Lucille

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Sitting on the couch late at night, as the smell of phenol sought escape from my pores, I slammed the damn Netter Atlas shut.

Done. I was done.

My brain could take no more. The exam the next day had already been passed or failed. Any further cramming I attempted to do was not likely to be of benefit.

Still, I knew sleep would not come.

I grabbed the remote. A joke, really, as my apartment was so tiny I could sit on the couch and prop my feet up on the TV table on the far wall.

The screen flickered then glowed.

“Call the psychic network, now! Only $9.95 for five minutes. Plus $1.99 for each additional minute.”

I laughed to myself. All of those suckers out there…

But wait.

I could call. Find out how I would do tomorrow. Maybe then I could sleep. That wouldn’t take long. Five minutes, max.

My purse sat mocking me from the end of the worn pea green sofa. My credit card was nestled safely inside. The cordless phone was on the table by the TV.

A dial tone.

“Hellooooo…..”

“Hold please as I connect you to Madame Larkin.”

Pleasant hold music.

“Good evening, I am Madame Larkin.” The voice was airy, like she had been smoking something illegal. I cringed, embarrassed at myself. “What can I help you with?” Oh, well. My five dollars was spent even if I hung up now. I was going to get my money’s worth. I sat my watch in front of me, watching the time.

“Perhaps you can tell me?” I sniggered.

Silence.

More silence.

The woman was trying to drag this out to maximize her charge!

Just as I was about to hang up, her voice returned. This time it was commanding.

“I see 4-5 people dressed in white pajamas hovering around a young woman. Lots of cold metal. I see a blade. A knife perhaps? But she is already dead.”

What?!!!!

My cadaver, Lucille, is young. We wear our white coats, scrubs. My heart is beating a bit faster as I realize that I am leaning forward in my seat.

“Do you say this to everybody?”

“No. The woman told me. She says her name is not Lucille.”

“What?”

“Her name is not Lucille. It’s Amy.”

“I see paintings.”

The medical school was in the arts district, surrounded by two world class art museums. Was she tracing my number? Doing a google search for my name? How would she know the name we gave the cadaver? My tank mates and I were the only ones who knew that!

“How did she die?” It was a detail she could not possible know. Hell, I didn’t even know.

Silence.

“Look, lady. How did she die?”

“Car accident.”

I hung up on her, relieved. Car accident was not possible. Too much trauma. No good for dissection.

My eyelids felt heavy.

I slept with the lights on.

The next day, after the exam, I told a classmate about my exchange with the psychic. Someone I could trust to not blab about the whole humiliating experience. She agreed the story was terribly strange, but her curiosity was piqued. It took quite a lot of cajoling to get me to agree to relate it all to someone who could vouch for the veracity of the “psychic”.

We found the head of the anatomy department, an old chubby fellow with a stringy comb over, and told him the story. He laughed it off, which made me feel better.

The next day, as my team was standing around the huge silver tank, staring a Lucille, I realized I could not cut. It was my day, my turn in the rotation. I couldn’t do it.

“Someone else is going to have to take the knife!” No one moved. “Please, people?”

In a few seconds the professor was standing at the door to the lab, trying to catch my eye. He motioned me into the hallway. He seemed genuinely excited.

“We don’t get names, only initials. So I cross referenced female bodies with the first initial ‘A’ and age between 20-40 who had trauma listed as cause of death. There is only one here, your cadaver.”

Oh, God. I am haunted. I will have a cadaver haunting me for the rest of my life now! I searched my memories, frantically making sure I had not done anything remotely disrespectful. Nothing. Except cut her! Oh, God!

“Have you had this sort of thing happen before? What do I do?”

His unhelpful shrug only made me feel worse.

First Day Of School

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“Curiosity is the very basis of education and if you tell me that curiosity killed the cat, I say only the cat died nobly.” – Arnold Edinborough

Today was the first day of “real” school for my son. He has gone to “school” in the form of daycare for some time now, so it was a bit anticlimactic for him except that he got to have a brand new Ninja Turtle backpack and a snazzy uniform.

Mind you, the child has only seen about a 2 minute clip of a Ninja Turtle episode in his life, but by golly he can rattle off the names Leonardo, Donatello, Raphael, and Michelangelo with an almost spiritual reverence. I thought I could use that to introduce him to the artwork of these masters. Not such a good idea as it turns out, FYI.

Truthfully, this first day was a bit anticlimactic for me, too, except to say that I miss my little guy. He is growing up so fast!

“Mommy, don’t be sad. I want to grow up!”

Well, $@(/:^<^~%|€<$.

Each day is about letting go a little more, until one day they are gone. Poof! They no longer need you.

Part Two: What is Wrong With Healthcare in the US? A Physician Perspective

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The pharmaceutical industry makes me feel like a dirty, cheap whore.

Why?

Read this fantastic article by the New York Times “The Soaring Cost of a Simple Breath” and then come back so we can continue our discussion.

Then read this article by the LA Times “When a Drug Costs Thirty Times What it Once Did”.

So when the Barbie and Ken types show up at my office to push their drugs, it makes me terribly frustrated. Many of them truly do not understand why. The plight of the average patient does not matter since it is just a paycheck.

Having to endure getting detailed (listening to drug reps try to explain why their drug is so much better than everyone else’s) so that I can receive free drugs to “help” my patients feels like prostitution.

You know what would help my patients? Affordable prescription drugs.

The industry argues that profit drives innovation. Sure. I get that. But how much profit is enough? And why does the US have to pay the price when the rest of the world does not?

Because we allow it.

So if you come to my office, you will see that drug reps are not allowed in the back to disrupt clinic flow. I will sign your pad only. Don’t talk to me. I don’t talk to them at lunches. I do not attend their dinners. I will write cheap generic prescriptions first whenever possible. If you are on a brand name medication that I have samples of, I will fill up a grocery sack of freebies so you don’t have to pay.

Because the pharmaceutical company pimps don’t have me yet.

Part One: What is Wrong With Healthcare in the US? A Physician Perspective

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First issue is electronic health records. Worse than insurance companies, this is the main thing that causes frustration, wastes time, and sucks the life out of me.

I have yet to meet a physician who actually likes their EHR. I am not sure why that is except that they virtually all suck.

Ten years ago I used a program called Epic. It was pretty awesome back then. I have no idea what it is like now. Currently, I use Centricity. Epic ten years ago was light years ahead of Centricity now, which should be embarrassing to GE. I really don’t think they care, though.

In the process of job interviewing I have played around with a couple of other programs: EClinicalWorks and NextGen. NextGen is way behind Centricity. Awful. I didn’t think that was possible.

Anyway, here are the top things I need from an EHR:

1. Fewer clicks to get the job done. I don’t know who the hell develops these programs, but they are not using them every day to see tons of patients, I can promise you. It takes me over 200 clicks to navigate a well child visit. Sometimes very common actions are buried in 2 or three layers of clicks. Makes me want to pull my hair out. I could shave 30 minutes off my day, easily.

2. Order time outs. If I order a test and a result does not come back in a week, I should get a notice that it was not completed. This is a safety issue but very few EHR’s think it is important enough to include. I had an IT guy say this sort of thing was not available anywhere. Wrong. Epic had this capability ten years ago. (You other people are robbing physicians and patients of a very powerful tool!)

3. Patient instruction handouts that are brief and to the point. I need a section at the top to free text my instructions. An active medication list. Discontinued medication list. New and changed medications (and which pharmacy they were sent to). Preventive care info (like when the last tetanus booster and mammogram were done). Vital signs from today’s visit. Date of next appointment. Cram this all onto two pages otherwise patients won’t read it. Our last update took the average length of the patient instructions from 3 pages to about 15. What the hell? Who has time to read that kind of crap? Granted, part of this was because of “Meaningful Use” mandates from the government, but that deserves its own special post…

4. A patient portal that meshes well with the EHR. A portal is where patients can get their lab results, copies of imaging reports, send messages to their doctor, etc. Ours goes to a completely different, isolated section of the EHR and is a pain in the butt to use. I cringe when a patient sends a note because it is a ton of work. In fairness, not all portals mesh as badly as Centricity’s does. Really, ideally, the interface would be seamless.

4. A stable system. No crashes. No ghosts or flukes in the system. It is terribly disruptive in the middle of a busy clinic to have to sit on the phone with the help desk for 20-30 minutes only to be told, “It is a known problem and we can’t fix it. We have engaged the vendor for a solution.” That is IT lingo for, “Suck it!” And I do. Because it rarely ever gets fixed.

5. Good grammar. So many of the visit templates that have you click symptoms or exam components put them together using gibberish or terrible sentence structure. “No masses and enlarged prostate.” It should say, “Enlarge prostate, no masses.” Missing punctuation. Stilted syntax. If I really spoke or wrote this way my clinical skills should rightfully be questioned. This infuriates me. I do not pretend to be a master of the English language but there are some basic tenants that should not be ignored.

6. The ability to free text at will. I like for my notes to tell a story. One program does not allow much free texting in the history of present illness section for example. Instead of being able to say, “The patient was riding her horse when she happened upon a paper towel that startled the animal. She was subsequently thrown to the ground and trampled repeatedly.” I would have to say, “The pain in the chest and arms and legs and back and head started on 2 hours ago. The quality is sharp. The severity is 10/10. The duration is constant.” This tells you nothing about the horse or the nature of the accident which is an important detail as it helps to indicate this is likely a serious injury, not to mention the grammar issues (see #5).

7. An easy way to see which preventive care items are due. I want a page that shows me what the last blood work was for a diabetic, when the last eye exam occurred, and if the numbers are all at goal. I want to be able to look further down the list to see when your last PAP was done and if you are due for your shingles vaccine. I do not have time to go searching through the entire frickin’ medical record to find each and every one of these things each office visit.

Bottom line: I want all of these things in ONE package. One program. Not 2 or 3 items. ALL of them.

Why can’t I have this? Physicians are pretty unanimous about what they want. Why can’t a single EHR deliver?

This is my theory:

Early on, groups made decisions about electronic health records based on cost, not quality, thinking incorrectly that they would get to help improve the system. Yet once they were a year or two down the road into an EHR and realized it was awful, it was too late. Switching means the potential of quite a lot of lost data, TONS of work preloading charts. Plus the frustration of learning an entirely new system. Once a company has you by the balls, they know they do not have to provide quality enhancements. All they have to do is make a passable attempt to try to “improve”. Then they can just kick back and reap the rewards in the form of big fat checks.

It is blackmail, essentially.

We let them get away with it, though, so we are all willing accomplices.

I am sick and tired of hearing at interviews, “Well, there is no perfect EHR.” Look we have smart phone apps that do anything imaginable, virtual reality games that are crazy realistic, and we have 3D printers for crying out loud! You cannot tell me that there is no one out there smart enough to make an EHR that is good, that is something to be proud of, that can save the lives of patients and doctors and nurses and ancillary staff.

If you are that person, I will be happy to help you!!! Meanwhile, if you are reading this and really do love your EHR, I would to hear which one you are using and why you like it so much!

Fountain

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“The hardest of all is learning to be a well of affection, and not a fountain; to show them we love them not when we feel like it, but when they do.” – Nan Fairbrother

This quote gave me pause. Thoughts?

The Bad Queen

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“Take down! They are putting someone in the tank! Come on!”

The nurse sprinted past me as Mickey and Minnie Mouse danced across her pink scrubs. A syringe was in her hand.

I could hear the commotion, but I did not want to see it. Not again.

Out here in the holding area I had watched what had taken place. The staff member sitting on the table, feet resting on the chair in front of her as if holding court. She had pushed buttons, egged on, taunted even… waiting for the explosion.

It was a game of sorts. Toying with “the crazies”. Like anyone was going to believe that it was not their fault.

I found myself standing outside the tank anyway. How did I get here?

The patient, or do they call them clients now, was fighting valiantly, screaming and kicking and clawing. Eventually she was pinned down and the “cocktail” was administered.

In a few minutes she was resting peacefully on the mattress in the bare room, arms and legs restrained by tan colored straps.

Staring at her through the little plexiglass window pane in the door, I could see that her midriff was showing. Dark hair was a tangled mess partially covering her face. No one had bothered to straighten her clothes.

Behind me, I could hear the high fives, celebrating another successful take down.

This scene repeated itself on an almost nightly basis in the psychiatric ER. Fragile people, brought here against their will, broken further by the system.

The next morning as we were giving check out, I was presenting this patient. She was mine. I had interviewed her initially. She was still sleeping off the drugs in the tank so I could not do a follow up interview yet.

I told the resident that it was not her fault, that she was provoked. He just stared at me for a few seconds, opened his mouth as if to say something, then closed it again.

“Next patient?”

It was my last day on psych rotation. I was a student doctor. I walked away.

Sightless

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“She killed three out of her four children by gouging their eyes out and then stabbing them in the chest.”

I stood watching her from across the room, my mind trying to wrap itself around this new fact. She had seemed so normal, pleasant. I had enjoyed talking to her every day.

“Why?” I asked.

“Why?” My attending stared back at me, puzzled.

“Why did she do it?”

He shrugged. “She said their eyes had glowed red so they were possed by Satan. She had to rid the world of them.”

My heart stopped. I wondered silently if it had been the red reflex that had been the basis for her observation; the thing that makes eyes glow red in photographs taken with a flash, the thing I am looking for when I shine a light into an infant’s eyes, the thing that tells me that they do not have a retinoblastoma tumor.

“What happened to the forth child?”

“She is blind…”

How can you listen to your child’s tortured screams, hold a bloody eyeball in your hand, and not question what you are doing?

I watched as she filed over to take her medications. She had been diagnosed as a paranoid schizophrenic. She waved happily at me. I waved back, afraid not to smile. I would have to talk to her in a few minutes, keeping up the appearance of normalcy.

“She has two more weeks here, then she is going to be released.” I was doing an elective rotation in forensic psychiatry at the state hospital.

I genuinely liked this woman. At least I had. I took that emotion out (like) and turned it over in my hand to examine it more closely. I didn’t want to stop liking her.

But if I had known this to start, I would not have given her a chance.

What bothered me most, aside from the fact that she should never be released in the first place, was that it was impossible to tell what this woman was capable of just meeting her on the street. How could society protect itself?

And if she can appear so normal, how many other “normal” people do I know that are capable of this? Maybe more than anyone cares to admit.

What makes me different from her? Am I different?

She is going to be released…

Getting My Feet Wet

Warning: What follows is a fairly gruesome presentation of a medical school experience. Worse, I think, than gross anatomy. You have been warned…

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“We were told this fellow ate dinner with his family, then went upstairs and shot himself in the head.”

The woman in pink scrubs was covered with a black plastic apron, blue knee high elasticized plastic booties, black gloves, a mask with face guard, and white bouffant surgical cap.

“One of my jobs is to make sure the story really happened the way we were told. So let’s check out the stomach contents.”

She lifted up the organ from the abdominal cavity and slit it open with a flourish for effect. Undigested spaghetti spilled forth onto the metal table with a splat and splatter.

“Well, it would appear that he did indeed eat.” Using a sprayer on the end of a hose, she swept the bits of pasta down the table where it disappeared.

It had resembled a tangled mass of mealworms.

Five of my fellow students were here with me at the medical examiner’s office, watching this autopsy. We were dressed similarly, surreptitiously gauging each other’s reactions through our masks and face shields. The fellow on the slab before us was missing the top half of his head and face. Bits of jagged flesh and bone peaked out here and there. There did not appear to be any bits of brain left.

I stared at the spaghetti as it disappeared, thinking that he could not have enjoyed it. To have been upset enough to put a gun into his mouth, any food he had tried to eat would have been tasteless at best. I could feel the lump in his throat that he would have had to swallow around, the feeling of food stuck in his chest.

I wondered why he had bothered to eat anything at all? Was it his favorite meal, intended to be his last? Was he trying to keep up pretenses?

Would he have used the gun if he had known his naked body would be dissected under the watchful eye of a room full of students, all of his secrets laid bare before us? Was he somewhere in this room, unseen, watching these proceedings as his organs were removed one by one, weighed and catalogued?

Then the smell of the stale spaghetti wafted its way across the room to me, triggering a memory.

I had eaten spaghetti myself the night before.

My stomach knotted. I could feel sweat beading up on my forehead. I bit hard on my tongue to focus my attention elsewhere until it passed.

The medical examiner was chatting, nonchalant as she deftly sewed up the Y incision with thick, black suture. Did I even hear what she said? It did not register. Something about plans for the weekend, a joke about spaghetti…

I filed out of the room with the others, shedding booties and aprons and masks as we went.

Pathology would not be my specialty. Ever. I did not want to become numb to this. But I could not begrudge this woman her coping mechanism, either. This was how she stayed human, doing a job day after day that was horrifying but necessary.