GI Prep

My gastroenterology team really thinks I need a colonoscopy now that three years has elapsed since they removed three benign polyps.  Now in my mid-70s, I've accumulated multiple conditions, none an immediate threat, all competing with each other to see which escapes indolent first.  My medical team now expands well beyond GI, which began innocently with normal surveillance colonoscopies at age 50 and 60, an inadequate cleansing at age 70 requiring a do-over, and now concern that something invasive may arise before either my actuarial table catches up with me or some other lingering process needs more than semi-annual lab assessment.  The NP answered all my questions.  The procedure got scheduled far more promptly than the last two times.  And I've been treated better by the office, which I suspect is a regional private equity enterprise that pays the lawyers who compose all their forms to sign more than they pay their endoscopists.  Or they have taken patient feedback more seriously than I remember.

With a failed procedure in the past, I extended my clear liquid restriction, as I did three years ago.  My tolerance has been good.  A little thirst, no hunger.  And no change in my weekly weight measurement from the previous week on an unrestricted diet.  

The cleansing procedure has changed.  Now I mix my own polyethylene glycol in two batches, one of two quarts, the other a half amount of powder and liquid.  I've taken the first capsule laxatives with no notable effect over the first hour.  The laxative powder mixes poorly in the lemonade, but a two hour head start should allow it to dissolve.  The second dose of laxative times to the procedure, so I will need to set an alarm for pre-dawn, but mix the powder after I have a lull from the first ingestion and its effect.  Or my wife can mix it.

As I get older, nearly all personal goals other than my 50th anniversary achieved, feeling pretty decent despite the vagaries and warning flags of the lab, a question of when to stop cannot be avoided.  When indolent moves to aggressive, biopsies, catheterizations, endoscopies, chemotherapy, and surgery remain consent procedures.  Some alleviate suffering, others delay the inevitable.  

Today, I just want to complete the intended colonic inspection and any new biopsies that the doctor does.  A few minutes with propofol will probably offset sleep deprivation of the dawn purging.  Then a summer's respite from medical care.  A chance to travel a little with my wife, share our next anniversary, maybe visit the grandchildren, express myself in cyberspace, entertain a guest perhaps, do something of use at synagogue once or twice.  The purpose of the GI ordeal and other lab surveillance should be to enable those things.  I can cooperate with a few days of deprivation to achieve all those things.

Registering

Worrisome lab work, results with the potential to reduce longevity, brought me to a specialist.  Despite my familiarity with possibilities and likelihoods, mostly in my favor, I fretted over the encounter.  I drove to a big place, a suite that comprised the entire third floor of the building's west wing.  Chairs everywhere.  Quite a lot of doors.  Stuff hanging on walls, with a small display case for awards that members of the medical group have received.  

My turn at the reception desk came quickly.  Insurance cards.  Driver's license to confirm that I am really me.  A clipboard with registration forms and a pen of the type they discount at back to school sales.  No practice promotional logo.

I took my clipboard, then headed to a chair with arms in a place largely unoccupied.  Demographic data straightforward.  Name, address, birthdate as medical facilities now use that to confirm identities.  Emergency contact.  That took some thought.  My wife came first.  Back-up?  Neighbor or Friend.  It reminded me of how few close people I have.  I named a friend who could rescue me in an emergency.  Who to discuss what to do if I couldn't engage in decisions myself.  My wife.  They needed a backup.  I have two children, both physicians.  One is a clinician, the other a researcher.  One can drive to my side in five hours.  The other can fly to my side in five hours.  They have different personalities.  I wrote the name of the more distant on the line.  A reminder that this specialty has patients who sometimes do not do well.  I might become one of them.  I have an advance directive.  I think I know where it is.

Next page, About Me.  Have I ever had?  Our electronic record keeping has distilled all responses to yes/no, ignoring context which often matters more than yes/no.  I have had a right upper lobe walking pneumonia,  no subtlety by X-ray.  I remember slight pleuritic pain, and I probably had a fever which is why they did the film.  I think I took a course of antibiotics.  I remember where the x-ray had been taken, at a facility that went belly up some time ago after private equity purchasers milked what they could of its assets.  So I have had pneumonia.  When the blood bank screener asks if I have ever had a problem with my lungs, I say no. No reason to deprive some really sick people of platelets that they need.  It healed and subsequent chest x-rays have been normal.  My cholesterol is controlled.  Do I have kidney disease?  By current criteria, I have minimal CKD of minimal clinical consequence other than a reluctance of my doctors to prescribe anything that might upset that stability.  Anemia?  It's been treated.  Covid?  Took a course of Paxlovid.

Surgery?  Appendix they care about.  Mucosal tags and arthroscopy and wisdom teeth they probably don't, but EHR record keeping still gives that a yes.  

Family?  I know very little of my relatives' past.  There have been malignancies.  There have been cardiovascular events.  My siblings, my closest genetic contemporaries, are not in my loop.  My children keep their adult medical situations private.  I know how long my parents and grandparents lived and their cause of death.  A few more Yes responses on the checklist.

My Review of Systems, a very cursory checklist.  A pittance of what I used to solicit from patients. HEENT OK, though I think they could figure out from my age that hearing decline and cataracts are in evolution.  CV, pulm, GI, musculoskeletal, hematologic all had some intrusions.  None limiting but all an invitation for the doctor to expand our interview when she thinks it helpful.

Medical parts done.  Statement of financial obligations signed.  Clipboard returned to the front desk for somebody to type my responses onto their computer forms to remain in cyberspace for perpetuity, though with some privacy protections.  I kept the pen, with their permission.

This introduces serious medical care.  Perhaps their registration form, carefully considered by whoever designed it, hints at what their new patients like me want out of the assessment, and later the treatment.  I think everyone, including me, wants the doctor's talent.  Usually that entails technical decisions that extend life when it is threatened, or at least ease discomfort.  But as I filled out my answers, an emotional component became apparent.  I've been through my share of illness.  Until now I've prevailed.  In my Medicare senior years, I've accumulated fewer people that I can count on than I might have anticipated in the years I was more fully engaged with other people.  My children remain available from afar.  My sibs no longer are.  When I needed to identify a backup person, I chose a friend over a neighbor.  Friends are few, though not absent.

Some diagnosis remains.  A chance to recoup my resilience exposed by my past medical history and my current array of symptoms.  I remain fully functional despite them.  I conveyed to my medical care team a few things they needed to know, some they probably didn't need to know.  Those fifteen minutes with the form, pondering that Yes But which an electronic data set cannot capture, enabled an overdue interview with myself.  It left me with a different impression when I returned the clipboard than I had driving to their office.

Going to the Doctors

Two doctor appointments this week.  Dermatology for followup of a pigmented facial lesion with gradual advancement.  I assume they will want to do a cancer screening as well, since technically for billing purposes I classify as a new patient due to the interval since last visit.  Forms filled out in advance.

Primary visit more problematic.  I really don't feel my best.  Withdrawing SSRI has made my mind more alive.  Joints hurt, BP higher, some lab concerns, Some decision branch points.  A few can be punted to the scheduled cardiology visit after a quick patch.  Or maybe the joints need to go to ortho.  I don't really want a knee arthroscopy if topical, or even systemic SSRI's will do the job.  May need some GI studies but very unhappy about what transpired with this last year.  May ask for referral to a different practitioner and GI group, if only to get a different prospective on safety of colonoscopy preparations.  Never had Covid, so not really Long Covid.  Some minor urologic symptoms.  While luxury Executive Evaluations at Mayo or Greenbrier claim expertise, their value is more to the companies that are highly invested in the highly paid people that get examined.  It's probably not good medical care for anyone. 

My medical care has been good, though with a few tweaks that may add benefit.  Best to just let it. proceed.