An Imperfect Perfect Start To The Workweek

I love Mondays. My clinic doesn’t start until afternoon, so after Hubby pulls out of the driveway to drop the kids at school, I have a bit of personal time. This is, of course, assuming that Hubby isn’t traveling, no kids are sick, I’m not sick, and it’s not a holiday….

This morning, after the kids were buckled into their car seats, and all the bye-bye hugs and kisses were evenly distributed, I stood in the driveway for a moment, just one moment, to savor the prospect of a couple of free hours. I plugged my old-school sports headphones into my iPhone, and dialed up my cheesy workout mix: Latin dance, bubble-gum pop, expletive-filled rap, hits of the 80’s, a bit of bluegrass and a smidgen of country…

And I ran. I ran up the hill past the statelier old homes, past the park where the fireworks display will be, through town and over the train tracks, to this gorgeous jogging path.

Seagulls and butterflies, mild brine and sunshine, smiling folks with dogs… I ran and grooved and spaced out completely.

I spaced out so far, in fact, that on my way back, I somehow missed my turn off the path and over the tracks.

I didn’t realize my error until I was another three quarters of a mile up the path. I decided to keep going, and pick up the next bridge over the train tracks, rather than turn back. But, the way the roads are, I had an idea that this meant a longer run than I had planned for.

As it turned out, it was a much, MUCH longer run than I had planned for.

Five miles in, I realized that I would have to kick it up a notch in order to have time to shower, eat, and catch a train into the city before clinic. I started stressing…

So I ran. I ran way harder than I usually do.

It felt awesome!

My fitbit logged this run at 6.2 miles, baby. I haven’t run that far in awhile.

Lessons learned:

1. Monday morning exercise is a fantastic way to start the week off right.

2. Spacing out to the point of losing touch with reality is generally not a good thing, but sometimes, it is.

 

This jogging and biking path starts in town, along train tracks, by the water and through several parks.

This jogging and biking path starts in town, runs along train tracks, by the water, and through several parks.

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When The Sky Is Falling… How Do You Tell Your Kids?

Our public library is now in regular and highly anticipated rotation. We take both kids, and we walk out of there with ridiculous piles of children’s books.

I never noticed this before, but in reading aloud to my two trusting and sheltered preschoolers, I’ve realized that many classic tales and fables are kind of violent.

The Gingerbread Man: The fox tortures an impudent little boy until his only choice is between drowning or being eaten alive.

The Golden Goose: A greedy man enslaves the magical goose, then chops off the poor creature’s head and digs out his insides looking for gold.

The Man, The Boy, and The Donkey: A man and hi son are bullied and criticized until their donkey is killed in a terrible accident.

With all of these, I kind of fudged the details, softened things, or skipped some pages.

But this week, we read Henny Penny. You know that silly Henny Penny. The acorn falls on her head, she thinks the sky is falling, and incites panic in the poultry kingdom. She and her gang of feathered friends are rushing to tell the king that the sky is falling. But, the wily fox tricks them all into his cave.

The ending is kind of subtle. The book ends with an ominous: “No one ever saw Henny Penny and her friends again…and no one ever told the King that the sky was falling. But the Fox and his family NEVER forgot the fine feast that they had that day.”

I didn’t think either of my kids would “get” the real ending. But Babygirl wouldn’t let me close the book. She got very quiet, staring at that last page, at the fox family licking their lips.

She thought and thought about it, and then, with a flash of understanding, she looked up at me. She drew in her breath and I knew questions were coming.

“Mommy, mommy, um, did the fox and his family eat the birdies?” She says birdies like buwdies. Her eyes were big and she was very concerned.

I was caught off guard. I tried to explain: “Uh, yeah, well, foxes naturally hunt smaller animals, like chickens and ducks and things, and they they didn’t mean any harm, they just were really hungry, and couldn’t resist, see…”

She pointed excitedly at the picture. “But, but, but, mommy, did the foxes eat the birdies? Did they really eat them all up?”

“Uh, well, yeah, I think that’s what the story is telling us.”

Babyboy piped up. “Well, the foxes didn’t have to eat Henny Penny and all of them. They could have just gone to the grocery store.”

And here we all collapsed into the sillies. Foxes don’t go to grocery stores! That’s so silly! Giggles all around. I was so relieved.

I remembered this as I rode the subway home, scrolling through news coverage of the church shootings in Charleston. I thought of the Newtown school shooting; the Boston marathon bombings; the boy who was murdered last week as he rode his bike. It goes on and on. Violence. Needless, senseless, ugly violence. Innocents hurt, and no explanation, no lessons learned.

I know that the day will come when my kids will hear or see the news, and with a flash of understanding, eyes big and full of concern, they will turn to us and ask if it really happened. And they will ask why.

I’m hoping I come up with some answers…

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Primary Care Provider/ Therapist

I was driving in a neighboring town last week, and I noticed a sign on an office building:

Metropolis Primary Care and Counseling: Your Medical and Psychological Resource*

I chuckled to myself. Brilliant! Of course, why not put it right out there. Possibly 75% of my job as an M.D. is psych. I don’t know if this Metropolis practice is one doctor, or a group that provides both services, but it makes total sense to me either way.

At the root of so many primary care office visits are depression, anxiety, insomnia, stress, addiction… Of course we internists do a lot of basic prescribing, counseling, and referrals around these bread-and-butter psychiatric issues.

But, I feel like I need to wear a therapist hat even when dealing with “pure” medical issues.

Let’s take heart disease, the number one cause of death in the US and the world. Per the CDC, 50% of Americans have at least one major risk factor: smoking, high blood pressure, high LDL cholesterol. For most patients, these major risk factors can be improved or even cured without using medications at all. The other risk factors: diabetes, obesity, inactivity, excessive alcohol intake- same thing.

How?

Lifestyle changes.

We can safely and accurately tell most of our patients with one, two, three, or more of these diagnoses that they can reduce or reverse their heart disease risk by simply quitting the smoking, cutting down on the drinking, eating a heart-healthy diet, exercising, and losing weight.

It sounds so easy. Just tell people what will likely happen to them if they don’t change their ways, and they’ll change! All they need is information, data, facts, and the the right meds, resources, followup.

Yeah, right. We all have the patients who still smoke/ eat fast food three times a day/ don’t move at all, and don’t take their Statin/ antihypertensive/ insulin despite their stroke/ MI/ grafted arteries.

It can be depressing. And though I know change is hard, I believe we docs can help make it happen.

Yes, some of it is in providing drugs and data. We can prescribe medications to help people quit smoking or drinking or binge-eating (they’re called antidepressants), and lower the cholesterol, blood pressure and blood sugars. We can offer referrals to various resources: psychiatry, therapy, nutrition, preventive cardiology. We can talk diets. Me, personally, I LOVE talking diets. I believe in the low-carb high-fiber plant-based diet. I know this diet, I live this diet, I lost fifty pounds on this diet. I can write it out for people, show them the apps I use to help me maintain, offer  followup appointments for weigh-ins, give suggestions for staying motivated…

But, to really delve into where a patient is at, to understand and connect with the patient, in order to help them take the next baby step towards a positive health goal… that is really hard.

I think we internists can absolutely help people make significant behavior changes. I think it takes a lot of skill, time, long-term followup, and belief in the process. Kind of like good psychotherapy.

I am most definitely NOT a therapist, and in my four years of residency and three years of fellowship, I never expected that this would be the bulk of what I do. I remember that in training, we had some instruction in effecting lifestyle changes; I even remember a module on motivational interviewing.

But I feel like I need a lot more… like a PhD in counseling psychology.

I have patients who have made amazing life changes. A few give me some of the credit, and this is SO professionally satisfying.

And, this is one reason why we docs need more time talking with patients, and less time typing everything into the computer or struggling with horribly designed lab ordering and billing software. But, that’s a whole other post…

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*Not the real name of course.

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Actually, The Primary Care Doctor Can’t Go Unplugged…

Last weekend, I enjoyed a whole 48 hours without checking my clinical account. That meant not checking on lab or imaging results, patient messages, or colleague’s messages through the electronic chart portal. I did, however, check my work email, since real emergency-type things will trigger a backup notification sent to that account. I felt good about this, as nothing emergency came over email, and by Sunday night, I was totally relaxed and ready to face the workweek.

Well, Monday morning back at the office was a disaster. I had left the office at 4 pm Friday afternoon, and somehow, in the space between then and Monday, I had an unusual number of patient and colleague messages, a few of which were somewhat urgent. The poor on-call doctor had to deal with those, and I could tell that it wasn’t ideal: time-consuming and stressful for her to quickly review charts and figure out what was going on, and awkward for patients to have to explain issues that I was already familiar with. EXACTLY the type of extra work and annoyance I try to prevent.

In addition, there were a number of messages and results that, while they weren’t things that had required same-day attention (like pneumonia on an X-ray, cancer on a biopsy, or a positive strep culture, for example) they were still important and ideally, would have involved a call from me to the patient over the weekend (see the below).

So, Monday morning found me not only prepping for my busy afternoon clinic, but also backtracking and covering all these issues from the previous week and over the weekend: a lady with an osteoporotic vertebral compression fracture that required further workup and better pain control; a complex patient with more questions than could have been answered by the on-call; pain medications refills that only the PCP is allowed to handle; low-grade abnormal labs that required notification and action.

I ended up feeling stressed, unprepared for my Monday clinic, and behind from the very beginning of it. I left later than usual that evening without my all of my charting or administrative work completed. My colleagues know that I’m compulsive about having ALL of my clinical notes and billing done, signed and submitted before I leave for the day, every day. It KILLS me to leave work with work undone.

So, in retrospect, I wish I had logged into my clinical account BEFORE Monday morning. It was NOT to my advantage to be completely unplugged!

That’s why I got up at 5:30 am this lovely Sunday morning. Ironically, there was nothing at all requiring my attention. Figures.

But, I feel a lot better, headed into tomorrow…

This raises the question: When can the primary care doctor unplug? Everyone from every walk of life needs to unplug sometimes. Don’t they?

More on my perspective on this later…

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Unplugged Time

We recently interviewed a promising candidate for a position in our practice. Several  of us were asked to meet with her, each focusing on a different practice area, like teaching, or clinical responsibilities. I was work/life balance.

Like most of us, she is a doctor-mom, and in thinking about the interview, I reflected on what work/life balance means. Six years into practice, with two preschool-aged kids, I have a better handle on what I need to do (or not do) in order to feel sane. At least most of the time.

There’s a number of things that I need to do to feel good and be able to do my job (as a mom and as a doctor). These include adequate sleep, regular exercise, and healthy food.

But, even when all of those ingredients are in place, it’s not enough. I’ve learned that a key component for me to stay balanced is to have regular “unplugged” time. This is a stretch of time, usually more than twenty-four hours, that I don’t log into work to check patient lab or imaging results, or check patient emails.

This is difficult to accomplish. Usually, even on weekends or holidays, there are important tests pending, or someone admitted to our hospital, and there are things that I just have to be checking on and aware of. Many weekends, I’ve promised a patient that I would call them with the result of some test, and I do, even if I’m not technically on-call. It’s much easier for me, who has met the patient and knows the story, to check it myself and make the phone call, than to try to explain everything to the on-call doc, for whom the task would be a thousand times more time-consuming and annoying.

Even when I haven’t made any promises, and I’m not aware of any important pending results or anyone inpatient, I regularly scroll through my work email account, just in case I get that dreaded “IMPORTANT RADIOLOGY RESULTS” email. This is when the reading radiologist sees something serious on an image and wants you to know, and if my pager is signed out, email is the only way that I’ll know. These can be anything from an abnormal mammogram that really looks like breast cancer, to a suspicious nodule on a lung cancer screening CT scan, to a mass on a pelvic ultrasound.

When I call patients on the weekend, I try to use our home phone, so that they see my name on their caller ID. Typically, they pick up on the first ring and say something like: “If you’re calling me on a Saturday, it must be serious.”

But I have now enjoyed two weekends in a row without needing to check anything or call anyone, and it’s amazing how clean my brain feels. Both weekends have been pretty packed, with good stuff: last weekend we traveled to upstate New York to visit family, and this weekend we had family and friend get-togethers, as well as a charity road race down the Cape. We’ve truly enjoyed all the gatherings and activities: it’s all been sustaining, rather than effort. But we have been running around a lot more than usual, for people who don’t often travel (or even have set plans) going into the weekend.

This afternoon, I was driving home from a friend’s house with the kids, and Babyboy asked:

“Mommy, is tomorrow a school day?”

“Yes, honey, today is Sunday, and tomorrow is Monday. It’s a school day tomorrow.”

He thought about this, then said, “Mommy, I don’t like Mondays. Can we make it be a Sunday again?”

But, I’m ready for Monday. I feel relaxed, and ready to jump into the week.

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Well, We’re Off To Kindergarten…

…BUT it’s not the kindergarten I had imagined.

Babyboy will be five next month, and we were very antsy about him moving from his special ed preschool program to a mainstream kindergarten. At our local public school, that’s all there is, and from what I understand, it’s twenty-something kids and one full-time teacher, with aides. Given Babyboy’s developmental/ social delay and toileting issues, we didn’t see that as a viable option.

So, we went into his I.E.P. (planning meeting with all of his teachers) fully prepared to pull him from the public school system altogether, pay for another year of preschool, and arrange for the support services (speech and occupational therapy) ourselves.

We’d actually made significant headway into this plan. Babygirl’s school was willing to take him, and we’d met with a private child development team that could provide services in the school setting. We actually have neuropsych testing set up as well. This has involved a lot of web research/ applications/ emails/ phone calls…

I was shaky and distracted the morning of the I.E.P. I anticipated conflict. I hate conflict.

But the team was all genuine smiles, and the attitude was truly caring. These are people we know, who have been working with Babyboy for two solid years now. He’s been with most of these folks since the very same week he turned three years old… summers too.

The basic facts were presented: he’s made huge strides since he started, from practically no speech to making speeches; from flopping on the floor in tantrums with every transition to running ahead of the other kids; from zero eye contact to initiating conversations with his teachers. Intellectually, he’s mastered their preschool curriculum. 

But, all agreed that socially, there’s work to be done. Social communication, relationships, expectations… and they presented a plan for next year that we didn’t even know was possible, because we didn’t know that the program existed. 

Our town has several elementary schools, and apparently, one of the smaller schools offers a special education kindergarten program, very similar to the preschool program he’s been in: half special needs kids, and half hand-selected developmentally normal peers. This kindergarten class has fifteen to eighteen kids, with two full-time teachers, one of whom is a special education teacher. The curriculum is heavy on social skills. He wouldn’t be the only kid in pull-ups. He can still receive services, his speech therapy, OT. 

This model continues through the fifth grade, and they recommended that he stay in this special environment with the same group of kids the whole time. Babygirl would then also have the option to attend the same school, either in their mainstream classroom, or as a peer in the special ed classroom. 

We were floored. 

How is it that we, who have been fretting and stressing for months, didn’t even know that this program existed? In our own town? It was, frankly, embarrassing. The doctor in me was peeved that I was ignorant of this rather important piece of information, and that it was my own fault. 

So, I’ve dissected this out: Yes, I’d been chatting with other neighborhood moms about kindergarten, but their kids are all developmentally normal, and so I was only hearing about the mainstream program. Our neighborhood school only offers the mainstream program, so I never saw those classrooms or heard anything about it from other local parents.

And, I’ve been avoiding the special ed parents’ group, because the one time I attended, there was a lot of complaining and negativity. I didn’t find that one meeting especially helpful, and actually, it really stressed me out, so I’ve skipped them for the past, uh, year and a half. Oops. If I’d even gone once and chatted with folks, I’d very likely have heard about this K-5 special ed program at the school a mile and half down our street. ON OUR SAME STREET. 

We were invited to visit the program, and so Hubby, Nana, and I went, last week. The school is very pretty: set back in the woods a bit, right next to our favorite duck pond, and a wooden bridge across a small stream leads to the front doors. The building is modern, light and open. The special ed kindergarten room is bright and cheerful. The three of us sat at a little table off to the side and watched the sixteen kids working in four small groups. Each group had a different assignment related to the life cycle of the butterfly: one had to cut, color and paste egg/ caterpillar/ cocoon/ butterfly pictures in the correct circular order, another had to re-create a copy of a poem about the cycle using velcroed words in large print on a display board; et cetera. The teachers roamed and offered guidance here and there, but mostly, the kids worked together in relative quiet and cooperation. Everyone was focused, engaged, happy. 

We registered Babyboy for the program later the same day. 

He’ll go to Babygirl’s school for the summer, and we’ll use those services we put together. But in the fall, he’s going to kindergarten, gosh darn it.

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Latest MiM Post: How Much Do You Share With Your Patients?

Some nice commentary generated by my post on the Mothers In Medicine Blog: How Much Do You Share With Your Patients? 

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