Monday
Summer has come and gone and school is back in session.
Big yellow buses dot the morning landscape, where fall
colours have slowly crept in. A few cool nights and
the trees give up, turn their leaves and drop them without
a fight. The colours are beautiful but fleeting. It
all seems very gloomy for a time of year that's usually
still warm and cheerful.
Perhaps I've gone off summer. I've
had two melanomas in my practice this season and that
depresses me. Both were measured as Clarke 3, a ranking
based mainly on depth of invasion. But now it appears
that Breslau, another depth ranking, is more important
in determining course of treatment. If the Breslau measure
is a millimetre or more, sentinel node mapping is usually
carried out. Of course, to get that information, I had
to get my hands on one of the surgeons who can carry
out the mapping technique. That caused a significant
delay for my latest melanoma patient, a forty-year-old
woman who's understandably anxious to get on with her
treatment.
General practice is often a slippery
slope. You don't see a melanoma for five or 10 years
and then you get two in a few weeks. But in that five
or ten years the management of the disease has changed
and your knowledge base needs upgrading. You're always
trying to keep up.
Tuesday
I get a call from emergency. I'm on orphan call, a service
we all provide but few of us enjoy. The emergency doctor
tells me they're admitting an 81-year-old woman with
weakness. They can't find anything specific. She's too
weak to go home and the family has left her here. I
wonder if this will end up being a social admission
and we'll spend hours trying to get her into a retirement
or nursing home. By the time I get to see her I'm already
working out what to say to the relatives.
As it turns out she has genuine
progressive motor weakness. Two weeks ago she was doing
her shopping and now she needs help getting onto a commode.
She's not febrile or toxic, has no anorexia or weight
loss, isn't depressed or demented. Her blood work, chest
x-ray and other investigations are all essentially normal.
She does have cystitis but her symptoms don't change
with treatment. After several days in hospital both
her lower legs have lost power. I enlist the help of
one of our internists who quickly surmises that she
must have a lesion affecting her cord, so we send her
up the road to the neurologists for an MRI. Her weakness
really was progressive weakness and my assumptions were
an impediment to her being diagnosed and treated.
In the afternoon we have a session
on teaching with the University of Ottawa. A number
of the doctors at our hospital have agreed to formalize
our teaching arrangements. We have an educational session
that focuses on teaching and evaluating medical students.
It's very well attended and there's excitement at bringing
students into our practices on a more regular basis.
Wednesday
We have a problem that won't go away. We've been without
an internet connection since the beginning of the week
and our Internet Service Provider (ISP) seems determined
to shirk any obligation to fix it. Our group has four
clinics and we've all converted to an Electronic Medical
Record (EMR) in the past 18 months. We have a central
"server" that keeps all the records and use the internet
to access the EMR from the outer offices. When the ISP
fails to provide you that service for several days,
you start to pull your hair out.
After waiting at the end of the
phone listening to irrelevant recordings, I finally
get to speak to someone. But even though these are the
people who guaranteed service within 48 hours of a problem,
this, it turns out, is "not really their problem." They
insist it must be something else. Of course it isn't,
but we still have to wait another day before they even
agree to look into it.
For three days we haven't been
able to access any medical information from the patient
records. The frustration for patients is enormous, but
the frustration for physicians and staff is overwhelming.
I expect that our experience is not unique, that as
more and more of my colleagues computerize and convert
to EMRs, they can eventually expect some similar experience.
My advice is to take service over price and don't believe
what the sales people tell you. Get a reference from
your peers.
Thursday
Today's a better day. Our middle child comes home from
Kingston en route to London, England, to begin a Masters
Program. It will be a fabulous opportunity for her.
In the evening, there's a CME event on NAFLD and NASH
(Non Alcoholic Fatty Liver Disease and Non Alcoholic
Steatohepatitis). The talk is educational, the discussion
is good and the wine and meal are excellent. Our livers
work overtime trying to keep our metabolism in order.
Friday
My inpatient practice is all discharged. The internet
is up and running and the clinic runs smoothly. After
the last patient is gone I spend some time trying to
catch up on letters and forms. These are joys that all
physicians face nowadays, but most of us would do anything
to avoid them. I hurry through it all as quickly as
I dare, lock the office door and escape home.
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