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No Substitute for Time

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NaBloPoMo 2017: Field Notes From a Life in Medicine

Day 3

How much time do you spend with your doctor each time you see them?  Is it enough?  If they had more time to spend with you, how would you use it?  Would it be better?

I’m too tired and it’s too late tonight to discuss the myriad factors that erode the patient-physician relationship, and thus our medical system in general.  But time comes to mind often for me, and I wonder if patients are as frustrated about it as I am.

Where I work now, I pretty much have as much time as I want with people.  It’s a sweet gig.  I can ask them about their work, their families, their interests.  I have time to listen to the answers, and even connect those with my observations about their health.  The most interesting parts of my interviews are the social history.  What do they spend their days doing at work?  What problems do they solve, who do they interact with, and what brings them meaning at the place where they spend the majority of waking weekday hours?  Then what do they do for fun, what’s life like outside of work?  I get to know my patients as individual, whole people, which I love, and that makes me look forward to every day at work with joy.

But time is not just good for me, for my professional fulfillment.   It’s good for patients, too.  When I spend time asking the important questions, putting together pieces of a person’s symptom puzzle, and do a directed exam, I’m more likely to come to a correct diagnosis and make an appropriate and specific care plan.  When I take the time to explain my rationale, decision process, and possible outcomes and follow up, my patients are more likely to feel seen, heard, and reassured.  They are more likely to stick with the plan and contact me if things change.  The next time they need help, they are more likely to call me and we have another chance to know each other better.

When the physician-patient relationship flourishes, we’re all healthier.

I love this article on The Health Care Blog, which essentially validates the time I take to talk to my patients.  My favorite line:  “More information about the value of a physician-patient encounter will always be found in the content of their communication than in what they ultimately do. The difference in… physicians’ behaviors will not be found in any database, electronic medical record, or machine-learning algorithm. I have yet to see data on the contextual information from a history of the present illness in any data set or quality improvement initiative.”

You may also be interested in this article, describing the origin of the 15 minute clinic visit, and why it really doesn’t make sense.

What do you think about physicians and patients advocating together to change this aspect of our flawed medical system? I know it’s complicated, requiring a hard look at our billing and compensation processes, as well as our productivity-driven, fee-for-service medical culture.  I still think it’s worth pursuing.  There is no substitute for time.  We must protect and defend it; our health depends on it.

The Doctor Becomes the Patient

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Grandma Has Hurt Herself.

Tonight at volleyball, I was given the perfect set, my timing was getting better, I sprang and hit the ball over the net… I think it landed in, but I was distracted by the crunching sensation and noise I felt in my left knee, and then breathtaking pain as I landed the jump.  Immediately I went rolling, writhing on the floor, lamaze breathing long and slow (nice how that comes in handy at times like this).

As I sat sidelined, the medical inventory began:  No torsive forces, just a buckle.  No ankle or hip pain, only knee.  It’s the bad knee, had similar pain landing a little jump a few months ago, though not nearly this bad.  Pain primarily posterior, deep, left of center, worse with knee extension and dorsiflexion.  Anteromedial joint line pain with weight bearing.  Immediate but mild swelling/effusion.  Hmmm, maybe medial meniscus, possibly also PCL strain/tear?  When should I get the MRI?  How long before I can start PT?  Where is that knee sleeve I got before?  600mg ibuprofen STAT.

The young people were so loving, gathered around asking me where it hurt, getting ice, helping me up, grabbing blocks to put my leg up, glancing over empathetically as I RICEd.  I felt cared for and also embarrassed.

Not just embarrassed.  I felt guilty, maybe even ashamed.  What had happened?  I’ve been training, I’m a good jumper, what did I do wrong?  Was it karmic payback?  I left home just as my kid was struggling with some homework—but nothing I thought she couldn’t handle.  Or maybe I had been getting too cocky that I could actually do this at my age?  Just yesterday I posted videos of my most recent progress on the TRX—I was openly bragging–“toot-toot!” I wrote gleefully.  Or it was an error in judgment: I have not slept enough this week, and I knew I was tired before I went tonight.  But I wanted to go meet my new friends, I wanted to play and have fun.

The frustration came all at once, and with considerable force.  Thankfully I had a friend nearby with a consoling ear and some crutches to lend.  All athletes get injured, she said.  I didn’t do anything wrong.  Yes, I’ve been training, and I was also weekend warrioring it all these months.  This has been my problem knee for at least 15 years, maybe it was going to happen anyway.  It’s still interesting to watch, almost from outside myself, the emotional lava lamp of fear, regret, anxiety, dread, catatrophization, and sorrow.

Experience and maturity, however, make me optimistic.  It’s a temporary setback, and I have resources available to me for recovery, growth, and even enhancement.  Now I get to learn how to use crutches, and I can relate much better to my patients with knee injuries.  I also get to test my newly formed theory that though we may slow down in general with age, we need not resign ourselves to inevitable and morose decline.  Patients ask me often, what should they expect to be able to do at this age or that, how can they know their limits?  For a long time I had no good answer.  But as I have regained strength, endurance, stability and mobility these last few years (tonight notwithstanding), I now tell them: It depends on what you want and how much you invest.  My 1977 Oldsmobile will not run like my 2012 Highlander.  But if I really want to drive that thing, I can put in all the special care and maintenance required and make it roadworthy.  It’s the same with our bodies.  They are incredibly resilient and adaptive, and also mortal.  So we must Fuel and Train, then Rest and Recover appropriately.

I guess I pushed past my current limits tonight.  Setback acknowledged.  I don’t regret the last five months–I made new friends and played and had fun!  I anticipate a high-learning road to recovery.  And I think I’ll get back before they forget me.

 

 

I Hereby Commit to NaBloPoMo 2017! Day 1: Shitty First Drafts

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2015 November Gratitude Shorts

2016 Letters to Patients

2017 Field Notes from a Life in Medicine

Day 1:  Shitty First Drafts

I first heard this concept listening to Brené Brown’s book Rising Strong.  It refers to Anne Lamott’s writing process, described in her book Bird By Bird.  Brown uses it as a way to work through strong emotions.  When something hard happens, intense emotions can get the best of us.  Anger, resentment, defensiveness, judgment, shame, and a multitude of other difficult feelings can overcome our senses.  How can we keep from getting sucked into a raging emotional vortex, dragging others along with us?

Write a Shitty First Draft, or SFD for short.  I have done this a few times recently.  I take a pen and paper and let loose.  I vent, rant, SWEAR IN ALL CAPS, draw angry faces, scrawl everything I feel, with total abandon.  This is the first, most subjective and raw version of the story I just experienced.  Man, it feels good, documenting everything from this (self-)righteous point of view!  But it doesn’t stop there.  Sometime later—whenever I’m ready, I return to the SFD to edit and revise.  Curiosity is key here.  What other versions are also plausible?  What am I missing from the other side(s)?  What other story will allow me to suffer less?  What makes me so attached to the SFD?  What core value has been violated here?  What is the most generous assumption I can make about the other people involved? I also learned that last one from my girl B2.

Turns out some SFDs are easier to edit than others.  Seems it depends on the circumstances, relationships, and (inter)personal stakes involved.  In the end, though, it’s well worth the effort.  I realized it this week and posted a musing on Facebook, and my friend offered me a chance to expound:

“CC: Curiosity, Transparency, Integrity, and Openness are saving me right now.

“Friend: I’m glad they are but curious to know how they are?

“CC: They are keeping me focused on the best and most meaningful contribution I can make to the team. As more moving parts get added to the process, I can stand on these practices to respond effectively. In the end, regardless of the project outcome, hopefully I can look back and know that I have very little to regret. …And if I do regret anything, hopefully I will have at least also learned some valuable lessons.”

The more I practice my SFDs, the sooner I can get to healthier iterations of my life stories—ones that allow for forgiveness, equanimity, gentleness (on myself and others), and inner peace.  I used to secretly berate myself for not getting to the peace part faster, easier, more efficiently.  But now I know, the healthiest way out of the shitty feelings is straight through.  The Shitty First Draft is the perfect vehicle for getting to the other side, and I get to drive every time.