Thursday, January 10, 2013

Day 208 - second opinions

I continue to struggle with my nose looking like Rudolph and my voice sounding like a frog. I've had enough of this virus, thank you.
This morning, I re-learned eDH, but this time from a specialist perspective and I am actually excited about it. Well, not exactly excited about eDH, but excited about getting to be at a palliative care clinic and getting to set it up the way I think will provide the best care. It is fun to think about doing that. There is a way in which palliative care feels so much more orderly than primary care. Like when Gerry shows how one can put one's most used orders in a collection and organize them by diagnoses or by symptoms, I feel like I could do that and somehow make order, organization, out of the field in a way I never could in general internal medicine. Or maybe I feel that way because I have just had six months without work to allow my subconscious mind to organize things. Or perhaps because I am excited about starting to do out patient palliative care and everything related to it seems shiny and beautiful. Anyway, it's a nice feeling.
In other activities, I'm working on a fifteen minute slide show to make the case for palliative care to primary care doctors. It's astonishing to see that there is almost no primary evidence about outpatient palliative care. This means the kind of low tech studies that some one like me could do would be interesting to other people. Hmmm.
I had the opportunity to tell the story of my second opinion twice today and it made me think about how John told me he had described my story to Dr Stone who said that three cycles of consolidation would be adequate and then when he saw me, he said he thought four would be better. I was thinking about how John had seen me and clearly been impressed with how sick I was with neutropenic fevers where Dr Stone had not. I had lived it and couldn't give a very good description of it to him (also I was not as impressed with how sick I was as John was). Perhaps that made a difference in how Dr Stone viewed the potential complications from a fourth round of chemo. The other thing I was thinking about is how giving second opinions is such a luxury in a way. To have the information that is available in hindsight and get to say "I would have done it a different way," to have the luxury of getting to do the cognitive part of medicine without the heavy lifting of dealing with the patient being scared or falling out of bed or refusing to take the meds you feel would be best. I have only done one general internal medicine second opinion in my life and that was a nursing home patient whose family picked my name at random. It turned out that the patient had an easily fixable problem that hadn't been noticed before so she had a great outcome and I found it a tremendously positive experience. Not quite the same kind of second opinion. My feedback loop was closed in a couple of days when her thinking cleared and Dr Stone's will come years from now when I have or haven't relapsed.
The other interesting experience I had today is related to a couple of years ago, I examined a patient after a non-sexual assault. The county attorney called me today and said they might like me to testify against her assaulter. They asked for my resume as I would be an "expert witness." Gosh, my life never lacks for interest.
For me, for tomorrow, I am hoping for a normal throat, a very non-interesting throat and a nose to go with it. For you, for tomorrow, I will hope for just the right level of interest in the details of your life (remembering the old Chinese curse "may you live in interesting times").

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