Baja Connections and the Trip Home

We arrived safe and sound in Loreto, Mexico. Expecting primitive conditions, I was pleasantly surprised to discover that this little town has better Internet service than my own community. It was a pleasure to log in to my WebMD Ear, Nose, and Throat board to catch up on my postings. When you miss a few days, you feel like you haven't answered your phone. I pride myself knowing that I try to answer every posting over the last 7-8 years.

After driving 1,400 miles, it was time to rest and have some fun. The next day, we did some hiking and kayaking along the beautiful beach. The following morning, we were given a private tour of the neighboring islands, teaming with seals and birds. Much to our delight, we were accompanied by a school of bottle-nose dolphins that seemed to be playing in the wake of our boat; leaping in tandem out of the water and darting back and forth. About noon, our hosts decided to swing by a little restaurant out in the middle of nowhere -- a thatched hut run by a wonderful family who recently relocated from Los Cabos. The tide was out, the restaurant did not have a dock to tie up, and my friend did not bring the anchor for the boat. No problem.

The owner of La Picazon (means "feeding frenzy") actually waded out to the boat carrying an anchor for us to use. He then carried the women, one at a time, on his back to shore. You don't find that kind of service in the States. We then were treated to a wonderful meal of fish cooked by his wife and speared by his two teenage sons' just hours before. The specialty of the house (hut) shrimp dish was baked inside a fresh pineapple and was unbelievably superb.

Our Loreto friends rent two other units, so we met Jules and Marilyn from the Chicago area. On our last day in Loreto, we decided to meet at a local lobster restaurant. We drove, but they were going to take a local taxi. Thirty minutes after we were to meet, they arrived with an interesting story. Apparently, the taxi got a flat tire, so he sent a friend in his pick-up truck to pick them up. The driver had a note from the taxi driver stating it was "okay" to go in the truck.

About the time we were just relaxing, it was time to make the 2 1/2 day trek home again. Other than being cheated at a gas station (my gas tank does not hold 50 gallons!) and the four-hour wait at the boarder crossing back to the U.S., we made it home safely. Not wanting to leave our purchased pottery and iron work unprotected in the back of the truck at some obscure motel, we decided to make a marathon run back to the Sacramento area -- a 22-hour drive.

We plan on going back again next year with a truckload of clothing to distribute in some of the more remote Baja villages. Children need shoes, socks, and jackets. I suspect I will have no problem getting donations in my practice. Next time, we will stay longer, I can assure you.

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Baja - The Connections Continue

I have always wanted to drive to Baja. I have a four-wheel drive truck; I need a vacation; I have been graciously invited to stay with friends, so why not? So, we loaded up our truck and headed South on a 2800 mile (round-trip) odyssey.

We started off with a three day pediatric continuing medical education course in San Diego. We stayed at a wonderful, upscale hotel (for once) and visited with our youngest son, who is an RN working in a local emergency room. We couldn't wait to start our real vacation, so at 6 AM, we were in our car heading for the Border. It was an uneventful crossing at that time of day; taking only a few minutes. For those of you that have never ventured past the tacky trinket stalls of Tijuana, you have not seen the real Mexico, or met the real Mexican people.

First stop: Ensenada for breakfast. Next Stop; La Bufadora - the site of an unusual blow-hole; a geyser caused by the ocean, located just a few miles from Ensenada. Twenty years ago, this was once our southernmost point in traveling the Baja. It was a tiny, seaside community with no electricity. A handful of fisherman shacks lined the picturesque hillside. La Bufadora is now no different than Tijuana - a tacky, tourist trap. This little community has been irreversibly ruined in my opinion. If you are looking for a ceramic donkey or a blue sombrero, this is the place. We took a picture of the blow-hole and quickly left; disappointed.

Final stop of the day: A long trek, hundreds of miles and hours south on the Baja Highway to the town of Guerrero Negro - Scammon's Lagoon is one of the three mating areas for the grey whales on the Mexican coast. This was our goal for the next morning. We have most likely seen some of these same whales in Vancouver Island and in the inland passage of Alaska. I doubt they will recognize me.

That night in the restaurant, we met a Canadian couple that spends a month each year volunteering at a local orphanage. They have been coming for four years now. They drive down in their travel trailer during the cold Canadian winters. Working in the orphanage warms their souls, more than their bodies. On our next trip (and there will be a next trip), we plan on dropping off a truck load of children's clothes that we are going to collect. Another connection.

Scammon was a whaling captain that nearly killed all of the whales that came to this lagoon. I find it interesting that they have his name attached to an area now highly protected. Early the next morning, we hopped on one of the pangas (small, open boats) operated by Mario's Tours -- a side business of a little, thatched hut restaurant. There were five of us: my wife and I and three Indian people from San Diego -- The Reddys. Dad was a gastroenterologist in San Diego that knew my RN son from the ER. His son was a student in Los Angeles that spoke fluent Spanish. The grandmother was along for the ride, wearing her sari and a bit worried about the whales. At one point, she told me that she was afraid they would eat her.

The boat buzzed past one the largest salt evaporation plants in the world, owned mostly by Mitsubishi. In no time, I spotted the first spouting of a whale. In the next half hour, it seemed we were smack in the middle of hundred of grey whales; too many to photograph. The four of us madly snapped our photos and grandmother sat in the geographic center of the boat. Suddenly, a baby whale popped his head up over the boat and stared at us. We touched him (or her) - the whale didn't get out of the water that high. It was wonderful.

"Did you hear what the whale said?" I exclaimed. This caught the grandmother's attention.

He said, "Hey, who likes Indian Food!?" The grandmother couldn't stop laughing. Her son told her not to worry since Indian people are much too spicy for whales.

After this wonderful experience, we headed across the Baja desert for the costal town of Mulege; another 175 miles away. The desert was not at its peak with flowers, but it was still unbelievably beautiful. We passed dozens of tiny towns, bordered on both ends by axle-breaking "topes" or speed bumps. You only go over those once while going fast. We also passed hundreds of highly-decorated roadside shrines of people that were killed along this challenging stretch of road. These were the sites that took the lives of fathers, mothers, or children; often still placed near the broken guardrail that failed to protect them. It made us sad; and reminded me to drive a lot more carefully.

We arrived in Mulege safely before dark. Only a fool would drive these roads at night, where cows often congregate to get warmth from the blacktop. Our hotel had its own dirt runway where U.S. private pilots land for the weekend. After driving the roads, I can see why someone would choose to fly. It only took a few minutes for someone to notice the license plate on our car. They were a couple who live about four miles from us. We shop at the same grocery store. Another connection.

Tomorrow, we head for our final destination: Loreto.

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Relationships and Medical Practice - Making a Connection

Over three decades of practice in the same community, I have a share of "grand-patients" - children of children that I have cared for over the years. There are patients in my practice that I forget immediately after I leave the examination room, but over the years, there have been numerous special patients and families that you never forget. No, it is not their illnesses or their special medical needs that trigger this attachment, but rather who they are as people.

When I first started in clinical practice, my physician boss advised me never to get personally involved in the people that I treat. Be friendly; but don't be friends. Although it sounded odd, I followed his advice for many years, missing opportunity after opportunity to get to know the wonderful plethora of human beings on this planet. I absolutely love people, so when I changed jobs so that I could raise my children in a smaller and safer community, I totally rejected this advice. I wanted to be a part of the community.

If my patient owned a gas station, I bought gas from him. This came in very handy during the gas crisis in the late 1970's. People lined up their cars for hours just to get gas, but not me. My friend (and he is still my friend) made sure my tank was full. When his kids were sick in the middle of the night, I was there for him. This is the way America used to be and the way it should be now. Medical providers are not different species. We are humans and humans simply enjoy the company of other humans.

I look for connections with patients that we all have. Everyone on this planet has a connection of some sort. We have the same hobbies; lived in the same area in the past; drive the same cars, or kids going to the same school, or whatever. If you talk to a person long enough and are really interested in who they are, you will find that all-important connection. Sometimes, the connection is profound.

Learning about your patients is a powerful way to understand who they are as humans. You don't treat an "ear infection in room one," you treat a PERSON who just happens to have an ear infection in room one.

So, during my ongoing effort to get to know people, you find friends. Back in the late 1970's, I took care of a family called the Hammons that I really loved. They were the greatest kids and the nicest parents you could imagine. I didn't need a chart when I saw them. I knew their medical histories, and who they were in my heart. Jump thirty years later and a lot of water under the bridge of life. A mother is bringing a little child to see me. She is smiling. This little child was another "grand-patient".

"Do you remember me?" She asked. "My name is Kim Hammon."

"Kimmy! You have grown up.", I responded.

"Of course, I remember you. How's your brother? How's your Dad, Randy?" A fond connection was re-established across three decades of our separate lives.

Her Dad and mother divorced years ago. Her mom still lives in town. Her Dad remarried and is now "sort-of-retired", living in Loreto, Mexico. She gave me his e-mail and asked that I send him a note. I remember that family like I saw them yesterday. There are days when I can't remember where I parked the car, or what I came upstairs for, but I fondly remembered this family. We had a connection.

E-mails were exchanged. Plans were made. To make a long story shorter, my wife and I just returned from a 2800-mile road trip to Loreto -- the longest house call that I ever made. This is my "old patient" and friend, Randy, with his grandson, Aturi.

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Part 5: The Top Five Reasons Why Patients Are Dissatisfied

In a recent patient survey in our medical group, there were five areas of dissatisfaction that were identified. This is the last of the top five reasons.

5. Waiting time in the reception area is too long (8.4%)

Reception area? I thought it was called the Waiting Room. Being a medical provider, and also having numerous opportunities of being a patient, this would be number one on my list. I absolutely hate waiting with a bunch of sick people.

When I go to the clinic, I enter through the employee entrance that just happens to go through the Lab Waiting Room (sorry, Reception area). Perhaps people are bored or anxious, but my entrance through the door creates some sort of diversion. Everyone, I repeat, everyone, stares and watches me as I walk through this area. I have always been taught that staring is impolite, but I have recently started staring back at them.

People are leafing through magazines or Watchtower flyers dropped off by Jehovah Witnesses, catalogs of classes offered at the community college, or yesterday's newspaper. A few are pounding away at laptops; teens have their iPods in their ears. Most are staring at me as their only form of entertainment. Perhaps I should dance? There is usually someone talking out loud on their cell phones.

"Yes, I still have that oozing rash. I am here at the lab to get some tests to see how contagious it is. What are you up to?"

In pediatrics, we have two waiting areas; one for the sick kids and one for the well ones. The receptionist and the parent usually decide which area is for them. We have another room that we use for "rashes," mostly to rule out varicella (chicken pox). There is usually someone in there with a non-contagious skin eruption, like eczema.

I always feel sorry for the people in the Sick Waiting Area. They could easily come in with one illness and leave with another. We do not charge extra for this service. Well adults are usually sitting with their sick kids wondering what they will catch. There are televisions with movies playing to make waiting more bearable, at least for the kids.

In the sick area, there are always plenty of "buffer" chairs separating the sick kids from the other sick kids and lots of hand sanitizer being used. Meanwhile, over on the well side, children are freely interacting. Since most viral illnesses are contagious a day BEFORE you know you are sick, our Well Waiting Area should probably be renamed, "Kids that are not sick... yet."

Any time spent in a waiting room or reception area is too long in my opinion. We have many celebrity patients, mostly highly-recognizable NBA basketball stars who often bring in their kids. So that the other well-meaning people will not hound them for autographs, we tend to bring them back quickly. I sure wish that I was seven feet tall sometimes, but when medical providers become patients, we are treated exactly the same as everyone else. We sit there and try to be a patient patient. When the receptionist looks up, we smile and glance at our watches, trying to portray that hurried look. It doesn't ever work.

I heard a comedian say that he claims to have chest pain when he goes to the ER so he can get prompt service. As soon as they get him to the back, he claims his chest pain is better now, but his finger (the real reason for the visit) is really sore. I don't recommend this approach, but people do change the reason(s) for their visit. This is one of the major reason medical provider tend to get behind. We call them "Oh, by the way..." issues.

Yesterday, I had a mother bring in a teenager for a headache. No sooner than I started to take the medical history regarding this headache, she brought up a good half-dozen other issues. Perhaps she felt this would better fill up the idle time I would have during this 15 minute visit. In addition to those headaches, there was back pain, a rash on her leg, a changing mole on her back, menstrual cramps, and ingrowing toenails.

Since I could not possibly devote the two hours needed to adequately cover these issues, we had to negotiate some to a future visit. To be nice, I spent twice as long on this visit as planned, arranging for her to return for the less "critical issues." Even after that, she pulled out some immunization records for me to review and a sport participation form she wanted completed. On the outside, I smile. Inside? Aaarrrghhhh!

There is nothing more pleasurable for me than seeing a patient promptly; on-time. As soon as my nurse finishes her part, I like to shoot right in before the door even closes, much to patient's amazement. Unfortunately, I can't always be as prompt, but I try my best.

"Wow, that was fast."

"I thought I would try and make up for all of those times you had to wait."

She takes out her list.

I smile.

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Part 4: The Top Five Reasons Why Patients Are Dissatisfied

In a recent patient survey in our medical group, there were five areas of dissatisfaction that were identified. This is the 4th of the five reasons, but this is nearly identical to the second one: Provider's ability to return your calls in a timely manner (10.6%)

4. Office phone calls not answered promptly (10.1%)

On some days, we may see upwards of 450 patients in our pediatric practice. For each patient see, there may be twice as many phone calls directed at the dozen or so medical providers in the practice. These calls must be answered by our staff. During the morning rush, when the phone banks open, we have about eight people answer our lines until things quiet down. Our medical group carefully tracks how long people wait on hold so that we can create bench marks to do better.

I think we do pretty well in our particular office, but other practices within our medical group may not be doing as well for this to make the top five. Most of our patients are able to get through, speak to a competent human, and have their issue addressed. Although we do have to put people on hold from time to time, depending on their request, we try to limit the idle time.

No one, I repeat, no one likes to be on hold. I am probably the worst person to be put on hold. I answer postings on the WebMD ENT board; I work on Blogs; I play solitaire. I count the minutes. What I don't do is listen to that awful music, which always seems to be Spanish Eyes or another tune that I hate. Tunes that you hate always result in the worst case of ear worms -- tunes that repeat over and over in your brain; tunes you cannot shake the rest of the day. Of course, if you didn't have the music, you would think you were disconnected and call back, getting a busy signal because they have you on hold.

When you are ill, being on hold makes you sicker. This is just a personal theory. First, you are already not feeling well. You listen to Spanish Eyes a few hundred times and life is no longer worth living. Once your call is finally answered, it is all that you can do to not take it out on the overworked person who was unlucky enough to get your call. If the person who answers the phone is (a) courteous, (b) efficient, and (c) accommodating to your schedule, you are unbelievably gracious.

xOur brief message that the patient hears first informs them of our "busy phone times" and suggests that they call back later if they can. Most people hope the other people call back, so you will not have to wait. Basically, most people wait.

Almost all doctors' offices have that disclaimer: "If you have an emergency, hang up and call 911." We have that announcement, but fortunately very few people with true life threatening emergencies call us first. The message is for those rare people who decide to remain on hold with a severed limb or something.

One of my patients told me that she starts calling immediately at 8:00 AM on Monday mornings if her kids need to be seen. If she gets a busy signal, she hits redial over and over until she gets through. I bet she is not the only one that does that. She prides herself in getting through relatively fast by this method. One woman called on her cell phone, was placed on hold. She was still on hold when she walked into our office, so when they answered her call, she was already sitting in the waiting room. I loved that story.

I had an important flight canceled one time. As soon as the announcement was made, hundreds of people ran like cattle, dragging bags and kids by the arm, to try and get on the next flight at another remote gate. I was second in line when they canceled the flight, which placed me near the end of the mob rushing to the new gate to be booked on the next flight. Perhaps out of fear of being trampled, I dialed the 800 number for reservations and booked my seat before those sweaty losers even made it around the corner. I don't know why I told you this story, but I love this one, too.

We don't have complicated voice mail announcements in our office. I find these worst than being on hold with Spanish Eyes:

"If you would like an appointment, press 1. If you would like a refill of an existing medication, press 2. If you have a question for our advice nurse, press 3. If you are calling about the status of a referral in progress, press 4. If you would like to speak to the receptionist about an existing appointment, press 5. If you have a severed limb, please hang up and call 911. If you would like these messages repeated, press 10"... and so on.

Maybe it is my short attention span, but by the time I get to the end of those voice mail messages, I either forgot the number I should have pushed, or NONE of those choices are really what I want. Usually, I just hang up, put my severed limb in a bag of ice, and call back later.

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Part 3: The Top Five Reasons Why Patients Are Dissatisfied

In a recent patient survey in our medical group, there were five areas of dissatisfaction that were identified by patients. This is the third of the five reasons.

3. Patient's ability to contact providers after hours (10.4%)

People do not always get sick between the hours of nine to five, Monday through Friday. Since medical providers cannot be in their offices at 3 AM when someone has an allergic reaction or a sudden bout of abdominal pain, doctors take call. In other words, they carry their beepers and cell phones with them in case their patients have an immediate need for advice. Unfortunately, although some medical providers practice advanced forms of telephone medicine, advice is just about the only safe thing that can be provided via the phone.

Medical providers are supposed to be available to their patients 24 hours a day, seven days a week. In large medical groups, doctors will share call, since no human being should have those 24/7 responsibilities. In our group of a dozen or so providers, call is shared about three times per month, depending on vacations, etc. That doesn't sound too bad, but when you realize that one medical provider is covering call of tens of thousands of patients, they are most likely in for a busy night.

I am fortunate not to have call duties in our practice. When I worked in family practice, we all shared call and Saturday clinic. One night, I was awakened at 2 AM by a person complaining about ankle pain. Apparently, she had twisted it two days ago, and chose 2 AM to share it with me. I remained calm; told her to elevate it, apply some ice compresses, and take some Motrin. She was also told to call in the morning to make an appointment to examine the ankle. She did not call or show up the following day. Her inappropriate call woke up our baby, too. Nice.

I am a bit embarrassed to share that I was on call again two days later. Again, I was startled awake by a patient call around 3 AM. This time, it was a woman that may have been going into premature labor. She was sent promptly to the ER. As I wrote her name down in our call book, I noticed the ankle pain from a few days prior. As much as I tried to resist, I dialed her number. A sleepy voice answered.

"This is Rod Moser from the clinic. You didn't show up at the office, so I am calling to see how that ankle is doing."

After a brief, sleepy hesitation, she responded, "Fine."

"Excellent. Have a good night."

When I started working for our medical group, there were no after hour options other than telephone care. If the patient needed urgent medical services after 5 PM, they were simply sent to the local urgent care facility or emergency room. Prior to joining this group, I worked in one of those free-standing urgent care facilities. We worked three, 12-hour shifts per week. There was absolutely no reason why I could not do that for my new group. I figured that I was there; I was dressed; and putting in another four hours was not a big deal. When I was younger, working those extra hours wasn't a big deal. It is not as easy now as it used to be, but at least we have coverage for our patients until 8:30 PM.

Some after-hour calls are certainly appropriate, like the premature labor. Unfortunately, many are like the sprained ankle. There is really not much that medical providers can do other than provide some advice. We have many new parents in our practice. There is nothing that panics a new parent more than fever in a child. Although fever is inherently harmless, the higher the number, the tighter the parent's anal sphincter becomes. If there is one child, a parent can only tolerate about a 100 degrees; two children, about 102; and three children, about 103. If there are more than three children, fever doesn't frighten them anymore. Kids basically have to have smoke coming off of them. In a pediatric practice, fever tops the list of after-hour calls.

The word physician means "teacher." An integral part of our job is to teach people when it is appropriate to call after hours, and when it is appropriate to (a) wait until the next morning; or (b) utilize urgent care or ER facilities. Yes, medical providers deserve a life and they should not be bothered in the middle of the night by two-day old sprained ankles, but part of our responsibility is to help these more "challenged" people make those decisions. If patients call, we need to answer. This is the job we chose.

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