Thursday, December 25, 2008

When the doctor gets sick

I am ill infrequently and it that is a good thing for many reasons. The last time I was sick was seven years ago. I woke up in the early hours of a Saturday morning with the worst pain of my life. That is another story. It and this current malady illustrate how illness happens at odd hours.

My current affliction began as my family was getting ready for the Christmas eve service. Fortunately not as severe as the bowel obstruction I had seven years ago, this problem will need a prescription medication for treatment. I would never call a doctor on Christmas eve. I might go to an emergency room - if I believed my death to be imminent. As the night wore on and I had looked through all the medicine cabinets in the house for left over antibiotics. No, doctors and their families fail to finish prescription medications just like everyone else and no, we don't throw them out either.

Failing to find anything left over that I might take I have settled for home remedies that I remember my mother using. Wishing it were office hours and I could just call my personal physician I am beginning to think about plan B which will be to scrounge through the sample cabinet at work to see if anything in there might help.

No, I don't just call in medications for myself. What is that adage, "A doctor who threats herself has a fool for a patient" especially in a state that has as many nonphysician members on the State Board of Medical Examiners as mine. Plan C is to find a doctor, any doctor and a pharmacy owned by Jewish people (Walgreen's in case you did not know) to get a prescription filled before 4 PM today. Even Jewish people go home early on Christmas.
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Sunday, December 21, 2008

On call

Reading a catchy column on the editorial page this morning pleading with the President-elect to put down his Blackberry because it will make him a better President, I realize that I too need to be pager-less from time to time.

The problem of increasing connection through the series of wireless signals that span the globe is a hazard to both individual and collective health. As a medical student and even resident I was dependent on the page operator at the hospital calling me over the public address system or on the telephone in the call room, if I ever made it there.

"Dr. B please call 2116. Dr. B, 2116 STAT!" Anyone out there who trained in the same hospital I did will recognize 2116 as the oncology floor. Of course in those days the cornary care units and the intensive care units had their own live in residents.

I then graduated to a page that worked with certainity only in the hosptial. That meant that if I walked out the front door, got into my car and drove half a mile to my apartment I was truly off call. Of course, being the obsessive complusive resident that I was, the page operator had my home phone number. I also frequently left it with the resident who was on call covering my patients. Cell phones, Blackberries, even wireless computers and the Internet were in the future.

I remember marveling at the stories of my senior partner, who by the way lived in the hosptial during the first year of his training. All the interns, as they were called back then, lived in the hospital. One story he told was about a classmate who married his childhood sweetheart the week after medical school graduation. The couple had a two week honeymoon and then his internship began with the young doctor living in the hospital and the bride at her parents home. Surely there were conjugal visits and I believe he got two weeks of vacation.

Another story that my senior partner told was from private practice before pagers. If physicians wanted to go out for dinner, the phone number of the resturant was left with the answering service. Even the movie theater would take a call from the answering service and send an usher down the isle to summons the physician to the phone. This necessitated telling the usher who you were and where you would be sitting.

I remember purchasing my first cell phone to be able to go to the grocery store on weekends when I was on call. At the time I had two small children. Any emergency could be made worse by having a cart full of groceries, kids in tow and the pager ringing forcing me to look for a pay phone wondering all the while whether I would have time to go through the checkout line and get the food home before returning to the hospital.

These convienences of the modern world are costly. Without a cell phone the drive home was spent in silence. Or, I would look at the pager and immediately return to the hospital if it was an obvious emergency. Finally, the number of phone call was less. Currently I am trying to decide a fee structure for phone advice. Prior to this 24/7 access I would joke that the patient would call her mother and then call me. Now the order is reversed. And that is why I have a cell phone. I want my children to call me first.
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Friday, December 19, 2008

addendum 2

The X-ray report crossed my desk about the time the phone rang. "What do I do about my foot?" demanded Ms. F.

"Impression: No evidence of fracture" read the report on the radiography of the left foot.

"Ice and elevation" ordered the obstetrician gynecologist.

Perhaps I am a general practitioner at heart but if my foot hurt as much as I suspect this lady's does I would probably take the time to actually go to the doctor.
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Thursday, December 18, 2008

Nursing home

Much of this blog is a reflection on many events I wish I had written down as they were happening. Those days in medical school, residency and private practice that are so clear in my memory that I can picture them as if they were yesterday.

In my second post on this blog, Choosing medicine, I mentioned the summer job that I had working as a nurse's aide in a retirement center. In 1976 these facilities were called nursing homes and the one I worked in cared for clients that spanned the economic spectrum. I have many fond memories of the people there and it was also a taste of just how cruel life can be.

Roberto H was a man that I still think about. The youngest resident of the facility, Roberto was in his mid fifties. He was not an American citizen. Twenty seven years before he was legally in the United States working when a terrible car wreck left him paralysed from the neck down. He had limited use of his left hand. To this day I cannot help but think about the barriers that prevented his rehabilitation. I am sure they were economic and cultural and his plight was not helped by the fact that he had no family in the United States. He was one of the people that I wrote to for several years after I left that summer job and returned to school. Though Roberto I learned how patentedly unfair life can be and how gracefully some deal with this fact.

Two other residents that I think about these many years later are Tammy and Opal. They were roomates on the women's hall for patients who could no longer walk. Both woman were over one hundred years old. Neither could see and while they could carry on a conversation with you or with each other, neither would remember what she had said thirty seconds later.

I met these two ladies on my second day at work. The other aides, most of whom were middle aged, had not yet decided what to make of me. I was twenty years old, fairly naive, and eager to please. The women's hall A hall was the most difficult. Some of the aides would skip several of the reguired duties since the work of bathing these women and changing their bed linens was so physically taxing.

Jo, who in the end would be my favorite coworker, had decided to play a little trick on me. She ask me to go "feed the two women in room A-3. I went to the kitchen and got the two trays, noticing the card on both trays said "mechanical soft." This meant that all the food was like mush. Everything both these women would eat had to be such since neither had any teeth.

When I knocked on the door and wheeled the cart with the trays in the room I was greeted by two thin, old women with opaque eyes who both turned their heads in my direction following the sound of my voice. Opal was Caucasion. Tammy was Africian American. They both had thick, white hair cut short for easy care.

"Come in Honey!" Opal called.

"Yes, yes, yyyyesss!" Tammy chimbed. "It is lunch time and I smell that food." Both seemed enthusiastic and ready to eat. How difficult could it be to feed two ancient women.

I kept them talking, set up the trays and gave first one and then the other a bite of food alternating spoons and entering into the conversation that they carried on with each other. They seemed to enjoy each others company and as with most people who are blind, their hearing was remarkable.

Suddenly Tammy stopped eating. "I'm hurting, Honey! Hurting, hurting, hurting!" she repeated with her voice reaching a cresendo.

"I'm sorry, Tammy" I exclaimed moving closer to her, looking to she what could possibly be causing this her pain.

"Oh hurting, hurting, hurting!" Tammy kept repeating shaking her head.

"Tammy, I am sorry! What is huring? How can I help?"

"Hurting, hurting, hurting!" Tammy kept repeating.

"I am sorry, Tammy," I stated again becoming a little frustrated that she would not tell me why she was hurting.

Then it came, in a clear, serious voice, "You're not kidding your are sorry! Your are as sorry as the devil!"

With that Opal, Tammy and to my crigrin, Jo and two other nurses aides standing just outside the door burst into laughter.

"You're not kidding. Your are as sorry as the devil." And then that 'I got you' laughter. I think about it every time I say I am sorry but am afraid I am not serious enough for the situation. I think about it every time I know I am about to learn a lesson that is bigger than the one I bargined for in a particular situation.

I learned a great deal in that nursing home about myself, about life, about living and about dying. I am not sorry that I spent a summer working there. It was a turning point in my life.
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Monday, December 15, 2008


Lest you believe that I am out of touch or that I cannot support the claims I make in this blog I have two "proofs" from the first hour of my work day.

While making rounds this morning a patient who delivered yesterday complained that her pediatrician of the past four years would not see her new baby until after discharge. "That is true," I explained to her as I also praised the very qualified "hospitalist" pediatrician who had already seen her newborn. Both of these physicians are employed by the hospital and with the division of labor one sees the "inpatients" and the other sees the "outpatients."

Secondly, I arrived at my office (I still go both places) to receive a call from one of the imagining centers where I send patients. "Dr. LMD, we have Ms. Smith, your patient here and she thinks that she has a broken foot." I remember Ms. Smith well since I delivered both her children. "We need an order for an X-ray."

"I can give you and order for an X-ray," I replied, "But who will treat the patient? I am an obstetrician-gynecologist."

"I know that but the orthopedic surgeon will not see the patient without the X-ray."

Allowing the X-ray I knew that it would be within my rights to make the patient come over to my office and see me first. After examining her foot, I could then collect a co-pay from the patient while filing a claim with her insurance company who requires my name on the order for the X-ray. The end result would be the same but it would have been more costly.

I did not have time to see this patient. I was seeing another patient who was just treated for pnuemonia. During her illness she had an abnormal laboratory test, ended up getting a total body CT scan where an abnormality was found in her pelvis. Though quite a distance from her lungs she was now getting her yearly gynecologic care.
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Sunday, December 14, 2008

ALL the questions

"If you finish the history without a clue to the diagnosis, you have a problem." I remember those words well. Spoken by our instructor in Physical Diagnosis during the second year of medical school their corollary was, "And if, after your physical exam, you still have no idea what is wrong with the patient then you are in real trouble."

I doubt that such warnings are issued today when young, eager medical students are taught to take a history from the patient. Today the patient more often than not, will tell you what is wrong by sighting Internet sources where she read about her symptoms.

As a second year medical student I carried a five by eight inch light blue card in the pocket of my white coat. On this card, in very small type, were lists of signs and symptoms I was in the process of memorizing. Not only were these queried to patients in the process of taking their history but the answers were all carefully recorded for completeness in my own hand on the patients chart. In this computer age such things are now recorded by a key stroke.

Approaching my first patients with this list I was careful to ask about breathing, sleeping, bladder and bowel habits, skin problems, leaving the reporting of no symptom to chance in my quest of the diagnosis. Interestingly a second year medical student occasionally made a remarkable diagnosis even though he was the fourth or fifth person in the chain to speak with and examine the patient. The diagnosis often came as the patient answered a question everyone else forgot to ask.

This tradition of speaking with the patient and carefully examining her is what physicians refer to as the history and physical. H and P for short. Time taken to listen to as well as to ask about symptoms. Time taken to touch, peer into, listen, followed by time taken writing down these symptoms and signs. This is how a diagnosis is made and how a treatment plan is formed. Or at least that was the case before CT scanners and instantaneous blood test results. I am ashamed to admit that often I see the results of such tests before I see the patient. I will also admit that reversing this order frequently results in misdiagnosis.

Several weeks ago a patient was referred to me for treatment of pelvic inflammatory disease. A sixty-seven year old widow, she presented to her internist with pelvic pain and fever. The internist ordered a sonogram which revealed an ovarian mass interpreted by the radiologist as a pelvic infection.

One of my questions to the patient as I went over her history was when she had last been sexually active. She admitted that her husband was impotent and she had not had sex in many years. While all of her symptoms and the pelvic sonogram fit with the diagnosis of pelvic inflammatory disease, her history did not. As I began to ask her about bowel habits the fact that she probably had inflammation in her colon became apparent. Last week she had definitive surgery to correct the problem.

Saying all this is patting myself on the back and that is not my point. The point is that it is necessary to ask all the questions. This patient's sexual history was critical to the diagnosis of her illness and proper treatment. The diagnosis was not made by a laboratory test or by a scan of body parts. It was made by questioning and examining the patient. And yes, I had a pretty good idea of what the problem was when I finished asking ALL the questions.
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Saturday, November 29, 2008

On course

"I find the great thing in this world not so much where we stand, as in what direction we are moving -- we must sail sometimes with the wind and some times against it -- but we must sail, and not drift, nor lie at anchor." -Oliver Wendell Holmes, Jr.

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Friday, November 28, 2008


All Supreme Court decisions aside I am loathed to use the above word. I hate it. I think it is vulgar and repulsive. Yet recently I find it popping into my mind with uncomfortable frequency. When does this happen? Let me give you an example.

Mikaela, the barely twenty year old mother whose baby I delivered in her final year of high school was in my office recently. Her live in boyfriend of the past two months came with her to the appointment. I am always a bit curious when a sexual partner comes with the patient to a gynecologic visit but over the years I have become increasingly comfortable talking with couples regardless of race, gender or their choice of sexual practices

Today the subject is a vaginal discharge. This particular patient has had a positive cervical culture for chlamydia twice since she has been under my care. The first time was at her initial prenatal exam in her pregnancy. She was then eighteen and she came to that visit alone. I asked her to bring her boyfriend with her to the next visit. Just as I had explained to Mikaela, I told that boyfriend chlamydia was a sexually transmitted disease. That it could cause a serious pelvic infection in her and blind their baby. It could even cause an infection in his reproductive system that could result in a great deal of pain and render him sterile. I instructed the two of them, just as I had instructed her when she was alone, that they were not to have sex again until they were sure that he too was free of this disease and that it was always best for him to use a condom to prevent the trasmission of this and other sexually transmitted diseases.

At this point the boyfriend seemed repentant, admitting that he had sexual relations with someone else and that he almost never used condoms. They were expensive. I gave him a hand full from a box that I keep in my samples closet. He also promised to go straight to the health department for treatment and screening for other sexually transmitted diseases, just as Mikaela had done in my office.

That was the first scenario with Mikaela. It was repeated six months after her baby was born when she had moved back home with her mother, who was now caring for the baby so she could work and go to school part-time. She and one of her college classmates began dating and she again contracted chlamydia. During her pregnancy and following it, I had several documented discussions with Mikaela about both contraception and prevention of sexually transmitted diseases.

As, I said, those occasions were two sexual partners ago and I recognized this man as someone new and I had introduced myself as I came into the room. Following the exam and genital cultures for bacteria, I again began to write out a prescription for the appropriate antibiotics, asking this new man if he was having any symptoms. When he answered, very politely I might add, "No ma'am!" I again explained the need for protection from sexually transmitted diseases as well as pregnancy.

Mikaela got an inquisitive look on her face as she said, "Now what did you say caused problem again?" Only the extreme patience I have developed over many years of practicing medicine and parenting kept me from replying, "F**king!"
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Wednesday, November 26, 2008

The list of "ists"

Twenty three years ago when I finished my residency and made the decision to go into private practice most obstetricians did the majority of their own patients' deliveries. While there were groups of two, three or four obstetricians, most of the time these guys (and yes, they were mostly men) were on call 24/7 at least where obstetrics was concerned.

Now I am a dinosaur sitting in labor and delivery on a night I am not on call, waiting for a worried patient to deliver. There are "laborist" and the one here tonight would have already done a C-section on my patient. Laborist are OB-Gyn physicians that take call staying in the hospital for 12 to 24 hour shifts being paid both an hourly rate and for the services they provide.

As a matter of fact there is now a list of "ists." Hospitalists see the patients who are admitted to the hospital so that the internist or the family physician can spend the entire day in their offices seeing patients. The intensivists see those patients in the hospital who are in an intensive care unit or (ICU) setting. Intensivist have specialized training in cardiology or pulmonary medicine since the heart and the lungs are critical organs to care for when the patient is that ill. Neonatologist see very sick infants caring for them in the hospital when they need care the pediatricians are not specialized enough to provide.

Focusing on this list takes me back to my original post, the local medical doctor, or LMD as we use to call them when I was in medical school. The LMD was someone who knew you well. He not only knew your lab values and what the CT scan shows but who your spouse or significant other is and maybe even the fact that you have both. The LMD is not a technician, working a shift, providing a product called "health care". She is someone who cares about your health.

What could be more important when you are ill enough (and it takes much more to make you that sick today) to be in the hospital? The rational however is that this "ists", with their special skills and twenty-four hour attention to hospital care, will save money managing care and getting you out of the hospital sooner. I am yet to be convinced but I am not here to argue the point.

And by the way, my patient just delivered a health eight pound little girl without a C-section. That is something we can all feel very happy about, even at 3 o'clock in the morning.
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Saturday, November 22, 2008


There are events that are so clear in my memory it seems they happened yesterday. Forty five years ago today is an example. I was in the third grade. The school I attended was new and the public address system did not work well. A crackly, unintelligible announcement was made and our teacher sent Lesli Andrews to the Principal's office to find out exactly what had been said.

Lesli returned bursting into the classroom with the words "President Kennedy has been shot!"

Miss Conklin, a brand new teacher, who knew everything, at least in her own opinion and in most of ours, shook her head, "No, no, Lesli. The President of the United States is a very important person. He travels with Secret Service men to guard him. There is no way someone could possibly shoot the President," she assured us.

No sooner were the words out of her mouth, than Mr. Bailey, the school Principal entered the room. Shaking his head, he looked at the floor rather than face us as he said, "Yes, President Kennedy has been shot and he is dead." By this time some of the older kids were in the hall crying. School was going to be dismissed early. We were to wait to be called to the office when our mothers arrived. I remember walking out into the bright sunlit afternoon, seeing the American flag at half mast and feeling that the world had changed a great deal in the few hours that I had been inside.

Since that time I have talked with my father about how he learned of the bombing of Pearl Harbor. He returned home from a Boy Scout camp out to hear the news. For him that day is also frozen in time. My sons seem to have the same type of recollection for the details of Tuesday morning September 11, 2001, another "day that will live in infamy." All of us had our sense of awareness heightened by the occurrence of seemingly impossible events.

Today, I have wondered what this day forty five years ago much have been like for the first lady. Jacqueline Kennedy arrived in Dallas as the wife of the most popular and powerful man in the world. She left a few hours later a widow, journeying home to tell her two young children that their father was dead.
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Sunday, November 9, 2008

The suture room

As a first year medical student my favorite Friday night activity was volunteering in the emergency room. A county hospital in a city of three million is busy anytime but on Friday night the "suture room" easily accommodated three or four medical students learning to repair lacerations. We were encouraged to sign up for a four hour shift immediately upon beginning medical school.

After sitting all day five days a week in a classroom listening to lectures, taking notes, and fighting back the fear that I would never know enough, the excitement of the emergency room along with the activity was therapeutic. A shift in the suture room made me remember why I had come to medical school.

That first night in the ER I change into the required clothing. The outfit, matching short sleeved, V necked top and baggy draw string pants looked like pajamas. Scrub suits as they are called were color coded to decrease bacterial contamination of the operating rooms. Green scrubs only could be worn in the OR but they were not to be worn any where else in the hospital. In the remaining parts of the hospital such as the emergency room everyone was suppose to be in white. There was a specific changing room for the students and residents. I quickly found a locker and changed into the suit.

Next I reported to the second year surgery resident who was in charge of the suture room. Patients came into the suture room from all over the ER. Anyone who had a laceration that did not need to be admitted to the hospital ended up there for repair. From the motorcyclist who was is shorts and a T shirt when he laid his bike down on the freeway to the two women who got into an argument at a restaurant and went after each other with steak knives, all of my patients had at least one cut and a story to go with it.

On that first evening I remember watching the surgery intern carefully clean a wound with betadine scrub before anesthetizing it with local anesthetic. He was very careful to explain to me the dosages that I could use and how not to inject directly into a vein. Next the cut must be probed for foreign bodies such as stones or glass. Then the wound could be sutured closed. This particular wound required three separate layers as the gash was deep, exposing muscle and even bone, when a drunken man fell out of the back of his friends pickup truck. Sobering up a bit the guy was very grateful for the care this young doctor provided. The laceration looked great as the final layer of sutures, all tiny blue nylon, went in to the skin pulling it together in a neat row. After applying a bandage and giving verbal and written instructions for care to the patient and his friend, the intern looked at me and said, "Next one's yours."

"What! I have only watched one repair." came my astonished reply.

"See one, do one, teach one! That is the motto here," came my young mentor's enthusiastic reply. About that time a teenager with bloody towel wrapped around his arm and filthy from head to toe walked into the room. "Here you go."

I was speechless. Not wanting to scare this poor kid by showing my inexperience I guided him to a table and stretched the arm out to take a look. Under the towel was a jagged wound, oozing blood with small pieces of rock embedded in the skin. "What happened?" I ask pulling on sterile gloves.

"I laid my dirt bike down as I turned off the highway," replied the young man dressed in a sleeveless t-shirt and cut off blue jeans. We were probably about the same age so I did not offer the advice that he should have been wearing more clothing. From experiences of my own I was sure that would come from a parent.

After getting the young man positioned comfortably on the exam table, I began to systematically clean the wound as I had been previously instructed. My mentor watch me carefully but allowed me to fill the syringe with lidocaine and injected carefully as I had been instructed. I had pulled the appropriate sutures on my own also under his careful watchful eye.

By the time I was finishing the final layer a man who looked like an older version of my patient showed up. "There you are!" he exclaimed, viewing the now also repaired laceration. He seemed glad to see his son but I also got the impression that this kind of reunion had occurred before. "What happened this time?"

After a brief explanation by my patient and following the admonishment that I withheld, the young man's father said, "Nice work doc. Thank you for taking such good care of my son."

Today, just as then, those words "Thank you," make me glad to have chosen this profession.
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Monday, October 6, 2008

The business of medicine

Sometime between my first day of medical school and entering private practice accountants arrived on the scene changing the practice of medicine into the business of medicine. Caring physicians became more interested in reimbursement than in the patients sitting in their exam rooms. More ancillary personnel were hired, not to facilitate patient care, which was now secondary, but to bill and collect money from insurance companies which are the real consumers of health care services.

In 1929 at the hospital where I currently practice, the first health insurance plan was fashioned to allow school teachers to spend 21 days a year in the hospital if they became ill. The cost each year: Six dollars a teacher. In a time of rather unsophisticated technology Blue Cross and Blue Shield of Texas easily turned a profit. From this humble beginning the health insurance industry has grown to a to a multi-trillion dollar business demanding a larger and larger portion of the annual gross national product and making health care outrageously expensive for those who pick up the tab.

Patients and providers alike are complicit in this growing problem. Patients schedule innumerable visits with physicians asking for every avaliable test because the health care premiums are a benefit provided by their employers. Little thought is given to the real cost or the real need when all that is required of the patient is a twenty dollar copay. What else can be purchased for twenty dollars today? The real cost is often hidden from the patient who pays little attention to the cost of the health insurance or the true charge for a visit. Health care providers are happy to serve the consumers with unnecessary tests and procedures increasing revenue but not necessarily improving health.

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Tuesday, September 30, 2008

Call me old

My age may be showing here but I cannot resist writing about this interesting encounter. A twenty something was in my office today for a routine check up. She has two children ages 5 years and 18 months. I delivered the eighteen month old and it was a miserable pregnancy as Christine (fictious name) was and still is single albeit with a good job that provides her with an excellent income. Let's face it, parenting a toddler is a full time job, so if economics necessitate that you work, qualified help is essential. Even marshalling all of her resources, Christine could never get enough rest and was pushed to the point of exhaustion trying to meet her commitments at work.

I was happy to learn that Christine is now engaged to the child's father. This will be her first marriage and a large, lavish wedding is planned in a few months. After catching up on this social history and congratulating her we moved on to current medications. Yes, she had seen a psychiatrist post pregnancy and her anxiety and depression are now marvelously controlled on three medications. I agreed that she is now much more animated than in the last months of her pregnancy or postpartum.

Her method of contraception is an IUD (intrauterine device) that I place at her postpartum appointment and yes, she has been very happy with this as it has required little thought and resulted in no side effects. Oh, by the way, she queries, could I just get that IUD out of there while I am in the process of doing her Pap smear?

I am sure I visibly swayed as I almost fell out of my chair. Why, I asked, would she want to get rid of a perfectly functioning IUD? Well, she replies, she had actually been lying to her boyfriend, now fiance of three years, that she was on the birth control pill when she got pregnant with their now 18 month old. Her cause for concern is that she did not get pregnant right away and now he wants another child once they are married. Did I mention that he is twenty years older than she?

I had to take a few moments to get this straight. She now has two children under the age of six, she wants a third with a man she is not quite married to yet whom she lied to about how their first child was conceived. She is so stressed with her job, these two children and this marriage to a man with whom she has been less than truthful that three medications are required to deal with her anxiety.

Reviewing the medications I informed her of the possible effects on a fetus. This convinced her to leave the IUD in place until she had a chance to review all of this with her psychiatrist. It also gives me a chance to gather my strenght for what will almost surely be another eventful pregnancy.
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Saturday, June 14, 2008

Old joke

Complaining about a billing procedure the medical group I practice with has recently adopted reminded me of a joke my father once told.

My complaint was about the practice of marking up the price of a laboratory test to the patient, sometimes as much as a hundred fold, over what the laboratory charges our practice. The patients who actually pay this price are the ones with no health insurance as insurance companies will discount these charges. Stating that I felt this price gouging to be illegal, one of my colleagues, who happened to be the obstetrician that delivered my children, told me emphatically, "No, it is not illegal!" His tone and demeanor led me to believe that this is a common practice of his office as well.

"Well, if it is not illegal then it is immoral," came my reply. "Which reminds me of the difference between illegal and immoral. An ill eagle is a sick bird."

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Tuesday, June 3, 2008

All nighter

It's into bed for me. Ten PM is early but this is a call night. Just as I am drifting off to sleep my beeper, clipped to the waistband of my pajamas, vibrates. Looking at it I reach for the phone at my bedside and call the number. It is a patient in early labor.

With the first patient heading toward the hospital, the second page jiggles. Someone has a urinary tract infection that will not wait until morning. The frequency of urination is too much. "I am not able to sleep!" the woman complains. I wait while she searches for the phone number of a pharmacy that is open all night. As I dial this number my beeper is buzzing again. The all night pharmacy has a message center however I know better than to leave a message there. Past experience has taught me that the patient will go straight to the pharmacy to get her pills. The pharmacy tech only checks messages every hour. I wait on hold to speak directly to the pharmacist to avoid a second call from this patient.

Fumbling with my beeper and the button to light the screen, I see a call from another patient who could be in labor. Finally, I am speaking to the pharmacist careful to leave not only a prescription for an antibiotic to treat the cause of the bladder infection but also medication to stop the burning so the patient can sleep.

Dialing the next number in my pager I am thankful for the lighted dial on the phone but wish I also had a pen with a flashlight attached. Now everyone in my household is asleep.

"I think I am in labor," the patient on the other end sighs. Experience has taught me that laboring patients normally do not sigh. They pant because they are slightly breathless. Women in labor have tight voices. I hear them anticipating the next contraction.

"How far apart are your contractions?" I ask.

"Well, I have only had about three," This patient sounds bored.

"When did they begin," I inquire.

"Well, I had one when I got home from work, another when I was getting ready for bed and I think I just had another one."

"Is your baby moving?" I patiently ask.

"Oh yes!" the voice on the other end brightens as of this is a sure sign that delivery is imminent. "She is always very active when I get into bed."

"Are you leaking any fluid."

"No. No, I don't think so."

"How about vaginal bleeding or discharge?" my inquiry continues.

"Nope, no, none of that."

Having exhausted my list of problems that need an intervention I ask, "Did Dr. H talk with you about labor?"

"Yes, I remember she did. I even have a little piece of paper here. I think she said something like 5-1-1?" the patient remembers.

"Do you remember what the 5-1-1 stands for?" I patiently ask. My beeper is vibrating again.

"Uh, oh, yeah, five minutes apart, lasting one minute for one hour. Do you think she wanted me to wait until the contractions are five minutes apart and lasting one minute for an hour before I called?"

"Yes, I do," comes my tired reply.

"What should I do now?" inquires the all too energetic voice.

"Try getting some sleep." This maybe wishful thinking on my part. "If you body gets too tired then you can't go into labor." I actually believe this and encourage women in the last month of their pregnancies to get as much rest as possible rather than walking, cleaning house or whatever to try and make themselves go into labor which almost never works and just leaves them too tired when labor begin.

"Oh, OK. You know, Dr. H told me I could take a Tylenol PM but I have never done that. Do you think it would be OK?"

"Absolutely!" I, the little known partner of the doctor this woman has been seeing for several months on the other end of the phone answers.

"OK. Well, when do I call you again?" She sounds less sure.

"When your contractions are five minutes apart, lasting a minute each and they have been that way for at least an hour OR if your bag of waters breaks which is usually a big gush of fluid." I remind her. Then I ask, "when is your next appointment."

"I am seeing you in the office tomorrow at 9 AM." she replies too cheerily. "Dr. H is on vacation."

Well, I forgot or maybe I never knew. Ignorance is bliss, right? "OK, I think I will probably see you in the morning. Good night," I reply.

"Good night. And thank you for talking to me." she redeems herself with the thank you. My beeper is vibrating again. I am two calls behind.

The rest of the story is that the first patient is in labor. I get up and dress, picking up a book on the way out the door. The beeper, cell phone, the book and I move to the hospital. I talk to another patient, one who is worried because she had some spotting after intercourse, while I am on my way. She is reassured by the time I arrive at the hospital.

After talking with the laboring patient and her husband, I write some orders in her chart and lie down in the call room. Getting comfortable, I realize that the call room I have chosen shares a wall with a room where the laboring patient is completely dilated and pushing to deliver her baby. "Push, two, three, four ..." up to ten, the dad's voice booms out. He stops at ten and there is a two minute break where all I hear is giggling. I am tired. Too tired to look for another call room. I close my eyes and I am lulled to sleep by "Push, two, three, four ...."

The call room phone rings. My laboring patient thinks she wants an epidural. She has talked to the anesthesiologist but she wants to speak with me again. Going to her room we discuss all the pros and cons both of us can think of just as we did in the office a month ago. While we are talking her contractions become even stronger. Now she cannot get the epidural fast enough while I am thinking I should have just stayed in bed for another fifteen to twenty minutes and then her pain would have made her decision painless for me.

As the night wears on I continue to go to bed and get up again until about 3 AM when the laboring patient is completely dilated. She begins pushing. I push with her for about thirty minutes and then go lie down again to gather some strength for the delivery. Setting the alarm on my phone, I get up after 45 minutes. The babies head is beginning to crown with a small about of dark brown hair visible at the opening to the birth canal. In addition to the patient, her husband and the labor nurse, her mother and mother-in-law are now present in the room. Of course all are excited. I even find myself getting excited as we see more of the baby's head. We all push together for about thirty minutes before the baby is finally born.

Lucky for me this is a vaginal delivery which I managed without an episiotomy. No lacerations occurred. I deliver the placenta and make sure that the uterus is firm, the cervix and vagina are intact with no injuries from the birth. Cleaning up the delivery table and doing the paperwork, I congratulate the patient and her family.

"You labored all night. Be sure that you get some rest." Leaving by an east door I notice the sun rising. I wish that I could take my own advice.

My beeper is going off again. It is a patient with pelvic pain. I could ask her to go to the emergency room where she would spend five hours getting the necessary tests. Instead I ask her if she thinks that she can wait three hours until the office is open. There the testing will take thirty minutes. "I can wait. I just woke up and thought I needed to call."

"You slept all night?" I am astounded.

"Yeah, I have had this pain for two weeks but it is not going away." came her reply. "I was worried and called your office yesterday but you didn't have any openings today so your office schedule an appointment for tomorrow but I am leaving on vacation tomorrow night and I was worried I would miss my plane."

Looks like another twelve hours for me. I had better go home, change clothes, eat, and hope that the rest of the day will be routine.
All nighterSocialTwist Tell-a-Friend

Friday, May 23, 2008

Holiday weekend

As an obstetrician my most difficult days are holiday weekends on call. These typically begin with calls from patients who have been trying to go into labor all week. Patients who know their own OB will be off for the next three days and they can't bear the thought of delivering their baby without him. Some of these patients actually make it in to labor, usually after their physician has left town. When they labor, the obstetrician on call delivers the baby and the patient is happy feeling so much better in her un-pregnant state. In these cases the on call obstetrician will be the hero by virtue of the fact that she drew the short straw and was the one who remained.

Of course there are patients who don't go into labor, many of whom are miserable near the end of pregnancy. Some of these women need to call and explain how terrible they feel. If these calls are between the hours of 7 AM and 10 PM and my family has left out of town for my weekend on call, these needs are easily met. I do what I do most days. I listen to the complaints, many of which come under the heading of "discomforts of pregnancy." Included in this category are maladies like indigestion, swollen feet and ankles, heat rash, and insomnia. Asking a few pertinent questions to determine there is no emergent need for the patient to be seen, I give her reassurance about the normalcy of her pregnancy along with tried and true home remedies for alleviating these discomforts.

What I do not do well with are calls at 2 AM and especially those that begin, "I have had this problem for the last two weeks and ...." Hearing this my first thought is "Well if this has been a problem for two weeks, why on earth did you not call your physician, who knows you much better than I, during daylight, weekday office hours for his advice and treatment." I never verbalize this however.

If an symptom that prompts these emergency calls in the middle of the night has been present for more than twenty four hours, I usually begin with, "What about (name the symptom) has made you call me now." The answer will usually fall into one of two categories. The symptom has gotten worse. Or, the most likely reason, at night the patient has time to think more about this symptom and how long it may have been there. Her thinking is compounded by the fact that she found out yesterday her mother's youngest sister, was diagnosed with breast cancer and she fears that she may have the same.

Again, if this is not a true emergency, I try reassurance and a promise to get the patient into the office as soon as the schedule will allow. If there is a need for someone to be seen in the emergency room for a gynecology complaint the wait can be a long one. The number of true emergencies rises as the holiday weekend wears on. More traffic on the highways and lakes along with increased consumption of alcohol will put ER space at a premium.

So, as the holiday weekend approaches, I have stocked up on message pads. I have two books to read and a movie to watch if I am stuck at the hospital with laboring or emergency patients. I have been playing classical music since I arrived this morning. And I could be pleasantly surprised with opportunities to do yard work, rearrange the den furniture and walk the dog between hospital rounds, deliveries and phone calls.
Holiday weekendSocialTwist Tell-a-Friend

Thursday, May 22, 2008

Natural childbirth

I am always curious about the patient's expectations when she informs me that she desires a natural childbirth. For some women this simply means that they do not want a Cesarean section. Others want to labor and deliver completely unmedicated: no drugs, no epidural, no interventions of any sort. A patient once stated that for her natural childbirth would mean that she did not have time to put her make up on before leaving for the hospital. A few months ago I was a participant in a birthing experience that was natural by any definition.

The patient, her husband and their two children arrived at the hospital in the middle of a week day when the labor and delivery unit is typically the busiest. She had called him at work when her contractions were three minutes apart. This was their third baby. The second baby delivered within two hours of the first contraction. The dad, who I will call S, left his high profile job downtown to rush home. Shuffling his wife and kids into the family minivan he rushed the entire family unit to the hospital.

When I arrived in labor and delivery the entire family, including the two older children were in the labor room along with two labor nurses frantically trying to fill out all paper work. Monty Python may have taught us that a delivery cannot occur with out all the proper noise making equipment* but the modern legal profession and hospital administration has hammered into the nursing staff that no baby may safely arrive with any blanks on the admission form.

"She's 5 centimeters." Michelle the primary nurse assigned to care for the patient called out as I walked in the door.

S, still dressed in his three piece Brooks Brothers suit complete with tie in place, informed me that they did not know the gender of the baby. "When the baby delivers, don't tell us the baby's sex," he instructed. "I will cut the cord." Continuing his role as the one in charge he told me, "I will be the one to hand the baby to L." L, his wife, mother of the baby, was lying in bed panting through a contraction oblivious to our conversation.

Always sure of my role as "captain of the ship" (a phrase attorneys use, usually when something has gone wrong), I was not bothered by S's assertions. I have long given up a need to tell everyone I am making the decisions. When there is a crisis usually everyone wants me to make the decisions and they give me their attention quickly. Otherwise I do my job and hopefully help make the birth the joyful experience that it truly should be for all who are present.

As soon as I received my instructions from S, L's bag of waters broke in a huge gush of pea soup appearing fluid. This is called meconium stained fluid and means the baby has had a bowel movement in the bag of waters. By the color the meconium looked old meaning the bowel movement probably occurred sometime before the onset of labor. Not a problem by itself, meconium stained fluid is dangerous if the baby sucks this thick, irritating material into her lungs as she takes her first breath. Called meconium aspiration, this is a condition can result in the need for a ventilator, lung damage and even death in the newborn. To prevent the occurrence of meconium aspiration the obstetrician must use a delee, a suction device to suck out the baby's nose and mouth after the head is delivered but before the shoulders arrive. This feat requires a controlled, cooperative patient, a skilled obstetrician, a helpful husband and a nurse to assist. It seemed that at least two of these four were present.

This is when I noticed the double stroller. The kind where there is a seat in front and one behind. Four year old big sister sat in the front seat playing with her dolls and a two year old about to be big brother was behind her with one of those "board books," the type with the thick cardboard pages that are easy for toddlers to turn. Both kids seems to be fairly calm and satisfied for the moment. Turned away from all the action they were facing into the corner of the room.

Looking around again to make sure all the equipment ready, I noticed a cord blood collection kit. The patient expected me to get a bag full of the baby's umbilical cord blood, after the dad had cut the cord of course. Coming from the umbilical cord and the placenta after the baby no longer needed it, rich in embryonic stem cells, this blood would be cryoperserved in a cord blood bank in case any of the family needed a stem cell transplant.

L cried out, "I need to push!" Checking her cervix again, I confirmed that she was completely dilated and should being pushing. Delivery was imminent. As the green head crowned, the future big brother began to harass his sister sitting directly in front of him in the stroller. Watching the baby's head with one eye, I saw the stroller begin to gyrate out of the corner of my other eye. I ask the second nurse, still attending to paper work, to please check on the older siblings. S was fully focused on his wife and helping her breathe and push. For them, it was as if these other two kids did not exist.

Some how even with S's arms grabbing for the as yet undelivered baby, I managed to delee the baby's nose and mouth removing a great deal of meconium stained fluid from them. Satisfied that he would not aspirate the meconium, I delivered the rest of the baby and continued suctioning until he began to cry.

At this point over in the corner, the now big brother was taking advantage of the opportunity of being totally ignored. He whacked his big sister over the head with his book and she began to wail louder than the newborn. Again, the parents were totally oblivious to anything their older two children were doing. I again ask one of the nurses present to please break up the fight.

L was holding the baby on her abdomen, helping the nurse to dry him off and wrap him in warm blankets while S photographed them both. The two kids in the corner continued to fuss with each other fortunately now without bodily contact while I collected the umbilical cord blood and the second nurse did more paper work.

The placenta delivered and I began massaging L's fundus, the top of the uterus, to prevent hemorrhage. S looked directly at me and commanded, "Stop that! She won't be able to smile for the pictures." At this point my patience began to wane.

Stopping the fundal massage for a moment, I explained to both S and L, "Without fundal massage L, you will bleed." Finally having their attention I continued massaging, "After a third baby there could even be enough bleeding to require a blood transfusion. There will be time for pictures in a few minutes."

With the post partum uterine bleeding at a minimum, I cleaned up the delivery table and the middle of the room, carefully placing all the trash and linen in their proper containers. Covering L appropriately with sheets and blankets, I then invited S to take all the pictures he wanted as I walked over to the stroller and turned it around so that the two occupants could meet their new baby brother.

This delivery was about as natural as a birth could possibly be in a hospital setting today. One of the nurses informed me that the patient had been there all of nine minutes when the baby was born. At this point, I congratulated the couple excusing myself to do my portion of the paper work.

*from the movie "The Life of Brian."
Natural childbirthSocialTwist Tell-a-Friend

Wednesday, May 21, 2008

Job description

From before the moment of our first breath we are on the path to our last, our hearts beats a finite number. As physicians we are charged with preventing disease, curing disease, restoring patients to health. Our training makes anything less seem a failure. Yet, life is such that disease and death are inevitable.

For those who practice medicine a worthy goal is also alleviation of suffering. In doing so disease does not always have to be eradicated to make and keep a person whole.
Job descriptionSocialTwist Tell-a-Friend

Tuesday, May 20, 2008


"It is not the strongest species that survive, nor the most intelligent, but the ones most responsive to change." -Charles Darwin
AdaptationSocialTwist Tell-a-Friend

Monday, May 19, 2008

Makes me smile

If, on a Monday morning, you are wondering, "Is it possible to drive the boat, pull a skier, hold on to the dog and still take a picture?"

The answer is "Yes!"

So "Why then?" you ask,

"Is the dog climbing in the boat, too?"
Makes me smileSocialTwist Tell-a-Friend

Friday, May 16, 2008

Need for less speed

Veering away from medicine for a moment please direct your attention to the problem of rising gasoline prices. Does anyone remember when the speed limit was dropped to 55 miles per hour?

On my morning drive to work I have routinely used this tactic as a way to conserve fuel in my already fuel efficent Honda. This morning as I drove 55 on a freeway where the speed limit is 60 and many drive 70 miles per hour, a city bus roared by me going at least 65. Five miles down the road, still driving my self imposed speed limit of 55 I caught up to the city bus and all the sports utility vehicles that had rushed by several minutes before. Traffic had slowed at the interchange as we were entering downtown and we were all now traveling at a reduced rate of speed. I suspect that all of us arrived at our destinations similtaneously.

This fact caused me to remember a reduction in something other than fuel consumption when the speed limit was reduced to 55 miles per hour. We saved lives with a lower speed limit. There are those that will refute this fact. One item that gets in the way here is that cars are now safer with elaborate air bag systems in place to protect passengers. We really don't know how many lives we would save driving a bit slower in these safer cars.
Less cost, less loss, about the same arrival time. Do we need all this speed?
Need for less speedSocialTwist Tell-a-Friend

Thursday, May 15, 2008

Diagnositic dilemma

More than 17 years ago I made the diagnosis of my mother's lung cancer. This happened inadvertently on a trip home. I was seven months pregnant with my youngest child and it was to be my last excursion before I could no longer travel.
As my mother greeted me when I arrived her fingernails jumped out to me. They were clubbed. At first I didn't believe it but through dinner and as we cleaned up afterwards I couldn't take my eyes off of her hands. I would look away hoping that when I looked back they would somehow be different.

I knew the differential diagnoses for clubbing of the fingernails. There were many illnesses on the list that were not lung cancer. I also knew that with all her years of smoking, lung cancer was the most likely cause of the clubbing. Over the years the worst dilemmas I have encountered as a physician are all the illnesses I diagnose in those that are not my patients. It is especially difficult to manage the role of family member and physician simultaneously.

I suspect that my mother had not been feeling well but she was not one to complain. She even denied feeling ill when I began to question her about her health. She had not seen her primary care physician in several months confessing to me that she did not really like him. So much for my first idea of calling and making an appointment with my parent's local physician, telling him what I suspected so that I could resume my daughter role.

By the time my visit was over, I had convinced my mother to return with me to my home where I could get her into see physicians I knew. Both my parents felt very comfortable with this arrangement. I suspect they were very relieved and even wanted me in charge of my mother's care.

While my parents were comfortable, I was miserable. The radiologist called me personally while reading my mother's chest X-ray rather than talking to the internist with whom she had an appointment. This left me to deliver the diagnosis to my parents rather than going with them to hear someone else break the news.

One of my closest friends ask me how I felt about all of this. The truth was I had been waiting all my life for my mother to get lung cancer. Since elementary school I knew that smoking could lead to lung cancer. I was not surprised. I was angry. I was angry about many things but I believe that most of all I was angry that I made the diagnosis.

I loved medicine. I loved my mother. I wanted someone to give me the diagnosis gently, holding out some hope, comforting me in some way as well as comforting my parents. Giving all this up seemed unfair. It also seems selfish but at the time and even now I regreted being a physician.
Diagnositic dilemmaSocialTwist Tell-a-Friend

Wednesday, May 14, 2008

First visit

Early in my medical career, I was privileged to practice with a wonderful, witty physician who was well known and respected by physicians and patients alike. Much of my philosophy of medicine developed as we worked together.

The son of a prominent gynecologist and the grandson of a prominent Methodist minister, I am sure that Dr. S had his choice of careers. His college major was philosophy. Enjoying both people and science he followed his father's foot steps into medicine. After four years of medical school, a year of research and four years of residency he joined his father's group of obstetrician-gynecologists in private practice. The following is a story that he once told me about a new patient he saw in his first week in the office.

It often falls to the newest doctor in a practice to see the newest patients. Sometimes these patients are the ones with the worst problems. At other times they are simply the patients that will take more time. This was the case one day when the young Dr. S was given the chart of a 15 year old girl brought to the office by her mother for prolonged and heavy vaginal bleeding. The girl's mother was a patient of Dr. S's father.

Dr. S carefully went through the new patient history recording every detail. The young woman was shy but his calm, jovial manner soon had her smiling as the two of them engaged in a conversation about her medical history with her mother present. The young woman stated that she had never had sexual intercourse nor used tampons and at the mention of an examination she seemed very hesitant. Dr. S explained in detail how he would do a pelvic examination to determine the cause of her heavy and prolonged bleeding.

Concluding his explanation, Dr. S ask the young patient if she had any questions. Amazed at the idea of a pelvic examination, which obviously her mother had not explained to her before their arrival, the young woman's face became quizzical. "I just have one question." She leaned over almost as if to whisper so her mother would not hear. "Does your mother know what you do for a living?"

Dr. S, with I am sure a gleam in his eye, leaned a bit closer to her as he whispered back, "I think she must," came his quick reply. "You see my father does the same thing."
First visitSocialTwist Tell-a-Friend

Tuesday, May 13, 2008

Birth certificates

In the fall of 1980, on a cool October Friday night, I delivered the first baby of my medical career. As a third year medical student, I was one week into my second clinical rotation. For those who are old enough to be fans of the television series Dallas, the delivery occurred during the episode where the world was finding out that Sue Ellen shot J.R. That fact was part of the reason I got to do the delivery assisted only by the mother of the baby and the lowest ranking LVN in the labor suite at Jefferson Davis Hospital in Houston, Texas. Everyone else in the hospital was watching Dallas.

At the time that I delivered that baby boy, the birth certificate, an important document which is key to much in life, was filled out and signed by the physician who delivered the baby. That night filling out that document seemed almost as important as the delivery of the baby. I was as meticulous with this task too. The resident physician who was supervising me (from the TV room) was required to sign it. 1980 was back in the pre-electronic era of pen and paper. A blank at the bottom of the page was for the physician or midwife who "attended" the delivery to sign, attesting to the truth of the information contained on that page.

Since that night I have signed countless birth certificates. When I was a resident obstetrician the hospital would not issue your pay check if you had any incomplete charts or unsigned birth certificates. Many of my colleagues were caviler about both. They must have missed the lecture on vital statistics in medical school.

In addition to the date and the time of the birth along with the weight of the baby, the birth certificate contains a wealth of information. Facts such as the county and state where the child's mother and if she is married, her husband, were born. If the mother is unmarried at the time of birth, the father must sign the birth certificate himself to have his information included. Information about the mother's other pregnancies if there were any and whether or not the birth was one of multiple births such as twins or triplets. Also the mode of delivery: vaginal, operative vaginal (forceps) or Cesarean section is listed.

Today birth certificates, in Texas at least, are not signed by the person who attends the delivery. The birth certificate is a computer generated document filled out by a records clerk in the hospital. The information is provided by the mother and also taken from the hospital delivery record. This allows the birth certificate to be filed in a timely fashion. It also facilitates the issuing of a social security number for the newborn.

In this the electronic age, I appreciate the need for swiftness in the filing of the birth certificate, a vital document in establishing an identity. Yet, I am dismayed when I think about the human touch that has been lost. There is no review of the information recorded by a person who knows the mother and hopefully the father of the baby. There is no signature of someone who was present with these parents in that all important moment when this person, whose birth is being certified, made her entrance into the world.
Birth certificatesSocialTwist Tell-a-Friend

Sunday, May 11, 2008

Thought to remember

"Although the world is full of suffering, it is also full of the overcoming of it."
-Helen Keller
Thought to rememberSocialTwist Tell-a-Friend

Thursday, May 8, 2008

We have come along way and...

In beginning The local MD I left the gender box blank deciding to avoid the issues of being a woman in medicine. The advantages to being female in medicine are many. For instance in an illness most of us want to be cared for by our mother. The advantages in my specialty of obstetrics and gynecology are also obvious, not only do most woman want their mother when having a baby, they want someone who has had a similar experience and has lived to tell about it.

I never spent time dwelling on discrimination issues when it came to gender. Recently when interviewed by a medical publication, I was ask, "What has been the most difficult aspect of being a woman and practicing medicine?" I didn't even have to think about it. "Finding nice looking comfortable shoes." was my instant reply.

On July 1 it will be thirty years since I matriculated at Well Known College of Medicine . I was not one of the ground breakers since women had been in almost every medical school class for well over fifty years. Yet the women numbered only twenty seven in a class of 168. All but one of us graduated four years later. I have no idea how many are still practicing.

I never found it difficult being female in medical school. If anything because women stood out a bit more than most of the men we seemed to have more opportunities. The surgeons I worked with wrote me wonderful recommendations but only after finding out that I was entering what was considered an acceptable specialty for women. For my friend who wanted to pursue cardiothorasic surgery the attitude was different.

Having done reasonably well in medical school, I chose a residency where there was a great deal of competition for positions. The program that I ranked number one on my match list had a special history. Only five women had finished the program in more than forty years. Two of the last four females this program accepted left after the first year. When I interviewed with the program director he asked me two questions: "Is your husband willing to move to this city and when do you plan on starting your family?" Rather than file a lawsuit, I quietly answered that my husband was ecstatic at the prospects of moving and we really wanted to wait until after my residency to have children. The truth was that my husband would have to give up his job to move. Finding new employment would be difficult in the economic down turn the area was experiencing and we could not even afford to thing about having kids.

I was awarded a residency spot and spent the next four years as the only woman in a program with eleven men. In the end I was one of the guys. It is funny now that I look back on those years and realize that I did learn to think like the men. I also became very good friends with many of the nurses and the few female attending physicians, most of whom were anesthesiologists and pediatricians, who were on the hospital staff.

When I finished my residency, I joined a group of physicians, all men of course, at Big Name Medical Center. Practicing medicine with them went smoothly until my first child was born. Strange as it now sounds, that was really the first concession I made to my gender. I never guessed motherhood would become such an important part of who I am. I only planned to take three weeks off after N was born. I did return to work after three weeks bringing N to the office with me as I arranged my schedule to breast feed while hiring an additional person to care for him as I saw patients.

When my second child, B, was born, I realized the envy that my situation produced among my partners. One of the younger partners, who had children and a stay home wife, told several of my patients that I was trying to "have my cake and eat it too" as if working and motherhood should be incompatible. I was taking six weeks of unpaid leave to "have it all". I did not have it all but I was getting the best portion. Proof of that fact was a conversation my partner had with his young son one morning. Asked why he had to go to work all the time, my partner replied, "That is what Daddies do. Mommies stay home." "No!" His son replied, "When I grow up I will stay home with my kids and my wife can go to work!"

My time off was not only for recovery from childbirth. My mother was diagnosed with lung cancer one week before B was born. As an only child I became her primary caregiver too. She had surgery and then began radiation therapy. My only solace during this time was the chance to be a mother myself nursing my newborn and playing with my two year old.

Yes, I took six weeks off to have my baby and help my mother, but the partner who complained the loudest fractured his leg snow skiing. He was in a wheel chair and then on crutches for twelve weeks. During this time I took all of his call. The other partner had a rotator cuff injury (also skiing) and could not lift his right hand for several weeks. I preformed all of his surgeries and many of his deliveries for six weeks without compensation.

I am not sure to this day why I did these things but doing them felt much like caring for my children and my mother. These were tasks that needed to be done. I was the junior partner in the group so I did them. One gynecologist outside our group asked me, "How difficult is it to be 'the boy' when you are a girl?" If ask that now, I would reply, "I am not 'the boy.' I am simply doing what needs to be done." I was the caretaker of my immediate family and of the family made up of those with whom I practiced medicine.

While much has changed in medicine, there is still a huge gap in salaries between men and women. I believe this is due to differences in practice patterns. I limit the number of surgeries that I will do on any given day. I am no good after a certain number of hours in the operating room. It has been shown in several studies that women spend more time with each patient than our male colleagues. I believe that I and my female colleagues ask and answer many more questions when seeing patients. We are not as procedure oriented and try to fix more with medication or life style changes.

I could go on but I think the point is that men and women do things differently. There is not a right way and a wrong way, a good way and a bad way. There are just different ways. As I watch patients and friends who are in other professions I see that we all struggle with this gender diversity. I also see that because the population is made up of men and women, women and men are needed in all professions.

After all I am raising sons. I want them to enjoy meaningful work, to have an adequate income and to be able to send time with their families. I feel that women have come a long way and I hope that men feel they have come a long way also.
We have come along way and...SocialTwist Tell-a-Friend

Wednesday, May 7, 2008


I first met Kate when she was 32 years old and coming in for her yearly check up. I was new to practice and her previous gynecologist was retiring. Kate's real given name was Mary Katharyn. She could not give me any information about her medical history but I soon learned that she loved to go to the movies and that her favorite actor was Omar Sharif. She must have seen every movie that he made many times.

Kate was strikingly beautiful. Tall, slender, dark haired with a quick smile and dancing eyes. She had a dramatic way about her and she would even sing a few lines of a movie tune as she became caught up in telling me about a movie she had seen. Kate was on the dean's list her first semester of college. That was prior to the car accident which occurred just before her nineteenth birthday. Now she spent her days much as a four or five year old would under the almost constant supervision of one of her parents.

Kate's mother was a saint. The most patient person that I have ever met, she lovingly and tirelessly she cared for Kate year after year. She never complained even when I gave her permission to do so. Her constant concern was for Kate's well being.

I was thinking about Kate tonight when at dinner I used a trivet that she gave to me. A trivet is one of those little hot plate holders. This one is ceramic and covered with the image of a beautiful butterfly with multicolored wings. The day she brought it to me Kate went into great detail explaining how she choose the colors, painted the ceramic piece and then fired it in a kiln. Her eyes jumped as she described every detail of the creation.

I have not seen Kate or her mother in almost three years. When her father died, an older sister became the executor of his estate. Every thing changed. Their home was sold. I imagine that Kate is in some sort of care facility now. I do not even know if Mrs. E is still living.

Using the beautiful butterfly trivet is not the only time I am reminded of Kate. At the delivery of every healthy baby, when the parents breathe that sigh of relief that everything is alright, I think of Kate and her mother. I am reminded that there are no guarantees in life. As a parents most of us do the very best we know how hoping that the skills that we have will match the needs of our children.

*All names have been changed though those who worked with me may recognize the people as the stories are real.
Kate*SocialTwist Tell-a-Friend

Monday, May 5, 2008


Frequently the response when I tell someone I am an obstetrician is "What a wonderful job!" It is a wonderful job however not in the way most people who make that statement believe it to be. Here are reasons that I believe my job to be wonderful:

First, obstetrical patients are the most appreciative people on the planet. Even if all the obstetrician did was show up as the baby is being born (let's face it, in a large percentage of cases childbirth could happen without an obstetrician), the mother, the father, the grandparents all think that this child could not have made her way into the world without the assistance of the obstetrician. I generally stop to remind the parents (and myself) that their job is much more difficult and much more important than mine. I know. I have been a parent for over eighteen years.

Second, I like my job because when complications do arise during delivery or if it is a difficult pregnancy and the outcome is indeed a good one then I do feel as if I have contributed in making life better for all involved. In these cases the patient may not be as grateful. Perhaps it was not the story book pregnancy she imagined for herself. She and her family may have struggled through some difficult days or even months where she did not feel well, was confined to bed or hospitalized. If she has a healthy baby and she herself is well at the end of the process I will celebrate and then commiserate with the patient and her family for the next several years about how a truly awful pregnancy produced such a wonderful child.

Finally, when the outcome of the pregnancy is terrible, when the baby is born much too early, when he doesn't survive the neonatal period or she is stillborn, I have a chance to be with the family as they begin to heal from a terrible loss. I have learned in my more than twenty seven years of practicing medicine that I will never be able to make sense of these outcomes. I should not expect these people grieving the loss of their child, to make sense of this either. Until the baby is born, I am working as hard as I can to find ways to prolong the pregnancy or treat the condition threatening the baby's health. Once the baby has arrived my job is one of emotional support. If the baby is disabled or dies then the parents will still need care.

Healing comes on many levels at different times through a variety of sources. At times the physician plays a very active role deciding, prescribing, preforming. At other times it is just as important that the physician be present and be still.
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Saturday, May 3, 2008


Propagated by the pharmaceutical industry the term generic means common. Consumers have come to understand that a generic drug will be cheaper than the brand name medication. Patients have also come to understand that this generic prescription may not work as well as the branded alternative. Most let their pocket book make the choice accepting the fact that generic medications only have to provide 80% of the bioavaliability of the original product.

There are other ways that the practice of medicine opts for generics. In health care there is now generic care. Patients are frequently seen and treated by health care providers, not necessarily physicians, who care not for patients but for clients. The care itself is determined by algorithms, flow diagrams that have often been developed by insurance companies or governmental agencies based on research evidence. While evidence based medicine certainly has a role in patient care, it should not stand alone as the sole method of decision making in medicine.

Speaking with health care administrators (the business people who run hospitals, insurance companies, physician groups) one learns that the reason for these changes to physician surrogates and algorithms is to provide better health care and also to save money but not necessarily in that order.

Generic does mean common. Yet when people are ill, common in the last thing that they want. Most patients want uncommon care from uncommon caregivers that they know and trust. This trust is the hallmark of a good patient-physician relationship. This trust plays a vital role in healing. This trust is never generic.
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Friday, May 2, 2008

Here goes!

"It's spring! The rest of you guys may not be ready but the days are getting longer, the grass greener, the sun brighter. It is time to get out of that rut and enjoy the world. Follow me!"
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Wednesday, April 30, 2008

Dangerous donations

The tall, shy, strawberry blond, freckled faced 15 year old seems strangely familiar. Her older sister was also a patient yet they seemed to have come from different families. Her sister was a petite brunette with olive skin and brown eyes like their mother. Both sisters were pregnant. Melissa, the oldest was a dental hygienist married to a dental student. Denise was, well, she was 15 and in high school. So was the father of her baby. Denise's mom came to all of the prenatal visits. Still, I felt there was family history that I did not know.

Both pregnancies were uneventful from an obstetrical standpoint. Melissa delivered first. Her due date was two months earlier than Denise's. Melissa had a healthy baby boy. She and her husband named him Jonathan. They brought a baby cap and blanket specially made for his birthday. Jonathan had a baby book with places for pictures and his new born foot prints. Grandparents from both sides along with close friends filled the waiting room on the night he was born.

Denise's delivery was more subdued. The father of the baby's parents were at odds with Denise's parents so they and the birth father stayed away. An adoption agency had been chosen. The case worker came to do the paper work before Denise was discharged from the hospital but neither she nor her parents wanted to see or hold the baby. Their plan was for Denise to sign away parental rights forty eight hours after the baby was born. The father of the baby had not decided about his rights. I suspected that he did not care but was using the fact that he had rights to get back at his parents.

When she was born Denise's daughter had her golden hair and fair skin. I handed the baby to the nurse as Denise turned her head away shaking it "No" when I ask again if she would like to hold her daughter. The fact that no one ran to the baby warmer to count fingers and toes or let the baby grab at a hand hurt my heart. The baby, "Little One", as I came to call her those two days she was in the hospital, cooed and gurgled as the nurse dried her off, weighed and measured her. Wrapped in a bundle of hospital blankets she made faces and sucking noises as if to say, "Where's dinner?"

I convinced myself that these sisters were so different because of their situations. One was married with a planned pregnancy. The other, still a youngster, still in need of adult supervision herself, was placing her baby for adoption. During Melissa's delivery I met the third child in this family, a brother, Timothy who was 13 at the time. Funny thing was I felt like I already knew him. He looked like a younger version of a friend of mine from residency.

Six months later I was seeing a work-in emergency for my senior partner. It was Melissa's and Denise's mother, Mary Ann. She had been a patient in the practice since her two youngest children, Timothy and Denise were born. Having delivered her grandchildren I was intrigued enough to look through the chart. "Secondary Infertility" was the diagnosis that brought Mary Ann in to see Dr. Banyon for her first visit. Melissa was ten and her parents had been trying for seven years to conceive. "Male factor" was noted at the end of the work up. There was a semen analysis with minimal sperm.

Minimal sperm on her husband's semen analysis but two children within two and a half years of her first visit. Then I saw it "AID" in fine print at the bottom of one of the pages. Artificial Insemination - Donor. "Excellent specimen, third year resident, red hair and freckles."

No wonder Timothy looked so familiar. Someone I knew, someone I had done my residency with was the father of Denise and Timothy. He was the grandfather of "Little one." I knew exactly who donated this sperm. I wanted to call him and tell him he had a grandchild. I wanted him to tell his children, all three close to the ages of these two kids, that they had two half siblings. Half siblings that they could meet. Half siblings that they could marry. Half siblings with whom they could make babies.
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Friday, March 14, 2008

I almost missed her

E was a former patient and a labor-delivery nurse, the little sister of one of my best friends from high school. That early spring day in 2003 I would say former patient because she fired me. That is right. Two years earlier she became angry with me and requested her records to see another gynecologist.

When I learned she had been diagnosed with acute leukemia I spent a week using the excuse of a bad cold to keep me off the sixth floor where the immunosuppressed heme-onc patients stayed. Finally, on Friday I bought flowers and made my way to E's room. She was sitting at the head of the bed with her knees drawn up to her chest. I remember how thin and pale she looked with shoulder length, straight, blond hair. The oncologist had been there earlier in the afternoon. The diagnosis was ALL, acute lymphoblastic leukemia. The doctor explained that chemotherapy would come first then perhaps a stem cell transplant from one of her four sisters.

E spoke with me about all this while I stood across the room wearing a mask. She looked terrified as she should. The five year survival rate for an adult with her diagnosis was under twenty five percent. As I left one of my physician friends, an oncologist, asked me what I was doing on the sixth floor. Upon hearing that E was a family friend he offered his condolences.

I went back the next day and the next and then many of the days in the next six months as E completed the courses of chemotherapy. She suffered many side effects of the medications and many illness from her lack of an immune system. She lost her hair, her face became as round as the moon and on many days she had ulcers in her mouth that made it difficult for her to swallow. Yet it seemed the sicker she was the more she smiled and joked with me about people and events from our past. E's older sister and I had been extremely close in high school we both knew a great deal of each other's "family history."

The most important thing that happened in these months of battling the leukemia was E's persona changed. She went from that timid, huddling figure on the bed the first week, to someone who smiled easily. Instead of huddling in her bed and making visitor stand across the room she stretched her arms out to give them a tight hug, after they had washed, gowned and masked themselves of course. She was not shy with her physicians either. She demanded information every time one came to her room. One of the hematologists told me she was angry with him at one point and "fired" him. I welcomed him to the club and I also noticed that he continued to come by and see E even when she was on the transplant service and no longer under his care. Like me, he wanted to cheer her on against almost impossible odds.

While I think E knew that the odds of her beating the leukemia were almost impossible that did not seem to deter her from the fight. I had watched as she and her sisters fought growing up. Those battles now seemed like preparation.

Weeks and months stretched out over a period of two years. E's first remission was six months. The second, following the first stem cell transplant was a little longer. E went back to work. Life was a bit more normal for her family. Finally, the monstrous leukemia returned. It was just a couple of weeks before Easter 2005 when E became septic with a overwhelming infection that antibiotics and her body could not handle. She died on a Wednesday morning with two of her sisters, her three children and a close friend at her bedside. I was in my office seeing patients when someone from the hospital called. I ran the three blocks to the hospital but I arrived too late.

I have decided that it was OK that I had missed her that morning. There had been many other mornings, late nights and occasionally a long afternoon when E convinced me of the value of living every day for all that one day is worth. And when I think about how close I came to not going up to her room that Friday afternoon, I shudder. I could have totally missed her. My pride and the rejection that I felt when she went to another doctor might have prevented me from going to visit on that very first week of her illness. I will forever be grateful that I was able to move past that and into the space of friend.
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Monday, February 25, 2008

Three conversations

On top the card read, "To Dr. LMD and Staff, for all the nice things you do for me." Underneath the foil wrap were two dozen fresh baked chocolate chip cookies still warm from the oven. As I truthfully exclaimed that these were my favorite, the patient related two stories of other doctors offices. Offices where the staff was in the patient's words, "more interested in my money than they were in me."

Later in the day I saw a patient who had lived in Brussels Belgium for the past six years. As she and I visited about her medical history for the years she had been away she remarked wishfully, "It certainly is different in Europe." I found out later that a member of my front office staff had badgered her for her husbands social security number. It seems that without it we could not file her insurance. Her primary care physician in Brussels was a single physician with his wife as the receptionist/office nurse. My patient had the up most respect for this physician and the care that she received as his patient. The cost of an office visit: forty Euros. A fee the doctor himself accepted after the completion of the office visit.

At the end of the day my office manager wanted to review with me a potential new hire for my office. The point sold my office manager on hiring this young woman was the fact that she had self appointed "goal" of collecting a certain amount of money from patients at check out in the course of each day.

Medicine it seems is a business more so than a generation ago. Many times I am disappointed in myself as well as my colleagues. We spend too much of our time thinking about monetary compensation rather than taking pride in the work we do or realizing how important that work is to the health of our patients.
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Wednesday, January 9, 2008

Showing up

Life is about winning, right?

On a recent call night I found myself watching the movie "Little Miss Sunshine" a comical and poignant story about a family traveling to a beauty contest for six and seven year old girls. The movie shows the family journeying several hundred miles in a yellow VW bus as they struggle with life and each other.

For me the message of the movie is distilled in to a moment when the oldest character, the grandfather, so damaged by life that he resorts to snorting cocaine to cope, calms the youngest character, Olive, the beauty queen contestant as she expresses her fears of failure on the eve of the contest.

"Grand paw, I don't want to be a loser. Dad hates losers." Olive cries.

"Your are not a loser. You know what a loser is?" Her grand paw replies. "A loser is someone who is so afraid of not winning they don't even try. Now you are trying right?"

Olive replies in the affirmative and Grand paw asks another question, "Now we are going to have fun tomorrow, right?" Again affirmation and the plot moves on.1

This scene reveals much about life. The cliche is "winning is not everything" and yet I find myself and those around me living as if being first, being at the top, is the only thing. More often than not in the most important aspects of life showing up and giving the task at hand our best effort possible is the most important part. This is when we become winners regardless of our place in the end.

1. Little Miss Sunshine Twentieth Century Fox Presentation 2006
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Sunday, January 6, 2008


The holiday decorations are gone, safely put away in the attic. One item is left. A manager scene. I thought that I would leave it until today is over. This is Epiphany. The day when the Christmas season ends with the arrival of the wise men. Taking the word literally it is the day when we see the essential nature of things.

Having these figures on the table before me gives me moments to ponder the characters that each represents. Mary, the God bearer, so close to the Christ that she holds him in her arms. Joseph, Mary's companion, who I imagine is probably just as bewildered about his role in the world as I often am about mine. A shepherd boy, confused beyond belief at the prospect that this is God in the flesh. Finally, the wise men, who, though male and dark skinned, seem to have more in common with me than the others.1

These wise men found themselves following something they could not explain. As astronomers, they had watched the sky all their lives. They were waiting, hoping to see such a strange phenomenon. Even more mysterious was the place were they ended up. Passing through the halls of power, the ruler's palace, these wise men end up staring at a baby born to an impoverished teenager and her betroth, a skilled laborer. I am sure they questioned the improbability of it all more than once.

Yet, as improbable as it all must have seemed, the wise men believed the force that led them to Mary, Joseph and the baby Christ. They acted on their belief. Leaving their riches, the astronomers returned home by another way thwarting the forces of evil.

At home, at work, even with in myself, how many times do I join with the forces that say it is acceptable to hate, to make more money than I need or to feel inadequate in more ways than I can name. It is indeed an epiphany to decide to live differently. Perhaps these figures will become a permanent part of my home decor as I hope that the message of this day will become a permanent part of my life. This scene will act as a reminder that there is a different way and it is mine to choose daily.

1. from a sermon preached today by the Rev. Shannon J. Kershner
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