In the Good Ol' Days People Just Died

Strolling into the former church social hall turned provider office area a fairly intense conversation was taking place as Doc Conway explained to Rebecca, our nurse practitioner, "Back in the good old days, people just died." Perhaps some context is needed here.

The townfolk of Wynoochee used to see the town doctor for straightforward issues. You break your leg working in the woods there is no question what the problem is. Contract typhoid and there are only two outcomes--you get better or you die. The most common reasons people went to see the doctor was injury or acute illness with clearly defined problems, perhaps a limited number of treatment options, but you knew when the course of the illness had been completed one way or another.

Modern medicine has stolen this clear endpoint from the physician. The success of vaccines and sanitation has decreased the amount of infectious disease compared to days past. Modern medications help blunt, but not cure pathologic processes going on in our patients bodies. What we are left with is a constant state of disability. Often this disability is self induced, of course, through smoking, eating crap, and being couch potatoes. The goal of the modern primary care doctor is not to cure, but to keep stable and minimize disability.

Rebecca had begun this conversation with Doc complaining she never actually made anyone better. The ARNP pulled out her schedule for the day filled with patients with diabetes, high blood pressure, COPD, fibromyalgia, and depression. It was painfully depressing just looking at it. Just every so often she wanted to actually fix someone. There's a concept. You get to the doctor and you get better. You get completely better.

After the old time physician reminisced over the good old days he searched his memory for something he did that day in which the patient left the office feeling better than when he or she came in. "A thrombosed external hemorrhoid. Treat a patient for an acutely thrombosed external hemorrhoid and you'll have a loyal patient for life."

Ahhh, the glamour and glory of the job.

Small Town Celebs

After a reader asked about small town high school football it's as if my mind suddenly opened to it. I began to notice many of the shops lining Main Street had poster sized pictures of football players and cheerleaders in their windows. Low and behold I had been missing out. I cleared all of these pimply pubescents to participate in sports, and now they were doing it.

Immediately after picking up on the obvious I tried to ask Doc Conway what the deal was about football games since prior to this year's festivities he was the king of the sports physical. He grumbled and I think pretended not to hear me choosing instead to walk into an exam room. Next I turned to Joan, his long time nurse who quickly spilled the beans Doc had been to every home high school football game for the last twenty five years as the team physician. He had been holding out on me.

After chasing him around the office the entire morning I finally cornered him by the drug samples. I told him I loved football. "I'm from Chicago, huge Bears fan," I said. With the intensity of mother protecting her young, he made it good and clear that this was still his gig after he retired. I could go with him, but as the junior team doctor and that's all I would be until he kicked the bucket.

When Friday finally arrived, the game, ahhh, it was okay. The band was pretty small and out of sync. Cheerleaders weren't the most attractive or athletic in the world, but the best the town had to offer. The game itself was exciting as even each point after touchdown was an adventure. Wynoochee Warriors beat a team from an even smaller town an hour away. There was an ankle sprain and a concussion, some good bread and butter sports medicine.

The best part of the game was hanging out with Doc even if he did make me carry his 50 lb. blue and white Warriors emblemed duffel bag as the junior member of the team. As we entered the stadium the old physician knew every soul he walked past. He pointed out each of the kids on the team and cheer squad he delivered and in a couple of cases had delivered their parents too. I realized I hadn't seen the man smile in months. He wasn't busy doing chart notes or fighting with insurance companies. He wasn't going over the practice's books or paying bills. For him standing outside in his town under those Friday night lights and bandaging kids up as they came along was what his idea of being a small town country doctor really was.

Dating Update

I realize it's been sometime since I've blogged on my love life and since these posts tend to be some of the more commented upon I thought perhaps I should catch the reader up. You may recall on the last episode of Dr. B's Love Life we had Mandy the Drug Rep versus Samantha the Social Worker. (Play dramatic music).

Mandy is straightforward fun. Incredibly hot with a perky personality, this former cheerleader loves to be dating a doctor and knows how to have a good time. We've been to the fair together and go to movies, hang in bars, and we had a great weekend in Seattle at a fancy hotel. She's the one you have fun with and when things get old (if they ever could with that body) you move on.

Samantha, on the other hand, is the type you have a long term relationship with and, dare I say, the M-word. She's that attractive oozer type with something between her ears and with some depth of personality. When we go out it's the picnic in the park or wine tasting. We've planned an upcoming weekend at a B&B which should be telling as to where this thing is headed.

Mandy is a lot more fun, but Samantha some how makes me feel better. Wrap you arms around that one for a while.

(Okay, reading this over it sounds like an episode of the The Bachelor. I'm really not that much of a male slut and while these women don't exactly know about each other at the same time we have never made any stipulations as to exclusivity.)

Career Choices

Received an e-mail from my Mom in Chicago yesterday telling me about how my Uncle Isaac has decided to leave his current firm and form an all in one legal--accounting--financial planning business with some of his colleagues. Hidden not so subtly in the note was the opportunity if I wanted to get out of medicine, here is an opportunity.

I've tried to give this doctoring thing a fair try, but I'm just as undecided as ever if it's right for me. While Wynoochee has been far better than residency, could I see myself spending the rest of my life doing this? Just look at Doc Conway. He's at the end of his career and wants to get out, but can barely keep the business afloat and find someone to take it over. Just look at the reimbursement structure for health care driven by specialists and their procedures. Who are we kidding that there will be a significant shift toward primary care? Are the cardiologists, gastroenterologists, and urologists suddenly going to decide they will accept less money and give it to their poor colleagues? They are the ones with the money who fuel the AMA into keeping the status quo.

At the same time, patients don't appreciate our services. Even in Wynoochee to them we are often a prescription pad or referral form. If I went back to Chicago to practice in the sea of specialists this would be a hundred times worse. It never ceases to amaze me the surprised look on patients' faces when they ask how long and hard the training is to become a lowly family doctor.

On the other hand, would I be happy as a financial planner? I'd get to go back home and make a comfortable salary without any concerns about getting sued, but would it be too boring. Is this a grass in always greener type situation?

I look at Samantha and she's happy being a poor used and abused social worker. How does she do it?

Doc's Solution

I settled on a solution which would help Doc keep his pride and hopefully alleviate some of the practice's cash flow issues. Unfortunately in the process I may have risked looking like not only an ass, but a stupid ass, but I can deal with that.

At the end of the day I stormed into the provider office area after Rebecca had left and brusquely sat down across from Doc who was filling out a prior authorization form for some patient to get their name brand drug. This was good, we all hate doing this, and this would surely get his dander up.

"Doc, I think I could be doing better here than the salary you're paying me," he looked back at me with shear disbelief and started to stand up from his seat presumably to deliver a roundhouse to my jaw. "Hear me out, Doc. I want to go on productivity. If I collect more I get paid more, if I collect less I'm paid less. I eat what I kill and if I don't eat anything I starve. I've been here long enough now and I deserve this chance."

He smirked at sat back down in his chair, "Yes, you do Dr. B, yes, you do. I have a compensation formula we can look at to subtract your portion of the overhead from the collections and we'll get it worked out by next pay period. Is that okay with you?" I nodded.

I turned and walked away knowing I had probably just taken a steep pay cut, but thrilled at my acting performance only wishing someone had been there to appreciate it. As I walked away I believe I heard Doc humming Willie Nelson's "On the Road Again".

Doc's Dilemma

Doc Conway has been moping around the office and been just kind of irritable for the last few weeks. No one knew why, or at least no one was fessing up. Instead of his usual light hearted repetoire of country diddies he hums and sings throughout the day he's been fairly silent.

As payday for the office came and went I noticed the only person without a check waiting for them on their desk was Doc. With a little arm twisting Marie confirmed it for me. Wynoochee Family Medicine is having cash flow issues.

Everyone thinks doctors are so rich and while I don't see any cardiologists or radiologists struggling, not all physicians are pulling in those bucks. Truth be told, most primary care docs would do much better away from medicine; hence, one of my desires to do this year and leave medicine behind. With increasing overhead costs, malpractice insurance, wanting to do the right thing and offer health insurance to employees, and mortgage sized student debt primary care is just a bad business decision. My Mom told me I should have been a lawyer. Could have gone into the family business and done just fine.

Anyway I indulge in my own issues again. The current problem is my student loan payments are guaranteed through the hospital, but my salary is guaranteed by the practice as an employee. Basically my salary is sucking the practice into a cash flow funk until my billing comes back from the insurance companies. Meanwhile, as owner of the practice, Doc Conway gets paid last or not at all.

I must admit I feel like somewhat of an ass now cavorting around going on here and there meanwhile Doc Conway goes without a paycheck and is probably eating franks and beans for dinner. I'm sorry to also admit this sure makes me want to leave when the year is done.

Do I give some of my paycheck back so Doc can have it? Do I tell Marie to make next month's check less?

Post Date Debrief

Usually I know why I'm attracted to someone. With Mandy the drug rep it's obvious; among other qualities she's the former perky cheerleader with an ass you could bounce a quarter off of, but with Samantha the social worker even after one date I just can't figure it out.

Saturday night we went out for a simple dinner and for a walk around a local park and it was absolutely amazing. It was so simple and easy, yet by the end of the night I felt this huge inexplicable rush. Inevitably we talked about work, but it was more than shop talk. She told me how she ended up doing hospital social work in the middle of nowhere and I shared a little of my journey here.

Don't get me wrong, she's attractive. She definitely has blue nice eyes with a wonderful smile and curves in all the right places, but really in every physical way Mandy is hotter. Mandy is also more extroverted, bubbly, and is just nonstop fun to be with.


Then what is it about Samantha that I just can't get her out of my head? Dare I say I'm actually drawn to her depth personality. Is it the giving hospital social worker who gets crapped on by patients and the rest of the health care system yet retains her idealism and desire to save the world somehow in her?

The bigger question this begs, however is this a sign I'm growing up? Hmmm, not sure how I feel about that.