Pantyhose As Icebreaker

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A number of years ago, back when I covered the hospital in addition to my out patient clinic, I was up before the butt crack of dawn seeing the ICU patients I had admitted on unassigned call after a particularly awful call night.

I wrapped up things in the unit (thankfully everyone had survived) and started down the hall to the radiology department to try to sweet talk the evil night radiologist into reviewing an abdominal CT scan with me.

About halfway there, I got the feeling that something odd was happening down by my left foot.

I kept going for a few more steps (truthfully my brain was still quite sleepy and was operating on autopilot) but eventually I glanced down. Nothing wrong that I could see. I gave the leg a little shake.

Nothing.

I went on for a few more steps but I could not shake the feeling that something odd was happening down around my feet. Finally, I looked down again and found a pair of my flesh colored pantyhose trailing about three feet behind me, snaking out from my pants leg.

Left overs from the laundry.

Damn static cling.

I looked up to find the night radiologist, an older fellow, standing dumbstruck in front of me. There was a cup of coffee from the cafeteria in his hand. Hurriedly I looked around to see who else had caught a glimpse of my skivvies. Otherwise, the hallway was empty. I quickly scooped up the offending item, wadded it up and threw it into my big red leather bag.

“Let’s pretend you didn’t see that, shall we?”

He nodded, still frozen in place.

I decided the CT scan could wait.

“Well. Carry on, then!” I smiled sweetly at him and headed to the elevators.

After that, I stopped wearing pantyhose.

Interestingly, the radiologist fellow stopped being such a crotchety old fool to me and we got on famously thereafter.

Sometimes people like to see you embarrass yourself. Is it that it makes you seem more human? More approachable? Does it give them the feeling of the upper hand because they have not been caught with their own pantyhose trailing from behind their own leg? Some people just need that, apparently. I wish it worked on everyone who was difficult to work with!

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My Favorite Number

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“Mommy, one is my favorite number. You know why? Because there is only one of ME!”

My son got his first real week of assignments back.

Pre-K!

He got check minuses for not coloring perfectly within the lines. And check minuses for not writing his letters perfectly. And a check minus for insisting on writing his name backwards all the time.

This is his first year in a formal school setting. He has not really practiced writing his letters extensively to this point. They are legible. But after three attempts he is not going to have perfect form drawing a B.

I love my kid. I think he is terribly smart.

So I am struggling with check minuses for my perfect boy. The baby that I did not even know that I wanted.

Part of me wants to make him spend the long Labor Day weekend practicing letters and coloring in the lines until he gets it right. I have to remind myself that he is FOUR and it is not necessary to have perfection at this point in his life.

Still. I want everyone else to see and appreciate the perfection I see in him.

It makes me sad that he will be judged from now on based on someone else’s ideals. This is why I grieve for him. Not because of school itself but rather because it is an allegory for the unfairness of life that will be foisted upon him and because I, like all mothers, will be defenseless to protect him in the end.

A Decent Egg… Scrambled or Fried?

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“It may be hard for an egg to turn into a bird: it would be a jolly sight harder for it to learn to fly while remaining an egg. We are like eggs at present. And you cannot go on indefinitely being just an ordinary, decent egg. We must be hatched or go bad.” – C. S. Lewis

On days when I am just overwhelmed and not able to keep up I use quotes to bridge the gap between meatier posts.

Today, you get both!

It started with my first patient this morning wanting me to offer a second opinion on his work up with a neurologist for neuropathy. I had no records. And oh by the way, I have this massive abscess on my chest wall that needs to be drained…

My second patient had a massive burn on his leg from the tailpipe of his motorcycle after an accident. And oh by the way my other ankle is hurting really bad and the ER did not do an xray… Turns out he did have a rather nice fracture and we had to locate an orthopedist that could see him today.

My third patient was a brand new patient just discharged from the hospital after her fifth stroke. Doc, no one is telling me why I keep having these… Turns out she has had years of poorly controlled diabetes, high cholesterol, and blood pressure issues that I had to wade through in addition to getting her set up for speech therapy, occupational therapy, and physical therapy. The proverbial train wreck. Then I had to discuss the fact that her strokes are probably going to keep happening.

My fourth patient… Aw hell. It only got worse from there.

By then I was running over an hour behind. You just can’t recover from that. The whole rest of the day was shot. And it was not like I could hurry through or skip any of these issues for these patients. Fortunately, I have very understanding patients who were kind about having to wait. Maybe they were spewing venom on Facebook, tagged in my waiting room, but at least they were kind to me and to my staff. I am grateful for that.

Multiple emails about administrative things had to be exchanged. Phone calls made. Staff moral boosted.

I did not get to pee all day. Or eat. Or breathe.

Then, I rushed from clinic to pick the kids up in the nick of time and headed home. We ate. We did Pre-K homework.

Wait! Pre-K has homework?!?!!

Bed. Bed still feels a very long way away.

So what does C. S. Lewis have to do with all of this? Not a damn thing except that this quote struck me square on the forehead when I saw it.

Change.

Am I that decent egg at risk of going bad?

Waging War

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“That was a plane that was used to kill a bunch of Japanese…” The docent paused proudly before the aircraft for effect.

My son tightened his grip on my hand. He stared up wide eyed at the machine guns poking through the canopy.

“Mommy. What’s a Japanese?”

We had come to the vintage aircraft museum because aside from frogs and lizards and ninjas and Star Wars, the thing that kid loves more than anything else is airplanes.

Up to this point though, we had not talked about how some airplanes are used to kill people.

Now, I am struggling with what to tell my son about war. Past and present and future.

Adventures At The Pet Store

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My son caught a little, tiny frog the other day. He stored it in a small mason jar for days. No food. What do you feed a tiny frog? Ants? So I told my son that he had to let it go. It was the humane thing to do. I figured it would be a good life lesson.

The poor kid cried for an hour straight, wracked with sobs, mourning his frog. He was hoarse from the wailing.

So to make it up to him, I told him he would get to pick out a “real” pet at the pet store the next day.

“Just NO dogs or cats. Got it?”

He nodded solemnly. “Got it.”

This morning he bounded into my room, hopped onto the bed, and yelled “Mommy, it’s PET day!!!” Huge smile…

So I took the kids to the pet store.

My son fell in love with a small lizard.

My daughter fell in love with a Miss Piggy dog costume and put it on her head.

“Your daughter has such beautiful hair, all golden and curly!” said the older strange woman as she passed down the aisle. “Thank you…” I said after her.

It wasn’t my daughter’s hair. It was Miss Piggy’s hair.

At any rate, the lizard’s price tag said $7.60. I breathed a sigh of relief. This is gonna be great!

Then, I was informed of everything I needed for the “habitat”.

$230 later… A dog would have been cheaper.

I should have just let him keep that dang frog!

Fine. Whatever. I did make a promise. Stupid me.

So then, at the checkout, who showed up behind me? A patient! She began talking with me, showing me her grandson.

My son, meanwhile, was so proud of his lizard that he wanted to get her attention so he could show her. How did he get her attention?

He grabbed her boob.

My 4 year old son (who looks like he is 7 1/2) grabbed a woman’s boob and then squeezed it. In public.

The world came to a screeching halt. There was a roaring in my ears. In slow motion I saw the horrified look cross this woman’s face. My son pulled his hand away. He took a step back. He stammered.

What to do? Call my son out and do a teaching moment about never touching a woman’s boob without her permission? Does she want me to make a scene in the store? Or should I just ignore it? I can’t ignore it. I cannot just ignore it. What if he does it again to someone else? But I wouldn’t want someone talking to their son about my boob in public.

So I apologized and told her that he and I would have a discussion about it in the car. I hurriedly paid for the cheap lizard and his expensive paraphernalia and the Miss Piggy dog/daughter costume, and made my exit.

In the end I lost a lot of money, my dignity, and probably a patient. All in the pet store.

Now, I will drown my sorrows in cold fried pickles and ranch dressing…

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Ethical Dilemma

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This week I had a patient in my office to follow up on her diabetes and high cholesterol.

She had spent almost five years without insurance and in May finally qualified for Medicare. So we went to work catching her up on all of the care she had not been able to receive for so long. Colonoscopy, bloodwork, mammogram, PAP, etc.

In the process we diagnosed her with diabetes and high cholesterol and started her on medication for these issues. She has worked hard losing weight. Her blood sugars are running in the 90’s before breakfast.

“Doc, I know you want to do blood work but I just can’t afford it today. I am so sorry!” She looked near to tears.

What a lot of patients don’t know is that I am measured on their numbers. Blood pressure, cholesterol, A1C, BMI…

Her numbers were awful last time. Those bad numbers are registered on her record. They are probably good now, but the only way to get those recorded and for me to get credit for those improvements is to do blood work. I can’t simply say, “Not indicated,” and skip doing it. I can’t make up those numbers.

Medicare part B does not cover 100% of everything. Patients are generally responsible for 20% of outpatient charges. So a fair amount of the cost of these tests is transmitted to the patient. She is not able to afford a supplement to pick up the remaining 20%.

What complicates matters is that her mammogram caught a mass. Turns out it was breast cancer. Thankfully we caught it just in time and she should do fine. She has had surgery and will start radiation this next week.

So from a money standpoint, right now what is most important? Getting her breast cancer treated or making my/her numbers look good?

KateCrimmons (She is awesome, check out her blog!) made a comment on my last post that got me thinking about this.

Sure, I could pressure her out of my own self interest and get her better numbers registered. She would do it if I made an issue of it.

But is that right?

How well I do on numbers affects my ratings with insurance companies. I get rated on the quality of my care on their websites (high ratings mean my numbers are good). And my numbers are flowed by Medicare. They are also followed by my employer. In fact, 5% of my income is tied to how I do on these quality measures and 5% is tied to my patient satisfaction scores.

Emphasizing quality IS a good idea!

I think as a whole the medical profession is doing a better job at this than we have in the past. There is nothing more infuriating to me than to have a young, otherwise healthy people with diabetes come to me saying their last doctor told them that their A1C of 7.8 was good. It is NOT good!!! When my name gets sent out to all of the physicians in my group, I want to be at the top of the list with my numbers better than everyone else’s. That means I am a better doctor, right? (Suck it all you losers! I rock!!!) It motivates doctors to follow evidence based guidelines and get those A1C’s under 7.0 in appropriate patients and prevents diabetic complications.

But there is a dark side.

When physicians start feeling the pressure financially, I believe they are going to be more inclined to make decisions for patients that are not necessarily in their best interest:

Pressuring patients to get blood work or take certain meds that may not actually be best for them. Firing the noncompliant diabetic rather than helping them to get compliant. Firing or not accepting overweight patients.

In fact this is already happening among my peers. We talk about it. I have pondered it myself, I will admit.

How do we balance quality in a way that is in the best interest of our patients?!?! Do we incentivize or penalize? How far do we take it? Is it OK to fire a patient for not losing weight or controlling their blood pressure? If we force them to seek another physician are we helping them by forcing them to think about their “bad” behavior so they will maybe work harder next time or serving them by having them maybe find a physician that can eventually reach them and get them to change their ways?

Thoughts from you?

Your Facade

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Today I had to tell a patient that they needed to seek care elsewhere in the future.

I hate, hate, hate dismissing patients from my practice but in this case, it had to be done. They had been consistently verbally abusive to my staff and made unrealistic demands that infringed on the rights and care of other patients.

I understand that when someone is ill and hurting and scared that their behavior is likely not representative of who they are in reality. Generally bark is much bigger than bite for most people, once you are able to get past their facade. So I make a lot of allowances.

It takes a lot to get yourself fired from my clinic. Really.

I have to act like I don’t care. I let all of the bravado bounce off of me. I am firm and unrelenting, the big boss woman standing up for everyone.

Still…. It makes me feel like a failure somehow.