Medical dictionary

This exchange happened in the urgent care recently:


Mom: He threw up bile yesterday.

Me: (doubting face) Was it fluorescent green or grass green?

Mom: (like I was crazy) No, clear.

So, now, my hand is forced. I must do the world a service in the form of an easy-to-read medical dictionary for the masses.

I give you the most commonly misused words by parents, which often lead to either unreasonable medical workup if we take you seriously, or—more likely—us not taking anything you say seriously.

Pay attention.

Bile—the fluid made in your liver, stored in your gallbladder, and released into the small intestine to digest fats. This means if you are truly throwing up bile, things are flowing backwards. That is bad. Fortunately, it’s also rare. Also, bile is DARK GREEN. The two weeks spent dissecting the abdomen in medical school turns all your gloves and tools green. Everything is green. It looks like the Naked Green Machine drink.

This is what bile looks like

              -therefore, clear? NOT bile. Yellow? NOT bile. Ecto-cooler? NOT bile. Snot colored? NOT bile.

NOT bile.

Fever—in an infant, 100.4 rectally or higher. Generally we use this number throughout childhood and adolescence (thankfully the rectal part goes away), although I was recently made aware that our own occupational health (based on AAFP literature) considers 100 a fever in adults. Good thing I don’t treat adults.

                -therefore, 99.1? NOT a fever. Felt really hot? NOT a fever. She normally runs low but was 98.6? NOT a fever (unless you have true hypothalamic dysfunction). I gave her motrin but she was still 100? NOT a fever.

High pain tolerance—this one is a trick question. Just don’t ever say this. Unless you once broke your tibia and walked three miles to get to medical care, or gnawed off your own arm to break free of a rock slide, no one cares. Trust me.

Lethargic—this one is tough, because Merriam-Webster and I might get into a fight about the real definition. Traditionally, it can be a synonym for lazy, sluggish, listless. In medicine, and in pediatrics specifically, “lethargic” means “I think this kid has meningitis”. It means nothing moves you, not even discomfort, not even your favorite cartoon, not even me trying to look in your ears. It’s not good. Please try to be more specific in what you are describing.

                -therefore, your child is less active than normal, but is still happily watching a movie? NOT lethargic. Your child is wanting to be held, but still throws a fit when you don’t let him have his toy? NOT lethargic. Your kid “just isn’t himself”? NOT lethargic.

That’s it. Easy, right? Now you can save yourself the humiliation of all the health care providers rolling their eyes at you, save your kid unnecessary testing, and practice saying what you actually mean. You’re welcome.

How to deal with the doctor in your life

Everybody has bad days at work, I won't argue with that. But in medicine, it's a little bit different. We can’t come home and vent our frustrations with just anybody. As part of the training I did this week as a peer supporter, we were discussing coping mechanisms, like talking things over with friends and family. Specifically non-doctor friends and family. The facilitator asked, "What does it look like when you go to a family member, or a friend, someone outside medicine, and they are able to help you cope?"

We all looked down at our papers, back up at her, thought about it. Finally, one of the anesthesiologists spoke up. "It's never happened. I always get blank stares, or horrified looks at what we deal with every day."

We all nodded. No one disagreed.

I’m sure it’s similar with fields like the military, first responders, law enforcement—where they see things the rest of us can only imagine. While any non-medical person could sympathize with a parent or patient yelling at me, an incompetent co-worker, too many demands on my time, or any number of other hassles of the day to day, they can’t understand what it’s like when a kid you sent home to get better comes back horrifically sick and has permanent damage. They can’t understand what it’s like when you have to tell a parent their child has cancer. They can’t understand when making a mistake really is life or death.

I’m fortunate to have two sisters in medicine and a host of friends from residency, as well as supportive co-workers that I can go to when I have a rough day. But the truth is that most of my family and friends aren’t that helpful in getting past those adverse events. It sounds harsh, I know, but it’s true. It’s not their fault, and I know they love us and want to support us.

With that in mind I’d like to offer a few tips for you non-medical people who know and love us doctors (God bless you).

Please don’t be offended. We still love you, and we appreciate that you’re not in medicine because that can often be a much needed distraction (when we want that, you’re the perfect person!). Just because we don’t come to you first about work stuff doesn’t mean we don’t value your support.

Don’t try to understand the medicine. It can be even more stressful to have to explain the jargon and physiology when we’ve had a bad event. The details of it are not as important as the fact that it makes us feel awful, so if we do talk about it (and we may not), don’t interrupt when you don’t know what a word means, or miss a piece of the story. Don’t try to figure out what it was that went wrong and offer suggestions. Just listen and offer a simple, “That sucks, I’m sorry.”

Don’t compare. This one seems unfair, I know, like my problems are bigger than yours. In general, I want to hear about your good days and your bad days. And when I have a story about a crazy parent, go ahead and one-up me with your crazy client story. When I have a co-worker driving me crazy, please tell me you do too, so it doesn’t seem like the worst thing in the world. But when I have a truly bad outcome, it’s just not helpful to hear about how much grading you have to do, or how you had to work through lunch. I still want to be supportive of you, but it’s not the same, and I need you to understand that.

Pray for us. We’re not perfect. We don’t handle stress perfectly. God’s grace is always appreciated.

The Second Victim

I recently had at work what we call an "adverse event". These are cases where something goes poorly, either because of an error, or just the natural progression of disease, but everyone feels it. A kid is very sick, or passes away, or is harmed in some way, and it shakes all of us out of our happy pediatric comfort zone. I obviously can't go into details, because HIPAA, but it hit home for me a concept that I wanted to share.

In 1999, when the Institute of Medicine published their famous (infamous?) "To Err is Human", detailing the widespread prevalence and effects of medical errors, a brave physician from Johns Hopkins thought to go one step further. In his sentinel paper, "Medical Error: The Second Victim", Albert Wu outlined the idea that medical errors, and all adverse patient events, harm more than just the patient and their families. He observed that "although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victim".

I can feel the cynicism rising up right now: How can doctors even compare their "suffering" to a patient death? Shouldn't they feel bad if they've done something wrong? Shouldn't we focus on the medical errors and stopping them instead of telling doctors "it's okay" after they mess up?

Those are all valid questions, and the answers to the last two are surely "yes", but that's not the whole story. Second victims have symptoms very similar to PTSD, experience higher rates of depression and burnout, and can have impaired performance due to maladaptive coping behaviors, decreased confidence, or fear of making a further mistake. I will attest that these are not theoretical; they are very real. And I think we can all agree that if we can avoid these effects, that's a win.

We are about to launch our own Peer to Peer Support Network at work to help second victims, and this experience has taught me a lot of things that I hope to carry forward..

I've learned that adverse events are going to happen, and that we all make mistakes. Let me repeat that: We all make mistakes. It just so happens that in our job, mistakes can range from forgetting to bring someone a blanket to causing a death, and that's terrifying. We make hundreds of decisions every day in a very stressful environment. We set up our systems to try to prevent as many errors as possible, but you can't remove the human element. We have to learn from our mistakes instead of letting them cripple us.

I've learned that I work with amazing people. One of the nurses I work with found out I was upset about the patient and said, without hesitation, "You know we all stand behind you because we know the kind of doctor you are." The other doctors, who had every right to critique the situation, instead offered their support and acknowledgement that our jobs are very difficult and we all have these days. It makes all the difference in the world to be able to have that support at work, which makes me excited to train as a peer supporter.

I've learned it's important to take a deep breath and remember why we do this. It can be so easy to get caught up in a busy day and miss the small details, miss the opportunities to really meet our patients where they are and be part of that encounter. Yesterday, with this fresh on my mind, I spend a few extra minutes in each room, talking to families, being thorough, not letting the 18 patients in the waiting room get to me. And I could feel it make a difference. I was a better doctor because of it. Hitting that reset button every now and then, without waiting for an adverse event, is crucial.


Finally, I've been reminded that I'm not doing this of my own accord. God called me to this profession, has given me the things I need to succeed, and can decide what to do with me from here on out. And that's okay. I don't have to be perfect, because He is. He is bigger than the adverse events, than the mistakes, than the bad outcomes. He also cares for His children and gives us the tools we need to move forward if we let Him.

Those who are healthy

Working in urgent care and emergency rooms, we see whatever walks through the door. That means whatever. It means the 64-year-old with appendicitis (yes, at the Children's ER), the 8-year-old who ran over his ankle with a motorized scooter and has severed nerves and blood vessels, and the toddler who had a black marker stain on his foot. At one in the morning. True story.

In the midst of all the real emergencies, it's so easy to become cynical towards the families bringing their kids in with marker stains (and trust me, it happens WAY more often than you would think!). It's so easy to judge parents, grandparents, foster parents who I think should know when to bring their kid in and when it's okay to watch at home. I get frustrated that after motrin, a popsicle, and a sticker, they look just peachy and ready to go home.

Then I read in the Gospel of Luke about the call of Levi, where Jesus tells the similarly judgmental Pharisees that "Those who are healthy do not need a physician, but the sick do." Can you see the 2x4 shaped mark on my head? Obviously no one wants to bring their kid to the Urgent Care at three in the morning. No one wants their kid to be crying and sick and miserable. They came because they need a physician. Even if all that physician needs to do is reassure them, give their kid a popsicle, and tell them what to expect for the next few days. Even if all that physician needs to do is check for an ear infection, eyeball a rash, or, yes, clean off the marker stain with an alcohol wipe.

And what a privilege it should be to treat those kids. What a privilege it should be to offer a little bit of hope, help, or healing. No matter what.

The last few days I've tried to remember that as I walk into my shift, to bring compassion to every patient, not just the ones who I think are sick enough to see me. After all, they wouldn't be there if they didn't need something.

Ecological breastfeeding and the slippery slope

I've recently become more and more aware of a baffling (and for me, frustrating) trend among young Catholic families. As a physician practicing within the reach of Boulder County, I'm used to the "all-natural" crowd. I hesitate to lump all of this into one label, but you know the ones I mean--the babies with their amber teething necklaces, lack of vaccines, homeopathic remedies, breast-feeding until 2, co-sleeping until 8, and a firm mistrust of anything "scientific".

I'm used to it from certain people, but when I started to see more and more young Catholic parents falling into this camp, I couldn't understand why. Now, I realize that to most of the secular world, Natural Family Planning (NFP) and big families and home-schooling place Catholics squarely in the kook camp along with the other stuff. But in my mind, the Church and science have gotten along pretty well since Galileo, and there's definitely a place for both in living life to the full. So why the shift?

I'm obviously not a mom, so I can't say for sure, but I think it comes down to one practice: ecological breastfeeding (EBF). For those moms who are using NFP, a non-hormonal way to ensure birth-spacing is probably desirable. There seem to be two main options--wait until your periods return and resume NFP, or breastfeed to keep your prolactin levels high enough to prevent ovulation. For those who are breastfeeding anyways, return of normal periods can take several months, so many are opting for the latter. There is some science (I haven't read all of it, but most of seems to come from a single source--Sheila Kippley--one of the founders of Couple to Couple League) that supports the best way to ensure lactation amenorrhea (lack of periods from breastfeeding).

The basic premise is that if you follow the Seven Standards, your prolactin levels will be high enough to prevent ovulation for an average of 14 months. Most of the support for this method touts the "natural" and "God-intended" practices, as if failing to adhere to these standards is somehow second-rate. And I think it then leads followers to embrace all other things "natural", especially since many of the breast-feeding, co-sleeping moms fall into that Boulder camp that I mentioned earlier, and that's what's out there on the internet.

I am not against EBF by any means. I think that it can be a wonderful way of bonding with your child, spacing birth without hormones, and supporting good nutrition and health as recommended by the American Academy of Pediatrics. However, there are several conclusions from the EBF mentality that I absolutely disagree with, and I think this is where my frustration comes in--seeing well-meaning, intelligent, faithful people sliding down a path of ignorance and frankly, sometimes danger.

I think if you're going to consider EBF, please also consider the following:

1. EBF is NOT the only way to space birth without hormones or contraceptives.

Those who do EBF can expect a delay in their periods for 4-24 months. That's a big range. Not every woman, even following the Seven Standards, can expect her body to delay ovulation 100%. Studies suggest that those who exclusively breastfeed can rely on their bodies not to ovulate before the return of periods up to 93% of the time (in other words, once you start bleeding again, even if it's irregular, you need to start charting). However, if you continue to chart temperature and mucous like before, you can fairly accurately predict ovulation even without menstruation over 90% of the time as well. I can't find the original data I read on this, but I'm sure NFP providers would know more.

2. If you are unable to do EBF, it does NOT make you a bad mom. Similarly, doing EBF does NOT automatically make you a better mom.

EBF is HARD. Those Seven Standards make it literally impossible to have a job, have a babysitter, be away from your baby pretty much ever, have your husband do one nighttime feeding so you can get some sleep, or use a pacifier in a pinch. Not everyone can do that; not everyone is supposed to do that. If you need extra sleep for your health, if you need to return to work for financial stability, if you need to step away for your sanity, that does not make you a bad parent. It makes you an aware parent who realizes that the baby's health is determined by more than just whether they can nurse on demand.

3. Co-sleeping does not have to mean bed-sharing, and there are safe and not-safe ways to do this.

From everything I've read, the Seven Standards allow for room-sharing without bed-sharing--a bassinet, a crib, a mat on the floor, a side-sleeper--all allowed. Further more, there are safe ways to bed-share and not safe ways to bed-share. You still need to have a firm mattress close to the floor without extra pillows or bedding. Avoid any medications, including alcohol, that make you sleepy, and never co-sleep in a chair or on a couch. Please, please, please talk to your doctor about how to make bed-sharing safe if you want to do it.

4. Using a "natural" method of child-spacing does not make all "natural" things better, and avoiding the "scientific" way of child-spacing does not make all "scientific" things bad.

This is the one that drives me the most crazy. Hemlock is natural. Marijuana is natural. Cocaine is natural. Are those safe? Of course not. Untreated water is natural, but led to extremely low life-expectancy before waste management was developed. Homeopathic remedies are not tested, are not necessarily harmless, and are mostly not effective. I accept that not all available medical interventions are necessary or even right, but there are proven things we can do to improve your child's health. Similarly, just because your doctor recommended artificial birth control after childbirth doesn't mean everything she recommends is against the Church teaching. Find a doctor you trust and make it a partnership. And for Pete's sake, throw away the teething necklaces.

5. The Church does not care whether you do EBF, or whether you espouse Attachment Parenting, whether you cloth diaper, or whether you home school.

The Church is here to guide us on matters of faith and morals, not on what kind of car you drive, whether you buy organic, or how to raise your children. There are obviously moral implications to many of the things we do, but it's not black and white. You also have to think about what your reality is, what your strengths and limitations are, and whether the benefits outweigh the downsides. Of note, the Church does support breastfeeding ("if possible") as the intended means of nutrition and bonding for a new baby, but doesn't care if you use a pacifier. She does, however, think it's okay, and even morally responsible to vaccinate.

 Again, I'm not saying EBF is bad. In fact, if you can make it work, more power to you. But it isn't the only way, and it doesn't necessarily condemn you to a life of following Jenny McCarthy and Dr. Oz.

Learning medicine

Last night I attended an awards banquet at the School of Medicine for physicians who volunteer as preceptors, taking on a student one half day a week for their first two years of medical school and part of their third, teaching them about clinical medicine in the real world. When the program was founded 30 years ago, most teaching was done in a university hospital, where less than 1% of those who sought medical care would eventually be treated.

I remember my Wednesday afternoons with my preceptor in medical school, me always feeling nervous beforehand, but excited to get out of the classroom and actually see patients. I left every evening grateful for the learning, but wondering how in the world would I ever know enough to practice medicine?

I remember my own student's first day, me still wondering if I knew enough--this time to teach it to someone else. And I guess it's going okay, because she nominated me for Best Pediatric Preceptor, which if you knew some of the others who were nominated, you'd know was a huge honor.

But there's a lot more than just imparting medical knowledge, and that was the takeaway for me yesterday. The best preceptors also invest in the relationship, becoming a role model for communication, empathy, integrity, balance, and perseverance. We have the opportunity to remind these students why they went into medicine, when they spend most of their days memorizing the Krebs cycle. We can show them the incredible gift it is to take care of patients. And in doing so remind ourselves of that very thing.

Top 5 Ways Hollywood Medicine Fails

I realize that all of Hollywood is fake. And that creative license exists to further the storyline. But I'm pretty sure the "medical consultants" on all major TV shows and movies are from "The Doctors" and don't actually know what they are doing. Or else everyone ignores them. Here are the biggest offenders.  

1.      The biggest flub no matter who you talk to: We don’t shock asystole.

 Nearly every code depicted on TV involves a patient suddenly flat-lining (that dramatic long beep where there is no heart beat, also known in medical speak as “asystole”) and someone yelling “clear!” just prior to the body dramatically jumping off the bed. So you all know, patients rarely just flat-line. When you start circling the drain, adrenaline kicks in and your heart rate speeds up to try to match the demands of infection, injury, stress, what-have-you. The heart tries its best to keep up, its internal pacemaker keeping things going even when the rest of the body is shutting down. Sometimes it works so hard and fast that it can’t beat in rhythm anymore, a condition known as ventricular fibrillation (or V fib).

This is very scary

If that word sounds familiar, it’s because those infamous paddles belong to a device called a de-FIBRILLATOR. Meaning “to stop fibrillation”. In other words the electricity stops that crazy rhythm and allows the heart to restart its own pacemaker. Guys, the paddles STOP THE HEART. Which makes no sense if the heart is already stopped. So shocking asystole is just bad medicine, and every one who’s ever taken an advanced life-support class knows it. Even the automatic defibrillator machines know that. If there is no heart beat, we instead make the heart beat by doing chest compressions and trying to restart it with epinephrine. Which I guess is just not as dramatic as “CLEAR!” But really, how hard would it be to put V fib on that monitor instead of asystole. Seriously.

2.      Medicine is boring. I realize it wouldn’t make for the most compelling story lines, but can we talk for a second about how much of my shifts are spent typing notes, putting in orders, reviewing results, or waiting on hold for a consultant? They’ve done studies about how much of a doctor’s day is actually spent in patient care, and it’s not much. Besides that, most of the cases are routine things like telling parents that their kid’s cough will go away on its own, or telling that adult patient (again) to take their blood pressure medicine. Fascinating, I know. Believe me, I know. So sure, glam it up, script writers, but at least on cop shows they talk about all the paperwork and leg work leading up to the dramatic show-stealing chase scene/shoot-out. Yes, that one helicopter flight to the ICU is what we talk about all week, but it’s a small percentage of what I actually do, and the paperwork from it takes almost more time than the case itself.

3.      Pen tracheostomies aren’t the norm. Speaking of over-dramatizing, I just want to make sure you all know that when someone drops dead in a restaurant/subway station/playground/their kitchen, doctors (especially medical examiners) do not come out of the woodwork to put in tracheostomies or remove bullets or perform emergency surgery with a bottle of vodka and a pocket knife. 80% of the job is having the right tools, which does not include a ball-point pen ever. We all still call 911, and then start CPR. The end.

Never gonna happen

4.      One doctor doesn’t do everything. “House” made it standard, but every show is guilty of expanding the lead character’s expertise to a convenient, but unrealistic scope. We aren’t usually the ones drawing blood, giving meds, hooking up the ventilator, running the CT scanner, and doing surgery. In fact, most of us don’t do any of those things. Medicine is a team affair, and yes, that would involve paying a lot of extras, or having the docs do the more mundane parts of their job on-screen (see #2), so I understand why Hollywood does it. Just don’t expect your doctor to.

5.      Michelle would like to add an honorable mention regarding TV pharmacists: When asked “Do you know what fentanyl is?” The correct answer is not “oh, synthetic heroin?” Everyone knows what fentanyl is.

A doctor's tools

I like to think of myself as a minimalist when it comes to running tests and ordering medications in the urgent care. The nurses love it. My mother hates it. “You mean all you do is give them Motrin and a popsicle? That’s it?????” Yes, mom, that’s it. That’s all they need. Most pediatric disease is self-limited, either caused by a virus, or idiopathic (that wonderful term for “we don’t know what causes it”). Most pediatric injuries heal without major intervention. And so running a bunch of expensive, sometimes invasive tests that will most likely be normal seems like a waste in every sense of the word.

Plus, there’s a reason I went to 4 years of extra school and 3 years of indentured servitude residency. It’s called making a clinical diagnosis. You know, what doctors used to have to do for every patient, based on a good history and a thorough exam. They had to know how different heart murmurs sounded, because there was no same-day echocardiogram. They had to learn the signs of heart failure, because measuring brain natriuretic peptide hadn’t been discovered yet. And yes, they had to do a rectal exam on patients instead of getting xrays to diagnose constipation (which is still a more effective diagnostic tool, by the way). Call me crazy, but I like being a clinician instead of merely an interpreter of lab results and imaging. I pride myself on it most of the time. I spend a lot of time convincing parents that it’s a better way to go.

But if you want to make me doubt my clinical skills, if you want me to long for the ability to check a quick BMP or grab a chest x-ray, frankly, if you want to make me feel helpless, then take it all away. Put me in a teepee on the side of a mountain trying to tease out post-surgical abdominal pain in a teenage girl. Or on the phone with a worried friend who doesn’t want to make an unnecessary ER visit for her child. Or on the flag football field when someone goes down with a “pop” in one of his joints. My calm reassuring voice becomes laden with doubt, and I forget all of my training. Or at least that’s how it feels. At least for a moment. Then reason kicks in and I start to work through the problem, ruling badness in or out, looking for red flags, gathering as much information as I can.

The few physicians in my Wilderness First Responder course were sick of being outside the hospital, without any of our normal comforting resources (labs, radiology, even monitors) and not knowing what to do. We all needed a reminder that we are, in fact, clinicians first. We can use our eyes, our hands, and our brains instead of machines. I try to remind students of this when they rotate through the urgent care. It’s what I try to practice on a daily basis, even when I don’t have to, because it makes me a better doctor when I do have to.

And in reality, a popsicle is sometimes all the tool we need.

I kind of want to post this everywhere

I know that Urgent Care is easy. And the hours are better. And you’re busy. But there are just some things that shouldn’t be seen at Urgent Care. To avoid the frustration of multiple trips, waiting too long, leaving with no answers, or being judged based on your chief complaint (it happens; I’m not proud of it, but at least I’m honest), try to follow these rules.

1)      We do not have unlimited access to specialists, nor will the specialists see you sooner if you are in the Urgent Care. We get countless walk-ins and even referrals from doctors wanting their patients to have an echocardiogram or EEG, see the pediatric dentist, or get in sooner with their rheumatologist. It’s not going to happen. If it’s truly emergent, you may be admitted at our main campus and see those specialists within 24 hours, who will then decide on any workup/treatment. Otherwise, we have to go through the same channels your pediatrician does to get to the specialists, and the vast majority of the time, we are only consulting by phone, often with a resident, fellow, or mid-level provider. The end result is usually adding you to their growing appointment list, often months out. If you want a specialist, have your doctor call them instead.

2)      Please don’t come in with 6 months of chronic symptoms without seeing your regular doctor first. If you’ve had something going on for more than a few weeks and haven’t been able to solve the problem with Dr. Google or with multiple trips to other ERs, chances are it won’t be a quick fix for us either. Our job is to rule out bad things and get you the right follow up, often with your regular doctor. Plus, if we start a lab workup or want to order tests, your doctor won’t always be able to follow up on the results (and chances are we won’t either, since many of the labs and imaging studies come back once our shift is over). Additionally, if you don’t get better in two days and decide to come back, you will be seen by someone different, who will have no idea how you looked the first time, may have a totally different approach, or may disagree with what has already been done. It’s a lot easier to solve long-term issues with a long-term plan—namely, your own doctor who can see you through the illness and follow up on what they recommend.

3)      We are an URGENT care. We are not an “I just had a quick question” or “I didn’t want to make an appointment with his doctor” care. The following are all real complaints that have come in to our Urgent Care or ERs—ear pain for 20 minutes (no meds given at home), band-aid stuck to leg, need a refill on Prevacid (which is now over the counter, by the way), the child felt warm, grandma said he needed to be seen, was exposed to someone with a sore throat but doesn’t have any symptoms. There are nurse lines for these sorts of things. We are always happy to offer reassurance, but please don’t expect me to rush in when I have other rooms filled with asthmatics, broken bones, migraines, seizures, pneumonia, partially amputated fingers, or other things more…urgent. It’s always the people who don’t really need to be there that balk at the wait times. Imagine waiting until your pediatrician’s office opened. In two whole hours.

Some days are worse than others

This week I had to tell a mom her daughter had cancer.

It did not go well.

When the patient checked in, I thought that “Fever, cough” indicated yet another flu victim. But as I heard the story and progressed through my exam, my suspicions grew. And as I left the room to put orders in, I told the nurse, “She has leukemia.” Twenty minutes later when I had the first of the lab results back, I got a sinking feeling in the pit of my stomach knowing that I would have to break the news. The worst news. The news no parent wants to hear.

There is no way to predict how someone will respond. I expected tears. I didn’t expect what actually happened. It’s probably one of the most disconcerting things I’ve ever experienced to be the cause of that kind of reaction—screaming, fist-pounding, falling to the floor, more screaming. Top of the lungs screaming. Heart-rending screaming. Agony. I hated being the cause—even indirectly—of that level of anguish. I could do nothing to make it all okay, to make it all go away. In that moment, I was powerless.

Maybe that’s what I hate. Being helpless. At least when I’m suffering, I participate in the struggle, I have a role, I fight. But watching someone else grieve, watching someone else ache—I can’t fight her battle. It breaks me. So I pray. Because God knows what He’s doing. He holds that toddler and her mom just as He holds me. I’m trying to convince myself of that even as I type it. That I don’t have to have all the answers. I don’t have to be perfect. I have to present, and I have to be faithful. He will do the rest.

God has created me to do Him some definite service. He has committed some work to me which He has not committed to another. I have my mission. I may never know it in this life, but I shall be told it in the next. I am a link in a chain, a bond of connection between persons. He has not created me for naught. I shall do good; I shall do His work. I shall be an angel of peace, a preacher of truth in my own place, while not intending it if I do but keep His commandments. Therefore, I will trust Him, whatever I am, I can never be thrown away. If I am in sickness, my sickness may serve Him, in perplexity, my perplexity may serve Him. If I am in sorrow, my sorrow may serve Him. He does nothing in vain. He knows what He is about. He may take away my friends. He may throw me among strangers. He may make me feel desolate, make my spirits sink, hide my future from me. Still, He knows what He is about.                                       -John Cardinal Henry Newman

Looking back

Today Mass was celebrated for a doctor who changed the life of a priest—Fr. Riley was one step from abandoning the Midwest misery of Notre Dame for the glamour of Hollywood, but typewritten letters from a friend convinced him to stick it out and here he is. Quite the legacy. It made me think of a priest who changed the life of a doctor…

Apprehension filled my heart as I sat in the stiff chair, clutching my test results. What if he couldn’t tell me what my career path was? What if I answered some of the questions wrong? What if he told me something I didn’t want to hear? I almost laugh looking back at it now, how anyone could be fearful of meeting with a soft-spoken five-foot jolly caricature of a Jesuit. 

As freshmen at Creighton, I’m sure there were many opportunities for career advice, but the only one anyone took seriously was Fr. Schloemer. (Reverently picture a garden gnome. In a collar. That's him.) His formal title escapes me, but he worked in academic counseling, and the general sentiment was that he was the one to tell you what to do with your life. There was a prerequisite personality and skills inventory whose results I carried to my appointment that day, but I was still skeptical.

The structure of the meeting was informal. We mapped out a sample course schedule based on my chosen major (biology) and I don’t even think he looked at the test. Near the end of the discussion, he set the course for my vocation as a physician. With his dulled pencil in hand, he humbly asked, “May I make a suggestion?” I nodded somewhat hesitantly. He scrawled “MCAT” on my schedule between the column of my prospective sophomore and junior year. I cringed.

“I don’t want to take the MCAT. I don’t think I want to go to medical school.”

“You’ll have all your prerequisites done. It’s better to do it before you forget. It doesn’t mean you have to apply to medical school.”

He had a point there. So I resigned myself to this new development and left feeling somewhat unfulfilled. I still didn’t have an answer. Or so I thought.

From that moment on though, I could see God chipping away at my wall. I wasn’t confident enough, or smart enough, or dedicated enough to be a doctor. But I started to want it. I would see a cluster of short white coats shuffling through our science building and I began to tell myself, “That could be me.” I began to see myself in medical school, taking care of people, studying for the long haul, and I was at peace with it, even excited about it. Within a few months, it was as if there had never even been another choice. This was what I was meant to do.

From the beginning of this long journey, I knew this was God’s plan for me, obviously not something I came to on my own. And every time I hit a road bump (from a failing grade—yes, those happened—to being belittled by a surgeon to staying up 30 hours straight), I knew I wasn’t doing this by my strength. I knew I wasn’t alone. God had foreseen this when I was a scared little freshman, and He knew I could it.

So thank you, Fr. Schloemer, for those four letters and your humble “suggestion”. It changed my life.

PSA for MIA parents

Imagine this. You finally get a vacation. With your spouse. Away from the kids. Hooray for Grandma and Grandpa! You hope they have everything they need, but really all you can think about is that king bed next to the window overlooking the beach. And sunshine. And quiet. You promise you'll check in every night...maybe.

Now imagine this. While you're gone, your slightly clumsy 4-year-old walks straight into a door, splits her head open, and gets taken to the wonderful pediatric urgent care down the road. Only they can't treat her. Because you are unreachable (darn cell reception on the beach), it's not a life-threatening emergency, and you forgot to give power of medical decision making to Grandma and Grandpa. Whoops.

This actually happened to me last week (well, I wasn't the one on vacation, obvi. I was the treating doctor). Mom and Dad were on a plane over the Atlantic and Grandma had one traumatized little girl and her restless older brother with no way to consent for medical care. Thankfully the plane landed and we got phone consent in time to get the patient the stitches she needed and home to bed, but there's an easier way.

If you are going to be out of town, unreachable, or leaving your kids in someone else's care for a prolonged period of time (in my mind, that's a couple of hours, given that you never know what kids will do), it's a good idea to give the caregivers medical power of attorney (MPOA) for your kids. Every state is different, but from what I know, here's the basics.

1. The MPOA does not ever supersede your rights as a parent, nor does it allow the temporary guardian the ability to let your child be adopted or get married (I know, we were all worried Grandma might go a little crazy, right?)
2. The MPOA is good for up to a year and allows a designated guardian the ability to make medical decisions for your children.
3. An MPOA is not necessary for emergency treatment. This qualifies as life- or limb-saving measures that any reasonable person would agree to for their children. This does not apply to cosmetic or non-emergent issues, even including facial stitches or broken bones (which can be set a few days later with good outcome).
4. The MPOA should be a signed document designating specific (named) people to care for your (named) children (include date of birth) during a specific period of time and should be signed and dated by the parent.
5. Our hospital (as far as I know) does not require a notarized form, and Kaiser's form says notary is optional, but for water-tight agreements, notary is preferred. Here is an example of the form for Colorado. Every state may have their own requirements.

So, next time you flee the madness of your offspring for sandy beaches (or if you know someone planning to do so), make sure an MPOA gets filled out so that we can take better care of all those kiddos.

Burnout and what to do about it

Physicians have the highest rate of suicide of any profession.

I told this to a friend of mine the other day and she was shocked. And I was shocked that she was shocked. To me, it seems obvious—we have high stress jobs, high rates of depression, and knowledge of as well as access to lethal drugs. We take on the suffering of the world without training in how to deal with burnout, loss, abuse, and failure. Residency is only possible for those who become, as Dike Drummond notes on The Happy MD blog, lone-ranger-superhero-emotionless-workaholics. How else are you supposed to survive being solo on an overnight call with the sickest patients in the hospital? So that’s how we cope. But that’s not the answer. In one study, 40% of interns (first-year residents) met criteria for major depressive disorder.¹ Forty percent!

I was discussing this with a colleague recently, lamenting the fact that we have to turn off our compassion in order to survive difficult situations. If you get too close to the teenager dying from cancer, it’s too hard to do your job. So you create distance. “You have to!” I said, meaning it. She looked at me sadly. “No, you don’t.”

I’m not sure I completely believe her, but I think that’s because I was trained (as we all were) to become a lone-ranger-superhero-emotionless-workaholic. Thankfully my faith and my amazing support system have kept me from going too far over the edge, but what if there was another way? One that didn’t involve having to always be right or never being able to ask for help? Medicine will always be difficult (especially in today’s world with its constant fight for reimbursement, poor access to care, and patients who diagnose themselves with Dr. Google and get their vaccine advice from celebrities) but we don’t have to get burned out.

General estimates among practicing providers are that anywhere from one-third to over half suffer from symptoms of burnout (defined as depersonalization, emotional exhaustion, and decreased sense of accomplishment). So what do we do?

There has been a lot of promising research in the areas of mindfulness and positive psychology, and I’m starting to immerse myself more in it as I take on the task of improving wellness and reducing burnout within our section (not a small challenge, with some 100 providers and the lowest employee satisfaction rates within the hospital).

I’m not under the impression that things will change quickly, or by great percentages, but I’m going to try to do something. I have to. Because the alternative is to accept the unreasonably high rates of depression, burnout, and suicide in my colleagues and friends. And we were made for more.

To finish, I’m going to borrow an exercise from the Positive Psychology department at Penn to challenge you, dear reader (and myself). It has been shown to improve wellbeing and to have lasting effects even 6 months down the road. It’s called “What Went Well”.²

Here’s how it works:

            For 2 weeks, at the end of every day, write down 3 things that went well that day. Doesn’t have to be big things. Then write down why those things went well.

            Example: I was able to work out today because I was disciplined and had the time to commit to exercise.

            Another example: My best friend called me to catch up because she cares about me and wants to know how I am doing.

            That’s it. That’s all you have to do. You don’t have to show it to anyone or make it eloquent. Just give it two weeks.

Here’s to wellbeing. For all of us.

1. Guille, C., et al. (2010) in Journal of Graduate Medical Education.

2. For more exercises and resources, visit www.authentichappiness.org