Saturday, January 25, 2014


Insomnia--Part Two

One of the things that bothers me the most is reading about sleep hygiene is how the articles always talk about relaxation techniques or visualization but then leave you on your own to figure out how to do that.

Basically, it's all about distraction. The goal is to get your brain to focus, not allow it to ruminate on the bills, tomorrow's tasks, your OCD, etc.

I remember doing Jane Fonda's yoga (yes I'm that old). At the end of the work-out you would lie on your back on a mat and do progressive relaxation and deep breathing. I never understood the command to follow your breathing. What the heck does that mean?

I could however, Tighten and relax muscle groups starting at my toes and working my way up.  The problem was, here I was ALL RELAXED and then my brain would say, "OKAY, Now what?"
 And the racing thoughts would LUNGE forward into my consciousness again.

So... I taught myself to be on a beach in Hawaii in my mind.  I didn't know it at the time but I had taught myself visualization.

"What is visualization, DoctorDiva?" 


Visualization is a way to imagine yourself someplace calm and quiet and to fully engage your brain in the process.  That way, that pile of bills on the table, and the list of stuff you have to do, has no where to go in your brain, but to be squashed up against your skull while you listen to the waves, and feel the sun, and ...Oh.  yeah.  I digress.

The best teacher I ever had for this was a surgeon turned psychiatrist. Can you imagine--- a surgical approach to psychiatry? She was magnificent. She didn't use much of the touchy-feely approach, but taught problem oriented solutions that worked.

She taught us a visualization technique by taking us through it. By the end, all of the old geezers in the class were SOUND asleep.


Close your eyes.  
(Oh Wait. You can't read this with your eyes closed)
Okay, after you read this, CLOSE YOUR EYES.  

Picture a blackboard. Picture the number 10 and try to relax your body 10 times more than it is at this moment.

Picture the number five. Relax your body five times more than it is right now.

Picture the number two on the blackboard and relax your body two times more than it is right now.

Now picture yourself in a hallway. My hallway is in a castle with suits of armor and paintings along the walls and a wooden floor with a runner down the middle.  Make it what make whatever you want. But you need to actually put yourself in the hall.

Walk down the hall.  Feel your feet on the floor or the carpeting with each step.
 Focus on what's around you.

At the end of the hallway there's an escalator.

Put your hand on the banister and your feet on the top step and actually feel yourself going down. As you are going down the escalator relax.

Get off and go down another escalator, again concentrating on how it feels to be on the escalator and as you go down, relax even more.

Get off and go down a third escalator, and relax even more.

 At the bottom of the third escalator, you enter another hallway.

Walk down the hallway to the end where there will be a set of double doors.

Throw open the doors to your relaxation place.

 One of my patients likes swimming with the dolphins.

 I like to be on a beach in Hawaii. Pick what works for you and then BE THERE.

Feel the sand under your feet.  Concentrate on the warmth and brightness of the sun.
Hear the waves and the seagulls.

Look around.  What do you see?          Be there.

 By this point you should be incredibly relaxed or completely comatose.

If at any point during the process your brain turns on and thoughts invade,  visualize yourself shoving the thoughts up against the walls of the hallway where they disappear.

 Sometimes, if my thoughts invade and I can't relax,  I have to start at the beginning again.

  Eventually, I get to my visualization place.

 It's a rare night where this does not work. It takes about 10 minutes in total. It also takes about  
six months of regular practice and then you will be able to skip the whole chalkboard/hallway thing and can go directly to your visualization place.

You will have trained your body to relax to the point where you can just open the doors and feel yourself relax.

Good night and Good Dreaming.

Thursday, January 23, 2014

Let Sleeping Dogs Lie. ALONE. GO to BED!

My son, as of late, has taken to sleeping on the couch. 

With our dog. 

Who smells.  Like a dog.  And now, so does the couch, the blankets, and my son.

(Okay, this isn't a couch, but they're all the time)

WHY?  You ask,  is he sleeping there?  And more importantly, why is this a problem?

He claims his mattress is old and uncomfortable.  He wants a new one.

I think he just wants to sleep with the dog.

The problem is, now my DAUGHTER has started to sleep downstairs.  With the dog.  Not in her bed. 

I want my privacy back.

You see, the kid's rooms are upstairs, and ours is downstairs.  Lots of privacy.  NOT.  Because they aren't sleeping up there.  AND they're crabby because they're not sleeping well. 

Let sleeping dogs lie.  ALONE!

 Yes, I am a light sleeper. By light, I mean I need a completely dark room and absolute silence. I can hear a mouse fart in the wall. 
When I was an intern and resident, it was a badge of honor to be up all night long taking care of emergencies and putting out fires(Literally. Once. Another story).

I was not very good at staying up all night. Once, I  fell asleep holding a retractor when I was a student during a gallbladder surgery. I was on my feet pulling as hard as I could on the retractor and I fell asleep. I had been up the whole night doing EKGs and taking care of post-operative patients. That's what third-year medical students did then. We were scut monkeys.

We used a book like this.  It weighed 400 lbs in our short white coats. 

I had never heard the word "scut monkey" until I became a medical student. "Scut" is all of the work that  interns and residents feel is "below" them.

Scut included drawing all of the morning bloods, changing all of the wound dressings, doing the EKGs and blood gases, drawing the blood cultures, and starting IV lines. Scut was delegated to the students and the interns. The second and third year residents  slept and studied. We were to call them only in the event of an emergency or with a question that we couldn't figure out on our own by going to the library and looking it up.

(Oh SO many things have changed...for one, Library?  What library?  Go look it up on line, scut monkey!)

The head of surgery told me that surgeons should only need to sleep for two hours a night and should feel rested. "Don't go into surgery..."  was loudly implied.

I self-selected myself out of Obstetrics and gynecology. Those residents were sleep deprived miserable human beings and were mean to the medical students. They made the medical students stay up all night long watching the women in labor. I mean really Watching.  Sitting in the room with a woman screaming while she had contractions.  To punish us. 

That's when I discovered that I needed sleep. Lots of it. I needed eight hours of sleep a night every night, all the time. 

 I craved it and coveted sleep. I would sneak off to sleep in the afternoons, following my surgical residents advice, "EAT when you can.  SLEEP when you can.  And don't F*^k around with the PANCREAS." 

 I learned all of the following:

 drinking caffeine after noon disrupts sleep.

 One glass of alcohol  wakes me up four hours after falling asleep.

 Exercising within two hours of sleep is a bad idea.
Reading in bed or having a TV in the bedroom disrupts sleep, makes it hard to fall asleep, and trains the mind to think of bed as an entertainment unit

Having the room too hot or sleeping with pets disrupts sleep.

Keeping odd hours messes with me.

Odd hours are the bread-and-butter of being a physician. We are awakened at all hours by the phone ringing.
A phone ringing at three in the morning to me is just routine. The phone ringing at three in the morning for my sister means someone is dying.

(This is a gratuitous photo of David Tennant because he IS the best Doctor Who.  You're welcome. )

As a result of having all of these interruptions to my sleep, I got really good at relaxation and visualization  techniques. 

 I learned how to partition off that part of my brain that was going 900 miles an hour with racing thoughts and worries. It was survival. As a physician you have to learn how to shut off in order to function.

Doctors learn how to shut off the part of the brain that makes you PANIC when you see something totally GROSS.  You HAVE to in order to function.  SO, I used that to help me sleep.  I learned how to SHUT OFF THE RACING THOUGHTS.

Next blog, I'll teach YOU how to do it too.

Saturday, January 18, 2014

Just the Facts, M'aam, or Born To Run ALWAYS Sounds Fabulous in the Shower.


  With Jimmy Fallon's and Bruce Springsteen's latest parody of Born to Run making the rounds on the internet, the song got STUCK in my head.  They call this an "earworm".  I call it AWESOME!  What better song to get stuck on replay?  It's high energy. It gets you going in the morning.  I feel FABULOUS.


     Naturally I started singing it in the shower.  I sang it in my natural alto tenor, in falsetto, loudly, softly, and of course with great feeling. I sounded SPECTACULAR.

     When I got out of the shower, I said to my husband, "Did you hear me singing in the shower? BRUCE!"
     He said, (with a straight face I might add), "Oh.  Was that what it was?  The words were the same but the tune was different!" 


Good thing I was in an amped up mood from singing Bruce and was able to laugh at myself. 

I replied, "EVERYTHING sounds better in the shower when you sing it.  It's like magic!  I sounded GREAT." 
He just smiled. 

Juan has mastered the art of deflating my bubble without insulting me. 

Once, when I had gained a little weight, I put on a pair of pants that were a little...snug.  I asked him,

 "Are these pants too tight?"

He replied,
"Clothing always looks better when it fits well."  

'Nough said.  I got on line and ordered myself some new pants a size up.  I figured it was his fault when the credit card bill came in.

So HOW do I tell my patients that they are fat, or out of shape, or need to bathe, or smell like urine, or have built up dead skin between their toes that smells just awful, or have really bad breath, all without hurting their feelings? 

I take a page out of my husbands book of getting his point across with grace and kindness.  

Just the facts, m'aam.  No embellishment.  No commentary.  No gross face.  No passing out or dry heaving  (although I almost did that when maggots fell out of a bandage on a wound after the patient hadn't changed it for a week).

Occasionally, when I know a patient has a good sense of humor, I calls 'em as I sees 'em. 

Here's a real conversation.

"I've gained a few pounds doc.  See this on my belly?" She squeezed a handful of fat. "I think it's all water weight."

Me:  "Oh, REALLY?  C'mon.  I hate to break it to you, but THAT is FAT.  THAT is not water."  

I only do that when I know someone has a good sense of humor.  Otherwise, I have to resort to:

"Water weight normally causes ankle swelling.  It goes where gravity takes it, the lowest point on your body.  That is adipose, or fatty tissue on your abdomen..."  and so on.  


"I noticed that your breath has a foul anaerobic odor to it.  When was the last time you saw your dentist?  Do you have recurrent sinus infections?"


"Hoooey!  That's some stickin' breath you have there. When was the last time you brushed those teeth?  Please turn your face away when you talk because I'm having a hard time seeing through the haze here!"

"You have a Body Mass Index that puts you in the Super Obese Range.  This puts you at huge risk for diabetes, hypertension, sleep apnea, arthritis, and early death.  Oh, no one ever told you that you were obese before?  You thought you were just a little overweight?  No.  I'm sorry to tell you this but our society is now 60% overweight or obese and the people around you that you think are 'normal' are likely overweight or Obese.  Three hundred and ninety four pounds at Five foot two inches tall is almost 180 pounds overweight."


 "Seriously?  Are you kidding me?  You didn't know you were obese?"  

It's hard.  You can't get people to change if you insult them.  You have to tread that fine line between pointing out painful truths that they have closed their eyes to, and hitting them over the head with it.  Sometimes the options are not good. 

But I DO sing in tune.  ESPECIALLY in the shower.  I DO!! 
(Okay.  Maybe I'll take voice lessons.)

Thursday, January 16, 2014

My Husband is an Evil Genius-OR-I'm EATING Your Cinnabons

Today I had an epiphany---My husband is an evil genius.

Every single morning, battle lines are drawn:

6:00 a.m.  I've been up for half an hour.  I call upstairs to my 15 year old son who has 45 minutes to get up, get dressed, eat, and get ready for me to take him to school.

6:10 a.m.  I call again.  "Tom, get UP!"
               "I'm UP. Leave me alone."   Deafening silence ensues.

6: 15 a.m  "GET UP!" I'm leaving in 30 minutes WITH OR WITHOUT YOU."

6:30 a.m.  I'm out of the shower, fed, caffeinated and putting the final touches on my makeup, searching for my cell phone and keys, and putting on my boots.
          "I'm leaving in 10 minutes!"

Sudden crashing of feet on the floor, a flurry of activity with a smattering of cursing which I pretend not to hear, and IT IS ALIVE and IT is in a foul mood completely directed towards me.  IT is mad because IT doesn't have time to eat and we end up in an argument because I'm super irritated that IT has the GALL to be mad at me.


THIS morning was different. It went like this:
I got up at 5:00 a.m. so I could do some paperwork for work.  I decided to make Pillsbury Cinnabons.  

6:00 a.m.  I call to get my son up.  I tell him about the Cinnabons. (yummy!)  I figured it would be magical bribery and would rouse him from his sleep. The wafting of the cinnamon-y goodness had already gotten my husband out of bed.

6:10 a.m.   Still no movement and now I'm peeved.  "Get your butt down here right now!"

Husband intervenes.
"That's not the way to do it.  Watch this."  He grinned evilly and I swear he said, "Muuahhaawww!"

"Hey Tom.  If you don't come down right now, I'm going to eat your Cinnabons."
CRASH. BAM. BOOM!  I'll be darned, but it WORKED.  Down he came, at light speed, dressed and ready to take on any potential Cinnabon thief.

"You gotta know what motivates your audience!" is my husbands response to my  raised eyebrow and query as to how he worked this strange magic.

Now I can hear you thinking, "He wouldn't really eat the Cinnabons, would he?"

"Darned straight, I would!" replies my husband to your well thought out question. "It's the Hereña rules."

Let me explain. Early on in our marriage, I learned that since my husband grew up in family with five children,  there were no leftovers--EVER.  If you didn't make it to the table in time for dinner, your portion would disappear. Vanish.  GONE.  Adios.  Make a PB and J and call it a day. 
If you tried to save something in the refrigerator for later enjoyment,  good luck with that because one of the other members of the family would eat it.

"How," you ask, "Did you learn this?"

WELL,  early in our marriage, I left some leftovers in the fridge for three or four days, went to retrieve them and--they were GONE.

"I thought you didn't want it.  You hadn't eaten it, so it was fair game," stated my husband.

We stored our Anniversary Wedding Cake in my mother-in-law's freezer after our wedding. Juan went to retrieve it and it was gone.  Rob, his brother, thought it was fair game and ATE THE WHOLE THING (not that I hold grudges or anything).  I was mad. Juan was philosophical. It was the Hereña Rules at work.

It got me thinking.  How do I motivate my PATIENTS to do the things I need them to do, like SHOW UP for appointments, take their medications, exercise, cut out salt and sugar?
Heck, How do I motivate anyone to do anything?  It was clear, my husband had a leg up on me on this point.

Some of my attempts at improving compliance with treatment included the following:

 Education,  often met by a glazed sheen in my patient's eyes. Come to think of it, it's the same look Tom and El get when I'm off on a "lecture."

Cheerleading--Instead of fussing at people because they haven't reached their goals, I  encourage them to keep trying.  Often this tactic works. It makes people more likely to come back too, since it's positive reinforcement instead of fussing at people and making them feel bad.  I consider a return visit a coup in and of itself.  I actually do a "Happy Dance" if they reach a goal.  It makes people smile.

Negative reinforcement or"yelling" at people.  I point out all of the bad things that will happen to them if they don't do what they should for their health.  For example, the end of the world as we know it, fire and brimstone, cats and dogs living together, etc. Sometimes that works.  When I point out to women that smoking causes premature wrinkling, that motivates them to stop. Cancer? Not so much.  Wrinkles? Yup.  Go figure.

Sometimes, all that will work are the Hereña Rules.

If a patient has not followed up, I threaten to hold their medications hostage.  Then, if they still don't come in for follow up, I do it.  I won't refill their meds.  It's a last ditch effort, after phone calls, letters, and plain old begging  haven't worked to get someone in for their follow up appointment.

I HATE doing it.  I will do everything in my power to avoid it.  I don't WANT people to run out of medications, but I HAVE to monitor their meds, and their side effects.  If someone doesn't come in for followup, I don't know if the meds are working, or if their kidneys or livers are in trouble, or ANYTHING!  It's really scary.  I'm responsible for my patient and I want them to be healthy.

Soon a frantic phone call will come in.  "DoctorDiva won't renew my meds!"

I say, "Tell them to schedule an appointment and I'll give them enough until they come in."

Works every time.   Take away their Cinnabon, and Voila! 
Hereña Rules. 
My husband is an Evil Genius.

Saturday, January 11, 2014

Frostbite, STDs and Teenage Butthead-ery

I was thinking about how incredibly cold it's been here in Chicago, (No, I will NOT call it Chiberia).  A post on hypothermia and frostbite came to mind, specifically because my teenaged son was being a butthead and refusing to heed our warnings about flash frozen fingers and frostbitten faces and ears.  My husband showed him some photos of gangrenous fingers, toes and ears and he got the message and wore gloves, a hat, and a scarf, but not without some gross pictures..

Then I saw Alexander Skarsgard in all his naked glory on the portable toilet in Antarctica.  What a great segue!  I heard it was warmer in Antarctica than it was in Chicago earlier this week.  Go figure.

 So I asked my husband how he thought of showing my progeny pictures to convince him to use gloves, and he said, "A picture is worth a thousand words."  He told me about how when he was a kid, his father, a surgeon, had a medical textbook with a picture of Pian disease or Yaws in it.  It so terrified my husband, he was so affected by it,  that he wouldn't go within 10 feet of his father's textbooks of medicine for years. (And yet, he became a pulmonary and critical care subspecialist.  Go figure.)

Tertiary YAWS/Pian disease:

THAT got me thinking.  Boys do not heed adult advice.  At least, that's been my experience.  They have to make their own mistakes, or make up their own minds about something.  All my kid hears from me is:  "Blah, blah, blah, Are you listening to me?  I'm telling you to blah, blah, blah..." and so on.

Pictures.  That's the ticket.

So, here's what I'm going to show him to prevent him from having unprotected sex and getting STDs.

Tertiary syphilis causes horrible disfigurement, and some of the pics were even too gross for me to show.  I plan to show him pictures of primary syphilis with ulcers on the penis, secondary syphilis with the rash all over, and pictures like this with the nose disfigured.

Lymphogranuloma venereum or Chancroid:
A lovely little infection caused by a chlamydia that causes massive swelling of the lymph nodes in the groin, which can open up and ulcerate.

And speaking of chlamydia (and gonorrhea):
The pictures of the penile drip are too gross to put here.  But trust me.  He'll see them.

Then there's GENITAL WARTS.
I've gotten him vaccinated against HPV, the virus that causes them, and I'm hoping that it works, but just in case he's attempted to go scuba diving without a wetsuit, I'll show him this, but on the penis:
I'VE seen this too many times to number.  It is devastating and difficult to treat.  The topical medications hurt, and the aftermath of surgery to remove large accumulations is painful too.  Plus, these lovely little warts cause cancer of the cervix, cancer of the anal-rectal area, cancer of the throat and mouth and voicebox.

Herpes Happens.
Herpes can happen ANYWHERE on the body.  Cold sores are from herpes.  Herpetic whitlow is a herpes infection of the finger.  Imagine if this was your penis or vaginal area instead.  Ugh. That's gotta hurt.

Of course, there is the big Momma of STD's, HIV/AIDS.  There is no one picture to show the horror of that disease.  I was a resident and student in the late 1980's early 1990's and I saw entirely too many people die from horrible awful complications of that disease.  I wouldn't wish that on my worst enemy.  I saw brain and lung lymphoma from it, Kaposi's sarcoma, blindness, terrible secondary infections from PCP pneumonia or even run of the mill bacterial pneumonia that decimated the patients who had no immune system left to fight off the diseases that ordinary people either wouldn't get, or could fight off.  
That will be a whole topic unto itself of photos and stories to prevent his not wearing a raincoat on his johnson. 

So, somehow my blog on hypothermia morphed.  But Hopefully, some other mom somewhere will show her kid gross memorable pictures of the reality of sexually transmitted diseases, and prevent it from happening to their child. 

Tuesday, January 7, 2014

Me and My Pressure Cooker

Okay, I'll admit it.  I love new gadgets.

I've always been afraid of pressure cookers, though.  My Mother in Law makes the best red beans  EVER in one, and I thought, well, I needed one.  My research scared the bejesus out of me though. Those things are DANGEROUS.

So I got other gadgets first.

The bread maker.  Sitting on a shelf right now, unused.

The big huge Kitchen Aid mixer thingee that is too big to leave on the counter, and too heavy to carry to the counter from the mud room.  My husband loves it though, and just got a meat grinder attachment for it.

A mandoline.  I'm terrified of the darned thing.  I don't have any suture material at home, just in case...and honestly, I like my fingertips.

Various lemon juicers.  I have an electric one.  It is dying.  I have one that sits on a bowl.  Too much elbow grease involved.  I do like this one:
Blenders:  They always disappoint me.  I like to make pesto, and cheese based Peruvian dishes and it just isn't strong enough.  Plus, I hate all of the stupid parts, especially the rubber ring thing.  I'm forever losing it.

Hand choppers:  Really?  They aren't really all that great.  They massacre the onions and garlic by mostly crushing them. 

Food Processors:  Again with the zillions of parts.  Unless you really need to shred a bunch of carrots, or cheese, it's almost not worth all of the clean up.  I do like these better for pesto, though. 

So, I finally bit the bullet and saw a 6 or 8 qt pressure cooker on sale for twenty bucks at K-Mart (or "Le-Mart" as I like to call it.) I figured twenty bucks was not so much that I would be devastated if I hated the thing. 

It was love at first use.  

I read and re-read the instructions obsessively so I wouldn't blow up my kitchen. 

I started making beans-from dried.  NO TIME AT ALL!! and SOFTER!  The seasonings got INTO the beans, and I used MUCH less salt or NO salt, compared with canned.

Rice--brown rice is better and quicker.  White rice, not so much.
Apple cake. Yum. 
Tamales take NO TIME. Did you know you can put in a tray and STEAM stuff?
Pot Roast.  With really tough meat.  30 -60 minutes.  WOW!
Steel cut oats that are SOFT?  Amazing. 

Soon, I needed a bigger pot.  I wanted to make corned beef.  LOTS of corned beef.  So I bought a canner sized pressure cooker.  It is HUMONGOUS. 


So now I'm addicted to my pressure cooker.  
Hoppin' John for New Years Day (It's good luck to eat black eyed peas and ham on NewYear's Day) took NO TIME.  I pressure cooked some smoked turkey necks first in water (the store was out of ham hocks) and soaked the peas for 4 hours or so in water.  I cooked them with some Country Ham (thanks Uncle Richard), onion, and garlic in the broth from the smoked turkey necks, with some meat from the necks.  OMG!

THIS gadget is getting good use.  I highly recommend getting one.  I found that a lot of Indian food is made using pressure cookers, and there are a zillion (okay, a lot) of YOU tube videos made by very talented Indian women, making yummy authentic Indian dishes with pressure cookers.  I love the internet.  

Sadly, since the Boston Marathon bombing, they are more difficult to find.

Sad, really.  

Pressure cookers save energy and time. They are eco-friendly and GREAT for Harried Last minute Moms and Dads trying to keep their heads above water.
AND cooking in a pressure cooker is healthy.
And it's more cost effective to use tougher cuts of meat, dried beans, whole grains, etc.
So go get one.
Start cooking!

 "Harried" brings up "Harriet" again and "Doctor Who" and since Captain Jack is really HOT and of course David Tennant is the BEST Doctor Who EVER, I decided to post this....

Saturday, January 4, 2014

Paper Work and Phone Calls. A Day in the Life of a General Internist

Okay, So I was looking for pictures of a HARRIED DOCTOR and HARRIET from Doctor Who kept showing up.  Since I am a huge Doctor Who fan, I decided to put it up.  

A Day In the Life of a General Internist

People wonder what it is that doctors DO all day, what our lives are like.  They wonder why we seem so BUSY all the time and why we don't return phone calls personally, or spend 45 minutes with each and every patient.

 It's really hard to describe because the work changes daily.

The other day, for example:I was awakened at 12:30 a.m. with an admission from the ER of a patient with a small bowel obstruction.  I've known him for a long time, and was able to give information without even looking at the chart.  I gave orders to a nurse who clearly was brand new.  After I hung up, I thought to myself, "I know she's going to wait 20 minutes, until I've just fallen back to sleep, and call me with a question."   Sure enough, at 1 a.m., the phone rang again and it was the nurse.  Fortunately, I've gotten REALLY good at falling right back to sleep.

I wake up at 5:30 a.m. for quiet time and wake up my son and husband at 6 a.m.  While my husband walks the dog, I'll make us breakfast, then I shower, and get ready to take my son to school.

If it's my late day, I start later in the office but work until 7 p.m. seeing patients. 
I'll work at home all morning finishing up my charting from the day before.  Charting requires doing a bunch of bureaucratic stuff to allow the bean counters to count things you did in order to justify your charges.  It's not just writing down what the patient said, what you found on exam, and what you want to do.  You have to write down a lot more than that.  You have to  justify your time to the insurance companies.  You have to figure out a diagnosis code (now called ICD-9 but is going to expand to a huge number of codes with more specifics called ICD-10 this year--requiring even MORE time to chart) and figure out what "Evaluation and Management" code to use.  Those are codes that say how much work you did to charge the patient/insurance company. 

I work part time which means that instead of working over 100 hours a week, I work 40-50, 24 of which are spent in the office just seeing patients, and the rest is on the phone, on the computer, charting, answering questions, and trying to deal with the inch deep pile of paperwork that comes across the fax or computer daily. (Paper free?  HAH!!)

Home visiting nursing orders.  These require me to periodically open up the chart and fill out a form for Medicare called the "Face to Face Encounter", to prove that I actually am seeing my patient and that they deserve to be in home care, and that I'm not committing Medicare Fraud.  It takes up to 5-10 minutes to fill out one of these forms and I get 3-4 a day.  I hate the Face to Face forms.

Physical therapy orders.  Written in another language, all acronyms.  I have to read and sign these.  

Xray reports.  I have to read, decide whether they need further action, and either call the patient myself if it's complicated or worrisome, or write a note to the staff to call the patients with results/instructions.

Lab reports.  I review these daily.  For diabetics, I have to enter the information into flowcharts on their charts.  Add 10 minutes each. Then I have to decide if I'm changing therapy based on the labs, write a note and either call or have the staff call the patient.  Half of my patients are diabetic.

Consult letters
.  I have at least 5-15 of these a day to read.  Many have requests in them, like, "please send the latest labs or xray reports."  I have to do that.

Emails from patients, and notes through the charting system from patients.  I get about 10 of these a day.  Some are urgent, some are not urgent.  I can't answer all of them the same day.

FMLA forms:  I HATE these forms.  The companies use these now to make the patients justify why and how often they'll be sick in the future.  I'm supposed to GUESS how often a patient is going to need to be off work based on a diagnosis.  If I'm wrong, the patients get penalized and I have to REWRITE a form with new guidelines.  I have 2-3 a week of these.  These take 20-30 minutes each to fill out.

Disability forms:  These come in many flavors.  There are short term forms for works, long term forms for work, State forms, Medicare SSI forms, Credit card forgiveness forms, etc.  I hate these too.  They all take 15 -30 + minutes to fill out.  

Handicapped driver placard forms:  These require me to open the chart up, search through it for diagnoses and reasons that someone needs a handicapped hanger or license.  These come in a flurry twice a year or so. If we give a placard or license plate to someone who doesn't qualify, we can get in big trouble. The criteria are very specific, and if the patient's health problems don't qualify, they cannot get one.

Phone calls. I get anywhere from 20-30 a day. Staff get calls from patients with questions.  With most, I can tell the staff what to tell the patient and the staff will call the patient back.  Some I have to call back.  Some INSIST that ONLY I call back.  Sometimes I HAVE to call people back because the issues are complicated or worrisome.  Sometimes I WANT to call back just to check in myself.  There are patients who NEVER call.  When they call, I worry. 

Seeing patients is my favorite part of the day.  What I really hate, is when my staff doesn't get my patient into the room in a timely fashion and makes me late through no fault of my own.  Guess who gets the grief?  You got it.  ME.  Now granted, there are times when I'm running behind because I've had a very complicated patient requiring extra time from me.  I ALWAYS apologize when I'm late, and make sure the next patient knows they'll get my full attention too.
Thinking about medical problems, trying to get to the real root of a problem, making complex diagnoses, these are the things I do best.  SOMETIMES there is a hidden agenda, like the patient is afraid they have cancer, but doesn't tell me.  I have to figure that out by LISTENING.  I love that part.  Listening, that is.

Listening entails WATCHING, HEARING, and NOT TALKING myself.  NOT thinking ahead of the next question to ask.  Lots of little clues are in the details of the story of the illness.

The electronic medical record is often a frustrating part of the visit for many of us now.  I can type as I listen.  I took typing in fourth grade (thanks Mom!).  The computer changed everything we do.  That is a whole 'nother post.