by Benish, Sarah MD
She assures us that while most medical TV dramas suggest that doctors have a fast-paced, action-packed day, she doesn’t see quite as much action as those shows would have you believe. But what she loves about her job is that she never knows exactly what is going to happen or who she is going to see.
Some days she is just recovering from being on-call at the hospital the night before, when her sleep is disturbed by patient phone calls and occasional emergency room visits to see stroke patients. Other days she sees patients in the hospital. Here is a timeline of her typical day:
7:35 AM I arrive in the office. I have to turn my computers on, prepare the exam room, change the exam table paper and pillowcase, and wipe down equipment with alcohol swabs.
8:00 AM My first patient of the day has not yet arrived for an 8:00 am appointment, so I use these few minutes to dictate an electromyography (EMG) report from yesterday; I typically use an EMG—which records the electrical activity of muscles—to diagnose movement disorders.
8:10 AM My 8:00 am patient has called and left a message to cancel the appointment, so I have a few minutes to spare. I use this time to read and dictate a report on another patient’s electroencephalogram (EEG). EEG, which measures electrical activity along the scalp, helps diagnose conditions like epilepsy and sleep disorders.
8:30 AM My second patient of the day is what is known as a “hospital recheck.” I met her twice while she was in the hospital for episodes of losing consciousness, and she was diagnosed with seizures. She has now been out of the hospital for one month and is on a medication to prevent seizures. She is doing well, but she has been unable to work because she is not allowed to drive, which is frustrating and is causing a financial hardship for her. We discuss the options she can review with her employer, such as working closer to home on a bus route. I encourage her to hang in there for another two months and to keep taking the medication.
9:15 AM I have a recheck appointment with a Parkinson’s disease patient I have followed for three years. His disease is well managed with medication, but he is experiencing some walking difficulties. Most of these complaints are related to his legs feeling weak. He refuses a referral for physical therapy because he says he is planning to move to an assisted living facility to help meet his increasing medical needs. He is nervous but hopeful.
10:30 AM I administer botulinum toxin (Botox) injections for a chronic migraine patient. Botulinum toxin comes in a vial that I keep in the freezer. When it is ready to be used, I have to mix it with sterile saline (salt water) for use that day. But Botox is a very expensive drug, and I don’t want to waste it if the patient decides not to have the injections. So before I mix it up, I have the patient sign a consent form. I review the risks of Botox, including bruising or bleeding from the injections and weakness from the action of the medication, which can result in problems like a droopy eyelid or double vision. It is up to the patient to decide whether the complication risks are worth trying to better treat their migraine headache.
11:00 AM A patient comes in for an assessment regarding his memory and dizziness. As is standard practice for all patients who come to us with memory complaints, we requested that he bring a friend or family member to provide extra history about his memory. He brings his wife. A typical first meeting for any new patient is 45 minutes long; a memory assessment like this one takes 60 minutes. The extra 15 minutes goes into taking time to do some more complex memory testing in the office. I refer the patient for further memory tests with a neuropsychologist, a specialist who has special training for memory testing that can take up to two hours to perform. I also refer the patient to physical therapy for his dizziness. I plan to see him again in one to two months to see how he is doing and review the test results.
12:00 PM I take 30 minutes for lunch each day. I typically eat during the first 10–15 minutes and then call patients or catch up with notes. Today, I call a patient with test results from an MRI (magnetic resonance imaging) scan. Unfortunately, the MRI has shown a tumor in her jawbone. This is not a neurological problem, so I tell her she needs to see a different specialist. I recommend she see an oral surgeon and get further testing to figure out the next steps. I discuss the situation with my patient care coordinator, and she starts making calls to figure out where we can send the patient and when we can get her an appointment.
12:45 PM Now I am running a little late. I start seeing a patient whose appointment was at 12:30 pm. This is a new patient who is here for a 45-minute meeting to discuss management of chronic migraines. I am the second neurologist she has seen for this longstanding problem. She has other health problems related to polycystic ovary disease and obesity, which makes it difficult to find medications that may help her migraines that she hasn’t already tried. A lot of the medication we typically use for migraine would make her weight struggles worse.
In the end, we decide the best course of action is to see if her insurance will approve Botox treatments for her migraines. My office staff will start working on getting approval from her insurance company. Each company has similar but slightly different requirements before they allow patients to try Botox. In the meantime, we switch the medicine she takes when a migraine occurs to something a little cheaper that should work just as effectively.
1:40 PM I am still running a little late. I see another new patient who had come into the local emergency room two nights ago; he was concerned because he was intermittently smelling a rotten smell that no one else could smell. He did not have a primary care provider, so he went to an urgent care center that sent him on to an emergency room.
The emergency room physician felt that the symptoms were most likely neurological in nature and was concerned about a possible seizure, but acknowledged that it could be some sort of infection. I had been on call at the hospital that night. The emergency room physician set him up with an order for an MRI brain scan and then asked me to see him within 72 hours. Luckily I had another patient cancel, so I was able to work him into this appointment time.
I have not yet received the MRI report from the radiologist, but during the appointment I can see the images of the MRI on the computer and I see that there is an abnormality in his upper nasal sinuses consistent with a collection of fluid (a cyst or an abscess). I call an otolaryngologist (ear, nose, and throat doctor, or ENT) and discuss the MRI findings. He agrees that this could be the source of the man’s phantom smells and will see him in one week. I also encourage the patient to find a primary care provider so he can avoid unnecessary emergency room visits in the future.
2:30 PM I’m still running late by about 10 minutes. I meet with a patient and his two daughters for a recheck appointment. His daughter brought him in one month earlier with concerns over his memory, and they returned today to discuss his test results. He had completed two hours of memory testing, which confirmed that he was in the early stages of a dementing illness, most likely Alzheimer’s disease.
Blood work and a head CT (computed tomography) scan did not offer any other explanation for his memory problems. The CT scan was performed to look for signs of stroke or other brain changes that could explain his memory loss. The blood work looks for problems with nutrition or thyroid function that could cause memory problems, which could be improved with treatment. I spend 60 minutes with the patient and his family discussing the test results and their implications. The family and the patient take the news in stride, but it is always a difficult diagnosis to hear. It’s also not an easy diagnosis for me to deliver.
The patient had completed an on-the-road driving test and failed, so I advise him to stop driving to maximize not only his safety but also the safety of others on the road. This is never an easy thing to discuss. A lot of people get quite angry, especially living in the Midwest where public transportation is limited. I often think about how I would get around if I couldn’t drive and know that it is this part of the diagnosis that forces changes in living situations. I am often nervous to discuss this and have tried several different ways to deliver the news, but I haven’t found an easy way to do it. I give the family resources from the Alzheimer’s Association and encourage them to join a support group.
3:30 PM Now I am running very behind! I see my 3:30 pm patient checking in as I walk through the lobby area and warn him that I am running late, possibly by as much as 30–45 minutes. He tells me he is in no rush. I am now just seeing my 2:45 pm patient, who is here to receive medications for her restless legs syndrome. This appointment only takes 15 minutes, so I’m able to catch up a little on the schedule and can see my next patient sooner than I expected.
3:50 PM I start to see my last patient of the day. He has developed slurred speech and swallowing difficulties over the past three months. Unfortunately, the EMG we did earlier this week suggests he may have ALS (amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease). This disease can involve weakness in the arms and legs or in the face muscles, causing speech problems. We discuss what we need to do to confirm the diagnosis, which is to send him to an expert (or subspecialist) in ALS. If the diagnosis is confirmed, the patient will be best served by staying with the expert and being seen in an ALS clinic. Both the patient and I hope that I am wrong, and that there is a treatable condition that I have missed that could explain his tongue weakness. It might sound strange to hope that your gut feeling about a diagnosis is wrong, but when the other option is an incurable disease, I am totally fine with being wrong!
4:35 PM I have now finished seeing patients. I take 20 minutes to return phone calls to three patients who called in with questions during the day. I also renew five prescriptions that have been requested through our electronic prescription service.
4:55 PM Today has been a particularly disorganized day and I haven’t completed a single visit note, although I do have some information that I typed during the day into the electronic record. I find it takes me about five to 10 minutes to complete a note for a patient visit. If the note is for a new patient and there is no information in the computer, it can take longer. I am able to complete all but one of the visit notes over the next 40 minutes. I will have to complete the last note tomorrow. I typically complete all my notes on the same day, but due to a meeting it isn’t possible today. I don’t like falling behind because it seems to turn into an endless cycle. The longer I go before completing the harder it is to make it a good and accurate note. I also run the risk of having too much to do the next day.
5:35 PM It’s time to pack up shop. Tomorrow I am working in Glencoe, MN, in my outreach clinic, which is about 60 miles away from my office. I grab my schedule and my neurology tools (reflex hammer, tuning forks, pins, stethoscope, cotton balls, etc.).
5:40 PM I am in my car and heading up the road to the headquarters of the Minneapolis Clinic of Neurology in Golden Valley for a board meeting. These meetings occur once a month and typically last four to five hours. We meet after hours because the board members are physicians and we all see patients during the day.
6:05 PM I arrive in Golden Valley for the meeting. Traffic was brutal today. I am not the only one running late and am actually one of the first to arrive. During the board meeting, we review the financial performance and policies of the clinic and our strategy for moving forward.
10:15 PM The board meeting adjourns and I’m finally heading home.
11:00 PM I arrive home (after more than 16 hours away from home) and quickly get into bed. My husband reports that I start snoring at 11:10 pm, but I strongly deny it!
© 2014 American Academy of Neurology