Category Archives: Healthcare

Health Care Culture

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woman-fitting-in

I usually find a way to fit in a new job pretty quickly. Years of working as a locum tenens makes fitting in a survival skill.  I am surprised that I am feeling a little more guarded than usual. A friend of mine would call it “well defended”.

So much of healthcare is cultural. In some places every one handles colds in one way ( everyone gets a ton of medications) and in some places, we recommend tea, honey and rest.  In the first weeks I am in a new place, there are always folks who misunderstand my “style”.   With some patients I have to WORK really hard to convince them that I am really on their side.

Then, there is the whole culture of handling urgent issues.  Some places have protocols- anyone has a blood pressure greater than 180/90 gets the 911 treatment, no matter what the provider thinks is right.  Some place rarely send anyone to the ER and try to handle everything possible in the clinic.  Today was one of those days of explaining that I know what I want to do with this young patient, but I need to know how this clinic handles things. Labs/imaging and then to ER, or just skip it all and send to ER. Direct admit? What goes with her? Do I print the note, or write a new one on a script?

Some clinics work as a team, while some are just people in the same building without much interaction. Some folks are much more serious, some laugh and goof off all day between patients.  I am trying to find out where I will fit in this new place.  I feel “stressed out” trying to adjust. I am trying so hard not to be too much of me. I am working this time on having unspoken thoughts.

But, somehow it ends up like this…

ballet

( I am also trying to let go of wanting things to be perfect- like blogging.  )

Chronic Pain

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Chronic Pain

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I was half listening to my latest audible book on the way to my first day of orientation at the new job. I say half because it is probably the 3rd time through those last few chapters. It isn’t because the book isn’t holding my attention, it is just it is one of those books I am talking back to as I drive and listen. It is one of the books that I will order in print and highlight and take notes in the margins.  I will review the book in more detail in some future post.

But she said something that had me wanting to scream.  She said that not treating patients in chronic pain amounts to torture.  I may be assuming too much, but it seems she was overly emphasizing opioids as a treatment for chronic pain. Firstly, opioids suck at treating most chronic pain and cause many more problems that they solve most of the time. Secondly, no one has a right to a pain free life. No one.

I was getting all judgy, as I am wont to do. Talking back to the book.  Really? Torture?  How is it my fault that you smoke, don’t exercise, drink like a fish, are 75 pounds over weight and now your knees and back hurt? Really? Sounds like that chronic pain is on your side of the net that divides us in this debate over opioids. I am not going to continue every patient in pain on the unholy trinity of Norco, Soma, and Xanax.

Then, doing my best Tevye impression ( from Fiddler on a Roof), I said, “On the other hand”, What about the obese, sedentary smoker who needs medication to control their blood pressure and blood sugars both of which are out of control because of their lifestyle choices? Do I want to say, No more Metformin for you unless you start exercising? No. Of course not.  But on the other hand, I don’t see Metformin sending the patient down a slippery slope of every escalating medications with all motivation sucked out of them now do I?

I should hold off my opinion of this book until I finish it completely.  I am finding it to be a fascinating if not somewhat biased account of the state of chronic pain diagnosis and treatment.  As loud as I shouted in the car at the author, she did not respond, so I am just venting a bit here.  Torture and not giving opioids to every chronic pain patient are entirely different things. Seriously.

I am not just frustrated with the patient, I am more upset with the system that got us on opposing sides in the opioid wars.  We all know it doesn’t work to just give folks opioids. It is so much more complicated than that.  Pain management is always a trial with an “n” of 1.   Each person is different.  Even that one person is different on a day to day basis.  Not giving out opioids to every patient is NOT torture.  Please review the history of any war of your choice to get a much clearer idea of what torture is and is not.

Crying

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crying

I was reading over on Kevin, MD about a photo that was captured by a paramedic. (http://www.kevinmd.com/blog/2015/03/why-did-this-image-of-a-crying-doctor-go-viral-heres-why.html )  The photo shows a young doctor crying over the death of a patient.  The photo has generated quite a lot of internet buzz.  Should healthcare providers cry? Does crying make us unprofessional? Are we supposed be detached? What kind of person is able to remain emotionally detached doing what it is that we do?

I am not sure if it is a nurse thing or not. I cry.  I cry in front of patients. I cry with patients. I cry with families. My last cry was happy tears while hugging a patient who had been told that the diagnosis of “metz” to his lungs was a mistake and he was going to be just fine.  Yes, I cried with him when he got the original bad news.

I cry because I genuinely care deeply. It makes me a good provider for the most part. It makes me sit up reading every thing I can find that might help.  Sometimes, there is nothing I can do but care about the other person.  Sometimes that is the most important thing.  Being human.

I laugh with patients. I joke with them.  I encourage. I tease. Sometimes, I am the ice princess.  But that is rare.  The emotions I don’t share are angry ones. At least, I try not to let it show that I would like to dump a glass of ice water on the head of a patient that is yelling at me or insulting me.  So, there are limits to being fully expressed.

It makes me sad to read about physicians being expected to “suck it up”.  I imagine all that compartmentalizing is crazy making and it may be one of the reasons that physicians have such a high suicide rate.  I don’t know why their training is so harsh.  I don’t think it makes them “better” as health care providers.  Their crazy high divorce and suicide rate should let them know it isn’t good for their health.

Do you remember Rosie Perez in White Men Can’t Jump? I love the part where she was trying to explain that she didn’t want the boyfriend to get up and get her a drink of water when she said she was thirsty.  She could get it herself.  She wanted him to just understand or care. She wanted him to say ” I too, have been thirsty”.  Sometimes, our patients don’t want a pill or advice. Sometimes, they just want someone to say: “Yeah, parenting a teen was so hard for me too”.

I hope that more physicians are talking about the “disconnect” from emotions. I hope that they start encouraging each other to talk about their feelings long before they consider suicide.  I think of all the young residents that I knew while working in that huge hospital.  It breaks my heart to think that they will feel so isolated from the rest of the world that they think that sedation or suicide is the only way to cope.

One of the physician blogs that I follow is “Behind the White Coat  beats a real human heart”.   We all need to keep that in mind, don’t you think?

Guidelines-schmidelines

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Guidelines-schmidelines

In a few days I will start a new job in a new place. The focus in this clinic is patient wellness. Visits are 30 minutes. The people that I have met so far are amazing and we seem to be on the same page regarding patient care.

But

I am wondering if  guidelines are imposed in the same way they are by private insurance companies. Those crazy, meaningless guidelines that had the folks in charge of that non-sense talking to me about my “numbers”.  I need to put the overweight 18 year old girl on a Statin because her lipids are a little high. I tried explaining that there is really no benefit to that and only risk. If I remember, the number needed to treat was 2418 and the number needed to harm was 10-20.  It was explained to me that their reimbursement is based on the surrogate markers being at where the guideline de jour says it should be. The physician and the bean counter both told me that my concerns for the patient were good, but they get docked somehow if they miss the “Star” measures.

Why I didn’t  put that teen on an antidepressant if they had PHQ-9 that was worrisome. I quoted studies right and left and tried to explain the risks of psychiatric medications, but more importantly, the lack of evidence to support their effectiveness but  It looks like I am not treating “depression”.  I say, of course, I am just not with drugs. I don’t think she has a Prozac deficiency . She is sad and she should be sad given the current situation. I am working to find a counselor that takes her stupid insurance. I have appointments with her regularly, sometimes more often than you would like.

Guidelines? Which ones? The ones that say we need to do a DRE and PSA on every male over 50 ish. Oh, snap! All those exams and labs didn’t do a damn thing to improve the mortality rate.  Women who are sexually active or (was it when they reached menarche?), should have a PAP.  Oh, never mind. That caused a lot more harm than good, now didn’t it? Let’s get those A1Cs below 6.5 even if the patient feels horrible. The blood pressures in seniors ? Let’s get those down so low that they have no quality of life, or maybe with a little orthostatic hypertension they will fall and break a hip.

When I imagine the folks writing guidelines, I always get this image in my mind of Yul Brenner saying ” So let it be written, so let it be done.”  Or maybe the writers of guidelines are more like the Great and Powerful Oz.   I know that I don’t believe much of what they say anymore.  I want to direct my attention to the person in front of me and not their surrogate markers.

My vocation calls me to look into the eyes of the person in front of me and figure out together what they want to do about their health.  Most of the time those markers have little to do with what will decrease the chances of having something “bad” happen. We all know that. Well, those of us who work with people know that.  The folks that write many of those guidelines may have never interacted with an actual patient. Certainly, those “Star” measures don’t reflect good healthcare don’t reflect good patient care anymore than patient satisfaction scores do.

When you start a new job-what is important to you? Money? Culture? Philosophy?

These boots are made for walkin’

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These boots are made for walkin’

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It is that time again. Time to move on to my next clinic. I have worked locum for about 7 years now. This means that I have had to learn to make friends fairly quickly.  Making friends with co-workers and forming attachments to patients is one of the things that makes saying good bye so difficult.  Good byes have become easier over time.

These next 3 days in this clinic will go by quickly as I struggle to tie up all those loose ends in the charts.  It means that I may not get to see the outcomes of a few of the “zebras” that wandered into the clinic in what seemed like a herd. It means I will not be working with the amazing Nurse Practitioner and the brilliant Physician Assistant, two of the brightest guys I know.  I have learned so much from them and can’t help feeling that I have so much more to learn.

On the other hand, I am doing a happy dance to get away from that one physician he who will not be named.  The squeezy feeling I get in my heart when I see I am following one of “his” patients will ease up. Rolling my eyes at  3 years of cut and paste notes leaving me with NO clue what is going on with the patient since every note for 3 years states they are here for hospital follow-up 5 days ago. Bye, Felicia.

I am looking forward to the new place. I have spoken with the medical director a few times and I have met so many of the admin folks and everyone seems great. I no longer feel the need to try to make myself sound like the person that they want. I have learned that it is best to be myself from the beginning. I am outspoken when it comes to my philosophy of healthcare and if we are not a good fit, better to know that right away. So far this place sounds wonderful ( except for the commuting).

The new job is closer to home. I will be sleeping in my own bed every night. I will have time to wear my gardening boots and my hiking boots this summer. Time to read under the grove of trees in my hammock with walls made of sunflowers.  But tonight? Organizing and packing so I can leave right after work on Thursday.

Zebra Hunter

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Zebra Hunter

zebraI am admittedly a Zebra Hunter.  In my defense, I worked acute care pediatrics in world famous children’s hospital when nearly all 300 of the kids were zebras of some sort. If not, they were more easily cared for in the community hospitals. For the years I worked there, I was surrounded by the most brilliant minds, amazing caregivers trying to puzzle out the most complex children. I had no idea that it was possible for so many chromosomes to be off just a little.

Everyday things were life threatening. Sinus infections and ear infections somehow had turned into empyema of the brain.  The rarest cancers, the most complicated neuro surgeries.  Once when Infectious disease and neuro surgery looked at images together, the neuro surgeon picked up that baby to RUN him to surgery.

So, when I first saw kids in the community with an ear infection or sinus infection, I would want to make sure it wasn’t going to be more serious.  Are those bruises on that toddler ” non accidental trauma.”?  In the hospital, everything was figured out immediately- it was like magic- Any image, MRI, MRA, or weird lab was just done almost immediately. Work ups were quick, often intense, but things were figured out before the child went home.

The “real world” isn’t like that at all. It is full of mostly horses. Sometimes some pretty fancy horses, but mostly mundane. Except for the past few weeks, when I have learned more about endocrine that I had no idea that I didn’t know. I am weirdly excited about it all. I mean, it is fascinating when it is something so unusual.

I think I find the weird stuff in part because I worry about missing something. I also tend to listen to patients.  I like to hear their stories. I like to try to put the pieces of the puzzle together.  I am endlessly curious about everything.

What is so very interesting these past few weeks is that these are things that one would think would be noticed long before I meet the patient. I don’t know how someone else didn’t think it odd that the 40 year old patient with palpitations was so weirdly bendy. Not yoga bendy but something unusual, that makes me ask if they can touch the floor with their palms, encircle their wrist with pinky and thumb, touch their thumb to their wrist. Can I see your palate?  Yeah, no one every asked or looked.

I am not a physician, so I didn’t have much exposure to radiology in school. Well, actually NONE. So I don’t just read the radiology report “impression” I read the whole report. I look up words. I pull out one of my radiology texts. I read, read, read. I question. I want the answers. I need the answers, so next time I will know. More times than I can count, what I read in the “Impression” doesn’t completely match what is in the body of the report. This is probably a reflection of those dreaded “pre clicks” on computer programs. I ask about that nodule or cyst mentioned.

These past few weeks I have been in the middle of a whole herd of Zebras!  Strange lung stuff that we are still working out. Pheochromocytoma in that “anxious” patient.  Some things that are so unusual that HIPPA’s ears will perk up if I think it too loud, but really, really strange endocrine stuff that is fascinating.

The term Zebra Hunter isn’t a compliment really. It would be more of insult, if I didn’t nearly always get that Zebra. As often as I might say that I long for less interesting practice,  I find the hunt makes me look forward to getting to work.  It is like turning the pages in a mystery novel. This next week, the pieces of at least 5 very odd cases will come together.

Don’t you dare!

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Don’t you dare!

I looked her in the eye and said calmly: If you answer that phone, our visit is over. You will need to reschedule.

She stares at the phone with that same look I have seen in the eyes of heroin addict. It is hard for her to lift her eyes to meet mine.  “What?” She asks honestly confused.

I said that if you don’t turn the cell phone off I will leave the room and you can reschedule. I won’t compete for your attention.

Again, she seems confused;  “Why? Does it mess up the equipment?”

“Firstly, it is rude. Secondly, it is distracting to me.  But most importantly  if whatever is on the other end of that phone is more important than your sick child, you need to go right now and take care of it.  You need to be here in this visit with your child for 10 minutes”

“Okay”. She doesn’t turn it off. She puts it down, screen up on her thigh. The toddler is nervous, but she doesn’t notice the kiddos  body language in the same way she notices the phone calling her.

We go back to the visit. The father looks at the mother, clearly annoyed, but she doesn’t notice. She is stealing glances down at the screen and pretending to be present. She isn’t.

The child has candy apple red ear drums and cries when I touch the pinna as gently as I can. It is hard for the mother to help comfort the child, because she only has the one hand for the child, the other is on the phone.

I am talking to the parents about the diagnosis, medications, the risks and benefits. During this, I start typing the prescription into the computer and ask the mother a question, she doesn’t answer.  She is texting. I am annoyed but the visit is nearly over except for the discussion about the medications, risk and benefits, supportive care and what to watch for.

She asks me what I just said.  I told her that I am not repeating.  The father was listening and she would have to ask him. The father gave her another annoyed look, but she didn’t notice.  I can tell that she truly doesn’t get it.  She doesn’t understand that her behavior is not just rude, but unsafe. It is important that you understand what I am telling you. Really.

This happens more often that I can count. I no longer ask for the patient’s attention more than once.   The signs are posted everywhere. The Medical Assistant tells them that the must turn them off.  If they are on the phone when I come in, I tell them I will come back in a while.  I don’t mind if they are playing games to pass time, but calling the phone company, their bestie for lunch is not okay.  I tell them after I see the next patient, that the cell phone needs to be off.

At least one a week when I walk into an exam room,  I  have a patient put their hand up to tell me that they will be with me in just a few. One motioned for me to come in and wait. Seriously.

If whatever it is cannot wait for our 10 minute visit, I don’t want you to come into the office for a visit.  If POTUS can give a 30 minute speech without checking his blackberry, so can you.

I don’t carry my cell phone into patient rooms. If my family needs to reach me urgently, they know the land line number and they can reach me.  You need to arrange your sitter, dog walker, girl scout cookie, facebook status update, electric bill and parole office contact in any other time slot. You can reschedule with me at a more convenient time.