I recently saw a patient for the first or second time.  He was paralyzed with terrible agoraphobia.  He claimed he had been vomiting every morning for two months.  He was vomiting acid sputum, occasionally blood-streaked.

The canonical approach, of course, is urgent endoscopy.  He wouldn’t hear of it.  And there’s all sorts of other stuff he should do, that he adamantly refused.

The Brave New Medicine would document his refusal, and try to scamper away from the patient before the Liability Bomb went off.  The Brave New Medicine would shame the patient for letting his wackiness spill onto MY job evaluation.  Contempt is a cardinal aspect of New Medicine.

Every failing must be traced to patient noncompliance.

I did document his refusal, of course.  And I gave him omeprazole TID to treat what was likely a simmering gastritis and/or esophagitis.

The Pharmacist, my Boss, at Walgreen’s Drugstore, disagreed, and sent the patient back to me with the assertion that I had “made a mistake” on the prescription.  Naturally, the patient’s tenuous confidence in me was shaken.

Whoever can make you explain your decision is your boss.  The pharmacist was used to omeprazole being ordered QD and BID.  Therefore, TID was a mistake – no need to look it up.  Apparently, the pharmacist was not familiar with patients having Zollinger-Ellison syndrome, or gastrinomas and such, who can receive up to 60mg omeprazole BID.

I do not suspect that my fellow has such an awful condition; such conditions are rare.  Esophagitis and agoraphobia are FAR more prevalent.  Nevertheless, 20mg omeprazole TID is not a harmful dose or a bad idea in simple esophagitis, in spite of the warnings the pharmacist dished out.

I have had a terrible time working for pharmacists recently.  I used hydroxyzine for a patient with chronic pain and insomnia.  The H1 blockers are considered of benefit to augment opiates.

My boss the pharmacist told the patient “No, that’s for itching.  Your doctor made a mistake.”  Back he comes, time wasted, and a little pissed off and paranoid.

How much of your “job review” looks at the actual quality of the medicine you do – lives saved, suffering ameliorated, etc?  I’d say that for me, it’s about 0%  Medicine is now a hobby I practice at work.

In a recent job, I did not get along with the Medical Records people.  They thought I sucked.  I thought they sucked.  But they said bad things about me to the Boss, and I was chastised.  So in that job, I worked FOR medical records.  Because we’re all team players.

Occasionally, some stone crone fussbudget hates me because I’m friendly with that bitch Janet whom SHE SWEARS stole her lunch back in April.  And that gets back to management, who doesn’t have a f’n clue what goes on in their shop, so shame-on-me.

I saw a guy as a primary care “preop,” saw some ST changes that made me unhappy, and halted the surgery to send him off for a thallium, which shows inferior wall ischemia.  He’s gonna be cathed, soon.  He’s grateful, about not dying on the operating table etc.

But who else cares?  Not my Boss at Walgreens’ nor my Bosses in Medical Records, Nursing Assistants, etc.  The “business” is a team model, which means that my medical decisions may only come in one flavor, vanilla.  I need to meet the medical expectations of the pharmacist, the nursing assistants, the secretary, the coders, the medical records personnel.  I shouldn’t do anything beyond what they would do in a situation.

In another – a patient had broken open a disposable razor and swallowed one of the blades.  People who actually ARE familiar with small edged metallic foreign bodies in the GI tract know that a BILLION YEARS of evolution has produced an organ system used to passing indigestibles through without tearing itself up.  The biggest danger is to the fingers, when the patient wipes at the time the blade exits.  That’s all.

But, fortunately, one of the team members knew better, and threatened to call the Television News if we did not send him STRAIGHT to the hospital before he bled to death.  She had not the slightest training in GI medicine, but she had her very own common sense to rely on.  So he spent 3 days in the hospital, getting serial x-rays until he pooped out the blade.

Your boss doesn’t know anything about medicine, but that’s hardly necessary.  All they need to know is simple common sense.  That’s the requirement for doctors of the next twenty years – common sense, an internet connection, and paperwork skills.

 

Advertisements