“Where did you learn this stuff?” I whispered back thinking about all the years he must have done this.
“The truth is that this is the first time I’ve judged a pie in my life. George Crum bowed out at the last minute when his back went out. So I did an online search for the criteria for pie judging.” He winked at me and I barely managed to keep from ruining the atmosphere by laughing out loud.
Dr. Greco pronounced “each and every pie here better than any I have ever tasted” but “we are here to award blue, red, yellow and honorable mention ribbons” and he did a very diplomatic and credible job of bestowing the coveted prizes. He thanked the competitors and we slipped out of the tent quickly before any of the post-competition trash-talking could begin.
Soon after a lunch whose nutritional value was just as suspect as breakfast, I heard a voice call,
“Dr. Vega…Dr. Vega!”
I turned around and there was the plumber I had seen with the “sinus” headaches that turned out instead to be migraines. He quickly walked toward me pulling a very nice-looking blond woman along by the hand.
“Dr. Vega, I don’t mean to intrude, but I just wanted to thank you for all you did for me. This is my wife, Barbara. Barb, this is the doctor who figured out my headaches after all these years!”
“That is very kind of you to say…” I began.
His wife was even more effusive. “Dr. Vega, I don’t know what we would have done without you. George was about to lose his job because of those headaches. He had missed so much work that they were about to fire him. Now that you started him on that medication, he is in line for a promotion to supervisor. We….well… we’re thinking about starting a family now…” She trailed off smiling and blushing and looking up lovingly at her husband all at the same time.
“The bottom line, Dr. Vega, is that if you ever have a plumbing problem in this town, you call me and that problem is fixed. Immediately,” he stated with conviction. “Anyway, we’ve taken up enough of your time, Doctors. Thanks for everything and have a really great time at the fair.”
The plumber and his wife disappeared quickly into the crowd.
I glanced over at Dr. Greco a little sheepishly, “I’m not sure I deserved that, considering you were leading me by the hand all the way.”
“First of all, you made the diagnosis and planned the treatment, Dr. Vega. I just made sure you didn’t jump to a premature conclusion. Second of all, take your kudos where you can get them. Patients don’t hand them out lightly.”
I wouldn’t get to enjoy the glow of the plumber’s praise for very long, because there was another visitor to the fair whose presence would bring me right back to earth. As dusk settled on the grounds and families sat on the picnic benches with their fried chicken and barbecued beef, I saw a woman walk by whose skin was an otherworldly shade of yellow. I knew instantly it was Mrs. O’Malley, the woman with the pancreatic cancer. She walked slowly and tried to smile with her children but I knew at a glance that she was both sad and in pain. Would this be her last fair? Should I walk over and say ‘hello’? And if I did, what would I say? “I’m sorry”? In the end, I left her to the privacy of her moments with her family.
Night fell and Dr. Greco and I sat watching the fireworks without speaking. I thought about all I had seen and felt today. The fair was such a great celebration of all that life had to offer. It reminded me of this town and beyond that the kind of professional life that Dr. Greco had found so fulfilling all these years. But could such a life be enough for me?
Chapter 15
The day after Fair Day brought me back to earth. The newborn nursery was uneventful and so the first challenge of the day awaited me back at Dr. Greco’s office.
Sandra Kramer, age 40, came for follow up of iron deficiency anemia. She was frustrated because no matter how much iron she was given as a supplement, her iron levels stayed low and her red blood cell count would not come up into the normal range. Up until now, she had been treated primarily by her gynecologist. The theory was that her anemia and iron deficiency were due to loss of blood from heavy periods. She denied abdominal pain, blood in the stool or black stools. She had been tested for blood in the stool and the test was negative. Iron-deficiency anemia was very simple really. For a woman, you were either losing blood through the stomach and intestines or from the uterus/vagina. Since the GYN had not found blood in the stool, they concluded her periods were the cause.
I asked Mrs. Kramer to describe her periods.
She replied, “They are very heavy. My periods come every 28 days and last 4 days. The first few days I go through about 3-4 pads per day and the last day 1-2 pads.”
Bells were starting to go off in my head. I was early in my career but I had spoken to a lot of women on my GYN rotation and those did not sound like heavy periods. And if she was not having heavy periods, then we had not really explained where the blood loss was coming from.
After I examined the patient, I made my presentation to Dr. Greco.
“Sir, we could send this patient for intravenous iron and that would normalize the iron levels and the blood count. But I don’t think we have fully ruled out the GI tract as a source of blood loss. She could have an ulcer or worse, a cancer of some type”
Greco gave me a thumbs-up and said, “I concur, Dr. Vega, now go and sell the idea to the patient.”
I went back to the exam room with a feeling of triumph. All I had to do was gently explain to the patient that she needed a couple of very simple painless tests and we might really save her from a serious disease!
Unfortunately, Mrs. Kramer had other ideas.
“I really don’t want to undergo those tests Dr. Vega. When doctors start looking into your body with tubes there’s no telling what could happen. I could have a hole poked in my stomach or intestine. I could have a complication from the sedative. And I know deep in my heart that my anemia is from my periods. So thank you, Dr. Vega, but I would rather just have the iron intravenously and be done with it.”
I excused myself one more time and went back to Dr. Greco.
“Dr. Greco, what do I do when I know what a patient needs a test but they refuse? Once I’m a doctor, what if a patient refuses a procedure and later dies because they didn’t have the procedure. Could I get sued for malpractice?”
“Dr. Vega, this is where you must protect both the patient and yourself. You’ve heard of informed consent—which is where the patient has a right to know the purpose of a procedure with the alternatives to and possible complications of that procedure before giving consent. Well, there is also something called informed refusal. That is when the patient listens to all that you have suggested and declines what you advised. If you carefully document everything, especially that the patient understands and accepts the consequences of the refusal, you are doing everything you can for the patient and the chances of a lawsuit are pretty small.”
He concluded, “And if you present everything in a way that is kind and non-judgmental, the patient may even change her mind later.”
I went back to the exam room with Dr. Greco in tow, and we got our informed refusal. I was very careful not to do anything which would convey disappointment in Mrs. Kramer’s decision.
And later that afternoon I got a phone message.
Mrs. Sandra Kramer called back. She changed her mind and would like the name of the gastroenterologist you wanted to refer her to.
It turned out that I wouldn’t have long to enjoy my feeling of accomplishment in the Kramer case. I would now have to decide what to do with my confused elderly gentleman Mr. Weinkopf. His blood tests showed no treatable cause of memory loss. There would be no easy way to way to halt the distressing hallucinations of his deceased wife or quiet his suspicions that the mail carrier might burglarize his home. With Dr. Greco’s help, I advised an anti-depressant which showed promise in reducing agitation in patients with dementia and another medication to help stabilize his memory. Jillian came with her grandfather once again, but she was all
business. No emotion of any kind flowed between us. Any connection we had made at the park eating Italian ice seemed long forgotten—at least by her. I succeeded in feeling detached and professional that day—but that seemed like a rather small victory in the grand scheme of things. We agreed to see Mr. Weinkopf again in four weeks.
After that, I was feeling a little low, but Dr. Greco came to me with an idea that made me feel a lot better.
“Dr. Vega,” he enquired, “May I ask your advice about something?”
My advice? That’s a switch. “Sure, Dr. Greco, what did you have in mind?”
“Well, you know I’m not exactly a technical genius…” he began.
Yes, and the Edsel was not exactly a Porsche.
“And I need to choose an electronic health record,” he continued.
Oh, no. My mentor, the electronic equivalent of a graying kindergartner, was contemplating making a leap directly into tech graduate school. Recently, the government had made it clear that it would be mandatory to start keeping medical records on computer with very specific kinds of software. This was not, as was popularly imagined, a result of recently passed health care legislation, but rather an outgrowth of mandates that had been evolving for years.
And so Dr. Greco was faced with adopting this software or facing stiff penalties.
“And”, he continued finally, “since you have worked with a number of different EHRs, I wondered if you might help me choose one that I could…maybe…figure out?”
“Dr. Greco,” I smiled, “I would be honored”
“I hoped you might,” he let out his breath with a relieved whoosh of air. “I have lined up three companies which were highly ranked by Family Practice Management for next Monday. Your job is to prep me for exactly what I should look for in a user-friendly system and then take me through the essential features of each system as they are presented to us. I want you to help me ask very probing questions. Then, you will advise me as I choose a system. If you feel that none of the above is a good choice, you will so state and tell me why. In return, I have something to offer you”.
“Liquidable securities? Numbered account in the Caymans? Super bowl tickets?”
He smiled. “Nothing so grand as that. You must have noticed that I have been in this business for an awfully long time. I have been incredibly happy and fulfilled, but I can’t do it forever. I need to retire while I am healthy enough to enjoy it. I am going to need someone to take over for me…someone whom I can trust and moreover someone who my patients will get along with.”
Is he saying what I think he’s saying?
“Dr. Vega…Carlos…I know you haven’t even chosen residency yet, much less completed it. I’m not even sure you want to pursue family medicine as a career. Yet you are the most accomplished, dedicated compassionate student I have ever worked with. More importantly, I have never had a student that my patients instantly took such a liking to. Provided you successfully complete a family practice residency and pass board certification, I would like to hand over my practice directly to you.”
Chapter 16
We both said more that day, but that was the gist of it. He was kind enough to make it clear that he wouldn’t be offended or upset if I turned him down, and that whatever happened he would be giving me a top grade for the family medicine rotation.
I had to admit that I was tempted. He wasn’t just offering me a practice, he was offering me a whole life in a town that was both vital and historic. The range of patients and medical challenges was enormous and ever-changing.
But there was one thing that family medicine in the country couldn’t offer that trauma medicine could and I was embarrassed to acknowledge it.
Money.
Now before you think that we doctors go into this profession to get rich, hear me out.
In the early 2010’s the average medical student graduated with $160,000 in debt between college and medical school loans, so the need to make some serious money early wasn’t so much about avarice as it was about paying the note. Remember that same student won’t start a career until age 28 and many may be 31 or even 33 years old. So hopefully it doesn’t seem quite so greedy when a young doctor takes into account monetary compensation when choosing a specialty.
Anyway, I had some significant student debt built up between Dickinson College and Midcentral State U even if the latter wasn’t Johns Hopkins when it came to tuition. And I still loved the idea of the gleaming tower of healing that trauma medicine represented with its vast array of gizmos and no issues (at least for me) with insurance or filling out forms.
I was more confused than ever about what to do with my life.
Chapter 17
On Monday morning I briefed Dr. Greco in detail with the “Electronic Record Gospel According to Not-So-Saint Carlos”. I explained that the great thing about these systems is that everything you put it these systems you can get back out. The bad thing is that learning how to put it in without spending your life doing it is a neat trick. I showed him how quick it is to send a prescription by computer (and how much the patients like it). I alerted him to many pitfalls of the systems and which ones were most avoidable. I told him point-blank that he would lose a bunch of money the first few months while he got used to the system and he should prepare for that.
We then interviewed all the vendors and took each system for a test drive using simulated patient visits. Dr. Greco rapidly came to a scientifically sound conclusion (with which almost all reviewers before him have resoundingly agreed) and made a sage pronouncement:
“They all suck.”
“My dear Dr. Greco,” I proclaimed with mock seriousness, “when it comes to electronic health records, the issue is not whether or not a certain system sucks but to what degree it sucks and whether its “suckability quotient “ is high enough to render it completely unusable”.
At that, Dr. Greco finally broke up in a huge belly laugh. “Alright, Dr. Vega. You’ve seen the systems, which do I choose?”
I didn’t want to choose for him. In the end, based on his needs and comfort with the software, he was able to choose a system that seemed reasonable. I prayed that he would be okay with it.
During the implementation phase, we saw half the usual volume of patients while Dr. Greco got introduced to the system—I didn’t say “comfortable” with it. It would be a little like getting comfortable with chickenpox.
The amazing thing was the inversion in our relationship. Now, I was the teacher and he was the student. Remarkably, it wasn’t awkward at all.
Chapter 18
Soon after we were up and running (or maybe crawling) with the electronic records, we got a call from a none-too-pleased Jillian Weinkopf. Her grandfather’s agitation was worse, he wasn’t sleeping and the burglary threat from the Domino’s Pizza deliveryman was greater than ever.
Dr. Greco and I met the evening before the scheduled appointment with Mr. Weinkopf and it was clear who was the student and who was the teacher now.
“You know the drill,” he said to me without preamble, “increasing agitation in a patient with Alzheimer’s who has no other treatable cause and didn’t respond to the anti-depressant/anticholinergic combination. We even did an MRI last week just in case his recent deterioration was due to unrecognized stroke and that came up normal also. Remember the next step?”
“There is debate,” I noted, “because a common next step is to use atypical antipsychotic medications, even though they are not FDA approved for this problem and even though some studies have shown a trend towards increased mortality”.
“So what you might have to say in English to the patient and family is this,” Greco advised, “At this point we have few options. If we don’t do anything, Mr. Weinkopf’s life becomes increasingly frightening for him--not to mention placing him at increasing risk for injury or worse in the event he decides to act upon any of his delusions or hallucinations. On the other hand, we can treat him with a medication which could make him feel a lot more comfortable,
allow him to sleep, make it easier to stay at home in a family environment and so on but with which there is a theoretical increased chance of dying somewhat earlier.”
“Wow,” I said, “this is definitely not a conversation I am looking forward to.”
“This, my boy,” said Greco, “is where you learn the art of medicine. Whatever they decide, we need to be one hundred percent supportive.”
Chapter 19
As the sun poured in through the window blind in the exam room the next afternoon, Mr. Weinkopf, Jillian Weinkopf, Dr. Greco and I finished discussing the scenario that Greco and I had rehearsed the day before. I was prepared for many potential responses—irate, angry, frustrated or tearful seemed among the most likely.
Imagine my surprise when Jillian said, “Well I don’t know what we’re waiting for, let’s have that medicine called into the pharmacy and get started as soon as possible.”
I couldn’t help making sure she had understood what we had proposed, “so you’re okay with this even with the…risks…we discussed”.
Jillian immediately gestured with her thumb toward the door. Even with my Y chromosome and confirmed case of chronic cluelessness with women, I was able to divine what this meant.
Once outside the door she said, “my parents and I have already discussed this. We love my grandfather and this is no way for him to live. If he could just get some sleep and some peace, what does it matter if there’s a risk that he might not live quite as long? What kind of life is this?”
“Okay, then let’s try him on a very low dose. Please call me in a week with a progress report. We can very gradually increase as needed. Call me sooner if there are unacceptable side effects.”
She nodded silently and we re-entered the room.
“So we are all in agreement?” Dr. Greco asked.
I’m definitely going to church with Abuela on Sunday.
Chapter 20
A few days later, I was surprised to get a message in my electronic inbox about Mr. Weinkopf. It read simply,