Friday, January 30, 2009
The evidence is clear that more tests do not make for better outcomes. That doesn't mean I always order the cheapest test. If the CT scan is the right test, I'm not going to order the ultrasound. If my patient needs imaging for a headache, I order the MRI. The wrong test is a false economy.
This is who I am. This is how I was trained. I have good reasons for what I do.
Except....except for the time one of my patients sees a covering provider for back pain, and the covering provider orders what I think was an uncessary Xray, and the Xray finds a fracture.
Which I would have missed.
What if I'm wrong?
What have I missed over the years?
Maybe I would have ordered it. I wasn't there when she examined him; maybe there was something different about his pain, or the exam. But maybe not. Maybe she's just someone who orders an Xray on everyone with back pain, despite the reams of evidence that such Xrays don't change outcomes. Maybe this was just pure chance.
If I'd seen him and hadn't ordered the Xray, he wouldn't have gotten better with conservative treatment and he would have come back, or called, and eventually we'd have found it. I know that. I don't know why this time, in particular, I am second-guessing myself - not even for something I did, but something I didn't do. Something I wouldn't do if the same patient walked into my office tomorrow with the same complaint.
It's hard to swim upstream, and I've been doing it for 20 years. Sometimes I get tired of holding the line. My brain knows that I've saved hundreds of patients from the anxiety of a false positive, a meaningless abnormal result, with the resulting re-testing and worry and further investigation. It's hard to feel proud of what doesn't happen.
I know that this uncertainty is what drives my colleagues to do more tests. I don't want to go down that road, but tonight I'm struggling to remind myself that I'm on the right path for me. Tonight I'm looking ahead and behind and wondering what if....and I don't like the answers.
Thursday, January 29, 2009
Wednesday, January 28, 2009
When I was a kid, there was snow, rain, hail and sleet. Of course, we also had to wait until the local evening news to hear the weather report, and we didn't hear about the weather anywhere else in the country unless somebody died.
Did someone just invent this? Did they just name it? Where did it come from?
Sunday, January 25, 2009
Nothing happened for a while, and then after a couple of months some of my college friends showed up. I started posting status updates and adding more info to my page, and I found the network for my high school. My high school was very small - a public high school which never had more than 110 students in a grade. I went to school with the same people from kindergarten until we graduated high school, and it wasn't always pleasant. I was a weird kid without social skills - I was great with adults but couldn't talk to other children, and I had very few friends. My social life improved in high school and I have mostly good memories of school after sixth grade. I'm also a little old for Facebook, or so I thought, and I wasn't surprised that most of the people on our high school network were post-2000 grads.
Now, all of a sudden, half my high school class has shown up - or at least that's how it feels. The popular jocks, the cheerleaders, the cool kids who smoked clove cigarettes and talked about going to film school. I see the familiar names and I feel - anxious. I clicked over to friend someone and I thought "oh, she won't want to be friends with me". I clicked away.
Funny, I thought I was over all that. Grew up, moved away, got married, built a career, have a life. But every now and then I realize I don't see myself, ever, as a member of the "in" group. I don't feel like I really belong, even when every objective measure tells me that I do. Now the original "in" group, the group that I surely wasn't a part of, has returned to my life, and those old insecurities have come back to life, sort of like Voldemort.
One of the teachers popped up and of course I friended him right away. Still better with the adults, even now that I am one.
Tonight I saw a little red notification flag on Facebook, and discovered that one of those women I was afraid to click on had friended me. Maybe we can grow up. Maybe it's time, finally, to put that story about myself to rest. I don't know anyone who thinks she was part of the "in" group in high school. Maybe we all felt like outsiders; maybe the cheerleaders thought us theater geeks really had it going on.
Maybe. Maybe not. Either way, Facebook is giving me a chance to rewrite the version of high school I carry in my head, and that's a good thing.
Sneeze. Sniff. Cough.
Tomorrow I have patients scheduled from 8:30-3:30, ending a half-hour early because I have a meeting at 6:00. Eve is going home from school with a friend and a babysitter is picking her up there at 6:00. The plan was for me to get home by 5:00, let the dogs out, feed them and take them out, and then go to my meeting (Growler and WackoDog are not the sorts who can be managed by the babysitter or the kid).
I don't think I'll be up to 7 hours of patients and all the associated paperwork, phone calls and office management. On the other hand, right now my next available follow-up appointment is February 10th; if I cancel 20 patients I have no other time to see them.
Sneeze. Sniffle. Sigh.
I have told at least four people in the past week (Sam was the first) that they have been dragging their bodies around behind their heads, and working when they should be home. I feel guilty about even considering that I should take my own advice. (No, he didn't).
Just thinking about this is making me anxious. I need a plan, or at least an option, to manage the anxiety. It's possible I'll feel better in the morning; it's also possible I'll wake up without a voice. So my Plan B is to cancel my patients tomorrow and open up office hours on Thursday evening and Friday afternoon. Assuming, of course, I feel better by then. If I don't, this whole house of cards will come crashing down on my already-aching head.
Sniffle. Sneeze. Sob.
I don't know if DHSS has made an official announcement yet, hence the title of my post. Here's hoping the report from CA NOW is accurate. If the President remains true to the remarks he made as he repealed the Global Gag Order, he will not be able to let that ill-conceived* rule stand.
*Yes, I know, and I left it in anyway.
Saturday, January 24, 2009
President Obama: Words for How We Feel Now from Emily Troutman on Vimeo.
The artist described her project
"This week I made my way around Washington, D.C. and asked hundreds of people to pick words to represent how they feel now, at the dawn of a new beginning for the United States. Participants chose from 26 words:
Alive, Angry, Anxious, Awed, Believe, Curious, Dancer, Excited, Grateful, Happy, Hopeful, Human, Humble, Jealous, Joyful, Love, Obama, Patient, Proud, Ready, Scared, Skeptical, Tired, Together, Wonder, Worried"
Bint chose "wonder", and so do I, although not entirely for the same reason. I am wondering what will happen next, but I am also filled with wonder at what we have seen already. It's that wonder that brought tears to my eyes when I watched Emily Troutman's video. I'm filled with wonder at her creativity and humor and at the respect she shows for each individual she photographs. I hope our leaders can now hold us with the same respect and care that Ms. Troutman's work demonstrates.
What word would you choose?
Friday, January 23, 2009
Tuesday, January 20, 2009
I raised one hand off the steering wheel and shouted.
Last time I did that it was for an Alex Rodriquez home run.
Today was better.
Saturday, January 17, 2009
My job? To study hard for my board re-certification exam.
I have been able to do it. I have been reading material I had assumed would be hard for me, material about subjects that I do not encounter in my current practice.
I have found that much of it comes back.
Of course I have my worries.
Will remember this or that on the day of the exam?
Will I be healthy on the day of the exam?
Will I sleep through my alarm on the day of the exam?
Will I find my way to the test site? (It is really far out into the suburbs)
Will any of the kids be sick the night before the exam?
I have a lot more to read and review before the exam day is here, but overall I feel a little better having confronted my fears about the material.
That's especially good since I have been consumed with guilt for not going on the fun trip with Tigerdad and the cubs. And jealous of their fun.
Back to the books.
Friday, January 16, 2009
There's a chamber music concert tonight which will feature friends of mine playing in the ensemble, one of my favorite pieces by Bach (the 5th Brandenburg) and a Stravinsky piece I love but have never heard live. I mentioned it to Sam, thinking we'd get a sitter, and Eve said "Violin music? Can I go?"
If we go to the concert, I won't be able to cook tonight. We're also going to a pot-luck party tomorrow for which I need to make a lasagna. I love making lasagna. I love eating lasagna. We never have it at home because Sam can't eat cheese, so I haven't eaten my own lasagna in years. I've been looking forward to it.
Can't make the lasagna tomorrow morning because we have services, and we may be a bit late leaving for the potluck because there's an adult ed after services that I want to attend - a discussion about the kaddish that's being held at my suggestion.
Food, music, prayer, learning, community - everything I need. A month's worth of sustenance. All in 24 hours.
Thursday, January 15, 2009
I'm having a hard time getting this crud out of the skillet.
Why don't you use the copper scrubby?
I don't use it on the enameled skillet. I'm afraid it will scratch the finish.
Well, enamel is basically glass, which is 5 on the hardness scale, and copper is copper, which is 3, so it won't scratch.
Do you have any idea how annoying it is when you do that?
Wednesday, January 14, 2009
I'm glad you come every day. It's important that our faculty are present for this experience.
I really enjoy it.
But sometimes, as program director, I have to provide some difficult feedback.
The other day you said something inappropriate.
I did? When?
You corrected the resident about his social history.
Oh. You mean the discussion about the woman who has four children under 6? The patient the resident said was "unemployed"?
All I did was suggest he say "doesn't work for pay" instead of "unemployed". It's less demeaning and more accurate. You've encouraged us to provide direct instruction to the residents during conferences.
I meant about medical issues. You're entitled to your opinion, but that sort of political commentary has no place in an educational session and it makes people uncomfortable. We had medical students at that session who were interviewing for the residency. I don't want them to think badly of us.
Several of those students were women. It's entirely possible - even probable - that my comment made them feel more comfortable.
I don't see why that would be true. Look, I'm just trying to help you. I hear the residents talking to each to other - they say things like "You wouldn't be able to say that if Dr. Jay were here". They're afraid of you because you're so PC.
I see that differently I think maybe people say that because they're upset or offended about something, and it's safer to hide behind me than to object on their own. I'm actually pleased to hear that.
Well, think what you want, but keep your mouth shut about this kind of stuff during conferences.
Tuesday, January 13, 2009
The next voice chimes in. "I think women raised after feminism were sold a bill of goods. We were told that we can have it all, and we can't. It's not possible to raise my kids the way I want to and run my house the way I want to and be the sort of professional I was taught to be. I can't do it all".
And I sit quietly and drink my wine, wondering if my face actually looks as flushed as I feel, and if the other people in the room can hear my heart pounding. I sit quietly because I know if I speak I will either scream or cry. I come home and go to bed, only to wake up in the middle of the night, wondering what I should have said, what I should have done. Wishing I could find a way to speak my truth calmly and really hear what others are saying. I want to transform my silence into listening, but all I can do is scream in my head:
After feminism? It's over already? Could have fooled me.
It wasn't feminism that devalued the work of the home. Raising children, doing the grocery shopping cooking and cleaning - that was all menial work well before Betty Friedan, before Gloria Steinem, before Bella Abzug. No one had to tell our mother's generation that their work wasn't valued; all they had to do was look at their bank accounts, or try to apply for a loan in their own names, or try to get a divorce for any reason save abuse or abandonment. If money is how you keep score, then you need money to even play the game. Staying home isn't a choice unless you have another option. The second wave gave women other options. The changes during the 60s and 70s got us onto the playing field.
But we're not done. Far from it.
The second wave marginalized women of color and queer communities, and we're not making a whole lot of progress even now on our attention to intersectionality. We haven't abolished the patriarchy, and we haven't even openly challenged most of the fundamental assumptions. Work is more consuming than ever. Some things are worse than they were. We've exaggerated the presumed differences between men and women and punished men for any hint of femininity. The women who've been most successful have managed to fit in to the culture, not revolutionize it. We've fetishized motherhood to make it appear the "natural choice". And we've turned on each other in Mommy Wars rather than look outward in alliance to see the forces still oppressing all of us.
I do believe that parenting is a valuable activity, and that someone has to pay attention to how things are going at home. I realize that on average, women are more comfortable in those roles than men are. Why wouldn't we be when our brothers aren't taught how to care for themselves?
We've all been sold a bill of goods if we believe that men have to be straitjacketed into jobs they hate, and women have to be stuck in the homes they keep. We've been sold a bill of goods if we believe that our jobs should take up all of our time, and if they don't, we're not living up to our potential. We've been sold a bill of goods if we believe that every child has to have thousands of dollars worth of toys and clothes and computers in order to be happy. But we didn't buy it from the feminists; we bought and swallowed it whole from the patriarchy.
I couldn't say all that at the party. I let my anger simmer just under the surface. It's safe to vent it here, far away from the villages on the slopes of the volcano, and maybe having let off a little steam I can figure out how to have the conversation for real the next time - because there will be a next time. It's not over. Not by a long shot.
Sunday, January 11, 2009
Then I saw this in the New York Times. News flash: Wall Street execs have lost their jobs, and don't know where to find them. And lo! and behold, no job means no income. It turns out that if Dad's role in the family is to bring home the money, and he can't do that, Mom no longer wants him around.
One mother in TriBeCa, who is married, at least for now, to a Wall Street executive, put it rather bluntly: “My job was to run the household and the children’s lives,” she said. “His job is to provide us with a nice lifestyle.” But his bonus has disappeared, and his annual pay has dropped to $150,000 from $800,000 a year. “Let me just say this,” she said, “I’m still doing my job.”(and yes, we're going to ignore for the moment that $150 K is still a lot of money for normal people and the whole if-it's-about-women-it's-in-the-Style-section thing)
This brings marriage back to its roots, I suppose. Marriage was originally a business arrangement. A man and a woman were married to merge the interests of two families, or to protect property rights, which included the rights to children born during the marriage. People who didn't have land or political power didn't get married, at least not nearly as often, until relatively recently.
The myth of romantic love has been layered on top of that business deal, and all the lace and ruffles and matching matchbooks have distracted us. Now we expect marriage to bring us our soulmate, to fill all our emotional and social needs, but underneath it's still about property. No surprise, then, that it unravels in times of economic hardship.
When Sam and I announced our engagement, my brother shrugged, as only an overly intellectual 18 year old can do. "If that's what you need to do..." he murmured. Pressed, he expanded. "Marriage is a null set for our generation. You don't need Sam to support you, and he doesn't need you to take care of him. You don't have to get married. If it's what you want, go ahead, but you don't have to".
My brother was right. It's time - past time - to give up on the antiquated idea that husbands are only valued for their paychecks, and wives are only valued for their decorative appeal and carpooling skills. What the Times describes is not "traditional", it's archaic. Maybe marriage is under assault, and maybe it should be. Once it falls, we have a chance to build something better in its place.
Wednesday, January 7, 2009
I'd have more time to write if I weren't doing quite so much reading. Mothers in Medicine is one of my current blog-sebssions. Women who are doctors and mothers - I'm home!
Except when I'm not, at least not entirely.
Like this post, which quotes a presenter at a family medicine conference - without questioning the infomation:
Apparently, there's a reference to support the assertion that these traits are professional assets and personal liabilities. It's a 1988 article to which I don't have access, so I don't know what evidence is brought to bear, but I'm dubious about the underlying assumption that these are all adaptive traits. Dedication, sure. And I suppose some degree of competitiveness is required to get good enough grades to get into med school in the first place. It's possible they are all rewarded by professors and attendings during school and traning, but good scores in school and training are not the same as professional success. In my experience, the other qualities - control, perfectionism, caretaking and emotional remoteness - have not been helpful for me or for my colleagues. Quite the opposite.
"These are attributes of physicians that serve them well professionally," said the presenter...
- perennial caretaker
- emotional remoteness
The family medicine conference attendees nodded and murmured in recognition, and he continued, "And these are the attributes of physicians that are liabilities in family life." He flipped to the next power-point slide:
- perennial caretaker
- emotional remoteness
Let's assume for the moment that "control" means self-control, rather than actually being controlling. We need enough self-control to manage a difficult workload and to put other's needs first. How could self-control be bad? Easy. If you control yourself so effectively that you suppress all knowledge of your own needs, you have lost any chance to care for yourself. When we can't care for ourselves, we can't care for anyone else, either.
Perfectionism may, again, help us get to and through med school, and nobody wants a doctor who doesn't try to be perfect. At some point we have to decide that imperfect is good enough. We have to forgive ourselves for being human, and we have to figure out a way to make our peace with our mistakes. The kind of unforgiving perfectionism that keeps us awake nights can also make us overly cautious, test-dependent docs who are so terrified of missing something that we can't trust our own clinical judgment.
Perennial caretaker? I don't want to be any kind of caretaker, annual or perennial. There's a level of responsibility for people in the idea of "caretaker" that is dangerous. We are not responsible for our patients. We are not in control of what our patients do (back to control again, in a different sense). We are in large part the coaches on the sidelines, and on good days we're partners in the game - but our patients need to take care of themselves. Some need to learn how, but a "perennial caretaker" is not likely to encourage them to do so, because then the perennial caretaker will be out of a job.
That brings us to "emotional remoteness". Do I even need to say this? Apparently I do.
A good clinician is not emotionally remote. A good clinician has access to her own emotions and can respond empathically to her patient. There's nothing remote about that. Controlled (here we go again), maybe. We need to be able to take care of our own emotions on our own time, without allowing our needs to invade the patient's time and space. Sometimes we need to be able to share our emotions with patients, when appropriate. "Emotionally remote" is the image we hold of the perfect scientist. It's a false image of scientists and builds on an inaccurate idea of science as purely objective, and objectivity as a moral good in the pursuit of knowledge. That's a dangerous path - almost as dangerous as trying to be emotionally remote when you're building a relationship with your patients.
Practicing medicine is about relationships as much as it's about knowledge and expertise. If I'm not fully present in my connection with my patients, then everything I know about statins and beta-blockers and antibiotics and accurate diagnostic testing is useless. If I'm not listening for emotion and meaning and fear and unspoken agendas, my patients will leave my office feeling as uncomfortable as they did when they came in. The very same qualities that help me build my marriage and parent my child and be a good friend - those are the qualities that sustain me as a doctor, and bring me true professional success. That's how I know I'm in the right job - as Robert Frost said in "Two Tramps In Mud-Time", the stanza that appears on my page in my med school yearbook.
But yield who will to their separation
My object in living is to unite
My avocation and my vocation
As my two eyes are one in sight.
Only where love and need are one
And the work is play for mortal stakes
Is the deed ever really done
For heaven, and the future's sakes.
When I encounter things that bring up my Issues, where do I go to to hash them out?
Husband is a great person and listener, but more of a problem solver when presented with Issues.
I want a listener, an interpreter, a kind warm shoulder on which to lean. And, of course, no judgment.
I have great parents. But, hey, some of these issues are likely related to my relationships with them and I wouldn't want them to feel blamed or do more of the same stuff that got me here in the first place. ;-)
I have friends who are lovely people, but busy with their day to day issues and lives.
I have friends who are super therapists. Really great listeners, interpreters, and kind warm shoulders on whom to lean. They are a good first place to start, but we all have good boundaries and I don't want to go where I should not.
I could pay for it like everyone else. But I know everyone in town. How do you pick a therapist when you know them all? Cannot really pick a friend. Pick someone you do not know well? What if they are not up to the task? Then you have let down your hair and have to put it back up and leave. Will they keep confidentiality? Really keep it? No pillow talk or sotto voce with their therapist friends?
Freud analyzed himself, but that seems full of potential problems. Do you really trust yourself to see all your own blind spots? Maybe Freud could, but it seems the height of narcissism to think I can see past my own.
Tuesday, January 6, 2009
Yes. Is there a problem with the Tylenol we sent in with her today?
Well, not the Tylenol, really. It's the note. We need authorization from the doctor to give her the medication.
Does the M.D. on my name count?
OK, I'll have to call the orthodontist. Eve had spacers installed yesterday.
If you really were a doctor, it would be different.
Um, I really am. Dr. Jay. I can give you my office number and my license if that would help.
Oh! Well, that's fine, then. As long you're REALLY a doctor.
Monday, January 5, 2009
Working to find our back packs.
Working to find our lunch boxes.
Working to find food to pack in the lunch boxes.
Working to find the books that went home with us over winter break to return to the teachers. Working to get up early this morning.
Working to do homework tonight instead of play on the Wii.
And off everyone went to school and work. Mondays I stay home to do everything else.
But for the next two months I am entering outside life hibernation to study for my board re-certification exam. Not a lot to ask. Give me three hours to study on Mondays and Fridays and I think I can make some good headway.
So I began my first hibernation Monday with a list of twelve things to do. None of them included studying. OK, I can knock them off early.
The heat went out this weekend so call #1 was call the gas company and get someone out to look at our heater. I planned ahead and got the parts and labor plan.
No record of my parts and labor plan purchase?
OK, I pull up my checking account on line and quote the person chapter and verse about my check number, amount, date sent, date cashed, and the memo line that read the exact version of the plan I was purchasing. Plus, I am cold, remember?
OK, he can see the payment in the system, just mis-attributed. Computer record updated. Sending someone out tomorrow. Pretty solid.
Garage door broke 6 weeks ago but the repair person can only come out when there is no precipitation. Tough scheduling over the holidays with half days for the day before this holiday and the day before that holiday and lots of local precipitation. But I spoke to the owner last Thursday and he promised me that if the weather was good today, he would send his guys out. So I am home today and looking forward to that.
There has been a sewage smell in my office for the last four weeks. Yuck. Especially to sit with a patient for a 50 minute hour and smell it. Partner and I have had to reschedule and work in other people's offices in the building while they problem solved and finally repaired the problem. Partner emailed yesterday that the office is still covered in dust, can I make sure it gets cleaned before we hit the ground running tomorrow. Sure.
Called the management office 8:30 this AM and left a message to check in. Called the management office at 9:05 this AM to talk with the real person and she got the messgae and will have the engineer call me directly.
One hour to go before I pick up the kids at school. Guess what happened? I called the garage door guy and he never told the secretary he was coming to my house. She didn't know anything about it. Can they come tomorrow? IT IS SUPPOSED TO RAIN TOMORROW!
Off to school pick up. Got the kids, delivered them to their after school activity.
Stopped by the office. COVERED IN DUST! Called the management company. The engineer never called you? Let me have him call you right away.
Wait. Wait. Wait. Don't return patient phone calls because I am waiting for my cell phone to ring.
Call the office back at 10 minutes before five. The gal conferences in the engineer who tells me he can have the office "detailed" tonight.
We shall see...
Saturday, January 3, 2009
When I heard "Hava Nagila" from the living room, I went and watched with her. Here's the Avalon String Band. You may not be able to see the beards and payess on the video, but they were clearly visible on TV.
The music made me smile, but the costumes and beards gave me pause. A bunch of goyim dressing up like stereotypical Eastern European Jews just makes me a little nervous. Apparently, it makes Eve a little nervous, too.
Mommy, are they making fun of the Jews?
Mommy takes a deep breath.
No, sweetie, I don't think so. They're playing the music so beautifully and having such a good time. I think they're celebrating a part of Jewish culture.
Please let it be so.
Thursday, January 1, 2009
Just when I feel competent with this technology, something comes along and makes me feel like mother all over again (well, not quite. My mother still hasn't figured out the difference between a file and an application, which makes for interesting phone calls, most of which end with me saying "Mom, you have a PC and I have a Mac and I can't help you". Which is not-quite-the-truth but if it saves my sanity, I'm going with it).
So why am I writing about this? I feel drawn to the idea of choosing a focus, a word to come back to as a centering point. I may not be fond of resolutions, but I do believe that I can choose my path at any time.
My word for 2009 is quiet. I'd like to work toward quieting myself internally and reducing the clutter in my environment - not just the clutter of things but the unnecessary busyness of my life. If it's quiet, I can rest; I can sleep; I can think. I can listen to what I really need to hear.