Wednesday, November 30, 2005

The Lawyers Won't Help, But This Might

There's been a lot of talk here and elsewhere about callous, mean or stupid doctors. An article in the Times today has a pretty good discussion of the topic. They also provide a link to a site where patients can rate their doctors.

I have mixed feelings about the rating site. I think it's a great idea in general, and I believe it has the potential to change physician behavior. However, it's not at all clear that it's reliable in any meaningful way. First, you can't tell who is managing the site (and whoever it is, they don't proofread carefully). Second, the site allows advertising, which makes me suspicious. Third, it doesn't appear that they vet the ratings at all. I tried it out by rating one of my doctors; I was able to do this without creating an account, and my rating appeared instantly. There is a way to flag ratings or listings you feel are suspect, but since it's entirely anonymous, there's no way to tell if someone has, for instance, padded his or her own rating. (No, I didn't rate myself.) Finally, I expect the site will be heavy on the doctors that serve the educated (and in my opinion overtreated) patients who have easy access to the web. Most of my patients won't have the opportunity to make use of it.

But it's a start, and perhaps will help doctors start thinking about whether they are being good instead of whether they might be sued.

Tuesday, November 22, 2005

Shh, He'll Hear You

HellBoy is starting to talk more, but his pronunciation stinks. The other day GoodCat wandered into the living room and HB started his usual "AT! AT! AT!"

"HB, can you say 'CAT'?" TrophyHusband asked.




Just then the cat started to do what cats are wont to do, and TH, getting bored of the lesson, said, "Can you say, 'The cat is licking his balls'?"

And HB shouted, "BALLS!!!!"

He also calls spoons "poon." We're going to start getting dirty looks at daycare if we're not more careful.

Saturday, November 19, 2005

And Some of My Best Friends Are Lawyers

Seems like I've been reading an awful lot of comments on other blogs lately in which the prevailing sentiment is that doctors are stupid and evil. Whenever someone has a story about some medical treatment that went wrong, usually in fertility treatment or childbirth, there are a bunch of comments insisting that the blogger should call a lawyer.

These comments leaves me feeling frustrated and a bit depressed. For the obvious reason, of course, but also because I think they illustrate a basic problem in healthcare in this country. There's this notion that if all doctors do their jobs right, everyone will be cured/get pregnant/give birth easily without drugs/have a healthy happy baby who sleeps through the night and never spits up.

There are few great doctors and a few bad doctors, and lots and lots of average doctors. But there is no doctor who will do the right thing all the time. And even when doctors do everything right, things will turn out wrong sometimes.

If things don't turn out perfectly, people often want to sue. But lawyers will not take most of these cases. Lawyers will only take the cases that will result in large monetary verdicts. These cases are the ones where someone is either killed or permanently physically damaged. The younger and cuter the patient is, the bigger the verdict.

So what does this system create? First, an environment in which doctors are afraid to admit when they have done something wrong, and therefore do not have any opportunity to teach others how to avoid mistakes. Second, a healthcare system that puts huge resources toward trying to avoid the outcomes that result in the largest awards -- efforts that are focussed on the minority of patients -- and little to no resources toward basic improvements that will benefit the majority of patients.

Take childbirth, for instance. An injured or dead newborn, whether the result of bad medical care or just bad luck, can result in an enormous jury award. The typical argument in these cases is that if the mother had received more aggressive medical care, the outcome could have been avoided. The obvious result of this is that OBs are under intense pressure to be aggressive all the time. Meaning, they quickly pressure women into induction, forceps, c-sections. They know they will not be successfully sued for bullying, but they could be sued for being gentle.

A lot of women turn to midwives because they know or sense this. Which can work ok, but midwives are also under pressure: they must quickly turn care over to the OBs if things start going south. And a doctor who suddenly has to pick up a tough case from a midwife, a doctor who doesn't know the patient or the whole story, is going to be even more aggressive than usual.

In the meantime, all of the things that can make childbirth in a hospital frightening, isolating, and frustrating are not addressed, because there's no money in it. There's no lawyer who will sue a hospital for arbitrary rules about visitors, for surly and overworked nurses, for failing to do everything possible to ensure breastfeeding success. And there's no insurance company that will reimburse hospitals for any of those things either.

I'm not defending bad doctors or crappy hospitals. I've been through my fair share of them myself, and it's awful. I do believe that sometimes suing is very appropriate. But I wish that everyone who is angry about the ways things are in healthcare right now -- and we should be angry -- would start thinking about what will actually make things better, and the answer is not to call a lawyer.

Monday, November 14, 2005

Interview Season

They're here. November through January is resident interview season, and they appear like a flock of black-suited birds migrating for the winter. I interview four in a row every interview day, and although we've only had two days so far, they're already starting to blur together. Same clothes (conservative), same hair (ditto), same questions ("How are the fellowship opportunities here?" "What changes are in store for your institution?") I desperately search their personal statements for something interesting to talk about, but I find the same statement every time:
I walked through the doors of [name of free clinic / institute in a developing country / hospital in a bad section of town] with [appropriately humble emotion]. I was faced with [appalling scene of human hardship / touching scene of expected death / inspiring scene of personal courage]. I knew then that I wanted to [help others / make a difference].

When I was [
age between 10 and 20], my [rather distant relative] fell ill with [not especially concerning illness]. Watching [him / her] suffer made me realize the impact of illness on others.

During my medical school career, I have volunteered at [
a free clinic / a highschool to talk about contraception / an elementary school to tutor youth]. This has taught me the vital importance of [giving of oneself / feeling grateful for my position in life].

I will never forget the face of my first patient to [
call me "doctor" / ask me to hold their hand / die]. I hope I will always remember the important lesson this taught me about [trust / empathy / death].

Ten years from now, I see myself as a practicing physician who is also involved in research in some way and who teaches students and residents, but I will never forget the feeling I had that first day I walked through the doors of [
name of free clinic / institute in a developing country / hospital in a bad section of town] and really [felt like a doctor / understood what it means to be human].

Afterward they all send the same thank-you note, as they were instructed to do by their medical school. So how can I be expected to keep them straight? How I wish they would leave their hair long, wear a purple suit or a nose ring, talk about politics or a broken heart or religion or the kids they hope to have. I know it's scary for them -- for the ones with so-so academic records, anyway -- but it makes me sad to see them so conformed.

I know there are some medical students reading this. When you go on your interviews, give me a break. Wear green -- or at least gray or brown. Ask, "What do you love about your job? What do you love about your life?" And if the above is your personal statement, throw it away and start over. It's not so hard -- just talk. Tell me what makes you you.

ADDENDUM: jgt asked,
My husband is making the interview rounds right now. They're told over and over that the majority of attendings are conservative folk and that anything that makes you stick out is more likely to tip the scales against you than for you.

Do you think you're less conservative than the average attending?

It depends on the specialty. In most surgical specialties (General, Plastics, Ortho, Urology, Ophtho), yes, they're relatively conservative, for doctors anyway. (In my unscientific investigations, doctors in general are more socially liberal than those in other professions, but surgeons tend to vote Republican whereas the non-surgical types are more often Democrats.) Peds, Family Practice, EM, and Internal Medicine are all fairly liberal groups, and Psychiatry is waaay out there groovy. (I'm not sure about Neurology and Dermatology; OB/Gyn is a mixed bag.)

Am I less conservative than average? Oh yeah -- I'm pretty much a lefty -- but a majority of my colleagues do agree with me on issues like abortion, the war, same-sex marriage, universal healthcare.

I certainly wouldn't advise anyone to try to be deliberately wacky to try to stand out from the crowd -- that's sure to backfire -- but hiding what's interesting about you seems like a bad idea too. What I'd do if I were on the interview trail today is try to get the interviewer talking first -- ask about a picture on their wall, maybe -- and get a sense of what they're like. If you have anything in common, start talking about that, and everything is easy after that. I love talking cats, kids, running, travel, photography, art, politics ... it's easy to get me going on any of it, and I'm not a very schmoozy person. Other colleagues would love to talk about cooking, sailing, biking, gardening, dogs, oh, I don't know. But if you don't start talking about something like that, you'll end up talking about how your worst quality is "my perfectionism!" and getting asked dumb questions like, "if you had to be the only doctor on a desert island, what two texts would you bring?"

The folks I remember clearly from last season were: the professional guitarist, the guy who drove ATVs during his every free moment, the guy from Ireland, the woman who had a baby the same age as mine (and was worried about even mentioning it in interviews), the guy whose parents immigrated to the U.S. and picked crops to get him through college, the almost certainly gay guy who directed an a capella choir with a cute name, the nine-months-pregnant woman, the professional surfer, the woman in a short skirt and spike-heeled boots ... if there'd been a juggler, I'd certainly have remembered him. And at the rank meeting months later, it wasn't hard to call these people to mind, unlike the rest of the plodding masses.

Friday, November 11, 2005

The Human Binky: The Downside of Cosleeping

I had to stay at work until 9:00 last night for my "leadership" course ("Goal Setting" and "Attitudes for Success" were the topics last night. My Goal = Endure This Class; My Attitude = Truculence). HellBoy was still awake when I got home, of course, since our bedtime routine is: mama nurses him until he falls asleep. That was fine -- I was happy to be able to at least see him. But starting at about 3am, he decided that he couldn't sleep unless one of my breasts was in his mouth at all times. I don't know if it's related to my being gone last night, but I hope so, because I can't take too many nights of that. It would be one thing if I had long floppy dugs that I could just sling over to him on demand instead of tiny compact ones that necessitate much contortion on my part. My neck is stiff and I'm feeling groggy.

An another subject, you know what there should be a word for? You know how when you have to pee for a really long time but don't, and then finally you go, and for about a half hour after you go your bladder feels all happy to be empty? It's more than relief. There should be a word for that happy-empty-bladder-feeling.

Monday, November 07, 2005

I Know I Should Love Them All the Same, But ...

There are patients I enjoy, and patients I enjoy less. Oh, who am I kidding, trying to be all PC. There are patients I can't stand. I have something of heirarchy when it comes to how much I like patients. I think most clinicians do, though the order can be very different.

At the top are the smart patients. Not educated, smart. They can be smart and follow all my directions, or they can be smart and ignore everything I say. I don't care. In fact sometimes the latter are the most interesting. I have one patient who smokes two packs a day and coughs and wheezes like a sick cat. I tell him to quit smoking, and he tells me, "Now you know I'm not going to do that!" But he doesn't ask me to fix his cough. He just comes to chat, and I love to chat with him.

Next are the crazy patients, provided that they aren't dangerous crazy. I didn't used to mind dangerous crazy, but one punched me in the face once and split my lip, so I'm a little more careful these days. (He wasn't my patient, by the way -- he was just walking by me in the psych ward and didn't like the looks of me.) (I always feel compelled to add this. Otherwise I'm afraid everyone will think I'm just annoying as hell and that I make my patients want to punch me in the face.)

Next are the dumb patients who do what I say. Boring and a little scary, these people.

Last are the dumb patients who ignore everything I say. God how I hate these folks. I have one guy who is cheating on his wife and keeps coming in for STD's and wants me to give him pills to slip to his wife in her food. (No, of course I don't give them to him!) (Should I?)

The other day I saw a woman who is five feet tall and 300 pounds. She said the same thing that 99.9% of really fat people say when the subject of weight comes up:

"I don't know why I keep gaining weight. I don't eat anything."

Now, this statement in itself is not the dumb part. Like I said, 99.9% of people say this. But I have a stock response that works 99.9% of the time:

"You may be right, and it's not fair, but however much you eat, it's too much for you."

Most people will nod sadly on hearing this. And it's not a line on my part; hyper people who jump around all day and jiggle their legs until the person sitting next to them on the couch screams "Would you cut it out?" can eat a lot more than serene folks. And most of the people on the planet are the product of generations of surviving starvation -- that Pack It On gene is powerful. I do practice what I preach -- I exercise, I don't drink soda and juice all day, and I try to avoid eating a lot of junk -- but I know that I have it easier than many people. For a lot of people, telling them to eat less is like telling them to breathe less. Especially in our society, with a Starbuck's and a McDonald's on every corner.

But this woman wasn't buying it. She stared at me for a long, long, moment, and said,

"No, I don't eat too much."

I was flummoxed. Finally I said, "Well, why do you think you gain weight?"

"Because there's something wrong. You need to do tests."

OK. A lot of people think thyroid disease can make you gain weight. And it can. But it can make you gain 15, 20 pounds, max. Not 180 pounds. But she didn't even think it was her thyroid, because her thyroid had already been tested multiple times. She believed that there was some other condition that was making her gain weight and that I hadn't tested her for this condition because I was either incompetent and didn't know about it, or evil and deliberately withholding it from her.

Oh, and I also needed to do tests to find out why her back hurts. And her knees.

I'd like to think I treat all my patients equally, but I know that's not possible. I have a pretty good poker face, but I'm sure my expression was less than entirely nonjudgmental and empathetic as I tried to explain to her that I was not withholding some magic treatment for obesity from her. And I offered her pills for weight loss. I don't mind doing this. They don't work very well, but I'm happy to have people try them. But she didn't want that. She wanted to know what was Wrong.

It reminded me of those plants -- you know, "Magic Plant! It Grows On Air!!!!" She could be a "Magic Human! She Absorbs Fat from the Atmosphere!!!!"

Wednesday, November 02, 2005

Only Ghosts Need Apply

This being our first year in our house, I wasn't sure how much candy we'd need for Halloween. So last week when I saw our neighbor from two doors up the street, who's been here forever, and whose house was decked out in Halloween-themed decorations, I asked her. And something kind of strange happened.

"Ah ... er ... well, for years we did ours on the Sunday before Halloween," she said. "But I'm not sure what the plan is this year ..."

I was confused. Halloween before Halloween? She explained that there is a tradition on our block to have Halloween early, just for our block. And then many people turn off their lights on the 31st.


It took me a minute. What would be the benefit in this? Well, your kids would only go to houses of people you sort of know ... but wait, you could do that just as well on Halloween itself, right? So the only benefit is, you wouldn't have to answer your door for the people who aren't on your street. And what, you might ask, is the difference between the people on our street and the people, oh, a couple of blocks over?

Exactly. Our neighborhood is racially mixed. Our street, not very.

I'm kind of slow. I didn't actually figure it out until after our neighbor left, but once I did, I was livid. And embarrassed to be living on this block. It's not the kind of thing one asks when going to an open house. And there were Kerry stickers all over the place. But I can't say that I didn't know about the general paleness of our neighbors.

Fortunately our neighborhood has a listserve, which we consulted. We found that we weren't the only ones who felt that this was racist, and everyone -- at least, everyone who was willing to post about it -- agreed that they would indeed be doing Halloween on Halloween. Still, on Sunday, there were some kids on our block going door to door and some people answering the door with candy.

But on Halloween we sat on our stoop with beer (for us) and candy (for the trick or treaters) and you know what? We had a blast. There were a lot of dark houses on the block, but also a lot with their lights on, and lots of people sitting on their stoops, and it was a big party. (The neighbor who told me about the Sunday thing was out on her stoop too.) AngelBaby had a ball watching the parade of kids. I only had to chase after him once, when he fell in love with a dog and wanted to follow it home. We took pictures of the kids, and even printed a few pictures on the spot to give to them -- it was like some corny TV ad.

This is what some people were afraid to open their doors for. And this. And this.