimpse that I got and be glad for the easier breathing.

Old School Medicine

Much of modern medicine now relies on tests. When someone comes into the ER they almost always get blood work to one degree or another and then if the diagnosis isn't clear, they get some imagining (CT scan, Ultrasound, etc). Often the physical exam portion of the interactions is perfunctory and really only done for billing reasons. That being said, there are some times when something on the physical exam is more important than imaging and blood work.

I had a patient come in to the ER the other night and we were called down to admit her to the hospital for abdominal pain. Abdominal pain is really difficult to work with because there are some many causes for it. You have the pancreas, stomach, small intestines, large intestines, liver, gall bladder, and appendix. If you're a woman then you also have the ovaries and uterus as well as pregnancy that could be involved in the list of things we need to look at. This lady was a 22 year old lady who was pregnant, had a previous C-section (meaning she had abdominal scarring added to the list), and had a previous umbilical hernia (more scarring). Added to the mix is that she lives at the Salvation Army with her husband and child, is adopted from Vietnam and still speaks with an accent. She has been seen a LOT of times in the last year by both the ER, Obstetrics, and our Residency Clinic.

Anyway, I get down to the ER and start talking to her. She has a very very strange style of interaction. She would just sit there and look straight ahead and mumble answers. Her husband would answer some of the questions, but she just wouldn't make eye contact and just gave off a weird vibe. But one thing I learned from my public speaking class is that people are very uncomfortable with silence. So I would ask her a question and then just wait for her to answer. 30-40 seconds doesn't sounds like a long time, but try sitting in a small room at 10:30PM staring face to face with a doctor answering questions and it becomes a very long time. After a couple of questions and some very long pauses she eventually broke down and started talking with me. Essentially she has had this pain prior to her C-section and Hernia repair (hence not scar tissue, and the duration points away from it being her organs as they usually present more acutely) and although heating pads have helped somewhat, mostly just not using her abdomen has been the most helpful. She said it was worse with movement. All of her lab work was perfectly normal as was her baby.

Still confusing.

However, on physical exam I had her lie down on her back and then do a straight leg lift while I tried to push her feet down. This was very painful for her and perfectly elicited the pain she has been complaining about. Eureka! My conclusion was that it was some abdominal muscle strain that hasn't resolved because she has continued to use it with her job. She needs some Physical Therapy and a little bit of strengthening exercises and she should be good to go.

Most of what I do that is particularly memorable usually involves some sort of tragedy. It was really nice to finally do some sleuthing that changed course from what could have been a big work-up and potential surgery to something simple and easily fixable all because of a simple physical exam.

Psychosis

One of my most interesting rotations last year was Inpatient Psychiatry. This involved patients on a locked ward for a variety of reasons. The most common was depression with thoughts of suicide, but we had our fair share of psychotic people as well.
Modern society has taken it to mean many different things, but here is the actual definition

"A mental disorder characterized by symptoms, such as delusions or hallucinations, that indicate impaired contact with reality."
One of my favorite patients regarding this was a 38 year old African-American lady with some interesting psychoses. When you would ask her about the day she would seem perfectly put-together and answer all your questions appropriately. But, if you asked her about her past and how she got here; hold on for a ride.
She told me that she is actually almost 100 years old and used to teach special education kids until one day they rose up in rebellion and beat her up (which is why she is black now) and pulled out all her hair (which is why she now has "nappy" hair). When she was white she looked like Pamela Anderson and men would stop in the street when they saw her, "riots would break out" when she was around. She also took a train to India where she used to be a doctor. She was also married to Shawn Kemp (former NBA basketball player) who also was much older than he looks. Oh yeah, she also used to be a pink alien at one time. The most interesting thing about these interviews was how she was deadly serious. She didn't laugh or wink or smile or anything. This was her reality.
One of the most interesting things I learned from this is that our brain has all sorts of filters in place. People with this type of mental illness can often have thoughts/ideas/sights/sounds bypass these filters. One part of their brain is telling another part of their brain that it is experiencing something. They are, in one sense, actually experiencing it. As you can imagine it's sometimes very difficult to tell them that these things aren't real. It's like me touching someone on their arm and then telling them that I'm not actually touching their arm. They have felt it, they know it's real, and then they are told that it's not real. Unfortunately for them, it's usually not something as benign as a touch on the arm, but can be "command auditory hallucinations" (where they hear a voice telling them to do something), or telling them people are watching, or that they used to be a fantastically good-looking white lady. Although the stories are fantastic and very interesting, overall it's very sad, because this type of thing doesn't get better very easily. The real story behind this African-American woman is that she had a mental break where she became psychotic all of a sudden and left her 3 young children in the department store that they were in, eventually getting them taken away by Child-Protective Services.

The Magic of modern medicine

I'm currently doing my cardiology rotation over at the other hospital in town (they have a Cardiac ICU with a lot more cardiac patients than my hospital). Given that we live in America and particularly in the State of Wisconsin there are a lot of people with risk factors for heart disease and we see A LOT of heart attacks in people. One of the standard treatments that everyone gets on is a medicine called a statin (Crestor, Lipitor, etc) for lowering cholesterol as well as some medications for lowering blood pressure. I was talking with a patient, who was only 55, about changing his diet and exercising after a heart attack and mentioned that we would be starting one of these medications for him. His response was, "Good, then my cholesterol is covered." As if he could now eat what he wanted and the medication would take care of the rest.

Sorry folks, no such luck.

Here's the quick and dirty...the risk factors that brought him to the hospital with a heart attack will continue to be risk factors for future heart attacks, and he will likely have another heart attack in the relatively near future (years time frame, not necessarily months).
There is something in medical research called the "number needed to treat (NNT)". Basically it means that if we take 100 people on a certain medication to prevent a future outcome, how many of those people who take the medication will actually benefit from it, or in other words what is the number of people we need to treat to prevent one bad outcome (heart attack, death, stroke, broken femur, whatever). Unfortunately, a good NNT is 20 or so. Many medications or interventions have much higher NNTs, like 100. Meaning that only about 5% of people at best are helped with our interventions. Not terribly impressive for our vaunted medicine.

Now if I could reduce my risk of a heart attack by even 5% with a largely benign drug that only costs $4 per month, then it's not much of a choice. However, if that drug costs $200-300 per month what would I do. What about a couple thousand dollars per month, what about tens of thousands of dollars for a major surgery? Suddenly it's not as easy as all that.

In the end, I think people put too much stock in what modern medicine does for them and not enough in stuff that is harder, slower, but has much more far reaching effects; exercise, a diet based on fruits, grains, and whole grains.