They Report, I Decide* ~ by Jay

George Tiller was murdered this morning.

George Tiller was many things, as far as I can tell: a churchgoer, a loving member of a family, a veteran of the US Navy, and a doctor. He was a family practice doc who served as the team physician for the Wichita professional soccer team and also held the position of medical director of a drug and alcohol treatment program.

Read that word again - doctor. Then read this article. See if you notice anything missing. Go ahead, I'll wait.

That's right - the word "doctor" is not present in that article. Try "find". You won't. You also won't find the honorific Dr. or the initials M.D. The headline identifies Dr. Tiller as "abortion provider"; the text uses his full name once and thereafter simply refers to him as "Tiller". His profession is erased as completely as his life was ended. So much for journalistic objectivity.

I find it horrifying that people can even try and justify murder (and I won't link to any of those comments; they're out there, and I don't want them coming here) and I have to think that it would be just a tiniest bit harder to justify murdering a doctor than an "abortion provider".

There are many words that we could use to describe Dr. Tiller: passionate, committed, brave, selfless, and, of course, murdered. Let's also continue to describe him, and the others who do this work, as what they are: doctors.
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*I decide that the writers at Kansas.com have been coopted by the anti-reproductive justice brigades, that's what I decide.
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UPDATE: Anette alerted me to a change in wording. The link now takes you to a revised story including the arrest of the suspect and his likely arraignment tomorrow, and identifies Dr. Tiller as an "abortion doctor". Still with the qualifier, though.

Conversations With Colleagues ~ by Jay

Hey, I'm sorry to bother you. I have a patient who's 10 weeks pregnant and wants to terminate. Can you suggest someone?

We can do that for her. Give me her name and I'll have someone call her today.

OK, but I already gave her your name and she called and asked; the staff told her you don't do abortions.

We do them for our established patients and for direct referrals, but we starting telling people we didn't to protect ourselves and our staff. Last year one of our staff members quit because she was being shouted at by her neighbors, and her children were harassed at school. Around the same time, someone sent an anonymous letter to my home address saying they would "terminate" my children. I think there's someone at the hospital feeding them the information, so we've had to be much more discrete.

Sounds like we're back to my grandmother's day: you can get an abortion if you have a connection.

Yup, that's basically it.

{RIP, Dr. George Tiller, and God save us all}

It's Official ~ by Jay

The Big Secret that I've mentioned once or twice is no longer a secret.

In mid-July I will have to edit my profile to take out the part that says "primary care doc". I'm leaving my practice to take a full-time job as the Hospice Medical Director. We've been in negotiations for about two months, and I just received the official offer.

I'm a lot excited and a little scared and still kind of amazed. I'd been thinking about looking for a full-time hospice job. I've made my peace with the compromises of primary care for the moment, but it's an uncomfortable balance, and I'm always aware that I don't quite fit. I hadn't actually applied for a job because I don't really want to move - this area suits us, and Sam has a job he loves. Getting out of primary care was a fantasy, one I tried not to think of very often, because primary care was paying the bills, and it wasn't as if I hated it. And then the Powers that Be designed a reorganization that moves the current Hospice Medical Director into a newly created position in Palliative Care, and they offered me his job. Win-win - the Hospice gets to pay one person instead of 1.5 people*, the network gets an organized Palliative Care service with greater capacity, and I get the job I really want.

I think of my professional life as having three components. There's the work - what I do every day. There's the job - the setting in which I do my work at the moment. And then there's the career, which progresses over time toward a goal. I've always liked my work but I'm not really comfortable with my job, and I've never had any idea about my career. Now I have the chance to do work I love in a job that really suits me, and maybe even build toward something more.

Baruch atah Adonai, eloheinu melech ha'olam, shechianu, vekiamanu, vehigianu, lazman hazeh.

Blessed are you, Adonai our God, Ruler of the Universe, who has created us, and sustained us, and brought us to this day.
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*I will not be doing 1.5 jobs. The current medical director has been doing both Hospice and Palliative Care, which he why he needed me. With the Palliative Care removed from the job, it becomes a 1.0 FTE job (well, close, anyway).

Connecting The Dots ~ by Jay

Astute readers may have realized that my last post was a response to therapydoc's recent post over at The Second Road. The drug-seeking addicted patient is familiar to every clinician. We've all met them, and we've all worried about them. In my experience the latter is more common than the former. Funny, I didn't notice "Jay's prescription pad" on the list in Mary's rumination on the causes of addiction. Prescription drug abuse is a real problem, but docs don't cause it any more than we cause pneumonia.

Fun fact: using opioids in adequate doses, on a schedule, with available medication for breakthrough actually reduces the total amount of opioid used after surgery and improves overall outcomes.

Docs can't cause addiction, but docs sure can cause drug-seeking behavior.

One of my partners left me a note this morning. "Mr. Thusandso called last night looking for more Percocet. Seemed like he was drug-seeking". When I looked at Mr. Thusandso's chart, I could see that I gave him 30 days worth of Percocet about 35 days ago, and the message he left last week asking for a refill never got to my desk.

He sure was drug-seeking. He was seeking the drug he needed.

Fun fact: The American Geriatrics Society convened a panel of experts to develop guidelines for pain management in the elderly. Conclusion: anti-inflammatories are more dangerous than opioids.

So if prescription drug abuse is a real problem, but I can't assume every drug-seeking patient is addicted, and I can't just prescribe ibuprofen instead, what do I do?

I screen my patients for addiction before I prescribe opioids. I make sure we have agreement about the goals of treatment, and I don't promise to get rid of pain. I use non-pharmacological treatment - physical therapy, massage, acupuncture - and non-opioid adjuvant medications in addition. I see patients more frequently once I start prescribing until the dose is stabilized. I don't replace lost prescriptions. I don't give early refills. I accept the fact that every now and then I will give a prescription to someone who has addiction; I hope I will recognize that quickly and help them find appropriate treatment.

The fear of addiction, and fear of opioids, makes my job harder - both parts of my job. People are generally more willing to accept opioid treatment at the end of their lives, but I spent several hours this weekend working with families and patients who just thought morpine was evil, even if it would relieve the shortness of breath or the pain. They don't want to ask for medicine. They don't want anyone to think they're drug-seeking.

Conversations With Patients ~ by Jay

I need a new prescription for my headache medicine. I'm sorry to bother you at night, but I need it. I can't wait for the office to open tomorrow.

Who's your regular doctor?

Dr. Y. He saved my life. I've had terrible headaches for years. Awful. Three or four times a week, really unbearable - I'd have to go to bed. I couldn't work or get anything done. I went to all sorts of doctors and nothing helped, not until I saw Dr. Y. The medicine he gave me is the only medicine that's ever worked.

Oh?

Yes. I'm terrified that I'll lose the bottle and then I won't be able to take it and then I'll get the headaches again, so I keep it with me. It's always in my purse. But today I had a company car, and I left the clasp of my purse opened and the bottle must have rolled out on to the floor. I didn't realize it until I'd left the car in the garage and it's locked up until morning - I can't get at it. I can't wait to call Dr. Y in the morning or wait for the garage to open because I have a 6:00 AM flight out of state for my daughter's wedding. I need a prescription called in tonight.

I see. I don't have your chart, of course. What medication do you need?

Inderal, for my migraines.

Oh! I can give you that.

You sound surprised.

In Which Other Women Blog So I Don't Have To ~ by Jay

Still in a liminal state, still feeling too distracted and disconnected from reality to focus on anything long enough to blog.

Meanwhile, I've found an awesome blog by high-school feminists. Check out Women's Glib and feel better about our future! Start out here; Jennifer, a high school junior, wonders why magazines aimed at young men don't have relationship advice. You go, Jennifer.

Follow-Up ~ by Jay

Don't know about you, but I love follow-up. One of the reasons I like primary care - I like to know how the story comes out in the end.

So the patient with hematuria (blood in the urine, sorry) came in today for an unrelated urgent complaint. Bloody urine persisted for about 36 hours and then resolved.

So, doc, what do you think?

I think you need to see a urologist.

Could this be cancer?

Yes. It could be a lot of other things, too, but I have to tell you that I'm concerned it might be cancer.

And that's the truth.

Conversations With My Father, 2001 ~ by Jay

Dad, I've wanted to ask you something for a long time. You once suggested to me that I withhold information from a patient, and I've always been troubled by that.

I did? Really?

Yes. It was a month or so after I started practice, and I told you I was upset because I had to tell a young women she had MS.

Oh, I remember. The symptoms had resolved, right? But you had the MRI results.

Right. And you said "Why do you have to tell her?" I was shocked.

That doesn't sound like me.

I know.

All I can say, honey, is that I remember being worried about you, and wishing you didn't have to go through with something that would be so painful for you. I knew you had to tell her, but I probably wanted to protect you. You may be a doctor, but you're still my little girl.

In Which I Break a Rule ~ by Jay

Rosemary Flanigan over at Practical Bioethics asks how we justify withholding information from patients these days. The 1950s let's-not-tell-Grandma story isn't supposed to happen these days - the revolution in bioethics in the 1970s placed truthtelling up there with benificence, non-maleficence and autonomy as a guiding principle. It's a principle I generally abide by (see my comment on Rosemary's post for my thoughts) but there are, of course, nuances and subtleties.

Dr. Jay, thanks for calling me back. I'm sorry to bother you on the weekend. I noticed some blood in my urine and I don't know what to do.

The caller is out of state at his grandson's college graduation. He feels well and has no signs or symptoms of infection or prostate problems. He's also a long-time smoker in his 70s, and the most likely cause of this blood in his urine is bladder cancer. I knew this as soon as I saw the message on my beeper, before I even spoke with him.

I didn't tell him. Not during that conversation. He'll be home in four days, and I can see him in the office then and arrange the appropriate evaluation. The delay won't change anything, but it will allow him to enjoy his trip and his time with his family. I reassured him that it was nothing that needed immediate attention, suggested he call me back immediately or go to a local ER if he developed any pain or fever, and made a note to have my assistant call him the day after he returns to make sure he comes in for an appointment. "I'm sure you will be fine this weekend" isn't really a lie, but it isn't really telling the truth.

Curse You, Shel Silverstein ~ by Jay

I don't think we spent all that much time reading The Giving Tree (or, as a friend of mine calls it, The Co-Dependent Tree). Seems to have made an impression on Eve, though.

Her class is working on "why" stories, and Eve decided to write about Why the Sunflower is Tall. Turns out, in the world according to Eve, that Sammy the sunflower told his friend Rose that he wanted to be tall. Rose went to the Mayor, Violet, and said "The sunflowers want to be tall, like we are". Violet said "We'll have to think about about this. Don't do anything". Rose ignored the Mayor and gathered all the sunflowers by the magic tree. She told them how to ask the magic tree for help and the tree made them all tall, as tall as Rose. The sunflowers were very happy, but when the Mayor found out, she made Rose short as punishment for breaking the rules. Rose doesn't care, though, as long as her friends have what they want.

OK, the Mayor is female, and Rose is clearly a powerful and empathic figure in this story. But was it really necessary for Rose to lose in order to give Sammy what he wants? And why doesn't she care? Why is a boy's happiness more important than her very self?

I know, I know, she's 9, and I'm reading way too much into this. Do I have to be an English major all the time? Apparently I do, and I have to be a feminist all the time, too. I can't shake the idea that my daughter's very imagination is already telling her that the very best thing she can do in the world is give up her stature in order to give someone else - someone male - what he wants. And that idea makes me deeply, profoundly sad.

Conversations With Patients ~ by Jay

What's on your mind today?

I keep gaining weight, and it's driving me nuts.

Hmm. Your weight's been the same for the two years I've known you.

Really?

Yup. See here? You go up or down a pound, but no significant change.

So why do my clothes fit differently? My pants are all tight around the hips and thighs. I can't stand it. I'm exercising more and nothing helps.

Your weight is the same, but your body is changing. That happens to everyone over time. You can't really change it with exercise. If your clothing is uncomfortable, maybe you need to have something altered or buy clothes that are cut differently.

Well, I can't live this way and I refuse to buy a bigger size. Every morning I look in the mirror and I just feel awful.

Where's Jay? ~ by Jay

I seem to spend a lot time writing posts explaining why I'm not writing posts.

The more I write, the easier it is. The longer I go between posts, the harder it gets. I don't know if it's a sense that now I need to write something important, or it's just inertia, but that's part of the reason I've been quiet lately.

The other part is something I can't yet write about. It's good stuff, but I can't write about it - or talk about it much in my 3-D life - until it's official. And of course it's the thing I can't write about that is occupying most of my mind at the moment.

I'll be back - I hope pretty soon - and I hope some of you will still be there when I return. Thanks for your patience, and watch this space.

Return ~ by Jay

Sam just texted me - he's on the ground, headed home.

We've been together 26 years, married 24, and he's only been gone two weeks - but I am so excited to see him again that I can hardly keep my mind on my work.

And it's not just because there are TVs that need to be reconnected and lightbulbs that need to be changed and the lawn needs to be mowed. It's not even mostly the TV and the lightbulbs and the lawn. I can't wait to actually touch him, to feel his hands on my skin and his arms around me. To know if I wake in the night he'll be there, next to me.

Ah, love.

Mother's Day ~ by Jay

One of the first posts I wrote for this blog was about Mother's Day. Guess that means I missed our blogiversay, again.

I didn't get a clean garage for Mother's Day this year. Instead I've had a day my daughter created for me. This morning I opened a framed picture she drew. Yesterday, I received a lovely bouquet of flowers, which is a rare treat - Sam is allergic to virtually all scented flowers, so we don't usually have them in the house. Since Sam's away, I get to keep them - irises and roses, chosen by Eve with help from my mother.

Eve also asked to go out for brunch, which we've never done. She heard a radio ad for a brunch at her favorite "real" restaurant, so I made a reservation and Mom, Eve and I went at 11:30. Nice meal, followed by a trip to the grocery store. We'll have friends over this afternoon and will be able to sit outside - first really nice day we've had in weeks. Eve is cleaning off the outside furniture, which was covered in crud from the winter's depredations. She's thrilled to be doing something real, and earning some money.

This stage of parenting crept up on me. I know it won't last - none of them do - but this one I will relish. Eve is increasingly independent but still eager for cuddles and good-night songs and meals out with the grownups. The storms of adolescence are waiting for us but for now we're anchored in a calm, sunny tropical lagoon.

Happy Mother's Day.

The Horror, The Horror ~ by Jay

I woke up yesterday morning and my computer did not.

After 45 minutes with the kind folk at the Apple store, it was determined that my hard drive had died. No problem, they said. Same day service, they said. We'll call you when it's done, they said.

They also said that restoring my data from the Time Machine backup (done Monday evening just before bed. Phew.) would take about an hour.

Hmm.

I have never used Time Machine to restore data, and it has been my experience that such things do not always go as smoothly as one might wish. So I moved patients around and managed to get back to the store at 6:45 instead of 8:30 in the evening. Which was a Very Good Thing.

They had not installed Leopard on my new hard drive but Tiger. They fixed that (20 minutes; I went to the nearby bookstore and bought a book).

They decided to check if I had a warranty. (15 minutes. They couldn't figure it out. I made them stop).

They started the restore process and discovered that there wasn't enough room on the hard drive for the data (30 minutes. I explained that yes, all that data had come off a hard drive that was precisely the same size, not 24 hours previously. They conclude that I have backed up the OS and therefore they are trying to reinstall it. Attempt a workaround. No dice. Take the computer in back again and do something. Come back to start the restore process again. I take my book and walk next door to get something to eat).

I return to find it is 8:35 and the remaining time on the Time Machine transfer is 1 hr 40 minutes. The store closes at 9:00 PM. They take in back again to do something that will allow me to have enough room to restore that data at home. "No problem! 10 minutes. (45 minutes. I finally left the store at about 9:15).

At home, I plugged in my external hard drive, clicked the right button for "restore" and went to bed.

And this morning.....it was all back, just as it had been when I went to sleep Monday night. Everything, including all my charts and photos and music and the picture of Eve with an ice cream cone. I have rarely been so happy to see her smiling face.

Conversations With My Daughter ~ by Jay

Sweetie, I'd like you to sweep the floor every evening after we're done with dinner.

Why do we have to do that?

Well, the dogs are at the kennel while Daddy's out of town, so the little bits of food just stay on the floor and they need to be swept up.

OK. I can do that.

Thanks.

Do I get paid?

No, you get fed.

Conversations With My Daughter ~ by Jay

I'm going to have coffee with Shira.

Why?

Because she invited me and I want to go.

Oh. It's one of those conversation cups of coffee, right?

Music Meme ~ by Jay

Swiped this from Dawn. It's about what I'm up for today. Tired, tired, tired. The Yanks lost, Sam is out of town, and I want chocolate but there's none in the house.

Name your top 10 most played bands on iTunes (Or Last.FM):

Dawn's right, this was hard to do because iTunes doesn’t show you most played artists — just songs. I did what she did - I chose the artists whose songs showed up most often in the top of the most-played list but I tried to put them in the right order. I usually play it on shuffle, so some of this is random, but I decided how many of each artist's songs are in the library and usually I pick a song to start with.

1. Karla Bonoff
2. Bonnie Raitt
3. Lucy Kaplansky
4. Tom Paxton
5. Bruce Springsteen
6. Dar Williams
7. Randy Newman
8. Indigo Girls
9. Debbie Friedman
10. Abayudaya (Ugandan Jews)

What was the first song you ever heard by 6 (Dar Williams)?
The Babysitter's Here. We found a local folk music station somewhere around 1995, and one of the albums they featured that year was The Honesty Room, Dar's first commercial album. We fell in love. I used to know that whole record* by heart, but this was our favorite song. The babysitter - tall, strong, talented - and her boyfriend, Tom, were familiar figures from my own childhood. "Will they get married with kids of their own?/Not if she's going to college he said....It's Saturday night, I can't sleep, and we're watching the news/Do me a favor, don't go with a guy who would make you choose...."

What is your favorite album of 2 (Bonnie Raitt)?

Nick of Time. I know, I know, but I love it.

What is your favorite lyric that 5 (Bruce Springsteen) has sung?

Oh, boy. The only reason Springsteen didn't turn up #1 is that I haven't gotten around to loading all our Springsteen CDs into my iTunes library. Choose one lyric? Well, the one that always makes me cry is from "My Hometown", on "Born in the USA". "Sit on his lap, the big old Buick, steer as we drove through town/He'd tousle my hair, say 'Son, take a good luck around. This is your home town/This is your own town'."

How many times have you seen 4 (Tom Paxton) live?

Once, at a folk festival when I was in college.

What is your favorite song by 7 (Randy Newman)?
"You Can Leave Your Hat On". Don't know why, but it is.

What is a good memory you have involving the music of 10 (Abayudaya)?

Eve, walking into the room while their version of "Adon Olam" was playing and looking up in surprise. "Are they Jewish"? And then starting to dance to the music.

Is there a song of 3 (Lucy Kaplansky) that makes you sad?
"Today's The Day", about the death of one of her parents. Funny, I've always thought it was about her father, but listening to it now, I realize it could be either parent. For me, of course, it is about the death of a father. "Finally I'll become the daughter I should be/You called me your beloved the last time you looked up at me....Out beyond the silent room/out beyond this blood we share/there's a place we both know/I will meet you there".

What is your favorite lyric that 2 (Bonnie Raitt) has sung?
"Find a man to take me home/instead of always for a ride".

How did you get into 3 (Lucy Kaplansky)?
She made an album with Dar and Richard Shindell, and we saw them live on tour. They sang everything from their CD ("Cry, Cry, Cry") and a few of their own songs. Lucy sang "Ten Year Night", and I was hooked.

What was the first song you heard by 1 (Karla Bonoff)?
Well, the first of her songs I ever heard were the three that Linda Ronstadt recorded on "Hasten Down The Wind", an actual vinyl album that I wore out when I was in high school. But the first song I remember hearing Bonoff sing is the version of "The Water is Wide" that's on her "Best Of" album. Still my favorite version of that folk song.

What is your favorite song by 4 (Tom Paxon)?
It's a toss-up between "We're Going to the Zoo" and "Can't Help But Wonder Where I'm Bound". Clearly for different occasions.

How many times have you seen 9 (Debbie Friedman) live?
Once, when she played a jubilee concert at a local synagogue.

What is a good memory you have involving 2 (Bonnie Raitt)?
Seeing her sing with (or to?) her father on some PBS tribute show, years and years ago. John Raitt originated the role of Billy Bigelow in Carousel and was the quintessential good-looking Broadway leading man for years. Oh, and he had a bass voice that was - well, Soliloquy from Carousel. Need I say more?

Is there a song of 8 (Indigo Girls) that makes you sad?

"Southland in the Springtime". Don't know why, but it always makes me cry.

What is your favorite album of 5 (Bruce Springsteen)?

I was 15 when "Born to Run" was released. Not the savvy insider answer, but the truth.

What is your favorite lyric that 3 (Lucy Kaplansky) has sung?

Still that song that got me the first time, "Ten Year Night".

Open your eyes and look at me, and look at me/Look at me/Open your eyes and look at me/Because I have all this love for you/Before this ten-year night is through/I'm telling you/Take it from me.

What is your favorite song of 1 (Karla Bonoff)?
"Someone To Lay Down Beside Me".

What is your favorite song of 10 (Abayudaya)?
I love their version of L'cha Dodi.

How many times have you seen 8 (Indigo Girls) live?
Never. Must fix that.

What is your favorite album of 1 (Karla Bonoff)?
Her Greatest Hits album, "All My Life". That's the first of her albums I ever heard, and it's the one with "The Water is Wide".

What is a great memory you have about 9 (Debbie Friedman)?
I sang Debbie's Mishebeyrach at a Hospice Service of Remembrance last year. In that moment, everything I am joined together.

What was the first song you heard by 8 (Indigo Girls)?
"Hammer and a Nail", which we played incessantly the summer we were starting to redo our first house.

What is your favorite cover by 2 (Abayudaya)?
The CD is a recording of Ugandan Jews singing the melodies that have been passed down in their community for longer than anyone knows. They don't so much do covers.

If you read the whole way, you deserve a cookie.

-----

* I'm old. It's a record.

Move Along, Nothing To See Here ~ by Jay

Sam is out of town for two weeks.

My mother is here to help.

It's a gala weekend for shul, with activities starting tonight at 5:45 and continuing through Sunday at noon. Sam's absence means I am shuttling supplies to various places, speaking on Saturday night, and going to the big party Saturday evening with my mother.

I have a meeting this afternoon that may change the course of my career.

There will be blogging again...we appreciate your patience.