Infertility 

Ellis Island hospital

Graciously bestowing 
You spilled your precious seed
Upon my barren ground
Ignorant and unknowing
An unfulfilled wanton need
Your attempt at marking 
A territory unfound
Traversing the open sea

The ownership unclaimed
My body left untamed
Believing you were deceived
I’m naked beneath the gown
Empty loss echoes down 
Long abandoned corridors
Infertility finally decreed
By the sterile orators 

Devoid of progeny 
The solemn sodomy
Repeats itself again
Another painful bleed
An unwelcome visitor
Testifing silently
Before the Inquisitor
Sounding the final amen

A viscous self loathing
Clogs the rusted plumbing
Magnified through your eyes
Value is forever drowned
Held down by a flood of lies
I’m merely something to breed
A conduit for birthing
Your immortality 

Proximity

Pizza shop in New York City

“I need to do a six month physician supervised weight loss program before I can get the gastric sleeve covered by my insurance.” She wasn’t even that heavy to start off with, her BMI was 32. She wasn’t diabetic and did not have high blood pressure. 

“You are going to be married to a fistful of vitamin supplements for the rest of your life.”

“I don’t care. I am tired of being fat, of having people judge me.” I understood. People can be so cruel. “My friends have all had it done and they look great,” she said hopefully. “But I can’t loose too much weight right now or I won’t qualify anymore…”

We both knew she had no intention of really trying. 

Sure enough she demonstrated a nice weight gain at each visit and steadfastly refused to count her calories or exercise or do anything except to say, “I’m cutting back, Doc. Really I am. I don’t know why I keep gaining this weight!” 

I don’t know why that sort of thing qualifies someone for surgery. A barbaric surgery with lifelong consequences. Sometimes I wonder about the ethics of the surgeons doing these things and why there isn’t better after care for people undergoing the knife. Cut them up and then cut them off seems to be the plan across the board. 

She had her surgery. 

Three years later her weight was back where it started from and then some and she wanted a referral for a surgery revision. 

I wanted to say, “I told you so.” And then I wanted to call her surgeon up and give him a piece of my mind.

But I didn’t….

A few weeks ago I was at one of those giant outdoor malls. There were easily 20-30 restaurants clustered around. Right there in the midst of it all there was a weight loss clinic. 

Having just eaten at the Melting Pot myself I was so stuffed it was hard to breathe. Way too much food to be healthy but then why didn’t I just stop eating? I was too focused on not wasting anything. Getting my money’s worth. I blame my upbringing. I blame past poverty. I blame portion sizes. 

I blame myself.

Where does that come from, anyway?

At first I was offended that this clinic placed itself where it did. Then I realized it was a brilliant marketing strategy. This is what we have become, isn’t it?

Binge. Purge. Binge. Purge.

Binge.

“How’s your daughter?”

He smiled and pulled out his smart phone, flipping through pictures of a grinning, curly haired toddler. They’d had so much trouble having a baby. 

“Oh, she’s beautiful!” 

He nodded, beaming.

“How is your wife?”

His face changed in a instant. He looked stricken. “You knew she had the gastric sleeve done?”

“Yes, I had heard.”

“Well, she developed Korsakoff Syndrome.” Oh. Wow. “She got confused, couldn’t remember things. Couldn’t walk straight.”

Thiamine deficiency.

“When she said she wanted to get the surgery, I didn’t say anything. I just wanted her to be happy. She suffered so much emotional turmoil over her weight. We had no idea something like this could happen, though. If I could go back in time I would tell her she didn’t need to do it. That I loved her just the way she was. Now she is not the same person. She has to carry a book with her to write everything down since she has so much trouble remembering things and she uses a cane to get around.” 

“Mommy, I’m thirsty!”

It was swelteringly hot. I stood in line to get our fifth soda refill of the day in the $15 red amusement park drinking bottle I had purchased earlier that morning.

*Free* refills on Coca-Cola products all day!

I don’t need Coke products. My kids don’t need Coke products. Water would do just fine to keep us hydrated. But STILL…. I paid $15 for that stupid cup since I could not bring anything into the amusement park. I want to get my money’s worth, dang it. A small bottle of water costs $4.50 a pop multiplied by at least five times per person per day… but soda pop in the big red drinking bottle? Yeah. What is anyone going to pick?

So here we are.

Making money by making people fat. Making money to make people skinny again. Making money getting them fat again. Making money to get them skinny again.

And so on.

It does not ever stop.

How do we make it stop?

Emergencies 

Sunset reflected in a road puddle
“I want a wart removed this Friday”

“The doctor does not have any openings for a procedure this week. We are short staffed and she is completely booked. We can get you in on Monday if you like.”

“I am going on vacation next week. The doctor always accomodates me! You tell her I want to have this removed on Friday.”

I do try hard to get people in when they need it. But sometimes…

Honestly, it has been a rough week. 

With one of my partners out, our nurse practitioner out, AND it being the week before school starts back for many kids in the area… the clinic has been crazy. Finding time to blog/breathe/pee has been hard to come by.

“Fine! You tell her I am finding another doctor.”

It is like this every year. 

Next week it will be a ghost town around here but for now those emergency wart removals are killing us. 

Past Pains

Ruins of the Ellis Island Hospital

A deafening shriek reverberated again off of the tiled walls and metal tables, the sound of pain and fear made all the more palpable as it echoed around the cold, hard surfaces and magnified until it shook the very core of anyone listening. 

The staff inside that room did not make eye contact with each other over their masks. To acknowledge anyone’s humanity, even their own, would only serve to distract from the task at hand.

*****************************************

This is another shot from inside the ruins of the Ellis Island hospital. Several areas contain art by JR, a French artist. Generally speaking, I prefer my ruins untouched but this image seemed to enhance the spooky feel rather than detract from it.

It is disconcerting to stand in the empty rooms and corridors imagining the hustle and bustle of a busy hospital. There are times you can almost feel the brush of someone passing or hear the echoes of fear and hope whispering off of the crumbling walls. 

I ran into some photos of the hospital taken in areas that I did not get to see when I was there and it makes me want to go back, to somehow have more access. I wonder what that would take? 

Have you ever felt drawn to a place in a way you cannot explain? 


Getting the Worm

Flowers in the NYC Metropolitan Museum of Art

“Mommy? Can I go potty?” 

Her voice pulled me out of a deep sleep in the midst of a nightmare about a movie set with Nicole Kidman and a patient who ran a telephone ministry dial-a-prophetess line. The movie was to be a psychological thriller. The prophetess had just robbed me of money and souvenirs I had pilfered from the set. I am not sure what a dream like that says about my life right now…

“Sure, baby. You don’t even have to ask, you know.” I have lost count of how many I times I’ve said this to her. 

“Ok!” 

I heard her skip down the hall to the bathroom. I glanced over at the clock. 3AM. I would have groaned out loud but that would have taken too much energy.

A minute or two later…

“Mommy, I wiped but I didn’t flush because I didn’t want to wake anyone up.”

“Thanks, sweetie. Go on back to bed.”

“Ok!”

And I heard her skip back down the hall to her bedroom.

Sleep? For me, it was gone. Just like that I was turned into the early bird. Too bad I don’t like worms.

Shopping Around

Macy's in New York City

“She doesn’t have physical exam coverage and her insurance only allows three office visits per year. No lab coverage. No preventive care coverage. She needs her blood pressure and diabetes meds refilled but she cannot come in for a physical.”

I’ve seen this a lot lately.

“No problem. Tell her to come in for a regular office visit so we can at least check her blood pressure. I will code a 99214 and she may get a 30% discount off that as a cash pay patient. I can send her to a discount laboratory for labs that will save her hundreds of dollars. In October she can get a $99 mammogram at one of the local imaging centers. Her flu vaccination she can get cheap at the health department. We will just have to postpone her PAP another year.”

So she came in….

Crying.

“I pay over $700 a month for this insurance.  I work for myself and with my diabetes no one will cover me otherwise. I can’t afford anything else. They told me that all of my doctors were covered and my meds were covered. They lied.”

She did not read the fine print. Not that she really had any other options available to her… 

It used to be like this ten years ago. People with expensive but essentially useless policies. Here we go again. Now, at least, I have access to a discount laboratory. 

Depressions

New York Public Library entrance

“I see from the medical assistant administered PHQ-2 that you have been feeling down lately. Tell me about that.”

“Uh, I am here for my knee. Why was she asking me about depression?”

“Well, we want to put a focus on mental health, you see…”

“What about my knee?”

“We’ll get to that at your next visit. Right now all we have time for is delving into this positive two question depression screen.”

“You guys never did this before.”

“I know. But here we are. Better late than never. So are you thinking about killing yourself?”

“NO!”

“Should we put you on medication?”

“I don’t like drugs.”

“Counseling then! Good choice. I’ve got a list of counselors in the area…”

“I am not paying for counseling and I haven’t got time for it in the first place. My knee is what is getting me down.”

“Yes, well. Come back in two week’s time and we can talk about the knee.”

*****************************************

That wasn’t real. But it could be….

The healthcare organization I work for is now measuring my quality based on my medical assistant asking patients questions about depression once a year right before they check the blood pressure. 

I have yet to have a patient say this was a good addition to their rooming procedure but that is beside the point. Why are we focusing on this in the first place?

To save lives.

Personally, I hate questionnaires. They are an attempt to oversimplify a very complex problem. Can we really put depression into a box? Should we?

If the PHQ-2 is positive it should be expanded into the PHQ-9. The PHQ-9 should be used to monitor response to treatment. 

I much prefer a conversation with a patient to reviewing a questionare. I can tell, usually, when a patient is having a hard time but even if I can’t I still ask once a year at the physical as part of my review of systems. And if they say they are having problems I pry, by golly. Are we talking about a chemical imbalance or did their mom just die? Is it affecting their ability to hold a job? To take care of their family? My medical assistant shouldn’t be the one asking the questions. It should be ME. That is my job. Which then brings me to documentation. Make it easy for me. Don’t hide it on a different screen. My review of systems documentation should be sufficient shouldn’t it?

It frees the physicians up to do other more important things.

What is more important than mental health? But then, I wonder, are we perhaps overemphasizing it on some level, too?

When we made pain into the “fifth vital sign” we created a whole population who became focused on feeling no pain, a pharmaceutical industry happy to create addictive drugs that prevented anyone from feeling pain, and physicians caught in the middle. Ultimately, the prescription narcotic addiction crisis was the unintended consequence.

So I worry that we will over diagnose depression. I am not sure that assigning labels like that is all that helpful for most people. I worry that those who are truly ill, who need the most help, will be pushed out of an already failing system that becomes glutted with everyone else. I am already seeing this trend. Making my very ill patients wait three to six months for an appointment with a reputable psychiatrist is unacceptable but it is par for the course nowadays.

The mental health system in the US sucks and that’s the truth. It especially sucks around here. There is a dirth of good psychiatrists in my area. Same with counselors and psychologists. What are we supposed to do? Should we as primary care just push drugs on everyone? Drugs that have side effects and risks and which are not appropriate for all patients? Who then will manage those drugs? Me? With very minimal training? And if we push drugs but cannot effectively pair it with counseling support, what have we accomplished? We are supposed to help, to make people better aren’t we?

I’d really like to know YOUR thoughts…