Category Archives: Health and Wellness

A Letter to a Young Writer

So.

Doug and I have grown three pretty amazing people. Mostly by luck, but we’ll take credit for having introduced them to good music and the great outdoors, and for teaching them to cook and to change a tire.

One of the best side effects of growing these people is that they end up finding other amazing people and bringing them into our lives. They’ve brought us a nice bunch of extra humans to love.

One of these delightful bonus kids is Caroline, a brand-new college graduate with fantastic culinary, percussion, and theatrical skills. She is also a writer. Her latest blog post deals with sensitive personal medical issues and she does an excellent job of explaining the clinical aspects. Her account is raw and honest. She also touches on doctor-patient relationship and communication issues, and she has kindly given me permission to weigh in on these. (You can read her post here – you’ll want to keep that tab open so you can click through and read more of her posts later – she’s a great storyteller).

Dear Caroline,

In your post, you share openly about experiences with very personal gynecologic issues, and in doing so you give other people the power of knowledge to seek help for themselves. You describe some interactions with doctors that are far from ideal, far from helpful, and which need to be addressed.

One can read what’s behind your words. Your title: “My Vulva is Melting (And Yours Might Be, Too),” was developed because of the shock/impact your physician’s specific word had on you. You put a picture of a slightly melting ice cream cone in the part of your story where you relay your doctor’s words. And you repeat the word “melting” a few different times. It obviously (and understandably) disturbs you.

Doctors learn a whole language of medical terms. We learn to speak precisely with this language. And then we learn to translate it back into language our patients can understand. Sometimes the translations leave something to be desired. What your doctor was describing is called “adhesions” – tissue can adhere to other tissue and become permanently attached. This is what your doctor meant. By trying to simplify medical terms, your doctor conveyed a confusing and upsetting image. Thankfully she was later able to explain what she had meant, and I am glad that she is helping you deal with your medical issues.

Several parts of your story hearken back to experiences with prior doctors, ones who do not seem to have been successful in positioning themselves as listening, caring, medical professionals who were in your corner. This is not to say that they weren’t, but they did not succeed in convincing you that they were.

When you describe an episode in high school in which mononucleosis caused gynecologic symptoms, you describe your doctors as not believing you (they were sure you had an STD even though you had told them you weren’t sexually active). You put a GIF in your post describing doctors as sadists who like to watch lesser people scream, and the caption of that GIF describes the physician doing a procedure roughly, as if to be punitive. It was humorous – you frequently use humor in your writing, and it’s humanizing and wonderful. But there are elements of truth behind much humor, and I worry that you thought a doctor was trying to hurt you or didn’t care that they were causing you pain.

I believe fully that this was your experience. And I highly suspect that this was not what was in the brain of the doctor.

My medical school class had 300 students. I knew most of them. One was an irredeemable asshole. The rest genuinely were there because they wanted to help people, but some didn’t have the best communication skills. I have found a similar pattern among the practicing physicians with whom I have worked. In fact, the doctor assholes are generally assholes to other doctors who they believe are not doing the right things for their patients. The overwhelming majority of doctors really do care about and want to help their patients, and they dedicate an enormous proportion of their lives to doing so. But sometimes they suck at parts of it.

Doctors are trained to look at signs and symptoms of a patient and synthesize everything they’ve learned in in-depth academic and clinical courses to come up with a differential diagnosis – a list of things that could be causing a patient’s presentation. Docs are taught that, in general, hoofbeats mean horses, but occasionally there’s a zebra. If it looks like a duck and quacks like a duck, most of the time it’s a duck. But not always.

If a doctor suspects an STD in an adolescent, it would be gross malpractice not to test for one, no matter what the patient says about risk factors, because missing that diagnosis could result in irreversible long-term sequelae, such as permanent infertility. Or severe systemic infection. And, for a variety of reasons, people frequently don’t give their doctors the full story (and a large proportion of sexually active teens deny sexual activity if they think their parents could find out). It’s simple to check and rule out an STD that could have potential devastating consequences. But that needs to be done in a way that respects the patient so that she feels she’s believed and listened to. “I know you told me that you’re not sexually active and I believe what you tell me. Because this looks so much like X, I’m going to test for it even though the fact that you’re not sexually active makes it very unlikely. I am looking for other causes, too, and I need to be complete.”

As far as the rough, painful specimen collection, there is of course a chance that the gynecologist was a sadistic asshole. But the far more likely scenario is that the doctor had not established trust and didn’t talk you through the procedure. I suspect it would have made a difference if the doctor had said, “Those ulcers are probably quite tender, so when I swab them to send some cells to the lab to figure out what it is that’s causing this, it’s going to hurt. I am using a soft, cotton swab, and I will be as gentle as I can be, but it may feel to you like I’m using sandpaper. I’m sorry that this is painful – I want to figure out exactly what this is so I can help you get better.”

In describing seeking help from a previous gynecologist for symptoms related to your new diagnosis, again there seems to be a deficit in communication. It seems that the doctor may have only been suspecting horses of making the hoofbeats, or at least the doctor didn’t let you know that other causes were being considered. It’s the doctor’s job to come up with the differential diagnosis, but sometimes it helps if a patient asks, “what else could this be?” – then you know what else, if anything, the doctor is thinking about.

When you reported to that doctor that you had pain during sex, the doctor made sure to tell you to stop your partner if you were in pain. Your response in your piece (not to the doc) was the equivalent of “no shit, Sherlock.” Yup. It’s all well and good to advise a patient not to do something that causes pain, but if a normal activity causes pain, it needs to be evaluated thoroughly. A reported symptom needs to be addressed. Perhaps your doctor would have investigated further had you not politely let it go when you received a “’Doc, it hurts when I do this,’ ‘So don’t do this’” message – a request for more thoughts might have prompted more response. “I of course stop when it hurts. But it’s not supposed to hurt. I’m not doing anything rough or unusual. What are your thoughts about why I might be having this pain?” might help a doctor who’s overwhelmed with patients stop for a moment and really focus on the one in the room. (Please note – I’m not at all “victim blaming” here – it’s absolutely the doc’s job to do all this anyway, but doctors are under significant pressure and sometimes a gentle nudge goes a long way).

Your advice to your readers is to listen to their bodies and investigate anything that seems abnormal for them. You balance this with a caveat against self-over-diagnosis. I second your advice wholeheartedly. Advocate for yourself. Don’t walk out of your doctor’s office if you don’t understand what was said to you (by the way, I’d be happy to discuss ureaplasma with you), or if you don’t think your issue has been heard and addressed. There might not be an immediate answer, but there needs to be a plan in place to find the answer and address the issue.

I also highly suggest that those on their way to becoming doctors listen to these stories. They need to hear their patients. They should be writers themselves – understanding the importance of words, understanding the importance of pictures, and always thinking about how their patients may be hearing them.

Thank you, Caroline, for sharing your stories. People are learning more from you than you know.

Some People Don’t Listen

My official medical advice is to avoid hot tubs. Always.

They’re germ soup. The temperature is perfect for bacteria to thrive and multiply. You can get some nasty skin infections from going in those things, it’s possible to get lung infections from pathogens aerosolized by all the bubbling, and heaven forbid you should get that water in your mouth.

Just say no. Period, the end.

So after my workout this morning, I got into the hot tub at the gym.

When you’re a doctor, you’re always weighing risks and benefits. You’re uber aware of risks. It’s such a bedrock of the years of medical education and training that it becomes ingrained, automatic, a reflex, to think of what can go wrong with any decision you make and how you could kill someone. You’re also weighing how any decision you make can help someone. It’s a balance.

Anyhoo, back to the hot tub.

I recently decided to kick my fitness routine up a few notches. I pushed it a little too hard, and a few days ago I pulled a muscle.

Nothing like doing that to make you feel old.

I rested it a couple days and got back to my workouts yesterday and today. And today’s workout finished in the pool. Right next to the hot tub.

My muscle was a little sore. And the pool was a little cold. And the jets in the hot tub were on. And I knew how good it would feel to get in that hot water and hold my sore muscle near a jet.

I thought about the likely bacterial level. And I thought about how I see gym personnel checking pH levels and adding disinfectant regularly in both the pool and hot tub.

I thought about potential skin infections. And I thought about the fact that I haven’t shaved my legs since two days ago so probably didn’t have any micro-nicks in my skin where bacteria were likely to get in.

I thought about potential lung infections. And I thought about the fact that I have a good immune system and healthy lungs.

I thought about the potential of accidentally getting any of that water in my mouth. And I thought about how easy it would be to keep my face out of the water, and that no one was splashing.

I got in. And put my sore muscle against the jet. And stayed there a good 10 minutes.

And damn, did it feel good.

And it stopped the soreness.

I got out, took a shower (I may or may not have soaped up a second time), got dressed, and went on with my day.

Glad that today I did not follow my own medical advice, and will let you know if I end up with hot tub lung.

A Pleasant Touch of Insomnia

I can’t sleep. It happens sometimes. So I’m downstairs in my parents’ house, reflecting.

Today I’m not annoyed at being awake this early, where normally I would be. Normally, when I do this early-wake-up thing (one of the joys of the hormonal changes of getting older that no one really warned me about), I look at the clock and get really pissed off. I lie there angrily, sometimes for a couple hours, until it’s time to get up. I play with my phone. You know, exactly what I tell my patients not to do.

I stayed up too late last night. I do this frequently when we’re all together. My son’s friend, who is with us for this trip, described it just as I experience it – wanting to be with people means he stays up way later than he should. I, too, am fueled by being with people. At least with people I care about. I probably wouldn’t want to stay up late hanging out with a bunch of assholes. But when it’s MY people, the draw of the social connection is stronger than the draw of my bed. It’s actually stronger than any other draw I can think of.

The four boys and I (and yeah, the “boys” range in age from 18 to 23, and they’re fully men, but from what I can tell about myself, I will always refer to them as the boys or the kids or the babies) went skiing/snowboarding yesterday. It was fantastic – conditions were perfect. It wasn’t crowded, the temperature was in the mid-to-upper-20s, the view was beautiful, the snow was great, and the feeling of flying over that snow was everything it always is. And it was physically exhausting – in that every-muscle-system-got-a-workout, got-my-heart-rate-up-for-hours, laughed-enough-that-my-abs-got-even-more-workout kind of way. So I was tired. I needed a good night’s sleep.

Around one a.m., I fell asleep in front of a movie we were watching together. That happens frequently – the family is together, we’re happy, and I feel so relaxed and content that I just fall asleep while watching a favorite. And of course the being-tired-from-staying-up-too-late probably plays a part. Movie was over around 1:20, and I went to bed and fell asleep next to Doug. A deep, contented, tired, good sleep.

And then I woke up at 6:30.

I talk to my patients all the time about sleep. I talk to my weight loss clients about it as well. I talk to my kids about it. It’s so basic, and yet so many of us don’t do it right.

We just don’t get enough. Adults really do need about 8 hours. It helps with brain functioning. We’re sharper when we sleep well. It helps maintain healthy cortisol levels. Our metabolism works better when we’ve had enough sleep. Our stress levels are better. Our blood pressure is better.

When we don’t sleep well, we don’t function at our prime. We handle stressful situations with less resilience. We put on weight. We don’t remember things as well. Our bodies and minds aren’t at their best.

And I’ve just had a 5-hour sleep.

But this morning I’m enjoying it. I am fully content. There are seven people I love sleeping peacefully under this roof. The view outside the window of the pond and trees covered in a light layer of snow is peaceful. I’ll read for a bit. Eventually others will awaken and join me, and we’ll talk politics and movies and music and sports and people. We’ll play games. We’ll eat. We’ll laugh a lot.

And I’ll stay up too late again.

So yes, it would be better for my health not to wake up early like this. But sometimes these late nights and early mornings are good for my soul.

A Well-Balanced Breakfast

So.

I was frying up some eggs this morning for me and my youngest son. Three of the four were in the pan, and as I tapped the last egg against the side of the pan to crack it, I saw a Huge. Ass. Motherf#@ing. Spider. In the pan. Sizzling in the oil.

I did what any reasonable, smart, well-educated, outdoorsy, nature-loving, competent adult would do: I stood there with the cracked egg dripping into my hand, and screamed.

Andrew ran into the kitchen. “Mom! Are you ok? What’s wrong?”

All I could do was gesture, egg dripping down my arm, to the pan.

He looked. And he did what any reasonable, smart, well-educated, outdoorsy, nature-loving, competent adult would do: he screamed. Well, to be fair, it was less of a scream and more of a really loud “holy shit,” but I’ll count it as a scream for literary purposes.

At this point, the sizzling spider popped loudly. I screamed again. “Do something!”

So my resourceful college sophomore grabbed a couple of spoons and extricated the deep-fried arachnid from the frying pan.

As he dumped the spider in the trashcan, I plopped what was still contained in the open eggshell into the pan.

I tossed the shell into the garbage and washed my hands, as I contemplated the big question: Do we eat the eggs from the spider pan?

Medical analysis: as Andrew pointed out, the pan was full of boiling oil – no spider-trafficked microbes were likely to maintain their pathogenicity.

Human analysis: Ew.

Medical analysis: any potential toxin from semi-exploded spider unlikely to be potent enough in whatever traces might have reached egg to cause any noticeable clinical effect.

Human analysis: Ew.

Practical considerations: out of eggs upstairs, in a bit of a rush, and hungry.

Verdict: Meh.

We ate the eggs. I gave the ones furthest from the spider to Andrew, took the somewhat close one for myself, and tossed out the one that had gone directly onto the spot where the eight-legged creature had actually been. I viewed that as a reasonable approach. You know, from a clinical standpoint.

Anyway, the spider was much worse off for the whole experience than I and my son.

We discussed the situation over breakfast, noting that we all eat plenty of bugs and bug parts all the time, in blissful unawareness.

But seeing it is different.

Our minds are powerful. Our defense mechanisms are powerful. We have the capacity to contemplate our mortality, the vastness of the universe, the complexities of DNA, or the presence of bug parts in our food. But we also have the capacity to put those thoughts aside so that we can get things done and live our lives.

Sometimes something comes along that knocks us out of our blissful, practical-repression-of-stuff state and makes us face our mortality (or a spider). The mortality is always there. We ignore it. The spiders are always there. We ignore them.

Until one drops into our frying pan. At that point, we deal.

Sometimes it’s a little spider. Sometimes it’s a really big one. Sometimes it’s venomous. Sometimes it’s kinda cute. Sometimes we notice its magnificent web. Sometimes it scares the daylights out of us. Sometimes we just brush it away.

And, the vast majority of the time, the spider causes us no harm.

But worrying about the spiders, thinking about the spiders, can be paralyzing.

Some of us live where there are dangerous, potentially lethal spiders. In those areas, it’s wise to take precautions.

We should shake out boots that have been left outside or in the garage before we stick our feet into them.

But worrying about any potential spider in our house? Not practical. Not helpful. And if we’re too meticulous about removing every known spider, who’s going to eat the other bugs?

There’s always a balance. Always a weighing of the pros and cons, the risks and benefits.

The eggs were good. As was the coffee.

We didn’t look too closely in our cups.

No. No. Just No.

Words matter. Words have consequences. Lies matter. Lies have consequences. People have understood this for a very long time – note the biblical prohibition against bearing false witness against one’s neighbor (that one actually made it into the Top 10 list).

What our current president stated at his recent rally in Wisconsin is false witness, defamation, slander, against doctors. It goes beyond that to incitement. His words, his lying, defamatory, slanderous words, will cause death.

Doctors do not “execute infants.” Full stop.

They do not wrap a living, breathing baby in a blanket and “determine whether or not they will execute the baby.”

This particular outright lie of Donald Trump has painted bullseyes on doctors, nurses, and patients for violent anti-abortion extremists. Doctors may be killed because of his words. Nurses may be killed because of his words. Patients may be killed because of his words. His false words. His slander. His lies.

He has harmed doctor-patient relationships with his slander. His defamatory words drive a wedge between those who have spent lifetimes dedicated to helping others in their times of greatest need and those who need their help.

He has born false witness. He is quite possibly inciting murder. He has put my colleagues’ lives in danger. He has put my patients’ lives in danger – both from direct violence by those agitated by his lies attacking people seeking care, and by alienating patients from doctors who are there to help them.

The blood will be on your hands, Mr. Trump.

It Happens

Spent a big chunk of the afternoon cleaning up shit.

No, this is not a metaphor. We have a dog, and although most of the year we make it a point to clean up the yard daily, it’s been really cold and snowy and rainy and cold and snowy and muddy and cold and rainy and did I mention cold? and I just haven’t been in the mood to do it for a while. And today it’s in the 40’s and dry and actually (I think) supposed to stay warm for many days in a row, and so it was time to get out there and clean up the mess. And today is garbage pick-up day, and although the recycle truck comes early, the garbage truck comes late in the afternoon, so if I got out there and did the turd pick-up quickly enough, I could get it to the curb in time to be taken away from my house today.

So out I went.

The process involves significant risk of stepping on poop land mines, so, wisely, I wore Doug’s shoes (sorry, Dougie, but you weren’t home and your shoes were conveniently located at the back door and I love you!).

In my “reduce/reuse” effort to decrease our plastic impact on the planet, I save produce bags and newspaper delivery bags to pick up after our pooch, and I filled up quite a few.

So here come the metaphors (you knew they were coming):

Health? Life? Politics? Let’s throw in a little of all of the above.

We’ll start with the produce bags: onions, broccoli, and zucchini in, poop out. So the produce bags can be a metaphor for intestines. And we’re discussing chores we don’t necessarily want to do. Perfect segue for an update on the American Cancer Society’s colon cancer screening recommendations. They now recommend that people of average risk for colon cancer begin screening at age 45 (the old recommendation was 50). Gold standard for screening is colonoscopy (starting age 45 and then every 10 years for the average-risk folks). Those at higher-than-average risk likely need to start earlier and do it more frequently. The prep isn’t overly pleasant, but it’s way better than late-stage colon cancer. So talk to your doc about it. This public service announcement brought to you by a bunch of canine backyard bowel movements.

Moving on:

It’s fairly easy to be methodical in the collection endeavor, as our pup is quite consistent in his tendency to defecate along the periphery of our property – he’s an edge-pooper. For the most part, I knew where to look: within a foot of the fence. This is true for most of us. We learn when and where to expect crap. Yes, every once in a while, there’s a big steaming pile in the middle of the lawn where you don’t expect it, but by and large, in the day-to-day, it’s where it usually is. There’s a lot of traffic at rush hour. There are long lines at Trader Joe’s the day before the Super Bowl. You don’t get as much sleep as you’d like when you have exams or when you’re on call. Your spouse is snippy when he/she is under stress. You expect it. You plan for it. You deal with it. It might not be pleasant, but it’s not surprising.

Along the perimeter of our fence we have all sorts of perennials – day lilies, crocuses, hydrangeas, peonies, various other pretty green and/or flowery things that I don’t know the names of. And under the piles of fecal matter I found a plethora of green shoots. The icky and the good are right up next to each other. The fertilizer feeds the flowers.

Much of the excrement has been through multiple freeze-thaw-get-rained-on-and-snowed-on-and-frozen-again-and-thawed-again cycles, and although you can certainly tell that it’s shit, it’s not fresh shit – a lot of it is really dried out and actually somewhat easy to scoop up and most of it doesn’t really even have much of a smell. When life throws general crap at us is can seem pretty awful at first. The fresh stuff stinks – we should pick it up right then and get rid of it, because if you step in it, it embeds in every crevice of your shoe and you have to do the twist on the grass to get the big chunks off and then bring the shoe straight to the utility sink and scrub the rest out of the treads. But if you’ve just stayed away from the crap for a good part of the winter, it might not be so bad when you come back to deal with it later. Works for some things, not necessarily others. Breast lump? Deal with it now. But some things that seem like a big deal right now turn out not to be such a big deal through the lens of time.

Of course, we’d never leave our dog’s waste on the ground when out walking – you don’t leave that for someone else to step in or have to clean up. But we don’t always afford ourselves the same courtesies we give to others. Maybe we should.

I seem to recall I said I’d find a way to tie this to politics as well. I used a bunch of newspaper bags. Need I say more?

Truth be told, I only got around 40% or so of our property’s perimeter-o-poop (there was only so much I wanted to deal with at one time), so will head back out later today or maybe tomorrow. My shoes (well, Doug’s shoes) are clean for now.

It Could Have Been Worse

Well, I just had a relatively shitty morning. But it could have been a lot worse.

I have a lot in my head these days – plenty that’s good (like starting a new business venture with another doctor), but quite a bit that’s not so good (relatives with health concerns, multiple friends with significant health crises in their families, a friend who just lost a sibling), and I’m a little tired. My brain is doing a lot of multitasking.

Our dog’s annual checkup/vaccine visit was scheduled for 9 o’clock this morning, and he gets very stressed out at the vet’s office (read: “wont-even-step-on-the-scale-so-I-have-to-lift-and-hold-my-60-ish-pound-dog-while-I-weigh-us-both-together-and-then-weigh-myself-and-subtract-my-weight-and-then-heaven-forbid-the-vet-should-try-to-look-in-his-ears”). So I started to think about how much I hoped he wouldn’t stress too much, took him for a walk, and seat belted him into the car for the 20-minute drive. Perfect timing, since it was 8:35 when I left the house.

Except it wasn’t perfect timing, because the freeway is under construction and they closed the exit ramp that I needed to take to get there. Not a huge deal – I’d have to take a later exit and wiggle back to get there from another direction – GPS would get me there just fine. I called the vet’s office to explain what happened and tell them we’d be a few minutes late – they said “no problem.”

Thought about friends’ family members. A few miles later, there was an open exit ramp. I took it, and started using my internal sense of magnetic north to navigate until the GPS recalculated.

Again, no problem. Cell signal was strong. Map was on the screen. The little blue circle representing my car was on the blue preferred route. I glanced down occasionally at the navigation as we made our way to the vet’s office. Thought about the condolence call we’d be making this evening. Thought about the website copy I needed to complete today. Thought about the talk I’d be giving tomorrow to the Science National Honors Society at the high school my boys graduated from. I had a lot to do.

And then the map shrunk down to a tiny little box in the bottom corner of the screen. No clue why it did that. Glanced down and tapped the little box with my thumb. Eyes back on the road. Thought about my friend’s father.Glanced back at the phone – map still tiny. Crud. Eyes back on road. Tapped at the tiny map square again. Eyes back on the road. Thought about the new business bank account I needed to open. Glanced down – map still tiny.

Of course, what I should have done was pull into a parking lot and figure out what my phone map was doing, but what I did instead was continue to repeat my same action while expecting a different result. I didn’t have time.

Eyes on the road. Glance down. Tap. Eyes on the road. Glance down. Tap. Eyes on the road – oh SHIT. The pickup truck in front of me was stopping because there was a bus stopping in front of him.

Slammed on my brakes. Hit him anyway.

We pulled immediately into the driveway/parking lot of a bank. It took all my strength to turn the wheel – the power steering was dead. I jumped out of the car as he exited his and asked immediately, “Are you OK?” “Yes, are you?” “Yes. I’m so sorry.”

The front of my 14-year-old minivan was hemorrhaging red liquid onto the ground. I started to smell something burning and realized I hadn’t turned off the engine, so I immediately turned it off. Our dog was sitting calmly in his seat.

Called the police. Stared at my bleeding car. Looked at the hole that was punched in my front bumper by the trailer hitch (now slightly bent) on the back of the other guy’s pickup truck.

And now there were no other thoughts intruding on the issue at hand. Nice timing, brain.

Police officer showed up, took our info, and was just generally really nice, as was the guy whose truck I hit. Called my husband, told him what happened, and asked him to call the vet’s office for me.

Called our car guy (when your family’s “fleet” consists of vehicles that range in age from 6 to 22, you have a car guy), who told me where to have it towed. Called AAA, who told me a tow truck would be there within an hour.

The police officer stayed until I knew the tow truck was on its way. He offered to drive us up to the vet’s office (about a mile away), but I needed to stay with the car until the tow truck arrived. The officer gave me his card and told me to call if I needed any help with anything.

A woman pulled into the bank parking lot to use the ATM. She saw me and asked if I was OK. I said yes and thanked her.

I called the vet again, and they said they’d fit our dog in whenever we got there.

After just a couple minutes, someone from the towing company called and said he had a truck nearby that would arrive within five minutes. It arrived within three. The driver was also extremely nice – offered to drop us at the vet’s office, but my dog did not want anything to do with going up the steps into the truck (and I was NOT about to attempt to carry him, struggling, up them – picture, if you will, a 60-pound bucking bronco with nails that need to be trimmed). So I paid the tow truck driver for the miles-beyond-which-AAA-covers and started the walk to the vet’s office.

I may not have mentioned that it was about 25 degrees. My hands were frozen. I stopped at a store along the way, where the employee kindly allowed me to bring the pup inside for a moment to warm up.

I may also not have mentioned that one of our other cars (the 1997 model) is in the shop, so My husband didn’t have a car at work. One of his colleagues lent him his car so he could meet me at the vet’s office and bring me home. His colleagues also changed the location of their afternoon meeting to be near where we live so that Doug could get there easily.

I still had to pick my dog up and weigh the two of us together and then subtract me, but he is fully vaccinated and healthy.

The collision shop has managed to find used parts for the bumper replacement. The red liquid was not coolant – I had just squashed and punctured the power steering fluid line. I should have a functional car back by Monday.

It could have been a lot worse. I could have caused an injury. The repairs could have ended up costing a lot more. Any of the people mentioned in this story could have been unkind.

So it allows for perspective. Because of my line of work, and because I and people around me are all getting older, I am frequently exposed to people’s sadness, worry, pain, and frustration. It can really get stuck in my head, because my drive is to fix it. And when it can’t be “fixed,” I still want to make it better. So sometimes I think about it more than is helpful. Sometimes, like last night, I lose sleep. Sometimes I think about it when I should be getting other things done, so I end up thinking about getting those things done when I should be thinking about the smart thing to do when my GPS screen shrinks.

Perspective. Priorities. I can’t let thinking about the big things get in the way of thinking about the little things, because a little thing, like driving to the vet, has the potential to become a big thing. Perspective. Priorities. Even when you can’t change what’s happened, you can change the experience of those it’s happening to by being kind. I called the towing company to tell them how helpful their towing guy was. I called the police chief to tell him how helpful and kind his officer had been. Perspective. Priorities. Allowing the stress of being late and of having things to do cloud my judgement so much that I thought it was reasonable to try to fix a GPS issue while driving caused worse issues than just being a little behind schedule and could have caused much worse still.

I’ll consider this a wake up call. And I hope that, if you need it, my morning can serve as a wake up call to you as well, so that you don’t need your own.

Seeing a Person You Love in a Number

A friend posted an article on her Facebook page discussing a recent research study out of Sweden showing that people on the autism spectrum have a decreased life expectancy. This friend has a child with autism. Autism coupled with learning disability, according to this study, is associated with the largest decrease in life expectancy. This friend’s child has learning disabilities along with autism.

My friend is scared.

On top of her worries about social isolation of her child due to her conditions, on top of worrying about her child’s place in society as she becomes an adult, on top of the fears of every parent about their children’s health and wellbeing and risks in general, my friend has had dumped on her frightening data clearly relating specifically to her daughter.

Only it doesn’t relate specifically to her daughter.

It is an aggregation of data that compares medical and mortality statistics of a pool of 27 thousand people with autism with that of a comparison group of 2-and-a-half million people without diagnoses of autism. It is not specifically about my friend’s child.

But it is about my friend’s child, because it is about every person with autism.

That’s the thing about statistics. They are about everyone, yet they are about no one in particular. That’s an aspect of practicing medicine in a world full of data that is particularly challenging, fascinating, and maddening. And people not practicing medicine have a similarly challenging, fascinating, and maddening time navigating this world of information.

Problem is, humans are extraordinarily complex. First, there’s the biological complexity of any multicellular organism, the variability due to genetics, the effects of environment, the interplay of internal and external forces. Then there’s psychology – individual predilections, societal influences – and how much of each of those is due to inborn versus external influences of the individual or of the interacting individuals of society? Even seemingly simple questions can become metaphysical – why are x and y correlated? Does x cause y? Does y cause x? Does a third thing cause both x and y? Do the combination of a third, forth, and fifth thing cause x under some conditions and y under a different set of conditions, some of which overlap the conditions which predispose x to be affected? Is there something inherent in x or y or both that lead to their association? What, if anything about the properties of x or y or the conditions that combine to give rise to certain outcomes are modifiable?

If my patient or my child or my neighbor ostensibly fits into a category being described in a general news article reporting on a scientific study, how much weight and credence do I give to it? What about a medical or scientific journal article? Does that specific person truly fit that category? If so, in what ways? In what ways does he not exactly fit? How important is the closeness of the fit? Even if a seemingly perfect fit, what does that actually mean for a specific individual? What exactly did the researchers look at? What did they miss?

The autism mortality article wasn’t meant for my friend. It wasn’t meant for the parent of a specific child with autism. It wasn’t written to alarm her. It was meant for society. It was meant for those who would influence the allocation of funds for medical research and social policy development.

Which means that the article was meant for my friend – a parent of a specific child with autism, a person who advocates for funding of research and services and societal support. It was meant to alarm/alert all of us, and my friend is one of all of us.

My job as a doctor is to take data and apply it to real people. To dissect the data, to judge the quality of research, to integrate it with what makes scientific and physiologic sense, to humanize it. My job as a friend, a neighbor, a family member, a general citizen of Earth, is to comfort and support others. So here is my reaction to that particular article as it relates to the person who posted it and to her daughter:

The article refers to a correlational study looking at aggregate numbers. Although the numbers and conclusions are laid out as straightforward, the actual data and meaning are exceedingly complicated. The study is a start, a call to look more closely at an overall population and see where dangers are. It is a study of averages – it is not a study of individuals. It leaves ever so many more questions than answers. It does not know your daughter. It does not know you and your husband and your other children. It does not know your child’s teachers or doctors. It does not know your social supports. Although this study does not know all of the above, it can help you as it draws attention to necessary lines of inquiry regarding a population (of which your child is a member) that needs serious attention.

This study was done in Sweden. We do not know how the data extrapolate to other countries. Are there genetic or cultural characteristics in the overall Swedish population that could affect these data? The data showed different main causes of premature death in two different populations of those with autism – those with learning difficulties and those without. We do not know if these differences hold true globally, and we do not know what other differences or characteristics play a part.

There may be specific age-related spikes for the most common causes of mortality which could skew the data. Distribution of data points is extremely important to investigate, not just averages. At what else did the researchers look? At what did they not look?

There are people looking at important questions: How can we begin discerning the causes of the disparities? How can we ameliorate the causes?

So many questions. So few answers so far. So glad people are asking the questions that will lead us to information that will help individual people, and in turn will help a population at large. And sending strength to all who look at a headline with numbers and in those numbers can’t help but see the face of their child.

A link to the original abstract: Article in the British Journal of Psychiatry

A link to a discussion of the article by an autism research and advocacy charity in the UK: Autistica’s call to action piece

Pet Parallels in End-of-Life Matters

(Note to my children – do not read this. Other people who are close to me – you probably want to skip it, as well.)

It has taken me almost two years to be able to write this. We said goodbye to our beloved dog in early May of 2013. I grieved for well over a year.

About a month-and-a-half prior to his death, we had a big medical scare with him. I wrote at that time about how dealing with a veterinary emergency can provide us with some insights and practice parallels to dealing with human medical crises (Pet Practice). A veterinary crisis also has definite parallels to human end-of-life issues, and can highlight ethical concerns as well.

He was an older dog – old enough that my husband and I would occasionally mention animals’ life expectancies in front of our kids. The boys were well aware of what we were doing: “Mom, Dad, we know dogs don’t live as long as people, and you’re obviously trying to prepare us, but it’s totally going to suck when it happens, whether or not you remind us of how long dogs live.”

So he was older, slowing down in general, with a seizure disorder which had developed in his later years and was generally kept in check with medications (with one episode of multiple breakthroughs a month or two earlier), but reasonably active and happy overall.

The big scare I mentioned above came on pretty suddenly. He became progressively ill over the course of a day, and I brought him to the vet, who did a thorough exam and extensive lab work. It didn’t look good – obstructive biliary disease – and we were referred to a veterinary specialist for an ultrasound, expecting that it would show cancer.

I filled the family in on the details of what was happening, and I took him in for the imaging study. The ultrasound did not show cancer, but elucidated an issue that would be rapidly fatal if not addressed with emergent surgery.

I called my husband. Our dog was old. We didn’t have spare thousands of dollars lying around. We loved our dog. Our children loved our dog.

We happen to live about an hour-and-a-half away from one of the best veterinary schools in the country. I called them and told them what was happening. They said that we could bring our dog out there, and their estimate on the surgical cost was a bit lower than our local place.

I called my husband back. We talked again. Yes, our dog was on in years, but this was fixable. He could have a couple good years left in him. We would figure out a way to cover the cost. I brought him to the boys so they could give him a hug, and then I took him out to the veterinary school’s emergency clinic.

I brought the ultrasound disk and the lab results with me. They looked at everything, concurred with the diagnosis, and agreed that surgery was a reasonable option. “The other vet did tell you that the mortality rate for this surgery is about 30 to 35%, right?” Uh, no. No, he didn’t. How could I not have asked that?

I wasn’t going to change plans now. The odds were still in his favor, even if not what I had assumed. I gave him a kiss, signed the release forms, and gave the front desk my credit card.

And it worked. The surgery, though complicated, went well. He recovered. Within a few weeks, he was prancing and bounding and chasing rabbits like he did when he was much younger. We were so happy – we knew we had made the right decision. We played joyfully with him over the next few weeks.

And then he started seizing. Not just one breakthrough, but multiple. I brought him in. The vet upped his anti-seizure medications. He lost bladder control with the seizures, so I slept in the kitchen with him for the next two nights. He had more seizures. And his post-ictal (post-seizure) agitation kept increasing. It got worse through the next evening. His vet said there was nothing more he could do, and he sent us to the emergency clinic, which had a veterinary neurologist on staff.

The vet who was on duty that night in the emergency/specialty clinic was very kind. She said that it didn’t look good, but we were not without hope. She assured me they would do what they could overnight, she would keep me posted and I could come back in the morning to speak with the neurologist when he arrived.

So I headed back there the next morning. The neurologist said he recommended an MRI, since his seizure history sounded consistent with a brain tumor. The MRI would cost two thousand dollars. And then if it did show a tumor, and if it looked operable, we would have to decide whether to pay for and put him through brain surgery to remove it. He also said he had one other thing to try with medications.

I talked to our regular vet (a very smart man who had always given us sound guidance and advice), and he said that our dog had been through so much, that the prognosis was grim, and that if it were his dog he would not do surgery or the MRI (which would require anesthesia). I talked to my husband. We decided to give the neurologist’s pharmaceutical idea a try.

It didn’t work. The updates from the veterinary hospital throughout the day were very bad. We knew what had to happen. We told the boys, and we took them with us to the hospital so we could all say goodbye. It was a sad, tear-filled car ride.

They brought our doggie into a room with us. It was awful. He was horribly agitated, and he had lost his sight. He really didn’t show much, if any, sign of recognizing us. After hugging and petting him as much as and as best we could and saying what we needed to say, I told my husband and boys to wait in the waiting room. My husband wouldn’t leave me. The boys (12, 15 and 17 at the time) said they’d be ok and went out of the room together.

And then it was time. The vet gave me euthanasia consent papers to sign. I don’t remember exactly what they said, but I think I recall acknowledging the finality of the decision. And then it was really time. The vet asked if I wanted to stay. I said yes. I told my husband he didn’t have to stay, but he would not let me stay alone.

It was so very awful. So very, very awful. Our dog was clearly suffering. His agitation was severe – it had not been alleviated by any of the medications. I will skip the full play-by-play of the final actions, but I will describe a bit of what went through my mind.

“I have to be here. I have to stay here. Good pet owners stay until the end. I don’t want my husband to have to see this. I’m the doctor. I should be stronger than this. What am I doing? Why am I doing this? Am I doing the wrong thing? What if this is fixable? How much did money play into this decision? What kind of a monster am I? How can I do this to my family? Did I make this decision to stop him from suffering or did I make it to prevent me from suffering as I watch him? How can I do this? How can I not do this? Oh God, it’s done. What have I done?”

I stayed as long as I could, with my hand on his fur and my husband’s hand holding me. Then I had to get up. I had to go to the door. I kept talking to our sweet puppy dog. The vet still had her stethoscope on him. He had stopped breathing minutes prior but probably still had a few slow heartbeats left, but I just couldn’t stay any longer. I failed him in those last few seconds. He wasn’t alone, but it was someone else’s hand on him at the very end. The vet had no choice – she had to stay.

They handed us the bill at the front desk. We gave them our credit card.

We gathered our boys, held one another, and had a silent, tearful car ride home.

We grieved. And we recovered. But it took me a long time to recover.

This was a dog. Yes, he was our dog, our pet, a “member of our family,” but he was a dog, not a person. Yes, we all tend to anthropomorphize our pets, but I was not grieving his loss as I would grieve a person. We develop strong emotional attachments to our pets, and they symbolize responsibility, loyalty, and innocence. That wasn’t all of it. It was more complicated. It was much worse than when I had grieved dogs in the past as a child and teenager (and those previous times certainly hadn’t been easy).

I’m a doctor. I keep coming back to this. A big part of why I went into medicine was to prevent death. To promote life. To promote good health. To help give quality to life. And, when not possible to do the aforementioned, then to help support patients and their families through the loss of life. I have been with patients and their families numerous times at the very end of a life. It has been at times when my colleagues and I did everything we could to save a person but were not able. It has been at times when someone has chosen not to be resuscitated or to have “extraordinary measures” taken. It has been at times when the choice was to focus only on easing any pain at the end of life. It has been when removing life support. Some of those times were peaceful, and some of those times were frantic. But never, during any of those instances, did I myself do (nor write an order for someone else to do) something with the express purpose of stopping a heart. Even when removing  someone from ventilator support, we were removing a breath-sustaining machine (and therefore a life-sustaining machine), but the person’s respiratory system had already failed on its own – we were not purposefully making a person who was spontaneously breathing stop that breathing.

Almost two years ago, I signed papers authorizing a veterinarian to kill my dog. We use the word “euthanize” (“eu” meaning “good”, “than” meaning death, translating to a word that means “to kill painlessly,” generally to relieve suffering), which sounds much better than “kill,” but it doesn’t change what is done. Our vet told us we had chosen compassionately. In all reality, it probably would have been cruel to allow an animal to continue to suffer indefinitely with no understanding of what was happening, and it is not financially feasibly to put an animal on the comfort measures that we afford people at the end of life – our choice is a much harsher one with our pets. But still, I signed the papers to stop his breathing. What if I was wrong? I did not handle well the thought that I had chosen to end his life and that I could have made the incorrect choice. When I failed him in those final seconds, it was because I had failed myself. I second-guessed my thought process. I questioned my motives. I felt unworthy of him.

Those feelings hung with me heavily. There was an intense, deep feeling of guilt. Honestly, my really wrong decision probably was to have had him go through that surgery when he was so ill that month-and-a-half prior. It would have been a peaceful death if we had opted out of that surgery. There was nothing about the way he ended up dying that was peaceful. If only we had known then what was going to happen six weeks later.

People lament how much money we spend on medical care in people’s last few months of life. Policy experts and politicians look at the numbers and say we are wasting money and resources. People lament how so many people end up dying hooked up to machines in hospitals when they would much rather have died peacefully at home. But the vast majority of time I was working in a hospital, caring for people at the end of their lives, we had not known it would be the end. Surgeons did not usually advise surgery if they thought a patient was not going to live. We did not give people ventilator support with the expectation that they would not recover. And most of our patients did survive and return home, and get to celebrate another holiday or wedding with their families, and see more sunsets, and sing more songs – how many sunsets, how many songs are worth the cost of that care? More than once, even when an outlook was grim and we expected the worst, a person surprised us and recovered well beyond what we would have expected. And sometimes a person who we had expected to do well’s last moments were on a ventilator or with people pushing on her chest during CPR. We spend those resources and efforts at the end because we don’t know it’s the end.

We don’t know everything. And it’s really hard not to know everything. Especially when you’re the person who is supposed to have the answers.

Battling Buffoonery

My career is based on communication and empowerment within the medical world. I educate on the patient/family side and the medical professional side. It takes understanding and empathy from both sides of the stethoscope to optimize communication. It takes communication between both sides to bridge perceived power differentials. It takes work on both sides to change a culture of uneven power dynamics.

I read two Facebook posts within the past few days dealing with a culture issue that needs changing. This is a matter from the “general” as opposed to medical world, but that which is present in society-at-large certainly spills into medical or any other subset of society.

The first was written by a woman in her early forties, discussing the details of recent times (while in retail establishments) she’s received unwanted amorous advances from strangers (including a time when she had her young teenage son with her, and they included her son in the harassing conversation). The second post was by a friend whose 17-year-old daughter, who works weekends at a toy store, has been receiving come-ons from customers while their children play in the store. Both women experienced definite “ick” feelings as they were being harassed.

Thankfully, the majority of public interactions are not icky. These incidents referred to above are happily the exceptions to the general rule of civilized, respectful behavior. But although they are exceptions, they are not rare exceptions, and they are threatening.

I am close to the 17-year-old young woman. I feel perfectly comfortable offering her advice. And while I would like to tell her to respond to inappropriate comments with something to the effect of, “I cannot figure out why you would think it’s ok to say that to me,” I am hesitant to advise her to engage these people at all. I’m also hesitant to tell her to walk away. The first option places the power with her, while the second seems more like it leaves at least some power with the tasteless cad.

The problem is, it’s difficult to know whether the label “tasteless cad” is sufficient and accurate. If the issue is simply a lack of manners and a poor sense of humor, then perhaps pointing out the rudeness will help prevent the person from creeping out someone else. But what if the demonstrated disrespect reflects a fundamental disregard for the personhood of those harassed, and attests to a sense of entitlement? A challenge to that entitlement could theoretically provoke more of an assertion of power. Tough for a 17-year-old to gauge when it’s even difficult for a forty-something-year-old to do.

There are protections set up in schools and in workplaces (to prevent harassment from bosses or other employees), but there are no systematic protections regarding interactions with the general public. I would certainly report such matters to business management. A good manager will work to provide a safe environment for both employees and customers. Something as simple as placing a prominent sign reminding people to show respect to others can help establish expected conduct. Management can also ask someone to leave.

It’s more difficult when a store owner is the one engaging in the misconduct. If it’s the owner, I’d avoid that establishment and would warn others. A complaint to the Better Business Bureau or to the state Attorney General’s office may in some circumstances be warranted.

And for everyone’s well-being, we need to teach our kids by always modeling respectful speech and behavior – not reducing people to sexual objects, not describing relationships as conquests, and not indicating that it’s ever ok to make suggestive comments to strangers. If we witness inappropriate behavior, we need to show support to the person being hassled, and when possible we need to report the harassment (to management, to administration, etc., depending on where it is occurring). We need to hammer into our kids that it is never ok for others to harass them.

It’s better than it used to be, and we can all work together to keep improving our world. It will never be perfect, but the exceptions to civility should become increasingly rare.