Looking Back

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Hey, you!

Yes.

YOU.

Some of you are starting to feel your hangovers from your celebrations last night. (Sorry, I haven't got any great medical advice for mitigating your misery.) Some of you are readying your champagne glasses for toasts tonight. (Take heed of the sufferings of our friends in other time zones and use moderation, please!)

As we are looking forward to another new year I wanted to say thank you to everyone.

All of you.

Another blogger, Gennie of the Gentle Giraffe, reminded me of my very first blog post here the other day. Just Why. I remember sitting down to write it, overflowing with angst and frustration and not really having anywhere to take it. I was going to explode if I did not have an outlet.

Blogging saved me.

I told myself that I didn’t care if anyone else cared, if anyone else was listening. I just needed to write, to get it out.

But, truth be told, I do care. I care an awful lot. So thank you.

Thank you for listening.

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Something Meaningful

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“Fifteen pages?!?! You can’t be serious?” I threw down the thick stack of pages. They slid off the counter onto the floor and scattered. I didn’t care. It felt good.

“You have to do it for Meaningful Use…” My office manager stared at me, frustration creeping into her voice.

“But a fifteen page patient visit summary? How is that going to be helpful for patients? What the hell could they possibly say that would require fifteen frickin’ pages after a fifteen minute office visit?!!!?” Rage. White, hot rage. I felt so much rage that I wanted to throw the damn computer against the wall. “And who the hell is going to ever wade through 15 pages of crap to find the important few bits?”

“Look, you have to get 50% of your patients using the online portal and this patient summary has to either be printed out for them or sent to the portal. You can document “declined” but if you do it on everyone, that will get you into trouble, too.” She was pleading.

The problem was that the online portal sucked. It was thrown together at the last minute and the interface on the physician side was awful. It was making my job so much harder and was confusing patients right and left. It was unreliable. Messages often weren’t getting sent.

“Ok. How’s this? I am not going to print it or send it to the portal or even document “declined”. I am going to continue printing out the two page summary that shows patients what I changed with their meds so when they drive over to the pharmacy they can make sure they are given everything that was prescribed. That handout has instructions and their preventive care recommendations and their vital signs. Everyone, but especially my elderly patients, need something concise in hand to take away with them. Since when did the government get to decide how I communicate with patients? This does not improve patient outcomes!”

They had also in one fell swoop taken away my ability to order immunizations in the EHR. My medical assistant had to now do that, so I could not print the superbill until after the immunizations were administered and documented. Completely disrupted work flow. Documentation of certain preventive care measures went from a single screen and two clicks to a multiple screen ten click ordeal. For each point. Worse, I could not document family medical history in my usual concise and organized manner: “Mother died age 45 due to heart disease, also had diabetes and hypertension”. I now had to use push buttons like “mother history of heart disease” and another button “mother history of hypertension” and another button “mother history of diabetes”. It was a difficult to read jumbled mess.

All because the government said so.

“You still have to play the game.” She shifted uncomfortably in her stiletto heels.

“Why?”

“You will get paid less for your Medicare patients.”

“I am not really paid much of anything at all anyway. How can I miss what I do not have?”

“They are following your data…,” she warned. Truthfully the powers that be here were following her data, too. If she couldn’t get her physicians to toe the line, the doctors who hired her to work at this clinic, she would be in trouble, too. I might have felt bad about that, but rage makes you blind to everyone but yourself. “AND, I am supposed to post this how-to instructional page here at your work space to remind you of what to do.”

I rolled my eyes.

“You know what you can do with that.”

“Yes, ma’am, I do.” She grinned at me, and tossed the how-to sheet into the waste bin as she walked away.

End of discussion.

I don’t know who exactly is responsible for this ridiculousness but you should be ashamed. All of you.

Curves Ahead

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I am going to deviate from my standard fare to something a bit selfish today. I need to get this off of my chest as I have wrapped up the worst call week I have had in over five years.

Tips for calling your physician’s answering service after hours:

1. Don’t cuss out the on call doctor if you don’t get what you want. That just goes in your chart. We are trying to help. Really. But if you have not been seen at the office for over two years, I am not going to call in an antibiotic over the phone for you for the head congestion that just started this morning. I just can’t. I am sorry.

2. Make sure this is something that cannot wait until the office is open. Case in point, a call I received on Christmas morning to let me know about hip pain. The fellow had had it for over a year, worse the past three weeks. After he went through the entire treatment course for the whole past year he told me that he didn’t really want me to do anything about it per se. He just wanted to have me send a message to his doctor so he could get in to the clinic to see her when they opened back up next week. He was a super nice man and I felt bad for him. But we were opening presents…

3. Stay by your phone until we call you back. Please. I beg you. That unidentified call about ten minutes later? That’s me. Sometimes it is longer if I am driving and have to find wifi or if I have to pry screaming kids off of me and lock myself in the bathroom. 90% of the time when I call back, no one answers and I have to leave a message or try to call back again in a few minutes. What you may not know is that I have to pull out my computer, boot it up, log onto the electronic health record, and scan your chart so I know your medical problems, medications, kidney function, allergies, etc. I don’t mind doing that at all. It makes it easier and safer to take care of you. But when I am having a meal with my family, it sure is nice to be able to wrap it up and close it down with one phone call instead of dragging it out into a 20-30 minute ordeal.

4. We call back with our number blocked because we are calling from our personal cell phones and believe it or not, many people abuse it when they have that info. Please don’t take it personally. Also, please take the unidentified number call block off your phone, at least temporarily. It is terribly frustrating to call, get rebuffed by some bitchy sounding automated woman, and then have to call the answering service and have them call you back and then patch you through to me.

5. Do NOT call me for severe chest pain and/or shortness of breath. Go to the ER. Now. No, I said go right now. Shush it. Just go.

Happy Monday, folks! I am so glad to be able to turn my phone to silent again that I feel almost giddy. Woohoo!!!

Freshly Squeezed

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Oh, the pressure!!!

Yesterday, my post Bridging the Gap With Silk Draperies was featured on Freshly Pressed. What a wonderful Christmas present!

Historically I have avoided that section of WordPress because it always reminded me of all of the bloggers who are so much better than me.

There are a lot of you, even if you have not been Freshly Pressed.

It has been almost a year of blogging and I am surprised at how many words have flowed from my fingertips.

That I have had that much to say.

That I still have things left to say.

That people read my words.

That people even care.

It is humbling.

Now as I am writing on the other side of Pressed, I feel even more pressure to say the right things, to be more profound. I have a new standard for myself and I am not sure that I will be able to live up to it. Forgive me if I flounder and if I stumble.

I am human after all.

Tinkling

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My step-father-in-law unrinated on our guest bed the last time he stayed with us.

At first, I was pretty upset about this. Not angry at him. Who chooses to urinate on a bed, particularly when they are a guest in someone else’s house? I was just upset about the event itself. A strange grown man’s urine on my bed? How could I ever clean that up sufficiently enough that I would not cringe next time my kids were rolling around on that mattress?

So when my mother-in-law asked if they could spend the night Christmas Eve, my first thought was, “Oh, please no…”

Then, I thought I should put a plastic liner under the sheets. Sure, it would be obvious, but I didn’t really give a rip. Mattresses are not cheap, after all.

Then, I thought about dignity. Is there really an object on this earth that is worth someone’s dignity?

No.

No, there is not.

Certainly not my mattress in the guest room.

As I am starting to age there are constant reminders every day of how my own body is no longer as cooperative as it used to be… the stray fart, failing eyesight, hair loss, super heavy flooding periods, lipomas, and those damn wrinkles around my lips.

My kids, however, have a somewhat warped concept of preserved dignity…

When the fellow arrived Christmas Eve, he was greeted by two very excited kids. They knew Granny and Paw-Paw’s arrival signaled the official start of festivities. They were jumping and screaming and full of exuberant joy.

Then suddenly there was silence. My daughter looked up solemnly at her adopted Paw-Paw.

“Paw-Paw, when you were here last time, you pee-pee’ed on our bed.” My daughter gave him a hug around the legs. “It’s OK, Paw-Paw. I do that, too, sometimes.”

Oh, dear. She was in the room when Granny had told me about the accident at the last visit. She had not said a single word about the incident until right then. It was apparent at that moment that it had made a huge impression on her, the realization that she was not the only one with a finicky bladder. She had received comfort in that knowledge and wanted to pass it on.

Fortunately, it was handled with grace by Paw-Paw who hugged her right back and a merry Christmas was had by all.

Flowers On The Water

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In residency many years ago, a woman who was newly pregnant for the first time, showed up in my clinic for her first OB visit. She was a graduate student at the local university and she did not have health insurance so she qualified for Medicaid.

For the uninitiated, obstetrics is a huge part of any family practice training program even though only a handful of us continue to practice OB on the other side of graduation. I delivered tons of babies as we did virtually all of the indigent care for the county and handled almost all of the Medicaid.

This woman, as it turns out, was married to a man who worked closely with my husband. Over the course of the next few months, we became good friends, having each other over, sharing food and fun. We taught them how to play 42. They taught us how to play poker.

Her pregnancy seemed to be going well until she went post dates (after 40 weeks) and then the baby’s heart rate started doing some wonky things during her follow-up OB appointment. Discussing with the attending, we decided it was time to induce. I sent her over to Labor and Delivery with handwritten orders to get the show on the road.

I was post call that day from a particularly rough internal medicine service call. This was before work hours restrictions and I had already been up for 36 hours. I was exhausted. I felt obligated, however, as her friend and physician, to be present throughout so I stayed on the labor and delivery floor for the next day and a half grabbing cat naps in a recliner in the call room when I could between seeing her and the other patients I was following on the medicine floor.

Thank heavens I had spare deodorant and lip gloss in my call bag and could change into a fresh pair of scrubs from the floor each morning. We won’t talk about my underwear…

Things were slow to progress, despite giving pitocin to stimulate contractions. Eventually, they picked up and she started pushing but the baby’s heart rate began to show prolonged late decelerations, a sign of fetal distress. There was meconium (baby poop), another sign of distress. She pushed and pushed but that kiddo was just not coming.

It was starting to look like we were going to require a C-section.

There were only two L&D operating rooms in that hospital and one OB attending who could do sections there at that time. My friend was third in line for the OR as we already had an emergency section in progress and another emergency getting wheeled into the other OR with a back-up attending on the way to perform that section.

This was not going well.

It was during the next late deceleration, as I waited holding my breath for what seemed like an eternity for the baby’s heart rate to climb back out of the 30’s, that I realized we were going to have to deliver now or lose the baby.

So I yelled at my friend to push harder than she had ever thought she could.

Harder! Harder! HARDER! You aren’t trying! HARDER!

By golly we got ourselves a baby. The chord was clamped and that little cutie pie was handed off to the NICU team.

In case you were wondering the baby did great and is growing up nicely…

A few years later, I stumbled across a post of my friend’s on Facebook, one of those silly questionnaires. The first question was, “What was the most horrible experience of your life?” She answered it with, “The birth of my first child.” The second question was, “What is the most ironic thing you have experienced?” Her answer? “That I am still speaking to the doctor who delivered my first child.” She went on to list her three closest friends. I was not on the list.

How do you tell someone that because they had Medicaid, they had to wait until they were dilated 4cm before they could have an epidural per hospital policy? How do you tell someone that because of staffing and space limitations at the hospital that they almost lost their baby? How do you tell someone, who blames you for a system and circumstances you had no control over, that you are not at fault? Someone that you thought was a friend but who really just thought you were ironic?

So I just didn’t.

We drifted apart. I don’t even think about them now unless it is Christmas. We used to spend all of our holidays together but now we don’t even rate each other’s Christmas cards.

This is the way of life. I do not regret my treatment during the delivery. I do not regret my relationship with her. I don’t regret not confronting her about her silly answers. I don’t regret drifting apart. She served a purpose in my life and we moved on. Like flowers on the water, here for time and then gone.

I do not mourn.

But I do think about them from time to time…

From One Addict to Another…

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In the spirit of yesterday’s post:

“Why is it drug addicts and computer aficionados are both called users?” – Clifford Stoll

Why the hell am I even posting on Christmas Eve? I have a disease. No post tomorrow, I promise. Maybe.

All week in my house so far:

“Mommy, is today a school day?” Hopeful eyes looking up into mine.

“No, sweetie.” Huge grin.

Or:

“Mommy, do you have to be a doctor today?

“No, baby doll. Let’s bake some cookies!”

Cue smile a mile wide.

From both of us.

These questions get asked several times a day as reassurance. They are not used to mommy having some time off. They are not used to having time off themselves.

Sometimes I forget that my kids work just as hard as I do.

It has been divine to be able to putz around the house in my jammies for days, shunning my standard uniform of high heels and make-up. If that doesn’t put you in the holiday spirit, I don’t know what does!

Happy Holidays, one and all!

The Seekers

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“My father is a patient of your partner’s. He’s leaving on a plane out of the country for his sister’s funeral and needs his medications refilled or he will run out!” She listed off a narcotic and a benzodiazepine and a blood pressure medication.

Technically, we have a policy not to prescribe narcotics, controlled substances, or antibiotics after hours. Sometimes the rules need to be broken, though. A funeral emergency would qualify.

I got the name and date of birth from her as I waited for the computer to finish booting up. Hurriedly, I typed in the info then hit search.

No go.

Thinking maybe I had misspelled or entered a typo, I asked her to repeat it.

Still nothing.

“He was just in there on Tuesday. There must be something wrong with your computer.”

I pulled up that physician’s schedule for the day in question and scanned though it. Nothing even remotely similar.

Perhaps she was mistaken.

“What pharmacy does he use?”

I got the info and told her I would call back. My thought was to see of my partner had ever prescribed medication for this fellow before, but truthfully I already knew the answer.

“Does this fellow ever get meds filled at your pharmacy?”

The woman on the other end of the line was silent as she looked him up.

“No…. But you are the third physician calling about this guy in the past two hours.”

Busted.

There are two kinds of drug seekers: the personally addicted and the professionals who probably sell what they get. Often I find that the personally addicted are sloppy, as they are typically the ones screaming “F- YOU!” through the phone. Their need gets in the way of calculation. Yet both types get more and more sophisticated as technology improves.

Major holidays are a favorite time for the professional seekers in particular. They are not stupid. They know that the odds are that physicians are less likely to be near a computer and the EHR (Electronic Health Record) during this time as we try to maintain some normalcy on call while celebrating as much as we can with our families.

I get to be on call for Christmas this year. There will no doubt be several of these calls. It’s par for the course. Fortunately, I have the ability to remotely access my EHR…

Which Way?

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I have a fault to confess.

This issue has haunted me since the day I first had a parent scream at me, “Turn right, damn it!!!! Turn right! Not left. RIGHT!!! Aw, for crying out loud….” Imagine brakes squealing in the background. They might be my brakes. Or someone else’s. But they are squealing.

I am directionally challenged.

There. I said it.

All I can say is thank the gods above for GPS and onboard navigators. They have saved my life, and the lives of those I hold dear, on more than one occasion.

When they are right.

Sometimes I wonder how my life would have been different if I had had Google Maps in those early formative years. What would have happened if I had shown up for the interview for the summer job with that attorney on time instead of wandering around lost for thirty minutes in a scary part of town?

Hmmmmm…..

Now you may say, “It is a dang good thing you are not a surgeon if you don’t know right from left!” You would have a valid point except that right and left on human bodies it not a problem at all.

I cannot tell you how my brain does it exactly. In a fraction of a second, the human body in front of me is flipped and I stick out my virtual right and left hands as correlation and TA-DA! Perfect placement documented.

Yet, I cannot do this while driving. I feel handicapped, even paralyzed, at a large intersection unless I can look over at the map projected on the screen in my car and see which way that blue line is going…

Why?

I would like to blame my parents. They make perfect scapegoats for all sorts of things, especially as they cannot defend themselves in this forum. Genetically, I could lack all those special neurons in the entorhinal cortex region of the brain. Or it could be that they forced my left handed early self to become right handed because of the perceived disability associated with left handedness.

Regardless of all of that, I am an intelligent woman (I think) with an advanced degree. I can help treat your diabetes and pneumonia and God forbid, your heart attack. Just don’t ask me for directions to my own clinic.

Get Out Of My Hair

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Rounds were done. Notes completed. Orders written. The attending and other students had left.

I stacked the charts in the rack for the nursing staff to complete.

I sat still for a minute at the nurses’ station amidst the beeps and buzzes and voices, enjoying the fact that I could finally breath. I was in no hurry to go home. Nothing was waiting for me there. Not tonight.

Still. I could not stay at the hospital all night. I was just a med student, tagging along. Unimportant. A nuisance.

I grabbed my bag and headed out.

Walking down the hallway, I stole a glimpse of my reflection in its short white student coat. I looked tired. My hair needed a brush. As I neared the elevators, I heard crying. Actually, it was more like whimpering.

I slowed, then stopped just outside the room.

An elderly woman was sitting up in the bed. I did not recognize her as one of the patients we were following.

The TV was blaring loudly. Her dinner tray was on the table in front of her but she could not reach it as her thin wrists were bound in soft restraints. Gray hair was tangled around her face. She needed a hairbrush much more than me.

I walked into the room.

“Do you need help?”

She nodded.

“Is it OK if I turn the television off?”

She grimaced a bit. I took that to mean “yes”.

I searched for the TV control and found it dangling off the side of the bed by the cord. Unreachable to her.

Silence.

“Are you hungry?”

“Please let me go,” she pleaded, her voice hoarse and gravelly. Maybe she had spent a few days here yelling? I weighed the situation.

“Let me help you eat. We can talk.”

She nodded.

I sat there beside her, sinking down slowly on the squashy mattress.

I lifted the plastic dome over her plate. Condensation cascaded off the inside, leaving a small puddle in the plate. Puréed diet. Blech. Still, she ate with gusto as I fed her.

How much of what she said was true, I did not know. She was demented and confused, jumping around from one subject to another. Kids. Husband. The nurses were trying to kill her. After hours and hours of super loud TV that she could not control, anyone else would have been a bit crazy, too. Isn’t that a torture technique, anyway?

This felt good. My heart soared, full of self satisfaction.

As I was finishing up with her last few bites of vanilla pudding, the aid showed up, the smell of tobacco from her smoking break hanging heavy in the air about her. She glared at me, her gaze full of animosity as she realized I had done her job. Did she see it as an indictment? Did she feel guilty that she had not done it herself sooner? I smiled at her, hoping it would show that I was on the same side. I was not judging, just trying to help.

“You students are all same,” she snarled. “Go home. You can’t save the world.”

My heart sank. I wasn’t special.