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. 

Split 

Room in the Metropolitan Museum of Art in NYC

Shadows watched from the corners of the room… ever present, ever vigilant. 

She waited.

Footsteps in the hallway. Raucous laughter. 

The door flung open and he stumbled in, drunk, clinging to the arm of a woman.

Who was it this time? 

It was hard to see clearly in the dim light. 

Her.

Their eyes met for a long moment. Silent words passing between them. Then she turned her attention back to him, allowing him to undress her. He fumbled. The process took much longer than it should have. 

Naked.

She glanced at the mirror again, seeing the other woman once more, the one who looked like her but was more charming, the one whose laughter came more easily. She was the one who was not ashamed of being naked, the one who demanded love and attention from everyone.

The drugs made her beautiful and charismatic. She knew the flame could not burn this high for very long. It would go out soon, extinguishing her in the process.

But it was worth it. 

Every day was worth the price to avoid the loneliness again.

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. 

A Supporting Role

Bridge in NYC

“She just won’t eat healthy stuff! If I give her a cupcake and some broccoli she always eats the cupcake.”

“Think back to when you were eleven. If you have a cupcake and some broccoli in front of you, what do you pick?”

He shrugged. “The cupcake.”

“Right? Me, too. We’re not idiots. We pick what tastes best to us. As kids that’s the sugar. So you cannot put them both in front of her and expect her to pick the broccoli. That’s just cruel. She’s eleven. YOU have to make that decision for her until she is able to make it on her own and that is not going to be for a great many years. Get the cupcakes and junk out of the house. She is beautiful no matter what size she is but you and mom both have diabetes so she is at higher risk herself. Be the parent. Don’t sabotage her. Help her learn healthy habits that will last the rest of her life.”

We had this conversation every summer for five years running. Each year the same thing, like it was her fault. But this time? This time, somehow, was different….

This time he listened.

What made the difference? I don’t know.

It gets discouraging, saying the same things over and over again. There are days when I open my mouth to say, “Stop smoking!” for the millionth time and wonder if there really is any point. You never know, though, when the seeds you sow will fall on fertile ground and take hold. 

With a Prayer

St. Patrick's Cathedral in New York City

I have prayed out loud with a few patients over the years at their request. I will admit, however, that I am personally very uncomfortable with public displays of my faith. I am not sure my prayers carry the weight and power that some people believe that they should. I feel somewhat hypocritical for that reason, as if I am selling a faulty product. 

That being said, I do pray privately for patients on a regular basis:

Please, God, protect my patients from my mistakes. Help your love for them to show through me…

When I pray for others, do I believe I am swaying God in any way? Not really. Prayer is not so much about others as it is about me, a sort of mindfulness. I need a reminder that I am a fallible human being and that I must demonstrate compassion to those who are vulnerable. I struggle with that from time to time, just like the next person. 

I could write a book on the various things people do to bargain with their God when they are desperate and in that respect I am just like them. I have my own rituals and my superstitions, my own pleading bargains that I have made. Some may mock me for that. 

Faith, though, keeps me sane. 

And that is good.

Salvation is Near!

There is nothing like prying your kids off of each other for the fifteenth time before 10AM to make you question your parenting skills. 

And your sanity.

We are on day five of me at home with my kids. I don’t have anyone reliable to watch them when they are out of school for the holidays (there is entirely too much time off of school nowadays if you ask me 😉) so their father and I split the time. Currently, it is my turn. Tomorrow I get to go back to work for a few days.

Yippie! (You didn’t hear me say that…)

Stay at home moms, I don’t know how you do it day after day, week after week, month after month. Honestly, I am not as strong as you are. I am beginning to think I look pretty sexy in sweats. That’s right. Not to mention the fact that all of the cookies I have baked have snuck off to hide somewhere… I couldn’t possibly have eaten all of them. AND I am talking to rising bread dough as an equal. 

All of this has convinced me that I am a much better parent in smaller doses. I had suspected this, but in the past my kids still napped. 

Now they don’t. 

So. 

I say all of this to say that if you hang with your kids all day every day and still like them and yourself, you have my respect. I send you a virtual fist bump of solidarity. 

Meanwhile, I am going to quietly sneak off to pack my work bag for tomorrow morning so as not to draw the attention of the angry hoards demanding that I fold yet another origami frog.

Woohoo! (You didn’t hear me say that…)

Reading Into Things


“I don’t want to see the oncologist you referred me to. I checked the online ratings and he got some pretty bad reviews. Find me someone else,” the phone message read.
The patient had multiple myeloma. The specialist I had picked was the best in the area for this condition. I had no idea what the reviews said. I just knew that this patient wanted to live. 

No amount of discussion would dissuade them. Even when I explained why I had chosen this specialist.

What do you look at when you are trying to pick a physician? What qualities are you looking for in a physician? Skill? Personality? What is the most important to you? How do you as a patient measure what is important? 

An interesting article I read the other day in the Journal of Medical Internet Research looked at cardiovascular surgeons in five states that allow reporting of outcomes data and compared the risk adjusted post-operative mortality rate with that physician’s online reviews from patients. 

Guess what?

There was no correlation. 

Now, here is something else provocative. In USA Today there is an article entitled, Don’t Want to Die Before Your Time? Get a Female Doctor. It is referencing a study published in JAMA today that found patients in the hospital who had female physicians were more likely to survive and less likely to be readmitted within 30 days of discharge.

“The researchers estimated that if male physicians could achieve the same results as their female colleagues, they would save an extra 32,000 lives among Medicare patients alone each year — a feat that would rival wiping out motor vehicle accident deaths nationwide.”

Practice differences between men and women translate into real, measurable differences in outcomes.

So, when we talk about income disparity between male and female physicians, one recent study showed that women are paid on average $20,000 less per year than their male counterparts

What a bargain, huh?

Getting Harder

Forge and anvil in black and white

“Doc, I just want to die.”

I nodded my head sympathetically. At a certain age, all patients say that. She was in her 90’s…. 

“I am so tired of hurting.”

She groaned and worked her way through her usual litany of aches and pains starting at her head and working all of the way down to her toes. She had pain medicine she could take for the arthritis so I knew that wasn’t really the issue. Not all of it, at least.

“I pray every day that the Lord just takes me away.”

She’d had a gentleman friend at the center. For a few months she positively glowed. He sent her roses for Valentine’s Day, bought treats for her little dog, left her love notes, told her she was beautiful. Never mind that he was twenty years younger than she was. 

At that age, what does twenty years mean? Nothing. It means nothing at all.

“I think they might be having sex…,” her granddaughter said. “Can’t you make them stop?”

My patient was not demented. She was not handing over her life’s savings. She was a consenting adult in an assisted living community who met another consenting adult and while there were significant physical challenges to a sexual relationship at her age if she really were having sex, who was I to meddle?

Then, he died. 

Here she was, left behind again. Sure, she had aches and pains but the real issue was this last man standing thing, or in her case last woman standing. She had already buried two husbands. Now this man. She could not bear to lose anyone else.

But what do you do? Give her a pill? Tell her to get counseling? Pat her on the hand and tell her the sun will come out tomorrow? What do you do for a grieving woman in her 90’s who wants to die but is not suicidal?