Marching and Madness

Statue covered in dozens of breasts
“I like how he responds to the media. I voted for him because of that. I hate the media…” she was watching video of the inauguration on her phone when I entered the room.

I moved to listen to her heart and then her lungs. 

“That sort of thing is how he won the election,” I murmured, careful to keep the judgement out of my voice. I quickly changed the subject back to her persistent nausea. 

My clinic is not the place for political debate. It is for healing.

At the end of the visit I picked up my computer from the counter across the room and caught his face leering back at me from the magazine rack again. I always moved him to the back of the stack but somehow, just like a bad penny, he kept turning up again at the front. How many pelvic exams had I done in this room with him looking on? I have tried to remain neutral publicly but I just could not take it anymore. I snatched up the magazine and threw it into the biohazard bin while the patient walked out of the exam room.

I wish he would shut up.

Does he even hear himself? The things he says? How he appears to others through his tweets?

“Watched protests yesterday but was under the impression that we just had an election! Why didn’t these people vote?” Donald Trump

I imagine there were women out there marching who did vote for him. That does not mean that they cannot stand up and protest. That march was not just about Donald Trump, even if he wanted to think it was.

I did not march yesterday but oh how I wish I had. Do I agree with everything the Women’s March was said to represent? Maybe. Maybe not. But I do stand as a woman who is more than a pussy, a woman who believes she deserves more respect and equal pay and better rights. A woman who believes that people have the right to kindness, love, safety, and respect regardless of religion, gender, sexual orientation, skin color, or country of origin.

This was how he should have responded from the first instead of as an after thought:

“Peaceful protests are a hallmark of our democracy. Even if I don’t always agree, I recognize the rights of people to express their views.” Donald Trump

Yes. That.

So I say this:

Unite us. Stop dividing and provoking. Be someone we can respect, even if we do not agree with you. 

Act like a president.

The Cost of Protection

Carved flowers on a Victorian tombstone.
There have been several times over my career that I have had to step in to protect a patient from their family. Each and every time it gets nasty. It takes a certain kind of person to abuse their child or to molest a mentally challenged adult or neglect an elderly person to the point they have maggots in their wounds. Those kinds of people fight and they fight dirty.

I marvel at how some attorneys can look at the facts of a situation and defend it by attacking and terrorizing the physician who had to make the call. It is exhausting and terrifying and can leave you questioning yourself and your judgement throughout the process:

Surprise subpoenas summoning you to appear in court in 60 minutes, requiring you to cancel all of your afternoon clinic appointments at the last minute.

Threats of lawsuits.

Antagonist depositions. 

Lies and accusations made publically.  

Nothing in medical school prepares you for this sort of thing. Physicians have malpractice insurance but this is not malpractice. There is no one to walk you through it unless you hire your own expensive attorney.

Eventually you are vindicated but not before your life is made a holy living hell. It takes a toll on your family and friends as well, as you cannot discuss it with anyone else. The process can drag on for months or even years.

You are isolated and alone.

Fortunately, all of my experiences have been before social media. I have seen, of late, some unbelievably ugly online attacks made on physicians who are only doing their duty and trying to protect the vulnerable. It appalls me how quick the rest of the world is to jump onto the hate the doctor bandwagon when they do not know the whole story. Physicians are not allowed to defend themselves due to privacy laws. The rest of the world will never know the whole story.

What some people seem to forget is that our role as physicians is to assess the situation and make a recommendation. We are required by law to report suspected abuse. We are not omniscient super humans and maybe we don’t always get it right. All we can do is our best. In the end is up to the courts to decide guilt or innocence. 

The price we pay to do so is often very, very high….

Founders Keepers

There is a term in population genetics called the founder’s effect and I have caught myself thinking about it a lot lately.

Basically, in a founder’s effect a small subset of a population is isolated from the larger population. For instance, maybe seven people went on a three hour boat tour but instead ended up stranded on a deserted island. The Professor and Mary Ann mate and reproduce, as people are wont to do, and several generations later the resulting population on that island looks very different from the larger population that it originated from. There is a loss of genetic variation and certain traits get reproduced at a greater rate than you would find elsewhere. Sometimes this is benign, like with a greater proportion of blue eyes or brown hair. Sometimes it is bad, like when you have a higher predisposition to develop colon cancer or maybe a higher rate of growing an extra leg out of your backside…

EPIC is one of the largest electronic health record in the US. It is highly customizable. Therein lies its power AND its weakness.

Keep in mind that I have only a small part of the picture and I am making certain assumptions, but here is what I have gathered:

When a healthcare system decides to go with EPIC there is a build out, or personalization, that occurs. The EHR that I see is very different from the one used by a physician in another healthcare system across town or in one across the country even though they are all called EPIC. 

From that initial build out, there are changes made as the product is tweaked. For instance, when we went live, we had to enter our password to log in but then had to enter it again with each and every note we signed, every single order we placed. Hundreds of times a day I was typing in my password. Now? I only type it in to log on. Good thing, too, as I was at risk of destroying expensive equipment.

I have staff in my clinic who have worked for three other major hospital systems in the area who also use EPIC. What they describe is much, much easier to use than what we have currently. In fact, they regularly threaten to leave and go back to those other organizations so they can feel at peace again.

How does that happen? 

How do they have such different products? 

Because they are all starting with a basic product. It is thrown out onto a deserted island with a few people making decisions and then everyone waits to see what you get down the road. 

The founder’s effect.

No one from the other hospital systems is sharing what works for them from what I can tell. There is no collaboration. So each one has parts that work well and other areas not so much. Why can’t we help each other?

THEN you have smaller islands. We are a small clinic in a huge system. We did not get support staff who came out to help us after going live until the following week and then only for two days. The bigger clinics? They had trainers there on day one. Some clinics never got anyone. Training classes done before had very little to do with the reality of the EPIC we were presented with on day one. So we have muddled through figuring out our own work arounds. Some good. Some bad. We need an infusion of fresh genetic material to correct our problems. 

That only works well when you have someone visiting your island to add to your gene pool and that only works if that person is genetically diverse themselves. Getting people to leave their islands is difficult. Distance to travel, time constraints, don’t know how to swim, etc… 

So we get this perpetuation of problems and errors… fractured systems. It has been really interesting to watch from my vantage point at the bottom, looking up. I wonder what this will look like in six months.

Wavering

Boy making ripples in water of pond with a stick

Last week a physician shadowed me to see if there is anything I or my staff can do differently with my work flow with this new EHR. I was looking forward to having a forum to vent my complaints with the system and hopefully to have a way to fix it but nervous at the same time, not knowing what to expect, worried that they would have suggestions that would make me look a fool.

The physician who happened to come was one that had a hand in writing some of the new EHR templates. I was so disappointed in those templates that between you and me I actually cried in frustration in the first few weeks of our changeover. How could we be expected to do what we needed to do when these were the tools we were given to do it with? I told him that I did not like the templates, that I thought they S-U-C-K-E-D. 

Yes, I used the word sucked and I cringe even now at the recollection. With that one word I dismissed all of the considerable time and effort he had poured into those templates. 

Have you ever been so frustrated and nervous that unreasonable things just flow out of your mouth? 

Of course you have. 

Ever been on the receiving end of someone else’s frustration, as they vented like that? 

Sure you have…

At times, when I feel passionately about something, my filter just ups and disappears. After listening to him tell me that I should hire a staff member to approve or reject all of my refills instead of doing it myself, after having him say that my desire to take and enter my own past medical and surgical histories was a waste of time, after being lectured that writing a narrative history of present illness was silly that I should be clicking buttons instead… I was no longer really hearing his words to me or my own responses back to him. 

But I LIKE doing those things! Interacting with my patients is what makes medicine fun and rewarding for me.

It was not until days later that a realization hit me. He believes this stuff just as passionately as I believe that he is wrong. My response was not just unprofessional, it was mean. I try to have compassion and respect for all of my patients, even the difficult ones, but where was my compassion for him?

You need to be flexible. Medicine isn’t what it used to be. You have to adapt.

I don’t want him to be right. 

I hate that he might be right. 

And so I have spent this past week after reading his write up of our interaction licking my wounds, pondering the next step. What do I do from here?

The first thing, I believe, is to apologize. I don’t know that it will matter to him, but I need to apologize for me. I don’t want to be *that* person, the one who believes their rude behavior is justified.

And then? What then?

There is the question. 

Menorrhagia

Light in Boston art museum

She was new to me.

She was mentally challenged although I will admit that I don’t even know what the right PC word is anymore. Clinically I have tons of appropriate labels but speaking to all of you, I don’t know what term to use that will guarantee that I do not offend someone. 

On top of that, she had developed dementia. 

Her sister spent her entire life as her personal caretaker… never married, never had children. Out of her several siblings, she was the one who stepped up to the plate. She genuinely cared. She had watched countless times as the medical community wrote off her sister. She had watched the untold emotional and physical suffering and she felt the unfairness acutely. 

One of the toughest things to deal with in this population is menstrual problems. Periods by themselves are bad enough when you understand them. Imagine trying to deal with your period when #1 you don’t know why you are bleeding from between your legs and #2 that bleeding is irregular and excessive. 

As a physician, working up menstrual problems is especially hard when you have a grown person who is willing to slug you, who screams and cries and is so terribly, awfully afraid of what you are going to do to her. I don’t believe tying someone down, forcing myself upon them, should be necessary. That sort of thing only exacerbates and perpetuates fear but it took us 45 minutes just to draw her blood. I held her hand. Her sister held her other hand. Two other staff members worked together to do the draw. No one got hurt, most especially the patient, but it took us 45 minutes to get her calm enough to endure four sticks to find a good vein.

In fact, it had been years since anyone had even tried to draw her blood because of how much of a challenge it was. Still, it had to be done. And we did it. But for the rest of the day I was running 45 minutes late. I could not catch up to save my life. 

I cannot go in to each patient afterwards and explain what happened. Patient privacy. Takes too long. Etc. etc. etc. But to all of those patients who graciously accepted my ambiguous apology, thank you. Thank you for not slamming me on patient satisfaction scores. Thank you for giving me the freedom to take care of this one person who really needed me.

You made a difference. 

You helped save a life. 

You are all my heroes and I am lucky to have you as patients.

Wavelengths 

Tiffany stained glass window at Chicago Navy Pier

My microwave died and went to appliance heaven. 

Well. More like fell apart. 

The door plastic started cracking and then the tempered glass front exploded all over the kitchen one evening as I was about to heat up water for tea. Freaked the kids out. Personally, I thought it was super cool. Did you know tempered glass can still pop and explode even as the pieces are lying on the floor? 

It might seem like a simple thing to fix, right? Just order a new door. Except they no longer make this model of microwave. There is no door replacement. We will need to replace the whole dang unit.

However, this is not a microwave that sits on the countertop. Oh, no. It is mounted under a cabinet over the stove/oven and also serves as the stovetop ventilation unit. Apparently, it is also hard wired in, meaning there is no plug to unplug. Getting someone to take this out and install a new one when it is hardwired in is no small feat as it turns out. 

So, for a number of weeks I have been forced to go without a microwave. 

And you know what? It has not been the end of the world. 

In fact, I have found that I prefer heating things up in my toaster oven. Reheated bacon is crispier. Pizza is heated evenly. Corn dogs are yummier. Left over scones taste like the first day they were made. Tea? There is something nice about a whistling tea kettle as opposed to a microwave ding and I swear the tea actually tastes better steeped in water from my kettle. 

The other thing I have found? The couple of extra minutes it takes to use those other methods? They don’t really make a difference in my life. Schedules have not come crumbling down. We have not run late, we haven’t had to make cuts elsewhere. 

Never would I ever have believed I would ever say this: I can live just fine without a microwave. Not only can I live without a microwave, I now choose not to have one. 

That is incredibly liberating.

Makes me wonder what else I can live without…

Show Off

My son finished his piano solo at the Christmas program. Oh Little Town of Bethleham. He played every note perfectly. I was so dang proud of him! I stopped the video I was taking with my smartphone so I could clap like a crazy woman. I *might* have even shouted, “You are so frickin’ awesome!” 

All of the other kids took a bow or curtsied while the audience clapped politely. My son? He paused right there at center stage, a slow grin spreading across his face. And then? 

He dabbed. 

Yes, the boy dabbed. In the middle of the church auditorium in front of hundreds of people, he dabbed. Dabbing, the weird dance move that appears as if you are sneezing at the same time as you are trying to fly off like a super hero.

People laughed. They screamed. They cried. Some whistled. One woman fainted. Strangers were giving him high fives and knuckles as he sauntered back to his seat. Every single boy that followed after him on stage also dabbed at the end of their performance.

And so I was left wondering how on earth did I end up with a cool kid? I was never that cool. I was so square I couldn’t even dream of being that cool. I am still terribly uncool, even in adulthood. Especially in adulthood….

Behind The Scenes

Gnomes in Switzerland

WordPress reminded me yesterday that I have been blogging for three years. Three whole frickin’ years. 

How the HELL did that happen, anyway?

I thought it might be fun to talk about the reality of what three years actually means here at Behind the White Coat:

5,060-ish people “follow” this blog as of this writing. When I wake up tomorrow it might be a few more or a few less. This number is meaningless, though, trust me. 

I average about 300 hits on my blog per day. That’s right. Sometimes less, like when I don’t post for a few days, and sometimes more. WordPress has changed how it calculates hits so many times that I don’t really know what that means anymore. I might get more traffic if I were on Facebook or Twitter or other social media platforms but honestly, I just don’t have that kind of energy. 

This post will be #865. That is a whole helluva lot of hot air. Some of it I am proud of. Some is painfully, woefully laughable. Some just flat out sucks. I have bared much of my soul here. Bless all of you who have taken the time to read anything I post. I appreciate all of you more than you could know.

Each day I spend between 2-3 hours reading other blogs and answering comments. Over three years that is an awful lot of time. Fortunately I don’t have any other serious hobbies right now. Anyone who tells you blogging is easy is either lying to you or selling something like SEO whatama-ever-thingamajigs (I have no idea what that really means, anyway, do you?).

I was Freshly Pressed in 2015 and featured on Discover WordPress in 2016. Those were huge honors but I found that they made me nervous. I don’t really want to become famous after all. That surprised me. When I started blogging I had delusions of grandeur. I was gonna be the biggest thing since KevinMD. Ha! Not my goal anymore. What is my goal? Having fun, making connections, and learning something new.

For 2016 I had a total of 112,879 page views and 27,416 visitors. The most viewed post was Black and White and Blurry All Over but not because it was some amazing piece of writing. It just happened to go up the day I was featured on Discover WordPress purely by accident. I got lots of hateful comments left by plenty of scary people on that one. 

Which brings me to the fact that I have had my fair share of trolls. The really psycho ones can be pretty scary until you figure them out…. They all have the same agenda, though, no matter who they are. It is best to just ignore that they even exist. 

In truth, I follow 1, 957 blogs. Only a small fraction of those still actually do any posting. This makes me sad. We have lost some fantastic bloggers over the years. Some left due to time constraints, intimidation, boredom… death. I hate to unfollow anyone, afraid I’ll miss their comeback post someday. 

Me, though? 

I’m not going anywhere anytime soon….