It's very strange when you are a pediatrician and taking care of your own sick child.  Last week, my daughter became pretty sick.  I'm convinced she had RSV, though never actually had it checked.  For three straight days, I listened to her wheeze and watched her breathe heavily and really fast.  I didn't sleep for 3 nights just because I was so worried about her breathing and whether or not she was getting enough oxygen into her body.  Part of me just wanted to take her in to see her pediatrician so I wouldn't have to worry about it any longer.  Or have to make the decision of whether or not she was too sick or not sick enough.  The other part of me kept thinking, "you know she's going to get better.  Just wait it out.  You're overreacting".  Then another part of me kept thinking "don't be THAT parent who keeps blowing off her child until she's so sick she end up in the ICU on a ventilator".  Three days of pure exhaustion, which just made the whole thing even harder.  So finally, at 3:30am on night #3, my daughter was breathing about 70x/ minute and wheezing constantly, despite repeated Albuterol treatments, I gave up and took her to the Emergency Room.  While I'm there, they gave her a dose of Ibuprofen for the fever that developed while we were there.  Of course, 20 minutes later, her fever is down, the breathing and wheezing have improved, and she's smiling and cooing.  So ER physician is giving me "How stupid are you to come here at 4am?" looks and explaining to me (in a very condescending manner) what are appropriate reasons to go to the ER, none of which my daughter happened to be exhibiting at that time.  I got so pissed off.  I explained to him that I am a pediatrician and am more than aware of when and why I should take my daughter to the ER, and would not have necessarily brought her in at 4am unless I thought there was a really good reason for it.  Then, with as much dignity as I could muster in my pajamas, I walked out.

 

I think all physicians should either become patients or deal with physicians while caring for a loved one.  It completely changes how you react to things.  It changes how you answer your patient's questions regarding their illness or their health.  It changes how you explain to your patient what is going on with them, or with their loved one.  It changes your honesty and how straight you are with your patients.  You understand, that when giving bad news, your patient didn't hear a word you said after the shock of diagnosis.  I have been a patient with a serious illness since I was 19 years old.  I had to deal with horrible and truly wonderful physicians.  But I did learn how to treat my patients.  With respect and dignity.  That's such a cliche they made a whole movie about it (The Doctor, which was an excellent movie, despite its cliche-ness).  However, it's hard to truly understand that concept unless you have personally gone though the experience of a disrespectful or callous physician. 

 

Anyway, my guess is that the ER physician has neither:

1.  been a patient himself

2.  nor is a parent.

 

Because the other experience that has made me a better physician is being a parent. 

 

And understanding what goes through a parent's mind at 4am while they watch their child try to breathe.

My husband and I have decided to make the move clear across the country to the West Coast.  We've been living in the Midwest our entire lives, and my husband couldn't find what he wanted here, we began looking all over.  It's a terrifying move.  We have two small children, a house full of crap we've managed to acquire, and a very strong Midwest mentality.  My husband has his job all lined up.  His future office is so cool.  His window will look out onto the water!

 

I have interviewed and verbally accepted a job as a pediatrician.  Not any adults at all.  I'm torn about this for multiple reasons:

1.  Although I know at heart I'm a pediatrician, I'm going to miss my adult patients.  I have really enjoy a lot of my patients because they are willing to work with me on improving their health.  And even when they're not, they've been honest about what they will and won't do (i.e. quit smoking)

*****side note:  I just got this absolutely disgusting poster that I have hung behind me where I sit to write the patients' notes and scripts.  It's got a woman standing (about life-like) and little cut-outs into her body that show the effects of smoking.  It's so gross and I've gotten tons of comments on it.  As a former smoker, I feel no guilt, nor any sympathy for smokers and think they should all quit .... especially if they have children.  *******

 

2.  I will not be working in a community care center again.  I'll be working with the neurotically insured.  Part of me is thrilled about this but part of me is feeling guilty.  There is such a huge population of people who require healthcare and are not getting adequate care.  I feel like I have made a pretty good difference in my patients' lives these past years, specifically because I treat my patients well.  I know there are not enough doctors who work with the underpriveleged populations so I'm not sure I should be turning my back. 

 

I guess the decision is not final, though I feel like it is.  There is a community health center about 20min away from where we'll be living that I can always join if I want to go back. 

 

 

Saw one of my favorite patients today.  Not because she's nice, or because she listens to me at all.  But she's so honest.  She's morbidly obese and refuses to even discuss losing weight.  We've gone over her weight and the connection with her knee pain (arthritis in her 30's), her uncontrolled diabetes, her hypertension.  We've discussed (no we haven't....I've just talked) ad nauseum about how much worse her health will get if she continues to gain weight, all the consequences of diabetes and high blood pressure.  I've described how the human body was not created to carry that much weight on its frame and how the arthritis in her knees and how her back pain will continue to trouble her.  Nothing works.  Like talking to a brick wall.  Except I know she's listening because when I finished, she smiles, tells me she doesn't care, and has no intention of changing her habits.  I've tried to get her in counseling to discuss depression, but again nothing.  She doesn't always smile when she tells me to "go to h-ll" regarding her weight.  Sometimes she's downright mean.  I've actually considered cutting her from my practice, citing a poor doctor-patient relationship, but what's the point.  I know she likes me, she continues to see me.  And all that will accomplish is more ER visits on her part.  So she continues to see me, I continue to tell her the errors of her ways, and she continues to ignore my advice.  So why do I like her?  Because there is some amount of freedom having a patient who is entirely comfortable and honest with her decisions to remain unhealthy. 

I have been slowly telling my patients that I'm leaving.  This has been incredibly difficult.  Not the pain med abusers, but the patients who I feel I've really helped or the children I've been taking care of since birth.  A lot of them are offering to make the cross-country trip to continue to see me which I think is really touching. 

 

I did get some really happy news last week.  My mechanic patient whose heart I was worried about is ok.  I got the results of his stress test and they were normal.  Yay!!!  Now granted, he may still have some heart issues, but I feel like I've gotten some breathing room with him.  Now we have time to truly optimize his care.  He still looks like I'm crazy whenever I suggest changing his diet, but I have high hopes for my last 2 months with him.

 

I recently lost two patients from my practice who were upset when I informed them that having a positive urine drug screen for cocaine mean that I am unwilling to continue to prescribe narcotic medication for them.  One actually went as far as telling me it was my fault she was on cocaine because I was not giving her enough Vicodin.  I offered Naproxyn, but she was having none of it.  Oh well.  I'm heartbroken.  Boo Hoo.

She really reminded me of a pregnant woman I saw at the beginning of my work.  There is an interesting phenomena that whenever a new physician shows up in a community, a lot of people who like  narcotics will make appointment to see if they can get some oxycodone out of the new doc.  Many times, these are patients who have been kicked out of other clinics for violating their narcotics contract.  I have seen this happen in my own practice and whenever we've hired a new physician to our clinic.  Anyway, she showed up 6 months pregnant, complaining of back pain, and absolutely refusing Tylenol.  In fact, she was specifically asking for Percocets.  So I explained that 1) she'd already violated her narcotics contract with our clinic by using illegal drugs while we were prescribing the narcotics; and 2) while pregnant, I don't like to use narcotics unless absolutely necessary.  This is as far as I got as she began to blame me for her heroin use because we didn't give her enough drug to control her pain (remember, this was the first time I had seen her).  I tried to calm her down so we could discuss alternate way for pain control, but she wouldn't have any of it.  She left my clinic screaming obscenities.  Fun girl.  Never saw her again.   I let our social worker know about her so we could make sure CPS was involved once she had the baby, but we were unable to find her again.  My heart bleeds for her child. 

 

Once in awhile, something happens that really reminds me why I'm doing this.  I've been getting extremely frustrated with healthcare and my practice in particular.  I didn't even realize it had been so long since I've been on this site.  I took my Pediatrics Boards 2 weeks ago, and they were hell.  Most (intelligent) peope take their boards immediately after residency, but no, not me.  Although I did take my Internal Medicine boards the months after residency, it has taken me 3 years to get around to the Pediatics ones.  and no, I'm  not exagerrating when I say they were true hell. 

Anyway, back to the point.  Yesterday, in clinic, I saw a small infant, 1mo old.  Looked pale, breathing funky.  Nothing else seemed wrong.  Gaining weight, eating, sleeping, no fevers.  Spot blood check was normal.  He was doing all those typical one month things.  I think this is where the "art of medicine" comes in.  Although by the book this child was ok, there was that gut feeling of oddness.  Couldn't shake the feeling that something was off.  So sent him and his mom packing to the ER.  Lo and behold, kid's in emergency surgery today to fix his heart.  This is why I'm here.  It feels really good.  I'm going to check up on him and his mom tomorrow.

Too often, I come home frustrated and upset, feeling like I've done nothing to improve anything for the day.  I have too many patients who want to get better, but don't have the insurance or money to get better.  I also have too many patients on welfare who shouldn't be, and who aren't bothering to get better.  No way in hell is this much of the population truly disabled because of back pain.  One of my favorite patients is a working mechanic who is supporting his family, his in-laws, and a brother, I think.  No insurance.  He's just over the Medicaid income level.  Now I have to tell him that I'm really worried about his heart and he needs stress tests and meds to keep him going.  May need a catheterization and definetely needs to start seeing a Cardiologist.  He just looks at me.  I can see in his head he's running the numbers, trying to figure out how he'll make this work.  His daughter is supposed to get married next month. 

I don't know what the answer is to this.  I truly don't believe in socialized medicine, but I don't have a good alternative.  I think a lot of people need to be kicked off of Medicaid.

Anyway, here's my rant, several months in the making.  Next time, I'll write happy stuff  ;)

Yeah right.

I am constantly amazed by the human need for bandaids - not the plastic kind that cover cuts, but the pharmacological kind.  Whether it be alcohol, drugs, or, what I see tons of, prescription drugs.  I have multiple patients who have complaints of chronic pain.  These patients usually request various types of narcotics.  Now I'm not necessarily talking about the people who have an addiction to the drugs and come in with as many symptoms as possible in order to get the drugs.  Instead, I 'm thinking about the people who do not necessarily recognize what they're doing.  Many of these patients have pretty severe depression, often times refuse to take any type of anti-depressant, and have very vague (but in their minds, very severe) pain.  I see a lot of stomach pains, headaches, or back pains that I suspect are just referred pain from something they're not dealing with.  These patients are very difficult to treat because they truly feel the pain they're describing.  And many times, they really need the pain medication to treat the pain.  However, they're usually unwilling to consider the possibility of anxiety or depression as the root of their problem.  So instead of actually treating the issue, they keep covering it up with band-aids. 

 

 I'm still unsure what my role is here.  Do I prescribe the pain medicine knowing it helps them in the short while and because they truly feel the pain they're describing?  Or do I refuse pain medication since it is a potentially dangerous (and addictive) drug, and let them deal with the pain, until they're willing to meet with a counselor or psychologist to deal with the baseline issue? 

 

Some of my colleagues are very hardline and refuse any type of pain medication unless they can find a physical reason for the pain.  They feel that because of the danger of narcotics, they're unwilling to prescribe them without a clear cut reason.  I'm  not sure I agree with this stance as I know pain is not always seen on x-rays.  I've also come across multiple physicians who readily give out narctoics for almost no reason at all.  Unless the patient is at some point willing to deal with the actual issue, it is near impossible to wean a person off the medicines.  I'm still really struggling with where the line is that I'm willing to walk.

My 22month old, Roger, is a wonderful kid.  Of course, I say this as a ridiculously proud parent, but he is.  However, I have found out that his daycare does not agree.  We changed daycares about 3 months ago because I needed one closer to work.  At first he was having trouble because he started biting other kids.  I had to meet with the director of the daycare (giving me disturbing flashback to sitting in the principal's office) to discuss my son's issue.  Don't forget, my son isn't even 2 yet.  So we came up with a reward system which consisted of giving him a sticker at the end of the day if he didn't bite anyone.  And we as parents were expected to reinforce the no biting idea on a regular basis.  Despite my doubts, it worked (mostly).  He generally does not bite at daycare anylonger. 

 

Now recently, I have noticed that the other kids at daycare easily recognize me as "Roger's Mommy".  I thought this was really cute. But today, the teacher told me how Roger has begun pulling hair and pushing the other kids.  So now I'm not so sure about the recognition.  Is it because the other kids are so thankful that I'm coming to pick up my son, the bully.  I was called in again to the principal ... uh..I mean, the director's office, to discuss the issue.  Again, my son isn't even two years old yet and displaying pretty typical toddler behavior.  But apparently this is not allowed at the daycare.  My child is now on probation.  Great, not even two and my son is already a delinquent. 

 

OK.  I"m exhausted.  It seems like I can never get another sleep any longer.  Gonna go to bed now.

Today I am writing in here for the first time.  I'm not really sure what I will be doing with this blog.  Mostly for my own rantings at the end of the day.  A way to let out some frustrations without letting it affect my home life.  Working in primary care in downtown Indy can sometimes be very trying.  A lot of our patients are unemployed and uninsured and trying to find the appropriate health care for them can be difficult.

 

Today, on my way home, I passed a pickup truck w/ a sticker on the back saying:

Above the sticker, they was another sticker:  In memory of IPD officer... 

I couldn't catch the rest.  I wondered if the person in the truck still felt as angry and frustrated as the sticker communicated.  It made me think of one of my patients today.  D  is young, in her mid-twenties.  She has a child in pre-K, but recently lost a child.  The baby was born still-born the day prior to her scheduled C-section.  She was seeing a high risk OB and had an ultrasound done that morning which showed that everything was ok.  That night, she began having trouble and went to the hospital.  They couldn't find a heartbeat.  This occurred almost a year ago, and she is still trying to get through her grief.  I'm seeing her with a counselor as well.  Today she brought pictures of the baby after it was born.  She told me how she waited for 12hrs after the ultrasound before delivering the child.  Some of the pictures showed her while she was crying and it was so stark.   I almost felt like I was intruding, the pictures were so vivid.  Her grief and loss were just laid out, completely caught in the photos.  It killed me.  I rarely get truly emotional in a patient's room, but I began crying.  I have 2 kids and I can't even wrap my mind around the possibility of losing one of them.  My mind just won't go there.  And yet, I see it, not regularly, but enough.  Watching these parents, my patients, try to deal with that type of loss is excrutiating.  I have no idea what I can do to help them.

 

It's weird as I'm rounding in the hospital on the newborns right now.  Such a strange dichotomy  - to go from healthy newborns to discussing stillborns.  Being a doctor can be so strange sometimes.