Thursday, October 29, 2009

Baby steps.

I just bought some fabric to use in our baby's room.

It doesn't really sound like that big of a deal. But this is the first purchase I've made for our baby. We're nearly 5 months in, and until tonight I hadn't bought anything specifically for our baby.

I'm not sure if that's what happens when you are pregnant after you miscarry, or when you are pregnant and also a doctor who does OB care, or maybe just pregnant and have an overactive imagination. But I've just been too afraid to buy anything. Even though we've made it this far, I know I'm not guaranteed to bring home a healthy baby, and it's like I don't want to jinx it. I've been afraid that if I get some things and then something happens, then what will I do with it?

It is, of course, a ridiculous way to live. I cannot live in fear. And even though I'm a bit of a fly-by-the-seat-of-my-pants kind of girl, I need to prepare and plan. I need to let myself be more excited.

And I need to remind myself that the God I serve is good, and nothing happens to me that doesn't first pass through his hand.

And in case you're curious, here is what I got:

Part 3

And now it's on to the really, really bad ideas.

1. One way they plan on increasing primary care doctors is to give a 10% medicaid bonus for 5 years. As in, for 5 years after the bill passes. As if a bonus for only 5 years will really sway medical students, who have many, many thousands of dollars of debt, to choose primary care over a sub-specialty which might mean earning 2-3 times the salary of a primary care doc for their entire career. Medical students are pretty good at math, and this is not going to change anyone's mind. For more people to choose primary care, there must be a BIG change in how doctors are paid.

2. The other brilliant idea (and this is in all the drafts) to increase primary care docs is to take unfilled residency spots from subspecialties and redistribute them to primary care. This is idiotic for numerous reasons. The main reason is that there really aren't any unfilled sub-specialty spots. Dermatology, Radiology, Ophthalmology, ENT surgery - these all fill every single year. In fact, there are always lots more people who want to go into the areas than there are residency spots. Family medicine, on the other hand, only fills about half of their available spots with students graduating from US med schools. EVERY SINGLE YEAR there are tons of open spots in family medicine - these often go to foreign medical grads. Adding more residency spots to primary care will do nothing to increase primary care doctors. (And like I said first, these "spots" they want to redistribute are non-existent.) Apparently, they didn't talk to anyone who has graduated from medical school in the last 10 years when deciding to put this part in.

3. Then there's the abortion issue... There is nothing in this bill to prevent tax dollars from funding abortion. Yes, there are the current bans, but since there will be things that insurance will be required to cover, this will most likely include abortion. Catholic schools or other businesses who have religious or moral objections to abortion or birth control will likely have to cover it. The government should not be able to force someone into paying for something they find morally reprehensible.

So there you have it... lots of my thoughts on health care reform.
I'd say write/email/call your congressperson and tell them what you think. Bills like this make me wish doctors as a whole were more involved in the process. But I know I need to be doing more to let my voice be heard.

Any further thoughts? I'd love to hear what any non-medical people think.

Tuesday, October 27, 2009

Part 2

If yesterday was "The Good," now it's on to "The Bad..."

1. A big issue I have is that most of the bills do not exactly address how this will all be paid for. One major idea is to cut future medicare/medicaid payments to doctors. Patients who only have medicare and medicaid already have a difficult time finding a doctor, and cutting the payments will only cause more and more doctors to not accept medicare and medicaid patients. Furthermore, this will hurt primary care doctors even more than sub-specialists, worsening the already fairly severe shortage of primary care doctors.

2. One of the BEST ways to save money would be to pass some sort of tort reform. Only ONE of the several bills says ANYTHING about tort reform, and the bill that does say something basically says it will "consider" implementing some sort of "pilot program" to test the idea out. (Meaning: a snowball's chance in hell this will ever come to pass) The CBO recently estimated that tort reform would save $54billion over the next 10 years. But since lawyers write the bills and other lawyers give big money to the lawyers that write the bills, they don't like this idea. But it's proven that doctors order more tests because they are afraid of being sued.

3. The house bill especially seems to create a LOT more bureaucracy. Bureaucracy usually means that you have non-doctors telling doctors what to do. We are the ones who went to medical school, so we should be the ones making decisions about our patients. Not, as is suggested by the house bill, Katherine Sebelius, who has been a politician for a long time and lobbied for... you guessed it... trial lawyers.

4. The big plan to encourage people to get insurance is to give them a tax credit. But there is no tax credit for people who are already getting insurance. Furthermore there will be some sort of penalty or additional tax if you don't buy insurance. But you can apply for a "hardship waiver." I think that many people who currently don't have insurance are unlikely to buy insurance, figuring they'd rather pay the fee. Plus, if something bad happens, they can just go to the ER, where care is "free." (This is unfortunately the perception of many people out there.)

5. The house bill also has this section that will set goals for primary care residencies. On the surface, this doesn't sound like a bad thing. However, we already have the GME (graduate medical education) that does this. Plus the goals are things like: "training to work in non-acute settings." Um.... I'm in our outpatient clinic (non-acute setting) 4 half days just this week, seeing 12-13 patients at a time. "Coordination of care" and "Understanding the cost and value of diagnostic options" - yes, so that is basically what I already do every day. I do not need the government to come in and create even more red tape and paperwork to tell my program to teach me what it already does.

6. Penalizing hospitals with high readmission rates - now certainly we shouldn't discharge people too soon. But certain hospitals, especially those in inner cities that serve the indigent have lots of patients who just don't take care of themselves. Or are actively doing things that harm themselves. We can't send people home and physically make them stop smoking or drinking. Or even get them to take their insulin. This one might be more of a neutral, since it is good to encourage hospitals to take good care of patients, but hospitals, especially those that have residents, likely will have a high incidence of readmission just because of the population we serve.

Again.... this is a non-exhaustive list of many of the problems I see. Tomorrow, or perhaps Thursday (since I'm on call tomorrow) I'll write a little about "The Ugly."

Monday, October 26, 2009

A Doctor's Thoughts on Health Care reform: Part I

One of my classmates did an excellent lecture on the different health care reform bills currently in congress.

Mostly, I left the lecture depressed. But because I have lots of thoughts, I'd thought I'd put a several posts up about specific ideas the bills contain. One thing I did learn is that there are 3-4 different versions going through congress right now, several senate bills and a house bill. So all the bills contain things that are slightly different.

Today's post will be about the things that I liked. This will likely be a rather shorter post than further thoughts to come, but I don't have tons of time tonight for the more lengthy posts about things that I didn't like. So in no particular order:

1. Setting standards for what insurance has to cover - a big part of what is in the bills is going to change laws so that lots of basic stuff has to be covered by health insurance. Things like pap smears, colonoscopies, mammograms, maternity care now will have to be a basic part of what is covered. There is a good focus on encouraging people to get preventative care so that we can prevent or catch earlier some of the diseases that cause lots of problems. This is good.

2. Preventing insurance companies from excluding those with pre-existing conditions. - Even if you have health problems, you will be able to get insurance. Hopefully some of the people without insurance now who are very, very unhealthy will be able to get insured so they can see doctors regularly, and not just when they are in a medical disaster and come to the ER.

3. No lifetime limits on benefits - insurance companies will no longer be able to say, "Sorry, you've used up too much of our money, we aren't paying for anything else."

4. Encouraging some competition by creating co-ops and health care exchanges so people can shop around for the best plan for them. The idea of the exchange is that there will be a place people can look for a clear description of different plans. Hopefully this will mean less "fine print."

5. More funding for loan repayment for people doing primary care. Some of the bills also have increased funding for low interest loans for those going into primary care. Hopefully this will help encourage people to choose primary care specialties.

Well, they may have been a few other things I liked, but that is most of what I can remember right now. What do you like about the bills? Any thoughts?

And come back later for Part 2, and if the post gets too long, Part 3 - things that I didn't like and things that are just bad ideas.

Friday, October 23, 2009

Pregnancy after infertility.

Being pregnant after you're struggled to get that way is an interesting experience.

You'd think that once I finally was pregnant, all those old feelings and frustrations would go away.

Nope. The truth is that even though I'm pregnant, I still think like someone who is infertile. Especially right at the beginning, I'd still have this twinge of annoyance on hearing someone announce their second or third pregnancy. It still bothered me when I'd hear of someone announce they were "trying" then get pregnant 2 months later. As the months have gone on, I find that happening less and less, but still it's a struggle not to be jealous of those who had it so easily.

Part of me still has a hard time believing that I'm actually pregnant. That the treatment we did worked. It just won't entirely sink in that we went through one cycle of treatment and immediately got pregnant, when others I know continue to struggle. I almost feel bad that even though in the midst of our struggle it was very difficult, now it all seems like it was too easy.

I'm slowly starting to feel tiny movements inside me, and it's becoming more and more real. Even though I don't understand why God has been so good to me, I praise him for his endless grace and mercy.

Thursday, October 22, 2009

The flustered physician.

Some days it doesn't take much to get me flustered.

Take today, for instance. I was under the mistaken impression that I didn't have clinic this afternoon. So sitting at my desk after lunch working on some paperwork I got a page to remind me to come to clinic. It was 1:50. Clinic starts at 1:30. Oops. I frantically gather my things, realizing my stethoscope is in the car, along with what I like to call my second brain, my PDA. I especially feel flustered when I don't have my own stethoscope, and without my PDA I can't look up drug dosages very easily. But since I'm 20 minutes late already, I don't feel like I have time to walk to my car which is in the absolute farthest away corner of the parking lot.

I get to clinic to find that everyone else is flustered too. One of my regular nurses was on vacation. Our nurse manager was gone. And everyone's schedule is really busy. Even though I'm 20 minutes late, there is only 1 patient in a room, and I'm immediately asked to see 2 siblings of another of my scheduled patients. Of course I don't mind, since they are my patients and it doesn't make any sense to split siblings up between two doctors, but I hate feeling like I'm going to be behind all day. I hate feeling like I have to rush through patient visits so I don't get more behind.

I don't want for my patients to notice how flustered I am. I want to be efficient, but not dismissive. In spite of my little rant today, I really do enjoy clinic - I love getting to know my patients, treating their problems, seeing them get better. I just need to deal a little better with the frustrations that come my way. I still have a lot to learn.

I guess I should start by remembering to show up for clinic.

Tuesday, October 20, 2009

Two Books

1. Pastor, by William Willimon.
Aubrey got me this one for my birthday a month or so ago, and it is excellent. The writing style alone made this book a joy to read, as Willimon is known for his delightful, well thought out, prose style. But he is not short on content either. This book is over 380 pages of Willimon's thoughts and reflections on Pastoral ministry. He clearly has a very pastoral heart, and has thought long and hard about the joys, difficulties, duties, and complications of a biblically grounded, word focused, church centered, pastoral ministry. I am already enjoying rereading parts of it, as I feel like I am sitting at the feet of a master. (pastor friends: you should read this!)

On a separate note, I enjoyed this book in part because Willimon is a Methodist, and I don't often read books from outside the reformed tradition. It was sort of refreshing to hear a voice from a different strand of Christendom.

2. Why We Love the Church: In Praise of Institutions and Organized Religion, by Kevin Deyoung and Ted Kluck.
I loved this book for the same reason I love watching Cubs games on WGN, where the announcers are as big of Cub fans as I am. (Its so much better than ESPN with their "impartial" announcers!) For the same reason I love writing poems about my Aubrey. The same reason I love reading books about the mountains. That is, I love to hear people extol the virtues of the things that I love.

I already love the Church. I love it in theory, and a lot of the time I even love it in practice. So I suppose I am not the target audience of this book, but I loved it nonetheless. The book is meant as a counterpoint to a "churchless Christianity" movement. (you don't have to know anything about that to enjoy the book. I don't.) But the real strength of the book is that it extols the biblical virtues of the Church as the bride of Christ, the body of which Jesus is the head. It takes honest inventory of the strengths and weaknesses of the church, both worldwide and local, and concludes that despite various shortcomings, the Church is the God given means of renewing the world, preaching the word, saving the lost, sanctifying the saved, building up believers, and establishing God's new creation. What could be better than that?

Saturday, October 17, 2009

Charleston

We're definitely enjoying our time in Charleston. The Farmer's Market, Folly Beach, the Battery - we've seen them all today. We're hoping to make it to our favorite restaurant, The Mustard Seed, for dinner tonight, and meet up with some of our friends.

We took Lucy to the beach for the first time today. Predictably, she was afraid of the waves and ran away from them. I think the scary, scary foam on the edge was just too much for her. She also tried to drink the water. It didn't go so well; she took one sip and then tried to spit it out. Hysterical.

I love weekends off.

Friday, October 16, 2009

Random tidbits.

A few random thoughts:

1. I now have two sore arms. The first is from a seasonal flu shot I got two days ago. The second is from the H1N1 vaccine I just got today. I'm sure there are plenty of people out there gasping that I would get vaccines during pregnancy, and gasping even more that I got two shots within the same week, but I'm relieved that I'll hopefully be more protected from getting something from my patients.

2. I have never looked so forward to a friday coming than I did this week, since I've been working every day since last Monday. And we're going to be in Charleston this weekend!! Hooray!

3. I don't really feel like I look all that different as far as the pregnancy goes, but I must look more pregnant that I realize. I've had several patients ask me if I am pregnant, and the nurse I saw today in employee health basically just made a declarative statement that I was pregnant without me telling her. So hopefully I'm past the I-just-look-like-I've-been-eating-too-much-cake phase and on to the Oh-what-a-cute-belly phase.

4. I am in desperate need of some maternity/bigger clothes. (I guess this should have tipped me off about #3) I haven't had time to really shop, although I did get some clearance maternity capris for $4.48 at JC Penny. Part way in to my work day today I realized that the button-up shirt I'm wearing was gaping a little too much in a certain area, and so I got someone to give me a safety pin so I wouldn't feel indecent. (Hopefully the clothing situation will be remedied this weekend.)

5.Part of the reason why I went ahead and got the H1N1 vaccine today (even though our clinic hasn't actually starting really giving it to anyone yet) is that I was exposed to it by a patient. Of course, I've seen numerous patients and probably been exposed multiple times during this flu season to H1N1 influenza, and have yet to get the flu, but being pregnant makes me more paranoid than usual. Employee health had emailed me about it, and told me to come and see them about getting prophylaxis. When I went, they told me that they wouldn't give me tamiflu since I was pregnant. But I personally have written prescriptions for pregnant women for Tamiflu, since pregnant women are one of the highest risk groups for having flu complications. So instead of getting the medicine, I convinced our nurse manager to give me the vaccine, since you can also be vaccinated to prevent the flu after you've been exposed.

6. I think I might be feeling the baby move sometimes. Or maybe it's just gas.

Wednesday, October 14, 2009

How to have a good day on medicine...

1. Discharge 5 patients, and this on a day after you discharged 7 on the day before, leaving you with a very nice looking (read: short) list.

2. Enjoy a nice walk to the nursing home in the rain. (I'm not sure why I've never walked to the Nursing home before - it's not that far. I'm also uncertain as to why the first time I did it was raining. All I know is that when I looked outside at the gray, drizzly day, I wanted nothing more than to enjoy some quality time outside.)

3. Have your husband come and visit you for lunch, and be able to play foosball and pingpong afterwards with him. Get to laugh and talk with him like you haven't done since you've been on medicine, when pretty much all you've done is work and sleep.

4. Have a relatively quiet day call (so far).

5. Look forward to your weekend off, when you might actually get out of town, and maybe even get to visit some old friends and family in Charleston!

Monday, October 12, 2009

Funniest ER check out yet.

When we need to admit a patient, the ER doctor will call us and give us a brief run down of who it is, and why they need to be admitted. Sometimes, they have their own very distinctive way of describing patients...

What I heard earlier today: [imagine this in a fairly thick southern accent]
I've got Ms. P. down here and she lives off the two-carbon fragment. Well, she's withdrawing now and they found her on her porch this mornin', shakin' and bakin'. She also has a seizure disorder. She's also so shaky right now she could thread a sewing machine with the needle running.

[Translation: Ms. P drinks a lot of alcohol (the chemical structure of alcohol has two carbon atoms in it) and had a withdrawal seizure. She is still very tremulous from her withdrawal.]

Alrighty then...

Apple Pickin'

Action shot:




















Posed Shot:















Artsy Shot:

Sunday, October 11, 2009

Reminded.

One of the more bizarre tasks we have responsibility for in our hospital is to pronounce people dead.

Apparently, nurses used to be able to do this, but now it can only be done by a doctor. So at night, whenever someone dies in the hospital, we have to go do an exam and actually pronounce them dead. It is strange for lots of reasons. By the time we are called, there is no question as to whether or not they are dead. They have usually been dead for a while.

Dead bodies are so, so still. Putting my stethoscope to their chest and hearing this void of sound is unlike anything else I do.

That said, just like anything else, you get used to it. I can go into a room and quickly do the necessary exam, write my brief note, and continue on with the rest of my responsibilities, without thinking too much about it.

Last night, though, I was called to do a pronouncement in the ICU. On my way to the nurses station to figure out where I was supposed to do, I passed a room with the door slightly ajar, and realized that one of my attendings was in the room, sitting next to a bed. I asked him what he was doing here.
"I'm here with my mom," he replied.
"How is she doing?"
"She passed away."
Gulp. "I'm so sorry."

I head to the nurses station just to make sure, but I realized that I was called up to pronounce her. The mother of one of my attendings. She suddenly wasn't just another body I had to pronounce. She was a mother. She was a grandmother. I went back into her room, and did my brief exam, but looking more intently at her quiet face. Her still hands.

It was good to be reminded that every time I do this, I need to remember the son, the daughter, the sister, the father who grieves their loss.

Thursday, October 08, 2009

You can't make this stuff up.

Some of my favorite phone calls from patients (either that I or a classmate received):

1. My baby has an ear infection, and I know I'm supposed to put pee in his ear. But is it my pee or his pee?

2. I was working on the washing machine when it was plugged in, and it blew up in my face. What should I do?

3. My wife is pregnant, and she has this brown goo in her mouth. What is it?
I don't know. Did she eat something brown?
Well, yeah.
Have her brush her teeth and see if it goes away.

(30 minutes later)

I'm pregnant and have this brown goo in my mouth. What is it?
Did your husband call a little while ago?
Yes.
Did you brush your teeth?
No. I was afraid it would go away and I wouldn't find out what it was.

4. (this one was by a really lonely woman who called very, very often, always with something equally ridiculous)
If I sit to close to the TV, will I damage my eyes?

5. Can your brain freeze from the inside out?

Wednesday, October 07, 2009

Giving up.

One of the biggest challenges of medicine is knowing when to quit.

We take care of lots of sick patients and sometimes we push and push and push. Sometimes we don't. I don't know if I'll ever learn enough to know how to decide what to do. We were taking care of a patient yesterday who was very, very sick. We basically were doing the absolute maximum medical therapy. Chances of recover seemed miniscule. Part of me was ready to keep pushing. You never can tell how people will respond and she had made a very, very slight improvement.

Most often in this situation, I am the one who is ready to stop. I am the one who has to tell the family, over and over, that there is no hope. That continuing is pointless. To try to get them to understand. Her family, though, hated seeing her intubated, with essentially no neurologic activity, being kept alive by machines. She had discussed with her family her wishes, and had said numerous times she didn't want to be in this situation. They were pushing me to quit.

And so we did. We turned off the medicines. Took out the breathing tube.

She died 7 minutes later.

Did we do the right thing? I think so. I really do not think she would have made any meaningful recovery. She was able to die peacefully, according to her wishes. Her family was able to say goodbye. But deep down, I always wonder what if.....

Tuesday, October 06, 2009

Lucy's new agenda

Our dog Lucy is not allowed on the couch. This has been a firm rule in our house since we got her. But lately Lucy has been mounting a campaign to have this rule changed. Apparently, at some point Lucy learned that the couch is an awfully comfy place to sit, much more so than the hard wood floor. And so lately, there have been numerous incidents of Aubrey or I walking into the living room only to find Lucy lounging away.

On the one hand, I admire her perseverance and tenacity. She's no dummy. When we first got her a little over two years ago, it was also a firm rule that while she was allowed in the house during the day, she slept in the garage. However, she immediately mounted a Sleep In The House campaign, filled with incessant door scratching and hiding from me at bedtime. And it wasn't long before her bed was relocated to the corner of our bedroom. Or again, two years ago we had a rule that dogs weren't allowed on our bed. But Lucy mounted campaign Allow The Dog On The Bed. And by means of repeated disobedience, and well, gosh darn cuteness, we eventually relented, and now Lucy is allowed on our bed (as long as we are not on it, she still sleeps on the floor).

So yes, Lucy basically has us wrapped around her little finger. And now she is mounting campaign Allow Lucy On The Couch. This morning after Aubrey got breakfast she found Lucy laying on the right side of the couch. Aubrey quickly removed the offending dog with a combination of stern disciplinary words and physical encouragement. But after getting dressed Aubrey came out to find Lucy on the left side of the couch. As though she understood the infraction only to lie in the fact that she had chosen the wrong side of the couch on which to lie. Like I said, this dog is no dummy. I'm convinced she has a master plan for gaining access to the couch, and is just working her way through the necessary steps. But Aubrey and I are equally convinced that this rule is a keeper, and we will not fold. So check back in a month to see what the rules are...

Friday, October 02, 2009

Revival Wrap-up

Last night we had our fifth and final night of our Community Revival in the park. Here are a few of the highlights from the last few nights.

- The last night was a great finish with one of the black choirs singing their hearts out, and one of the energetic black preachers bringin' it like only a black pastor can.

- The pastor of the Spanish church made several announcements in Spanish with his daughter translating for him. With my poor-to-mediocre Spanish skills I could tell that she was giving fairly loose translations. My favorite was her translating "hermanos" with "ya'll," she was going straight from Spanish to Southern.

- Every night we had over 100 people turn out, always a good mix of races, backgrounds, ages, and every other demographical category.

- It was good to get to experience some of the other traditions of other churches. Some of them made me grow in appreciation for the other traditions, and some of them made me grow in appreciation for my own tradition!

Thursday, October 01, 2009

Busy.

I'm back on inpatient medicine. That means longer days, earlier mornings, and not much of anything else.

I had forgotten how much I love seeing patients in the hospital every day.
How much I enjoy eating a hot breakfast every morning.
How much I love being there when my patients are sick, and thinking through how best to make them better.
How fun it is to work with students and teach them a little bit about being a doctor.
How much I love being there to comfort families as we know there is nothing else to do, and making a patient's death just a little less bad.

It's been a good, long, tiring, learning-filled week.