When “good” isn’t good enough

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Dear parents-of-college-students: before you decline your kid’s college health insurance plan because you have “good insurance”, please check to make sure that “good” will be good enough.

Recently, a patient came to see me with a history of recurrent ovarian cysts. She presented her story like it was old news, since this has been happening to her since she was 14 – or in other words, since well before she left the comfort of her parents’ home for the big wide world of college.

Her issue is that three or four times a year, she experiences what she describes as several weeks of progressively intense unilateral lower abdominal pain, culminating in severe pain (which she assumes is from a cyst rupturing) that eventually resolves on its own, with the help of lots of pain meds and missed class. 

Generally speaking, she manages things on her own, but yesterday, the pain was worse than usual. Her prescription NSAID wasn’t cutting it. She’d missed a midterm. I had a few questions: who does she normally see for this? When was the last time she’d had a pelvic ultrasound or any other imaging? Was there a plan to change her birth control pill, which she was ostensibly taking to keep things like this from happening? Was it time to dig a little deeper, to see if maybe something else was going on?

Well. It turns out that she hasn’t seen a health care provider (besides our college clinic) in years. Why? Because she grew up in New York. Her parents continue to live, and work, in New York. Their insurance allows her to be seen by providers in New York, and to have labs, and imaging, and procedures, and pretty much anything medically-related she might ever need, in New York. I’m sure it’s very “good” insurance – in New York.

If she actually lived in New York, well, that would be just fine, wouldn’t it?

BUT SHE DOESN’T.

I know, I know. Parents have a hard time thinking of their grown-up kids as no longer living with them. Sure, they’re away at school, but that’s just temporary. Their permanent address is still here with us, at home, right?

Hold up. If your college kid wants to keep listing your house as their permanent address while they’re bouncing around between dorms, sublets, and friends’ couches, living the typically transient life of an undergrad, that’s all well and good (after all, those parking tickets have to be sent somewhere).

But they need to have medical coverage in the place where their physical body actually spends the most time. If you live in California, but your daughter goes to school in Arizona, the place she needs coverage is Arizona.

You might be thinking something like this:

“I’m not worried. We just schedule her routine care while she’s home on break.”

Great, but what if she needs care that’s non-routine? What if something happens in the middle of the semester that might not meet criteria for being rushed to the ER, but really warrants being evaluated by a gastroenterologist, or a cardiologist, or whatever-ologist this week or the next, rather than months from now when she happens to have a few days off from school?

And what about that time – that not-too-distant time – when she stops coming home every summer or spring break? When she gets an internship, or a part-time job, or decides to take classes over the summer? How do you expect her to be able to get even routine, preventative health care if her insurance doesn’t allow her to have Pap tests performed in the state where she lives 95% of the time?

“Well, our insurance is pretty good. I’m sure she’ll be covered.”

Really? You might be surprised. One way that insurance companies trim costs is to limit where you can access care, so even if you’ve been pleased as punch with your plan’s low co-pays, and local provider network, and coverage for fun stuff like acupuncture, you can’t assume it covers anything beyond emergency care once you – or your dependents – leave the state.

Back to my patient from New York. Our options were limited to this: ER or no ER, since emergency care is all that her plan covers here in the state of Not-New-York. Beyond bringing her to an ER, my hands were tied – I couldn’t run labs; I couldn’t order an ultrasound.

Even though she was in pain, she didn’t want to miss yet another midterm. So against medical advice, she refused to allow us to transport her to the ER down the road, and instead returned to her dorm room, clutching her lower right side, with strict instructions to call the campus police to bring her to the hospital if things got worse overnight.

Had I been these parents, had this been my daughter, I would NOT be okay with this state of affairs. I would insist that we find a plan somewhere, somehow, that allows my daughter to access medical care where she actually lives. And I would insist a whole lot harder if she had a chronic or recurrent medical condition.

If, despite my best efforts, I couldn’t find a plan for our entire family with decent in-state and out-of-state coverage, I’d look really, really closely at the plan offered by my daughter’s college before checking the little “waive school insurance” box hidden somewhere within all that orientation paperwork.

So. My humble request to the college parents of America is this: if you’re planning on waiving out of the health plan they’re offering through your kid’s school, please, please, PLEASE read the fine print, or pick up the phone and sit through the terrible hold music until you get a human being to talk to, and find out whether your plan covers medical care – specialists, labs, imaging, etc. – in the state your child is about to move to.

Those insurance premiums aren’t cheap. So make sure they’ll pay for the care your family actually needs.

One hot potato

20140221-182240.jpgI love science.

Today, Dr. Awesome*, myself, and an NP student were discussing something called “hot potato voice” – specifically, whether use of the term is limited to patients with peritonsillar abscess, or could also be used to describe patients with particularly gnarly cases of tonsillitis.

Imagine you decided to stick a few jumbo-sized marbles in the back of your mouth.

Or, if you will, a potato. Maybe even a hot one.

Then, imagine yourself trying to pretend like there’s nothing amiss when your friend, mom, the cashier at Starbucks, whoever decides to chat you up about the weather.

Not so easy, right?

Trying to talk when you have one or two enormous, angry tonsils sounds kind of like that. (Except with more pain and sadness.)

For some reason, at some point in time**, the term “hot potato voice” started being used to describe this super special sound. So much so that nowadays, it’s just one of those things health care providers do without thinking much about it.

As NP Student and myself are going back and forth with some uninspiring blahblahblah, Dr. Awesome consults Dr. Google and finds this:

Mahmood F. Bhutta, George A. Worley, Meredydd L. Harries (2006). “Hot Potato Voice” in Peritonsillitis: A Misnomer. J Voice, 20:4, pp 616-622.

I love everything about this.

I love that someone was sitting in their office one day and said, “What is UP with ‘hot potato voice’? Puh-lease! I’d bet good money (that I don’t have, since I’m a voice researcher) that someone with an ACTUAL hot potato in their mouth wouldn’t sound anything like these people with peritonsillitis.”

I love that this person didn’t let their contempt for “hot potato voice” end there, and instead started digging through the existing literature to discover that WHAT!? Has NO ONE bothered to prove what people with actual hot potatoes in their mouths sound like??

Sounds like a knowledge gap right there! IRB TIME.

Next thing you know, you’re taping and analyzing and comparing voice recordings of people with peritonsillitis with those of healthy subjects (aka you and your pals from the lab, who are presumably as amused by all this as you are) holding whole microwaved potatoes in the back of their mouths.

Et voila. Legit, published, peer-reviewed research proving that you were right all along. NOT THE SAME. (Drops mic, walks away.)

Thank you, hot potato skeptic. Thank you for making my day, WAIT NO my entire existence, a little brighter.

*not her real name. BUT IT SHOULD BE.

**disclaimer: not a medical historian. Clearly.

Let’s talk about…

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Did you know that 1/3 of all routine health maintenance visits with teens don’t include ANY discussion of sex or sexual health? Like, NONE?

And in those visits that do, the conversation lasts an average of 36 seconds?

I’ve been told I’m a fast talker. But if I tried to cram everything sex-related that I wanted to talk about into 36 seconds, I’d sound like an auctioneer on Adderall – and I’d STILL be providing my patients with lousy and inadequate counseling about their sexual health.

So, health care providers, what’s the deal? Don’t pretend it doesn’t occur to you that your teen patients might be having, or at least be thinking (constantly) about having, sex. It hasn’t been THAT long since you were a hormone-fueled adolescent yourself, has it?

Nope. Providers aren’t avoiding The Talk because it doesn’t occur to them. They’re avoiding it because it feels uncomfortable. The sense that you’re asking someone you barely know to discuss the most intimate details of their life feels vaguely icky. Far easier to ask a few general questions about how your patient has been feeling, chat about their plans for the summer, maybe (just maybe) ask about smoking, sign a few forms for school and send them on their way.

It used to make me feel uncomfortable too. But changing the way I thought about taking a sexual history and talking about sexual health with patients made things a little easier.

1) First of all: Get over it. You need to get used to talking sex with your patients. ESPECIALLY if you’re caring for teens and young adults. There’s just no way to do this job well without it. I’m not saying you should feel like you have to talk condoms with every patient who comes to see you about their runny nose… but you and I both know your patients are coming to you with more than runny noses.

2) Create a little script for yourself. Practice it. The less time you spend in the visit fishing around in the dark abyss in your mind for the next question, the less opportunity there is for the awkwardness to expand and grow to fill the void left by your silence. Know that the more you do it, the easier it gets. Pinky swear.

3) You may think that the fact that your patient isn’t bringing it up means they don’t want to talk about it. Unlikely. More likely, they’re feeling just as uncomfortable as you are, yet they also have a million sex-related questions and thoughts and worries, and they’re just waiting for an excuse to pretend to reluctantly be dragged into a conversation about it.

4) From your perspective, you’re asking about morbidity and risk factors: exposure, prophylaxis, pregnancy risk, infection risk, symptoms. But think about it from the patient’s perspective: what you’re really asking about is relationships. The guy who asked them out once and texts every once in awhile just to keep them hanging on. The girl they dated for a whole semester until they broke up, and now she’s dating your best friend…but they might have hooked up again that one time a few weeks ago. Framing the history as a series of stories allows your patient to tell you what’s going on in a familiar language, as well as providing you with context that you just won’t get with a few yes or no answers.

5) The more presumptuous and judgey the questions (“You’re using condoms, right?”), the less likely it is that you’ll get the full story, or that your counseling will make much of an impact. Is actively shutting down an open, honest conversation actually worse than no attempt at all? Well, probably not. But this isn’t a race for the bottom. (No pun intended.) You can do better.

Any other suggestions? Were you as surprised as I was by the results of this study? What do you think we can do as health care providers to improve these numbers?

More than an absence of No

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The chief complaint varies: “STI testing”, “pregnancy test”, “GYN problem”. It’s not until I enter the exam room and see my patient, eyes downcast and voice in a near-whisper, that the real reason for the visit becomes clear.

Apparently, it continues to be open season on questioning the legitimacy of the sexual assault epidemic. This time, it was the Wall Street Journal that decided the world needed yet another article blaming women for their own rape. So brave, WSJ! It’s about time someone stood up for those poor accused assailants.

I mean, it’s not like assault survivors have had their trauma minimized and dismissed for years – er, decades – wait, no, EONS now or anything. “She was drunk, so she was asking for it” is today’s “she was wearing a short skirt, so she was asking for it”, which is really just another version of “she’s female, so she’s always, somehow, asking for it”.

In case you missed it, the numbers around rape in college are pretty insane: approximately 1 out of every 4 to 5 college women will experience sexual assault at some point while they’re in school. Numbers like this are hard to ignore; a incidence rate of 20-25% must meet epidemic criteria by pretty much anyone’s standards. But rather than saying “holy crap, we need to do something about this”, some people prefer to respond to these numbers by questioning their legitimacy, citing evidence that assaults involving college students often involve alcohol — ergo and therefore = not-rape.

If you’re one of these people, a question: have you, or anyone you know, ever actually been to college? You know, that place where day-that-ends-in-Y is cause for celebratory drinking? Where the next generation’s ingenuity is expressed through the laborious construction of elaborate snow-carved beer pong tables? Where it’s often harder to find an event WITHOUT alcohol involved than with?

In other words, yeah, binge drinking in college is a legit problem. I’ve seen more injured wrists and broken collarbones than I’d care to admit due to the ubiquitousness of college alcohol use. But part of being a young adult living on your own for the first time sometimes means figuring things out the hard way – like how to consume alcohol responsibly, without the puking and blackouts. Today’s monster hangover paves the way for tomorrow’s dignified glass of Malbec (or three) with dinner. We’ve all been there. I know I have.

Which is why I see myself in the eyes of my patients. The ones who come to the clinic after a night where yeah, maybe they had too much to drink, but that didn’t mean they planned, or deserved, to wake up too-early the next morning, dawn not quite ready to breach the horizon, in an unfamiliar room, clothes and hours unaccounted for. In pain.

There is no amount of alcohol, no level of intoxication, that justifies assault.

If you think that the real epidemic is one of morning-after-regret-turned-false-accusations, spend some time with me at work. Look in my patients’ eyes as they struggle to tell their stories. And know that you, and others like you, are part of the reason that most of them will never file a formal report, no matter how many ways I talk to them about their rights, and resources, and recourse. All they can handle, in that moment, is a modicum of damage control: please, just tell me what I can do, what I need to do, to be okay.

Today, all I can offer is damage control – antibiotics, EC, labs, lots of counseling. But tomorrow, I’m hoping for more. I’m hoping I’ll stop waking up to rape apologia in the mainstream news. I’m hoping that the socially accepted definition of consent will shift from an absence of “no” to an enthusiastic “YES!”

Because eventually, I’m hoping that the gradual elimination of rape culture (eternal optimist that I am) will mean that I get to spend more time focusing on the more mundane aspects of a career in college health: strep tests, ankle sprains and contraception.

Fake it till you make it

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Last weekend, I found myself at my first sample sale.

Apparently, there’s this clothing brand out of the UK called Boden, which, as far as I can tell, makes very nice, very pricey clothes for your most well-dressed aunt. The young, cool aunt – the one with a successful boutique business doing something lucrative enough to afford a fabulous, crave-worthy condo and a closet full of, well, Boden.

I shop the clearance racks at Target and H&M. Maybe Loft, but only if I’m feeling a little spendy. So how did I find myself at the back of a mile-long line waiting to file into a convention center filled with communal dressing rooms, aggressively sharp elbows, and piles of off-season fashion?

I blame obstetrics.

*****

Before I’d even started nursing school, I had the idea bouncing around somewhere in the back of my mind that I might want to teach someday. I like talking, I like people, I like the idea of sharing my deep and vast knowledge about the secrets of nursing with the next generation of nurslings. It’s not like I’d actually acquired this deep and vast knowledge at the time I was telling myself all this, but I was confident it was on its way.

And then before I knew it, there I was, a newly minted health care provider, with a license and prescriptive authority and a raging case of imposter syndrome. I’d put on my white coat and grab my stethoscope and bluster into an exam room with a confident smile, certain that any minute now someone was going to figure out that I didn’t belong.

There was no way in hell I felt ready to teach. I barely felt ready to go to work every day.

Thankfully, spending a few years actually working as an actual nurse practitioner does wonders for treating imposter syndrome, and eventually, I felt legit enough that I agreed to start precepting NP students. Precepting is kind of like dipping your toes in the shallowest wading pool at the water slide park of nursing education. You don’t even really need to be wearing a bathing suit. All you’re really doing is explaining why you’re doing what you’re doing with the patients you’d be seeing whether you had a student with you or not.

Don’t get me wrong, the clinical placement is in many ways the crux of the whole learning experience for the student. It’s super important. Check. But for the preceptor? Your expertise is only expected to encompass the stuff you already do every day. Easy peasy.

So when one of the nursing schools I’ve been working with asked me if I wanted to teach a clinical seminar, I thought, you know what? I’m pretty decent as a preceptor. How much harder could teaching a real, live, in-person class be? Nah, I got this. Let’s go.

But it wasn’t until I started really preparing for this class that I realized one of the problems with for-real teaching: you don’t get to only teach the stuff you know and like the best. My class of women’s health NP students wouldn’t be expecting an entire semester of the kinds of things I see in a college health clinic.

In particular, they’d be expecting to spend at least half their time learning about obstetrics.

I haven’t cracked an OB reference book since grad school. My role in managing my patients’ pregnancies typically begins and ends with a urine hCG, a long talk, and a referral.

The first couple weeks of class we managed to keep things firmly in my wheelhouse: vaginitis, molluscum, herpes, IUDs. HEY LOOK, I KNOW SOME THINGS. A one-off question about first trimester screening was deftly turned back to the students, since those things change constantly and who could possibly be expected to keep them all straight? Please.

But next week, I’ll be forced to lead an in-depth discussion of cervical incompetency and cerclage. And just like that, imposter syndrome comes roaring back.

Solution #1: retail therapy. I can’t wear a white coat to class, but if I start dressing Iike an actual grown-up, maybe my students won’t laugh me down from the front of the classroom, right? Which is how I ended up in line on a Saturday morning with hundreds of other women at this sample sale. Yes, I now have a few nice things that I didn’t have before. And they are quite pretty, even though I’m 100% sure I’ll be trashing these cashmere and silk blends in a hot second with my unsorted, overloaded laundry style.

Yet for some reason, the $125 I spent on blouses (not shirts! BLOUSES) doesn’t seem to make me any more of an authority on cervical cerclage than I already was.

So I suppose I need to deal with my discomfort with not knowing everything about everything the same way I did as a new NP: a confident smile, and a metric ton of reading.

And in the meantime. “Hey, you look like a professor!” was an actual quote from one of my colleagues in the clinic this week. BEHOLD THE POWER OF THE BLOUSE.