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.

It's all about the Hamiltons, baby!

NewFNP realized that she censors herself and that is so weak. So fuck it, let's talk about poverty.

It feels a little like a Seinfeld episode to say "not that there's anything wrong with it," but perhaps it is not entirely transparent that newFNP thinks that there is nothing wrong with being poor. That being said, there is also nothing wrong with wanting to not be poor either.

Poverty sucks. Urban poverty super sucks. Almost five years into practice, newFNP continues to be struck by the difficulties experienced by her patients -- difficulties truly unknown to her. Urban poverty often means gangs, school failure, cockroaches in ears, overcrowding, poor nutrition, medical debt, precarious housing, stress.

NewFNP grew up kinda poor after her parents divorced. Her dad often didn't pay the $400 child support payment that was to be shared between newFNP and broFNP. The first duplex in which we lived post-divorce was in the shadow of the interstate. But newFNP's mom had a college education and newFNP very frequently heard the mantra of the importance of a college education. And this was when she was in third grade. So while newFNP's family was financially poor, she had some socioeconomic buffer based on her mom's education.

NewFNP's patients, by and large, have no such buffer. They often live day to day, hand to mouth. Daily life beats them down enough that there is very little future orientation.

A patient today, a 30-year old unemployed woman with three children, eight year-old rippled breast implants and a tubal ligation, was interested in A) reversing her tubal in order to have another child with her boyfriend of four months and B) getting a do-over on the implants. Yes, get those rippled things switched out before something bad happens, absolutely. Yes, your health is worth the $5000 or whatever the new boobs cost. Reversal of tubal ligation? Likely very expensive and likely not covered by one's state-funded insurance program.

But are these out of pocket expenses financial priorities? Does she have Suze Orman approved savings? Do her children have college savings funds? Is it a universal truth that all parents want their children to succeed and be financially stable?? Does newFNP have any fucking business in encouraging her patients to think about such things or even thinking these thoughts in the context of patient care?

NewFNP doesn't know, nor is she any kind of sage financial guide. Lord know that if newFNP had an extra three grand laying around, she would have a Bertoia Bird Chair faster than you can say sham-wow!

But newFNP's gut says that even the least educated, financially marginalized champurrado vendor would prefer that her child be a teacher than sell shoes on a corner. But how does she help her child get there if she herself has no idea, if she's illiterate, if she hasn't set foot in a classroom since the 7th grade?

Or what is a family teaching their children if the parents don't work, if they hang out and watch TV and have state aid? Like, if the goal is state aid, end of story? If there are four fathers of four children?

(Is newFNP completely losing her liberal credibility for even thinking such things??)

There is definitely an argument that goes like this: NewFNP, just shut the hell up and see your patients for their ear infections, et cetera et cetera.

Then there is the argument that goes like this: People need help and they often come to clinic for more than just what their chief complaints might have one believe. And people who impact the lives of others do more than the bare G.D. minimum.

Perhaps she should adopt the former approach when she notes feelings of judgment towards a patient, as she did with the BTL-reversal wannabe today. Providing good medical care is, after all, a good outcome in and of itself.

But helping to teach someone avenues through which to escape poverty - that seems like an okay thing to do as well. Is that just too pie in the sky? Is it classist? Is it even a realistic goal given the constraints of clinic? Ah, fuck it. Who knows.

Hard times

NewFNP noted recently that the economy is really hurting her patients.  

It's worse now.  

NewFNP referred three adult men and one pregnant women to food banks this week.  Adult men in newFNP's clinic, as a rule, are a stoic bunch.  They do not tell you that they are hurting or sad or worried.  This week, newFNP saw desperation and fear in her patients' eyes - worries that they will not be able to feed their families, let alone pay their rent.  

NewFNP hears on the news that lines for food assistance are longer, she hears the monthly unemployment numbers.  She wonders if robbery is increasing as people become more desperate.  Will the incidence of domestic violence increase?

During the Great Depression, unemployment rates were around 25%.  In newFNP's county, they were almost 11% in January, a 3% increase since September.  In newFNP's service area, unemployment is between 12-19%, depending on the zip code.

If you live in the hood, this is a depression.  It is a depression.  NewFNP's 401k is going through a recession but she has food on the table and gas in the car and not one but three paying jobs.  

NewFNP is acutely aware between the haves (her) and the have-nots (her patients) as she sits in the exam rooms, listens to their stories and provide them with the best care she can given that the answer to their worries lies outside of the exam room walls.  

On a lighter note, the aggressive-statement-maternity T-shirt shop does not appear to be struggling at all.  NewFNP's non-fronting pregnant teen showed up to clinic this week wearing a shirt telling everyone to STOP HATIN.  The graphic was, of course, a faded stop sign.

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.  

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.

Unqualified

NewFNP works in the poorest service area within her county. Almost every single health outcome indicator (overall mortality, teen births, infant mortality, obesity, cardiovascular mortality, insurance coverage - you get the picture) is the worst in her entire huge county. Her patients are exclusively covered by public health insurance, if at all.

So when newFNP has a patient who has some wealth accumulated, she finds it, frankly, a little surprising.

For instance, when newFNP asks her patient if she has health insurance and her patient responds that, no, she doesn't qualify for health insurance because she owns her home, newFNP is surprised. NewFNP's patient's net worth is greater than that of newFNP, yet newFNP is working, paying off five years of grad school loans and going home to her rented apartment, albeit a sweet-ass apartment with hardwood, washer & dryer and arched doorways located in a chic and safe area of her city. Perhaps newFNP will one day achieve the dream of home ownership herself, but she is currently unwilling to sacrifice her HMO and 401(k).

NewFNP's landed gentry patient must think that state-funded insurance is the creme de la creme, because she asked newFNP if newFNP "qualified" to receive it. Almost! If the state took newFNP's loans into account, she just might qualify for public insurance and section 8 housing!

At any rate, newFNP believes that this speaks to the need for universal health insurance. Should newFNP's patient have to sell her house in order to qualify for public health coverage? Does being a homeowner make newFNP's patient a woman of means? Might newFNP's patient end up costing the public health system more money if she can't get the care she requires? No, no, yes.

NewFNP does not like to think about how much longer we have until the next presidential election, but is she ever hopeful that the pendulum will be swinging left!

Heavy metal

Amongst many other ills one might see in an economically depressed community, newFNP's clinic sees a lot of children with elevated lead levels.

Now, when newFNP was in school, she was taught that it was the 18-month old child snacking on deliciously sweet paint chips off of brightly colored Mexican pottery or the child in an urban setting who lived next to a freeway/refinery/#2 pencil factory who was at risk for lead poisoning. In newFNP's clinic, we have another lead source: tamarind or 'chili' candies.

Now, newFNP is an unabashed sweet tooth, but she has never developed a taste for the chili candies. Little did she know that she was preventing herself from lead exposure. If she had developed this taste, she would be able to buy such candies by the bag-full from her local ice cream truck, the corner market or the streetside vendor. The lead is plentiful in newFNP's hood!

Getting these kids off the chili candies can be like getting Barry Bonds off the 'roids. According to the parents newFNP sees, it's the grandparents who are the tamarind-lead pushers. It's always those who you least expect!