Integrity…my 2 cents

 

I initially thought that my description of integrity would be easy to put together as an essay that would lay down my personal principles about how one could obtain and pursue a life of integrity. It seems however that the concept of integrity has many facets.

Integrity reflects how consistent one is with their adherence to a belief system or moral code. It is the quality of being predictable according to a set of values or a dogmatic approach to situations and lifes problems. To judge someone as having integrity usually means that they have adhered to most of the standards that we think of as important.

I come from a long line of dogmatic individuals. I was taught a code of moral values and honesty that has remained increasingly incorruptible as I have gotten older. This dogma contributes to one’s integrity. Obviously, this dogma needs to be sound and based on what are considered good and appropriate social values.

Honesty and truthfulness is another significant part of my perception of integrity. That you speak what you know as the truth with the qualification that it is your personal belief and experience, must be mandated as part of the formula for integrity. For example, writing this essay about my personal beliefs and practices as opposed to putting to paper what I think you might want to read is a great example of personal and academic integrity. I have always been taught that you should keep your “word” and be thought of as someone who always “keeps his word” and”does what he says”.

I think an unbiased approach to the truth is an important part of integrity. I tried to instill this principle of integrity in my students and advisees by telling stories. I have many stories from my experience as an orthopedic surgeon over many, many years. The stories that I remember convey consequences and outcomes about integrity and life choices. My response to the personalities in these stories speak loudly about the principles of integrity as well as about my perspective about integrity

I think that it was important (when I was on faculty at a local college and had advisees) to tell my advisees that they don’t make good medical school candidates and that they need another plan for their life if that is indeed the truth. I think that it is a disservice to them if they are given false hope for a career that is really not within their abilities to grasp. It is not easy to do this but I feel that my integrity as an advisor requires me to do this.

Social context cannot be forgotten in describing integrity. Those societies that encourage people to be honest with themselves and use their abilities to be critical of their own persona, are usually more conducive to promoting integrity. This society would promote values of honesty and individual responsibility, as opposed to those of success and career at any cost.

I think that personal adherence to this values system is also a manifestation of integrity. One must “walk the walk” and live their life following the principles that you preach, otherwise you have no credibility or integrity. One must be continually self-aware and maintain a constant watch over the incessant bombardment of the world against personal standards and beliefs. To acknowledge these conflicts and to declare them to others helps them learn how to live with integrity. You must care enough about yourself and others to maintain your personal integrity as one of your highest priorities.

I try to portray integrity to my students by being fair and just in my handling of their grades and academic measures. I try to portray Integrity by being available when I say I will and by being on time or early to appointments. I try to be fair in assignments and responsibilities in course work and try to put myself in their shoes. Part of integrity is having respect for the views of others. These small things leave an impression on my students and advisees. I try to tell the truth and if I don’t know, I tell them I don’t know. I try to convey the lessons about life that I have learned by using my life as an example, sometimes as a bad one as well.

When all is said and done in life, the only thing that people will know about you is your character. Once that is damaged, it is very difficult to repair. They will know whether you were fair, honest, straightforward and trustworthy in dealing with them. How you behave when no one is watching is the best assessment of how you really are as a person.

Integrity-is-doing-the-right-thing-when-no-one-is-watching

Proverbs 19:1: Better is a poor man who walks in his integrity than a rich man who is perverse in his speech and is a (self-confident) fool

 

 

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You can’t be serious!!!!

In our practice, I saw a number of individuals with carpal tunnel disease. The problem with these Worker’s Compensation patients is that it’s sometimes difficult to discern real pathology.

Workman’s compensation is a unique section of my practice and that there is also all sorts of secondary gain that is available to patients who find that they have a disability. They will be able to have time off from work plus first dollar coverage of their care with no deductible.  As a result, the insurance companies that cover Worker’s Compensation have made any an extra special effort to ensure that valid claims are made.

I had a young lady come into my practice with classic symptoms of carpal tunnel disease under the w/c carrier from a local company. She had tingling in her thumb and index finger and long finger at night and with use, and she had numbness in the median nerve distribution as well. She had a positive tinel’s sign.  This is a test that is done by tapping over the median nerve at the wrist which causes numbness and tingling in the involved fingers.  The confirmatory test for this disease and the “gold standard” for testing is an electrical study done in the office called an EMG or a nerve conduction velocity (NCV).  This young lady in my office had such obvious symptoms that I thought it not necessary to do this examination because it was clinically obvious and that it was expensive for the insurance company and uncomfortable for the patient.NCV

I call the insurance adjuster and explained to her that this situation was such that the test was probably unnecessary.  She said that the only way that she would approve surgical treatment for this disease and this problem was if there was a positive EMG and nerve conduction velocity test done.  I explained to her that I would do the test myself in the office.  It was going to be positive.  I want her to make sure that she understood that I was going to do the test in the office and that in the exam was going to be positive.  She said to call her back when that test was done and it was positive.  This caused the insurance company to have to pay me another several hundred dollars and did not change the findings of my examination or the diagnosis.

I did the exam. It was positive, and on the return the phone call to the adjuster I explained to her the positive findings. Then, she was more than delighted to pay me for not only the office visit but the EMG /NCV studies as well as scheduling her for some future surgery.

 

Ridiculous!!! But she eventually got her surgery and did well and returned to work.

 

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Halloween, and something afoot….

 

It’s always amazing to me how all people try to fool their physician. Sometimes they must think we are absolutely dense. (Sometimes we are!)

A Mark industry is a large carpet and flooring manufacturer in this region (names and significant facts have been changed). The people that run Mark industries have strong ties to the area and “Mr. Mark” used to live down the street from the first home I rented when I moved to town.

Mr. Mark lives in town is a fine gentleman, and except for the fact that he is a huge Georgia Tech supporter is a great guy. I had the privilege of taking care of all his employees and workers comp for orthopedics.  Workers compensation is a situation where people who are injured on the job or will go to specific physicians for specific problems.  There were some great people at Mark Industries and when they get injured, it was our job to return them to work at some sort of useful job and as quickly as possible.  This helps employers take good care of the employee and in the long run was cheaper for everyone.

It was Halloween. The mood was festive and we were having a fun time at the office.  My nurse always dresses up for Halloween and all the office staff always had all their best Halloween costume.  Pumpkins were hanging as well as spiders and webbing from the office ceiling.  As you might well imagine an orthopedic office with skeletons and bones hang everywhere is a natural for Halloween.  It’s almost a national holiday.

I received a call from one of the Worker’s Compensation nurses  at Mark Industries, who said that she had a young lady who had said something dropped on the top of her foot and she was in excruciating pain and need to be seen right away.  We told her to come right to the office.  She was ushered in the office rapidly, and it was apparent that she had a huge blue bruise on the top of her foot.  She was ushered into the x-ray room and we took x-rays which were normal.  Normal, fortunately.  Dorsal foot injuries can be very painful.  This young lady appeared to have a large bruise on the top of her foot that was 4 inches in diameter, and she had hose on the top of her foot.  I did not want her to have to remove her panty hose because it would be more uncomfortable for her to do at the office and she could take them off at home, so we basically gave her some crutches and told her to elevated it and use ice for the first 24 hours and we would see her back in 2 days. There’s usually a lot of swelling with foot injuries of this nature and the description was that something large had fall on the top of her foot, which would result a lot of swelling pain and discomfort.foot contusion

She returned two days later.  But the foot wasn’t swollen enough; in fact it looked like a normal foot except for this 4 inch blue mark on the top of her foot.   It didn’t quite look like a two day old bruise.  In fact, it looked as fresh as the day that it occurred.  She reported was in some discomfort, but not to the extent that she should have been after two days. This all just didn’t come together for me.  I looked at the foot, and something began to dawn upon me. Plus, she didn’t have on her pantyhose.

Women’s face powder has upon occasion flecks of shiny sparkle in it so that reflects under bright light. You could see a reflection in the overhead lights in the examination room, a little bit of a reflection or glint on this bruise.

 This young lady had painted a bruise on the top of her foot using makeup!

In her defense, she had done a quite a good job. However, I was infuriated.  The fact that she would simulate an injury to get time off and narcotics made me a bit perturbed. Plus, she fooled me!!! (that seems to be the most egregious part, that I had been HAD) I took an alcohol swab and calmly wiped the bruise off while she watched me, and I told her that I thought that he could return to work and sent her on her way.  I then called her employer and told her employer that she committed fraud and that if I were the employer I would fire this young lady.

 

So, Halloween came 2 days too late!

http://www.wikihow.com/Fake-a-Bruise

 

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Downtown, summer in the city,…

Hot and breezy. A couple of Saturdays ago, one of the downtown stores is trying to build up the local music “scene” by booking folks to play outside their store on Saturday afternoons from 12-3 and then booking Friday nites at the local amphitheater.  I think its a good idea , and being a supporter of live music, the EJS big band was asked to play. Well, we don’t have a combo or a small unit to play so I volunteered to do it as the EJS representative.  It was hot all week and I was worried about a scorcher until a cold front came in Friday nite and cooled things off.   Breezy yes, but not unbearably hot. Warm, yes but tolerable.

The downside of playing downtown and outside is that you are right on the street with the traffic etc, but your audience is always changing. So, I just look upon it as good rehearsal time and play for me , myself, and I.  No pressure that way!!

 

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Are you really a “superman”?

We will call this guy Mark(friend and local race car driver/mechanic/etc) came into the office one day with a problem and said he wanted to speak to me in private.  He took me aside and whispered that he was going to get a tattoo that afternoon.  He was concerned that he was afraid it would be uncomfortable at the time of the tattoo and because of this he wanted me to inject Novocain into the area where he was going to get tattoo.  I explained him several things about his tattoo. First, it is uncomfortable and that I thought the pain was part of the deal about getting a tattoo.  Secondly, I explained to him that getting a tattoo is probably not a very wise thing to do.  He had selected a tattoo of Superman to be tattooed on his right buttock

As a resident at the VA hospital I had the opportunity to see a number of wartime tattoos placed on soldiers during their time of stress and remembrance of their girlfriend or family back home. These tattoos however were not in the same location or the same shape they were in when they were applied originally during war time.  30 or so years had passed and the tattoos were sagging drooping and sometimes difficult to read the formerly proud American Eagle would be nothing more than a droopy penguin.  The flag flying high would be drooping down and at half-mast. Gravity is an all-powerful force and works on tattoos and elsewhere as well.

I eventually agreed to “numb him up”, so here we were in the exam room as I was trying to do what’s called a “field block” on his right buttock. This is infiltration just under the skin to anesthetize the area or “field”.

I wasn’t sure of the exact location for the tattoo so I was hopeful that I’ll get it all in the right spot. The other fact about Local anesthesia is that it is important not to exceed a certain number of milligrams per kilogram. You need to stay below the toxic dose for these medications; if you’re trying to field block where you’re covering a large surface area you have a large volume of medication.  The problem is that as you use large medication volume you must lower the concentration of medication so that you’re inserting a more dilute medication to get the effective coverage, which means it doesn’t last as long…

I explained all this to Mark, but he was not to be deterred. One of the things that you need to know about any of the local and aesthetics is that their pH is such that it is a bit acidic.  So infiltration of a slightly acidic medication underneath the skin is a little bit uncomfortable.  For those of you who have had sutures in an emergency are well aware of the fact that sometimes the needle for the anesthesia is as uncomfortable as suturing the  cut itself.

So there we were in the exam room, infiltrating a large area of his buttock with local anesthetic…so…that he could get a picture of Superman on his rear end.

I never saw Mark’s buttock after he received his tattoo. I had reports that it went well.  I’m suspicious that it went as well as he reported.  I know that I did not use a very concentrated solution and I also know that it is highly possible that it wore off before he received the last part of the tattoo. I’m not sure that I covered the entire area with appropriate level of anesthetic.  I’m not sure exactly what transpired at the tattoo parlor.

Makes great story, howeverSuperman-Tattoos-52

 

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Back Pain on the Weekend!! OMG!!!

Any is a registered nurse with a local obstetrician. She was on vacation with her family in Florida.  Before she left for vacation, she began having insidious onset of low back pain.

She went to the local “doc in the box” in Florida when the pain began to be more uncomfortable for her.  The x-rays were taken, and she had an exam and was given some muscle relaxants.  She continued with uncomfortable low back discomfort and more pain in her leg.  Then she began to have pain in both of her legs shooting down from her lower back. The pain was unrelenting and not relieved by any medication.  She called me on the phone when she returned to town on the weekend because of her increasing pain in her lower back and legs.

A “low back pain” call on the weekend is something that we usually treat on the phone.But Amy had always been a reliable nurse, and we had always depended upon her clinical judgment. In addition, several of the girls in my office, used her at the OB/GYN office.  So when I got her phone call I was a little bit concerned.  I agreed to meet her in the emergency room at the hospital.  She had bilateral numbness and tingling in both of her legs and was beginning to lose a little bladder control.  We ordered a CT scan and saw that she had a mass and her spinal canal.  I called up a good neurosurgery friend at local nearby hospital and had her transferred there immediately.  She underwent relatively urgent surgery for her spinal cord tumor and regained all of her function.

To this day, she remains grateful, because I did not treat her as a standard low back pain patient, but as someone with some good clinical judgment.

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Aneurysm and good press…..

When you first start out a private practice, you’re not sure how things are going to go. You’re not sure how to get your name out in the community because advertising at the time I went into practice was “verboten.”  You do the “Retired Mens Club” and the school career day and try to give “Free School Physicals”. You’re not sure how to relate to everyone and you’re not sure how to recruit patients.  It’s a difficult time.

My wife was one of my greatest assets because she was in the community. She played tennis, we had young children that were in school she was active with the school board etc.  So those were great marketing opportunities.  The other opportunity that you have is by sheer luck and pure serendipity.  A time will occur in your practice when by chance you have a famous person or someone who is well known in the community and you happen to take excellent care of them and then the word gets around.  It’s even better if there’s a great story associated with it.

There was a well-known gentleman in the business community who came in to visit with me because he had back pain. Low back pain is not very unusual or very exciting in someone is about 40 or 50 years old.

Workup usually entails taking some x-rays, a cursory exam, and to explain to them that “rust and mileage” have probably taken their toll. You add usually that exercise in moderation and maybe some aspirin would be an excellent treatment.

This gentleman had something interesting, however, and for some reason, his story just didn’t seem the same as everyone else. There were some elements of his complaint that just didn’t fit mechanical back pain. So, I spent a good bit of time examining him and possibly I did this because he was prominent and well known.  I know that’s not a very good reason to examine someone more extensively than anybody else, however, that’s what happened.  The thing that clued me in to there being something unusual about this fellow, is that he had some more abdominal complaints then just plain back pain.  His back pain constellation of symptoms was not standard.

On x-ray he did have some small calcifications in the front of his spine, which is an unusual location. I examined his abdomen and began to hear a small swishing noise about the location of his aorta. .

When I had been recruited to Cartersville, I came at the same time as a medical school classmate of mine who had gone to do a vascular fellowship at the University of Mississippi. Interestingly enough, his office was right next to mine in the new office building that the hospital had built for us.  So it wasnt  too difficult for me to just walk next door if I had a vascular question.

It’s interesting how many times you have patients that present with symptoms that are not orthopedic in origin but are more of a vascular nature such as claudication or lack of circulation. They would present with leg pain but not mechanical leg pain. Also, my cohort next door would have people with osteoarthritis that did not have a vascular problem. We would shuffle these folks back and forth so they could get the care that would address their problem. Also I first came to town we had a discussion as to who would do the below the knee amputation patients, which is a fairly common operation for vascular surgeons in the end-stage disease.

I’d done enough of those operations and felt that I would be more than happy for him to do those that he thought appropriate but I would be more than happy to do the prosthetic orthotic treatment as necessary. I digress.

The abdominal aorta descends from the heart in the chest down to both legs in the abdomen it sits right in front of the spine and splits into two large Iliac arteries…. one for each leg. It is usually a “silent” tube because usually, the only thing that makes noise in a vasculature, vessel, or a hose for that matter is turbulence.  There shouldn’t be any turbulence in the abdomen in the aorta.  I asked my next door vascular surgeon therefore, to come examine this gentleman and it was apparent from his examination (as well as mine) that this gentleman had an aortic bruit (or noise).  The aorta was enlarged and was what we call aneurysmal. A ruptured aneurysm is a catastrophic event in that the aorta is a large vessel and will empty the contents of the vascular system into the abdomen in short order if it ruptures, and is a cause for a high percentage of mortality in a significant number of these events.  My vascular neighbor  and I decided that he needed immediate treatment and rushed him down to Emory Hospital in Atlanta. They were baffled that we had picked this up on a routine examination and were high in their praise of our physical diagnosis abilities.

They (Emory Vascular Surgery) then proceeded to operate on its aneurysm several times before they figured out that he had what they thought was an infected aortic aneurysm, which would have ultimately resulted in his catastrophic demise at some point in the near future had we not picked it up on exam. This is always good press in addition to the fact that he recovered after his surgery and did well. He has three brothers in town, an architect and accountant and other business person all who see a lot of people around town and soon it was known that Dr. Jones” saved his life”

Always good press.

initial mD at CMC

The Newbies!!!!!

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