Tuesday, February 5, 2013

Day 234 - bring on the normal!

Today had lots of very nice little parts. Work was good; a couple of the patients had happy surprises for me. Then I got to have coffee with Jeanne-Marie who I hadn't seen in ages and who seems to be doing stellarly. To round out my afternoon, Ellie told me the entire plot of the most recent book she's read which involves a girl and her crush time traveling to pre-Civil War times in the U.S. It's funny how sometimes pre-teeners really don't want to talk at all and sometimes they can keep going with breaks only to inhale for twenty minutes.
There isn't a whole lot to report on today, just nice normal normalness so let me point out a couple of nice articles in the 1/24/13 NEJM. There is a nice viewpoint which they summarize as "Awaiting surgery for a malignant pleural effusion, the man is in pain and looks much older than his 50 years. The medical oncologist thinks he's dying. But the surgeon believes the procedure will help, and medical hierarchy discourages questioning of such decisions." I think I have played the part of everyone in this tableau (except the patient, hopefully). Go read it; it's worth the ten or fifteen minutes it takes. One of the things he doesn't talk about that I think is operative in this case is the "herd mentality" where the more people involved in a patient's care, the less likely any particular one is to speak up about things that seem to be going astray. I've had the experience myself where I feel like the patient has five specialists involved in their care and they all evidently think this is OK so why should I, the lowly generalist, make my differing opinion known. There are times I have wished that I had made my lowly opinion known and times it was just as good I hadn't. I try now not to be swayed and to make sure that things make sense to me in any case I'm involved in, but sometimes it's tough. Now that I think about it, I've had that experience most frequently as a hospitalist. I wonder if that is a typical hospitalist feeling or if I'm just special that way. When I've been in the office, I really feel like the internal medicine slogan of "internists: doctors who specialize in you" is true; that I may not be as expert in any medical field as the five specialists this patient is seeing, but chances are I know the patient better than any of their specialists and often I am the only person who understands what all the specialists have to say.
Yesterday, when I ran into some of my old pals, one of them is a specialist who has sent me a few patients all of whom I was very attached to. As we talked about them, I felt a real sense of sadness and real missing of my old primary care practice.
Back to the NEJM. There are a couple of nice articles on smoking, too. This one is on the hazards of smoking and benefits of cessation and has lots of cool statistics for the U.S. like this: "smokers lose at least one decade of life expectancy, as compared with those hwo have never smoked. Cessation before the age of 40 years reduces the risk of death associated with continued smoking by about 90%." Check out figure 2 which shows the survival curves of never smokers versus current smokers. At age 80, it's 70% versus 18%. Whoa, huh? There's also a nice "clinical practice" article about alcohol use. The CPC is a good one and, I am embarrassed to say, one that I should have figured out pretty early on and completely missed. A good reminder to me about that particular disease. (I don't want to say anything more in case you're going to read it; I don't want to spoil it for you.)
Tomorrow is planned to be another really lovely normal normal day. I'm all for it.
I'm going to hope for continued pleasant normalness for me and for you, I will hope that you are having pleasant normalness and that it continues. If not, I will hope that you are able to get to pleasant normalness.

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