Friday, December 12, 2008

THIS is why I am no longer in primary care medicine


As a diabetes specialist, I see plenty of obese, lazy, self-indulgent, "Oh, whoa is me" people with type 2 diabetes. The patient I saw a few days ago takes the cake, however.

You see, this guy was an engineer until he became 'disabled' from his chronic fatigue syndrome and fibromyalgia six years ago. He is on Medicare now. Both he and his wife weigh roughly 300 pounds. When I saw the patient the other day he whined about how his "total body aches that no one could possibly understand" have been so much worse on his new diabetes medication. Funny, that is not a side effect that has ever been reported to be any higher than placebo...EVER! However, good news! He stopped his proton-pump inhibitor for acid reflux last month and his left knee pain went away! HOLY FUCKING SHIT, BATMAN! He also demanded to know why the tips of his two big toes were tingling sometimes. "I don't know", I said. "Maybe your shoes are too tight, or maybe little alien life forms are intermitently sticking you with microscopic needles, or maybe you simply have no friggin' clue how to deal with a sharp pain now and then like most of us do."

When I left the room after listening to this pathetic shit for 20 minutes I wanted to shoot myself. I was reminded of my little visit to a fibromyalgia message board a few months ago...how entertaining to read what these people share about their 'fibro' and how to find a doctor in your area that 'understands' fibro. Seriously, pour yourself a martini and log onto this fibro message board and thank your lucky stars that your parents raised you to have some gumption.

When my in-laws were failing to convince me to vote for Obama a few months ago, they tried to get me to understand that the majority of Americans were going to vote for change. I reminded them that half of Americans are overweight/obese and believe in UFOs. So kiss my ass. I am rather proud of not being like most Americans these days.

Wonder why very few residents are going into primary care medicine? Because they have to deal with patients like this all day long for 1/4 the pay of their classmates who chose to specialize in gastroenterology or cardiology. I couldn't do it anymore if I had to...luckily, I don't have to.

So, I told him to stop the diabetes medication, call his primary care doctor if his blood sugar rises, and to get a fucking life. I no longer lose sleep over having to be emotionally-invested in people like this.

Lofty

36 comments:

  1. Aye, I agree that Americans, as a whole, are a bunch of wimps who don't even know how to deal with standard aches and pains. But the diagnosis of Fibro seems to be just a catch all for general aches and pains. However, in the example you give...I think even I can identify what's causing this guys "fibro". It's because he's bloody fat and his Primary Care Physician/Provider is too much of a coward to tell him to lose some weight. When you're that heavy(and have no muscle behind it), I have no doubt that it can put some stress on your entire body and therefore make it "ache". Now, I even understand this because I'm quite a bit overweight but I actually exercise and keep in somewhat decent shape.

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  2. ouch. Lofti. this post hurts. my fat rolls.

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  3. "The patient I saw a few days ago takes the cake, however."

    Did you mean for this to be as funny as it was? Takes the cake? Right after obese, self indulgent? Either way, it honestly made me laugh out loud.

    Are you an endo? Do you ever deal with thyroid cancer? Or just Diabetes? What would you do about a cervical lymph node that showed up on ultrasound? Would you "watch it and wait"? or take it out? Biopsy it? Is that a common place for thyroid cancer to return? (You don't have to give me free medical advice. I understand if you don't want to answer).

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  4. Game, set and match...Lofty!!!!

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  5. This may sound like a stupid question, but you stated

    "or maybe you simply have no friggin' clue how to deal with a sharp pain now and then like most of us do."

    So, I take it that it is normal for random sharp pains to occur suddenly and then go away after a few moments?

    This happens to me on a fairly regular basis, not everyday, but often enough. I have NEVER asked my doctor about it because it seems pretty inane and doesn't really effect my daily life.

    Btw, I am 24 and in pretty decent shape.

    Like I said, may be a stupid question, but I have never asked it and I don't know the definite answer as to if it is normal.

    And I can be fairly anonymous here.

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  6. Ahhh....but Roman Wolf....informing patients that they are fat and need to lose weight, while in their best interests, would not improve our Press Ganey scores!!!

    Medicine today is all about "customer service..basically teaching us to be Stepford healthcare providers....many times at the expense of our "customer's health.

    And here, I thought it was a more noble mission to give our patients what they needed (including what they need to hear)....as opposed to what they wanted.

    and Lofty....what ED do you work in that these losers don't come in.....I want a job there!

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  7. Yeah, I guess my body would be screaming in pain if I forced it to carry an abnormal amount of weight. We weren't made to carry that much weight - but I guess that would be insensitive to say...

    Who's toes wouldn't hurt with that much bearing down on them?

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  8. Ah, yes, you are right Jennifer. Doing the right thing is especially hard when you have greedy unethical idiots above you and whiny patients below.

    I get lectured about my weight each time I go to the Doc. And I do believe that many physicians have too simplistic view of weight...however, I always remind myself that weight IS a bad thing for most people because they don't exercise at all. (And I'll admit, I could stand to lose 20-30 pounds)

    Yeah, you can only really get away with being 300+ when you're either a pro weight lifter or a furniture mover.

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  9. i am with you roman,

    i think that weight loss is poorly understood and this is partly a self serving comment.

    clearly there are genetic factors that play heavy (pun intended) in this area and some folks will never have a weight problem.

    that being said, whether it be cigarettes, alcohol, or drugs, pointing out the consequences of un-healthy behavior is not sufficient to get most people to stop said behavior.

    if it were, our prisons would be empty and we would all have wonderfully normal BMIs, marlboros would rot on the shelf and no one would know how to make malt liquor. sheez... just scared myself thinking about such a world, because such a world is also one in which liberals would not exist as no one would need their help.

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  10. Aye. I hear ya, 911.

    The idea that humanity will act perfectly rational in all situations is a silly pipe dream. I think Saint Thomas More made it quite clear how silly the Utopia idea is. Heck, the utopia idea is in fact the fatal flaw in most leftist ideologies. They fail to take into account that human behavior can be irrational at times.

    Anyways, I don't want a Utopia if I couldn't get any whiskey.

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  11. 911...

    You are right...it is not realistic or possible for everyone to look like Betty Page (RIP, by the way) or Jason Statham.....BUT there is a big difference between being 20 lbs overweight and 100 lbs overweight. There is a big difference between the overweight who can still complete a marathon and those who get short of breath just walking from couch to bathroom.

    I am basically unique among health care providers in that I don't believe in behavior control or even preaching behavior modification....the worst think our ED has done is make our hospital "a non smoking campus" ...it makes the psych patients nuttier and the meth/crack addicts tweakier when the can't go out and have a "breathing treatment" I don't believe in banning trans fats...hell....I even think all drugs should be legal. BUT I also don't agree with enabling these patients or limiting/removing the consequences of their actions.

    What kind of "patient advocate" that makes me...I don't know LOL

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  12. Interesting post. My doc has no problem at all telling me to lose weight every 6 mos when I go in for a recheck. Of course, he is kind about it - but when you try to give him a song and dance, he pretty much stands on your toes and tells you how much weight he wants to see gone on the next visit.

    Now the tingling toes I find intrigtuing. When my husband was diagnosed Type 2 last year, that was one of the questions the doc asked HIM. Mind you we weren't there for that at all. We were then told that is sometimes an indication of blood sugar over 200. Was that a legitimate dx and a great way of scaring my husband into losing 62 pounds or was that a load of hooey? Hmmmmmmmmmmmmm....... no I'm wondering....... But I'm enjoying looking at my slim/trim hubby - so who the heck cares!!!!!!!!

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  13. I know people like your patient(s).
    Two especially come to mind: very overweight, eat a lot and the wrong foods, no exercise and sing the "woe is me" song on a daily basis.
    They find it easier to pop pills - or whatever it is they do chemically for their blood sugar levels - than make the effort to watch their portions, diet and activity levels.
    In a way, I feel sorry for them, because they do not have a happy life: they are very limited in what they can do, wear (yes, I am that shallow) where they can sit, how long they can stand and walk; however they choose to live that way. Would it not be a relief on your blood pressure and suicidal thoughts to just humor them?

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  14. I don't feel sorry for people who make bad choices and then whine about it...I say amen to you lofty save your sympathy for those who are in true need of it

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  15. Hey I think I know that Patient! Hes the one sueing me about that Avandia Rx from a few years ago..Of course it might be one of the 12 other 300 lb fatties...Remember back in the 80's when on Surgery Rounds a resident told a similar patient not to worry about those tingly toes...they'd need to be amputated soon anyway..Hope you remembered to document a foot and fundoscopic exam, check his glucometer, and his 5.5% Hb A1C

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  16. I reminded them that half of Americans are overweight/obese and believe in UFOs.

    Oh, oh my GOD. I wish I had thought of that when MY in-laws were failing to convince me to vote for Changey McHoperson.

    Now, of course, I just bitch that my unicorn is on back-order. When your patient gets his unicorn, all his health problems will magically go away.

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  17. I had a patient the other day who complained of nausea. He said he'd lost a bunch of weight and demanded to know where his appetite went. I asked if he'd been able to keep anything down. "Only beer. That's all I can have. I've had nothing but beer and liquor to drink for the past week. Even water makes me sick."

    I was so bamboozled by this statement I didn't respond initially. Did this man just tell me he's had no solid foor or even water intake due to his "sickness" but he has been consuming a case of beer daily? I thought about grabbing the blue phone for the language line to find someone who speaks Fucktard translate this into English, but they don't have anyone like that.

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  18. BTW, this patient I mentioned just above was also "disabled", despite being some 34 years old, because of his "chronic pain" and PTSD.

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  19. That fibro board is either high comedy or physical torture:

    "My goal is to do something productive for 45 minutes a day if I do that I feel like the day's not wasted..."

    "Resting my mind. That means no TV, no computer, no music, no books--nothing that could 'exercise' my brain."

    (Jesus, yeah, you wouldn't want to exercise your mind with television -- that would be too hard.)

    "I have learned to listen to my body, I am ever so aware when I get to tired or just have bad days, instead of always fighting my body to do as I need it to do, I listen and rest and try little bits at a time, or if thats not a option, then I give myself the hall pass of being ground to thy bed!!!!"

    I give myself a pass to stay in bed all day. Courage, man, courage.

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  20. Don't get me started on gastric bypass patients who think the procedure will automagically make them slim and trim and gives them a free pass to resume inactivity and poor eating habits. Sure, load-bearing joints and other parts will hurt under excessive strain. Have a Celebrex, it'll make you feel better. (Disclaimer: I need to lose 30 lbs myself, but am nowhere near bariatric surgery eligibility .)

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  21. Hey, watch it now.... the fatties of the world make me a whole heckuva lotta cash.....

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  22. changey mchoperson? okay, you got me to laugh there crankylitprof. very nice.

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  23. Eheh...Changey McHoperson.

    God, as annoying as Obama can be, his sycophants are even worse. Pretty much any of my friends my age voted for him(minus two, both former military). And now they're talking about how great things are going to be, you'd think once Obama becomes President, the entire world would become a great Utopia and nothing bad will happen ever again. I've got tired of crushing their dreams using verbal jujitsu. Guess you can't crush hope, even when that hope is in a person of questionable moral character.

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  24. While Lofty is right onon this one..
    The weight thing does get me a bit stirred up..
    The vast majority of insurance actuarial tables don't go higher than 6'4"..Therefore I must not exist to them or they know I'm at a very high risk for dying from any reason and do not chose to insure anyone over that height. On the one table I managed to find that listed someone my height
    (5'19") I swear to God I was supposedx to weigh 215lbs!
    Said all this just to say weight is an individual thing and must be treated medically part of an individual's overall health assesment..Ask 911 what I would look like at 215lbs!..
    Ahh but for the old days when, honest to God, I would tell fat phucks with "back pain" to LOSE WEIGHT!!!!

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  25. This comment has been removed by the author.

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  26. Ooops... I think I deleted my previous post by mistake, but thanks for the answer. I think... :-)

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  27. I would have recommended bariatric surgery (the bypass, not the band). If he doesn't have self-control, this is probably the only option.

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  28. Great Post ! Do invite me if you ever have a cocktail party!

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  29. Just curious-do any of your patients actually lose weight when you tell them they need to lose weight? Because when my doc told me I was about 50 lbs overweight, then told me what would probably happen if I didn't lose it (diabetes, heart failure, you know the litany) I lost the weight. I'm comtemplating my first marathon next year, thanks to my doc. I told him, too-he knows I'm grateful.

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  30. clearly there are genetic factors that play heavy (pun intended) in this area and some folks will never have a weight problem.

    You forget, that stupidity is also a genetic factor, it runs in families.

    that being said, whether it be cigarettes, alcohol, or drugs, pointing out the consequences of un-healthy behavior is not sufficient to get most people to stop said behavior.

    Again, stupidity runs in families.

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  31. From the board:
    "For anyone who can't afford to buy a bunch of supplements, I suggest acquiring as many credit cards as you can and then filing bankruptcy over and over. I know someone who does this, or at least used to. I understand they changed the bankruptcy laws a few years ago to make it more difficult, but if you're already bedridden and about to lose everything, then you have nothing MORE to lose by trying it. You need to give the body what it needs to function....Doctors will not treat you with what your body needs, but only with drugs. If you don't believe this, then you have to research this subject and get past this hurdle... Doctors and drug companies exist to make money, not to cure illnesses. You need things like coq10, magnesium, amino acids, enzymes, etc, and your doctor will not recommend ANY of these. To quote Robert Ripley: "Believe it or not". But if you don't, you will suffer at the hands of your doctors for years. I would much rather recommend that you do the immoral thing with credit cards and bankruptcy rather than lay around suffering in agony while your life slips through your fingers."

    GREAT-repeatedly file for bankruptcy?

    "Glutathione - main body detoxifier next to growth hormone. It's vital. Supplementing with pills or IV usually doesn't work, it's very poorly absorbed. Take NAC (I'm using), maybe 250 mg 2-4 times a day. If the liver is in bad shape, this may be toxic to it, start slow. This will produce glutathione. So will undenatured whey powder, available from immunesupport. But if you have a dairy intolerance, probably not a good idea. I tried it and sneezed the next day. If you're in really bad shape, try just a little bit first! Like 1/2 teaspoon. If you're detoxing, that's one thing. But if you sneeze or get an allergic reaction, it will just harrass the immune system. Same with transfer factor which is from colostrum. It made me sneeze. Glutathione is included here but it isn't only for the th2-th1 shift, YOU HAVE TO HAVE IT TO GET BETTER."

    They SNEEZED? That's my favorite, all bet's are off now, can't possibly use it now since they sneezed once within 24 hours of using it. I can't stop laughing. This board is too much fun.
    (username was catseye)

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  32. I did know a patient who hit 300+ pounds while in a bad relationship and being told she was nothing, daily. She also complained of sundry aches and pains. With only a little coaching and encouragement, plus support from a women's shelter, she dumped the prick, lost the weight, and is now gainfully employed and a great mother to her three kids.

    I wasn't her doc, but she did have a doc who refused to give her a diagnosis of fibro (though she asked for one). She thanks him every time she sees him.

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  33. So, You Want To Be A Doctor…..

    In recent times, others have appeared to express concern about the apparent shortage of primary care doctors in particular in the United States. Both presently as well as in the years to come, others speculate that the shortage of doctors will continue to progress to even greater absence of PCPs that what exists now. Less than 20 percent of medical school graduates go for primary care as a specialty as a residency program today. Typically, the main reason believed by many is lack of pay compared with other medical specialties. Some anticipate a shortage of 60 thousand or so primary care doctors in the future within the United States. The PCP doctors who practice right now would not recommend their specialty, or their profession, it has been reported.
    It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. Ironically, PCPs have been determined to be the backbone of the U.S. Health care system, which I believe them to be. For example, PCPs manage the many chronically ill patients, who benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly half of the U.S. population has at least one chronic illness- with many of those having more than one of these types of these illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget, who are largely cared and treated by PCPs.
    The shortage of primary care physicians is possibly due to other variables as well- such as administrative hassles that are quite vexing for the physician vocation overall- along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients due to decreasing reimbursements from various organizations the doctors receive for the services they provide. For reasons such as this, it is believed that some PCPs are retiring early, or simply seeking an alternative career path. As mentioned earlier, the PCP specialty is not desirable for a late stage medical student, so this is quite concerning to the public health in the United States. The number of medical school graduates entering family practice residencies has decreased by about half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers with decreased pay, comparatively speaking.
    Despite the shortage of these doctors, primary care physicians do in fact care for the populations they serve and are dedicated to their welfare, as difficult as it may be for them at times. Studies have shown that mortality rates would decrease due to increased patient outcomes if there were more PCPs to serve those in need of treatment. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if numbered correctly to serve a given population of citizens. In addition, PCP care has proven to improve the quality of care given to patients, as well as the outcomes for these patients as a result are more favorable. Most importantly, the overall quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase mildly if at all in the years to come. The American College of Physicians believes that a patient- centered national health care workforce policy is needed to address these issues that would ideally be of most benefit for the public health. Policymakers should take this into serious consideration.
    “In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero
    Dan Abshear (ex-military medic and physician assistant for nearly 20 years)
    Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.

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  34. wow, that's a whole lot of words!

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