Wednesday, January 25, 2006

Pet Peeves

There are a few things that turns newFNP off during the clinical encounter. And I'm not talking about all the patients who ask me about my marital status.

Nope, I mean the ones who open the door and stare at me when I'm reading another patient's chart in the hallway. Estimada paciente, do not go back into your room and leave the door open while waiting for me. Read the thoughtful en espanol educational materials that I have photocopied on cheerfully-colored paper on my own time and that will offer helpful suggestions to help you lose 30 [read: 50] pounds. I hate that you continue to stare at me while I read your chart in the hallway so as to garner a shred of an idea as to why you might be visiting me. I understand that you are waiting a long time for me. I promise that I'll be in ASAP. Now shut the damned door.

But even more than the patient-imposed open door policy, newFNP gets all bunched up when, after opening the door, she sees the patient perched on the rolling stool. I'm telling all y'all motherfuckers that I have two graduate degrees, a stethoscope and a white coat. I have earned the rolly stool. Who doesn't know that the rolly stool is for the one who writes the prescriptions? Move it, buster. If it's a kid, I let it slide because - hey- the rolly stool is fun. But adults get no love from newFNP is they steal the stool.

Why is newFNP so lame as to even give a fuck if the patient wants the rolly stool? A) It's a safety thing. I am positioning myself closest to the door in case you are a weird-o or mentally disturbed like the guy who stabbed Carter on 'ER'. B) I don't want to sit in the regular chair. Period. C) The rolly stool is mine. D) Respect. It's silly, but it seems disrespectful somehow. I'm sure it's not intentional but nonetheless, you go to your seat and I'll go to mine.

End of story.

Wednesday, January 18, 2006

The apple doesn't fall....

When newFNP was a student, she wrote a (fascinating and insightful) paper about parental loss in childhood, but specifically adolescence. It doesn't take a frigging genius to know that this is one of the most painful losses a child faces, that its consequences are potentially devastating and can be life-long. The legacy of that loss can profoundly shape the child.

Given that newFNP has such keen acumen, she should be incredibly prepared with all of the right words when a patient tells her that he or she has, in fact, experienced parental loss.

My 11-year old patient's mom died when she was 8 - complication of diabetes. My 11-year old patient is 243 pounds. Her acanthosis is pronounced. Can you see the trajectory?

She knows. I know.

She is scared. She is terrified to have her sugar checked because what will happen to her if she has diabetes? Will the same end meet her as met her mother? And she is only 11.

It is so complex. Her dad tends to give her whatever she wants because he cannot give her what she has lost. So she gets honey buns and Hot Cheetos. She is too young to know how to really do anything different. She is too scared to honestly talk to me (in 15 minutes) about her weight because of what it signifies.

This is the poignancy of family practice. This family is in crisis. They both need to make changes and they both need support following their loss. I want to give them the tools to mend their family as best they can. But 15 minute appointments. Damn.

I don't know if what I did was right, but I told her that I was there to help her and that I wanted her to know that there are people in this world who care for her, who love her. I told her that I would be there for her even when she wasn't sick, that she could come in just to talk if she needed to. I told her that my mom died when I was young because I remember thinking that I was the only person in the world who could ever experience such heart-wrenching loneliness. Shit, I hope that still falls within the confines of holistic care. Patients feel free to ask me about my marital status and parity, so I can tell other patients personal stories if they are relevant, right? I just wanted her to know that she had somewhere to turn and I didn't know how else to make her see that.

And now I need to find a childhood grief specialist. Who takes public insurance. Motherfuck.

Tuesday, January 10, 2006

Don't send me back

There are days when newFNP is simply unable to dodge all the shit being thrown her way. Today, of course, was one of those days. From 10 AM on, I had nothing but problems. Here they are.

One. Depression followed by PTSD. The depression was just sad. The PTSD, on the other hand, wasn't entirely convinced that he wanted to live. Clearly not an easy appointment. At least now I know how to write a 'safety contract' in Spanish. Oh, and when you are telling me that you think you'd be better off dead in one sentence, the next sentence sure as shit had better not be 'why do you think my throat hurts?'!!

Two. Hi, my new diabetic patient. I see you are 39 and have already had a below-the-knee/above-the-ankle amputation. I see that your burn wounds, affecting both hands, are not healing after 1 month, are slightly smelly although not infected and that your sugar is 'HHH.' Oh, you say you're peeing all of the time and that your vision is blurry? I can't say that I'm shocked.

Diabetes. Damn! Did everyone read the special in the NY Times about Spanish Harlem and the 20% prevalence of Type 2 amongst the residents there? Read it. It actually gives some good insight into how people cope (or don't) with the illness.

Three. It's 4:35. You're my 55-year old 3:30 complete physical and pap. It's not your fault that you're in my room late. I'm sorry you had to wait for me. Blame it on the diabetic guy.

Four. Prescription nightmare. Not my fault, but my mess to deal with nonetheless.

Five. My two incorrectly scheduled pediatric physicals, both scheduled at the same time, both 30 minutes late. Yes, your mom was pissed. I'll tell you what: next time be on time or call and let us know that you're late. Don't tell the receptionist that you didn't know you had to be on time. Have common sense and don't be mean to the front desk staff. This happened while I was with the patient who wanted to die, trying to get the social worker on the phone. So, no, I won't leave my patient to explain to you why I'm not seeing you today.

Is it any surprise that I cannot remember the other 18 patients I saw today? None of them were really 'easy,' many of them were new.

As I looked at charts in the hall before entering the patients' rooms, I was very conscious that I had to keep my frustration with my day to myself. I had to tell myself that Sra. X deserved the best of newFNP, not the frazzled and borderline tearful newFNP. That is a tactic I haven't had to employ frequently, but it was indispensible today.

And, thankfully, it worked. Yes, I was miserable with stress. Yes, I thought of requesting a phenobarbital-induced coma. Yes, I was thinking of ways to avoid ever going back to work again as long as I live. But I treated my patients well at the end of the day.

Even the one whom I saw at 5:15.

Friday, January 06, 2006

A Cure for the Obesity Epidemic

I've got it. It's a plan that will never come to fruition, but one I think has the potential to be quite effective. No, it's not the removal of sodas and Taco Bell, Golden Arches,Burger King and vending machines from schools. It's not more exercise or daily P.E. in schools. It's not 'you'll get Type 2 diabetes and have hypertension and dyslipidemia, all predisposing you to a big old MI.' Those are good ideas, by the way, great ideas even, but my proposed campaign is meant to have a visceral response, striking at the very core of insecurities all over the world.

(I love hyperbole.)

It's fair to say that all people have some degree of interest in their genitals, right? I mean, we have penis pumps, Brazilian waxes thanks to those evil J Sisters, circumcision, female circumcision as well as various nether-region accoutrement. Men can't stop touching their goods from infanthood until, well, until they die I guess. This obsession is the basis for my campaign.

My idea is this: let's raise the awareness of the 'hidden penis' and the 'fat vagina.'

I mean, does any guy want to exchange his average penis for a huge pannus? It's not even a fair trade!

And ladies have labiaplasty in order to have a perfect genital portrait. Not my patients, but I've seen the advertisements and if plastic surgeons can play off vag insecurity, then so can public health. So don't get a huge vag!

And after this awareness raising campaign, we can transition back to the more traditional interventions. It's worth a shot. The other methods sure as hell aren't working very well.