My husband and I made one New Year's Resolution for 2014 together: to have friends over for dinner more regularly. Whenever we do, we love it, and the kids have a blast. However, it has always seemed like a lot of effort to coordinate, to clean ("clean" underestimates the amount of prep our house needs to be able to be opened to the public), and it's just so much easier not to do it. Plus, we're introverts. Now, it's not like we are hermits or anything (although I don't really know what a normal social life with a family is), but we both agreed that having people over more would be good for our whole family. I'd estimate that last year we probably had people maybe 4 or 5 times, but we are aiming to host dinner once a month.
As of April, we've had four families over - including neighbors, good friends we don't get to see enough of, friends we haven't seen since grad school, and new friends from church. We are loving it. We've relaxed some of that need-to-have-a-perfect-house compulsion when entertaining - and no one has run out screaming yet. (Still have some degree of compulsion, I won't lie, but it's definitely less severe that it was. Think: overall order with occasional pockets of entropy. We have a butcher cart in the kitchen that is so hopelessly disordered from top to bottom, we joke about pushing that whole thing out the front door one day in joyful riddance, imagining it dropping off the porch stairs and going straight into the garbage truck. Well, half-joke. At least I'm only half-joking. We also still have zebra streamers up from a wild-animal-themed birthday party many moons ago that will stay up until they degrade on their own. I personally enjoy the added festivity, and will enjoy it until I can't stand it anymore.)
And the kids. They run around screaming like lunatics, chasing each other in pure joy, even with children they are meeting for the first time. (Don't you miss that?)
It has been surprisingly effortless to invite people, and we're always talking about who we're going to have over next. So far so good. Reward to effort ratio remains favorable, and no sight of inertia setting in...yet. Having the house look presentable for longer than the 1 hour after it is cleaned every two weeks (sometimes the house destabilizes in 20 minutes thanks to 3 very talented children) has the added benefit of keeping me in a better mood. And, if we skip a month or two or three...no pressure. We'll take it as long as the motivation lasts.
Thursday, April 24, 2014
Monday, April 21, 2014
Guest post: Coming home
I come downstairs after grabbing a few hours sleep in between busy night shifts. I can hear Rose crying in frustration at once again trying to grab the key from the back door. I walk into the chaos in the kitchen. My husband is absorbed in the newspaper surrounded by the toddler carnage. Why is there breakfast still on the table? Why have the pots and pans been pulled out of the cupboards? Has she really got porridge still stuck on her forehead and what on earth is she wearing? Oh and why is she chewing hay from the barn?
I open my mouth to say something but hesitate and hold my tongue. I remember that it's his turn to look after Rose while I am in work mode. We do things differently- I'm the surgeon with the perfectionist streak wanting everything to be tidy and clean; he is the artist and is happy to let Rose run free and wild. I smile to myself.
"Family hug?" I pick up Rose and we all collapse on the sofa together in a warm embrace. A memory to take with me to work that night. Invaluable.
Lotte is a 33 year old general surgery registrar in the UK with an 18 month old daughter Rose and a non medical husband. She works full time.
Wednesday, April 16, 2014
Consumer Driven Healthcare - Where is it Going?
After I read Red Humors blog on Open Notes, I struck up a discussion with a radiologist friend. We commiserate over laws and loopholes in laws that cause system abuse. I am so happy that Obama recommended to close the loophole in the Stark Law in his 2015 budget. That loophole has created some rampant abuse.
I worry about and applaud the possible effects of patients being able to read their notes online. We doctors need our own forum to make notes without worrying about hurting our patient's feelings. But patients also need to be able to review the discussion in the doctor's office in their own space, with all of their mental focus. Open Notes seems like a step in the right direction, but not entirely. We need two spaces. One for the patient, and one for the doctor.
When I was in CT, waiting on a specimen from the lung to review, I was telling the radiologist about Red Humor's blog topic. He told me that there is a push to the radiologists for the patient to be able to see their diagnosis online, as soon as it is available, before they have even discussed it with the clinician.
RED FLAG.
I wrote a post here before, called Poker Face. In a nutshell, it was about me accidentally conveying during fellowship a patient's negative diagnosis by delaying my answer too long when being probed directly by the patient. It was an excruciating experience that taught me to use expert words to delay the fact that I knew someone's cancer had returned or was diagnosed or had metastasized. After all, I am just a pathologist. I have no treatment options or good perspective on prognosis and treatment. That is Red Humor's job, not mine.
The radiologist worried, as I do, that all the great tools and information that our oncologists and clinicians have to offer a patient will not be there, in the privacy of their own home, while they are reading the ominous information. He worried aloud that the information might overwhelm them. As he was saying that he mimed a gun to his head. I completely agree.
There is way too much misinformation out there on the internet and you need an educated professional to reassure and guide you through it. I depend on my mechanic to fix my car. I depend on my accountant to do my taxes. As doctors, our patients need to depend on us to pick them up when all seems lost.
Last week the New York Times released a big article allowing patients to look up how much their doctors received from Medicare over the last year. It's telling information, but muddy. We doctors enjoyed googling each other to find out who is getting what. Pathologists are at the bottom of the list. If you consider Medicare reimbursement is about 30% of overall practice (in conjunction with private insurance), the information is not enough. It's a step in the right direction, but like many steps mentioned above, it falls short.
I see the need for change in healthcare. But the problems are multifactorial, and it will take lots of time and energy to fix them. In the meantime, let's try to keep a proper perspective to protect our patients. Let's delve back into the reasons we went into medicine in the first place. To help people, to protect and serve. Don't give them information in the privacy of their own homes that they aren't equipped to deal with, or anything that might hurt their feelings. That's a nasty can of worms that doesn't need to be opened.
I worry about and applaud the possible effects of patients being able to read their notes online. We doctors need our own forum to make notes without worrying about hurting our patient's feelings. But patients also need to be able to review the discussion in the doctor's office in their own space, with all of their mental focus. Open Notes seems like a step in the right direction, but not entirely. We need two spaces. One for the patient, and one for the doctor.
When I was in CT, waiting on a specimen from the lung to review, I was telling the radiologist about Red Humor's blog topic. He told me that there is a push to the radiologists for the patient to be able to see their diagnosis online, as soon as it is available, before they have even discussed it with the clinician.
RED FLAG.
I wrote a post here before, called Poker Face. In a nutshell, it was about me accidentally conveying during fellowship a patient's negative diagnosis by delaying my answer too long when being probed directly by the patient. It was an excruciating experience that taught me to use expert words to delay the fact that I knew someone's cancer had returned or was diagnosed or had metastasized. After all, I am just a pathologist. I have no treatment options or good perspective on prognosis and treatment. That is Red Humor's job, not mine.
The radiologist worried, as I do, that all the great tools and information that our oncologists and clinicians have to offer a patient will not be there, in the privacy of their own home, while they are reading the ominous information. He worried aloud that the information might overwhelm them. As he was saying that he mimed a gun to his head. I completely agree.
There is way too much misinformation out there on the internet and you need an educated professional to reassure and guide you through it. I depend on my mechanic to fix my car. I depend on my accountant to do my taxes. As doctors, our patients need to depend on us to pick them up when all seems lost.
Last week the New York Times released a big article allowing patients to look up how much their doctors received from Medicare over the last year. It's telling information, but muddy. We doctors enjoyed googling each other to find out who is getting what. Pathologists are at the bottom of the list. If you consider Medicare reimbursement is about 30% of overall practice (in conjunction with private insurance), the information is not enough. It's a step in the right direction, but like many steps mentioned above, it falls short.
I see the need for change in healthcare. But the problems are multifactorial, and it will take lots of time and energy to fix them. In the meantime, let's try to keep a proper perspective to protect our patients. Let's delve back into the reasons we went into medicine in the first place. To help people, to protect and serve. Don't give them information in the privacy of their own homes that they aren't equipped to deal with, or anything that might hurt their feelings. That's a nasty can of worms that doesn't need to be opened.
Tuesday, April 15, 2014
R-E-L-A-X
I'm having a lot of trouble trying to relax.
Lately I've been just completely overwhelmed with the stress of working and managing two kids. My mind is always whirling with all the things I need to do. Feels a bit like the entire universe rests on my shoulders. It doesn't help that when I'm going to the bathroom there's usually somebody knocking on the door within 30 seconds asking when I'm coming out.
It's stressful.
For that reason I've really been trying hard to think of ways to relax. I know meditation would help me but it's just very hard to do. I can't seem to turn my brain off. Plus there isn't that much time to do it.
What are ways in which you relax?
Lately I've been just completely overwhelmed with the stress of working and managing two kids. My mind is always whirling with all the things I need to do. Feels a bit like the entire universe rests on my shoulders. It doesn't help that when I'm going to the bathroom there's usually somebody knocking on the door within 30 seconds asking when I'm coming out.
It's stressful.
For that reason I've really been trying hard to think of ways to relax. I know meditation would help me but it's just very hard to do. I can't seem to turn my brain off. Plus there isn't that much time to do it.
What are ways in which you relax?
Monday, April 14, 2014
Guest post: Tales of a hybrid doctor/stay at home Mum-- Part II
April, 2014.
That day five years ago, was the lowest point. (see Part I) Today I work “full time” (whatever that means!) in what is probably my dream job: a perfect mix of innovative clinical care, cutting edge research, medical education and being a leader in my chosen specialty. I am on faculty at one of the most prestigious medical schools in the world and get to work with the brightest and the best, in an environment that is intellectually rewarding and super collegial. …and I feel this is just the beginning!
My husband (who got a raw deal in part I—sorry babe) and I have never been closer and more happier in our marriage—we are both fulfilled in our careers, but most importantly, feel like we are reaping the rewards of our hybrid parenting model now: family life is fun, filled with endless bliss and joy.
Our kids (now 10 and 6) are doing fantastic: healthy, happy and thriving at school and play.
Don’t get me wrong-- it’s a juggling act, for sure, but we are juggling joy and I have never felt more balanced in my life.
Still, the reason I wrote part I is that I never wanted to minimize (or forget) the complicated journey (and decisions) I endured to get me to where I am today.
I only wish my 2014 self could have whispered in the ear of my 2009 self and told her the following:
#1. It will get easier as the kids get older; there will be new parenting challenges and hurdles but the physical dependency will be less and that will give you more freedom. Be patient.
#2.You (as Mum and Dad) have to do what feels right to you (as parents). This is unique for every single family in the world.You have to decide how best to work to your strengths as a team.Never compromise on your childcare beliefs and preferences. Do what you think is the right thing to do and everything else will fall into place with time. Your husband is your biggest supporter of your talent and career. This is, in part, because he is equally passionate, ambitious and talented in his own career. It’s hard to have two parents be ambitious at the same time when there are two young kids at home. Right now, you have both agreed it makes sense that it should be his turn, one day it will be yours. Be patient.
#3. Whatever you do, don’t “opt out”. You will get deskilled and limit your future career options. Keep up the hybrid model—it will work to your favor in the end.
#4. Think of work as a career not as a job. Keep investing in yourself. When the kids nap/sleep engage in scholarly activities that will keep your CV looking attractive. You feel like a tortoise right now (and I know you hate that, because you are not a tortoise type of gal) but slow and steady will win the race (one day).
#5. Stay connected to the reasons you became a physician in the first place. Don’t’ let anyone distract you from that—these are crucial reasons that are core to your identity as a human being.
#6. Your ARE privileged. Your job entails you coming up with creative solutions to some of the world’s most difficult problems—you impact humanity every time you work. You also get paid better than most, have societal respect and a “voice” AND have the option to work “part time”. Many working mothers do not have that type of job. Be GRATEFUL
#7. Don’t become a hovering parent—you have seen them, overeducated parents with time on their hands creating projects in the school so that they can get called to implement them! Be a good citizen in the school but better you put your skills to use in a zip code that needs your specialized skill set, not the zip code where your kids are lucky enough to live and go to school.
#8. Always DELEGATE non- essential tasks (it will be money well spent) and use that time for love, laughter and being in the moment. Take care of those who take care of you.
#9. Learn to let go (a little)—it will all be okay.
#10. Don’t pay too much attention to labels, “working mum”; “stay at home mom”; “part time physician”. Don’t be defined by these terms, they undermine the complexity and power of who you are as an individual. You are unique, you will find a way to make it all work.
Above all remember:
Becoming a mother has made you a better physician and remaining a practicing physician has made you a better mother.
Dr. S is a married physician and mother of two.
That day five years ago, was the lowest point. (see Part I) Today I work “full time” (whatever that means!) in what is probably my dream job: a perfect mix of innovative clinical care, cutting edge research, medical education and being a leader in my chosen specialty. I am on faculty at one of the most prestigious medical schools in the world and get to work with the brightest and the best, in an environment that is intellectually rewarding and super collegial. …and I feel this is just the beginning!
My husband (who got a raw deal in part I—sorry babe) and I have never been closer and more happier in our marriage—we are both fulfilled in our careers, but most importantly, feel like we are reaping the rewards of our hybrid parenting model now: family life is fun, filled with endless bliss and joy.
Our kids (now 10 and 6) are doing fantastic: healthy, happy and thriving at school and play.
Don’t get me wrong-- it’s a juggling act, for sure, but we are juggling joy and I have never felt more balanced in my life.
Still, the reason I wrote part I is that I never wanted to minimize (or forget) the complicated journey (and decisions) I endured to get me to where I am today.
I only wish my 2014 self could have whispered in the ear of my 2009 self and told her the following:
#1. It will get easier as the kids get older; there will be new parenting challenges and hurdles but the physical dependency will be less and that will give you more freedom. Be patient.
#2.You (as Mum and Dad) have to do what feels right to you (as parents). This is unique for every single family in the world.You have to decide how best to work to your strengths as a team.Never compromise on your childcare beliefs and preferences. Do what you think is the right thing to do and everything else will fall into place with time. Your husband is your biggest supporter of your talent and career. This is, in part, because he is equally passionate, ambitious and talented in his own career. It’s hard to have two parents be ambitious at the same time when there are two young kids at home. Right now, you have both agreed it makes sense that it should be his turn, one day it will be yours. Be patient.
#3. Whatever you do, don’t “opt out”. You will get deskilled and limit your future career options. Keep up the hybrid model—it will work to your favor in the end.
#4. Think of work as a career not as a job. Keep investing in yourself. When the kids nap/sleep engage in scholarly activities that will keep your CV looking attractive. You feel like a tortoise right now (and I know you hate that, because you are not a tortoise type of gal) but slow and steady will win the race (one day).
#5. Stay connected to the reasons you became a physician in the first place. Don’t’ let anyone distract you from that—these are crucial reasons that are core to your identity as a human being.
#6. Your ARE privileged. Your job entails you coming up with creative solutions to some of the world’s most difficult problems—you impact humanity every time you work. You also get paid better than most, have societal respect and a “voice” AND have the option to work “part time”. Many working mothers do not have that type of job. Be GRATEFUL
#7. Don’t become a hovering parent—you have seen them, overeducated parents with time on their hands creating projects in the school so that they can get called to implement them! Be a good citizen in the school but better you put your skills to use in a zip code that needs your specialized skill set, not the zip code where your kids are lucky enough to live and go to school.
#8. Always DELEGATE non- essential tasks (it will be money well spent) and use that time for love, laughter and being in the moment. Take care of those who take care of you.
#9. Learn to let go (a little)—it will all be okay.
#10. Don’t pay too much attention to labels, “working mum”; “stay at home mom”; “part time physician”. Don’t be defined by these terms, they undermine the complexity and power of who you are as an individual. You are unique, you will find a way to make it all work.
Above all remember:
Becoming a mother has made you a better physician and remaining a practicing physician has made you a better mother.
Dr. S is a married physician and mother of two.
Thursday, April 10, 2014
MiM Mail: Banking for the future?
Hi Mothers in Medicine,
I am writing to ask for advice. I am a 28-year-old 2nd year medical student about to take Step 1. I got married last year. I don't want to have children until I am done with residency but I'm not sure how long residency will last because I'm not sure what I want to go into. I recently became aware of an opportunity to participate in a research study of natural IVF that would offer me a free cycle. I love the idea of having my eggs (or maybe an embryo) stored away for future use and not having to worry about my fertility anymore. I hate procedures though and I have a lot of anxiety about pain-inducing procedures (like egg retrieval). Can anybody give me some perspective on this?
Thanks!
I am writing to ask for advice. I am a 28-year-old 2nd year medical student about to take Step 1. I got married last year. I don't want to have children until I am done with residency but I'm not sure how long residency will last because I'm not sure what I want to go into. I recently became aware of an opportunity to participate in a research study of natural IVF that would offer me a free cycle. I love the idea of having my eggs (or maybe an embryo) stored away for future use and not having to worry about my fertility anymore. I hate procedures though and I have a lot of anxiety about pain-inducing procedures (like egg retrieval). Can anybody give me some perspective on this?
Thanks!
Wednesday, April 9, 2014
open notes
Today our electronic charting system was moved to Open Notes, which will allow patients to access their clinic notes online.
This was not a voluntary transition, nor is it specific to oncology. Notes from all outpatient clinic visits – including cancer counseling (Not considered “mental health”) are now available for online viewing.
I was once told that you shouldn’t write anything into a patient’s medical record that you wouldn’t have to read aloud in court. While this does seem like an extremely “CYA” way of practicing (or at least documenting) medicine, it is still sound advice. Medical records are not confidential and patients have a legal right to them.
But prior to Open Notes, a patient would have to go down to medical records and request a copy of their chart. This took some effort on their part, an effort that might have come about because they felt mistreated or that there had been a gap or misstep in their care. That is no longer the case – the same records are now available for casual online viewing on the couch for a very different purpose.
The argument for Open Notes is that patients will participate in their care more if they understand the doctor’s assessment of their condition and care plan. Last night I heard an NPR bit about the difficulties of getting people with low-reimbursement health care plans into see physicians. The story featured a woman in her fifties who had been trying to see a physician for months, and when she finally did was told to stop smoking, modify her diet, and get some exercise. My initial reaction was to wonder why people need a doctor to tell advise them on such basic tenets of personal health. But we, as physicians, are told time and time again that patients who hear “stop smoking” from a doctor are more likely to do it than if they hear it from a friend or family member.
So maybe Open Notes will help get some people engaged in their health, and to understand their “goals” as we see them – LDL, Hgb A1C, prolonged survival without likelihood of cure, etc. But the same studies that show patients engage more when they can read the doctor’s notes also confirm that patients do not react well to seeing “morbid obesity” or “noncompliance” documented in their chart. From a medical perspective, those are important aspects of a patient or his/her behavior that influence why I do what I do. Chemotherapy can be dosed on ideal or actual body weight. If a patient has a history of being non-compliant, I might be more inclined to prescribe neutropenic fever prophylaxis than I would otherwise. Abbreviations are also a problem - we were asked to use the EPIC autocorrect function to change SOB to read “shortness of breath”.
But I also use my notes to remind myself about the personal aspects of a patient’s life – that their son is getting married next month or that their mother is dying or that that their spouse is not a very good source of emotional support. I suspect I will do less of this type of documentation in the future.
The other reason my group adopted Open Notes is that our competitors are doing the same – a patient’s ability to access their medical record online will become the standard of care in the future and we might as well get used to it now. Although I have strong suspicion that Open Notes will generate more questions than it answers, and that my tendency will be to write less, I am trying to withhold judgment.
And maybe it will be helpful – maybe if a patient reads that I documented his need to stop smoking, he will take me more seriously. Maybe a patient who reads that I wrote that her marriage is rocky will see I understand she’s dealing with more than just a cancer diagnosis. Maybe fewer patients will claim to have “never been told this isn’t curable” when they read it online.
I don’t know. TBD.
This was not a voluntary transition, nor is it specific to oncology. Notes from all outpatient clinic visits – including cancer counseling (Not considered “mental health”) are now available for online viewing.
I was once told that you shouldn’t write anything into a patient’s medical record that you wouldn’t have to read aloud in court. While this does seem like an extremely “CYA” way of practicing (or at least documenting) medicine, it is still sound advice. Medical records are not confidential and patients have a legal right to them.
But prior to Open Notes, a patient would have to go down to medical records and request a copy of their chart. This took some effort on their part, an effort that might have come about because they felt mistreated or that there had been a gap or misstep in their care. That is no longer the case – the same records are now available for casual online viewing on the couch for a very different purpose.
The argument for Open Notes is that patients will participate in their care more if they understand the doctor’s assessment of their condition and care plan. Last night I heard an NPR bit about the difficulties of getting people with low-reimbursement health care plans into see physicians. The story featured a woman in her fifties who had been trying to see a physician for months, and when she finally did was told to stop smoking, modify her diet, and get some exercise. My initial reaction was to wonder why people need a doctor to tell advise them on such basic tenets of personal health. But we, as physicians, are told time and time again that patients who hear “stop smoking” from a doctor are more likely to do it than if they hear it from a friend or family member.
So maybe Open Notes will help get some people engaged in their health, and to understand their “goals” as we see them – LDL, Hgb A1C, prolonged survival without likelihood of cure, etc. But the same studies that show patients engage more when they can read the doctor’s notes also confirm that patients do not react well to seeing “morbid obesity” or “noncompliance” documented in their chart. From a medical perspective, those are important aspects of a patient or his/her behavior that influence why I do what I do. Chemotherapy can be dosed on ideal or actual body weight. If a patient has a history of being non-compliant, I might be more inclined to prescribe neutropenic fever prophylaxis than I would otherwise. Abbreviations are also a problem - we were asked to use the EPIC autocorrect function to change SOB to read “shortness of breath”.
But I also use my notes to remind myself about the personal aspects of a patient’s life – that their son is getting married next month or that their mother is dying or that that their spouse is not a very good source of emotional support. I suspect I will do less of this type of documentation in the future.
The other reason my group adopted Open Notes is that our competitors are doing the same – a patient’s ability to access their medical record online will become the standard of care in the future and we might as well get used to it now. Although I have strong suspicion that Open Notes will generate more questions than it answers, and that my tendency will be to write less, I am trying to withhold judgment.
And maybe it will be helpful – maybe if a patient reads that I documented his need to stop smoking, he will take me more seriously. Maybe a patient who reads that I wrote that her marriage is rocky will see I understand she’s dealing with more than just a cancer diagnosis. Maybe fewer patients will claim to have “never been told this isn’t curable” when they read it online.
I don’t know. TBD.
Tuesday, April 8, 2014
Guest post: The morning departure
The whole drive to work I relish in the wet spot left on my cheek from the sweet goodbye kiss of my two year old son. It was tough to leave today. Never wanting to just disappear on my little one I always say goodbye and explain I'm off to be "Dr. Pohl" for the day. This is a funny concept that my two year old disputed at first, saying "You're not a doctor, you're a mommy!" Well I'm both.
This particular morning everything about my little guy was endearing and I wanted to capture every cute phrase and silly look. It was a "this is it" morning - ordinary and wonderful. Aiden running around in his footed pj's and his baby sister lounging in the boppy. I'm in the kitchen packing up my breast pump and he yells to me "She smiled a big one at me!"
When it is time to finally depart he clings to me, giving me the cuddle I desperately try to get from him when I have the time to enjoy it. He follows me to the door, and against my better judgement, I lift him up again. He then contorts his little body so I can't put him down. I plead with my husband to come help me. I say, "My heart is breaking," because it is. He takes him from me and each kisses me goodbye. Then they wave from the window. I put on a show of waving wildly back but I'm close to tears.
I carry the feel of that kiss all the way into the hospital, cherishing it- until I finally wipe it off, crumbs and all, to put on my mask.
Dr. Pohl is an anesthesiologist with a 2 year old and a 4 month old.
This particular morning everything about my little guy was endearing and I wanted to capture every cute phrase and silly look. It was a "this is it" morning - ordinary and wonderful. Aiden running around in his footed pj's and his baby sister lounging in the boppy. I'm in the kitchen packing up my breast pump and he yells to me "She smiled a big one at me!"
When it is time to finally depart he clings to me, giving me the cuddle I desperately try to get from him when I have the time to enjoy it. He follows me to the door, and against my better judgement, I lift him up again. He then contorts his little body so I can't put him down. I plead with my husband to come help me. I say, "My heart is breaking," because it is. He takes him from me and each kisses me goodbye. Then they wave from the window. I put on a show of waving wildly back but I'm close to tears.
I carry the feel of that kiss all the way into the hospital, cherishing it- until I finally wipe it off, crumbs and all, to put on my mask.
Dr. Pohl is an anesthesiologist with a 2 year old and a 4 month old.
Monday, April 7, 2014
Homeschooling options for the busy parent
My husband and I are products of public school education. Don’t get me wrong, we are both extremely motivated and successful but we both believe that our education was lacking in very significant ways. My husband now teaches college students who have only been taught under “No Child Left Behind” and we are both very concerned about the results of this method of learning. As the parents of an extremely bright and energetic 2.5 year old, many of our conversations revolve around preparing him for a future that requires tools that traditional education will not provide him with.
One of my best friends from college who is an innovative teacher and curriculum developer attended Montessori schools for her early education. The methods she used to remain organized during college amazed me. She color-coded and charted and organized in ways that I did not even know existed. Studying for me was always about picking up my book, reading, taking notes in the margins, and more reading. It wasn’t until medical school that I learned how I most effectively studied. I began drawing funny caricatures (nothing close to Netter’s) and charting and mapping things out so that I could better process the material and retain it later. As a second year Resident I still use this method. I can’t even imagine how much stress could have been relieved and how much better I could have learned if I studied better earlier.
Back to Zo, my little genius in the making. He amazes us. He is more than a sponge. Every day he comes home and does and says something new; something that makes us pause, smile, and say "how/when did he learn that?!?" My husband and I are exposing him to as many good things as we can. We listen to music (kiddie things like the Dino V, adult things like soul, jazz, rap, classical) and dance all of the time. He helps us cook (he mixes), plays outside, goes to museums. He attends an amazing Spanish-immersion daycare and knows more Spanish than both of us. We got rid of our TV when he was an infant, though he does watch a few hours of Netflix Dinosaur Train and Turtle Tales on the weekends while we straighten up and prepare breakfast. Every 2 weeks we get a new book kit from the library that contains 15 books on a toddler-friendly subject.
But he’s learning so fast and I know he can learn more, I just don’t know how. I read Amy Chua’s Tiger Mom and I’m not a fan of her parenting philosophy, but I will incorporate some of the things that I agree with and like. I want Zo to learn the best way he can, I want him to learn a martial art, to be fluent in another language (Spanish), and play an instrument (kind of got this from Chua and Fifty Shades of Grey, LOL!). I belonged to an amazing mommy-group in the mid-Atlantic before starting residency where many mothers home-schooled and their children were so inquisitive and learned; it was inspiring. I love being a doctor and homeschooling full-time is just not an option for us.
I have begun researching “homeschooling” options for working parents and am looking for more resources. If you have done modified homeschooling or know anyone who does, please send them my way. I promise to keep you all updated on our progress. Things will be kept very simple since we only have a toddler, but I’m sure as he ages, I will find other fun, innovative ways to supplement what he learns at school.
So for this week’s "Homeschooling for the Busy Parent" activity:
- lots of fun time and play, dancing, riding our bikes outside, and time at the playground
- nightly reading of our colors books
- I will make some simple flash cards and we will focus on primary colors and then secondary colors using a concept called “isolation” that I learned on YouTube from a video-blog called “Preschool Homeschool”
One of my best friends from college who is an innovative teacher and curriculum developer attended Montessori schools for her early education. The methods she used to remain organized during college amazed me. She color-coded and charted and organized in ways that I did not even know existed. Studying for me was always about picking up my book, reading, taking notes in the margins, and more reading. It wasn’t until medical school that I learned how I most effectively studied. I began drawing funny caricatures (nothing close to Netter’s) and charting and mapping things out so that I could better process the material and retain it later. As a second year Resident I still use this method. I can’t even imagine how much stress could have been relieved and how much better I could have learned if I studied better earlier.
Back to Zo, my little genius in the making. He amazes us. He is more than a sponge. Every day he comes home and does and says something new; something that makes us pause, smile, and say "how/when did he learn that?!?" My husband and I are exposing him to as many good things as we can. We listen to music (kiddie things like the Dino V, adult things like soul, jazz, rap, classical) and dance all of the time. He helps us cook (he mixes), plays outside, goes to museums. He attends an amazing Spanish-immersion daycare and knows more Spanish than both of us. We got rid of our TV when he was an infant, though he does watch a few hours of Netflix Dinosaur Train and Turtle Tales on the weekends while we straighten up and prepare breakfast. Every 2 weeks we get a new book kit from the library that contains 15 books on a toddler-friendly subject.
But he’s learning so fast and I know he can learn more, I just don’t know how. I read Amy Chua’s Tiger Mom and I’m not a fan of her parenting philosophy, but I will incorporate some of the things that I agree with and like. I want Zo to learn the best way he can, I want him to learn a martial art, to be fluent in another language (Spanish), and play an instrument (kind of got this from Chua and Fifty Shades of Grey, LOL!). I belonged to an amazing mommy-group in the mid-Atlantic before starting residency where many mothers home-schooled and their children were so inquisitive and learned; it was inspiring. I love being a doctor and homeschooling full-time is just not an option for us.
I have begun researching “homeschooling” options for working parents and am looking for more resources. If you have done modified homeschooling or know anyone who does, please send them my way. I promise to keep you all updated on our progress. Things will be kept very simple since we only have a toddler, but I’m sure as he ages, I will find other fun, innovative ways to supplement what he learns at school.
So for this week’s "Homeschooling for the Busy Parent" activity:
- lots of fun time and play, dancing, riding our bikes outside, and time at the playground
- nightly reading of our colors books
- I will make some simple flash cards and we will focus on primary colors and then secondary colors using a concept called “isolation” that I learned on YouTube from a video-blog called “Preschool Homeschool”
Saturday, April 5, 2014
Sentinel Lymph Nodes
Sen.ti.nel: A soldier or guard whose job is to stand and keep watch.
I have a close friend who was standing in the shower one day and noticed a lump under her arm. She is in medicine, and despite trying to blow it off she knew what it might herald, and eventually manned (I mean womanned!) up and made herself an appointment with a breast surgeon. Ten years ago she was diagnosed with metastatic breast cancer. She had a mastectomy with lymph node dissection. She had treatment. She got off her meds, had a child at 47. She has a handsome first grader. She is in her early 50's and she looks like a movie star in her late 30's.
I look at a lot of sentinel lymph nodes. Sure, there are other ones besides those in the breast axilla, but they are by far the most routine. The surgeon injects a radioactive tracer attached to blue dye around the tumor and follows the path to the nodes that the tumor cells would take to locate them. There are a bunch of nodes in the axilla, but chances are if the cancer is not in the sentinel nodes - the guards - then it won't have traveled any farther. There are exceptions to the rule but like most rules the exceptions they are few and far between.
In the gross room we receive the sentinel nodes and our techs do a gross analysis. Lymph nodes are floppy and brown-grey, much the size and consistency of a kidney bean. Massive metastases are grossly obvious - stellate, white hard infiltrates scream positivity, which is easily confirmed by microscopic examination. But many metastases are insidious - not grossly obvious. We do step examination of multiple levels of sentinel lymph nodes (sometimes there are more than one) which can fill a tray or two of slides (20 slides per tray).
When I get a tray or two of sentinel lymph nodes I often wait until I have a cup of coffee to settle down and look at them - it takes time and major focus. The kidney bean shaped node is full of small round blue cells called lymphocytes with reactive germinal center follicles - white round circles dotting the blue landscape. The border contains the sinus of the node - the most likely place (a small space) for occult isolated tumor cells or clusters of cancer to sneak into. If you blink you might miss some. It takes slow and methodical cruising at high power. I occasionally sub at breast conference for my partner who presents at it regularly, and I am continually amazed at the tiny, almost invisible foci my partners unfold. I know how hard it is to really see that. I have great respect for the amount of time and effort it demands to discover it. I know, I do it too, it's part of the job, but it continually amazes me.
These days we routinely use pancytokeratin immunostains to look for small, isolated tumor cells and clusters. While this is a nice adjunct to help us sleep better at night, it is not a safeguard or panacea to allow us to slack on the job of the routine H&E slide. I have seen cancer cells on H&E that are cut away on the special stains. I have seen cancer cells on the special stains that are not on the H&E (this stands for hematoxylin and eosin - the pink and blue Easter egg colors that we use to stain all tissue for examination). It's enough to keep you up on a bad night, wondering what you might have missed.
You would never guess my friend had metastatic breast cancer - I didn't even know for the first few years I knew her - she was diagnosed before I met her. She has shared struggles with treatment side effects but doesn't touch on what I know I would obsess over - fears of leaving behind my children. She is a perfect picture of poise, elegance, and grace. But she has this underlying Tiger Mom thing, an aggressiveness and intensity that I know must have come with what she has faced in life and dealing with the unknown of the future. Sure, we all have unknowns - I could die in a car crash tomorrow but I haven't dealt with nearly as much adversity as she has in my own personal health arena (yet!).
I love the definition of sentinel. The guard. The lymph node that tries to hold it all in check. I can empathize, as I am sure my friend does too. We women in medicine, and mothers too - we are always on constant watch and hyper-vigilance. For our patient's health, and for that of our children. We can't protect our charges from everything, but that doesn't keep us from trying with all of our power and might. It's the best we can do, and it's good enough.
Thursday, April 3, 2014
Regrets...
I have a few. One major, a few minor. I keep reminding myself that I am the kind of person for who the grass is always green on the other side. So, even had I made other decisions, I would probably have regrets. Not definitely, but probably.
How do you all deal with your regrets?
How do you all deal with your regrets?
Tuesday, April 1, 2014
On the Move
A few months ago I bumped into a pulmonologist in the doctor's lounge I enjoy chatting with. She likes to travel, and I enjoy hearing about her latest trip - I like travel too and would much rather sock new car or house or clothes or jewelry money away and spend it all on traveling. As we were finishing up the conversation she cocked her head, looked at me straight in the eye with a slight smile on her face, and said, "I am so jealous of you pathologists. You get to stay put at your microscope. Do all your work at the same hospital. We are running around all day."
I was so shocked I didn't answer her, but as I walked away I thought "What a false impression she has of us!" We run around from hospital to hospital, covering different ORs and radiology rooms in shifts. Maybe not in one day, but certainly up to a fourth or more of the month. Increasingly, outpatient clinics are putting in histology labs, necessitating more travel to do cases - this can demand travel to two or three different places in one day. Furthermore, we dole out lab directorship amongst ourselves, covering the many different labs we service in our overall domain. This requires weekly or monthly travel to fulfill clinical pathology duties, which are more and more demanding every year with increasing regulations and education requirements. As our designated lab inspector, I travel to different hospitals around the state and outside of it with teams of expert lab technicians as part of our duty to regulatory agencies that certify us as an "approved" laboratory, meaning we hold up to the scrupulous demands that we require of the labs we inspect in return.
This means that I know how to use many different EMR systems and up to four different sign out programs - some of which are hospital based and some of which are internet based. I can access my home computer remotely to juggle work couriered in from different hospitals in attempt to even out the workload amongst all of us, as it changes daily (I do not envy the math that the gross room has to coordinate daily based on workloads at multiple different hospitals and different clinics!). Yes, I am grateful that I am more of an information-gathering voyeur than an interactive participant in the EMR system, for the most part - we do write notes on fine needle aspirates we perform, as well as apheresis procedures. But I think we make up for this on the back end with our individual dictation and report release software. It's ever evolving and more and more confusing as the years progress.
The days of the hospital-based pathologist sitting (hiding) in the office behind a microscope are over, for better or for worse. We are on the move, my dear travel pulmonologist friend - someday I will explain. In the meantime, envy me with your wrong impression and I will continue to envy your world travels. I'm starting to catch up. Conference in Hawaii in February and Spring Break ski trip last week to Colorado. I'll break the borders as the kids get older. In the meantime, I'm busy enough traveling for work.
I was so shocked I didn't answer her, but as I walked away I thought "What a false impression she has of us!" We run around from hospital to hospital, covering different ORs and radiology rooms in shifts. Maybe not in one day, but certainly up to a fourth or more of the month. Increasingly, outpatient clinics are putting in histology labs, necessitating more travel to do cases - this can demand travel to two or three different places in one day. Furthermore, we dole out lab directorship amongst ourselves, covering the many different labs we service in our overall domain. This requires weekly or monthly travel to fulfill clinical pathology duties, which are more and more demanding every year with increasing regulations and education requirements. As our designated lab inspector, I travel to different hospitals around the state and outside of it with teams of expert lab technicians as part of our duty to regulatory agencies that certify us as an "approved" laboratory, meaning we hold up to the scrupulous demands that we require of the labs we inspect in return.
This means that I know how to use many different EMR systems and up to four different sign out programs - some of which are hospital based and some of which are internet based. I can access my home computer remotely to juggle work couriered in from different hospitals in attempt to even out the workload amongst all of us, as it changes daily (I do not envy the math that the gross room has to coordinate daily based on workloads at multiple different hospitals and different clinics!). Yes, I am grateful that I am more of an information-gathering voyeur than an interactive participant in the EMR system, for the most part - we do write notes on fine needle aspirates we perform, as well as apheresis procedures. But I think we make up for this on the back end with our individual dictation and report release software. It's ever evolving and more and more confusing as the years progress.
The days of the hospital-based pathologist sitting (hiding) in the office behind a microscope are over, for better or for worse. We are on the move, my dear travel pulmonologist friend - someday I will explain. In the meantime, envy me with your wrong impression and I will continue to envy your world travels. I'm starting to catch up. Conference in Hawaii in February and Spring Break ski trip last week to Colorado. I'll break the borders as the kids get older. In the meantime, I'm busy enough traveling for work.
Monday, March 31, 2014
Keeping it moving on an overnight call
5 admissions, 4 discharges, PICU transfer. That sums up my night.
I could dwell on the negatives (exhaustion, cold under-heated hallways with headache-inducing fluorescent lights) or I can focus on the positives.
The positives. We managed the craziness with style and grace. No one died. Though one Nurse did come down with something and ended up in the Emergency Department. We (Interns and I) learned many things about patient care and prioritizing. I learned that even though my eyes are burning and my reaction time has slowed down considerably, I know enough to keep patients alive, manage a variety of conditions pretty darn well, and even alleviate some parental anxiety. I can successfully perform a lumbar puncture even after the Intern is unsuccessful and I have to bust through the big ole’ hematoma he left behind. Bammm how do you like all those red blood cells?!? What lab representative, red blood cells aren’t good?!? Of course I know that but at least I have enough cerebrospinal fluid for a gram stain and culture. Could you run those STAT please?!? I can scrounge up a makeshift meal (cereal, graham crackers, peanut butter, diet Coca Cola) to avoid my own hypoglycemia in spite of the fact that due to budget-cuts the cafeteria now closes at 8pm. I can snuggle sick babies and help position them so that they don’t become hypoxemic at 2:30am. I can make my exhausted Intern laugh at our horrible night. I can make my Nurses feel appreciated and not hate me even though they are ready to label me a “Black Cloud”.
And just to cap the whole night off, after a particularly crazy admission where we were all unknowingly exposed to some infectious respiratory goobers, we exited the room quickly, donned our masks and proceeded to do a modified line-dance down the hallway back into the room where we provided judgement-free exemplary service.
At this point, I just want to curl up in the call room, but there are far too many labs to follow up on and kiddos to check up on.
So to those out there in call-land, keep it moving and keep those patients alive! Cuz’ you know I will :-)
I could dwell on the negatives (exhaustion, cold under-heated hallways with headache-inducing fluorescent lights) or I can focus on the positives.
The positives. We managed the craziness with style and grace. No one died. Though one Nurse did come down with something and ended up in the Emergency Department. We (Interns and I) learned many things about patient care and prioritizing. I learned that even though my eyes are burning and my reaction time has slowed down considerably, I know enough to keep patients alive, manage a variety of conditions pretty darn well, and even alleviate some parental anxiety. I can successfully perform a lumbar puncture even after the Intern is unsuccessful and I have to bust through the big ole’ hematoma he left behind. Bammm how do you like all those red blood cells?!? What lab representative, red blood cells aren’t good?!? Of course I know that but at least I have enough cerebrospinal fluid for a gram stain and culture. Could you run those STAT please?!? I can scrounge up a makeshift meal (cereal, graham crackers, peanut butter, diet Coca Cola) to avoid my own hypoglycemia in spite of the fact that due to budget-cuts the cafeteria now closes at 8pm. I can snuggle sick babies and help position them so that they don’t become hypoxemic at 2:30am. I can make my exhausted Intern laugh at our horrible night. I can make my Nurses feel appreciated and not hate me even though they are ready to label me a “Black Cloud”.
And just to cap the whole night off, after a particularly crazy admission where we were all unknowingly exposed to some infectious respiratory goobers, we exited the room quickly, donned our masks and proceeded to do a modified line-dance down the hallway back into the room where we provided judgement-free exemplary service.
At this point, I just want to curl up in the call room, but there are far too many labs to follow up on and kiddos to check up on.
So to those out there in call-land, keep it moving and keep those patients alive! Cuz’ you know I will :-)
Sunday, March 30, 2014
The Day I was Nearly Arrested on Assault Charges {subtitle: How I'm Finding Time to Train for a Marathon}
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Earlier this week I found myself stuck at a “doctor-y” event. As I made small talk with a colleague, I mentioned that I was training for a marathon. Despite that fact that I am currently blogging about running and training consumes most of my thoughts, I promise I don’t talk about it incessantly to random people, but in this instance it did come up in conversation.
After I mentioned my training, her face contorted into what can only be described as a scoff. She then replied, quite condescendingly, “Must be nice to have THAT kind of time.”
My face turned beet red and my blood began to boil. Then without thinking I pulled my hand back and smacked her right across the face, leaving a bright red hand print on her left cheek. She was was stunned at first, but then her instincts took over and she kneed me in the gut. Before I knew it, we were in an all out fist fight in the middle of a cocktail party. My husband broke up the fight, but not before someone called the cops. I am currently writing this from jail.
Ok. So, nothing in italics ACTUALLY happened (except in mind. repeatedly. for about a week). In reality I smiled and walk away, like a good girl, who didn’t want to have to explain a criminal record.
Obviously in a state of pure boredom, I decided since there was nothing else going on in my life, I would run a marathon. I’m busy and so are my running mates. The expenditure of my time is not something I take lightly. We all have a lot on our plates, but like all things that are important to us, we are finding the time for this marathon.
How do I find the time for this?
5. Follow a Plan
We are following Hal Hidgon’s Novice 2 training program. The best way to avoid injury and reach my goal is to stick to the plan as close as possible. Each week I check off my boxes as I pound out each mile.
4. Run When I Can
The only time that works for me is mornings. Some mornings have been painfully early and cold, but nevertheless I’m out there.
3. Accountability
When my alarm goes off at 5:30 and I check the temperature and it’s 13 degrees, knowing that my friends are out in the Arctic air waiting for me is what gets me out of my cozy bed. There are 6 of us training in my neighborhood. Though we can’t do every run together, we are each other’s cheerleaders.
2. Giving Myself some Grace
I have missed a few workouts. If I’ve been at the hospital all night delivering babies and I have to choose between running and sleep, then I choose sleep. I don’t make up my runs in the evening, because that’s my family time. Yes, my Type A personality would like to follow the plan to perfectly, but life happens and that’s OK.
1. Have an Awesome Husband
Obviously, somebody has to get the kiddos ready in the morning while I’m out torturing myself, and that somebody is my super husband. You need your spouse to be supportive (or a least tolerant) of your crazy hobby when you start logging this many hours.
Despite being a runner for the last 17 years, I have never ran a full marathon. In my early 20′s, I did races all the time, but never more than a 15 K (The Tulsa Run, which is still my favorite race). Over the years the responsibilities of life kept my running to 3-4 miles a couple of times a week, barely enough to stay fit.
As my kids have gotten older, life has gotten a little smoother. I've decided this is my year to check "26.2" of my bucket list. Wish me luck, I'm a month away from my goal and I can't wait to cross that finish line.
Haters gonna hate. But I'm gonna run.
originally posted at drheatherrupe.com
Friday, March 28, 2014
Jack Of All Trades, Master Of None
(Patient accounts have been altered so as to protect their privacy and identity)
When I walked into my internal medicine practice office yesterday morning at 6:30 a.m., I was surprised to see only three patients on my schedule. Then I remembered there was a major winter storm forecast, and no one was sure how bad we were going to get hit. By the time the early administrative staff was arriving at 7:30 a.m., patients had realized the storm was basically just alot of wind, and they started calling. And booking. The 8 a.m. slot filled, then the 8:20, soon all the rest... I had an almost-full schedule in no time. And it was almost all "urgent care".
I love urgent care. It's so nice to take a break from the "comprehensive annual exam". Or at least, the way I approach those... I tend to obsess over missing something, and so I take the annual exam as an opportunity to comb through the patient's chart, and attempt to make appropriate note of every past, present, and possible future health issue. Plus, this is my big chance to catch up with folks on their Real Lives. So, What do you do when you're not sitting on my exam table in a johnny? Of course, folks come in with their own agendas, the lists of questions jotted down on the backs of envelopes or in the iPhone. Some docs shut all that down, citing "This is your preventive health time only!" which is ridiculous. So, the issues are addressed. Then there's the vaccines review, and lab ordering... These may or may not be straightforward, and more often than not involve additional discussion. My physical exams always run overtime.
So, a day of mostly urgent visits, those single-issue problem visits that can be serious, but at least, straightforward, are a welcome change.
On the other hand, these days highlight what is beautiful, difficult, and terrifying about primary care specialties like internal medicine:
1. You're supposed to know everything about everything.
2. Because we're trained to be always thinking about the Whole Patient- Nothing is ever straightforward.
First patient. The check in sheet states "Cough". Ha, easy. Well, not so much. The cough was undertreated asthma in the setting of a mild cold. But his blood pressure was very elevated. And a quick perusal of the chart showed, this was someone who hadn't been in for a couple of years. Turns out this was someone who had extreme doctor anxiety and alot of issues that needed more fine-tuning. So the visit turned into counseling and negotiations. I set up a followup appointment with the actual primary care and sent my note... Hoping the guy comes back.
Now, running fifteen minutes behind, next patient. "Rash". This is only easy if it's Shingles... and it was. But, the patient is a healthcare provider. And they wanted to know- needed to know- know all the occupational health issues around Shingles. Did they need to notify all the patients they had seen in the past day? How long did they need to be out of work? Did my recommendation around that differ from our hospital's occupational health policy? I wanted to be able to provide a modicum of accurate counseling in all of these areas. I spent some time with her researching the guidelines and then asked her to contact both her supervisor and occupational health for the rest. Then she needed a note. We wrestled over how to phrase it. I hit "print". The printer wouldn't print. Had to run to another computer. Time ticking away.
Then done with that, I had to check my clinical messages (our in-office messaging, where the secretaries and nurses send me anything from patient phone or email queries, VNA concerns, controlled substance medication requests, or abnormal lab or radiology results). I need to quickly scan the list and make sure there is nothing requiring urgent attention. Then deal with those. Someone emailed about their ankle sprain. Nurse: They just want X-rays ordered. Can we do that? Me: Not really, please have them make an appointment. Et cetera.
Then, my email. There's several more emails for me in a now-massive email chain regarding one patient of mine. She has a large team of specialists; her case is complicated; she may need to be admitted, and I would need to arrange that. I read quickly and make sure no one has asked me to do anything yet. I know the specialists probably roll their eyes at my questions. I haven't treated many cases of what she has. I have to read up every time she has labs. But she comes to me, and I'm doing the best I can.
Now hopelessly behind. Next patient: STD screening. Ha, easy! Not. Upon questioning, she tells me one of her partners is a recovering IV drug user. I deliver alot of counseling around this, do a pelvic exam with cultures, send for bloodwork and arrange more followup with bloodwork in two months.
Next: Elderly patient with shortness of breath. She was pretty sick. She told me she had almost passed out in the waiting room. Long and short of it, this person was too sick for my office. But, she resisted my emergency room suggestion. We went into negotiations. I called the emergency room to expedite. We waited for a wheelchair. I typed up my assessment and impression so the emergency docs would have it. Why take the time to chart, when the next patient is waiting? I felt like I needed to present at least a reasonable hypothesis for her condition, as well as defend my decision to send her to the emergency room. I delved more into her chart. Why do her lungs sound like a freight train screeching to a halt? Asthma in someone who's never had asthma? COPD is someone who's never smoked? Pneumonia more likely. Pulmonary edema, maybe.... Type it up. Hit "finalize."
Next: Wrist pain in a guy who does martial arts. I had to do a quick review of the possibilities. Refresh myself on the exam findings in occult scaphoid fracture. Then look up what type of immobilizing brace to prescribe while that is being ruled out. Then the printer didn't work again.
Next: Lovely lady with- finally! A very straightforward issue. Simple. I took care of it and was ready to wrap it up, when, she wanted my opinion on the new blood thinners. She's on Coumadin for atrial fibrillation, for stroke prevention. These new blood thinners are advertised on T.V. The cardiologists are prescribing them right and left. I have never prescribed these. I look it up, with her right there, and review some of the major pros and cons. There's no testing to see if someone is on too low or too high of a dose. That's nice. But, they aren't as readily reversible, so if someone has a car accident or a bleeding ulcer, they may bleed to death more easily than otherwise. Basically, that's what I told her, adding that we can also ask her cardiologist about it. No, she said, I like to know my numbers.
Next, next and next. There was a physical exam in there, and a few more not-so-straightforward urgent care visits. That was it. Nine Patients, and a barrage of clinical messages and emails. I was starving, and I had to pee. I peed, ate something at my desk, and delved into charting, billing, and all the messages/ emails, as well as the arrangements to be made for that very sick patient. I checked in with the emergency room on the lady I had sent in- she was to be admitted. Ha. I knew she was sick.
Mixed in there, I check in with home. I'm thinking about my kids. On my personal email, there are messages back and forth about our autistic son who's had some issues at his special education preschool. School aversion, we don't know why. It's getting better, with a good and patient teacher. But, I worry I'm not doing enough reading and research on autism, that we're not doing enough behavioral work at home. So I got on Amazon and researched, ordered some books.
At the end of the day, I wonder why I'm so fried.
Is it a good, or a bad thing, to be in a job where your mind has to hop, skip and jump and WORK from case to case and even within a case? We see everything and anything, and we're expected to counsel on even more. That, plus the balance with home life, taking care of a family...
Is it a good thing to be a Jack of all trades, Master of none?
-posted by Genmedmom (generallymedicine.com)
When I walked into my internal medicine practice office yesterday morning at 6:30 a.m., I was surprised to see only three patients on my schedule. Then I remembered there was a major winter storm forecast, and no one was sure how bad we were going to get hit. By the time the early administrative staff was arriving at 7:30 a.m., patients had realized the storm was basically just alot of wind, and they started calling. And booking. The 8 a.m. slot filled, then the 8:20, soon all the rest... I had an almost-full schedule in no time. And it was almost all "urgent care".
I love urgent care. It's so nice to take a break from the "comprehensive annual exam". Or at least, the way I approach those... I tend to obsess over missing something, and so I take the annual exam as an opportunity to comb through the patient's chart, and attempt to make appropriate note of every past, present, and possible future health issue. Plus, this is my big chance to catch up with folks on their Real Lives. So, What do you do when you're not sitting on my exam table in a johnny? Of course, folks come in with their own agendas, the lists of questions jotted down on the backs of envelopes or in the iPhone. Some docs shut all that down, citing "This is your preventive health time only!" which is ridiculous. So, the issues are addressed. Then there's the vaccines review, and lab ordering... These may or may not be straightforward, and more often than not involve additional discussion. My physical exams always run overtime.
So, a day of mostly urgent visits, those single-issue problem visits that can be serious, but at least, straightforward, are a welcome change.
On the other hand, these days highlight what is beautiful, difficult, and terrifying about primary care specialties like internal medicine:
1. You're supposed to know everything about everything.
2. Because we're trained to be always thinking about the Whole Patient- Nothing is ever straightforward.
First patient. The check in sheet states "Cough". Ha, easy. Well, not so much. The cough was undertreated asthma in the setting of a mild cold. But his blood pressure was very elevated. And a quick perusal of the chart showed, this was someone who hadn't been in for a couple of years. Turns out this was someone who had extreme doctor anxiety and alot of issues that needed more fine-tuning. So the visit turned into counseling and negotiations. I set up a followup appointment with the actual primary care and sent my note... Hoping the guy comes back.
Now, running fifteen minutes behind, next patient. "Rash". This is only easy if it's Shingles... and it was. But, the patient is a healthcare provider. And they wanted to know- needed to know- know all the occupational health issues around Shingles. Did they need to notify all the patients they had seen in the past day? How long did they need to be out of work? Did my recommendation around that differ from our hospital's occupational health policy? I wanted to be able to provide a modicum of accurate counseling in all of these areas. I spent some time with her researching the guidelines and then asked her to contact both her supervisor and occupational health for the rest. Then she needed a note. We wrestled over how to phrase it. I hit "print". The printer wouldn't print. Had to run to another computer. Time ticking away.
Then done with that, I had to check my clinical messages (our in-office messaging, where the secretaries and nurses send me anything from patient phone or email queries, VNA concerns, controlled substance medication requests, or abnormal lab or radiology results). I need to quickly scan the list and make sure there is nothing requiring urgent attention. Then deal with those. Someone emailed about their ankle sprain. Nurse: They just want X-rays ordered. Can we do that? Me: Not really, please have them make an appointment. Et cetera.
Then, my email. There's several more emails for me in a now-massive email chain regarding one patient of mine. She has a large team of specialists; her case is complicated; she may need to be admitted, and I would need to arrange that. I read quickly and make sure no one has asked me to do anything yet. I know the specialists probably roll their eyes at my questions. I haven't treated many cases of what she has. I have to read up every time she has labs. But she comes to me, and I'm doing the best I can.
Now hopelessly behind. Next patient: STD screening. Ha, easy! Not. Upon questioning, she tells me one of her partners is a recovering IV drug user. I deliver alot of counseling around this, do a pelvic exam with cultures, send for bloodwork and arrange more followup with bloodwork in two months.
Next: Elderly patient with shortness of breath. She was pretty sick. She told me she had almost passed out in the waiting room. Long and short of it, this person was too sick for my office. But, she resisted my emergency room suggestion. We went into negotiations. I called the emergency room to expedite. We waited for a wheelchair. I typed up my assessment and impression so the emergency docs would have it. Why take the time to chart, when the next patient is waiting? I felt like I needed to present at least a reasonable hypothesis for her condition, as well as defend my decision to send her to the emergency room. I delved more into her chart. Why do her lungs sound like a freight train screeching to a halt? Asthma in someone who's never had asthma? COPD is someone who's never smoked? Pneumonia more likely. Pulmonary edema, maybe.... Type it up. Hit "finalize."
Next: Wrist pain in a guy who does martial arts. I had to do a quick review of the possibilities. Refresh myself on the exam findings in occult scaphoid fracture. Then look up what type of immobilizing brace to prescribe while that is being ruled out. Then the printer didn't work again.
Next: Lovely lady with- finally! A very straightforward issue. Simple. I took care of it and was ready to wrap it up, when, she wanted my opinion on the new blood thinners. She's on Coumadin for atrial fibrillation, for stroke prevention. These new blood thinners are advertised on T.V. The cardiologists are prescribing them right and left. I have never prescribed these. I look it up, with her right there, and review some of the major pros and cons. There's no testing to see if someone is on too low or too high of a dose. That's nice. But, they aren't as readily reversible, so if someone has a car accident or a bleeding ulcer, they may bleed to death more easily than otherwise. Basically, that's what I told her, adding that we can also ask her cardiologist about it. No, she said, I like to know my numbers.
Next, next and next. There was a physical exam in there, and a few more not-so-straightforward urgent care visits. That was it. Nine Patients, and a barrage of clinical messages and emails. I was starving, and I had to pee. I peed, ate something at my desk, and delved into charting, billing, and all the messages/ emails, as well as the arrangements to be made for that very sick patient. I checked in with the emergency room on the lady I had sent in- she was to be admitted. Ha. I knew she was sick.
Mixed in there, I check in with home. I'm thinking about my kids. On my personal email, there are messages back and forth about our autistic son who's had some issues at his special education preschool. School aversion, we don't know why. It's getting better, with a good and patient teacher. But, I worry I'm not doing enough reading and research on autism, that we're not doing enough behavioral work at home. So I got on Amazon and researched, ordered some books.
At the end of the day, I wonder why I'm so fried.
Is it a good, or a bad thing, to be in a job where your mind has to hop, skip and jump and WORK from case to case and even within a case? We see everything and anything, and we're expected to counsel on even more. That, plus the balance with home life, taking care of a family...
Is it a good thing to be a Jack of all trades, Master of none?
-posted by Genmedmom (generallymedicine.com)
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