I’ve been working a lot this week and staying nearby to work as we just had our second record breaking blizzard for the winter.  I’m trying to write a post each day for one month (30 consecutive days, not necessarily a calendar month) in order to getting my writing brain going again.  It’s a little flabby right now.   But I have so little to write about. . .I can gripe about work.  Or express my frustration about the fact that my hotel lost power this morning so I was left showering in the dark and missed my hour of lying in bed, watching HGTV before I came in for my sixth shift this week.  (Yes, I recognize that in the scheme of the world’s suffering, this is fairly minor.  But I’m going to spend the next 12 hours trying to be compassionate to people who are also not suffering so sometimes a little escapism helps me deal.  Oh well, should I see another person complaining of mild ear pain for one day with no other associated symptoms who has not tried tylenol, I guess I can just tell him what I really think.  “You are an idiot.  There is no cure for that.  Please go home.  Please do not have children.”  Or, when I see the 20th person for a finger amputation after sticking their hand in a snow blower I can comment, “Well, that just about serves you right, doesn’t it?”  Hmm, my patient satisfaction scores may be dipping after today.)  (So much for not griping about work.)

In other news. . . well, turns out that’s all there was.  I’m off starting Wednesday morning so perhaps I’ll have something good then.  In the meantime, I’ll keep trying to post something every day, but expect more drivel like this.  It’s like a Facebook update, but way longer.

It’s a good thing we don’t have cable. I cannot NOT watch Iron Chef.

Hopefully home in 24 hours. I miss BH.

Sleeping in a hotel to be sure I get to my shift tomorrow, as Nameless East Coast City is in the midst of one big ass snowstorm. Will be here tomorrow as well. Left house today at 6:15 AM. Hope to get home Monday morning around 2:00 AM.

Hey kids, when you pick a career, think about snow days. Oh, and NEVER pack for a weekend at work-hotel-work-hotel-repeat-as-needed without packing your laptop.

 

I have a philosophy of medicine.  It’s something I’ve thought about at length.  It is a combination of personal experience, mentoring, life values and touchy-feely goodness.  A large part of my philosophy is that medicine is a team sport.  I am one of member of that team.  I am not the coach.   I am not the star player.  I may call the plays at times, but I’m just another member of the team.  Everyone else working at the hospital caring for the patient is also a member and, most importantly, the patient is a member of team.  They, if they have cognizance and appropriate intelligence, are just as integral to their care as I am.  

Part of my philosophy means approaching patients as a team player and one way that I’ve chosen to symbolize this is by using my first name with patients.  I routinely address myself as “Moxie” with them, and rarely use “Doctor.”  I want us to be on equal footing, approaching the problem together and working as a team towards the solution. 

The problem? 

Apparently not everyone shares my philosophy, especially patients.  Many patients and families still want me to be “in charge.”  They want me to fix things.  They want a pill.  They want to walk in hurt and walk out fine.  Unfortunately, the human body is far too complex for this.  It is not given to the easy fix, the fast way out.  

A colleague of mine, a woman I highly respect and admire, recommended the other day that I change my introduction.  She believes that patients will respond better if I’m more formal and use my title as well as my last name.  

Is she right?  Am I holding on too tightly to the symbol of my philosophy and sacrificing the actual principles?  Do patients need me to lead the team?  Or is this important?  Should I stand my ground, believing in my goals and aspirations?  

I’d love to know what you all think.

I came out of the room the other day and said causally to the resident, “Well, let’s go ahead and discharge her with some pain medicine and the free clinic list and hopefully next time she comes in she’ll actually have cholecystitis instead of just gallstones.”
I stopped for a moment then, realizing that I had just wished harm on a patient.  I had verbalized my desire for her to develop a potentially life-threatening complication.  It wasn’t that I didn’t like her.  She was pleasant.  She had severe pain and a reason for pain.  She was cooperative and understanding of the limitations of the emergency department.  No, it wasn’t her fault that I had specifically stated that I wanted her to come back, but worse.  And it wasn’t that I was in a particularly foul mood.  Oh sure, it’d been a challenging night, but no more than many.   It wasn’t even that I was confused by her case.  There are plenty of cases where I throw up my hands and say, “I have no idea what’s wrong with you!  I don’t know what to do next.”  This woman’s case was straight-forward.  A clear problem, a simple solution.

So why the frustration?  Why am I still thinking about her two weeks later? What was the issue?

Insurance.

She didn’t have any.  And she needed it.  She needed a little assistance in getting her gallbladder taken out, an easy, in-and-out procedure, go home the same day kind of thing.  But even simple, in-and-out kind of things still take money and a whole damn lot of it.  I had a quick procedure last year, probably about 45 minutes at the most, and it cost $10,000.  Ten.  Thousand. Dollars.  Enough money to buy a car.  Or a semester at college.  Or a down-payment on a house.  Or groceries for a year.  I almost fainted when I saw that price-tag.  And of course, the bill comes after the procedure, so it’s not like you can say, “Oh wait, that’s out of my budget.  Can I return this surgery?  I still have my receipt.”  They won’t even give you store credit.  The day I looked at that bill and then looked at the amount due, “$0.00” was the day I thanked my lucky stars that I live the privileged life that I do.  Because I owed nothing.  Nada.  Zip.  All hospital costs were covered.  Sure, I still had to pay the physician fees but they were a fraction of the total cost.  And even part of those was covered.  And I realized that I’ve got it all—coverage, access, benefits.

Everything this woman doesn’t have.  So even if she does everything right—calls all the clinics on that list and waits the three to six months for a first appointment and then waits another three to six months for a surgery referral and then works out a payment plan with a surgeon, she is still looking at months until final resolution and that’s only if she can figure out how to scrape together a few thousand dollars.  On her housekeeping salary!  That, kids, that is an urban fairy tale.  The probability of things working out for her is about the same as a handsome man riding up on a horse and whisking her away to his castle.

So what happens next?  Well, she takes the pain medicine I gave her and then things subside and she thinks she’s fine and then a few months from now she has some pizza at her nephew’s birthday party and it trips up everything again and she comes back to the emergency department and we repeat the blood work and the ultrasound and we confirm that she has gallstones but no acute infection or inflammation and we discharge her with pain medicine and the clinic list and then a few months later it happens again and then again and then again and then finally one day the ultrasound shows some fluid and some swelling and finally we can actually call a surgeon to the emergency department and they can admit her and then a couple days later when things are calmed down they’ll do the procedure that she needed years before but never could get.  And the total cost for all the emergency visits and the inpatient admission and the surgery and the possible complications will now be much more than $10,000.  $50,000 maybe.  Maybe more.

And that’s how we are “saving” money.  By denying coverage to very nice, very sweet people who are working hard and busting their asses and not looking for a handout.  She just needs her freaking gallbladder out.

The healthcare reform debate has stirred up a whole lot of feelings.  And there are good points on both sides.  And maybe it’s not even worth bringing this up, because the whole issue may be dead in the water anyway.  But every time I hear take about universal coverage, I get a little hopeful.  Because for me, it’s not just about political affiliations and misuse of the words “socialism” and “freedom” and “tyranny.”  It’s about people.  People that are real, who have real pain and real problems and solutions that are real too, just unattainable.  And that’s why I hope health care reform is not dead.  That we come to our senses and realize that this system is not working.  Sure, it works for a few, but that’s not enough.  We can do better.  We have to do better.

Oh 2009, I will remember you.

The first birthday in a long time where I didn’t weep.

Surgery, and recovery, and feeling useless and old.

The last time I saw my best friend.

The last time I had a best friend, at least one like that.

Falling in love with a whole country.

Graduating and saying goodbye to an era.

Spain.

Morocco.

Oregon.  Oh, Oregon, how I love you!

Canada.

Attending!

Boards.

Anguish.

Joy.

My first tattoo.  The brilliant husband’s first tattoo.  Funny how ink and flesh felt more concrete than wedding vows in front of 300 people.  Maybe the religious right needs to outlaw gay tattoos along with gay marriage.

Falling in love, day after day after day.

Brandi Carlile.

Doubt.  Uncertainty.  Second guessing.

Oregon.  Twice.  In person.

2009, you are almost gone.  By the time I hit “publish” you will be over.  Thanks for the time.  Thanks for the memories.  You weren’t the best.  You probably weren’t the worst.

What does your successor have in store?  Things I’d like to see in the coming year:

Sleep. In fact, we could start tonight.  I’m awfully tired and the alarm is going off in just 4.5 hours.

Picnics in the park.

Bike rides.

Late nights on the roof with dear souls.

More leafy greens.

Oregon.

Peace.  Personally, globally.

Love.

Grace.

More writing.  Even when it’s shit.

Less angst.

I imagine I will close 2010 with a similar list of hopes and wishes.  But for now, I’ll take the possibilities, the dreams, the unmarred landscape that’s mine to fill.

And hopefully I’ll fall asleep shortly.

The gas light came on yesterday morning when I started the car.

I drove the 25.6 miles to work anyway.

It was 5:30 in the morning.

I was running late already.

I got there with three minutes to spare.

And the car still started when I left.

Now that’s a car to love.

Last week I finally got to catch up with some John Stewart and The Daily Show.  I happened to see this clip:

Betsy McCaughy on The Daily Show

While I think most people have realized that “death panels” were nothing more than hyperbole and fearmongering, I think the underlying issue–how do Americans plan end-of-life care–still merits discussion.

In the interview with John Stewart, Ms. McCaughey seemed particularly concerned that there would be a checklist for doctors to go through with families, detailing their thoughts on hydration, nutrition, antibiotics, etc.  THAT’S AWESOME.  I think most people believe that if a patient chooses to have a DNR, then nothing will be done for them if they come to the hospital.  Absolutely not!  A DNR/DNR (Do Not Resuscitate/Do Not Intubate) covers what to do in a code situation–a person’s heart has stopped or they have stopped breathing.  This does NOT help doctors know what a patient would want if they have a UTI or pneumonia and can’t vocalize their wishes.  And while it seems callous to ask someone if they want nutrition in these situations, it’s an important question to ask.  This does not mean starving someone who can eat for themselves.  It means if I am so demented that I can’t eat by myself, do I want a tube inserted into my stomach so that someone can pour a can of Ensure down every 4 hours?  HELL NO.  If there is little or no chance that I will make a meaningful recovery from my illness/injury, than LET ME DIE.  DO NOT FEED ME THROUGH A TUBE.  DO NOT HYDRATE ME JUST TO KEEP ME ALIVE.  LET ME DIE.  A checklist is a great idea, because it takes the conversation past just the last few minutes of life (essentially what a DNR/DNI covers) and broadens the discussion to the quality of life issues than can arise in the last few days/weeks/months of life.  And I’m not saying everyone needs to feel how I do.  If you want a g-tube and Ensure, then by all means, you should get it.  What this proposal is doing is allowing people to think about these issues and vocalize their desires.  And that is a good thing.

Another reason I’m so glad that this is in the draft of the bill (although given the hoopla surrounding it, I doubt it will make it in to the final cut) is that doctors can now be paid for having a discussion with patients about end-of-life issues.  Working in the emergency department, I often grumble that primary care doctors aren’t talking with their patients enough about end-of-life care, even if they have a severe or terminal illness.  Then the patient arrives in the ED, sick as shit, and I have to figure out what they would like to have done.  I grumble, but I realize that a minimally adequate conversation on this topic can take a half hour or more.  In a pressured, tightly scheduled primary care practice, there simply isn’t time to do this and still cover the overhead (my feelings on how insurance companies have choked the life out of primary care doctors can come another time).  If, however, the conversation can be billed separately, then doctors can allocate the appropriate amount of time, and still pay their rent, their staff and their malpractice.  Trust me, doctors don’t want to get paid for this because it’s going to be quite the money-making scheme.  They want to get paid because given the amount of time it takes, they need to be paid for it.  You wouldn’t expect a surgeon not to get paid to take out your appendix, would you?  Well, a good surgeon can take out an uncomplicated appendix in less time than it takes a primary care doctor to discuss options, answer questions, explain alternatives and reassure patients that their wishes will be respected.

And why is McCaughey so up in arms about the possible penalties that doctors face about NOT having these conversations?  The government and various regulatory bodies have already decided that some specific measures should be implemented–certain vaccines for those over 65, antibiotics within a certain time frame for pneumonia, an aspirin and beta-blocker for those with acute coronary syndrome and so on.  Data is collected and doctors and hospitals must meet a certain threshold or they will lose money under the Pay for Performance structure.  So, assuming that it’s good if patients get a chance to say what they want done if  they are sick and can’t speak for themselves, then why shouldn’t it be part of Pay for Performance?  (The benefits of Pay for Performance can be debated another time).  It seems as if the proposal is simply trying to be consistent in how it approaches quality measures.

My last beef is that McCaughey feels that it is inappropriate for doctors to be assessed on how well they are adhering to advance directives/living wills.  If a patient and their family sits down, thinks about the options, discusses what should be done and then makes it into a binding legal document, is it not reasonable for doctors to adhere to that?

This issue is particularly fresh in my mind as I had a very challenging case the other day.  A family brought in their 97 year old grandfather.  He was very sick–his heart was pumping twice as fast as usual and his blood pressure was tanking.  His abdomen was rigid, a sign of possible infection or air within.  The usually spry and feisty man was simply lying in bed, murmuring occasionally in Russian.  I knew almost immediately that I had only a few minutes to intervene, but no matter what I did, I likely would not be able to change the outcome.  I said to the family, “Your grandfather is very ill.  I can be aggressive in his care but I may not be able to save him.  What would you like me to do?”  They said, “Do everything you can do.”  And so we did.  Several people held him down so we could put a large IV in his groin and a catheter in his penis and a tube down his nose.  We were thinking that soon we’d have to put him on a ventilator.  There were complications, leading to more needles and pain.  All throughout, I kept thinking, “This poor man.  Is this really how he wants to die?”  I knew that even doing everything I could, he was too sick, his body was too old for me to make a difference.  After two hours, we finally had the reason he was so sick.  An ulcer in his stomach had eroded through the stomach lining, realizing air and bacteria into the abdomen.  I went back to the family and explained that even if I could convince a surgeon to take him to the operating room (a VERY big if), he likely would die in surgery or shortly after.  I asked if they would like to stop intervening, stop being aggressive, stop trying to save his life and instead focus on treating his pain, on making him comfortable, on letting him die with dignity and grace.  With tears in their eyes, they said they would.  So we pulled out the tubes, we turned off the monitors and we let his son and daughter-in-law and grandsons gather around him and hold his hands and tell him how much they loved him.  It was beautiful.  And I know, beyond a shadow of a doubt, that it was the right thing to do.  My only regret in his care is those first two hours–the pain, the restraints on his wrists, the turmoil in the room as we tried to do a thousand things at once.

Please, please, please, talk with your family members about what they would like at the end-of-life and what you would like.  Be informed.  Know the options.  Discuss it with your doctor and put it in writing.  Five Wishes is a great way to learn more.  This is your body.  You should choose.

Ah, internets.  . .it’s been a long time.  But I’ve been busy.  Seriously.  And I’ve missed you.  I really have.

I just completed my first week as an attending.  A quick primer for those unfamiliar with medical education.

Steps to becoming a doctor:

1. Undergraduate education–”college”:  Fairly commonly understood. Pop culture reference:  Too many to choose from.  Pick your own.
2. Medical education–”Med school”:  Four years of schooling after college.  First two years are usually mostly book work and the second two years are “clinicals”–running around a hospital in a short white coat and experiencing various aspects of medicine.  Pop culture reference:  Abby on ER after she was a nurse but before the last season.
3. Residency–”Hell on earth”:  Three to eight years after med school spent learning a particular specialty.  Contrary to popular thought, these folks are “real” doctors.  Much medical care in many hospitals is given by residents and they do a pretty fine job.  Think of this as an apprenticeship where someone is learning a field from a more experienced practitioner.  Pop culture reference:  Meredith on Grey’s Anatomy.
4. Attendingship–”Real job”:  Once you’ve completed residency, you then get a job in that particular field, such as family practice, surgery, obstetrics, etc.  You can now take an exam in your chosen field and then be board certified.  In addition, you can supervise residents and help them develop their skills in that particular area.  Pop culture reference:  Dr. Cox on Scrubs.

So, now I’m technically on my own and in charge and know what’s up and all that.  Except I don’t.  I’ll go in and see a patient and come out of the room and get ready to put in orders on the patient and I’ll think:  “Hmm, maybe I should CT him?  No, maybe I should spare him the radiation.  But what if he needs the CT?  But what if he doesn’t?  I’ll just treat his pain and then reassess.  But wait, maybe I shouldn’t give this medication.  If he’s bleeding and I give him this medication, he’ll just bleed more.  But the narcotic might be too much, because maybe there is nothing seriously wrong with him.  But he’s in pain, so he needs something.  I could give him pills but what if it turns out there is something bad going on and he needs surgery?  Probably should give meds IV.  I wonder if he has insurance.  I don’t want to do an unnecessary workup that he has to sell a kidney to pay for, but I also don’t want to miss anything.  I should call his doctor.  Oh no, there are four new patients to see and I have three patients to dispo.  I still have to tell the guy in room 6 that he has an appendicitis but his wife will have a thousand questions so I really don’t have time.  But communication is important and since I’m now being evaluated on my patient satisfaction scores, I really need to get in there.  But I’m also being evaluated on my time to disposition so maybe I should dispo people first.  Oh, except I need to look and make sure all the results are okay.  Hmm, what does that mean?  I should call the radiologist just to double check.  But I need to get orders in on that other guy so that we can get his workup started.  Maybe I should CT him. . .”

I’m like a schizophrenic that can’t turn the voices off.  I find it hard to concentrate on what people are telling me, because the din in the back of my head just gets louder and louder.  And to add further fuel to the “maybe I’m not competent to practice medicine on my own” fire there was this little event. . .

The group that I’m working for actually staffs four separate emergency departments.  I’ll spend most of my time in the main ED but occasional will be at the other sites.  For my orientation week I went to each site once, just so I could see how things work, where they are at, etc.  All of the sites are in neighborhoods that I don’t know, far from my familiar grid-pattern surroundings.  I mapped out the locations and then set off.

As I exited the highway, planning to go “0.2 miles, then right on Willshire Boulevard.  Destination will be on your right.” I was surprised to see a hospital immediately on my right.  I quickly made the assumption that the mailing address was off Willshire, while the actual entrance was on a different street.  I made a quick turn in and after circling the hospital five times (a couple more times and maybe I could have brought the walls down, Jericho style) I finally found the physician parking lot.  My ID badge failed to get the gate to open but a free lot was right next door so I wasn’t too concerned.

I walked in, introduced myself to the very nice and mostly deaf man at the front desk who turned me over to Glenda, a pleasant, if no-nonsense nurse who started talking a mile a minute.  “Here are the green rooms we open those at ten o’clock but don’t worry a different doc will staff those and here are the charts we’re on the T-sheet system and these are the critical care rooms and . . .”  I tried to follow what she was saying but we were walking and she was talking and I was mostly trying not to run into things so I just nodded and smiled a lot.  A slight alarm went off in my brain when she mentioned the paper charts as I thought all the sites I’d be working at would have computer charting but I snoozed that warning and followed her down the corridor.  As we rounded the corner she stopped abruptly, “Oh there’s Dr. Mills.  Dr. Mills, the new attending is here.”

A very tall, very doctorly looking, very manly man turned around, looking puzzled.  He sized me up, noting the short hair and the nose piercing and the general lack of any doctorliness and said, “I’m sorry, who are you?”

I dug deep and pulled up all the confidence I could muster and stuck out my hand as I said, “I’m Dr. Moxie.  I’m here for an orientation shift.”  All alarms in my head were now going off. . . the entrance off the wrong road. . .the lack of access to the physician parking lot  . . . the paper charts. . .the different address.

As he continued to stare at me most quizzically I tried to suppress my panic.  “Who do you work for?” he asked, staring down at me from his lofty height.  I imagine he had trouble not adding the “my child” at the end of the sentence.

I barely was able to eek out the name of my group and as I did he chuckled.  “Well, my dear.  That group doesn’t work here, but if you’d like to work our weekend nights, I’d be happy to hire you on the spot.”

I wish there was a stronger word for embarrassment.  Something to convey the total and utter shame, mortification, chagrin and vexation I was feeling that moment.  I uttered some sort of apology as I fled the department, formerly friendly and now very perturbed Glenda staring me down for wasting her time on a tour.  Some kind soul gave me quick directions to the ACTUAL ED I was supposed to be at, a half-mile down the road.  As I drove away, I kept imaging that doctor and the rest of the staff standing there, shaking their heads and wondering how I’m supposed to save lives when I can’t even find the damn hospital.

Quite honestly, I was thinking the same thing.

Ah, April. . .the flowers are blooming, the air is warming and the mailbox is overflowing with wedding invitations. With June just a few weeks away, it’s time to get those invites out.

Last week we received three invitations. Two were addressed to “Mr. and Mrs. BH Moxie” and one was addressed to “BH Moxie.”

Two things crossed my mind:

1. I hate titles. Really, I prefer to take people as people and I think titles often times obscure that. Even at work, I go by my first name as much as possible. I know that some people, however, choose to be more formal. If you’re going to be formal, though, make sure you do it right.

I am not a “Mrs.” My formal title is “Doctor.” Now, I’m not saying people need to address me as “Dr. Moxie” (despite the title of this blog.)   I actually hate being referred to as Dr. Moxie, especially outside of the hospital. But if there is something I hate even more, it’s being called “Mrs.” Which leads me to my next point. . .

2. Who makes the rules of etiquette? Seriously. I want to know. Because they need to fast forward their thinking and recognize that women are now actually considered to be people. Independent people. With identities outside of their husband. I know that the appropriate way (as per my research on Knot.com this morning) to address a married couple on a wedding invitation is “Mr. and Mrs. John Smith.” But that’s bullshit. One hundred percent bullshit. Women have names and those names should be used. I am not “Mrs. BH Moxie.” I love BH more and more every day and I cannot fathom a life without him, but I am not just a subset of him. I am me. I am Moxie. And that deserves to be recognized, just as his identity is recognized. So future brides and grooms, I call out to you. Rise up! Rise up against centuries of patriarchal tradition! Rise up against outdated “etiquette!” Rise up against the idea that “it’s just a little thing.” Yeah, well, it’s the little things that give credibility to the big things, like denying the right to vote or requiring seperate drinking fountains.  We’re moving on and our stationary needs to reflect that.

An interesting sidenote–there’s an educational bias/discrimination built in to this whole etiquette thing.  The standard approach for a couple is to use the man’s first name only.  However, if the woman has a formal title, then her first name can be used, ie “The Honorable Joan Smith and Mr. John Smith.”  What a crock of shit!  As if a woman has to earn her own identity.

Sources:

http://wedding.theknot.com/wedding-planning/wedding-invitations/articles/wedding-invitations-etiquette.aspx

Ranting done.  Back to working.