Wednesday, March 5, 2014

11 Reasons Why You'd Be Lucky to Have a Family Physician and 10 Reasons Why Your Family Physician is Lucky to Have You

Here are two complementary "top 10" lists I felt inspired to write this week. I was going to name them Why you should love us and Why we love you, but this all sounded much too egocentric and a bit too cheesy, even for me.

The first list is inspired by the realization that some people don't really know what a family doctor is or does. I tend to think we're pretty useful, and, quite honestly,  I think more of you should have one of us in your lives. Here's why.

The second list is in honor of my community of family doctor friends, too many of whom struggle with self doubt, high stress, and crazy dysfunction in their work worlds. Sometimes it doesn't feel worth it, but it is. Maybe I can remind you guys why.

I put the two lists together in one post because-- well-- doctors and patients go together. You cannot really have one without the other.

11 Reasons Why You'd Be Lucky to Have a Family Physician ( or Why you should love us)
1) We know our birth control. There is definitely someone in your life who needs good birth control. Perhaps it's you, your daughter, your niece, your nephew, your neighbor, your hairdresser, your grandson, heck even your mother (yes, your mother has sex too). Unintended pregnancy is one of the most avoidable life-changing events on this planet. And birth control can actually prevent unintended pregnancy. Imagine that?! We family docs know a lot about birth control and can help you find the right option for you-- and please remember, we are no longer limited to your mother's birth control pill. Ask us. We'll help.

2) You are not just a blurry eyeball. Or a broken heart. Or a sore hip. Or an irritated gallbladder. You are a complicated coordinated system that, put all together very carefully, is unique you. And only you. Specialists are amazing and important. We need them when things get crazy. However, most specialists are unlikely to make a connection between your blurry eyeball, your diabetes, its effect on your sexual health, your emotional well-being, your neck pain, your new job, your diet, and your dad's recent illness. That's my job. I'm here to look out for unique you.

3) We can talk about death. And we actually want to talk about death. We are poised to help you explore your wishes and desires and fears, and we are trained to help you and your family make the most informed, empowered decisions you can make when death may be near (or far). We can guide you through the process of creating an advanced directive or help your family make a cohesive decision about what to do with a failing parent. We want you to think about death before it's right on your doorstep-- that way you will know what to do when you open the door.

4) We are a one stop shop. We can check out your mole, examine your itchy vagina, and make a decision about your painful ear all at the same time. Well, not exactly the same time, but definitely during the same visit. And we know when we need to refer you to a specialist-- that's part of our training. So, you know how sometimes you have to go all over town to do your shopping: to Trader Joe's to get crackers and cheese, Imwalle to get veggies, Oliver's to get fruit, G&G to get staples, and Costco to get toilet paper? I hate that, but it's my grocery-shopping reality. I'd argue it's pretty unavoidable when it comes to groceries, but health care needn't (and shouldn't) be that way.

5) We like to talk about uncomfortable things. You don't have to be embarrassed talking about your constipation or your diarrhea or your itchy butt with us-- in fact, these are some of our favorite topics (mostly because we can make these things better, and so many of the diseases we manage don't actually get better). We don't even mind talking about sex, erectile dysfunction,  toe jam, or body odor. Or all those put together (see #3).

6) We can translate. So much of what is scary and overwhelming when someone is ill are the plethora of things patients and families literally don't understand-- these include explanations of a diagnosis you have never heard of, interpretation of weird lab results, medications that have multiple names that you cannot even spell, much less pronounce. We family docs can speak both human language and doctor language, and usually we can give you a clear and honest interpretation of what the heck is going on. Try us out. We are even better than Google translate.

7) We know care coordination. Once you actually understand what the doctor is saying the next step is helping to make it happen: get the cardiologist to talk to the oncologist, get brother to talk to sister, get the home health aide into the home to help mom get a shower, help get a breast pump that works so you can get back to work, figure out how to get wheelchair transport or recurring laboratory draws. We are not the gate keepers--we are the orchestra conductors. We want to help everyone stay on the same stage.

8) We have technical skills. Many of us can still deliver your baby (my favorite work activity), sew up that laceration, put in your IUD, take off that mole, circumcise your son (after empowering you to make an informed decision about that), clean out that boil, and even biopsy your cervix. And we can do so with a decent bedside manner. And all, hopefully, causing you less overall anxiety because you actually enjoy coming to see me because you know I know your name AND I actually care about you and your family.

9) We do depression. And anxiety. And insomnia. And panic. And a whole other slew of mental and behavioral health things that come up for people. That's right, that's health too.

10)We take care of people across their lifespan. We can follow you from first screaming breaths into accident-prone toddlerhood, up through awkward puberty, over the hill into birth control and young adulthood, past college, into parenthood, menopause, grandparenthood and off to the grave. Pretty freakin' cool.

11) We do health too (not just illness).  And health is hard stuff to pay attention to. Health includes vaccines and preventive care, diet and exercise, emotional strength in the face of stress or loss, recovery after something knocks you down, avoidance of common health events like heart attacks and strokes (even if you are convince YOU are never going to have one of these). Health is hard to pay any mind until it's slipped away. Don't let that happen. This is the only body you will ever have. And the only mind.
Please note that I am not intending this list just to advertise for my specialty, though, quite honestly, I do think that being a family doctor is pretty freakin' cool; hopefully those of you who have a family doctor who you love and who loves you agree with me.

This corresponding "flip side list" is dedicated to my doctor friends, who sometimes lose sight of the privilege of our position because we are so wrapped up by the quotidian bureaucratic tasks, the sense of feeling behind, the belief that what we did was futile and frustrating without actually promoting healing, and our own struggles to figure out how to serve our patients in a horribly broken down system.

10 Reasons Why Your Family Physician is Lucky to Have You (or Why we love you)

1) You honor me by allowing me to be witness to the miracle of your birth. And not only do I get to be there--physically present-- at the moment the world changes forever, one beautiful new baby at a time, but also, I get to be the very first one to touch your sweet baby's head and his strong little body. Such a privilege. So amazing. Every. Single Time.

2) You trust me. When you walk into my office feeling scared and out of my office feeling relieved, my day becomes worthwhile. When we are anxious or worried or sick, having someone we trust to reassure us and comfort us is indispensable. Plus, your trust in me makes me trust myself.

3) You keep me on my toes when you ask me challenging questions about topics like the hepatitis outbreak associated with organic berries, the risks and benefits of starting an antidepressant in a teenager, the weird side effects of a thyroid medication, or the latest study showing that mammograms may not be as important as we think they are. You keep me reading, thinking critically, and reaching for some semblance of truth.You make me smart.

4) You humor me by actually listening to what I have to say, unlike my toddler, my husband, my dog, and my mother. For example, when I educate you about your asthma inhaler and the importance of using your maintenance Advair and not just your rescue albuterol, you nod your head, and at least pretend to agree. This makes me feel valuable, or at least more valuable than when my husband rolls his eyes at the very same lecture.

5) You share your pain with me and trust me enough to tell me you are having thoughts of hurting yourself tonight. Those are thoughts you share with no one, thoughts you can hardly share with yourself. And yet, when I ask, you look me in the eye, and you share the deepest, darkest vulnerability. Thank you.

6) You say "thanks" for something I did last year that put you at ease, something that I did in passing, that I cannot even remember exactly what it was, but it was the thing that needed to be done. The fact that I don't remember what I did or said isn't important--what's important is that it meant something to you in the moment.

7) You quote me to myself (e.g. "Doctor, the last time I was here, you told me. . . ") Who doesn't love being quoted to thyself?! Being told that my words are important enough to you that you replay them (perhaps even replay them over and over) reminds me to be careful and thoughtful and loving with my words. After all, those words that may stay with you for decades simply because I said them.

8) You tolerate my running late and running frenzied and even running out of the office to go 'catch a baby' and then next time I see you, instead of being upset and feeling jipped, you ask me about the baby. Somehow, the short time we have together is precious enough that you don't remind me of how ridiculously long you have been waiting for me to rap on that door. And the time we spend together is enough.

9) You refer your mother to me. I am a daughter, I know how much that means.

10) You tell me that just seeing me makes you feel better, and I think you actually mean it-- even on days when I could do nothing to calm your anxiety or take away your pain. Nothing, that is, except to be present. The interaction is basic. You speak, I listen. I speak, you listen. And through that most simple of interactions, we walk together-- through birth and death, confidence and uncertainty, diagnosis and treatment, illness and wellness. And, hopefully, when all is said and done, we know one another enough to say I love you.

Sunday, March 2, 2014

Every Woman Counts

Maria is a very quiet woman. Una mujer muy tranquila.

I have never heard her complain. Not once. Not when I examined the drain left in the place where her left breast had once been, not when her eyebrows disappeared, not when her skin sloughed off in layers under the blistering burn of radiation. Never.

Most questions I ask her, even open-ended ones, are answered with a shy nod or a few soft-spoken words. She has a pursed smile and an awkward shrug of both her shoulders when she is uncomfortable. When I ask her how she is doing, she always has the same response, "Bien, doctora".  To call her understated is an understatement itself.

The day I met her--almost five years ago now--is an indelible memory-- one that will be part of my physician-consciousness forever. Maria walked into the residency training clinic where I was literally pretending to be a doctor and told one of the front office workers she needed an appointment. She was having "a breast problem". An astute receptionist picked up on the understated urgency in her face and stuck her in an opening in my schedule that afternoon. Maria waited for a couple of hours before she was finally roomed, and when I knocked on the door, I had little idea of what was on the other side.

After I introduced myself, Maria told me that she had un problema with her breast that she had been ignoring. She needed help. Her Spanish was a little challenging to understand, and as such, I wasn't quite certain exactly what she was trying to tell me. But when Maria lifted her shirt, it was clear to me that the "breast problem" was not something minor. The Spanish no longer mattered.

Breast cancer. Visible breast cancer. A terrible oozing mess of abnormal tissue, red and dimpled and irritated and just about the ugliest site you can imagine. Cancer that had grown from a seed much deeper in her left breast, enlarged slowly over time (probably years), and eventually eaten from its origins up through her skin-- until she could ignore it no longer. Cancer looks just like you might imagine cancer would look like-- hideous. Undeniably gross.

These are the reasons I imagine Maria ignored her breast cancer.

Initially, she didn't know what it could be.
After all, most of us haven't been to medical school. We can convince ourselves in the middle of the night that we have foot cancer only to discover with the sunrise that it's just a blister on our foot. Most of us also delay seeking treatment-- I am going on eight weeks of a tooth ache and still have managed to avoid making myself a dentist appointment to evaluate that ache.

She was taking care of her family and ignored her own needs in the context of her family's needs
After all, that's what plenty of mothers do on most days of the week-- you know who you are: you're the mama that should really work today out but instead you go to the grocery store to stock up on lunch materials for your kids. You should go get your pap smear but it's lower down on the priority list than taking Junior to soccer practice or to library reading time. You have been meaning to pick yourself up a few new pair of undies but always find yourself in the kids section of the store checking out the clearance items rather than in the hot mama sexy lingerie section.

Once it started to become more clear, she got scared.
Fear is a huge barrier for all of us. It's hard to understand the immense power of fear. I was speaking to a local breast surgeon last week, and she actually said "I liken women with open breast cancer tumors to situations where people need to drop children off in safe drop zones, no questions asked. It just seems to get harder and harder for women to access care as the cancer gets grosser and more obvious. I dream of having a sign on my door that says, 'Please bring your horrible tumor here. I promise I won't ask why you didn't come sooner."

She didn't speak any English. 
When is the last time you got on the phone with some bureaucratic agency (think DMV or your own dear health insurance company) to try to make yourself an appointment or clarify an oblique notice you got in the mail? You were probably on hold forever or stuck in some crazy bramble of phone-tree hell. Just imagine doing that in another language. Virtually impossible.

She had no health insurance
Fear of a diagnosis is one thing, fear of a medical bill is an entirely other beast. As Covered California continues to take hold here, I am happy to see some people having access to insurance for the first time in years (or even ever), but undocumented immigrants are completely ignored in our new legislation. Hopefully, there will be political will in the coming years to change that (see more here). Thankfully, in California, we have a wonderful state-based program called "Every Woman Counts", also known as the Cancer Detection Program (CDP) and its sister program Cancer Treatment Program (CTP). Both of these wonderful safety net programs were essential in getting Maria expedited diagnosis and care. Thank goodness for our safety net! I really hope everyone knows how important it is that there are programs in place. Please don't disregard the power of the safety net.

I am happy to report that it has been over four years since Maria's diagnosis, and though she went through a lot during that first year, she is currently cancer free. She continues to do well physically and emotionally. She still never complains.

Our health care system is pretty ridiculous, even for well-educated, English-speaking, documented citizens with excellent top-of-the-mark health insurance coverage. It's scary, often overwhelming, difficult to navigate, and generally not user-friendly. And yet, there are some amazing gems that enable providers like myself to continue doing the work we do. Every Woman Counts is one of those gems-- designed to offer appropriate screening AND treatment for vulnerable populations. It is funded by a combination of federal funds and augmented California tobacco taxes. Woo hoo!

It's awesome for me to discover that there are similar such cancer detection and treatment programs available in all 50 states (see link here). It's administered differently in every state, but the CDC provides matching funds and support for these programs. Thank goodness they exist! But, unfortunately, this program are limited to specific diseases, namely breast and cervical cancer.

Now with our new health care legislation, more gaps are being closed, but there is still much work to be done. Don't you think the next best step is to figure out a way to provide similarly excellent care for all people in our country? And not just for their breasts and their cervices, but perhaps also for their migraines, diabetes, depression, heart disease, and even ingrown toenails.

I do.

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