Family Webicine

By Rod Moser, PA, PhD

Most of my 40-year career has been in primary care, mostly family medicine. Even when I was in medical training, I loved working with children. My undergraduate thesis involved reducing a child’s fear of having surgery.  For the last 13 years, I decided to practice pediatrics full-time. Why not end your clinical career doing something that you love?

I had a dozen years of full or part-time academic medicine and found that graduate medical students whine more than little children. Don’t get me wrong. I like adults as well, but I find that children give me more happiness in joy in my stressful clinical day. I still deal with parents and grand-parents, so in a way, I am still heavily immersed in family medicine.

My days are long (12-13 hour shifts with only one lunch break). I choose to do some of the more technical aspects of our practice, like suturing bleeding kids, removing their ingrown toenails, or managing their broken bones (Thank you, monkey bars). If teenagers are worried about an ugly mole, I take it off for them. About half of my patients are teenagers; the other half starts at age two days old.

I am often the first one who gets to deal with new parents, seeing the pride (and fear) in their faces as they enter the dreaded “4^th trimester” (the first three months). I can discuss breast-feeding issues, the pros and cons of circumcision, why belly-buttons stink, and why baby poop looks like mustard. Every day, I address concerns about immunizations, and deal with picky eaters, ear-pullers, snotty noses, coughs, boo-boos, thumb-suckers, and bed-wetters. I perform routine physical exams for scout camp, sports, and Mormon missions. I address the under-weight, the overweight, and the ones that hate to wait.

I have five grandchildren, but I sort of have about 5,000 grand-patients as well. Some of the parents were actually patients of mine when they were children. If I stay working long enough, I may have a few great-grand-patients.  Compared to adult medicine, kids are fun, or at least I try to make a stressful medical visit, less-stressful for them.

It doesn’t hurt that I look like Santa. Just yesterday, a little boy kept teasing me about my Santa-like appearance, until I threatened to put his name on the Naughty List.  Lately, the discussion of the Easter Bunny has come up, as well as the beloved Tooth Fairy. Of course, I have added a few “fairies” to the team. I have a Stitch Fairy and a Toenail Fairy.  I am conversant about superheroes, the most recent kid movies, and know just about every character in the sticker box. I watch the high school.  We give out thousands of sugar-free (and kosher) lollipops. I get lots of giggles when I tell them that we only have the following four flavors: onion, kitty litter, stinky feet, and broccoli.

I search for little birds that live in their ears, boogers in their noses, and cookies in their tummies. I count lots of toes (I can trick the little ones into thinking they have six toes on each foot).

Children can be frightened when they come into a medical office. Their biggest fear? Shots. When I know in advance that there will be no need for any immunizations, I mention this up front. You can often see the relief in their face. Doctors in white coats can scare children, too, so I don’t wear one. As much as I can, I first let them get used to me. Then, I involve them in their own care, from just holding a tongue depressor for me, or turning on the otoscope to look in their ears. Children are much more cooperative when they think they have a little control, like deciding which ear that I examine first.

One boy said that I was a silly doctor, so I told him that I could be any kind that he wanted. I could be a serious, mean doctor or a funny, silly one. His choice?

He picked “silly”.

By Rod Moser, PA, PhD

To say that (American) medical care is expensive is a gross understatement.  An office visit can cost over a $100; an ER visit for a non-emergency can cost thousands. X-rays are expensive and often unnecessary. Prescriptions costs have skyrocketed. And, it is going to get worse.

Many of my patients who have insurance have chosen high-deductible plans in order to make their premiums more affordable. Paying the first few thousand dollars is quite common.  Co-payments for each visit are getting higher and higher, and insurances are limiting the amount and type of medications on their formularies. Insurance companies are finding ways of cutting costs, so the consumer will need to be equally as vigilant in doing the same.

1. Be your own doctor (sometimes): Providing your own medical care requires a great deal of common sense. I wouldn’t want you to try and remove your own appendix or sew up your own wound with the sewing kit. Most medical care in the world is self-administered, so you will not be alone. Practice good prevention and personal hygiene to limit your illnesses. When you get sick, it is perfectly fine to try proven home remedies (no quack cures, please). You will also need to know when to call in the professionals.
2. Get large quantities of regular medications: Monthly or even three-month prescriptions can be pricey, but if you can arrange to buy a year’s supply of a medication for cash, you may find it less-expensive than paying your insurance co-pay. Some medications, like controlled drugs or narcotics, may only be available in month-supplies.
3. Shop around for the best prices in medical care or prescriptions: If you are paying for your medical visits or have high deductibles, it would be wise to call around to various urgent care facilities and ask prices. Prices on pharmaceuticals also vary wildly, so call around. Big-box stores often have less-expensive prescriptions.
4. Buy generics: Whether over-the-counter or prescription, generic-brand medications are considerably less-expensive than their brand-name cousins. Liquid generics for children may not have the same flavoring, but they are bio-equivalent when it comes to efficacy. They are the same drug; just cheaper.
5. Self-educate: Use the Internet (especially WebMD) to research your medical condition. While you may not be able to accurate diagnose (or treat) yourself over the Internet, at least you will be an informed consumer if or when you seek professional care.
6. Trust your immune system. Long before there were convenient clinics, there were illnesses. Many, many human afflictions will self-resolve if you give the immune system a chance to work. A cold is not going to go away in a day; so why not wait a few days. Some illnesses do require immediate care, so make good judgments for yourself and your family.
7. Avoid the ER unless you have a true emergency: The ER is a busy place with many critically ill or injured patients. Your sore throat is not considered an emergency even if you think it is. You will wait hours to be seen for minor illnesses, so why bother? True emergencies – those that may cause the loss of a life or limb – should be in the ER.
8. Question the rationale or medical necessity of any lab test, medication, or x-ray: Many medical providers order unnecessary x-rays or lab tests. Some feel that this will protect them from malpractice, but they can be a waste of time or money. If the medical provider orders tests, they have a responsibility to justify the need. Sometimes, you can negotiate and agree to have them later if the case permits. If you get better, they may not be needed at all.
9. Make every medical visit count: As a medical provider, I tend to hate the “Oh, by the way….” extra medical issues, but it is important to get your money’s worth. Most medical appointments are 15-20 minutes or longer, so have your list ready. Make sure the issues are important. Get refills of any medications while you are there, and get ALL of your questions answered. Medical offices are getting fewer and fewer pharmaceutical samples to hand out, but don’t hesitate to ask. A generous medical provider can save you lots of money.
10. Marry a doctor, dentist, or pharmacist: Medical care can be less-expensive if you marry one of these professionals or encourage one of your children to pursue a health professions career. If you can’t marry one, you can always try and find a good one. Developing a friendly relationship with your health professionals can be very important when it comes to saving money. If someone asks me to try and keep their medical costs down, I will listen. I have even been known to charge nothing on occasion just because if feels good to help someone in need.

Finding affordable medical care is no different than any other consumer purchase. You may research a half-dozen stores looking for the best deal on a flat-screen television or cell phone plan. You take care of your vehicles as long as you can, and carefully research and negotiate the best deal when you have to get a new or used car. When it comes to medical care, I find the people are often reluctant to shop around, but you should.

By Rod Moser, PA, PhD

Recently, I’ve noticed that medical groups are collecting all sorts of demographic data when people come for their appointments. I can understand the Date of Birth (very important), but why are they asking for Social Security numbers? Granted, we deal with hundreds of different insurance plans, but they are not supposed to be using Social Security numbers for identification purposes (but some do). In this age of identity theft, all it takes is a birth day and a Social Security number and a clever thief can get a credit card in your name (or your child), buy a car, or apply for a home equity loan (on your house!).  I checked my own medical records and lo and behold, they had my Social Security number prominently displayed for anyone to see. I never gave it to them and no one knows how it got in the system. It is now 000-00-0000.

In most cases, your doctor’s office, your dentist’s office, and just about everyone else does NOT need your Social Security number, so don’t give it to them. You need to adamantly refuse when this happens. I am so concerned about identity theft, that I even change my birth date and Driver’s license number (another identification that they do not need). Of course, I always forget which one that I gave them. I get birthday cards throughout the year now. I thought about giving false SS numbers, but I have always been afraid that I will use one that actually belongs to someone else.

This year when I submitted my taxes, they bounced back because someone has used (or attempted to use) my Social Security number to file a false tax return about a month or so prior. I have no idea how my Social Security number was compromised since I protect it like Fort Knox. It may have been someone who works for our vast medical system for all that I know.

So now I have to spend my day off filing a police report, standing in line at the Social Security office, and calling all of my credit card companies and bank to put them on an even higher alert.

The phone rings. It is my credit card company alerting me to a possible fraudulent charge. It was a legitimate red-flag charge, but it was for my semi-annual delivery of fuel. They thought someone put $800 of gas in their car!  They also question another charge (a legitimate one) that I did this morning: my annual fee for fraud protection. A half-hour later, the same credit card company called (different person) to inform me of a duplicate charge attempt. The fuel company tried to do charge my twice for the same fuel delivered a month ago. I called and had a pleasant conversation with them.

I pay for fraud protection and regularly scrutinize my credit reports, but what about the vast majority of people who don’t do this? What about the people who just blindly hand out personal information to anyone who asks? So far, I have limited my identity compromise to a few cell phones (with calls to Columbia) and this most-recent tax refund attempt.

If someone wants to read my medical records, more power to them. I suspect many people have been nosing around in them. They are not very interesting in my opinion. When we used paper charts, just about anyone could access private records, and many offices still use them. When I changed practices, I made sure to take (steal) my own records when I left. I cannot do this with Electronic Medical Records, however.

Ten Pearls for Fraud Prevention:

• Refuse to give out your Social Security number to your medical or dental office, unless they can show you (a) it is absolutely essential to your insurance billing, and (b) they have a mechanism in place to protect your private information from unauthorized eyes. A Social Security number and a birth date is all most people need to steal your identity.
• My dentist asked to make a copy of my “photo ID” (driver’s license). I refused. Then, they told me that it was my right to refuse!
• Scrutinize any itemized medical bills. I have personally found hundreds (No, thousands) of dollars of charges for services that were never rendered or provided.
• Keep receipts for everything, including that $20 co-payment. You would be surprised how cash payments often come up “missing”.
• Periodically, get copies of your medical records and read them. Dispute any inaccuracies.
• Several people could have your name. Make sure your medical records are actually yours; at each visit.
• Pay attention to medications and refills. Years ago, we had a medical assistant who would call in refills of narcotics and then pick them up herself.
• Shred anything that could compromise your identity, including medical information. Dumpster-diving for private information, especially around tax-time, is big business.
• Mail important papers and bills inside the post office. Avoid putting them in insecure, neighborhood mail boxes that are frequently vandalized.
• Check your purses and wallets for missing credit cards. One physician had her credit card stolen out of her purse (sitting under her desk) by another patient who was waiting. Watch your purse and watch where you hang your wallet-containing pants before you get into that lovely, medical examination gown.

By Rod Moser, PA, PhD

What really defines a true emergency? A serious medical event that may be capable of causing a loss of life or limb is a true emergency. An example would be chest pain thought to be cardiac (a heart attack) or an automobile accident where a victim may have multiple injuries.  Abdominal pain that may be appendicitis, a concussion, and an obvious broken limb are other true emergencies. If you have ever sat in the waiting room of a busy emergency department, you will see that most people do not meet the criteria for emergent medical care. Someone with a sprained ankle is likely to wait a long, long time before being seen. They have been triaged to the back of the line, a concept that is really misunderstood by many who feel that it should be “first-come, first-served.”

An “urgent” visit would be several steps down from a life-threatening emergency and would be considered a medical event that could not wait until for a normal, scheduled office visit. A laceration (cut) that may require sutures should be seen in a reasonable amount of time since wounds should be closed by sutures within eight hours or so.  Someone who may have a fracture is an urgent visit, although many orthopedic injuries are often days old when people seek care.

If you walk in with back pain, a cold, sore throat, sinus infection, diarrhea, or an earache….or, if you need a note because you missed work, didn’t have time to get seen during normal office hours, you really have no reason to be seen in an emergency room. Your care would be better served at an urgent care or your regular medical provider’s office. When these folks show up at an emergency room, I can assure that no one is in a big hurry to meet your needs, no matter how urgent you feel your problem is.

Emergency rooms are busy, over-crowded, and unbelievably expensive. Insurance companies are fully aware of the costs, so they often set high co-payments (around a $100 or so) to discourage inappropriate utilization. If you are paying cash for your medical care, you would be a fool to use the ED (emergency department) for a minor medical problem. A sore throat could cost you a thousand dollars or more by the time you pay the ED fee, the lab tests, the doctor’s fee, and a prescription! If your medical care is free…absolutely free…then there are no barriers; no reasons not to use the convenient, 24-hour services available at the ED.

By Rod Moser, PA, PhD

She weighed more than three-hundred pounds and had diabetes. She needed to follow a strict diet to control her blood sugars and lose that excess weight. The food diary she had been keeping showed that she ate about 600 calories a day, but she  had gained weight since the last visit two weeks ago. We had a heart to heart talk and she promised to try harder. A few hours later, I ran into her at an all-you-can-eat buffet.

He didn’t smoke yet he smelled of cigarettes. My non-smoking nose never lies, but it could be second-hand smoke. I listened to his lungs and again asked, “Are you sure you don’t smoke? Your lungs are telling a different story.” He sat quietly for a moment and then handed me his remaining pack of cigarettes. I threw them in the trash. A month later, he was a non-smoker.

Teenagers who smoke weed (marijuana) will deny it on a stack of Bibles. They will deny it as they take a urine drug screen, and deny it again when the test comes back positive.

The vast majority of health issues are caused by behavior. Unless you come clean, it can be very difficult for a medical provider to help you. We all fib from time to time or tell half-truths, but when it comes to changing life-threatening health behaviors, you must tell the truth; the whole truth and nothing but the truth.

Seasoned medical providers really know when you are stretching the truth.  Many will just pretend that they believe your story, but deep inside, we often know that the story does not fit. Many medical providers are parents, and as such have served as judge and jury in the past dealing with kids, so lie-detecting is not a newly-acquired skill.

It can be very difficult to open up to a medical provider that doesn’t really seem to care or appears to be rushed. A disclosure of a hidden secret can be that proverbial “can of worms” that we often talk about, and many medical providers miss (or choose to ignore) these very important, teachable moments during a medical encounter.

Deep down inside, patients want to tell the truth. They want to disclose the real reason for their visit today. They may desperately need help in losing weight or stopping smoking, but they must have a medical provider who is understanding, compassionate, and approachable. Medical providers can be unbelievably busy and get complaints when they are late for the next patient, so sadly, these “Oh, by the way” disclosures are often brushed off. For the patient, it would be better to just to make an appointment for “weight control consultation” or “smoking cessation” rather than to just causally mention it in passing. These issues are much too important to be diluted in an already-impacted medical encounter.

If you are not taking your blood pressure medications, you must fess up, whether you are confronted or not. Medication non-compliance is something medical providers see dozens of times every day, so your disclosure will not be a surprise. If you don’t disclose, your medical provider is likely to order more expensive tests or change your medications to something stronger. Remember that this is your high blood pressure, not your doctor’s. You have to take ownership of your disease or health issue in order to be effectively helped.

The disclosure of the whole truth is not easy for your doctor, either. Medical providers are not priests, but we often have to function in that capacity. Like priests, we are bound by a strict law of confidentiality. If a guy discloses that he has been cheating on his wife, and his wife is also my patient, think of the ethical dilemma that the provider faces. We have an obligation to help both parties.

Teenagers are highly-skilled at the fine art of deception. When I exclude the parent from the room to have a confidential talk about sex or drugs, I am often surprised by their sudden honesty. Claims of “no sexual activity” can sudden change to multiple partners and high-risk activities. The teens want expert advice and help, but they don’t want their parents to know.

There is nothing to gain by lying to your medical provider. While the truth may be hard to swallow and be embarrassing, you cannot be helped unless you open up during a medical encounter. If you feel medical provider is not sympathetic or highly judgmental, you may need to change providers first.

We are all human. Medical providers “fib” and patients “fib” but there comes a time when we all have to tell the truth – the whole truth and nothing but the truth.

An effective medical encounter depends on both parties trusting each other totally, no matter what.

By Rod Moser, PA, PhD

Allergy season is upon us. When you work with children, it can be difficult to know whether that runny nose is an allergy or a cold. Here are some ways you can tell.

You will see this  subtle sign a dozen or more times per day.  A child with a constant runny nose will use their hands on an upward stroke to wipe the drainage and quell an itchy nose. We call this the allergic salute.  Some children do this so often that an allergic, transverse crease will form across the nose.

Less common are allergic shiners – dark circles under watery, bloodshot eyes indicating that they have been repeatedly rubbed and knuckled, also due to itching. People with eczema (atopic dermatitis) will often get a flair-up during allergy season, so their skin will be itchy as well.

Some people with allergies will get a good case of hives (urticaria). Some hives can be so serious that they result in respiratory difficulty requiring a home injection of epinephrine from the EpiPen, as you are on the way to the emergency room.

Then, there is the sniffing. A dozen times per minute, allergic kids (and adults, too) will sniff back the watery mucous that tends to drip, 24-hours a day. One could choose to deplete an entire box of tissues, but sniffing seems a good alternative. The more you sniff, the more mucous that will drain down the back of your throat. This leads to a constant cough.

The coughing associated with allergies can be very annoying to parents, since it goes on all day and all night. When you are in the supine position during sleep, gravity will send rivers of mucous down your throat, triggering a cough. Coughing causes throat irritation and throat irritation causes a cough!

Of course, people with allergies are also prone to asthma, so along with that annoying cough, will often come wheezing. Air goes into the lungs just fine, but has a difficult time coming out through irritated airway. Asthma can be easily controlled, or not. Asthmatics are puffing away on their nebulizers, taking a plethora of drugs (including steroids), just so they can exist in the world with the rest of us non-asthmatics. The one’s that are not improving are crowding emergency rooms across the country.

In our area, it can be difficult to get an appointment with an allergy specialist.  Allergy sufferers are getting hundreds of allergy tests that prove that their allergies are unavoidable (like trees, grasses, weeds, and their beloved cat), so desensitization shots (allergy shots) are started.

Pharmacies are stocking their over-the-counter shelves with antihistamines, hydrocortisone cream, and allergy eye drops. Zillions of prescriptions are being filled for prescription allergy and asthma meds. Notes are being signed so children can use their inhalers at school.

Here’s how to endure the allergy season:

1.       Take your prescribed medications for allergies and asthma and understand what they are and how they work.

2.       If you have severe asthma requiring an ER visit or hospitalization, make sure to have your rescue inhalers and an EpiPen at hand at all times.

3.       Limit your time outdoors during the height of your “season”. If you know what you are allergic to, try to avoid them!

4.       Allergy-control your indoor environment, especially your bedroom. Have a thorough Spring Cleaning

5.       See an allergist for allergy-testing and possible desensitization shots.

By Rod Moser, PA, PhD

My elderly mother is dying. She is 91 years old and in a nursing home near my brother’s home. She has had severe dementia for a decade and is not ambulatory anymore. About two weeks ago, she developed pneumonia (again) and continues to battle the devastating effects of trying to breathe, yet she rips off any extra oxygen that is offered. Her oxygen levels are very, very low.  She is refusing to eat, drinking very little; mostly a few sips of Coca Cola (her lifetime favorite).

She is on “comfort care”, which mostly consists of relatively-high doses of morphine. The morphine is not for pain. The morphine slows her respirations, gives her some dream-like euphoria, and helps her die more peacefully. I have watched her on Face Time today and she is resting.  Looking at her ancient face now, it is difficult to remember the feisty woman that raised me. In her younger days, she could swear like a sailor, clean like a white tornado, and cook for an army. For the last six years, she has resided in a nursing home where she laughs, sings, holds her beloved doll (Larry), and eats candy usually pilfered from others.

My father died of lung cancer when I was six. My father was 39. He wanted to be a doctor, but he never had the opportunity. I only remember a few things about him since I was sent to live with my uncle when my dad was dying at home. While I was cleaning out some old books at the medical museum over the weekend, I came across a book called “Lung Cancer Treatment” written in 1957; the same year that my father died. The treatment of cancer has changed so much since those early days. I have always wondered how life would have been different for me had my father lived a normal lifespan.

My mother grew up in a three-bedroom, no bathroom home with 15 people in rural Appalachia. This experience can change a person. When she had a family of her own, it was very important that we not be hungry. I suspect that she experienced hunger many times as a child. While she had a limited array of things that she was willing to cook, we were always well-fed even though we were poor. Dinner was promptly at 5 PM. If I came home at 5:30 PM, she was finishing up the dishes. Any leftovers were in the refrigerator.

Cleanliness was another obsession. She changed our beds with fresh, sun-dried, ironed sheets every day. Daily baths were required and towels were only used once. She washed clothes every day and hung them out on clothes lines in the back yard. In sixth grade, I decided to wear a white dress shirt every day to school (don’t ask me why), so I always had a clean, ironed shirt in my closet.

Her style of parenting was more free-range. Sadly, she was not very involved in our lives. She only came to my school once when I graduated high school. She would secretly brag about my accomplishments but never once said that she was proud of me or my brothers. We could do what we wanted; go where we wanted, so we did. I was hitch-hiking long distances by age 12. She would often give me a lift to the main road so that I could catch a better ride. My friends considered her “mean” since she was always yelling at me about something. The staff at her nursing home loved her as always being kind and pleasant. Her longevity had given her the opportunity to be vindicated.

She was not the type of person who showed overt love to her three sons, so full-bellies, clean clothes, and clean sheets were basically her parenting contribution. She had a lot of siblings in our little town as you can imagine, but she would only associate with one or two at a time. I suspect she is dying with a lot of painful secrets of her troubled youth; secrets that she would never tell us.  Of her twelve brothers and sisters, there are only two others still alive. She also outlived two husbands and a near-third husband. She survived the Great Depression and World War II. She raised three boys on what she earned from tips as a waitress. She was really more amazing than we realized.

I just got another Face Time call. I can see my mother lying in bed with her beloved doll that she named after my older brother. She is now unresponsive and breathing erratically.  During our video chat, several of the nursing home staff came by to see her. My brother refers to them as Angels. Being 3000 miles away, I can’t reach out and touch her wrinkled hands.  My brother said they are cold now. My brother is working on a video of my mother’s life. He plans on using the music, “Coal Miner’s Daughter”, since she was.

I started writing this Blog three days ago. I got the call this afternoon at work; my mother has died.

Life has a beginning and an end, but it is the time in-between that really matters.

By Rod Moser, PA, PhD

My three dogs are my alarm clock. Within five minutes, every morning, a designated dog (usually Ellie) will jump up on the bed and lick my face so they can go outside to pee. Twice a year, they get confused because of the time change spring and fall time change.  My own biological clock and circadian rhythm gets disturbed as well.

You never really count up the clocks in your house until have to manually adjust some of them. I lost the manual for one of my cars, so that clock never gets changed; at least until I have time to figure out how to do it.  There are clocks on the microwave, the oven, alarm clocks, clock radios, the television, all of the telephones, my watches, decorative clocks, antique clocks, etc. I always pity the people that own clock shops. Some of the newer clocks and computers reset themselves for daylight saving time (DST) via radio waves from some place in Colorado. I wish all of them did that. Right now, at least four of my house clocks are a minute or so off.

I was told that daylight-savings time saves money. The real savings is supposed to be energy, but that exact amount of savings remains controversial. I think we could all save lots of money if we just turned off the lights in rooms we are not using and use energy-efficient bulbs.

That extra hour of daylight is also supposed to reduce traffic accidents and reduce crime, but I am not so sure it makes a big dent. Funding more police would seem to be a better solution.

I work 12-hour shifts which are hard enough on my aging body, but when my biological clock gets tinkered with, I feel somewhat different for a week or so after any time change. On my day off, I tend to crash in my chair about 3 p.m.; now I am an hour off. I usually stay up late reading, so I am feeling a bit sleep deprived right now. Maybe it is just my imagination, since the 24-hour day still has 24 hours. I heard that there are more heart attacks and male suicides around time changes, so one cannot be too careful.

The Monday after the time change, I had twice as many no-show appointments at work. It appears that my patients are equally confused. Our college student granddaughter who lives with us was late for her chemistry lab on Monday since she didn’t reset her clock(s). We reminded her, but the lesson she learned was more poignant.  She also went to a meeting at church a week early yesterday, but that has nothing to do with the time change.

All of this DST madness started in World War I, so perhaps it is time to re-evaluate the overall need in our society. Is the minuscule benefit of electricity savings and reduced crime worth the hassle and possible health risks?

I am in favor of just letting the sun call the shots, the way it has since the Dawn of Time.

By Rod Moser, PA, PhD

I just read an interesting article about how to tell if your patients are lying, and it made me think about some of the “little white lies” that I use in my medical practice. For most of my career, I practiced family medicine. My patients ranged from newborns to the geriatric crowd. As a matter of fact, since I also did prenatal care, I was caring for babies before they were even born. Now, 40 years later, those babies are bringing their babies and teenagers to me for care – these are my beloved grand-patients.

I lie to my wife (sometimes). I once splurged and bought an expensive necktie, telling her it was a fraction of the cost. I was caught when she went to but another one for her father for his birthday.

As parents, we lie to our children all of the time. We tell them to be good for Santa. We sneak money under their pillows and tell them it was from the Tooth Fairy. The Easter Bunny left a basket for them and a bunch of eggs in the yard. I told my daughter that broccoli made her hair shiny and that too much candy will give her zits. I even told my kids that they had to make their beds very tight so spiders would not trapped under their sheets and bite their toes at night.

My mother told me that Coca-Cola (her favorite beverage) caused zits so I wouldn’t drink her sodas. My aunt told me that Jesus kept a list of my lies and that I had a good chance of ending up in Hell. We will see.

Now that I am working with kids again, I find myself with a whole new array of stretched truths. I don’t consider it a lie if the truth would hurt more. Can you imagine my day, if I told the whole truth, and nothing but the truth?

“These shots are going to hurt like Hell, so be prepared!”

“I have some good news. You don’t have syphilis, but you do have just about everything else.”

Some of my more clever white lies that I use in pediatrics:

• Nutritional Lie: You don’t have to eat vegetables if you don’t want, but I may have to give you a “green bean shot” or “carrot shot” once per week. If that does motivate the kids to eat their veggies, I tell them that the vegetable shots go in the eyes! This usually does the trick.
• Immunization Lie: You have to get some school “shots”, but you are in luck. We ran out of the big needles today, so I will need to use the tiny ones…the ones that we use for the babies. They don’t usually hurt, but if they do, I will tell the nurse to take it out right away.
• Number of Shots Lie: You appear to need five shots today, but if you don’t tell anyone, I will just have the nurse do three. (they only needed three, of course).  So, how many would you like? Five or three? If they say “None”, I will say that I will just put them down for five and pretend to write it down. Immediately, they will yell out “THREE!”
• Laceration Repair Lie: I know that you do not want stitches, so I will just use little kitty whiskers to fix your cut. The only problem is that they tend to tickle. If you promise to not laugh too hard or giggle, I will use them.
• Wound Care Lie: I have to clean your boo-boo so it may sting a bit as those germs die. Close your eyes and I will do it real fast so your cut will go to sleep. (This is when I inject the lidocaine)
• Maintain a Quiet Exam Room Lie: You are not allowed to scream in this room, because you will wake up the babies in the next room. If you wake up the babies, you will have to help me change their poopy diapers.
• Thumb-sucking Lie:  Did you know that cats will rub their butts on your thumb when you sleep at night? This is why it tastes funny sometimes.  I think you should stop sucking your thumb, or get rid of your cat.
• Stinky Feet Lie: When kids are afraid, I often pretend that I am seeing them because of their stinky feet, which I confirm by smelling them and jumping back in disgust. After they are done giggling, I also notice that they are also here because they have an earache or sore throat.
• Little Birds in the Ear Lie: I tell kids that they can hear little birds when I look in their ears, so they have to be quiet and not frighten the birds. While I am examining them, I do a few subtle “tweets” (I am very good at bird sounds).

I suspect that I have a few hundred more of these….

There comes a point when we all have to fess up to the truth. I have a 22-year old man still seeing me a “pediatric” patient. Why? He is terribly needle-phobic and even cries when he has to get any injection. When he was five-years old, I told him that I would use the baby needles for him if he didn’t tell anyone. He didn’t, so I am still seeing him annually for a flu shot and other vaccines because I secretly use those damned “baby needles”. So far, I didn’t have the heart to tell him that there is no such thing as baby needles. I need to tell him before I retire, that I have been lying to him; using the standard needles that we use for everyone.

He probably needs to know the truth, especially now that he is the high school football coach!

In my blog next week, I will discuss how medical providers tell when YOU (the patient) lie to us!

By Rod Moser, PA, PhD

There comes a time in a person’s career that changes must be made. Usually, these are due to health reasons. For the first 40 years of my adult life (starting at age 18), my health problems were nil; just a few colds and some injuries from a motor vehicle accident. In the last five years, I felt that I was literally falling apart (see previous post by the same name). Perhaps it is time to purposely “wind down” a bit.

I once worked five jobs: a full-time clinical job, part-time university faculty, teaching community health education courses, writing articles and books, and various volunteer activities. I held a few political offices at the same time, so I guess you can count that as a sixth job. There is really no way that I could do that pace now. I am down to three jobs: still working full-time in my practice, working for WebMD, and being active as a community volunteer (I am the curator at a Medical History Museum and guest faculty for the university and our statewide professional organization). I would like to wind down even more during these next three to four years.

In the last few years, I have become physically unable to participate in the recreational activities that I once enjoyed, especially kayaking. Two back to back shoulder surgeries with a third one in my future, prohibits me using the kayak paddles.

Work keeps us alive, and for some of us, it defines who we are. I can’t imagine not seeing patients on a regular basis, or answering every WebMD posting, but there comes a time to re-evaluate your 24-hour day, and allocate it differently. I don’t think I will ever totally stop practicing. There will always be opportunities to fill in for my colleagues or teach a class at the university. There are plenty of medical volunteer opportunities out of the country – a way to tie in little travel with a dose of giving back. I love writing and I still have several books (in my mind) that I want to get on paper; or at least as an e-book.

Blogging is a painless. Like most old farts, we have an inexhaustible supply of stories, and of course, opinions. I have long-learned that the best blogs stir up controversy by awaken those sleeping masses that just read them, but rarely take time to comment. When you push their buttons – whatever that button might be – they rear up like an angry, pitchfork-carrying mob. My intention has never been to please everyone, but I do like to think of myself as a good listener. Just like a police officer telling you that you have the right to remain silent. I often have the inability to remain silent.

Should we all have a bucket list? I think so. Unless we know our goals…our destinations…how in the world will we know when we get there? I don’t have a written bucket list, other than trying not to prematurely die. Yes, I have places to go, things to do, books to write, and dogs to pet, so an untimely death would really screw things up. I will plan on postponing my eventual demise as long as I can. That is all that I really ask my patients, too.

Everyone knows their health risk. If they appear to be in denial, they are not. People know that cigarette smoking will either kill them or make the simple act of breathing a living Hell; yet they smoke. I know that carrying some extra weight on my aging bones is not good for my arthritis or my blood pressure, but losing weight is not easy for foodies.

We don’t know our timeline. There are only so many times that we can wind our watches (or replace the batteries) before it finally winds down to zero.  I am looking at three old watches right now; none of them working. I hope this is not a bad omen.

In the next several years, I will not be  answering each and every posting on the Ear, Nose, and Throat Community. This should give more opportunity for people to help each other in this active community. I will still be there and jump in from time to time, but just not as often. I will still write a blog a week on Family Medicine as long as I have an audience, and as long as WebMD will have me. I will be answering less questions on WebMD Answers, but I will continue to address some of the more bizarre and unusual questions.  For those of you who have not visited this site, you are in for a voyeuristic treat – a cross-section of questions from the touching and poignant to the eyebrow-raising, “Oh, my God!” questions. Some questions are just too good not to answer.

Yes…I am winding down (a bit) by choice. No, I will not be hanging up my stethoscope or my neutralizing my acidic charm on the social sites and blogs.  For those of you who have become my Internet family over the years, I thought you should know that. I am tired, but not tired from doing the things that I love.