Tag 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…

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

Crying

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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.

Alogophobia, Kinesiophobia and Chronic Pain

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Alogophobia,  Kinesiophobia and Chronic Pain

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This morning I fell at work. Hard.  I was in a hurry, putting my purse down in the provider charting area, grabbing my Starbucks red coffee mug and stepped quickly out into the freshly waxed hallway. I didn’t notice that the floor crew had soaked the first two feet of carpet in our little office and my boots were wet.  It was such a strange fall.  I had no sensation of falling at all. I was just suddenly face down on the floor, landing mostly on my left knee, hip and outstretched hand.

My knee is bruised and hand are bruised and my left thigh started cramping up by the end of the day. I put an ice pack on every time I sat down to chart. Here is what I know: I am going to be just fine. I will probably be a little more sore tomorrow but my body is designed to heal. I am not going to sue. I am not going to develop any chronic pain syndrome as a result of this fall. I am not going to believe that I will develop arthritis of my knee or that I did anything to discs in my back that won’t heal on its own.

Sadly, many of the chronic pain patients that I see have had similar minor accidents or falls sometimes as long as twenty years ago that set their lives into a tailspin of chronic pain syndrome. When I talk to them, they tell me that they have degenerative disc/back/knee problems.   There were told by someone they respected that they will develop arthritis in the area of injury. They may have been told that they have a bulging disc, which they may have had before the injury since many times this is asymptomatic. They believe that discs can never improve or heal.

The most interesting thing to me is that they become afraid to move. They are convinced beyond reason that  if they move or exercise they will do damage to their area of injury. This idea remains fixed for what seems to me to be the rest of their life. Physical therapy has never worked for them because they are convinced that the pain means that something is wrong. Really wrong and it not going to heal ever.

Today, I tried to “walk it off” between icing the knee and thigh. I stretched my back gently. I believe that if I sit still, my muscles will spasm. I believe I will be fine. I don’t need Norco or likely even Tylenol for pain. Trust me, the bruises and swelling are pretty impressive. I know I will be just fine because I am not afraid. No one put a soft collar on my neck or took x rays of anything.

I love my vocation. I am happy with my life. But what if I were unhappy? What if I hated my job? What if I believed in lawsuits for slip and fall? What if I didn’t know all the things that I know about pain and the brain? I could be off work for months as many patients that I see are. Some patients are off for more than a year for a very simple slip and fall.

I think one of the most important things we need to do is to teach people that our bodies are designed to heal. There is virtually nothing that is made better by prolonged rest. Teach that the longer you rest, the more the muscles atrophy, weaken and weak muscles hurt when you use them. We need to teach that pain does not always mean disability.

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.