Tuesday, February 24, 2009

Oh give me a home

If you are looking for a medical home, pal, newFNP's clinic ain't it.

Truly, in no way does newFNP's ramshackle community health clinic meet the criteria for a medical home.  Access to one's regular provider* and a personal relationship with this person?  No.  Evidence based practice and support for providers?  Nope.  Expanded access to one's primary provider via phone or email?  Sorry, no.  Comprehensive care?  Yeah - no.  Reasonable wait times?  Ha!  That might be the most blatant 'no' of all.

Jesus, newFNP is a little bummed just thinking of all the ways in which her clinic sucks.  

When newFNP thought of how she wanted to impact the well-being of the urban poor, she thought that she would help her patients to achieve health and thereby the ability to work given that they are - you know - not having MIs and diabetic retinopathy and teenage pregnancies.  In her obviously skewed and possibly delusional pre-community health clinic mindset, access to healthcare led to health which led to well-being which led to productivity which led to the promise of financial stability and a brighter future for themselves and their families.

Ha!  What the hell??!?  Where has that wide-eyed girl gone?  It's hard for newFNP to imagine herself being so idealistic.

There are times in which newFNP wonders exactly what good she is doing when her patients wait five hours to see her for a follow-up visit.  

As newFNP has mentioned, her days have become busier since pulling back on her clinical hours.  During this transition, newFNP has noticed a change.  Her patients are waiting to see her despite the ridiculously long wait.  

They come to clinic on newFNP's assigned days and wait.  When they are assigned to other providers on a given day, they advocate for themselves and assert that they will wait rather than being cared for by someone whom they do not know.  Of course, this is normal and the ideal situation - patients should not have to explain their diagnoses and personal situations over and over again.  But newFNP just loves that these patients dig in their heels and say no.

They are medical homesteaders.

If newFNP was running the show, she would make one small change that might decrease the wait times for her loyal patients - and all of her other patients as well.  She would schedule her patients on her actual schedule.  

Seriously people, where is newFNP working?  In a fucking MASH tent? Her clinic does not even schedule patients using newFNP's schedule template, yet newFNP sees 25+ patients every day she works.  Does that make sense?  If so, someone please drop some knowledge on newFNP because she would love to know.

* The literature about medical homes all use physicians as the team leader.  While newFNP appreciates the importance of physicians in the medical team, she does not believe that physicians need to be the primary care provider with whom patients have a relationship.  NewFNP is not about 'us vs. them' but rather believes that there is room at the table for everyone.  As the old saying goes, there is no "bite me" in teamwork.  Or something like that.

Wednesday, February 18, 2009

On the OB front

NewFNP's practice includes routine, low-risk office obstetrics. In some ways, it's a really nice practice - moms, babies - what's not to like??

Unlike other offices, newFNP's clinic does not have on-site ultrasound. Nor does her site have a family practice MD, an OB/GYN or a certified nurse midwife. Therefore, when newFNP runs up against a concerning finding, she has a few options. She can call the family practice MD at another site, she can consult with Dr. Dual-Ivy-League-Degrees who has some ER OB experience, she can page an attending OB at a nearby hospital or she can call BostonCNM for a telephone consult.

NewFNP wasn't expecting anything unusual with her 37-week primip yesterday. Sure, she was wearing a t-shirt with the phrase "OTHER BITCHES JUST FRONT" emblazoned across her chest in red 200-point font, but other than that, nothing out of the ordinary.

(As an aside, what does that even mean? Does it mean that she is a bitch, but that she in no way fronts? And if she is 100% not fronting, to what does that even refer? NewFNP is very confused.)

As newFNP starting asking her routine prenatal care questions, it came to light that her patient had been seen in the ER for preterm labor a mere six days before. Of course, she did not go to the ER where she is registered nor did she bring paperwork detailing the visit. According to her, she did not receive medications to stop the contractions, she had a normal NST, was observed overnight and then released. She had her paperwork at home, she assured newFNP, and would bring it to her next office visit.

NewFNP proceeded with the exam and was startled when she auscultated distinctly irregular fetal heart tones.

"Why they sound like that," her patient asked. "They was like that in the hospital too."

"What did the doctor say," asked newFNP.

"I dunno. He said it's normal I think," she replied.

Great. Sure, it can be normal. It can be a totally benign finding. Her 24-week level II ultrasound was normal in every way. But a repeat ultrasound or a fetal echocardiogram would provide newFNP with the reassurance she so sorely lacked at that moment.

NewFNP filled out the referral form for a perinatology consult and a repeat ultrasound.

When it comes to prenatal care, newFNP does not front. Whatever that means.

Saturday, February 14, 2009

You shouldn't have!

NewFNP isn't one to buy gifts off the street.  Maybe in Milan or Oaxaca, but not so much in her clinic's urban area.  However, judging by the amount of temporary vendors that pop up around the holidays - real or created - the urban stuffed animal street gift economy isn't suffering too much.

In fact, there are all manners of crappy gifts to be purchased streetside!  NewFNP's interest in the street gifts was piqued when she noticed a trend, some may say disturbing, several years ago around Mother's Day.  The hot ticket item that year was a ceramic swan in one's choice of ladylike pastels with a faux flower arrangement sprouting from the swan's hollow back.  

No swans for Valentine's Day 2009.  No sir.  Of course, there are many options for Winnie the Pooh stuffed animals - small and large and extra large - wrapped in clear cellophane.  There are carnations and roses and mini balloons.  All of these things are available, sure, but are they really special?  Is the mini Pooh with carnation combo really going to say "I love you" and possibly lead to mind-blowing amour on this potentially amour-filled day?

Or is a four-foot tall mirror in the shape of Tinkerbell going to nail it?  Because if it is, newFNP knows where to score one.

Now, it might be said that newFNP's tastes tend toward the finer things and often exceed her budget.  Her current obsession is the Bertoia bird chair (and ottoman) and the Tiffany & Co. platinum and diamond anchor pendant.  

Alas, newFNP is not holding her breath.  

Happy V.D. everybody!

Wednesday, February 11, 2009

Damned if you do

NewFNP feels pretty confident about her diabetes management, her hypertensive skills, her strep throats and all the day to day family practice stuff.

But where newFNP gets a little tripped up is with the more uncommon diagnoses, such as Myasthenia Gravis, a pretty horrible autoimmune disorder in which your body creates antibodies that block its acetylcholine receptors, thus causing muscle weakness.  A gross oversimplification, but it's late and newFNP needs to get out her physiology book to really explain this any better.  End result is weakness because bodies need acetylcholine for muscle contraction.

Anyway, some people have ptosis - or weakness causing eyelid droop.  Others have generalized weakness which frequently causes weakness and fatigue with chewing (a bulbar symptom), neck weakness that can lead to head droop and limb weakness.  Still others have respiratory muscle weakness which can necessitate intubation.  Not so fun.

NewFNP's patient has the generalized, bulbar weakness kind of myasthenia.  She had a thymectomy about a year ago.  It didn't help too much.  She saw her neurologist a few weeks ago and was told to increase her aceylcholinesterase inhibitor - Mestinon - as well as her immunomodulator - prednisone.  She is taking 8-10 tabs of Mestinon daily, as well as 8-12 tabs of prednisone 10mg - a hefty dose indeed.  And her jaw continues to fatigue with chewing.

Because she was worried about her nutrition, she supplemented her diet with Ensure.  Five to six Ensures a day for the past month, in fact.  According to the Ensure website, each Ensure has 350 calories and 22g of sugar.  And because everyone needs a little treat every now and then, she had been indulging in QID mini-doughnuts for about a week or so.  

Anyone who has ever taken prednisone in the past knows that it can make you hungry, even ravenous.  It can also in and of itself tip a heavy prednisone user into steroid-induced diabetes.  Combine that with 1750 kcal/day in Ensure alone and you end up with a random glucose of 236 when you present to your well woman exam.

Frankly, newFNP was surprised that her sugar wasn't higher.  Twice normal is so pedestrian in her clinic!

So then what do you do if you are newFNP?  NewFNP cannot just take the patient off of her prednisone and start her on something else - that is neurology's purview.  She can, and did, encourage her patient to chill out on the Ensure and doughnuts, to call her neurologist and let him know that her sugar is high, and to start taking Metformin.  

Did newFNP mention that this patient is also depressed and was previously abused by her partner?  Then she was diagnosed with myasthenia and had a thymectomy.  And now she has diabetes.  

The whole situation sucks.  

Sunday, February 01, 2009

It's the economy, stupid!

Beginning a few months ago, newFNP noticed a disheartening trend.  Many more of her patients - young, generally healthy patients - were coming with in complaints of things like dizziness, tingling in the arms and fingers, headache and diffuse muscle pain or, as a colleague likes to call it - total body dolor.  NewFNP recognizes these symptoms as depressed mood.  As newFNP is not a fan of the don't ask, don't tell policy in regards to a few things, including the medical history, she attempts to suss out the true cause of these symptoms.  Her patients appear relieved that someone is actually asking them about the quality of their lives.  Generally, they had experienced months of financial stress including food insecurity, home loss or inability to pay rent and zero prospects for imminent improvement.  

When newFNP asks the questions about life stress, the question is often answered in a deluge of tears, seemingly pent up for all these months - perhaps trying to keep a strong face in front of the kids or family but unburdened in the small exam room.

Do these people need medical care, per se?  No.  What they need are jobs.  It makes newFNP wonder about how bad things really were in the countries from where her patients came.  They must have been awful to risk moving illegally to the US, to move to impoverished areas where their children often flounder - for a variety of reasons - in school or are introduced to gangs and to where supply greatly exceeds demand for unskilled laborers.

NewFNP did not go into healthcare to make the big bucks.  But the truth is, she's OK financially.  The only change in newFNP's life is that her clinical hours are busier than ever before and her 401k balance is dismal.  What a relief that newFNP has decades of work ahead of her to recoup those losses!  Decades of work.  Fuck.

Anyway, newFNP supposes the real question is: what has this multi-multi-multi-billion dollar bailout done for the average middle-class person, the working class, the poor?  NewFNP knows that AIG executives are doing fine, but her patients aren't and neither are many families across the country.  We need a TARP for real people, a new New Deal.  How about more student loan debt relief for teachers, nurses, physicians?  How about actually giving money to taxpayers to pay they mortgages and student loans to the banks, who will then not have to ask for a bailout?  How about putting a TARP over impoverished communities to bring better options for disenfranchised youth?  To parents who want to work?

And now the Republicans don't want to pass the current stimulus package because there is, among other things, money for contraception??  What the fuck?  People who can control their fertility tend to be more productive.  People who work in clinics where contraception is a part of care earn money and pay taxes and mortgages and credit card bills.  

NewFNP swears to God, enough is enough.