Hit me with your best shot

NewFNP has had better days at work.

To begin with, newFNP's back is jacked up and she is walking like she has a stick up her ass. Then she saw 17 patients before lunch.

Then her last patient hit her in the face. Open hand, but with the force of 202-pounds of mother-fucking crazy behind it.

NewFNP has never, ever been hit before. She is a white girl from the suburbs who went to top tier schools and watches Jon Stewart and goes to spin classes and shops at J. Crew. She does not engage in fisticuffs. And, quite frankly, she could go the rest of her life without ever being hit again if she has her way. It hurts. NewFNP was actually dizzy. And she was completely fucking shocked.

After her patient was forcibly removed from the clinic 5150-style and newFNP spoke with the officers about her being a victim of battery (not her words, but noted on the very official police report), she was told that she should go home for the rest of the day.

No shit.

It's one hell of a way to get half a day off, but you don't have to tell newFNP twice to get the hell out of dodge. Why couldn't her patient unleash the crazy at 9 AM instead of at 12:30??

NewFNP, that's who.

NewFNP has long been fascinated by two behaviors she often notes as regular occurrences in her clinic.

The first is that patients feel absolutely empowered to walk into the patient care area and ask the medical providers any number of questions while the provider is in between patients. These are patients who may have just happened to drop by, or who received a letter stating their labs were abnormal or who wanted to show a provider a rash or insect bite or what have you.

NewFNP finds this frustrating and fascinating. She would be hard pressed to stop her doctor in the hallway to ask her a question or show her a derm lesion. For being disempowered in many ways, it is remarkable - albeit somewhat misguided - that her patients have found a voice in this way.

The second behavior is fighting and swearing and name calling in clinic.

It was full-on baby daddy drama in clinic today as prenatal patient A and prenatal patient B realized in the reasonably tranquil waiting area that they were both carrying fetuses fathered by the same man. Although it did not come to fisticuffs, clinic security was on heightened alert.

As newFNP's medical assistant was vitaling prenatal patient B, newFNP heard the word "bitch" resonate down the hall four times. At this point, newFNP said, "Uh-uh. Not on my watch." She entered the vital sign area, closed the door and told the patient that while she understood that she was frustrated, that language was not tolerable in clinic.

To which prenatal patient B replied, "Who the fuck are you?!!?"

Indeed.

Fortunately, the remainder of the appointment went much more smoothly and newFNP noted that, in addition to sharing a baby daddy, newFNP's prenatal patients shared the exact same tattoo in front of their right ears on their cheek.

The remaining lot of tattoos - neck, chest and hands included - were all different.

There's an app for that

NewFNP dodged a bullet today. Not literally, but technologically.

Outside the exam rooms, newFNP's clinic has lovely fold-down desks. In her fold down desk, newFNP has lab slips, routing slips, medication order forms and, frequently, her iPhone 3GS.

Today, newFNP looked in her desk and her beloved iPhone had disappeared. "Mother fuck," she thought, "Somebody stole my phone." She looked in the providers office and was denied. She looked again in her fold down desk and was again denied. It was at this point that she truly began to lose her shit.

She thought about why in the world she would return to a place where people are stealing phones. She realizes that poverty leads to desperate acts - such as her patient who presented to the emergency room with abdominal pain and cholelithiasis using a fake name in order to avoid receiving a bill she could not afford. NewFNP does understand that these acts are of desperation, of not seeing any other way.

Nonetheless, they are wrong.

NewFNP is not insensitive to the fact that many bankruptcies are results of medical debt. But she does not condone what is essentially stealing health care from the emergency room. The medical system is broken. But when one lies in order to receive services, then is that person a part of the problem? Or are they just making the best of a fucked up system?

Today in clinic, newFNP's colleague blew up her cell time and time again. Given that it was password protected and that the mute function is not immediately accessible if one is unfamiliar with the phone, the culprit had to ditch newFNP's phone in the baby scale. She then walked around the clinic and went to her mental health appointment.

NewFNP had started her on Paxil yesterday and made a referral to mental health -- today's appointment. She had stolen another employee's phone several days before. No one has confronted her. The current plan is to have her escorted to every aspect of her clinical appointments, but apparently to never acknowledge her sticky fingers. NewFNP's clinic manager specifically asked newFNP not to confront her.

Fine. NewFNP will keep her mouth shut. She does, after all, have her phone back. And she learned a valuable lesson: keep your shit with you, newFNP!!

But newFNP is pretty damned certain that she does not want to give her time, service and care to this woman in the future. This patient does not get to have the special newFNP touch. She spent a shitload of time (read: 20 minutes) supportively encouraging this patient yesterday. She does not want to give that of herself to someone who takes and takes and takes, then takes some more.

As an aside, this incident has caused newFNP to re-evaluate her aversion to the lab coat. Perhaps it's time to pick it up off the floor of the coat closet and bring it back to clinic.

More Mirena

Again with the Mirena hatin'!  Different patient, of course.  NewFNP is trying not to take it personally.

Clearly newFNP needs to do a neurology CME to try to understand why the brain would cause a normally reasonable enough woman conclude that her headache of three days duration had its etiology in her IUD which newFNP placed a full five months ago.  

And then, what stops someone from just popping a Tylenol or two?  NewFNP finds this to be such an irony in her clinical population.  No one hesitates to borrow a penicillin or a couple of tetracycline when they have a cold or eczema or whatever.  But to take an over-the-counter analgesic - not gonna happen.  Better to just head on into the free clinic and get some Tylenol there.  

WTF?

Phone-y baloney

There are maybe two cell-phone conversations which newFNP would like to overhear.  

One goes like this, "Hey Brad Pitt, this is George Clooney calling.  I am absolutely awestruck by the beauty and witty repartee that I have been enjoying with this lovely NP sitting in front of me.  I do believe that I shall fly her to Lake Como on my private jet and bed her."

The other may be something along the lines of, "What - they are giving away free flattering Theory trousers and cashmere sweaters at Bloomingdales at exactly 5:00 today?!?!"

What newFNP does not want to hear is your bullshit whatever conversation while she is attempting to get a health history on your two-year old kid during his physical exam appointment.

Can you hear newFNP now?  Hang up your goddamn phone!!!

For a solitary in-exam-room-phone-pick-up that is quickly ended with the words, "I can't talk now -- the newFNP is in the room," newFNP grants you a pass, but is nonetheless displeased.

After the second, third and fourth times, newFNP believes you to be unacceptably disrespectful.  During the fourth call, as the patient's mother was repeating an 800-number and credit-card number to the woman on the other end of her phone, newFNP exited the room, stating that she would return when the mother was more ready for the exam.  As she opened the door to leave, she overheard the mother stating, "Look - you made the newFNP leave" to the person on the other end.

Come again?  The woman who called - not knowing that the mother of the patient was in the exam room - bears responsibility?  No, ma'am.  

Sorry, sister, but one is not obligated to pick up the stupid phone while the provider is in the exam room.  In fact, one should be obligated to put the damn thing on vibrate or turn the fucking thing off after the first time it disrupts the clinic visit.

For the love of all that is holy, how do people not know this?  

Not even on the list of differentials

A while back, newFNP saw a guy who came into the clinic and was quite distressed about the painful ulcer he had on his penis.  He somewhat bashfully showed newFNP the lesion which required him to retract his foreskin.  What was revealed was a bright purple glans with a single ulceration.  

The first time newFNP saw the purple liquid covering something or other, she was quite surprised.  Tincture of violet, or violeta, is a much loved antiseptic in the Latino community.  NewFNP's patients don't seem to use it as advertised in the natural stores - as a tincture of be consumed - but rather paint it on any manner of superficial injuries including, it seems, the ones that show up on the penis.

Despite the violeta, newFNP did a herpes culture - negative -  as well as a syphilis test - also negative.  Her patient wasn't giving up any clues as to what may have caused this ulceration.  No zipper misjudgment, no history giving newFNP a single damned clue about why his penis had a big fat ulcer.

Well, newFNP's colleague elicited a story that is incredible.  She saw this gent for follow-up, penis still purple and ulcerated.  According to her, he must have felt like confessing because he told her how he got the ulcer. 

NewFNP knows this man to have been a former crack user.  Apparently, he had been a crack dealer as well.  His storage space: the cozy area between his foreskin and his glans.

Is that even possible?  There is no drawstring!  How does the crack stay there?  Not having a little foreskin pouch of her own, newFNP frankly just does not understand.  But if it's true, that is gross.  And apparently very dangerous.  And yet another reason to add to the 'con' column when considering crack smoking!

Dr. Dual-Ivy-League-Degrees had a good point about this one - the most important question in the history is often, "What do you think might be causing this?"

Mama mia!

Yesterday afternoon, as newFNP looked at the pregnant seventh grader sitting across the room from her, she searched her eyes for a glint of fear, of recognition of the gravity of her gravid situation, and for a seed of doubt that would allow newFNP to introduce the topics of abortion or adoption.  She struck out.  She brought them up anyway.

Perhaps it was because this young woman appeared to have the IQ of a toadstool.  Perhaps it is because her sister is twenty-one and has five, yes five, children.  Perhaps it is because her dad was deported a few years ago or because her brother recently died.  Perhaps the ole 1-2-3-4 punch - shitty life circumstances leading to seeking love and affection in the arms and bed of a horny fifteen-year old boy, infinitely desirable in his scowl, his Nightmare Before Christmas hoodie and his Vans slip-ons.

Whatever the reasons, this just-turned-fourteen-year old girl was convinced that motherhood was the best option for her.  OK.  NewFNP took a deep breath, attempted to put her judgements aside and started talking more about self-care, about breastfeeding, about finishing middle school and then high school, about bringing her frigging mother to her next prenatal appointment.

  

NewFNP auscultated fetal heart tones, reviewed lab results, talked a little about fetal development and the importance of nutrition and then exited the exam room to have a shit fit and find the prenatal care coordinator who would hook this very young lady up with prenatal case management, parenting classes and God knows whatever else a fourteen-year old needs in order to become the best parent she can be.  

NewFNP's prenatal care coordinator, PCC, is lovely.  She is twenty-four and she also got pregnant for the first time when she was thirteen.  As she tells it, her Pentecostal preacher father was none too pleased.  She delivered her now ten-year old son at the age of fourteen and her daughter at the age of eighteen.  Despite many bumps in the road with her children's father, they remain married and, as far as newFNP knows, happy.  She started out several years ago as an MA in newFNP's clinic.  Because she is personable and talented, as well as smart, she was promoted to the position of prenatal care coordinator and has done remarkably well with the new responsibilities.  

NewFNP's patient is no PCC.  NewFNP is concerned the PCC is the exception and newFNP's patient is the rule.  Nevertheless, newFNP will continue to support her in having a healthy pregnancy and baby and, if she decides that adoption is a good plan after all, newFNP will be there with the referrals.

As an aside, since when are fourteen-year olds in seventh grade?  NewFNP was a sophomore year in high school when she was fourteen.  Aren't we at least supposed to be in ninth grade?

The Michael Jackson Parenting Award

NewFNP sees plenty of examples of parenting which she hopes to never incorporate into her repertoire.  

Most, but not all, involve feeding practices.  These include Gatorade or chocolate milk in a baby bottle when a child is 6 months old, Hot Cheetos in the hands of an 18-month old, fast food on a daily basis and tamarind/lead candies from the ice cream truck.

Some "don'ts" involve discipline and behavior modification.  Spanking and name calling. NewFNP will take a pass on these.  Threatening a child with vaccines if they don't behave.  Telling them that a shot won't hurt.  NewFNP frowns upon these as well.

Others involve soothing techniques.  Feeding a crying child just to stop them from crying is a no-no in newFNP's Theoretical Guide to Child-Rearing.  

NewFNP does, however, approve of gently rocking and employing a soothing voice to calm a child after vaccine administration.  However, when a mother soothes an infant by lovingly saying, "It's not my fault... they're assholes.  Yeah, there there, they're just assholes," newFNP believes that she must modify her approval of the soothing voice technique.  

NewFNP hears a fair amount of crazy shit, but she had never heard a parent attempt to calm a crying child by calling clinic staff assholes.   

A class act indeed.

If the shoe fits

If newFNP didn't have photographic documentation of herself salsa dancing and Corona-drinking in a far-far-away city a mere five evenings ago, she would swear that she had been trapped in her urban community health clinic Gulag for ages.

NewFNP wants to storm into the packed waiting room and scream: People! Let's band together and stop this nonsense! You have a cold? Go home! You have diabetes and ate a doughnut, a tamale and a double mocha frappuccino before your appointment? You're fired!

And those would be the easy cases. Today, newFNP's cases were not so.

Influenza? Check.

Child sexual abuse? Check.

Crying overweight ladies (plural) who don't want to have sex with their husbands? Check. (Prayer - please, please, please do not let newFNP ever fall into this group!!)

Parent who cannot name her child's apparently chronic, perhaps genetic, illness? Check.

NewFNP is not a parent, but if she were, she is pretty sure that if her child had some inborn error of metabolism or some genetic defect, she would at the very least have the wherewithal to write down the name of the fucking thing on a sticky pad. This would hold true even if newFNP were not an FNP. If newFNP were a fancy nail salon girl or a go-go dancer or even a rodeo clown, she would know enough to learn the name of the condition. Even more so if she herself had undergone genetic testing and had some genetic-something or other, as her patient's mom had.

When one spends nine years in post-secondary education, one's bar for normal intelligence is so absurdly skewed. Friends, newFNP is living 'regression to the mean' and this lady was at least two standard deviations below! NewFNP thought that everyone was like herself and her super-education friends.

Wrong. Oh sweet Lord, how wrong she was.

NewFNP hates to just chalk it up to 'stupid,' but sometimes the shoe fits. Can newFNP write "Mom not so bright" in the progress note? It only seems fair to give the next provider fair warning.

Priorities

NewFNP is no Dr. Ruth, but she does pretty much accept that the most important body part in many a man's life is his penis. No big surprise there.

So when a 50-something year old guy presents to clinic with the chief complaint of the old johnson not working, newFNP is generally willing to help a dude out. She does, however, want to know why said johnson might be flying at half mast.

Thus, the history. Onset? Two weeks ago. Taking any meds? No. Any known health problems? No. Hmm, not much there. Glucose is normal. Chest pain? Maybe a little this morning, but none now. Next up, EKG.

This is where it gets interesting. It's not so often that one catches a guy in the middle of an M.I. but one might think to delve further into this possibility when one's EKG shows both ST elevation and T-wave inversion. When newFNP brought up this likely scenario, her patient noted that he had, in fact, been diagnosed with an M.I. a mere three days ago in the emergency department. He received some medications, but wasn't taking them because he didn't trust the doctors there.

Didn't think to bring that up, did you pal?

Well, buddy, newFNP won't be bringing your penis up with a Viagra prescription since you are actively infarcting. Now, take an aspirin and high-tail it back to the ED, would ya?

Maybe we should all take a lesson from Harlequin romance novels and embrace the notion that if you take care of the heart, my friend, generally the penis will follow.

Unless, that is, you've decroded its blood supply with Gatorade, tortillas and Sugar Babies.

Happy 5768, Jewish Style

Shana Tova, newFNP readers!

Nothing has been very exciting in newFNP's world, except that she did go to a yoga class this week with her friend CDCMPH and got her ass kicked. Jump back into plank? No thank you. NewFNP will step into plank and will pretend that she and her pal are not the only yogis who are sweating like wild boars!

Clinically speaking, newFNP has been recently plagued with the mind-numbing "same old-same old." The potentially interesting cases have not followed up and, thus, newFNP is in the midst of several clinical cliff-hangers. Does the seven year-old with B-cups rivaling those of that 'High School Musical' nude-internet-picture-girl merely drink too much hormonally-ridden milk or is she in the dangerous clutches of McCune-Albright syndrome? NewFNP would love to tell you, but this young lady has not returned for further evaluation. NewFNP hopes that she has followed up on her endocrine referral.

What newFNP has noticed of late is that she is spending an inordinate amount of time educating her patients on something that she herself has taken for granted for years, no - decades: the medication refill. NewFNP expects that when she gets her Retin-A prescription, it will damn well come with a year's supply of clear skin and wrinkle prevention, all with a simple automated phone call to her friendly neighborhood pharmacy. To newFNP's patients, most of whom hail from countries where over-the-counter meds are the norm, the concept is foreign. "What?!?" they say with raised brows, incredulous that they could have more than one month's worth of hydrochlorothiazide! Ah, yes, newFNP explains. All you have to do is call. Then newFNP reviews why it is important to, therefore, use the same pharmacy for all prescriptions. This interaction takes significantly longer than one might assume.

NewFNP is a joker, but she is not joking about this. Patient after patient, newFNP must review the concept of a refill. Swear to God. No fucking joke.

The other thing which newFNP finds striking is the all-too-common answer to a question posed by newFNP during each and every well-child visit: What kind of milk do you drink at home? To newFNP, it is as relevant as the presence of smoke alarms, medication allergies, asthma and if there is a frigging TV in the three year-old's bedroom.

And how do the vast majority of newFNP's patient's answer?

"De galón."

Oh, no shit? You get your milk from a gallon container? As opposed to, say, drinking directly from the teats of the many cows freely roaming the streets of newFNP's urban metropolis! What the fuck? NewFNP is not sure if she is missing something in the translation, but, in writing this, allows that she could simply ask if the 50-pound toddler is still drinking whole milk.

But shit, where's the fun in that?

"De galón." L'chaim!!

Va-va-va.... hey, wait a minute

As of late, newFNP has been using her spare time in between patients to help the higher-ups at work compile data for a new program application. As such, she has learned many statistics about the area in which she works. For instance, she works in the area that has the highest all-cause mortality in her county of residence. The area has the highest rates of uninsured adults and children in the county. The majority of the residents in her clinic service area speak a language other than English at home. Only a quarter of the residents have graduated from high school. The average income is in the low 20,000's.

All this to say that the patients who newFNP serves are poor and largely disenfranchised. No shit, right? They're waiting 2 hours for a 15-minute appointment at a free clinic after all.

Generally, when newFNP is conducting a health history during a physical, the past surgical history that she elicits include cholecystectomies, BTL's, hysterectomies and traumatic injury repairs. It is rare, exceedingly rare, that newFNP has a patient who has had breast implants, a tummy tuck and a face lift - all conducted in the US. Any plastic surgeries that newFNP's patients may have had are generally conducted in Mexico.

So let's see... breast augmentation. What does that even run a person? Thankfully, newFNP will never have to know! But she thinks that it is in the neighborhood of $5000. Tummy tucks? $7000? Who the fuck knows? And a face lift? What, another $5000?

So if you are dishing out upwards of fifteen grand to spruce up the bod, it seems egregious to then seek out the services of a free clinic and use public funds for your physical. At the very least, it seems as though a generous donation is in order.

NewFNP didn't say anything, though. She just did her first implant breast exam and then sent out the referral for the mammography.

Breaking the law

It was yet another busy Monday in newFNP's clinic and, with newFNP still fighting her URI, she was fighting to stay afloat. She has eight charts at home to finish and some unfinished business to attend to tomorrow.

As such, newFNP was certainly not counting on a knock on her exam room door at 4:15 as she was conducting two well-child checks on siblings. She never expected her colleague FNP to say, "You have got to see this. Someone forged a prescription on a patient you saw last week."

But this is, in fact, exactly what happened.

Apparently, the two-year old patient's mom felt that the Ibuprofen prescribed by newFNP just wasn't enough. She thought that she should just add on "amoxicillina 250mg." Just like that. Just a Spanish language medication and dosage written in chicken scratch above newFNP's graceful and fluid script.

Thankfully, the pharmacy faxed over the prescription in order to verify it. They, however, asked newFNP to verify the sig, not to verify that it was a big fat forgery. What the fuck? Doesn't the pharmacist say something to the patient? Something such as, "Ahem, do you know that it is fucking illegal to forge prescriptions, you cow!?! You know, illegal as in jail."

The patient's mom had the audacity to call the clinic today, demanding that her child be given Amox and threatening to take him to the hospital, change clinics and make a scene if we didn't give it to her. She insisted that newFNP wrote her the prescription. NewFNP refused to talk to her. She let her clinic manager know what the situation was and went about her business.

Why do patients like this always think that threatening to change clinics is something newFNP will respond to? Please, newFNP will pay this patient five bucks to change clinics so she never has to deal with her fraudulent-prescription-writing ass again.

So long sucker!

Ahhh... cable TV

NewFNP likes to fancy herself as healthy, but here she is - sick again. NewFNP attributes her illness to being exposed to all manners of rhinoviruses day in and day out and believes wholeheartedly that it is only the most virulent of said viruses that tend to knock newFNP on her ass. Which is where she has been all weekend. On the couch, flat on her ass, in and out of consciousness, thanking God that her boyfriend had the good sense to buy a huge flatscreen TV so that she may be entertained by the likes of Dirty Dancing, CSI and Caddyshack.

Nobody puts Baby in a corner.

NewFNP did take some time during her convalescence to think about her current employment situation. She reviewed some physical assessment texts and thought about where she might be taking her career. As we all know, her attitude is in the toilet. However, newFNP would like to change that and certainly does not want her career to follow that path.

But here is why newFNP's attitude sucks.

Sometimes people just break newFNP's heart. When newFNP hears about food insecurity from a featherweight 22-year old man, it just makes her emotional. Imagine leaving one's country to come to the US, in hopes of a better existence, and not being able to find adequate food. Of knowing that you have latent TB, but not being able to afford the $10 medicine to avoid active TB infection. Of finally securing a job, but working six days per week and not being allowed to leave early to get to the clinic. There was something more about this patient, though. His modesty, his sincerity... he really touched newFNP.

Then there are the people who make newFNP want to scream. This week, a patient told newFNP that no matter how much he weighs, he never changes in size. In fact, he claimed, one time he lost one hundred pounds, but still wore the same sized jeans. "One hundred pounds?", newFNP verified. Confirmed. One hundred pounds and still a size 42 waist. Diagnosis: delusional liar? Reality challenged? How is newFNP supposed to help someone who has clearly lost touch with all that is real? NewFNP notices that her trousers are roomier of she loses 1/100th of a pound.

And finally there is that old chestnut about support staff not providing support. NewFNP does not want to micromanage, nor does she have the time to do so. But when newFNP's reputation is on the line, you bet that she will be all over the staff's asses in order to get things done. You betcha that newFNP can find 30 seconds in between patients to ask if phone calls have been made and abnormal pap logs have been updated.

A friend of newFNP's recently noted that he felt that newFNP sometimes feels anger toward her patients. NewFNP disagrees, but she certainly does feel frustration toward many patients. Quite simply, how could one not feel frustrated given the challenges one faces in community health and probably in all healthcare settings?

Working through these frustrations is one of the challenges that newFNP faces. Sometimes she is great at it, sometimes not so much.

You think you had a bad week?

OK, listen. There are many difficult situations which newFNP must control in the course of a work week. These include, but are not limited to, the following quotes from patients and/or clinical experiences from last week:

• 'I stopped taking my Benadryl because it makes my eyes hurt.'
• 'My cholesterol medicine makes my throat hurt.'
• 'My hernia [umbilical] is hurting and I didn't go to my ultrasound appointment, nor did I call to cancel or change the date.' This is a paraphrase. This same patient also told me that she felt "little balls" on her abdomen. Yeah, sister, that is called cellulite. Tummy cellulite. Now goodbye.
• 'All I eat are fruits and vegetables.' Hmmm.... 276 pounds and a glucose of 350, all from those dastardly fruits and vegetables? Perhaps newFNP is approaching diabetes care all wrong.
• Let's see, what else: fat kid, fat kid, fat kid, kid with possible ocular tumor, fat kid with hypertension, primagravida with a fetal ultrasound too devastating to describe, fat kid, hugely fat adult.... you get the picture.

But do you know what made last week a fucking nightmare? I'll tell you.

NewFNP has lost her palm pilot. The son of a bitch is gone, along with ePocrates, Kid-O-Meter, BMI Calculator, 10 year risk assessments, my hairdresser's phone number, my facialist's phone number and a plethora of other useful information. NewFNP has a new PDA on the way but misses her piece of crap Clie.

Sony Clie, wherever you are, newFNP loves you.

Parenting 101

A little about me. NewFNP is not a parent. However, newFNP knows crappy parenting when she is beaten over the head with it.

Take for instance the mother and daughter pregnancy test walk-ins this week. Mom in her late 30's, daughter in her late teens. Mom's test negative, daughter's test positive. Mom relieved yet concerned about having had two menstrual periods the previous month. Daughter devastated, crying, fallen, crushed.

Mom wrapped her arm around her daugher's shoulders and told newFNP that her daugher had been raped in February. NewFNP inquired as to post-sexual assault care. She had none. No health care, no police report. No menstrual period for two months. No knowledge of whether she had been infected with an STI. No counseling.

Mom repeated over and over to the daughter, "It's OK, it's OK." OK? Fourteen weeks pregnant as a result of a rape is OK? No, not OK. Pretty fucking far from OK.

After a 20-second series of "it's OKs," mom turned her attention back toward herself and inquired as to her irregular periods. NewFNP said something polite but dismissive in order to re-direct the conversation to the daughter. Mom played along, but would not be deterred from receiving the answer to her relatively pedestrian query. NewFNP encouraged her to follow-up with an appointment. What newFNP wanted to tell her was to drop it and to focus her attention on the needs of her re-traumatized daughter.

Is newFNP out of her tree or is there a time during which you let your needs fall aside in order to deal with a crisis? Isn't that part of being a parent? That's part of the reason why newFNP is sans child - still selfish, this newFNP! Still putting her needs first.

Speaking of, J. Crew has some cute frigging spring flats. Perfect with smart trousers for clinic-wear!

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.

Ayyyyy me duele!!

Culture. We all have it. In mine, stoicism in the face of pain - emotional or physical - is valued. I'm not saying that's right, I'm just laying it out there. Apparently, an ever-elusive perfect weight is valued as well as newFNP's family always has a comment about weight during any visit - too much, too little, but not-as-of-yet just right. Anyway, internal demons aside, newFNP is one to grin and bear it, pull herself up by her bootstraps - bootstraps which will one day bear the Prada insignia if all goes well.

This cultural bias and placement makes it exceedingly difficult for newFNP to stomach the (perceived) histrionics of pain during exam. The vocalization of "Ayyyyyy, me duele.... aqui, ayyyy me duele!! Doctora, me duele!!! Ayyyyy, dios mio, me duele!!" It makes me crazy. I don't doubt that it hurts, but I would have to be carrying my own detached arm to the doctor to complain half as much as these women do. A good fashionista pal pointed out that perhaps some of these women have no other place to vent their pain - a good hypothesis, I believe.

Cultural bias takes on other forms as well. Today, a 40-year old patient came in for a pap. She had sex last night - no condom. Generally, no condom = no pap, but her case was different. This woman has had sex virtually every day for the past 26 years with her husband, whether she wanted to or not. According to her, she "rarely" wants to. According to him, it's her responsibility. Even though she complies with this, again, nearly daily activity, her husband has had many extra-marital relationships and has, according to my patient, transmitted chlamydia, gonorrhea, herpes and pubic lice to her throughout the course of their relationship.

How is that for insult to injury? Sexually transmitted infections through forced sex. Incidentally, she denies IPV. Hmmm..... can you see where newFNP's culture is sneaking in?

I asked her if she thought it was okay for her to have sex with her husband when she didn't want to. She responded, "No se." If she doesn't know, how am I supposed to know? I know what the answer is for me, but is this a universal truth or a newFNP truth? Her affect and her tears told me what she really believes, but I could only offer her the tools available to us: our counselor.

I am so glad I got to come home to my apartment, no abuse, maple yogurt and Boston Legal on the tube. I wonder what her night will be like.

Incidentally, in the area where my clinic is located, I have noticed a cultural value of slow-assed fucking driving. Ayyyyyyy, me duele, the slow drivers. Mueve!