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…

Power Lines

Power lines

“Hey, Doc. Remember me?”

I quickly glanced again at the name on the chart. He was a new patient. His name did not ring a bell. I squinted at his face. Dark beard and hair with some gray in it, a bit shaggy, but fairly well groomed. Lips. No. Then his eyes. I remembered the eyes from somewhere….

My heart caught and my fingertips went numb.

“How do I know you?” I asked, playing dumb. 

I knew good and well who he was. 

He smiled at me. “February 14th, 2016.” He paused a second to let it sink in. “That was the day you found me guilty of aggravated sexual assault and sentenced me to 10 years in jail.”

I quickly tapped a help message on IM to my office manager. 

“I don’t remember…”

“Sure you do, Doc.” He leaned forward close, too close, and spoke again in barely a whisper. “They made a big deal about who you were during jury selection. Got out a bit early. I had very, very good behavior. Not a day went by, though, that I did not think about what I was going to do to you when I got out. I have a very good memory.”

He sat up straight. There was a knock on the door and my office manager popped his head in. 

“This visit is over. Leave,” I rasped, embarrassed that my voice caught in my throat like a frightened fool instead of conveying strength and force. 

Damn.

A look of mock hurt crossed his face and he laughed. “Fine. See you around, Doc.” 

He sauntered out, slowly, pausing before rounding the corner to look over his shoulder and wink.

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

In case it needs clarifying, this IS a work of fiction. 

Showing Up

Empty barn at a livestock show

“Well, at least you will have some time off!”

I marvel at this well meaning sentiment because truthfully, jury duty does not feel like time off. It is more work than my real job.

First, I am spending hours on the computer trying to make sure patients’ results are communicated, orders and refills get sent, questions are answered.  I do this in the mornings before I go to court and at the lunch break if they give us enough time. I have a ton of anxiety… that someone is going to get hurt, that a patient is going to get upset, that a ball will get dropped. The office is terribly short staffed right now and I have to be out next week for my kids’ spring break. My jury summons could not have come at a worse time.

Second, while it is mind numbing, it is necessary to pay attention to everything that is presented so as not to miss the details. Someone’s future hangs in the balance here. It isn’t like I can sit in the jury box tapping away on my phone or reading a good book. I still have to focus on what is being said, boring or not. In the clinic I get to talk, interact with people, use my hands. Here? I am a fly on the wall, watching. Always watching. Never speaking.

My fingers and toes have frostbite. Why the heck do they have to keep the room so cold? So the one big man in robes doesn’t sweat while the rest of us freeze our asses off? A sweater is just not enough. I need a parka.

Here is something else: I don’t like any of my fellow jurors. They are annoying as all get out. What are the odds of selecting a room full of crazies? And what does that say about me, getting picked to sit here with them? Hmmm?

I hate that the judge and the attorneys have made a big deal over what I do for a living. “We have a doctor here, let’s pick on her.” I have to give my employment details on all of the forms. Why is it then necessary to announce to the entire court room who I am, what I do? They did not do that to anyone else. I hate the silly, ridiculous and even inflammatory medical statements people like the bailiff make around me as if they are wanting to goad me into weighing in, handing out free medical advice. It isn’t the free that I mind, it is the fact that I know nothing of their history and we do not have time to do a proper consult about their chronic cough right here, right now. 

This whole experience has been eye opening. 

Rant over. For now.

Chimera

Small white flower bloom

I read the chromosomal analysis.

Partial trisomy of sex chromosome… mosaicism…

Well. What was that going to mean? I needed an answer before I called this baby’s mom. She had been waiting anxiously throughout her pregnancy after the initial testing had showed a probable genetic anomaly. Mosaics are tricky. Some cells are normal. Some are not. The end result can vary. I searched everywhere at my disposal professionally. 

Nothing. 

So then I turned to Google. 

“Likely no developmental delays. No fertility issues. Phenotypically normal appearance.”

I breathed a sigh of relief. I was still sending them to genetics but I wanted to be able to reassure the family if I could. It had been a very emotional pregnancy.

And since then I have been thinking about this more and more.

Now that OB/Gyns are offering, and sometimes pushing, these more advanced genetic tests during pregnancy I wonder what it is going to mean for the babies as they grow up. We would have never known there was an issue genetically for this child 10 years ago. We just would not care. They would have grown up as a “normal” child. Now this kiddo will have “sex chromosome anomaly” hanging around their neck for the rest of their life. 

Is more information really better? Just because we can do something… should we?

Maybe not.