Asking for directions

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I have to tell you about this chicken.

A few weeks ago, our kid’s new kindergarten BFF invited us over for a play date. BFF’s parents are far more worldly and sophisticated than we are. They speak about 72 languages combined (or something thereabouts). And they served us this CHICKEN.

The chicken was soaked in magic and rubbed with ambrosia and rolled in fairy dust, before being grilled to perfection by a team of trained unicorns, probably. We ate all the chicken we could eat, licked our plates, and then promptly proceeded to get a little obsessed. Okay, more than a little. We begged them for their secret.

As it turns out, the Secret of The Chicken involved driving just 10 minutes into the Portuguese part of town. They gave us the name of the deli-turned-restaurant and we assumed we’d be set. “Surely, they make nothing but the magic chicken! We’ll just walk in, look at the first person who makes eye contact with us, and say the word ‘chicken’. Maybe we can even add what sounds like a question mark at the end, thereby convincing them that we’re in need of their pity, and their chicken. FAILPROOF PLAN.”

What we didn’t realize is that the deli-turned-restaurant was actually some sort of wormhole/portal directly TO Portugal. The menu was entirely in Portuguese, which is close enough to Spanish to make you think your distant college-level foreign language requirement will come in handy, but just different enough to be useless. We walked in there and felt utterly lost. We sort of tried to pretend like we knew what we were doing (“Chicken?”, paired with lopsided smile and uncomfortably loud volume), but we were fooling nobody.

We went home with the wrong chicken.

I was thinking about our unfortunate Magic Chicken journey as I was reading an article about how easy it is for patients to lose their way when it comes to navigating our crazy, convoluted health care system. In summary, the author proposes that there are a few areas where patients need a little more guidance and thoughtfulness from their health care providers. His list of problem areas includes insurance coverage and cost, scheduling appointments, communication between team members, and management of transitions between care settings. In response, I say: Yes, yes, yes, and yes. All that and more.

What our patients really need is a guide. An empathetic advocate who happens to bilingual in both medical jargon and their language of choice, and who knows the geography and arcane rules of Medtopia (Healthland? Careifornia? What’s that, please stop?) that only the locals seem to know about.

My patients are pretty smart cookies (most of them). They’ve passed a bunch of tests to make it into college. They have a shelf full of participation trophies at home. And they have the consumer-based retail world down cold. But the medical world? A total mystery. All they know is that when they’re experiencing some sort of discomfort, they can come to us have it evaluated. Perhaps various tests and treatments may be ordered, and ideally that discomfort will eventually go away, maybe even because of the care they received.

But how are those tests paid for? And scheduled? Do they need to ask someone for permission first? Will their insurance pay for this prescription? Will their parents find out? How can they be sure they need these tests, and not others? Is their birth control pill considered a medication? How about that sketchy energy supplement? Donde esta la bibliotheca??

What I’m saying is, this stuff is seriously, impenetrably, mind-numbingly confusing. It’s like when my CPA tries to explain my taxes to me. Except worse. Terms like “referral” and “out-of-network” and “co-pay” and “deductible” and “crappy insurance that covers nothing” tend to cause most people to nod automatically while their eyes glaze over, until the bill arrives containing a seemingly endless string of zeros.

It’s not that we HCPs don’t know this on some level. Health literacy is the center square on Medical Buzzword Bingo (right between “shared decision making” and “medical home”). But it’s easy to get caught up in the daily hamster wheel of 20-minute appointments – hellohello, history, exam, plan and thankyouverymuch, please schedule your next appointment on your way out – and before the patient knows what’s happened yet another appointment is over, and they don’t feel any closer to understanding what’s going on inside their body than when they arrived.

So they need more than to be handed over to a dozen other different people who will each then manage a tiny fragment of their care (appointment for mammogram, desk 1. insurance questions, desk 2. specialty referral, desk 3). They need someone to be their guide – to lead them through town, explain where the important stuff is, act as translator when necessary. As their HCP, as much as it may feel overly onerous (ugh, beneath my extensive training and fabulousness, ugh), we really should be that person – especially since we did, after all, order all those tests/treatments/referrals that follow (OWN IT).

So even if this feels like yet another thing to be delegated away, it’s worth it to spend the extra minute or two at the end of your visit to be sure the patient knows their way around.

Because everyone deserves to know how to get the Magic Chicken. Everyone.

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Here’s why I care about your migraines

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I prescribe a lot of birth control. A LOT. Not surprising – over 60% of college students use The Pill as a form a birth control, and they have to get it from somewhere, right?

There are some things I have to ask about when you come to me for a pill prescription. Medical history, smoking history, menstrual history, sexual history. And I’ll ask you whether you have a history of migraines.

Common response: “Not too often” – said chirpily, almost dismissively. So…that’s a yes, then?

As you may or may not have heard, “migraine” is not synonymous with “really bad headache”. So: Step 1 for me here is to filter out the “bad headaches” from the actual migraines. Step 2 is to figure out whether the people with real migraines have migraine with aura.

If the answer is “NO” to either of those first two questions, we can stop talking about them. And please, keep in mind that I’m not dismissing or minimizing the burden that headaches place on your life here. Headaches are super lame, I couldn’t agree more. I’m no fan of headaches myself! Moreover, I’m sure yours are terrible.

But you didn’t come here today to talk about your headaches, right?

The reason I’m asking is because if you keep answering “yes” through steps 1 and 2, and if I then verify that what you’re describing as “aura” before your migraines are, in fact, aura, there’s a very good chance you won’t be leaving with that prescription refill today.

Why? Oh, only because every organization with a vested interest in either headaches or contraception has issued statement after statement that combined oral contraceptives are absolutely contraindicated for women who get migraines with aura. Contraindicated means DO NOT PRESCRIBE.

If you’re coming to see me to talk about starting birth control for the first time, this is typically not major news. You weren’t particularly attached to the pill, anyhow. And IUDs sound pretty good, now that I mention it. Or maybe even Depo! Who wants to have to take a pill every day, anyhow? Such a pain. What I’m saying is, you’re usually more open to options if you haven’t already fallen in love with your current method.

But when you’re like the girl I just saw today, who has been getting migraines with aura since high school, and who has been ON THE PILL since high school – both which were managed by her beloved family pediatrician/PCP/gynecologist – you’re going to look at me like I just grew a second head when I talk to you about stopping the pill. And since you’ve always felt that they really shouldn’t be giving prescription-writing licenses to people with two heads (which seems more than a little unfair, btw) I am clearly unfit to give medical advice.

Look. I’m not trying to find excuses to not give you your birth control. In fact, I was more than happy to step right in and refill your prescription when your provider at home refused just because you hadn’t come in for that yearly-pap-you-don’t-really-need. I’m all about talking up IUDs for young adults to anyone who will listen. I’m really, truly, enthusiastically pro-contraception-for-all. But I can’t just un-read the piles of medical evidence that tell me that continuing your estrogen-containing contraceptive pill puts you at an uncomfortably high risk of stroke. Really, you’re a healthy 20-year-old. There are essentially zero reasons why you should be having a stroke. And I don’t want to be the provider that gives you one.

Why has no one ever mentioned this to you before, you ask?

This is a good question. One that, perhaps, you should be asking them.

In fact, in all seriousness, I really would like to ask them myself. And if they can show me the evidence base that supports their statement to you that staying on the pill “should be fine” (sounds convincing), I would be happy to reconsider my position.

Until then, if you’re open to it, I’d be delighted to talk to you about the wide, wonderful world of non-estrogen-containing contraception. LET’S TALK.

HIPAA Fail

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Everyone knows what HIPAA is, right?

“Uh, yeah, obvs. It’s that law that means anything and everything about my medical record is totally confidential. I may not know anything about the ACA, because let’s face it, that thing’s completely impenetrable, but I know all about HIPPA. Starting with the fact that you spelled it wrong. Two Ps. Like hippo. I’m pretty sure about that one.”

Okay. First of all, it’s the Health Care Portability and Accountability Act. One P and two As. Check it.

Beyond that, you’re basically right. It does some other stuff that no one ever remembers about not losing your insurance when you change jobs, but mostly it’s about privacy.

Unless you’re a young adult covered by your parents’ health insurance.

Now your chart, the medical record in your health care provider’s office where we write down all the details about your visits and file your lab results and whatnot, IS protected. So when you come see me about starting birth control, our entire convo about how your boyfriend really doesn’t like condoms and you’re afraid you’ll have trouble remembering to take a pill every day and btw there was that oops/hookup with your ex last weekend… all that stays inside the walls of our clinic, unless you specifically request we send it over to someone else.

But as soon as you use your health insurance to pick up the prescription I gave you, or to get the STI test I gently yet firmly recommended (c’mon, you know it was overdue), there’s a chance your parents could find out. Why?  Because of this obnoxious little thing called the Explanation of Benefits.

Here’s what happens: your health insurance provider pays for some sort of service related to your medical care – a lab test, a prescription, an imaging study, a clinical visit, whatever. Then, because the insurance company wants to justify its existence with whoever pays the premium every month, they send that person an EOB to detail all the stuff that they’ve paid for. The EOB doesn’t include test results, but it may include the name of the test performed.

I’ll be honest. I never really look at my EOB. Probably because it looks too much like a bill for my comfort, and bills stress me out, so I usually decide it’s best just to pretend it doesn’t exist. I know. Mature. But say what you will, the decision to ignore that EOB is mine to make. (Before you get all judgey on me, remember: not actually a bill.)

Not everyone is as chill about their EOBs as I am. Let’s say, for example, that you’re an anxious mom of a college freshman. After 18 years of micromanaging every moment of your child’s life, you’re having trouble letting go. You spend your weekends driving to campus and hand-delivering care packages of tissues and snack packs. So when an EOB for services rendered to the youngest enrollee on your family insurance plan arrives in the mail, chances are good you’re going to pay attention. And if that EOB uses words like “CHLAMYDIA/GC DNA PROBE” and “HIV ANTIBODY”, well, now you’re really paying attention. Cue the frantic call to your technically-an-adult child, forcing that awkward conversation that you’ve both been avoiding since s/he was in middle school (and is probably way too late for anyhow).

If you were the timid college freshman with the neurotic mom and you thought there was even a slim chance of this scenario playing out, would you make that appointment? Of course not! Everyone knows your mom is CRAZY. And you know she’ll tell your dad. And then he’ll give you that LOOK when you’re home for Thanksgiving break. Like something fundamental has changed about the way he sees you.

No thanks. Besides, you feel fine, you probably don’t need that STI test anyhow. And condoms aren’t so bad, even if you have trouble using them 100%…70%…50% of the time. Or ever.

See what I’m saying here?  This is a problem.

Keep in mind that because of the ACA, you can now stay on your parents’ plan until you’re 26. Great news for all those recent college grads still looking for a halfway-decent job that comes with benefits, since your parents’ insurance is way better than no insurance at all. And yet: even though you retired your fake ID years ago and can spend your meager entry-level paycheck on overpriced drinks at the bar like the rest of us, your parents still get to know every time a strep test, chest x-ray, or STD TEST is performed.

As you can imagine, your more thoughtful college health providers (AHEM) will have a few workarounds for you: directions to the pharmacies with cheap-o generic pills, negotiated rates for paid-up-front STI tests with the lab company. But not everyone has these options. And remember, these are people WITH INSURANCE – they shouldn’t NEED access to super-low-cost health care services.

The good news is, HIPAA has a way around this, but you have to know about it. And it takes a little effort. But it’s worth it.

What you need to do is call your health insurance company, as well as any health care providers/hospitals/labs where you’ve been receiving care, and ask them to send all the bills and EOBs TO YOU. If the uninformed lady on the other end of the line says she’s not sure she can do that, you just tell her that HIPAA says so. Because it does. (You’re allowed to use a snotty voice here.)

But if you do this, you have be willing to put in a little extra work. You need to remember to call them whenever you change your address, or cell phone number, or email address. Actually setting up your voice mail might be a good idea too. (Just saying.) And you can’t ignore the bills that keep getting sent to you. Even though it sounds like a lot of effort, I promise it’ll be worth it, since it means that you can finally feel comfortable accessing any and all of the health care services that your hefty insurance premiums entitle you to.

And to my fellow college health providers: let’s be proactive about this. Create a policy, handouts, cheat sheet talking points, whatever it takes to make sure our patients are informed about their right to keep their most intimate health care secrets away from their nosy family, so they can get back to using their health insurance to pay for the kind of health care they need the most: contraception and chlamydia tests.

The trouble with “supervision”

Nurses Pulling During Tug of War Competition

I’m a nurse practitioner, or NP. You may have heard of my kind.

We come up a lot in the media these days. Maybe it’s because NPs are going to save health care by filling the looming provider gap. Or because we’re going to ruin health care by filling that provider gap with undertrained, incompetent clinicians. MAYBE BOTH.

The volume’s been turned up lately on this line of dialogue because of the looming full implementation of the Affordable Care Act. Apparently, NPs* will either be the salvation or the undoing of the ACA, with its flood of new patients demanding health care services. As if there were millions of people who didn’t exist previously, and the ACA has willed them into existence. Even though I’m pretty sure it doesn’t extend coverage to zombies. If so, my apologies. The backlash makes a lot more sense now.

It could also be because it’s more likely than ever that you’ve seen one of us as your very own health care provider at some point. After all, there are 171,000 of us in practice here in the U.S. In fact, I’m willing to bet it’s 50/50 whether that inappropriate antibiotic prescription you got last week for your cold – oh, I’m sorry, bronchitis – came from an MD or an NP.

What I’m saying is, we’re everywhere. And once we’re in practice, we’re really not all that different from physicians when it comes to delivering primary care.

THAT’S RIGHT. I SAID IT.

People in the “NPs need constant supervision, like small children – I’ve definitely seen them eating paste and coloring outside the lines and misdiagnosing and over-referring to specialists WITH MY OWN EYES” camp seem unwilling to admit that there are some pretty mediocre-to-lousy physicians out there too. Everyone makes mistakes; some people make them more often than others.

And people on the “NPs are sunshine and light and won’t kick your puppy on their way to a golf game after dismissing your puny concerns about your blood pressure” side are hesitant to admit that there are plenty of cold, rushed, and/or unpleasant NPs out there too.

What I’m saying is, we’re all just people.

Which is why I sort of hate the heated debate over the question of MD supervision of NPs, which is what every legislative battle over NP practice has been about since the profession came into existence. As a recap for those who might be unfamiliar with this concept, according to The Law, NPs can work with varying degrees of independence from physicians, depending entirely on the state where they’re licensed. In most states, NP practice is either completely independent or is expected to exist in “collaboration” with medicine, but in 12 states, your practice needs to be “supervised” by an MD. See how I put “supervised” in quotes there? Not an accident.

Now obviously, the very idea of mandating the supervision of an independently-licensed professional is somewhat condescending, but it’s also misleading. The phrase “MD supervision” suggests a physician peering over my shoulder constantly, wearing a hand-knotted white coat and one of those hats with the light on the front, checking all of my notes and prescriptions and probably reexamining my patients to ensure a certain level of quality of care.

This NEVER HAPPENS. Not even close.

When I’m caring for a patient, it’s just me and that patient in the room. I examine them. I diagnose them. And then: I write the prescriptions, and the note, using my name and my license. The only place my supervising physician’s name comes up on a daily basis is as an automatic attachment to each of my prescriptions – which, if you think about it, is kind of unfair to that MD, who was completely powerless over the decision to write it.

And yet, I can’t imagine practicing medicine (because let’s just be honest for a second, that’s what NPs are doing) in the vacuum of my own mind. I need to be able to walk out of that exam room and run a challenging clinical scenario by a trusted peer, whether that peer is an MD or an NP. I need to be able to collaborate with other providers, because collaboration makes everyone’s practice stronger. Whether I’m trying to decide if I should send a patient with probably-nothing-but-maybe-a-PE chest pain to the ED and want to run it by my MD officemate, or the physician down the hall comes to me for advice on managing abnormal vaginal bleeding in a patient who just started the pill, collaboration goes both ways.

I was reading an article today by a woman who left medicine because she just couldn’t deal with the pressure – the constant worry over “did I make the right call?” or “did I write the right dose?” or, ultimately, “will the patient get better or worse because of my care?” I, and every single clinician I know – regardless of their educational background or the letters at the end of their name – feel exactly the same way, all the time.

So when I hear about some new legislation to restrict or extend MD supervision of NP practice, my first (lazier) thought is to say, Well, this doesn’t really apply to me. I don’t particularly want to “hang my own shingle” anyhow. Thanks, but I’ll just keep reading HuffPo and watching the Real Housewives marathon instead of writing that letter to my state rep about HB29378130sdi293832b.

But writing that letter matters. And it doesn’t matter because I want to take a job away from a deserving physician, or because I plan to open my own practice, or BECAUSE SOCIALISM. I just want The Law that describes what I can and can’t do to reflect reality.

And if your provider is still eating paste, whether they have NP or MD after their name, I think we can all agree that they’re the ones that need a little more supervision.

*I don’t take the time to mention PAs here nearly as much as I should. But I would apply pretty much everything I said here about NPs to PAs as well. And on that note: is Physician Assistant not the most inappropriate name ever for what you do? It is absurd that your name wasn’t changed to Physician Associate years ago. You guys should get on that.

Identity crisis

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I’m pretty sure that for just about anyone who’s worked anywhere, ever, a favorite water cooler or dinner party topic is how busy everyone always is. “How’s work?” “Oh, you know…busy.” Followed by a deep sigh of exhaustion, as if to say “I DARE you to top my inhuman level of busy-ness. I mean, seriously. Most mortals would be crushed under the weight of my workload.”

So maybe take what I’m about to say with a grain of salt.

I work at a college health clinic. It’s October. It’s busy. Crazy busy. It’s pretty much nonstop busy from September through May, minus a couple of holiday-related slowdowns. And because we’re human beings and have a vested interest in preserving our own sanity, conversations among the clinicians at work frequently veer into the the realm of trying to find ways to decrease demand for clinical services. Meaning, get the students to stop coming to see us quite as often as they do now.

There are several ways to decrease demand:

1) Be really lousy at your job. Be unfriendly; give crappy advice; deliver unwarranted lectures on personal responsibility when your patient just wants Plan B. The more you suck, the more likely it is that word will spread about the poor quality of care available at the student health center, and the less likely it is that students will ask to be seen, leaving you more time to online-shop for the holidays. BAD IDEA NUMBER ONE.

2) Turn people away when your schedule is full. On the surface, sounds reasonable. This is how most of the non-ERs of the world match supply with demand. And speaking of them, there are several hospitals with high-quality ERs nearby. But take my word for it when I say that all it takes is one or two letters to the president from well-connected, pissed-off parents to make this BAD IDEA NUMBER TWO.

Now we start to veer into the realm of magical thinking…

3) Make it so that people get sick less. Aside from giving out free flu shots (done) there’s not a lot we can do here without a really fancy magic wand. The vaccines against colds, lacerations and pregnancy remain in development. Fantastic but impossible and therefore BAD IDEA NUMBER THREE.

4) Teach the students how to take care of minor complaints on their own, without coming to see us. In other words, ask them to be fully mature, self-sufficient adults, with the life experience that allows them to already know what to do when they get a runny nose, or get a little scraped up falling off their skateboard, or burn their hand on an over-microwaved slice of pizza last night.

“Can you believe the things these kids come in here with? I would never IMAGINE going to see my health care provider for something like that!”

OF COURSE YOU WOULDN’T. You’re a middle-aged adult. You have kids of your own. And you’re also a health care provider yourself, BTW, which gives you an unfair advantage.

I’ll be honest. I’m not immune. Last week a kid came in to see me because he was afraid he could have gotten rabies from eating a sandwich made with a slice of bread that shared a loaf that MAY have been nibbled on by a mouse. I’m not making this up.

But therein lies the dilemma. What is college health? Why do we exist? Are we an urgent care center, one step above advice from the CVS pharmacist (and/or Google) and one step below an ED? A quasi-Planned Parenthood, meeting all your contraception and STI-related needs? A primary care provider creating a medical home-away-from-home for young adults? Dispenser of free condoms and hand sanitizer? Host of awkward health promotion talks that nobody attends besides the health science students?

YES.

But we’re even more than that.

I had a minor epiphany a few weeks ago while I was dropping off my kid’s immunization record at the school nurse’s office. Two little girls, I’m guessing 3rd or 4th graders (which made them look like GIANTS next to my tiny kindergartener), ran into the office. One of them had fallen down on the playground. She’d scraped her hand. Classic palmar concrete burn. The nurse leans over the desk, glances at the hand, and sends her over to the sink to wash it off, then gives her a colorful band-aid and a baggie full of ice.

If that school nurse spends her days complaining about the kids coming into her office for minor abrasions, then she’s in the wrong line of work.

Your average college student may look like a fully formed grown-up, but in many ways, s/he’s not. Until now, if they’ve experienced physical discomfort, they’d go tell someone about it. That person takes care of it for them. Maybe that person is Mom or Dad. Maybe, if the discomfort happens at school, it’s the school nurse.

Our patients are really only one overly-long high school graduation ceremony removed from this earlier, easier stage of their lives. They’ve entered that awkward phase of life where technically, and according to the U.S. military and casinos everywhere, they’re adults. Yet they still have a pediatrician as their PCP. And they still need someone to help them figure out what to do when they fall down on the playground. (The playground is just a little larger now. AND FULL OF HERPES.) (Just kidding.) (Sort of.)

So the thing is, we need to be that, too. Whether we like it or not, we’re as much school nurse as we are urgent care or PCP. College health centers need clinicians with a higher level of training than your average school nurse, since our patients are also busy becoming professional insomniacs, and swimming in giardia-infested water holes in Nicaragua, and having lots of unprotected sex on spring break in Punta Cana, and spreading strep and norovirus around campus like wildfire. But at the same time, our patients still need someone to show them how to wash the gravel off their hand and cover the ouchie with a band-aid. Because next time, maybe they’ll find the sink themselves.

If we spend all our time complaining about it, we’re in the wrong line of work.

Identity crisis

20140215-133918.jpg

I’m pretty sure that for just about anyone who’s worked anywhere, ever, a favorite water cooler or dinner party topic is how busy everyone always is. “How’s work?” “Oh, you know…busy.” Followed by a deep sigh of exhaustion, as if to say “I DARE you to top my inhuman level of busy-ness. I mean, seriously. Most mortals would be crushed under the weight of my workload.”

So maybe take what I’m about to say with a grain of salt.

I work at a college health clinic. It’s October. It’s busy. Crazy busy. It’s pretty much nonstop busy from September through May, minus a couple of holiday-related slowdowns. And because we’re human beings and have a vested interest in preserving our own sanity, conversations among the clinicians at work frequently veer into the the realm of trying to find ways to decrease demand for clinical services. Meaning, get the students to stop coming to see us quite as often as they do now.

There are several ways to decrease demand:

1) Be really lousy at your job. Be unfriendly; give crappy advice; deliver unwarranted lectures on personal responsibility when your patient just wants Plan B. The more you suck, the more likely it is that word will spread about the poor quality of care available at the student health center, and the less likely it is that students will ask to be seen, leaving you more time to online-shop for the holidays. BAD IDEA NUMBER ONE.

2) Turn people away when your schedule is full. On the surface, sounds reasonable. This is how most of the non-ERs of the world match supply with demand. And speaking of them, there are several hospitals with high-quality ERs nearby. But take my word for it when I say that all it takes is one or two letters to the president from well-connected, pissed-off parents to make this BAD IDEA NUMBER TWO.

Now we start to veer into the realm of magical thinking…

3) Make it so that people get sick less. Aside from giving out free flu shots (done) there’s not a lot we can do here without a really fancy magic wand. The vaccines against colds, lacerations and pregnancy remain in development. Fantastic but impossible and therefore BAD IDEA NUMBER THREE.

4) Teach the students how to take care of minor complaints on their own, without coming to see us. In other words, ask them to be fully mature, self-sufficient adults, with the life experience that allows them to already know what to do when they get a runny nose, or get a little scraped up falling off their skateboard, or burn their hand on an over-microwaved slice of pizza last night.

“Can you believe the things these kids come in here with? I would never IMAGINE going to see my health care provider for something like that!”

OF COURSE YOU WOULDN’T. You’re a middle-aged adult. You have kids of your own. And you’re also a health care provider yourself, BTW, which gives you an unfair advantage.

I’ll be honest. I’m not immune. Last week a kid came in to see me because he was afraid he could have gotten rabies from eating a sandwich made with a slice of bread that shared a loaf that MAY have been nibbled on by a mouse. I’m not making this up.

But therein lies the dilemma. What is college health? Why do we exist? Are we an urgent care center, one step above advice from the CVS pharmacist (and/or Google) and one step below an ED? A quasi-Planned Parenthood, meeting all your contraception and STI-related needs? A primary care provider creating a medical home-away-from-home for young adults? Dispenser of free condoms and hand sanitizer? Host of awkward health promotion talks that nobody attends besides the health science students?

YES.

But we’re even more than that.

I had a minor epiphany a few weeks ago while I was dropping off my kid’s immunization record at the school nurse’s office. Two little girls, I’m guessing 3rd or 4th graders (which made them look like GIANTS next to my tiny kindergartener), ran into the office. One of them had fallen down on the playground. She’d scraped her hand. Classic palmar concrete burn. The nurse leans over the desk, glances at the hand, and sends her over to the sink to wash it off, then gives her a colorful band-aid and a baggie full of ice.

If that school nurse spends her days complaining about the kids coming into her office for minor abrasions, then she’s in the wrong line of work.

Your average college student may look like a fully formed grown-up, but in many ways, s/he’s not. Until now, if they’ve experienced physical discomfort, they’d go tell someone about it. That person takes care of it for them. Maybe that person is Mom or Dad. Maybe, if the discomfort happens at school, it’s the school nurse.

Our patients are really only one overly-long high school graduation ceremony removed from this earlier, easier stage of their lives. They’ve entered that awkward phase of life where technically, and according to the U.S. military and casinos everywhere, they’re adults. Yet they still have a pediatrician as their PCP. And they still need someone to help them figure out what to do when they fall down on the playground. (The playground is just a little larger now. AND FULL OF HERPES.) (Just kidding.) (Sort of.)

So the thing is, we need to be that, too. Whether we like it or not, we’re as much school nurse as we are urgent care or PCP. College health centers need clinicians with a higher level of training than your average school nurse, since our patients are also busy becoming professional insomniacs, and swimming in giardia-infested water holes in Nicaragua, and having lots of unprotected sex on spring break in Punta Cana, and spreading strep and norovirus around campus like wildfire. But at the same time, our patients still need someone to show them how to wash the gravel off their hand and cover the ouchie with a band-aid. Because next time, maybe they’ll find the sink themselves.

If we spend all our time complaining about it, we’re in the wrong line of work.

This is why you’re tired

Fatigue. One of my very favorite complaints. Right up there with dizziness.

Let me preface this by saying that if you’re 80-something with an 8-10 page medical history and you’re coming in to be evaluated for a recent onset of fatigue and/or dizziness, you have my attention.

But you are not my patient. (Unless going back to school and spending the rest of your retirement and reverse mortgage on university tuition was on your bucket list.) No, my patient is generally somewhere between 18 and 22 and has a negative medical history. As in, completely negative. I ask if they’ve ever had any significant medical problems, EVER, and the answer is no. (With a quizzical look. As if to say, what, people actually have those?)

But they’re always absolutely certain there’s a medical reason they’re feeling tired. A “serious” reason. Maybe it’s mono. Maybe it’s their thyroid! Dr. Google and/or their parents know all about the thyroid.

I’ll order some labs – since, let’s be honest, that’s really why they’re there – but unless they have some other, more (cough) substantial symptoms, the labs will nearly always be normal. But of course they were. After 5 minutes of talking to them, I knew why they’re tired.

Here’s the thing. Teens and young adults are notoriously terribly to their bodies. They drink like fishes, and eat nothing but fried chemicals shaped like food, and fall off things, either at high speeds or from great distances.

But eventually, it catches up with you. I KNOW. IT SUCKS. If you’d like to file a complaint with the universe, I’d totally understand. But your body can’t remain your personal punching bag forever. Eventually, it starts to fight back. And it fights dirty. Like, street dirty.

You can’t blame it. It’s acting in its own self defense. Since you clearly can’t be trusted to allow for adequate sleepy time voluntarily, you body will shut. it. down. until even the thought of pulling on your mini and heels for another night out with the girls makes you want to curl up in your floral comforter and cry quiet tears of exhaustion.

This is not pathology. This is your body acting perfectly rationally to ensure its own survival well into and beyond middle age – or at least long enough to earn its own 8-10 page medical history.

My recommendation:
You’re tired? GET MORE SLEEP.