Heavy

Heavy

by Mary Oliver

That time

I thought I could not

go any closer to grief

without dying.

I went closer,

and I did not die.

Surley God

had His hand in this,

as well as friends.

Still I was bent,

and my laughter,

as the poet said,

was nowhere to be found.

Then said my friend Daniel

(brave even among lions),

“It is not the weight you carry

but how you carry it—

books, bricks, grief—

it’s all in the way

you embrace it, balance it, carry it

When you cannot, and would not,

put it down.”

So I went practicing.

Have you noticed?

Have you heard

the laughter

that comes, now and again,

out of my startled mouth?

How I linger

to admire, admire

the things of this world

that are kind and maybe

also troubled—

roses in the wind,

The sea geese on the steep waves,

a love

to which there is no reply?

flashback Thursday: May

And the return of FLASHBACK THURSDAY commences!  This feels so critical to me - like re-reading through my old journals - like a conversation with my past selves, asking their advice on if I'm living my life right and true now.  But because it's a lot, I think I may just do one entry at the first Thursday of every month (trying to make more realistic expectations of blogging for residency!).  Same thing as before - to read the full entry, click on the date (e.g. "May 2012").

What could you learn from your past MAY selves?  

What were you doing last May?

in May 2012, I was on my night float acting internship delivering babies and not sleeping very much.  It was a critical time for me because it solidified my decision to be an ob-gyn; even though I was constantly more exhausted than I had ever been before, I loved it.  Some of the guidelines for night float I wrote down then:

1. first thing you do when you get home is shower.  I don't care how tired you are, [other people's] amniotic fluid should not be on your sheets.
2. bring lots of healthy snacks - especially water-heavy snacks (fruits, veggies, just plain old water)
3. when you wake up (or if you feel alert before heading to sleep): work out.  even if it's short, ugly, traumatic - there's not a day when it will feel good so if you start using that as your measure if you should go work out, it'll never happen.

~~~~
in May 2011, I was on my family medicine clerkship and telling lots of stories about my amazing interactions with my patients.  My tribe also came to visit me in northern maine and we took a trip out to Acadia!  During that time, I came up with a list of "things I learned in family med" including:

1. Everyone is doing the best they can with what they have (even if sometimes what they have is a history of an alcoholic mother and bad coping mechanisms)

that one needs a pause for emphasis. okay, next:

2. Trust but verify. (Ronald Regan, about the Soviet Union)

3. Manage the unavoidable and avoid (or prevent) the unmanageable (-Friedman, about climate science)

4. Try not to work too much harder than your patients are working for themselves.

5. Results can be good or bad news, so deliver all results neutrally until you know how people feel

~~~~
in  May 2010, I was finishing up first year of medical school and trying to do a million things at once.  Also, the world cup was happening and I was maybe falling in love with the manfriend - slowly but surely!  (here's us at a US soccer game in CT where we drove through the night to get back for class the next day)




~~~~
in May 2009, I was preparing to move to Vermont and start medical school.  I only have one blog entry from that month and it is entitled "Loosening the Moorings on the Soul". For some reason this one feels the most fitting right now, perhaps because, four years later, I'm in yet another transition.  Here's an excerpt:

Question: How do we adjust our lives in a world that requires us to be in so many more places?

Answer inspired by a novel by Salman Rushdie, called the Enchantress of Florence:

"In a small wooden box concealed behind a sliding panel...[he] kept a collection of beloved 'objects of virtue', beautiful little pieces without which a man who traveled constantly might lose his bearings, for too much travel....too much strangeness and novelty, could loosen the moorings of the soul"
-Salman Rushdie, The Enchantress of Florence

~~~~
in May 2008, I was living in Boston, finally comfortable being single, still working at my very first job, and running along the Charles River pretty much daily.  Here's a passage from an entry reminding me to continue to interact with strangers:

So after I passed the Pretty Good-Looking Guy the second time, I'm smiling all happy-like. Ahead of me, walking the other direction listening to his old school Walkman is a slightly tattered Old Man. And because I'm feeling so happy, I smile briefly at the Old Man as I run by, thinking very little of it.

But a few strides later, I hear him yell back at me (yell in a kind, not aggressive, way) "thanks for the smile; that was very nice". I regret that I didn't turn, I just gave him a behind-my-head thumbs up and kept going the other way. 

10 Things I Learned in Family Med

1. Everyone is doing the best they can with what they have (even if sometimes what they have is a history of an alcoholic mother and bad coping mechanisms)

that one needs a pause for emphasis. okay, next:

2. Trust but verify. (Ronald Regan, about the Soviet Union)

3. Manage the unavoidable and avoid (or prevent) the unmanageable (-Friedman, about climate science)

4. Try not to work too much harder than your patients are working for themselves.

5. Results can be good or bad news, so deliver all results neutrally until you know how people feel

6. Just because it's common practice doesn't mean it's evidence based or good medicine

7. Over 1 in every 4 women will experience intimate partner violence in her life, the risk increases dramatically when a woman is pregnant - try to ask all women in a confidential way

8. For a differential, think about the three things it's most likely to be and the 3 things it could be that you would never want to miss - and make sure you cover them ALL with your workup.

9. The sick baby test.

10. Say hello to everyone on the staff and in the patient room every time - it's the surest way to feel like you belong and make everyone a part of the patient's health care.

last minute question

My last patient yesterday was a 15 month well child check. Matthew (we'll call him) was a healthy boy with soft brown curls who came in with his mom and maternal grandfather (who told me to call him Grampy with a huge proud smile on his face) and proceeded to run all over the exam room. We slowed him down just long enough for me to examine him and go through my exam with the resident with whom I was working. At the end of the (approximately 45 minute) visit, we're wrapping up our discussion about how Matthew seems very healthy, that he'll have to have some immunizations today, and we'll see him again in 3 months for the 18 month well child check, when his mom says, "I have a quick question for you, actually". "so I just found out I'm pregnant and I have MRSA. What will that do to my baby?"

whoa.

so after addressing her actual question (we'd probably treat you for MRSA, it's possible your baby would be exposed and would also have to be treated, but this isn't something too concerning), the resident says, "so. how are you feeling about being pregnant? have you figured out OB care?" she pauses and looks at the ceiling and says, "actually, not yet. I'm gonna keep the baby because I couldn't possibly not keep the baby. but I just broke up with the father and haven't thought about prenatal care. maybe you could do it?"

the resident says, "of course. I do OB and since I'm already your primary care doctor, and I'm already your son's primary care doctor, I think that would make it easy." and then he pulls up her chart in the EMR and begins to ask her some screening questions before setting up another appointment for her to come in herself.

oh family med - how all-encompassing you are.

5 changes towards better primary care?

From the Archives of Internal Medicine via the Wall Street Journal Health Blog, physician's responses to the question "What could primary care physicians do differently to benefit patient's health and cut risks, harms, and costs?" They grouped them into lists based on specialty, so Family Med, Internal, and Peds (the trio of primary care) said: (directly quoted here from the Health Blog)

Top Five List, Family Medicine

1. Don’t do imaging for low-back pain in the first six weeks unless certain red flags are present.
2. Don’t routinely prescribe antibiotics for acute mild to moderate sinus inflammation unless certain symptoms last at least seven days or improve, then worsen.
3. Don’t order annual ECGs or other cardiac screening for low-risk patients with no symptoms.
4. Don’t perform Pap smears on patients younger than 21 years of age or in women who had a hysterectomy for benign disease.
5. Don’t use DEXA screening for osteoporosis in women under age 65 years or men under 70 with no risk factors.

Top Five List, Internal Medicine

The list included the same recommendations on low-back pain, cardiac screening and DEXA screening, as well as:

1. Don’t obtain blood chemistry panels or urinalyses for screening in healthy adults with no symptoms.
2. Use only generic statins when initiating lipid-lowering drug therapy.

Top Five List, Pediatrics

1. Don’t prescribe antibiotics for a sore throat unless the patient tests positive for strep.
2. Don’t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors.
3. Don’t refer patients to a specialist for fluid behind the eardrum in the middle ear early on unless there are other red flags (such as learning problems or structural problems).
4. Advise patients not to use cough and cold medicines.
5. Use inhaled corticosteroids to control asthma appropriately.

the sick baby test

the past few weeks I've seen a lot of babies. babies with pneumonia, babies with strept throat, lots of babies with rashes, lots of babies with ear infections, lots of babies who did something strange and so their mom/dad/aunt/grandpa brought them in so that the doctor could tell them everything was okay. at the beginning, my attending said, "okay, Erica, there's a 1 year old in room 22 who has been vomiting, go check her out" I hesitated a moment too long and my attending looked at my quizzically, so I said "actually, I haven't really had that much experience with babies and I'm not quite sure how to examine her".

That's when my attending told me about the sick baby test: you walk into the room and look at hte baby: is she sick or not sick?

It's a good screening test, she told me, because unlike adults, when kids are well they're running around, poking at things, trying to get your attention. They're pooping and peeing and asking someone to give them food. So if a kid isn't doing all these things that a kid does, they're probably sick. If they are doing all these things, they're probably okay.

the sick baby test, I like it. it's going to be awesome to know that for my next rotation, peds.

(PS: the 1 year old in room 22: not sick)

~~~~~~~~~~~~~

"some days even my lucky rocketship underpants won't help"

- Calvin (from Bill Waterson's Calvin and Hobbes)

you are beautiful and have so much to offer the world

today I met Natalie*, a 18 year old woman who just had her first baby this winter. I wasn't even supposed to meet her - but my preceptor's last appointment didn't show up, so I asked one of the nurse practitioners if I could work with her for the last hour of the morning. she sent me into Natalie's room saying, this should be an easy one. Come out and get me in 10 minutes when you're done.

she's wearing a sundress, it stretches gently over her full abdomen. she still has the pregnancy glow, even though she's 3 months postpartum, or maybe that's just what it looks like to be 18. she kicks off her flipflops as we speak. she doesn't look sick. she speaks softly, but directly, and asks me if she has hypothyroidism.

hypothyroidism means not enough of the thyroid hormone (T3 or T4), which is responsible for regulating all sorts of important things, like your metabolism and heart rate.

her whole family has it, she tells me, and she thinks she has it too and that's why she can't lose weight.

"okay, we can check that," I say, "but I have to ask you some questions too, is that okay?"

she says sure and we talk about how she has incredibly heavy periods, has always battled with her weight (she had an eating disorder in her early teens, and since then her BMI has been consistently above 30), she gets cold when other people are hot, her hair falls out in the shower, and she has been depressed most of her life.

all of these are the symptoms of hypothyroidism. so I do a physical exam to check her for the signs of hypothyroidism: she has an enlarged thyroid, dry skin, marks of hair loss on her eyebrows and head, her deep tendon reflexes are decreased (though I can't tell if this is just because I still feel badly hitting people's knees very hard). yup, the signs are all there.

now all that's left is to run the lab test for thyroid disease, a TSH level. But first, for some reason, I decide I should also screen her for diabetes - because if she's getting lab tests, and her family has a history of obesity (and diabetes), we should at least have a baseline. So I ask her if, not counting when she was pregnant, she has increased frequency of urination. She says yes, and in fact, she wet the bed until she was in the 5th grade. Hm. Was there anything else that caused you to wet the bed that long (thinking, stupidly, wow, that's really young to have diabetes). "Oh yeah," she says, "I was sexually abused from the age of 4 until the age of 11 - well, really 14. I think I was anxious." <> "and I've never told any doctor that before".

Before I can say, well...you still haven't, because I'm not actually a doctor yet...

I bite my tongue and think: okay, she has a history of depression and anxiety, obesity, migraines, bedwetting until 4th grade, eating disorder in early teens that became dramatic obesity in her later teens, yup - that does make sense. why did I not ask about psychiatric issues at all? but by this time we were getting way past the end of our visit. But I want to ask her if she sees a therapist (yup, weekly) okay, good. so she's told someone else. and if she feels safe in her current relationship (yes, definitely, that's all in the past). Okay, so no immediate threat. We talk a little more about her support network and home life. I make a note to talk to her PCP about this before giving her the lab order forms and sending her on her way.

My mind is not at ease about this and thoughts run through my mind:

Was that good medicine? Did she even feel good about that visit? Is helping with her thyroid my role right now? Or is it bigger? How can I have been learning so much about violence against women and not have asked her? Especially with her history of medical problems?

After seeing a few more patients, I break for lunch and run out to grab a salad - Natalie is in the hallway with her fiance and their new baby. As I walk by she smiles shyly and says to her baby, "hey honey, want to meet Mommy's doctor?" and brings her baby over to me. I try to think, oh dear, I am not your doctor - but instead I take the baby and look at her and say, "oh, you must be so proud. she's a beautiful baby."

*obviously not her real name,

some information has also been changed for confidentiality

~~~~~~~~~~~

"you are beautiful

and have so much to offer the world"

halfway across the bridge

I want to tell you a story about a patient I just met. I'm going to tell you his story in his words and then I'm going to tell you his medical story - or rather, his story put to medical language.

Jack* is a 55 yo man who lives nearby with his four grandchildren (ages 4-11) who have lived with him since their mother died and absolutely adore him. He lets the 8 year old paint his nails and do his hair. He does not believe in physically punishing kids, because he wants them to fear consequences, not him. Other family members on the children's father's side have been trying to take the kids away from him ("for a welfare check" he says) by enticing them with toys and vacations, but they choose to stay with him because they adore him.

He was a marine from age 20 to 35, where he trained dogs with a magical touch and met the love of his life. Things were going great until he found out on a random physical (the marines have these pretty often) that he had diabetes and was discharged. In the time that followed, he and his wife raised three daughters and he worked in local construction. After his children moved out, he got divorced - though his wife "is still my best friend" and lives across the street.

After a life of caring for other people but not himself, his body is wrecked from diabetes, both his lower legs have been amputated, and his kidneys are failing so he's on dialysis 4x/week. He's trying to stay positive and take care of the kids, but he's been feeling bored and useless when they're at school. He's trying to volunteer to train dogs, but all 4 places he called told him that his wheelchair is too limiting. When he feels low, he wonders if he should just stop his dialysis and die within 7-10 days.

He comes in today because he has a cough that just won't go away.

Now, the medical story:

55yo white man comes in today with a non-productive cough x 2weeks. It comes on about 5x a day, causes him to gag, and is worse in the morning. He also complains of knee pain where his prostheses connect to his stumps. He is allergic to penicillin and fluorescent dye.

His medical history includes poorly controlled diabetes, resulting in end-stage renal disease for which he is on dialysis 3x weekly and peripheral vascular disease with two amputations which have caused him to ambulate in a wheelchair. He also has congestive heart failure, COPD, depression, and high cholesterol. He takes 14 different medications for his diabetes, cardiac disease, depression, and back pain - including oxycodon. He is a current smoker with 60 pack/years and drinks alcohol occasionally.

He is divorced, unemployed, and lives with his 4 grandchildren (ages4-11) who he has cared for since their mother died 1 year ago.

***

When I walked into the room to talk with Jack* I was not looking forward to talking with him. I was ready for a grumpy man who clearly didn't care about his health or anything else and was ready to just give up.

But after talking to him, I saw how kind and thoughtful he is, how much he loves his grandchildren, and related to how much he wants to feel useful.

I felt incredibly guilty for how much I misjudged him but feel lucky I had the chance to prove my own snap judgments wrong.

We ended up giving him a prescription for a "therapeutic" dog and adjusting some of his medications to try to help him with his cough. He'll be back in a few weeks to see how it's going.

*obviously not his real name; some other facts have been

altered slightly to protect his anonymity

~~~~~~~~~~

"you're starting out on the journey across this bridge, this education,

and right now you are on the same side as your patients.

as you get halfway over the bridge, you'll find yourself changing

and the language the patient had and you had

is being replaced by this other language -

the language of medicine -

their personal story is being replaced by the medical story

when you find yourself on the other side of that bridge

you're part of the medical culture.

while you get there,

I want you to hold on to every bit of your old self

your now self

I want you to remember the stories of these patients."

-Dr. Alita Anderson,

Yale Medical School

I think that's maybe part of what I'm trying to do with this blog... ?

photo source

Quick Little Beats

today was amazing.

I heart got to play with babies AND hear fetal heart sounds! Each time I placed the machine in the right place, I felt my heart leap my throat and my eyes tear up because it was so incredible!

the beat is so quick and you can actually hear the valves open and close. I think I was happier than some of the moms - even the really happy ones. I actually said to the first mom "Oh my goodness, your baby's heart is SO BEAUTIFUL!" Of course, she actually spoke Mandarin as her first language and didn't quite understand me, plus she's exhausted and super pregnant and has been feeling her baby move for quite some time now - so she mostly rolled her eyes and smiled like, "yup, silly medical student, of course it's a miracle"

miracle, indeed.

Book Review: Every Patient Tells A Story

Q: What book have you read lately that feels really relevant?

A:

I have two actually - one is Zeitoun, by Dave Eggers, which tells a story about one family's experience with Hurricaine Katrina, the disaster that was the response to it, and the prejudice against Islamic Americans in the aftermath of 9/11. Until I read Dave Eggers narrative, I don't think I truly grasped just how horrible the US's response to Hurricaine Katrina was. I recommend it highly - it's beautifully written and super easy to read.

The other is maybe more relevant to what I'm learning about right now - "Every Patient Tells A Story" by Lisa Sanders, MD, a columnist for the NYT who was a journalist before going to medical school and is the current medical advisor for the show House, MD. The book is filled with all the puzzles of the cases in her column and on House, but also with some lessons in what skills good doctors have to approach these puzzles. The first lesson, maybe unsurprisingly given everything I've written about on this blog (or just the title of her book), is that really good doctors LISTEN TO THE PATIENT'S STORY.

I'm about to begin my clerkship rotation in Family Medicine, which besides strictly diagnostic fields like Pathology and Radiology, is the division of medicine that does the most problem solving - and unlike Radiology and Pathology - it's reading the PATIENT, not his tissue sample or X-rays. Dr. Sanders' book is awesome in that it's fascinating, but also because it reminds us that being doctors is not so unlike being detectives - that not only do you have to know what the clues mean, but you have to actually notice they're there in the first place.

In her intro, Dr. Sanders says that studies have found that Doctors interrupt patients in the first 11 seconds of their story, and that if they waited, they might get a whole lot more information. My goal for my family medicine rotation is to not interrupt my patients to ask questions unless it's absolutely necessary (still have to stick to some time limits)

~~~~~~~~~~~~~~~~~~
"...It [diagnosing a sick patient] is a wayward process

filled with unreliable narratrators - both human and technological -

and yet, despite the unlikeliness,

that answer is often reached and lives are saved"

-Lisa Sanders, MD

the role of a physician is NOT

The past few days have been focused on many issues that mainly affect women - obviously this interests me a lot, both because I am a woman and because I'm interested in women's health. I reviewed pelvic exams yesterday and breast exams today, talked about prenatal care and the changes that happen during pregnancy, then learned how to do an endometriol biopsy and place an IUD, talked all about contraception, then had the afternoon to discuss intimate partner violence. The afternoon was challenging, so I thought I'd share some tips.

The first is that a statement of confidentiality - that the doctors office is confidential, that nothing will be said to your partner without your permission - is very powerful. This seems to most naturally fit in right before I start to ask questions about alcohol, drugs, sex life. Just a simple "I ask everyone these questions and I just want you to know that..." And before asking specifically if the person feels safe saying "Because violence is so common, I try to ask everyone about it every time".

The second is that the role of a physician is NOT many things that any person would instinctively want to do (especially one who is spending so much time on a career path to solving problems and helping people).

Namely, the role of a physician is NOT:

to end the abuse,

to make the person leave their abuser,

to solve the victims problems nor is it

to provide lengthy counseling

I think that would have been more difficult for me to accept if I had not just had my psych rotation. But now I am beginning to understand that much of medicine is about giving someone the option to make their own choices. It can be more dangerous to try to get someone to leave their abuser or to confront the abuser or to call the police than it is to wait until the person who has being abused has decided what they want to do.

The role of a physician DOES include:

asking people about intimate partner violence

telling the person it's not their fault

telling the person that no one deserves to be treated like that

providing resources that the patient could use

including an emergency 24 hour hotline

continuously assessing the person for escalations in violence

helping the person get help in whatever way they want it

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

photo source

(I'm not sure this totally fits, but it kept running through my head this afternoon: )

"will I lose my dignity, will someone care

will I wake tomorrow from this nightmare?

there's only now, there's only here

give into love, or live in fear

no other path, no other way

no day but today"

-RENT