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…

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 ūüėČ) 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…)

On The Clock

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I felt as if I had been kicked in the chest. My face flushed. We were in the midst of a staff meeting, going over the patient satisfaction surveys as mandated by corporate. I was fresh out of residency, trying to make a good impression…

“She didn’t spend enough time with me and didn’t answer any of my questions.”

The truth was, I knew who wrote it. The surveys are not anonymous…. Not really.

Over the previous month I had spent about 45 minutes with her. Twice. I was only supposed to spend fifteen. Each time, after we had worked our way through her list of 7-8 items, I summarized the plan and asked if there were any questions.

No, she said, she didn’t have any.

After the initial embarrassment wore off, I felt defensive. Angry. I tried to explain the circumstances to everyone in the room. I wanted them all to know it was not my fault…. All of the other docs in the room just nodded their heads in supportive understanding.

This was my introduction into one of the many laws of medicine:

It is always the patients that I spend the most time with who are the ones who feel I have not spent enough time.

A wise friend said recently, “With certain patients I have found that the visit will end the same whether I spend five minutes or an hour so I try to keep it closer to five minutes for those kinds of patients.”

I will admit that I, myself, am terrible at cutting people off. 

When patients are upset about how long I spend with them, generally speaking, it is not at all about time. Not really. There is something else going on. A personality conflict perhaps. They don’t want a collaborative relationship with their physician, instead they want to be told what to do. Or maybe they want to tell me what to do. They want a solemn, quiet physician and not someone who laughs and smiles and uses their hands when they talk. Maybe they have unrealistic expectations or a past history of bad experiences with other physicians that has left them with trust issues that I cannot break through.

For many years I struggled with this. I wanted everyone to like me. I am competitive. I wanted perfect scores on everything. In the end, though, I finally realized that I cannot be all things to all people. I pick what I am good at, try to help as many people as I can, accepting that sometimes I won’t be that patient’s favorite person. 

All I can do is my best and make sure that patients understand that I care even if I am ultimately not the right doctor for them.

He Had Balls

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I don’t remember for sure what grade I was in. Second? Third? All I know was that I was once again standing alone outside at recess, shivering in the cold, watching everyone else play with their friends. I had wanted to play soccer but as they were choosing teams no one picked me. I was left behind at the edge of the field trying to pretend that I didn’t care. 

There was nothing else I could do by myself so I stayed to watch with the familiar lump sticking in my throat.

Don’t let them see you cry.

One of the boys left the field and came over to me. I had never really paid much attention to him. Boys had cooties, you see. He was nondescript. Perhaps a bit stocky. Brown hair. Freckles. These things I remember only vaguely. I am not sure we had ever actually spoken directly to each other before.

“You know why they don’t pick you?”

“No.”

“Because they think you don’t know how to play. Do you know how?”

I started to nod my head yes then decided to be honest. “No.”

“I will teach you, then.”

And he did. Over the course of the next few recesses, he taught me the rules, how to kick, head butt… everything. 

He did it in spite of being made fun of by everyone else. He was playing with a girl. 

He was playing with that girl.

They still didn’t pick me for teams. They still all made my life miserable. But now I knew how to play soccer because Craig Mercer taught me. That made me somebody. 

I don’t think we ever really played or talked much together again after that and I don’t remember if I ever said thank you. I have no idea where he is or what his life is like now but I will always, always remember his name.

Another Post

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This morning I saw three patients, ran to my kids’ school Christmas program for an hour and a half, then ran back to the clinic and saw more patients. 

At the time this gets posted I will be having lunch with the office staff for our Christmas party: exchanging gag gifts and eating some terribly unhealthy, yet super tasty, fast food salads. You see, salad is a ranch dressing delivery system in the South (United States)…. And being a doctor’s office, we like to at least pretend we are healthy, even at Christmas.

I got off topic. Sorry.

To be honest, I felt terribly guilty about taking time off for my kids’ school program. I wrestled with it for a couple of weeks when I learned of the change in time (it was supposed to have been last night). This time of year the clinic is crazy busy and those slots were already booked weeks in advance. I HATE making patients reschedule…

Sometimes I *think* I am a better person than I really am, though. I told myself it was all about the patients. That IS true to a large extent….

AND YET, while I love and adore my kids, probably to a fault, I realized last night that I would NOT feel as guilty playing hookie to go see Star Wars *if* I had tickets for today. I am not saying that I would have no guilt. Just less guilt. I don’t have tickets but if I DID I would probably even have ditched the school program for it. You can judge me if you want, but those school programs are beatings and, well, Han Solo is still awfully darn sexy.

Act Three  

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I peered into the scratched up blue and white metal Holly Hobbie lunch box.

Please, God, can I have something good? Just this once?

“Hey, can you move down two seats?” It was a freckled classmate with braids who spoke with a lisp due to a cluster of missing front teeth. It was not a question, really. It was a command.

She was mean.

So I moved.

I opened the lunch box again. There were three thin slices of something resembling turkey sandwiched between two slices of soggy whole wheat bread. There was a single leaf of semi-wilted iceberg lettuce to give it some color. I sighed as I pushed it away.

Not even edible.

I would have to figure out a way to sneak it into the garbage to avoid trouble at home for uneaten food.

“Hey, why don’t you move down another seat?” It was a dark haired girl from my class. She glared at me. “I want to sit with my friends.”

I moved down two seats instead of one just to be safe.

My stomach grumbled. The thermos. There was always milk but it was probably room temperature by now. I sniffed at it, then tried a sip just to see.

Gag.

I screwed the top back on.

“We need some more room. Can you move over again?” There was a group of three girls standing over me with their hands on their hips, laughing. Were they laughing at me? One feigned concern. “You don’t mind do you?” She flipped her hair.

I shook my head no, then sighed again quietly as I scooted once more.

Maybe there was something under the napkin? A cookie? I lifted the paper. Nope. Celery. Yippee. The worst vegetable in existence right here in my lunchbox.

Cookies never happen to me anyway.

There was a tap at my shoulder. I turned to find the freckled toothless girl with braids standing there again. “Move.” She pointed to an empty table behind us.

I nodded and closed my lunchbox. The lump in my throat was going to keep me from eating anyway. I moved to the other table, closed my eyes, and put my head down on the cool surface to wait until the bell rang.

“Is there a problem?” Someone touched my shoulder.

I looked up to see a teacher. She looked angry.

“I’m fine,” I lied.

“You should be sitting over there with your class.” She indicated the table I had just vacated. There was still an empty seat.

“They don’t want me there,” I replied quietly. I didn’t want those girls to overhear and give them any satisfaction in my misery.

“What?”

I cleared my throat a bit and tried again. “I said, they don’t want me there.”

“Then sit up straight,” the woman barked before walking away. 

I sat up straight.

If I could talk to that little girl, I would tell her it will all be OK, that the story works out just fine in the end. She will find her shoe, that one shoe that will change her life forever, and with it she will see the world.

Bummed

  

“Doc, my knee has been bothering me for a few months now. It began when I started doing lunges in crossfit.”

“Did you stop doing crossfit for a bit to see of it would get better?”

“No.”

“Have you been taking any antiinflammatories?”

“Uh, no.”

“Icing it?”

“Well, no. I know I should do all of that, Doc, but I just haven’t.” Cue nervous laugh. “Can’t you just fix me?”

At this point, invariably, I laugh back good naturedly and say, “Well, guess what we are going to start with first…”

It struck me the other day while listening to some audible crepitus and wincing with pain as I took the hotel stairs because of a nonfunctioning elevator, that I have been nursing my own bum knee for a few months. Of note, I have not been resting it or icing it or taking any meds. I still sit at my desk and vigorously pedal away on my mini-elliptical contraption while I am doing charts every day at the clinic, even though the pain and stiffness are more pronounced when I stand up afterwards. Even though my knee is not getting better. It is, in fact, getting worse.

Sometimes I even limp.

So I considered this fact for a moment. Why am I engaging in the very same behavior that my patients are exhibiting that drives me nuts? I should know better, right?

Denial. I don’t want to admit that I have a problem, so I ignore it. Because to have a problem means I have to accept my own finite existence. Surely it will just go away? Eventually?

Time. I am too busy. I do not have spare time to spend taking pills and applying ice. Maybe I should actually call it Lazy.

Stubborn. I am too tough for this to really affect me. Pain? I scoff at pain. 

Fear. What if I really do have a problem? Surgery? Knee replacement? OMG. How will I burn calories if I cannot exercise while I work? Will I gain weight? How will I find time to do some other form of exercise?

Attention. “Doc, what happened to you?!?!!? Why are you limping? Here, let me help you with that…”

So, ok. Now I understand. It just took some time for my smug, know-it-all self to live this so I could truly appreciate and respect the nuances at play here. 

Lesson learned. 

Sort of…

Do you know what I am doing right now as I type this out? I will give you a hint: It does NOT involve ice or pills or rest. I am pedaling on that damn elliptical machine.

Alright, alright! I am stopping now. Well. Maybe. I’ll just slow down. Some.

Shuttered

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I have had a number of nurse practicioner students come through my office over the years. I love to teach even though it is very stressful, patient satisfaction scores drop, and my production takes a hit. 

It is very frustrating, given this, to take on a student weeks from graduation who cannot tell me what is an appropriate oral antibiotic for strep throat or if an EKG is abnormal or not. Worse, they do not seem to care to learn.

After turning down multiple students so far this year, I finally agreed to take on another one a few weeks ago:

“What is your differential diagnosis for chest pain?”

Blink. 

“Tell me the current PAP guidelines.”

Shrug.

“What antibiotic would you choose for community acquired pneumonia?”

Blank stare.

“When do you graduate?”

In a month.

I realize that this may stir some controversy. Let me say that there are some really great nurse practicioners out there. I have met them. I have learned from some of them. There is a great role for NPs. 

Yet, each year the students I am getting sent to me seem less and less equipped to handle the responsibility they are about to assume. There is a wide range of skill level in physicians, too, but it is particularly frightening that these people will be wielding a virtual prescription pad in a matter of weeks. I get students from three different schools and it is not just one that is the issue. It is all three.

I am not sure I can keep doing this…