Category Archives: Patient

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?

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.

Snitches Get Stitches- Protecting the Guilty

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For weeks, I have been conflicted about talking about a situation in my work world. I am not sure what the “right” thing to do is. No, that is a lie. I know right from wrong, damnit and what is going on is wrong.  I worry about big scary words like slander and liable.  I know that my vocation calls me to protect my patient from harm. Sometimes, that harm is another health care provider.

On the other hand, we all have this not quite unspoken code of keeping our mouths shut when we are all aware of another health care provider who is dangerous.  We talk among ourselves. We roll our eyes. We call someone to the computer and say- “Did you see this?”.  We ask each other how that person gets away with this. Of course, that is as far as it goes, right?

There is a physician who is routinely seeing 70 patients in 5 hours. We joke that on the evening he works later, the whole waiting room looks like a scene from the Walking Dead.  I found myself humming the Leper’s song from Jesus Christ Super Star.  They are all there for Norco, Xanax, and Soma as a cocktail along with more other drugs that I can count. We know this is wrong.  We worry. We whisper. No one says anything to him though.

Yesterday, I shared clinic hours with him. In my defense, I was in and out of rooms too, and doing some much needed catching up on four inch stack of labs and images. I was working as hard as I could to stay on task and focused. Once, I walked into the common nursing area and heard folks talking about “not responding right” and he was standing the doorway and I assume this is his patient and he is a physician who has this handled. I went back to office/charting area a few doors away.  In the hallway I heard someone say something about an ambulance and again, assumed he was taking care of his patient and had called the ambulance. I was only mildly concerned because I had worked in clinics where it is just protocol to call 911 for things as minor as elevated blood pressure. I briefly wondered if one of the COPD patients was having a very hard time.

I went back to the nurses station area to get some forms as ambulance was arriving, the physician wasn’t in sight, so I assumed he was in the room with the patient. I had called 911 in other clinics and stayed with the unstable patient until care is turned over to the paramedics.

But no. Later, several assistants came in the providers charting area and asked me if I knew what happened. The physician walked into the room, the elderly female patient seemed groggy to him. He came out after a minute and told the assistants- “She won’t answer my questions” and said something like she had probably taken too many medications. He gave no orders, no concerns and moved on to the next patient. It took a few minutes for the assistants to figure out to go in the room and check, and they found her nodding out and barely responsive. One got a blood sugar of less than 30 and called the ambulance. On their own because he was ignoring the whole situation.  They didn’t come to me, because HE is the DOCTOR.  He continued seeing all his patients and ignoring the whole scene and the patient who became completely unresponsive before the ambulance arrived.

I find this out after the ambulance has gone.  We are all not as shocked as we pretend to be. We know he is horrible. We know he doesn’t examine patients. We know. We talk. We DO nothing.

I came in this morning and looked for a trusted colleague and he told me he had just heard the whole story. I told him, I am not staying silent. I am going to the clinic director.  We each spoke with her today.  I doubt anything will happen. Not for her lack of trying, but he is a powerful person in this community.  This is not the first or even second time I have been to a clinic that is so scary.

I am scared for his patients.  When I see them and update the problem and medication list, explain that some medications are not safe to be taken together or shouldn’t be taken with their condition, or that they need some tests and I do a physical exam, they tell me that it is the first time someone has touched them or examined them in 3,5, or 7 years.  I am quiet.  I don’t criticize other providers.  I think I am a coward.

Who are we protecting when we stay silent? Are we protecting the other provider? Are we trying to protect the patient? Are we protecting ourselves?

I am the locums. I am the outsider. I was raised that tattling is the worst thing you can do. No one likes a tattletale. “Snitches get stitches”. “Not my circus, not my monkeys”

What do you tell yourself when you protect the dangerous provider with your silence? We all know these “bad apples”, don’t we?  Have you confronted them personally? Do you think administration will handle this?  What do you do? I really want to know.

Medicalization

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Pristique  More times than I can count during my week and often my day, a patient presents with what they tell me is anxiety or depression and requests that I write a prescription for whatever pill they have seen advertised on television or a tranquilizer that works for their friend or relative. I can, however, likely count the number of times I have actually written such a prescription. I am not against medications. I am not a practitioner of “woo”, as some of my more conservative colleagues would call me. I just don’t know when being fully human became a disease.

One patient came into the office in tears, telling me that she needed Ativan or Valium because she could not stop crying since her husband died. She couldn’t sleep. When I asked when he died, she told me
” Last night”. A fairly young adult asked for antidepressants because he had problems sleeping since his wife of 10 years left him two months ago. He also sometimes felt very sad, like he wanted to cry. People have lost their jobs, their home is danger of foreclosure and their son just went to jail. They don’t think that they should cry, or worry or have problems sleeping.

I will save the discussion or rant about Big Pharma and disease mongering for another day. Today, I just want to ask, why isn’t it okay to cry your eyes out and not be able to sleep when your loved one dies? Why is not okay be anxious, sleepless and worried when you lose your job and your life seems to be falling apart? I think not only is it okay, but it is important to fall apart now and then.

There was a time when it was expected to show appropriate emotion. The Bible talks about sack cloth and ashes and gnashing teeth when grieving. In some cultures women used to cut off a finger when their husband died. Thank Goodness that now they only chop their hair off very short as a demonstration of grief. In many cultures people wore black as a symbol of their mourning for a full year after the death of someone they love.

Today, people want a pill or six so they can go about their lives “normally”, as if it all didn’t matter really. Not the marriage, or the job or home or the damn kid in jail. There is very little chance that I am going to give them a pill. I am going to talk to them about normal human emotions of sadness, grief, despair, worry, nervousness and problems getting that elusive 8 hours of uninterrupted sleep brought to you by a beautiful moth. I am going to talk about the importance of crying, and pacing the floor, of looking through photo albums and crying until you can’t cry. Cry until you cry yourself to sleep.

Yes, it is okay. It is healthy. I prescribe a good cry or several. I suggest we stop spending so much time, energy and money trying to avoid feeling sad, hurt, angry, lonely, sleepy, or whatever scary emotional reaction we are having to a situation.

In the real world, not everyone gets a pony, eats rainbows and poops butterflies. Life is sometimes messy and painful. We will get through it. We will. We can do it without sedation. I don’t believe that we should be trying to take away unpleasant feelings for the most part. I believe that we can’t dampen the negative side of life without also dampening the joyful side of life. Human emotions are not a disease. I am not talking about psychosis or self harm. I am talking about healthy reactions to painful situations.

We need to make it okay again to get the blues, feel melancholy, sad, scared, hurt, angry, lost, confused or lonely. We need to talk to each other again. We need to accept that humans have a full spectrum of emotions and rarely is it a disease to feel things deeply.

Provider Boundaries

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I freely admit that I have always struggled with boundaries. I take things personally.  I worry about my patients when I should be taking care of my own health. I want to help my patients feel better, to move toward “wellness” whatever that means to them. I want to share everything I know about pain, depression, Big Pharma in the 10 minutes that I have with my patients.

Unlike the parent who can never admit that they have a favorite, I have no problem telling you that I have favorite patients. Of course, I enjoy the well-read, pleasant wellness focused patient who wants to avoid medications as much as possible. But some of my favorites are the cranky, rude, demanding patient who over time lets me see their broken and sad parts.  They are the ones that challenge me with their demands and don’t quickly accept my reasons for the proposed healthiest way to treat their illness.

Some of them hate me at first and they let me know that later.  One of those patients who hated me at first told me that he didn’t want me to violate principals that I hold dearly and so he was going to get his Ambien, Xanax, Soma and Percocet from the other provider, but wants to see me for everything else. He started to read the books I recommended. He started to talk about his fears of a life without all of those medications. We would make progress every visit on healthier choices. And we laughed a lot.  I looked forward to the visits where I could see those baby steps happening.

I have recently grown fond of a patient who actually convinced me to give him Ambien-( Including that patient I still have written fewer than 10 prescriptions for that drug in the past 7 years ).  We have this sort of inside joke about “playing the cancer card”.  I have been fighting with his demon insurance company trying to get a medication approved for several weeks without success. I actually wrote a  letter to the crazy insurance folks explaining why he needed a particular form of a medication he could use at home instead of coming in the office for injections and get exposed to all the contagion that floats around in community health clinics. So when I saw the name on the schedule I was surprised since I had just seen him a few days before. This time the “cancer card” got him. Very bad news, my MA cautioned me outside the door  I took four deep breaths outside that door before entering.  Still, I  took one look at his face and cried when I hugged him.

I am going to worry. I am going to search the inter webs in a vain search for some miracle cure that all the experts just happened to have missed. I pulled up the imaging that I don’t even know how to read and tried to imagine that they mixed up the films. Maybe all those spots are just some weird artifact. I am going to sit and cry more than once over this one.  I am going to send cards and books.  I am going to cheer lead. My heart is going to break.

Do I want to change this about me? I used to want to change it sometimes, but only for a moment or two. I do what I do because I feel deeply and passionately that we need to hear their stories. We need to understand their lives. We need to get close enough to be able to lead them out of that dark place of chronic illness when they are unable to even imagine that there is light at the end of that tunnel. When I meet them in that dark place, I get to celebrate that dance in the light when they fight their way back to health.

Yes, it hurts a lot today. But real life is messy. Problems don’t get fixed in 43 minutes and 8 commercials for fast food and faster pharmacological treatments for the diseases of fast food. So, tonight, I am practicing what I preach.  Having a cup of herb tea and a good cry before bed.

Measles Panic?

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people_measles7 Many of my social media friends and real world friends work as pediatric providers and nurses. Much of what I read in the blogosphere and my custom news feeds focuses around healthcare. If I knew how to filter out the word used the most often, I have no doubt that it would be measles. The past few weeks I have had several very concerned seniors asking about getting a measles vaccine. The coverage of this measles outbreak is ridiculous and disproportionate to the threat involved.
2013:

41,249 people committed suicide.
33,854 people died in motor vehicle accidents
2,800 people died from medical complications
10 people died of malaria, ( yes ,malaria)
46,717 people died of drug overdose ( many of them prescription) and
29,000 of an alcohol induced deaths.
Measles? ZERO. Really. ZERO. There were 159 confirmed measles cases from Jan-Aug of 2013 and no one died.

This coverage and the resulting near panic is because measles is just sexier to the news folks than the 249,000 folks that die from diabetes related causes each year. Showing pictures of a measles rash gets the CNN endless loop of coverage. My physician friends are furious at the anti-vaccine crowd in a way I never see them at parents who feed their kids junk food, which will kill so many more than measles.

There is a viral video of pediatrician saying he will not allow the non vaccinated or the alternate vaccine scheduled kids in his practice. This sort of over reaction serves no one. We should always be careful with our patients with compromised immune systems. We need to put down our pitch forks and torches and let the measles monster go so we can direct out time and talent to much more pressing health concerns.