Showing posts with label doctor patient relationship. Show all posts
Showing posts with label doctor patient relationship. Show all posts

Wednesday, January 25, 2017

Reverberations

March 20, 2003. I stand with other students, staring at a television in my university's student union building, watching Baghdad being bombed. Explosions light up the screen. "Shock and awe". I'd spent many hours in the preceding months organizing, marching, due to the pressing need I felt to do whatever my small part was to stop the impending attack on Iraq. In the end, not surprisingly, it went ahead. I was grateful that Canada wasn't a part of it, but still, here it was. I stand watching war on television. 

In the strange happenstance of life, I now spend my days in family practice, seeing Iraqi refugees resettled in my city, still reeling from the effects of the war. Crippling PTSD pervades some of their lives. Yes, they have built new lives in Canada and many are thriving, but the ones who aren’t take up most of my attention. Layers upon layers of trauma. And for all of them, the sense of loss remains. I think of these effects as the reverberations of those initial explosions - rippling out across the world and the Iraqi diaspora, for years. 

This is, of course, not unique — the longstanding, multi-generational effects of trauma are felt within many communities.  But it’s one that’s close at hand to me, almost every day. During the student and community campaigns that I worked with to urge non-violence, I strove to think of the individual men, women and children who would be affected on the ground in Baghdad. Today, I know some by name.


  

Saturday, November 12, 2016

What's This Week Been Like For You?

I’m sure we all have an opinion about the election outcome; most likely, a strong one. I was following with intense anticipation as a Canadian. I am utterly despondent with the result. The day after, I met a friend for coffee and together we tried to process the reality. It felt much like the morning after 9/11, where we knew we were facing a ‘new world’ and an uncertain future. 

Our national public radio station’s coverage was filled with interviews with Americans relaying their uncertainties about the future. One gentleman felt a sense of betrayal by his neighbours; that he did not feel he really knew his city as he thought he did. I know that some of you are heartbroken, as I am. Others may be elated, or at least satisfied with the outcome. Some of you may feel conflicted. Still others may be Republicans who feel dismayed that Trump was their candidate. Maybe none of these captures your sentiments. I know many people are struggling to talk to their children about the outcome. Many American citizens and residents of colour and other vulnerable populations are especially worried about the “Trump effect” on their children, and perhaps some of you are seeing its effects in your daily life in medicine. In Family Medicine, it's not uncommon for some patients to bring up political topics, but I try to stay pretty balanced and general.  Personally, I found inspiration here, which cites this great article about talking to your kids about the result. Reading personal accounts and opinion pieces by those who are processing the results thoughtfully is helping me deal with the result. 

I realize that politics in general, and this election in particular, can be polarizing to discuss, and I know this blog does a great job of being a safe space. A refuge from the constant barrage that was so consuming during this campaign, perhaps. I think we can maintain that safe space by respectfully sharing our own personal experiences, fears, and worries. Because no matter your political stripes, I think it’s fair to say that the months ahead are uncertain for the United States, and the world.  

I have great faith in the American people, and the American system, to uphold their democratic values. I believe that most people are decent and that political and social tides ebb and flow throughout history. Let's help one another navigate the best way forward for our families, communities, countries, and the world. 

Wednesday, July 27, 2016

Talking Politics and Public Health With Patients- Is It OK?

Genmedmom here.

My Friday morning clinic was slow. There were two last-minute cancellations and a no-show. So when Mrs. Smith* came in for her physical, I wasn't in a rush, and we had some time to chat.

We talked about her recent hip replacement, and how thrilled she was to be finally pain-free and physically mobile, so that she could help care for her grandchildren again. Her face was bright with joy as she spoke of the beach and playground and the zoo and how much she loved experiencing the world with her two young grandchildren.

But she hesitated and frowned as she remarked: "I watch the news, and with everything going on today, I worry about them. We're moving in the wrong direction as a society. I mean, look at this presidential election, isn't it ridiculous, to think that a person so flawed could end up as a candidate? I'm frightened for their future."

Then she asked, "Your children are little, what do you think about all this craziness, do you lose sleep over it too? How can we protect them from it all?"

Up to that point, we had been slowly moving through the physical exam, and I had been wordlessly responding to her lighthearted description of her days as Nana the nanny with laughter, positive nods and smiles… When she admitted her fears, I reflected back grim countenance and shook my head, as if to mime What a shame, what a shame, but I didn't say anything. 

I had no idea at this point what her specific views were. Her comments could reflect the opinions of anyone anywhere on the political spectrum. The flawed candidate she was referring to could be either Democrat or Republican. I didn't want to say anything potentially inflammatory, or even mildly awkward.

But she sat there awaiting my opinion.

Her questions hung there, between us, as I shook my head and tried to think of something to say.

Is her idea of crazy the same as my idea of crazy?

Does she want to protect her grandkids from the same things that I want to protect my kids from?

Do I really want to talk about this? And, is it appropriate?

I thought about my morning commute. There's an app on my phone that pulls articles from all the news sources I choose, and I have chosen just about every possible news source, even those representing the far other side of my political leanings. I like to know what's going on, through all the looking glasses. I read it all on the train on the way to work.

For months now, the news has been increasingly disturbing. Mass shootings, terror attacks, senseless violence against minorities and law enforcement alike, war abroad, mass displacement… it's all horrible.

But what's worse in my eyes is that here in the land of equality, in a country founded on sound principles and thoughtful discourse, we are witnessing the ugly rise of a potential dictator. Here is a divisive fascist whose behavior already mirrors that of the worst dictators in history. Historians and scholars continue to make observations and deliver warnings. This kind of a man, this kind of rhetoric, these lies and sick ideas, are what have led to genocide and war in the past. And if that isn't a public health issue, I don't know what is.

So, what do I think about all this craziness? I think about it all the time. It makes me sick to my stomach. But specifically WHAT I think about it may not be appropriate to discuss with patients. I believe that the candidate on the right is a bona fide public health issue, on many levels. But so is gun control, and beyond asking patients if they have a gun in the house and how it is stored as a basic home safety screening question, I don't get into the issue with anyone.

Perhaps we should. Perhaps we, as educated professionals with a sworn oath to promote the health and well-being of our patients- ALL of our patients- should be open about our views on matters that effect patient safety. Maybe that could be a means of educating the public on important issues, like gun control.... and rhetoric that promotes violence.

This all went through my mind...

So, what did I say?

I murmured "I know, it's really scary…", paused and smiled and declared, cheerfully: "Your grandkids are so lucky that they have you. I'm so happy for you that the hip surgery had such a good outcome."

She smiled back, and we went on as if nothing at all was wrong with the world.



*Patient identifiers such as social history and medical issues altered.

Thursday, March 24, 2016

The Most Intimate of Jobs

A random Saturday earlier this month marked the first time I provided sedation anesthesia for patients in the same IVF clinic where I was a patient for 3 years. It was surreal and a little emotional driving up the hill to the clinic and thinking about the many times I went there as a patient myself. All the shots, the blood draws, the ultrasounds, the procedures... Also all the letdown and disappointment that was flanked before and after by hope and excitement. I now have a beautiful baby girl to show for my time as an IVF patient!

A friend of mine who is also in the medical field said to me, "I bet it took a lot of courage to do that. Creepy and scary". While I instead had viewed the experience with gratitude and excitement at the ability to give back to a group of people who had given so much to me, I can understand what she meant. As physicians, we are faced with daily reminders of unpleasant things. Things that have happened possibly to us or to our loved ones, or things that are at the very least reminders of our own mortality.

I think these reminders are a gift, one that doesn't come with many other lines of work in this world. They keep us appreciative of what we have, what we've been through. Has anyone else had an experience like this in their practice? Share your thoughts with us.

Monday, November 2, 2015

That parent: you know the one who makes the front desk staff have nonepileptic seizures?!?

For those that don’t know - nonepileptic seizures also known as pseudo-seizures are a phenomenon when a person does not have a real seizure, but they just mimic the movements of a seizure. Sometimes it is for secondary gain such as getting out of school and getting attention or sometimes it is a manifestation of underlying psychiatric illness.

Well, this is a post about patients that really stress providers and staff out and cause us all kind of angst.

I will take a moment to perform some serious self-reflection: I love me some difficult patients (yes, “love me some” as my Granny would say), blame it on my mother being a Social Worker, me being an interdisciplinary major who took a ton of medical anthropology and ethics classes, and me being extremely committed to social justice. Add to that the fact that most of the difficult patients come from places where my cousins still live and culturally I just feel connected to the loud, passionate, trash-talking patients. And finally, blame it on the fact that I have read countless accounts of the biases we providers have for folks we relate to and have against those who aren’t like us. I continually find myself being the only person bringing these biases up. I get it, I'm usually the only person of color in the room and to me these are issues I deal with every day and most of the time these biases harm folks that look like me and come from where I come from (see references below).

In spite of the very real and significant way we providers treat patients differently based on how we perceive them (see references below), what to do when a parent crosses the line? When their own mental health disorder gets in the way of their interactions with care providers? What happens when a parent only knows how to speak in a way that is viewed as overly aggressive to my colleagues and other staff but is culturally tolerable to me (loud, hands waving, maybe with a few expletives)? What happens when essentially an entire staff is overwhelmed with these interactions. There has been at least one time when I felt like the only one still advocating for a family but even I began questioning if I was really helping at all? What happens when we collectively have nonepileptic seizures when a parent comes in the door because we know the ish is about to hit the fan? I'm just wondering. What to do about "that parent"? The one we all want to avoid but who we still want to find a way to work with?

References:
1. Association of Race and Ethnicity With Management of Abdominal Pain in the Emergency Department. http://pediatrics.aappublications.org/content/132/4/e851.full
2. Problems and barriers of pain management in the emergency department: Are we ever going to get better? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004630/
3. Unequal treatment. https://iom.nationalacademies.org/Reports/2002/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx

Monday, October 5, 2015

This child and his sensitive skin

It all started out as a little papule on his left buttocks. In the middle of a busy week of relatives visiting and make-up clinic days, what started out as a small papule morphed into something worse. Zo has had exceedingly sensitive skin since he was 1 years old. Hyperkeratotic plaques behind his knees that sprout up in the span of 2 days if he isn’t slathered in a thick mixture of shea butter and petroleum jelly twice a day. Diffusely itchy maculopapular rashes if we miss his nightly dose of cetirizine. That type of sensitive skin.

I thought I had things under control. But I didn’t.

Monday - I see a little papule on his left buttocks. I put on a thin layer of triamcinolone 0.025% on it. Later that night, I see a few more papules. I put him in the bathtub and then put on more triamcinolone and begin our twice a day ritual for exacerbations.

Tuesday - I see more papules. He is itchy. Is that a ring? Nahhh, I’ll just step up the emollients.

Wednesday - I return home and notice him scratching. How was swimming? His response, “it was fun” as he continues to scratch. Bathtime. Is that a 2 centimeter scaling ring-lesion?!? Oh goodness! He’s got tinea!!! I don’t have time to get clotrimazole and I forget to text my hubby what medicine to get from the pharmacy.

Thursday - satellite lesions. After clinic I run to the local CVS and wait in line for 15 minutes to purchase clotrimazole and by the time I arrive home he's asleep. That peaceful sleep where you know not to interrupt them or all hell will break loose so I let him sleep as I fret about his tinea outbreak.

Friday morning - we begin twice a day clotrimazole use.

Weekend - more lesions. Lower back, posterior and anterior thigh. Areas I won't mention for fear of him one day reading this. But seriously who knew tinea could spread so quickly and that toddlers can get jock itch! Major fail!!! Quick consult to my doctor friends with pictures of all of the lesions minus his groin. Definitely tinea. Definitely spreading; it’s all of the summer camp fun and splash park play dates. Primary care friend KJ says just go ahead and suck it up and put him on griseofulvin too, it’s already too out of hand and you'll stop it before it spreads to his scalp.

And just like that, I have written my first prescription for my son. Too ashamed and time-pressed to bring him in to my new clinic for tinea corporis. I knew the liquid wouldn’t go well as he is now 16 kilograms and our last go round with amoxicillin ended in us making daily smoothies. Based on my calculations, he could do one-half of a 500mg tablet daily - and after all of the pill swallowing for kids I observed due to an awesome program one of my co-residents did, I knew what to do.

Tuesday - I took him to the pharmacy to get him excited about his new medicine to help with his itchy parts. He shook the bottle to a nice beat and did a happy dance. We got home and I cut the pill. Hubby says “shouldn’t you crush this, it’s huge.” I say “nawww, we’ve got this.” Equipped with 1 tablespoon of honey and half of the pill, I say, “okay, you’ve got to swallow this without crunching it up.” Zo smiles, says okay and then hubby offers him some extra water and then VOILA!!! My almost four-year-old swallowed his first pill!!! Proud doctor-mommy moment in the midst of a crazy week.

Wednesday, August 12, 2015

When the Patient Brings Presents… or Punishment

Genmedmom here.

This was an odd week. One patient brought me a beautiful bouquet of flowers as a gesture of thanks… and another totally reamed me out. Both are uncommon occurrences in my practice.

The thing is, I didn't feel like I deserved either.

I told a colleague about it, and we laughed. It's so funny, but so often the case, that we're as surprised by the patient who is grateful as we are by the patient who is angry.

Both cases ended up being professional victories for me:

Usually, when I've received gifts from patients, I have felt some pressure to treat them a bit extra-special, overly gently, with kid gloves. Oh, I won't go there this visit. But in the case of the flowers, I approached a touchy subject anyways, and we were able to address it in a positive way during the visit.

In the case of the reaming, which was really a lengthy declaration of my recent deficiencies as a provider, I was able to hear the patient out. They never raised their voice, used vulgar language, or got personal, so I was able to sit, impassive, and take it. I felt it was therapeutic for this particular patient to get it all out… I apologized for the perceived inadequacies, we reflected together, and then we were able to move on to actual medical issues. Usually, when I get criticized, I get heated up, embarrassed, emotional.

I don't know exactly why, but I was able to stay cucumber-cool. Maintain that professional distance. And, best yet, not bring it home with me.

Of course there have been other cases that have found their way into my head and into my home, intruding on the kids' bedtime routine, making their way into quiet conversation with my husband, delaying desperately-needed dreaming…

In our practice, we have a monthly Balint-style group moderated by a psychologist. We often share cases that get in our heads, and these themes have definitely been explored. Be it gifts or criticism, we have all experienced it. It's been very helpful to hear not only what other providers do in response to these challenging situations, but also to hear what they feel.

We're not made of Teflon, and the water sometimes soaks us. How do other physicians respond in these cases? and, more importantly, how does it make you feel?

I'd love to hear!