Why I’m Running Late

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It may not be rabbit season or duck season but it definitely seems to be doctor season.  Physicians are lined up squarely in the gun sights of the media,  government agencies and legislators, our health care industry employers and coworkers, not to mention our own dissatisfied patients, all happily acquiring hunting licenses in order to trade off taking aim.   It’s not enough any more to wear a bullet proof white coat.  It’s driving doctors to hang up their stethoscope just to get out of the line of fire. Depending on who is expressing an opinion, doctors are seen as overcompensated, demanding, whiny, too uncommitted, too overcommitted, uncaring, egotistical, close minded,  inflexible, and especially– perpetually late.

One of the most frequent complaints expressed about doctors is their lack of sensitivity to the demands of their patients’ schedule.  Doctors do run late and patients wait.  And wait.  And wait some more.  Patients get angry while waiting and this is reflected in patient (dis)satisfaction surveys which are becoming one of the tools the industry uses to judge the quality of a physician’s work and character.

I admit I’m one of those late doctors.  Perpetually 20-30 minutes behind.

I don’t share the reasons why I’m late with my patients as we sit down together in the exam room but I do apologize for my tardiness.  Taking time to explain why takes time away from the task at hand: taking care of the person sitting or lying in front of me.   At that moment, that is the most important person in the world to me.  More important than the six waiting to see me, more important than the dozens of emails, electronic portal messages and calls waiting to be returned, more important than the fact I missed lunch or need to go to the bathroom, more important even than the text message of concern from my daughter or the worry I have about a ill relative.

I’m a salaried doctor, just like more and more of my primary care colleagues these days, providing more patient care with fewer resources.  I don’t earn more by seeing more patients.  There is a work load that I’m expected to carry and my day doesn’t end until that work is done.  Some days are typically a four patient an hour schedule, but most days my colleagues and I must work in extra patients triaged to us by careful nurse screeners, and there are only so many minutes that can be squeezed out of an hour so patients end up feeling the pinch.  I really want to try to go over the list of concerns some patients bring in so they don’t need to return to clinic for another appointment, and I really do try to deal with the inevitable “oh, by the way” question when my hand is on the door knob. Anytime that happens, I run later in my schedule, but I see it as my mission to provide essential caring for the “most important person in the world” at that moment.

The patient who is angry about waiting for me to arrive in the exam room can’t know that three patients before them I saw a woman who found out that her upset stomach was caused by an unplanned and unwanted pregnancy.   Perhaps they might be more understanding if they knew that an earlier patient came in with severe self injury so deep it required repair.   Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection, but is showing potential signs of a pulmonary embolism caused by oral contraceptives.  Or the man with blood on the toilet paper after a bowel movement finding out he has sexually transmitted anal warts when he’s never disclosed he has sex with other men,  or the woman with bloating whose examination reveals an ominous ovarian mass, or finding incidental needle tracks on arms during an evaluation for itchiness, which leads to suspected undiagnosed chronic hepatitis.

Doctors running late are not being inconsiderate, selfish or insensitive to their patients’ needs.  Quite the opposite.  We strive to make our patients feel respected, listened to and cared for.  Most days it is a challenge to do that well and stay on time.  For those who say we are being greedy, so we need to see fewer patients, I respond that health care reform and salaried employment demands we see more patients in less time, not fewer patients in more time.  The waiting will only get longer as more doctors hang up their stethoscopes rather than become a target of anger and resentment as every day becomes “doctor season.”  Patients need to bring a book, bring knitting, schedule for the first appointment of the day.  They also need to bring along a dose of charitable grace when they see how crowded the waiting room is.  It might help to know you are not alone in your worry and misery.

But your doctor is very alone, scrambling to do the very best healing he or she can in the time available.

I’m not yet hanging my stethoscope up though some days I’m so weary by the end, I’m not sure my brain between the ear buds is still functioning.  I don’t wear a bullet proof white coat since I refuse to be defensive.  If it really is doctor season, I’ll just continue on apologizing as I walk into each exam room, my focus directed for that moment to the needs of the “most important person in the whole world.”

And that human being deserves every minute I can give them.

 

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The Doctor’s Waiting Room Vladimir Makovsky 1870

This Doctor is Open For Business

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Astonishing material and revelation appear in our lives all the time.
Let it be.
Unto us, so much is given.
We just have to be open for business.

~Anne Lamott from Help Thanks Wow: Three Essential Prayers

 

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I have the privilege to work in a profession where astonishment and revelation awaits me behind each exam room door.

In a typical clinic day, I open that door up to thirty plus times, close it behind me and settle in for the ten or fifteen minutes I’m allocated per patient.  I need to peel through the layers of each person quickly to find the core of truth about who they are and why they’ve come to clinic that day.

Sometimes what I’m looking for is right on the surface: in their tears, in their pain, in their fears.  Most of the time, it is buried deep, often beneath a scar I must search to find. I need to wade through the rashes and sore throats and coughs and headaches and discouragement to find it.

Once in awhile, I actually do something tangible to help right then and there — sew up a cut, lance a boil, splint a fracture, restore hearing by removing a plug of wax from an ear canal.

Often I find myself giving permission to a patient to be sick — to take time to renew, rest and trust their bodies to know what is best for a time.

Sometimes, I am the coach pushing them to stop living sick — to stop hiding from life’s challenges, to stretch even when it hurts, to get out of bed even when not rested, to quit giving in to symptoms that are to be overcome rather than become overwhelming.

Always I’m looking for an opening to say something a patient might think about after they leave my clinic — how they can make different choices, how they can be bolder and braver in their self care, how they can intervene within their own finite timeline to prevent illness, how every day is just one thread in the larger tapestry of their lifespan.

Each morning I rise early to get work done at home before I actually arrive at my desk at work, trying to avoid feeling unprepared and inadequate to the volume of tasks heaped upon each day.   I know I will be stretched beyond my capacity, challenged by the unfamiliar, the unexpected and will be stressed by obstacles thrown in my way.  I know I will be held responsible for things I have little to do with, simply because I’m the one who often acts as decision-maker.

It is always tempting to go back to bed and hide.

Instead of hiding,  I go to work as the exam room doors need to be opened and the layers peeled away.  I understand the worry, the fear and the pain because I have lived it too.   I know the limitations of a body that wants to consume more than it needs, to sleep rather than go for a walk, to sit rather than stand.

Even now in my seventh decade of life,  I am continually learning how to let it be, even if it is scary.  It is a gift perhaps I can share.

No matter what waits behind the exam room door,  it will be astonishing to me.

I’m grateful to be open for business.  The Doctor is In.

 

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A Bleeding Heart

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Love your neighbor as yourself is part of the great commandment.

The other way to say it is, ‘Love yourself as your neighbor.’ Love yourself not in some egocentric, self-serving sense but love yourself the way you would love your friend in the sense of taking care of yourself, nourishing yourself, trying to understand, comfort, strengthen yourself.

Ministers in particular, people in the caring professions in general, are famous for neglecting their selves with the result that they are apt to become in their own way as helpless and crippled as the people they are trying to care for and thus no longer selves who can be of much use to anybody. 

It means pay mind to your own life, your own health and wholeness, both for your own sake and ultimately for the sake of those you love too. Take care of yourself so you can take care of them.

A bleeding heart is of no help to anybody if it bleeds to death.
~Frederick Buechner from Telling Secrets

 

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We are reminded every time we hear safety instructions on an airplane before a flight takes off: “in the event of a sudden pressure change in the cabin, oxygen masks will appear – remember to put your own on before helping others with their masks.”   

If we aren’t able to breathe ourselves, we won’t last long enough to be of assistance to anyone around us.  Too often,  sacrificing self-care threatens others’ well-being.

A headline appeared in my email from the American Psychiatric Association this morning: “Physicians Experience the Highest Suicide Rate of Any Profession” – there is rampant depression and burn-out among those who should know best how to recognize and respond to the danger signs — for women physicians, nearly 1 out of 5 are afflicted.   Yet the work load only seems to increase, not diminish, the legal and moral responsibility weighs more heavily, and the hours available for sleep and respite shrink.  In forty years of practicing medicine (my father liked to remind me “when are you going to stop ‘practicing’ and actually ‘do’ it?”),  the work has never gotten easier, only harder and heavier.

I see suicidal patients all day and am immensely grateful I’ve never been suicidal, thank God, but anxiety is embedded deep in my DNA from my non-physician fretful farmer ancestors.  Anxiety becomes the fuel and driver of the relentless physician journey on long lonely roads, spurring us to stay awake too many hours and travel too far when we should be closing our eyes and taking a break to breathe, just breathe.

However, we are trained to respond to anxiety from the first day in anatomy class:
“and while you, Miss Polis, are trying to think of the name of that blood vessel, your patient is exsanguinating in front of you– drip, drip, drip….”

Terror-stricken at the thought I was inadequate to the task of saving a life, it took years for me to realize the name of the vessel didn’t bloody matter as long as I knew instinctively to clamp it, compress it, or by the love of the Living God, transfuse my own blood from my bleeding heart into my patient’s.

I learned well those many years ago:

To save a life, I must preserve my own.

 

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Be Obscure Clearly

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A wind has blown the rain away
and blown the sky away
and all the leaves away,
and the trees stand.
I think, I too,
have known autumn too long.
~e.e. cummings

 

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Be obscure clearly.
~E. B. White

 

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As a family doctor in the autumn of a forty year career, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation.  That is hard work for my patients, especially when they are depressed and anxious on top of whatever they are experiencing physically.

There is still much unknown and difficult to understand about psychology, physiology and anatomy.  Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem.  Sometimes the solution is very muddy, not pristine and clear.

Let’s face the lack of facts.  A physician’s clinical work is obscure even on the best of days when everything goes well.  We hope our patients can communicate their concerns as clearly as possible, reflecting accurately what is happening with their health.  In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study.   Our footing is quicksand much of the time even though our patients trust we are giving them rock-solid advice based on a foundation of truth learned over years of education and training.   Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.

Forty years of doctoring in the midst of the mystery of medicine: learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with a little silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients.  What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for.  Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm.  The complex reality of health care reform may dictate something quite different.

The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records.  The pitfall of not knowing what work up was previously done can be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The time has come for the patient to share responsibility for maintenance of their medical records and assist the diagnostic process by providing online symptom and outcomes follow up documentation.

The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops,  reflecting a relationship able to transcend the unknowns.

So we can be obscure with clarity.  Our lives depend on it.

 

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A Moment of Peace

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It had happened many times before, but it always took me by surprise.

Always in the midst of great stress, wading waist-deep in trouble and sorrow, as doctors do, I would glance out a window, open a door, look into a face, and there it would be, unexpected and unmistakable. A moment of peace.  

The light spread from the sky to the ship, and the great horizon was no longer a blank threat of emptiness, but the habitation of joy. For a moment, I lived in the center of the sun, warmed and cleansed, and the smell and sight of sickness fell away; the bitterness lifted from my heart.  

I never looked for it, gave it no name; yet I knew it always, when the gift of peace came. I stood quite still for the moment that it lasted, thinking it strange and not strange that grace should find me here, too.   Then the light shifted slightly and the moment passed, leaving me as it always did, with the lasting echo of its presence. In a reflex of acknowledgment, I crossed myself and went below, my tarnished armor faintly gleaming.
~Diana Gabaldon – Claire’s observations from Voyager

 

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I’ve known this moment of peace in the midst of my work; it comes unexpectedly after a day of immersion in troubles and anguish.  As I leave the clinic and breathe in a sudden rush of fresh air, and as I drive down our country road as the sun is setting, I remember that for all of us, the sick and the not-yet-sick, there still are moments of grace and beauty.

It isn’t all sad, it isn’t all anxious, it isn’t all anguish. The moment may be brief, it may be elusive.

But it is there. And I seek it out every day.

 

 

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(written with gratitude to author Diana Gabaldon for her insights into the complex workings of an innovative physician’s mind in her Outlander series of novels, for Caitriona Balfe‘s insightful characterization and understanding of Claire and for Sam Heughan‘s sensitive portrayal of the man who loves her beyond the boundary of time in Starz’ Outlander  – if you don’t know these stories yet, you should.)

 

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Not Just Another Day

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“This is another day, O Lord…
If I am to stand up, help me to stand bravely.
If I am to sit still, help me to sit quietly.
If I am to lie low, help me to do it patiently.
And if I am to do nothing, let me do it gallantly.”
— Kathleen Norris citing the Book of Common Prayer

 

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This day is the wrap-up to my twenty-eighth academic year working as a college health physician,  the most demanding so far.  Despite budget challenges, inadequate staffing, a higher severity of illness in a patient population with burgeoning mental health needs,  our staff did an incredible job this year serving students and their families with the resources we do have.   Reaching this day today is poignant: we will miss the graduating students we have gotten to know so well over four or five years,  we watch others leave temporarily for the summer, some to far away places around the globe, and we weep for those who have failed out, given up or fallen away from those who care deeply about them, some never to return to school again.

In my work I strive to do what is needed when it is needed no matter what time of the day or night.  There are obviously times when I fall short– too vehement when I need to be quiet, too urgent and pressured when I need to be patient,  too anxious to do something/anything when it is best to courageously do nothing.  It is very difficult for any doctor to choose to do nothing but I vowed in my own graduation ceremony over forty years ago to “First do no harm.”  And I’ve tried hard to live up to that vow.

In a sense I graduate as well on this last day of the school year– only not with cap and gown and diploma in hand.  Each year I learn enough from each patient to fill volumes, as they speak of their struggles, their pain, their stories and sometimes hearing, most tragically, their forever silence.

I honor our students and their families on this day, sharing the blessings from us who work toward the goal of sending them healthier and better equipped and joyful into the rest of their lives.

It is not just another day.

 

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A Z-Pack Pas De Deux

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I’ve been really miserable for three days and need that 5 day antibiotic to get better faster.

Ninety eight percent of the time these symptoms are due to a viral infection and will resolve without antibiotics.

But I can’t breathe and I can’t sleep.

You can use salt water rinses and a few days of decongestant nose spray to ease the congestion.

But my face feels like there is a blown up balloon inside.

Try applying a warm towel to your face.

And I’m feverish and having sweats at night.

Your temp is 99.2. You can use ibuprofen or acetominophen to help the feverish feeling.

But my snot is green.

That’s not unusual with viral upper respiratory infections.

And my teeth are starting to hurt and my ears are popping.

Let me know if that is not resolving in a week or so.

But I’m starting to cough.

Your lungs are clear so breathe steam, push fluids and prop up with an extra pillow.

But sometimes I cough to the point of gagging. Isn’t whooping cough going around?

Your illness doesn’t fit the timeline for pertussis.  You can consider using an over the counter cough suppressant.

But I always end up needing antibiotics. This is like my regular sinus infection thing.

There’s plenty of evidence they can do more harm than good.  They really aren’t indicated at this point in your illness and could have nasty side effects.

But I always get better faster with antibiotics. Doctors always give me antibiotics.

Studies show that two weeks later there is no significant difference in symptoms between those treated with antibiotics and those who did self-care without them.

But I have a really hard week coming up and I won’t be able to rest.

This could be your body’s way of saying that you need to evaluate your priorities.

But I just waited an hour to see you.

I really am sorry about the wait; we’re seeing a lot of sick people with this viral thing going around.

But I paid a $20 co-pay today for this visit.

We’re very appreciative of you paying promptly on the day of service.

But I can go down the street to the walk in clinic and for $130 they will write me an antibiotic prescription without making me feel guilty for asking.

I wouldn’t recommend taking unnecessary medication that can lead to bacterial resistance, side effects and allergic reactions. I truly believe you can be spared the expense, inconvenience and potential risk of taking something you don’t really need.

So that’s it?  Salt water rinses and wait it out?  That’s all you can offer?

Let me know if your symptoms are unresolved or worsening in the next week or so.

So you spent all that time in school just to tell people they don’t need medicine?

I believe I help people heal themselves and educate them about when they do need medicine and then facilitate appropriate treatment. 

I’m going to go find a real doctor who will listen to me.

A real doctor vows to first do no harm.  I know you want something different than I’m offering you and I wish you the best as you recover.