Doc With a View

Found a newborn. I was outside carefully cultivating my weed garden when I heard a cry. I don’t think he was trying to hurt it, but my dog had that poor baby almost entirely in his mouth. I told him to “drop it” and he tossed that little baby up in the air before dropping it. It screamed so loudly and my heart plummeted. Terrified that he hurt it. I carefully picked up this tiny baby and she was still breathing, but cold and wet. I took her inside to warm her up and figure out what to do next.

So, I looked up “How to care for a newborn mouse”. Surprisingly little information out there. But the important things are to keep them warm and fed. By this time my husband is helping me. He found her a little box, dried her off and put her in it with some washcloths and turned our tiny electric heater on full blast to try to warm her up. Apparently, soy baby formula can be used to feed them, but I was fresh out. One website says concentrated milk can also be used. I have a can of evaporated milk – same thing right? So, we feed her with a teeny syringe and she eats. Next thing, “After the newborn eats the mother will stimulate a bowel movement by licking the anus”. Hold the bus!! No way in heck am I doing that. Sorry little baby. I’ll rub the tummy with my gloved finger and maybe that will work. She didn’t poop, but I think she went to sleep. Hard to tell since she’s too little to have her eyes open. We leave the room to tend to some other matters. I continue reading. “Even if you do all these things perfectly the chances of the newborn mouse surviving are very low”. What!? I run back into the room. Poor little mousy is not breathing. Then we had a mousy funeral.

Threatened by a teenager: Induction of labor. This is a first time mom and we were, of course, hoping for a vaginal delivery. Cervical ripening with misoprostol was unremarkable. Finally got her to a favorable cervix and started pitocin. Baby did not like this at all. She made it to 6 cm then stopped dilating. I called the OB for a C section. I was counseling the patient on the need for a CS and that this was the safest thing for her and her baby. She was not excited, but understood and was willing to proceed. Her boyfriend, however, completely flipped out! He was very agitated, called us a “bunch of little bitches” then threatened the nurse and me and threw a bottle across the room. Dude, it’s 2am, I’m trying to keep your baby and your girlfriend safe and healthy. I am not putting up with your attitude. Naturally, we kicked him out, called security and told him there was no way he was coming in the OR to see his baby born after threatening our safety and throwing things. Hope he thinks it was worth it.

Mansplained: Enter the room for an establish care visit. Introduce myself and confirm his name. He says, “You’re the doctor?” and looks really confused. I learned a few things in med school like – acknowledge the emotion. So, I say, “You seem confused? Am I not the doctor you were expecting to see?”. He says, “I thought you were supposed to be a man?” to which I responded, “I don’t know what I was supposed to be, but I assure you I’m a woman.” He goes on to explain how it’s OK that I’m a woman and he doesn’t mind seeing a woman doctor, he thinks it’s cool that women can be doctors just like men. This went on an excessive period of time until I thought – this is ridiculous. It’s 2018. The first physician that happened to be a woman that we have record of is Merit Ptah. The chief physician to an Egyptian pharoah in 2700 B.C. In the last 4000 years I think we have established that women can be doctors. I don’t need you to tell me that it’s “OK”. And frankly, I don’t care if you DON’T think it’s OK. Finally, I said, “Sir, today I’m just your doctor regardless of my gender. Let’s start talking about your medical issues”.

I’m actually fairly tired of people commenting on my appearance or gender first thing when I enter the room. Just a sampling from the last few months:

– You look like you’re just out of high school.

– Are you sure you’re old enough to be a doctor?

– Your face doesn’t look nearly as fat as it did in the paper.

– I’ll come back to see YOU good-lookin’ (with a creepy wink)

– If my other doctor looked anything like you my diabetes would be under better control because I would’ve been here all the time.

– I’ve never had a woman doctor. I think it’s distracting.

– You don’t look like you’ve even pumped your own gas.

In my head I have some great responses all dripping with sarcasm, but I hold back. Because I am a professional. I worked my butt off to get where I am and we’re really here to talk about medical issues and not the circumference of my face.

The last flight I went on had a female, African-American pilot. I saw her walk by and thought, “Dang, she looks wide awake at 4 am”. I overheard three men comment on how the pilot was a woman. One went so far as to tell her that he thought it was so cool to have a black, woman pilot. I don’t really understand how this is still a topic. Women are pilots, doctors, scientists, politicians, CEOs of major companies. Nobody sees a man working at these jobs and comments how cool it is that a man can have that job. Maybe when people stop saying things like “female doctor” and “female pilot” and commenting on their appearance instead of their accomplishments we can move on and start talking about more important things than gender and outward appearance.

Highlight of the Whole Week:

Solo: 91 year-old lady came to establish care. Sang an entire Broadway song to me in her beautiful soprano. A private solo just for me.

You can’t turn on the news today without hearing something about “The Opioid Crisis”. And here I am signing pain medication agreement contracts DAILY.

I’m one of the newest physicians in my group and the community that I’m working in recently had 3-4 doctors leave. This means that I am seeing a TON of new patients every day and a lot of these patients are requesting a “pain management contract”. How is it that this terminology is so ubiquitous in our culture? Why are there sooooo many patients on chronic opioid therapy.

I’m frustrated that I’m signing these contracts to continue these medications. I’m frustrated that I’m frustrated. I’m a physician. I’m supposed to help people. If my patient is in pain then why would I withhold something that provides them with pain control? I suppose that was the thought process of the physicians that started these patients on opioid pain medications 10-20-30 years ago. But now, it’s fallen to me to determine if this patient sitting in front of me is appropriate for this type of medication. Or if something else might be better treatment for them. So, I spend time – and a lot of it – in new patient/chronic pain appointments.

Here’s how the encounter goes:

Patient requests “pain management”. I agree to discuss this.

They tell me they’ve been on oxycodone 15 mg every 4 hours for the past 20 years. I say, “Gosh, that’s a lot of pain medicine” and calculate the morphine equavalent to 135 using this calculator http://www.agencymeddirectors.wa.gov/calculator/dosecalculator.htm.

I then discuss the recommendations that opioids not be used for chronic pain at all and if they are that the MED be below 50 to avoid bad effects – like DEATH. The patient launches into a long explanation of why it’s impossible for them to take less than what they are on right now.

I try to take a good history. Figure out where the pain is (all over), what work up has been done (everything that could be, but of course they can’t provide records from prior physicians), and what treatments have been tried in the past (EVERYTHING, but nothing else worked and they can’t possibly be expected to go through all that again. PT just made everything hurt more).

I discuss the way that mental health and physical health are intertwined and especially how chronic pain and depression are related. Does this patient have any mental health issues? Would they be willing to attend counseling or a chronic pain group to help them deal with this? (No, they’ve done that before and it didn’t help. They’ll be fine if I just give them the oxy).

I ask about drugs and alcohol use (they act indignant. Of course, they would never use drugs or drink any alcohol).

I check the state prescription monitoring program and see if what they’ve told me jives with what is on the report. Often not. There’s always some reason – I moved, my doctor left, they cut me off for no reason, my doctor doesn’t understand my pain.

Would they provide me with a urine sample for a drug screen? (well, they can’t pee right now and their other doctor never made them do that).

At this point I have a good idea of whether I think I am willing to enter into an agreement with this person. I will hardly ever prescribe opiates on a first meeting. Maybe if everything is in order – meaning I have records from prior physician, I agree with the indication for opiates, the PMP shows no aberrency and the patient provides me with a clean drug screen — Maybe. Frankly, nearly all the contracts I have continued have been transfers from my partners that retired. Sometimes I’ll tell patients I need more information and they’ll have to come back with records.

Often, I will tell people that I don’t feel there is an indication for continuing opioid medications and that I am not willing to enter into a contract with them. Most will argue and tell me again how much pain they are in. They will threaten to go buy it off the street. They will threaten to kill themselves. They will threaten to report me to the medical board for malpractice. I ask them if they would like to discuss other medications for chronic pain (nothing works). I ask if they’d like to talk to someone about their mental health (no way – and this usually makes them really angry). I ask them if there is any other aspect of their health they wish to discuss.

If not, I exit the room and will probably never see them again. They will try the next doctor. This thorough evaluation has cost me about 30 minutes of my time or more. Is it wasted time? I don’t know. It feels like it. These encounters suck the life out of me. Like I’ve been in the room with a dementor from Azkaban for 30 minutes! I suppose one could argue that it does provide education for the patient and each encounter they have like this is reinforcing the agenda that we are trying to achieve. It sure doesn’t do much for my agenda to fight physician burn out though.

I hate that I roll my eyes every time someone comes in for chronic pain. Because, you know what? People have legit pain that needs evaluated! I try to approach every encounter in an objective way, but it’s hard. How do I help people use these medications judiciously and with a functional goal in mind? How do I help people who have been on them for 20 years wean down? Or should I? Should I leave well enough alone and allow them to continue as long as there are no significant adverse effects, they follow the contract and they feel they are getting benefit? Am I vilifying a potentially helpful treatment option?

And it really stinks that the new generation of physicians are stuck dealing with this crisis that we did not create.

I’ve started keeping count of everyone that I help wean off opioids, decline to continue or decline to start. It makes me feel a tiny bit better to look at it as it gets longer.

So, teaching people how to manage chronic pain without opioids — that’s my opioid crisis.

My patients often say that once they have a name for their condition it makes it easier to deal with. It can be dissected and studied. It’s easier to talk about with others. They can chime up, “Oh, yeah, I have that too!” and a camaraderie is formed. Support groups are formed around conditions.

My condition has no name – So, I’m giving it one.

“Post-Residency Syndrome”

It is closely related to Imposter Syndrome which is very common among medical students and residents. In this condition one feels that one is “less than” their peers. That somehow they are in the position they are in due to a glitch in the system, an errant electron, a fluke. And that someday they will be revealed as a fraud.

Those with Post-Residency Syndrome may suffer from Imposter Syndrome as well, but it is more than that. This person is in a unique position in life. They have just completed (minimum) 4 years of undergrad, 4 years of  med school and 3 years of residency (of course this varies dependent on specialty) and are setting off into their own practice. It’s exciting, but terrifying.

I’ve not decided on the exact criteria, but hey! I’m making this up so I can change it later.

Tentative DSM criteria

1. Feelings of complete inadequacy and incompetence despite proof to the contrary

2. Going home at night and looking up 13 things that you saw in clinic and questioning if you should have made a different decision.

3. Freaking a little each time you have to see your partner’s patients because you wonder if they will think you are an idiot.

4. Missing your residency friends like crazy because now you’re all scattered across the continent.

5. Questioning your career choice in coming to the middle of nowhere where you have to make really hard decisions in the middle of the night all alone, but it’s too late to turn back now because – – – CRUSHING MED SCHOOL DEBT. (This might be a tad narrow for DSM criteria, but I’m making the rules here.)

I’ve been working on some ways to effectively treat this syndrome.

• Talking to my colleagues. I know this sounds lame. And no, I don’t go fishing for compliments. I do ask for honest feedback and how I could have done better if I feel something went poorly. Also, a few of my partners are about 3-4 years out of residency, so they still remember what it’s like and are very supportive.
• Limit the amount of “agonizing time” that I allow myself after clinic. I look up the most important 2 things from clinic that day and move on.

Do you suffer from Post-Residency Syndrome? Have you come up with ways to combat this?

I’m sitting here at 5 pm on the last day of my first vacation in 6 months thinking about going back to work tomorrow. Of course, I’m on 24 hour call. Of course, my in basket will be over flowing with URGENT requests. Of course, I’ve been sleeping late this past week and have to get up 3 hours earlier than I have been. Of course, today is a great day to start a blog!

So, here I am world. Or rather the 4 people I expect will read this – my mom and dad (because they love me and support me in everything), my best friend (because I’ll text her and she’ll guilt read it so she can answer my question) and my husband (who will want to make sure there’s no personally identifiable information). 4 people is a start! C. S. Lewis was only writing The Lion, The Witch and The Wardrobe for his granddaughter and that turned out pretty well.

I’ve looked back on a lot of things in my life and said, “Well, it seemed like a good idea at the time.”

1. Moved away from family and friends to go to college,
2. left a steady, decent paying job to go to medical school
3. somehow acquired 2 dogs and 3 cats
4. chose a residency in family medicine
5. decided to do rural family medicine with OB
6. moved halfway across the country to pursue #5

And here I am starting a blog. My probably ill-conceived plan is to use this as a medium to start writing again and as a bit of decompression therapy for me. I’ll tell you of my challenges and successes both today and in retrospect. I’ll tell you about being a female family physician who finished residency, moved halfway across the country to the middle of nowhere to practice medicine and find peace in a small town.

And we’ll see how long it takes me to say, “Well, it seemed like a good idea at the time.”