Tuesday, December 28, 2010

Family Medicine: Grief, Loss and Death at Christmas

"All mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated...As therefore the bell that rings to a sermon, calls not upon the preacher only, but upon the congregation to come: so this bell calls us all: but how much more me, who am brought so near the door by this sickness....No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."  ....John Donne, Meditation XVII

"Are you willing to sign the death certificate on ________?," the county coroner's representative asked me a week or two before and again a few days after Christmas, during one December.  They need to know if the patient had a medical condition that could be lethal under certain circumstances, or do they have to consider making the death a coroner's case.  I reflect in my mind on the conversation I had with the emergency physician about my patient who had a respiratory infection that suddenly overwhelmed the lungs, weakened by chronic disease, leading to respiratory failure.  Their efforts to revive my patient were unsuccessful and I felt empty, reflecting on a ten plus year relationship with a unique person and their family.  Three generations of the family are patients of mine, too.  The same is true of the person who died a few days after Christmas, both having children and grandchildren who have a relationship with me and my family medical practice.

Loss is difficult for families at any time, but often seems to hit harder at Christmas time.  I frequently see patients in December who can't wait for "the holidays" to end.  They lament the loss of their grandmother, mother, father, grandfather, child, favorite aunt, sister, brother, etc. which overwhelms their senses during the anniversary day, week or month.  The grief often is prolonged for years, generally not generating a focused attempt to integrate it into their "in fond memory" files.  It may even get the mental status of a post traumatic stress syndrome (PTSD) person with lingering emotional pain instead of positive life lessons.  I know their pain is a legitimate situation in their life.

Some of the most difficult situations with Christmas Grief come with multiple losses over the years near Christmas that get "stacked" into one grief reaction.  Individual losses may become tolerable as time passes and the patient reflects on the meaning of the deceased person's life, but stacked grief puts several grief reactions into one inseparable pile, making the grief less likely to be resolved.

In these situations of stacked grief, when the patient has enough energy to deal with grief, I ask them to list the losses and schedule times on their calendar when they will grieve each individual loss, as their brain and heart allows.  "Get the grief off your head, where it sits like an anvil, and put it into your calendar", I suggest, in an attempt to make the grief more understandable for the individual.  "Calendaring" the losses frees the patient from continuous grief, giving them freedom to live their life when not in a scheduled grief appointment with themselves.  Separating the grief reactions may allow resolution of some grief while pointing out areas where special counseling might help.

Pathologic grief often requires the help of counseling professionals (including clergy) to effect the best outcome.  Many grievers, however, put off recommended counseling for years, sometimes stating that it would dishonor the deceased if they didn't feel miserable.  The suicide of a child, spouse or parent comes to mind as the intense type of grief that requires special skills and lots of time.  Sometimes the brain just blows the facts of the loss into separate brain areas, preventing the whole story from being mentally reconstructed until there is enough life energy to handle it.  Soldiers with PTSD are a special group who provided counselors and physicians with broader insights into how the brain protected itself from intolerable mental anguish.

Physicians grieve for patients, both living and deceased, at times and places away from usual patient care.  The professional "auto-pilot" may turn on to get through a loss situation to finish "the work" before processing the grief.  We must also schedule the grief for a specific time in the calendar to avoid "Non-Grief", which could be detrimental to our patients and ourselves.  This also includes Christmas Grief of and by the physician, professionally and personally.

We all share the same humanity and seek peace in our lives.  We periodically should again reflect on the words of John Donne as a reminder:
 "No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."

Wednesday, December 22, 2010

Family Medicine: Influential with Patients, Hospitals and Employers- Let's Talk!

"You are a scarce, valuable resource," I told my colleague about 20 years ago when he felt rejected by the local hospital when bumped out of the practice he had served since proudly joining the family physician who had delivered him and cared for his family.  He was inspired by the man who had served the community so well, eventually for over fifty years, and became a family doctor, just like his role model and mentor.  Now, he saw the practice, in the neighborhood where he grew up, that he inherited at his mentor's retirement and merged into the hospital network to help with recruitment and management, redirected away from his philosophy of care toward hospital corporate values.  What happened?  Why did they close the office and order him to take the patients and practice where another recently trained family physician had been placed in practice two years ago in another retired physician's office in another neighborhood?

Hospital administrators think differently than physicians.  Family physicians may even think differently than many other physicians.  We care about our patients and their well-being.  We haven't taken the time to verify our thought processes and our differences with hospital managers and other physicians.  We need to clarify our similarities and differences now, though.  We have to find our areas of mutual interest and mutual misalignment.  We have to agree to disagree on many issues because of differing philosophies and business models.  A creative tension between family physicians and hospital leadership benefits patients and the local economy.

Hospitals need to fill beds, CT scanners and cardiac cath labs.  Patients don't want to fill them unless there is a clear need.  If there are excessive medical resources such as CT scanners and cath labs, there will be a push to fill them by changing decision thresholds to use them.  The creative tension between family physicians and hospital leaders can serve to find a balance in use of resources.  As the family physician becomes a more scarce, valuable resource, their influence in hospitals is needed even if their presence is diminished.  We are one of the keys to decreasing re-admissions of patients.  We are key influencers of how our patients use health care resources, e.g. which hospital they relate to and where they go for physical therapy.  We are key translators of healthcare system intentions to our patients.  We are important communicators with small employers and some large employers in communities.  We are trusted.

Let's get some better communication going between family physicians, hospitals and employers.  It will better serve our patients and communities.

Monday, December 20, 2010

The Human Centered Health Home: Detecting Patient Alignment or Misalignment Using "Get, Give, Merge and Go"

"One of the paradoxes of our time is that the healing relationship seems most in jeopardy at a time when we need it most.  ...A preoccupation with a disease instead of a person is detrimental to good medicine....Any physician who looks upon a sick patient as an exercise in diagnosis or treatment is not a complete physician....it is tempting for a physician to rely too heavily on his science."...G. Gayle Stephens, MD in The Intellectual Basis of Family Practice (1982)

Clinical knowledge and skills require continuous learning and practice by physicians, including frequent upgrades of clinical science.  Patients assume that we know a lot of science and medical facts.  Still, that leaves us incomplete as physicians.   The interface of physician and patient is a dynamic human engagement with elements beyond the two primary persons and their momentary roles that seek to effect a mutually beneficial outcome.  I have written before about clinical decision making in the family medicine office as a shared endeavor in which patient and physician explore, reach a level of understanding and act on a plan.

The patient has unique insights about their illness and life context (often including biological and medical knowledge) while the physician has unique insights about human biology, diseases, conditions, therapies and medical situations.  Education, experience and the internet seem to better prepare patients for clinical situations and environments.  Many physicians believe that it's more satisfying to care for patients who have information access and motivation.  Many others clinicians fear informed patients because they may feel threatened or have to vary their work flow to accommodate the (usual) extra information sharing.

Sometimes, the physician may hide behind their "white coat" to pressure the patient with important and/ or costly recommendations, leaving the patient little negotiating room.  Many physicians are trained to withhold information from the patients, who don't understand Bayes' Theorem or p-values in clinical studies because it would only confuse them.  They become coercive in pressuring patients to accept diagnostic testing or therapies that they don't adequately explain to patients.  They don't really inquire about patient values that would drive the decision in a direction other than the one chosen by the physician.  How could the patient understand the complexity of our clinical decision?

How can physicians better understand the complexity of the "illness" for the patient?  How can either communicate effectively with the other, and with themselves, in the work context where medicine lives and patients seek healing?  I still believe that it starts with two humans, equal in their humanity and their respective quests for meaning.  The mutual respect for each others humanity anchors the dyad at the starting line of health care quality and precludes the participants from "using" each other.

Disease oriented medical literature assumes a valueless patient initially for the purposes of learning.  Behavioral aspects of patient care are seen as less important.  So patient values aren't subjected to statistical analysis.

A model that often helps me in Family Medicine is "Get, Give, Merge and Go", developed by Carkhuff Associates in Amherst, MA and published by Human Resource Development Press, also in Amherst.  The Patient and Physician both use the same model, as indicated.  First "Get" the other person's perspective on what they think is happening (referring to other posts about the HCHH, this could include a SPIT differential diagnosis or Biopsychosocial analysis at least by the physician and possibly by both).  Then "Give" your perspective.  Next, seek to "Merge" the two perspectives, integrating aspects of both parties insights into the analysis after engaging and clarifying.  Lastly "Go" ahead with the mutually agreed to plan.

What do you do if the two parties can't seem to agree?  Dr. Carkhuff published a book in 2010 (Saving America) introducing:  "Get, Give and Grow".  Keep learning and growing until the "Merge" element might occur, leading to a mutually agreed "Go" step.  Examples of the place to use this model include patients and/or physicians with strongly held beliefs about immunizations or opiates.  These can be challenging discussions, but family physicians and their patients need to commit to "Getting and Giving".  The mutual human respect will allow the dyad to have a better chance to "Go".

Wednesday, December 15, 2010

Family Medicine: Hospital Staff Holiday Parties, Diminished Family Medicine Presence and Bananas Foster

Around Christmas time, hospital medical staffs have Holiday Gatherings to hold the quarterly medical staff meeting and celebrate with a lavish dinner, music and pleasant comaraderie.  Each physician or non-physician member of the medical staff is invited to bring a guest to share in the celebration after the meeting.  The exact format varies from medical staff to medical staff.  I belong to two hospital medical staffs in one hospital network.  I enjoy the Holiday Parties.  I'm curious about what's happening with the physicians and the system.

This year, for the Holiday Party, the big community hospital rented the main level of a performing arts center downtown in the major city nearest the hospital.  Hundreds of physicians, spouses and significant others and hospital leadership gathered in a grand "eatathon" and brief medical staff meeting.  The chocolate fountain was a hit, but many missed the Bananas Foster that was a tradition at the smaller venue of previous holiday meetings.  The Indian food was wonderfully spicy but the music was too loud for casual conversation within about 90 feet of the entertainment (forcing some to eat more to remain sociable).

Near the salad bar, I conversed with a cardiothoracic surgeon about a shared patient who  had a difficult situation.  He was worried about her and the complex decision process that faced her.  I offered to help in the clarification session to aid in patient understanding.  I picked a seat at an empty table where a plastic surgeon joined us for conversation.  He is in private practice and proud of his certified operating room where he can do plastic surgery without a hospital.

The chief of staff announced the retirement of a general internist who had practiced in the area and admitted to the hospital for 45 1/2 years.  Wow!  How many thousands of patients must he have served.  I felt humble.  While later walking around the performing arts center to find a less noisy location to be able to hold a conversation with a friend about our family, another physician greeted me and stated that he was closing his endocrinology practice in 4 months.  He thanked me for referrals over the years.  A greeting to a medical school classmate and polite,"What are you up to these days?"  brought the response, "A lot, we just sold our practice to this hospital network, who out bid the competition."

Retirements and selling practices in bidding wars caught my attention.  There is movement in the system.  People are jockeying for position.  How do you hedge your bets?  How do you best serve your patients?

One day later, my wife and I attended the small community hospital Holiday Medical Staff Meeting.  We voted for staff leaders before the meeting.  All candidates ran unopposed and were announced as winners later during the meeting.  A brief slide show showed the progress with the new hospital next door to my office.  Enthusiasm bubbled through the room.  The food was great (pecan crusted walleye and sushi were unique items).  The dessert included the Bananas Foster and the same chocolate fountain as the previous evening.

Conversations with an urgent care medical director who trained in family medicine and another family physician who has a huge practice both centered on family medicine workforce development.  Who is going to see all these patients?  More and more are showing up at the urgent care with no family physician.  Many are from practices recently vacated by the 5 1/2 family physicians who left our county in the last 19 months.

The hospital network trains physicians, including cardiology fellows to help with the new heart hospital they just opened, but none in primary care, so they have no way to replace these physicians unless they come from elsewhere.  To make matters worse, the flagship hospital of the competing hospital system which just opened a new heart hospital tower, closed and bulldozed their family medicine training center, so they train no family physicians.  The Osteopathic hospital in town still has a small family medicine training program as does another community hospital in the northwest area of the city.  That hospital acquired a heart hospital  in 2008, so we now have three heart hospitals in case anyone didn't notice.  The biggest family medicine training hospital in the area closed over ten years ago, eliminating twelve new family physician graduates yearly.  Is this area turning into a cardiology over-served and family medicine under-served area?  Who pays attention to the primary care needs of this area?

Conversations with three independent practice physicians who are generalists resonated with some concern about their relationship with the new hospital, since other groups may show up and compete for patients.  Many are concerned about the big groups being bought by the hospitals.  "How can we compete with hospital owned groups?" they wonder.

Holiday Parties enable relationship enhancement and have information and food ups and downs, sometimes with Bananas foster (it was delicious).

Monday, December 13, 2010

Family Medicine: Fun, Facts, Reality and Challenge

Fun:  Five year old children are delightful.  Spongelike learners, they are very engaging and cooperative, except when confronted by the need for the three injections to be fully immunized before entering kindergarten.  If their parents wish, the child can get them when they're four and easier to restrain (yes, restrain, with the help of the parent holding hands or legs).  Neither four or five year old is happy for the opportunity to be immunized.  They are delightful again at the next clinical encounter, having already clarified with their parent that shots are not part of this visit.

Facts:  Flu shots were slightly more popular this year than last year, even without any pandemic concerns.  People seem relieved to know that the H1N1 protection is included.  Many get them at pharmacies when filling one of the prescriptions for a chronic disease.  It's one sign of the times that many health care prevention services will be provided away from physician offices.  Pharmacies want to become the patient's primary care provider.  I have a problem with that concept.  They also sell cigarettes a few feet from where they provide health care services.  I have a problem with the duplicity of health and sickness being sold together.

Reality:  People are getting older, along with their doctor.  More knee, back and neck pain.  I see five or six people per week with a pinched nerve in the neck or back.  One or two per month get surgery when the medicine and physical therapy don't provide relief and the subsequent MRI shows nerve root encroachment or a herniated disc. It then takes them another three to six months to fully recover. 

Challenge:  Every two years, someone continues with low back pain, after having disc surgery, which remains severe.  In these patients, there is always a family history of other family members with brain problems that may include, depression, intractable pain and/or chemical dependency (alcohol or opiates).  Their brain has a dysregulated pain management system and things often hurt more than in most other people.  That's just how their brain is, they didn't make it up or intend it to be that way. 

We may have these folks on medication such as Vicodin, Percocet, Morphine, or Oxycontin plus a base of Ibuprofen, often combined with Trazadone, Neurontin and maybe Zoloft or Celexa for more brain support.  They also get ongoing physical therapy, if helpful and, if there is an injection potential, I encourage them to see a pain specialist for the injections.  I do not have the pain specialist manage the monthly medication prescriptions and ongoing evaluation and management of the patient.  They have focused training in procedures that are very focused and costly, which they do well when needed.  They don't deliver continuous comprehensive care, which is what my patients need.

We ride the waves with these people who have intractable pain with some intense misery at times, especially  when their brain seems to be "stealing" their opiates from the site of their pain.  This tells me we may need more opiates briefly and intense focus on extra therapies that may convince the brain that it doesn't need to steal the opiates.  Each patient is uniquely different, requiring a personalized treatment strategy.  Some have intense fear of the pain flare ups and we address the fear and may medicate it, if the Trazadone, Neurontin and Celexa haven't reduced it or prevented it.  Suboxone may replace the opiates later when the pain and brain aren't going the right way chemically.  Some also benefit from extra counseling support from a psychotherapist or their clergy.  Faith and religion are almost always a big factor in how our patients cope with chronic pain.  Family support is another important part of coping.
Winter Facts:  Winter weather changes  the behavior of people.  In fact, in Ohio each season has specific health risks, both positive and negative.  Vitamin D3 deficiency is rampant in winter, causing many to feel blah, down or even depressed.  Snow and ice generate more caution with travel and walking outside.  We see increased fractures of the hip and the humerus (upper arm) caused by senior citizen falls.

All these phenomena and more are components of Family Medicine, a relationship based medical specialty not limited by organ systems or pathological processes.  I still love it!

FMEC, Inc. Meeting and Hershey, PA October, 2010

Saturday, December 11, 2010

Family Medicine: I Love It

I love being a Family Physician.  My mirror agrees.  It is an amazing privilege to get to hear people's stories about their lives, families, careers, struggles, goals and dreams.  Over 150,000 patient encounters later, I'm convinced that people matter and they care for each other.  Their resilience is impressive.

Sometimes they need a little help to clarify where they're headed, especially when they're lying on the exam table moaning with pain of one sort or another.  If they can't sit up it's about 50-50 that they need a hospital and 50-50 they have a significant mental health problem.  (Just an observation over the years).  There's a high probability that they need an injectable medication if they can't sit up, maybe Toradol, Penicillin, Rocephin and /or Phenergan.

People will let the family physician know who is drinking again, if given the opportunity.  Sometimes, the offender is a person who was in my office recently singing the praises at how much money he's (almost always a he) now saving by not drinking anymore.  The truth filter comes up for the physician to try to clarify who's "truthing" the most.   Over the years, I've come to realize that the alcoholic is lying to themselves more than me.  They start to believe the lie and feel that it's true.  So when they tell it to me, they feel truthful. In the alcohol treatment health professions, they have a saying,"If their lips are moving, they're lying."

People care about each other in families.  Our practice focuses on families, so we only take families as patients, like the whole household or none of them.  Family members often come in together in twos, threes and fours.  They will share information and concerns about one another with the family doctor.  Sometimes they can't figure out what to say in front of the designated patient so they call in a message to the doctor before the visit, listing their concerns.  This happens most often with cognitive decline, alcoholism and chemical abuse in our practice.  The caller is trying to help in the best way that fits with their comfort and communication style.

People have more special requests near the end of the year.  Most are insured and may require information for the IRS to get their tax deducations.  They may need renewals of special apparatus prescriptions, such as their breathing equipment or C-PAP for sleep apnea equipment.  They want to know which insurance companies are still OK, to explore for their health insurance annual decision and why we're concerned about insurance company X as indicated by the sign in every exam room and the waiting room.  "Should we switch insurance companies now?", they ask if they are covered by that plan. It's hard to tell, I answer, but this company suddenly eliminated a dozen or so family physicians from their plan as providers in mid-plan year in another Ohio city, severing the physician-patient relationship for many senior citizens.  That concerns us a lot.

Christmas is meaningful for most of our patients, who reside in suburban cities and towns where unemployment is over 10%.  They have to watch their money closely since the next job lost might be theirs.  In spite of that, they have optimism about Christmas for themselves and their families.  Less money means less shopping and more togetherness with family and friends.  The non-Christians are comfortable with the mention about Christmas by other patients from their community.  In our local communities, the people seem to respect each others religious preferences. 

Another aspect of family medicine in the winter is infection such as viruses, strep throat and influenza.  We see infected persons daily and notice that the meaning of their illnesses vary from person to person.  One sick person with strep throat might need to be well the next day for a college final exam, while another is pleased to get a couple days off in an isolated room from family.  It's satisfying to help people understand the meaning of their illness and to validate them as people who matter.

Each day in Family Medicine is a unique one with well and ill people wanting to optimize their health while minimizing their expenditures.  I love it!

Tuesday, December 7, 2010

Connecting as Humans First; Then as Patients and Doctors. Doc U R Fat: Insulin Resistance

The Dr Synonymous Show December 7, 2010  BlogTalkradio.com/DrSynonymous
"Connecting as Humans First; then as Patients and Doctors.  Doc U R Fat:  Insulin Resistance"

Introduction/ Disclaimer
Tribute to Pearl Harbor and WWII

Patient Blog:Since I've Been Gone by Stephanie
Medical Student Blog  http://futureoffamilymedicine.blogspot.com

New Blog from Jennifer Middleton, MD:  The Singing Pen of Dr Jen

Physician Blog Post AFP Community Journal: Kenny Lin, MD: Close-Ups Bringing Patient Perspective to AFP

Dr Synonymous Blog Posts 11/22 Human Centered Health Home (HCHH) Detecting Alignment or Misalignment & 11/30 Human Centered Health Home: Biopsychosocial Model
12/03 at drsynonymous.blogspot.com

Clinical Focus:  Insulin Resistance
Healthy for Life by Ray Strand, MD
Syndrome X by Challem, Berkson and Smith
The Glycemic-Load Diet by Rob Thompson, MD
Combat Syndrome X, Y and Z by Stephen Holt, MD
Perspectives in Nutrition by Wardlaw and Hampl

Next Show 12/14/2010

Friday, December 3, 2010

Personal Health: "We're Not Here to Hurt You" ...Dr. P., my oral surgeon

"Ouch", I thought as a sudden, intense, but familiar pain struck my tooth.  A throbbing, rhythmic classic toothache was dancing with my favorite molar, the one on the lower left (later named as #18 by my dentist) that had a fracture and a root canal in 2008.  The same favorite molar is the posterior anchor to my bridge which acts as a memorial to the adult tooth that was congenitally absent, becoming a "no-show" when the "baby tooth" graduated to a valuable spot under my childhood pillow and then to the tooth fairy, who always left some money.

A throbbing night with tooth pain, buffered by Aleve and acetaminophen, inspired me to call my dentist's office.  Laura at "Dr. Mike's" office was caring and professional in getting me an appointment 4 hours later, during which the x-ray showed a radiolucency.  Dr. M. examined the area and the x-ray before determining that I had an infection in  precarious proximity to the aforementioned molar #18.  He prescribed an antibiotic and recommended evaluation by an endodontist for potential tooth-saving surgery.

Three days and several aches later (sometimes treated with the addition of topical brandy which had a numbing effect late at night when it throbbed the most), Dr S, the endodontist whom I'd seen for a root canal 14 years ago, smiled as he greeted me enthusiastically.  He had reviewed the history taken by his dental assistant and the x-ray she took.  He proceeded to examine my mouth and the tooth with it's swollen gummy home.  "Look at that, Jennifer!" he exclaimed, wishing to show her something horrific (so thinks the patient who definitely doesn't want to impress any dental professionals with his pathology).  I started to have a grief reaction silently for my tooth.

He drew a picture to show why the tooth needed the grief reaction. Cracked Tooth Syndrome causes gum separation from the tooth allowing my saliva to percolate down where it causes infection leading to tooth extraction, which I needed soon.  He applauded the quality of the root canal performed by Dr. Mike on the tooth in 2008, reassuring me that it was wonderfully intact and not related to the infection.

As I checked out, the receptionist volunteered to call Dr. Mike's office to find out who he used for extractions (the dentists are narrowing their scope of practice just like us physicians).   I continued to thank my tooth for years of good service while driving to my office where I called Laura and asked what course of action Dr. Mike would recommend.  I heard her enthusiasm for the oral surgeon in the office next door to them.

Laura knew that since I have the bridge, Dr Mike had to "section" (cut) the bridge just before the extraction.  After calls to the favorite and next favorite oral surgeons whose schedules didn't match my need,   I called Laura back and she made a personal contact with Dr. P's office and called me back.  Can you come here at 11:45 to get the bridge sectioned and then go to Dr. P's office at 2 PM?

I had my schedule in my hand and already knew how we could shift patients to the nurse practitioner's schedule that was light today.  "Yes", I said to Laura, and proceeded to see patients until 11:30.  Then off to Dr. Mike's for sectioning the bridge.  "It's Laura's birthday," the office staff at Dr. Mike's happily noted.

Dr P was in his office in the city 23 miles east (not the one next door to Dr. Mike), so GPS for guidance and Wendy's drive through for the 99 cent chili plus a 30 minute nap in my car got me into Dr. P's office at 2 PM.  Dianne efficiently got me to fill in the forms and sign three pages about information transfer and payment, etc.and immediately a dental assistant called me back and into room 4 where I gave a brief history and listened to Christmas music on the overhead speaker.

Dr. P. entered, engaged me about the history and said, "Let's get that numb for the extraction."  He injected me with 3 or 4 chunks of lidocaine and left for several minutes.  I enjoyed "O Holy Night" and a couple other songs while he was gone.

On re-entry, he applied a device to the tooth and leaned.  He heard a moan and noted that my body wasn't touching the dental chair and stated, "We're not here to hurt you.  Let's inject that some more and wait a few minutes."  I appreciated the heck out of that approach.  Many physicians I've seen over the years tend to ignore patient "discomfort", but Dr. P. was not out to hurt people.  God bless you, Dr. P.

Ten minutes later, after Dental Assistant Sidney reaffirmed that I understood the post op instructions about wound care, he was back.  As he securely grabbed the tooth and started to rock back and forth to loosen it, I noticed that "Rockin' Around the Christmas Tree" was playing and I didn't re-experience the pain of the previous attempt.  I got a prescription for Vicoden, an envelope full of gauze squares to press into the hole until the bleeding stopped.  I paid my half of the fee and left.

Then to Wendy's drive through for a small frosty per Sidney's instructions and back to the office to see one patient who refused to see our nurse practitioner.  I mumbled through the gauze as I took the history and examined the patient who didn't share my confidence in our nurse practitioner.  I was still numbed by the extra lidocaine and didn't take the Vicoden until safely back home in my recliner.

Lessons learned or reaffirmed:
If you need to see three dentists in one day, you're going to get some pain and probably lose a tooth.
The primary dentist and his staff know the system and the players, they know how to get things done.
Receptionists make things happen, especially on their birthday.
Family Nurse Practitioners are flexible, valuable members of the health care team.
Teamwork and relationships are really important aspects of health care.
Get an oral surgeon who believes, as Dr P, "We're not here to hurt you." (And thank/honor them)
Don't forget to ask the dentist for your extracted tooth so you can put it under your pillow.
(If I could put it under my pillow, I'd give all money /coupons left by the tooth fairy to Laura, Dr. Mike's receptionist for good work on her birthday.)