Hypocrisy

cutie the mini orange

Today was a slow day. Downtime between semesters = fewer students on campus = blessed, rare open appointment slots = more time with the few patients who happen be around.

Consequence: actual time to spend on actual health promotion-type counseling. And not only my faves, like safer sex (because I always find time for topics that actually interest me. how many times have I found myself running behind because I can’t seem to get a convo about herpes back on the rails? so many). No, these days, I have no excuses not to talk about things like exercise. And stress management.

And…diet. Ugh, diet.

Unintended consequence: overwhelming sense of profound shame as I realize that while I spent a not-insignificant amount of time today earnestly counseling patients about the benefits of a plant-based diet and loading 50% of your plate with fruits and vegetables and generally not eating processed crap every day of your life, I consumed:

1. 3 cups of coffee in an approximately 3:2 ratio with the sweetest of sweet vanilla flavored creamer (caloric density approximately equal to melted vanilla ice cream – yes, I’ve checked)

2. 1 slice of the neighbor’s holiday pumpkin/walnut/raisin pound cake, breakfast of champions

3. some sort of sad microwaved marinara ziti thing (work lunch, what can I say)

4. a single small mandarin orange (I brought two, but the second one tasted a little funny, so)

5. 2 generous servings of small bits of chicken, breaded, fried, and tossed in a sweet soy glaze (thank you forever for your delicious attempt at recreating General’s chicken, Trader Joe)

6. a glass of wine, because Friday

7. delicious, sticky white rice to go with the salty sweet chicken

8. a cookie, dipped in chocolate and tiny bits of candy cane

9. another half glass of wine, because cookie + wine = yum

10. a generous slice of ridiculously decadent chocolate peppermint cake for second dessert

11. yet another half glass of wine, because you can’t eat chocolate cake without red wine, pretty sure it’s illegal

And that’s my day. 24 hours, and 1 orange for my entire fruit/veg consumption. And we’re not even a talking a regular-sized orange, but one of those tiny things rebranded as “Cuties” in an attempt to improve shelf appeal. Regular oranges scoff at diminutive nicknames like “Cuties”. Not so for my tiny, adorable mid-afternoon snack.

So. When does the semester start again?

The luxury of time

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I have had a lovely week.

Really. I mean that. I’m not just talking about the perfectly-grilled steak I had for dinner last night, or the fact that I’ve been lucky enough to find Girl Scouts selling cookies at my subway stop, even though those were definitely highlights.

No, this week was something special. This week, I was able to be the health care provider I always want to be, the kind I always aspire to be, the kind I hope I’ll be able to be on any given day. With every patient.

Except I typically have at least 3 patients waiting and OH WAIT another double-booked emergency visit between me and this shining ideal. But not this week!

Why? Because as a grown-up woman, I’ve found myself once again completely, swooningly in love with that unique college tradition known as Spring Break. While most of my patients spend the week in exotic locales, enjoying all-inclusive cocktails and remembering what it feels like to experience above-freezing temperatures (MUST BE NICE), I get to stay behind inside the endless polar vortex, holding down the clinic-fort and taking care of the students who are opting out of paradise in order to spend their week sleeping in and catching up on House of Cards.

But that’s okay. My week may not have involved jell-o shots, but it did involve something even more delicious: time.

The clinical schedule was relatively light, but steady. Functionally, this meant that I was able to spend about twice as much time with each patient as usual.

Functionally, this meant that when I thought this one patient and I had reached a decision point, only for the patient to stop and ask to explore, from the beginning, a completely different possible option, I didn’t internally groan and look at the clock.

Functionally, this meant that when another patient continued to send me wordless signals that she was still worried that Something Serious might be going on beyond being unlucky enough to catch a third cold this winter, I dug a little deeper and asked, and listened, and talked until the signals indicated relief.

Functionally, this meant that when a different patient decided to “oh, by the way” me as our visit was ending with a completely unrelated, and much more complicated, symptom of concern, I asked her to tell me more with a warm smile. And I meant it.

It made me fantasize about an alternative reality: one where I’m empowered to spend as much time with each patient as the patient needs – as much time as we both might need – to feel confident that I’ve done everything I can do on that day, in that moment. Fewer patients might be seen. Which means the clinic might need to hire more providers. Which, I’m quite certain, won’t be happening any time soon.

Spring Break can’t last forever. The party has to end sometime.

But the memories last forever.

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?

Letting your garden grow

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“I’m sorry, I haven’t shaved.” Delivered sheepishly, with a cringe.

Le sigh.

I know it’s been awhile since I was in college (I mean, not THAT long <cough>), but let me just say that the scorched earth look was uncommon back in my day.

However. I like to think of myself as a hip old. I read Jezebel. I tweet. So I get that the social mores of grooming from my day are a thing of the past. It’s all about the prepubescent look now. Got it.

Or is it?

*****

There are upsides to this trend of complete hairlessness. Well, um, so there’s one. Crabs, a.k.a. pubic lice, that notorious entity of teen nightmares, is practically nonexistent today, rendered obsolete by a wave of wax and razor blades (wow, so that’s not a completely terrifying image). When I finally saw my first case ever last year, I was actually a little excited, with that thrill that comes with the discovery of a rare and endangered creature. I know, I know. JUDGE.

But the quest for bare skin doesn’t come without a price. Razor burn, ingrown hairs, folliculitis, microtrauma from waxing and shaving, and oh so much more… And, I dunno, all those many hours dedicated to lady area maintenance that could be redirected towards…saving the whales? World peace? Kardashian marathons? Take your pick.

I’ve heard the back and forth – it’s all porn’s fault! it’s my choice, and it’s hygienic! – but I can’t help but feel as though this trend is working against us ladies more than for us if you feel as though you need to apologize for being a smidge grown out when you come see me for your Pap.

*****

But. BUT! There are signs that the pendulum might finally be swinging the other direction.

Recently, those leading arbiters of classy, American Apparel, created a window display with mannequins wearing both domestic-construction spandex-cotton blend and full bush. Bold move, AA.

Seriously though, pubic hair’s been all over the news lately. (Pun not intended! I mean it, now THAT would be unhygienic.) You might have missed the articles in Slate and The Guardian, but you can’t deny the legitimacy of the New York Times. If the gray lady is deigning to write not one, but two, pubic hair trend pieces, you know it’s both a legit happening and maybe a year or two behind.

So there you go, ladies. Feel free to shave or not shave, wax or not wax, but please, at the very least, know that regardless of the choice you make, you should never feel the need to apologize for it.

Impatience

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I get it. We all have somewhere to be.

But waiting a few extra minutes for a clinical appointment isn’t the same thing as a long line at Sbux.

Our appointments are scheduled in tidy 20 minute chunks of time, as if all the work it takes to listen to a patient’s story, perform an exam, come up with a diagnosis, discuss the plan, write the prescriptions and lab orders and referrals and then maybe, MAYBE, write the note couldn’t possibly take more than this randomly assigned amount of time.

In reality, things don’t work that way. Patient care takes the time it takes, and exactly how much time that might be is impossible to predict with 100% accuracy.

Sometimes, a visit is straightforward, and this 20-minute guess isn’t too far off: your colds, your strep throats, your uncomplicated UTIs.

But what about the patient with a constellation of nonspecific and/or seemingly unrelated symptoms over several months? Something that requires a little detective work?

What about the patient with a list of 4-5 separate problems, all of which need to be evaluated here and now, and fine, why not, since by the time you’ve asked enough questions to determine whether some of these list items are non-urgent enough to be rescheduled for another visit you’ve already done most of the work anyhow?

What about the patient presenting for the first time with an eating disorder? Or suicidal ideation? Or a sexual assault? Do you really think it’s appropriate for their clinician to enter that visit with a clock ticking in his or her head, rushing the history and exam, and then at some predetermined time chirping “Welp, time’s up! Good luck with all that!”

This is not an academic question. This stuff happens to clinicians all day, very day. It happens to me all day, every day. It’s the nature of the job. And so when one of these particularly challenging situations presented itself in my office earlier this week, did I rush the patient through her impossibly difficult story? Did I even look at the clock once? OF COURSE NOT.

But did that mean I was crazy behind for the rest of my patients that afternoon? Uh, DUH. Obviously. I can’t make extra time materialize out of thin air. I can’t be in two, or even three, rooms at once. Believe me, I wish I could. Because that would be spectacular. For so many reasons.

I suppose I’m writing this because I’m tired of being asked to do the impossible. I’m tired of being measured by all the wrong benchmarks. I’m tired of getting heaps of attitude when I’m running late because you know what, I was providing care for another human being in need of care, dammit, and spending that time with them was the right thing to do. Sorry, but one person’s suffering means more to me than another’s inconvenience.

Wait, no. Not sorry.

Shouldn’t the quality of the care I provide mean more than how long someone waits to see me? Isn’t the part of the visit that really matters the part that happens AFTER the visit begins, rather than before?

Can’t everyone just be a little more patient?