Treat Yo’ Self!

Drawing of a human body by a preschooler
Death was approaching over my left shoulder. I could sense it. And yet I was surprisingly calm. It felt surreal. The bit of chicken lodged itself in my esophagus and now I could not breathe. I was going to die in this very hotel room. Tonight. I knew it with a certainty that rivaled the certainty of taxes. It was my time.

Choked to death on Thai chicken curry.

People would judge, wouldn’t they?

Except that I really could breathe. It just felt like I couldn’t. I was not going to die after all unless it was from embarrassment. I imagined the humiliation of that ER trip.

I could not swallow that damn piece of meat down no matter how hard I tried. I could not cough, hork, or vomit it up. I made the most awful gagging, retching noises. I wondered what people passing in the hallway were thinking. 

Fortunately, I was not alone. I rasped the word, “Heimlich!” and motioned at my throat. He complied and in short order the offending bit of Thai chicken curry sailed across the room, bouncing off of a panel of neutral colored drapery, leaving a mark for the next guests to wonder about. 

Sorry about that, housekeeping staff….

From then on, I chewed and chewed and chewed everything, figuring that this happened only because I was a glutton, stuffing my face too fast. I was ashamed. I told no one. 

There were several close calls after.

Fast forward a few months.

Standing at the counter typing clinic notes I felt the wave of nausea hit me again. It had been building for weeks, getting worse every day. Always in the mid morning. But why? Why was this nausea happening? It was not pregnancy, not unless God felt the immaculate conception needed a do-over and since I was no Virgin Mary I figured that was highly doubtful. I draped myself over the counter, holding my head in my hands and closed my eyes until the wave passed. Wow, did my epigastric feel…. odd. What was that sensation? Pain?

Whoah. 

And just like that, it all dawned on me. 

Acid reflux. A terrible case of GERD. Esophageal structure. Dysphagia. Time to crack out that acid blocker and go see a GI specialist. 

So whenever people say, “You’re so lucky. You can just call stuff in for yourself. You don’t need a doctor!” I roll my eyes. I have no business treating myself or anyone else that I love because you know what? I’m crap at it. When it comes to myself and my family I am just too close to the subject matter to see straight. My family doesn’t even appreciate how dangerous that can be. Instead they get all offended when I refuse to weigh in or offer to take over their medical care.

The physician who treats himself has a fool for a patient.” William Osler

Truth.

Remember that next time you hear about a doctor treating themself or their spouse or their kids except in the direst of circumstances….

Fulfilling

“When was the last time you saw a doctor?”

“Three years ago.” 

I looked at his blood pressure reading and cringed.

“How long have you been out of your blood pressure medication, then?”

“Out? I haven’t been out. My old doctor just kept refilling it.”

Our clinic recently instituted a protocol for allowing staff to authorize patient medication refills. It is a system wide thing, across our healthcare organization, so it is being utilized in every practice. Supposedly it is to free physicians up for more important things, like seeing patients, generating revenue. Isn’t that nice.

I hate it, though. 

I hate the whole idea.

Sure, I have trust issues. That is the first problem: Trusting that staff is always doing the right thing is hard for me in this case because these are drugs. Drugs can kill people if used wrong. Doing my own refills gives me oversight. Then, there is the self importance issue. If a medical assistant can refill meds, then what does my degree really mean? Less then it did before. And most importantly, if I don’t have time to handle simple refills for my patients, then am I too busy? 

I enjoy keeping tabs on my patients, doing their refills. Maybe I am crazy? I really do enjoy it. Taking refills away from me makes me feel less useful, less fulfilled. But I am going to try it. I’ll give it a go for a bit and see…. I don’t want to be labeled an old fogey. Yet. 

Well…. It’s a Deep Subject

Water tower in a storm

It happened suddenly.

I was going along like I always have, working on several posts at once, when BAM! Out of the blue….

The frickin’ well dried up. 

There’s a string of half written posts saved in my que but when I go back and read them, they sound incredibly lame, like something I would roll my eyes over if someone else posted it. Seriously. So embarrassing.

Gah.

Why? I have asked myself this over and over again. Is it possible that I have simply burned out? Is there just nothing left to say anymore? Am I too happy in my current life to stir up anything angst worthy enough to post? Is it a time issue?

Or is it something else…

And then I realized that just like I had been in the habit of blogging and reading for so long, I was suddenly out of the habit. Do you all know how much time I put into this every day? Newbies have no idea. Then life happened and here I am, weeks later. People are noticing how quiet I have been and honestly I don’t even know what to say to them.

So I don’t say anything at all.

The words are coming back, though. I just have to do things differently in order to preserve my sanity. Please bear with me as I try to figure out exactly what “differently” means….

In the meantime, I am not dead nor have I suffered from some terrible tragedy. My fingers are all intact and I am working my way back. Thank you to everyone who took notice and said something and even to those who didn’t.

I love you all!

A Virtual Reality Devotional

Stained glass window

The body lies prostrate

On the confessional floor

A weakened avatar

Your closed door

Heartbeat slowed

From afar

Fading finally

Into empty code

Mere tokens

Conquests

Meaningless and broken

Nothing of value

Can be taken

Only the memories of love

Gained and lost

And gained again

Virtual virtue

Virtually gone

And truth now clear

Life

Turned into fear

Death 

A final frontier

Hold your breath

It is not so painless 

As they wanted us

To believe

Doctor’s Day

Cute butterfly on a blossom

Doctor’s Day was yesterday. Did you know that?

Caught me completely by surprise.

It used to be a big thing ten years ago. The hospital hung banners up and handed out logo emblazoned umbrellas, bags, pens, and whatnot. My staff signed a big card the office manager picked up and a new potted plant would now sit on my desk. Drug reps dropped off cards and swag. There would be emails celebrating doctors sent from the suits. Well not really from the suits. From their secretaries. The point was, though, you just could not escape what day it was. 

To be honest, all of the hoopla back then made me feel very uncomfortable. 

This is not why I am doing this. I am not here for the accolades or the potted plants and I resent the insinuation that these things matter to me. Please leave me alone.

Each year it is less and less of a big deal. This year? Silence. Not a single frickin word from anyone. In fact, my only clue was a post from someone else on WordPress. 

Yesterday I told a woman she has metastatic ovarian cancer. I told a man that he now has diabetes and we developed a treatment plan together. I did a newborn visit on a precious two week old baby. I cried with a woman over her divorce and saw a man whose mother just died from the same disease he now has. Then I watched the last few minutes of my son’s karate class and picked up cupcakes for my daughter’s class party. 

This is life. My life. Every day. 

And you know what? Despite any bitching and complaining that I do here, I really, really love my job. It is such an honor and a privilege to care for people, to be there when they need help. THAT is what keeps us going… keeps me going.

In truth, I’d do this job for free. Just don’t tell the suits that I said that. 😉

Cash Flow

Fountain at the Alamo in San Antonio

“You tell that doctor to write me a prescription for something affordable!”

*Click*

My medical assistant glanced up at me with a shocked look on her face. There was no need to repeat the conversation. I had heard every word.

“That does not make any kind of sense. It is a generic medication. It should only cost $40. Max. Call his pharmacy and find out what that med is going to cost him there.”

Later in the day I read the computer message that said it was going to cost $340 for a one month supply. Hell. I wouldn’t even pay that. 

I typed out a quick message and routed it back, asking why it was going to cost that much.

It is the brand name. If you want them to fill the generic you have to write for the generic. 

Except that I HAD written for the generic. I always write for generic. 

I sent back a stongly worded message pointing this out and telling them to fill the frickin’ generic. 

This was followed by a string of other patients with similar complaints all from the same pharmacy chain. Insurance companies refusing to cover prescriptions that patients had been getting without issue because the pharmacy chain was filling brand name instead of the generic option. It makes them more money. I would have never known this was occurring if the insurance companies had not denied coverage. 

From a drug coverage standpoint we love to hate on insurance companies but pharmaceutical company and pharmacy shenanigans are one of the reasons healthcare costs in the US are skyrocketing out of control. 

So I tell patients to be aware of what they and their insurance companies are paying for. If there are significant changes, please ask questions. Shop around to other pharmacies. The variability of cost from one pharmacy chain to the other is astonishing. AND, talk to your doctor. The only way I find out about these kinds of things is from patient complaints.

Just maybe don’t yell at my staff… 

Behind Your Back

Detail of building in San Antonio

So. 

One of the biggest time drains in my life is sorting through paperwork from insurance companies telling me that Mr. or Ms. So-and so is not filling their medication and therefore “likely noncompliant”. 

My question to you good people is this:

Do you want your doctor calling you to say your insurance company sent us this message and you need to take your meds, or else? Or do you prefer that we pretend that never came across our desk?

A Down Sizing

Mission San Jose in San Antonio

I see and touch an awful lot of breasts. 

Just about every “uninhanced” woman on the face of this Earth has one breast that is slightly larger than the other. I certainly do. As I age it becomes more and more obvious… the left is fuller than the right. Every time I put on a bra or look in a mirror, I am acutely aware of it and I wonder if other women notice or care about their subtle discrepancies in size. Not that I would ever bring it up in the clinic, mind you. That would be akin to your beautician asking if you want her to wax your upper lip… creates a paranoia if there was not one there to start with. 

Thankfully, I have never had a man look at my chest and run away screaming.

Every once in a while I come across a patient with a more dramatic mismatching, like the woman with one breast a cup size A and the other one a size DD. It created a serious self esteem issue. She had never had a relationship as she was terrified of anyone see her naked. She stuffed her bra with whatever she could find until someone sewed her a pillow to tuck in there instead.

Hey! Sugery can FIX that for you…

You would think this would be a no-brainer, but no…. Invariably the response from insurance companies on the request for augmentation or reduction is, “Not medically necessary.”

I always wonder who the people are making these decisions. Men? Women? If a man, would a woman make a different decision? Or vice versa?

I know the angst I have had over the years over my slightly different sizes. I cannot imagine the psychological burden carried by these women with their really noticeable differences. So what determines medical necessity? We allow breast reconstruction in breast cancer. Is is “medically” necessary? Maybe not. But it is psychologically necessary. 

So then, what determines something being psychologically necessary? What size disparity is traumatic enough to warrant coverage? One size? Two? Four? How do you measure something so subjective?

And then what else causing cosmetic angst should be covered? I had a mole removed from my face while I was still in med school. Right next to my left nostril. It wasn’t huge in real life but in my brain it covered half my face. Best thing I ever did for myself, getting that sucker whacked off. 

So, what are your thoughts? How is your breast size? What do you think about insurance covering breast augmentation or reduction? 

The Gate Keeper

Door of a San Antonio mission

There was something weird going on. I could not quite put my finger on it. Things just did not add up. I told the attending what I thought.

“Was he really asleep?”

“No.”

“Why did you feel that way? What did you observe?”

He steepled his fingers, elbows on the desk, staring intently at me over the tips. He waited patiently, expectantly for my answer, like Mace Windu the Jedi master. 

Why is he asking me this? 

I thought back to the shackled man in the orange jump suit who had sat in front of me. He was not answering my questions. Then, his head lolled to the side and a soft snore escaped his lips.

“The way his eyes were moving underneath his eyelids, his breathing.”

Back to the Jedi master, I watched his face for a clue. 

Was I right?

“Good work.” He nodded slightly, a subtle tip of his nonexistent hat. “Why did you tell me that you felt he was faking it? You could have just said the interview was cut short because he fell asleep and left it at that. That would have been an easy way out.”

“Seemed important.”

“So then why didn’t you try to ‘wake’ him up? Why did you leave him then?”

“Because he was signaling the interview was over. I didn’t think my pressing him was going to get me any further than I already was.”

“Trust your gut.” He spoke clearly, each syllable measured and distinctly enunciated. I could see that he relished this role of the guru, the sensei. “So then, if he is faking sleep, is he also faking mental illness? Is he really hearing those voices telling him to hurt people?”

“I don’t know. Maybe?” 

“It all paints a picture. Now you have to decide, do we keep him here or send him back to jail?”

Me? I have to decide? I’m the student for crying out loud! I don’t want to be the one to have to decide. But then…. this is what I signed up for. I won’t always get it right. I just have to do my best, right? The universe would sort everything out in the end.

“Well?”

“Send him back.”

He scribbled his signature on the paperwork and it was done.

I carried the weight of that with me for a few days. It was my first taste of what my decisions would mean for lives hanging in the balance.

Did I make the right call?

Later the attending told me that he had seen this fellow multiple times before and each time he presented with a different constellation of psychiatric complaints as an excuse for violent behavior. By then I had decided that forensic psychiatry was most definitely not for me…