Confessional Time

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I realized Thursday that I was not taking care of myself very well. It is a long story but I found myself closing the door of my office and crying out of anger and frustration. I can take a lot of anger and frustration before I break down so this was alarming. I decided that I needed to play hookie from the clinic for a few days to take care of me.

In the process of that, I read this:

Medscape Physician Lifestyles Report for 2015 (It is in slide-show format and also talks about physician usage of weed if you were curious.)

Physician feelings of burn out were 50% for family medicine in the US. Family medicine is my specialty. We were third over all specialties. Only critical care and emergency medicine scored higher at 53% and 52% respectively.

Causes of physician burn out? The top five were: too many bureaucratic tasks, too many hours at work, income not high enough (before you roll your eyes thinking we are all spoiled brats, remember physicians are making less and less every year and that combined with the other issues listed here magnifies the sense of loss, right or wrong), increasing computerization (which would be fine if someone would just make an affordable, user friendly electronic health record for crying out loud), impact of the Affordable Care Act (I need to do a post on that specifically as I am starting to see the issues more here now that it has been in place for a bit).

Overall, 43% of men and 51% of women were burned out. I thought that was an interesting statistic.

I was sitting on the tenth floor of the big system hospital reading that report yesterday. Where did I flee on my day off? To the hospital because it has wifi and it is not my house. I had my work computer open in front of me, logged into my EHR (electronic health record) flipping back and forth from it to the director’s cut of Kingdom of Heaven I had playing into my earbuds. I sat there for eight hours. It was blissful.

I have issues.

This morning I am a basket case again and I cannot figure out if it is the extra cup of French press coffee I had this AM or something else more sinister coming back….

Anxiety.

I have a fear of being sued that hangs over my head like a dark cloud that could break open, pouring forth at any moment. It is remarkable that I have made it to this point in my career without facing that as a reality but it feels closer and closer every year that I am in practice. Flirting with the odds. (Bear with me as I superstitiously knock on wood. It is a thing I do whenever I talk about this sort of thing. It helps ward off the bad juju.)

I fear corporate medicine and the changes it has wrought.

I have significant anxiety about my professional reputation.

I worry about my patients constantly.

I worry about my kids just as much.

I am anxious the whole time I am away from the office that when I get back to the office I will have to put out tons of fires. That is not an irrational fear. It usually happens.

But I don’t bring this up so you will pity me. We all have stresses. We all have fears and anxieties. I have a pretty dang good life when all is said and done. I just want people to understand that I am human, not super woman. Not even hardly. I may seem like I have everything together. I don’t.

Blogging keeps me sane. Truthfully, I probably get more from you all than you get from me in the end….

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Regretful

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Do you ever buy comfort food after a really terrible day but realize it doesn’t taste as good as you need for it to because of that lump in your throat?

Then the next day you feel all bloated and poofy and ick from it and wonder why the hell you spent all of that money and calories on something that made no positive difference in your life?

(Raises hand slowly and looks around…)

The Haunting

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“Ma’am, I am here to save your daughter’s life.”

I looked over my mother’s shoulder to see the handsome hunk standing in the dark shadows of my front porch.

I had skipped studying for my calculus exam that day so that I could go with a friend to check out a college (actually to visit my boyfriend at his college but my parents didn’t need to know that). As I had sat down with my textbook after arriving back home I realized I was in way over my head. It was not going to be pretty.

There were hushed whispers as my mother conferred with my father to see if they could allow a strange boy to study calculus with their daughter in the middle of the night.

I was a senior in high school. My curfew was 8PM. My bedtime was 9PM.

It was 8:30 when the doorbell rang.

I was not holding out much hope.

Thankfully, they relented and let him stay until 10.

Truth be told, I would have dumped my boyfriend for this guy. I had THE biggest crush on him. I thought this put me one step closer to a prom date.

I did pass the calculus test the next day.

He didn’t ask me to prom.

Neither did my boyfriend, for that matter.

I went by myself.

Alone.

Fast forward fifteen years. I am now married to that boyfriend, practicing medicine in a small town when I get an email that a certain ear, nose, and throat specialist is coming for a visit. He practices two towns over.

That name.

It’s him.

Tons of angst about what to wear, how I look. Why do I even care?

Because I want him to care. Not because I want him to love me now or even because I still have a crush on him. I want to validate that quiet, lonely high school girl who went to prom by herself.

I invite him and his wife over for dinner a few weeks later. I realize quickly that I don’t really like this man.

What a relief!

Fast forward another five years and he is moving his practice to this small town. My town.

Go away.

The Beautifulest Pony

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“Who wants to marry the prince?” my son asked.

“I do! I do!” my daughter’s ponies clamored.

“Only the beautifulest pony will be allowed to marry the prince!”

He and my daughter lined them up and discussed the merits of each.

This one was a nice shade of pink.

That one had nice hair.

The clencher was the one with the long eyelashes. She got to marry the prince and there was much celebration throughout the kingdom.

Who taught them this kind of judgement? I have never remarked about eyelashes. Or have I? Hair? Maybe. Talk about beauty? Yep. Quite a bit.

When my daughter was a toddler a physician friend looked at a picture that I took of her and said, “Ooooh. She has a bit of frontal bossing doesn’t she? Don’t worry. Maybe she will grow out of it.” I just about clawed her eyes out. Instead I smiled back and agreed.

Sometimes we don’t hear ourselves. We don’t realize what we are saying.

Our children sure do, though.

Empty Corridor

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He leans in over the hospital bed for the kill, one hand on the arm of the young man lying asleep there.

He has given this speech hundreds of times. He knows from experience that here, right here, he needs to pause for dramatic effect.

“The only humane thing at this point is palliative care.”

He stands up straight and crosses his arms across his chest and waits, satisfied with his delivery.

She looks down at her baby, the boy trapped here in a man’s body.

This doctor does not know that her first husband, her boy’s father, beat her. That he tried to kill her and the boy but the gun jammed and that a short time later, thankfully, he died in a car accident before he could touch her again.

He does not know that her second husband, the love of her life, died unexpectedly at age forty, two weeks after his metastatic melanoma diagnosis. They told her palliative care then, too.

Or that her third husband shot himself in the head last year because he could no longer take the severe physical pain anymore. Palliative care did not ease his suffering.

And now they want her to kill the one remaining tie to herself, to that wide eyed, unjaded young woman that she used to be before she learned what cerebral palsy really meant…

The doctor gives her his best understanding, compassionate smile. He knows what she must be thinking.

You, sir, don’t know shit.

Woman Hood

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Let me start by saying that I enjoy being a woman. I like dressing pretty. I like wearing skirts and high heels and lingerie. I like men opening doors for me or rising to stand when I arrive on the scene.

There are well established drawbacks for women in leadership, however.

For instance, I have heard over and over again that I have a reputation, even among people I have never met or worked with, for being demanding and difficult.

Truthfully, it used to really bother me. Lots of anxiety and depression.

What the hell is wrong with me for crying out loud?!??! Why can’t people I work with like me as much as my patients do?

I don’t yell at my staff or anyone else. I don’t call them names or belittle them. I don’t throw things. I don’t go looking for trouble, stirring things up.

But I work in a field where precision is a must. Lives are at stake. Hundreds if not thousands of dollars are at risk for each of our patients if something is not done exactly right. I want everyone striving for perfection, getting as close to it as possible, even though I understand we will never actually reach it.

To that end, I try to discuss errors to understand how to prevent them from occurring again. I ask questions before agreeing to changes in work flow handed down from corporate so I can make sure it is going to benefit and protect patients and staff instead of endangering and alienating them. If there is a problem with the EHR (electronic health record) I am going to tell someone so they can fix it. Not that they ever do…

All of this makes me difficult.

I realized recently that the problem was not really with me. I cannot do a single thing to make myself more friendly and less threatening unless it is just simply always keeping my mouth shut. It is a cultural problem with how I am perceived. Even if I am smiling and respectful, I am a woman. I will always be a woman. Whenever I open my mouth I appear threatening to other women and bossy to the men.

For years I struggled with this, feeling ashamed that I could not make others like me all of the time. Should I just keep my mouth shut, no matter what, since that is what makes everyone else more comfortable?

No.

I cannot in good conscience keep silent.

So I have decided that if I am speaking up in a way that is fair and balanced and respectful, I can rest knowing that I have done my due diligence. Now I have at least some degree of peace.

There was an article from November in the BBC here discussing women in leadership and depression. I encourage everyone to read it if you have not already done so.

Truthfully, I am guilty of the same behavior myself. A woman openly criticizes me and I think to myself what a bitch she is, whereas if a man does the same thing, I take it. He isn’t saying it in a more diplomatic way. I just simply respond differently.

Why?

Why, indeed…

Drugs, Drugs, Drugs!

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Doobster wrote a nice little post this morning, an observation on how many drug commercials he witnessed during a 30 minute TV news program. Check it out.

Direct advertising of pharmaceuticals is a HUGE pet peeve of mine. I have held back from ranting to this topic before because I am afraid that I might not be able to control the vitriol but I feel compelled to touch on this subject today.

I am often presented in clinic with requests for various drugs that patients have seen on TV or in print. It is not unusual for a patient to dig out an advertisement ripped from a magazine for the latest drug and show it to me. “What do you think about this one, Doc?”

How do I address this?

First, I ask the patient to discuss cost with their pharmacist, telling them that if the cost is something they can live with, they can call me for a prescription.

I have yet to have anyone call me back.

Why?

Because these drugs that are advertised are still under patent. They are marked up to exorbitant levels in order to make the most money possible. Your insurance company doesn’t want to pay that, so they don’t cover it or of they do, they don’t cover it well. The drug company hope is that you will pressure your physician into forgoing a trial of less expensive, very effective medications so they can make money off of you. Truthfully, rather than the litany of fine print they rattle off, there should be a disclaimer giving the average per month cost for patients. That would save me a lot of time.

Well, aren’t these medications safer, you may ask?

No.

Case in point, Vioxx. Avandia. Zelnorm. To name just a few. If you are old enough and have lived in the US, you can maybe remember the onslaught of advertising for these drugs… the best things since sliced bread, right? You can bet those drug reps were clamoring outside my office, lined up with gifts to buy my loyalty.

But they killed people.

I have seen many people hospitalized with pancreatitis from some of the newest diabetes drugs. It seems that drugs now have to be on the market for a few years before we get a true feeling of what the risks and side effects are. I am not saying the drug companies are withholding that info per se, but I advise my patients to let those drug companies experiment on other people first. They are not interested in *helping* humanity.

Not really.

The UK and Australia and everywhere else that does not allow direct advertising has got it right. We are not stupid people. At least I like to believe that is the case. We need to lobby the government to stop allowing the pharmaceutical industry to manipulate us, essentially robbing our bank accounts and treating us like expendable lab rats.

Ok. That felt good. Carry on.

Fly, Fly Away

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She looked up from her place in the wheelchair when I walked through the door, tears staining her face.

“Oh, no. Why are you crying?” But I didn’t have to ask. I already knew.

“I am tired of hurting, Doc.”

I knew she was suffering. Since her lupus diagnosis two years ago her life had crumbled. She had been a vibrant, funny, joyful young woman.

Now she was a shell of her former self.

Bloated with an over 100 pound weight gain from the steroids. Hair falling out. Disfiguring skin rashes. In and out of the hospital with infections and blood clots. Kidney damage. Lung involvement. Losing her vision. She was in so much pain that she was wheelchair confined and maxed out on opiates.

We could find NO medication that could bring her disease under control.

She had a physician from every known specialty. Coordinating visits was a challenge especially as her eyesight was failing. Friends stopped coming around and offering to help. A teenage daughter, was falling apart under the weight of raising herself and the baby and caring for her mother.

“I just want to stop hurting…” she said again as big, fat tears continued to roll down her face.

“I am so sorry.” I hugged her. Gently. I didn’t want to hurt her.

I have nothing left to offer.

Nothing left.

Human Resources

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“Doc. We need to talk.” My office manager was giving me that half smile that meant she had something not terribly nice to say. I had packed up my belongings and was heading out the door. She realized this. “Oh, are you leaving? Well, I am going to call you and we are going to have a chat…”

Yeah. That was NOT going to go well with my kids screaming in the car as I was driving home in the rain after dark.

“Come on back to my office. Let’s talk. I have a few minutes.”

She closed the door behind her and leaned against it. “Well, you got what you wanted.”

“No. I didn’t. What I really wanted was for them to do their jobs.” I sat down and motioned for her to have a seat.

She sat.

“Well, they have all quit now. You cleaned house.”

“And you think I am happy about this? The biggest tragedy is that each of these people are capable of doing amazing things, of being truly great, but they chose not to. Even after repeated opportunities.”

“Well that email that you sent saying you could not trust them? They all said that was the reason they were leaving.”

“Am I not allowed to say that I do not trust staff that are not trustworthy?”

“No. You cannot. I have to do that for you.” Her eyes flashed. “They also said that they felt you were different, not as friendly after the incident.”

“After they do something so awful, so egregious that technically they should be fired, I am supposed to treat them as if nothing happened? When they stomp around and refuse to speak to me or the other physicians that is not going to change the dynamic of the relationship?”

To give some background, check out this post about the Thanksgiving debacle then come back.

After uncovering the fact that they were refusing to schedule patients the afternoon before thanksgiving, it was recommended that I fire them that day.

But I didn’t.

I like to believe in people. I decided to make it a final warning to send a message but stopped short of actual termination. The holidays were coming up after all.

I expected them to acknowledge what they did was wrong. I expected contrition. I expected them to work hard to prove that they could be trusted again.

Instead, there was sulking. There was outright animosity. It lasted for weeks. And my schedule? Slammed. They were booking me through until 4:45, putting in 15 minute physicals, double booking without clearance… It was a nightmare of astronomical proportions. At 5PM, they would walk away, leaving my nurse and myself to finish up with patients late into the evening.

I waited it out for a week or two, thinking their anger would die down and things would go back to normal. They did not.

Finally, I had enough.

I told my office manager to make sure they all understood how the schedule was supposed to work and that if they did not observe the rules, they would be disciplined (read fired). Furthermore, someone had to be available at the front to check out patients until the last one left. She did this by sending out an email to the entire front desk staff and CC’d me.

One employee responded by saying that she did not have to obey those guidelines because she and I had a special relationship that allowed her to do whatever she wanted.

I replied simply, “I cannot trust any of you right now. We will discuss it further during the staff meeting tomorrow.”

You cannot take liberties with my schedule.

HR was upset that I wrote that, saying that by doing so I was discussing disciplinary issues with other staff members and it could be considered a breach of privacy. Wrong. I made no mention of the disciplinary incident.

HR also did not want us having a meeting with the staff to discuss patient access to care because that could be deemed harassment.

As the staff continued to have issues in other areas, we were told we could not fire them for those reasons. The patient portal was too new (over six months) and they had not received enough education on it (despite having to complete an online training AND being reminded repeatedly to take care of patient messages). You can’t fire someone for a bad attitude they said and if I did, it could be considered retaliation. Etc.

Throughout this whole process never once did the staff involved say they were sorry and I was told that I could not tell them individually how hurt I was over what had occurred and their subsequent reactions.

Now, one by one over the past two weeks they have resigned.

Admittedly, I am angry. I am angry that I truly do not own this practice, that I do not have autonomy no matter what they say. I am angry at my staff for cheating patients, blocking access for their own self serving reasons without permission, and then not even showing remorse. I am angry with myself for not being able to inspire them to do the right thing, for being such a poor judge of character to have hired them in the first place.

Most of all I hate HR for making me question my sanity.

The “Wonderful” Wizard of Oz

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“Doc, I wanted to ask you about something. I was watching Dr. Oz and he suggested this to help me lose weight.”

She started rummaging in her very large hot pink purse. There were about a dozen bottles of various supplements. One by one she pulled them out and placed them on the counter between us.

Once they were lined up in a neat row, she stared at them, brow furrowed.

“I can’t remember which one it was.”

“Wait. Do you take all of these?”

She looked over at me sheepishly. “Well, yes. He says they are good.”

“How much did this cost you?!?!?”

“I dunno. $200? Maybe?” She shrugged.

“You just told me you could not afford your generic blood pressure and cholesterol medications. Is this why?”

“Uh. Yeah. But he said they are good and I figured if I lost some weight I wouldn’t need the drugs. These are natural.”

“Did you change your diet? Start exercising?”

“No.” She looked incredulous.

“Look. He is full of crap. Here is an article discussing that fact.” I provided her with a copy of one of the many articles summarizing research published in the British Medical Journal here showing that over half of what he is saying has no supporting research. “Furthermore, he had to testify before congress last year because of the dubious nature of his claims.”

I tell patients all day long they have been had. They don’t like hearing it. Often, they are angry with me for debunking. Who doesn’t want that magic pill the quick solution to all that ails us, or at least will make us lose enough weight that we look good doing it? I shatter dreams.

The magic pill does not exist. It will never exist.

Does Dr. Oz know or even care that this woman’s blood pressure was out of control? That she had stopped taking her cholesterol medications for months because of something he said? That countless others do the same, wasting their hard won earnings on things that are not going to work? Does it matter to him that I waste tons of valuable time on a daily basis fighting his snake oil claims?

That does not mean that all supplements are bad. There is an increasing amount of data supporting some and refuting others. More needs to be done.

Admittedly, he is human. He is susceptible to greed and fame just like the rest of us. Truth be told, if I had been singled out to be THE ONE I probably would have succumbed. I have been on TV. Once. (Read about “The Boob Tube” here if you need a good laugh.)

I get less and less of this blind following from patients now. Hopefully that means Dr. Oz’s time has come… and gone. Sadly, there are plenty of others ready to take his place. I prefer treating conditions without drugs if possible, and there is nothing I celebrate more than taking someone off of meds, but sometimes they are necessary.