What that "MD" really means...

So, this morning, I'm driving to the Target (again) in the cold nasty raininess, and I was thinking, you know, my blog posts of late have so often been just a chronicle of my day. Nobody cares, dude. I should really have a topic today...

Uh, thanks, Dad, but that wasn't entirely what I was going for.

There are upsides and down sides that come with being a good doctor. Or being a doctor, period. One of them is that you become a nightmare for your family's doctors.

Okay, maybe I'm not a nightmare, but only because I work at being more reasonable. And I'm not sure how often I succeed...

So my father calls me this morning. No, wait, let me back this story up even further. I call home Thursday night, and my mother answers the phone, and the reception is terrible. I assume it's me, so I'm wandering all over the house, and it doesn't get better. Meanwhile, she's being all evasive. I finally get tired of piecing together words and phrases across the cell phones (it's cheaper to talk cell-to-cell under our family plan) and was like, forget it, I'll call you on the house phone.

There's a pause. She finally says, "Uh...we're not home."

Oh, okay, so they went out. On....Thanksgiving...but, okay....I ask where they are, and there's another pause, and she tells me they're at the little community hospital by their house. At which point my stomach curls up into a cold little leaden ball. Because my dad always goes back to the hospital where I went to medical school when he's sick. The little community place by them is actually pretty good, but all his doctors are at my med school, it's a tertiary care center, they know him well, etc, etc...the only time my dad goes to the local place is when he goes by ambulance.

Or, it turns out, when he does something dumb that doesn't actually require the hour-long drive to the tertiary care center.

So my father - older, on steroids for his COPD - is coming down the stairs on Thursday carrying something, and whacks his hand on the side post. Which tears a three-inch flap of skin off the back of his hand. What does my dad do? Smooths the flap BACK OVER THE EXPOSED TENDONS and goes about his day (Daddy, I love you, but these are the times I wish I still lived close enough to smack you upside the head). So, finally, at some point later (as the story was told to me....I suspect my mother's influence in this turn of events), he decides, you know, maybe someone who isn't me should look at that. Two hours, several stitches, and one bottle of PO antibiotics later, all is well, and my still-completely-nonplussed father can't understand why I'm all exasperated that it took him so long to go to the hospital.

So this morning, I get up early (all I was doing was lying around coughing anyway), and trek out into the cold and rainy with the goal of beating all the other people to the Target (and also of buying an area rug for the front room). I get out of the receptionless Big Box Dead Zone and I have this voicemail from my folks. At 8:00 my time. And I'm all, why on earth did they think it was a good idea to call me that early...and then I hear my father's tone of voice. And I get this far through the message - "Hi, Kate. It's us. I woke up this morning and my right knee's really sore-"

Which is when I hung up and called home to tell him to get his ass to the hospital. Right about the time the paramedics were arriving.

And so there's all this fuss which ends with my dad in a private ambulance on the way to my medical school and the Fire Department medics telling the contract service, "His daughter's a doctor in North Carolina, so if he gives you any trouble, call her and she'll yell at him."

I...um...if it weren't true....

So what do *I* do? I pick up the phone, call my med school hospital, and have the Ortho resident on call paged. Because that's the logical option, right? An gosh, it was just such a characteristic exchange.

I called the operator, right? Asked if she could page the ortho resident on call. I gave the story, the patient's name, date of birth. She asks for a callback number. Was I calling about a transfer? No. And the she asks what my name is.

I gave the usual last name, but I gave my first name as "Doctor."

Because I know if I see "Dr. Smith 888-555-1212" on my pager it means whole other things to me than some random name with an out of state number. So this little intern gets on the line, all full of attitude and already exhausted at 9am (don't worry, hon, I remember what it was like to be a surgical intern). I an hear the OR monitors beeping in the background. I had a small moment of, ohhh, maybe I shouldn't have called. But I held my ground.

I told her my name and that I was a physician out of state

(get it out there right up front. Both a demand and an apology)

and that my dad was a patient of Dr. H's who'd had bilateral TKAs in the past

(so, yeah, I speak your language)

and now has an open wound on his hand and woke up with severe pain in his knee this morning.

(which, I expect you to know what I'm angling at, here. You'd better be on your game)

I give her a little more, remind her that I'm out of state and haven't looked at the knee, but according to my mother there's a one-inch area of redness. So, should I send him to her or should I have him go to the nearest ER to get antibiotics started as quickly as possible?

She's like, well, I can't tell you over the phone what's wrong.

(No shit, kiddo.)

We fumble with this for a minute. I throw in things like, well, you know, I admit I haven't done any ortho

(although my advisor in medical school was an orthopedic. For four years. I did several dozen knee and hip replacements with him)

in like five years

(I've been a doctor longer than you have)
(For those of you playing along at home, this does not make me right, but it gives me seniority. Which is everything in the surgical world)

but my memory is that it's pretty imperative to start antibiotics as soon as possible if there's any question of infection at a prosthetic joint.

(my hackles are up. I'm not showing my teeth yet, but, don't fuck with me)

She says, is it swollen? An inch of redness doesn't make it a septic joint. But he's welcome to come to us if they want to drive out here.

(so, an equal display of, you don't scare me)

I say, they're headed to one ER or the other. In an ambulance.

(a low little growl)

She says something about not being able to judge it over the phone. I say, "okay, so the question is..."

(I haven't told her what specialty I practice yet, but "what is the question?" is something that consultants use a lot. Which actually doesn't narrow the field down much, but establishes that I'm someone that other doctors routinely ask for help. The fact that *I* posed that phrase to *her* - the actual consultant in this scenario - is a total display of power. Power that I don't have - 850 miles away. Family member, not a treating physician. Psychiatrist, not an orthopedist - but it works. She rolls over)

Well, she says, yeah, I mean, tell him to come in to our ER,

(as in, don't expect me to be down there waiting for him. She hasn't rolled over completely)

the ER doors are always open.

(but I've flustered her and established the upper hand)

And, then we can consult Dr. H's team as soon as we know what's wrong, and his records are here, and yeah, you know, it's just hard to know over the phone.

I say, tell me about it.

(I know I'm being a pain in the ass)

She says, yeah, and it's hard because it's your dad.

(I understand. I'm just as much of a pain in the ass when it's my family)

We hung up, I called my mom back and told her they were aware he was coming in.

Amazing how much goes on between the lines, though, isn't it? And that's the Cliffs Notes version.

At so many points in that exchange could I have gone off on her (Listen, newbie, my 77 year old father, who's on steroids, and has two prosthetic knees, and has now failed PO Keflex and likely has a festering infection in his joint, he's coming to you, so don't fuck it up, because if he loses his joint who do you think I'm going to come after?) but...that's just counterproductive. I'm not all that interested in the politics of it, and if he's going to lose the joint he's going to lose the joint. Plus, I actually was asking for her advice about whether or not delaying treatment by an hour would make enough of a difference to warrant going to an outside facility with fewer resources. This is not about my ego, my power trip, or my need to defend myself from narcissistic injury.

But so often, with medical family members, it is. Because they're worked up and scared and trying to fall back on their favorite defense mechanism - intellectualization - and it's failing them, because they're not in the driver's seat. And in general, doctors really like driving the bus. So some can get pretty nasty when you tell, say, an oncologist that the appropriate treatment for his psychotic daughter is not what he thinks it is.

And a lot of times, a little bit of knowledge is a dangerous thing. See above re: oncologist. If we're talking about a patient, and that rational distance is there, it can go very differently. Quite often, when my patients are getting what I think is not substandard care (or maybe just a little substandard) from another specialist, but not necessarily what I'd do, I'm willing to throw up my hands and say, well, if you don't tell me how to practice psychiatry, and I don't tell you how to practice nephrology, eh, the patient will probably be just fine on both fronts.

(I'm very protective of my patients, though, so while I may not challenge them directly, you can be damn sure I'm keeping an eye on things.)

However, when you lose that detachment, maintaining that same perspective becomes almost impossible. We make pains of ourselves at best; at worst, we get in the way.

What's a doctor to do except know that about themselves? I try hard to be nice, to listen and learn, to be respectful even when I'm getting attitude, and try to be really appreciative when my family's doctors take the time to speak my language. And when I'm on the other side of it, I try really, really hard to be thoughtful and accommodating and understanding and empathic.

So if you're wondering how this story ends, they admitted him, but so far everything looks okay. They tapped his knee (sounds better than "stuck a long needle in it and drew out fluid", doesn't it?) and found more inflammatory cells than they'd expect, but no frank bacteria. So right now we're on the watch-and-wait program. His ortho's going to see him in the morning. We'll see what the big boss thinks.

And, the resident I talked to swears to my parents that I didn't offend her at all when I called. So, maybe I'm doing a decent job of staying on my chain after all.