Showing posts with label doctoring. Show all posts
Showing posts with label doctoring. Show all posts

Monday, November 16, 2015

Guest post: Unexpected gratitude

I love Raymond Carver's poem "What the Doctor Said." The doctor tells the poet he has widespread metastatic lung cancer. The poem ends with this:

I jumped up and shook hands with this man who'd just given me
Something no one else on earth had ever given me
I may have even thanked him habit being so strong

I may even have thanked him. 

I don't have to tell people they are dying. I'm a hospice doc. My patients know they are dying before they meet me. Everyone knows they are dying. They may not want to say it out loud, and they may use a variety of euphemisms, but everyone knows. I don't have to say it. I do have to find a way to answer the question "How long?" I always start and finish my answer by saying "I don't know." We never know for sure. I am frequently surprised - I am surprised how quickly some people die and how long some others linger. I am surprised by so much about this work. I am surprised by the peace that I feel at the bedsides of the dying, and how comfortable it can be in our inpatient hospice unit. I am surprised at the laughter I find when I make home visits. I am surprised by the capacity of family members to do the hard, dirty, physical work of caring for their loved ones.

And I am surprised when they thank me.

Patients thank me for coming to their homes. "A doctor who makes house calls! In this day and age"! Caregivers thank me for the medication that eases the symptoms and makes their job easier (even though it's the nurse who tells me what they need). Family members thank me for clear explanations of the medical system and for signing forms (although most of that credit should go to the social workers who do all the actual work). All of that makes sense. I have done something, given them something, provided an answer or solved a problem.

Then there's the question no on ever wants to ask: "How much longer, Doc?" It's often asked in the hallway of our inpatient hospice unit. Someone is usually crying. Sometimes the someone is me. I am as honest as I can be when I don't really know. I say "I don't see anything that suggests it will be the next few hours...", but I know the patient might be gone when we walk back into the room. I ask what the family needs - what decisions are they wrestling with? Who needs to come in from out of state? Who are they trying to protect? And at the end of the conversation, they say "Thank you." I am always surprised.

I don't really know why they are thanking me. Perhaps it's for some clarity and honesty after the muddle of modern medical care. Perhaps it's for the moment of connection and the respect I hope I'm communicating. And perhaps it's what Raymond Carver wrote about - that I have given them something no one else ever has.

Those moments will continue to confound and humble and amaze me, and for that, I am thankful.

Jay is an internist working full-time in hospice and palliative care and mom to a 15-year-old daughter.

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?

1. Association of Race and Ethnicity With Management of Abdominal Pain in the Emergency Department.
2. Problems and barriers of pain management in the emergency department: Are we ever going to get better?
3. Unequal treatment.

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!

Tuesday, June 16, 2015

MIM Intro: Doctor Professor Mom

Hello, I am Doctor Professor Mom.  No, that’s not my real name but it’s a name that makes me really proud.  My oldest son coined it a few months ago when he learned that I am not only a doctor but I am also a professor and I am also a mom.  He seemed genuinely proud when he coined the name and, of course, I was equally proud both at his creativity and at some of my accomplishments.

Even as a Doctor Professor Mom, it’s hard to feel accomplished.  Maybe it’s something about academic medicine where I feel pulled in a million different directions. I teach; I do research; I see patients – it’s easy to feel like a jack of all trades and master of none.  Add on a busy family life and mastery is not in my cards.  But academic medicine has given me incredible flexibility, variety, and satisfaction.  Plus, I get to proudly say I am a doctor and a professor.

Of course my proudest accomplishment is not that I am a doctor or a professor but that I am a mom to three boisterous, energetic, and absolutely wonderful sons.  They are ten, eight, and six (gasp - how did they get so old).  After ten years of motherhood I have a lot to reflect on in managing a household with two equally ambitious working parents and ever changing challenges of parenting. 

I became interested in writing about my experience as a doctor and mother after my first son was born.  I spent 18 months crying every day when I went to work and decided (with the incredible support of my husband) to leave my job and stay home.  Then I struggled trying to find my identity as a stay-at-home mom (I wrote about this experience in an essay called Dr. Mom).  I returned to work and decided to focus on research and a career in academic medicine.  For me, it was an excellent choice.  That being said, the struggles of being a working mom, finding meaning and satisfaction in your work, and all the other challenges of life never go away even when you feel like you’ve found the perfect job.

When I wrote Dr. Mom in 2007, so many women contacted me and thanked me for sharing my story.  I promised myself I would write more, but, not surprisingly, life got busy.  I’m thrilled to have a place to write, to be a part of a community of women in medicine and hope that something I write will resonate with someone else. 

Monday, April 20, 2015

Hurtling toward the next phase

I have searched but I cannot find the flying trapeze story I read a few years ago that explains my life, so I’ll paraphrase and add to it here:

I swing back and forth preparing for my next take off. I have prepared, but I know that this leap is longer and more challenging than ever before. In spite of a long line of successful jumps, there have been some near-misses, some full on misses, some blood, scrapes and even some still healing deeper wounds. This time I jump, my husband is watching and waiting readying himself for his jump into dissertation land and as we prepare Zo waits by ready to take off with us.

Well MiM friends, it’s official, I have accepted a position as a Pediatrician in my dream clinic. I’ll be back in DC working at an academic center-affiliated community clinic. I did my community pediatrics rotation there as a medical student and so many of my respected supervisors and medical school friends are still there.

Interviews were a whirlwind. I met so many nice people, got lost countless times, learned even more about what I need, want, and will compromise on.  

And now onto school finding. Every day I have a mini-freak out when I think about Little Zo starting pre-k. Our cherubic toddler has been replaced by an almost 4 year old hilariously funny and extremely sweet rib-protruding knock-kneed ball of energy. And then I freak out more about making pick up and drop off work and I pray so intensely that we find the right environment for him and that we will find balance so I can rock my boards and O can finish his dissertation expeditiously. I wish I could transplant his daycare to DC.

And house hunting on a single income in a very tight housing market is not my favorite thing to do but I guess house hunting without the beloved Property Brothers will always be lackluster. We have several leads on promising houses and are heading up next weekend prepared to make an offer. Can’t wait to have our first home secured and then on to do-it-yourself projects for years to come.

This jump seems epic. Push-pull-push-pull, forward backward forward backward, take off.

Friday, January 23, 2015

Do Female Physicians Need Female Chaperones?

Genmedmom here.

Our department is considering a policy that would require female chaperones to monitor every pelvic exam. This would include pelvic exams performed by female providers.

As a primary care women's health doc who performs pelvic exams every day, I felt vaguely insulted by this.

But, as both a female physician as well as patient, I understand the reasoning behind this potential policy. In our department's case, it was apparently proposed in response to a complaint involving a female physician; we have no idea what the issue was. Of course, historically there have been cases where there was abuse of the doctor/ patient relationship in this context. Also, cases of perceived abuse. To have an official "observer" present can help to prevent any abuse, or false claims.

My own OB/GYN office uses chaperones. But it always strikes me as odd and impractical. My own OB/GYN is an excellent physician with superior bedside manner who has overseen both of my pregnancies; she even guided me safely through a VBAC. But even she has to leave the exam room and go fetch a medical assistant, who may have never met me and is not involved with my case, so that they can stand there and observe what is basic, routine office care. I've considered requesting that she NOT go fetch the superfluous eyeballs, as I think it's kind of weird, and it would save time, too. But I haven't wanted to rock the boat.

So, as I have myself experienced, having an additional person present for this exam can also in and of itself be uncomfortable, and can make routine medical care feel weird. It may not help many women to feel more comfortable at all.

Are there things we providers can incorporate into practice that can help minimize discomfort and prevent abuse, or perceived abuse?

I really try to help patients through what is generally considered, at the very least, an uncomfortable and awkward examination. For many women, a pelvic exam can even be a traumatic experience, either physically due to atrophy or inflammation, or psychologically due to past rape or sexual abuse.

I think there's some basic things that we can do to help women feel more comfortable and in control when a pelvic exam is necessary. These include explaining why we are doing the exam and what we are looking for before we even start. Does she need a Pap smear, or STD screening, or both? Is she complaining of pain during sex, abnormal discharge, abnormal bleeding? Is there a strong family history of GYN cancers? Is there a family or personal history of melanoma? Then we'll discuss whether the exam will include a speculum exam, or a bimanual exam, or just an external exam, and why. Not everyone always have to do have all of these.

It's important that the patient knows what's going on at all times. I think it's better if the back of the exam table is slightly elevated and the paper drape is pushed down, so that the patient can easily see the provider. I also try to explain everything I'm doing in real time. I don't even touch the patient in that area at all, without saying what I'm doing and why immediately beforehand. I'll hold the plastic speculum up, and explain that it's the same diameter as most regular tampons, that we use plenty of lubrication with this, and it's usually cold. I tend to talk through the entire procedure, Rachel Ray-esque. Often I'll suggest yoga breathing, letting the pelvic muscles and buttocks relax.

In some cases, urinary incontinence is a problem. If Kegel exercises may help, I ask women if they know how to do these. Then, I either test their Kegel, or ask if they want to learn this. What I've seen is that many women who think they're doing a good Kegel squeeze will actually be tightening their buttocks, or simply tilting the pelvis. So I add pelvic floor physical therapy here: a lesson in isolating the pelvic floor muscles, and a test to see if the patient is able to do a decent Kegel. I think if someone walked in as I'm saying "Squeeze!" they'd wonder what was going on. But since Kegel exercises are effective for preventing and treating urinary incontinence, we'd better make sure patients can do them before we recommend them.

Sometimes, a patient is extremely uncomfortable with some part of the pelvic exam. Then, the exam must be halted. I usually pull the drape back down and discuss, ask if they would like to try again, or hold off. I really don't think a provider can proceed in those cases without a time-out and discussion. It's okay, and sometimes absolutely necessary, to just skip the exam. It can be rescheduled; special arrangements can be made as well, as in cases of extreme physical or psychological discomfort, such as exam under anesthesia.

I've had patients tell me that the pelvic exam "really wasn't that bad", or even that they learned something useful. I take this as positive feedback! I'm sure I can do better; we all can. I'd be interested to know what techniques other providers have found to be useful.

If we are required to institute this female-chaperone-for-pelvic-exams policy, it would mean significant logistical hassle. In our office, we work one-on-one with the medical assistants, and several are male. Would the guys need to be let go, transferred to other practices? In addition, our medical assistants perform the phlebotomies on the patients they've checked in. Were this policy to be put in place, we would need to reorganize our whole system, and likely need to adjust the operating budget to include additional staff. And, of course, if we're required to go fetch a chaperone before every pelvic exam, that will add time to all of those patient visits. Either we'll all run even more behind, or we'll have to restructure our scheduling, and likely need to institute longer days for us and our staff, to accommodate. Again, this could mean a budget problem.

In summary, I don't think that requiring a chaperone to stand there and observe every single pelvic exam is a good idea.
But, I'm very curious what women physicians think about this, both as providers and as patients.

What better place to ask, then the physician-mom blog? What's the vote: Yay or nay?

For those docs that perform pelvic exams, what have you incorporated into your practice to help women feel more comfortable and in control?


Monday, November 3, 2014

MiM Mail: Types of practices and family life

Hello fellow Mothers in Medicine!

I am a senior resident in a medical subspecialty, about to graduate next year, and am in need of frank advice on different types of practices and having a full family life. I have a child under the age of 1, and plan on having a second child within the next few years. My specialty allows for some flexibility, and I think that either solo practice, small private practice, or hospital employment are all viable options. Ideally, I would like to work part time while my children are young. I am hoping to gain some perspectives on others experiences with the varying different practice types, what worked well for young families and what presented challenges. Thank you in advance for sharing your experiences and thoughts!

Friday, October 17, 2014

Would You Care For A Patient With Ebola?

Genmedmom here.

Last week, a patient with risk factors for Ebola exposure, and who had medical issues, walked into our office.

Kudos to our N.P., who handled this very well. Upon learning of the potential exposure, she called infectious disease at our hospital, and they walked her through the appropriate screening interview questions. It took awhile, but she was able to determine that this patient was extremely low-risk for direct contact with the Ebola virus, and was not exhibiting any suspect symptoms. She was given the all-clear by infectious disease, and proceeded to take care of the patient.

Of course, this drove home very quickly the fact that any of us could be called upon to make a similar evaluation at amy time. I know I opened our hospital-issued Ebola risk stratification and action guidelines and read them over several times.

All day and on the long drive home, I imagined what I would do.

My first instinct was: Of course I would step in and help, no matter what any patient had or may have. I'm a healthcare provider. That's my job.


There are now two nurses who contracted Ebola through caring for an infected patient in Dallas, despite knowing the diagnosis and wearing all the recommended protective gear. This is a virus with a 40 to 50% case fatality rate (now reported as closer to 70% in West Africa, due to lack of resources and care).

I'm a mother to two very special little kids. Could I justify knowingly exposing myself to a highly contagious virus with a grim fatality rate?

I went back and forth in my mind.

There are many healthcare workers in this country... But my kids only have one mom.

On the other hand, I do think that nurses and nurses' aides are at far greater risk of exposure, due to the inherent nature of their jobs and the mode of transmission of the virus. Now that I am an outpatient attending, I am rarely exposed to patients' body fluids.


It only takes one, tiny exposure.

Of course, we have had a providers' meeting about this, and we did review our office protocol again. If needed, we have the "moon suits" and a designated isolation room. We have all the phone numbers to call to arrange transport of a suspected case. We have solid resources, so unlike our counterparts in West Africa. My heart goes out to them and to all the poor people suffering with this. We are lucky over here.


I don't know much about donning layers of protective gear. I would likely screw it up. It only takes one, tiny exposure.

How would I then limit contact with my family, not get too close with my kids, for twenty-one days? I'm always clearing noses, changing diapers, wiping binkies... it would be near-impossible, and nerve-racking.


I don't know what I will do, given the choice.

I know that many hospitals are compiling lists of volunteers, staff who are willing to care for patients with Ebola, including aides, nurses, physicians.... I understand that most of these lists are pretty short. I have no idea what our hospitals' list looks like. I know I am not on it.

I am very curious what others have thought about this, especially the hospitalists and nurses out there, who would likely have more direct and frequent contact with a case should one come in.

Healthcare provider-moms, what are your thoughts?

And if you haven't thought about it, you should....

--Genmedmom, also at

Friday, November 1, 2013

The Opiate Epidemic And Us

Our 25-year-old nephew passed away last week.  He had been fighting an addiction to prescription opiates for some time, and despite great efforts on the part of himself and his family, he died. I've written about this on my own blog.

His death has caused me to reflect on my own role in the larger problem. It has brought home an ugly issue that we all, as prescribing physicians and mothers, should reflect on.

When I first started as an attending in our small internal medicine practice, I learned to dread one aspect of the call more than any other: dealing with the requests for narcotics prescription refills.

We take a week of call at a time, and call starts Friday at 8 a.m. Friday afternoon call would roll around, and so would the requests. Not hundreds, and not always, but very commonly, one to five requests.

There was a pattern: usually someone was requesting a refill early, with a story about how the original prescription had been lost, or stolen, or  left in the glove compartment of the rental car they were driving while their car was being fixed but now the rental car was re-rented and the prescription was gone (true story). Or they had used more than was originally prescribed because they had had a particularly bad flare of back pain/ knee pain/ fibromyalgia secondary to a new injury or stressful event of some kind. Typically there would also be a mention in there of a sick child, a recent family death, a failed marriage, or a lost job. Usually the prescribing doctor or PCP was not readily available, and usually the electronic medical record showed a history of similar weekend early refill requests with notes like, "Filled amount for just a few days until PCP returns" or "Rx sent with no refills with instruction to f/u with PCP". And I usually did the same. (Except sometimes when I was really peeved).

Why didn't I (and we) generally refuse to fill these? Because you could put someone into serious withdrawal if they suddenly stopped their Oxycodone 20 mg three times a day. And if the medication was truly needed for pain, it would be cruel not to provide it, and you just never really knew.  In addition, to outright deny these requests could be construed as sort of a slap in the face of the prescribing PCP, my (senior) colleague, thereby questioning their medical judgment in writing this prescription in the first place. And, honestly, a huge time suck as well, as if I were to refuse, I would need to spend so much more time  dealing with the mess then if I just gave the patient a few, just to get through a few days until the PCP returned or the office reopened.

Luckily, soon after I was hired, more stringent prescribing standards were encouraged, and then, within the past few years and even months, actual legislation has emerged to practically help us physicians to deal with narcotics prescriptions. Pharmacies cannot accept phone orders for refills, and patients must have a signed hard copy of the narcotic prescription. Weekend phone call refills are no longer even possible. Pharmacies' databases are now linked up so that patients cannot use more than one pharmacy to fill these types of prescriptions. We have directives from our hospital to meet with all of our patients who are on any chronic narcotics, review a Pain Medication Contract, have them sign it, and then test their urine for the specific pain drug as well as for illicit substances.

Because we are in an epidemic.

All sorts of people are getting high on these prescription opiates. I see prescriptions for #90, #120, even #180 of 5 mg oxycodone. I've seen prescriptions for more. If someone or their family member is diverting even a few of those on a regular basis, it's enough to get others hooked.

Diversion is tempting. It's a good income. A Google search right now says that Oxycodone is worth about one to three dollars per milligram on the street, so that 5 mg tablet has a street value of at least five and perhaps fifteen dollars. If someone has a bottle of 180 tablets? Whoa.

Opiates are extremely physically addictive. And lives are crushed by addiction.

Physicians have a wide range of practice habits and comfort levels. Me, especially when I first started, I had zero comfort level with narcotics. Unless a patient just had major surgery or had metastatic cancer, I was NOT going to prescribe a narcotic at all, never mind chronically, long-term.

Now, honestly, I'm comfortable with these prescriptions, under certain circumstances. Surprisingly, in my own practice, most of the people I have started on narcotics (who hadn't had major surgery and didn't have metastatic cancer) are my very elderly ladies with bad arthritis who can't take anti-inflammatories (like Ibuprofen and those meds) and are maxed out on things like Tylenol, Lidoderm patches and Capsaicin cream. And so, yes, I do have a handful of patients who take Oxycodone 2.5 or 5 mg once or twice a day for breakthrough arthritis pain. Most of them walk with a cane, and I hope that their grandchildren aren't pilfering.

Then, I inherited a panel of patients on larger doses of an assortment of controlled substances, and I am currently struggling with these cases. I'm using laws and hospital guidelines as best I can to get a handle on things... it's a discomfort zone. My gut feeling is that some, probably a very small number, of these patients are sharing or even distributing these medications. But without obvious red flags or violations of the Pain Medication Contract, such as a urine screen negative for the prescribed medication and/or positive for an illicit substance, I cannot, in good conscience, refuse to prescribe.

In my own practice, I have tried to shift people towards alternative pain management, like healthy living, physical activity and physical therapy, acupuncture, yoga, massage... I really believe that a low-carbohydrate diet and regular exercise helps to reduce overall inflammation and decrease pain perception. This is not going to work for bone-on-bone arthritis, I am aware of that. But for low back pain and fibromyalgia sufferers, I give it a hard sell.

I'm curious to hear what are the thoughts and experiences of other physicians on this issue...

Wednesday, September 11, 2013

I Care About You, But I Hate What You're Doing: The Internal Struggles of a Primary Care Doctor

Gizabeth, a pathologist, just wrote about needing to maintain a "poker face" when she did a patient's biopsy, because she knew the diagnosis was metastatic cancer, and she knew it wasn't the right time or place to deliver that diagnosis.

This hit on something I've been struggling with for some time, now, and what I suspect many doctors struggle with (unless they've become completely detached):

Over these past five years as an internal medicine attending, there have been patients who have broken my heart, who have made choices I strongly disagreed with. Of course, as long as the choices are legal and not harming anyone but themselves, they can do that, and the point of my writing about these cases is not to debate these choices. It is to learn how to manage my emotions as both a physician and as a thinking, feeling human being.

How do other doctors deal in the immediate moment, and then in the long-term, when a patient follows a path you believe is wrong?

 I'm thinking of several cases (all details obscured or altered to protect true identities):

Several years ago, I took care of lovely, vibrant, fifty-ish year old woman, who in addition to living extremely healthfully, also saw a holistic provider. One appointment with me, we reviewed some test results that suggested she had cancer. I arranged for immediate referral to a wonderful specialist. The specialist confirmed cancer, and outlined a reasonable treatment plan that involved surgery and chemotherapy. About a week later, the specialist sent me a note that the patient declined all of it, and instead chose her holistic provider's plan of herbal remedies.

I was horrified. I called the patient and asked her if this was true. She said yes, that she thought of cutting and chemotherapy as worse than cancer, and would take her chances with the herbal tinctures, powders, teas, cleanses and energy healing offered by her holistic provider.

What would other doctors say to that?

I said, something along the lines that I respected her decision, but felt that I, as her primary care doctor, needed to inform her that she was choosing untested and unproven treatments, treatments that were not likely to help her at all. She said she would take her chances, and we hung up. That was the last I ever heard of her.

The above case is actually a combination of a few similar cases... It's not unusual for patients to turn down the 'Western medicine' treatment plan. Again, of course, the choice is the patient's, that is not debatable. What I struggle with is my own feelings. Because I know that when this situation comes up, when I KNOW the "Western Medicine' plan, though imperfect, is the patient's best shot at extending their life and quality of life, I know my heart beats like crazy, my palms sweat, and I have to work very hard to control myself, to NOT stand up and scream: "ARE YOU CRAZY?? You're planning on taking all kinds of potentially toxic and useless herbal crap when you have access to the best treatments in the world for this, and suffering people in every developing country would give anything to be here in YOUR place with the chance YOU have at a cure, and YOU are turning it down???"

Then, there's the opposite scenario.

I once took care of a lovely and also quite seriously ill man. He was extremely elderly and debilitated, with some dementia, enough dementia that all of his finances and logistics were managed by family members, though with enough insight and judgment to contribute to his own medical decisions. He had a terminal cancer diagnosis, on top of multiple medical problems, making his care quite complex. He was feisty at times. He had been asked to consider his palliative care and hospice care options on several occasions, and always became quite angry, usually ending up by shouting things like "I'm not going to let you kill me!".

He was admitted for serious, life-threatening complications related to his cancer. It was very likely that he would end up on life support without a chance of any meaningful recovery. He was asked again if he would consider hospice/ comfort care. He refused. His family, who had power of attorney, chose to abide by his wishes. He ended up near cardiac arrest and was sedated and intubated, and stayed in the intensive care unit on a ventilator for a very long time before he passed away, without ever having regained conciousness.

I don't need to tell many people in healthcare that this scenario is so common, I've seen in many many times. It plays out every day. It's just as heartbreaking to me, to see someone choose the cold, often prolonged ICU death, when they could have had the chance to go a homey hospice - or even home!- with the comfort of a morphine drip, holding hands with family members all around them, saying goodbyes or telling stories, until a naturally peaceful end.

Again, the choice is the patient's. But how do you deal with seeing this over and over again, trying to convince yet another human being that the choice they are making really, really sucks?

There are many other situations where my heart breaks. I hesitate to write about it, such a huge can of worms is the subject of abortion. It's with a heavy sigh that I even type this, as I know it stirs strong feelings and stronger words, pro- and anti-, either way. My point in writing is, again, not to debate the choice. In this country, thank God, the choice is up to the woman.

But I struggle, sometimes, to contain my own emotions when I am counseling a patient through her options.

I am pro-choice, and do believe that someone needs to provide safe pregnancy termination services to those who choose that. But at this stage of my life, I am personally, for my own self, pro-life. I did not choose to have any early risk assessment in my pregnancies, despite my own advanced maternal age. It wouldn't have changed mine nor my husband's decision; we agreed to carry on with any chromosomally imperfect fetus. We had even agreed to carry on with a pregnancy if it happened before we were married. We agreed that we have the financial resources and family support to care for a child, any child.

So, I struggle when I am counseling women who, like me, are financially stable, partnered, educated... who, in short, I perceive as having the resources available to care for a child, any child, special needs or not... and yet, they choose to terminate a pregnancy. In the room with them, I am professional; I smile kindly; I hand them the list of termination clinics; I counsel on birth control; I often see them after a procedure for followup.

But it is not uncommon that I tear up. I often need some space after one of these sessions to recover before I can go into the next patient's room. And I take it home with me. It makes me very, very sad.

How do other doctors deal with this? Especially, doctors who are mothers?

So many situations in medicine can affect us. We are all different in our beliefs and actions... But there must be situations that affect all of you, as healthcare providers. What are they? What touches you, and what do you do about it?

Friday, December 14, 2012

Guest post: Compartmentalizing work

I watched a child die.  Literally.  Took his last breath in front of me.  It wasn't an unexpected death, but nonetheless, still very sad.  What do you say when your partner says "How was your day at the office honey"?  What do you say?  How many of you share your bad days with your spouse?  If you don't, how do you assimilate what you deal with into your life?  Life went on that day, as it has to, after his death.  Yet, I couldn't help but think the universe should have stopped in some way, briefly, to mark his passing.  A leaf should fall, or the world should go quiet for 60 seconds.  We lost a child.  Our community lost a child. We lost the promise of his life, the contribution he could have made to our society.  What would his life have looked like?  The impact of watching life slip away was huge, on all the staff, as well as the family.  I found myself wondering, watching his mom stroking his arm just before he died, how do you comprehend that this evening, your child will not be with you? That your family will go from 5 to 4.  How do you tell his siblings that he died?  I watched my colleague go straight from his death to a mundane meeting, wondering how is it that life goes on after this little boy has just died?  I know it must, as mine did, and I know that the family's loss is not mine.  My children are safe and well.  So, my question is, how much do you share with your partner and your friends?  Do you have people in your life that you can share your sadness with, or do you have to deal with this on your own?  Not being able to debrief because you need to protect others is a lonely business.  Are we destined to cope alone, because we chose this path?


Bio - I live in the South, currently working part time in pediatrics.  I am happily married, with two healthy gorgeous babes.  I stumbled across MIM a few months ago and have been following it avidly since, as it helps me to deal with some of the issues I face, being a working mother in medicine. 

Tuesday, December 11, 2012

MiM Mail: The what-ifs

Ever had one of those cases where you look back and just wish you'd done things differently? What's your way of handling this feeling? Might you be willing to share your moving forward strategy?

I'm an anesthesiology resident transitioning back to work from maternity leave. While I love what I do, there have been quite a few days when I definitely feel that the transition back to work is not as fast as I'd like. The days where I feel like I'm relearning things I used to know. Yes it's kind of like riding a bike after you haven't been riding one in a while, but when you're training, sometimes you don't feel like you ever really knew how to ride it that well even. And I have many moments where I am mentally kicking myself because I just remembered something I should have done or handled differently.

[The case below has been changed to protect patient and staff confidentiality]

For instance, recently there was a code blue at the hospital. A man who had been undergoing a line insertion was now having massive hemoptysis. A double lumen tube was inserted to isolate the bleed. Some air seemed to be entering one lung. The PAC balloon is inflated and the hemoptysis seems to have stopped for a while. The patient seems relatively stable with good sats and bp and the patient's main physician consults ICU to take the patient for close observation. At the back of my head is this niggling feeling as I am not quite sure whether this tamponade from the PAC balloon will hold - should we consider if we need a surgeon to sew up whatever's bleeding? But soon, the patient is bleeding again, CPR is started, the surgeon shows up but the patient is too unstable and despite best efforts, the resuscitation is unsuccessful. When I get back home, I read up on this, and more questions fill my thoughts. What if we'd gotten a cardiothoracic surgery consult much earlier on? Or heart-lung bypass? But now it's too late for the what-ifs and should-haves. I just wished I had known more at the time to be more useful.

Shortly after, I was in a simulator session. While I was fast on initial management managing a crashing patient and securing the airway, I got hung up on troubleshooting ventilator equipment that had failed, without moving on to switching my equipment. It was one of those how-stupid-of-course-I-should-have-thought-of-that moments - if something's not working, sometimes the best option is not to try and fix it, but to switch it entirely. I know that! But hadn't done it fast enough. In a simulator, it's not a real patient crashing and that's great. But if this was a real-life situation, that patient may not have been as good.

I find it hard not to mentally kick myself, or to look with envy at other colleagues and wonder how they seem so much more confident and competent. When I look at my flubs, I often feel like a Bridget Jones while others seem like a Grace Kelly or better yet a MacGyver - always there with the best plan in the nick of time, executed with calm and grace.

I hope I'm not the only one out there who has felt this way - trying my best but feeling incompetent or stupid at times. Yes it is a learning opportunity, and yes, I hope it gets better, and yes I feel I know more than I used to - but when does one start to feel confident and competent, and bring-it-on-because-I-can-handle-it rather than I-hope-I'm-seeing-bad-stuff-when-there-is-someone-else-on-who's-better-than-me-there-to-guide-me-through-it? When I was a med student, I looked at the residents with awe for their competence and confidence, and now that I'm the resident, I don't know that I feel that way.

Have you ever felt this way? Have you ever had cases that didn't go as well as you'd liked? How did you handle it?


Thursday, November 1, 2012

Guest Post: Five Lessons Learned on Being a Patient

Last summer, I was enjoying a relatively smooth second pregnancy despite my “advanced maternal age.”  It was a warm, sunny Sunday afternoon, closing a (miraculous) full weekend off of clinical shifts.  I lay down to take a little nap; my then-two-year-old daughter climbed into bed next to me. Suddenly – life changed.   I felt a gush of fluid, and knew that I was either bleeding or had broken my water.  To my dismay, it was blood.  A lot of blood.

At that moment, I made the transition that all doctors will make at some point in their life, but which we all fear:  from physician to patient. 

I was now G2P1, EGA 31w2d, with a spontaneous abruption, praying to feel the baby move.   I had no history of trauma, no cocaine use, no history of bleeding disorders.  My husband (who was, luckily, at home) scooped up our daughter and me and drove at what felt like 100mph to the hospital.   I sobbed in fear the whole way.  Thank god, on arrival to the hospital, our little one had a healthy heart rate.  But I was still bleeding, and contracting, and had some cervical dilation.  What followed:  8 long hours of being NPO in fear that I’d need an emergency C-section.  A long discussion with the NICU fellow about prognosis if my little one needed to be delivered that night.  An admission to the labor & delivery floor “just to watch.”  Then a week in the hospital.  Then 2 months on bedrest.   

No one knew why I had spontaneously abrupted, and therefore no one could say if or when the abruption would recur.  Although no large clot had been visualized on my ultrasound, that didn’t mean that my placenta was okay.  I was a nervous wreck, hoping my little one would gestate until he was big enough to avoid the NICU.

Thank goodness, nothing happened over those long 2 months.  I had occasional contractions, occasional spotting, no bright red bleeding.  And 1 week shy of my due date, my son was born, small but healthy.  And I was healthy.  I realize how incredibly lucky I am, and how much tougher things could be.

Still – it was the scariest two months of my life.  And it has changed my way of doctoring.   I walked away from this experience with 5 major lessons for my own practice of doctoring. 

1. Empathize with patients’ and families’ anxiety.

I now understand why people over-interpret their symptoms.  I get why the patient with a history of CABG comes back to the ED every week for twinges of chest pain.  (“What if?.... Last time… I don’t want to be home alone….”)  Often, my primary role as a doctor in the emergency department is to assuage this anxiety, especially if patients have had a long wait prior to being dispo’ed.

2. Be honest about a lack of knowledge, and explain what we can given the limits of our diagnostic/prognostic ability.

I am a physician, and understand medicine!  But I am not an ob/gyn, and have been out of residency for more than a few years.  The only abruption I saw during my training resulted in a stillbirth, so had no practical experience in this diagnosis.  Scarier yet, even among my ob/gyn’s group, management of moderate abruptions differed.  This was scary.  Luckily my personal physician was stellar at making me feel comfortable both with the lack of an evidence base, and with the recommendations she made.

For my patients who are sent home without a diagnosis or clear prognosis, I now try to acknowledge my frustration with this fact, and give an outline of both what I know they do NOT have (e.g. “I am pretty sure your really bad headache isn’t a bleed, or a tumor, but I’m not really sure what’s causing it”) and an outline of when/why they should come back.  I make sure they feel heard, and reassure them, which is often the whole reason they sought medical care in the first place: just to make sure they were okay.

3. Don’t be offended when patients ask for their personal physician when they present to the ED.

In a moment of fear, you want someone you can trust.  I was lucky that my personal ob/gyn was on call the day of my abruption.  I’m not sure how I would have responded to non-evidence-based recommendations had they come from someone other than her.

Now, when patients’ first words on seeing me are: “Have you called my doctor [X] yet?” – I tell them how lucky they are to have such a great doctor as their PCP/cardiologist/whatever, and reassure them that I will work closely with her/him.

4. Give good, thorough discharge instructions.

I left the hospital not understanding exactly what “bedrest” consisted of, and how much I could/could not do, and what would/would not increase my chances of doing well.  I think this was because no one really knows the right answer!  Still, not knowing was very tough for me at first, as I was scared stiff of re-aggravating the abruption.

I now try to be as clear as possible with my patients about what their instructions mean.  (What is “weight bearing as tolerated”?  When can they stop taking Motrin?  At what point should they return to the ED or their PCP?) … .This often involves rewriting or augmenting our computerized discharge instructions, of course.

5a. Acknowledge, and encourage, the use of social supports.

Being sick is scary.  And I wasn’t even physically sick – I was more worried about my fetus!  I can only imagine how difficult life must be for my patients with limited support systems, no money, and fear of losing their job if they stay out of work.  I know how tough it is for people to ask for help, but I encourage them to do so, for their own sake.

5b. Encourage the exploration of online support groups – Especially for chronic conditions, or diseases with little evidence base, the online community is a godsend.  For me, it was my only “good” source of information (although it was also a source of fear, if I didn’t triage sources well).  Heck, think of how important is for all of us!

 Before my abruption, I was already interested in the use of technology to support patient engagement and behavior change.  After two months of bedrest, I became an evangelist for “mhealth”…

Of course, I don’t think that I was non-empathetic at baseline.  I am, honestly, one of those people who always wants to be liked.  But now I try to listen more.  I try to ask what patients are scared of.  I try to reassure more, and to include patients’ families and social supports.  I try to give clearer indications of “if/then” and “what if” scenarios:  e.g. “I don’t think you’re having a stroke, but here are the things to come back for, and here is what I think is going on”.  I now try to explicitly acknowledge patients’ and families’ fear, and encourage my patients to turn that fear to good service:  to use it to increase their engagement with their families, the online patient community, and their own bodies. 

Most of all, I am now actively researching ways to use technology to facilitate patient engagement with their own health.  I don’t want this message to stop with me.

I welcome thoughts, comments, or partnership in so doing!

Emergencymom is an academic emergency physician and public health researcher on the East Coast.  She is proud mother of 2 (aged 4 & 1), and wife of a small-business-owner.  Her work-home balance is precarious, but generally enjoyable.  She still can't believe that she gets to do research for half her work-week!  She welcomes suggestions on how to get 4-year-olds to stop whining, how to have dinner cook itself, and how to not be perenially 1 hour shy of a good night's sleep.

Saturday, August 13, 2011

The 4 Stages of EMR Adaption

Stage 1: Naïve anticipation
Last summer, as we began the process of choosing which EMR (electronic medical records) system that we would buy, I was filled with my usual optimism. Despite the naysayers, I was sure that our efficient office would have no trouble adapting from paper charting to computer charting. Above all else, I was convinced that Moi, ‘Ms. Computer Savvy Blogger' would love EMR. In the months leading up to the transition, I began to look condescendingly at our cumbersome paper charts and our 3x5 card tracking system for abnormal labs, as I anticipated their retirement. They seemed quaint relics, like cassette tapes or Ms. Pac-man machines. I could hardly wait for the charts to be replaced by information at my finger tips and the promised fool proof tracking systems that would improve quality, while making my life easier. Though my partners voiced trepidation about what we were to endure, I had little doubt that we would be paper free in just a few months. It would take work and there might be a few hiccups along the way, but I knew that if we put in the time and effort, the transition would go smoothly.
Stage 2: Adaption Angst
We decided on Greenway, a system that was specifically marketed for OB/GYN. Training was scheduled for early November, with the plan to ‘GO LIVE’ the following week. Leading up to our training, I (as self appointed EMR point person) had several conference calls with our trainer. It was during these calls that the first inklings of doubt began to set in.
Every question I posed to our trainer was answered the same way, “Oh, yeah, that is SUPER easy, I’ll show you next week.” Her voice was high pitched and bubbly, like an excited Barbie doll. While I was naïve enough to think that the transition would go well, I was not an idiot. I knew that not every aspect of EMR would be, as she repeatedly intoned to me, “SUPER EASY!”
Training week did not flow well. While we all did manage to learn the basics of charting notes and navigation of the software, any question outside of basic charting was met with a blank stare from our Barbie doll trainer.
“How do we order labs?”
Blank stare.
“How do we track labs?”
Blank stare.
“How do we fax?”
Things weren’t quite so “super easy” anymore.
She abandoned us after a two weeks. That’s when the fun began.
Stage 3: Self Pity/Anger/Denial
While I did learn the EMR fairly quickly, my biggest disappointment came in the realization that it did not make my life any easier. On the contrary, it added at least an hour to my day. Everything just takes longer.
It took us several months to figure out the extremely cumbersome tracking system for labs. I began to look longingly at the 3x5 note card boxes that I had previously scorned. It takes me 14 clicks to sign off a lab, IF ITS NORMAL! While it used to take two seconds to make a quick signature, now it takes 14 clicks. My nurse also has several extra steps involved with routing documents back and forth. If there is an abnormal lab, I then have to open multiple documents to decipher the plan, task it to the correct staff and turn on all the tracking mechanisms.
Home has always been my sanctuary, unless I was on call. Now I find myself leaving work before my charting is completed, so I can attempt to be home for dinner. After the kids are asleep, I dial in to finish charting. Home is no longer a safe haven. I really hate the fact that I can ‘work from home.’
I began to relish the last few paper chart patients. When I would see a paper chart in the door, I would get that giddy excited feeling, like when a patient brings in hot fresh chocolate chip cookies for you at three o’clock on a Friday afternoon. I realized that it is so much easier for me to remember the patient details by leafing through a paper chart, rather than clicking on 17 different documents in the electronic file. Paper charts were nostalgic for me. I would flip through and see the handwriting of previous employees; coffee stains of the day I was running late and the smiley faces I would draw on the lab results when a patient’s cholesterol finally came down or their Chlamydia finally cleared up. Paper charts are full of physical, tangible memories in a way that an electronic file can never be.
I felt betrayed by Miss ‘Super Easy”. Yes, the actual charting was not difficult, but it was time consuming and the orders tracking system was cumbersome. Most importantly, I didn’t HAVE an extra hour in my day for charting.
And did I mention the FOURTEEN CLICKS?
Stage 4: Acceptance
Slowly, things have become slightly better. I will admit that being able to READ everything is very much a benefit (the computer gets bonus points for penmanship!). Also when on call, it is great to be able to pull up charts at home to review the patients history while talking to them. There is no more hunting down prenatal records when someone goes into labor on a weekend. As patients come back for return visits, it definitely gets easier. EMR still adds time to my already packed work day, but slowly I am figuring out how to make it work for me.
It was the following encounter that convinced me that I had to truly accept EMR and stop my grouching about it:
Last week I was seeing a young girl for a check up before she left for college. She was having issues with her birth control pill and wanted to switch.
This is the type of encounter that makes me hate EMR the most. While in the room with the patient, I have to attempt to look through her old chart which is in a zillion different saved files in her new electronic chart. So as I’m clicking on each file, attempting but failing to find the one that tells me which pill she was on before this one, I make some smarmy comment about how I hate my new computer.
“That’s Ok,” she says in a slightly patronizing voice,” My Grammy is a nurse, and she has a hard time learning computer stuff too!”
At this point my jaw literally dropped. It took every ounce of self control to maintain my composure at that moment.
Ummmmm did she just compare me to her GRAMMY? I am 36 years old!
After a few deep breaths I regained my composure, found the file I needed and sent her on her way with a new script. Sent by e-prescribe, of course.
From that day forward I have vowed to never complain about EMR again. Not even the fourteen clicks. No its not perfect, but it is here to stay.
Every time I get frustrated and want to complain, I just take a deep breath, smile and whisper the word, “Grammy.”