18 June 2011

Practice Medicine, Not Martyrdom

There is no one in the practice of medicine today who has not walked the corridors of their hospital, ankles swollen from thirty consecutive hours of standing, and wished they had chosen a different profession. When this happens there is usually someone older, wiser, and with far more experience lurking close by, ready to tell you that they had it worse. In fact, I have found this a much more reliable constant during my years of training and now practice in Pediatrics than the basic tenet that kids in daycare always seem to be sick and parents are harder to care for than the patients themselves.

This is why, disappointing though I found Karen S. Sibert’s recent Op-Ed bemoaning the gap between the healthcare needs of this country and the physician work force’s ability (or willingness) to provide them, its message was not surprising. Dr. Sibert, physician and mother of four works full time, which is by implication the right thing to do, and so everyone else should strive to as well.

As much as I find fault with her conclusions, there is much in the piece she has written that is unassailably true. The medical school and residency training slots in the U.S. are limited, yes. An increasing percent of the physician work force are female – hurray. Women doctors are more likely than their male counterparts to work only part-time, perhaps. The conclusion, however, that the lost physician work hours that result from part-time positions is bankrupting the system and denying the poor people of Noxubee County, Mississippi (and other heavily underserved areas) the access to medical care they need and deserve is shaky at best.

The most glaring omission to her reasoning is the assumption that if all female physicians did work full time, as she does, these very real issues of access to care would be righted. But even if I, a female physician and also a mother, were to pick up an extra shift in the ER each week, it would not be in Noxubee. I did just buy a hybrid, but even so the commute is too long. Instead, I live and work (as Dr. Sibert does) in a metropolitan area where it is impossible to run out for a Starbucks without tripping over a nephrologist or interventional radiologist, so high is the physician to patient ratio in these cities. Luckily, there is sure to be an orthopedist nearby, to make sure nothing is broken after your fall.

Scott Shipman and colleagues wrote about just this problem of geographic disparities in the availability of healthcare providers for children in the January issue of Pediatrics and though the data is compelling, there are no easy solutions. As much as I, like Dr. Sibert, would like to see patients have greater ease in accessing care, I have a husband, a generously sized mortgage, and a hyperactive Labrador, the result of which is that I won’t be moving to Mississippi anytime soon.

So I am not as good a person as I, or Dr. Sibert, would like me to be. Despite working full time and trying my very best to give good patient care, there are deficits in our nation’s health care that I am not willing (or able) to fully address. The question now is, do I care? Do I owe more, by virtue of my partially taxpayer funded medical education and training, that I am not repaying in full? More than the myriad of academics who spend more time in the lab than they do seeing patients? More than the nearly two-hundred-thousand dollars in student loans (plus interest) I will undoubtedly have to delay retirement in order to pay back? More than the engineers and other scientists who also rely on the government to subsidize their higher education and who often graduate with PhDs and no student loans at all? More than the lost years of income incurred during my seven years of medical school and residency that Dr. Benjamin Brown suggests in his book, The Deceptive Income of Physicians, is impossible to regain? 

Do I owe, in addition to these very real financial debts, a promise that I will never, not ever, curtail my work schedule to care for a sick parent, teach my daughter to read, write a book, take an art class, travel to another country to provide medical care in a place with even fewer physicians than Noxubee County, Mississippi?

I think not. But I do know, without a doubt, that if this is the manner of promise physicians are expected to make, neither I nor Dr. Sibert will be happy with the sort of physicians we get when we find ourselves not in the role of doctor but patient, as we all eventually must. In fact, we may find ourselves without physicians at all.

After all, medicine is not necessarily a calling. It is also a job. I happen to think it is a wonderful job, a complex and rewarding field, but it is not a job that any one person can do on their own, whether or not they are working full time. It requires, as Atul Gawande suggested at this year’s Harvard Medical School commencement, communication and teamwork. And although he did not point this out explicitly, I would venture to say that the best thing about teamwork, about having supportive colleagues who are not only kind to their patients but also to each other, is that they get each other out the doors of the hospital at day’s end and back to our families. Without teammates like these, I fear medicine will be a job the next generation decides to forego, increasing the shortages of physicians Dr. Sibert so rightly highlights.

10 June 2011

Well Baby

I saw a close up photo of a newspaper clipping once that had been posted on the internet because it was too wonderful not to want to share with the whole world. It must have been from the very local news section of a small local paper.

Now that is clearly one impressive burrito.

This week I had the good fortune of meeting some very impressive babies. New to the world, their achievements included such notable events as passing meconium, remaining unconscious long enough for mom to take a shower, and crying with gusto after demonstrating the Moro reflex entirely against their sad little wills.

Lucky for me, the babies came with equally lovely families. As much as I hate to admit it, this is not always the case. Generally speaking, I appreciate that parenting is the hardest job there is in the world. There is no special formula for who will excel and who will let their daughter eat chocolate ice cream until she throws up.

You can just never tell. I'm sure that some of the seventeen year olds I've sent home with their brand new bundles of joy are attentive and encouraging mothers. Conversely, I've admitted infants to the hospital because their PhD parents didn't realize a baby can't sleep ten hours through the night at two weeks old and not be fed at some point during that time. There are many different kinds of wisdom. I only wish I ended up with more of them.

In the meantime, these parents let me do all the sundry annoying things to their babies that good parents do. No one told me they were going to forego the shot of vitamin K because they wanted their brand new son's or daughter's first few days in this world to be serene and peaceful, as if being shoved out of a vagina was somehow a Zen experience they didn't want to break the mood of. As a result, I get to breathe easy that none of their babies will have horrible preventable strokes and end up paralyzed. 

They also let us prick their infant's heels for blood to send to the state lab to test for various rare (granted) but truly horrifying illnesses that are generally better off treated than ignored. Yes, some people choose to skip this step while they hold hands and sing Kumbaya.

So this week my job was easier because everyone let me do my job. Simple though that may sound, it is a rare but wonderful thing. I have to say, it did make me feel deep down warm and fuzzy, or maybe that was just the fresh clean baby smell.

08 June 2011

Botany Bay

I know that infants have memory of a sort from the time they are born. The voices of their parents are familiar. Being swaddled is soothing because it is reminiscent of their life in the womb, synched tight on all sides. But Emmaline has recently developed memory of another kind entirely.

"Butterfly," she says without fail upon entering the part of the yard where she once, on a single occasion, saw a butterfly ascend through the air and disappear over the roof of the neighboring house.

And more recently, when asked what she dropped into the ground along the front of the yard by the road, she says," Seeds!"

It is a declaration that contains not a small piece of pride. Her cheeks glow. Her smile widens.

"And what did we say?"

"Yea!" she replies and claps her hands vigorously.

We had, in fact, stopped to clap and cheer after each and every sunflower seed of the dozens we planted was dropped ceremoniously into the dirt.

"And what did we do next?"

"Water," says Emmaline triumphantly. "Papa."

"You're right," I reply. "Papa watered the seeds so they would grow."

And grow they did. They sprouted surprisingly quickly. The seeds I had planted in a starter greenhouse in the back bathroom where the heat was somewhat dependable had failed to do anything at all until they were placed in the front garden. Now they are thriving. Paradoxically the zinnia, which sprouted quickly while inside, have taken a beating in the great outdoors and have not done well at all.

So the sunflowers seemed more dependable for a young girl's first foray into planting.

Someday I'll take her to see the Secret Garden and remind her of this. In the meantime, I put stakes around the patch to remind us where not to cut the weeds...I mean lawn, and for the space of about two weeks I was very pleased indeed.

Then last night, upon returning from a walk in which Emmaline tried to catch up with the moon, we found Scout lying in the center of the sunflower seedlings. Needless to say we should not have been surprised since she is generally the ruiner of all things wonderful. This is made up for in part by her restraint in not killing or maiming the baby when Em sits on her head. Tonight she rolled over while Em was on top of her and gave her a hefty bruise on one arm, but I saw it happen and it was entirely Em's fault.

So I am trying to forgive Scout for what I am sure is now a garden of dead sunflowers. I am trying to forgive her because when it became clear that she was ruining the gardens around the house as well, patches of barren dirt from whence the poison ivy had been (incompletely) removed thus leaving it empty, an area that I have spent countless hours toiling over and more than a few dollars installing new bulbs and seedlings into, when Scout made it clear that  she believed this was her territory to dig in, I moved the red flags from the perimeter of her electric fence to contain the garden and she has not gone in there since.

I suppose in the end that it does not actually matter. Em will be proud of her memories whether or not there are sunflowers to show her later this summer. What she remembers is the accolades for a job that was well done. That should be enough. And maybe, if we can find some more red flags to use for protection, we'll be able to salvage a few of her sunflowers as well.

07 June 2011

Ice Cold A/C

When black smoke begins to billow from your tailpipe and the Volvo station wagon that was meant to be a tank and to keep your family safe begins to chug and shutter at the slightest provocation and the estimated costs of repair are twice the Blue Book value of your ancient piece of crap vehicle, it's time to get a new car. So we did.

We did our homework and as much as it pains me to say that a kicking moon roof and heated leather seats are not worth the ten grand the Prius seemed to be charging for them, they just aren't. Also, is it just me or do heated seats make you feel like you've peed your pants? It's a sensation akin to being given IV contrast for those of you who, like I do, obsess about the weird bumps and nubbins we all have somewhere in our bodies and end up being given unnecessary CT scans. I don't need to pay extra for that.

The result of much angst and frustration is that we are now the proud owners of a shiny and new Honda Insight, a car that has managed to get 49 miles a gallon on the two occasions I have driven it. Well done, Honda.

Of course this meant that we had to say goodbye to the station wagon. Goodbye ice cold A/C. Goodbye to the torn leather seats. Goodbye to the strange black fuzz on the passenger side ceiling. Goodbye to the missing drive shaft. And, thus, goodbye to the hole in the transmission where said drive shaft should have been.

Yes. We got fleeced. We're aware. Time to move on.

Move on we will, at 49 mpg and a range of 400+ miles per tank of gas, we'll move far. Like to Canada.

Then, while we were wading through the paperwork, a couple walked into the dealership with their brand new baby in tow. What better way to celebrate a new life than a new car? Fine. The infant, all of seven or eight pounds, slept angelically in its carrier. The baby's mom and dad, seemingly in their mid twenties and without any other children (we were to confirm with our sales rep) went straight for the Pilot.

Now I don't mean to tell anyone else how to run their lives, but might I at the very least suggest that maybe this is what's wrong with our country? That and, you know, the really bad stuff. But seriously, do two adult and a child the size of a small pumpkin really need a car that comfortably seats eight and gets only 17 miles per gallon in the city? Do they, perhaps, have to ferry three large Alsatians to and from doggie daycare on a regular basis? They do not. Nor do they carpool with a family of circus clowns. They just really, really like big cars. That's what they told the sales rep as they signed on the dotted line and drove the monster truck away.


Now obviously we're not the most energy efficient family. We try. In fact, Daryl spent six hours today meeting with a lovely man from Next Step Living only to be told that our house is so far beyond help that we don't actually qualify for the government subsidies covering such frivolities as insulation, for example, or the new lightbulbs that were painstakingly replaced in all forty light fixtures and then taken out again. He giveth with one hand and with the other he taketh away. Regardless we have a long way to go.

In the meantime, we bought a hybrid.

It's the least we can do to make up for the fact that our house literally bleeds heat through the winter months and there is nothing we can do, so it seems, to stop it.

01 June 2011

Parking the Car in Harvard Yard

I'll be at the Coop in Harvard Square tonight at 7.

In the meantime, I'll be ripping the poison ivy out of my garden. Is it possible to both be discouraged and determined at the very same time? I'm trying it out.