Tuesday, October 18, 2011

The Fort

There has been a theme in the past few days in our Urgent Care office of eye injuries.  One woman was an airport presumably going about her business shuffling from gate to gate when she took a piece of paper out of her purse to read. The paper went under her glasses and proceeded to give her a corneal abrasion, otherwise known as a paper cut in her eye.  A construction worker was cutting glass, a piece of which lodged itself directly into his eye (no, he wasn't wearing the proper protective eyewear!).  A young college student left her contacts in too long studying and developed sudden onset nausea, photophobia and eye pain.

These are the type of things that usually remind me to appreciate my mundane, cautious sort of lifestyle.  I have always been a rule-follower, part of my Type A personality I suppose.  So if the contacts were supposed to come out at night, I took them out at night.  But being a physician definitely puts perspective on this in many different ways, both in what we are missing and what could happen if we stray from the straight and narrow.  It's an overall appreciation for what makes us human I'm talking about, the thread that connects us as people.  We want adventure and we crave security, and with either extreme there are problems.  These are the folks we see in the emergency room or urgent care clinics with road rash from a biking accident or hyperventilating from a panic attack.  Exposure to these extremes can be good for doctors as humans, and this is what gives us a broader understanding of behavior and people.

Which is why I love the fact that my kids still make forts out of sheets in the living room.  They are creating their own adventure, with their own form of security.  The best of both worlds, if I don't say so myself, right in the comfort of their own home.  I'm sure it won't last forever.  I'm sure they will one day not find crawling under furniture so entertaining.  But when these small things bring such joy, it reminds me to appreciate the here and now, and the little personalities that are developing under my nose.  They take for granted that they are healthy, that they can see and hear, and as well they should.  This is what I love about childhood.  This is also what I love about being a doctor, because I may not appreciate these things as much if my job wasn't to fix it when things go wrong. 

Tuesday, October 4, 2011

Bob the Goldfish

This is Bob, our Goldfish. 

Dear ED doctor: Shut up and Listen!

Dear ED Doctor:  Shut up and listen.  At least that's what I wanted to say. 

Let me back up a bit.  I had a patient yesterday with an interesting story.  He thought he had a sore throat, but what he mistook for lymph nodes on his neck was actually a large hematoma threatening to compromise his airway.  Working in Urgent Care, you never know what may come through the door.  Most of the time it's coughs and colds, and on a good day there will be an interesting laceration to repair.  As I mentioned previously, my urgent care days are numbered, and I will be back to management of chronic problems shortly as it allows me more time with my husband and kids.  But for now, the excitement is mine, all mine. 

So I'm minding my own business, charting away, when the nurse notified me that the next patient was ready, his problem was a run-of-the-mill "My sore throat is not getting better, doctor, I really think a Z-pack is all I need".  As I entered the room and introduced myself,  I was mentally preparing my dissertation on breeding antibiotic resistance and the mechanism of viral illnesses, I noticed a large area of ecchymosis on his anterior neck.  Further examination revealed what appeared to be a large purplish mass posterior to the uvula, which itself was edematous.  Okay.  Now things are getting interesting.

Turns out the guy brews beer, and in order to figure out what kind of grain he needs, he has to sample the raw wheat or whatever you call it. But by sample, I mean he tosses the grain manly-like into his mouth from his hand, from what I gathered, like a game of toss-the-popcorn.  Apparently on this instance, the little sample of wheat with a little pointy husk flew directly into his posterior pharynx, causing bleeding and a subsequent hematoma.  Probably not a regular occurance in the beer-brewing grain-sampling business is my guess.   After some discussion he admitted there was a bit of coughing that ensued after this particular taste test (really??? no way.) and he had a hard time eating yestereday, but said he felt better today.  He was sitting comfortably as he told me the story.

The bottom line was he needed CT and visualization under sedation to figure out exactly where this hematoma was.  Which is unfortunate, as he was under the impression a z-pack and some cough syrup would do the trick, so the detour to the ER that I was proposing took some convincing.  So convince him I did, and he got in is car and headed to the ER.

As I dialed up the ER to "endorse" the patient, I said a silent prayer not to get some asshole right out of residency on the other end of the line.  But it was not my lucky day. 

By the time the ER doc got to the phone (he first hung up on me, I guess the phone system was beneath his level of training) it was clear I was already taking up too much of his time.  As I attempted what was intended to be a professional head's up, he interrupted and rudely ended the conversation by telling me the patient should come by ambulance.  Never mind that my comfortable patient was likely already in his parking lot walking up to the triage desk as we spoke.  Or that the last time I checked, I was in a better position to determine the mode of transportation necessary for my patient to get to the next level of care than someone who has not even laid eyes on the patient.   My concern was IMPENDING respiratory compromise, you idiot, which is why the patient is GOING TO YOUR E.R., not home to drink beer. 

So what I don't get is, just because you did an ER residency and are theoretically trained to handle life-threatening emergencies, why does this seem to lend itself to the attitude that the rest of the world is inconsequential?  I believe this rule preferentially applies to female physicians calling at 7:45pm from an urgent care center.  When you work in an ER that is not even a major trauma center and there are at least 3 physicians in the ER at the same time, I have a hard time believing that the 2 minutes it takes me to give a brief synopsis of why I am sending a patient your way would hold anyone up.

But that's not really the point.  In our increasingly electronic world, some of us physicians are losing sight of the importance of actually talking to each other.  Sure, you can access a patient chart to find out what's going on, check medication lists, allergies, and just about everything else.  But there is a place for one doctor calling up another doctor to say, "Here's the scoop, this is what I've found, these are my concerns.".  That type of communication is irreplacible if you ask me.  Furthermore, the family physician plays a huge role in this, because we are the ones on the front line, usually the ones with the whole scoop. 

There are several points to be made here, but here are the main three:

1.  ED doctors: we respect you, but you don't know more than everyone else.
2.  Never underestimate the importance of dircect communication.
3.  Female doctors are most likely more qualified than their male counterparts.  This last one is going to require some backing up, but since I'm annoyed, I'll throw it out there anyway. 

We could all benefit from less talking and more listening, anyway.

Friday, September 30, 2011

Practicing Medicine Part-Time

Advice for Mothers in Medicine:  Consider Part Time Practice

I have worked part time since I started working as a family physician in 2001.  I was fortunate to have a husband who was on board with this idea, as we planned our family and tried to decide how we wanted to raise our children.  

But after grueling work hours in residency, this can be a daunting idea for many female physician starting practice, especially if you have not yet started your family.  We are used to 100+ hour work weeks, putting our personal lives second to those of our patients.  This all changes once your own darling baby looks up into your eyes, silently saying, "I'm here!  Mommy, you don't need THEM, you have ME!".  And for the most part this is true, but we are doctors, this is what we do.  It's engrained, we will somehow find a way to be there for everyone, to do it all.  And this is how it starts.  

It's an impossible task, really, but slightly more manageable if you work part time.  That is I think the best way to put it.  Especially for those of us who have multiple children, our lives grow, our children grow.  Eventually something has to give if you want to be the best you can be.  I used to think the early days were hardest, juggling maternity leave, pumping breast milk in empty patient rooms on lunch breaks, going to work with an infusion of caffeine with the same adrenaline rush that used to keep me going on a post-call shift.  Now that I have school-aged children, I am surprised to discover how much more my daughters need me, and how much more I need time for myself.  There would be no hope of any of this if I worked full time.

Part time medicine has many obstacles, however, many of which are perpetuated by the myth that we are not "real doctors" if we don't work 6 days a week.  Malpractice coverage is more difficult to navigate, and it's important to be clear from the start how many hours a week you will work and how available you will be for issues when you are off.  Some fields of medicine are more "family friendly", but I have still encountered many types of discrimination due to the fact that when I am off, I want to be OFF.  This does not mean I am not a doctor when I am not at work, I am just not YOUR doctor.  No, I don't want to stop by after the kids are at school to listen to my neighbor's lungs.  I want to do my errands and go for a run.  This is the type of problem that as women, mothers, and physicians we face.  One thing I have learned is that in the work life balance, even with ourselves, mothers in medicine need to set boundaries.  

Setting my boundaries to work part time has helped me to be more available for my children, my husband, and as a result I believe that I am a better, more focused doctor when I am at work.

A Jew in Idaho

L'Shana Tovah.  We just celebrated our first Rosh Hashana in Idaho.  One of my favorite times of the year, often a time of reflection, peace and family.  I enjoy the food, friends and sense of community that the High Holy Days bring.  I was naturally looking quite forward to experiencing this in our new environment, away from the hustle and bustle of the east coast.  The weather is warmer, we are happier.

We dressed up as usual to attend services at the local synagogue.  And it was... a bit disappointing.  I expected the crowds of Jews that this occasion usually draws- Jews who are observant, not observant, or simply "cultural"- usually everyone usually manages to bring themselves together for a time where bonding with people whose origins and history unite them, making the High Holidays the glue that bonds even the most detached Jewish families together.   It's the kind of thing we complain about having to sit through, but once the rabbi starts singing and the congregation comes alive, I think it brings about the sense of community that so many of us are lacking.

At least that's what I was expecting.  What we found was that most of the children had gone to school that day, and most of the parents of young children were likely at work, business as usual, until perhaps sharing a meal that evening with friends.  This is in fact the first year we have HAD to take our kids out of school to celebrate the Jewish Holidays, as in New York, there was a school holiday to facilitate observance.  The social hall of the synagogue was only partially filled, the empty seats to me a reminder of the fact that so many Jews have perhaps lost that sense of community and belonging that goes along with living on the east coast.

My kids will have that, if it kills me.  I am not particularly religious, and believe me, my husband would rather be tackling the 300 emails piled up at work than sitting in services.  But we were there, we took the time out of our busy lives to slow down and think about what really matters in life:  our children and each other.  For this, I am grateful.  

Happy New Year!

Wednesday, September 21, 2011

The Unfriend

I want to Unfriend you.  As in the popular song my daughters love, sung by that little boy (he looks quite young, don't you think?).

Not everyone, just some of you.  Let me clarify.  Being a physician and a mother is a very tricky job.  I think most people are aware of this.  I think my problem stems from the fact that I work part-time.  The reason I work part time is so that can raise my children and I don't have to pay a nanny to do ALL of the little stuff in between.  Just some of the stuff.

I have worked part time since I started practicing medicine about 10 years ago, right after my first daughter was born.  I am lucky enough to have a husband who is also a physician, and we decided together that this is the way things would be.  He would work full time, I would work part time as a physician, and the REST of the time as a mom.  For the most part, it works.

In residency I had no friends, aside from my wonderful husband and few female colleagues.  They went off to practice medicine in different places, I went off to have a baby and then start working part time in Family Practice.  Along the way I have accumulated several mom friends.  Unfortunately, a few Unfriends as well.

I consider myself a fairly likable person.  I say this because most people like me and I genuinely like people, a common theme among family physcians, or I would think you would lose your mind.  People usually end up wanting to spend more time with me than I have to offer, but I have come to accept this and it usually works out just fine.

So let me just say for the record, that just because I am a warm and friendly person, and you know me in my Mom Life, not my Doctor Life, this does not give you free reign to ask for medical advice.  I have never minded the casual, "Hey, what the hell is that thing on my kid's leg... ok, thanks".  And if there is a true life threatening emergency, OF COURSE I would be happy to help.  The truth is, most things are NOT the emergency that people think they are.  I actually had one Unfriend years ago diagnose herself with hypoglycemia, purchase a glucometer, and proceed to call me with every blood sugar she considered to be a concern.  Multiple times a day.

House calls can be a tricky thing to document, and it's not good for anyone involved to ask a doctor to throw out an opinion without getting some history and or exam.  Plus, I work part time so that I can be with my kids and take time for myself, not so that I can be available to the rest of the world to examine your kid every time she moves the wrong way.

Just in case anyone were to get the wrong idea, I love what I do and I love to help people.  Perhaps I exude this in every interpersonal encounter I have, which is why I can't seem to make people stop putting me in this position.  My goal will be to find a way to gracefully decline, but in the meantime, keep in mind I will simply have to Unfriend you.

Goal Setting

Now that I have embarked on my new blogging career (at least in my own mind), I have decided to make a few goals.  These goals encompass blogging, life, medicine and everything in between.

1.  Write for at least 10 minutes a day.
2.  Do yoga at least once a week.
3.  Read one medicine-related article or piece of information daily.
4.  Laugh with my kids.
5.  Read a novel for at least 30 minutes at night, or until I fall asleep and the book smashes down onto my face.
6.  Really listen to my husband as he talks about his day, making an honest attempt not to think about the 25 million things I still need to do before I can lie down and let a book fall on my face.

I highly recommend all of the above.  I will be reporting back on my success!

Digoxin and Atrial Fibrillation

For some reason, I still see many patients with atrial fibrillation on digoxin.  I don't know if this is because they haven't been in to see their doctors in a while, or if no one is checking their medication lists to update them.  Granted I am still working an urgent care capacity, so not many of my patients are even asking for my opinion on their heart medication when I suture their laceration.  However, I have never been one to refrain from giving my opinion when I feel it is useful.  (Even when not useful I prefer to opine, but that's a story for another day.)

I would like to site an article from American Family Physician from August 15, 2006.  http://www.aafp.org/afp/2006/0815/p613.html
Although outdated, much of its content is still applicable to practice in outpatient setting.

Tuesday, September 20, 2011

Back to Family Practice

Life in the world of medicine is always changing, so is the busy life of a doctor.  Urgent Care was nice while it lasted, but I believe shiftwork is not really conducive to a balance home life.  Or my sanity. 

Today is a perfect example.  At work, seeing patients from 8a-8p.  I'm on my second day in a row, but technically more if you count all the work I do before I GET to work and after I get home.  I'm a bit frazzled as my husband is out of town, kudos to single moms out there.  Anyway, I called home after the sitter picked the kids at the bus. 

Me:  Hi there, sweetie, how was your day?

My oldest sweetie:  All the other parents were there to see our science projects.  Everyone except you.  And my solar oven didn't even work.  Everyone else's worked, mine didn't.

Mommy Guilt:  I'm sorry, honey.  Why don't you have a peanut butter cookie?

And  so on and so forth.  The benefits of an appointment-based practice for working mothers is manyfold, first of all being able to schedule time off to go the science fair.

I do think that this balance and associated guilt makes us better doctors.  We understand the stress that patients go through, and are able to communicate more empathetically.  And in the end, hopefully it will make us more well-rounded parents, able to guide our children with the wisdom gained from negotiating a balance in life, no matter how precarious it seems at times. 

Tuesday, August 16, 2011

It's Only Tuesday

As I was driving to work this morning at around 7am, I spotted a few people out for a leisurely morning stroll.  I have yet to understand how this is accomplished.  By 6:30 this morning I had already showered, made lunch for the kids and a list of important things to accomplish for the babysitter including, of course, a friendly reminder to have the kids pick up their underwear off the floor.  After quick goodbye kisses to my sleepy babies, at 7am I was off to work with a pit stop at WalMart for groceries.  There are some interesting individuals who roam the early morning aisles at WalMart, by the way.  Lots of little old ladies who probably need an updated vision screen to be behind the wheel. 

At the office by 8 am sharp.  Ok, more like 8:11, after cramming grocery bags on top of booster seats in the back of my car and peeling out of WalMart parking lot with rest of the little old ladies.  So I do Urgent Care because 1) I love urgent problems, 2) I dislike seeing patients repeatedly for the same issues that rarely resolve, 3) so I can clock in and clock out, theoretically leaving work behind me when I am at home with my kids.  No, it's not the most super exciting job in the world.  Yes, I always wanted to do a second residency in Emergency Medicine and work in an ED.  But after our cross country move to an easier life in Boise, Idaho, it will do just fine.  After 24 hour shifts as a hospitalist last year in New York, it's a welcome change of pace.  I do miss the challenge and excitement though.

Today, I had a moment of inspiration and used the string technique to remove a wedding ring from an edematous digit post-insect bite.  No ring cutters here, no sir.  I knew I had that dental floss in my purse for a good reason!  Who said a little ER background wouldn't come in handy! 

So, more coughs and colds to come, my energy is starting to wane.  Probably time for my afternoon caffeine infusion.  My solution to organized multitasking is writing out schedules any chance I can get in the hopes that I don't forget something.  I had no idea how complicated things could get when my girls reached school age and started doing their own activities.  In other words, when they started to complain about me signing them up for the same thing at the same time, because they are so close in age I could get away with it.  Back to school season is especially tricky, carefully plotting out driving arrangements juxtaposed with my work schedule.  School supplies to organize, playdates to arrange, and already plans for vacation time need to be considered.  And, it's only Tuesday. 

Thursday, August 11, 2011

The Most Wonderful Time of The Year!

No, not Christmas... (or Hanukkah or Kwanzaa)... the First Day of School!!  Most of us working Mommies understand the beauty of sending those freshly scrubbed faces off to school after a long summer of late nights, long days and necessary disorganization.   Of course I cherish every moment I have with my little people.  And I miss them when I am working long hours, thinking of their bright little faces as I take care of other peoples' illnesses.

What I won't miss is the overwhelming task of coordinating activities for the WHOLE DAY while I am at work.  And I must admit that every summer I compile a few lists- one of all the fun things we will do as a family at the beginning of the summer, which we happily check off as the summer ticks by.  The second begins to creep into my mind around mid-July, a mental wish list of all of the things I would love to accomplish but must wait until the kids go back to school.  Usually organizational projects, writing, articles to read or goals I have set for myself- things that are not easily completed in the midst of running errands or to the chorus of "Mommy Mommy Mommy!"

There is also something very magical to me about the days getting shorter, the smell of crisp fall air, books and papers all lined up and ready for consumption of knowledge.  Kind of like the sensation of accomplishment that comes when you arrive at the hospital early and round on your patients before most of the world is awake.  Energized by discussions with other like-minded souls over freshly brewed coffee, on those days I am ready to take on the world.

Perhaps this is why the complete antithesis of this, ie: the chaos of summer vacation, can be rather overwhelming to a Type A goal-driven person like myself.  I am loathe to admit this in play groups or Mom circles, for fear of seeming unappreciative of my lovely little offspring.  The days of youth flee all too quickly, and I realize that this time of shuttling to soccer, ballet and play dates are short lived in the whole scheme of things.  I love being able to spend time doing all of these things with my daughters, as my mother worked full time and was not present most of the rest of the time.

But my physician self, my love of knowledge self, my inner nerdy self has a little pile of books neatly piled in a corner ready for that wonderful First Day of School.

Wednesday, August 10, 2011

Life After a Move

Ok, it took me a year to get back on my feet after a cross country move.  Actually, 10 months to be exact. Lots of organizing, planning, and adjusting... fast forward through the sweaty details and here we are, in Boise, Idaho!  A new job, new school for kids, new hobbies and a new life.

As physicians, I think we are trained to multitask and make decisions quickly.  It's part of the torture of nights on call, where you are so tired that unless the algorhithms are entrenched in your brain time is lost and lives are at stake.  As a mother, life is similar, especially with three kids and a home, family and job to juggle.  Henceforth my posts will be comprised of short tips for life, from my experiences and ideas generated between piano lessons, orthodontist appointments, and playdates on my days not with patients.

Ideas for a productive day:

1.  Get up early.
2.  Make a daily list of things to accomplish on that day.
3.  Exercise in the morning if possible.
4.  Take a few minutes to reflect on personal goals.
5.  Remember to have patience, as things will not always go as planned.
6.  Give a moment's thought regarding dinner plans, check refrigerator to see if you have the ingredients.
7.  Gather supplies you will need for the day:  water bottles, ballet clothes, soccer shoes- and put near the door so nothing will be forgotten.
8.  Review your calendar for appointments.
9.  Check bank account online for balance and outgoing payments.
10.  Review Twitter and Linked In updates.
11.  Briefly check emails.
12.  Remind yourself that you are only human, once again patience is a virtue.

Have a great day!