A touch of tenderness

This is a wonderful post about the importance of touch in life and death. Please pop over and read it if you have not done so already.

Sue Vincent's Daily Echo

The Cathedral by Rodin.

My son gleefully squeezed harder at the knotted muscle in my shoulder, with a ‘Now I’ve got you’ as I groaned in agony. We have established and agreed that he has a slightly sadistic tendency where I am concerned. It may have something to do with my knack of getting just the right spot on the painful muscles as we got his body working again. Day after painful day, for months on end. So now it is payback… and he appears to enjoy it. He still manages to lay the blame squarely on my aching shoulders, muttering something that sounds vaguely like ‘hereditary’.

He is a little more squeamish than I. His face screws up in horror as my wrist bones crunch back into place when he applies traction. It is, however, nice to regain freedom of movement occasionally. So I make him do it…

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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…

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.

Games Played

Pelican on the water

“The staff doesn’t like you. They are all scared of you.” She sat across from me, feigning concern.

“Why?” I felt my face redden and struggled to keep the emotion under control.

“They just think you are too demanding. You should stop talking to them. Let me handle it for you so they can be mad at me.” 

Too demanding? I was not being ugly. I just asked the front desk to check on a patient’s insurance coverage. How could that be construed as anything but an honest and necessary question so I could take better care of a patient? 

“If you have a problem, come to me and I will take it to them.” 

And with that I was not supposed to communicate directly with my staff anymore. Because they feared and disliked me. The practice administrator over her and HR supported this she said. 

Whatever. 

My head reeled. She left. I closed the door and had myself a good cry.

Unbeknownst to me, that office manager was telling the staff that she was the boss, not the physicians, that they should stop taking their concerns to us. If there was an unpopular decision the staff was told that it came from the docs even if it didn’t really. If it was something good, she told them that she had done everything in her power get us to reluctantly agree. She lied and lied and lied to the staff about everything.

If you have been reading my blog posts for a few years you may recall the angst of this period of time. How could I be doing the same thing I always did but now all of a sudden everyone thinks I am the bitch from hell? Is it really that I am so evil? Or is it that I am woman and as such people are taking everything I say and do and twisting it into something I am not? If so, why now? 

What was going on?!?!!??!!

I had this niggling suspicion, as my staff continued to leave the clinic one by one, that my office manager was not supporting the physicians or the staff, that there was something else going on to which I was not privy. I reached out to upper management and they listened for a change. Within a couple of months she was gone. It was startling how quickly that occurred. Typically there is a huge HR process and blah, blah, blah. At the time I felt guilty, terribly guilty, blindsiding her with it when HR showed up to escort her out of the building. I worried that I had destroyed her career. 

Yesterday I found out that there was an investigation going on, that each employee who had left the clinic during that period of time was approached by a contracted firm for statements as to why they left. The investigation supported what I was saying which was why upper management moved so quickly. But no one ever told me this occurred. I found this out from one of the employees that we rehired. 

In fact, virtually everyone who has left this clinic has asked to come back at one time or another. On some level I knew it was not really me but how to rationalize that with what I was being told by an office manager that I trusted?

That whole period of time really messed with my head.

Friends and family started to doubt me. Hell, I doubted myself. I questioned my judgement. I questioned everything. In the end I realized that I had to let it go. All I could do was what I thought was right and I found my peace with that. While the maelstrom swirls around me, I can stand upright knowing I am doing right. In that respect the whole experience has been invaluable. I care so much less what people think about me. 

Just do what is right.

I have been back to communicating directly to my staff again for over a year. The practice administrator last week complimented me on my “level of engagement with the staff,” saying that everyone always had positive things to say about me.  

Ok. 

But I am doing the same thing I have always done. Maybe it is just the tequila I keep in my office?

‘Tis the Season

Dried flower

There was a time I believed that the longer I was practicing medicine the easier the dying would get. Practice or callous formation, call it what you will. I just thought it would be easier.

That is not the case, though. 

These long standing relationships, the people I see for years and years, are the hardest to part with even when you are expecting it. It still hurts. And with each passing it brings me closer and closer to my own end.

This is the dying season, it seems, those couple of months after the holidays when everyone who was holding on is now ready to let go. 

Everyone but me. 

Not yet, anyway…

The Light At The End Of Your Tunnel

Torpedo tube on a submarine.
The floodgates open

Murky waters flow

In preparation 

For an invasion 

Down below

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

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Katrina

Calm waters
“He needs a letter saying he’s disabled so he can get his check. All of his medical records were destroyed.”

His mother handed me a newspaper article clipping with a man of similar height and build pictured. It told of all of his physical disabilities and how he was working to conquer them. A journalistic fluff piece but now they presented it as proof of his condition and identity. 

“He can’t talk and he has to use the cane.”

“Why?”

“He had a stroke.”

“Which side did it affect?” 

“What do you mean?”

“Which side of the brain did it affect?”

“Both sides.”

Odd thing to say but it was not impossible and then sometimes people don’t really understand their medical conditions. I wanted to give him the benefit of the doubt but a nagging in my gut told me there was something not right. Was I being too judgemental? After all so many people had suffered so much.

Even stranger was that while there was some resemblance to the man in the article photo, they actually appeared to be two different people. I checked the date on the article. Five years. People age, they change with time. This man, though, appeared to be younger than the fellow in the photograph. Furthermore, when I did my exam, he was very clearly faking weakness.

“I am sorry. I cannot write that letter.”

“What? So what is he supposed to do without his check?” Hostility crept into her voice then progressed to outright indignation. “We lost our house, our money, everything we owned. We waded down the street past dead bodies. You have no idea what we have been through.” 

She was right. I had no idea what anyone in New Orleans had been through. Had they actually been there, though? I had no way of knowing for sure. I wanted to give everyone the benfit of the doubt but after several of these, I found myself becoming bitter and jaded.

“Let me send you to a neurologist who has also volunteered to see evacuees for free. Maybe he will have a different opinion….” 

“Forget it!” she yelled back at me.

They both stood and exited the room. I stared after them. He didn’t even bother to maintain the pretense of using the cane at this point.

This is what I remember about Hurricane Katrina… all of the people using the disaster and the very real suffering of hundreds of thousands to further their own interests and the feeling that nothing I did ended up helping a single soul.

Take Me Higher

Entrance to St. Peter's Basilica at the Vatican.
The young woman glanced down at the distinguished, gray haired gentleman propped up on pillows as she hung the bag of potassium from the IV pole at the head of the bed. 

He was more handsome in person than he appeared on TV, she decided.

“This might burn going in,” she murmured. “The computer says your level was a smidge too low.” They were piloting a new AI program that made treatment decisions instead of doctors. It was said to be more effective and more reliable, better outcomes.

The patient looked up at her from his newspaper and nodded, winking. “Thanks for the heads up.” A great wracking cough rattled through his chest at that moment, leaving him gasping for breath. He sat down the paper. There was his face on the front page in an article talking about his admission to this very hospital for pneumonia.

“That sounds… better?” It was a statement and a question. She looked at him hopefully.

“Oh, believe me, I do feel better than I did yesterday.” He spit out the great glob of yellow phlegm that had caught in his throat, then wiped his mouth.

“On the mend, then!” She smiled down at her VIP patient. Her shift was approaching its end and she felt some degree of melancholia about that. Rubbing elbows with the rich and famous was quite fun.

Illness was the great leveler, after all.

She couldn’t wait to tell her fiancé! 

And her mom. 

And her best friend. 

Technically she was not supposed to tell anyone about this fellow, privacy laws and all that, but how could she be expected to keep a secret like this? She had really met him, spoken to him, touched him. The part she would not tell anyone about was the number in her pocket. He had slipped it to her after telling her she was beautiful and that he would like to hook up sometime. She patted her scrubs absently to make sure the paper was still there. Not that she would ever take him up on it, mind you.

Power was sexy…. but phlegm? Not so much.

She walked out of the room and back to the nurses station where she charted her activities of the past hour or so in the EHR. She caught sight of the man’s wife getting off an elevator and she found herself watching with envy. The woman was beautiful in a way she herself could never hope to be. His wife walked purposefully, a blue coat draped elegantly over her arm, a slight smile curled on her lips. No one at the hospital had ever seen her smile before. They were all warned to stay out of her way.

He must have called to tell her he was feeling better.

The nurse glanced back at the computer screen. There was a new order for another six bags of potassium for the fellow in room 432. 

How odd.

A quick check of the blood test results reassured her. His potassium level was indeed very low.

She checked her watch. It would be another 30 minutes before she could hang the next one. The next shift would be kept busy, that was for sure.

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

The papers and news stations all shouted about his death. Across every front page. Leading every news program.

He was dead.

She couldn’t believe it. How? He was getting better.

Then fear. 

Did she do something wrong?

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

The voice on the other line spoke a greeting in Russian. 

“It is done?” she asked.

“Da,” the voice said gruffly then hung up.

She smiled to herself as she dropped the burner phone into the crackling fire and poured herself a glass of champagne.

Yes. Of course it was done. A simple hacking right under their noses and no one would ever know. Cardiac arrest from a potassium overdose. In the hospital. They would do everything possible to keep it hidden if it were discovered. No one wants to be the hospital that killed someone like him…

It was a beautiful, elegant thing.

There would be no other women.