Tuesday, August 7, 2012


Despite what it might seem, "weight" is a four letter word.

Doctors don't bring it up as often as they should. Patients also rarely bring up how their weight bothers them - embarrassment, denial or other factors might cause them to sit quietly in the office chair. I will often talk to patients about it, if it factors easily into their disease - people with high blood pressure or diabetes, for example. Then, I feel I have a legitimate reason to call attention to their obesity. Even then, many patients do not want to engage in a conversation about it. They start making excuses about how they are too busy to work out, or about how things are really stressful right now, but they have a plan to fix things in the future.

I am not trying to make light of these very real scenarios. In my experience, patients usually do not take responsibility for their weight. Some external force is keeping them from being healthy. It is very difficult to talk to people about weight loss in a 15 minute office visit, when there are other things to talk about. I always like when patients make appoints to talk only about their weight. It gives me more time to find out about their eating habits. But, more often than not, I am the one trying to talk about their weight. It's actually very frustrating to see someone come in every few months and not see their weight drop. I end up not talking about it any more, because it doesn't seem to be helping. I understand that it's hard to lose weight. I don't think it's as expensive as people think. I do think it's easy to make small diet changes that can have a big impact. I need to not get frustrated with my patients when they struggle with their weight. Perhaps if I keep bringing it up, something will stick and they'll actually make some changes.

Thursday, April 12, 2012


I've been seeing a lot of young patients recently with Hepatitis C. Kids in their 20s who have gotten into IV drug use, and who are now struggling with both sobriety and having Hepatitis C. That's a lot for a kid to deal with. I go in to the room, sit down and look over at them. More often that not, they come in with a parent. I mean, they're kids. They're not fully mentally developed. People who abuse drugs are in a sort of arrested development. They have poor coping skills. Thy have impulsivity issues. They don't do well with mental or physical pain. Babies.

I explain what Hepatitis C is, what the treatment is like, why it's important to try and cure it. I explain that the treatment is difficult, and I talk about the side effects: nausea, fatigue, muscle and joint aches, headaches, depression. I then explain that the most important thing they can do is stay sober. They are so eager to start treatment, that some are disappointed they can't start now. I explain that the treatment can drive them back to their drugs of choice. I explain that unless their depression is under control, the treatment might cause them to become suicidal. Some of them recognize that they are not ready, and they breathe a sigh of relief.

I have them come back in 6 months to talk again. Sometimes I think I'm too eager to start them on treatment as well. I've had 2 patients who have relapsed after starting meds. I feel a little responsible. Maybe I should asked more questions or listened to my gut. It's just hard to hold back treatment and explain how important that gut feeling is. I think I'll need to figure that out, so that I can help get people treated when it's really the right time.

Tuesday, January 31, 2012

Just Don't Lie to Me

Florence + the Machine has an awesome CD out. I love it. One song on there has a line, "I'm not calling you a liar, just don't lie to me." I find this very apropos to a patient I'm dealing with.

He has an infection in his knee. As I've mentioned here before, working in infectious diseases, I have to ask people a lot of personal questions. Where do you live, what do you eat, what drugs do you do, who do you sleep with, etc. I try to be very open and use nonjudgmental language. During my physical exam, I look at his hands and arms, trying to find other signs of infection. He has track marks on the backs of his hands and in the crooks of his elbows. These are scars from injection drug use. I already asked him about drug use, and he denied any. We don't make eye contact during my discovery, but he must have noticed that I saw them. He mumbled something about donating a lot of blood products in the past.

I sat down at the end of the exam to tell him my plan - antibiotics and such. I said again, "You know, in this job, I have to ask a lot of personal questions, and I'm sorry for that. However it's not to judge anyone or notify any one else. It's simply to help me do my job the best that I can." He said that he understands and that I shouldn't worry about it, ask whatever I want. Again I asked about drug use and told him why this is important. Again he denies it. I tell him that I'd like to test him for HIV and Hepatitis B and C, and he said ok. He doesn't seem concerned. He's been very pleasant through this whole interview, even if I don't very well believe much that he's told me.

I'll wait to get his labs back and make a plan for his treatment. He'll probably need a few weeks of IV antibiotics at home. I'm more than a little concerned that he'll go home with the nice IV we put in place and shoot whatever he'd like into it. I explained to him the dangers of this, and he shook it off and said he'd never do that. I smiled and said ok, as Florence's words rolled through my mind.

"I'm not calling you a liar..."

Sunday, January 8, 2012

One Sock

I was asked to consult on a patient this weekend. She is 80+ with severe dementia. She opened her eyes when I said her name, but I'm not sure that it wasn't a coincidence. She doesn't follow commands or even track me with her eyes. Anyway, she had gangrene of her foot. Her family wanted it to be amputated, because they felt it caused her pain. Unbelievably, this is not a post about medical ethics or how we treat the elderly or the quantity vs quality of life. Her other leg had a bone infection, and the doctor wanted an opinion on how to treat it. The surgeon was going to amputate her gangrenous leg above the knee. The family knew that there was a very high likelihood that she wouldn't survive the surgery; they felt that the pain she was having from the leg made that risk one worth taking.

I saw her post-operatively as well. She made it through. I was quite surprised. I went in to see her today, and she wasn't on the board. Turns out she died. Just sort of suddenly, peacefully and completely out of the blue.

I saw a list of her belongings: one neck scarf, one blanket, one winter hat, one sock. One sock. That struck me for some reason. Kind of sad, kind of heartwarming. For some reason, I felt very relieved that her sock made it home.