Secret #19 Work is not quite what I thought it would be…and I’m usually okay with that.

A college student shadowed me in clinic this afternoon. That means she followed me around clinic to see what a half-day in the life of a pediatrician was like. She had followed a family nurse practitioner that morning. They had seen one patient. He cooked her a spinach lasagna for lunch. My jaw dropped when I heard this, and I was immediately envious. One patient? She ate lunch?

Rosie arrived to shadow me at 1:30. I had missed lunch in attempt to finish up my charts from the morning. My neighbor dug up my home internet cable in a massive remodeling project the day before, which meant I couldn’t finish charting at home like I normally do. I had spent the lunch hour trying to get the notes from the morning done before I forgot what had happened in the visits. Skipping lunch meant that I had made up for food in cups of coffee. The tremor was only noticeable if you looked close.

First up was a set of three siblings, 13y, 11y and 7y. . It was a mad visit. Mom was concerned the 7 year old wasn’t sleeping enough. Further interview revealed that she stayed up until her father got home from work at 11pm to say good night and then had to get up at 6 for school.

True. That kid was not getting enough sleep.

The 11year old was mean to his sister and routinely spends his spare change on candy bars and chips, resulting in a heavier weight than his mom desires. When I asked if he was willing to change the way he eats, he rated his desire to change at a 5 on a scale of 10. I thought-ooh! This is a great way to show off my new motivational interviewing skills. I asked why he wasn’t at a lower number, like a 3. He said,” I don’t want to be fat, but I really like chocolate.”

True. I had to give the kid credit. I felt his pain, especially today.

The 13 year old was last. I gave a brief discussion about drugs and alcohol, recommending a weekly check in with his parents about what he sees at school and whether he has been offered anything like alcohol or marijuana. His dad interrupts me to say, “I tell him everyday about drugs and not to do them. He knows not to disappoint me.”

True. But if your kid was at a party being pressured to drink, would you want him to be so afraid of disappointing you that he didn’t call for a ride home?

The afternoon went on. We listened to wheezing, diagnosed strep throat, prescribed antibiotics, discussed the merits of allergy testing, mentioned the advantages of vaccination at every visit.

I handed my stethoscope over so Rosie could listen to a heart murmur and saw joy cross her face as she listened to a heart. Damn, I thought, I used to be like that. I felt a surge of love for my work that I haven’t felt in months.

When I was Rosie’s age, I didn’t think I was smart enough to be a doctor. I definitely didn’t think I had enough money to go to school. Its good to look into the eyes of a newbie. I realize how lucky I am. Now if I could just get internet turned on at home….

Not-So-Secret Secret #17: There’s a Good Reason Why Your Doctor is Late.

I hate being late. I’m the one at the airport two hours before the flight (more time to stretch my legs before taking off!). I’m the first person to come to the party (and if I’m way too early, I’ll wait in the car until I’m just a little early).

Same goes when I am in clinic. I want to be on time to see you. I want to address your concerns in a thorough and timely manner. I respect your time. So when I show up in the exam room after your appointment time, what just happened there?

I thought a lot about this today. I was pretty late for my last patient—almost by a half an hour, sorry to say. Where did the time go? The minutes and hours were filled with urgent phone calls with other providers and patients; visits that needed more time than we had; concerns that needed attention sooner rather than later– on top of an already full schedule. Here’s a snippet:

7:40 am: Get to work after dropping the kiddo off at preschool.  My first patient is not until 8:20, and I like to start early and set myself up for success– organize my desk, listen to my voicemail, clean my stethoscope, look at my schedule, turn on KEXP. (John in the Morning is the perfect soundtrack for a good day.)

8:05 am: Just started to look at the chart of a complicated patient scheduled later today when I get a call– it’s a psychiatrist I have been playing phone tag with for the past 2 weeks.  I have to answer this. I put my chart review on hold.

8:40 am: Still on the phone with the psychiatrist when my medical assistant knocks on the office door. My 8:20 patient just arrived. She’s already 20 minutes late, and with the additional 10 minutes it’ll take to get her vitals, I’ll be 30 minutes late (and my day hasn’t even started!). I agree to see her– she took 2 buses to get to clinic and doesn’t have any other free time to bring her kiddo to the office.

9:05 am:  Finishing up with my first patient– thankfully the visit was relatively uncomplicated, giving me some time to catch up and see my 8:40 patient, not too late.

9:10 am: While I am in the exam room, my pager goes off. I glance at the message while pulling up the growth chart for the little one here for her well visit. Looks like an urgent lab result for a patient I saw in the nursery over the weekend. The babe was still working on feeding, and her bilirubin level was just on the cusp of being too high. Should I answer the page right now or finish up with my visit? I decide to finish up with my current visit first—hopefully the lab tech will stay close to the phone for the next few minutes.

9:17 am: Out of the exam room, placing orders for vaccines for one patient while calling back the lab about another patient. The baby from the weekend has jaundice and needs to be hospitalized. The family is primarily Spanish speaking, so I’ll need to call a phone translator first in order to explain the lab results and the need for hospitalization to the family. My 9 am patient is already roomed and ready to go. It’s one of my patients with chronic complex medical needs. I really need our time together to be uninterrupted, so I ask the nurse to complete all of the routine screenings before I am in the room—this will be more efficient for the visit, and also buy me some time so I can admit the baby to the hospital.

9:32 am: On a phone call with the Spanish interpreter, the baby’s mom, hospital admitting, the hospitalist team, and myself. Mom has a great understanding of what is going on with the baby and agrees with the need for admission. The RN pops into my office– all of the screenings are done for my patient here in the clinic, and the vaccines have been consented to and done as well. I give my nurse a thumbs up and quickly glance at the clock. It’s more than 30 minutes past my patient’s appointment time, and still I have to finish the admission, and then see my clinic patient who is here. On top of that, the 2 cups of coffee I had this morning are coming back to haunt me—I have to pee. Really badly. We don’t have a staff bathroom in the clinic (it’s for patients only), which means I have to go to the other side of the building to empty my bladder. Time wise, this translates to 5 minutes of walking, 5 minutes of pee-ing, and another 5 minutes of walking. That’s 15 minutes that I don’t have right now. I guess my urinary needs have to wait—maybe I should schedule voiding time at the end of the day??

So what does all of this mean, for you as a patient? First of all, I hope my little schedule expose helps you realize that there is probably good intention behind why your provider is late. We are trying our darndest to address everyone’s needs. Secondly, I hope this glimpse into a busy day helps you find ways to get your medical needs addressed in an efficient yet thorough manner. Here are a few of my thoughts:

Schedule medical appointments at the start of the day or right after lunch: Unless an emergency crops up, you are likely to be seen right away.

Come to your appointment on time:  Or better yet, come early. In a busy practice, every step of the process takes time, and every bit of time counts. We ask our patients to come 10-15 minutes early- that way, all the necessary registration, paperwork, and rooming (which usually includes taking vitals, growth measurements, and answering historical questions) is done before the actual scheduled time.

Find ways other than an appointment to get your medical needs met:  In the era of internet connectivity, many providers have the capability of communicating with their patients via email or electronic messaging. Ask your provider about it. Oftentimes I find that this a great way to communicate about non-urgent needs. I can also let my patients know if I think an appointment is needed.

Come to your appointment organized:  I love lists. When patients make lists of questions, then I feel confident that we are addressing the most pressing issues.

Talk to your provider:  Let him or her know your concerns. We care about you, and we want to make things better.

-Lena

Not-So-Secret Secret #41 Take good care of yourself.

Whether in doctoring or parenting, we all need to take good care of ourselves in order to have the capacity to show up to our own lives. That might mean trying to find time to sleep and exercise with a new baby in the house, or finding time to eat when you are on a 30 hour shift at the hospital as an intern.  In stressful times, it can be easy to feel overwhelmed by life.
When the back of my neck starts to hurt, and my heart rate picks up, I think back to the last time I slept for more than 6 hours, or went for a run. At 40 years old, I have learned to think a bit before I put my hand in the candy jar, and instead of getting a cup of coffee, I occasionally try to walk outside for a few minutes instead.  Don’t worry, I hit up the candy jar and coffee pot on a regular basis too, but I’m trying to pay attention to what helps me feel better for an hour or a day, not what distracts me from reality for a few seconds.

So…tips for new parents (and all of us)
-Ask your friends for help. Especially with a newborn, it is easy to feel overwhelmed and alone with a new soul needing you, your boob, and your attention. So call in your friends and family to come over and do your laundry, vacuum your house, take you on a walk, or hold your baby while you take a shower.
-Make a short list of things that calm you and bring you joy. For me, it is five minutes sitting in the sun, a 20 minute yoga practice, and sleep. Find a way to do those things. It will often require asking for help.
-Wash your hands. All of the time. It will keep you and your baby healthy which will allow much more time for all of the above. As a doctor, I wash my hands religiously at work. I don’t get sick from working in clinic, but bring a toddler to my house and I will be sniffling in a few days. All those loves and slobbery toys get me sick every time. I can’t say it enough. Handwashing!
-Feel the love. Make a list of the people you can count on. Family, friends, husband, colleagues. Bring those people to mind when you feel overwhelmed. Call them.
-Read about post partum depression. Having a baby is hard on both parents. And the horomone roller coaster as your body recovers from birth can be a wild ride. Your pediatrician and obstetrician will have the information about local resources and support groups. Postpartum International at http://www.postpartum.net is also a good place to find support.

-Kristi

Not-So-Secret Secret #52: Breastfeeding is Hard Work.

I’m just coming off a weekend working in the newborn nursery, and these days there’s a lot of talk about breastfeeding. My hospital is in the process of becoming “Baby Friendly”, which means that the medical center is taking big steps to encourage the best way to feed that little one– with breast milk.

And it make good sense– the “delivery system” is built into us mamas; the nutrition is optimal (human milk for human babes, right?); and through antibodies in breast milk, babies get protection from certain diseases that they can’t build on their own just yet.

Now, don’t get me wrong– breastfeeding is awesome and I’ll be the first one to jump in and say that. But in all of our talk about the virtues of nursing, we often neglect to mention just how HARD it really is. It takes practice. And commitment. And it’s painful. Learning to breastfeed was harder than taking my medical boards. Really.

When I was pregnant with my little guy, I thought that breastfeeding would be a snap– moms have been doing this for centuries, right? Babies have built in reflexes to make them eat– what could possibly be hard about it? It would be like in the movies (if there were movies about nursing)– I would deliver my newborn (sans pain medication of course); within minutes he would immediately latch on; I would magically have gallons of colostrum. And all of this would happen with a warm glow of sunlight shining behind both of us– a halo, if you will. And my hair would not be messed up.

But what really went down was this: I was in active labor for 3 days (no kidding); I pushed for 5 hours (no kidding). I had to have a C-section and went on to have a postpartum hemorrhage with a uterine clot that had to be manually extracted (again, no kidding). So needless to say, there was no immediate latch, there was no magical let down, and there was no shining sunlight– I was in an operating room in Portland in the fall, for Pete’s sake. And most certainly, my hair was seriously messed up.

What I did have was an amazing nursery nurse who made it her priority to get that kid on the boob, in the recovery room no less, and even when I felt too tired and worn out to do anything. (I had the chance to watch her in action with a mom and baby this weekend, and she has mad skills!). My great husband kept us on track with the nursing schedule and kept ME on track with my own eating schedule. My lactation consultant’s constant support helped me realize we were doing a good job even when I felt like we weren’t. To me, this is what “Baby Friendly” means– in whatever way possible, supporting moms and babes through the feeding tough patches in order to ensure long term success.

A few tips to get things off to a good start:

— Breastfeed early and often. Having the baby latch on in the first hour after delivery, while he or she is still awake and active, is the first step to establishing nursing. Feeding often, up to 8-12 times a day, not only helps establish milk supply, but also helps mamas read hunger cues better.

— Lactation consultants are your best friends. They are there to help you make good decisions about feeding, and are often a part of a nursery care team. Definitely take advantage of their amazing knowledge and skills.

— Ask for help, and take it whenever and however you can get it. If having your father-in-law do a Target run buys you some time to rest between feedings, so be it. More support for the cause!

— Resist the urge to offer the bottle early on. Breast feeding is all about supply and demand– once the demand (the baby) is gone, the supply dwindles as well. Protect that supply!

— Pumping can help build and maintain supply. After the first couple of weeks, starting a pumping schedule can help establish a stash of milk and also increase demand by a little bit. Remember, when you first start out pumping, you may not get very much out– this doesn’t mean that your not making milk. Rather, your body has to make more supply to keep up with the new demand (pumping). So, more milk down the line.

— Be good to yourself. Eat well, laugh a lot, snuggle with that baby. And remember, no matter what happens, if you are trying to breast feed, you are doing a good job already.

— Lena

Not So Secret Secrets

Welcome to our “Not so Secret Secrets of Doctors!”

Lena and I are creating this blog to share some of the lessons we have learned in our combined 20 years of “doctoring.” We are passionate providers of pediatric care and want to share some of the latest research and hot topics in child health and well being with you.

Lena and I met a decade ago, while we were both working on the Navajo Reservation in northeastern Arizona. I had gone to rural America convinced that I would spend my career there. My journey through my five years on the reservation is a long story that will no doubt be an entry here at some point, but the short version is that I saw a child die almost every month in my five years on the reservation. Infectious disease, poverty, drug use, suicide and accidents occur in as high a rate there as in many underdeveloped countries. It was a very hard job.

When I made the move to Oregon in 2009, the United States was in the recession, and though I thought that I would change from being a federal employee to joining a private practice, I found that decisions necessary for the local pediatric groups to financially survive were just too hard. The private practice in town that had served much of the Medicaid community for the prior 30 years had to stop taking new Medicaid patients at a time when many families were losing their income and needing state supplied insurance. Refusing to see patients who needed care because of finances felt wrong to me, so I took a job as an employee with our local community health center. It has been an interesting transition. Small town politics, changing patient demographics, and lack of mental health resources have had a profound effect on practicing medicine in this town. National debates touch us too. Whooping cough outbreaks, meningococcal outbreaks, and teen suicide are issues in our community. Measles has come to Oregon via Disneyland, though not to either of our pediatric practices yet. We are well aware that Oregon has the highest childhood vaccination exemption rate in the country.

I hope you enjoy our perspectives and use our blog as a resource and sounding board.